|Year : 2014 | Volume
| Issue : 3 | Page : 26-87
|2nd ISTM Annual Conference, TRANSMEDCON 2013, Bangalore
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|Date of Web Publication||17-Apr-2014|
|How to cite this article:|
. 2nd ISTM Annual Conference, TRANSMEDCON 2013, Bangalore
. Asian J Transfus Sci 2014;8, Suppl S1:26-87
| Free Papers|| |
RDP prepared by the Buffy Coat method from Buffy Coat stored overnight: Advantages and benefits
Samantha Kumarage, Joseph Philip, T Chatterjee, Surg Cmdr, R S Mallhi
Armed Forces Medical College, Pune
Introduction: Random donor platelets (RDPs) are prepared almost entirely by the platelet-rich plasma method in North America. RDP is prepared entirely by the Buffy Coat method in Europe. In India, when RDP is prepared by the Buffy Coat method, it is done so, almost entirely, from the whole blood stored at room temperature for less than 8 h as per the DGHS India specifications. Advantages of the Buffy Coat method are less activation of the platelets, recovery of more number of platelets and recovery of more volume of plasma for clinical use.
Aim: Our aim was to evaluate the platelet count, WBC contamination, platelet activation and other biochemical parameters of platelet concentrate prepared from the Buffy Coat within 8 h and within 24 h of collection, respectively, in order to assess and compare the two methods.
Materials and Methods: We prepared 40 units of RDP by the Buffy Coat method from whole blood stored at room temperature within 8 h of collection (fresh BC) and another 40 units from Buffy Coat stored at 22°C for less than 24 h before preparation of RDP(stored BC). We analyzed the platelet counts, platelet activation by CD62P expression by flow cytometry, WBC counts, plasma glucose levels, pH, partial pressure of oxygen and carbon dioxide in both the groups of RDPs 24 h after the respective preparation. IBM SPSS statistical software version 2.1 was used for statistical analysis. P-value less than 0.05 was considered as statistically significant.
Results: The platelet count from stored BC was distinctly higher than that in fresh BC. CD 62P expression was low in stored BC compared with fresh BC, indicating lower platelet activation. There were no differences of pH, pO 2 , pCO 2 and plasma glucose levels in fresh BC and stored BC. WBC contamination was higher in fresh BC compared with stored BC, but it was not statistically significant.
Conclusion: Our study concluded that stored BC contained higher platelet counts, less WBC contamination and less platelet activation. The lesser platelet activation could be due to the fact that on longer keeping, platelet activation would automatically reduce. The higher platelet counts could be because of better mobilization of platelets into the plasma interface because of lesser activation of platelets. WBC contamination will be less due to the increased period of settling. Platelets can be prepared from stored BC during the business hours of the following day. Fewer RDPs are discarded due to low platelet counts as this method recovers comparatively more platelets. Therefore, a less number of units require to be transfused to the patients, which eventually lead to less donor exposure. We conclude that RDP prepared from the Buffy Coat method stored at room temperature for 24 h is the better method for production of RDPs.
Factors affecting the quality of cryoprecipitate: A study from a tertiary care hospital in North India
Rajeswari S, Ashish Jain, Neelam Marwaha, Jasmina Ahluwalia
Background: Cryoprecipitate (CRYOPPT), a concentrated preparation of antihemophilic factors, is routinely produced in blood transfusion services throughout the world. The average factor VIII:C content of CRYOPPT is 70 units and the biological activity per milligram protein is enhanced 10-20 fold compared with plasma. This yield of factor VIII:C represents only 30-35% of that available in plasma. Knowledge of the conditions that govern the yield of factor VIII procoagulant activity (VIII:C) in the CRYOPPT is incomplete. In our efforts to increase the amount of active factor VIII in the CRYOPPT effect of important variables (time interval between donation and freezing of plasma, freezing technique) during the preparation of CRYOPPT was investigated.
Materials and Methods: One hundred and ninety-two units of whole blood were collected (96 each from in-house collection [group I] and outdoor camps [group II]) and processed for CRYOPPT preparation. The sample size of the blood units from each blood group (A, B and O) were 32 within each of the groups (group I and group II). After separating the packed red cells within 1 h of collection, liquid plasma was analyzed for factor VIII:C (IU/bag) and fibrinogen (mg/unit) by single-stage clotting assay using a coagulometer (Stago Diagnostics). Within each group, 50% of the plasma units were frozen using a blast freezer and the remaining using a conventional mechanical freezer (−80°C). The CPYOPPT samples were analyzed for fibrinogen (mg/unit), % recovery of fibrinogen, factor VIII:C (IU/bag) and %recovery of factor VIII:C by the single-stage clotting assay using a coagulometer (Stago Diagnostics).
Results: The independent T test was used to compare the quality of CRYOPPT from two groups (group I and group II) and two freezing techniques. The analysis of variance test was used to analyze the effect of blood groups on the fibrinogen and factor VIII:C levels in the CRYOPPT. The factor VIII:C levels and fibrinogen were higher in liquid plasma processed from whole blood units collected in camps (p Conclusion Factor VIII recovery in CRYOPPT seems to be determined by the baseline of factor VIII:C, blood group of the donor, A group donors having higher levels and rapid freezing using blast freezer).
Impact of pre-transplant donor-specific
antibody (DSA) detected on the Luminex
platform on outcome in renal transplantation
Mary Purna Chacko
Christian Medical College, Vellore
Introduction: Anti-human leukocyte antigen (HLA) antibodies are well known to mediate renal graft rejection. This knowledge has spurred the invention of more sensitive and specific platforms as compared with the traditional complement-dependent cytotoxicity (CDC) assay for the detection of such antibodies. The Luminex donor-specific antigen (DSA) assay using donor lysate detects donor-specific anti-HLA antibodies of the IgG class with a degree of sensitivity that exceeds most other platforms. This study assesses whether positive results on this sensitive assay translates into poor graft outcome.
Materials and Methods: One hundred and twenty-six patients who underwent renal transplant at our center had their final pre-transplant sera retrospectively analyzed by the DSA assay using donor lysate (LIFECODES Donor Specific Antibody [DSA] kit from Gen-probe). All the sera were negative or showed only IgM antibodies with no detectable IgG by CDC with di-thiotreitol treatment (CDC-DTT). The test results, viz. positive (mean fluorescent intensity [MFI] >1000) or negative, MFI values for class I and class II antibodies, a mean of these two MFIs and maximal pre-transplant MFI were analyzed with regard to post-transplant complications in terms of clinical or biopsy-proven rejections, graft function in terms of estimated glomerular filtration rate (eGFR) on the 7 th day, 14 th day, 1st month, 3rd month, 6 th month and 1 year post-transplant, 24-h urine protein at 1 year post-transplant and graft loss defined as graft failure or death with a functional graft. The duration of follow-up ranged from 1 to 5 years.
Results: Of the 126 recipients, 32 (25.4%) had pre-transplant DSA values exceeding 1000, the cut-off for positivity - 6 for class I DSA (18.8%), 21 for class II DSA (65.6%) and 5 for both classes (15.6%). MFIs for Class I ranged from 12 to 2818, with a mean of 242.05 and a standard deviation (SD) of 322.53, and for Class II from 1 to 4184 with a mean of 418.19 and an SD of 539.05. DSA positivity was observed in four of 12 (33.3%) cases who had biopsy-proven rejection episodes and 28 of 114 (24.6%) who did not experience biopsy-proven rejection (P = 0.499). No significant correlation was found between any of the test parameters considered and rejection or graft loss. There was however a significant association between DSA positivity with the 14th day eGFR (P = 0.05) and DSA class I with the 3rd (P = 0.014) and 6th month (P = 0.02) eGFR.
Discussion and Conclusion: Pre-transplant DSA values in patients with negative CDC-DTT did not show any significant predictive value for rejection or graft loss in the time period assessed. However, higher DSA values consistently correlated with reduced eGFR. Considering that eGFR in the short-term post-transplant is a surrogate marker for long-term outcome, it may be reasonable to conclude that the pre-transplant DSA may have a significant effect on the long term, for which further follow-up is indicated.
Donor-specific antibody using donor lysate MFI values among CDC-positive patients undergoing desensitization: What do they tell us
Christian Medical College, Vellore
Background: The complement-dependent cytotoxicity cross-match (CDC) is still considered the standard to determine immune compatibility prior to renal transplantation. However, solid phase antibody detection platforms like Luminex provide greater sensitivity as well as objective, numerical results that help to monitor progress in patients undergoing desensitization. This study assesses how the mean fluorescent intensity (MFI) values of the donor-specific antibody using a donor lysate assay (DSA) alter in patients with a positive CDC undergoing desensitization and whether the values prior to initiation of therapy can be a predictor for successful desensitization.
Materials and Methods: In our hospital, all patients awaiting renal transplant undergo CDC initially. Patients found to be positive on initial CDC undergo desensitization with monitoring by CDC and DSA, and are transplanted only when both turn negative. The study included all patients with an initial positive CDC cross-match who were separated into two groups - those with only IgM but no detectable IgG on CDC using dithiotreitol (DTT) (group 1) and those with IgG (group 2). Only those with a recorded positive or borderline DSA (MFI > 500) prior to treatment were included in the study. Class I and II DSA values were recorded at presentation and at an end-point where CDC turned negative. We compared the values at presentation between the two groups and also compared the end-point values with those in a control group (10 male patients, with no history of transfusions and negative CDC on presentation). Finally, we compared the initial DSA results of patients who eventually became CDC negative with those who showed persistent positivity. Groups were compared using the unpaired t test.
Results: A total of 29 patients were studied, of whom 16 had class I antibodies (MFI range 513-14,767; mean 2561.8) and 19 had class 2 antibodies (MFI range 585-16,056; mean 3329.4). In those with class I positivity, six belonged to group 1 and 10 belonged to group 2. In those with class II positivity, seven belonged to group I and 12 to group 2. Comparison of MFI values at presentation between group I and group II showed no significant difference for either class (P = 0.3937 and P = 0.9574). Subsequently, 19 patients became CDC negative on treatment. Significant differences were observed when comparing MFIs at the end points for group 2 with the control cohort (class I P = 0.0001, class II P = 0.0277). The initial MFI values did not significantly differ between those treated successfully and those with persistent CDC positivity; however, the difference in class II approached significance (class I P = 0.3746, class II P = 0.0542).
Discussion and Conclusion: Patients with only IgM on CDC-DTT with positivity on DSA indicating underlying IgG might be expected to have lower MFIs as compared with those with IgG on CDC. However, MFI values did not differ significantly between the two groups. Our study also indicated that patients who turned CDC negative are not immunologically equivalent to unsensitized patients at this point. How the difference translates into transplantation outcomes however needs to be studied. Our results suggest that the Luminex DSA using donor lysate is a relevant adjunct to CDC for monitoring desensitization.
Utility of platelet growth factors from allogenic platelet-rich plasma for clinical improvement in split-thickness skin graft
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow
Introduction: Platelet-rich plasma (PRP) may enhance wound healing through the formation of a platelet plug that provides both hemostasis and the secretion of biologically active proteins, including growth factors such as platelet-derived growth factor, transforming growth factor (TGF)-β, TGF-β2 and epidermal growth factor. The release of these growth factors into the wound may create an environment more conducive to tissue repair and could accelerate post-operative wound healing. With the advent of platelet-derived growth factors and biologic substances, we can augment or modulate the wound healing process itself. The field of biologic wound products aims to accelerate healing by augmenting or modulating these inflammatory mediators. Polypeptide growth factors are a class of biological mediators that promote cell proliferation, alone or in concert, by binding to specific cell surface receptors. It is known that platelets and the formation of a provisional matrix play a prominent and likely determinant role in the initiation and maintenance of wound healing. Upon activation, platelets release their granular contents into the surrounding environment. The platelet α-granules are abundant and of particular interest because they contain many of the growth factors responsible for the initiation and maintenance of the healing response. The purpose of this study was to assess the benefits of PRP in clinical improvement in split-thickness skin graft.
Materials and Methods: Blood samples from 20 healthy platelet apheresis donors (16 male and four female) were taken randomly for platelet count and transfusion-transmissible infection testing. These donor were subjected to platelet apheresis and approximately 200 ml PRP was collected. Segments of 2 ml each were prepared from the PRP bag. Two cycles of freeze - thaw technique at -80°C were used to lyse the platelets. One segment was provided on demand to the Department of Plastic Surgery for clinical application on split-thickness skin graft.
Result: The study comprised of 20 subjects including seven females and 13 males. The age range was from 5 to 60 years. There were six cases of post-burn contracture, three cases of malignancies with ulcers, four cases of arteriovenous malformations and seven others. Of the 20 patients included, eight showed full take of skin graft.
Conclusion: A variety of potentially therapeutic growth factors are released in PRP preparations. Sufficient concentrates and release of these growth factors through autologous platelet gels may be capable of expediting wound healing in a variety of as yet undetermined specific wound applications.
Marrow donor registry India (MDRI): Journey so far
Tata Memorial Hospital, Parel, Mumbai
Background: The Marrow Donor Registry India (MDRI) is a database of voluntary unrelated marrow donors and facilitates marrow and peripheral blood stem cell transplants for patients with life-threatening diseases such as leukemia, aplastic anemia, etc. It recruits donors, maintains a registry of potential donors and initiates searches for human leukocyte antigen (HLA)-typed marrow donors for patients requiring transplant.
Journey so far: International scenario: There are 69 registries from 50 countries with a donor strength of 21,054,703 donors (as on April 2013). www.bmdw.org
- Rich cultural heritage (linguistic and ethnical), history of different waves of migration and deep-seated caste system in India makes it a unique and isolated group.
- The Indian population is scarcely represented in international registries.
- The cost of transplant after obtaining the matched cells from any international registry is too high for the Indian patients.
The MDRI has registered 15,000 donors in the past 4 years after its establishment in 2009. The MDRI has received 60 donor search requests from various national and international centers and has been able to find a 6/6 match for eight patients and 5/6 match for 43 patients. Among the eight donors that matched 6/6, six donors agreed for further testing.
- To classify the Indian population in linguistic groups.
- HLA being the most polymorphic gene, we investigated 15,000 donors registered with the MDRI for HLA A, B and DRB1 loci.
- Determine and compare the haplotypes in each group.
Materials and Methods:
- Fifteen thousand voluntary bone marrow donors were included in this study.
- Linguistic groups: Donors having the same spoken language and numbers greater than 100 per group are included in the study.
- DNA extracted using the salting-out kit from BAG Health care.
- HLA typing done using a sequence-specific oligonucleotide probe (SSOP)-based reverse line blot technique as well as the Luminex- xmap technology - by Gen-probe, USA. All donors are typed for the HLA A,B and DRB1 loci up to intermediate resolution.
- Any ambiguity arising from the above techniques are resolved by using sequence-specific primers (SSP) at low resolution.
- Arlequin software, version 3.1 was used for the haplotype frequency analysis.
Results: The most common haplotypes were A*33-B*44-DRB1*07 and A*01-B*57-DRB1*07. A few unique haplotypes such as A*33-B*14-DRB1*01, A*26-B*08-DRB1*03 and A*01-B*40-DRB1*15 were seen in some groups.
Conclusion: Our data demonstrate that each linguistic group has unique haplotypes along with a few common haplotypes thus creating a unique HLA gene pool. In order to adequately represent the Indian population on the registry, each linguistic group should be targeted for donor recruitment. This would enable a better chance for any patient to find a match.
Leukoreduction in cardiac surgery: Comparison between RBC and LR-RBC
Jaisy Mathai, PV Sulochana, Sathyabhama
Sree Chitra Tiruna Institute for Medical Sciences and Technology, Trivandrum, Kerala
Passenger leukocytes are the major cause of alloimmunization to human leukocyte antigens (HLAs) and leukocyte-specific antigens in transfusion recipients. Allo-immunization may result in febrile transfusion reactions, platelet refractoriness and acute lung injury. Leukocytes are also the vector for transfusion-associated cytomegalovirus infection.
Technological advances in leukocyte reduction of cellular blood components have made it possible to reduce the number of leukocytes to fewer than 10 7 per transfusion. It is suggested that the use of leukocyte-reduced cellular blood components may minimize or prevent recurrent febrile reactions and allo-immunization to leukocyte antigens. Leukocyte reduction in red blood cell and platelet transfusions using third-generation filters is indicated for selected patients who are likely to receive long-term transfusion support and to prevent recurrent febrile transfusion reactions or delay allo-immunization to leukocyte antigens.
A comparative study was carried out on the effect of leukoreduction in RBC and LR-RBC using study parameters like Hb, wt, age, sex, diagnosis, blood group, previous history of transfusion, no. of units transfused and transfusion reactions if any. Leukoreduction is the removal of white blood cells from the blood or blood components. It is theorized that transfusions that contain white blood cells may cause adverse effects through multiple mechanisms. White blood cells may themselves harbor infectious disease and some pathogens may be more concentrated in white blood cells than the rest of the blood products. It is also theorized that the donor white blood cells may suppress the recipient's immune system. A 2007 meta-analysis by Blumberg and others studied 3093 patients who received leukoreduced blood and found that it reduced the frequency of post-transfusion infection by 50%.
We have performed a comparative study between RBC and LR-RBC with 100 samples each in the RBC and LR-RBC arms. Parameters studied were blood groups, Hb level, age, diagnosis, weight, sex, h/o previous transfusion, duration of red cell storage, per-operative use and length of hospital stay.
Antibody screening with the Asian cell panel: Can we still do away with
Max Superspeciality Hospital, Delhi
Cross-matching patient's serum with the donor unit is still the foundation of compatibility testing in India. Yet, time and again, debates for doing away with cross-matching and implementing type and screen policy occur. We often conclude that if an indigenous cell panel representing our population is available, we might consider issuing blood units after type and screen.
Aim: In this study, we aimed at identifying irregular antibodies using an Asian cell panel and to compare the results of screening with cross-matching.
Materials and Methods: We analyzed the 1-year data (July 2012 to June 2013) for cross-matching and irregular antibody screening. A total of 4218 cross-matches were performed manually using Diamed gel cards. A total of 1415 antibody screens were performed using a three-cell Asian panel from DIAMED. All cases where screening was positive were subjected to antibody identification using a Diamed ID 11 cell panel and H/O pregnancy or transfusion was obtained. DCT was also performed on all positive samples. Antibodies if detected were categorized into allo-antibodies or autoantibodies. All cases where cross-match was incompatible but screening was compatible were also evaluated.
Results: Of the total 1415 patients screened, 20 (1.4%) patients had antibody screen positive. Of these 20 cases, antibodies were identified in 15 cases (4 - autoantibody and 12 - allo-antibodies). One patient had multiple allo-antibodies, i.e. Anti D and Anti C (?Anti G). In five other cases, the antibody could not be identified. The specificity of allo-antibodies were Anti Mi a-4, Anti D-3, Anti C-1, Anti E-1, Anti K-1, Anti M-1 and Anti N-1. Of the four autoantibodies, specificity could be determined for only one, i.e. Anti e.
Positive screens with incompatible cross-matches were seen only in five of the 20 cases. Two cases were associated with Anti M and Anti N (naturally occurring allo-antibodies). The other two incompatible cross-matches were associated with autoantibodies and in one case, antibody specificity could not be resolved. On the contrary negative antibody screens but incompatible cross-match were seen in three cases. In two of these cases, the unit cross-matched was DCT positive.
Conclusion: The frequency of allo-antibodies was 0.8%. The most common antibodies detected were antibodies of the Rh system (5 (41.6%)), Anti Mia (4 [33.33%]) followed by antibodies from the MNS system (2 (16.7%)) and Kell (1 (8.3%)). Anti Mia, although detected in four patients, did not pose any problem during cross-match. This indicates the need to have our donor population typed for the presence of Mia antigen and also to evaluate the use of having an Asian or indigenous cell panel.
Our experience of transfusion support of patients with AIHA: To transfuse or not?
Background: The red cell autoantibodies appearing as a pan-agglutinin in the serum makes it difficult for transfusion medicine personnel to provide transfusion support for patients with AIHA. Our major concerns in such patients are the presence of the underlying alloantibody that can cause hemolytic transfusion reaction, releasing the incompatible unit and convincing the physicians to accept such units. We have reviewed the laboratory profile and outcome of the patients with AIHA who have received the incompatible units for the management of anemia.
Materials and Methods: We have reviewed the data of AIHA patients who have received transfusions in the last 2 years. All the patients with AIHA requiring transfusion were approached according to a well-designed departmental protocol, which was in accordance with the accepted guidelines. Communication with the physicians has been done to obtain the history and to decide about the transfusion. Whenever there was a history of exposure to allogeneic red cells, further immunohematological (auto/allo-adsorption) work-up to rule out allo-antibodies was carried out. For patients with the coexisting allo-antibody, corresponding antigen-negative blood was transfused. Pre- and post-transfusion laboratory values suggestive of hemolysis (Hb, reticulocyte count, indirect bilirubin levels and lactate dehydrogenase) were noted and analyzed (paired t test) using SPSS software.
Results: A total of 28 patients with AIHA received 63 units of transfusion over the last 2 years. Seven patients had primary AIHA and the remaining had secondary AIHA (infections: 5, thalassemia: 2, lympho-proliferative diseases: 3, autoimmune diseases: 7 and miscellaneous: 4). Majority (68%) were female patients and 64% were above 25 years of age. In 66% of the patients, pre-transfusion hemoglobin level was less than 6 g/dL and in 25% of the patients, it was between 6 and 8 g/dL. Four patients had ABO discrepancy and were resolved accordingly. Coexisting allo-antibodies were present in two patients (anti E and anti c), and they were supported with an antigen-negative unit. All patients tolerated the transfusion of incompatible (best matched) unit very well, and no patient had immediate transfusion reaction. The average turnaround time taken was 4.5 h. There was a significant increment in the post-transfusion hemoglobin level (P = 0.000) and no significant change in the parameters suggestive of hemolysis were observed.
Discussion and Conclusion: Risks associated with transfusion in AIHA patients are greater but not transfusing is even greater than that in patients with severe anemia. Transfusion may be lifesaving in AIHA patients with reticulocytopenia and severe progressive anemia while awaiting response to the primary treatment. Our results support the opinion that the in vivo survival of incompatible blood is comparable to the patients' own cells once the allo-antibodies are ruled out in such patients.
Experiences of ABO-incompatible living donor liver transplantations in a tertiary care center in South India: Preliminary results of five consecutive cases
Amrita Institute of Medical Sciences, Cochin
Background: ABO-incompatible liver transplants are still controversial because of the high risk of antibody-mediated rejection due to pre-formed antibodies.
Aims: We aimed at monitoring ABO isoagglutinins in planning the transplantation and elimination of anti-donor ABO isoagglutinins to prevent acute rejection after transplantation.
Patients and Methods: Major ABO-incompatible liver transplant recipients in 1 year (2011-2012) were retrospectively reviewed at a single center in South India. ABO isoagglutinin levels were performed to assess the risk of antibody-mediated rejection (except in a patient with acute liver failure due to ZnP poisoning). The initial immunosuppression was induction therapy with anti-CD20 antibody (rituximab) and one to three sessions of plasma pheresis. Post-transplant immunosuppression consist of Methyl prednisolone, Mycophenolate mofetil and tacrolimus.
Results: Between 2011 and 2013, five incompatible transplants were performed (four males/one female). The mean recipient age was 43.8 years. Of the five cases, the indication in four patients was acute decompensation of chronic liver disease and in one patient was acute liver failure. All five patients had major incompatibility with the donor graft. Baseline isoagglutinin titers were high (≥64) for two patients whose blood group was O Rh D positive. Rituximab and plasmapheresis decreased the isoagglutinin titers in all except one patient. The patient and graft survival was 3 out of 5 (60%). The mean follow-up period was 14 months. Two patients (O blood group) died within 1.5 months of transplant: One due to graft failure because of antibody-mediated as well as cellular rejection and the other due to sepsis and multiorgan failure. None of the patients were re-transplanted. Acute rejection episodes occurred in three patients, and two patients were reversed by modifying the immunosuppressive doses. The pre-transplant titers well below 16 were found to have a better outcome.
Conclusion: Proper immunosupression protocol under careful monitoring and elimination of ABO-specific isoagglutinins is very important in ABO-incompatible liver transplants. Pre-transplant titers less than 1:16 predicts a better outcome in these patients.
Experiences with Luminex bead assay for HLA cross-match in living donor kidney transplants
Sridhar Kesireddy, Sudha Ranganathan, Shyamala Sesikeran
Apollo Hospitals, Hyderabad
Introduction: Human leukocyte antigen (HLA) cross-match of kidney recipients with kidney donors contribute to long-term allograft survival by decreasing the likelihood of chronic rejection. Although the complement-dependent microlymphocytotoxicity (CDC) test has been used for over four decades, more sensitive and specific assays like enzyme-linked immunosorbent assay (ELISA), flow cytometry and the donor-specific antibody (DSA) method on the Luminex are being practiced. This study is an attempt to compare the CDC method with the Luminex-based assay.
- To compare the CDC method with the Luminex-based assay for HLA class I and class II cross-match between the renal recipient and the renal donor
- To study the panel reactive antibodies for patients on the Luminex
Materials and Methods: The serum samples of 102 patients undergoing live related kindney transplants in the pre-renal transplant phase were cross-matched with the renal donor for HLA class I and class II by both the CDC assay and by the donor-specific antibody method on the Luminex (Gen Probe transplantation Diagnostics, USA). The patient samples were also investigated for the presence of panel-reactive antibodies (PRAs) on the Luminex. Of the 102 patients, 72 were male with a history of transfusions ranging from 0 to 4 ,with an average transfusion of two, and 30 were female patients with a history of pregnancies ranging from 0 to 4 and transfusions 0-6 with an average of three. The cut-off for the CDC method for the detection of complement-mediated lysis was set according to the guidelines set by the American Society of Histocompatibility and Immunogenetics (ASHI), where lysis >50 was considered positive for the Luminex assay and a micro fluorescence intensity of >1000 was considered positive.
Results: Of the 102 cross-matches, 86 patients (84%) had the same results on both the CDC and the Luminex. Fifteen patients (15%) showed a compatible cross-match by CDC and incompatibility by Luminex. The incompatibility on the Luminex correlated well with the presence of Class I/Class II HLA antibodies as shown by the PRA test on the Luminex. This is significant because the CDC detects only complement fixing antibodies whereas the Luminex detects both complement fixing and non-complement fixing antibodies that are clinically significant. One patient showed incompatible cross-match by the CDC method and compatible when performed on the Luminex. The incompatibility by the CDC method may be due to non-specific IgM antibodies. This was confirmed by performing a CDC - DTT (Dithiothreitol), which came negative and may not be clinically significant. This patient was transplanted with the donor kidney and did not have a hyperacute rejection. Of the 102 patients, 54 (52%) were positive and 48 (42%) were negative for panel reactive antibodies.
Conclusion: There was a correlation of the cross-matches done by the complement-dependant microlymphocytotoxicity and the Luminex in 84% of the cases. However, in 15% of the cases where the CDC was compatible and the Luminex was incompatible, patients showed the presence of panel reacting antibodies to both class I and class II HLA antigens. If transplanted with these kidneys, patients would have had an acute or a chronic rejection. Hence, the Luminex method seems to be more specific and sensitive than the CDC assay.
Evaluation of therapeutic efficiency of phlebotomy on symptomatic relief and hematocrit levels in post-renal transplant erythrocytosis
Sanjay Gandhi PGIMS, Lucknow
Introduction: Post renal transplant erythrocytosis (PTE) is defined as persistently elevated hemoglobin and hematocrit levels that occur following renal transplantation and persist for more than 6 months in the absence of thrombocytosis, leukocytosis or another potential cause of erythrocytosis; most agree that a persistently elevated level of hematocrit more than 51% suffices to define PTE (corresponding to a hemoglobin concentration of approximately 17 g/dl). A substantial number of patients with PTE experience malaise, headache, plethora, lethargy and dizziness. Thromboembolic events occur in 10-30% of the cases. When the hematocrit value exceeds 55%, therapeutic phlebotomy is required in order to prevent thromboembolic events and to give symptomatic relief to the patient. This study was conducted to evaluate the effect of therapeutic phlebotomy on hct levels and abatement of signs and symptoms of erythrocytosis.
Materials and Methods: This was a retrospective study conducted over a period of 1 year in the Department of Transfusion Medicine in a tertiary care hospital. Cases of renal transplant recipients who had developed PTE were included in the study. Their main complaints were redness in the eyes, facial erythema, blurring of vision and headache. Therapeutic procedure was planned at weekly schedule for 6 weeks as per the Standard Operating Procedure. As a routine practice for such patients, 350 ml of whole blood was withdrawn in each sitting and their vitals were monitored. Their relevant parameters were recorded both pre- and post-procedure. The medical therapy that the patients were receiving concomitantly was also taken into account.
Results: The study subjects were 12 males and two females with an age range between 26 and 60 years. Most of the recipients developed PTE within the first year of renal transplantation with an average of 11 months (range, 7-17 months). All patients were non-smokers. The immunosuppressive therapy prescribed was standard doses of cyclosporin, prednisolone and azathioprine. All patients were hypertensive and were treated with antihypertensive medicines. The mean hct level before any therapeutic phlebotomy was 56.56%, which was reduced to 45.3% after 6 weeks of initiation of treatment. Most of the symptoms such as redness in the eyes, facial erythema, blurring of vision and headache due to hyperviscosity were relieved after the initial two episodes of phlebotomy procedures. Two patients demonstrated symptoms of thromboembolism in the form of acute and severe pain in legs and shortness of breath even after repeated therapeutic phlebotomies.
Discussion: Post renal transplant, erythrocytosis usually occurs after 8-24 months post-transplantation. In our study, two patients developed PTE after 7 months of transplantation. High hct values and symptoms of hyperviscosity were the reasons of referral for phlebotomy procedure. Although these patients were prescribed medicines like Angiotensin receptor (ACE) inhibitors to decrease the hct value, however, the therapeutic phlebotomy procedure remains the mainstay of therapy when the patient is symptomatic and also to prevent thromboembolic events.
A study of serum ferritin levels among voluntary blood donors
Deepa Devi G, Arumugam P, Hamsavardhini S
The Tamil Nadu Dr. M. G. R. Medical University, Chennai
Introduction: The frequent blood donations may lead on to iron deficiency and iron deficiency anemia. Therefore, there are more chances that the regular donor will leave the donor pool after being deferred for low hemoglobin. Estimation of hemoglobin and hematocrit levels alone in voluntary blood donors may not be adequate; serum ferritin estimation is also needed to be performed to detect iron deficiency states.
Aims and Objectives: To estimate the serum ferritin level among voluntary blood donors with a different frequency of donation and compare with the hemoglobin levels.
Materials and Methods: This cross-sectional study consisted of 314 voluntary blood donors. They were grouped into control groups donating blood for the first time and groups donating blood once, twice and thrice in a year. The red cell parameters were measured by an automatic cell count analyzer and estimation of serum ferritin was performed by the enzyme-linked immunosorbent assay (ELISA) method.
- There were 88.2% males and 11.8% females.
- The distribution of donors on the basis of the frequency of donation per year - 50% first time, 23.9% once a year, 19.7% twice a year and 6.4% thrice a year donation.
- There was no statistically significant relationship between hemoglobin and other red cell parameters and frequency of donations and serum ferritin.
- A statistically significant correlation was seen between frequency of donation and total number of lifetime donations and serum ferritin levels.
- The mean ± standard deviation of serum ferritin in the first time donors were 47.5 ± 37.6 ng/ml and 18.4 ± 8.8 ng/ml in the male and female patients, respectively; in donors donating yearly once, the levels were 38.1 ± 27.2 ng/ml and 18.4 ± 11.1 ng/ml in male and female patients, respectively; in donors donating yearly twice, the values were 26.5 ± 17.4 ng/ml and 13.5 ± 4.9 ng/ml in male and females, respectively, and in donors donating yearly thrice, the value was 20.5 ± 16.7 ng/ml in the male donors.
- Distribution on the basis of number of donations per year and serum ferritin <15 ng/ml in male donors was 6.9% in first time,19.4% in once a year, 26.7% in twice a year and 50% in thrice a year donations.
- Among the female donors, 40.7% in first time, 50% in once a year and 50% in twice a year donation had serum ferritin levels <15 ng/ml.
Conclusion: In this study, there was a definite correlation between dwindling of serum ferritin level and the frequency of donation. The reason for the lack of correlation is decreased serum ferritin level a part of donor hemovigilance program. The study suggests estimation of serum ferritin level, iron supplementation and donor health education on balanced nutritious diet for at least female donors and regular male donors to maintain an adequate donor pool.
Antibodies missed by doing a red cell antibody screen only in the AHG phase: Are these clinically significant?
Aseem Kumar Tiwari
Medanta - the Medicity
Introduction: Patients may develop irregular red cell antibody (ies) from previous transfusion, pregnancy or sometimes even without such apparent stimulus. It is therefore important to perform a red cell antibody screen in patients to make blood transfusion safer. Such antibody is identified and the patient is provided a corresponding antigen-negative red cell component after anti-human globulin (AHG) cross-match. However, most centers including ours routinely perform an irregular antibody screen only in AHG phase with an assumption that all clinically significant antibodies will be detected in the AHG phase. To test this assumption, we carried out an irregular antibody screen at two other phases, i.e. room temperature and 37°C also in all patients who had tested negative for antibody screen at the AHG phase.
Materials and Methods: This study was conducted at the Department of Transfusion Medicine in a large tertiary care center in north India on 350 patient samples, which were negative for antibody screening in the AHG phase. The tests were performed after the patient had received blood transfusion following a standard-of-care protocol. This standard-of-care protocol was limited to blood grouping and antibody screen at AHG phase and cross-match for red cell components. All 350 samples were screened for red cell irregular antibodies by a commercially available three-cell panel (Surgiscreen, OCD) at two different temperatures, i.e. room temperature and 37°C, by the column agglutination technology in a reverse diluent card (without AHG). The samples that showed positivity in the antibody screen at either room temperature or 37°C were further run for identification using an 11-cell panel (Resolve Panel-A,OCD) at the same temperature on which they were found to be initially positive.
Results: Of the 350 consecutive patient samples tested, two samples (0.57%) showed positive reaction in a three-cell panel at room temperature only. The antibodies identified were anti-Leb and anti-M, respectively. Both the identified antibodies were clinically insignificant antibodies.
Discussion: The incidence of irregular antibodies detected at phases other than AHG is relatively small. Both the detected antibodies were clinically insignificant and harmless. Both patients were followed-up after blood transfusion for clinical and serological evidence of hemolysis, and had none. Therefore, the authors feel that adding an antibody screen at room temperature and 37°C would not add much to transfusion safety.
RBC antigen phenotype matching for red cell transfusions to thalassemia patients for prevention of alloimmunization: How much is enough?
Sanjay Gandhi Post Graduate Institute of Medical Sciences
Introduction: Provision of RBC antigen phenotype-matched blood beyond ABO and Rh D antigens is advocated in multiply transfused patients including thalassemics to prevent alloimmunization to other RBC antigens. The extent of matching varies from extended to limited phenotype matching depending on whether all or some clinically relevant RBC antigens are matched. It is a technically and logistically challenging task for transfusion services to provide such services and therefore there should be an attempt to differentiate between the relevant and the redundant. We conducted a study in our department to determine the feasibility of providing extended phenotype-matched blood from our daily stock to minor phenotyped thalassemia patients and to compare the different protocols of phenotype matching for their efficacy in our patient population.
Materials and Methods: Extended RBC antigen phenotypes for 12 major clinically significant blood group antigens, i.e. D, C, c, E, e, K, Jka//b, Fya/b and S/s were analyzed for 57 minor phenotyped thalassemia patients. These were used to determine the prevalence of these phenotypes in a single day inventory (n = 1000) based on the RBC antigen frequency reported from the same center donor population. Five different phenotype matching protocols were compared to determine which of the alloantibodies reported in 280 thalassemia patients at our center could have been prevented by the use of these protocols. Feasibility of providing blood for the best protocol from the daily inventory was calculated.
Results: In our patient population, the frequency of none of the extended RBC antigen phenotype profiles exceeded 3.5%. On the basis of the antigen frequency calculations, these phenotypes were calculated to be between 3% and 5% in our donor population. Hence, for providing two units for a single patient from the inventory, 50-100 units will have to be tested for all the 12 antigens. This demonstrates that it is next to impossible to do this unless we have a fully phenotyped donor directory from which donors can be dedicatedly assigned to patients. Twenty-eight alloantibodies were found in 24 patients. Five patients had autoantibodies, which included one patient who subsequently formed an alloantibody. Using Protocol 2, it will prevent alloimmunization in 83.35 of patients and matched blood availability will vary from 23.5% to 94% for the three most common Rh phenotypes in thalassemia patients. Offering limited phenotype matched blood only to patients once they have formed one alloantibody or autoantibody would further reduce the requirement to only 28 patients (10%) instead of all 280 patients.
Conclusion: Thus, this study shows that it is neither possible nor necessary to provide extended phenotyped blood to prevent alloimmunization to all thalassemia patients. Prophylactic matching using Protocols II and III would have prevented alloimmunization in 83.3% and 91.6% of the patients. To further economize the use of resources, matching can also be limited to patients who have formed at least one alloantibody or an autoantibody.
Alloimmunization and autoimmunization in transfusion-dependent thalassemia major patients: A study on 319 thalassemia major patients
Hair Krishan Dhawan
Background: Transfusion support is the mainstay of management in thalassemia major patients in India. The development of anti-red cell antibodies (both allo- and autoantibodies) remains a major problem in these patients. These antibodies complicate RBC cross-matching, shorten in vivo survival of transfused cells, delay provision of safe transfusions and may accelerate tissue iron loading. We studied the frequency of RBC alloimmunization and autoimmunization among thalassemia patients who received regular transfusions at our center and analyzed the factors that may be responsible for development of these antibodies.
Materials and Methods: The study was carried out on 319 multiply transfused patients with β-thalassemia major registered with the thalassemia clinic at the Advanced Pediatric Centre of Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Clinical and transfusion records of all patients were examined for age of patients, age at initiation of transfusion therapy, total number of blood units transfused, transfusion interval, status of splenectomy or other interventions. Alloantibody screening and identification was done using three-cell and 11-cell panels (Diapanel, Bio-rad, Switzerland), respectively. Autoantibodies were detected by incubating patient's own cell with patient's plasma on a gel card containing polyspecific antihuman globulin (anti IgG + C3d).
Results: The study included a total of 319 (235 male and 84 female) thalassemia major patients. The age of the patients ranged from 1.5 to 27 years, with a mean age of 15.18 years. Eighteen patients of a total of 319 patients (5.64%) developed alloantibodies and 90 patients (28.2%) developed autoantibodies. Nine of 18 patients with alloantibodies also have autoantibodies. Age at first transfusion was significantly higher in alloimmunized than non-immunized patients (P = 0.042). The total transfusions received by patients were not correlated with development of alloantibodies, but a higher number of transfusions was significantly associated with the development of autoantibodies (P = 0.01). Of the 23 alloantibodies, 52.17% belonged to the Rh blood group system (Anti-E = 17.39%, Anti-D = 13.04%, Anti-C = 13.04%, Anti-Cw = 8.6%), 30.43% belonged to the Kell blood group system, 8.6% belonged to the Kidd system and 4.3% belonged to the Xg blood group system. Fourteen patients (77.77%) developed a single antibody while four patients (22.22%) developed dual alloantibodies. Most of the autoantibodies showed a 1+ reaction on the gel card and did not interfere with compatibility testing.
Conclusion: Alloimmunization was detected in 5.64% of the multitransfused thalassemia patients. Rh and Kell blood group system antibodies accounted for more than 80% of the alloantibodies. This study re-emphasizes the need for RBC antigen typing before the first transfusion and the issue of antigen-matched blood (at least for Rh and Kell antigens). Early institution of transfusion therapy after diagnosis is another means of decreasing alloimmunization. Alloimmunization leads to increased difficulty in finding cross-match-compatible units and predisposes the patients to a risk of delayed hemolytic transfusion reactions.
Prevalence of platelet-reactive antibodies in patients refractory to platelet transfusions
Introduction: Although platelet transfusions have greatly reduced the incidence of major hemorrhagic complications associated with the management of hematological and oncological disorders, refractoriness to infused platelets becomes a major clinical problem for many of these patients.
Materials and Methods: The present study was performed to determine the percentage of platelet alloimmunization due to platelet-reactive antibodies in 340 patients with hematologic or oncologic diseases who had received multiple transfusions (>10) of blood and blood components and showed platelet refractoriness in the 1-h post-transfusion sample.
Results: Platelet-reactive antibodies were detected in the sera of 127 of 340 patients (37.35%) who received multiple transfusions (>10) and showed platelet refractoriness. Platelet-reactive antibodies appear to be an important cause of platelet refractoriness in patients of acute leukemia, aplastic anemia, NHL, MDS and multiple myeloma receiving multiple platelet transfusions. Platelet refractoriness in patients of ITP and chronic leukemia appears to be due to other causes and not due to platelet-reactive antibodies.
Conclusion: Most of the centers in India are still providing ABO- and HLA-unmatched, non-leukoreduced platelets to the patients. This is high time that this strategy of testing for platelet antibodies and providing cross-matched platelets be started at centers across the country.
Phenotypic frequencies of Rh, Kell, MNSs, Duffy and Kidd system antigens in blood donors: First report from Western India
Sonani R Gajjar, Bhatnagar NM, Patel TR,
Gupta S, Prajapti,
Civil Hospital, Ahmedabad
Background: In India, ABO grouping and Rh D typing are performed on all donor units as per regulatory requirements. Very few centers have adopted partial phenotype-matched (i.e., D, C, E, c, e and K matched) red cells to chronic transfusion-dependent patient populations, and only two studies on minor blood group system antigen phenotypes and frequencies have been reported in North Indian donors till date. Below, here is the first report of extended phenotyping of red cell antigens from Western India.
Aims and Objectives: To perform red cell phenotyping of the antigens of the minor blood group systems and calculate antigen frequency and imply this knowledge in improving transfusion practices.
Materials and Methods:
- Two hundred repeat voluntary, blood group O donors, either RhD positive/negative, were randomly selected from the nearby areas of the transfusion services after taking written consent.
- All the donor samples were typed for Rh antigens (D, C, E, c and e), antigens of the MNS system (M, N, S and s), Kell system (K and k), Kidd system (Jka and Jkb) and Duffy system (Fya and Fyb) using commercial anti-sera (DiaMed test sera, DiaMed, Switzerland) in a tube method along with known positive and negative controls (DiaCell, DiaMed) during each test.
- Of the 200 donors, 32 (16%) were RhD negative and 168 (84%) were RhD positive.
- Among the RhD-negative donors, rr (90.62%) was the most common presumed phenotype whereas in the RhD-positive donors, the common presumed phenotypes were R1r (44.04%), R1R1 (29.76%) and R1R2 (16.07%).
- The antigen frequency of C, c, E and e was found to be 76%, 73%, 19.5% and 97%, respectively.
- The antigen frequency of M, N, S, s, K, k, Jka, Jkb, Fya and Fyb was 83.5%, 72.5%, 13.5%, 89.5%, 5.5%, 100%, 93.5%, 33%, 56% and 49.5%, respectively. No Fy(a-b-) or Jk(a-b-) phenotype was observed.
- Remarkable differences were observed in many of phenotypes of the Duffy, Kidd and MNS blood group systems with two earlier studies, which imply that similar studies from other parts of the country will also be useful to look for regional differences in antigen phenotype frequencies.
- When clinically significant antibodies were encountered in recipients, this database was used more than 30-times to provide the corresponding antigen-negative red cells.
- The donor phenotyping results have been successfully used in 12 patients with autoimmune hemolytic anemia with a recent history of blood transfusion for allo-adsorption to look for the underlying alloantibodies.
- A screening cell panel for detecting the presence of red cell antibodies can be prepared from the phenotype data of the donors.
- No rare phenotype was observed in any of these donors and the tube technique was found to be cumbersome for red cell antigen typing. Hence, automated methods of red cell antigen phenotyping on a larger number of donors are desirable to search for and create a rare donor registry.
Analytical review of 80 cases of therapeutic plasma exchange in a tertiary care center with emphasis on technical and operative details
Nizams Institute of Medical Sciences, Hyderabad
Introduction: Plasma exchange (PE) is a well-established extracorporeal therapeutic procedure commonly used in many neurological, hematological and connective tissue disorders of autoimmune etiology. PE is a procedure in which the plasma is separated from the blood, discarded in total and replaced with a substitution fluid such as albumin or with donated plasma from a healthy person. Even though the procedure is in practice since four decades, there is lack of evidence-based data in the literature. There are different types of practices of therapeutic aphaeresis.
Aim: To analyze retrospectively all the therapeutic plasma exchange procedures performed in our institute, emphasizing the changes in the technical and operative aspects occurring during the period 2008-2013 till date.
Materials and Methods: We have evaluated 80 patients who underwent therapeutic plasma exchange therapy from September 2008 to 2013 till date. The following points are considered for evaluation: Indication for the procedure, patient preparation, vascular access, intravenous fluids pre- ,post- and during the procedure, type of equipment and calculation of total plasma to be removed in each cycle. We have also reviewed the extracorporeal blood volume, plasma volume collected, replacement fluids, total duration of therapeutic plasma exchange, interval between each cycle, other medication and clinical outcome.
Results: We reviewed the medical records of 80 patients who had been consecutively treated by therapeutic plasma exchange between September 2008 and April 2013. Mainly, neurological indications included Myasthenia gravis (MG, 31 patients), Guillain - Barre syndrome (32 patients) and miscellaneous diseases (17 patients). The median therapeutic plasma exchange session number was 5, with a range of 1-8; the total number of therapeutic plasma exchange procedures in all cases was 484. All MG patients improved with therapeutic plasma exchange during their hospitalization time. Therapeutic plasma exchange was not effective in the treatment of the patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and two patients post-thymectomy MG. During the therapeutic plasma exchange procedures, four patients had hypotension. One patient had arrhythmia and succumbed to death post-procedure. Ten patients had citrate toxicity treated by calcium gluconate. The procedure was uneventful in patients with diabetes, pregnancy and the elderly age group and one pediatric patient (NMO). A central venous catheter was used in 35 patients. Replacement fluids used were 5% albumin, FFP and colloid solutions. Plasma volume (1500-3000 ml) targeted for removal was calculated on the basis of weight (35-80 kg) and hematocrit of the patient. Both small volume and large volume procedures were carried out.
Conclusion: Technical advancement improved the patient tolerability to the procedure. Hemodynamic status and good vascular access helped in removing the target plasma volume. Therapeutic plasma exchange is associated with less adverse reactions and expected clinical outcome in established conditions. Key words: plasmapheresis, Guillian - Barre syndrome, Myasthenia gravis, etc.
Transfusion support to bone marrow transplant: An experience from a tertiary cancer center
Ojha S, Nagaraju P, Kamble M, Rajadhyaksha SB
Tata Memorial Center, Advanced Center for Treatment for Research and Education in Cancer (ACTREC), Kharghar, Navi Mumbai
Introduction: A blood bank has traditionally been viewed as a support department in the management of patients. However, with the separate Department of Transfusion Medicine (DTM), the role has changed. The Tata Memorial Center is the leading center in India for bone marrow transplant (BMT) to treat hematological malignancies. DTM is actively involved in the collection, processing, cryopreservation, storage and issue of stem cells. The aim of this study is to highlight the same.
Materials and Methods: All the pre-mobilized patients/human leukocyte antigen-matched donors are counseled regarding the procedure of stem cell harvest. After adequate mobilization, the donor/patient are taken for stem cell harvest by leukapheresis. Each leukapheresis on an average is performed for 4 h and the patient/donor blood volume is processed approximately three times. Based on flow cytometric CD34 evaluation of the stem cell product and patients requirement, a decision for further harvest is taken. All allogeneic stem cell products are stored at 4°C and infused on the same day or on the next day. All autologous products are aliquoted and cryopreserved with 15-20% DMSO in a −80°c mechanical freezer. Each aliquoted product is stored in specially designed and labeled cassettes. Location of the cassettes with all details is maintained in a separate inventory register. Before issuing, the viability of the stem cell product is assessed by trypan blue vital dye and the sample is sent for microbial testing. All single-donor platelets (SDPs) and packed red blood cells (PRBCs) are leukodepleted and gamma irradiated and microbial screening is done by an enhanced bacterial detection system (eBDS). The transfusion protocol followed is per the AABB criteria.
Results: From October 2007 to 13 June 2013, we have performed a total of 497 harvests. Of the total, peripheral blood stem cell (PBSC) harvests were 94% (n = 467 for 289 patients/donor) and bone marrow harvests were 6% (n = 30). Of the total 289 PBSC subjects, the autologous subjects were 60.55% (n = 175) and the remaining 39.45% subjects (n = 114) were allogeneic. Three hundred and eleven PBSC sessions were performed for 175 autologous patients and 156 sessions were performed for 114 allogeneic donors to obtain the target dose CD34 viable cells/kg of the recipient. Of the total harvest, 353 cryopreserved harvests autologous were 332, and 21 were allogeneic. The incidence of microbial contamination in the PBSC product was 9.8% in 33 PBSC harvests for 25 patients. The average per patient transfusion was two PRBCs and four SDPs for the autologous transplant cases and three PRBCs and six SDPs for the allogeneic transplant cases. All units were leukodepleted, gamma irradiated and microbially tested.
Discussion: To be a part of the active transplant program, a robust infrastructure along with a qualified and trained team is needed. Because of the active participation of our department in this program, an overwhelming majority of BMT is through PBSC harvest by leukapheresis. Not only is our department involved in collection but also in quality control, cryopreservation and storage of stem cells through a properly maintained inventory. Simultaneously, we are ensuring the special transfusion need in BMT patients of leukodepleted, gamma irradiated and microbially screened blood components. In a nutshell, DTM has now become a critical part of the BMT unit and is contributing tremendously in successful running and patient management.
Solving blood group discrepancies: The role of molecular genotyping
Soonam J, Amalraj P, Chacko MP, Daniel D
Christian Medical College, Vellore
Background: Blood group discrepancies exist when reactions in forward grouping do not match reactions in reverse grouping, when the expected reactions are negative or weak or if the previous and current blood grouping results do not match. Discrepancies may be caused by intrinsic problems with the tested red cells/serum or by technical errors. If transfusion is necessary before resolving such discrepancies, the patient should be given O red cells and AB plasma in the case of ABO discrepancies and, ideally, Rh(D)-negative red cells in the case of Rh typing discrepancies, which can put a strain on these blood groups, particularly with reference to Rh-negative blood and AB plasma. In this context, molecular testing offers a platform for grouping with high accuracy. Technologies in use include polymerase chain reaction (PCR) with sequence-specific probes (SSPs), sequence-specific oligonucleotide probes (SSOPs) and microarray. This study assesses the utility of molecular typing in resolving blood group discrepancies in the blood bank of a tertiary referral center.
Materials and Methods: In our blood bank, blood grouping is routinely performed independently by two technicians on two different automated platforms, viz. the microtiter plate and the column agglutination technique (CAT). In case of a discrepancy, a new sample is requested and the tests are repeated using a manual tube method in addition to the microtiter and the CAT methods. Antisera from different manufacturers, and lectins where indicated, are used. Persistent discrepancies are processed for molecular typing using the PCR-SSP technique.
Results: In the study period from January 2012 to April 2013, there were 21 blood group discrepancies, of which 14 (66.7%) were ABO discrepancies and seven (33.3%) were Rh discrepancies. Twelve of the 21 discrepancies (57.2%) were resolved using multiple platforms and lectins. Nine cases (42.8%) were subjected to molecular typing. Six of the nine cases (66.7%) were ABO discrepancies while the remaining three cases (33.3%) were Rh discrepancies. Eight of the nine cases (88%) were resolved by molecular typing; however, one case of ABO discrepancy could not be resolved.
Conclusion: Performing molecular genotyping resolved 88% of the discrepant cases, thereby reducing the percentage of unresolved blood groups from 42.8% (when serological methods alone are used) to 4.8%. Therefore, we conclude that molecular typing provides a valuable addition to the resources that can be of use in the scenario of blood grouping discrepancies.
Blood inventory management in a tertiary care hospital
Ravneet Kaur, Kshitija Mittal, Tanvi Sood, Gagandeep Kaur, Vinay Kumar, Gurpreet Singh
Medical College and Hospital, Chandigarh
The ideal blood inventory levels are those that provide adequate supplies of blood and blood components for routine and emergency situations with minimum wastage and outdating. We present our experience with blood inventory management over the last 1.5 years. A total of 19,179 blood units were collected at the Government Medical College and Hospital, Chandigarh, between January 2012 and May 2013. During the first 6 months of the study period, the highest collection of 1082 units was observed in the month of March 2012. As a result of this, outdating of approximately 15 blood units was seen in the month of April 2012. Subsequently, the following strategies were adopted for management of stocks. During excess stocks
- Segregating the blood inventory into two parts (1-15 days of collection and 16-35 days of collection).
- Cross-matching units of Days 16-35 collection for clinical conditions where blood is likely to be issued (trauma patients, patients on chemotherapy, upper gastrointestinal bleed, antepartum hemorrhage and post-partum hemorrhage patients).
- Blood units of 1-15 days of collection were cross-matched for patients where it is less likely to be issued (cholecystectomy, prostatectomy, uncomplicated pregnancy, etc.).
- Reducing the holding period of blood units in blood bank from 72 h to 24 h.
- Strictly following a first-in, first-out issue policy. During low stocks
- Preparing and regular updating of the donor's list (along with blood group) to be contacted whenever the stock of a particular group falls.
- Motivating the replacement donors to donate blood voluntarily after 3 months.
- Retention of regular voluntary blood donors by sending them birthday greetings and honoring them on special occasions.
In September and October 2012, because of the dengue epidemic in the region, 1217 and 1508 blood units were collected, respectively. Following the above strategies, only two blood units outdated. At present, neither any blood unit is wasted due to outdating nor is any patient refused blood due to non-availability. Maintaining consistent inventory levels is tedious and complex. However, adequate inventory levels can be managed by taking these simple measures.
A prospective study for the quantification of cytokines and growth factors from blood and assessment of the role in non-healing cutaneous ulcers
Roopam Jain, Preeti Jain, S Sharma, Naina Srivastava, Shivanshu Srivastava VK Mahadik
R D Gardi Medical College, Ujjain, MP
Background: It is widely accepted that growth factors (GFs) and cytokines play a central role in the healing process and tissue regeneration. A recent strategy to promote the wound-healing cascade is to prepare an autologous growth factor and cytokine-rich concentrate that contains growth factors and administer it to the wound sites. As we have learned, platelets also release many bioactive proteins responsible for attracting macrophages, mesenchymal stem cells and osteoblasts, which not only promote removal of necrotic tissue but also enhance tissue regeneration and healing. Although non-healing cutaneous wounds represent a challenging problem, this concentrate can affect inflammation, post-operative blood loss, infection, narcotic requirements, osteogenesis, wounds and soft tissue healing.
- To access the role of GFs and cytokines in the healing process and tissue regeneration.
- To access the role of GFs and cytokines in early wound closure and epitheliazation.
- To access the role of GFs and cytokines in decreased pain, lower blood loss and fewer narcotic requirements.
- Quantification of platelet and GFs by advanced bead-based multiplexing technologies in terms of sensitivity and reproducibility of the results.
Materials and Methods: About 60 ml of whole blood is drawn into the syringe in CPD with an aseptic technique from the anticubital vein. The blood is then separated into 10 ml cytoine and GF-rich concentrate after buffering and activation. Quantification of the platelet and PDGF, TGF-(β), VEGF, EGF, and IGF-1 measurements from WB and concentrate by advanced bead-based multiplexing technologies. The GFs applied on the non-healing cutaneous ulcers and the effects have been studied.
Results: Results from this study demonstrate that platelets can be sequestered and concentrated eight-fold from whole blood without activating the platelets before desired. To understand the better sensitivity/reproducibility of the results, we cross-checked our samples in a fully automated multiplex enzyme-linked immunosorbent assay (ELISA). Complete blood count analysis was performed on WB and concentrate samples from each study participant. The concentrate group was significantly higher in platelet number than the baseline WB group, with a value of P <0.001.The PDGF, TGF-(β), VEGF and EGF cytokines were all significantly greater in the concentrated samples than in the WB baseline samples by both methods. The increase was calculated per patient for both platelet number and GF levels. The greatest increase is seen with VEGF (8.1-fold increase), followed by PDGF (6.1-fold increase) and EGF and TGF-(β) (3.8- and 3.6-fold, respectively) by advanced bead-based multiplexing ELISA.
Conclusion: In conclusion, a variety of potentially therapeutic GFs such as PDGF-BB, TGF-(β), VEGF and EGF are released from the platelets in significant levels in the concentrate. The PDGF, TGF-(β), VEGF and EGF cytokines were all significantly greater in the concentrate samples. It is concluded that the concentration of GFs also increased with an increasing platelet number. These GFs and cytokines are capable of decreasing inflammation, post-operative blood loss, infection and narcotic requirements and play a central role in the healing process and tissue regeneration.
Preparation and validation of an in-house reagent red cell antibody screening panel (IHASP): A cost-effective and highly sensitive method for antibody screening
Introduction: In India, for the purpose of antibody screening, most of the blood banks are using commercially available antibody screening reagent red cell panels (CRASPs) consisting of two or three individual group O cells. Instead of the availability of the expertise, the short shelf-life of the imported reagent red cell panels and logistics involved does not allow most of the blood banks to perform antibody screening. This study was conducted with the aim to prepare an in-house reagent red cell antibody screening panel (IHASP) and validate it for routine use in blood banking.
Materials and Methods: Written consent was obtained from all the three donors in the rare donor registry to participate in the study. The Standard Operating Procedure of the department and the manufacturers' instructions were followed. Reagent red cell panels were selected with the aim to express the antigens associated with the most commonly encountered antibodies (D,C E, c, e, K, k, Jka, Jkb, Fya, Fyb, M, N, S, s, P, Lea, Leb). We also made an attempt to demonstrate the dosage effect (Rh, Duffy, MNS and Kidd). These donors were tested for viral markers (human immunodeficiency virus [HIV] I/II, hepatitis B virus [HBV], hepatitis C virus [HCV]) with the enhanced chemiluminescence method and the ID-NAT method. DAT, antibody screening and blood group was repeated. For the preparation of the panel cells, 15 ml of the sample was taken from each individual with a unique identification number in five ethylene diammine tetraacetic acid vials (3 ml in each vial) and the samples were washed thoroughly for six times with 0.9% normal saline (2500 rpm × 3 min). Three percent to 5% of the red cell suspension of washed red cells was prepared in a red cell preservative solution, ERYWELL (Tulip diagnostics, India). For the purpose of validation of IHASP, two positive (anti-Fya and anti-D) and two negative controls were used(PC/NC). PC and NC were the antibody screen positive/negative sample tested with two different lots of commercially available gold standard reagent red cell panels (Surgiscreen, OCD and JnJ). The initial titer of anti-D with CRASP and IHASP was 16, while that for anti-Fya was 8. Further double dilution was performed of the PC samples till 32 (one dilution above the initial titer) to define the limit of detection. The doubly diluted samples were tested on Day 0 and Day 56 to further augment the suitability of its use. To define the shelf-life of the same, PC and NC were tested every week till Day 56 by considering the first day of the test as Day 0 (8 weeks) in parallel with CRASP. Performance evaluation of IHASP was carried out using statistical parameters. To avoid the repeated freezing and thawing, the controls and doubly diluted samples were aliquoted on the day of the preparation and stored at −80°C. Tests were performed only at 37°C and in the IAT phase using polyspecific AHG cards (Autovue Innova, OCD, JnJ, USA).
Results: Among the 300 donors in the voluntary rare donor register, we could find three most appropriate donors for the purpose of making an IHASP. An antigram of the IHASP is shown in [Figure 1]. The PC and NC demonstrated consistent results till Day 56 with IHASP, while CRASP could demonstrate its result till Day 42 only.
Serial assessment of biochemical changes in irradiated red blood cells
Patidar G, Joshi A, Marwaha N, Dhavan HK, Sharma RR, Prasad R
Background: Transfusion-associated graft versus. host disease (TA-GVHD) is a delayed effect of blood component therapy with a very high mortality rate. The use of irradiated blood components is the only proven method to prevent TA-GVHD in susceptible patients.
Aim: Our study was designed to analyze the quality of irradiated packed red blood cells (PRBCs) in terms of their biochemical parameters during a storage period up to 28 days post-irradiation.
Materials and Methods: A total of 80 PRBC units were analyzed, 40 units each stored in CPDA-1 and additive solution-SAGM. The units were evaluated for biochemical parameters like plasma/supernatant potassium, sodium, pH, glucose, lactate, plasma/supernatant hemoglobin and red cell ATP. We further evaluated the differences in these parameters between units irradiated on Day 1 and Day 7 of storage, and stored these units for 28 days and 35 days, respectively. Ten units in each group were used as the control. The assessment was performed at weekly intervals from the day of irradiation.
Results: Within each group of red cells, there was a rise in the mean concentration of plasma potassium (K+) from Day 1 to the last day of storage. There was a highly significant difference (P < 0.01) between the irradiated and control units after the first week of storage in both types of PRBCs. Irradiated CPDA-1 PRBC have significantly higher K+ than irradiated SAGM-PRBC. Plasma hemoglobin was significantly higher in irradiated SAGM-PRBC as compared with the control units. Intergroup comparison revealed significantly higher (P < 0.05) mean hemoglobin in the irradiated CPDA-1 PRBC as compared with SAGM-PRBC. The mean pH was significantly higher (P < 0.05) in irradiated CPDA-1 PRBC as compared with irradiated SAGM-PRBC only on Day 7 of storage. ATP levels significantly decreased in irradiated units as compared with the control units. SAGM-PRBCs had significantly higher (P < 0.05) mean ATP concentration than CPDA-1 PRBCs.
Conclusion: Our study demonstrates that SAGM-PRBCs show better stability after irradiation compared with CPDA-1 PRBCs. The limits of safety for CPDA-1 PRBCs appear to be 2 weeks after irradiation. SAGM-PRBCs on the other hand show acceptable limits of safety up to 3 weeks of irradiation. Thus, units can be irradiated and stored in a blood bank provided the shelf-life of the irradiated units is limited to this period.
Knowledge, attitude and practice of transfusion medicine among resident doctors: A survey-based study
Armed Forces Medical College, Pune
Introduction: Transfusion medicine (TM) has been recognized as a basic specialty. However, in the undergraduate curriculum, not much emphasis is given on training in TM. Clinician's knowledge about blood products and their preparation, storage, demands, doses, administration and knowledge of immunohematology may have a profound impact on patient care and transfusion outcomes. Variations from the standard in practices may result in poor patient care and jeopardize their safety as well. This problem can be addressed by imparting transfusion medicine education to resident doctors in their residency period who have an active role in decision making. No data exists in our country to assess the awareness and TM education needs for resident doctors and clinicians. The aim of this study was to assess the essential knowledge of TM in resident doctors and to explore the methods to improve their knowledge of the subject in order to have a better connect between clinicians and TM.
Materials and Methods: A descriptive cross-sectional study using a self-administered anonymous survey was conducted in this large teaching hospital. A questionnaire comprising of 45 items and a feedback was developed to assess the essential knowledge of TM. Resident doctors from those clinical specialties that are involved in frequent bedside blood transfusions were included in the study. The questionnaire covered the essential areas that are relevant to the practice of blood transfusion. Questions were in multiple answer type formats, and each question included an option of "I don't know" to minimize guessing. Participation was voluntary.
Results: A total of 80 residents from different specialties participated in the study. Variable response to different aspects of the questionnaire was received. The overall mean score for correct response was 46.6%. Among the various specialties, none of the groups showed significant differences over the other. Lowest knowledge was found for tests and procedures carried out in the blood bank. A low knowledge score was also noted in the preparation of special products, their carriage to wards, handling in wards, storage lesions, immunogenic hazards of transfusion and their significance. A good score were observed in blood administration and management of transfusion reactions. The majority of participants (97%) believed that extra training in TM education was required at their level.
Conclusions: Appropriate use of blood products impacts clinical outcome and financial resources. Our study shows that majority of the resident doctors have a bare essential knowledge of transfusion medicine, which is comparable with the other international studies. However, there are weak areas where more emphasis is required to improve the patient safety, like demand for the special products, its preparation and immuno-hematological tests and their indications and the important immunogenic and non immunogenic hazards of TM. It is recommended that mandatory 2 weeks training for all residents who are involved in direct blood transfusions, should be organized in the Department of Transfusion Medicine. These measures will definitely connect our clinician to TM better, and ultimately result in improved patient care.
New methodology to recruit and retain replacement donors as repeat voluntary blood donors
All India Institute of Medical Sciences, New Delhi
It has been proven through various studies on national and international levels that voluntary non-remunerated donors are far more superior to replacement/family donors. When we compared the reactivity rate of all replacement donors with all voluntary donors, it was just a notch higher in replacement donors, but incidentally when we compared the data between replacement and "First time voluntary donors," the reactivity was higher in voluntary donors to our dismay and surprise. This phenomenon, although not unseen, is a rare occurrence and could be attributed to the following:
- Most of camp organizers like corporate industries/banks, etc. are keener on exhibiting their social responsibilities, rather than actually following it.
- Employees/junior staff are under pressure to donate blood and be on good terms with the employer and therefore there are more chances of them concealing any high-risk history or behavior.
- Some in-house voluntary donations were made by high-risk donors only to check their reactivity status by a highly sensitive test like the NAT.
This led us to the very fact that it is not only the voluntary but also the REPEAT voluntary donors that are key to a safe and effective blood transfusion services (BTS). We scrutinized our policy and redirected our resources to increase repeat voluntary donation by retention of non-reactive replacement donors by adopting measures like:
- The blood donors coming for donations at the blood bank are told about the various benefits of regular blood donation by our efficient social workers, counselors, nursing staff and doctors.
- All non-reactive blood donors are contacted through phone/e-mails to thank them for their noble gesture and are reminded to be our repeat voluntary donors.
- On their second blood donation visit at our blood bank, donors are provided with
- A personalized gift with their picture on it (photo mug, key chains, etc.)
- Assurance of assistance by the blood bank for an appointment by clinicians of our hospital in case the need arises for the donors and their immediate family members
- Assurance to the donors that blood will always be made available, in case need arises, for the donors and their immediate family members.
- All voluntary blood donors donating more than five times at our blood bank are felicitated at a function on the blood donor day.
These endeavors have helped us in many ways in the last 1 year:
- Increase in our donor base and reducing transfusion-transmissible infection reactivity at our center.
- We reduced the number of our camps outside Delhi. Many of the times, these outside camps resulted in wastage of blood due to hemolysis and also resources and manpower.
- The resources saved were used for the betterment of blood bank processes and also for organizing various educative seminars/Continuing Medical Education programs for spreading awareness.
- These donors were also motivated to register as platelet apheresis donors in case of any emergency platelet needs.
Thus, we conclude that recruitment and retention of replacement donors as voluntary donors can be an effective and fruitful exercise to increase the confidence of the donors and general public in the blood transfusion services.
Evaluation of endocrine adaptation response to stress during the blood donation procedure associated with adverse donor reactions
Solanki A, Agarwal P
Sanjay Gandhi Post Graduate Institute of Medical Sciences
Background: Blood donor reactions and injuries are transient and self-limited events. Emotions, pain or stress directly affect the brain (hypothalamus) leading to vasovagal attack. Cortisol is a hormone classically involved in stress responses. Hence, changes in the serum cortisol levels are expected in blood donors as an endocrine adaptation response to stress during the blood donation procedure.
Aim: To study the changes in serum cortisol levels for evaluation of endocrine adaptation response to stress during the blood donation procedure associated with adverse donor reactions.
Materials and Methods: A total of 600 whole blood donors were taken into consideration. Of these, 100 donors each were assigned to six different categories (50 in each subgroup of each category), viz. voluntary and replacement donors, first time donors with and without reactions, repeat donors with and without reactions, donors with adequate and inadequate sleep, donors with waiting period more or less than 30 min and unrelated and related donors.
Results: The mean cortisol levels in replacement and voluntary donors were 380.76 ± 112.16 nmol/l and 302.79 ± 125.29 nmol/l, respectively. In the second category, the mean cortisol level of first time donors with reaction was 529.10 ± 113.95 nmol/l in comparison with first time donors without reaction (208.20 ± 68.27 nmol/l). In the third category, the mean cortisol levels of repeat donors with reaction and repeat donors with no reaction were 253.89 ± 75.78 nmol/l and 210.71 ± 62.63 nmol/l, respectively. The fourth group consisted of donors with adequate and inadequate sleep, and the cortisol levels were 184.58 ± 55.84 nmol/l and 399.12 ± 142.07 nmol/l, respectively. In the fifth group, the mean cortisol levels in donors with waiting period less than 30 min was 215.76 ± 74.96 nmol/l in comparison with donors with a waiting period of more than 30 min, 399.52 ± 74.96 nmol/l. In the above five categories, differences in mean cortisol levels were statistically significant (P-value < 0.05). In the last group, the mean cortisol level of the related with unrelated donors was compared (313.64 ± 127.7 nmol/l vs. 289.54 ± 104.82 nmol/l), and the difference was not statistically significant (P-value > 0.05).
Conclusions: A significant difference in the mean serum cortisol levels was found in five of six categories. However, blood donation per se is not a stressful event and that moderate stress, as suggested by the increase in cortisol levels, is secondary to emotional rather than physical factors and occurs during a never experienced before event.
Assessment of pattern and effectiveness of neonatal transfusion
Government Medical College and Hospital, Chandigarh
Background: The small blood volume and immature organ system of neonates requires special approaches in neonatal transfusion practices. Although physiologic anemia of infancy is self-limited, anemia due to repeated phlebotomy, sepsis, on-going bleeding, etc. requires transfusion of blood/blood components. Although neonatal transfusion guidelines exist, many issues pertaining to transfusion triggers, dosage and clinical outcomes still remain debatable. Hence, this study was conducted to get an insight into the laboratory parameters and clinical outcomes in neonatal transfusion practice.
- To evaluate the incidence of blood product use and donor exposure among neonates admitted in the Neonatal Intensive Care Unit (NICU).
- To evaluate the efficacy of blood product transfusion in resolving the indication of blood transfusion.
Materials and Methods: We conducted a prospective cohort study over a period of 18 months in the NICU, Government Medical College and Hospital, by recruiting neonates of gestational age ≥26 weeks, birth weight >700 g and duration of stay in NICU >6 h. Neonates with major congenital malformations were excluded. The subjects requiring blood product transfusion were followed-up in a blood bank for lab parameters and clinical parameters, and outcome was noted from the case file. Blood component transfusion was assessed by product type, indication, product details, serum bilirubin, hematocrit, donor exposure, platelet count and PT/INR. Clinical parameters are assessed by main indication for admission to NICU, morbidities, duration of stay, adverse reaction to transfusion and final outcome. Packed red blood cell (PRBC) transfusion affecting clinical parameters was assessed by pre- and post-transfusion parameters, viz. respiratory support, FiO 2 , lactate levels, base excess, weight gain, feed intolerance, inotropic support, respiratory distress, tachycardia, hemoglobin concentration and packed cell volume. Platelet and FFP transfusions were assessed by presence or absence of bleeding and site of bleeding.
Result: Over this period, 232 newborns were admitted in the NICU. Of these, 61 newborns received blood product transfusion (15 received PRBC transfusion, 28 received platelet transfusion, four received FFP transfusion, four received PRBC and platelet transfusion, six received platelet and FFP transfusion, one received PRBC and FFP and one received all three components). The average number of donor exposures per patient was 1.5. Increment in lab parameters was seen in all newborns except three newborns. These results varied due to the presence of sepsis, ongoing thrombocytopenia and bleed. It was also found that the effect on clinical parameters like weight gain, respiratory support, etc. was not significant.
Conclusion: We did not find any clinical benefits of PRBC transfusion, such as improved weight gain, improved apnea or ventilation/oxygen needs (FiO 2 ).
Neonatal platelet transfusions: Where do we stand?
Aaditya Shivhare, Sudha S Bhat, Shamee Shastry, Mohandoss M
Kasturba Medical College, Manipal, Manipal University
Background: Low platelet counts are often found among sick neonates, especially among preterms, and prophylactic platelet transfusions are given mainly to prevent intraventricular hemorrhage. Formulating guidelines specific for platelet transfusion in newborns will improve Neonatal Intensive Care Unit (NICU) transfusion practice. To address this issue, we studied the pattern and triggers of platelet transfusions in NICU patients.
Materials and Methods: The study was carried out retrospectively in neonates admitted in the NICU, between June 2012 and May 2013, and receiving platelets. Clinical and lab parameters were retrieved from the hospital information system and documented in a data collection form. All platelet transfusions were analyzed using SPSS software.
Results: During the study period, 91 platelet transfusion events occurred in 41 NICU patients, with an average of 2.2 platelets per patient. Most transfusions were prophylactic (75%), followed by bleeding (19.5%). The mean trigger for platelet transfusion in the prophylactic group was 15.4 × 10 9 /L and in the bleeding group was 23.5 × 10 9 /L. The pre- and post-transfusion counts were missing in 30% and 74% events, respectively. Corrected count increment (CCI) was performed in 13 patients, and was found to be 4.09 × 10 9 /L. In eight patients, the platelet trigger was more than 30 × 10 9 /L. Majority of the patients were preterm (55.5%), and mortality was high among the patients receiving more than two platelet transfusions.
Discussion and Conclusion: Despite the limitation of this retrospective study, it clearly depicts that our NICU platelet transfusion practice adheres to the AABB guidelines. Multiple transfusions were given to unstable neonates as a last resort to control their deteriorating clinical condition. A neonatal prophylactic platelet transfusion trigger of less than 30 × 10 9 /L is likely to represent "safe\" practice for the majority of NICU patients; it is also likely to result in unnecessary transfusion for a significant number of patients.
Therapeutic efficacy and safety of plasma exchange in pediatric Hemolytic Uremic Syndrome (HUS) patients
Rekha Hans, Ratti Ram Sharma, Neelam Marwaha
Background: Therapeutic plasma exchange (TPE) in the pediatric age group is technically demanding due to issues such as low blood volume, difficult venous access and poor co-operation of the patient during the procedure. Here, we present our experience of TPE in pediatric patients with Hemolytic Uremic Syndrome (HUS).
Aim: To access the effectiveness and safety of TPE in pediatric patients with HUS.
Materials and Methods: TPE was carried out in 27 pediatric patients (age - 14 months to 13 years) with HUS (25 - D negative HUS and two - D positive HUS) presenting with renal failure.TPE procedures were performed on cell separators (CS 3000 plus, Fenwal USA and Cobe spectra, Caridian BCT Lakewood, Colorado) daily or on alternate days depending on the clinical condition of the patient. Patients' 1-1.5 plasma volume was replaced with normal saline and fresh frozen plasma. The TPE kit was primed with group-specific, screened and cross-matched packed red blood cells for all procedures in order to avoid anemia or volume overload. Details of the procedural complications, if any, were noted and analyzed. Pre- and post-procedure renal functions along with hematological parameters were compared to assess the response to the procedures.
Results: A total of 133 TPE procedures (range, 1-20/patient, with an average of five procedures per patient) were performed for 27 pediatric HUS patients presenting with acute renal failure over a period from 2001 to 2013. More than three TPE procedures were performed in 16 patients, of which 14 patients showed improvement in renal functions and normal urine output. One patient did not show any response and succumbed to the disease. In the remaining 11 patients, only one to two TPE procedures could be carried out due to financial constraints. Complications were observed in 13 (9.7%), procedures which were well managed. Allergic reaction to FFP was the most common complication, observed in six procedures. Other complications were hypovolemia (n = 3), return line blockage due to poor venous access (n = 2), hypocalcemia (n = 1) and vasovagal reaction (n = 1).
Conclusion: TPE is effective in improving renal functions in pediatric HUS patients who undergo at least four TPE procedures. It is a safe procedure when volume shifts, calcium supplementation and venous access are taken care.
Significant association of antenatal maternal serum IAT titer with severity and fetal outcome in Rh alloimmunised pregnancies after intrauterine fetal blood transfusion
Armed Forces Medical College
Introduction: Intrauterine transfusion (IUT) is a process where blood is transfused to the fetus in order to provide a better chance of survival from life-threatening conditions associated with severe anemia, including Rh isoimmunization. The incidence of Rh negativity in India is about 1-5% and the rate of Rh sensitization is approximately 0.79% of live births. This study evaluated the role of an antenatal maternal serum indirect antiglobulin test (IAT) titer in predicting the feto-neonatal outcome.
Materials and Methods: This prospective analytical study was conducted from January 2008 to December 2012 at our center in Pune, Maharashtra, India. This study reports our experience with 75 IUTs carried out for 42 cases of severe Rh-isoimmunization. IAT was performed by ID gel cards and a test tube method was used for titration. Results were analyzed by odds ratio with 95% confidence interval.
Results: Of the 42 cases of severe Rh-isoimmunization who underwent IUT, 11 (26.2%) had hydropic fetus, resulting in eight (73%) live babies, two intrauterine and one neonatal death. In the remaining 31 (73.8%) non-hydropic fetuses who received IUT, one intrauterine and one neonatal death were observed. The overall survival rate was 37/42 (88.1%).
Conclusion: Severity and fetal outcome in Rh-isoimmunized pregnancies showed a significant association with antenatal maternal serum IAT titer. More the antibody titer, more would be the fetal and/or neonatal severity with respect to immune hemolytic anemia. Requirements of multiple IUTs are also associated with high antenatal serum IAT titer. Neonatal top-up and/or exchange blood transfusion was assessed in relation to DAT positivity, which showed statistically insignificant results.
Prevalence of platelet cross-match positivity among pediatric oncology patients in a center in South India
S Kingsley, Amalraj P, Chacko MP, Leni M, Dolly
Christian Medical College, Vellore
Background: Platelet refractoriness is defined as a lack of response in post-transfusion platelet increments after two or more consecutive transfusions of an adequate dose of allogenic platelets. Alloimmunization to class I human leukocyte antigen (HLA) and human platelet antigen (HPA) are important causes for refractoriness. The current standard of care for immune refractoriness involves testing for anti-HLA antibodies, and, if present, choosing HLA-matched platelets to prevent the same. This is an expensive and often not feasible option. The platelet cross-match test offers a simple alternative to assess whether donor platelets are compatible with the patient prior to transfusion, without HLA typing either the patient or the donor.
- To measure the occurrence of platelet cross-match positivity among pediatric oncology patients using a solid-phase red cell adherence assay (SPRCA).
- To observe whether cross-match positivity can predict platelet refractoriness.
Materials and Methods: All pediatric oncology patients who received platelet transfusions between March 2013 and May 2013 were included in the study, excluding those with known non-immunological causes of platelet refractoriness. The pre-transfusion platelet count was documented on all patients. A blood sample was collected 1 h after completion of the transfusion and assessed for post-transfusion platelet count. Using the pre- and post-transfusion counts, the corrected count increment (CCI) was calculated. A CCI <7500 was considered as evidence of an unsuccessful transfusion. Subsequently, plasma was separated from the pre-transfusion sample and a platelet cross-match was performed against the issued random donor platelet units by the SPRCA assay (Immucor, India) to assess compatibility. A Chi square test was used to assess the association between unsuccessful transfusions and cross-match positivity.
Results: During the study period, 64 platelet cross-matches were performed for 32 patients. Sixteen patients (50%) showed cross-match positivity for 27 units. Twenty-eight patients received more than one unit, of which nine patients (32.14%) showed positivity for multiple units. All 16 patients who had positive cross-matches had poor CCI correlating to unsuccessful transfusions. Among the 16 patients with negative cross-matches, 10 (62.5%) showed a CCI of >7500 while six had a CCI of
Discussion and Conclusion: The platelet cross-match simplifies the selection of a compatible platelet unit in patients who are previously sensitized. Our study indicates that in the absence of other non-immune causes of platelet refractoriness, a patient receiving a cross-match-negative product is likely to have a good increment. The sensitivity of the test for indicating unsuccessful transfusions is 100% and specificity is 62.5%. Therefore, we conclude that the test is an effective instrument in the management of patients with immune refractoriness.
Prevalence of alloimmunization to human platelet antigen glycoproteins and human leukocyte antigen Class I in β-thalassemia major patients in western India
Armed Forces Medical College, Pune
Background: The present management of β-thalassemia major by packed red blood cell (PRBC) transfusions poses a risk of alloimmunization not only to red blood cell antigens but also to human platelet antigens (HPA) and human leukocyte antigens Class I (HLA I). However, data in this context are very limited. The aim of the study was to determine the prevalence of alloimmunization to HPA and HLA I in β-thalassemia major patients who received multiple PRBC transfusions over the years.
Materials and Methods: A cross-sectional study was performed at our tertiary care blood bank. B-thalassemia major patients of more than 6 years of age who were receiving fresh, leukoreduced and irradiated PRBC units regularly with an annual requirement of more than 10 PRBC transfusions were included in our study.
Results: A total of nine out of 80 (11.25%) patients were found to be alloimmunized for HPA antigens of various specificities, and 24 of these 80 patients (30%) developed antibodies to HLA-I.
Conclusion: The awareness of development of alloimmunization to HPA and HLA antigens in multi-PRBC-transfused thalassemics, despite the use of leukofilters, will prompt us to look for improvement in our current PRBC preparations to minimize platelet alloimmunization. This is of importance, especially in view of providing suitable platelet cross-match when required in future hematopoietic stem cell transplants.
Are voluntary blood donations decreasing at campsite? An assessment of actual collection versus projected blood collection
Jignasa Kamleshbhai Gami
Rajkot Voluntary Blood Bank and Research Centre
Introduction: Adequate voluntary blood collection is essential for any of the blood bank services. In the Saurashtra region of Gujarat, most of the collected blood originates from voluntary blood donation (VBD) camps. We largely relay on blood collected through VBD camps.
Aim: To assess the reasons for decreasing voluntary blood collection at the campsite with reference to actual blood collection against proposed blood collection.
Materials and Methods: We analyzed the shifting trends of proposed versus actual blood collection, blood donation frequency, donors' and camp organizers' feedbacks on camp location and arrangement with following demographic details since 1st Jan 2010 to 31st May 2013 in this study.
- New camp organizer
- First time donor vs. repeat donor
- Donor and camp organizer's expectations
- Knowledge of VBD process
- Service charges of blood components
- Campsite arrangement.
Various aspects linked with VBD were also examined and were scrutinized to make newer strategies.
Results: In a period of 41 months (3.5 years), our center conducted 675 VBD camps with an average of 76 units/camp where 91% blood was collected from male donors and 9% blood was collected from female donors. The mean of the proposed collection was 150.5 units (ranging 146.5 to 154.5) and the mean of the actual collection was 76 units (ranging from 71.5 to 80.5). During the study, we collected 51,093 blood units in camps, which was 72.04% of the total estimation. A total of 5% camps were repeat camps on the same locations where repeat blood donors were 13.5%, which is higher than general repeat donation rate of 7.3%. Maximum blood collection was between the age of 21 and 30 years (39.32%), followed by 31-40 years (28.85%). Young donors of the age group of 18-20 years contributed 12.7%. A total of 84% feedbacks of camp organizers were considered and categorized. Of this, 79% was on awareness, 62% on token of appreciation, 73% on blood service charges, 37% on refreshment and 28% was on the overall process of blood donation and camp arrangement.
Conclusion: We have observed a very high average gap, i.e. 74.5, between proposed and actual VBD collection, which is alarming as to implement newer strategies to enhance awareness and providing facilities of blood collection at the door step with consideration of donors' and camp organizers' feedbacks. A blood bank should focus on appropriate token of appreciation and sharing knowledge about blood donation and blood donation process in context to charges of blood units. Post-donation care of donors and qualitative parameters of campsite help to boost the rate of repeat camps at the same location. This study exaggerates focused areas for various other blood centers to enhance VBD without compromising with the safety of blood as well as motivation of VBD camp organizers and blood donors by justifying their need as per the national VBD policy and government directives.
To prioritize the voice of customers for improving customer satisfaction
The Mission Hospital, Durgapur
Introduction: Customer satisfaction is one of the most essential elements of customer retention. The art and science of customer satisfaction involves strategically focusing on creating and reinforcing pleasurable experiences. Quality function deployment (QFD) is a systematic approach used by quality management teams to identify, communicate and prioritize customer requirements so that an organization can improve products and services to exceed customer expectations. It is an effective approach to build customer's requirements into the products and services, to beat the competition and to meet the customer's needs. A CT matrix, a simplified QFD, is a very helpful tool in translating the voice of the customer into measureable metrics that can be quantified thus, prioritizing the metrics that enables focus on those most critical for satisfying customers' needs and the most critical steps in the process that need improvement. Donors are one of the important customers in the Department of Transfusion Medicine, and retention of non-remunerated voluntary donors is essential for promoting the economic collection of much safer blood.
Materials and Methods: The study on the prioritization of voice of the customer is a qualitative analysis. The study was conducted in the month of March on all the donors who came for blood donation to the Department of Transfusion Medicine and to the blood bank, The Mission Hospital, Durgapur. All 657 donors were explained about the donor feedback form. The donor feedback form comprised of various processes involved in the donor selection, which includes information given to the patient regarding the amount of blood components transfused and counseling regarding the replacement, donor registration, donor examination and selection, phlebotomy and refreshment with post-donation counseling. The voice of the customer was captured and translated to technical requirements by using a CT matrix. The voice of the customer was captured from the suggestions of the donor feedback form and is listed in the left hand side with the customer priority numbers. The nine process steps: Pre-donation counseling, registration, waiting for medical examination, medical examination, waiting for phlebotomy, phlebotomy, post-donation rest, refreshment and post-donation advice, are entered as columns on the top of the matrix. Further, the strength of the relation between the voice of the customer and the process steps is expressed on a 1-5 scale in the relationship matrix. Typically, three scores are used - 1, 3 and 5, corresponding to low, medium and strong relation. The priority numbers and corresponding relationship scores are multiplied and cumulative scores are calculated for each of the process steps. Higher the cumulative score, higher is the importance of the process step thus translating the customer requirement into the measurable/technical metrics.
Result: The respondents were asked to mark their satisfaction level on venue, pre-donation counseling, registration, phlebotomist, post-donation counseling and overall satisfaction with the three remarks Excellent, Good and Unsatisfactory. On analysis of all 657 feedback forms, it was shown that 259 (39.42%) and 353 (56.77%) respondents had an excellent and good overall satisfaction level, while the remaining, i.e. 25 (3.81%) respondents, were unsatisfied on the overall services given by the Department of Transfusion Medicine. The CT matrix showed a cumulative score of 716 with the highest score, in a two-process step of phlebotomy and refreshment, of 146 and 144, respectively. Thus, to increase the donor satisfaction, the quality team has to focus on these two process steps instead of all the nine process steps.
Conclusion: In the absence of a clear and objective prioritization, the quality team tends to focus on all processes or focus on some things, which are very minor from a customer point of view. The CT matrix is a valuable and simple tool to translate customer needs to technical requirements and have an objective prioritization.
Time to revisit the selection and re-entry criteria for plateletpheresis donors in the Indian scenario: Recommendations based on extended follow-up of a cohort of plateletpheresis donors
Medanta - the Medicity
Background: According to the AABB and DGHS technical manual, a platelet count is not required before the first plateletpheresis (PP) procedure, but still most of the blood banks have a criteria of a minimum platelet count above 150 × 10 9 /L. This study was performed with the primary objective to demonstrate the effect of PP on hematological parameters at an arbitrarily chosen threshold of 100 × 10 9 /L. The second and most important objective of this study was to follow a cohort of donors for a period of 2 weeks to determine the long-term effect of PP on thrombopoiesis so that the criteria for the selection and re-entry of donors can be revisited.
Materials and Methods: This prospective study was performed at a tertiary healthcare center in India between March 2012 and February 2013. According to the Standard Operating Procedure (SOP), the minimum platelet count required before the first PP procedure is 100 × 10 9 /L and Hb is 12.5 gm%. The donor should be otherwise fit as per the SOP. PP donors were divided into two categories to determine the immediate effects of PP on donor's hematological parameters. Category one consisted of PP donors who had a pre-procedure platelet count above 150 × 10 9 /L and the other one category (category two) was consisted of donors who had a count between 100 × 10 9 /L and 150 × 10 9 /L. The hematological parameters assessed were the donor's platelet count (PC), hemoglobin (Hb), hematocrit (Hct), WBC count, platelet distribution width (PDW) and mean platelet volume (MPV). A cohort of 125 donors conferred consent for follow-up till 14 days to see the effect of PP on the regenerative capacity of thrombopoiesis by measuring PC and MPV. Results in both the categories, post-procedure drop in Hb%, Hct% and PC from baseline (pre-procedure) were observed to be statistically significant; however, in none of the cases did the Hb% drop below 11 gm%. In category one, 1.2% (14/1185) of the donors developed thrombocytopenia (below 100 × 10 9 /L immediately after the procedure, while there were 3.8% (2/53) donors who developed the same in category two. Follow-up data showed that the markers of thrombopoiesis did not return back to the normal baseline level even on Day 7, and required 14 days to reach within the normal range. There was no significant difference in the rate of hypocalcemic adverse effects between both the categories, and all of them were the mild one with presentations only like perioral tingling and feeling of cold in the extremities. None of the procedures were aborted due to citrate toxicity and managed conservatively. Prophylactic oral calcium carbonate supplementation in a dose of 3000 mg helped to reduce the probability of citrate toxicity in category one, while 1500 mg was required by the donor in category two.
Conclusion: In the Indian scenario, relaxation in the criteria for the selection of a naive first-time donor would reduce the deferral of valuable donors with simultaneous enhancement in the pool of PP donors. Prophylactic oral calcium carbonate supplementation (3000 mg and 1500 mg in category one and two, respectively) reduces the probability of citrate toxicity and makes the procedure more pleasant.
Blood utilization in elective surgeries: Prevalent ordering and transfusion practices in a tertiary care teaching hospital
St. John's Medical College Hospital, Bangalore
Background: Blood and blood products are routinely ordered in elective surgeries, most of which are not utilized. Thus, blood is held in reserve and is unavailable for other needy patients. This can lead to problems in inventory, loss of shelf-life and wastage of blood and adds to the financial burden of the patients. A number of strategies for ordering of blood and blood products have been proposed for efficient use of a blood inventory, which also leads to reducing the blood bank operating costs and ultimately be economical to the patients.
Materials and Methods: A retrospective study was carried out on patients who underwent elective surgeries over a period of 6 months (December 2012 to May 2013). The type of surgical procedure that each patient underwent was obtained from the theater records. The number of units demanded and cross-matched and the number of units issued and transfused was retrieved from the blood bank records. Thereafter, different indices such as cross-match to transfusion ratio (C/T), transfusion probability (%T) and transfusion index (TI) were calculated and maximum surgical blood order schedule (MSBOS) was estimated.
Results: A total of 2225 units were cross-matched for 1185 patients, but only 608 units were transfused to 388 patients, i.e. only 27% of the cross-matched blood were utilized. In most of the elective surgeries, where only one unit was requested, blood was not utilized. The overall C/T was 3.6 and MSBOS was 0.75.
Conclusion: This study showed that blood was overordered much in excess of the anticipated need. Implementation of the "Type & Save" procedure and, in cases where transfusion probability is high, MSOBS are introduced will avoid overordering and maximum utilization of blood.
Transfusion practice in obstetric emergencies
Government Medical College, Trivandrum
Introduction: Worldwide, obstetric hemorrhage is the most common cause of maternal death, causing 24% or an estimated 127,000 maternal deaths annually. It has also been reported that massive (>2 L) and life-threatening obstetric hemorrhage occurs in 3-5% and 0.1% deliveries, respectively, and blood product support is needed in 0.3-1%.
Aims and Objectives:
- To describe the blood transfusion pattern in obstetric patients admitted to the Sree Avittam Thirunal Hospital, Trivandrum.
- To assess the risk factors associated with massive obstetric hemorrhage.
Materials and Methods: Transfusion request forms of 300 patients with obstetric hemorrhagic disorders who underwent blood product transfusion in the Department of Obstetrics in the Sree Avitam Thirunal Hospital during a 5-month period (January 2013 to May 2013) were retrospectively reviewed for the types and volume of blood product transfused. Data collected were analyzed using SPSS software. Indication for each blood product transfusion was noted. Patients who had massive obstetric hemorrhage were further analyzed to estimate the ratio of the components.
Results: During the period of analysis, 300 cases received transfusion. Two hundred and twenty cases (73.3%) received transfusion during the peripartum period: 28 cases (9.3%) of ectopic gestation, two cases (0.8%) of vesicular mole and 50 cases (16.6%) of anemia complicating pregnancy received packed red cell transfusion. Single-unit transfusion was given to 35 cases (11.6%). 85.5% of the cases received red cell transfusion, with a median of 6 units and range of 2-14. 92.35% of the cases received FFP transfusion, with a median of 10 units and range of 4-18. 28.2% of the cases received platelet transfusion, with a median of 6 units and range of 3-12. Indications for peripartum transfusion were placenta praevia - 53 cases (24.1%), abruption - 50 cases (22.7%), atonicity - 30 cases (13.6%), rupture - 20 cases (10.4%), eclampsia - 20 cases (10.4%), inversion - 15 cases (6%), HELLP - 15 cases (6%), acute fatty liver of pregnancy - 10 cases (4%), gestational thrombocytopenia - 5 cases (2%), amniotic fluid embolism - 1 case (0.4%) and Glanzman's thrombasthenia - 1 case (0.4%). Massive obstetric hemorrhage was defined as those cases that needed more than 4 units of packed red cell transfusion. Eighty cases of massive obstetric hemorrhage were reported. Of these, 40 cases (50%) of placenta praevia, 20 cases (25%) of abruption, 10 cases (12.5%) of atonicity, eight cases (10%) of uterine rupture and two cases (2.5%) of inversion were reported. Multivariate logistic regression was performed using SPSS version 17. A significant odds ratio was observed for the following risk factors: Placenta previa - 3.5 (95% CI [2.1-5.8]), abruption - 3.4 (95% CI [2.4-4.7]), atonicity - 2.4 (95% CI [2-2.8]), rupture - 2.3 (95% CI [1.6-3.4]) and inversion - 1.4 (95% CI [1.2-1.7]).
Conclusion: Placenta previa, abruption, atonicity, rupture and inversion are the significant risk factors for massive obstetric hemorrhage in transfusion for massive obstetric hemorrhage in terms of appropriate supply of coagulation factors ratio of red cell to plasma of 1:1.3-1.4 may be desirable.
Transfusion consent: Can we document it better?
Kasturba Medical College, Manipal
With the majority of hospitals going for accreditation, there is an increased emphasis for hospitals to have a formalized informed consent processes in place. The minimum elements of consent for blood transfusion set forth in the AABB standards include (1) description of the risks, benefits and treatment alternatives, (2) the opportunity to ask questions and (3) the right to accept or refuse transfusion. Patients should be informed about the risks and benefits of blood transfusion and their consent should be documented in the patient record. However, this is not routinely practiced in India. The present study was aimed to improve the transfusion practice by auditing on the documentation of transfusion consent in the patients records. As a part of the NABH accreditation for our hospital, written informed consent was required prior to blood transfusion. To achieve 100% documentation of the same, the blood bank adopted a policy in 2011, in which clinicians were repeatedly informed about the need for transfusion consent in all hospital transfusion committee meetings, and all requests for blood components excluding emergency requests were accepted along with consent for transfusion. The requests were not accepted if the consent was absent. The consent forms were filed in the patients' records later. This policy was discontinued from January 2013. Random sample auditing was performed along with Medical Record Department from January 2011 to April 2013. Patient records were reviewed for documentation of transfusion consent. The turnaround time (TAT) from registration of transfusion request to cross-match of blood components was also studied. The data were entered in an excel sheet and the statistical analysis was performed using the chi-square test and the Student's "t" test.
Bank to bedside: A reliable and efficient transportation of blood by the pneumatic tube system
Manipal University, Manipal
Background: The current trends in healthcare require optimum utilization of its resources for an extended safety and utmost care to patients. The pneumatic tube system (PTS) provides one such benefit that yields a safe and secure means of transportation of blood components to the patients, considerably saving a lot of time and manpower.
- To compare the time taken by the PTS with the manual transport of the blood components from the blood bank.
- To infer about any technical errors causing the delay, and thereby wastage of the blood component
Materials and Methods: The pilot study was carried out from December 2012 to May 2013. The authors used the in-built PTS (Swisslog GMBH Germany). It is connected to 29 stations with its state-of-the-art facility. The system transports the carrier (one at a time) at an average speed of 7.6 meters (25 feet) per second using positive and negative air pressure. Acknowledgment forms filled by the technician were sent along with the blood components through this carrier system. These forms were signed from various wards and were sent back to the blood bank. The time of sending and receiving the carrier was noted by us. The difference between the delivery time displayed by the system and that mentioned by the ward staff on these forms was considered as the hibernating time, which denoted the time in noticing the carrier after it had reached the designated station. Any delay or failure of the delivery of the carrier to the exact location was also observed. The data were analyzed using an IBM SPSS Statistics version 20.
Results: The PTS was used for 160 events to deliver blood components to patients with varied clinical diagnosis during the study period. The blood components sent were PRBC (70.0%), FFP (15.0%), platelet concentrates (12.5%) and Cryo (2.5%). The mean time calculated when using PTS was 1.360 min ± SD 0.3413; range, 0.36-2.5 min. The mean time using the manual delivery of blood components was 7.927 min ± SD 1.400; range, 5.45-11.12 min. The mean time in noticing the carrier (hibernating time) was 5.856 min ± SD 4.3953; range, 1-33 min. There were three separate instances when the delay was around 25 and 33 min, respectively, twice due to technical errors and once (19 min) due to mixing of the carriers. The delay of 33 min resulted in a wastage of the PRBC component.
Conclusion: The PTS is rapid and mostly reliable for the expedited delivery of the life-saving blood products. With effective communication and coordination of the users, a faster and convenient technology such as this can help us reduce a lot of turnaround time and manpower, which can further be devoted to better patient care.
Assessment of hemostatic changes by a viscoelastic method in patients undergoing cardiac surgery
Ashish Jain, Anupam Verma, Priti Elhence
Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
Introduction: Patients with valvular heart disease undergoing surgery have an increased risk of ischemic as well as bleeding complications, the mechanisms of which remain poorly explored. Thromboelastography (TEG) provides a rapid global assessment of hemostasis from clot initiation and development to fibrinolysis involving both the cellular and the plasmatic components of the hemostatic system. The aim of this study was to assess the hemostatic changes in pre-operative patients undergoing cardiac surgery by laboratory-based TEG.
Materials and Methods: A total of 12 patients were assessed during the perioperative period. TEG was run on Kaolin-activated citrate blood samples within 1 h of sample collection. The TEG parameters assessed were (a) maximum amplitude (MA): Marker of platelet function and ischemic risk; (b) reaction time (R): Marker of coagulation status and bleeding risk; (c) Alfa angle: Marker of the rate of clot formation; (d) K value and (e) coagulation index (CI).
Results: Of 12 patients, six (50%) patients had a hypocoagulable picture (CI < −3), wherein five of them had an abnormally high R value and one patient had a low MA value, although the PT/APTT values were increased in three patients only. High hematocrit seen in a patient with right to left shunt resulted in a hypocoagulable picture mainly due to increased R and decreased MA values [Figure 1]. Two patients were on warfarin, who showed bleeding diathesis. Repeat TEG in one hypocoagulable patient after stopping warfarin revealed a normal tracing. Two bleeding patients received FFP transfusion based on their TEG findings. An increased MA value (hyperfunction of the platelets) was observed in two patients on treatment with thyroxine, although CI was within the normal range. The PT results were not available in 16% and the APTT results were not available in 83% of the study cohort. TEG was normal in the remaining six patients, and none had a hypercoagulable picture.
Conclusion: Cardiac surgery patients are frequently characterized by abnormal hemostatic profiles as assessed by TEG.
Seroprevalence of TTI in blood donors (voluntary and replacement) at blood bank
Paras Hospitals, Gurgaon
Introduction: Transfusion of blood and blood products on one hand can save the life of patients, however, on the other hand if not screened and tested appropriately can transmit life threatening infection to the Pt. Even today the quality and safety of blood transfusion is a concern for health professionals.
Objective: To study the seroprevalence of HIV, HB sAg, HCV, and Syphilis in blood donors.
Materials and Methods: The study was conducted at a super speciality hospital blood bank of Gurgaon during the period (Jan 2011 to Dec 2012). The total donor units (voluntary and replacement) collected were 10,138. The donors were in the age group of 18-65 years. The blood was collected in the SAGM-450, DB-450, SB-350 bags. Blood was tested for the infectious markers by the ELISA KITS (fourth generation for HIV, third generation for HB sAg and HCV) and RPR method for Syphilis. All the reactive samples were retested by different methods before being labeled as seropositive.
The percentage of voluntary and replacement donors were
The percentage of male and female donors were
The seroprevalence of the infectious markers in both the years were
Discussion: The percentage age of voluntary donors is very low compared to replacement donors in both the years which is 7.9% in 2011 and 6.7% in 2012. Also the percentage age of female donors is (2.3% in 2011 and 1.5% in 2012)
There was significant prevalence of HBsAg followed by HCV, HIV, and Syphilis in the year 2011. But in 2012, the prevalence of HBsAg is followed by HCV, Syphilis, and HIV.
Conclusion: As in our study none of the voluntary and female donors showed infection, we should make efforts to increase the number of voluntary and female donors. The total units discarded because infectious agents in both the years were 174 which is 1.7%. Even testing by these serological tests we may miss the agent if the donor is in the window period; hence, Nucleic Acid Testing is the advanced method now available to enhance the further safety of blood.
Seroprevalence of hepatitis B virus and hepatitis C virus among blood donors at a tertiary care hospital in Kashmir: A 10-year study
Zubair Qureshi, Fehmeda Akhter, Meena Sidhu, Vijay Sawhney
Humiara Bashir and Ashu Dogra GMC, Jammu
Background: Hepatitis B virus (HBV) and Hepatitis C virus (HCV) are important transfusion-transmissible infections. This study was performed to assess the prevalence and yearly trends of HBV and HCV seropositivity among blood donors at a tertiary care hospital-based blood bank at SKIMS (Srinagar, Kashmir).
Study design and Methods: The blood donation records over 10 years (2003-2012) were reviewed retrospectively, for a total of 97,427 donors, ranging from 18-60 years. The hospital has a policy of using a standard blood donor screening questionnaire and excluding the high-risk donors. Replacement donations (from family, relatives, and friends of the patient) accounted for the majority of the donations while the voluntary donors formed the rest. Standard ELISA kits were used for detection of Hepatitis B surface antigen (HBsAg) and antibody to Hepatitis C virus (anti-HCV) in human plasma.
Results: Total of 97,427 donations were received over a period of 10 years (Jan 2003 to Dec 2012). Of total donations 95,258 (97.8%) were males and 2169 (2.2%) were females. The replacement donations comprised 94,406 (96.9%) while voluntary donations were 3021 (3.1%) of total donations. Maximum donors 46,181 (47.4%) were in the age group of 18-30 years, 25,234 (25.9%) were between 31-40 years, 16,757 (17.2%) were between 41-50 years, and 9,255 (9.5%) were between 51-60 years. First time donors, who had no history of previous blood donation were 63,523 (65.2%) and repeated donors who had history of one or more previous blood donations were 33,904 (34.8%). For HBV overall seropositivity over 10 years was 0.48%. The prevalence ranged from 0.53% in 2003 to 0.36% in 2012, showing decreasing trends. The overall prevalence rate in males was 0.48% while in females it was 0.41%. The prevalence in replacement donors was significantly higher compared to voluntary donors (0.49% vs. 0.16%). The prevalence rates of hepatitis B were lower among young donors between 18-30 years of age (0.45%), as compared to older donors between 51-60 years of age (0.66%). Higher seroprevalence of HBsAg was observed in repeated donors (0. 54%) as compared to first time donors (0.45%).
For HCV overall 10-year seropositivity was 0.20%. The prevalence of HCV infection among blood donors in the past 10 years showed a decreasing trend, from 0.28 in 2003 to 0.12 in 2012. Seroprevalence of HCV was seen more in males (0.20%) as compared to females (0.14%). The prevalence of HCV in the replacement donors was significantly higher compared to the voluntary donors (0.20% vs. 0.09%). Seroprevalence of HCV was found higher in the age group of 51-60 years (0.26%), with the lowest seroprevalence in the age group of 18-30 years (0.18%).
Conclusions: It appears from this study that the overall prevalence of HBsAg positivity and anti-HCV antibodies in blood donors is low and much lower in voluntary. To make it more safe, stringent donor screening measures such as dissemination of information, strict screening of blood and blood products, better donor recruitment, and promoting voluntary donations are taken.
Prevalence of transfusion transmitted viral infections among blood donors in tertiary healthcare center, Puducherry: Two-year Study
Mahatma Gandhi Medical College and Research Institute
Introduction: Blood is a scarce and life saving resource; however blood transfusion can be a source of transmitting life-threatening infections if screening is not carried out properly. The prevalence of HIV, HBV, and HCV serology positivity in Indian blood donors is 2-5%, 1-4.7%, and less than 2% respectively which is comparatively more than other transfusion transmitted infection (TTI). There is lack of available data in the Indian literature regarding TTI in Puducherry. Hence, the aim of this study is to find out the serological prevalence of HIV, HBV, and HCV infections among blood donors in a tertiary healthcare center, Puducherry
Materials and Methods: This is a retrospective study of 2 years from April 2011 to April 2013 at Blood Bank of Mahatma Gandhi Medical College and Research Institute, Puducherry. Total of 3,830 blood units were screened during this period. Replacement donors had come to the center to donate blood and were either relatives or friends of patient. Professional donors were excluded; however, there were no professional donors during the study period. Voluntary donors were primarily spontaneous donors with free will. Donors were selected by the standard criteria for donoritness. The screening for detecting antibodies for HIV was done by MICROLISA kit, HBsAg was done by HEPALISA kit and for detecting antibodies for HCV by HCV MICROLISA kit (all kits are approved commercially by J. Mitra & Co).
Results: In this study, total 3,830 units of blood was screened, of which 96.49% were from replacement donors and the remaining 3.5% were from voluntary donors. Seventy six (76) blood units were serologically positive. Two units were positive for HIV, 71 for HBV and three for HCV. The seroprevalence of HIV, HBV, and HCV was 0.05%, 1.85%, and 0.07% with overall incidence of 1.98%. In this study none of the voluntary donors were serologically positive for HIV, HBV, and HCV.
Discussion: This study highlights the seroprevalence rates of HIV, HBV, and HCV among blood donors at a tertiary healthcare center, Puducherry, which is lacking in the Indian literature. Seroprevalence rate of HIV, HBV, and HCV is 0.05%, 1.85%, and 0.07%, respectively, which is comparable to studies from other places. The seroprevalence rate of HBV is more than HIV and HCV, probably due to asymptomatic carriers. Moreover, India lies in the intermediate zone of Hepatitis B endemicity. So, advanced techniques for nucleic acid testing (NAT) like TMA (transcription mediated amplification) or PCR can resolve this issue. However, the threat of transfusing potential infectious units of blood for HBV including window period donations and seronegative infections still continues. As per drugs and cosmetics act, 1940, and amendments thereof, only screening for HBsAg to detect HBV is mandatory in Indian blood banks. All the 76 seropositive samples were from replacement donors in this study. None of the voluntary donors were seropositive, emphasizing the role of voluntary unpaid donors in ensuring safe blood transfusion.
Nucleic acid testing yields versus quantitative PCR: Where do we stand?
Eliza Sherin Koshy
Christian Medical College
Background: With the rising trends of transfusion transmissible infections (TTI) and a greater stress on the safety and quality of blood products, there is an urgent need to develop an effective blood screening strategy. The introduction of nucleic acid testing (NAT) has added an additional layer of safety by identifying HBV, HCV, and HIV infected donors much earlier than the standard serological tests. This study applies the gold standard, quantitative polymerase chain reaction (Q-PCR), to examine the significance of NAT yields.
Materials and Methods: Analysis of HIV, HCV, and HBsAg screening data for all donor samples from the period between May 2011 and March 2013 was done to determine NAT yields. Anti-HIV Ab, anti-HCV Ab, and HBsAg were tested by Vitros ECi (Ortho Clinical Diagnostics) till October 2012 and thereafter using Monolisa HBsAg Ultra, Monolisa HCV Ag-Ab Ultra, and Genscreen Ultra HIV Ag-Ab on the Evolis (Biorad Diagnostics). Each sample was also tested by ID-NAT using Procleix Ultrio Assay on the Procleix Tigris system (Novartis). Viral load determination of all the ID-NAT yields NAT positive, seronegative samples were taken using quantitative PCR (Abbott Real time PCR m2000sp and Abbott m2000rt).
Results: Among the 52,083 donors screened during the period between May 2011 and March 2013, the total number of NAT yields was 47 (0.09%), of which 43 (91.4%) were for HBV, 3 for HCV, and 1 for HIV. Q-PCR confirmed 28 of 47(59.6%) NAT yields. All of these were for HBV, whereas none of the purported HBV and HCV yields were positive by Q-PCR.
Discussion and Conclusion: Our results showed the NAT yield amounts to 0.09% samples or 1 in 1,108 samples, a number that in a blood bank like ours accounts for approximately 2 weeks turnover. Approximately 60% of our NAT yields were confirmed by Q-PCR. The significance of the remaining Q-PCR negative samples is uncertain. However, if they are taken as false positive, this would account for blood wastage of 0.04% translating to 1 in 2741 bags, attributable to NAT. This, undeniably, is a diminutive price when it comes to improving.
Low cost preparation of in-house external quality control for TTI infections
The Tamil Nadu Dr. M. G. R Medical University, Chennai, Tamil Nadu, India
Background: Quality control is a measure taken to monitor the quality of the test itself. Quality control ensures that the test is working perfectly and the testing personnel can report accurate test results with confidence.
Objective: To prepare low-cost external quality controls (QC) human serum and scientifically evaluates advantages/disadvantages when compared with commercially available sera.
Materials and Methods: The in-house QC serum was prepared as per WHO recommended protocol from the positive control sera of the confirmed cases of HIV, HCV, and HBV in the Department of Transfusion Medicine from 2007 to 2012. The in-house and commercially available external control were used for HIV, HCV, and HBV screening tests to monitor the consistency of performance, enough variation and to validate whether the run is in-control or out of control for TTI screening tests with the ELISA method. The initial values were used for calculation of means and SDs and the results were compared with those of commercially available kit sera.
Results: We found 100% specificity for both in-house and commercially prepared antisera for all the three diseases. However, in comparison with the in-house antisera, commercially prepared antisera, showed 99% sensitivity for HIV, 98.25% for HBV, and 98% for HCV.
Conclusion: In our study, with comparison to commercially prepared serum, in-house external quality control serum is cost effective, has higher sensitivity and specificity and fulfils the WHO recommended protocol for screening of HIV, HCV, and HBV in blood banking. Additional advantages include easy preparation and no need for reconstitution. Hence, in-house external control is a good substitute for quality control especially in developing countries like India.
Evolving testing protocols for
HBV-serology yield cases: Our experience
Satawase P, Kalgutkar S, Pathare A, Sawant R, Deshpande A
P. D. Hinduja National Hospital & MRC
Background: Background nucleic acid amplification testing (NAT) is a molecular technique that provides simultaneous detection of HIV RNA, HCV RNA, and HBV DNA in a single reaction. In March 2009, Individual ULTRIO NAT (ID-NAT) was implemented in conjunction with EIA at a tertiary care multispecialty hospital in Mumbai. However, there is a need to have a uniform testing algorithm for evaluation of discrepant results of EIA and NAT especially with reference to HBV, which is most prevalent transfusion transmitted infection (TTI) in India.
Aims: To study the HBV discrepant samples and evaluate the effectiveness of algorithm and ULTRIO plus.
Materials and Methods: Routinely, all blood donor samples were tested by EIA (Axsym and Architect) for the detection of anti-HIV and anti-HCV antibodies, HBsAg and also by ID-NAT assay using Transcription Mediated Amplification (TMA) (Procleix® Ultrio® Assay, Novartis). All reactive donors by ID-NAT were subjected to discriminatory assay for the detection of specific virus. December 2011 onwards, an algorithm was implemented in case of discrepancy in EIA and NAT results. According to algorithm, NAT assay was repeated three times each with an EDTA sample, plasma bag sample, and discriminatory assay to detect NAT-yield. To detect sero-yield, NAT assay was repeated three times with an EDTA sample and confirmed when at least one NAT assay was reactive. Additional biochemical, serological, and molecular tests were also performed in such cases. Discrepant results were evaluated using real-time PCR, algorithm and ULTRIO plus assay.
Results: Out of 22,656 donors 245 were HBV reactive by EIA; however, only 238 were reactive by both EIA and NAT resulting in seven discordant cases. All the cases had normal liver function (SGPT, SGOT, Alkaline phosphatase, Bilirubin). HBV serology profile of all seven donors showed positive results for anti-HBc(total), negative anti-HBc(IgM), and negative anti-HBsAg. Out of these seven cases, five had detectable HBV viral load by real-time PCR (sample was not sufficient in two cases). Out of these five cases, four were reactive by ULTRIO plus, resulting in one sero-yield case. After the implementation of algorithm, three more HBV cases were observed to be reactive by EIA (titer>250 IU/ml) and nonreactive by initial NAT assay. However, all these cases were detected to be NAT reactive using the algorithm. Moreover, all the three cases were reactive by ULTRIO plus. Out of 22,656 blood donors one was observed to be NAT-yield case when tested using algorithm (2/3 times NAT reactive with EDTA, 1/3 reactive with plasma bag, and 1/3 with discriminatory assay).
Conclusions: Implementation of NAT algorithm and ULTRIO plus enhanced the analytical sensitivity of NAT assay. This has helped us in resolving discordant HBV sero-yield cases.
A study of seroprevalenc retrospective e of common transfusion transmitted infections amongst blood donors in a tertiary care centre
Father Muller Medical College, Mangalore
Introduction: Blood is elixir of life. Transfusion of blood and its components, as a specialized modality of patient management, saves millions of lives worldwide each year and reduces morbidity. It is well known that blood transfusion is associated with a large number of complications, some are only trivial and others are potentially life threatening, demanding for meticulous pretransfusion testing and screening for transfusion transmissible infections. The priority objective of blood transfusion screening is thus to ensure safety, adequacy, accessibility, and efficiency of blood supply at all levels. The objective of this study was to assess the seroprevalence and trend of transfusion transmitted infections among voluntary and replacement blood donors in the blood bank of a tertiary care centre.
Materials and Methods: The records of all the blood donors from 2008 to 2012 were analyzed for the presence or the absence of common transfusion transmitted infections. The data was analyzed using statistical tools such as mean, frequency, chi square test, and Fishers exact test.
Results: A total of 29,195 donors were screened over a 5 year period. The overall prevalence of HIV, HbsAg, HCV, syphilis, and malaria were 0.06%, 0.30%, 0.06%, 0.12%, and 0.0 1%, respectively.
Conclusion: Every blood unit collected should be screened for transfusion transmitted infections, thus, ensuring safe blood supply to the recipients. With the implementation of strict donor selection criteria, by use of sensitive screening tests and establishment of strict guidelines for blood transfusion, it is possible to reduce the incidence of these transfusion transmitted infections in the Indian scenario.
A hospital based study on the trend in seroprevalence of transfusion transmitted infections among blood donors in Puducherry
Sri Manakula Vinayagar Medical College and Hospital
Introduction: The evaluation of the prevalence of transfusion transmitted infections (TTI) such as Hepatitis B, Hepatitis C, HIV, syphilis, and malaria among blood donors permits an assessment of the transmission of the infections in the blood donor population and consequently the safety of the collected blood. It also gives an idea about epidemiology of these infections in the community. The laboratory screening remains the key step in identifying donations from infected individuals. Hence, the screening of donated blood for a minimum set of TTI is mandatory. Therefore, the aim of the study was to provide information about the trend in seroprevalence of TTI s among blood donors in our hospital over the study period and this would allow the comparison of seroprevalence over the course of time. The findings could also be used to update intervention programs that focus on the prevention and control of TTIs.
Materials and Methods: This is a retrospective study carried out at SMVMCH blood bank from January 2010 to May 2013. Data were retrieved from records of the blood bank. All blood donors who donated at the blood bank during the study period were included in the study. The seropositivity was diagnosed using third-generation ELISA for Hepatitis B, Hepatitis C, and HIV. Malaria parasite was diagnosed using peripheral smear and by rapid visual antigen test. Syphilis was diagnosed by using antibody detection by rapid immunochromatographic test and by RPR card test.
Results: A total of 4,982 blood donors were screened for the presence of TTIs over a period of 3 years and 5 months. Out of 4,982 donors, 150 were positive for TTIs. Out of these 150 donors, 23 are voluntary donors and 127 are replacement donors. Of these 2.65% were positive for hepatitis B, 0.08% were positive for hepatitis C, 0.20% were positive for syphilis, 0.02% was positive for HIV, and 0.06% were positive for malaria. HBV positive donors in the year 2010 were 2.75%, in the following years 2.03%, 2.67%, and in the current year up to May it was 3.2 1%. Seropositivity was more prevalent among the blood donors in the age group of 18 to 30 years followed by 31 to 40 years.
Conclusion: From our study we infer that HBV seroprevalence is comparatively high than other TTIs among blood donors in our hospital. This study revealed that HBV infection was more prevalent among replacement donors than voluntary donors. So nonremunerated voluntary blood donors should be encouraged and steps should be taken to promote voluntary blood donations. Public health education programs on HBV infection, adult hepatitis B immunization programs, raising socioeconomic standards, predonation counseling, and donor self-exclusion will be effective in decreasing the hepatitis B infection rate.
Malaria screening among voluntary blood donors: To find out the prevalence and to evaluate the sensitivity of different techniques
Villupuram Medical College Tamilnadu
Background: Malaria can be transmitted by transfusion of blood from infected donors and was first reported in 1911. One of the most common transfusion-transmitted infections to be prevented is transfusion malaria. The risk of acquiring transfusion malaria is very low (one case per 4 million) in nonendemic countries such as the United States, whereas in the endemic countries, it is much higher (>50 cases per million donor units). As per NACO, Ministry of Health and Family Welfare, Government of India guidelines 2007, test for malaria in all blood units should be performed for malarial parasites using a validated and sensitive antigen tests. Although the microscopic detection of blood considered the gold standard for malaria diagnosis for decades, it is quite labor intensive and require adequate technical skill and man power. This had spurred the development of other microscopic malarial and rapid detection test based on the detection of malaria parasite antigen in the whole blood.
Aim and objectives:
∙ To study the prevalence of malaria among voluntary blood donors.
∙ To compare the various screening methods and to find out the most sensitive technique to screen malaria parasite among voluntary blood donors.
Material and Methods: A cross-sectional study was conducted to study the prevalence of malaria among voluntary blood donors. Voluntary blood donors were recruited from the blood bank of the department of Transfusion medicine, The Tamil Nadu Dr. M.G.R. Medical University. Two milliliter of EDTA blood sample was collected and used for screening malaria parasite by Peripheral blood smear, Quantitative Bufy Coat method, and Rapid Card Test.
Results: The prevalence of malaria among the voluntary blood donors was 0.4%. Among 250 donors, one of the donor blood samples was found to be positive by Microscopy, QBC, and RDT. The species identified was Plasmodium vivax.
The sensitivity and specificity of QBC and RDT were 100% with respect to the gold standard microscopy. The positive asymptomatic donor had past history of malaria, for which he was treated with antimalarial drugs four months prior to blood donation.
Conclusion: Since intermittent asymptomatic period, recrudescence and relapse are known with P. vivax infection in an endemic area, especially in semi-immune individuals, it is imperative to screen all donors by less-laborious, less time-consuming, and more sensitive methods, irrespective of a strict donor questionnaire. The rapid detection test in our study was found equally sensitive to Quantitative Bufy Coat method and microscopy. The Quantitative Bufy Coat method is more sensitive; however, it needs specialized instruments, higher technical expertise, and costlier compare to rapid detection test. Hence, to prevent transfusion transmitted malaria in endemic areas like India screening of malaria by rapid detection test may be included along with microscopy. However, a study on large number of voluntary blood donors is necessary to arrive at a definitive conclusion.
Wide variation in actual hemoglobin content of donated whole blood units
Fortis Hospital, Shalimar Bagh, Delhi
Introduction: Blood is a drug and every donation is considered as an independent batch or lot. This is primarily due to individual donor characteristics that vary widely across populations. Hemoglobin (Hb) level is one of the prime considerations for collecting a unit of blood from a donor. Since, Hb in a blood unit may affect post transfusion Hb increment in a patient, we planned to study the variation in donor Hb in our population. This variation in donor Hb is a direct reflection of variation in Hb content in individual blood units derived from these donors.
Material and Methods: We retrospectively analyzed the data of 7,000 consecutive whole blood donors coming to our blood bank in a tertiary care hospital in Delhi. We analyzed the variation in Hb according to age and gender of the donor. For convenience of analysis and interpretation Hb data were analyzed in ranges of 12.5-13.0 gm/ dl, 13.1-14.0 gm/dl, 14.1-15.0 gm/dl and so on till the highest limit of 18 gm/dl.
Results: Out of 7,000 blood donors 6,712 (96%) were males and only 288 (4%) were females. Amongst all the donors (irrespective of gender or age), 77% had Hb value greater than 14 gm/dl and 50% of donors had Hb greater than 15 gm/dl, against a minimum acceptable limit of 12.5 gm/dl. 80% of male donors had Hb greater than 14 gm/dl while same proportion of female donors had Hb less than 14 gm/dl reflecting generally lower Hb levels in female donors. Hb level started decreasing towards lower Hb range bracket of 14.1 to 15.0 gm/dl and 13.1 to 14.0 gm/dl with age advancing from 45 years to 55 years and above
Conclusion: Post-transfusion increase of Hb in a patient after a blood unit transfusion is estimated as 1 gm/dl. However, this generalization may not hold true in view of variation in Hb content of these blood units. Hb content of a unit donated by a young male donor is significantly higher than that by a female donor. Effect of this variation in patient needs to be studied to rationalize and customize blood transfusion
To Determine the bacterial contamination in packed red blood cell units: A prospective study
The Tamil Nadu Dr. M.G.R Medical University, Chennai.
Background: Bacterial sepsis from a contaminated blood component is rare but potentially a serious complication of blood transfusion. Timely recognition and appropriate management of a septic transfusion reaction can be critical to the well being of the patient. The estimated rate of bacterial contamination of a unit of packed red blood cells ranges from 1 per 31,000 to less than 1 per 1 million units. The rate of bacterial contamination from a platelet product is estimated to be 1 in 1000 to 1 in 3600 units. Background red cells are stored at 1-4°C for up to 42 days; organisms that survive at cold temperatures in the presence of heme and dextrose are the usual pathogens. Yersinia enterocolitica is the most common organism associated with septic reactions to red cells. Besides Yersinia, these include Serratia, Staphylococcus epidermidis, Stapylococcus aureus Bacillus species, Pseudomonas, and Enterobacter species. Organisms which survive in red cells are most often gram negative types which can produce endotoxins. Because of these endotoxins, transfused patients may rapidly develop septic shock. A key point to remember is that autologous donation has the same risks of bacterial contamination as allogenic donation. Bacteriologic surveillance is done as part of haemovigilance in some countries. It usually involves culturing of various blood products as part of quality assurance.
Aim: To determine the bacterial contamination in packed red blood cell units.
Materials and Methods: Blood was sampled from the 96 donor units on the 1st day, 3rd day, 21st day, 35th day, and 42nd day of storage and cultured for 7 days on Blood agar, Chocolate Blood agar, and Mac-Conkey agar. Bacteria isolated was determined by Gram stain.
Results: A total of 96 packed red blood cell units were sampled; one unit was positive for bacterial contamination on the third day of storage. The organism isolated was Staphylococcus aureus. However, this was not statistically significant.
Conclusion: Several precautions are routinely taken to minimize the risk of collection or transfusion of a bacterially contaminated blood product. Standard procedures performed include: assessment of the donor's health by history and physical examination; sterilization of the venipuncture site; sterile collection and processing techniques; and a visual check of the product by blood bank personnel prior to issuance of the product. Despite these measures, bacterial contamination of packed red cells and platelets does occasionally occur. More recently, attention has been focused on ways to reduce or eliminate bacteria from a cellular blood product. A simple method currently used is to divert the first 10 ml of a collection into a sampling pouch. Considering the fatal outcome, in spite of infrequent occurrence of bacterial contamination of packed red blood cell units being stored at 1°C to 4°C, it is absolutely necessary to subject 1% of all units collected with minimum of four units per month have to be subjected for bacterial culture study, irrespective of any aseptic phlebotomy procedures followed.
Standardization of PRP-PC method of platelet concentrate preparation to get best platelet yield
Background: There is no consensus regarding optimum centrifugation speed and time for preparation of PRP-PC. The critical issues during calibration of centrifuge for PRP -PC preparation which can affect the quality and yield of platelets are centrifugal force, time of centrifugation, temperature of refrigerated centrifuge, and the rate of acceleration and deceleration. This study was planned to find the centrifugation program for PRP-PC with shortest time and lowest centrifugal force (g) to get best platelet yield without compromising the quality of PRBC and FFP component.
Materials and method: In this study, 132 units of whole blood collected in 450 ml triple bags (Make:Terumopenpol) were processed for preparation of platelet concentrate by the PRP-PC method using variable Relative Centrifugal Force (RCF) 'g' and time for first spin. Centrifugal forces used were 800, 900, and 1000 g, for 7, 8, 9, 10, and 11 min each. Second spin was kept constant at 5,000 g for 5 min. Acceleration and deceleration was kept constant at 9 and 4, respectively. Centrifugation was done in refrigerated centrifuge (Cryofuge 6000i Heraeus, Germany). Platelet count was done by automated hematology cell counter (Orion-60) which is based on impedance method of cell counting.
Result: Maximum platelet yield in PRP (87.6%) and PC (79.4%) was observed with program using centrifugation at 800 g × 7 min. Platelet yield in PC was above 70% in programs (800 g × 7 min, 800 g × 8 min, 800 g × 9 min, and 900 g × 9 min) and mean platelet content of PC was > 5.5 × 1010/Bag in these programs. The mean volume of all the components was in acceptable range except for volume of FFP (142 ml) in program (800 g × 7 min) and PRBC (236 ml) in program (1000 g × 11 min).
Conclusion: From our study we found that centrifugation at 800 g × 8 min in the first spin and 5000 g × 5 min in the second spin is best combination of time and speed for the preparation of PRP-PC without affecting the quality of PRBC and FFP component
Quality of blood components
Kokilaben Dhirubhai Ambani Hospital, Mumbai
Background: Maintaining blood safety is of utmost importance for patient's life and in order to maintain safety of blood in the blood bags they need to be maintained in Cold Chain system, that is, 2-8°C. Kokilaben Hospitalis concerned that from the moment blood bags are collected from Donors to the point given for use in OT and returned back, there is no active system in place to monitor the temperature experienced by the bags which are, out of necessity, removed from the cool boxes for labeling, checking, and preparation for use.
Aims: To ensure good quality product is being transfused and minimal chances of bacterial growth and contamination. To ensure unit can be accepted back into blood bank inventory and Re-issue of returned units, with quality assurance Timestrip Plus 8°C (TP 065): Temperature monitoring labels after activation show color change the moment temperature goes above 8°C and these can be used for Blood Banks concerns as stated earlier.
- Study of the suitability of Timestrip Plus: for measuring the temperature breach occurrence experienced by blood bag.
- From blood collection from donor to release to cold room.
- From issue of blood bag for use and return of unused blood bag to blood.
- Study the temperature breach occurring during
- Blood transportation and storage.
- Labeling, checking, and preparation of use.
Materials and Methods: Sample size: total 30 bags, five blood bags to be studied per day each, over a period of 6 days
- Of the total temperature breach occurring for the blood bags, nearly 77% temperature breach occurs in untested fridge section and rest nearly 23% temperature breach occurs in the cold room section.
- Of total 15 blood bags, all of them showed temperature breach in untested fridge section, that is 100% of blood bags showed temperature breach in untested fridge.
- Of total 15 bags, 7 bags showed temperature breach in cold room at the time of taking inventory, that is, 47% of blood bags shows temperature breach in the cold room section.
- Of total 13 bags issued to operation theatre, 7 bags showed temperature breach in cold room, that is, 53% of blood bags shows temperature breach before handing it to operation theatre
Conclusion: Major temperature breach occurring at the untested fridge section can be reduced by having and following proper working procedure by blood bank.
Temperature breach is believed to be occurring only during labeling, checking, and preparation for use and other activities etc.
Activated Timestrip is an active system that reports the time of total temperature breach occurring.
Timestrip ensures that cold chain is maintained for blood bags and helps blood bank to take necessary action/changes, if breach occurs.
Considering if 10% error in above trial then also nearly 900 bags per month (Monthly inventory of 1,000 bags per month) will have temperature breach in untested fridge and 430 bags will have temperature breach before going out of blood bank.
Path we traveled in quality assessment: Lessons we learnt
Background: The quality assessment program is a valuable management tool destined to improve the efficiency and service of a laboratory in particular and a hospital in general. Continual improvement of blood bank laboratory performance can be achieved by internal quality control and external proficiency scheme. It provides competent external proficiency testing to improve the existing standards of diagnostic services in transfusion medicine. External quality assessment is used to monitor blood bank ' s continual performance and improvement. Our institute got registered for external quality assessment in red cell serology in 2006, in order to improve the quality level and decrease the errors in blood banking.
Aim: This retrospective study was performed to know the journey of our quality status in red cell serology testing and to highlight the importance of quality assessment.
Materials and Methods: Since 2006, samples were evaluated for ABO grouping, Rh typing, compatibility testing and from 2011 for antibody screening and identification three times a year under the EQAS- Transfusion Module, CMC, Vellore. All tests were performed using conventional tube technique in the initial years followed by both tube and column agglutination technology when the latter was introduced in our institute. Antibody screening and identification were done using commercially available red cell panels. The entire tests will be done by the technicians who routinely do the serology test. The same tests will also be done by our residents separately as a part of internal quality assessment.
Results: Out of 153 samples assessed, negative scoring which we got was about 3.27%. Clerical error in the interpreting ABO group (20%) and improper documentation in compatibility testing (60%) were the main reasons for our negative scoring. In one instance, we failed to detect one incompatible sample that made us to analyze the problem and to rectify it. There were no interobserver variation between our technicians and residents denoting that our internal quality control is in pace. Increased negative scoring in the earlier years has now decreased to a major extent due to continuous improvement in our quality systems.
Conclusion: Regular participation in an external quality assessment scheme is critical for ensuring acceptable laboratory performance. Quality assessment program helps participants to detect their potential problems. Such a practice not only furnishes the outcome of a correct result, but also maintains confidence in the facility. It appears to be an important tool that contributes to safer blood supply. It assisted us to identify and minimize errors and recommend corrective measures. Though the results were satisfactory in majority of the situations, the real outcome would be known if the sample were tested without any bias. So, quality assessment should be maintained in all blood banks in order to ensure effective transfusion service and safety of patients. We believe that global participation in such a program will definitely improve the quality of a hospital service because no health care facility can be totally self-sufficient and there is always an inclination for improvement and development in a system.
Evaluation of the quality and extension of shelf life of packed red blood cells: A prospective study
P B Arumugam
The Tamil Nadu Dr. M.G.R Medical University, Chennai
Introduction: In blood transfusion service, the primary goal of quality is 'transfusion of safe unit of blood'. The objective is to ensure availability of a sufficient supply of blood, blood components of high quality with maximum efficacy, and minimum risk to both donors and patients. A failure in the quality of blood collected or screening of donated blood unit can be very serious and may result in fatal consequences. Good quality control measures help us to attain minimal accepted standard limits for viable and potent blood products.
Aim: To ensure that packed red blood cells units prepared, consistently meet requirements for quality, safety, and potency and find out the possible extension of shelf-life of Packed Red Blood Cells units.
Materials and Methods: Forty units of packed red blood cell units prepared by platelet-rich Plasma method and stored in CPDA-1 were tested on 0, 7, 21, 35/42, days for the following parameters: volume, hematocrit, plasma hemoglobin, potassium, sodium, glucose, LDH, malondialdehyde, and bacterial culture. The parameters were evaluated as per the DGHS, AABB, and WHO guidelines.
- Volume and Hematocrit values were within the acceptable range as per DGHS norms.
- Plasma hemoglobin values from day 0 to day 35 was gradually increased and were found to be within the acceptable range as per DGHS norms except on 42nd day.
- Plasma potassium and sodium levels were gradually increased and decreasing respectively from day 0 to day 35. The values obtained were within normal range, fixed by DGHS, except on 42nd day.
- Plasma glucose level was gradually decreased from 345 ± 67 to 38 ± 18 mg/dl from day 0 to day 35 of storage. These findings are supported by two studies. However, on day 42 the level of plasma glucose is drastically reduced to 6 ± 3 mg/dl.
- The measurement of markers of oxidative injury to red cells 'Malondialdehyde ' along with LDH show gradual increase in their levels from day 0 to day 35. Similar findings were observed in two other studies.
- Bacterial culture study showed no growth in all samples except 1 sample on 42nd day.
Conclusion: Our study on evaluation of the quality of packed red blood cells (PRBC) in a consecutive scheduled time period within fixed and slightly extended shelf life revealed adherence to various quality parameters. However, the study of various quality parameters evaluated on the extended storage period of packed red blood cells (PRBC) showed noncompliance to the standardized quality control. Hence, extension of the shelf-life of Packed Red Blood Cells in CPDA-1 from 35 days to 42 days would not be possible. However with the help of additive solutions, storage period of red blood cells can be prolonged. Since most of the biochemical parameters including markers of lipid peroxidation increases in Packed Red blood Cells in CPDA-1, it is also advisable to study further with regard to shortening of shelf life to alleviate adverse effects of transfusing blood units nearing expiry. The quality of blood components may further be studied by rapidly developing science like proteomics, which helps to assess protein composition and its modification.
Error identification, reporting, and preventive measures implemented at RVBB & RC: A standalone blood centre
Rajkot Voluntary Blood Bank & Research Centre
Background: Stand-alone blood bank faces more challenges in transfusion services in error identification and reporting system as compared to hospital-based blood centers, because all requests for blood and blood components are received from independent hospitals and clinics. RVBB & RC is a regional blood centre of the Saurashtra region and therefore we planned a study to assess transfusion-services-related challenges and implemented preventive measures.
Aim: To determine the effect of monitoring of blood request forms for error notifications and promoting judicious use of blood components.
Materials and Methods: This study was conducted from Jan 2011 to Dec 2012 and all the blood request forms were thoroughly assessed. Requisitions (N = 27,377) were monitored by trained Medical Officers for compliance with institutional guidelines. We focused on incomplete blood request forms and samples received. Appropriate blood component therapy still remains a challenge in our region. Continuous communication with clinicians was made for promoting blood component therapy and for advising across the group transfusion as well as post transfusion reaction notifications.
Result: A total of 27,377 blood requisition forms were analyzed over a period of 2 years, out of which 405 (1.47%) were incomplete. Majority of the incomplete forms (N = 405) were lacking the stamp of the hospital (N = 352) which is 86.91% of the total. With dynamic communication with clinicians better understanding of criticality of each was understood and observed by gradually decreased level of incomplete patient ' s blood requests. Acceptance of across the group transfusions also increased after active intervention. Four hundred and one (1.46%) patient requests were successfully converted for across the group components and a total of 1,315 units (RCC: 11.71%, FFP: 7.98%, PC: 67.52%) were transfused to 401 patients. Unnecessary transfusions were avoided and cross-match to transfusion ratio (C:T) was 1: 1.02 (42,010: 41,089) as compared to the ideal CT ratio, that is, 1:1.5
Conclusion: The study was useful to capture the error related to patient ' s blood request. Monitoring of blood request forms also reduced inappropriate transfusions. Single unit blood transfusions were minimized and hospital transfusion committee is formed to ensure appropriate blood product use by developing local policies, educating clinicians, and auditing blood usage.
Effect of ambient temperature on the clotting factors of fresh frozen plasma produced after 24 h of whole blood collection
Armed Forces Medical College, Pune
Introduction: Inventories of components in blood banks are facing challenges due to the voluntary donor pool shrinking and restriction of processing time.
Aim: The aim of this study was to assess whether the quality control parameters of fresh-frozen plasma produced from whole blood stored at ambient temperature for 24 h are adequate for their intended use.
Materials and Methods: We compared the amounts of factor VIII, ibrinogen, and vWF of fresh-frozen plasma produced from whole blood after storage at room temperature for 24 h of donation (24FP), with plasma prepared within 8 h of donation (FFP). Each donated whole blood unit was divided into equal halves and one-half kept at room temperature for 24 h and other part for less than 8 h.
Results: The fibrinogen levels were 251 ± 53 and 236 ± 63 mg/dL in FFP and 24FP, respectively. Six percent reduction of fibrinogen in 24FP was observed. The values of FVIII activity were 70 ± 35 iu/ml and 56 ± 26 iu/ml in FFP and 24 FP, respectively. Twenty percent reduction of FVIII was statistically significant. The values of vWF were 92 ± 41 and 68 ± 34 iu/dL in FFP and 24FP, respectively. This 26% reduction of vWF was statistically significant.
vWF in blood group B and FVIII in blood group O has reduced to statistically significant amount in 24 FP.
Conclusion: Despite the significant reduction of factors, in 24 FP the levels are still higher than normal homeostatic values and hence can be used clinically. The analyzed quality of 24FP separately, among individual blood groups, has revealed that 24FP surpasses the mandatory quality control requirements, and therefore, can be utilized for the same indication as FFP.
Comparative analysis of activity of coagulation factors V and VIII and level of fibrinogen in fresh frozen plasma and frozen plasma
Background: The aim of this study was to analyze and compare the activity of Factor V, VIII, and fibrinogen level in fresh-frozen plasma and frozen plasma frozen after 8 h but within 24 h after phlebotomy.
Materials and Methods: Fresh-frozen plasma separated from whole blood within 8 h was compared with plasma separated within 24 h after phlebotomy in terms of coagulation factors V and VIII and level of fibrinogen by standard methods using semi automated coagulometer Sysmex CA50.
Results: Longer storage of whole blood before processing resulted in significant decrease (18.4%) in activity of factor VIII but the fall in activity of factor V (6.52%) or level of fibrinogen (1.81%) was not significant.
Discussion: These data suggest that there is good retention of coagulation factors in both types of plasma. Although there is significant fall in activity of factor VIII, but it is an acute phase reactant and raised in most of the diseases so it is suggested that frozen plasma would be an acceptable product for most patients requiring fresh frozen plasma.
Blood is a drug, but does salt concentration (Hb) in a unit matters
Fortis Hospital, Shalimar Bagh, Delhi
Introduction: Packed red blood corpuscle (RBC) transfusion decisions are primarily based on hemoglobin (Hb) level of patient and other parameters like end organ ischemia are seldom considered. All RBC orders are for units of blood and Hb content per bag - which varies considerably and is not mentioned - is ignored. We planned to study the effect of Hb content of bag on actual increase of Hb in patients post RBC transfusion.
Material and Methods: Fifty (30 female and 20 male) nonbleeding, euvolemic, adult patients who received only RBC transfusion, were randomly selected for measuring actual increase in Hb post-transfusion. Hb content of blood bag, used for transfusion to these patients, was calculated using donor data in blood bank. An expected increase in Hb of patient was calculated based on this Hb content and patient ' s total blood volume. Actual increase and calculated increase in Hb were analyzed for correlation. Student t-test was applied to check the statistical significance.
Results: One RBC unit led to an increase of 0.8-1.3 and 1.0-1.9 gm/dl of Hb in male and female patients, respectively. Mean increase in Hb was more in females as compared to males (1.50 vs. 1.07 gm/dl; P = 0.001) per RBC unit transfused. Based on Hb content of individual RBC unit, an excellent correlation between calculated and actual Hb increase on individual patient basis was found (r = 0.856; P < 0.01).
Conclusion: Notion of 1 gm/dl increase in Hb per RBC unit transfusion both under and over estimates the actual outcome in individual patients. This may vary from 20-90% which is unacceptable in today ' s individualized patient care scenario. RBC transfusion based on actual Hb content of bag gives an excellent outcome prediction and should be used to make RBC transfusion decisions. Unscientific ' number of units ' based system of RBC transfusion should be abandoned. However, more studies on bigger sample size are required to further this concept.
Blood inventory management of Rh negative blood groups based on clinician needs in a tertiary care centre
S Vijaya Laxmi
Nizams Institute of Medical Sciences
Introduction: The Rh blood group system is the most polymorphic of the human blood groups, consisting of at least 45 independent antigens and, next to ABO, is the most clinically significant in transfusion medicine. Rhesus negative inventory management is different from Rhesus positive. Demand for Rhesus negative red cells tends to be variable and based on clinicians need which may not be balanced with regular blood donors thus facing shortages at certain times Prevalence of the Rh-D negative phenotype is 8-10% of the population. Awareness, distribution, and utilization of Rh-D negative ABO groups are very important in effective management of massive transfusion protocols and emergency blood transfusion.
Background and Aim: To study the ABO Rh-D negative ABO group distribution among the donors, utilization in patients, and wastage in a tertiary care centre.
Materials and Methods: Total number of donors included in the study were 66,628 over a period of 2009-2013 till date. Reviewed the following details type of blood donation, clinical use of O, A, B, AB Rh-D negative red cell units, age of red cell unit at the time of transfusion, and wastage of Rh negative blood units.
Results: Among the total blood units (66,628) collected during 2009-2013 till date, O, Rh-D neg - 2.75% A Rh-D neg - 0.94%, B Rh-DNeg -1.5 1%, AB Rh-D-Neg - 0.36%, Oh Rh-D Negative - 0.03%. Among these Rh negative units 20% were utilized in first 5 days of collection, 50% utilized during the 6-20 days of collection. There is 10% of wastage for 'O' negative blood units. Twenty percent of wastage for AB negative blood units. 13.5% for A negative and 12.5% for B negative blood groups. The reason for discarding these blood units was 30% infectious marker positivity (transfusion transmitted disease) and 70% expiry. In emergencies on case basis patients are transfused with Rh-D- positive groups, 'O' negative as universal donor.
Conclusion: Total Rh-D negative ABO groups constitute 10% of the collection. Building donor panels by blood type is mandatory for these blood groups. Large-scale predonation blood grouping will help in establishing the population distribution of these Rh negative groups.
Blood discard rate at a tertiary care hospital: Reasons and resolutions
Sri Ramachandra Medical College and R.I, Sri Ramachandra University
Background: Blood utilization rate and blood discard rate are quality indicators for a blood transfusion service. Blood is the essence of life. Considering the fact that human blood is a precious resource that should not go waste, blood discard rate should ideally be near 0; but in practice, it is not so.
Aim: To estimate the discard rate of blood components and determine the reasons for discard in order to implement effective strategies to prevent wastage.
Materials and Methods: This study was undertaken by the Department of Transfusion Medicine, SRMC & RI, Sri Ramachandra University, Chennai, during the period January 2013 to April 2013. Discard of blood components were recorded everyday in the 'Blood Discard Register' with the reason for discard. Data were analyzed subsequently.
Results: The discard rate for the individual blood components was as follows: packed red blood cells (PRBC) - 2.3 1%, fresh-frozen plasma (FFP) - 6.63%, and platelet concentrates (RDP) - 23.2 1%. The most common reason cited for discard of PRBCs was (surprisingly) 'outdate' of the units. FFP discard was commonly attributed to leakage of the bag. As is expected, because of their short shelf life, platelets had the highest discard rate. Other reasons cited for discard were - clots/lysis (in PRBC bags), precipitates and RBC contamination (in FFP). A root cause analysis (RCA) and corrective and preventive action (CAPA) were carried out on the aforementioned issues subsequently. Discard rate for apheresis platelets (SDP) was zero.
Conclusion: Considering the immense benefits and value of human blood and the shrinking donor pool, measures to minimize blood discard rates have to be taken drastically. Appropriate inventory management, staff education and training and proper communication between the physician and the blood bank will help in reducing the blood discard rate. Platelet discard rate can be minimized by preparing apheresis platelets as and when required.
Blood components discard rate as an indicator of quality
Latha fathima J
St. John's Medical college Hospital, Bangalore
Background: The transfusion of blood and blood components has become an integral part of treatment regime. Blood bank plays a vital role and is responsible for ensuring the quality and safety of blood and the blood components transfusion. Adequate units of blood and components should be made available in blood banks, to ensure availability to needy patients. This is a major challenge which all blood banks face. To overcome the deficit, the blood banks have to increase the resources of blood supply, like motivating the voluntary donors and organizing blood donation camps. Besides this, blood banks can contribute to conserving the blood supply by reducing the wastage of blood and blood components. Blood is discarded due to various reasons like, seropositivity for viral markers HIV, HBV, HCV, the presence of malaria parasite and VDRL reactivity. Improperly managed blood inventory, difficulties in the collection and processing of blood can also contribute to a small percentage of discard. This study is undertaken to study the discard rate, various causes of discarding of blood and blood components in the past 5 years and steps that can be taken to minimize the discarding.
Materials and Methods: A retrospective study from February 2013 to March 2008 (5 year period) was undertaken in blood bank services, St. John's Medical College Hospital, Bangalore, India. The blood bank records were reviewed and analyzed.
Results: Total number of donors for the 5 years (February 2013to March 2008) was 75,882. The average number of donors in a year was 15,176. Total HIV reactive units in 5 years were 328(0.43%). The reactivity was 0.4% in the year 2008 and has declined to 0.1% in the current year. Hepatitis B reactivity ranged from 0.7% to 1.4%. HCV reactivity ranged from 0.3 5% to 1.1%. VDRL test results show a declining trend from 0.4% in 2008 to 0.04% in 2013. The percentage of broken units of fresh frozen plasma discarded varied from 3.1% to 4.8%. The rate of discarding of expired units of platelet concentrate ranged from 0.7% to 4%. Technical difficulties in blood collection is also one of the causes for discarding blood.
Conclusion: According to this study the rate of discarding of blood and blood products due to transfusion transmissible infections show declining trend. This is probably due to stringent donor screening procedures and improved awareness. The discarding of expired units of platelet concentrates could be minimized by methods that can facilitate extended storage of platelet concentrate. In addition, the preparation and usage of platelet concentrates need to be monitored continuously to minimize discarding due to expiry. Technical difficulties contributing to discard of blood could be minimized by regular training for technical personnel especially the new recruits.
Audit of platelet transfusion in Tata Memorial hospital
Tata Memorial Hospital, Mumbai
Background: In oncology cases, platelet count is affected primarily by the disease, particularly in hematolymphoid malignancies, as well as by the intensive therapeutic agents. The platelet count can fall to its nadir making the patients dependent on transfusion of platelet products to prevent bleeding complications.
In our hospital, the transfusion service provides random donor platelet (RDP) concentrates and single donor platelet (SDP) concentrates. Due to short shelf life of platelet products and their considerable requirement it is difficult to maintain adequate platelet inventory. Hence, judicious use and adherence to guidelines is important for platelet transfusions. Based on AABB and BCSH guidelines hospital transfusion guidelines are set for platelet transfusion.
Aims: To study practices of platelet transfusion in different oncology sections based on medical or surgical indications, treatment, and whether RDPs or SDP is transfused.
To study practices with reference to modalities such as plasma reduction and gamma irradiation.
Materials and Methods: This was a prospective study of 500 platelet transfusion events at Tata Memorial Hospital. Patient details namely case number, age, sex, clinical diagnosis, blood group, indication for platelet transfusion like fever, infection drug therapy, invasive procedure, or symptoms of internal or external bleeding, pretransfusion platelet count, and number of units and blood group of units issued were noted from requisition form. Cases were discussed with clinicians wherever required. Indication for modification of platelet units such as plasma reduction and gamma irradiation were noted and analyzed.
Result: Among 500 platelet transfusion events, 345 (69%) were for adult patients and 155 (31%) were for pediatric patients. Total 447 (89.2%) platelet transfusions were done for patients of hematolymphoid malignancy while remaining 53 (10.8%) were for different medical and surgical oncology cases. Three hundred sixty one (72.2%) events were in inpatients while 139(27.2%) were for outpatients. Three hundred eighty seven (77.4%) were prophylactic and 113 (22.6%) were for therapeutic purpose in bleeding patients. Two hundred and seventeen (43.4%) requests were catered with 583 units of RDPs and for rest 283 (56.6%) cases 161 units of SDPs were issued.
Only 22 (4.4%) SDP transfusions were done across ABO group amongst which 10 units were either ABO plasma compatible or plasma reduced and rest were plasma incompatible and non plasma reduced, but were divided into half units to reduce antibody exposure. Four hundred and forty one (88.2%) transfusion events were as per the guidelines while remaining 59 (11.8%) were not. Requirement for gamma irradiation was in 424 (84.8%) cases. All platelet products were gamma irradiated to prevent transfusion associated graft versus host disease.
- In our setup majority of platelet transfusion were done for prophylactic purpose and most of them were as per the guidelines.
- 8729; Plasma reduction for SDP unit was done to reduce amount of incompatible plasma non-ABO-specific products were issued.
- Gamma irradiation was requested in 84.8% of events. However, at our centre all platelet products are gamma irradiated to prevent TA-GvHD.
- Continuous coordination between clinician and transfusion services allows judicious use of platelets.
Analysis of the partial units issued at Blood Bank of Guru Gobindsingh government hospital
Dimel K Bhuva
M. P. Shah Medical College, Jamnagar, Gujarat
Background: The partial units issue by aliquots is mostly indicated in neonates, the volume required for transfusion is as per patient ' s weight. Instead of issuing the entire bag, the required volume to be transfused should be made into aliquots and issued. This will also help in inventory management.
Aim: To analyze the issue of partial units data.
Materials and Methods: The period of study is from January 2010 to May 2013. During that period total number of issues had done 54,190 units. Aliquot was prepared using sterile-tube-connecting-device system, which is a closed system. Hence, the expiry date remains same which is 35 days from date of collection.
Result: The total number of partial units issued 4, 140 which are 7.64% of total issue. The most common group for which aliquot was done was O+ve which is 35.63%. Minimum and maximum volume was 10 and 320 cc, respectively. Maximum numbers of partial units were issued in the month of October 2012 which was 152. Minimum numbers of partial units were issued in the month of April 2010 which was 49. The remaining blood volume of the mother bag was issued to other patient after doing cross match.
Discussion: O+ve group partial units were maximum issued as O+ve units were compatible with mother and baby's sample. Depending on the weight of neonates the volume of aliquots can be prepared. Thus, remaining blood volume which was used to be discarded after 24 h due to open system, now can be reduced as sterile tube connecting device are used. Maximum issue of total blood units was in the month of October 2012; hence, partial units issued were also increased.
Conclusion: Issuing of partial units to the neonates and infants using sterile tube connecting device helps us to maintain the same expiry as that of mother bag, also the same bag can be issued to same patient for 2-3 times as per requirement, and thus enabling us to manage our blood bank inventory.
An audit on the pattern, determinants, and outcome of blood transfusion in a tertiary neonatal unit
Aboobacker Mohamed Rai
Jubilee Mission Medical College & Research Institute
Background: Blood transfusions are very common in a neonatal unit. Patients often need a large number of blood transfusions but each may be as little as 9 ml. Our guideline was developed in 2013 and a retrospective audit was done.
Objective: To determine the pattern and determinants of blood transfusion in JMMC & RI neonatal unit.
Materials and Methods: Newborn babies who required blood transfusions between September 2012 and June 2013, were studied. The sex, gestational age, birth weight, inborn or outborn, clinical conditions such as the presence of congenital heart diseases and hyperbilirubinemia were included. Indications, dose, time to completion of all transfusions, and their outcome were analyzed.
Results: A total 1,165 of neonates were hospitalized and 129 had blood transfusion; 120 had exchange transfusion, 57 had red cell transfusion, and 4 had plasma transfusion. There were transfusions with a rate of 15 transfusions per week. Blood transfusions were done for severe jaundice, severe anemia. Weight < 2.5 kg, outside delivery, and jaundice were independent determinants of neonatal transfusion. Out of 622 transfusion episodes for different components, no episodes were detected inappropriate. Highest inappropriate use was for FFP. Babies received between 1 and 12 blood transfusions. There were babies who were exposed to up to 12 unnecessary donors.
Conclusion: The blood transfusion rate in this facility was remarkably high. Improved standard of newborn care and infrastructural support are required to reduce the transfusion rate. There was very poor adherence to the protocol resulting in unnecessary exposure to multiple donors. This was felt to be due to poor compliance with the guideline, poor communication between the neonatal unit, and transfusion physicians and an increase in the need for blood transfusions.
To ensure small volume aliquots for each baby from a single donor.
To have regular CME/sessions for the clinical staff on transfusion aspects.
To improve communication between the neonatal unit and blood transfusion.
To re-audit to ensure that improvements have occurred.
A retrospective audit on blood requirements in primary total knee replacement surgery
Global Health City, Chennai
Introduction: A maximum surgical blood ordering schedule may lead to the wastage of valuable resources due to over-ordering of blood and/or under-utilization. Total knee replacement (TKR) surgeries are usually associated with significant blood loss and perioperative transfusion. The aim of this retrospective study was to determine perioperative blood loss and blood transfusion requirements in patients who underwent primary unilateral total knee arthroplasties at our hospital.
Patient and Methods: A retrospective audit of 50 consecutive patients, who underwent primary unilateral total knee arthroplasties at the orthopedic unit between July 2011 and January 2013 (18 months), was undertaken. Patients undergoing revision or bilateral TKR surgery were excluded from the study. The following information was recorded for each patient: age, gender, duration of surgery, preoperative hemoglobin, estimated blood loss, the number of units requested, number of units patients transfused, cross match to transfusion ratio (C:T), transfusion indices. Data collected were analyzed using Microsoft Excel Descriptive statistics.
Results: During the study period, 50 patients (35 females, mean age 66 years) underwent primary unilateral TKR. The duration of surgery was 250 ± 51 min. The estimated blood loss during surgery was 684 ± 425 ml. Two to three units were crossmatched and reserved for each patient before the surgery. Out of one hundred and nine units of blood crossmatched, only eight units (7%) (two intraoperative and six postoperative) were transfused. Ninety percent (n = 45) patients received no transfusion. Only five (10%) patients received blood during surgery (n = 2) or postoperative phase (n = 3). There was no use of autologous or intraoperative salvaged blood also. Preoperative hemoglobin level for nontransfused patients was 12.2 (9.8-15.4) gm/dl while preoperative hemoglobin for transfused patients was 10.7 (8.8-13.4) gm/dl. More than 93% of the cross matched units were not transfused. Therefore, the primary TKR procedure had a high CT ratio (13).
Discussion: For routine primary unilateral TKR, Group and save policy is implemented after the approval from hospital transfusion committee and orthopedic surgeons. Reduction in nonutilization of blood has economic and cost-saving implications for limited healthcare resources. However, a patient's risk of requiring a transfusion during surgery and in the immediate postoperative period is an important element of effective blood management. It is essential for every institutional blood bank to formulate a blood ordering schedule in conjunction with the clinicians for appropriate blood usage.
Effect of the hemochromatosis mutations on iron overload among the Indian beta thalassemia carriers
National Institute of Immunohematology
Background: Hereditary hemochromatosis (HH) is an autosomal recessive disorder of iron metabolism characterized by increased iron absorption and progressive storage resulting in organ damage. HFE gene mutations C282Y and H63D are responsible for the majority of hereditary hemochromatosis cases. The aim of this study was to determine the allele frequency of these two mutations in the HFE gene among the Indian population and evaluate the effect of these mutations on the iron status.
Materials and Methods: A total of 100 beta thalassemia traits with 100 normal control individuals were screened for the C282Y and H63D mutations using PCR-RFLP. The serum ferritin levels were determined using ELISA kit and were correlated with HFE gene mutations.
Results: We did not find the C282Y mutation in our study group. The allelic frequencies for H63D mutation did not differ significantly between beta-thalassemia carriers (8.5%) and normal controls (9%). In the beta thalassemia carriers mean serum ferritin levels were increased among heterozygotes (H/D,143.16 + 80.3 ug/dl) and homozygotes (D/D,504 ug/dl) for the H63D mutation as compared to individuals showing the absence of this mutation ( H/H,88.64 + 92.43 ug/dl). In both the study groups a statistically significant difference was seen between the mean serum ferritin values in the H/H and D/D groups.
Conclusion: These results suggest that iron load in beta-thalassemia trait tends to be aggravated with the co-inheritance of the H63D mutation, even when present in the heterozygous state. Haplotype analysis of the mutant H63D gene showed the presence of haplotype 6 which is reported in the European population suggesting a common origin in both the populations.
Titer of ABO antibodies in group O blood donors
Saket City Hospital
Background: Use of O blood group transfusions to patients of all groups has continued since long. The clinical significance of ABO antibody titer in ABO-I kidney transplantation is well known. Very few studies have been done to detect ABO antibody titers in the collected plasma components of group O blood donations. These passively acquired antibodies may destroy the recipient's own red cells and tissue grafts, cause acute hemolysis, hemoglobinemia, jaundice, progressive anemia, spontaneous agglutination, positive direct antiglobulin test, and increased osmotic fragility of the patient's red cells.
Objective: The aim of this study was to evaluate agglutinin levels in blood donations. Group O donor population, was randomly titrated using tube technique to identify the titer levels for Anti A and Anti B antibodies. Both IgM and IgG titer levels were evaluated to identify the best source.
Materials and Methods: Samples from 90 blood group O donors were tested by ABO antibody titration using the conventional tube technique at 37°C. ABO antibody levels were categorized as those higher than eight and those lower than eight. After treatment with Dithiothretiol (DTT) for characterization of only IgG class, the titer's levels were again tested in the same O group blood/apheresis donors. Statistical analyses were performed using the Chi-square and Kruskal-Wallis tests.
Results: Most donors in the blood bank were male (96.6%). ABO antibody titers were categorized as 0 to 8 and 8 to 128 for both IgM and IgG titers. The estimations of prevalence for the titers were: anti-A IgM8 in 36.67 %donors; anti-A IgG8 in 90% blood donors; anti-A IgM > 8 in 63.33% of blood donors; anti-A IgG > 8 in 10% of the blood donors studied and anti-B IgM8 in 56.67% blood donors; anti-B IgG8 in 90% of blood donors; anti-B IgM >8 in 43.33% of blood donors anti-BIgG >8 in 10% of blood donors. Overall it is seen that for anti-A and anti-B IgG antibody, antibody titers >8 is prevalent for approx. Ten percent of the population and is statistically significant (P<0.001). Higher titers were noted in age groups 30 to 39 years as compared to above 40 years.
Conclusion: The study confirms that titration of ABO antibodies in blood banks will increase safety in nonidentical ABO transfusions and transplants. Also that over 40-year-old O group males should be preferred as blood/apheresis donors in nonidentical ABO transfusion situations.
Serologic profile in a bidirectional ABO incompatible HSCT
Tata Medical Center, Kolkata
The ABO blood group system is of critical importance in transfusion practice but has had less impact in hematopoietic transplantation. Post-transplant there is a delay in recovery of red cells until loss of isoagglutinins directed against donor red cell antigens. We describe the serologic findings in a case of bidirectional ABO incompatible allogenic HSCT Case history: A 62-year-old male, case of Chronic idiopathic myeloibrosis, JAK2V617F mutation negative, received ruxolitinib and was transfusion dependent since August 2011. He was given Fludarabine + busulfan conditioning regimen and underwent ABO incompatible HSCT on January 31,2013. The donor was the patient's brother. Patient was group A Rh-D positive and the donor was group B Rh-D positive. Hence, there was bidirectional ABO incompatibility. Six weeks after the transplant, the patient developed pure red cell aplasia (PRCA) on bone marrow examination. At our center, patients blood group, direct antiglobulin test (DAT), antibody screening and antibody titration was done periodically and patient is on follow up till date. Blood group and isoagglutinin titer was done. Blood grouping was done by tube technique and column agglutination technique (Ortho Biovue System). The iso agglutinin titration was done by the dilution method, AABB Tehnical Manual (16th edition). Saline method for IgM antibody and AHG method for IgG antibody was used. Major serologic findings: Pretransplant blood group was A-Rh (D) positive. Pretransplant saline titer was 16 post transplant the titer peaked between 3rd to 6th week at 2048,1024 and 512 and then remained steady till the 13th week post-BMT. Thereafter, titer gradually declined over the next 8 weeks. Present titer, at 21 weeks is 4. The AHG titer was missed out initially but when the saline titer was rising, AHG titer was done. The pattern of AHG titer was similar to that of saline titer and was 1,024 at 12 weeks, 128 at 17 weeks. The AHG titer has also now declined and come down to 2, at 21 weeks post BMT. The reverse group still continues to be A Rh (D) positive. Direct antiglobulin tests (DAT) and antibody screening tests were negative till date.
Discussion: The ABO type of blood components transfused to ABO incompatible transplants depends on both, recipient and donor blood group. For this patient, we used O Rh (D) positive packed red cells and AB group FFP. The preferred choice of platelets was AB Rh(D) positive, but when these were not available, out of group platelets were given. Both the platelet and red cells given were irradiated products (25 Gy irradation, on Co 60 irradiator). The recipient RBC requirement remained same throughout the entire post-transplant period. A high iso-agglutinin titer may be an early indicator of complications such as PRCA. The blood group determination, and their interpretation is also important. It is necessary to use sensitive techniques (CAT) in addition to the tube technique so that weak reactions are not missed.
Prevalence of Sickle Cell disease in Soligar Tribe of India
Shashibhushan S Varekar
Bangalore Medical College and Research Institute
Background: Sickle cell disease (SCD) is genetic disorder caused by mutation leading to abnormal haemoglobin synthesis. Several studies have reported high prevalence of SCD in few tribal areas in India. Symptoms of sickle cell disease have also long been observed in the Soligar tribal population of the BR Hills region of Karnataka. For many years, patients at the hospital founded by the Vivekananda Girijana Kalyana Kendra (VGKK) organization have undergone genetic screening to test for sickle cell disease regardless of their symptoms. These medical records were compiled and examined in the course of this study to assess the prevalence of sickle cell disease in the population.
Materials and Methods: Data were obtained through routine genetic screening of all patients in the region's central hospital regardless of symptoms over two time periods, from 1995 to 2000 and from 2003 to 2005. Each patient's genotype was determined through hemoglobin electrophoresis.
Results: Out of all the records present, 1,099 had complete information. Prevalence of SS genotype was found to be 1.91%. Heterozygotes formed 23.66%. There was slight female predominance in SS group. Sickling rate was found to be 0.256 based on gene frequency calculation.
Conclusion: Prevalence of sickle cell disease in Soliga tribal population was found to be higher. Targeted diagnostic and therapeutic interventions are needed to protect this vulnerable population.
Prevalence of irregular red blood cell antibodies among healthy blood donors in (East) Delhi population
Guru Tegh Bahadur Hospital and U C M S
Objective: To evaluate the prevalence of the anti-red blood cell antibodies among healthy blood donors. Introduction Regional Blood Transfusion Centre (East) is collecting more than 30,000 units of blood annually. The Centre has the Blood component separation supported by NACO, Govt. of India. We have started donor antibody screening with three cell panels in July 2011. This is the presentation of work that we have done in our centre.
Material and Methods: Retrospective data of Blood Donors was recorded in Regional Blood Transfusion Centre, during the period of about two years from July 2011 to May 2013. Three cell panel ID-DiaCell I-II-III (Bio-Rad, Cressier, Switzerland) was used on Bio-Rad ID-System to determine the presence of antibody in donors. Positive antibody screening cases were further identified for specific antibody using ID-DiaPanel (Bio-Rad, Cressier, Switzerland).
Results: Total 60,224 units were collected during this time period and out of which 48 antibody screen positive donors were found. So frequency of antibody positive donor in our hospital is 0.079%. All positive donors by antibody screening panel were further processed for the specific antibody. We have got 39 donors with single alloantibody specificity - anti-N: 10 nos. (20.8%), anti-M: 8 nos (16.6%), anti D: 6 nos (12.5%), anti Lea: 5 nos (10.4%), anti-E: 3 nos (6.25%), anti S: 3 nos (6.25%), anti C: 1 nos (2.08%), anti-c: 1 nos (2.08%), anti-K: 1 nos (2.08%), anti-Cw: 1 nos (2.08%). We have got seven donors with multiple alloantibodies: 5 with Anti E+ Anti K (10.4%), one with Anti E+ Anti K + Anti S (2.08%) and one with Anti Lea + Anti Leb (2.08%). In two donors the specific antibody could not be found out.
Conclusion: Antibody screening of donor must be performed as a routine test. Preferably it should be done with three cell panel carrying all the clinically significant antigens in homozygous stage, or it should be performed with commercial available pool O cell as it is carrying all the clinically significant antigens so that transfusion of donor plasma containing red cell alloantibodies can be prevented.
Prevalence and specificity of unexpected red cell antibodies and factors affecting their formation in multi-transfused thalassemia patients: A prospective study at a tertiary care center
Civil Hospital, Ahmedabad, India
Background: Palliative treatment of thalassemia in the form of blood transfusion is eventually compromised by the concomitant problems of iron overload, alloimmunization, and blood-borne infections. Alloimmunization to erythrocyte antigens is one of the major complications of transfusions, particularly in patients who are chronically transfused. Rate of alloimmunization is higher in patients receiving nonleuko reduced blood and in whom splenectomy is performed.
Aims and Objectives: To screen and identify unexpected antibodies in multi-transfused thalassemia patients and to study the effect of splenectomy, age of start of transfusion, number of transfusion on formation of alloantibody, and autoantibody.
Materials and Methods: A total of 200 patients diagnosed with β-thalassemia major, who received regular transfusions, were screened by using BIORAD three-cell panel. In patients who were found screen positive, antibodies were identified by eleven cell identification panel.
Results: Red cell alloimmunization was found in eight (4%) patients. Out of eight, four (50%) of them developed Anti-K antibody, three (37.5%) developed Anti-E antibody, and one of them developed both Anti-E and Anti-Jka. Out of 200 patients, 38 (19%) patients were likely to develop autoantibodies, as determined by persistent or transient positive direct antiglobulin test (DAT) using polyspeciic coombs gel card. Out of 38 patients who were positive for direct antiglobulin test (DAT), 33 (86.84%) were positive for IgG antibody and 5 (13.15%) were for cold IgM antibody. Two (1%) of the patients in our study developed both alloantibody and autoantibody. Out of 38 (19%) DAT positive patients, 15 had positive auto-control confirming the presence of autoantibody.
Conclusion: Across the world, the frequency of alloimmunization among thalassemics ranges from 3.7% to 38%, most common alloantibodies being directed against Rh and Kell blood group systems. The complications of alloimmunization that may occur are many; some antibodies may become nondetectable over time, endangering future transfusions, and placing the patient at risk for anamnestic antibody production, which may lead to delayed hemolytic transfusion reactions. It is difficult to find compatible blood in patients having multiple alloantbodies. In this study no significant association was observed between splenectomy and the development of alloantibody. It has been observed that transfusion at an early age (less than 3-year old) may offer some immune tolerance and protection against alloimmunization. To prevent alloimmunization to RBC antigens, antigen-matched RBC transfusion (at least Rh and Kell) should be provided to all thalassemia patients. Prestorage leukoreduction has shown a major role in preventing alloimmunization and autoimmunization. Routine extended red cell phenotyping should be done for all chronically transfused thalassemia patients before starting RBC transfusions. A nationwide standard transfusion policy is the need of the hour for these patients.
Incidence of Coomb's positivity in the blood bank of a tertiary care center
Father Muller Medical College
Introduction: The direct and indirect agglutination tests are one of the most important diagnostic tools used in immune mediated disorders that can be of various etiologies. Main objective of this study was to enumerate these causes.
Materials and Methods: A retrospective study of all samples sent for Coombs test in a blood bank of a tertiary care centre was done. The tests were done using both gel card and tube method.
Result: Total number of Coombs test done for 3 year and 5 months (January 2010 to May 2013) were 1982. Out of which 100 cases were positive. DCT-74, IDCT-26, both positive-4 clinical diagnosis were available for 58 cases. Out of which the following were noted:
Conclusion: Study revealed that majority of Coomb's positivity was due to Rh incompatibility followed by AIHA, ABO incompatibility, chronic liver disease with portal hypertension, anti-pospholipid antibody syndrome, hemophagocytic syndrome, ALL, AIDS, and SLE.
Hemolytic disease of newborn with pure red cell aplasia due to anti-M
PGIMER and Dr Ram Manohar Lohia Hospital
Introduction: Fetal erythroblastosis as reported in the literature is caused by Rhesus alloimmunization. However, many other blood group incompatibilities may cause hemolysis in newborn but are without any treatment consensus. Antibodies with anti-M specificity, usually IgM, have been reported to be detected in 10% of pregnant women with a positive antibody screen. However, 0.01% to 0.7% of pregnant women would trigger anti-M IgG that can cross the placenta, resulting in variable degrees of hemolysis in fetuses.
Case: Blood bank received a requisition for reconstituted whole blood for an exchange transfusion for newborn twins having bilirubin in the exchange zone, with falling hematocrit and reticulocyte count of 3%. Mother was gravid two with one living daughter 3 years and no history of transfusion. The twins were normal vaginal deliveries at 38 weeks of gestation. Blood group of mother as well as twins was found to be O Rh(D) positive. Direct antiglobulin test (DAT) of the twins was negative, indirect antiglobulin test (IAT) of mother was positive at room temperature (RT), 37°C and AHG phase, indicating the presence of an alloantibody of both IgM and IgG type (by DTT treatment). Further identification panel showed antibody against M antigen (IgM and IgG type). Similar antibody was identified in the serum of both twins but reacting at AHG phase only (IgG type). The antibody titer was 16 for IgG and 8 for IgM type in mother at the time of birth whereas IgG titer of 16 in twin 1 and 8 in twin 2. Mother and father were homozygous for N & M antigen, respectively, and phenotype of twins as well as elder daughter was M+N+. The twins initially presented with the feature of hemolysis till 3 weeks of life and subsequently features of hemolysis subsided but continuous fall of HCT without reticulocytosis was observed till 45 days of life. Twin 1 required transfusion twice whereas twin 2 required it only once, with M-N+ packed red cells.
Discussion: We present a case of anti-M immunization due to previous pregnancy and severe neonatal anemia. Only a few cases have been reported in the literature where anti-M has caused fetal and/or perinatal anemia. The other diagnoses such as G6PD deficiency, Diamond Blackfan anemia, and Parvovirus infection were also ruled out. Such prolonged anemia with normal reticulocyte count and normal platelet and leukocyte count suggests toward destruction of erythroid precursor cells by the anti-M, which being previously also reported. Detection of such cases is crucial for the point of view of management of these neonates. There are known reported cases with high titer of anti M who have been successfully treated with intrauterine transfusions and also by therapeutic plasmapheresis.
Conclusion: This case was a rare presentation of maternal alloimmunization by M antigen causing hemolytic disease. The biologic mechanisms explaining why a normally clinically insignificant antibody, in a small proportion of cases, would be aggressive and cause severe fetal anemia still remains to be elucidated. Thus, attention to and further studies of anti-M immunization is desired.
Frequency of Rh and irregular antibodies among pregnant women and its implications
Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Background: In view of the role played by the antibodies other than anti-D in the development of hemolytic disease of fetus and newborn (HDFN), it may be necessary to screen all antenatal mothers irrespective of whether they are Rh (D) positive or negative, to identify clinically significant alloantibodies that might cause HDFN. Most developed countries have guidelines for screening all pregnant women for irregular red cell antibodies. The aim of this study was to determine the frequency of Rh and irregular antibodies among antenatal mothers attending JIPMER and to develop a protocol for maternal antibody screening.
Materials and Methods: This was a descriptive study on antenatal mothers attending the outpatient department of JIPMER on a particular day of the week from October 2010 to September 2011. Antibody screening was performed in antenatal mothers by Column Agglutination Technology; those mothers in whom antibody screening was positive were further subjected to antibody identification and followed by estimation of antibody titer. Baby's cord blood of antibody positive mothers was tested for direct antiglobulin test (DAT). Results were analyzed using the chi-square test.
Results: Antibody screening was done on 1,350 antenatal mothers and antibody screen was positive in 10 mothers. Prevalence of red cell antibodies among the antenatal mothers was 0.8%. Anti-D was the most common antibody (50%) identified. Anti-D along with anti-C was the next most common antibody identified followed by anti-M (10%) and anti-H (10%). The percentage of antibody positive in Rh negative mothers was significantly higher.
Conclusion: Anti-D is still the most common antibody detected among antenatal mothers. The occurrence of other irregular antibodies is very low. Even among those with irregular antibodies, alloimmunization caused severe hemolytic disease of newborn only in about half the women. The scarcity of resources makes the universal screening of all antenatal mothers for irregular antibodies not cost effective.
Frequency of red cell alloimmunization in a tertiary care hospital
Government Medical College and Hospital, Chandigarh, India
Background: Alloimmunization to erythrocyte antigens is one of the major complications of blood transfusion. Red blood cell alloimmunization results from the genetic red blood cell antigen disparity between donor and recipient or from mother and fetus, the recipient's immune status and the immunomodulatory effect of the allogenic blood transfusion on the recipient's immune system. The objective of this study was to explore the frequency of red cell alloantibodies amongst various groups of patients.
Material and Methods: This is a retrospective study conducted in the Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, India, from a period of January 1st, 2012 to May 31st, 2013, in order to determine the frequency of alloimmunization against red blood cell (RBC) antigens. Blood transfusion records of patients with β-thalassaemia major, antenatal Rh D negative mothers, and patients requiring transfusion were analyzed.
- Of a total of 74 β-thalassaemia major patients included in the study, 4.05% (3 out of 74) of patients developed alloantibodies (two had anti-Kell and one had anti-E antibody).
- Out of 268 antenatal Rh D negative mothers, 30 (11.19%) developed anti-D antibody. Of these 30 mothers, 27 mothers gave history of Rh Ig prophylaxis leading to positive anti-D antibody identification. Antibody titer levels were low in these pregnant females (range: near to 1:2).
- Frequency of red cell alloimmunization was 0.056% (19/34000) in the remaining patients requiring transfusion over this study period. The alloantibodies identified were anti-Leb antibody in five patients, anti-E antibody in three patients, two each developed anti-S, anti-Lea antibody, and anti-M antibody while one patient developed anti N-antibody. More than one alloantibody was seen in four patients. Ant-D along with anti-C antibody was seen in two patients while the other two patients had made anti-D along with anti-K and anti-E along with anti-c antibody.
Conclusion: Alloimmunization is a known complication of blood transfusion for which type and screen policy is recommended. However, in a resource constrained country, at least extended phenotyping for Rh and Kell blood group antigens should be done.
Frequency of ABO and Rhesus blood groups in Dakshina Kannada district of Karnataka: A study from rural tertiary care teaching hospital in South India
K S Hegde Medical Academy
Background: ABO and Rh blood groups are most important blood groups in human beings. The frequency of four main blood group system varies in population throughout the world and even in different parts of country.
Aims and Objectives: To identify distribution of ABO and Rh blood group system in patient and donor population from a tertiary care hospital from South India.
Materials and Methods: The study was conducted in department of Pathology, Justice K S Hegde Charitable Hospital Blood Bank, Deralakatte, Mangalore, India from January 2008 to December 2012. Data were collected from Blood Bank grouping records. All blood samples processed during period of observation (donor plus patient samples) were included in study.
Results: During the period of observation total 43,103 number of blood groups were performed. Patient's samples were 28,305 and donor's samples were 14,798. The frequency of blood group O in our population was 42.0% (40.1% O Rh positive and 1.8% O Rh negative). The frequency of blood group B in our population was 27.3% (25.6% B Rh positive and 1.62% B Rh negative) followed by blood group A was 25.8% (24.3% A Rh positive and 1.4% A Rh negative) and blood group AB was 4.8% (4.4% AB Rh positive and 1.4% AB Rh negative) and a two Bombay blood group donors (0.0046%). Rh positive were 94.64% and Rh negative were 5.35%.
Conclusion: O positive blood group is significantly high in our population. Every transfusion centre should have a record of frequency of blood group system in their population. It helps in inventory management. Knowledge of blood group distribution is also important for clinical studies, for reliable geographical information and for forensic studies in the population.
Extended Rh and Kell phenotyping in voluntary blood donors from Western India
Amit Kumar V Prajapati
B J Medical College, Ahmedabad, Gujrat, India
Background: According to The International Society for Blood Transfusion (ISBT) Working Party on Terminology for Red Cell Surface Antigens, there are 30 blood group systems recognized till now. ABO is first and most important blood grouping system relevant in transfusion and transplantation medicine. Rhesus (Rh) blood system is the next most important system that consists of 45 denied antigens of which five (D, C, c, E, and e) are the most relevant in context of the adverse hemolytic transfusion reactions. The D, C, c, E, and e antigens are determined by two adjacent genes, that is, RHD and RHCE encoding for RhD and RhCE proteins, respectively. The Kell system, discovered in 1946, is the third most potent system at triggering hemolytic transfusion reactions and consists of 25 highly immunogenic antigens, all of which are peptides within the Kell protein encoded by the KEL gene. Little data are available regarding the frequencies of the blood group antigens other than ABO and RhD in the Indian population. This study was conducted to obtain such phenotype frequencies.
Material and Methods: A total of 363 voluntary blood donors were typed for Rh ( D, C, c, E, e ) and Kell(K) using Erythro-Megnetic Technology (EMT) on Diagast Qwalys3 from March 2013 to June 2013, at Civil Hospital, Ahmedabad, India.
Results: In total of 363 blood donors, the phenotype frequency of D, C, C, E, e, K antigen is as fllows in percentage (%): D: 93.39, C: 88.43, c: 45.45, E: 17.91, e: 98.62, K: 2.48.
Discussion and Conclusions: This study was carried out on voluntary blood donors of locality of the blood bank so that the donors can be contacted to provide antigen negative blood in emergency in patients with clinically significant antibodies. Knowledge of the antigen frequencies is important to assess risk of antibody formation and to guide the probability of finding antigen-negative donor blood, which is especially useful when blood is required for a patient who has multiple red cell alloantibodies, chronic blood transfusion, transfusion in thalassemia, and transfusion in premenopausal women. The data will be utilized for provision of Rh and Kell antigen matched blood for regularly transfused patients once sufficient number of typed donors will be available.
Erythrocyte alloimmunization in multiply transfused patients of beta thalassemia
All India Institute of Medical Sciences, New Delhi, India
Background: β- thalassemia is a congenital hemolytic anemia caused by defects in β-globin chain synthesis. Alloimmunization to red blood cells (RBCs) antigens is a frequent complication in management of patients with this globin synthesis abnormality. Development of these alloantibodies and erythrocyte autoantibodies complicates transfusion therapy in thalassemia patients.
Material and Methods: In this study we analyzed the clinical and transfusion record of 255 cases of thalassemia major patients, who are registered at our blood bank and get regularly transfused as per their clinical status. We investigated for development of alloantibodies against red cells by Indirect Antiglobulin Test using Three Cell Antibody Screen. An Eleven Cell Antibody Identification Panel was used for the identification of antibody found during screening.
Results: Out of 255 patients, 182 (71.3%) were males and 73 (28.7%) were females. Of these 255, 16 (6.27%) patients developed a total of 20 RBC alloantibodies, including eight anti-E, five anti-c, two each of anti-Fya and Jkb, and one each of anti- K, anti-Lea and anti-D. All patients having multiple antibodies invariably had anti-E as one of them.
Conclusion: Alloimmunization is not an infrequent complication of chronic transfusion therapy. Thus, it is important to monitor patients carefully for the development of new antibodies and to eliminate donors with the corresponding antigens. The hemolysing nature of antibodies should be determined in patients who develop these antibodies, and transfusion should be arranged accordingly.
Distribution of ABO and Rh D blood groups among blood donors of Manipur and comparison with the Asiatic trend
Shija Blood Bank and Transfusion Services
Background: The ABO blood group system is discovered by Karl Landsteiner in 1901 and it is the most important blood grouping system with respect to blood transfusion.
Aim: To determine the prevalence of ABO and Rh D blood groups among blood donors (voluntary and replacement) of Manipur and compare it with the Asiatic trends.
Material and Methods: This study was conducted in Shija Blood Bank and Transfusion Services, Imphal, Manipur on 1,500 donor units (our target is 10,000 donors study within September this year) from the month of December 2012 to May 2013. ABO and Rh D blood grouping was done by the conventional tube method. Both cell grouping and serum grouping was done by the quality-checked reagent. All blood groups are documented properly in the register.
Results: Out of total 1,500 units following data are obtained: male donor 89% - A group 33%, B group 24%, O group 35%, and AB group 8% Rh D negative 3%; female donor 11% - A group 25%, B group 29%, O group 36%, and AB group 10% Rh D negative 2%.
Conclusions: Asiatic trend of blood group is O>B>A>AB. As per our study trend in male Manipuri population is O>A>B>AB, that is, A group is slightly higher than B group. In the case of female Manipuri population it is O>B>A>AB; it is matched with the trend of Asiatic Blood Group. From our study it is also clear that Rh D negative female blood donor is less (2%) compare to male donors (3%).
Diagnostic utility of DAT in a tertiary care hospital
All India Institute of Medical Sciences, Rishikesh, Uttrakhand, India
Background: Direct antiglobulin test is performed to detect in vivo sensitization of red cells with antibodies and complement. This test is considered as a hallmark in establishing the diagnosis of hemolytic anemia of immune origin and hence ordered indiscriminately by the treating physicians.
Aim: This study was conducted to assess whether the practices of ordering direct antiglobulin test in our hospital setting was judicious or not.
Result: DAT results were positive in only 15% cases. Of the total, 58.1% cases underwent a complete laboratory evaluation for hemolytic anemia. On comparing the laboratory parameters, DAT positive patients have lower mean hemoglobin level, higher mean reticulocyte count, and higher mean LDH level.
Conclusion: All DATs performed in our immunohematology laboratory in a period of 6 months were reviewed. Biochemical parameters of DAT positive and negative patients were compared using chi-square analysis.
DAT ordering practices in our hospital are non judicious. Complete laboratory evaluation should be performed in patients with anemia before ordering for DAT in order to utilize this modality in a righteous way.
Bombay blood group prevalence in southern Bengal
MCH, Kolkata, India
Background: In 1952, Dr. Y. M. Bhende discovered the Bombay blood group (Oh phenotype). Persons with the phenotype (hh) do not express H antigen that is normally present in blood group O. H antigen is a tetra-saccharide. At its terminal galactose molecule and a fucose molecule is attached via alpha 1-2 linkage. The enzyme responsible for attachment of fucose and the expression of H antigen is Fucosyltransferase. It is encoded by two different genes known as FUT 1 (H gene) and FUT 2 (Se gene). Homozygosity for defective mutation of both FUT 1 and FUT 2 genes causes lack of H(hh) antigen and nonsecretor (se,se) expression. This is known as Bombay phenotype. Prevalence of Bombay blood group in general population is about 1 in 10,000 individuals in India and 1 in 100,000 individuals in Europe. A study from northwestern Orissa reported an average of 1 in 278 Bombay phenotype among Bhuyan tribal population. Bombay phenotype can donate RBCs to any member of the ABO blood group system, if the Rhesus (Rh) antigens are compatible. However, they can receive blood only from Bombay phenotypes. It is this exclusivity that demands the creation and maintenance of a 'Bombay donor registry' system in our region. We have performed a study to calculate the prevalence of Bombay Blood Group in donors and recipients of our region.
Materials and Methods: A total of 28,934 donors, from various parts of southern West Bengal, donated blood in the blood donation camps organized by the Medical College Hospital, Kolkata, in 2012. Routine blood grouping of these individuals was done by tube methods. We detected two male donors (aged 35 years and 40 yars) having Bombay (hh) phenotype. Among the recipients, Bombay (hh) phenotype was present in 4 out of the 27,531 patients who received blood or blood components from our blood bank. However, the blood bank could supply only two units of Bombay phenotype red cells to two of these four patients, for whom blood was required due to obstetrical emergencies. Two samples were collected from each individual: one in K3EDTA and one as clotted. Forward and reverse grouping were done. Bombay group was confirmed by no agglutination with anti-H lectin in forward grouping and positive agglutination with OH group red cells in reverse grouping. We could not perform secretor status of the individuals due to communication difficulties.
Results: On basis of the aforementioned results we have noted the prevalence of Bombay phenotype to be 0.007% (2 out of 28,934) in donors, and 0.014% (4 out of 27,531) among patient population, with an overall prevalence of 0.011% (6 out of 56,465).
Conclusion: It is very difficult to supply Bombay phenotype RBCs to hospital admitted recipient in an emergency situation. Therefore, maintaining a Bombay phenotype donor registry is of paramount importance in order to save some of these patients and some of these patients and every blood bank should maintain a proper registry system of Bombay and other similar rare groups (Diego, Yt etc).
Assessment of maternal red cell antibodies implicated in hemolytic disease of the newborn
PGIMER, Chandigarh, India
Background: Hemolytic disease of the fetus and newborn (HDFN) results from shortened life span of the infant ' s red cells due to their immune destruction by transplacental passage of maternal antibodies. These maternal antibodies could be anti-A or anti-B; or immune antibodies to any of the blood group antigens, commonly the Rh (D) antigen.
Aims: To determine the frequency of maternal ABO antibodies and red cell alloantibodies implicated in hemolytic disease of the fetus and newborn, and to correlate the antibody specificity with the newborn outcome.
Materials and Methods: This was a prospective study conducted over a period of 18 months. All pregnant women, both Rh(D) positive and negative, with 35 completed weeks of gestation were enrolled and assessed for the presence of antibodies by the indirect antiglobulin test (IAT). All newborns of mothers with IAT positive results and newborns with significant jaundice (requiring phototherapy) were tested for the direct antiglobulin test (DAT). Antibody identification was done as and when necessary, using standard procedures.
Results: Anti-D was the most common antibody detected. Among the 2,500 mothers screened, the frequency of alloimmunization was 0.68% (excluding ABO HDN). Rh D alloimmunization was seen in eight (0.36%) cases and non-D alloimmunization seen in seven (0.32%) cases. The non-D antibodies included one case each of anti K, anti-E, anti-E + anti-c, and anti-S. There were three cases of antibodies to the Lewis antigen. The frequency of ABO HDN was found to be 0.2% (six cases), of which one was in a Rh (D) negative mother. Maternal alloimmunization and/or ABO HDN occurred in 11 Rh (D) positive mothers. The need for phototherapy and exchange transfusion was found to be statistically more in HDN due to ABO and Rh D incompatibility as compared to the non-D category.
Conclusion: Hemolytic disease of the newborn was detected both in Rh(D) positive and negative mothers. Anti-D was the most commonly detected antibody. Phototherapy and/or exchange transfusion was more often required in ABO HDN and Rh(D) HDN as compared to non Rh(D) HDN group.
Analysis of direct and indirect antiglobulin test in blood group serology in a tertiary care blood bank
Dr. Ram Manohar Lohia Hospital, New Delhi, India
Background: Antiglobulin test is useful in differentiating immune-mediated hemolysis from hemolysis caused by other factors. It is important to note that a small but significant number of patients have a positive DAT without shortened erythrocyte survival; a positive DAT result without evidence of hemolysis has been reported in 1:1-14 000 healthy blood donors and 1-15% of in-hospital patients. The predictive value of a positive DAT is 83% in a patient with hemolytic anemia, but only 1.4% in a patient without hemolytic anemia.
Materials and Methods: This study was carried over a period of 6 months to evaluate all the requests for the DAT and IAT in relation to the indication, diagnosis, demographic profile, and result outcomes. The technology used was column agglutination using glass beads ID cards from Orthoclinical diagnostics using semiautomated Biovue equipment.
Results: A total of 300 requests for antiglobuin tests were received during the study period. Out of these, 187 (130 of ABO and 57 Rh) requests were for routine neonatal screening (blood group confirmation and DAT), and the rest 113 were from the patients with medical and surgical ailments with hyperbilrubinemia and immune-mediated hemolysis. Female to male ratio was 107:80 with age ranging between day 1 to day 3 of neonatal life. The indication in seven cases for DAT and IAT along with group confirmation was suspected hemolysis. Out of these seven, only one was IAT positive and rest all others were DAT and IAT Negative. The IAT positive case on further analysis revealed the presence of an alloantibody (anti-M) attributing to the HDFN. Among the medical and surgical cases comprising 113 requests male to female distribution was (48:65) and the average age was 22.8 years with age ranging from day 7 of birth to 70 years. Main indications were Immune hemolytic anemia (AIHA and drug-induced SLE), immune pancytopenias, hyperbilirubinemia and antenatal screening of high risk pregnancies (Rh HDFN). Among the 113 cases, 24 were DAT positive and 6 were both DAT and IAT positive. Further evaluation revealed four cases with the presence of auto-antibodies with no alloantibodies and two cases with the presence of anti-M, anti-Le-b alloantibody.
Conclusion: Our experience of performing antiglobulin test at our blood bank as a routine screening procedure is one of our efforts in making the transfusion services safer. It is a well established fact that the patients with associated medical and surgical ailments with repeated transfusions along with the newborns are prone to have a positive antiglobulin test (DAT/IAT). In our study, there was no DAT positive case among newborns but one had IAT positive with anti-M causing HDFN. Among the patients with medical and surgical ailments out of 113 requests, two cases of clinically significant alloantibodies (anti-M, Anti Le-b) and four cases of autoantibodies were detected. Hence, analyzing the role of Direct and Indirect antiglobulin test in blood group serology, its immense importance is established enabling the evolution of the Immunohematology laboratory from merely cross matching blood to making the blood immunohematologically safe too.
ABO Discrepancy in a common variable immunodeficient patient
Sanjay Gandhi Postgraduate Institute Of Medical Sciences, Lucknow, Uttar Pradesh, India
Background: Common variable immunodeficiency (CVID) is a heterogeneous group of diseases that is characterized by recurrent bacterial infections and an increased incidence of autoimmunity, malignancy, and other inflammatory complications. It is the second most common primary immunodeficiency disorder after selective immunoglobulin A [IgA] deficiency, but it is clinically most significant. The hallmark of this primary immunodeficiency disease is hypogammaglobulinemia that can be proved by serum immunoglobulin analysis, but a diagnosis of CVID is sometimes incidentally made by routine laboratory testing other than the full immunologic evaluation.
Case Report: In this case report, we describe ABO discrepancy in a young adult that led to the diagnosis of CVID. Patient was referred to department of immunology and his chief complaints were recurrent upper respiratory tract infections (URTI), intermittent fever, and pain in abdomen, diarrhea, polyarthalgia, and 4-days-old right-side hemiparesis. His blood sample was sent to immunohematology laboratory for routine ABO blood grouping. On routine blood grouping test he was O Rh D positive in forward (cell) grouping, while there was no reaction in serum grouping. To resolve this blood group discrepancy, saliva grouping was performed, which showed that the patient was a secretor of H substance. On investigations, the patient's serum immunoglobulin levels were markedly decreased and there was no Bruton's tyrosine kinase (Btk) mutation. Based on his clinical manifestations and laboratory findings, he was diagnosed as a case of CVID.
Discussion: This is a case of class-I ABO discrepancy where there are missing or weak antibodies on reverse grouping. Isohemagglutinins are decreased in extremes of ages, acquired immunocompromised state, or rare primary immunodeficiency. The titer of isohemagglutinins has been reported to differ among ages, ethnic populations, and environment. In this case, there was complete absence of anti-A and anti-B in reverse grouping but the presence of H substance in saliva, indicating toward an immunodeficiency that was further confirmed by deficient immunoglobulin levels in blood. Thus, CVID should be kept as a differential diagnosis when a patient presents with recurrent bacterial infection and class I ABO discrepancy.
ABO and Rh(D) group distribution and gene frequency among the blood donor and patient population in a tertiary care centre of South India
John Miller V
Global Health City, Chennai
Background: Blood groups are genetically determined and the incidence of ABO and Rh(D) vary in different parts of India. The aim of the study was to determine the ABO and Rh-D group distribution and gene frequency among blood donor and patient population in Chennai, Tamil Nadu.
Material and Methods: Blood grouping records of blood donors and the patient population (including inpatients and outpatients) during December 2011 to May 2013 were analyzed. ABO and Rh (D) grouping was performed in blood bank using gel technology.
Results: During the study period, a total of 20,065 blood samples were collected. Of these, 7,812 were from blood donors and 12,253 from patient population including transfusion recipients, inpatients, outpatients as well as health checkups samples. The study showed that O (41.8%) is the most common blood group followed by B (3 1.1%), followed by A (21%) while AB is the least prevalent group at 6.1%. 93.7% population was Rh (D) positive and rest (6.3%) were Rh negative. There were only three (0.015%) samples (one donor and two patients) out of 20,065 samples with Bombay blood group (Oh). The gene frequency was calculated according to Hardy Weinberg law of Equilibrium. The calculated gene frequency IA (p), I B (q), and IO(r) in donor population is 0.14, 0.20, and 0.66, respectively. The calculated gene frequency in patient population is 0.15, 0.21, and 0.64 for IA (p), I B (q), and IO.
Conclusion: The study provides the distribution of ABO alleles in south India population and shows the Asiatic trend O>B>A>AB. Other studies from south India have also shown the similar pattern of ABO and Rh distribution. The gene frequency shows variation among donor and patient population as later group included patients from different parts of India as well as overseas patients. Knowledge of blood group distribution is important for clinical studies, for reliable geographical information, and helps in planning health challenges, particularly regarding blood transfusions.
A case report of cold agglutinin disease encountered in the department of blood bank, northeastern Indira Gandhi Regional Institute of Health and Medical
NEIGRIHMS Shillong, Meghalaya, India
Background: Cold agglutinin disease (CAD) is a hemolytic anemia due to pathogenic cold reactive antibodies. In our experience, in Meghalaya, India, we have come across numerous cases of reactive cold auto antibodies which could be attributed to many factors one of which could be the cold climatic condition. This case report assumes significance because of the management that was provided to the patient.
Case Report: A 59-year-old male patient, a known case of type II Diabetes Mellitus with hypertension with old CVA was admitted to the ICU with history of fever and respiratory distress and diagnosis of community-acquired pneumonia with septicemia was made. Hemoglobin at the time of admission was 8 Gm% and the neutrophil count was 40,000/cumm with the presence of toxic granules. There was rapid decrease in hemoglobin level and Packed Red Cells (PRBCs) were requested for after a week by which time the hemoglobin level had come down to 4.4 Gm% with a bilirubin level of 1.7 Gm/dl. Even after two units of transfusion, the hemoglobin further dropped to 3.1 Gm%.
Materials and Methods: The sample showed auto agglutination in the EDTA vial which was a significant finding. Suspecting Cold Agglutinin Disease, thermal amplitude estimation was done at three different temperatures (4°C, 22°C, and 37°C). After heat inactivation of the sample at 37°C for a longer period than usual, ABO grouping, Rh (D) typing along with autocontrol were performed where reverse grouping was carried out by indirect antiglobulin test (IAT) using AHG (IgG). Direct antiglobulin tests (DAT) using AHG (IgG+C3d, IgG and C3d) were performed. Pretransfusion testings were done. Titer estimation was performed at 4°C for 45 min.
Results: Visible agglutination was seen on naked eye. The thermal amplitude of the cold auto agglutinin was 37°C, with a significant titer of 1:1024. Blood grouping was confirmed as 'B' positive and DAT showed the presence of C3d. Cross matching showed compatibility and antibody screening was negative with AHG (IgG).
Discussion: This was the first time a case of CAD with such severity was encountered in our department. The thermal amplitude of the cold autoantibody was 37°C with a titer of 1:1024. As we worked up the case, a diagnosis of CAD was made and an advice was given to keep the patient warm and to warm the blood units and any fluid for transfusion or infusion. But even after transfusion of two units of PRBCs, hemoglobin level further dropped to 3.1 Gm%. This led us to re think our management and instead prepare Washed PRBCs. After two units of transfusion of washed PRBCs marked improvement was seen in hemoglobin concentration with an increment of 5.0 Gm% to an Hb of 8.0 Gm%. The Hb level was stabilized and we did not receive any further requests for PRBCs. Thus, when the pathogenicity of the Cold agglutinin is high, plain warming of Packed Red Cells may not be good enough in the management of Cold Agglutinin Disease. In such cases, Washed Red Cells may be the solution.
A frequency of Red blood cell alloantibodies in patients and donors attending the department of blood bank
Lyngdoh Lutika Nepram, Bhattacharyya Debdutta
NEIGRIHMS, Shillong, Meghalaya, India
Background: There is very limited data or practically none available on the frequency of red cell alloantibodies in the populations of the northeastern states of India, particularly Meghalaya. The population of the state of Meghalaya is extremely heterogeneous because of the high rate of mixed marriages between the locals and people from all around the country and even abroad. The aim of this study was to determine the frequency of the prevalence of alloantibodies in the patients and donors attending NEIGRHMS Hospital which may reflect the prevailing frequency in the population of Meghalaya.
Materials and Methods: Antibody screening and identification data on patients and donors who attended the department of Blood Bank, NEIGRIHMS, from September 2008 to December 2012 was retrospectively analyzed. This included 6,908 patients and 8,724 donors. During the initial study period, column agglutination technique using commercially prepared reagent red cells was performed, which was switched to conventional test tube technique using in house prepared reagent red cells as this was more representative of the local population. The minor blood group antigen systems included were D, C, E, c, e, Jk(a), Jk(b), Fy(a), Fy(b), Le(a), Le(b), M, N, S, s, K, k, Kp(a), K(b), P1, Lu(a), and Lu(b).
All the antibodies identified were confirmed by phenotyping, adsorption, elution, enzyme treatment, and neutralization tests.
Results: During the study period a total of 15,632 samples were screened out of which 8,724 (55.80%) were donors and 6,908 (44.19%) were patients. A total of 93 (0.59%) cases were found positive on antibody screening of which the specific antibody could be identified in 79 (84.94%) cases and the rest 14 (15.05%) remained unidentified.
Out of the 79 identified cases, single antibody was found in 60 (75.94%) cases, dual antibodies in 16 (20.2%) and triple antibodies in 3 (3.79%). Of all the minor antigen blood group systems alloantibodies against the Rh system was the most prevalent, that is, 38 (48.1%), followed by Lewis 23 (29.11%), MNS 9 (11.39%), Lutheran 3 (3.79%), Kell 1 (1.26%), P1 1(1.26%), and Sd (a) 1 (1.26%).
Discussion and Conclusion: Our results may be representative of the population of Meghalaya as ours is the only centre in the state with antibody screening and identification facility till date. The rate of the alloantibody presence is 0.59%. Alloantibodies against the Rh system especially anti-D (12 cases) were the most common. Alloantibodies were identified in 60 cases between September 2008 to January 2012, and 33 cases between February to December 2012. This increment could be attributed to the use of in house prepared reagent red cell panels that showed great potency. Some of the alloantibodies were seen to be naturally occurring as there were no histories suggestive of prior sensitization, like, Lewis, M & N. Extreme heterogeneity is seen in the state of Meghalaya due to the high rate of mixed marriages between locals and nonlocals that surely has a bearing on the antigen distribution pattern and thus in the incidence of alloimmunization. The presence of Miltenberger antigen system in our population is a reality which needs to be further studied.
Value addition to the complement-dependent cytotoxicity cross match through the ntihuman globulin assay
Christian Medical College Hospital, Vellore, India
Background: The complement dependent cytotoxicity (CDC) cross match described by Patel and Terasaki in their landmark paper in the 1960s established the unquestionable role of antibodies detected on this platform. However, many variations and modifications to this assay have since been added on to make it more sensitive and specific. The antihuman globulin assay (AHG cross match) on this platform is one such and has added tremendous value both in terms of sensitivity and specificity. We report here an experience comparing the standard NIH cross match, the extended incubation and the AHG cross match in picking up anti HLA antibodies in prospective renal transplant recipients over a 5-month period.
Materials and Methods: A total of 113 cross matches were performed on 81 patients over a 5-month study period: from February 2013 to June 2013. All patients had a routine NIH cross match, an extended incubation cross match and an Antiglobulin cross match. Dithiothrietol (DTT) was used to define if the antibody was IgG or IgM in nature.
Results: Of the 113 cross matches performed, 17 were positive on the standard NIH cross match (8 IgM and 9 IgG antibodies), and an additional three (total 20) were positive on the extended incubation (all additional three being IgM antibodies). On the AHG platform, all patients detected to have IgG antibodies by the standard and extended incubations showed positivity, however, an additional five patients were detected to have anti-HLA antibodies on the AHG cross match. All five patients who showed reactivity only on the AHG cross match also showed a positive Luminex cross match.
Conclusions: The AHG cross match raises the sensitivity of the CDC platform greatly, and aids in detecting IgG anti HLA antibodies with far greater sensitivity which is reproducible on the Luminex platform. It is critical, therefore, that this be incorporated into routine pretransplant algorithms.
Can Luminex donor specific antibody cross match be a better alternative of complement dependent cytotoxicity cross for renal transplant cases in developing countries like India?
Rotary Bangalore TTK Blood Bank, Bangalore Medical Services Trust, Bangalore, Karnataka, India
Background: Since Patel and Terasaki first reported relevance of pretransplant lymphocyte complement-dependent cytotoxicity (CDC) cross match to post-transplant outcomes in 1969, the available test options for cross matching potential transplant recipients have grown dramatically. Many transplant programs in western world have discontinued the CDC and use newer methods of identifying donor specific antibody (DSA) in transplant recipients.
In 1998, a novel testing strategy was described that use purified human leukocyte antigen (HLA) molecules coated on microspheres. These microspheres are also coated with luorochromes that can be detected by low-cytometry-based techniques. Thus, recipient sera can be crossmatched with the HLA-coated microspheres prepared from donor lysate.
In countries like India where pretransplant tests are very limited and donor-specific antibodies are not identified because of cost constrain, Luminex cross match using donor lysate could be a more sensitive and cost effective alternative of CDC cross match.
Since there is lack of data from India on use of Luminex cross match for renal transplant patients we decided to compare both the methods.
Objective: Comparison of a new Luminex cross match method with classical method of leukocyte cross match, that is, complement-dependent cytotoxicity.
Material and Methods: Total 60 living related renal transplant cases were included in the study. All samples were tested for CDC as well as Luminex DSA cross match using donor lysate. The kits used were Gen Probe (Gen Probe transplantation diagnostics, Inc., 550 West Avenue, Stamford, CT 06902).
In CDC cross match less than 20% cell lysis was considered negative and Luminex cross match mean louroscence values (MFI) 1000 was considered negative for class I and II each. All the patients were followed up after 3 months.
Result: Out of 60 cases, 45 were negative for CDC as well as for Luminex DSA cross match class I and II. One case was found positive (MFI value was 16,165 and 13,219 for class I and II) for both and transplant was not done. In 14 cases CDC was negative but Luminex cross match was positive. Out of 14, nine patients transplanted, no acute rejection reported. One patient died due to cardiac arrest. All eight patients followed up after 3 months. In three patients creatinine was found abnormal between 3-4. When these patient ' s pretransplant test records were checked, two of the patients were class II positive DSA with MFI of 7,372 and 4,317 and one patient was class I positive with MFI value 6,322. Rest other cases found clinical good with the normal serum creatinine value less than 1.
Conclusion: CDC cross match found less sensitive than Luminex cross match. It came positive when Luminex MFI values were more than 10,000. Three out of eight cases which were positive for either class I or II by Luminex cross match but negative CDC cross match have high creatinine value but no clinical sign of rejection within 3 months of transplant. Luminex DSA cross match using donor lysate more sensitive than CDC cross match, therefore, could be a better and cost effective pretransplant testing in India.
Role of local application of autologous platelet-rich plasma in the management of pressure ulcers
Pt. B.D Sharma PGIMS, Rohtak, Haryana, India
Introduction: Platelet-rich concentrate is an autologous concentration of platelets and growth factors that is an effective therapy for pressure sores. Degranulation of platelets takes place due to activation of PRP with 10% calcium chloride that transforms them to a bioactive state. Activated platelets release transforming growth factor, vascular endothelial growth factor, and platelet-derived growth factor. Thus, the platelets at the repair site ultimately set the page of wound repair. PRP is being extensively used worldwide for chronic wounds and it promises to be a useful tool in their healing.
Aims and Objectives: To evaluate the role of local applications of autologous platelet-rich plasma in the management of pressure ulcers (PrU).
Material and Methods: This study was conducted on 25 patients of pressure ulcers admitted in the department of orthopaedic surgery, paraplegia, and rehabilitation, Pt. B.D Sharma PGIMS, Rohatk. Pressure ulcers were graded according to European pressure ulcer advisory panel (1999). Platelet-rich plasma (PRP) was applied in grade IV PrUs. Photograph was taken before application of PRP and after every week to observe the healing of pressure ulcer. After observation and measurement, the PrU was categorized with respect to surface area, exudates, and type of wound tissue. A subscore was recorded for each of these ulcer characteristics. Punch biopsy was taken from the margins of the wound initially, in first, third, and fifth week to monitor histopathological signs of healing.
Results: The decrease in wound surface area was statistically significant (t = 4.98, P = 0.000). Mean-healed surface area of PrUS-reduced atinal follow up. After 5 weeks of PRP therapy, 60% wounds had shown well-formed granulation with epithelization on histopathology. In this study 96% of PrUs cases were improved after PRP therapy.
Conclusion: PRP application on PrUs is simple, rapid, and cost effective and a complication-free procedure with excellent outcome.
Plasmapheresis in a case of severe acute hemolysis
Institute of Liver and Biliary Sciences
Background: Acute hemolysis is a difficult situation to treat and usually leads to acute renal failure due to acute tubular necrosis. The patient ' s vascular system is loaded with free hemoglobin and toxic effects of the same are seen. Here we present a case of acute hemolysis of unknown origin treated successfully with plasmapheresis.
Case: A 22-year-old male presented at the emergency unit with fever, jaundice, for 2 days associated with progressive shortness of breath and altered mutation for 1 day. The patient was labeled as acute severe hemolysis with jaundice and put on symptomatic therapy while awaiting investigations. The patient was unresponsive to symptomatic therapy and plasmapheresis was suggested as a therapeutic modality in consultation with nephrology and transfusion medicine.
Treatment: Two sessions of plasmapheresis were done on alternate days starting from day 2 of admission in which one volume of plasma was exchanged using fresh frozen plasma as replacement. Postplasmapheresis there was improvement in the patient ' s parameters. Investigation for all possible causes of hemolysis was done. The patient was negative for all viral hepatitis markers, leptospira, HIV, and mycoplasma. Blood and urine culture were negative as were in indirect and direct Coombs test. The patient gave no history of intake of any poisonous substance or animal bite. The cause for the acute hemolysis remained an enigma.
Outcome: The patient suffered from acute tubular necrosis of the kidneys from which he recovered and was discharged.
Conclusion: Therapeutic plasmapheresis was a life-saving intervention in the aforementioned case and should be considered when routine therapies fail to bring about the desired outcome.
Optimization of donor pool and product quality in single versus high yield plateletpheresis
K M Chawan
Tata Memorial Centre, ACTREC
Background: In an oncology setup with bone marrow transplant unit, patients require prolonged support during bone marrow transplant, and multiple platelet transfusion will be required. It is often difficult to arrange more number of donors over a period of time due to the lengthier duration of treatment especially in rare blood groups. Platelet inventory management becomes even more difficult due to short shelf life of product and apprehension of donors toward the apheresis procedure. Collecting high yield of single donor platelet (SDP) from eligible donors will help in addressing these factors. The aim of this study is to compare and analyze single and high yield SDP collections on the basis of donor parameters and quality of product.
Material and Methods: Total of 120 procedures were included in this study, 60 each for single and high yield, respectively. The entire procedure was done using 2 cell separators - Cobe spectra and Fenwal (Baxter) Amicus. Three arms of study were taken with donor precount between 150 to 200 × 109/ml for single SDP collection and pre count between 250 to 299 × 109/ml and 300 to 350 × 109/ml for high yield SDP collection, respectively. In all three arms donor parameters (preplatelet count), procedure parameters (ACD infused volume, TB processed, Time of procedure) and product parameters (platelet yield) were analyzed. An SDP with minimum yield of 6 × 1011 platelets per unit was considered as high yield product.
Fenwal(Baxter)Amicus Cobe Spectra 1 Mean total blood processed
Discussion: The average volume processed and average procedure time was higher in high yield procedure as compared to single yield irrespective of the cell separator used. However, in both arms of high yield procedure more average volume and longer time was observed in arm with lower donor platelet count (2.5 × 109/ml to 2.99 × 109/ml). There was not much difference in final yield of product in both high yield arms. Platelet yield was better with Amicus compared to Cobe spectra except for donors in lower high yield arm (2.5 × 109/ml to 2.99 × 109/ml). In nutshell high yield platelet collection helps in maintaining better platelet inventory with optimization of donor pool and product quality without compromising donor and patient safety.
Fenwal Amicus or fresenius Com.Tec: comparative analysis of various aspects of plateletpheresis on two cell separators
Amit Kumar Biswas
Armed Forces Medical College, Pune, Maharashtra, India
Background: It is a prerequisite for an optimally functioning apheresis setup, to have an efficient cell separator machine. In our study, we compared two apheresis instruments (Fenwal Amicus and Fresenius COM TEC) at our centre with regard to the donor peripheral blood parameters, operational variables of the instruments and the quality control parameters of the products obtained. The collection rates and collection efficiencies was calculated and collated. Additionally, the platelet yield and platelet activation levels (CD62P) of both the instruments were also estimated for comparison.
Material and Methods: Donors undergoing plateletpheresis were randomly separated into two groups (either the Amicus or the COM.TEC cell separator). One hundred platelet collections were carried out with different protocols in the two devices (Amicus and COM.TEC). Platelets were measured by an automated analyzer and activation statuses of the platelets were analyzed by flow cytometer. Residual WBC contaminations were determined manually with Nageotte chamber.
Results: The blood volume processed to reach a target PLT yield of η 3.0 × 1011/bag was higher in Amicus compared to the COM.TEC (2972 vs. 2853 ml; but it was not significant, P > 0.05). No major adverse events were observed during the procedures, in both the machines. The median time needed for the procedures was significantly longer with the COM.TEC (74 vs. 68 min; P < 0.05). There were no significant differences in pre- and postapheresis WBC counts, pre- and post-Hb levels, preapheresis hematocrit (Hct) levels and platelet loss percentage values. The postapheresis PLT count was lower in the Amicus compared to the COM.TEC group (195 × 103/μl vs. 208 × 103/μl; P = 0.24) but was not considered significant. All products obtained with both instruments had WBC counts lower than 5 × 1 06/bag. There was no statistical difference with regard to collection efficiency (56 ± 12 vs. 56.2 ± 11.5%; P > 0.05) and collection rates (0.056 ± 0.014 × 1011 vs. 0.044 ± 0.001 × 1011 PLT/min; P >0.05) between the devices.
Conclusion: Both instruments collected platelets efficiently with minimal donor discomfort. Additionally all quality control parameters were met with both the instruments. Consistent leuco-reduction was achieved with both the instruments. However, compared with the COM.TEC instrument, the Amicus reached the PLT target yield more quickly.
Donor hematological variables before and after plateletpheresis: An institution-based study
Suresh Babu B
Sri Venkateswara Institute of Medical Sciences
Background: Recently the use of single donor platelet concentrates has grown steadily due to its employment in chemotherapy protocols. This is especially due to lower alloimmunization and transmission of viruses to patients afforded by reduced donor exposure. Technical advances in automated cell separators have substantially improved the productivity and quality of the collection of apheresis platelets. Various studies on automated plateletpheresis have investigated the quality of platelet concentrates and its relation to the biological contribution (platelet count and/or total mass) of the donor. However, only few studies have studied the safety issues that occur to the donor after donation which is an important factor of clinical implication to donors. In this study, we investigated the changes in hematological values after plateletpheresis in apheresis donors. This information will be of value in establishing postdonation reference ranges that could be utilized when reviewing the suitability of donors for subsequent donations.
Materials and Methods: This prospective study was conducted on 77 healthy donors who volunteered for single donor platelet collection in our department. All procedures were performed using Fresenius Kabi comtech (Fresenius Kabi AG, Bad Homburg V.D.H, Germany). Two milliliter of EDTA anticoagulated blood will be collected from the donor immediately before and after the procedure after getting informed consent from him. Pre- and postdonation hematological values such as hemoglobin (Hb), hematocrit, platelet count, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, platelet distribution width, and red blood cell count were measured using calibrated automated analyzer (BC-5 300 Auto Hematology Analyser, Shenzhen Mindray; China). All data were analyzed with SPSS software version 16. The results were analyzed using paired sample t-test.
Results: We noted a significant decrease in pre- and postdonation platelet count (279.21+55.66 × 109/L vs. 172.9 1+46.79 × 109/L; p
Discussion: This study addressed donor safety issues with regard to reductions in hematological values after plateletpheresis. Although such reductions could be expected, adverse clinical outcomes, such as thrombocytopenia and anemia, as a result of these decreases should always be prevented. The greatest concern regards those donors with a low normal predonation platelet count or Hb concentration.
An analysis of various factors that affect platelet increment in thrombocytopenic patients after receiving plateletpheresis
Rotary Bangalore TTK Blood Bank, Bangalore Medical Services Trust, Bangalore, Karnataka, India
Background: Platelet transfusion is one of the most important forms of support therapy for thrombocytopenic patients. Plateletpheresis [single donor platelet (SDP)] has the advantage of lowering the risk of increased donor exposure per transfusion, preventing alloimmunization, platelet refractoriness, and transmission of infectious diseases. The apheresis platelets are used for Dengue cases as well as many other thrombocytopenic cases. We analyzed the various factors which may affect the past transfusion platelet increment.
Aim and Objective: To assess the effect of preprocedure donor platelet count, whole blood volume processed, & patient ' s clinical diagnosis on post transfusion increment in the patients.
Material and Methods: The study is done at Rotary Bangalore TTK Blood bank in Bangalore which is a Regional Blood Transfusion Center in South India. The Blood Center performs almost one thousand plateletpheresis procedures in a year. The machines used for plateletpheresis are Hemonetics and Amicus.
Total 110 plateletpheresis cases were included in the study in the period of 3 months from October to December 2013. Among these patients 65 patients were diagnosed as Dengue and remaining 45 had other clinical diagnosis such as leukemia, aplastic anemia, cardiac surgery, neurosurgery, and nonhematological malignancies.
For each case, donor information like donor's age, gender, preprocedure platelet count, ABO type was recorded. The machine parameters such as whole blood volume processed, time taken, ACD infused were recorded and patient ' s post transfusion platelet count was recorded. This count was done within 24 h of the transfusion.
Total 110 cases were divided in two groups. Group A: patients who have increment of more the 15,000/ μL after one unit of SDP transfusion. The group B was of patients who have increment of less than 15,000.
Each group was evaluated with donor ' s pre count, WB volume processed and patient's clinical diagnosis.
Results: Out of total 110 patients who received SDP, 41 were in Group A and 69 in Group B. Among 41 patients of group A, only 7 (18%) had dengue and remaining 34 (82%) had other clinical diagnosis. In this group, donor preplatelet count ranged from 2,25,000 to 4,09,000/μL and mean count was 3,54,000/μL. The whole blood processed ranged from 2,114 to 2,550 ml and mean was 2,240 ml.
Among 69 patients of group B, 58 (84%) patients had dengue and 11(15.8%) were diagnosed with other clinical conditions. The preplatelet count of the donor ranged from 1,86,000 to 3,71,000/ μL with the mean value 2,66,000/μL. The whole blood volume processed ranged from 1,770 to 2,315 ml with mean value of 2,164 ml.
Conclusion: The patients of dengue showed significantly less increment from one unit of SDP as compared to patients of other thrombocytopenic conditions. It is observed that in dengue cases use of SDP has very limited therapeutic benefit.
Post-transfusion platelet increment has strong correlation with preprocedure donor platelet count and WB volume processed. It was observed that both these parameters have significant impact on patient platelet increment.
Therapeutic phlebotomy: A main stay in management of polycythemia
Sri Ramachandra Medical College & R.I, Sri Ramachandra University
Background: Polycythemia is a hematologic disorder in which red cells, platelets, and granulocytes are produced in large numbers. Polycythemia can be attributed to primary and secondary causes. Primary being aberration in the genome causing a mutation (V617F) in JAK2 protein. Primary condition also known as Polycythemia Vera in which overproduction of red cells occurs in the absence of physiologic stimulus. Secondary polycythemia occurs in various lung, cardiac, renal disorders, and some tumors. Therapeutic phlebotomy is considered the mainstay of management in polycythemia where reducing the hematocrit to below 45% in males and to below 42% in females avoids thrombotic complications.
Aim: To study the role of therapeutic phlebotomy in management of polycythemia.
Material and Methods: This study was carried out in the Department of Transfusion medicine at Sri Ramachandra University from 2012 to 2013. Forty patients were included in the study. Diagnosis of polycythemia is made in department of hematology. Mutation in JAK 2 has been investigated. Patients were referred to the Department of Transfusion medicine for therapeutic phlebotomy. SOP for therapeutic phlebotomy adhered. A volume of 8 ml/kg body weight of blood subject to maximum of 500 ml was removed by therapeutic phlebotomy. Patient ' s treatment regimen, frequency of phlebotomy, complete blood count, symptoms, and signs are observed for the period. Data were analyzed to arrive at the results.
Results: Seventy five percent of patients had symptoms related to polycythemia of which neurological manifestations were seen in most (67%) cases. Twenty percent had breathing difficulty and a few manifested with other symptoms. In 25% of the cases, diagnosis was made incidentally when investigating for other ailments. Mutation in JAK2 was detected in 20% of cases. 25% of the cases had smoking history. Forty percent had hypertension and 20% of cases had thrombotic complications. Hematocrit at the time of diagnosis was 55-60% in 70% of the cases. Rest of the 30% had hematocrit between 48% and 54%. Seventy five percent of the patients were managed with therapeutic phlebotomy alone. Twenty five percent of the patients in addition required hydroxyurea. Most patients with high hematocrit required 5 to 6 therapeutic phlebotomies at weekly or less than a week intervals to reduce the hematocrit to 45%. Maintenance of therapeutic phlebotomy at interval of 3-6 months was required after stabilization of the hematocrit. Patients on hydroxyurea required maintenance therapeutic phlebotomy at intervals greater than 6 months. Adverse events were noted in 10% of the cases during venesection. Forty percent of cases also received antiplatelet drugs. Ninety percent of the cases felt symptomatically better after the procedure.
Conclusion: Effective red cell mass management by therapeutic phlebotomy can help patients with polycythemia to lead a comfortable life. Therapeutic phlebotomy proves to be cost effective and a safe mode of management opted by both medical practitioners and patients. The use of blood obtained from people with polycythemia (tested negative for gene mutation) for allogeneic transfusion though seems acceptable is still under debate.
Unexplained change in color and loss of swirling in an apheresis platelet unit: An illustration
P.D. Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
Background: We use inspection of platelet units for swirling phenomenon as a first-line, noninvasive quality control measure for platelets. All platelet concentrates (PC ' s) are further investigated for PH and discarded if they fail to meet the current standard of PH >6.2.
Case Report: An apheresis platelet unit showed the complete absence of swirling and change in color from yellow translucent immediately after collection to turbid greenish yellow on day 2 of storage. PH was found to be 5.8, thus, raising a high degree of suspicion for bacterial growth. Samples from the platelet unit as well as blood sample drawn from the donor were submitted for gram stain and aerobic and anaerobic cultures. The donor-related factors contributing to bacterial contamination were ruled out by re-interviewing and re-examination of the apheresis platelet donor. Platelet aggregation studies showed a reduced response to collagen and Ristocetin. Bacterial culture results were negative after 5 days and 14 days incubation. The platelet unit was not used for transfusion. The cause of greenish discoloration of platelet unit could not be identified. Though highly suggestive of bacterial contamination, the unit and donor remained culture negative even after extended study. The possibility of an unusual contaminant or other physical reasons leading to loss of platelet viability and lowering of PH could not be ruled out. Correlation between lack of platelet swirling, fall in PH, decreased platelet function and probability of contamination and its effect on in vivo survival in patients needs to be demonstrated further.
Therapeutic red cell exchange in two pediatric patients with severe sickle cell crisis: Case report
P. D. Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
Background: Therapeutic red cell exchange (TREX) has been used successfully over the past few years, in a variety of clinical conditions as a therapeutic modality. Therapeutic red cell exchange by apheresis is a well-established procedure for the treatment of severe complications of sickle cell anemia in adult patients. TREX has been sparingly used in pediatric cases due to concerns related to vascular access, patient's blood volume, and extracorporeal blood volume during the procedure. We present two pediatric cases of sickle cell disease in crisis, treated successfully by TREX.
Case Report: TREX procedure was performed in two children (aged 3 and 5 years) with sickle cell anemia, who presented with bilateral pulmonary infiltrates, respiratory distress, and hypoxemia, unresponsive to other means of conservative therapy. A single blood volume TREX procedure was performed after priming the apheresis kit with RBC units with hematocrit >55%. Leukoreduced RBC units with hematocrit of 60% were used for volume replacement. The procedure time was 79 and 52 min, respectively. The hemoglobin S concentration reduced from 71% to 14% and 77% to 31% in the two cases. There was no major complication related to the procedure in both patients. The patient experienced dramatic improvement within 24 h, progressing to complete recovery within a few days.
Conclusion: The advent and ready availability of automated apheresis equipment may alter significantly the approach to management of pediatric patients with sickle cell disease. Currently available automated systems allow the performance of RBC exchange in a very reasonable amount of time, with relative ease, safety, and efficiency.
Therapeutic plasma exchange in myasthenic crisis: A case report
B J Medical College, Ahmedabad, Gujrat, India
Background: Since the introduction of automated cell separators in the 1970s, therapeutic plasma exchange (TPE) is an established procedure in the treatment of a diversity of diseases including neurological disorders (e.g. myasthenia gravis and Guillain-Barre syndrome). Myasthenia gravis (MG) is a neuromuscular disorder characterized by weakness and fatigability of skeletal muscles. The underlying defect is a decrease in the number of available acetylcholine receptors (AChRs) at neuromuscular junctions due to an antibody-mediated autoimmune attack. Therapeutic plasma exchange/intravenous immunoglobulin (IVIg) is first line treatment in cases of Myasthenia crisis. We report our first experience in a case of Myasthenic crisis.
Case Report: A 36-years-old female patient weighing 50 kg came to OPD with complains of giddiness and diplopia for 1 month, drooping of upper eye lid for 1 month, difficulty in swallowing for 1 month, and difficulty in breathing for 1 month. Patient was diagnosed as a case of myasthenia gravis presenting in crisis and five therapeutic plasma exchange procedures were advised as first line of management according to our hospital policy. Five procedures of therapeutic plasma exchange were done on alternate day using automated cell separator Spectra Optia (Terumo BCT). In this patient, total blood volume processed is 20,577 ml, total plasma exchanged is 10,487 ml, and mean replacement fluid given is 1950.2 ml, so 209.74 ml/kg plasma exchanged in five procedures. ACD used in procedure is 342.8 ml; ACD to patient is 57.6 ml. the procedures were completed in a mean time period of 91.4 min. No intra or postprocedure complications noted
Discussion: Myasthenia Gravis is not rare, having a prevalence of 1-7 in 10,000. It affects individuals in all age groups, but peaks of incidence occur in women in their twenties and thirties and in men in their fifties and sixties. Overall, women are affected more frequently than men, in a ratio of approximately 3:2. The cardinal features are weakness and fatigability of muscles. The weakness increases during repeated use (fatigue) and may improve following rest or sleep. If weakness of respiration becomes as severe as to require respiratory assistance, the patient is said to be in crisis as in our case. Such cases are treated with IVIg/plasma exchange as first line of treatment. Most common side effect of plasma exchange procedure is citrate toxicity. To prevent citrate toxicity, 10% calcium Gluconate in 1,000 ml normal saline is infused throughout the procedure. The amount of ACD to patient was extremely low, thus no citrate toxicity was seen.
Conclusion: Plasma exchange can be easily done in patients with Myasthenia gravis presenting in crisis, where blood pressure is adequately maintained. Strict monitoring of blood pressure and fluid balance should be done to prevent complications.
Tetany caused by transfusion of small volume of blood: A rare case report
Government of Medical College and Hospital, Chandigarh
Background: Tetany is characterized by carpopedal spasm and is associated with tingling around mouth and distally in limbs.
Case Report: A requisition for two units of packed red blood cells for correction of anemia was received at the Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh for a 54-year female, known case of genitourinary carcinoma. The patient ' s blood group was B Rh D positive. Two units were cross matched by the AHG phase tube technique. After transfusion of approximately 15-20 ml of blood, a call was received from resident in charge radiotherapy ward stating that the patient had complaints of clenching of hands after starting of transfusion. Blood bag along with EDTA and plain vial samples were received. After the initial clerical checks in the department, complete work up of transfusion reaction was done.
- Supernatant of post-transfusion sample was clear.
- Blood group of pretransfusion sample, post-transfusion sample, and blood bag was reconfirmed.
- Cross match was found compatible on pre- and post-transfusion sample using AHG phase technique.
- DAT and antibody screen on pre- and post-transfusion sample was negative.
On bedside examination, classical carpopedal spasm of right hand was observed in the patient. The patient also complained of tingling and paraesthesias in rest of her body. Her investigations showed decreased potassium levels (2.5 meq/l). But there were no reports of her serum calcium and magnesium levels. On subsequent follow up, serum calcium levels were also low (6.5 mg/dl).
Discussion: Tetany is a disorder with extremely variable clinical presentation. Mild symptoms may include circumoral numbness, muscle cramps, or paresthesias of hands and feet. In severe cases, patients may present with laryngospasm, generalized muscle cramps, and seizures. Tetany can be a manifestation of multiple disorders, namely hypocalcemia, alkalosis, hypomagnesemia, hypokalemia, and hyperventilation syndrome.
Our patient developed tetany by transfusion of small volume of approximately 20 ml blood. Her total serum calcium was low. Magnesium deficiency could have been a contributory factor but serum levels were not available. Our patient ' s dietary intake was minimal and could be hypomagnesemic. Hypokalemia has also been reported to cause tetany and our patient had hypokalemia that could have further contributed toward causing this event. All these above mentioned factors could have resulted in tetany even with transfusion of small volume of blood. In transfusion medicine, tetany is a known adverse event following massive transfusion due to calcium chelation by citrate present as an anticoagulant in blood bags.
Conclusion: In our patient, multiple electrolyte disturbances could have precipitated tetany even by small volume blood.
Skewed lyonization of X chromosome causing severe hemophilia in female carrier: A case study
Christian Medical College, Vellore, India
Background: Hemophilia A is a bleeding disorder characterized by FVIII deficiency. It presents with symptoms such as easy bruising and hemorrhage following trauma or surgery. Severe cases may lead to hematomas and hemarthrosis. Hemophilia A is an X-linked recessive disorder typically affecting homozygous male and females who are homozygous for mutant F8 gene on the long arm of X chromosome (Xq28).
Case History: A 20-year female presented with history of gum bleeding, deep hematomas and hemarthrosis of large joints including bilateral elbow and knee joints was diagnosed to have Von willebrand ' s disease at the age of 7 years. She had received multiple transfusions with cryoprecipitate and FFP. She had been referred to our hospital for further evaluation. She is second born child of nonconsanguineous marriage. Family history revealed two younger brothers with prolonged bleeding and one brother had expired at age of 3½ years due to prolonged bleeding (hemophilia). Her elder sister's son has been diagnosed with hemophilia at the age of 1 year. Her maternal uncle died following circumcision (definite cause not known).
Results: While complete blood counts, bleeding time, Prothrombin time and thrombin time were found to be within our normal reference range. Activated partial thromboplastin time was found to be elevated and hence further mixing studies were done which showed the following results.
Platelet Aggregometry: Normal response to normal and low dose Ristocetin. For father and mother of patient same response to Ristocetin is seen as earlier.
Conclusion: It is extremely rare condition to have severe hemophilia in females, but there are studies to support it (1, 2, 3, 4) and suggest that X-linked recessive inheritance may be seen in females under rare circumstances such as skewed inactivation (lyonization) of X chromosomes leading to predominant expression of the mutated alleles as the result of a preferential inactivation of the X chromosomes with wild type F8 gene, Turner's syndrome and homozygosity at disease locus.
Single-donor platelet transfusion: A study of 30 cases
Kamineni Institute Of Medical Sciences
Background: Single-donor platelet transfusion given in the cases at Kamineni Hospital KIMS, Narketpally, from January 1st, 2013 to April 30 th , 2013 are analyzed. A total number of 30 patients had SDP for various criteria. The need for SDP based on WHO criteria taking into consideration of platelet count is analyzed. Both appropriate and inappropriate use of SDP is calculated.
Serious hazard of transfusion reaction: A case report
Dr MGR Medical University Guindy, Chennai
Background: Application of blood and blood components throughout decades is very successful and mostly safe procedure in patient's therapy. However, it may lead to unfavorable effects, such as hemolytic transfusion reactions. Hemolysis (or shortened red blood cell survival) in a patient receiving, or having recently received, a blood transfusion is more often than not an immune-mediated phenomenon, properly referred to as a hemolytic transfusion reaction (HTR). There are also a number of nonimmunemediated causes of RBC destruction associated with transfusion. These phenomena (sometimes referred to as pseudo-hemolytic transfusion reactions include RBC lysis caused by thermal injury, osmotic injury, mechanical injury, infection, congenital hemolytic anemia, acquired hemolytic anemia, and drugs)
Objective: To report a case of hemolytic transfusion reaction due to improper storage of blood unit after delivered from blood bank.
Case Report: A 50-year-old female, with a case of postoperative hysterectomy with Hb7.0 gms% required two units of 'B positive' packed red blood cell; the same was issued after compatibility testing. Subsequently, on the next day a transfusion reaction report along with post-transfusion sample and blood bag was received from the hospital stating that patient had acute transfusion reaction after starting the second unit of compatible blood unit. Immediately, the transfusion was stopped and patient was treated with IV fluids and supportive therapy and the patient made an uneventful recovery from the reaction. To determine the cause of the post-transfusion hemolysis, immediately after the reaction, the patient's pre- and post-transfusion serum investigations were performed. The patient pretransfusion blood and post-transfusion blood samples were rechecked for blood grouping, cross matching and antibody screening to rule out clerical and technical error. On visual inspection post-transfusion sample showed hemolysis; however, DAT was negative, postreaction urine showed free hemoglobin in the urine. The blood bag and transfusion set both showed hemolysis. Blood bag was sent for bacterial culture later found to be negative.
Since the tests did not give conclusive result related to immune-mediated reactions, other causes of nonimmunological reactions were considered. On subsequent look back it was found that the second unit of blood bag that was transfused 24 h after issue from the blood bank and was stored in the ordinary refrigerator without adequate temperature maintenance.
Conclusions: To avoid occurrences of such nonimmunological adverse reactions at the bed side, component should never be stored or held in patient care unit unless there is a controlled monitored environment. At the blood bank except in case of emergency, there should not be an issue of more than one unit at a time. It is also imperative to introduce strict hemovigilance programs to have a continuous process of data collection and analysis of transfusion related adverse reactions in order to investigate their causes and outcomes. There should be a continuous education and awareness program for healthcare professional involved in 'cold chain maintenance and its importance in blood transfusion reactions' to prevent such incidence in future.
Multiple red cell alloantibodies in antenatal patient: A case report
PGIMER, Chandigarh, India
Background: Universal screening of all antenatal women is mandatory in most developed countries. The irregular erythrocyte alloantibodies that may be present in the serum of these women can cause hemolytic transfusion reaction in the mother or hemolytic disease of the fetus and the newborn in the offspring. This is particularly important in multiparous or multiply transfused women. We report a case where multiple red cell alloantibodies were formed in an antenatal patient due to previous transfusions and resulted in hemolytic transfusion reaction.
Case Report: An antenatal patient with history of transfusion reactions that occurred twice in the previous 15 days in a peripheral hospital was referred to our hospital for transfusion support. Her hemoglobin was 7.8 g/dl. Previous immunohematological work up had been done for this patient 4 years ago in our department and showed the presence of anti c and E antibodies in the patient ' s serum at that time. The patient had also been issued a special immunohematological report from our department. During her present admission blood grouping was done by conventional tube technique. Antibody screening and identification was done on gel cards (Diacell and Diapanel, Biorad, Switzerland). Antigen typing of donor units was done on appropriate gel cards. The patient ' s blood group was O Rh D positive. In addition to anti-c and anti-E that were previously present, the patient had developed another antibody-anti Jka. Twenty-five units of O Rh D positive red cell units were phenotyped and three units which were negative for c, E, and Jka antigens and compatible on AHG phase by gel technique were reserved for this patient. Baby was delivered by emergency LSCS and had no jaundice. No blood transfusion was needed for both the mother and the baby during their hospital stay.
Discussion: Multitransfused and multiparous patients have high chances of having irregular red cell alloantibodies. Patients who develop clinically significant antibodies should be provided with an immunohematology work up report or card mentioning the specificity of antibody along with the caution: ;To be transfused with that particular antigen(s) negative blood in future'. This patient despite having the report failed to bring it to the notice of the clinician or blood bank staff in the peripheral hospital. More effective communication with patient ' s attendants and clinicians in such situations is essential to avoid further transfusion reactions. Maintenance of electronic records can further improve the traceability of such patients.
Management of Bombay phenotype patient with congenital heart defect
Kokilaben Dhirubhai Ambani Hospital, Mumbai
Introduction: Bombay phenotype is a rare autosomal recessive phenotype characterized by the absence of A, B, and H antigens on red cells and secretions. Generally Bombay phenotype (Oh) individuals are homozygous for nonfunctional H(hh) and Secretor (sese) genes. For the Bombay phenotype patient admitted for cardiac surgery, it becomes difficult to get a safe compatible blood for transfusion in case of blood loss during surgery. We report here the management of a case of a 7-month-old baby of Bombay phenotype with Tetralogy of Fallot (TOF) admitted for cardiac surgery.
Case Study: In Kokilaben Dhirubhai Ambani Hospital, Mumbai, a 7-month-old baby got admitted in June 2013 for the surgery of Tetralogy of Fallot and a request was received at Department of Transfusion Medicine for want of four units of packed RBC, two units of FFB, and two units of RDP. Blood grouping both forward and reverse grouping was done by column agglutination technique and found to be O positive. In reverse grouping, positive reaction was observed with pooled O cells. The blood sample was subjected to H lectin study and found to be H antigen deficient. The baby ' s blood group was found to be Bombay phenotype having anti H antibody.
Blood samples from both parents were collected and the blood grouping ICT and DCT was carried out. Mother was found to be AB positive and the father was A positive. Both parents were negative for ICT and DCT indicating the absence of unexpected antibody. The case history analysis revealed that mother had 3 abortions earlier and the fourth baby was expired due to cord around the neck. Fifth baby is female child of 4-years old and the Bombay phenotype patient is 6th baby of 7 months. The Bombay phenotype may be possible if both the parents are carriers of incomplete H deficiency (Hh).
The cardiac surgeon was informed about the Bombay phenotype of the baby and advised to use blood conservative strategies like giving blood in aliquots and hemodilution. Bombay phenotype blood was arranged after calling the rare Bombay phenotype blood donor from our donor registry. The blood unit was made into three aliquots and issued for transfusion during surgery. The cardiac surgery was carried out successfully and the blood was transfused blood in aliquots. The hemoglobin rose up to 13.3 g/dL postsurgery. The baby got discharged without any complications.
Discussion: Individuals with Bombay phenotype must be managed either with predeposit autologous blood transfusion or with blood from other Bombay phenotype individuals. The incidence of Bombay phenotype in India is 1:13,000, especially in Maharashtra. Since in this case, the patient is of 7-months old, it is not possible to collect autologous blood units prior to surgery. Hence, the patient was managed successfully with Bombay phenotype blood donors, identified from our donor registry.
Inherited factor X (Stuart - Power factor) deficiency and its management in transfusion medicine: A case report
Amit Kumar Biswas
Armed Forces Medical College, Pune, Maharashtra
Introduction: Factor X is a vitamin K-dependent serine protease, synthesized from liver. It plays a pivotal role in coagulation cascade system and is the first member of the final common pathway to thrombus formation. The gene for Factor X is located on chromosome 13. There can be both inherited and acquired causes of Factor X deficiency. It is an extremely rare autosomal recessive inherited coagulation disorder in children (1 in 2 million). Only 50 cases have been reported worldwide. In heterozygous state it remains asymptomatic, but in homozygous state it presents with bleeding manifestations, resembling moderate hemophilia. Marked deficiency may present as severe post-traumatic bleeding, hemarthropathies and even intracranial bleeds. We present a case of a 1-year-old child, who manifested with complaints of easy bruise ability and hemarthrosis (Rt) knee, since 4 to 5 months. No family history of trauma or any bleeding diathesis. No history of liver failure. Complete hemogram, red cell indices, and BT were within normal limits. PT, aPTT, and TT were prolonged, which showed correction after mixing studies with normal pooled plasma Russell viper venom time also increased. He was further evaluated for Vit K deficiency by doing assay of Vit K-dependent factors (Factor II, VII, IX, and X) and individual factor assays using factor X-deficient plasma. Results showed isolated deficiency of factor X (< 1% of the normal value). The patient was diagnosed as severe factor X deficiency and treated accordingly. Presently he is on follow up and is advised to take FFP in case of severe bleeding. The diagnosis of factor X deficiency is usually suspected when both the PT and aPTT are prolonged that is corrected with aged serum but not with adsorbed plasma. Patients are classified into three groups according to the levels of Factor X: severe (FX: C, < 1%), moderate (FX: C, 1%-4%), mild (FX: C, 6% - 10%). Congenital factor X deficiency is of two types. In type I, there is reduced synthesis of factor X, while type II is a qualitative defect associated with production of dysfunctional molecule. Our case had severe factor X deficiency (< 1%), and in our country, sporadic cases of severe factor deficiency have been reported. As the inheritance pattern of factor X deficiency is autosomal recessive, our case was diagnosed as hereditary factor X deficiency, since both the parents had normal factor level and patient did not have any of the underlying acquired causes of Factor X deficiency. For minor bleeding symptoms, topical therapies and anti-fibrinolyitic agents may be sufficient, while for more severe bleeding, factor X replacement therapy can be accomplished with FFP or prothrombin complex concentrates, which contains significant amount of activated Vit K-dependent factors. Both these modes of treatment have their own side effects. The biological half life of infused factor X is 2 0-40 h but response varies among individuals. Targeted levels for treatment are not well established. Patient with Factor X level of 10-40% have been considered for hemostasis well established. Patient with Factor X level of 10-40% have been considered for hemostasis.
Hemophilia with inhibitors: A Case report
Seth GSMC & KEM Hospital, Mumbai, Maharashtra
Background: Hemophilia is a common disorder with known and defined modalities of therapy. Yet the clinical course of a patient is unpredictable and has challenges such as development of inhibitors that make the treatment of hemophilia challenging. A 19-year-old patient, known case of severe hemophilia A since the age of 4 years came with a swelling in right knee (hemarthrosis). Patient was given factor VIII correction and chloroquine. Patient improved and discharged. Till 2006 patient had not developed inhibitors but in november 2006, the inhibitor level was 6 BSU and in 2013, high titers of inhibitors of about 600 BSU were detected. The patient is managed with Novoseven and FEIBA. The patient showed improvement with this treatment. Transfusion medicine physicians have an important role to play in the treatment and hence must be aware of the modalities available for such patients. Current options like Novoseven, FEIBA, immune adsorption, immune tolerance induction are the newer modalities of treatment in which transfusion medicine physician can intervene.
Guillain-Barre syndrome in a pregnant patient: A case report
Adulkar D G,
Background: Since the introduction of automated cell separators in the 1970s, therapeutic plasma exchange (TPE) is an established procedure in the treatment of a diversity of diseases including neurological disorders (e.g. myasthenia gravis and Guillain-Barre syndrome). Guillain-Barre syndrome (GBS) manifests as rapidly evolving are lexic motor paralysis with or without sensory disturbance. Therapeutic plasma exchange/intravenous immunoglobulin (IVIg) is the first line treatment in cases of GBS. We report our first case experience of therapeutic plasma exchange in a pregnant GBS patient.
Case Report: Twenty-year-old female patient weighing 50 kg was admitted at our institute with complains of bilateral lower limb weakness for 1 day. The onset of disease was insidious and it was gradually progressive. Patient has history of 8months amenorrhea. Patient was diagnosed as Guillain-Barre syndrome (GBS) and three therapeutic plasma exchange procedures were advised as first line of management according to our hospital policy. Three procedures of therapeutic plasma exchange were done on alternate day using automated cell separator Spectra Optia (Terumo BCT). In this patient, total blood volume processed is 11,757 ml, total plasma exchanged is 6,095 ml, and mean replacement fluid given is 1,893 ml. so 235.14 ml /kg plasma exchanged in three procedures. ACD used in procedure is 339.3 ml; ACD to patient is 48.33 ml. The procedures were completed in a mean time period of 101.33 min. No intra/postprocedure complications were noted.
Discussion: GBS manifests as rapidly evolving are lexic motor paralysis with or without sensory disturbance. The usual pattern is an ascending paralysis that may be first noticed as rubbery legs. Most patients require hospitalization, and almost 30% require ventilatory assistance at some time during the illness. Most common side effect of plasma exchange procedure is citrate toxicity. To prevent citrate toxicity, 10% calcium Gluconate in 1000 ml normal saline is infused throughout the procedure. The amount of ACD to patient was extremely low, thus no citrate toxicity was seen. Another treatment modality for this patient was IVIg. Dose of IVIg is 2 g/kg body weight. Comparing with therapeutic plasma exchange total cost of IVIg for this patient comes around 1.8-2 lacs, while TPE can be done in under INR 75,000.
Conclusion: Plasma exchange can be easily done in pregnant patients with GBS. Strict monitoring of blood pressure and luid balance should be done to prevent complications.
Factor XI deficiency: A rare case study
T.D Medical College, Alleppey, Kerala, India
Background: A 45-year-old male patient presented with severe epistaxis and giddiness of 2 days duration. He is a chronic liver disease patient also a pulmonary tuberculosis case on category I ATT. He had similar episodes from his childhood, that is, on and of epistaxis nearly about 100 ml per day. He has similar history of mucosal bleeding running in his family with an autosomal dominant inheritance. On investigation, his hemoglobin was low, bleeding time normal, and there was isolated APTT prolongation. Then mixing study was done and APTT got corrected and it also showed correction with both aged and adsorbed plasma. We evaluated some of his family members and they also showed same results. So a factor XI deficiency is considered. Patient got better with fresh frozen plasma transfusions.
Delayed hemolytic transfusion reaction caused by Anti-S antibody in a beta thalassemic patient
Samar Kumar Barai
Department of IHBT, MCH, Kolkata, India
Background: Delayed hemolytic transfusion reactions (DHTR) occur 3-21 days after blood transfusion. It usually presents as fever, anemia with mild jaundice and sudden drop in hemoglobin level few days after transfusion. Here we present a case of DHTR in a 24-year-old Beta thalassemic female with blood group of O positive caused by the alloantibody to S antigen.
Material and Methods: The patient was transfusion dependent for last 12 years. Recently her hemoglobin dropped to 3.2 g/dl, 1 week after two units of O positive packed red cell transfusion (pretransfusion hemoglobin was 6.8 g/dl). So a work-up was performed to detect the cause of this sudden drop in hemoglobin level. Accordingly a direct antiglobulin test (DAT), autocontrol and antibody screening by three and 11 cell panel were performed in polyspeciic coombs card ( anti IgG+C3d).
Results: Both DAT and autocontrol showed no agglutination. Panel cells showed agglutination in no 1 and 3 column (1+ in no 1 and 3+ in no 3 column) and in 11 cell panel except column no 2, 6, 7, and 8 all the columns showed positive results (2+ in no. 1, 5, and 10 and 1+ in no. 3, 4, 9, and 11 columns). Extended phenotype of patient ' s red cell could not be performed because of recent history of blood transfusion.
Conclusion: The alloantibody to S antigen was detected and the reaction showed 'Dosage effects, heterozygous expression of S with s reduce the strength of agglutination. The frequency of (S+/s-) antigen in western population is 10% in whites and 6% in blacks. 1 S antigen negative O positive packed red cell was given for safe transfusion in this patient. Alloantibody is the major cause of DHTR in transfusion dependent patients and IgG type of alloantibody to S antigen has a great potency to cause DHTR in transfusion-dependent patients.
Dat negative severe DHTR in a patient with multiple alloantibodies: No reason to panic
P.D. Hinduja National Hospital and MRC, Mumbai
Background: Patients with multiple alloantibodies often pose significant challenges to the transfusion service in terms of interpretation of compatibility test results, interference with detection of new blood group alloantibodies, etc. This may lead to significant delays in the provision of compatible red blood cells by necessitating additional testing and sometimes it may be virtually impossible to find compatible RBCs for some patients.
Case Report: We report the case of 64-year-old male with multiple alloantibodies with delayed hemolytic transfusion reaction (DHTR) due to anti-Jkb antibody. The patient, a case of alcoholic liver disease, recurrent Coeliac disease, and ankylosing spondylitis presented with autoimmune Hemolytic Anemia (AIHA) (IAT positive) with a Hb of 9.3 gm% 5 years back. Anti-c and anti-E alloantibodies were detected on immunohematological work-up. Patient was transfused two units of blood and put on steroid regime. He then presented with anemia (Hb-6.2 gm%) after 5 years and was transfused two c and E antigen negative blood units. Within 10 days, he again presented with Hb of 6.6 gm% and was transfused two antigen negative units as given earlier. After transfusion of the first unit, patient developed signs of acute transfusion reaction and patient had total bilirubin of 9.6, indirect -7.8, increased LDH, and decreased haptoglobin. Anti-Jkb antibody was identified on further work-up of the patient ' s blood sample. However, DAT was found to be negative at this juncture. The second blood unit was then transfused uneventfully and the patient ' s Hb increased to 9.0 gm% post-transfusion. Both the donor units were subsequently phenotyped and found to be negative for ' Jkb ' antigen. On phenotyping the units transfused 10 days back, both were found to be positive (one homozygous and other heterozygous expression) for Jkb antigen. The patient ' s phenotype was Jka+Jkb-. The cause of DAT negative, severe DHTR may be explained by anti-Jkb antibodies destroying the previously transfused JKb+ RBCs. This case highlights the unique presentation of severe DHTR caused by anti-Jkb antibody.
Co-infection among blood donors: A report of two cases
Sri Devaraj Urs Medical College, Kolar, Karnataka, India
Background: Transfusion medicine has become an integral component of all healthcare delivery systems in preventing transmission of infectious diseases through blood and blood products. Measures for safe transfusion services include donor selection criteria donor interviews, donor deferral, and serological tests for infective disease markers. Epidemiological studies of blood-borne diseases are important for revealing the risk groups and identifying the risk factors. Screening helps to solve difficulties in collecting information among healthy populations. Co-infection with HIV and HBV, HCV respectively, is common, because of shared modes of transmission.
Cases: We present two first time male voluntary blood donors who were co-infected by HIV along with HBV and HCV pathogens respectively and were referred for subsequent follow up.
Conclusion: Safe transfusion not only requires the application of science and technology to blood processing and testing, but also social mobilization to promote voluntary blood donation by sufficient number of people who are healthy and are low risk of infection that can be transmitted to the recipients of their blood. To achieve maximum safety at an acceptable cost, multilayered risk reduction strategies are required, which include proper donor screening.
Clinically significant anti-M antibodies: A case series
Shah S, Kalgutkar S., Sawant R., Siddhi Shah,
P.D. Hinduja National Hospital and MRC, Mumbai
Background: Experts concur that anti-M, not reactive at 37°C, is not clinically significant. Some reports of clinically significant anti-M antibodies causing hemolytic disease of the fetus and the newborn (HDFN) and delayed hemolytic transfusion reaction (DHTR) are available. We report 13 cases of clinically significant anti-M antibodies. Of all the antibodies identified in our institute during the study period, anti-M constituted about 14%. All were alloantibodies and were found in patients of varied age group (11 months to 85 years) and had varied clinical diagnosis. 2/13 (both male) patients had a history of prior transfusion. 3/13 patients were females and all were multigravida. In all cases, antibody screening was positive at room temperature as well as at IAT phase using column agglutination technology (CAT). Anti-M antibody was identified using 11 cell identification panel (Bio-Rad, Switzerland) and cross-match with ABO group identical units was incompatible at room temperature and at 37°C in all cases. This indicated presence of IgM and IgG component, however, testing with Dithiothreitol (DTT) was not done in any case. M-antigen negative status was confirmed by extended red cell phenotyping in all 13 patients. Total 192 donor units were screened for M antigen negative status, of which 42 units were found to be M antigen negative. A total of 31 units were transfused to 11 patients. None of these patients developed any new alloantibody or developed DHTR within a follow-up period of 6 months.
Conclusion: If the patients anti-M reacts at 37°C, it should be honored as clinically significant and further investigated for the potential to cause DHTR and HDFN. Providing M negative transfusions is the best therapy in this situation. Probability of finding a M antigen negative donor is 1 in 5 in our experience. Provision of RBC antigen phenotyped donor registry shall ensure quick provision of antigen negative blood for transfusion in emergency situations.
Clinically significant anti M antibodies: A report of two cases
Government Medical College and Hospital, Chandigarh, India
Background: Most anti-M antibodies are not active at 37°C and are thus of no clinical significance. Occasionally these antibodies have a wide thermal range and can lead to hemolytic transfusion reactions or hemolytic disease of the new born.
Patient and Methods: We describe two cases of anti-M antibodies, both of which were clinically significant. Results: The first case was detected due to cross match incompatibility and the second presented as a blood group discrepancy.
Conclusion: When the antibody is active at 37°C, M antigen negative red cell unit should be issued.
Case studies: Our experience in managing myasthenic crisis with therapeutic plasma exchange
Sri Ramachandra Medical College and R.I, Sri Ramachandra University
Introduction: The goal of using therapeutic plasma exchange (TPE) in a patient with myasthenic crisis is to remove pathological antibodies from plasma. The plasma is replaced by replacement fluids there by maintaining the patient in a normovolemic condition at the same time removing the pathological elements from the body.
Aim: To describe the efficacy and dependability of TPE in managing Myasthenic crisis.
Methodology: The study was undertaken in Sri Ramachandra medical college from July 2012 to January 2013. The study was done on two female patients admitted in intensive care unit with history of breathlessness and generalized weakness. Both were intubated and were on steroids, pyridostigmine, immunosuppresents (mycophenolate mofetil), antibiotics, and other supportive medication. The machine used for undertaking the procedure was Fresenius Kabi Com Tech Cell Separator. Acid citrate dextrose was used as anticoagulant in a ratio of 1:7.2. Pre- and postprocedure monitoring of the blood hemoglobin, total count, platelet count, electrolyte profile, total calcium, coagulation profile including fibrinogen and albumin to globulin ratio were assessed. Patient vitals and general condition were monitored during the procedure
Result: Five cycles of therapeutic plasma exchange was done in both patients. 1-1.5 volume exchange was done replacing with one-third crystalloids (normal saline), one-third colloids (6% Hydeoxyethyl starch), and one-third with fresh frozen plasma. No adverse reactions were experienced in one patient, but the other had tachycardia and hypertension that was managed by reducing the rate of exchange. No significant variation in laboratory values were observed postprocedure except for fibrinogen.
Conclusion: Both patients started to show improvements from the third cycle onwards and were extubated and shifted out of intensive care unit after the fifth cycle and later discharged. Intravenous immunoglobulin is a possible alternative to TPE but the latter can be considered a better option keeping into account the fastness of action, longer remission from the symptoms, and lower cost of therapeutic plasma exchange.
Case report: Bombay blood group (phenotype hh sese) in a blood donor
Tata Memorial Hospital
Introduction: The Bombay Blood Group is a rare autosomal recessive blood group. The first case was reported in Mumbai by Bhende et al. in 1952. Individuals with this group do not possess A, B, and H antigens on RBC due to the inheritance of double dose of h gene, thus producing the rare genotype hh. Their serum has anti-A, anti-B, and anti-H antibodies. Latest incidence for Bombay blood group has not been published but prior reports claim it to be 1:10,000 in India.
Case Report: A 21-year-old male donated blood in a blood donation camp. Cell grouping by tube method revealed O group. There was discrepancy between cell and serum grouping with serum showing agglutination with pooled O cells. Testing with several O cells gave similar results. Indirect antiglobulin test was positive and direct antiglobulin test was negative. Test with anti-H (ulex europeus) was negative. To verify the absence of H antigen, donor cells were tested with sera of two confirmed Bombay blood group individuals. Anti-A, anti-B, and anti-H titers were evaluated in the donor. Para-Bombay phenotype was ruled out by salivary secretor studies and adsorption elution studies wherein there was absence of H substance in saliva and also the absence of adsorbed H, A, or B antigen on donor cells.
Discussion: During routine blood grouping or only cell grouping, Bombay phenotype can be wrongly categorized as O group because the cells do not react with reagents anti-A and anti-B as is seen in group O individuals. Also, cross matching with several O blood units shall yield incompatibility that should be a warning signal for further evaluation. Hence, serum grouping (reverse grouping) is recommended and crucial to detect the Bombay Blood Group. This donor was classified as Bombay blood group RBC H deficient, nonsecretor, also known as Bombay phenotype (hh sese). Other related phenotypes like RBC H partially deficient Non secretor (HH sese or Hh sese) and RBC H-deficient, secretor, also known as parabombay phenotype (hh Se) should be ruled out. The clinical significance of Bombay blood group is that individuals belonging to this group should receive blood transfusion of the same group only, to prevent lethal consequences. Availability of Bombay group can be challenging, especially during emergencies and maintaining a registry of this rare group can help in overriding the situation.
Conclusion: It is possible to detect rare blood groups during routine screening of blood. The staff needs to be alert and aware of the various blood group systems to make an accurate diagnosis. Molecular techniques for confirmation can be applied as a research tool in these rare cases.
Case report: Anti-M in an obstetrics patient
Bhushan Bandu Amle
Seth GSMC and KEM Hospital
Background: The MNS system was the second blood group system discovered in the year 1927. The first two antigen M and N were derived from the word immune, while S antigen was named from the city (Sydney) were it was discovered. MNS antigen are carried on glycophorin A(GPA) and glycophorin B (GPB) which are encoded by homologous genes on chromosome 4q 28-q3 1. The frequency of saline reactive anti M in routine blood donors is 1:2,500 to 1: 5,000.
Case Report: Blood sample of a 30-year-old female patient, admitted in obstetric ward was processed in blood bank. Cell grouping by tube method revealed B Rh positive. Serum grouping showed weak positive reaction with O pooled cells. Indirect anti globulin test was positive and Direct Coombs test was negative. Anti-M pattern was seen in the IAT phase of testing with 11 cell panel but not in enzyme phase.
Discussion: Many examples of anti M are naturally occurring saline agglutinins that react below 37 °C. Although we may think of agglutinating anti M as IgM, 52-80% are IgG or have IgG components, regardless of their immunoglobulin class and they do not react with enzyme-treated RBCs. Anti-M appears to be more common in children and in patients with burns. As long as anti-M does not react at 37 °C, it is not clinically significant in transfusion. It is also sufficient to provide units that are compatible at 37 °C. Anti-M rarely causes hemolytic transfusion reaction, decreased cell survival, or HDFN. However, when 37 °C reactive IgG anti-M is found in a pregnant woman, the physician should be forewarned because it can cause severe HDFN.
Conclusion: Anti-M in pregnancy and its effects on the fetus is a grey area with most reports suggesting a benign course. It is possible to detect rare blood group antibodies during routine screening of blood. The staff needs to be alert and aware of the various blood group systems to make an accurate diagnosis. Complete work up is required to identify the irregular antibodies thereby providing appropriate unit of blood component to the patient.
Case report: Hemolytic Disease of the fetus and newborn due to Rh alloimmunization: Still a cause of Cancer
Seth G S Medical College & K. E. M. Hospital
Background: Hemolytic Disease of the fetus and newborn (HDFN) is one of the important causes of in utero deaths and neonatal morbidity and mortality. Alloimmunization to D antigen is the most common cause of severe HDFN. The spectrum of HDFN has changed over the last few decades because of adoption of antenatal and post natal Rh IgG immunoprophylaxis. But anti-D continues to be the most common cause of severe HDFN in India. The prevalence of HDFN due to anti-D is higher in India than Western countries. This can be attributed to the lack of implementation of standardized and universal anti-D immunoprophylaxis and inadequate pre natal care in India. Antenatal screening and immunoprophylaxis guidelines are not implemented in most developing countries because of poor infrastructure, unawareness, and lack of health facilities.
Case Report: A full-term female neonate was delivered via vaginal delivery by a 30-year-old lady G2P2. The neonate ' s birth weight was 2.3 kg. Cord blood Hb was 12.6 gm% with normal platelet and WBC count. Peripheral blood smear showed polychromasia and anisocytosis. Total bilirubin: 6.8 mg/dl, unconjugated bilirubin: 4.4 mg/dl, and conjugated bilirubin: 2.6 mg/dl. Baby was AB Rh D positive. Father's blood group was AB Rh positive, Mother's blood group was A Rh negative and Du negative. DAT was positive (4+) on fetus blood sample (LISS/Coombs card, Bio-Rad). Postdelivery (Day 1) antibody screen test in mother ' s serum was positive with antibody identified as anti-D using an extended 11-cell panel for antibody identification (ID-Dia Panel, Bio-Rad). Titer of antibody was 1:16 in antiglobulin phase by tube technique. Antenatal screening during second pregnancy was positive and titer in 8th month was 1:8. Mother had history of pregnancy with Rh positive baby 6 years back. She was given anti-D prophylaxis after delivery of first baby but anti-D immunization was not given antenatally. The neonate was managed with phototherapy as HDFN was mild and discharged on day 8 of life hearty.
Conclusion: HDFN due to anti-D continues to occur in developing countries like India due to non compliance with ante natal screening and Rh IgG immunoprophylaxis guidelines, poor antenatal services in India, lack of awareness among obstetricians and patients. Inadequate dose of immunoglobulin is also one of the reasons for occurrence of the disease. Therefore, dose of immunoglobulin should be calculated after calculating amount of fetomaternal hemorrhage to ensure adequate immunization.
Anti-Xga antibody: The first case report from India
Lions Blood Bank New Delhi
Background: Xga blood group system is the only known sex-linked blood group. The gene encoding Xga is located on the X chromosome. About 34% of random males and 11% of females are Xga negative. Anti-Xga antibody is extremely rare antibody and to our knowledge no case has been reported from India so far.
Case report: Request received for packed red cells for a 38-year-old male patient, native of Nigeria, clinical diagnosis chronic kidney disease with anemia, with history of kidney transplant 3 years ago in India and had received multiple blood component transfusions in Nigeria as well as in India. Patient had been on dialysis since last 3 months. He had received transfusion of one unit packed red cells about 20 days ago from some other facility. Hemoglobin was 4.2 Gm%. Blood group was O positive, antibody screen by column agglutination technique (CAT) positive (3/3 showing 2+ mixed field reactions) 11 cell antibody identification panel by CAT was positive; 6/11 showing 1+ to 3 + mf reactions. The reaction pattern matched exactly with Anti-Xga antibody and all clinically significant antibodies were ruled out in double dose. Anti-Xga antisera was not available anywhere for antigen testing. Direct antiglobulin test was 3+ and autocontrol was also positive 2+ by CAT suggesting a possibility of delayed hemolytic transfusion reaction in view of multiple transfusions. Cross matching with seven O positive units, by CAT, revealed two compatible and five incompatible units.
Discussion: Anti-Xga is an uncommon antibody and has not been implicated in HTR or HDN. It is usually an IgG antibody, reactive by indirect antiglobulin test, but some are complement binding. The antibodies may be naturally occurring also. It is sensitive toicin/papain. One example of auto-anti-Xga has been reported. This is a very rare antibody and a few cases have been reported from world over mainly from Korea and Japan. This is perhaps theirs t report from India but in a Nigerian patient. The prevalence of the antigen in Indian population has not been studied very well. The Xga antisera is not available commercially.
Conclusion: There is need to have a centralized referral lab with availability of rare antisera and ability to identify rare blood group antigens and antibodies. It is very important to have screening and identification cell panels to meet the requirements of Indian as well as foreign patients in view of increasing medical tourism.
Anti-M antibodies complicating transfusion therapy in patients of sickle cell disease and impending congestive heart failure: A report of two cases
Sangeeta Pahuja Sindhwani
P Lalita Jyotsna, Lady Hardinge Medical College
Introduction: Anti-M is a frequently encountered naturally occurring antibody. It is often found in the sera of persons who have had no exposure to human red cells. Although predominantly of IgM type, these antibodies may have an IgG component. It is more common in infants than in adults. Majority of anti-M antibodies are not considered to be clinically significant due to their thermal amplitude of 4-22°C. Since most anti-M antibodies are not active at 37 °C, they can generally be ignored in transfusion practice. However, these antibodies have been shown to cause delayed hemolytic transfusion reactions (DHTRs) or hemolytic disease of fetus/newborn (HDFN). Apart from their propensity to cause DHTRs/HDFN, they behave as nuisance antibodies by causing discrepancy in blood grouping as well as cross match incompatibility, leading to delay in transfusion. We present here two cases of anti-M, one of which, of IgG+IgM type occurring in a never-transfused child of sickle cell disease, could have potentially caused delayed hemolytic transfusion reaction
Anti-M in an antenatal setting: A cause for worry?-A report of two cases
Christian Medical College
Background: Allo anti-M is generally described as a cold reactive IgG/IgM antibody, usually reactive at 4°C and room temperature, and not usually responsible for transfusion reactions or hemolytic disease of the newborn. During the period January to June 2013, 24 antenatal patients were detected to have antibodies, of which two were identified as anti-M. We report here two cases of anti-M, reactive at 37°C and the antiglobulin phase, which were associated with clinically significant hemolytic disease of the fetus and newborn.
Patient 1: A sample received in blood bank for this patient revealed a blood group B Positive, and an antibody screen to be positive. Antibody identification using an 11 cell panel identified the antibody as anti-M. She delivered twins, and while one twin died in utero, the second baby born was severely anemic (Hb 7.3gm%), blood group O Positive, with a positive direct Coombs test (2+), hyperbilirubinemia and was found to be M antigen positive. Cross matching was performed using maternal serum and incompatibility was noted in 4 of 5 units cross matched at 37°C and the antiglobulin phase. The single unit that was compatible was M antigen negative. The baby was successfully transfused with M antigen negative, Coombs compatible blood.
Patient 2: This lady was brought with atonic postpartum hemorrhage after delivery of an anemic baby outside. Her blood group was AB positive, and her antibody screen was positive, with the 11 cell panel again showing the antibody to be anti M. The baby's blood group was AB positive and the hemoglobin was 11.6 gm%. Direct Coombs test was positive (2+) and the baby was M antigen positive. The antibody was not reactive at saline/room temperature, but only at 37°C and the antiglobulin phase of testing.
Conclusion: We report here two cases of clinically significant anti-M - in the context of hemolytic disease of the new born, within a period of 6 months, constituting 8.3% of antibodies identified in the antenatal setting at our centre. It is critical therefore that this antibody not be ignored as it evidently bears implications on transfusion as well as hemolytic disease of the fetus and newborn.
Anti Lewis B antibody: Missed on gel, detected on tube
PGIMER, Chandigarh, India
Background: Antibodies against Lewis (Le) antigens are of IgM iso-type, mostly naturally occurring in sera of Le(a-b-) individuals, reacting at room temperature. The antigen antibody agglutination reaction is fragile and requires gentle re-suspension after centrifugation. Generally, anti-Lewis(Le) antibodies are clinically insignificant.
Case Report: A 60-years-old female patient was admitted to emergency ward with diagnosis of left staghorn calculi who was posted for left nephrectomy. Patient ' s hemoglobin was 8 gm/dl. Blood requisition for two units of PRBC was received at our blood bank. While performing the pretransfusion testing, the cell grouping was found B Rh \ΆD\Ά positive. The serum grouping showed reaction of 4+ strength with A-cells and 2+ strength with O-cells at room temperature after immediate spin. Screening for irregular antibodies was done on Coomb's cards using 3-cell commercial panel (ID-DiaCell, BioRad.) and was negative. DCT and auto control on gel were also negative. Since, reaction occurred at room temperature, IgM antibodies were suspected. Henceforth, screening for irregular antibodies was repeated on tube by using the same 3-cell commercial panel and positive results of 3+ strength were found in Sc I and Sc II cells in immediate spin phase. 11-cell commercial ID-panel (ID-DiaPanel, BioRad) was used to identify the type of antibody on tube and was confirmed to be anti-Leb antibody. Patient phenotype was Le(a-b-). Random typing of five units PRBC units for Lewis antigen was done and one unit was found Le(a-b-). Pretransfusion testing was conducted for this unit and cross match was found compatible till AHG phase. However, the patient did maintain her vitals stable and was not transfused The transfusion history was investigated and found to have been transfused with 1 cross match compatible unit, 1 year back in 2012, with no reported transfusion reaction then.
Conclusion: Unlike ABO antigens, Lewis antigens are extrinsic glycolipid antigens that are readily eluted and shed from the transfused cells within a few days of transfusion. At 370°C, regardless of Lewis phenotype, compatible red cells have normal in vivo survival
An ABO mismatched renal transplant recipient with an anti-HLA antibody: The single antigen bead assay, the step forward
Christian Medical Collge, Vellore
Introduction: Donor-specific anti-HLA antibodies (DSA) are detrimental to transplant survival resulting in antibody mediated rejection and graft loss. In high risk ABO incompatible kidney transplant (ABOiKT), clarity in detection of DSA is very crucial before proceeding with desensitization and transplantation. We describe a case of ABOiKT with anti-HLA antibodies that elucidates the role of Luminex-based single antigen bead assay in clearing the donor - recipient pair for transplant.
Case Report: A 44-year-old lady with of blood group O-positive with two children, was to receive a renal allograft from her husband whose blood group was B-positive. Her initial Anti B titer in Coombs was 1:5 12. Among HLA A, B, DR, and DQ antigens she had single A and DQ match with her husband. The initial screen for anti-HLA antibodies was negative in CDC lymphocyte cross match and Luminex cross match (Donor lysate DSA) was negative. Anti HLA Ab screening ELISA was negative.
Subsequently, she underwent desensitization for ABO mismatch with Rituximab, 16 sessions of plasmapheresis and intravenous immunoglobulin infusion. A repeat CDC cross match was 10-15% positive possibly due to Rituximab effect on B cells. At this time, the DSA using donor lysate was negative for anti-HLA antibodies and ELISA was positive for Class I anti HLA antibodies. Since DSA using donor lysate is standardized against HLA-A, B and DR loci the negativity in this platform could not rule out antibodies against other HLA antigens like C, DP, and DQ. To resolve this, we performed the Luminex-based single antigen bead assay that revealed that the recipient did not have significant antibodies against HLA A, B, DR antigens but had antibodies against HLA Cw7. Subsequent donor typing revealed that donor did not have HLA Cw7. Thus, it was clear that this recipient had no Anti HLA Ab against the donor. The donor recipient pair was cleared for ABOiKT once the anti B titer was less than 1:8 on two consecutive days. She is 10 days post-transplant and has a serum creatinine of 1.1 mg/dL with persistent post-transplant anti-B titers of 1:2 and negative DSA.
Conclusion: This case demonstrates the utility of Luminex-based single antigen bead assay in high risk ABOiKT, to rule out a donor specific anti-HLA Ab and provide clearance for the desensitization and transplantation with confidence and clarity.
Alloantibodies in a male Rh negative donor: A case report
PGIMER, Chandigarh, India
Background: Alloimmunization is an immune response in a recipient stimulated by foreign donor cells and this immunologic incompatibility may cause hemolytic transfusion reaction. Although hemolytic transfusion reactions due to irregular erythrocyte alloantibodies in donors are a rare occurrence, high levels can cause destruction of the recipient's cells, and lower levels have to be considered in transfusing infants mainly in heart-lung bypass procedures. In our department Indirect Antiglobulin test (IAT) is performed on all Rh D negative donors. Greater prevalence of alloimmunization, reported in females, with a male: female ratio of 1: 2.7 as per Giblett (1977), can be attributed to immunization through pregnancy and transfusion. However, we hereby present a case report on a male donor with irregular antibodies.
Case Report: A 34-year-old male donated blood in a blood donation drive conducted by the department of Transfusion Medicine, PGIMER. The donor had donated blood on six occasions previously, the latest dating about a year ago. The results of cell and serum grouping of his blood sample were suggestive of AB Rh ĄDΆ Negative blood group. An indirect antiglobulin test (IAT) was performed using group O reagent RBCs by tube technique. This meets the National Blood Policy 2007 (NACO) guidelines and AABB guidelines. It gave a positive result. Using column agglutination technology, the donor ' s blood was screened for irregular antibodies using a commercial three cell panel (ID-DiaCell I II III Biorad) and the alloantibody was identified using an eleven cell identification panel (ID panel 11 cell Biorad) which revealed the presence of anti-D and anti-C antibodies. Extended phenotyping of the donor revealed D -C-E-c +e+. Subsequently, antibody titration was also performed for the anti-D and anti-C antibodies at the AHG phase, the values of which were 1:8 and 1:1, respectively. Telephonic conversation with the donor revealed history of one episode of blood transfusion 15 years ago following a road accident.
Conclusion: Screening donor serum for irregular antibodies is simple and efficient and also serves to simplify the work of cross matching by eliminating the need for the minor cross match. IAT of donated blood is not being done in many centers across India. Blood containing an antibody should be issued in the form of packed red blood cells and the use of such blood for pediatric patients should be avoided. Eliciting transfusion history in donors beyond one year has significance for alloimmunization purposes.
Acute hemolytic transfusion reaction due to 'anti-c' antibody precipitating fatal acute liver failure in a patient with compensated liver disease
Global Health City
Background: Acute hemolytic transfusion reactions (AHTR) occur when transfused cells interact with preformed antibodies in the recipient. Anti-c antibody has been reported to cause delayed hemolytic transfusion reactions, hemolytic disease of the newborn and accelerated clearance of RBCs in vivo. We report a rare case of AHTR due to anti-c, its delayed recognition leading to fatality in a patient with chronic liver disease (CLD).
Case Report: A 53-year-old male, a known case of HCV related CLD since 2008 was admitted with complaints of jaundice, abdominal distension, generalized weakness, tiredness, and dehydration. During the course of follow up for HCV infection, he received intermittent blood transfusion during episodes of variceal bleed almost once in 3 to 6 months. In January 2013, following a blood transfusion in outside hospital, he developed high grade fever, chills and severe pain in abdomen within 3 h of the transfusion. He subsequently developed jaundice, dark-colored bloody urine suggestive of hemoglobinuria. Next day, the serum bilirubin peaked from baseline 1 to 9 mg/dl and hemoglobin level maintained at 6.7 g/dl. However the appropriate evaluation or management of transfusion reaction was not performed. After 1 week, at the time of admission to our hospital, patient was pale, deeply icteric and he was hypotensive (B,P 90/60 mm Hg); he had bilateral edema legs and ascites. Laboratory investigations were as follows: hemoglobin 7.0 gm/dL, Hematocrit 21 %, platelet count 81000 cells /cu mm, Total serum bilirubin 28.8 mg/dL, direct bilirubin 24.12 mg/dL, serum alanine transaminase 160 U/L, serum aspartate transaminase 53 U/L, serum alkaline phosphatase 131 U/L. Patient was on supportive treatment. During antibody screening of blood sample, high titer (512) anti-c antibody was identified in serum. The direct antiglobulin test (DAT) was 4+ positive by polyspeciic antihuman globulin (Diamed) and Monospeciic DAT (Diamed) showed the presence of IgG antibodies only (4+). Anti-c was identified in the elute obtained from patient's red blood cells by acid elution method (Diacidel, Diamed). Cross match compatible c-antigen negative packed red blood cells, platelets and plasma components were issued. Despite supportive care, the general condition of the patient progressively deteriorated and patient succumbed to his illness.
Discussion: It was confirmed that the case is of that of AHTR (i.e. within 24 h of transfusion) with delayed identification precipitating fatal acute liver failure in a patient with HCV related chronic liver disease. Early recognition of signs/symptoms suggestive of an AHTR and prompt reporting to the blood bank are absolutely essential for timely management. In the future antibody screening test should be included in the panel of pretransfusion tests for safer transfusion, and should be mandatory for patients requiring multiple transfusions, in pregnant women and preoperatively in patients to decrease the risk of hemolytic transfusion reactions.
ABO hemolytic disease of fetus and newborn: A case report
PGIMER, Chandigarh, India
Introduction: ABO hemolytic disease of fetus and newborn (HDFN) occurs almost exclusively in infants of blood group A or B who are born to group O mothers because IgG anti-A or -B occurs more commonly in group O than in group A or B individuals. We report a case of clinically significant AB O-HDFN where the mother was blood group O with elevated IgG anti-A and anti-B titers and delivered a child with blood group A Rh(D) positive.
Materials and Methods: A request for double volume exchange transfusion (DVET) of a full-term neonate born to an O Rh(D) negative gravida-2 mother on day 1 of life with birth weight of 2.8 kg and cord blood total serum bilirubin (TSB) and hematocrit (Hct) of 4 mg/dl and 56%, respectively. The mother had normal vaginal delivery at 38 weeks of pregnancy. The first baby was an intrauterine death (IUD) delivered as full-term vaginal delivery. The immunohematological work up was done as per the departmental protocol.
Results: The direct antiglobulin test (DAT) on baby's sample was 2+ on IgG gel card and was 1+ on tube with polyspecific antihuman globulin (AHG) (anti-IgG+C3d). Maternal serum screening for the presence of alloantibody on gel technique (LISS-CoombsΆ card, Biorad, Switzerland) using three cell screening panel (Diacell, Biorad, Switzerland) was negative. Monospeciic DAT performed on neonatal red cells showed presence of only IgG component (DC Screen II, Biorad, Switzerland). Elution prepared from neonatal red cells showed anti-A antibody reacting strongly with A1 red cells (acid elution, Diacidel, Biorad). Maternal titer for anti-A antibody was 64 in saline phase and 256 in AHG phase tube technique. After dithiothreitol (DTT) treatment of the maternal serum, the IgG titer of anti-A was 64. As the TSB value rose to 8 mg/dl within 4 h after delivery the baby underwent one DVET on day 1 of life. Baby was given IVIg 2.5 gm over 4 h on day 3 of life and the TSB and Hct were 12.1 mg/dl and 50%, respectively. The baby was discharged on the following day.
Discussion and Conclusion: In ABO HDFN, neonates may be clinically affected but have a negative or only very weakly positive DAT. DAT is usually positive due to IgG component and even in severe ABO HDFN the infant ' s red cells do not react with anti-C3d. This is due partly to the weak expression of A and B antigens on the red cells of newborn infants but also to the relatively low level of complement in the serum of newborn infants. In ABO HDFN, when the DAT is only weakly positive or even negative, elutes from the infant ' s red cells may give strong indirect antiglobulin reactions with adult A1 red cells. Also, the maternal IgG antibody titers are directly co-related with degree of ABO HDFN. In this case, IgGanti-A titer was 64 causing severe ABO HDFN.
A case of platelet refractoriness secondary to hLA Class- I antibodies: A case report
Apollo Hospitals, Hyderabad, India
Introduction: Platelet refractoriness due to HLA antibodies is a cause of concern in patients undergoing chemotherapy and requiring platelet transfusions. We present here a patient who required HLA compatible platelets.
Case: A 48-year-old man with a history of fever on and off for over a month was admitted for evaluation. He gave a past history of transfusion with three random donor platelets 8 days ago. On evaluation, the patient was diagnosed as having AML M4 and was administered chemotherapy including cytarabine. During the course of treatment patient required blood transfusions including red blood cells and platelets. The trigger for red cell transfusions was set at hemoglobin (Hb) of < 8 gms% while that of platelet transfusions was set at a platelet count of <10,000/ul. The Hb and platelet count on admission were 9 gms% and 20,000/ul, respectively. The patient had to be transfused with six random donor platelets on the third day of starting chemotherapy when his platelets fell to 10,000/ul with epistaxis. This was followed by a further drop in his platelet counts to 8000/ul the next day when a single donor, ABO compatible, leucodepleted platelets were transfused. The platelet counts continued to drop to 5000/ul over the next 24 h despite one more single donor platelet transfusion. On day 6, the patient had bleeding from the gums and a platelet count of 4000/ul. A suspicion of platelet refractoriness was entertained as the patient remained unresponsive to two consecutive platelet transfusions. This was confirmed by measuring the corrected count increment at 10 min and 1 h after the platelet transfusion, both of which showed 5,000/ul. The patient was investigated for a panel reactive antibody test (PRA) which was done on the Luminex (Gen Probe transplantation diagnostics, USA ) and was positive for Class I HLA antigens. HLA cross matching was done with donor lymphocyte lysate by the donor-specific antibody method on the Luminex with the patient ' s serum with six donors and only two donors were found to be compatible. The patient was then transfused with single donor platelets from the two HLA Class- I compatible donors with a subsequent platelet increment. The patient was finally discharged with a platelet count of 2,40,000/ul on day 15.
Discussion: One of the main reasons for platelet refractoriness in patients receiving non leucodepleted blood/platelets is the development of HLA antibodies in the patient. The patient in discussion had a history of transfusion of only three random platelets which was the cause of development of HLA antibodies and hence platelet refractoriness. This explains the fact that even a small exposure to non leucodepleted platelets could cause platelet refractoriness. In this case the Panel reactive Antibody and the HLA cross math done on the Luminex proved to be of great help in identifying suitable HLA compatible platelet donors due to which patient had a sufficient increment of platelets.
A case of ITP complicating pregnancy managed with TPO-mimetic drug Eltrombopag Olamine
Introduction: ITP is the most common cause of acquired severe thrombocytopenia. The incidence of ITP during pregnancy is reported to be 1 to 2 per 1,000 deliveries. ITP in pregnant women has more limited therapeutic options and is infrequently complicated by severe neonatal thrombocytopenia. The approach to treatment of ITP during pregnancy is different from that in non-pregnant women because the potential side effects of drugs may complicate both fetal development and the course of pregnancy. Glucocorticoids are considered for initial therapy, if there is no life threatening bleeding symptoms. Other treatment options include IVIgG which is safe for the fetus but often is associated with maternal side effects and high costs. Experience with anti-Rh(D) therapy in pregnant women is limited. TPO-mimetic drugs like Elthrombopag and Romiplostime has been used successfully in many nonpregnant individuals with ITP, but studies and experiments regarding its effects on pregnancy is limited. Case Report 27-year-old multigravida who was a known case of ITP with very bad obstetric history was presented to our hospital at 26 weeks of pregnancy with worsened signs and symptoms of ITP with a very low platelet count. After two weeks of hospital stay recognizing the fact that patient is not responding to steroids, immunosuppresants and platelet transfusions, she was given TPO -mimetic drug Elthrombopag olamine from 29 weeks of pregnancy till delivery with successful results. Discussion Elthrombopag olamine is a thrombopoietin receptor agonist indicated for the treatment of thrombocytopenia in patients with chronic immune (idiopathic) thrombocytopenia (ITP) who have had an insufficient response to corticosteroids, immunoglobulins, or splenec tomy. It is an FD aapproved pregnancy category C drug. There are no adequate and well-controlled studies of eltrombopag use in pregnancy. In animal reproduction and developmental toxicity studies, there was evidence of embryolethality and reduced fetal weights at maternally toxic doses. Elthrombopag should be used in pregnancy only if the potential benefit to the mother justifies the potential risk to the fetus. But in this case since Elthrombopag was started at 29 weeks of gestation there is no such risk of embryolethality and the outcome of treatment was very good by giving a healthy baby and a healthy mother.
A case of hemolytic disease of the newborn due to maternal anti-D and anti-C
Suresh Babu B
Sri Venkateswara Institute Of Medical Sciences
Background: Hemolytic disease of the fetus and newborn (HDFN) is a condition in which the lifespan of an infant ' s red blood cells (RBCs) is shortened by the action of specific maternal IgG antibody. Rhesus hemolytic disease of the newborn is a prototype of maternal isoimmunization and fetal hemolytic disease. Other rare blood group antigens capable of causing alloimunization and hemolytic disease are c, C, E, Kell, and Dufy. We report a case of HDFN due to anti-D and anti-C in the maternal serum.
Case Report: A 22-year-old female (G3P 1 L1A1) attended government maternity hospital at 9 months of gestation. There was no history of Rh Ig prophylaxis and blood transfusion previously. Her blood group was AB Rh D negative. Antibody screening was positive and both 'anti-D' and 'anti - C' were identified in the maternal serum. The antibody titer for anti D was 1:32. She delivered a baby having HDFN with serum bilirubin levels of 32 mg/dl. The baby was treated postnatally with phototherapy and double volume exchange transfusion with compatible blood, and was discharged in stable condition.
Discussion: Antenatal services in India are fragmented and not uniform. There is a limited amount of published data on alloimunization rates. Sangeeta et al. found an overall alloimmunization rate of 1.25% in pregnant women. Among this anti-D was about 78.43%, anti-c about 1.96% and the remaining all are antibodies against C, Kell and MNS. In a prospective study which was carried out on 624 antenatal cases, red cell antibody screening was positive in 9 (1.4%) out of 624 cases. These were identified as Anti-D antibody (6 cases, 66%), Anti-D with anti-C antibody (2 cases, 22%), and anti-M antibody (1 case, 11%) (2). The management of anti-C isoimmunization or iosimmunization with any other irregular red blood cell antibody is similar to the management of anti-D isoimmunized pregnancy, with a specification that blood used for fetal and/or neonatal transfusion should be negative for the specific antigen.
Conclusion: Despite prophylactic use of Rh immunoglobulins, anti-D is still a common antibody identiied as the major cause of alloimmunization. In this case, a moderately severe type of HDFN was detected in a neonate, which was caused by a combination of anti-D and anti-C. There is a need to impose antibody screening at first visit and a close follow-up throughout pregnancy if unexpected RBC antibodies are present.
Unmasking hypercoagulability: Using thromboelastography as a surrogate test
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Introduction: Coagulation disorder, especially a trend toward hypercoagulability is common in critically ill patients and correlates with bad prognosis. Available laboratory coagulation tests to assess hypercoagulability are expensive and time consuming. Here we present report of three cases wherein thromboelastography was able to diagnose prothrombotic state and thus a rational approach to blood component therapy could be taken.
Case 1: A 35-year-old female presented with postpartum sepsis along with acute pancreatitis in intensive care unit. She received six units of PRBC for correction of anemia and seven units of FFP for bleeding diathesis over a period of 2 days. Post-transfusion her standard coagulation tests revealed INR-1.5; APTT- 48s (control 3 1s), Fibrinogen-5g/L and platelet count of 112 × 109 suggesting coagulopathy with an increased risk of bleeding. Therefore, four units of FFP were ordered to be transfused however, TEG showed normal tracing along with mild platelet hyperaggregation (MA> 69 mm) consequently, no blood products were transfused. Standard coagulation tests also normalized within next 2 days.
Case 2: A 26-year-old female patient with chronic liver disease was posted for liver biopsy. Her PT/INR values were increased so the resident doctor ordered for four units of FFP transfusion prior to biopsy anticipating bleeding during the invasive procedure. TEG tracing showed R value on lower side of normal range and coagulation index value>3 suggesting rather a mild hypercoagulability, hence, patient was advised against prophylactic FFP transfusion. Eventually patient had uneventful liver biopsy without requiring any blood product.
Case 3: A 23-year-old patient of nephrotic syndrome admitted for renal biopsy had normal PT and APTT test results with platelet count of 104×109/L. Four units of RDP were requested to be reserved for this patient by the clinician. Her TEG tracing however, revealed a prothrombotic state as shown in [Figure 1] with MA>75. Patient underwent procedure uneventfully and did not require any transfusion.
Discussion: TEG analysis of patients without history of thromboembolic complications can detect deranged coagulation parameters. Apart from low R value, hypercoagulability (~MA) seen on TEG may be due to high platelet count and/or highibrinogen levels seen after surgery, sepsis and other proinlammatory states. These conditions are known to increase platelet adhesiveness and decreaseibrinolysis, resulting in a prothrombotic state. In our studyirst patient had highibrinogen level besides, in third case R value which represents plasmatic component was shortened, although APTT was also less than the control value. Unnecessary FFP transfusion could be avoided in our patients based on TEG results which has been linked toibrin deposition leading to multiorgan fuilare. However, long-term clinical follow up of patients should be done before apparent prothrombotic state in TEG tracing can be implicated in causing thromboembolic complications.
Conclusion: TEG may be helpful in screening for hypercoagulable states. Transfusion should not be solely based upon results of traditional coagulation tests as sometimes this can lead to unnecessary blood component transfusion.
Transfusion across ABO: Is it acceptable?
Sri Ramachandra Medical College & R.I, Sri Ramachandra University
Introduction: Blood and blood components are considered drugs because of their use in treating diseases. Transfusion therapy is used primarily to treat two conditions: a) inadequate oxygen carrying capacity and b) insufficient coagulation proteins or platelets to provide adequate hemostasis. When multiple transfusions are needed, ABO compatible units can be provided instead of ABO identical units to meet the increasing demand.
Aim: To analyze the effects of transfusion of blood and blood components across ABO in patients and their outcome in a tertiary care hospital in South INDIA.
Methodology: This study was carried out in the Department of Transfusion medicine, Sri Ramachandra University, Chennai during the period January 2012 to December 2012. Seventy five patients who needed single/multiple units in emergency situations were taken up for this study. ABO compatible units were provided instead of ABO identical units. ABO compatible units were provided after consultation with the treating physician. Depending upon the time availability and inventory, compatible units were issued.
Results: Total of 75 patients were included in the study - 43 males, 25 female and 7 neonates. A total of 159 units were issued. Packed Red Blood Cells - 37 units, Platelet concentrate - 112 Units, Fresh Frozen Plasma - 5 units and Cryopreicipitate-5 units. Packed Red Blood Cells were given to maintain tissue oxygenation, platelets were given to control bleeding and FFP / Cryo were given to maintain the coagulation profile. The desired therapeutic effect was achieved and no adverse effect of blood transfusion was observed.
Conclusion: Maintaining stock position is a challenge to the blood bank. Donors are the back-bone of the blood transfusion services. Hence maintaining a good donor pool will help in providing better patient care. Collection of blood components by apheresis holds great promise in case of rare blood groups.
RFID in Transfusion Medicine: Looking in to the future
Priyanka C G
Sri Ramachandra Medical College and R.I, Sri Ramachandra University
Introduction: The production and release of blood products is subject to rigorous regulations. To meet these requirements most of the blood centers now utilize computer based data management systems. Currently most of the blood centers use bar code solution to safely identify blood products. Now in industrial applications, a newer technology, radiofrequency identification is used to identify products as they migrate through the supply chain. RFID uses radio waves to automatically identify product, animal or person for purpose of identification.
Aim: To describe RFID application in transfusion medicine.
Materials and Methods: The RFID tag consists of chip or small circuit board coupled to antenna. Technical aspects of RFID system - it has three parts: antenna - provides means of communication and energy to communicate with RFID Tag (permanently affixed or handheld). Transceiver has a decoder to interpret the data. RFID tag (transporter) is programmed with information. Based on memory function tags can be divided into 'read only write once', 'read/write', and 'kill command'. 'Read only write once' tags are preprogrammed at the factory level and programmed only once by the user. 'Read/write' includes a chip with designated memory blocks that can save and update user-defined data at different stages. 'Kill command': an RFID special command designed for permanently erasing the memory and disabling the tag so that it cannot be read by any reader. Frequency ranges also varies between different tags. For blood banks high frequency (13.56 MHz) is recommended. In transfusion medicine, RFID tags can be applied to different areas like donor management, blood product management, blood processing, storage and distribution, finally to patient identification and transfusion management. RFID tags can be attached to donor ID, blood bags, patient wrist bands, sample tubes, can even apply to medical devices. Blood bags: it can be attached to base label of bag, should be embedded into bag or sandwiched to donation identification. Tag storage capacity is 2 KB. Studies have concluded that there is no biological adverse effects on blood products by these RFID tags.
Conclusion: The use of RFID in transfusion medicine may streamline supply chain processes by enabling better tracking and reconciliation of products; increasing the precision of product locations, making it possible to read multiple products simultaneously, and without line-of-sight. This will significantly improve efficiency, increase productivity, and reduced operational costs. The main cost categories included in the model are RFID tags, RFID hardware, IT infrastructure, software, integration, and implementation.
Retrospective analysis in beta thalassemia patients on transfusion therapy
Dr. Ram Manohar Lohia Hospital, New Delhi
Introduction: Thalassemia syndromes are a heterogeneous group of inherited disorders caused by genetic lesions leading to decreased synthesis of either α or β globin chain of adult Hemoglobin (HbA) resulting in ineffective erythropoiesis, chronic hemolytic anemia and iron overload. The rates of alloimmunization have been variably reported in thalassemia patients across the world.
Materials and Methods: A retrospective pilot study was carried out on 58 beta thalassaemia (57 thalassaemia major and 1 thalassaemia intermedia) patients registered with our hospital from May 2011 to May 2013. During the study period ABO RhK phenotyping and antibody screening were done on patient ' s samples. The data were analyzed from the patient and blood bank records.
Result: Fifty eight patients comprised of 37 m and 21 F in the age group of 1 to 25 years having blood groups as B positive 25, O positive 15, A positive 11, AB 5, and 1 each for B negative and A negative. Age at the time of diagnosis confirmed by hemoglobin electrophoresis, high performance liquid chromatography or both tests ranged from 2 and half months to 7 years. Pre-transfusion hemoglobin levels ranged from 4.9 to 8.8 mg/dl. Number of blood transfusions per year ranged from 4-36. The serum ferritin level as high as 6,740 ng/ml was observed in the oldest patient (25 years). Majority of patients are on oral iron chelation (Tab Desifer). Splenectomy was observed in one patient. Baseline Rh Kell phenotyping of 58 revealed 31 patients with DCcee, 20 DCcEe, 2 DCCee, and 1 dccee. Out of all tested, five patients were found to be Kell antigen positive. None of the patients showed presence of any red cell alloantibody by the three cell panel for antibody screening whereas in three patients autocontrol was positive. No acute transfusion reaction has been reported by the clinician in thalassaemia ward.
- Socioeconomic status of the patient also play a vital role in quality care of the disease.
- Patients coming from long distanced failed to maintain recommended hemoglobin level due to their inability to abide by the set protocol for timely transfusion and maintenance of hemoglobin levels.
- Higher volume of transfusions needed in older patients to maintain adequate hemoglobin levels.
- Rational use of leucoreduced SAGM suspended packed red cells has led to a decline in transfusion reactions like febrile non hemolytic and allergic reactions.
- Compliance to iron chelation therapy is required to bring down toxic levels of serum ferritin in body.
- A dedicated team of doctors, nurses and social workers is required for appropriate management of thalassemia patients.
Hemolytic transfusion reaction due to anti E alloantibodies missed by tube technique
PGIMER, Chandigarh, India
Background: The purpose of pretransfusion compatibility testing is to prevent immune mediated hemolytic transfusion reactions. For compatibility testing tube technique, gel technology and automated solid phase methods are available. In our department we receive approximately 250 blood requisition everyday and all the compatibility testing is done with tube technique.
Case Report: The patient M.B. thirty-five years old G5P3L2A1 at 36 weeks of gestation presented in emergency with postpartum hemorrhage and severe anemia. A blood requisition was ordered. Three hours after the start of transfusion, the patient felt cold and was noted to be shivering. The transfusion was stopped and a transfusion reaction workup was ordered. The patient was typed as A Rh D positive in both pre- and post-transfusion sample. On clerical check no errors were detected. Supernatant of pretransfusion sample for hemolysis was clear while post-transfusion sample for hemolysis was positive. Cross match was repeated with same PRBC unit with pre- and post-transfusion sample on both tube and gel technique. Cross match was compatible on tube while it was incompatible on gel cards. DAT of post transfusion sample was positive with IgG specificity on monophasic gel cards and negative for pretransfusion sample. Antibody screen using Diacell (Bio-rad) was done and screen cell II showed positive (2+) in both pre and post transfusion sample indicating possibility for anti E and Kpa antibody. On Diapanel (Bio -rad) antibody identification panel showed anti-E antibody specificity. Extended Rh typing of patient showed absent E antigen. Anti E titer was negative on tube while 1:8 on gel that reduced to 1:4 after 4 days.
Conclusion: From this case we re-emphasize that the gel test is a better method than the conventional tube test for antibody detection because of its higher sensitivity and technical safety. Hence, cross matching for all multi transfused and all antenatal patients should be done preferably on AHG gel cards.
Ferritin levels in multitransfused beta thalassemia major patients
Seth Gs Medical College and Kem Hospital, Mumbai-12, Maharashtra
Background: Tissue iron overload inevitably occurs in patients who receive regular red cell transfusion. In β-thalassaemia major, repeated blood transfusions, ineffective erythropoiesis and increased gastrointestinal iron absorption lead to iron overload in the body. In developing countries like India with limited availability of noninvasive measures of hepatic and cardiac iron, there is still reliance on the serum ferritin level as a means of monitoring the iron overload and the efficacy of chelation. This study was done on 60 multitransfused known β-thalassemia major patients.
Aim: The aim of the study was to measure the ferritin levels in multi-transfused β-thalassemia major as an indicator of transfusion iron overload.
Objective: To study the association of serum ferritin level with number of transfusion, various complications due to repeated transfusion, compliance of patients to iron chelation therapy.
Materials and Methods: A total of 60 cases of known β-thalassaemia major was included in this prospective study. This study was conducted at KEM Hospital Mumbai, from December 2012 to February 2013. The patients registered for transfusion were randomly selected. Serum was ferritin levels were performed by using ELISA.
Result: In a total of 60 cases studied, 32 were males and 28 females with a male to female ratio of 1.14: 1. The age of patients at the time of diagnosis ranged from 3 month to 3 years. The age at the time of this study ranged between 1 year 4 months to 16 years. 10% (6/60) patients were not confined to KEM hospital, they received transfusion from other center also. The mean serum ferritin levels were 3801+/- 1675.20. Only one patient (1.67%) had serum ferritin levels of less than 500 ng /dl, four patients (6.67%) had levels between 500-1500 ng/ml, nine patients (15%) had levels between 1501-2500 ng/ml, fifteen patients (25 %) had levels between 2500-3500 ng/ml, while remaining 31 patients (57.67%) had levels more than 3500 ng/ml. 77.35% ( 41/53) were compliant to the iron chelation therapy were as 22.65 % were non compliant to the therapy. The thyroid function test was abnormal in 9.43 % (5/53). Liver function test (LFT) was derranged in 49.12% (28/5 7) patients. The 2D Echo for heart function was abnormal in 14.28% (3/2 1) patient. 2 patients (3.33%) were sero-positive, one for HCV and second for HIV antibody. The cause for seropositivity was mainly transfusion related.
Conclusion: Assessment of iron overload is an important aspect of patient management and better indicator of iron overload than serum ferritin should also be considered in centers having facilities such as LIC (Liver iron concentration), heart function (LVEF), cardiac MRI T2, NTBI. The study also emphasizes on the importance of NAT in testing of blood especially to reduce the TTI in multitransfused patients.
Evaluation of pneumatic tube system for transportation of packed red cell units
Tata Medical Center, Kolkata, West Bengal
Introduction: At the Tata Medical center, transportation of blood samples from various collection stations to the Diagnostic laboratories is done via the pneumatic tube system. We evaluated sending blood components by the pneumatic tube system. Improper transportation and handling can result in non- immune hemolytic transfusion reactions in recipients
Aims and Objectives: This study was designed to evaluate the effect of mechanical transportation, in a modern pneumatic tube system, on the quality of packed red cells. The details of the Pneumatic tube are as: Brand Name: Aerocom, Germany Indian Partner: Protos Engineering Pvt Ltd. The speed of Canister during transaction is 6 meters/s. Total no. of stations is 26 nos. Details of irradiation given: Cobalt radio-isotope (Co 60) irradiator model BI - 2000 was used Duration of irradiation: varies with the decay, at present is 3 min 15 s Radiation dose: 25 Gys A total of 50 packed red cells in SAGM, will be subjected to transportation via the pneumatic tube (as yet, 18 nonirradiated and 17 irradiated units have been processed). These will include 25 irradiated red cell units and 25 nonirradiated red cell units nonirradiated units: belonged to variable storage periods; from day of collection, till day 42 of storage. Irradiated units: belonged to variable storage periods; from day of collection, till day 28 of storage. Red cell units were evaluated pretransportation and post-transportation, for the following parameters:
- Hemoglobin concentration
- Lactate dehydrogenase
- Plasma hemoglobin
Hemoglobin estimation was done on the Beckman Coulter - LH 780 plasma hemoglobin will be done using the Hemo Cue Plasma/Low Hb system - photometer for low Hb estimation (presently samples have been stored and will be evaluated) LDH estimation done using the UV kinetic, pyruvate, automated dry chemistry auto-analyzer potassium estimation done using the Ion sensitive electrode, direct potentiometry, putomated dry chemistry auto-analyzer statistical evaluation will be done and comparison will be made between: the prepneumatic tube and postpneumatic tube parameters between irradiated and nonirradiated categories for different storage periods. Preliminary results storage period The storage period ranged from day 3 to day 40 for nonirradiated bags (NI bags). The storage period ranged from day 2 to day 25 for irradiated bags (IR bags). Results only range of parameters given nonirradiated units - prepneumatic chute (pre) Hb 15-24.5g/dl; LDH 490-1,902 U/L;K (day5) 6.15 mmol/l. Postpneumatic chute Hb 15.4-26 g/dl. LDH 360-3,925 u/l. Potassium (day 5) 5.3 mmol/l. Irradiated units: Pre - Hb 16.6-24.8 g/dl; LDH 543-1253 U/L; potassium (day 8) 9.9 mmol/l Post - Hb 16.7-25.8 g/dl; LDH 476-3400 U/L; potassium (day 8) 13.5 mmol/l. Evaluation of the logistics required problems and their resolution for sending red cell units through the pneumatic tube will be assessed. These will include quality of the red cell component and procedure for issue of the unit, sending the cross match report and documentation.
Discolored plasma: A dilemma for transfusion specialists
Government of Medical College and Hospital, Chandigarh, India
Background: It is not uncommon in transfusion practice to see blood and blood components with abnormal colored plasma. Such discoloration is due to a variety of factors that alter the blood and/or plasma units and can range from hemolysis, bacterial contamination, metabolic conditions, and certain medications or large doses of vitamins taken by donors. This study was conducted to identify blood and/or blood components showing altered color and to determine the etiology of such discoloration.
Materials and Methods: This study was conducted in the Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, over a period of 7 months. All the blood units and/or the blood components having an abnormal appearance were segregated after collection and/or during component preparation. These discolored units were divided into three main categories:
- Green discoloration of plasma.
- Yellow discoloration of plasma.
- Bright cherry red color of packed red blood cells (PRBC)/whole blood (WB).
The donor ' s history was carefully evaluated and relevant investigations and tests were done depending on the discoloration. All the components of these discolored units were quarantined and not taken into the inventory till the preliminary investigations were not complete.
Results: Over this period, 11 units out of 7,370 donations (0.15%) showed discoloration. On physical examination, in three units the plasma was green, in five units the plasma was yellow in color and in the remaining three the PRBC/WB unit was bright cherry red. The culture reports of all 3 green discolored units were sterile. The total bilirubin of all the five donors with yellowish plasma ranged from 1.6-2.3 mg/dl (normal range: 0.2-1.0 mg/dl). The plasma liver enzyme levels (SGOT and SGPT) and alkaline phosphatase levels were within the normal range. Two out of three donors with cherry red discoloration of PRBC/WB were young males donating blood for the first time. Their hemoglobin was borderline (12.5 and 12.6 g/dl). One of the donors had a mean corpuscular volume (MCV) of 100.7l and peripheral blood smear examination revealed occasional macrocytes and hypersegmented neutrophils. The third donor ' s hemoglobin was 13 g/dl but was a cigarette smoker for last 1 year.
Discussion: The dilemma faced by most transfusion specialists is whether to take discolored units into the inventory or not. Intake of oral contraceptive pills causes bright green discoloration of plasma. The most probable cause for latent jaundice in blood donors is congenital hyperbilirubinemia while there was no evidence of hemolysis in the units showing cherry red discoloration.
Conclusion: The existing rules prohibit issue of blood and blood components if the plasma is abnormal in color. Our study showed that discolored units could have been safely transfused but further larger studies are required to confirm the safety of recipients receiving such units.
Correlation of transfusion reactions in thalassemic patients with leukodepletion status of blood products
K G Gaikhonlungpou
St John's Medical College, Bangalore, Karnataka, India
Background: Multitransfused thalassemic patients are prone to transfusion related complications. Study of the reactions and correlating it with the leucodepletion status of the packed red cells issued can reduce the transfusion reactions due to leucocytes in these patients.
Materials and Methods: Study was carried out on 1,152 transfusions in 161 thalassemic patients who came for transfusions at St. Johns Medical College Hospital between Jan 2011 and Dec 2011. The total transfusions were classified into three categories depending on the leucodepletion status of the packed red cells. The clinical records of these patients were reviewed. In the patients who had transfusion reactions, the reaction workup was done to rule out hemolytic transfusion reaction.
Results: In this study 1,152 transfusions were studied in 161 thalassemic patients. 8.4% (96) transfusions were done using bed side filters where there was no record of any transfusion reaction. 76.9% (886) transfusions were done using leucoreduced packed red cells using Buffy coat method, where there were 2 reactions(0.2%). 14.7%(170) transfusions were done using non leucoreduced packed red cells where there was one reaction (0.5%).
Conclusion: Leucodepletion by using filter in a better method for avoiding transfusion reaction. Though in a resource limited setting leucoreduced blood using Buffy coat method is also effective in reducing the transfusion reactions as seen in this study. Hence, exclusively using leucoreduced blood by Buffy coat method for thalassemic patients will be helpful in preventing transfusion reactions.
A study on efficiency of leukofilter used for percentage leucoreduction of red cell in the blood donor: First time in northeast India
Shija Blood Bank and Transfusion Services
Background: Leucocytes were important in the pathogenesis of febrile non-hemolytic transfusion reactions and could cause aloimmunization, which would later interfere with organ transplantation or platelet transfusion. There are some potential adverse effects of leucocytes in blood components such as immunogenic effects (like aloimmunization, febrile nonhemolytic transfusion reactions, rejection of transplanted organs, Graft versus Host diseases and transfusion related acute lung injury), immunomodulation (such as increased bacterial infections, increased recurrence of malignancy. etc.), and infectious disease transmission (such as cytomegalovirus infection, HTLV-1 infection and Epstein - Barr virus infection etc.).
Aim: To determine the efficacy of Leukofilter used for percentage leucoreduction. First time in northeastern India.
Materials and Methods: This study was conducted in Shija Blood Bank and Transfusion Services, Imphal, Manipur, on a 200 donor units from the month of January to May 2013. Inline filter were used for this study. The cell unit is leuco filtered within 6 h of donation. Pre filtration total leucocytes count in the red cell unit and Post filtration total leucocytes count was done. All the count was done in Sysmex cell counter. The cell counter was calibrated properly and the machine print out was firmly attached in the register for documentation. The efficacy of leucoreduction was measured.
Results: Out of total 200 units leucodepleted blood bag following data are obtained: Leukocyte log reduction: two log reduction 4%. Three log reduction 35%. Four log reduction 61%. Ninety six units showed total leukocyte count less than 5 × 10 6 after filtration and 4% units shows total leukocyte count greater than 5 × 1 0 6 after filtration. Average filtration time is 30 min.
Conclusions: Prestorage leuco-filteration by using fourth generation Leukofilter prone to be more beneficial considering the demand of quality blood product.
A hemovigilance endeavor: Review of blood transfusion reactions in a tertiary hospital blood bank
St John's Medical College Hospital, Bangalore, Karnataka
Background: Transfusion of blood and its products are vital therapeutic procedures in clinical medicine today. However, patients may still be at risk of adverse effects of transfusions despite stringent blood safety measures. Hemovigilance is conducted to detect and analyze all untoward effects of blood transfusion in order to correct their cause and prevent recurrence.
Aim: This study was designed to analyze the incidence and spectrum of adverse effects of blood transfusion so as to initiate measures to minimize risks and improve overall transfusion safety.
Materials and Methods: In this study, we retrospectively reviewed data from January 2004 to June 2012. All the acute transfusion reactions of blood and blood components in various clinical specialties that were reported to St John's Medical College Hospital blood bank were included in this study. Platelet concentrate transfusion related reactions and delayed transfusion reactions were excluded. The transfusion reaction workup done for these reported cases included; verification of patient identity and clinical records, examination of blood transfusion set and bag, ABO and Rh blood grouping, compatibility testing (pre- and post-transfusion samples) and urine analysis.
Results: Of the total 1,67,470 transfusions during the study period, 312 (0.19%) acute transfusion reactions (ATR) were reported. The most common type of reaction noted were of the allergic type (ANHTR) (n = 234;75%), followed by febrile non hemolytic transfusion reactions (FNHTR)(n = 72;23%), 6 (2%) hemolytic transfusion reactions (HTR). Two cases of the NHTRs presented with clinical suspicion of TRALI. All the HTRs were due to packed red cell (PC) transfusions. Two hundred and thirty four NHTRs were due to red cell transfusions, 69 due to FFPs, and three due to cryopoor plasma.
Conclusions: The NHTRs were far more in number (esp the ANHTRs), effective leucodepletion holds the key to their prevention. Though fewer, the HTRs were completely preventable and far more dangerous clinically. A strict protocol needs to be followed not only in the blood bank, but also in other relevant procedures such as pretransfusion sampling, storage outside blood banks, bed side patient identification and monitoring of transfusion to ensure blood safety and reduce such adverse effects.
Evaluation of core and surface temperature distributions in resuspended red blood cells withdrawn from refrigerated storage and exposed to ambient temperature and evaluation of temperature-sensitive labels for containers of RBCs
Background: Current guidelines recommend that blood for issue must be maintained continuously between 1°C and 10°C. The 30-min rule was established to limit red blood cell exposure to uncontrolled temperatures during the time the unit was out of a monitored refrigerator especially during storage and transportation. Purpose of this study was to reevaluate this rule. The aim was also to investigate relations between surface, core, and peripheral temperature and the corresponding times when they exceed 10°C during warm-up. Also the validity of the use of temperature monitoring devices, attached to the units of blood, was studied.
Materials and Methods: Thirty units of RBCs, outdated, leucoreduced and resuspended in SAGM (saline-adenine-glucosemannitol) additive, were exposed to ambient temperature for periods of time between 0 and 60 minutes. Core, peripheral, and surface temperatures of all units were measured at 10-min intervals using a calibrated thermocouple device (Make-MECO). Performance of the temperature-sensitive Time - Strip Plus labels for accuracy, precision and irreversibility, applied according to manufacturer's instructions to the external surface of the blood containers, was evaluated and compared with the thermocouple readings.
Results: Temperatures, in different locations inside containers of RBCs, as they warmed to ambient temperatures after removal from refrigerated storage were measured. A 13°C bag surface temperature was equivalent to a mean core temperature of 9°C. Following observations were made: Contents of the refrigerated RBCs changed from one homogeneous temperature to a range of temperatures, if allowed to warm (undisturbed) to ambient temperatures. Core temperatures of the contents of RBCs remained relatively lower for several minutes, whereas temperatures near the surface began to increase within lesser time toward ambient temperatures. Temperature-sensitive labels satisfactorily reflected the temperature of the major proportion (core) of the contents of the container. Resuspended RBC s units reached a mean core temperature of 10°C at 16.15 min, 12°C at 30 min, and 15°C at 50.76 min. RBC core temperature ranged from 6.4 to 12.5C during first 30-min RT exposures.
Conclusion: In view of the results and with the use of new range RBC products, the 30-min rule needs to be reviewed and the time to be reduced. During transport, thermal isolation of RBC units is necessary to control RBC temperature. Temperature monitoring Time-Strip Plus indicators do provide a simple and relatively inexpensive method to assure the temperature of the blood in the bag, under constant surrounding temperature conditions.
Study of donor deferral and adverse donor reactions at a tertiary care hospital
St Johns's Medical College Hospital
Background: A good donor screening is necessary to improve the quality and safety of blood transfusion. Implementation of good screening procedures like history taking, medical checkup, and screening for the infectious diseases will reduce the rate of discarding of blood and blood components. Blood transfusion is an important part of treatment of diseases such as thalassemia, patients with chronic renal disease requiring dialysis, and for patients undergoing surgical procedures. For these purposes the blood should be collected from the voluntary, nonremunerated donors to maintain the quality and safety of the blood or blood component issued to the patients.
This study is undertaken to analyze the various causes for which the donor are deferred from donating blood. The study also analyzed the adverse donor reactions during and after donation.
Aims: To study the causes of donor deferral in a tertiary care hospital in Bangalore. The study also analyzed the adverse donor reactions.
Materials and Methods: A retrospective study for the period of 5 years, from March 2008 to February 2013 done in the Department of Blood Bank, SJMCH. The data were obtained from the blood bank records. The first step of screening is carried out by the technicians by eliciting history, examining the local site of bleeding, and estimating the hemoglobin levels and blood group and measuring the body weight. The second level of screening is performed by the medical officer by a brief medical examination that includes recording the blood pressure, pulse rate, and temperature Any donor declared unit during these two steps are deferred from donating blood.
Results: The total number of donors screened in 5 years (from March 2008 to February 2013) was 79,255. The number of donors rejected in these 5 years is 6756 (8.5%). The rejection rate ranged from 5.7% to 12.1%. The M:F ratio of rejection is 1.7:2.3. The major causes of donor deferral were low hemoglobin (47.2%), history of medication (8.3%) and giddiness during the time of screening (1.8%). Other causes of deferral were high blood pressure, low blood pressure, history of jaundice, donors who underwent dental procedures within 6 months, asthma, malaria, typhoid, tuberculosis, diabetes mellitus, hypertension, cardiac diseases, fever, chicken pox, dog bite, and skin disease.
The percentage of donor adverse reactions ranged from 0.9% to 1.2%. The common adverse reactions encountered were giddiness, sweating and vomiting. Other rare adverse reactions were convulsions, tetany, and hypotension
Conclusion: The major causes of donor deferral in the present study are low hemoglobin and high blood pressure. The commonest postdonation adverse reaction encountered was hypotension.
Study of adverse whole blood donor reactions in normal healthy blood donors experience of tertiary health care centre in Jammu region
Background: Blood is the most precious and unique gift that one human being can give to another. The life saving fluid cannot be created artificially. Blood donors are precious resources. Donor retention is directly linked to donor services and donor care. Whole blood donation is generally a safe procedure, but sometimes adverse reactions of varying severity may occur during or at completion of blood donation process. There is little information in the transfusion medicine literature that describes adverse donor reaction during and immediately after whole blood donation based on solicited information. The aim of this study was to estimate the frequency and type of adverse events during blood donation.
Material and Methods: This retrospective study conducted from November 2011 to December 2012 at Department of Blood Transfusion Medicine GMC Jammu. All whole blood donations made at our department was analyzed. All adverse events occurring during or at end of donation were noted using standardized format.
Results: In our observation, a total of 29,524 donations were recorded amongst which 26,871 were replacement donors and 2,653 were voluntary donors. Male donors were 29,007 and female donors were 517. Mean (S.D) age of donors was 32 ± 9 years, with range of 18-60 years. Mean (SD) weight of donors was 70 ± 9.5 kg, with range of 45-110 kg. Total adverse reactions observed were 108 (0.365%). Presyncopal symptoms, in other words vasovagal reactions of mild intensity were the most commonly observed adverse reactions and accounted for approximately 53.70% (58/108) of all adverse reactions noted. They affected 0.196% of donors (58/29524). Minor Syncopal complications accounted for 25.92% (28/108) reactions and affected (28/29524) 0.094% donors. Major syncopal reactions accounted for 0%. Among local complications, hematomas accounted for 12.03% (13/108) reactions and affected (13/29,524) 0.044% donors. Numbness/tingling/soreness accounted for 8.33% (9/108) reactions and affected (9/29524) 0.030% of cases. In our study, men were half as likely to have adverse events (AE-Males 0.2 96% vs. AE-Females 4.25%). Most of reactions occurred in first time Donors who were more apprehensive. Repeat Blood donors had fewer AEs than first time blood donors (1.15% vs. 13.429%). All cases resolved themselves with minimal resuscitation. All donors were sent after they felt comfortable.
Conclusion: As only 0.365% of whole blood donations were complicated by adverse events and most of these events were pre syncopal symptoms, thus our study confirms that blood donation is a very safe procedure which could be made more event free by following, certain friendly, reassuring and tactful practices. In conclusion, blood donations have an obligation to constantly monitor risks of blood donation and to make a concerted and committed effort to achieve the lowest possible rate of complications.
Recruitment of platelet donors through platelet donation drives
Tata Memorial Hospital
Background: The most important strategy to ensure a safe and an adequate supply of blood and blood products is motivation, recruitment, selection, and retention of voluntary nonremunerated blood donors. Specialized units, dealing with hematological and oncological cases need to estimate the platelet requirement to set the targets for platelet collection. The first platelet donation drive in the city of Mumbai and to the best of our knowledge, in India was conducted by Tata Memorial Hospital in November 2009.
Aims: To identify target groups, make effective PowerPoint presentations and empower them with essential platelet donation information. To expand donor database and measure effectiveness of the recruitment strategy by increase in number of voluntary donors and the impact on clinical services. To acknowledge the donors altruistic contribution and felicitate them Study design a core team consisting of transfusion medicine specialists, clinicians, and an NGO (nongovernment organization) was formed. Target groups like colleges, corporate offices were identified and meetings held with their organization chiefs. The best suitable date and venue were finalized for the platelet camp. Transfusion and medical oncology specialists addressed the target group with effective PowerPoint presentations and an interactive session to answer all queries for approximately 1 h. Willing donors were registered. Preliminary health checks (hemoglobin test, weight, medical history, and blood sample collection) were conducted. Laboratory tests on the blood samples were performed in the hospital blood bank. Donors were contacted on phone for the actual donation as per patient requirements. Repeat, voluntary platelet donors were felicitated in the subsequent camps and encouraged to share their experience with the new audience.
Results: Study period 27 months, Number of camps 11, donors registered 895, donors donated 284/895 (31.7%), donors donated more than once 87/284 (30.6%), total number of single donor platelets (SDP) donated 45.
Discussion: The donors were contacted whenever a group specific patient needed platelets. 30.6% of 284 donors came back repeatedly for the donation and were satisfied with the experience. Donor satisfaction depended on a clean environment and uneventful donations amongst other reasons. The largest number of platelet donations by a single donor was 15. All donations were altruistic as no incentives were offered to the donors.
Conclusion: Donor education helped in developing a successful recruitment program which could efectively transform hostility into sympathy, prejudice into acceptance, apathy into interest and ignorance into knowledge. This has contributed to an increase in voluntary platelet donations and coming closer to one of the targets of Indian National blood policy.
Prefaint and systemic vasovagal reactions in whole blood donors analysis of determinants
Poornima A P
Govt Medical College Trivandrum
Introduction: Blood donation is generally well tolerated. However, some experience adverse events ranging from small hematomas and prefaint reactions to systemic vasovagal reactions. Anticipation of such adverse reactions, close monitoring, and selective deferral is of utmost importance in donor retention. An idea about the determinants of such reactions in the Indian population may be helpful in this context.
Aims and Objectives: To assess the prevalence of prefaint and systemic vasovagal reactions among whole blood donors and to identify the risk factors for such adverse donor reactions.
Materials and Methods: This is a cross-sectional study on prefaint and systemic vasovagal reactions among allogeneic whole blood donors during a period of three months from March 2013 to May 2013 at the department of transfusion medicine, Government medical college, Trivandrum, India. Information on donor characteristics was collected using a proforma at the time of donor registration. Blood collection was done using 350 ml collection bags. Inclusion and exclusion criteria for donation were in accordance with AABB standards. Donor reactions were classified as no reaction, prefaint reaction and systemic vasovagal reaction. Phlebotomy related reactions such as hematoma were not included in the analysis. Overall donor reaction rates were calculated. Factors analyzed were sex, age, donor status (first time and repeat), height, weight, and estimated blood volume (according to Nadler ' s formula). Chi-square test was used to assess the overall difference of frequency distribution of reactions among subgroups. Logistic regression analysis was used to identify the major determinants. All data were analyzed using SPSS V.18.0.
Results: A total of 6353 donors were registered. 362 (5.6%) were females. 2009 (3 1.6%) were first time donors. 1060 (16.6%) were less than 20 years old, 4,877 (76.7%) were 20 to 40 years old and 416 (6.5%) were more than 40 years old. 10 16(16%) had estimated blood volume.
Conclusion: Prefaint and systemic vasovagal reactions are commoner in females, first time donors, young age group, and those with low estimated blood volume. Special attention should be given to these donors during and after donation.
Knowledge and behavior toward voluntary blood donation among students
Life Line Blood Bank and Research Centre
Background: Voluntary Blood donation is the only way of acquiring blood to meet emergency requirements in cases of road traffic accidents, complications of pregnancy and childbirth, various anemic disorders, and surgical emergencies among others. The objective of this study was to determine the behavior of the students towards voluntary blood donation.
Materials and Methods: This is a descriptive cross-sectional study, which involved students in various colleges in around Tirunelveli, southern Tamil Nadu. A total of 2,720 students from seven colleges participated in this study. Among 2,730 students, 2,068 were male and 652 were female students. A multistage sampling technique was employed in selecting the participants for this study. A semistructured self-administered questionnaire was used to collect information on sociodemographic characteristics, knowledge, attitude and factors affecting voluntary blood donation.
Results: About 2,123 students (78 %) of total respondents had good knowledge of blood donation. 2,040 students (75%) of the respondents had never donated blood. Of the 25% that had donated, only 8% donated voluntarily. Among those that had ever donated, males (87%) were more than females. Many of the donors donated for relatives (68%). The majority of the respondents were compelled to donate because of emergency situations (81%). The reasons why many did not donate were lack of opportunity (51%) due to tight lecture schedule and inadequate knowledge (28%). Gift items such as Keychains, Caps, T-shirts and wrist bands (35%) would motivate respondents to donate.
Conclusion: The Principal, NSS co-ordinatior, and other Departments in the colleges should include a blood donation drive in their monthly. If a lesson on blood donation is included in the curriculum it will be of immense use for voluntary blood donation.
High female donor deferral: Need for the review of the guidelines for donor selection
Deepthi Krishna G
Sri Venkateswara Institute of Medical Sciences
Background: One of the important measures taken for safe blood supply is proper selection of blood donors. As per the existing guidelines the person should have minimum hemoglobin (Hb) of 12.5 g/dl to be selected. Individuals not having this required level of Hb are disqualified from donating blood and are called Deferred donors. In India, the same minimum Hb is required for both male and female donors. Average Hb levels reported in an Indian adult are 9.9 and 11.3 g/dl in females and males, respectively. Women seem to be more willing to donate blood than men despite the limitations that affect their donation rate. The importance of this study is to find out the major reasons of deferral in a particular voluntary blood donation camp that had equal number of both males and females. This study was conducted to analyze the deferral rates as there was high rate of deferral in a single particular camp.
Materials and Methods: It is an observational study done from the data collected from a single voluntary blood donation camp in an engineering college in Tirupati. Donor eligibility criteria were followed as per guidelines. Hemoglobin estimation was done using calibrated Hemocue method.
Results: A total of 257 donors in the age group of 18-20 years volunteered, of which 109 (42.5%) were males and 148 (57.5%) were females. About 117 donors were deferred among which 12 were males and 105 were females. Most common cause for deferral was low hemoglobin.
Conclusion: Our results showed that the major cause for deferral was anemia both in females and males. One-third of the deferred donors had Hb between 12-12.5 g/dl. Rejecting the potential donor will leave the donor with a negative feeling and so the deferred donors were advised for further evaluation and treatment. The required Hb of 12.5 g/ dl is essential for donor and patient safety, yet in developing countries like India it is desirable that the guidelines should be relaxed because the valuable voluntary blood donors have to be deferred by a narrow margin (0.5g/dl).
Evaluation of the routine dual antiseptic solution versus single antiseptic INJECTA solution for donor phlebotomy site preparation
Rajkot Voluntary Blood Bank and Research Centre
Background: Bacterial contamination of blood components is serious threat to transfusion safety and mainly skin microbes imposes greater risk, if phlebotomy site disinfections is compromised. Blood collection procedure needs more attention to prevent microbial contamination. Traditional antiseptic technique (Spirit-Betadine-Spirit) is currently practiced in majority of blood banks for arm preparation before phlebotomy procedure but in general protocol is tedious and troublesome for donor and staff.
Aim: The single antiseptic INJECTA solution was evaluated with traditional antiseptic solution for phlebotomy site preparation and its effectiveness was assessed.
Materials and Methods: The study was conducted at Rajkot Voluntary Blood bank and Research Centre in the month of June 2013 and a total of 20 blood donors were enrolled to evaluate the process systematically. We divide these donors into two groups and each group contains 10 healthy donors. In first control group, traditional dual antiseptic solution applied and in second study group single antiseptic solution INJECTA (contain Ethanol 70% and 0.5% Benzalkonium Chloride) was used. A total of 40 bacteriological culture swabs were collected from pre and postphlebotomy site and sent for microbial growth study to other centre.
Result: Among 20 samples (10 each from both control and study group) collected from pre phlebotomy site preparation, where showed growth of Staphylococcus epidermidis, Staphylococcus aureus, and Streptococcus pyogenes microbes in all 20 samples (100%). While all 20 samples taken postphlebotomy from study and control group were negative for aerobic and anaerobic microbial growth on 48 h and 7 days of culture in media of blood agar, Rose Bengal Agar, MacConkey's Agar with NLF (nonlactose fermenters).
Conclusion: The new single antiseptic INJECTA solution is found effective in donor phlebotomy site preparation and the results were comparable with traditional dual antiseptic solution. New INJECTA disinfection solution in preferred over traditional Spirit-Betadine-Spirit technique as only single solution is sufficient and phlebotomy site preparation procedure became smooth which is highly beneficial in large blood donation camps. As INJECTA solution is odorless, it is recommended for those donors who had problem and allergy with spirit as an effective replacement solution.
Era of blood component therapy: Time for mandatory pre-donation platelet count for maximizing donor safety and optimizing quality of platelets
Apollo Gleneagles Hospitals, Kolkata
Background: No blood bank regulatory agencies including the Drug and Cosmetics Act (DCA) of India mandate a predonation platelet count in whole blood (WB) donation. A hemoglobin (Hb) value of η 12.5 gm/dl can prevent donor iatrogenic anemia and optimize quality of red blood cells but quality of platelets prepared from the same unit needs investigation. Platelet count in an individual is population specific and varies from region to region. Therefore, estimating donor platelet count before blood donation will definitely prevent donor iatrogenic thrombocytopenia and maintain quality of random donor platelets (RDP) in terms of platelet yield and patient therapeutic benefit.
Aims: We observed poor platelet yield in RDP concentrates prepared at our centre with a significant number not meeting the DCA guideline of η4.5 × 10 10 per bag. Therefore, we planned this study to evaluate the predonation hematological values in our blood donor population and effect of these values on the quality of platelet concentrates and patient therapeutic outcome.
Materials and Methods: The prospective study included 221 blood donors eligible for donating 450 ml of WB. Following the departmental standard operating procedure RDPs were prepared using the 'Top and Bottom' quadruple bag system and automated component extractor. Donor pre and postdonation hematological parameters were measured. Quality of RDP was assessed as per recommended guidelines. All results were recorded and subsequently transcribed to SPSS working sheet.
Results: The mean reduction in donor Hb and platelets were 0.72 g/dL and 22.1 × 10 9 /L respectively (P < 0.001). Post donation platelet counts of nine donors were < 100 × 10 9 /L and by definition they suffered from iatrogenic thrombocytopenia. Quality of RDPs in terms of platelet yield was significantly better (P < 0.001) when the donor platelet count was > 200 × 10 9 /L. Although platelet yield significantly correlated with the donor platelet count (r = 0.87, P < 0.00 1), quality of RDPs in terms of red cell contamination showed no correlation with the donor hematocrit (r = −0.01, P = 0.89).
Conclusions: Platelet quality is a concern in Eastern India. A yield of 4.5 × 10 10 per bag as mandated was only achieved when the donor platelet count was > 200 × 1 0 9 /L. Post-transfusion platelet recovery (PPR) as observed in seven new patients of nontransfused aplastic anemia was unsatisfactory (mean 17% after 20 h transfusion). The mean platelet yield was 1.8 × 10 10 when the donor preplatelet count was < 150 × 10 9 /L which indicated that 10 units of RDPs or even more may constitute a single hemostatic platelet dose. The Hb and platelets reduced by 0.72 g/dL and 22.1 × 10 9 /L, respectively, but none of our donors had a hemoglobin decrement of >1 g/dL. However nine donors who suffered iatrogenic thrombocytopenia was a concern and needs further investigation. Therefore, with regards to optimization of blood component therapy and ensuring donor safety it may be suggested to mandate predonation platelet count before WB donation.
Complete blood count: Appropriate tool for screening of iron deficiency in regular blood donors
Ravi C Dara
Background: Iron deficiency anemia (IDA) is common in regular blood donors. Before donation the iron status is assessed in blood donor most commonly by measuring hemoglobin (Hb) levels. Serum ferritin is the most efficient marker for assessing the iron stores but it is time consuming and requires batch assay. The objective of this study was to identify hematological parameters (red cell indices) useful in screening for iron deficiency among blood donors.
Materials and Methods: During the time period from December 2011 to July 2012, a total of 200 regular nonremunerated voluntary blood donors donated at least twice in previous year were enrolled in the study. All were screened for hemoglobin (Hb) on finger-stick blood and Hb>12.5 gm/dl by HemoControl were accepted for donation. Predonation venous blood sample was assessed for serum ferritin (by ELISA) together with other hematological parameters (Hb, hematocrit (Hct), red cell indices (MCV, MCH, MCHC, RBC count) and red cell distribution width (RDW) by Sysmex automated hematology analyzer.
Results: Mean age of the donors was 39.3 ± 9.9 years while mean Hb was 13.1 ± 1.2 gm/dl. 61 (30.5%) donors had a serum ferritin level of
Conclusion: Alternative hematologic indices have diagnostic value in the diagnosis of IDA. Complete blood count (CBC) should be done at regular interval and assessing the hematological parameters (MCV and RDW) may identify the donors at risk for iron deficiency anemia. CBC acts an important tool for the safety and health of blood donors because it is able to give us information about early detection of abnormalities or pathological states. Donors with the abnormal values on complete blood count can be investigated further and treated adequately to re-enter the donor pool.
Comparison of hemoglobin levels in blood donors by three different methods: A prospective study
The Tamil Nadu M.G.R Medical University, Chennai
Introduction: Voluntary blood donors are the roots of the transfusion tree. Donors are to be selected with stringent criteria so that the donor or the recipients are not affected. The primary step in donor screening is the hemoglobin (Hb) estimation. Hemoglobin or the hematocrit should be determined each time from the blood donor before donation. As per the DGHS guidelines the Hb should not be less than 12.5 g/dl or hematocrit less than 38%. The Hb estimation may be measured by different methods. But, copper sulfate method remains the most commonly used method for Hb estimation to screen blood donors.
Objective: This study was planned to evaluate the results of hemoglobin estimation by three different methods (automated cell analyzer, Copper Sulfate method and HemoCue) and to in d out the most sensitive method.
Materials and Methods: This study was conducted on 1,500 voluntary blood donors in a tertiary care hospital. Out of the 1,500 voluntary blood donors, 85% were male donors and 15% were female donors. Hemoglobin estimation was done by three different methods (automated cell analyzer, Copper Sulfate method and HemoCue). Two milliliter of venous blood sample in EDTA was collected from apparently healthy donors after obtaining their consent. Samples were analyzed by the above mentioned Hb estimation methods and the results were statistically compared.
Results: Mean value of HemoCue (mean ± SD = 13.9 ± 1.26 g/dl) was lower by 0.12 compared to automated cell analyzer (mean ± SD = 14.3 ± 1.22 g/dl) but not statistically significant (P > 0.05). HemoCue had sensitivity of 99% and specificity of 87%. Copper sulfate method revealed 5.2% false negative results in comparison to automated cell analyzer values.
Conclusion: In our study, in comparison to automated cell analyzer, HemoCue proved to be the best method for hemoglobin screening of blood donors. However, due to high cost, it may be used sparingly as point of care testing for female donors with borderline hemoglobin values. Copper sulfate method is cost effective for screening blood donors in camps and if strict quality control is applied, it gives accurate results and is the best method in Indian Scenario.
Analysis of attitude and intention of donors and non donors towards blood donation: Have we motivated and encouraged them enough?
All India Institute of Medical Sciences, New Delhi, India
Background: There lies a marked disparity between the requirement of blood products and the number of voluntary donors available. So, there is a felt need to look into the causes responsible for the same. This may help in finding possible solutions to this problem, thereby narrowing this gap.
Aims and Objectives: To analyze the reasons for the gap between the requirement of blood products and their availability through voluntary blood donation.
Material and Methods: It was an observational, cross-sectional study enrolling voluntary blood donors, persons accompanying blood donors, and college students over 18 years of age. A 47 item validated questionnaire, both in English and Hindi, was administered to all the participants after taking informed consent. The concepts covered in the questionnaire were based on subjective and personal moral norm, self-efficacy, behavioral intention, positive attitudes, and negative beliefs related to donating blood. For the persons who had donated blood at least once, any adverse postdonation reaction and their satisfaction with the donation process was also noted.
Results: A total of 1,935 participants were enrolled in this study. The maximum number of individuals were from the age group 30-39 years. The male to female ratio was 10:1. The participants were divided into English speaking (n = 787) and Hindi speaking (n = 1 138) population based on the language in which the proforma was filled by them. The language in which the proforma was filled was taken as a surrogate marker for their educational status and awareness. In further analysis, the results obtained were compared between these two population groups. Out of the study population, 342 individuals had never donated blood, 642 had donated blood only once, while 811 of them had donated blood two or three times and 141 of the participants were regular blood donors, who had donated blood more than three times. The reasons for donating blood were specific in 1,009 participants while 154 individuals donated for altruistic reasons. The number of participants who donated blood for altruistic reasons was 89/787 among the English speaking population, while it was 65/1138 in the Hindi speaking population. [Table 1] summarizes some of the important aspects of the attitude, personal moral norm, self-efficacy, positive attitude and negative belief seen in the study population.
Conclusion: This study highlights important facets of the attitude of general population towards blood donation. The reasons to donate blood are clearly specific and not altruistic. There is a felt need of educating and encouraging the general population to develop positive attitude towards voluntary blood donation.
An analysis of plateletpheresis donor deferral pattern in a tertiary healthcare Institute
Sanjay Gandhi PGIMS, Lucknow, Uttar Pradesh, India
Introduction: With increasing awareness among clinicians related to clinical efficacy of transfused blood components, the transfusion services significantly expanded their activities to ensure safety and quality of blood and blood components. Adhering to the appropriate donor selection criteria for platelet apheresis procedure is important starting step to ensure safety of donor as well recipient and also to produce a quality product. The majority of platelet donations in India are made as replacement by family members or friends and most of the time this poses difficulty in arranging suitable donors for patient under treatment.
Objective: The objective of this study is to assess the current rate and reasons for platelet apheresis donor deferral in our hospital.
Materials and Methods: A retrospective study on predonation deferral pattern of prospective apheresis donors was conducted in the department of transfusion medicine, at a tertiary care hospital of north India. Records of all predonation deferrals over a 3 months period were analyzed. Predonation screening interviews followed by mandatory investigations such as estimation of Hb and platelet count and testing of transfusion transmissible infections were conducted as per SOP.
Results: During the study period 483 pre-donation screenings for platelet apheresis procedure were conducted. There were 25.25% deferrals. The most common reasons for donor deferral were low platelet (30.3 %), low hemoglobin (30.3%), and poor veins (26.22%). Other reasons such as medication, chronic medical illness, history of jaundice, whole blood donation less than 3 months, presentation outside the acceptable age limit caused 29.43% of all deferrals and 5.7% donors were deferred as their predonation blood sample was found to be reactive for viral markers. Low hemoglobin (80%) was the most common reason of deferral among females. Low platelet count (2 3.4%) was the most common reason of deferral among males.
Discussion: In a developing country like India, voluntary blood donor recruitment and retention program is picking-up because of constant support from organization like NACO. It had great impact on increasing safety and fulfilling the gap between demand and supply of blood. On the contrary, platelet apheresis component supply is mostly dependent on replacement donors. This study emphasized the need of voluntary platelet apheresis donor registry. A separate program for recruitment and retention of voluntary platelet apheresis donors must therefore be started through increasing public awareness to meet the ever increasing demand.
Adverse events in blood donors: An institutional experience
Sri Devaraj Urs Medical College
Introduction: The safety and sufficiency of blood supply is dependent on the altruism of healthy donors, to provide blood. Blood donation is generally safe, approximately of 2-6% of donors experience complications that resolve promptly but are still unpleasant for donors, and blood services have an obligation to minimize them.
Aim of the study:
- To estimate the frequency and type of adverse events.
- To estimate the time for the donor to recover.
- To suggest remedial measures to minimize them.
Materials and Methods: Voluntary donors were selected as per guidelines laid down in Drugs and Cosmetics Act, Ministry of Health and Family Welfare, Government of India. Blood was collected using a 16 gauge needle from the antecubital vein under proper aseptic technique. Three hundred and fifty milliliter of blood was collected from donors weighing between 45-55 kg and 450 ml from those weighing more than 55 kg. Minimum eligible hemoglobin (Hb) level was considered to be 12.5 g%. Hb screening was done by copper sulfate (CuSo4) method. Predonation medical examination was done in all donors and those who did not confirm were deferred. Donors were closely observed during and after donation for any adverse events (AE).
Results: In the 2-year study period from January 2011 to December 2012. 25,000 whole blood donations were collected, of which 20,000 were voluntary and 5,000 were replacement donors. AE ' s were recorded in 350 donors. Of the 350 AE's, 280 were presyncopal or vasovagal reaction. Syncopal minor reactions observed in 40 cases characterized by transient loss of consciousness, lasting for few seconds. Hematoma formation was observed in 20 donors. Minor events such as tingling, numbness, soreness of arm, local allergy, etc. were observed in seven donors. There were three major events one each of convulsion, loss of bladder sphincter control, and accidental arterial puncture were noted. Appropriate statistical analysis was done.
Conclusion: AE analysis helps in identifying the donors at risk and adopting environmentally appropriate measures to reduce risk and improve donor satisfaction in order to ensure regular supply of blood and blood products and there by maintain an effective hospital transfusion service.
Adverse donor reactions in a normal healthy donor
Dhara J Ardeshana
M P Shah Medical College, Jamnagar, Gujarat
Background: It has been estimated that 2-3% blood donors experience vasovagal reactions and 0.08% to 0.3% of these reactions progress to syncope. Reaction may result from psychological influence or by neuropsychological response to actual blood donation. This study was performed with the objective to demonstrate the prevalence of vasovagal reaction in blood donors.
Materials and Methods: Donors weighed more than 50 kg and with hemoglobin of η12.5 gm/dl were selected for blood donation. According to SOP, all vasovagal reactions were divided into three categories - mild, moderate, and severe. During or after blood donation, if blood donors presented with anxiety, tachypnea, tachycardia, pallor, sweating, dizziness, nausea/vomiting, cold, or clammy skin, it was categorized into mild category. If they presented with signs and symptoms of transient loss of consciousness and those who presented with mild reaction but for more than 15 min, they were categorized into moderate category. Donors presenting with convulsion and/or incontinence (fecal/urine) were placed in severe category.
Conclusion: Among 5,276 blood donations, reaction rate was higher in female than male. Amongst males, maximum reactions in group of 18-24 years of age, while in female donors the reaction rate highest between 25-30 years of age. Reactions were commonly seen in camps during hot and humid months. Incidence of mild vasovagal reactions (0.8 1%) was highest, while that of severe vasovagal reaction was lowest (0.01%).
A study of knowledge and awareness of nurses regarding blood transfusion services and practices in a tertiary care teaching hospital
Postgraduate Institute of Medical Education and Research
Introduction: Blood is a precious resource for saving patient lives. The aim of blood and blood component therapy is to provide suitable and safe blood products to achieve best clinical outcomes. Nurses have an important role in ensuring safe blood transfusion. It is crucial for nurses to have sufficient knowledge about blood donation and collection, storage, component preparation, possible adverse effects of blood transfusion and necessary management and care. The aim of this study was to assess the knowledge and awareness of nurses regarding blood transfusion services and practices.
Materials and Methods: The study was carried out at our institute hospital which is a tertiary care teaching center. A total of 100 nurses working in various areas of the hospital were included. Amongst these nurses, 50 were of ' Grade-I ' designation and 50 were of ' Grade-II ' designation where Grade-I nurses were senior to Grade-II and had more work experience. A self-developed questionnaire was used for the assessment of knowledge and awareness of these nurses regarding blood transfusion services and practices. A total of 20 questions were included in the questionnaire pertaining to: general awareness (three questions), blood donation (two questions), testing and blood component preparation related (two questions), storage of blood/blood components (two questions), and pretransfusion checks and bed-side transfusion practices (11 questions). The response for each question was recorded as ' correct ' or ' incorrect ' . The statistical analysis of the data was carried out using SPSS version 15.0 for Windows.
Results: The overall mean percentage of ' correct ' responses was 70.33% for general awareness-related questions, 65% for storage of blood/blood-components-related questions, 59.09% for pretransfusion checks and bedside transfusion practices related questions, 57.5% for testing and blood component preparation related questions and 51.5% for blood donation related questions. There was no significant difference [Table 1] between Grade-I and Grade-II nurses in terms of mean percentage of ' correct ' response pertaining to general awareness, blood donation, testing, and blood component preparation related questions and pretransfusion checks and bedside transfusion practices related questions except for storage of blood/blood components related questions ( = 0.0 13) where Grade-II nurses had better mean percentage of ' correct ' response (74%) than Grade-I nurses (56%).
Conclusion: This study assessed the knowledge and awareness levels of the nurses regarding blood transfusion services and practices at our institute. There was a significant difference in the mean percentage of ' correct ' response for storage of blood/blood components related questions between Grade-I and Grade-II nurses, where Grade-II nurses fared better. Further improvement in the knowledge and awareness levels can be achieved through continuous education and training of nurses.
Source of Support: None, Conflict of Interest: None
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