|Year : 2015 | Volume
| Issue : 3 | Page : 45-119
|3 rd annual conference of ISTM, TRANSMEDCON, 2014, Ahmedabad
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|Date of Web Publication||14-May-2015|
|How to cite this article:|
. 3 rd annual conference of ISTM, TRANSMEDCON, 2014, Ahmedabad. Asian J Transfus Sci 2015;9, Suppl S1:45-119
| Free Papers|| |
Turn around time (TAT) for emergency blood issue: A quality indicator
T Ramanathan, K C Usha
Government Medical College, Trivandrum, Kerela, India
Background: Quality indicators in transfusion medicine are necessary for patient safety and customer satisfaction. The turnaround time for issuing blood products has emerged has a quality indicator but it is not an established benchmark. So establishing an appropriate TAT for issuing blood units in response to stat request with regular monitoring important for Quality management. We examined the TAT from receiving the blood request to the components exited the blood bank.
- To analyse the turnaround time (TAT) in issuing blood units using Immediate Spin Cross-Match (ISCM).
- To identify the factors leading to prolonged TAT.
Materials and Methods: TAT was defined time of request received (start time) to when components exited the blood bank(stop time). Cases where PRCs units issued after immediate spin cross-match and FFP and PC issued for emergency cases are included in the study. Start and stop times are recorded by the TEAM.TAT was recorded at different shifts - FORENOON 8 am-1 pm, AFTERNOON 1 pm-6 pm, NIGHT 6 pm-8 am. Reason for delay is noted in cases of prolonged TAT.
Observations: In total of 125 cases, mean TAT in forenoon, afternoon and night shift are 30.02, 30.32, 32.46 respective standard deviations are 14.212, 17.890 and 16.246. One way ANOVA was done to compare average TAT recorded at different shifts shows NO SIGNIFICANT DIFFERENCE (i.e. 'P' value = 0.863). Mean TAT of whole day in our study is 30.933 minutes which was almost same as the standard TAT (30 minutes). Main Reasons for prolonged TAT identified in our study are sample labelling issues, non-availability of staff, multiple requests overloading.
Conclusion: Standards for TAT currently do not exist within the field of transfusion medicine. This study serves as a starting point for establishing a benchmark for TAT of blood products. Strategies like education, improving work force distribution, re-assigning technician duties on demand will improve the quality of blood bank services.
Quality indicators in transfusion medicine: Improving process outcomes
Ajju Agnihotri, Saranjeet Kaur, Takdir Singh
Max Superspeciality Hospital, Shalimar Bagh, Delhi, India
Background: Quality indicators (QI) are major tools of quality management system that enable continuous quality improvements. Stakeholders of transfusion services like DGHS, NACO, SBTC and NABH etc are now asking for concrete evidence of performance quality. However, the relevance of monitoring quality lies not only in collecting data but also focusing on what needs to be measured, how and why it should be done and most importantly on devising strategies to improve process efficiencies.
Aim: The objective of this study was to identify vital factors across Blood Bank processes that can be monitored and improved.
Materials and Methods: Entire process flow from blood collection, component preparation, serology, infectious marker testing and aphaeresis was analyzed. Detailed process mapping was done based on SIPOC model. Critical control points identified and potential QI selected. Selection criteria for QI were based on their importance to patient safety, accreditation requirements and organization needs. Besides these, scientific soundness of indicator along with feasibility of data collection were considered. Frequency of monitoring, methods for data collection and targets were defined.
Results: Process map for Blood bank processes was prepared and 25 different indicators were identified which could be monitored. We tracked ten of the available indicators-Donor reactions, Double pricks or hematoma, under collected units, TAT for component preparation, number of QC failures in Infectious marker testing, PRBC units discarded, discard percentage, delays in TAT for issue of blood components, stock out situation for blood components, Transfusion reactions and adverse events. To achieve predefined targets- tools like Root Cause analysis, prioritization, Lean, Six Sigma were usedalong with process remodeling and action plans.
Conclusion: QI are an indispensible tool for TM specialist. They provide concrete evidence of ongoing quality initiative, meant to achieve or exceed predefined targets.
Future of transfusion medicine as a post graduate course: Resident's perspective
Aboobacker Mohamed Rafi, Nithya Mohanan, Susheela J Innah
Department of Transfusion Medicine and Immunohematology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
Background: Blood transfusion science has made tremendous progress over the last century. A department exclusively for this purpose came up in different parts of the world named as Department of Transfusion Medicine and Immuno hematology Emergence of new specialties is another hallmark of medical sciences which was due to high-end medical care and segregation of specialties into super-specialties. Transfusion medicine had become a semi-clinical discipline as it dealt not only with patient's samples but also with blood donors and patients who are alive. This specialty has gone to the bedside for active involvement in patient consultation by clinicians. Many centers are taking up procedures like therapeutic apheresis and exchange procedures on patients as bedside procedures. Even then there is anxiety and apprehensions in our minds on several issues.
Aim: The study aims to assess the anxiety and understand the thoughts and view points on the future of Transfusion Medicine as a Post graduate course from among the Post graduates and those who have passed the course and working.
Materials and Methods: A questionnaire including basic demographics of the Resident and other questions pertaining to Transfusion Medicine was made. It was send to all the Residents in different institutes across the country after taking consent regarding there willingness to be part of the study. The data will be collected and analysed.
Results: The results will be published later as the study is going on now.
Conclusion: Even though Transfusion Medicine is a new speciality. There are lot of apprehensions in the minds of the doctors taking up this speciality. This study will bring out all the apprehensions and problems faced by the future transfusion medicine specialists. So lets all work together so that it does not die out very early. I take this opportunity to inform our seniors and leaders to work out a solution for all the above problems, which we face, and to report and work for it in colloboration with the authorities concerned.
RFID based device for ensuring quality control and hemovigilance: An Indian attempt
Veena Doda, Vikas Verma, Satyam Arora
Department of Transfusion Medicine, Dr. Ram Manohar Lohia Hospital, Post Graduate Institute of Medical Education and Research, New Delhi, India
Introduction: Quality control and quality assurance is an essential mandatory requirement for any transfusion service. Precise temperature monitoring and appropriate cold chain of blood and blood components is essential to ensure adequate therapeutic benefit to the patients receiving transfusion. Our attempt was to design a real time device for monitoring such quality control parameters from collection to bed side transfusion and retreiving the e data from the blood bags by a device.
Aims: To design a RFID based device to uniformly collect data and to ensure the quality check of the blood bags.
The Device: An open electronic Digital Platform was designed, with advance digital chips for real time QC monitoring, cold supply chain monitoring as well as advanced tampering protection mechanism. This platform also possess easy report generation and visualization utility in clinical setup (pre and post transfusion data analysis) by Near Field Communication using personal cell phone a touch and see technology.. These RFID enabled devices duly labelled and fixed on each blood bag with various time slots can monitor temperature dynamics in the blood bag during blood collection, processing, storage and at the bedside before transfusion.
Advantages of the device
- A real time account of all these steps providing more evidence based approach to the transfusion medicine.
- Collection of exact data to define time interval between each step as well as a real time temperature monitoring of each unit of blood.
- Providing tamper proof evidence with regard to quality of the blood or blood component issued.
- Ready access to the data for the clinician, make them more confident of transfusion therapy (with regards to the component transfusion) as well as help him make appropriate choices for the transfusion.
- This active surveillance on the bag would help us to study the dynamics of the collected and stored blood and their effects on the patient upon transfusion.
Conclusion: This is one of its first of its kind attempt to standardize and formalize the blood transfusion services in India. The device is presently under trial at our blood bank to scientifically assess the benefits of the utilization in transfusion medicine.
Haemoglobin QC by maintaining levey: Jennings chart
Rashmi Sood, Sushma Rani, Asha Bora, Vineeta Gupta, Deepak Kumar, Vijay Parewa, Sushil Pawar
Saket City Hospital, New Delhi, India
Background: Haemoglobin Estimation is an important and an essential part in blood donor selection. Though a wide range of methods and techniques are available for measuring haemoglobin, no technique has emerged to be the most suitable for haemoglobin testing in the blood banks. But the quality control of a particular instrument used for Haemoglobin estimation is very important. Levey-Jennings chart is a graph in which the quality control data is plotted on to, to give a visual indication whether a laboratory test is working good or not. The distance from the mean is measured in standard deviations (SD). The Levey-Jennings chart has the days of the month plotted on the X-axis and the control observations plotted on the Y-axis. By observing the data plotted in the L-J chart, we can determine if test results are in control and accurate, or if test results are not in control and consequently unacceptable. It is named after Levey and Jennings who in 1950. Westgard rules are commonly used to analyse data on LJ control charts.
Aim and Objective: The aim of this study is to highlight the importance of Levey-Jennings Chart as a Quality Indicator in Haemoglobin estimation in the blood bank.
Materials and Methods: A prospective study was carried out in a tertiary care hospitalSaket City Hospital (A unit of Gujar Mal Modi Hospital Research Centre for Medical Sciences) situated at Mandir Marg Saket New Delhi. Over the period of 1 year 1 month by maintaining Levey-Jennings chart as well as by running Haemo-Controls (make-Eurotrol): Low Control (7.8 to 8.2 gm/dl) High Control (15.8 to 16.2 gm/dl) Normal Control (11.8 to 12.2 gm/dl) in Haemocue machine by every day. By performing every day QC with haemo controls and recording the results in L-J chart we can check the accuracy of the Haemocue Machine.
Results and Findings: Study was carried out from July 2013 to July 2014
Deviation sorted out after re testing.
Conclusions: Quality control data is most easily visualized using a Levey-Jennings chart. By the end of every month we were able to compare the result variation in the control values,as recorded daily. We suggest, all blood banks to maintain L-J chart as a Quality Indicator.
Evaluation of delayed complications in post-donation period: A step ahead towards donor care
Hem Chandra Pandey, Atul Sonker, Rajendra Chaudhary
Department of Transfusion Medicine SGPGIMS, Lucknow, India
Introduction: Complications associated with blood donations are not only the problem of donors but they are also important to transfusion services as some complications may negatively affect donor recruitment and retention. Complications arising during and immediately after blood donations are well characterized and are taken care of by transfusion services. Yet a number of complications especially those associated with the phlebotomy process are noticed when the donor has left the transfusion centre. We conducted this study with the aim of identifying these complications in the post donation period.
Materials and Methods: Blood donors were selected as per the SOP of our department and donations were collected under observation. Donors were observed during the donation period and post donation instructions were given before the donor left the blood centre. The donors were then telephonically interviewed three weeks later regarding any post donation complications. Complications which the donors attributed to blood donations were also noted during the interview.
Results: A total of 989 donors were interviewed of which 99.6% were male and only 4 donors were female. The donors belonged mainly to younger age group with the mean age of 31.6 years. 92.1% of the donors were replacement donors with 60.3% donors being first time donors. A total of 148 post-donation complications (14.96%) were noticed in our study, fatigue being the most common with a frequency of 6%. Other common complications were sore arm (2.7%), bruise (2.3%), vasovagal symptoms (1.6%) and hematomas (0.7%). Other complications included band-aid allergy (0.6%), headache (0.4%), pain at the needle site (0.1%) and increase in appetite (0.1%). 85.14% of the complications occurred within 7 days of donation.
Conclusion: Complications during the post donation period are common with majority of them occurring within a week of donation. It is necessary for blood transfusion services to educate the donors about these complications and give them necessary post donation instructions. Efforts should be done to develop donor hemovigilance services so as to gain the confidence of donors and retain these donors.
Effect of pre-donation fluid intake on interstitial fluid shift among blood donors
Deepika Chenna, Shamee Shastry, Mohan Doss
Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
Background: During blood donation donors compensate for the acute volume loss due to various physiologic reflex mechanisms. One of the principle mechanism is by restoring the lost plasma volume by influx of fluid from interstitial space.
Aim: To study the effect of fluid intake on the amount of interstitial fluid shift during blood donation.
Materials and Methods: We conducted a prospective study on 300 blood donors. Donors are divided into 3 groups and randomly categorized into one of the groups. Group I donors donated without any pre-donation fluid intake, Group II donors with water intake and Group 3 donors with an Oral Rehydrating Fluid intake. Data related to age, gender weight, height and Pre and post donation Hemoglobin was noted. The blood volume of donor pre and post donation was calculated using Ogawa's equation. The difference between pre and post donation blood volume is calculated as the amount of fluid shift during donation. The influence of oral fluid intake, age, gender and body mass index (BMI) on volume of fluid shift was analyzed.
Results: A total of 300 donors (male = 275 and female = 25) have donated. The mean fluid shift was 104 ± 62 ml in males and 116 ± 76 mL in females. The fluid shift was significant between donors without fluids (G1: 126 ± 81 ml) and donors with fluid intake (G2 and G3: 96 ± 45 ml) (P < 0.05). The difference was not significant between donors with water intake (G2: 100 ± 47 ml) and ORF intake (G3: 86 ± 42 ml). Volume collected didn't significantly influence fluid shift, with mean shift of 94 ± 58 ml in 350 ml donations and 107 ± 62 ml in 450 ml donations. The shifted volume increased with increasing BMI, but the difference was not significant. Only three donors had VVR, of which, one had severe (344 ml fluid shift) and two (61 and 87 ml fluid shift) had mild reactions. Conclusions: The age, gender, BMI did not significantly contribute to the volume of fluid shift following donation. As per our observation, the oral fluids before donation doesn't contribute to increase in fluid shift during donation.
To study the effect of fresh frozen plasma on pre transfusion international normalized ratio (INR)
Purva Shinde, Ashu Dogra, Shivangi Patel, Komi Vyus, YR Premalatha
SBKS Medical Institute & Research Centre, Vaghodia, India
Background: There is always demand of fresh frozen plasma (FFP) whenever there is increased international normalized ratio (INR). This study helps to know effectiveness in improvement of INR by the use of FFP.
Objective: To study the effect of FFP on pre transfusion international normalized ratio (INR).
Materials and Methods: In three months 100 patients who received FFP in our institute were studied. FFP usage was classified as appropriate based on the guidelines by national health and medical research council. Pre and post transfusion INR were recorded and effect of FFP on pre transfusion INR was studied in patients who appropriately received FFP.
Results: Total 295 units were issued for 100 patients. Surgery and medicine departments. Total 196 units (60.6%) in 70 patients were appropriately transfused and 99 units (39.4%) in 30 patients were inappropriately used. Mean improvement in pre transfusion INR per unit of FFP was 0.75 (median 0.52, range 0-3, SD 0.94). A significant improvement in pre transfusion INR per unit of FFP was seen in 63.9% patients. A linear relationship was noted between the pre transfusion INR and improvement in INR per unit of FFP.
Conclusion: Proportion of inappropriate FFP usage remain high. A significant improvement in INR is more likely with high pre transfusion INR. The improvement in INR per unit of FFP is also more with higher pre transfusion INR.
Bacterial contamination of packed red blood cell units in a blood bank
MH Shariff, Vidya Pai 1 , Qudusia Sultana 2
Departments of Pathology, 1 Microbiology and 3 Anatomy, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
Background: Blood bank services provide human blood intended for transfusion. Tominimise the risk of infections, rigorous screening towards HIV, Hepatitis B, Hepatitis C, Treponemapallidium and malarial parasites is carried out on all the units of blood and its products. Sepsis from a contaminated blood unit though rare, is potentially a serious complication of transfusion. In the United States, bacterial contamination of blood accounted for 15.9% of all transfusion related fatalities. The estimated rates of bacterial contamination of packed cells range from 1/31,000 to <1/million units. The common bacteria contaminating the blood units are Y. enterocolitica, Coagulase negative staphylococci, Bacillus species and Pseudomonas species.
Aim: To determine the prevalence of bacterial contamination in packed red blood cell units and to identify the types of contaminating bacteria.
Materials and Methods: A total of 106 donor packed red blood cell units were sampled for culture on the 0 day, 5 th , 21 st , 35 th and 42 nd days of storage. 5 ml blood was collected using a needle and syringe and dispensed into 15 ml BHI broth. Subcultures were done on agar media and the growth identified by standard methods.
Results: One unit was positive for bacterial contamination among 106 packed RBC units tested. The isolate was identified as Coagulase negative staphylococci.
Conclusion: Knowledge of the prevalence of bacterial contamination of blood for transfusion and the sources or the causes of contamination is important for the planning of preventive measures at blood transfusion centres and the reduction of transfusion transmitted bacterial infections. Despite the routinely adapted standard measures in blood banks, bacterial contamination of the blood product may rarely occur. The outcome of transfusion with such contaminated unit can be fatal. Though such occurrence is infrequent, it is absolutely necessary to subject a minimum1% of all units collected for bacterial culture.
Audit of plasma usage in a tertiary care hospital
Saurabh Lahre, MD Gajjar, Nidhi Bhatnagar, Vaidehi Patel, Megha Shah, Nirav Patel, Shital Soni
Department of Immunohematology & Blood Transfusion, B J Medical College & Civil Hospital, Ahmedabad, India
Aims and Objectives: To Audit the current situation of use and misuse of fresh frozen plasma (FFP) in various clinical Situations. Introduction: FFP transfusion is always associated with risks like TRALI, HLA alloimmunisation, Allergic reaction, anaphylactic shock, TTI etc, so FFP should only be transfused when indicated and in adequate volume to achieve haemostasis so that its benefits of transfusion overweigh the hazards of transfusion.
Materials and Methods: A prospective study was done between Jan 2014 to July 2014 in terms of appropriateness and inappropriateness. The total number of patients during our study period was 129 receiving 447units of plasma. Each file record was checked for the diagnosis of the patient, coagulation profile and doctor's indications for blood transfusion. The indications of FFP were checked according to guidelines for plasma transfusion as given in American Association of Blood Banking and WHO manuals in terms of indication and adequate volumes for transfusion.
Result: In this study 447 units of FFP were used during study in 129 patients in 139 episodes in which in 47 episodes transfusion was appropriate and in 92 episodes transfusion was inappropriate. So appropriate requests were 34% while inappropriate requests were 66%. The department of general surgery and obstetrics and gynaecology were the departments with maximum number of inappropriate requests.
Conclusion: A continual system of staff education and administrative intervention by conducting regular CMEs with clinical department will be helpful to reduce inappropriate use in future by making other departments aware of appropriate usage of plasma so that unnecessary transfusions and hazards of plasma transfusions could be minimized and plasma usage would really benefit the patient.
Sensitivity of individual donor nucleic acid testing (Id-Nat) for detection of hepatitis B infection by studying diluted HBV NAT yiled donor samples
Satyam Arora, Veena Doda, Tapanidhi Kirtania
Department of Transfusion Medicine, Dr. Ram Manohar Lohia Hospital, Post Graduate Institute of Medical Education and Research (PGIMER), New Delhi, India
Background: Screening by HBsAg for hepatitis B virus infection among the blood donors has remained the back bone of blood safety for many years. Occult Hepatitis B (OBI) infection among donors is an unresolved challenge when screening by HBsAg only. Introduction of NAT for blood screening is capable of detecting OBI among the donors. Screening individual donations or testing in pools of donor sample by NAT is still to be studied in Indian context.
Aims: To study the sensitivity of NAT for detecting OBI, by testing diluted OBI donor samples.
Materials and Methods: The study was conducted at Blood Bank in the Central Government Hospital in India. The kits used for serology testing were BioRad Monalisa HBsAg Ultra for HBsAg screening, Abbott Architect for Anti HBcAg (total) and Anti HBsAg testing where as Vitros 3600 by Ortho Clinical Diagnostics for Anti HBcAg (IgM). For molecular testing Procleix Ultrio was used for ID-NAT and Abbott m2000 for HBV DNA estimation. 25 donor samples were ID-NAT reactive out of 28,134 HBsAg non reactive donors. Out of these 25 only 18 samples were further studied at different dilutions to analyse the efficiency of NAT. Besides the undiluted sample being tested for all serological testing and for HBV DNA estimation, each sample was also tested at dilution of 1-in-2 to 1-in-16 with NAT. Doubling dilutions were made by HBV non reactive AB plasma.
Results: Out of 18 samples studied 9 samples were NAT reactive at a dilution of ≤4 and 5 out of these showed presences of antibody to core antigen (total). Antibody to surface antigen was present only in 2 samples out of 9, one with antibody to core antigen and other without. Six had the viral load in the range from <10 to 38 IU/mL where as the viral load in the remaining three samples were not determined. The 9 samples which were NAT reactive at dilution ≥4, showed presence of antibody to core antigen (total) in 7. Out of 7 samples one had the antibody to core antigen of IgM type and antibody to surface antigen was detected in 2. Viral load among these 9 samples ranged from 16 to 1 × 10 8 IU/mL. Genotype estimation was possible in 4 samples and all were found to be genotype A.
Conclusions: Our study reflected that, among the total HBV Nat yield samples studied, 33.33% of samples would escape detection if screening is limited only to HBsAg and antibody to core antigen. On screening of donated blood by HBsAg and NAT at dilution of 4 (MP4) 50% of OBI would escape detection whereas on screening by MP4 in addition with screening of antibody to core antigen and HBsAg 22.22% OBI (potentially infectious) blood units would escape detection. Our study showed that ID-NAT testing along with HBsAg screening could detect all the potential HBV infectious donors (including OBI). NAT screening for HBV on diluted samples could compromise blood safety as low viral load sample will escape detection.
Pre-donation screening for hepatitis B surface antigen reduced the proportion of blood discards at fort portal regional blood bank, Uganda
Mugume Ambrose 1 , M Mukembo 1 , J Ngobi 1 , J Matovu 2
1 Uganda Blood Transfusion Service, Fort Portal, Uganda, 2 Makerere University School of Public Health, Kampala, Uganda, India
Issue: Blood discards due to transfusion transmissible infections (TTIs) leads to significant waste of donated blood. Prior to July 2013, no blood donors were screened of TTIs before blood donation at the Uganda Blood Transfusion Service regional blood bank, Fort Portal, western Uganda. Evidence from data collected between October 2012 and March 2013 indicated that Hepatitis B virus was a significant contributor to the proportion of blood discarded (accounting for 40% of all blood discards) in addition to HIV (35%) and inadequate blood volume (12%), among other factors. We implemented a pilot intervention aimed at improving pre-donation screening for hepatitis B surface antigen (HBsAg) to reduce the rate of blood discards due to Hepatitis B.
Project Description: The pilot project focused on reducing blood discards due to Hepatitis B virus at Fort Portal regional blood bank between July and October 2013. Eleven field staffs were trained on the use of a rapid strip for a HBsAg test. A total of 2,419 blood donors were screened for HBsAg before donation. Data on blood donors screened before blood donation was entered into database and analyzed.
Out Comes: The proportion of blood discards due to Hepatitis B in all blood units donated reduced from 40% in March to 23% at the end of October 2013. There was an un-intended reduction on blood discards due to; HIV from 35% to 27% probably due to co-infection, inadequate blood volume from 12% to 7.8% and expiry of blood from 4% to 0% due to strengthened blood collection and laboratory screening processes respectively.
Conclusion: Screening for Hepatitis B alone not only reduced the proportion of blood discards by 17% within 4 months but also minimized costs by USD1, 468, made the final blood products safer and reduced blood discards due to HIV, Inadequate blood volume and expiry. These findings suggest a need for introducing free Hepatitis B vaccination to all regular blood donors to prevent costs due to future Hepatitis B blood discards.
Fourth generation ELISA for detecting the seroprevalence of HIV is a more sensitive and cost effective alternative blood donor screening method, for use in resource poor countries
Roshan Jayamanna, Joseph Philip, T Chatterjee, RS Mallhi, AK Biswas
Department of Immunohaematology and Blood Transfusion, Armed Forces Medical College (AFMC), Pune, Maharashtra, India
Background: The introduction of more sensitive and economically viable screening methods have played a significant role, in reducing the incidence of transmission of Human Immunodeficiency Virus (HIV) during blood transfusion.
Aim and Objective: To assess and compare the sensitivity of 4 th generation Enzyme-linked immune sorbent assay (ELISA) and 3 rd generation ELISA to detect HIV in blood donors.
Materials and Methods: This single centre prospective study in Western India included 15000 blood donors of which 10130 were voluntary donors and 4870 were replacement donors. All samples were screened with 3 rd as well as 4 th generation ELISA. By using 3 rd generation rapid test all samples found positive, or in grey zone, with either 3 rd or 4 th generation ELISA were re-tested. Any sample that came positive only with 4 th generation ELISA was confirmed using PCR technique.
Results: The seroprevalence of HIV among voluntary donors was estimated to be 3.2/1000 donations with 3 rd generation ELISA and 3.3/1000 donations with 4 th generation ELISA. The prevalence of HIV among replacement donors was 5.3/1000 donations with 3 rd generation ELISA and 5.7/1000 donations with 4 th generation ELISA. Cumulative prevalence among all donations tested showed that seroprevalence for HIV by 3 rd generation ELISA was 3.9/1000 donations and 4.1/1000 donations with 4 th generation ELISA. Thus out of total of 15000 blood donor's testes, 59 samples tested positive with 3 rd gen ELISA and 62 samples came positive with 4 th gen ELISA. This would indicate that for every 15000 blood donors tested three more HIV positive donors would be detected by using 4 th gen ELISA.
Conclusion: Fourth generation ELISA is a more sensitive method than Third generation ELISA for daily cost effective donor screening in blood bank practice, in resource scarce countries.
Enhanced chemiluminescence immunoassay: A screening tool for infectious disease markers (IDM) in 8545 plateletpheresis donors
Ravi C Dara, Aseem Kumar Tiwari, Dinesh Arora, Ganesh Rawat, Vimarsh Raina
Medanta - The Medicity Hospital, Gurgaon, Haryana, India
Introduction: Laboratory testing of donated blood prior to transfusion is intended to ensure that recipients receive the safest possible blood products. Transmission of viruses through blood transfusion has been effectively reduced due to stringent donor selection criteria, screening methods like ELISA, Chemiluniscenece and detection of viral nucleic acids by NAT. But coming to platelet-pheresis donations where screening of the donor is performed before procedure in shortest time period majority of the blood banks use immune-chromatographic test strips for screening viral infections in blood donors.
Aim: The present study was designed to evaluate the performance of the enhanced chemiluminescence principle in comparison to immunochromatography as a screening test for the plateletpheresis donation.
Materials and Methods: This study was undertaken over a period of 32 months (Jan 2012-Aug 2014). All donors registered for plateletpheresis were tested by enhanced chemiluminescence assay (Vitros EciQ, Ortho clinical diagnostics, Johnson and Johnson, USA) for the detection of HBsAg, anti-HIV and anti-HCV antibodies. All serpositive donors were retested by immuno-chromatograhy and Enzyme Linked Fluorescent Assay (mini VIDAS) for HBsAg and anti HIV antibodies. For HCV, reflex testing was done by immune-chromatograhy and NAT. Seropositive donors were counseled and permanently deferred for future blood donations. Turn around time (TAT) of testing was also recorded.
Results: Out of a total of 8545 donors screened during the study period, 2.1% (185) donors were permanently deferred (HIV- 0.05%, HBV-0.51%, HCV- 0.58%, Syphilis- 0.97%) due to seropositive for viral markers with a true positive rate (TPR) of 100%, true negative rate (TNR) of 99.03% and false positive rate (FPR) of 0.9%. True positive, True negative and false positive rates of HIV (TPR-100%; TNR-99.9%; FPR-0.04%), HBV (TPR-100%; TNR-99.8%; FPR-0.18%) and HCV (TPR-100 %; TNR-99.4%; FPR- 0.5 %). 6 (3.2%) reactive cases were missed by immunochromatography with a TPR- 94.5%. TAT of 50 minutes was observed.
Conclusion: Enhanced chemiluminescence is an effective assay system than immunochromatograhy as a screening tool in plateletpheresis procedures with 100% sensitivity, rapid turnaround time, random access, full automation, and high through put along with a drawback of high false positive rate of 0.9%.
Evaluation report of vitros syphylis assay over syphylis antigen trust assay at Bombay Hospital blood bank
Paresh Marathe, Maya Parihar Malhotra, Kalyani Bapat
Department of Transfusion Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
Background: Syphylis comprises one of the five most important transfusion transmitted diseases besides HIV, Hepatitis B, Hepatitis C and malaria. It is a chronic veneral systemic infection caused by the organism Treponema Pallidum. The disease is characterised by episodes of active disease interrupted by periods of long latency. The disease is characterised by various stages namely Primary stage, secondary, latent stage and tertiary stage. Diagnosis is very difficult in very early phase, latent stage, neurosyphylis and congenital syphilis. Syphilis is seen as a coinfection with HIV/AIDS. Serological diagnosis remains the mainstay of diagnosis of syphilis. Serological tests for syphilis are divided into 2 categories, nontreponemal and treponemal, according to the type of antigen used. Currently in pretransfusion testing of blood and blood products the nontreponemal tests of syphilis are used. However they have several limitations. These detect antilipoidal antibodies which are nonspecific, as a result biologic false positive reactions are seen. Lack of sensitivity in both early stage and late stage of syphilis making diagnosis difficult in these stages. This study was undertaken to evaluate and the performance of specific treponemal tests in screening of syphilis infection over the exsisting nontreponemal tests which are routinely used in screening of blood and blood products prior to transfusion.
Aims and Objectives:
- To validate the performance of VITROS Syphilis TPA in donor screening in comparison with the currently used Syphilis TRUST antigen assay.
- To evaluate VITROS syphilis assay in terms of its sensitivity, specificity and precision in screening syphilis infection.
Results: In this study, Vitros Syphilis TPA assay showed
- 100% sensitivity-No false negativity
- Excellent dilutional sensitivity-Low level of antibody can be detected which may helps in early detection.
- Excellent inter assay precision
- Good specificity-No reactivity with potentially cross-reactive patient samples.
- No observed impact from potential interfering substances like hemolytic, icteric or lipemic samples.
Conclusion: The study brought forth definite benefits of introducing VITROS Syphilis TPA for screening of blood and blood products. Firstly it detects Treponema specific IgM and IgG antibodies instead of the nonspecific anti-lipoidal antibodies. Treponema specific IgM antibodies can be detected very early in disease course. Also biological false positive reactions seen with the nontreponemal tests are minimized. Hence there is enhanced confidence in reporting the results and releasing safe blood. Thus due to excellent sensitivity and specificity the test is very reliable in screening of blood and blood products prior to transfusion.
Antibody titres in Group O donors by microplate method
Puneet Jain, Anita Tendulkar, S Velaye, Sunil Rajadhyaksha
Department of Transfusion Medicine, Tata Memorial Hospital, Mumbai, India
Background: Passively transfused antibodies can cause hemolysis during group switchover in platelet transfusions. This is a challenging scenario in oncology centres, as there is a high demand for single donor platelets (SDP). Maintaining a group specific inventory for platelets is a daily requirement. Isoagglutinin titre >100 has been labelled as 'dangerous' in some developed nations, however there is no consensus across the globe, including India for the same.
Aim: The aim was to identify percentage of O group voluntary blood and platelet donors with high titres of isoagglutinin A and B, and to identify any specific patterns of distribution with relation to age and gender.
Materials and Methods: A prospective study of 3 months is being presented. A standard 96 well micro-plate method was used. All titres were performed using a 2% saline suspension of pooled group A and group B red cells and read after 1 hour of incubation at room temperature. Tube technique was used for comparison with the microplate method for a few samples to support concordance between the two.
Results: 1380 group O donors (M = 87.2%, F = 12.8%), aged 18-60 years with mean age 31.07 ± 9.903 were screened. The median titre for Anti-A and Anti-B was 128 with range from 4 to 2048. A doubling dilution technique was performed for titre quantification. 60.4% of the donors were ≥128 for Anti A, 54.1% for Anti-B and 45.07 % for Anti-A and Anti B.
Titres were significantly higher in younger female donors (89.9% of age 18-30 years >128, P = 0.03).The titres were found to decrease with age in males (51.5% males of age 51-60 years had combined Anti-A and Anti B titres <128). Correlation for Microplate method was high (Pearson's coefficient = 0.907, significant at P = 0.01).
Conclusion: Out of 1380 group O donors, 53% had high titres for Anti A and Anti B. It is advisable to screen all O group blood donors whose platelet and plasma products are intended for transfusion against ABO barrier.
Significance of quantitation of autoantibodies in eluate of sensitized red cells in warm autoimmune hemolytic anemia
Sudipta Sekhar Das
Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India
Background: A reactive direct antiglobulin test (DAT) with clinical and laboratory evidences of in vivo hemolysis establish the diagnosis of autoimmune hemolytic anemia (AIHA). Concentrated autoantibodies obtained by elution can be subjected to total serological characterization including thermal amplitude, specificity and autoantibody quantitation which help in proper management of the patient.
Aim: The present study was performed to correlate the quantity of immunoglobulin (Ig) G (IgG) autoantibodies in eluate with DAT reactivity and markers of in vivo hemolysis in warm AIHA (WAIHA).
Materials and Methods: Antibody class, IgG subclass, DAT dilution and quantification study on eluate was performed on 41 samples. Hemolysis in a patient was documented as per the previous guidelines. Cold acid elution was performed on DAT positive red cells and quantitation of IgG in eluates was done using ELISA. Number of IgG molecules eluted per RBC was calculated using Avogadro's number. A calibration curve was generated using corrected OD values of known different concentrations of standard and IgG antibody in eluate was quantified from this curve. The sensitivity of the assay was 7.8 ng/ml.
Result: We observed a significant correlation between concentration of IgG in eluate and DAT strength (r = 0.49, P = 0.011), hemoglobin (Hb) (r = -0.44, P = 0.03), serum bilirubin (r = 0.57, P = 0.000) and serum lactate dehydrogenase (LDH) (r = 0.52, P = 0.03). The number of IgG molecules/RBC also correlated significantly with the DAT strength (r = 0.63, P = 0.001) as well as DAT dilutions (r = 0.57, P = 0.006). With DAT strength ranging from 1+ to 4+, the number of IgG molecules eluted per RBC varied from 343-1291 IgG/RBC.
Conclusions: Blood banks with no facilities of high sensitive methods may quantify autoantibodies in eluate to label the severity of AIHA and plan appropriate management.
Prevalence of "Unexpected Antibodies" in the antenatal women attending the Government Maternity Hospital, Tirupati
Suresh Babu Bandi, KV Sreedhar Babu, T Bharathi, DS Jothi Bai
SVIMS, Tirupati, India
Introduction: All antibodies to red cell antigens, other than naturally occurring anti-A and anti-B are considered unexpected. They can be either alloantibodies or auto antibodies. Unexpected antibodies in donor plasma may destroy recipient red cells, while antibodies in the recipient may cause accelerated destruction of transfused red cells. In pregnant women, these antibodies may cross the placenta and cause hemolytic disease of the fetus and newborn (HDFN). Some may have only mild jaundice on first day of life, but rapid fall of hemoglobin than other newborn infants. In others, jaundice develops more rapid; unless treated by exchange transfusion, may lead to kernicterus and permanent brain damage. Reports regarding prevalence of such antibodies are not available from Andhra Pradesh. Timely detection of such antibodies in antenatal women is essential both for transfusion safety in mother and early management of HDFN.
Materials and Methods: A prospective cross-sectional non-interventional study was carried out on 2060 multigravida women to detect prevalence of unexpected antibodies, attending the Government Maternity Hospital, Tirupati. The women were grouped and typed for ABO and Rh D antigens by tube method and screened for alloantibodies by column agglutination technology. The medical history and detailed obstetric history of these women were reviewed.
Results: The overall prevalence of alloantibodies was 1.1%. There was a statistically significant difference between alloimmunization rates in the Rh D-antigen negative and D-antigen positive women (12.78% versus 0.26%). The antibodies detected in this study were, anti-D (63.65%), anti-D+C (13.65%), anti-c (4.54%), anti-M (4.54%), anti-Le a (4.54%), and anti-Le b (4.54%). Anti-D contributed to 77.27% of total alloimmunization in this study.
Conclusion: In spite of the introduction of prophylactic Rh-Ig, anti-D (77.27%) is still a common antibody identified in the antenatal women of our region. In developing countries like India, universal antenatal antibody screening, though desirable may not be justified at present as the cost and infrastructure required would be immense. However it is necessary to impose properly formulated protocols to screen at least the pregnant women with adverse obstetric history.
Frequency of alloimmunization in rhd positive pregnant females and its correlation with neonatal outcome
Neelam Marwaha, Ashish Jain, Rashmi Bagga 1 , Parveen Kumar 2
Department of Transfusion Medicine, 1 Department of Obstetrics and Gynecology, 2 Department of Pediatrics, PGIMER, Chandigarh, India
Background: Hemolytic disease of fetus and newborn (HDFN) has been a major preventable cause of mortality and morbidity. Antibody screen during the antenatal period can detect the alloantibodies implicated in HDFN. Aims: To determine the frequency of alloimmunization in RhD positive pregnant females and its correlation with neonatal outcome.
Materials and Methods: 1000 RhD positive pregnant females attending the antenatal clinic in our institute were included in this prospective study out of which 500 were of 'high risk pregnancy'. Blood grouping (ABO and RhD) and extended Rh phenotyping (C,E,c,e) were done by tube technique. Antibody screening and identification was done using the commercial 3-cell and 11-cell panel respectively by gel technique (LISS-Coombs' AHG card, BioRad, Morat, Switzerland). Antibody identification was performed only when the screen was positive. Antibody titration was done using tube technique. Husband's and neonatal blood grouping and extended Rh phenotyping; and neonatal direct antiglobulin test (DAT) were done for alloimmunized mothers.
Results: Out of 1000 pregnant females, 7 were alloimmunized (0.7%). All of them belonged to 'high risk pregnancy' category (P = 0.015) and were multigravida. The antibody specificities were anti-E (85.70%), anti-c (71.43%), anti C w (14.29%) and anti-S (14.29%). The antibody titers ranged from 2 to 16. Out of the 7 alloimmunized cases, 6 had a history of transfusion (P < 0.01). DAT was positive in only 4 neonates (out of 7). The mean duration of phototherapy in the DAT positive neonates was significantly higher than in the DAT negative neonates (P < 0.01) and 2 of them required double volume exchange transfusion.
Conclusion: The frequency of alloimmunization was 0.7% in RhD positive pregnant females. High risk pregnancies and antenatal patients having a history of blood transfusion should be considered for regular antibody screening.
Titres of ABO antibodies in blood group 'O' male meitei donors of Manipur
Barilin Passah, A Meina Singh, Avila Sangtam, Pratima KH, A Barindra Sharma
Regional Institute of Medical sciences, Imphal, Manipur, India
Background: The ABO antibodies in group O donors may cause hemolysis to non-O group recipients if the titres are high, especially when plasma containing units are transfused. Aims: To determine the levels of anti-A and anti-B antibodies, their prevalence of high (64) and critical (128 or more) titres and the age wise variations among the 'O' group male blood donors of Meitei ethnicity.
Materials and Methods: This is a prospective and cross sectional study conducted in the department of IHBT, RIMS, Imphal from June to August 2014. Blood samples from 100 (hundred) group 'O' (irrespective of Rhesus type) male Meitei blood donors, who donated blood in the IHBT Department during the study period were tested for anti-A and anti-B titres using conventional tube technique at room temperature. For the study, the donors are grouped into four age groups i.e. 30 donors each of 18-29, 30-39, 40-49 years and 10 donors of 50 years and above.
Results: Both anti-A and anti-B titres ranged from 8 to 128. Most frequent anti-A titre was 64 which were found in 33% of the donors, of which 43% of the donors are in the age group of 30-39 years. High titre anti-A (64) and critical titre (128+) were seen in 33% and 4% of the donors respectively. Anti-B titre of 16 was the most frequent (36% donors), of which 40% of them were in the age group of 18-29 years. High titre anti-B were found in 14% of the donors and only one case (1%) had a titre of 128. No significant reduction in titres noted in oldest age group (for anti-A: P = 0.137).
Conclusion: High titre anti-A (64)observed in 33% of group O donors and transfusion of large plasma volume containing group O units to non-O group recipients may pose a significant risk of transfusion reactions, hence the need for evaluation of titres as per the geographical and ethnicity of the populations.
Association of lewis phenotypes with coronary artery disease
N Ramasubramaniam, HK Dhawan, R Vijayvergiya, N Marwaha, R Prasad
Department of Transfusion Medicine, PGIMER, Chandigarh, India
Background: Associations between blood groups and disease have been described ever since the discovery of ABO blood groups. The Lewis blood group has been described as a new genetic marker of coronary artery disease (CAD).
Aim: This study was designed to see the association of Lewis negative phenotype with coronary artery disease along with other conventional risk factors so as to establish Lewis phenotype as an independent risk factor for CAD in Indian population.
Materials and Methods: A total of 232 patients who were suspected of coronary artery disease and scheduled for coronary angiography were included in this study. A total of 161 angiographically positive patients were included as cases. Seventy one patients who were suspected of CAD but angiographically negative were chosen as control group 1. Three hundred normal blood donors were included as control group 2 to study the distribution of Lewis phenotypes in the general population.In cases and control group 1, history of smoking, alcoholism were noted and mean BMI, waist hip ratio, fasting blood sugar, lipid profilewere measured and blood grouping [ABO, Rh (D)] and Lewis phenotyping were done. Statistical analysis was carried out using SPSS software.
Results: Mean BMI, waist hip ratio, history of smoking, alcoholism, diabetes, hypertension, fasting blood sugar, lipid profile were all significantly higher in the angiography positive group when compared with the angiography negative control group (P value <0.001). When males and females were considered together, the prevalence of Lewis negative phenotypes was not significantly different among the angiography positive group and both the control groups. When females were considered separately, Le (a-b-) females had 4.6 fold higher incidence of coronary artery disease as compared to control group 1 Table 1. There was no statistically significant difference in mean BMI, mean waist hip ratio, the prevalence of diabetes, hypertension, fasting blood sugar and lipid profile between Lewis positive and negative phenotypes.
Conclusion: Le (a-b-) females had higher incidence of coronary artery disease while this association was not observed in males and in overall population together. Larger studies taking into account gender differences are required to delineate the risk assessment.
Distribution of "Abo" And "Rh(D)" blood grouping in the central part of the state of Gujarat
Madhur Y Modi, Ashu Dogra, Swapan Goswami
Department of Pathology, Dhiraj Hospital, Sumandeep Vidyapeeth University, Vadodara, Gujarat, India
Background: The "ABO" and "Rh(D)" Blood Group System is the most important system in Transfusion Medicine and Organ Transplantation. The knowledge of the distribution of "ABO" and "Rh(D)" Blood groups is also very essential for the effective management of blood banks. It is therefore important to have information on the distribution of these blood groups in any population. People of various communities are present in the study mainly Tribal Communities. Aims: The present study have been undertaken with the objective to provide data on the "ABO" and "Rh(D)" Blood Group Distribution in the Central part of the State of Gujarat.
Materials and Methods: A total of 5000 healthy blood donors who have donated in Dhiraj Hospital Blood Bank, Sumandeep Vidyapeeth University, Pipariya, Baroda were included in the present study."ABO" and "Rh(D)" grouping was performed on all these samples. Data on the frequency of "ABO" and "Rh(D)" blood groups was reported in simple numbers and percentages.
Results: The present study showed that "B" was the most common blood group (33.6%) donated in Dhiraj Hospital Blood Bank followed by "O" blood group (29.4%),"A"blood group (25.3%) and least common blood group was "AB" (11.7%). Few "A 2" blood groups were also donated which was detected by "Anti-A 1 Lectin"antibody.Extremely few donors were also found to be "Bombay blood group" which was detected by "Anti-H Lectin" antibody.
Conclusion: The present study will be prove out to be very useful for all the blood banks in the Central part of the State of Gujarat to maintain its blood stock according to the blood group requirements.
Therapeutic plasma exchange (TPE) in patients with high MELD: Is it a bridge to liver transplant?
Joy Vaghese, Ilan K, Srinivas Reddy M, Dinesh Jothimani, Jayanthi V, Mohamed Rela
Department of Transfusion Medicine, Hepatology, Anethesiology and Institute of Transplantation surgery, Global Health City, Chennai, India
Background: Patients with high MELD (Model for End-stage Liver Disease) score, listed for liver transplant (LT), manifests with any one or more than one combination of severe jaundice, encephalopathy, coagulopathy, or multisystem organ failure. Mortality rates are high. Liver transplant (LT) is considered an ideal option with long-term 1-year survival rates exceeding 88%. Therapeutic Plasma Exchange (TPE), which restores coagulation parameters and removes toxins, has been introduced in children with acute liver failure. It may be an alternative therapeutic option for patients with high MELD score, registered for liver transplant (deceased and live donor LT).
Aims: Was to determine the utility of TPE in liver cirrhotic patients with high MELD during their Liver transplant waiting period.
Materials and Methods: Patients with High MELD Score (≥25) listed for LT who presented with either severe jaundice (S Bilirubin >10 mg/dL), encephalopathy (Grade II or III), or coagulopathy (INR >2) during the wait period for LT were enrolled for TPE. TPE was done using Spectra Optia apheresis system via a central or a peripheral venous axis with citrate as an anticoagulant. One to 1.3 plasma volume was removed and was replaced with fresh frozen plasma (FFP). Vital parameters were monitored during TPE for any adverse effects. IV Calcium gluconate was given as prophylaxis or when indicated. Parameters including baseline demography, etiology, other organ failure, pre and post TPE MELD score, liver function tests, coagulation parameters, ammonia levels, serum calcium, serum Creatinine and pre and post clinical assessment of encephalopathy were noted. TPE was repeated based on MELD score. The mean interval between TPE sessions and final outcome were noted.
Statistical Analysis: Mean, student t test.
Results: Fourteen men and 2 women (mean age 43 ± 6.1 years) patients received 40 TPE. Average TPE per patient was 2.4 (range 1-4). There was no TPE related adverse reaction. Severe alcoholic hepatitis was most common indication for TPE. Pre and post TPE MELD score (31 vs 25.2; P < 0.05), serum bilirubin (27.8 ± 10.1 vs 20.6 ± 7.9; P < 0.05), and INR (2.7 ± 0.7 vs 1.8 ± 0.3; P < 0.05) showed a significant good response. S. Albumin did not show a change. On follow up, 3 patients had LT, 7 died and remaining are on maintenance TPE.
Conclusion: TPE improves encephalopathy and MELD score. It is safe, tolerable and is recommended as a liver support for complications encountered during pre- LT work up while waiting for Liver transplantation.
Pediatric experience with large volume leukaphresis efficacy for peripheral blood stem cell harvest
SH Sumathi, Shashank Ojha, P Nagaraju, SB Rajadhyaksha 1
Department of Transfusion Medicine, Advanced Centre for Treatment, Research and Education in Cancer, Navi Mumbai,
1 Tata Memorial Hospital, Mumbai Maharashtra, India
Background: The potential benefits of peripheral blood stem cells [PBSC] as source of hematopoietic progenitors in treating varied malignant disorders have extensively been demonstrated in the literature. However, due to limited reported experience and the procedural constraints in pediatric subjects, large volume leukaphresis [LVL] for PBSC is an unpopular option.
Aim: To explore the LVL procedure feasibility and determine strategies to optimize PBSC harvest in pediatric subjects.
Materials and Methods: Retrospective data retrieval of all chemo-mobilised and/or G-CSF mobilised only pediatric (Age <17 years) LVL procedures on Cobe Spectra (version.7) cell separator from January 2008 to August 2014 was done. Central venous catheter was established as venous access along with strict aseptic catheter care procedures. The criterion for blood priming the extracorporeal circuit with undiluted, leucodepleted irradiated, compatible red blood cells was dependent on body weight of subjects. Flowcytometric CD34+ enumeration was done using dual platform ISHAGE protocol and CD34+ Collection Efficiency [CD34-CE]% to achieve a targeted dose of >4 × 10 6 CD34+ cells was calculated. Procedure-related variables were analyzed using SPSS software 21.O.
Results: A total of eighty four LVL procedures on fifty four patients and thirty donors with mean weight (range) of 33.6 kg (11-47) were done as per standard recommendations. The clinical indications were majority for Acute Lymphoblastic Leukemia in allogenic and Hodgkins disease in autologous setting. Blood priming and central catheter insertion was necessitated in 26.1% and 80.9% LVL. The mean (range) total blood volume (ml) processed was 7927 (3206-13436) with anticoagulant (ml) usage of 660 (226-1026) in 224 minutes (150-260) of duration. Mild tingling complaints (22%) were observed. Mean CD34-CE% (range) achieved was 96.4 (38-227) from pre-CD34+cells of 127.2 (15-220).
Conclusion: With the sophistication of cell separators and expert operator experience, pediatric LVL is feasible and controllable in a satisfactory manner. However, the selection of patients in whom it is beneficial vis-a-vis bone marrow harvest as source of hematopoietic progenitors is a continuing learning experience.
Effectiveness and safety of therapeutic plasma exchange in paediatric patients
Meghana Solanki, Kruti Patel, Nidhi Bhatnagar, MD Gajjar, Tarak Patel, Sangita Shah, Shital Soni
Department of Immuno Haematology and Blood Transfusion, BJ Medical College, Civil Hospital, Ahmedabad, Gujarat, India
Introduction: Therapeutic Plasma Exchange (TPE) is a well established modality of treatment in variety of neurological, haematological, renal and autoimmune diseases. It is performed effectively and safely in adult patients, but the use of TPE is limited in paediatric patients due to lack of universally accepted indications and technical challenges like establishment of adequate vascular access, low blood volume, increased incidence of adverse events during procedure and poor co-operation of patients during procedure. Here we present our experience of TPE in paediatric patients.
Aim: To assess the effectiveness and safety of TPE in paediatric patients.
Materials and Methods: A total 122 TPE procedures were performed in 40 paediatric patients between the 3 to 15 years of age group with Guillan Barre syndrome (GBS). TPE procedures were performed on Spectra Optia apheresis machine (Manufacture TERUMO BCT) daily or on alternate days depending on the clinical condition of the patient. The TPE kit was primed with group specific, screened and cross matched packed red blood cells for all procedures in order to avoid hypoxia and hypovolemia. 1-1.5 plasma volume of patient total blood volume was exchanged with normal saline and fresh frozen plasma. Details of the procedural complications if any were noted and analyzed. Pre and post procedure renal functions along with haematological parameters were done at every procedure.
Results: A total of 122 TPE procedure (with an average of five procedures per patient) were performed for 40 paediatric patients over a period of one and half year from jan-2013 to jul-2014. More than three TPE procedures were performed in 29 patients, of which 27 patients showed improvement from grade 0 (complete paralysis) to grade-III (movement possible against gravity but not against resistance) (Grading of muscle power is as per Medical Research Council Scale). One did not show any response and succumbed to the disease. Complications were observed in 9 procedures which were well managed. Inadequate vascular access was most common complication observed in six procedures. Other complications were allergic reactions to fresh frozen plasma(FFP), hypovolemia, hypocalcaemia and vasovagal reactions.
Conclusion: TPE in paediatric patients has been increasing and has been shown to be effective as first line or adjunctive therapy in selected diseases. It is safe procedure when volume shifts, calcium supplementation and venous access are taken care.
Comparison of thromboelastography and conventional coagulation tests to monitor fresh frozen plasma transfusion in intensive care unit patients
Ajay S Praveen, Ravneet Kaur, Satinder Gombar, Anshu Palta
Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, India
Background: Transfusion of Fresh Frozen Plasma (FFP) is commonly used therapy for coagulopathy in ICU patients. Coagulogram is deranged in >30% of patients while only 13.6% of patients experience bleeding unexplained by any of local or surgical factors. Thus, many of the plasma transfusions are inappropriate. Certain complications are more likely with plasma transfusion. New modalities like Thromboelastogarphy (TEG) are available to assess the coagulation status. Therefore, this study was planned to assess the efficacy of TEG over conventional coagulation tests to monitor FFP transfusion in ICU patients.
Materials and Methods: The study was conducted in the Department of Transfusion Medicine in collaboration with Department of Anesthesia and Intensive Care and Department of Pathology of the Government Medical College and Hospital, Chandigarh. Total 25 patients were observed during their stay in the Intensive Care Unit of the institute. Blood samples of the patients were taken and TEG analysis was done in addition to conventional coagulation tests. The obtained results were evaluated against the clinical status of the patient.
Results and Conclusion: Of 25 patients studied, 3 patients experienced bleeding and had an abnormal TEG and conventional coagulation tests. TEG was abnormal in 7 patients who were not bleeding compared to 21 patients with abnormal conventional coagulation tests. Thus, sensitivity of TEG was found to be similar while specificity was found to be considerably higher than conventional coagulation tests both pre and post FFP transfusion. TEG can be considered as an effective tool to assess the coagulation status of ICU patients because of its several advantages over conventional tests. Moreover, it is more specific and will decrease inappropriate FFP transfusions.
Intrauterine packed red cell transfusion, management and outcome: A procedure evaluation in a tertiary care hospital
Archana Bajpayee, Vijay, Anupam Verma, Rajendra Chaudhary, M Pradhan
Transfusion Medicine and Blood Bank, AIIMS, Jodhpur, India
Background: This study was conducted in the Department of Transfusion Medicine in collaboration with Maternal and Reproductive Health Department, at Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow. This was a prospective study of ANC patients with Rh D Negative blood group, during a period of 2 years.
Aim: To study the outcome of red cell alloimmunized pregnancies treated with intrauterine red blood cell transfusions.
Materials and Methods: A total of 188 pregnancies with bad obstetric history came in Maternal and Reproductive Health Department were included in the study. Out of 188 women, 166 were found to be Rh(D) negative group and 22 were phenotyped as Rh(D) positive. Among these 166 women, IAT was negative in 118 and positive in 48.Out of 48 IAT positive and Rh(D) negative women 16 women showed significant rise of antibody titer and evidence of fetal anemia on USG. Out of 22 Rh(D) positive women cases, 1 case presented with positive IAT due to ant-M and fetal anemia on USG. In these 17 cases IUT procedures were done to treat fetal anemia and to prevent IUD.
Results: 17 cases had undergiven overall 52 episodes of intrauterine transfusion among these50 episodes were intravascular transfusion (IVT) and one intraperitoneal transfusion (IPT) and one intrahepatic transfusion (IHT). In 17 cases 14 delivered live baby in which 8 were normal delivery and 6 underwent LSCS remaining 3 baby was died. Among 14 live babies 11 babies underwent exchange transfusion and in all phototherapy was given. Among 14 live babies 9 babies received IVIg.
Conclusion: 82.4% of the live delieveries and the foetal loss rate was 17.6%.Intrauterine Transfusion is a safe modality for the treatment of fetal anemia, however the outcome can be improved by early diagnosis and creating awareness regarding antenatal management of HDN.
Prolonged anemia in an intra-uterine transfused neonate with Rh hemolytic disease and role of anti-D titre in prognosis
Sunita Tulsiani, Anna Thomas, VP Antia
Breach Candy Hospital Blood Bank, Mumbai, Maharashtra, India
Background: Rh hemolytic disease may be complicated in some cases by a prolonged post natal anemia with an extended need for postnatal red blood cell transfusion.
Case Report: This is a case report of a newborn with Rh hemolytic disease caused by Anti D (along with anti C) who received several intra uterine transfusions (IUT). At birth, Hb was normal, DAT was negative, blood group was reported as O Rh negative (because of IUT transfusion of O negative red cells). No evidence of hemolysis was found as bilirubin was normal and retic count very low. So Rh incompatibility was ruled out. Further investigations were done to rule out cause of fetal anemia with low retic count i.e. ineffective erythropoiesis. However, no cause found. After a week, infant's Hb started decreasing, thus red cell transfusion was necessary. IAT of the mother and infant's sample was positive. Anti-D and Anti-C antibodies were identified in the mother and infant's sample. So, the infant was transfused O negative (and Antigen C negative) red cell units. At 3 rd week, anti- D titre of infant was 256. Regular monitoring of Anti D titre, Hb and retic count was done of the infant's sample. Reticulocyte count started increasing 7 weeks after birth, when anti D titre had decreased to 4.Hemoglobin also started to increase and no further treatment was necessary. At 9 weeks, the infant's own red cells were released into circulation and D+ cells were detectable in the peripheral blood. Blood group of the infant was reported as O Rh positive.
Conclusion: Anemia in this patient seemed to be mainly caused by ongoing intramedullary hemolysis due to persistent high anti-D titres. In such cases variables of hemolysis are not necessarily found. Release of patient's own red cells into circulation may become sufficient when anti-D declined to a very low level. Monitoring of post natal Anti-D titre is important in prognosis of anemia in Rh HDN.
Platelet transfusion in a case of Bombay group patient with Non-Hodgkin's lymphoma (NHL)
Sunil Rajadhyaksha, Priti Desai, Nidhi Sharma, Dipali Patil, Rajesh Thakkar
Department of Transfusion Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
Introduction: Managing transfusion requirements for Bombay phenotype patients is challenging. O h individuals must be transfused with only O h red cells, but very few reports are available in literature about platelet transfusions in such individuals.
Case Report: An 8 year's old tribal child from Jharkhand presenting with anulcerative inguinal growth, was diagnosed as a case of NHL. The child was typed as O h Rh positive and had high titres of A, B and H antibodies. Salivary grouping and adsorption-elution studies were done to confirm the patient's blood group. Parents were found to be non-Bombay phenotype secretors. The patient was started on intensive chemotherapy. Anticipated transfusion requirements were discussed with the clinician. In view of limited availability of Bombay group blood, the patient was put on Erythropoietin and iron supplementation by the clinician. Requirements for packed cell transfusion were fulfilled by calling voluntary Bombay blood group donors. Requirements for platelet transfusion were fulfilled by providing A 2 /A 2 B platelets on a total of 3 occasions. All transfusions were uneventful. 1 hour and 24 hour Corrected Count Increment (CCI) could not be performed as the patient left Day Care immediately after transfusion. However even after 48 hours the platelet counts showed adequate increment.
Discussion: Since Bombay group platelets are difficult to obtain extensive literature search was performed to decide on choice of platelets. It was evident from available literature that A 2 and A 2 B would be the most preferred. A 2 platelets have the least expression of A and H antigens on their surface, hence are considered comparable to Bombay group platelets.
Conclusion: A 2 /A 2 B platelets showed adequate increments without any adverse effects and can be considered as group of choice for platelet transfusions in Bombay group patients.
Role of extended phenotyping in an alloimmunized patient
Kruti Patel, Maitrey Gajjar, Hardik Raval, Nidhi Bhatnagar, Tarak Patel, Meghana Solanki
Department of Immunohematology and Blood Transfusion, BJ Medical College, Ahmedabad, Gujarat, India
Introduction: Red cell alloimmunization is an immune response against foreign RBC antigens, occurs due to blood transfusions and pregnancies. These antibodies may result in clinically significant hemolytic transfusion reactions, difficulty in compatibility and decrease in RBC survival.
Case Report: A 50 years old female patient, with a history of ostium secondum defect with Left to Right shunt, mild TR (tricuspid regurgitation) and mild MR (mitral regurgitation) was admitted in cardiology department for planned cardiac surgery. Patient's obstetric history was (G4 P3 A1 L3). One unit of red cell concentrate (RCC) was transfused two days prior to surgery to correct haemoglobin level. Fresh blood samples were received to keep four units compatible RCC ready for planned surgery. Antibody screening with three cell panel and eleven cell identification panel was panreactive with autocontrol negative. Her DAT and IAT were grade 4 positive. Specific alloantibody could not be identified. No compatible RCC unit was found due to possibility of multiple alloantibodies or alloantibody against high frequency antigen and surgery was postponed. Patient was given immunosuppressive therapy for three and half months, after which her DAT and IAT became negative. Phenotyping of patient, her brother, son and her husband was done. Phenotype matched blood from her brother was irradiated and transfused during surgery and transfusion was uneventful.
Conclusion: Alloimmunization can be decreased by providing phenotype matched blood. In alloimmunized patients, Autologus transfusion (predeposited, or intra- operative blood salvage) and phenotype matched blood transfusion can be used.
What is it really? Anti-G or Anti-D plus Anti-C: Clinical significance in antenatal mothers
Soumya Das, Shamee Shastry, Mohandoss Murugesan
Department of Immunohaematology and Blood Transfusion, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
Background: All "C" or "D" positive red cells contain G-antigen. Serologically anti-G give a similar picture as of anti-D plus anti-C. Differentiating them is important as anti-D plus anti-C causes severe hemolytic disease of newborn (HDFN) than anti-G. The alloimmunization to "D" antigen could be prevented by prophylactic administration of RhIg during pregnancy in patients having anti-G.
Aim: To differentiate between anti-D plus anti-C from anti-G in alloimmunized pregnant mothers.
Materials and Methods: Sera from 5 antenatal mothers, whose antibody identification by 11-cell panel gave a pattern for anti-D and anti-C were selected. Patients extended phenotype for Rh system was performed. Differential adsorption and elution studies using R2R2 cells initially and r'r cells subsequently was performed. Titration for anti-G was done with O-pooled cells and for anti-D and anti-C, R2R2 and r'r cells respectively was used. The clinical outcome in the newborn was studied.
Results: The extended Rh phenotype of all cases were rr (dce/dce). Two cases had anti-D plus anti-C and three had Anti-G antibodies respectively. The titre for anti-G was 16 while for anti-D, it was 16 to 128 and anti-C was between 2 and 4. Follow up was done in four pregnancies. All newborns had a positive direct globulin test. Elution of DAT positive cells confirmed the antibody. One baby received exchange transfusion while two babies had phototherapy. Another baby received both exchange transfusion and phototherapy.
Conclusion: We found that differential adsorption and elution studies will help in identifying anti-G from anti-D plus anti-C. Follow up titre and selection of antigen negative blood for exchange transfusion improved neonatal outcome.
Complement dependent cytotoxicity (CDC) in the solid phase era: A comparative analysis of results obtained using CDC and Luminex crossmatches during pre transplant screening for anti HLA antibodies
Mary Purna Chacko, R Santhi R, A Augustin, S Aruldoss, D Daniel
Department of Transfusion Medicine and Immunohematology, Christian Medical College and Hospital, Vellore, India
Introduction: Complement Dependent Cytotoxicity (CDC) has been the gold standard in anti-HLA antibody detection. However, newer solid phase assays, with higher sensitivity and specificity have redefined algorithms in pre-transplant screening. In this context, we examined the respective roles of the cell based CDC and the solid phase Luminex crossmatch, through a comparative analysis of results.
Materials and Methods: Pre-transplant CDC (with extended incubation, Dithiotreitol/DTT and antihuman globulin/AHG modifications) and Luminex crossmatch (using donor lysate; Tepnel; USA) results over one year were retrospectively examined.
Results: 210 samples were compared on both platforms. 43 (20.5%) were positive on both, and 126(60%) were negative on both. Results were discordant in the remaining 41 (19.5%). Among 24 samples that were positive on CDC alone, reactions were doubtful (5% or less cell death) in nine, and ten showed only IgM. Five samples showed definite donor specific IgG antibody not detected on Luminex. 17 crossmatches were positive only on the Luminex platform. Four were positive for class I, and 13 for class II with median MFIs of 2457.5 and 1650 respectively. Only one sample had an MFI that exceeded 5000. 17 samples exhibited doubtful positivity on CDC. Eight of these were also positive on Luminex. 4 samples that showed only IgM on CDC, showed IgG on Luminex.
Discussion and Conclusion: We observed good concordance between CDC and Luminex, with results in agreement 80% of the time. Most discrepant results could be attributed to Luminex being designed to detect only IgG, or the relatively lower sensitivity of CDC. While we used an extremely low cut off of 5% cell death on CDC, positivity in half these doubtful cases was confirmed on Luminex. CDC has a proven role in compatibility testing. The Luminex crossmatch complements this, particularly in detecting and characterizing weak antibodies, and confirming doubtful positivity.
The efficacy of generic plerixafor in mobilization of haematopoetic stem cells: A single centre experience
Basudevi Mishra, SS Das, N Jain, Md Musheb, S Bhartia, S Bhattacharya, S Sen, J Chakrabartty
Department of BMT and Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India
Background: The advent of new pharmacological agents for mobilization of stem cells (SC) to peripheral circulation has made their collection easy. Drugs like granulocyte-colony stimulating factors (G-CSF), high dose chemotherapeutics, CXCR4 antagonist singly or in combination are widely used in SC mobilization. CXCR4 antagonist has been found to be promising recently. Aims: Here we share our experience of using a generic CXCR4 antagonist - Plerixafor in patients who were poor mobilizer with other agents.
Materials and Methods: The study included 10 patients of various hemato-oncological malignancies who were potential transplant candidates. All patients received appropriate standard conditioning regimens and SC mobilization was performed using subcutaneous plerixafor (Mozifor) 0.012 mg/kg/day, as the secondary agent to G-CSF failure. Peripheral blood stem cells (PBSC) were collected by using COBE-Spectra machine exactly 11 hours after plerixafor administration with a target dose of ≥2 × 10 6 /kg CD34+ cells. Cryopreservation was performed whenever indicated. Patients were followed up meticulously and transplantation done on appropriate day. Hematological monitoring for all patients was done to evaluate successful engraftment.
Results: A total 15 harvests were performed in 10 patients (M:F = 4:1) suffering from Myeloma (N = 7), Lymphoma (N = 2) and AML (N = 1). The mean pre-harvest CD34+ cell count was 55 ± 25.9 cell/μl. In 224 ± 34 min harvest time, mean 14421 ± 1683 ml whole blood was processed using 908 ± 179 ml anticoagulant. The mean final dose of CD34+ cells was 5.7 ± 1.9 × 10 6 /kg. Engraftment was successful in all patients with a mean engraftment time of 12 ± 1.6 days. All patients were discharged at 16 ± 1.2 days of transplant.
Conclusion: CXCR4 antagonist plerixafor is very effective in patient who are otherwise poor stem cell mobilizers with the conventional mobilizing agent. All patients under study received adequate stem cell dose and were discharged successfully.
Comparison between flowcytometric crossmatch and Luminex crossmatch in detecting anti HLA antibodies
Ancy Susan John, MP Chacko, D Daniel
Department of Transfusion Medicine and Immunohematology, Christian Medical College, Vellore, Tamil Nadu, India
Background: The serologically based complement-dependent cytotoxicity (CDC) crossmatch had been the cornerstone technique for the detection of anti HLA antibodies since the 1960's, until the introduction of newer methodologies such as the luminex crossmatch and Flow cytometric crossmatch. The luminex system uses micro beads coated with Class I or Class II HLA antigens and a flow analyzer, whereas the flowcytometry uses viable lymphocytes.
Aim: To assess correlation between the Luminex crossmatch using donor lysate and flowcytometric crossmatch in detecting anti HLA antibodies.
Materials and Methods: A total of 23 sera had a flowcytometric crossmatch and a luminex crossmatch. Using donor lysate performed. Using flowcytometry as the gold standard results were compared.
Results: Of the 23 patients, five showed anti HLA antibodies to HLA class I and II antigens using the luminex crossmatch. All these five showed positivity by flowcytometric crossmatch as well, three to both T and B cells and two only to T cells. Ten patients showed the presence of anti HLA antibodies to class II antigen only in the luminex crossmatch assay. Six of these showed borderline positivity while four were strongly positive. Flowcytometry revealed only three of these ten to have positive results, irrespective of whether they were borderline or otherwise. All samples negative on the luminex platform were negative on the flowcytometry as well.
Conclusion: The luminex crossmatch appears to show good correlation with flowcytometry in the detection of class I and II antibodies together. No false negatives were found in our study. Class II positivity on the luminex crossmatch seems fraught with the problem of false positivity, if one were to take flowcytometry as the gold standard. Considering the high sensitivity of the luminex platform though, it might be useful testing these discrepant samples using a single antigen bead assay before they are conclusively labeled as false positives.
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Hemovigilance in managing blood transfusion needs through transfusion audit
Rushabh Patel, Jasmin Jasani, SS Goswami, RK Tandon, RK Pasale
Department of Pathology, Smt. BK Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
Background: Transfusion audits are useful tools in the education of those ordering blood components, potentially resulting in the reduction of inappropriate use of blood components.
Aim: Educating clinicians to improve documentation of transfusions, in addition to appropriate indications for transfusion, may serve to enhance the efficiency of the blood utilization and safer transfusion practices.
Materials and Methods: Retrospective analysis of 512 consecutive requests for transfusion in a 6 month period. The blood bank requisition forms sent by the clinicians were analyzed and details of patients for following factors-age, sex, diagnosis, department, type, amount and indication of blood products at time of retrospective data collection was noted.
Results: The total blood units supplied were 953.The male to female ratio was 2.2:1. Packed red blood cells were the most utilized products, followed by whole blood. Supply of blood was maximum to surgical wards. The patient of elective surgery followed by trauma required blood mostly. The most common indication for whole blood, packed red cells, Fresh frozen plasma and platelets were elective surgical procedures, anemia, bleeding and thrombocytopenia respectively.
Conclusion: This retrospective study shows a positive relation between the lack of knowledge about transfusion indication of prescribing medical officers. This information is relevant for quality management of transfusion practice, cost analyses and for planning local and regional blood donation programs.
Setting up the "MSBOS" in a new hospital
Rashmi Sood, Tarun Kumar, Sushil Kumar, Sushma Rani, Vineeta Gupta
Saket City Hospital, New Delhi, India
Introduction: Maximum surgical blood ordering schedule (MSBOS) is a table that lists the number of units of blood routinely requested and/or cross matched/saved for a number of common elective surgical procedures performed in a setup. Based on study of C:T ratio, transfusion probability and transfusion index for the procedure, it relates the ordering of blood to the anticipation that a transfusion will be required and thus helps in predicting normal blood usage for elective surgical procedures. The group and screen G and S policy should be used for procedures rarely requiring blood and for procedures predictably requiring blood, request can be placed from MSBOS, for cross-matching a predetermined number of crossmatched units before surgery. Hazards of over-ordering of blood include outdating of blood because of loss of shelf-life hence an avoidable cause of blood wastage, burden to blood bank, unnecessary wastage of hospital resources, mental and physical stress to patient's attendants.
Aim: To establish a rational MSBOS.
Materials and Methods: The use of:
- Cross-match to transfusion ratio (C/T ratio) = No. of Units Cross-matched
No. of Units Transfused
- Transfusion probability (%T) for a procedure = No. of patients Transfused
No. of patients cross-matched
- Transfusion index (TI) = No. of Units Transfused
No of patients Cross-Matched
- Constant review over a long period of time, audits performed on clinical blood use by the transfusion department and the clinical specialities.
- The list does not supersede clinical judgement.
- In cases where blood usage is seldom, a valid group and save serum request must have been processed in the case of unforeseen bleeding.
- Procedures not included in this list do not require a transfusion sample to be processed.
Conclusions: The criteria for ordering blood are often vague. The established policies, may get outdated, and may need to be reviewed, since new procedures for surgeries may change the amount of blood/blood component requirement. MSBOS provides all staff requesting red cells the standard amount of blood cover a procedure usually requires. The figures in the MSBOS table have been circulated to clinical heads and their comments absorbed into the document. Each surgical unit should have a blood order schedule in place, which should be used as the basis for blood ordering.
Assessment of impact of training in improving knowledge of blood transfusion among intern doctors
Paramjit Kaur, Gagandeep Kaur, Ravneet Kaur, Tanvi Sood
Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, Haryana and Punjab, India
Background: Blood is a precious resource that needs to be prescribed, handled, stored and transfused as per guidelines to ensure recipient safety.
Aim: The present study aims to assess the basic knowledge of intern doctors pertaining to safe transfusion practice, impart relevant training and assess the impact of such training programs.
Materials and Methods: A total of 25 fresh MBBS graduates were enrolled for the study. The participants were given a pre assessment questionnaire related to the entire transfusion chain followed by interactive training of the participants and post training re-assessment.
Results: The mean score in the pre training assessment was 51% while in the post training assessment the mean score was 85.4% and the difference was statistically significant. There was a significant difference in knowledge pertaining to storage temperature, shelf life of red cells and platelets, alternate group choice for fresh frozen plasma and documentation of transfusion reaction. The participants had inadequate knowledge pertaining to cross match procedure and management of transfusion reactions.
Conclusion: The study assessed the knowledge and awareness of intern doctors regarding blood transfusion practice. Mandatory training and inclusion of transfusion medicine as a subject at undergraduate level can help in improving transfusion practice and ensuring recipient safety.
Tools for effective compliance with legal and quality standards in blood transfusion services: Our experience
K Ambuja, C Shivaram
Department of Transfusion Medicine, Manipal Hospital, Bangalore, Karnataka, India
Background: Legal, national (NACO), accreditation standards (NABH) and institutional requirements call for a structured documentation to capture all elements of blood transfusion services (BTS). Standardized formats bring in uniformity and consistency in operations and help monitor major events from vein to vein.
- To achieve 100% compliance in capturing indication for transfusion.
- To achieve 100% compliance in patient consent for blood transfusion.
- To achieve standardization in documentation of blood transfusion and adverse reactions.
- To monitor all elements of safety by vein-vein vertical audits.
Materials and Methods: The following forms/formats have been designed at our institute to meet aims stated above.
- Electronic request form with coded indications for transfusion from a list box in the HIS [Figure 1].
|Figure 1: Electronic request form with coded indications for transfusion from a list box in the HIS|
Click here to view
- Patient consent for blood transfusion: Blood was issued against a signed consent form only.
- Transfusion card [Figure 2]: A comprehensive yet simple and time saving card with details of patient and blood unit, with columns for indication, vital signs was put into use. Adverse transfusion reaction forms were already in place; however a root-cause analysis form was added [Figure 3].
|Figure 2: Transfusion Card with details of patient, blood unit, indication for transfusion and vital signs|
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|Figure 3: Root cause analysis form for investigation of adverse transfusion reaction|
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Nursing staff and junior doctors were trained on a continuous basis and for monitoring a monthly vertical audit was initiated.
Result: 100% compliance in capturing indication for transfusion was achieved by making this a mandatory field in HIS. 100% compliance in blood transfusion consent was achieved by verifying consent before blood issue. The transfusion card being simpler than existing system found widespread usage (>90%). Making this electronic may help to achieve 100% compliance. These are audited by a monthly vertical audit which traces a unit from time of collection to its transfusion or disposal. Results of monthly vertical audits will be presented.
Conclusion: Wider implementation of standardized formats at a national level will bring about uniformity and better compliance to requirements in transfusion services. Frequent vertical audits will in help monitoring the same.
Return blood to blood bank: An audit
Rashmi Sood, Gaurav Aroskar, Tarun Kumar, Deepak Kumar
Saket City Hospital, New Delhi, India
Introduction: Blood bank is designed to collect, store, process and rationally issue red blood cell and blood components that are screened and safe for transfusion to the needs of the patients. Transfusion Service to establish policy detailing parameters for acceptability of returned units for re-entry.
Aim: Audit blood/component bags returning to blood bank, within and beyond permissible limit of 30 minutes.
Materials and Methods: Compatibility report mentions time of issue of blood/components. Once an issued component is received back to blood bank, time of receiving the same is clearly noted. Data related to return of blood/components, retrospectively collected and analysed.
Results: Total 3733 units issued from July 2013 to July 2014 as:
PRBC - 1843 - PRBC 1808 PA-PRBC 35
Platelets - 743 RDPC - 622 SDPC - 121
FFP - 1095 FFP 1092 PA-FFP 3
CRYO - 38
CPP - 13
WB - 1
Returning back of issued units from July 2013 to July 2014, was:
PRBC - 18 (0.97%)
FFP - 1(0.09%)
RDPC - 3(0.48%) All units were returned after the limit period of 30 minutes, hence discarded leading to wastage of not only human blood, but man-power, blood bags and work hours as well.
Reasons for returning blood/components:
- No need for transfusion
- Having Fever
- Suspicion of Transfusion Reaction
- Operation Theatre patient transferred to ICU, blood requested in OT refused by ICU doctor
- Attendant refused Transfusion
- Went LAMA
Conclusions: Blood/Blood components request has to be based on rational criterias. Many points are to be clarified before sending request by the doctor on duty rather than nurses. Return blood should be within 30 minutes.
Active hemovigilance significantly improves reporting and mortality due to acute non-infectious complications of blood transfusion
Naveen Agnihotri, Ajju Agnihotri
Department of Transfusion Medicine,Fortis Hospital Shalimar Bagh, Delhi, India
Background: One of the key purposes of a hemovigilance program is to improve reporting of transfusion related adverse events and subsequent data-driven improvement in blood transfusion practices.
Aims: We conducted a study over 3 years to assess the impact of healthcare worker training and an active feedback programme on reporting of adverse reactions to blood transfusions.
Materials and Methods: All hospitalized patients who required a blood transfusion were included in the study. Healthcare workers involved in blood transfusion to patients were sensitized and trained in adverse reaction reporting by conducting training sessions and meetings. All the transfused patients were 'actively'monitored for any acute adverse reaction by using a uniquely coded blood issue form.
Results: A total of 18,914 blood components transfused to 5785 different patients resulted in 61 adverse reaction episodes. This incidence of 0.32% in our study was found to be significantly higher (P < 0.005) than that reported from the same region in the past. Red blood cell units were the most frequently transfused component and thus most commonly involved in an adverse reaction (42.6%), however apheresis platelets had the highest chance of reaction per unit transfused (0.66%). There was no mortality associated with the blood transfusion during the study period.
Conclusion: An active hemovigilance program significantly improves reporting and management of adverse reactions to blood transfusions.
Planning of blood bank through focus: Pdca cycle
Deepak Kumar, Rashmi Sood, Sushma Rani, Asha Bora, Vineeta Gupta
Saket City Hospital, Delhi, India
Introduction: This is a Planning process that has following features:
- Identifies the goals or objectives to be achieved.
- Formulates strategies to achieve them.
- Arranges or creates the means required.
- Implements, directs and monitors all steps in their sequence.
The control of development by a local authority through regulation and licensing for land use changes and building. The plan-do-check-act cycle is a four-step model for carrying out change. Just as a circle that has no end, the PDCA cycle or Deming cycle or Shewhart cycle should be repeated again and again for continuous improvement.
Materials and Methods: The study was carried out in a tertiary care hospital situated at Mandir Marg, Saket, New Delhi -110017, is to be established up to 1000 bedded multi speciality along with stem cell project facility in future. Currently 256 bed are functional. Planning was carried out in this hospital with different Specialization such as-Cardiac sciences, Neurosciences, Orthopaedics and Joint Replacement, Pulmonology and Critical Care, Urology Sciences, Obstetrics and Gynaecology, Minimally Access and Bariatric Surgery, Gastroenterology and Internal Medicine.
FOCUS -PDCA cycle:
F ind a process to improve
O rganize an effort to work on improvement
C larify current knowledge process variation and capability
S elect a strategy for continued improvement
The PDCA cycle is a way of continuously checking progress in each step of the FOCUS process.
Need of FOCUS -PDCA Cycle in blood bank of mentioned hospital:
In past Architect had planned blood bank map & building two times but there were multiple gap.
Then a management and blood bank experienced person has joined for the same and focused on gap. Now FOCUS PDCA cycle was followed.
Plan: Approval taken from management for blood bank planning including budget - Discussion with management team for budget, map, infrastructure, staff selection, timing of project, stationary, consumables items, reagent rental items and equipment planning etc.
Do: Work was started according to map - daily reporting to management-simultaneously planning of equipment quotation and purchasing, stationary, consumables items, electric load, staff selection, applying for license.
Check: Before act it was ensured to check entire system accordingly as per joint inspection audit format.
Act: Based upon above mentioned action, went for joint inspection audit.
Results: At the end of March 2013 blood bank was ready for joint inspection audit. It ensured all system is on right path. Hospital project was started on Nov 2012 and blood bank was established first in March 2013 within time limit. It was a Real example of FOCUS-PDCA cycle.
Conclusion: Joint inspection was carried out in first week of April 2013. No any Non Compliance regarding planning during first joint inspection audit was received. License was granted on that period only. Drug Inspector suggested some point related to process flow and it was resolved shortly. License was received in second week of July 2013. If a Blood Bank plans through FOCUS-PDCA cycle it definitely save precious time, money, budget and patient satisfaction.
Under graduate knowledge assesment in transfusion medicine
D Poojitha, Suryatapa Saha, Pratibha, Tirumagal, HM Prakash, Sashi
Vinayaka Mission Medical College, SALEM, India
Aim: To document the effectiveness of under-graduate students regarding knowledge in transfusion medicine before and after an education programme.
Materials and Methods: This experimental study was conducted on II year MBBS students of VMKV medical college, SALEM. They were given a pretest questionnaire before the educational seminar and asked to fill and was immediately collected back. Following this, educational seminar was conducted by the postgraduates of Department of Immunohematology and Transfusion Medicine. Key features included discussion on topics involving Blood Donation, Tranfusion transmitted infection Screening and Blood Components. Following the discussion, post seminar questionnaire was given and collected. Pre and post test were evaluated to assess the improvement in knowledge of the students.
Results: The questions were categorized into 3 topics; donation, TTI screening, and blood components. Regarding criteria on donation, improvement of 18% improvement was noted (the pre and post result were 48.1% and 66.1% respectively). On TTI screening pre and post result were 47.55% and 63.5%. On blood components pre and post result were 47.1% and 52.8%. Good improvement was noted regarding donation criteria, while limited improvement was seen regarding to blood components.
Conclusion: Comprehensive evaluation revealed increased understanding but still limited knowledge among II yr undergraduate students in relation to transfusion medicine. Recommendations were made to the management to include more similar educational programmes from MBBS I year undergraduation onwards to improve the knowledge of students regarding transfusion medicine.
Documentation, error reporting and preventive measures-making it safer before issuing blood products
Ch Srinivasa Rao, Aparna Sharma
Yashoda Hospital, Somajiguda, Hyderabad, India
Background: The blood transfusion process is Multifactorial and involves many different staff groups. Human error can occur at any point in the process; Error management plays a major role in facility process improvement efforts. By detecting and reducing errors, quality and, therefore, patient care improve. Obviously, the best corrective action is prevention.
Aim: To determine the effect of Prospective auditing of blood request forms for error notifications and promoting compliance to be maintained to minimize errors in documentation in future.
Materials and Methods: All the blood request forms from August 2013 to August 2014 were thoroughly assessed. Requisitions (N = 5049) were analyzed for compliance with the hospital policies. We focused on incomplete blood request forms, samples received, blood group discrepancies and Lab side errors. Continuous communication with the Nursing staff was done to inform regarding any error arising during blood request received at blood bank.
Results: Prospective auditing of requests and issues when analyzed for compliance, Out of 5049 blood requisition forms, transcribing errors were found in 522 (10.32%) blood requisition forms. During these 13 months, 6289 blood components were issued and 45 (0.72%) lab side errors were identified during the same period. These errors in documentation could have jepordised patient safety if unnoticed.
Conclusion: Improving patient safety is a team effort - most medical errors cannot be prevented by attempts to perfect the skill-level of individual health care professionals. Continuous improvement is a fundamental goal in any quality management system. Active Monitoring programs are setup to help identify non conformance's. Preparation of the quality report in which data from all the sources are aggregated and analyzed, Can be valuable tool to identify issues for performance improvement "To Err is Human" Identify and learn from errors through reporting system.
Detection of transfusion related errors: Identifying key errors that threaten patient's™ transfusion safety. A report from tertiary care centre, Jammu Province
Naveen Akhtar, Meena Sidhu
Department of Transfusion Medicine, GMCH, Jammu, India
Detection of Transfusion related errors: Identifying key errors that threaten patient's transfusion safety. A report from tertiary care centre, Jammu Province.
Introduction: The safety of transfusion. Has not received the same recognition and attention as blood safety. Errors in the transfusion process are unfortunately common. This study provides insight into the transfusion errors occurring at various levels and aims to detect the errors that threaten transfusion safety of the patients.
Materials and Methods: The study was conducted prospectively in the Department of Transfusion Medicine, Shri Maharaja Gulaab Singh Hospital, Jammu from Jan 2014 to Aug 2014. Error was defined as any deviation from the standard operating procedures of transfusion services. Error can be Preanalytical, Analytical and Postanalytical, occurring either in blood bank, clinical department or both. Depending on the outcome they were categorized according to the Transfusion Error Surveillance System (TESS), Canada. Results were compiled as percentages.
Results: A total of 26,988 requisitions for transfusion of blood and its components were received for cross matching, of these 21,442 blood and its components were issued to various clinical departments. A total of 3139 transfusion errors were detected during this period with the mean of 392/month and 13/day. Most of the high severity errors 2767 (88%), like unlabelled or partially labeled samples (39%), information of requisition form and sample not matching (26.55%), wrong blood in the tube (0.68%) and inappropriate request for blood component (33.7%) occurred in the clinical department. High severity errors in transfusion services were 11.8% (370/3139), they were sample accepted in error 63% (234/370), errors related to issuance 31% (118/370), labeling errors 3.2% (12/370) and analytical errors were 1.8% (9/370). Two errors occurred both in the transfusion and clinical departments. Harmful events due to these errors occurred in the 13 patients. Of these 8 occurred due to errors from clinical services due to inappropriate requisition of components and wrong blood in tube, 4 from transfusion services due to labeling and analytical errors and one due to both clinical and transfusion services because of wrong issuance and subsequently not checking at bedside.
Conclusion: Errors occurred at every point in the transfusion process. Most common errors that lead to harmful events were inappropriate request for components, labeling errors, wrong blood in tube and wrong issuance.
A novel way to attain 'Safety and Adequacy' in Indian blood transfusion services
Rimpreet Singh Walia, Kulbir Kaur
Life line blood centre, Patiala, India
Background: India lacks a centralised blood transfusion service and still relies on a fragmented mix of blood banks with different levels of sophistication. National Blood Transfusion Council has made appreciable efforts to streamline the processing charges of blood/blood components according to quality of services being provided, however, due to a general lack of public awareness, blood banks are still compared on the basis of processing charges levied rather than the advanced processing standards employed.
Aims: To devise a point based system wherein blood banks can be evaluated and categorized according to methods that are employed to enhance transfusion recipient safety.
Materials and Methods: A detailed point-based system was constructed that includes blood banks using only conventional methods, at the basic level. Additional points are given for using additional means to improve safety which have been placed under four headings, including type of blood donors, methods of blood component processing, immunohematology and infectious disease testing. For each of the interventions under these headings, five or ten points are awarded depending on the degree of efforts/resources required for their attainment. Based on total points obtained, star ratings are given, from 1 to 5 stars in ascending order of enhanced safety.
Results: This model awards 1 star rating to blood banks using conventional methods only. Blood banks, which secure 01-20, 21-40, 41-60 or 61-80 points, are given 2, 3, 4 or 5 star rating, respectively.
Conclusion: Categorization of blood banks according to blood processing standards should be made mandatory by the government and public awareness must be created for the same. The star ranking system is easily understandable and would immensely help patients to choose safer transfusion options and would also encourage the existing blood banks for up gradation.
Retrospective clinical audit of blood transfusion request in a tertiary care hospital
Prathiba L, Suryatapa Saha, Poojitha Datla, Thirumagal, V Shasi, HM Prakash
VMKV Medical College, Salem, Tamil Nadu, India
Introduction: The inappropriate use of medical technology is a major factor in increased health care expenses and inappropriate use of blood is costly. There is a need for continuous audit of the use of products as therapy. Audits are useful tools in the education of those ordering blood components, potentially resulting in the reduction of inappropriate use of blood components.
Aim: A retrospective clinical audit of blood transfusion requests in patients at a tertiary care hospital.
Materials and Methods: This retrospective clinical audit conducted at VMKV Medical College, Salem for a period of 2 months from 1st July 2014 to 31st August 2014. A retrospective analysis of blood and its component requisitions in all patients from different clinical departments was reviewed regarding diagnosis, indication for transfusion, number of units requested and the speciality prescribing it. Reports of silent investigations like hemoglobin, platelet count, coagulogram was also recorded.
Results: Out of 458 requisitions, 260 were for male patients and 198 were for female patients. Total number of blood components distribution request was 991. 246 were for whole blood, 544 were for packed red cells, 149 were for FFP and 52 for platelet concentrate. The maximum request was from Department of Cardio-thoracic surgery (240).
Conclusion: Clinical audits help to reduce inappropriate use of blood and blood components, avoid blood transfusion reaction and avail the deprived patients.
Illustration on problems faced in day to day use of blood bags
Fortis Escorts Heart Institute, New Delhi, India
Introduction: International Standard specifies requirements of blood bags for the collection, storage, processing, transport, separation and administration of blood and blood components. These requirements are intended to ensure that the quality of blood and blood components is maintained as high as possible, make possible efficient and safe collection, identification, storage, separation and transfusion of the contents, with special intention of reducing to a minimum the risks resulting from microbiological contamination, air embolism, errors in identification of container and any representative samples of contents. At our centre, we face problems of variable nature in blood bags used for blood collection. Looking at the gravity of situation associated with blood bags, we thought this information to be shared with users, suppliers and authorities to come forward for solution.
- Blood bag broken during centrifuge
- Breakage of FFP bags during snap freezing
- Thick needle causing extensive pain to donor
- Change in colour of anticoagulant
- Needle gets detached from Blood bag
- Leakage of blood from borders after centrifugation
Causes: Many times it is difficult to point out the cause:
- But certainly manufacturing defect could be the main reason.
- In our country storage conditions of empty blood bags are not specified which may be difficult to decide in a country which is geographically varied.
- Training of blood bank staff towards proper use of blood bags during collection, preparation & storage of blood/ components.
- No national regulation/guideline available for selection of blood bags by blood banks.
Clinical Implications: The blood bag manufacturers are supposed to follow all the standards required. Indian blood banks face many problems related to blood bags. The manufacturing defects of the blood bags leads to the
- Discard of the precious drug.
- Loss of time & effort of the blood bank.
- Dissatisfaction in the donor which results in demotivation towards blood donation.
Conclusion: Though on lodging complains, company person replace the supplied lot but there must be some regulatory authority in India that helps to control wastage of valuable blood products.
Audit of donor deferral in large government sector blood bank
Neetu Singh, Anil Kumar Gupta, Anand K. Verma, Ajay Sagar
Department of Transfusion Services, Post Graduate Institute of Medical Sciences & Research (PGIMSR), ESI Hospital, New Delhi, India
Introduction: Donor screening prior to donation is mandatory & essential step for safety of donor and recipient as well. Deferral is a cause of anxiety to both donors and blood bankers; Thus factors affecting the deferral in a local population is essential for management of positive attitude in prospective donors.
Aims: We analysed the donor deferral at ESI hospital to find out the incidence and various factors influencing the donor deferral.
Materials and Methods: We retrospectively analysed last 200 deferral donors started from June 2014 to august 2014 for various mandatory parameter as defined in Drugs and Cosmetic acts 1942 (Hb, BP, Age, sex, etc).
Result: Out of 200 deferred donors, 11.5% donors were females. In our setup 20% donors were deferred due to high BP and equal number (20% )were rejected due low Hb level (<12.5 gm%). Other significant cause for deferral were history of jaundice in 8% donors; medicine intake in 7%; localised skin lesion in 6.5%; h/o tattoo or ear piercieng in 6%, underweight in 6% cases. Other causes like TB, Dog bite, DM, underage, prior donation less than 3 months, viral fever etc. were accounted for 16.5% deferral.
Conclusion: Our hospital cater the beneficiary of ESI, usually belonged to workers and their family. However donor deferral were surprisingly high due to hypertention and anemia and each one accounted for 20%. Other causes for deferral were jaundice (8%), skin lesion (6.5%), less weight (6%) in descending order. Thus it is emphasized that hypertension has to be evaluated properly amongst donors.
Temperature monitoring in transportation of blood
Hetal P. Randeri, Snehalata C. Gupte
Surat Raktadan Kendra and Research Centre, Surat, Gujarat, India
Background: Optimal storage and transport condition of blood is necessary to preserve the biological function of the constituents, decrease their metabolic activities and prevent bacterial contamination. NABH standards state that that temperature during transport of blood shall not exceed 10°C and shall be monitored.
Aim: To maintain cold chain during transportation of blood from camps and while sending to storage centers.
Materials and Methods: Blood collected in camps was kept in insulated box contain gel packs in three layers - first layer at bottom covered with silver foil and then blood units, one layer in the center and one layer above. The gel packs were frozen previously at -20°C to -40°C. The transportation of blood from camps was in AC van and refrigerated transportation van was used for transportation to storage centers. Temperature was monitored using data logger calibrated against temperature indicator with PT-100 sensor used as reference. Number of gel packs as standardized earlier was at least 50% of the blood units. The number of blood units, gel packs, the distance of camps and storage time and temperature was recorded.
Results: Data of 120 out door camps was analyzed on the basis of seasonal temperature. Mean temperature maintained during transportation in summer was (March-June) 12.90 ± 1.15 ° C, monsoon (July-Oct) 10.53 ± 1.75 ° C and winter (Nov-Feb) 8.74 ± 1.28 ° C. The mean distance of the camps was 11.5 ± 1.53 km in Surat city and the storage time of blood from collection to reaching the blood bank was 4.30 ± 0.74 hours. Mean temperature during transport to storage centers in refrigerated transportation van was 5.12 ± 1.27 ° C.
Conclusion: Desired temperature can be achieved when monitored regularly and maintaining the number of gel packs and using refrigerated transportation van.
Serial assessment of biochemical parameters of red cell in the Blood unit segments kept at 4 °
Deva Japa Ajith, M Mashhadi, Sanjeeth Peter
Gujarat Methodist Church Centre Care (GMCCC) and Research Society Blood Bank, Nadiad, Gujarat, India
Due to the gradual decomposition of RBCs and as a result of the accumulation of products of cellular metabolism, the biochemical composition of RBC concentrates undergoes changes. Although it is not clear to what extent, the anaerobic storage prevents morphological or biochemical changes at low temperature.
Aim: The aim of this study is to assess the relative importance of these diverse biochemical changes in the stored RBC.
Materials and Methods: The donors of the blood units included in this study were healthy by all parameters considered for blood banking. Whole blood of 450 ml collection bag unit containing 63 ml CPD/SAGM (which has a permissible life span of 42 days) and containing 63 ml of CPDA (which has a life span of 35 days) were subjected to standard component separation. A total of 35 consecutively separated blood bags with 7 segments each were studied. Each segment from the Packed Red Cell unit was removed on days 0, 7, 14, 21, 28, 35 and 42 of PRBC storage, were investigated. The biochemical and hematological parameters such as pH, Lactate, Sr. Potassium, Plasma Haemoglobin, Heamoglobin and Heamatocrit were analyzed in fully automated analyzer.
Results and Analysis: RBC unit characteristics just before storage on Day 0 pH (37 ° C) 7.03 ± 0.94 (7.20-6.79) Hb (mg/dL) 15.3 ± 2.2 (17.9-13.9), Plasma Hemoglobin 3.1 ± 1.2 gm/dl Lactate (mmol/L) 2 ± 1.4 (1.3-3.1)Potassium(K) (mmol/L)1.7 ± 1.2. Extracellular K and Lactate showed a constant increase as the bags aged. Hemoglobin and Haematocrit levels did not change appreciably throughout the storage period.
Conclusion: Clinical implications collectively known as the RBC storage lesion released by leucocytes in the storage medium, such as lactate, histamine, lipids and cytokines, which may exert direct effects on recipients, presumably due to structural or functional changes in RBC that occur during storage. But this study suggests that older RBC may have adverse effects like increase in potassium, lactate but the transfusion department can help the clinician by knowing the patient's clinical status as well as the age, critical variables like Sepsis by issuing the recent dated Blood units.
Retrospective analysis of blood donor demographic statistics and its relation to infectious marker positivity in Blood bank at a tertiary care hospital in Western India
Akhilesh Verma, Rachna Narain, Sunita Bundas, Richa Gupta, Varun Capoor, Parmendra Pachori, Rachna Narain
Department of Immunohaematology and Transfusion Medicine, SMS Medical College and Hospital, Jaipur, Rajasthan, India
Background: Provision of sufficient and safe blood collected from voluntary non remunerated donors is the target of all blood bankers. Understanding of the donor pool serves to delineate areas to target motivational strategies.
Aim: To determine the demographic distribution of donor and relation to infectious disease marker status.
Materials and Methods: In this retrospective study, donor data between April 2011 and March 2013 pertaining to age, sex, blood group, type (voluntary, replacement), district and infectious disease markers status was collected from data center. Chi square test was used to analyze the results.
Results: Total 106356 donors were included in the study (0.4% females, 99.6% males). Most common blood group was B positive (33%). Maximum donors belonged to Jaipur zone (83.2%) and were in the age group of 20-34 years (73.2%). Total TTI marker positivity was 2.06%. Most prevalent infection was HBV (1.4%), followed by Syphilis (0.37%), HCV (0.12%) and HIV (0.09%). Highest percent of TTI positivity was found in the 35-49 yrs age group (2.6%). Those belonging to Bharatpur zone (4.07%) had the highest percent positivity. Replacement donors who constituted 79% of the total donors had higher infectious disease marker positivity than the voluntary group (2.23% and 0.99% respectively) (P < 0.05).
Conclusions: Lower prevalence of TTI in 20-34 yr age group indicates greater awareness in the largest donating group. A low female donor contribution, less voluntary donations and high infectious disease marker positivity in Bharatpur zone are areas to be targeted for safer blood supply.
The study of deferred blood donors at tertiary level hospital based blood bank of south Gujarat
Snehal Patal, Jitendra Patel, Arpit Patel, Sangeeta Wadhwani, Kruti Raja, Gopi Dobariya
Department of IHBT, Government Medical College, Surat, India
Background: Pre-donation donor screening is must for the safety of the blood donor and recipient. Deferrals lead to loss of precious whole blood donors and blood units available for transfusion purposes.
Aim: To record and document the current rate and reasons for donor deferral in our tertiary care hospital based blood bank to modify recruitment strategy for blood donors.
Materials and Methods: Study was conducted by retrospective analysis of data of whole blood donors (voluntary/replacement), arrived for donating blood at blood bank and in outdoor camps, during the period 1 st July 2010 to 30 th June 2014. The donor selection was done by pre-donation screening tests like questionnaire followed by physical examination and haemoglobin estimation. National guidelines were used for selection and deferral of donors. The deferred donor's data was analyzed statistically.
Result: Out of 34380 blood donors who came to donate blood, 31049 (89.63%, out of which 97.51% voluntary donors) were eligible for donation and 3331 (10.37%) blood donors were deferred. The deferral rate among male population 7.47% and female population 42.09% were observed. Odds ratio for deferral in female donors was 8.99, implying thereby that chance of deferral in females is nearly 9 times higher as compared to males. The five leading causes for male donor deferral were low haemoglobin, hypertension, medication, malaria and alcohol intake in last 48 hours and for the female donor deferral were low haemoglobin, menstruation, medication, low weight and hypotension.
Conclusions: Studying the frequency and the different causes of donor deferral will help to identify sections of the population which could be targeted for increasing and retaining of the existing pool of voluntary blood donors and also to guide and provide the necessary essential database for the policy design and programme implementationat local, regional, and national level.
Do Indian donors have more adverse reaction in 450 ml whole blood collection than 350 Ml?
Trupti Barot, Farzana Kothari, Milind Dighe
Department of Immunohematology and Blood Transfusion (IHBT), SSG Hospital, Baroda, Gujarat, India
Introduction: Blood donation is considered safe, however adverse reactions of differing severity do occur during or after the blood donation process and it is one of the reason preventing the donor to become a repeat donor.
Aim: A retrospective study of Adverse Events (AE) in all blood donations made between January 2013 to August 2014 was done to estimate the frequency and type of AE, to know whether the quantity of blood collected is a factor determining adverse donor reaction as well as the to know the time of onset of adverse reaction after venipuncture.
Materials and Methods: Records of a total of 5455 in house blood donors between January 2013 to August 2014 were analysed for AE. The classification scheme employed for recording the adverse events was as per American Red Cross Hemovigilance Program. Vasovagal reactions were divided into Mild, Moderate and severe as per the definitions provided in Hemovigilance program by American Red Cross. We then analysed donor's weight, sex, time elapsed after phlebotomy for the adverse event to occur in order to discover the attributable risk factors for AE.
Results: A total of 5455 blood units were collected from Jan 2013 to Aug 2014 at Blood Bank of SSG hospital, Baroda. Out of the total units collected donors were segregated into Male/Female donors, donating 350 ml/450 ml. A total of 52 AE were noted. These 52 AE were then analysed for occurrence in Male/Female, 350 ml/450 ml collections, first time/repeat donations and for the time taken for the AE to occur after venipuncture.
Discussion: Safety and sufficiency of blood supply depends on healthy donors. About 2-6% of the donors experience AE with most of them resolving promptly. AE is one of the limiting factor in donor returning back to the blood center for repeat blood donation. The results obtained from the analysis of our AE data was compared with those reported from India and other international studies.
Conclusion: AE are noted more in female donors, in donors donating 450 ml of blood and in first time donors. Proper pre- donation counseling is an essential element to minimize the adverse donor reactions and increasing blood donor pool.
Analysis of blood donor deferral criteria
Chirag Chaudhari, Milind Dighe, Farzana Kothari
Department of Immunohematology and Blood Transfusion (IHBT), SSG Hospital, Baroda, Gujarat, India
Introduction: Deferrals lead to loss of precious whole blood donors (WBD) and blood units available for transfusion purposes. Knowledge of rate and causes of donor deferral can guide the recruitment strategy for whole blood donors.
Aim: To find the incidence and causes of deferral in whole blood donors and apply relevant findings to modify recruitment strategy for blood donors.
Materials and Methods: Data for WBD presenting for donation in a blood centre and outdoor camps from April 2013 to August 2014 were analyzed retrospectively. National guidelines were used for selection and deferral of whole blood donors (WBD).
Result: 312 whole blood donors (WBD) were deferred out of 8767 presenting for donation during the study period. Incidence of deferral was 3.55%. Most common reasons for deferral were low Hb (34.61%), abnormal blood pressure (14.74%), under weight (9.29%) and history of antibiotic/medication use (8.65%). Majority of them (82.05%) was being deferred for temporary reasons. Permanent deferral accounted for 17.66 % with hypertension being the most common cause (83.6 %) in this category. Most of these deferred donors (65.06%) were age 18-30 years old.
Discussion and Conclusion: It is important to determine the rate and causes of whole blood donors deferral to guide the recruitment and retention efforts at local, regional, and national level.
The evaluation of blood donor deferral causes: A tertiary care center based study
Dhaval Nagajanbhai Chauhan, Killol Desai, H J Trivedi, A S Agnihotri
C. U. Shah Medical College, Surendranagar, India
Background: Donor selection is necessary in addition to the screenings of blood bags for infectious diseases. Deferrals lead to loss of precious blood/components available for transfusion. For preventing this, we should be having knowledge of causes of deferral and their frequency.
Aims: To evaluate blood donor deferral causes and possibility of donor retrieval.
Materials and Methods: Causes of donor deferral were evaluated retrospectively from January 2013 to July 2014 in the blood bank of C. U. Shah Medical College, Surendranagar, Gujarat. Total 14347 donors were screened and out of them 660 donors were deferred.
Result: Temporary deferral was more common than permanent deferral. Most common cause in permanent deferral was HBsAg positivity (23.64%). Causes among temporary deferral were anemia (Hb <12.5 gm%) (24.11%), jaundice, weight <45 kg, age <18 years, patients on antibiotic, previous donation in last 3 months, typhoid in last 1 year, dog bite etc.
Conclusion: Analysis of deferral patterns may help medical personnel and doctors to be more focused in donor screening especially of those who are having higher frequency. Temporary deferred donors require proper follow up and management so as not to lead to a diminished supply of future donors. It is important to determine the rate and causes of blood donor deferral for the safety of blood/component transfusion and also to guide the recruitment efforts to prevent loss of precious blood/components at local, national and international levels.
Analysis of adverse events and predisposing factors in voluntary and replacement whole blood donors: A study from our teaching institution
Anjana Mohan, Meena D, Sasikala N
Department of Transfusion Medicine, Government TD Medical College Alappuzha, Kerala, India
Background: Lack of awareness and community motivation, compounded with fragmented blood transfusion services in our country, often leads to shortage of blood. Donor recruitment and retention are essential for ensuring adequate blood supply. However, adverse events (AEs) in donors have a negative impact on donor return.
Aims and Objectives: The present study was aimed to assess the frequency of AEs in whole blood donors and analyze the predisposing factors for AEs.
Materials and Methods: The study was conducted on allogeneic whole blood donors over a period of 12 months, i.e., from August 2013 to August 2014. Total of about 9000 donors were monitored for any AE.
Results: Overall reaction rate and each donor reactions are assesed. Vasovagal reactions showed a significant association with young age, lower weight, first time donation status, female gender, and nature of blood donation camps. Majority of donors (85%) with vasovagal reactions admitted to some fear or anxiety prior to donation. Hematoma formation occurred significantly more when less trained staff performed phlebotomy.
Conclusion: Donor safety is an essential prerequisite to increase voluntary blood donation. AE analysis helps in identifying the blood donors at risk of donor reactions and adopting appropriate donor motivational strategies, pre-donation counseling, and care during and after donation.
Study on knowledge, attitude and practice of blood donation among college students in Bhavnagar, India
Prakruti Panchotia, PH Shah, MV Thaker, SK Suri
Department of Pathology, Government Medical College, Bhavnagar, Gujarat, India
Background: World Health Organization advocates that 3-5% of the population should donate blood per year, which would be the ideal rate for maintaining a country's demand. According to One of four components of WHO's integral strategy for safe transfusion, Youths who are healthy, enthusiastic and approachable as a group, if recruited young may become future donors and motivators.
Aim: To assess the level of knowledge, attitude and practice regarding blood donation in college students in Bhavnagar, India.
Materials and Methods: A cross-sectional study was conducted on 268 students of 18-25 years of age from different colleges of Bhavnagar. Self-administered Questionnaires was used to collect data from cases selected by cluster sampling.
Results: Out of total 268 students, female students outnumbered males (Female 57.46%, Male 42.54%). 98.50% of them were graduate students. Interestingly only 12.32% (33 out of 268) had donated blood previously, most of them were voluntary donors. The most common reason (36.18%) for no donation was the lack of arousal of situation for donation. Most of them were aware about the criteria for age (96.26%), weight (51.87%), Hb (66.43%) needed for donation. But majority (67.19%) lack knowledge about the amount of blood being drawn while donation. 51.89% students were willing to donate blood after getting proper counseling and knowledge for blood donation.
Conclusion: Major obstacle for voluntary blood donors was the lack of arousal of situation for donation. To overcome that and to improve donation rates, Students must be educated and counseled properly. By increasing the awareness about voluntary donation, a blood bank can improve the number of voluntary donors.
Anxiety causes vasovagal reactions in blood donors and water provision prevents them
Vikas Hegde, RN Makroo, Mohit Chowdhry, Aakanksha Bhatia, Uday Thakur
Indraprastha Apollo Hospitals, New Delhi, India
Background: Vasovagal reactions (VVR) are one of the prominent adverse blood donor reactions. We tested the ability of water provision before blood donation in preventing the VVR, compared it with other factors causing VVR. We also hypothesized that pre-donation anxiety is a major factor causing VVR.
Materials and Methods: The study was conducted prospectively for a period of 3 months. The donors eligible according to the Drug and cosmetics Act of India 1940 were included in the study. The provision of water was planned such that half of the donors would be given 1 glass of water (about 400 ml). Donors who denied water were considered in the non-water-provision group. Donors were also categorized as having pre-donation anxiety based on the questionnaire. Partial regression analysis was carried out to assess the risk factors. Factors showing significance were put into multivariate model.
Results: During the study period a total of 5519 donors donated the blood at our center. Among them 2001(36%) donors were provided water. It was observed that provision of water reduced the VVRs and pre donation anxiety increased the VVRs significantly (P < 0.05).
Conclusions: Provision of a glass of water to the donors is a very productive intervention. It is less expensive and can be introduced without much effort in any setting to effectively reduce the VVR rates among the donors. The pre donation counselling questionnaire should include an enquiry on anxiety. This helps in identifying the anxious donors and prevents them from reacting.
Voluntary blood donation among college youth: A Kerala perspective "High time to make a move in the community"
Susheela J. Innah, Nithya Mohanan
Department of IHTM, Jubilee Mission Medical College, Thrissur, Kerala, India
Background: Despite having over one billion population, we are unable to tap blood requirements for 8 million!
Aim: Asses the knowledge, attitude and practice of voluntary blood donation among college youth of Kerala.
Materials and Methods: Pilot study among randomly selected college students of Thrissur using pretested questionnaire was followed by an awareness class. SPSS software was used for analysis.
Results: Of 1091 participants, 337 males and 753 females; age ranged from 18-25 years. 93.6% knew blood groups, 91% were interested in donating and 82% never donated blood. Among donors, 61% were one-time donors and 77% donated voluntarily. Most common reason for not donating was "not being asked" (25%) followed by "fear of pain" among females, significantly high among non-medicos (P < 0.001). Attrition rates in donation due to deferrals were significantly more among females (22%) and medicos (22.3%) (Both P < 0.001). 50% know blood can't be manufactured.18%believed that blood is into commercialization. Significantly higher numbers of non-medicos believe work of blood banks in Kerala is excellent as opposed to medicos (P < 0.001). Only 54% ever attended motivation classes for blood donation against 80% for organ donation (P < 0.001). Only 37.9% knew amount of blood withdrawn. 21.4% believed that only one life can be saved through blood donation whereas 18.4% knew upto 4 lives could be saved. Significantly higher number of non-medicos believe the cost of blood products is for 'profit-making', whereas 33% medicos believed it is for blood-tests (P < 0.001).31% medicos correctly knew the shelf life of blood components (P < 0.001). 98% knew HIV is blood-borne, 6% wrongly believing nutritional deficiencies are also blood-borne. Health education class was the favoured mode to increase awareness.
Conclusion: There are serious lacunae in tapping available blood resources from effervescent youth. It's high time to move to the community, educate and mobilize them. Blood bank machinery in India runs for, of and by the people!
Evaluation of deferral and retrieval donors in a rural blood bank
Deva Japa Ajith, M Mashhadi, Sanjeeth Peter
Gujarat Medical Education and Research Society, Blood Bank, Nadaid, Gujarat, India
Background: Health and safety of the donor as well as the recipient must be safeguarded. The rate and reasons of deferral differs from region to region and from one centre to other.
Aim: The aim of this study is to analyze the incidence and various reasons for deferrals and their retrievals in a rural voluntary Blood Bank.
Materials and Methods: The study was conducted at a voluntary Blood bank from January 2011 to June 2014. The study involved all voluntary donors of the Blood Bank as well as Voluntary Blood donation Camps. The donors were screened for all parameters according to the NACO guidelines by the Medical Officer and the retrospective data were analyzed.
Results: A total of 6378 potential donors two hundred and sixty one donors (261) were deferred, in which 86.6% were males. The most predominant age group of donors is 18-30 years. Among the donors, 76.3% (201) were temporary deferral donors and rest were permanent deferral donors. In permanent deferral donors, hypertension was the predominant reason with 74.6%, transmissible diseases were reactive in 11.6 % and other diseases like Epilepsy, Cardiac diseases were noted in13.8 %. A total of 35.32% donors were temporarily deferred because of low Heamoglobin and in that 8.6 % were with dual deficiency anemia. Among the temporarily deferred donors, 21.39% were under medication, in which 3.4% were retrieved after seven days. The reasons for other deferred cases included tattooing in 3.8%, recent blood donation in 2.3%but were retrieved after reaching minimum donation interval, alcohol consumption in 6.47% in which 2.9% were retrieved later, 2.99 % due to age factor (under 18 years). Iron supplements were given to Low Heamoglobin donors and follow-up was done to retrieve such donors.
Conclusion: A rigorous and balanced process to assess the suitability of prospective donors is essential to protect the safety of the donors, while ensuring that the suitable donors are not deferred unnecessarily. Counseling, education and proper follow-up of deferred donors is absolutely necessary to retrieve the temporary deferred donors which can increase the donor pool. Hence, more than one third of the deferral donors are temporary and can be retrieved in the donor pool.
DAT positivity in blood donors: A perplexing scenario
Nishant Saini, Ravneet Kaur, Kshitija Mittal, Tanvi Sood, Ajay S Praveen
Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, Haryana, Punjab, India
Introduction: The direct antiglobulin test (DAT) is a simple test used to determine if red cells have been coated in vivo with immunoglobulin, complement, or both. We hereby report a case of a DAT positive donor with no clinical and laboratory evidence of hemolysis.
Case Report with Results: A blood request was received for 70 year male patient suffering from chronic obstructive pulmonary disease with anemia. One unit was found incompatible in AHG phase. Patient's antibody screen, indirect antiglobulin test, DAT and auto control was negative. DAT of donor unit was positive with anti IgG gel card and negative with C3d reagent along with positive auto control. Donor was 30 year male with no history of blood transfusion and medication with no evidence of hemolysis.
Conclusion: There are no clear cut guidelines and established policy for deferral of DAT positive donors and referral of such donors to physician. Donors with positive DAT should be deferred, notified and referred to physician but further studies are required.
Donor deferral characteristics for plateletpheresis in our hospital: A retrospective analysis
Chintamani Pathak, G Sharma, P Lalita Jyotsna, S Pahuja, M Jain
Department of Pathology and Blood Bank, Lady Hardinge Medical College, New Delhi, India
Background: The demand for single donor platelets has increased manifold in our country due to occurrence of dengue epidemics during the last 10-15 years and increased awareness regarding merits over random donor platelets. However, there is a dearth of apheresis donors due to greater dedication and time required for the procedure.
Aim of the Study: The aim of the present study was to analyse the reasons for deferral of apheresis donors at our hospital.
Materials and Methods: This retrospective analysis was conducted to study the causes and frequency of plateletpheresis donor deferral at Lady Hardinge Medical College and associated Smt. Suchita Kriplani Hospital and Kalawati Saran Children's Hospital. The study was undertaken over a period of 4 years from January 2010 to January 2014.
Results: Out of total 352 donors screened, 88 donors were deferred, the overall deferral rate being 25%. The most frequent cause of deferral was a low platelet count accounting for 34.09% of all the causes followed by non prominent antecubital vein in both arms (21.59%). The donors deffered for anemia represented 10.22%. Among them, 55.55% of deferrals had Hb ranging from 11- 12.5 g/dL.
Conclusion: As in our country there is a major dependence on replacement donations than voluntary blood donations which leads to scarcity of apheresis donors. Relaxing the donor deferral criteria for hemoglobin could have enabled recruitement of 5/9 (55.55%) donors deferred due to anemia. Thus, the selection criteria for plateletpheresis donors should be revised to accommodate more donors and reduce deferral rate without compromising on the health of the donors.
Blood pressure changes in blood donors and their correlation with BMI
Anupama JK, MP Chacko, Dolly D
Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
Background: Blood pressure (BP) drops when a person loses blood. This drop eventually gets corrected due to inbuilt baroreceptor mechanisms. Our aim is to estimate the fluctuation in BP of blood donors and to correlate the same with body mass index (BMI).
Materials and Methods: 200 male blood donors were included. Height and weight were recorded and BMI calculated. Donors were grouped based on BMI into low, normal, high and obese categories. Systolic (SBP) and diastolic (DBP) BP were recorded at four time points:-1) immediate pre-donation (supine), 2) immediate post-donation (supine) 3) before post donation refreshment (sitting) 4) after refreshment (sitting). Paired t-test and one way ANOVA were used as statistical tools.
Results: SBP showed a highly significant drop from point 1 to 2 (mean 8.37; P < 0.0001), a drop from point 2 to 3 (mean 2.08; P = 0.0067) and a highly significant rise from point 3 to 4 (mean 4.48; P < 0.0001). There was also a highly significant drop between 1 and 4 (mean 5.97; P < 0.0001). The DBP between points 2 and 3, showed a significant drop (mean 1.61; P = 0.0235) and between 3 and 4 showed a highly significant rise (mean 2.23; P < 0.0001). There was no significant correlation between BMI and BP fluctuations. However, among 6 donors with low BMI (<18.5), 3 of them showed SBP drop more than 16 units from point 1 to 2.
Conclusion: Significant fluctuations in BP were observed related to blood donation. In addition to fluid loss, these may reflect raised BP immediately prior to donation, and postural changes. A significant fall seems to occur when the donor arises from the couch, which indicates that particular care may be required then. No particular relation to BMI was noted. Further studies on donors with low BMI may better indicate whether they are at higher risk of hypotension following donation.
Blood donor history of RLS and Pica: A tool for determining iron deficiency in donor population
Ashutosh Singh, A Sonker, HC Pandey, RK Chaudhary
Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Background: In India, there is no recommendation for screening blood donors for iron deficiency, even though several scientific work have noticed high prevalence of iron deficiency in these population, particularly among females. Furthermore, this iron deficiency is associated with neuropsychological changes such as restless leg syndrome (RLS), pica, hair loss etc. Our objective was to assess the predicative value of history of RLS and pica in relation with iron stores in blood donors.
Materials and Methods: A total of 200 blood donors (male; n = 103 and female; n = 97) were participated in the study. On the basis of pre-donation Hb estimation, they were categorized in to two groups deferred (n = 100) due to anemia and accepted (n = 100) for blood donation. During medical examination, apart from routine questionnaires specific history of RLS and pica was elucidated from both the groups. Venous blood samples were taken for assessment of serum iron, ferritin and hepicidine apart from hemogram using automated cell analyzer.
Results: Out of 100 deferred blood donors history of pica/pagophagia/RLS or combination of these, was present in 30 (30%: group A) while these history was present in 11 out of 100 accepted donors (11% group B). The level of serum ferritin was found to be low (≤18 ng/ml) in 21 among group A and 01 in group B. The level of serum iron had corresponded in the same line to that of serum ferritin. The process of estimation of serum Hepcidine is underway and will be given in final presentation.
Conclusion: Iron deficiency is a potential problem for all blood donors. Lab investigations for estimation of iron stores are not feasible for each blood donor. In our study significant correlation was observed between history of RLS and/or pica and iron deficiency. We found that history of pica and/or RLS could be used as tool to predict iron deficiency in blood donor.
Quality of red blood cells collected from fixed vs mobile blood collection facilities: A comparative study
Anumole Jose, K.C. Usha
Government Medical College, Trivandrum, Kerela, India
Background: Primary goal of any blood bank is to promote high standards of quality in all aspects of patient care, related products and services. Stringent quality control measures and adherence to Good Manufacturing Practices (GMP) helps to achieve this goal in the setting of a fixed blood collection centre. But voluntary blood donation camps present special challenges.
- To compare the quality of red blood cells collected from fixed blood collection centre vs. voluntary blood donation camps in a tertiary care setting.
- To assess the adherence to Good Manufacturing Practices at voluntary blood donation camps.
Materials and Methods:
- Voluntary blood donors (satisfying DGHS criteria) from 4 peripheral blood donation camps held between 11 th and 21 st of July 2014 by Department Of Transfusion Medicine, Govt Medical College, Trivandrum and voluntary blood donors from Blood Bank, Government Medical College, Trivandrum on the corresponding days were included in the study. Systematic sampling was performed and every 5 th donor at the peripheral voluntary blood donation camp and blood bank was included.
- Adherence to Good Manufacturing Practices was evaluated using a prepared checklist. Component separation protocols, storage temperature and other storage settings were standardized for all units. On Day 14 the following quality parameters assessed for the Packed Red Cell units collected from the study subjects of the two groups: Hemolysis, Volume of blood collected in ml, Hb, Total WBC Count, Platelet Count, Hematocrit, RBC Count and pH.
Observations: Independent T test was used to compare Quality control parameters of PRC from blood bank and VBD camp donor units.
Conclusions: The present study, documents no significant difference in quality parameters between the PRC units collected from blood bank and VBD camps. Adherence to Good Manufacturing Practices was satisfactory in the VBD camps. A Voluntary Blood Donation camp checklist based on Good Manufacturing Practices should be formulated and made mandatory by all blood banks
Implication of deferral pattern on the donor pool: Study at a tertiary care hospital
Deepika Chenna, Shamee Shastry, Mohan Doss
Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
Background and Objectives: Blood safety and sufficiency are fundamental to provide high quality medical services, but they remain major challenges to any health care institution. Donor screening process is one of the most important steps in protecting the safety of blood supply. Donors who do not meet specified criteria are deferred either temporarily or permanently. These criteria are designed to protect both donor and patient safety. Due to the varied prevalence and reasons for deferrals in the existing literature, we aimed to evaluate the patterns and prevalence of deferrals in our institution.
Materials and Methods: This study was conducted at Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal to evaluate the various reasons for blood donor deferral from January 2011 to January 2014. Demographic data of blood donors was obtained through the blood bank database and secondary measures like type of deferral (permanent/temporary, pathogenic/nonpathogenic, harmful to donor/recipient) were assessed.
Results: A total of 54,653 subjects presented to our blood bank during this period out of which 2935 (5.6%) (5.2%, 4.6% and 6.2% in each year) were deferred. The deferral to donor percentage was higher in females (36.54%) than males (3.64%). Low hemoglobin was the major deferral criterion seen in our participants (48.1%) followed by hypertension (16.4%), underweight (8.9%) and underage. Leprosy, low pulse rate and fasting donor were the least prevalent reasons. A total of 36.8% of the reasons for deferral were harmful to donors while 14.5% were harmful to recipients. Non-pathogenic causes for deferral constituted 88.2% of the deferrals and temporary deferrals were 98.1%.
Conclusion: 98.1% causes for deferral being temporary causes they can be recruited back into donor pool by proper counselling and modification of lifestyles. Low hemoglobin was the major cause of blood donor deferral and can be treated with iron supplementation. All this would help in bringing down donor deferral rate.
A single centre retrospective study to determine the reasons for temporary or permanent deferral in whole blood donors over a period of one year
RN Makroo, Brinda Kakkar, Mohit Chowdhry, Aakanksha Bhatia, Vikas Hegde
Indraprastha Apollo Hospitals, New Delhi, India
Background and Aim: In this era of decreasing altruism and in view of shrinking donor pools, donor deferrals are a major cause of concern. This study was conducted with the objective to determine and characterize various reasons for deferral and their respective frequencies in order to devise some appropriate strategies so that the eligible donor pool may be increased.
Materials and Methods: The records of all donors who were registered for blood donation but were deferred either temporarily or permanently after undergoing donor screening between 1 st January 2013 and 31 st December 2013 were retrieved, reviewed and analyzed.
Results: A total of 24,813 potential donors were screened during the study period, out of which 1907 (7.68%) were deferred either temporarily (7.37%) or permanently (0.35%). The deferral rate was 8 times higher in females (46%) as compared to males (5.5%). Maximum deferral was noted in the age group 31-40 years (52%) in females and >50 years (11%) in males. A low hemoglobin level was the most frequent cause of temporary deferral (3.64%) both in males (2.02%) and females (32.3%), while endocrinal disorders (0.13%) was the most common cause of permanent rejection. Other reasons for deferral are provided in Table 1.
Conclusion: Blood donor population is largely representative of the general population of a region and the various reasons for deferral identified, reflect on the general health status of the population as a whole. Measures must be undertaken by government and health care providers to educate and increase public awareness on common health problems such as anemia, hypertension, diabetes etc, which will help in maintaining the health status of the general population and in long run help in maintaining a healthy and safe donor pool.
Age and gender distribution of voluntary blood donors
Usha S, Deepa D, Shoganraj S
The TN Dr MGR Medical University, Guindy, Chennai, India
Background: According to 2012 WHO report, India is facing a blood shortage of 3 million units. This problem could be addressed if 2 % more Indians donated blood. Demographic information of blood donors is important for formulating and monitoring recruitment strategies. As per 2008 WHO statistics, most of the voluntary unpaid donors in India, belonged to 18-24 yrs age group (53%). Only 6% of blood donors were women. We analyzed the age and gender distribution of voluntary blood donors at our centre.
Materials and Methods: Data was collected retrospectively over a 10-month period (Nov '13 to August '14) from Donor Register and the results were analyzed in terms of age and gender distribution.
Results: Among 1773 voluntary blood donors, 967 (54.54%) donors belonged to 18-24 yrs age group (highest); 738 (41.62%) in the 25-44 yrs age group and 68 (3.83%) in 45-65 yrs age group (lowest) 1709 (97.10) % were male donors and only 64 (3.60 %) were female donors.
Discussion: This study data was similar when compared to 2008 National statistics 53% (18- 24 years), 29% (25-44 years) and 19% (45-60 years) respectively, but the donation by older people is less. Similarly, blood donation by females is lower (3% compared to 6%).
Conclusion: In our study, voluntary blood donation was highest among younger people. If these donors are continuously motivated, the percentage of voluntary blood donation can be increased among older people also. Percentage of female donors is very low, if in-depth analysis for reasons behind such under performance are found out, there is a definite possibility for increase in the percentage of voluntary blood donation among female donors.
Technical difficulties in phlebotomy and blood inventory loss
M Sri Devi, M Chitra, A Sivaramakrishnan, Deepa Devi G
The TN Dr MGR Medical University, Guindy, Chennai, India
Background: There is a short fall in demand- supply position of blood throughout the world hence good management of the blood inventory is crucial. Low volume unit collection is not uncommon, which may lead to loss of rare blood groups in the blood inventory.
Aim: To study the impact of low volume collection units in blood inventory loss.
Materials and Methods: During the one year study period from August 2013 to July 2014, data was collected regarding the total blood units donated, number of low volume units and their blood groups. Calculation of the percentage of blood inventory loss due to low volume (<10% volume of blood bag as per DGHS) collection units and percentage of inventory loss in each blood group were done.
Result: During the study period:
- Total no. of camps: 46.
- Total no. of units collected: 2078, total components prepared: 3661.
- Total no. of low volume units collected: 79 (3.8%).
- Total no. of low volume units collected in each blood group: A POS: 20 (25.31%), A NEG: 3 (3.8%), B POS: 19 (24.05%), B NEG: 1 (1.26%), AB POS: 5 (6.33%), AB NEG: 0 (0%), O POS: 28 (35.44%), O NEG: 3 (3.8%).
- Percentage of blood unit loss due to low volume collection among total number of units discarded: 79 (10.6%).
Discussion: Above results show that loss of rare blood groups in the blood inventory is significantly contributed by low volume units' collection. Measures like prior donor counseling, well trained phlebotomist, selecting pertinent vein, performing smooth venepuncture and keeping vigilant watch over blood flow can help bring down Low volume collection.
Conclusion: Low volume unit collection can be brought down by periodical clinical competency assessment of blood bank personnel, thereby enhancing the rare blood group availability and better blood inventory management.
TTI screening outcome: safety concern for phlebotomist
M Chitra, M Sridevi, A Anbarasi, S Hamsavardhini
The TN Dr MGR Medical University, Guindy, Chennai, India
Background: Phlebotomy, a centuries old practice is a common invasive health care procedure. Phlebotomy poses risk for the phlebotomist with needle-stick injury and transmission of blood borne diseases. Eventhough blood borne infections have come down among donor population drastically; health care workers and patients are still at risk of blood borne infections.
Aim: To highlight risk of blood borne infections for health care workers during phlebotomy.
Materials and Methods: TTI screening outcome of our center for donated blood during the study period of one year (August 2013-July 2014).
Results: Total blood units collected: 2078 TTI positive units: 16 (0.77%) % of TTI POSITIVITY for: HBsAg-12 cases (0.58%), HIV 1 and 2-2 cases (0.1%), HCV-1 case (0.05%), VDRL-1 case (0.05%) and Malaria: NIL case (0%).
Discussion: Best phlebotomy practices protect donors and health workers from blood borne pathogens and prevent bacterial contamination of blood. Safety procedures can reduce the risk of transmission by 75%. Health workers should be educated to avoid two handed needle recapping and manual disassembly and to dispose sharps in puncture proof Biosafety containers immediately after use. Best approach to discard the needle is to discard needle and syringe as a single unit into appropriate Biosafety container with disinfectant. Blood establishments need to develop and apply thoughtful biosafety programs to address staff training, accident prevention, HBV vaccination and followup titers, handling spills, managing contaminated waste, transporting blood specimen and support services like PEP.
Conclusion: Improved knowledge and awareness of the risks associated with phlebotomy, where Biosafety Level 2 guidelines are to be implemented in all areas handling open samples, will help to reduce the blood borne infections among health care workers.
Comparison of pre donation hemoglobin screening methods: Implications of quality and cost
Ganesh Mohan, Ramesh Bhaskaran, Susheela J Innah
Department of Immunohematology and Transfusion Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
Background: Pre donation hemoglobin screening is among the first and foremost test done for blood donor selection with the main intention of preventing donation from an anemic donor. The minimum acceptable Hemoglobin (Hb) for blood donation is 12.5 g/dl or Hematocrit (Hct) of 38% for both males and females.Despite the availability of various methods like CuSO4, Hemocue, Hemoglobin colorimetric scale andcyan meth hemoglobin; no single technique has emerged as the most suitable for hemoglobin testing in a blood donation scenario.
Aims and Objectives:
- To compare CuSO 4 and HemoCue against a standard hematology analyzer.
- To ascertain which one of this method could be ideal based on their lower false negative and false positive rates.
- To compare the financial implications of using CuSO4 and Hemo Cue method.
Materials and Methods: A prospective study analyzing 111 blood samples for quality evaluation of CuSO 4 , HemoCue 301 and Horiba Microsemi CRP analyzer (reference) was carried out in our blood bank. Tests were done by a single person within one hour of sample collection. All the equipments were calibrated. Data statistically analyzed using software SPSS16.
Results: Total of 111cases were analyzed. Statistical mean of HemoCue 14.002 ± 2.78. Statistical mean of analyzer 13.18 ± 2.57. Statistical mean of CuSO 4 couldn't calculate. Sensitivity of HemoCue andCuSO 4 is 1 when compared to analyzer. Cost per test of CuSO 4 and HemoCue is 0.02 and 25 rupees respectively.
Conclusion: CuSO 4 had a higher specificity and positive predictive value. False positivity was more with Hemo Cue.
Adverse blood donor reaction-reporting and analysis: Improvement of blood safety and donation services
Kalpesh Vala, Yogesh Domadiya, M D Indrodiya, Sahjid Mukhida, Kamlesh Dharajiya
Rajkot Vountary Blood Bank & Research Centre, Rajkot, India
Background: Blood donation is a power source of blood banks. Donor motivation, recruitment and retentionare basic requirements for blood donations. These main 3 things are dependent on donor satisfaction and donor services. Previous donation experience is a motivator for blood donor retention.
Aim: To study adverse blood donor reactions and their management to increase the blood donation, decrease the donor reaction rate and improve the blood donation services.
Materials and Methods: This retrospective study was conducted from January 2011 to July 2014 at Rajkot Voluntary Blood Bank and Research Centre, Rajkot, Gujarat. We monitor and study In-house blood donors' experience and adverse donor reaction with their management. We also do donor counseling aboutpost-donation care during pre-donation screening and study their impact on adverse blood donor reaction rate. All adverse blood donors' reactions are noted using the standard format.
Results: In our study, total 70453 donations were recorded. Out of these 18693 donations were collected at In-house. In this numbers 18386 (98.35%) are male donors and 307 (1.64%) are female donors. Out of total 18693donations, total 214 adverse donor reactions were recorded. Out of adverse donor reactions 189 were male donors and 25 were female donors. Out of 214 adverse donor reactions 178 (83.17%) donors were first time donors and 36 (16.82%) donors were repeat donors. Most common adverse blood donor reaction is Vaso Vagal Syndromes (94.39%). Other adverse blood donor reactions were hematoma (3.73%), Nausea (1.83%), Vomiting (1.83%) etc. During this study we noticed that proper management of adverse blood donor reaction can decrease the adverse blood donor reaction rate (1.45% to 0.75%). All cases resolved themselves with minimum resuscitation. All the donors were sent after they felt comfortable and took a telephonic feed back on the next day to know the donor status.
Conclusion: Proper donor screening and information can prevent adverse blood donor reaction. If donor motivation is done with proper information and donor screening criteria with counselling, it can prevent adverse events. Blood donation is a very safe procedure which could be made more event free.
Whole blood donor with a history of jaundice: Reviewing the deferral criteria
Swati Bhardwaj, Veena Doda, Satyam Arora, Urveshi Kotwal
Department of TRansfusion Medicine, Dr Ram Manohar Lohia Hospital & PGIMER, New Delhi, India
Introduction: As per the national guidelines the prospective donors with a history of jaundice, due to hepatitis B/C or due to unknown cause, are to be permanently deferred. A pilot study was undertaken on donors deferred due to history of jaundice with an unknown cause to analyse the residual risk associated with them.
Aim: The aim of our study was to assess the donors deferred with a history of jaundice.
Materials and Methods: This study was a done from July to August 2014. Donors with the history jaundice were deferred from donation and samples were taken for serological and biochemicals (LFT) work up. Serological work up included screening for HbsAg, anti HCV and ID NAT. Descriptive analysis was done using SPSS 17.0.
Results: All the deferred donors were male with mean age of 30.34 ± 6.58 years. Frequency for high risk activities included history of tattooing (14.1%), shaving outside home (56.61%), needle prick (10.1%), blood transfusion (1%) and unprotected sexual intercourse (4%). About 4% subjects reported of receiving vaccination for Hep B. Out of 100 such prospective donors screened 1 out of them was concordant reactive for HBV by ELISA and NAT whereas 4 were NAT yields of HBV and one was HBsAg sero yield.
Conclusion: There is a significant prevalence of hepatitis B reactivity among prospective donors with a history of jaundice. A careful history taking and enforcing a strict deferral criteria's for donors is essential.
Donor deferral pattern at a tertiary health care hospital in Uttarakhand, India
Ananya Doda, Manjubala S. Talekar, Gita Negi, Dushyant S. Gaur, Meena Harsh
Department of Pathology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
Address for correspondence: Dr. Ananya Doda, Department of Pathology, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jolly Grant, Dehradun - 248 140, Uttarakhand, India
Background: Stringent selection of blood donors is one of the prerequisite of Drugs and Cosmetic Act for any blood transfusion services. Donor acceptance depends on fulfilment of specific eligibility criteria designed to protect both the donor as well as recipient in the need of safe blood.
Aim: To evaluate the reasons for donor deferral.
Materials and Methods: Retrospective data from donor records was collected from Blood Bank, Himalayan Institute of Medical Sciences, Dehradun from 1 January 2014 to 30 June 2014. Donor deferrals based on donor questionnaire, donation interview, vitals, physical examination and hemoglobin testing were analysed for temporary and permanent deferral of donors.
Result: During the study period a total of 4716 blood donors were registered as potential blood donors and screened. Out of these 3859 donated blood on being declared medically fit and 857 were deferred (18.17%). Temporary deferrals comprised 95.33% (n = 817) and 4.66% (n = 40) were permanently deferred. The most frequent reason for temporary deferral was low hemoglobin, which constituted 32.21% (n = 276). The other major reasons, in descending order were history of infections 11.20% (n = 96), less bodyweight 10.73% (n = 92), female related issues 6.06% (n = 52), medication 5.36% (n = 46), consumption of alcohol 4.08% (n = 35). Permanent deferrals included hypertension 3.61% (n = 31) and history of jaundice 1.05% (n = 9). Demographically, the deferral rate was highest in the 17-30 age group i.e. 74.5% (n = 639) and higher in females in comparison to males (0.92:1).
Discussion: Donor deferral has a negative impact on the future donor return particularly for the first time donors. The major limiting factor in our donor population was low hemoglobin. Donor education and treatment for low hemoglobin should be an important strategy for motivation and retention of these prospective donors. Besides this, the other reasons such as history of infections, less bodyweight, female related issues, medication etc. though ≤10% are very important issues for further study and intervention. Permanently deferred donors should be encouraged to contribute by motivating others to donate blood.
CMV prevalence among donor population in South Indian population
Nittin Henry, Susheela J. Innah
Department of Transfusion Medicine, Jubilee Mission Medical College, Thrissur, Kerala, India
Background: Cytomegalovirus (CMV) can lead to serious health hazards interms of morbidity and mortality in neonates and immunocompromisedpatients. Latent infection makes CMV dangerous even years after the infection. Very few studies have been undertaken on seroprevalence of CMV in South Indian population.
Aim: To determine CMV seroprevalence (IgG and IgM) among blood donors in South India.
Materials and Methods: Cross sectional descriptive study on 500 donors in a teaching institute in Kerala. IgG and IgMseroprevalence was measured by Enhanced Chemiluminescence Technology using OrthocareVitrios. The social demographic details and other transfusion transmitted infection prevalence was also considered and their statistical relation to seroprevalence was assessed in the study.
Results: Data is being evaluated as the study is in progress.
Discussion: This study will help us in addressing the concern regarding the risk of transfusion transmissible CMV infection. It will provide us direction in managing the issue with leukoreduction or screening for CMV amongamong blood donors. It can also provide us a demographic and age based distribution of CMV, which can be valuable in obstetric and neonatal management.
Screening of β thalassemia trait and related haemoglobinopathies among blood donors in Punjab
Rajesh Kumar, Sonia Gupta, Aikaj Jindal, Amarjit Kaur
Department of Immunohematology and Blood Transfusion,Dayanand Medical College & Hospital, Ludhiana, India
Background: Hemoglobinopathies are common genetic disorders of haemoglobin, which can be prevented by population screening and offering genetic counselling. The cumulative gene frequency of hemoglobinopathies in India is 4.2%. The carrier state for β thalassemia in India varies from 1-17% with an average of 3.2%.
Aims: The present study was undertaken to find out the burden of hemoglobinopathies and spectrum of this disorders among the blood donors.
Materials and Methods: The study included 975 students between 18-25 years who donated blood. They were screened for β thalassemia trait and related hemoglobinopathies by High Performance Liquid Chromatography (HPLC) using Bio-Rad variant. Samples were also run on hematoanalyzer for Red cell indices and peripheral smear for red cell morphology.
Results: A total of 41 donors showed abnormal haemoglobin fractions in HPLC. Out of these 32 (3.3%) were diagnosed with β Thalassemia trait, 8 (0.8%) with Hb-D Punjab and 1 (0.1%) with Hb-S trait. The frequency of β thalassemia trait in different geographical region varied from 0.8% to 4.44%, being highest in Punjab and frequency of β thalassemia trait in different caste group varied from 0 to 4.74%, being highest in Jatt Sikh.
Conclusion: A universal approach of screening for β Thalassemia trait should be included as a part of standard blood testing among college students, premarital and extended family of thalassemics. Population group with high gene frequencies requires screening programmes as well as increased awareness and education programme to control the birth of thalassemia major.
Donor clinic-Nursing the unhealthy donor to health
Ravi C. Dara, Aseem Kumar Tiwari, Dinesh Arora, Geet Aggarwal, Ganesh Rawat, Devi Prasad Acharya,Vimarsh Raina
Medanta-The Medicity Hospital, Delhi, India
Background: Revised national blood policy states that the reactive donors may be offered post-test counselling in the centre itself or should be sent to the Integrated Counselling and Testing Centre (ICTC). These ICTC centres deal only with HIV and syphilis but not with hepatitis B and C infections. Moreover, NACO (National AIDS Control Organisation) provides free treatment for only HIV and not for hepatitis though the latter has considerably higher prevalence than HIV. Therefore, for Hepatitis B and C, we started informing donors telephonically and asked them to attend counselling and re-testing clinic called as "Donor Clinic".
Aim: Study was conducted to determine the response rate of donors after being notified of their reactive status and to assess the outcome of post-test counselling of hepatitis reactive donors including management.
Materials and Methods: Blood collected from donors were screened for HBsAg, and HCV by enhanced chemiluminescence assay and ID-NAT assay. Reactive donors were further confirmed by supplementary testing. Donors with confirmed reactive status were telephonically informed confirming the identity by the resident doctor about the tests results and were asked to attend the donor clinic. Confidentiality was maintained in revealing the reactive status. Respondeddonors were retested,counselled and offered information about confirmation, evaluation, consultation,early treatment, follow-up, contact testing, transmission prevention and tips to maintain good health.
Results: Among the 20256 donors donated during the study period (Sept 2013- July 2014), 189 (0.93%) were found to be confirm reactive (HBsAg and HCV) in the screening tests. 159 (84.1%) donors were notified about their reactive status telephonically. In all 76 (63.3%) donors with 66 (59.4%) HBsAg and 10 (52.6%) HCV reactive donors attended the clinic while 21 (17.5 %) donors visited local physician. Two of the responded donors knew their status earlier. Total of 11 (14.4%) donors came for contact testing.
Conclusion: Donors must be notified and counseled about all events associated with their donation that may affect their health. Disclosure of positive results should be in place to ensure prompt diagnosis, counselling, management that will avert spreading the infection in the family and community.
Donor notification and counseling: Experience and challenges
Gagandeep Kaur, Paramjit Kaur,Sabita Basu, Ravneet Kaur, Simmi Sharma
Department of Transfusion Medicine, Government Medical College and Hospital (GMCH), Chandigarh, Haryana and Punjab, India
Background and Objectives: In India, screening of blood for human immunodeficiency virus, hepatitis B surface antigen, and hepatitis C virus is mandatory before issue for transfusion and donors should be informed of their reactive status. Advising donors who test reactive for viral markers are an essential adjunct to blood donor testing and is part of donor care. We realized that donor disclosure is an important public health issue. Therefore, we took the initiative of post test counseling of blood donors.
Materials and Methods: The donors reactive for any transfusion transmitted diseases by enzyme linked immuosorbent assay in duplicate as well as by rapid tests, were notified of their reactive test results and called for counseling. We maintained confidentiality at each step. Counseling and information about confirmation, evaluation, early treatment and prevention of transmission were given to responding donors.
Results: The results were analyzed for the period from 1 st April 2011 to 30 th June 2012. Among 15844 donors, 172 were found to be reactive for various infectious markers. Letters were sent to all reactive donors. Only 60 donors responded and were counseled. The counseling rate was 49%, 45.5%, 50% and 17% for HBsAg, HCV, HIV and syphilis respectively.
Conclusion: This study describes our experience and challenges faced in implementing the programme of donor counseling in a resource poor setting.
Analysis of predisposing factor and adverse donor reaction in blood donors
Maitrey Gajjar, Nirav J. Patel, Nidhi Bhatnagar, Tarak Patel, Shital Soni, Bhargav Prajapati
Department of Immunohaematology and Blood Transfusion, Civil Hospital, Ahmedabad, Gujarat, India
Introduction: Blood is the most unique gift that one human being can give to another, which cannot be created artificially. Replacement donors can be retained as future voluntary donors. While blood donation is a safe procedure, a small percentage of donors may experience an Adverse Donor Reaction (ADR). The most frequent ADR is usually a mild vasovagal reaction, but for the donor it acts as a deterrent for repeat donation. It has been documented in various studies that 2-6% of donors experience an AE, but only 0.08-0.3% have a syncopal reaction where there is loss of consciousness.
Aims and Objective: To estimate frequency of adverse effect in apparently healthy donor and to identify the high risk group.
Materials and Methods: This study was conducted for the period of 1 year from July 2013 to June 2014.Basic health check-up, post donation care and laboratory test that performed on all donors blood. An adverse donor reaction was defined as the symptoms or signs of donor discomfort of sufficient severity such that either the donor called for attention of the staff or they were noticed by the staff and classified as mild, moderate and severe.
Results: Out of 32693 donors, ADRs were observed in 100 donors, giving an overall incidence of 0.30%. Out of 100 vasovagal reactions 90 (90%) were mild in degree. Most of the donors had a reaction during or immediately after donation, while the donor was still lying on the donor couch.
Discussion: Young age, lower weight, female gender, and first-time donation status were associated with significantly higher reaction prevalence. Special care needs to be taken to reduce ADRs in this category of VDs so that they can be motivated to become regular donors. Allocation of apprehension in donors, both through motivational strategies and pre-donation counselling should be done.
Conclusion: I concluded that stringent selection criteria in high risk group decreasing adverse donor reaction.
A study on the causes of deferral of blood bank donors attending the blood bank of the Gauthi Medical College Hospital
Arijit Rumu Baruah, T Chaliha
Gauhati Medical College and Hospital, Assam, India
Introduction: Blood transfusion is one of the indispensable part of Medical Science. The lifeline of the whole process of Blood Transfusion is Blood Donation by health donors. In a state like Assam, Where there are a huge number of Anaemic pregnant ladies, thalassemia and other Haemoglobinopathies patients, etc., blood donation is of utmost importance to save the life of many patients. But, due to strict screening of blood donors in recent times prior to blood donations due to the fact that blood is a potential source of many diseases, a large number of blood donors have been deferred by blood banks.
Objections: This study will be done to find out:
- The various causes of deferral of blood donors attending blood bank of the Gauhati Medical College Hospital.
Materials and Methods: A retrospective study was done by collecting secondary data related to the causes of deferral form the proformas of blood donors who were deferred by the state of the art model blood bank, Gauhati Medical College Hospital from the period from 1 st January 2013 to 31 th July, 2014. A permission was obtained from the Incharge of the blood bank prior to the collection of data. Ethical clearance was by the Ethichal committee of the Gauhati Medical College. All the data collection was done maintaining the strict confidential nature of the proformas.
Results: Out of the 49297 blood donors who attended the blood bank of the Gauhati Medical College Hospital, 3677 cases were deferred. Among the leading causes of deferral, low haemoglobin level, alcohol consumption prior to 72 hours prior to blood donation, less than 3 months of previous blood donation and recent tattoo making were prominent. But if seen combined, the greatest deferral is people suffering from diseases, or injury or under medication or had recent surgery.
Voluntary blood donation: Miles to go, celebrating the WBDD
Rashmi Sood, Asha Bora, Vineeta Gupta, Vijay Kumar, Deepak Kumar, Tarun Kumar, Sushil Kumar, Sushma Rani, Manohar Kumar, Sis Asha, Sis Jomol
Saket City Hospital, New Delhi, India
Introduction: WHO World Health Organisation is the directing and coordinating authority for health within the United Nations system. The day 14 th Jun is the WHO's annual Blood Donor Day. Blood Donor Day forms part of the WHO's campaign to raise awareness of the need for safe blood and blood products, to thank unpaid donors for their life-saving gift, and to look forward to the continued efforts to achieve the strategic goal for all countries to obtain 100% of blood supplies from voluntary unpaid donors by 2020. Continuous efforts are needed for maintaining a healthy blood donor pool. There have been significant increases in voluntary unpaid donations from low- and middle-income countries, with an annual increase of 7.70 million donations from 2004 till 2011.
Aim: To recruit more blood donors by implementing a system of educating blood donors and celebrating with the blood donors, so as to take it as an opportunity to retain them as donors to have a safe and continuous blood supply.
Materials and Methods: An extensive celebration of the World Blood Donor Day 2014 was organized by the Department at Saket City Hospital, New Delhi, India.
These days were utilized as a platform to communicate with and to educate people on the goals behind the blood donation campaigns and also to get their blood tested. Three days, i.e. 12,13, 14 June 2014, were celebrated by holding a free testing camp for past donors, all employees, patient-attendants, anybody visiting the blood bank. Invitation and information was send to the past donors via email. It was a highly organised and coordinated event. Visitors were educated on the uses of blood /blood components prepared for various categories of patients, benefits of the blood donation to them and also tested them for their hemoglobin levels, blood group, hepatitis B and Hepatitis C status by ELISA testing. The visitors were also oriented to various areas of the blood bank and to the work done in each area. Last day was celebrated with a cake-cutting ceremony, in which a huge cake in form of red drop was cut and cake and eateries were served to all present and invited. The past voluntary blood donors were especially invited for the ceremony.
Results: Most people coming to blood bank were willing to donate blood, but they were instead enrolled as potential voluntary donors for future. Total of 312 donors enrolled themselves as potential voluntary blood donors in these three days. They included 56 Apos, 105 Bpos, 27 ABpos, 89 Opos donors and 11 Aneg, 11 Bneg, 4 ABneg and 9 Oneg blood donors.Each day one voluntary blood donor is called from among the enrolled donors for a voluntary blood donation.
Conclusion: Our camp was infact a way devised to have effective communication with the blood donors. Communication and education are critical success factors towards the goal of WHO 2020.It is necessary to improve the understanding, and not just awareness, of the need for blood. Important message to be delivered to all donors is the need of regular blood donation. This study also enlightens on the need to invest resources and research in the area of promoting voluntary blood donation to ensure healthy development.
Streamlining the process of donor notification: Experience at a tertiary care hospital in Delhi, India
Daljit Kaur, Sangeeta Pahuja, Manjula Jain, Rama Khaspuria
Lady Hardinge Medical College & associated Hospitals, New Delhi, India
Background: Donor notification is an essential process whereby the otherwise asymptomatic donor is informed of the harboured transfusion transmitted infection (TTI). The stigma attached to the TTI makes notification process a serious social concern and demands careful planning and execution in a hospital setting.
Aim: This study was done to analyse the response rate of the seroreactive donors to notification and to visualize the limitations associated with the process.
Materials and Methods: A total of 41,000 donors donated during the study period of four and half years (January 2010 to June 2014).All the seroreactive donors were notified and the response rate to notification was observed during the study period.
Results: A total of 1184 (98.83%) reactive donors were contacted through letters or telephone. In year 2010 only 9.58% reactive donors responded out of 234 contacted (23/234), 15% (48/270) in 2011, 1.85% (05/270) in 2012, 54% (155/260) in 2013 and 47.7% (83/102) mid 2014. Only 1.85-15.09% of reactive donors turned back to blood bank during the years 2010 to 2012 when they were being contacted through letters alone. The response rate increased to 54% and 47.7% in 2013 and mid 2014 respectively after communicating through hospital telephone first.
Conclusion: Personal contact is a better way of recalling donors by explaining them of their inconclusive blood tests report on telephone first without actually revealing seropositive result. The reactive donor should be referred with a referral slip mentioning the TTI test result as well as detailed address of the concerned physician to get better response out of notification. Continued efforts of a trained counsellor for donor notification as well as integration with gastroenterologists and dermatologists for HBV, HCV and TPHA positive cases for referral can bring back huge number of reactive donors for further medical help and hence safeguarding the society of potential threat of transmitting disease.
Trend of blood donation and prevalence of seropositivity in blood donors of tribal areas of Gujarat
Deepika Dave, Harsh Shah, KV Panchal
Indian Red Cross Society Blood Bank & Component Centre, Godhra, India
Background: Human blood is scarce and very precious for saving lives of patients. Despite of constantly carrying out awareness programs, blood deficiency remains. Transmission of infectious diseases through donated blood is another concern in the field of transfusion medicine.
Aims: For the first time, this kind of study was undertaken on the people of tribal areas of Central Gujarat. Its main aim was to see the trend of blood donation and find out the seroprevalence of HIV, HBsAg, HCV and Syphilis among blood donors.
Materials and Methods: The study was undertaken at Indian Red Cross Society Blood Bank and Component Centre, Godhra, Gujarat. HIV, HBsAg and HCV were tested by ELISA method approved by NACO and RPR was carried out for screening of Syphilis. Records of previous 5 years were analysed retrospectively and the data analysed. Trend of blood donation among the people as well as seropositivity among blood donors were evaluated.
Results: A total of 30,704 blood donations were carried out in five years amidst which 28,765 were male donors and 1939 were female donors. Seroprevalence of HIV, HBsAg, HCV and Syphilis was 0.28%, 1.04%, 0.47% and 0.29% respectively.
Conclusion: In spite of increasing numbers of blood donation year after year and the untiring awareness campaigns, our area is still lacking behind in blood donation. The contribution of female donors is negligible. Hepatitis B still outnumbers other infective etiologies. We all collectively need to do much more to overcome the blood deficiency in our area.
Does whole blood remain relevant in our blood transfusion services?
R Raj Bharath, Lalitha C Pillai
Department of Transfusion Medicine, SRM Medical College, Kancheepuram, India
Background: The advent and use of blood components has revolutionized the field of transfusion medicine. The blood components carry a lot of advantages over whole blood transfusion. Through component separation, a single unit of blood can not only save four patients but also adverse reactions such as volume overload, allergic reaction and other transfusion reactions is reduced when compared to use of whole blood.
Aim: To find out the utilization of whole blood and components in each department over the period of 3 years.
Materials and Methods: A statistical study was done in our SRM Medical College and Hospital to find the total number of issues of whole blood and components between the years 2012 to July 2014. We also compared the use of whole blood and components in each individual department.
Results: The total number of whole blood and component issues were 1420 and 14349 respectively. The transfusion of whole blood has decreased drastically overall from 1233 in year 2012 to 136 in 2013 and also in each individual department. Packed cell transfusion were overwhelmingly more when compared to the transfusion of other components in Medicine, Surgery, 0.G, Ortho, Nephrology and Urology departments. F.F.P was utilized more than the other components in cardiothoracic department. Intensive Care Units and Paediatric Departments utilized all of the available blood components.
Conclusion: Whole blood has gone out of favor among the clinicians irrespective of the departments. However, the transfusion of packed cells exceeded than F.F.P and platelets in all the major departments except in the intensive care, cardiothoracic and paediatric units. More studies have to be done regarding the clinician use of desired components in every institution which will help in promoting the proper utilization of blood components.
Study of haematological and biochemical changes in stored blood
Vinayak Dave, Bhumi Aggrawal, SG Chiplonkar, Milind Dighe
Department of Pathology, Medical College, SSG Hospital, Baroda, Gujarat, India
Introduction: In blood transfusion medicine, Red blood cells are the most frequently transfused blood components, world wide. The transfused red cells should have enough efficacy to perform its function.
Aim: The goal of this study is to compare changes of various hematological and biochemical properties in stored blood.
Materials and Methods: Twenty five blood units of whole blood with CPDA (Citrate Phosphate Dextrose Adenine) and twenty five units of packed cells with CPD-SAGM (Saline, Adenine, Glucose, Mannitol), as anticoagulant, were examined. Various hematological parameters, which were estimated are plasma hemoglobin, red blood cell count, haematocrit, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, plasma Sodium level, plasma Potassium level. These parameters were estimated weekly from each blood unit.
Observation: There was rise in plasma hemoglobin, plasma potassium level and depletion of plasma Sodium level. It was observed that rise of plasma hemoglobin and plasma potassium level was more elevated in CPDA bags as compared to CPD-SAGM bags. While plasma sodium level showed more reduction in CPDA bags as compared to CPD-SAGM bags.
Conclusion: Hematological and Biochemical changes do occur in stored blood cells. Packed cells and whole blood Units of CPD-SAGM showed less deterioration at the end of their life(after 42 days of collection date), as compared to the deterioration in CPDA packed cells and whole blood units at the end of their life (35 days). So packed cells and whole blood units of CPD-SAGM units should be preferred over CPDA units for transfusion.
Utilization of blood components at a tertiary care centre in Chattisgarh
Prerna Mohan, Akhilesh Bhave, Rupma Ruha
Apollo Hospitals, Bilaspur, Chattisgarh, India
Background: Correct Transfusion practice is directed towards the optimal utilization of Blood components. Packed red cells are frequently transfused to anaemic patients, suffering from sepsis, bleeding, or volume loss. Fresh Frozen Plasma (FFP) is frequently used for patients with DIC, abnormal coagulation profile, and in liver diseases. Platelets are usually used for patients with thrombocytopenia, on chemotherapy or secondry to sepsis. Dengue and malaria are also predominant causes for platelets transfusion in Chattisgarh.
Aim and Objectives: To study the utilization pattern of Blood components in a 300 bedded tertiary care centre in Chattisgarh. Apollo Hospitals Bilaspur is a multi speciality hospital with a burn unit, renal transplant unit, cardiac surgery unit and a full fledged cancer hospital as a subsidiary unit. The hospital boasts of facilities for radiotherapy and all the amenities of a Corporate hospital. The centre is the only tertiary care centre in the city of Bilaspur and the state of Chattisgarh with an NABH accreditation.
Materials and Methods: The Blood Bank at Apollo Hospitals Bilaspur had started in 2002, and has completed 12 years of service. The centre has been practicing 100% components since the beginning and the audit has been done to study the efficacy of the transfusion practices since 2002.
Results: Despite practicing 100% components, the PRC utilization rate has been at 61%, with FFP at 24.10% and Platelets at 20.12%.
Conclusion: In a multi speciality centre, the FFP and platelets are highly underutilized despite being rampantly available, giving rise to low usage rate. The same should be more readily used and utilized for optimum usage and efficacy. This can be achieved by clinicians being educated and informed about the right dosage and availability of the same.
A study to assess the quality control of leucocyte reduced red blood cell components seperated by buffy coat method in teritary care hospital
Sindhuja Kondareddy, KV Sreedhar Babu, Arun R
Sri Venkateswara Institute of Medical Sciences, Tirupati, India
Introduction: Donor leucocytes present in cellular blood components can result in complications like Febrile Non Haemolytic Transfusion Reactions(FNHTRs), HLA Alloimmunisation, platelet refractoriness in multi transfused patients and transmission of leukotrophic viruses such as Ebstein Barr virus and cytomegalovirus. So in order to reduce these complications leucocyte reduction method is a highly effective and widely practised prevention strategy. Leukofilters are used in order to prevent all the above causes where as buffy coat method is used to prevent FNHTRs.
Aim and Objectives: The main aim of the study is, to assess the quality control of leucocyte reduced red blood cell components seperated by buffy coat method in teritary care hospital.
Materials and Methods: In this study hundred top and bottom bags were taken, the samples were collected before and after component separation by buffy coat method and WBC count was done using automated haematology analyser and the percentage of leukocyte reduction and log reduction of each sample bag was assessed.
Results: Out of hundred bags,91 bags showed log1 leukoreduction,7 bags showed log 2 leukoreduction and 2 bags showed <1 log Leukoreduction.Out of 91 bags, 67 bags showed >90% Leukoreduction,17 bags showed 80-90% of Leukoreduction and 7 bags showed 70-80% of leukoreduction.
Conclusion: From the above study buffy coat method of preparation showed 1 log leukoreduction which is sufficient to prevent FNHTRs, there by decreasing most common adverse reactions in our institute. As leukofilters are not cost effective, buffy coat method of preparation can be implemented in Indian setting.
Quality management procedure of platelet concentrate
Sachin Aggarwal, Jasmin Jasani, RK Tandon, SS Goswami, RK Pasale, Ashu Dogra
Department of Pathology, SBKS Medical Institute & Research Center, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
Background: Platelet concentrates are increasingly being used as part of supportive therapy in the management of haematological malignancies. Platelet transfusion therapy is also indicated in thrombocytopenia due to various causes including all forms of bone marrow failure. Production of platelet concentrates is expensive and rigorous. They also deteriorate rapidly during storage and have a short shelf life. Therefore it is important to evaluate the quality of platelets concentrates transfused so as to prevent wastage, ensure efficacy and maximum benefit of the patient as well as to avoid exposing a patient to multiple transfusions.
Aim: The aim of this study were to assess the processes employed in preparation of the concentrates and to determine and describe several quality parameters of platelet concentrates.
Materials and Methods: Whole blood samples from 80 donors and the respective platelet concentrate units were tested. Platelet concentrates were tested (platelet count, aggregation and pH) on days 1, 3 and 5 of storage. Additionally a leukocyte count was done only on day 1 and microbiological tests on day 5 of storage.
Results: The result show that platelets count present in a whole blood is 100% and separated platelet rich plasma in platelet count in 90%, less than 10% of the platelets should be left in whole blood after the low spine (1 st round). The hard spine of IInd round after preparation a platelet concentrate the count of platelets is 83%, less than 10% of the platelets should be left in platelet rich plasma.
Conclusion: The quality management in platelet concentrate upon a Selection of donor, Quality of the blood bag container, Technique of phlebotomy, Storage temperature of blood bags before centrifugation, Setting or programming of refrigerated centrifuge machine, Platelet concentrate separating procedure or method, Storage of platelet concentrate in Incubator and agitator in proper temperature.
Scenario of platelet transfusion at Medical College Gwalior: A 4 year study
Lokesh Tripathi, DC Sharma, S Rai, S Iyanger, Mahesh Yadav, Bharat Jain
Gajra Raja Medical College, Gwalior, MP, India
Background: Half a century ago, most of the blood transfused was whole blood. In 1961 Platelet concentrate was recognized as treatment for reducing the mortality from hemorrhage in cancer patients. In 1969 Murphy S. and Gardner F. demonstrated the feasibility of storing platelets at room temperature, revolutionizing platelet transfusion therapy. Since then, the aim of blood transfusion is to transfuse only those components which patients required and keep the rest for others. Platelet transfusion is critical due to lack of alternative; and hence be used rationally.
Aim: To know the rationality of Platelet transfusion and efficacy of different Products i.e., P.R.P., Pooled Platelets, Buffy Coat Platelet and Aphaeresis Platelets in medical practice.
Materials and Methods: The study was conducted in Blood Bank, Department of Pathology, G. R. Medical College, Gwalior. 5510 transfusions were performed in 1630 Patients in 4 years i.e. 2010-2013. Relevant clinical findings, pre/post transfusion platelet count along with complete haemogram and diagnosis of patients were considered in compiling the data. Quality of Platelet was maintained as per standard.
Result: Average increase in platelet count by Random Donor Platelet was 8000/mm 3 and in Single Donor Platelet was 40,000/mm 3 . Out of 5510 Transfusions to 1630 Patients, 4408 (80%) were therapeutic and 1102(20%) were prophylactic, 283 were Aphaeresis Platelet (S.D.P.) in 242 Patients and 5227 were Random Donor Platelet (P.R.P. and B.C.) in 1388 Patients. 1388 Patients where RDP were transfused, 488 transfused singly and 900 got multiple transfusion (rationality 91.14%). Clinically thrombocytopenic Patients diagnosed as Dengue 35%, Malaria 20%, Malignancy 14%, Chemotherapy/Drug induced 12%, Aplastic Anemia 5%, Trauma 4%, and Idiopathic 20%.
Conclusion: Akin to previous studies, our study showed that SDP is preferable to RDP as prophylactic and therapeutically usable Platelet concentrate and thus the Platelet concentrate is used rationally and judiciously in our institute.
Determination of percentage of wastage of blood components at tertiary level hospital in West India
Manoj Gupta, Nidhi Mehta
Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute, Mumbai, India
Background: The implementation of quality system and continuous evaluation of all activities of BTS can help to achieve maximum quantity and quality of safe blood. Optimizing blood collection and processing would reduce the rate of discard and improve the efficiency of the BTS.
Aims: This study was conducted for a period of 5 years i.e. from April 2009 to Dec 2013 at Kokilaben Dhirubhai Ambani Hospital and medical research institute, Mumbai.
- To determine the rate and causes of wastage of blood and blood components (Concentrate of human red blood cell, Fresh frozen plasma, platelets, and cryoprecipitate) at tertiary level hospital in West India.
Materials and Methods: All Blood units collected over period of 5 years were included in study. A detailed analysis of the number of blood units collected, number of blood/blood component units discarded is done.
Results: The total blood units collected during study period was 30900. All the blood units were subjected to component separation. 65.67% blood components were issued to recipients, 7.96% components issued to RPFC and 9.45% units discarded. 16.92% blood components were in inventory at the time of data analysis. Blood components units discarded due to sero-positivity 4.7%. 0.10% of whole blood units discarded as quantity not sufficient (Q.N.S). 42.89% of platelet discard was due to expiry and 0.18% due to leak. 10.08% of FFP discard was due to unused bags after thawing, 2.49% due to lipemia and 1.33% expired units.
Conclusion: Blood transfusion is an essential part of patient care. In order to improve the standards of blood banks and the blood transfusion services in our country comprehensive standards should be formulated to ensure better quality control in collection, storage, testing, and distribution of blood and its components for the identified major factors affecting blood component wastage.
Evaluation of bacterial contamination: A comparitive study using triple bags with and without diversion pouch
Aboobacker Mohamed Rafi, Susheela J. Innah, Danusha
Department of Transfusion Medicine and Immunohematology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
Background: Bacterial contamination of blood products is a main concern of blood safety. It is the second highest cause of Transfusion Reactions in the United States Platelets are the main components which are affected as they are stored at 20-22 degrees.
Aim and Objectives: To evaluate bacterial contamination of Random Donor Platelets in Triple SAGM bags with and without diversion pouch and to determine the incidence and significance of the contamination. We also plan to Compare other QC parameters like pH, swirling and platelet count of the platelet concentrates in these bags.
Materials and Methods: The study was conducted in the Dept Of Transfusion Medicine, JMMC&RI over a period of 4 months period. Donor arm was disinfected as per SOP by the same Phlebotomist 25 Whole Blood each were collected in SAGM bag with and without Diversion Pouch respectively. The donors where Age Matched and were taken from among the in house voluntary blood donors. Random Donor Platelets (RDP) were used for the study which were prepared within 6 hours of collection of whole blood The product was kept undisturbed for 1 hour after preparation, before keeping it in an agitator at 20-22 degrees Celsius.
Results: A total of 50 donors blood was collected of which 25 units were collected in Triple SAGM bag with diversion Pouch and 25 units were collected in Triple SAGM without diversion Pouch. Seven samples showed positive culture in bags without diversion pouch compared to only one in the bag collected with diversion pouch. No marked variation in pH and Platelet count were noted.
Conclusion: Bacterial contamination of blood products is a very important problem faced by the BTS worldwide. Most of the contamination is due to unsterile techniques through which bacteria enters the blood bag. This can be easily prevented or reduced by introducing a system where by the initial few ml of blood is diverted into a pouch as shown in this study
Analysis of reasons for discard of whole blood and its components in a tertiary care teaching hospital blood bank in southern India
B Suresh Babu, KV Sreedhar Babu, R Arun
SVIMS, Tirupati, India
Introduction: People are the only source of blood. Much of the medical and surgical specialties depend on the steady supply of blood. So each unit of blood is precious and has to be utilized properly with minimal discards. The aim of this study was to find out the reasons for discarding blood and blood components.
Materials and Methods: This study was conducted for a period of 1 year and 6 months from January 2013 to June 2014 in a tertiary care teaching hospital blood bank in southern India. All whole blood and blood components collected during study period were included.
Results: A total of 298 (5.66%) whole blood bags were discarded. Out of these 298 blood bags, 146 (48.99%) were discarded because of seroreactivity for transfusion transmissible infectious diseases. A total of 1449 (7.4%) blood components were discarded against 19586 blood components prepared during the study period. Among blood components discarded, most common units were platelets (16.28%). The most common cause of discarding the blood components was due to date expired (36.92%).
Conclusion: A properly conducted donor screening, notification and counseling of permanently deferred donors will help in discarding less number of bags which are positive for different TTI. Properly implemented blood transfusion policies will help to utilize the blood components in proper way resulting in discarding the less number of blood bags due to expiry. Proper visual inspection and storage facilities will decrease the breakage/leakage of the FFP.
Analysis of demand and utilization of blood and its components in a tertiary care hospital: Advocating a restrictive policy
Ujjwal Dimri, J Philip, T Chatterjee, RS Mallhi
AFMC, Pune, India
Background: Blood and blood components are precious resources, with no substitutes, that are required in dire situations. Every possible step should be taken to ensure judicious use and implement proper inventory management of blood and blood components.
Aim and Objectives: To analyze the demand and utilization of blood and its components in a tertiary care hospital in order to advocate a restrictive policy with the objective to avoid unnecessary man-hour wastage, artificial paucity of blood units and exposure of the patients to various undesired hazards of transfusions.
Materials and Methods: In a retrospective study, details of blood and its components demanded and transfused in different specialties, in last 04 years (2009-2013), were noted and correlated with the patient's diagnosis and requirements for transfusion.
Results: Total number of components demanded was 1,35,554 and total number of components which were utilized was 92,189, amounting to an overall difference of 31.9% or more than 40,000 units over demanded in just four years. Percentage difference in demand and utilization of individual blood components in last 04 years, in decreasing order, was maximum for packed red blood cells at 52.1%, 22.5% for fresh frozen plasma, 4.7% for cryoprecipitate, 2.91% for single donor platelets and minimum for random donor platelets at 1.75%. The most common diagnosis for which blood and its components were required was for surgeries related to cardiac anomalies amounting to 37.6% of total units utilized, followed by hematological illnesses (13.3%) and malignancies (12.6%).
Conclusion: There was a considerable difference in demand and utilization of blood and blood components. Hospital transfusion committee, periodic audits and implementation of Maximum Surgical Blood Order Schedule (MSBOS) can play an important role in the correct and rationale use of blood.
Comparison of quality of cryoprecipitates prepared by two different methods
R Ramachandran, JJ Mammen, SC Nair, Jennifer J, M Thenmozhi
CMC, Vellore, India
Background: Cryoprecipitates are frequently transfused as a source of Fibrinogen, Factor VIII and von Willebrand factor. Cryoprecipitates are prepared from Fresh Frozen Plasma (FFP) which in turn can be prepared by two methods- 1. centrifuging whole blood using a heavy spin at 4 ° C to separate plasma from red cells and 2. using a light spin at 22 ° C to prepare PRP first and then heavy spin at 22 ° C to separate plasma from platelets. We conducted this study to see whether any difference exists in terms of quality between cryoprecipitates from FFPs prepared by these two different methods.
Study Design and Methods: 272 units from a total of 3455 cryoprecipitates prepared between March 2014 and August 2014 from FFPs prepared by freezing plasma separated at 22°C (method 1, N = 166) and 4 ° C (method 2, N = 106) were included in the study. These were analysed for Fibrinogen, Factor VIII and von Willebrand factor activity.
Results: The mean (±SD) levels in method 1 and method 2 were as follows: Fibrinogen (mg/unit) 499 (±207.68) and 541.08 (±206.18; P = 0.107), Factor VIII: C (IU/unit) 390 (±238.38) and 407 (±219.86), vWF (IU/unit) 286.43 (±163.97) and 301.20 (±170.76) respectively.
Conclusion: There was no statistically significant difference in quality of cryoprecipitates prepared by two different methods in terms of levels of Fibrinogen, Factor VIII and vWF activity. Hence either of the two methods may be followed for cryoprecipitate preparation.
Prevalence of transfusion transmitted infections among 5,24,039 blood donors at a tertiary care centre in Jaipur
Rachna Narain, Sunita Bundas, Varun Capoor, Richa Gupta, Parmendra Pachori, Mamta Soni
Department of Immunohaematology and Transfusion Medicine, SMS Medical College and Hospital, Jaipur, Rajasthan, India
Background: Transfusion of blood and blood components are associated with a large number of complications, among which Transfusion Transmitted Infections (TTI) form a major threat.
Aims: The aim of study was to find out prevalence of transfusion transmitted diseases (TTI) in voluntary and replacement donors in our hospital transfusion service setupto evaluate the efficacy of donor screening procedures employed in our blood bank.
Materials and Methods: This study was to done retrospectively in voluntary and replacement donors in the Department of Immunohematology and Transfusion Medicine at SMS Medical College and Hospital, Jaipur (Rajasthan) during the period from 2002 to 2012. Blood samples were collected from 5,24,039 blood donors and screened by EIA 3 rd Generation for HIV antibody, HBV antigen, HCV antibody, RPR for Syphilis antibody and Random peripheral blood film examination for Malarial parasite. Data collection and analysis was achieved by compiling the data on Microsoft excel 2007 computing program. Simple statistical application was used to calculate the percentage prevalence.
Results: Prevalence rate found in this study are HIV (0.18%), HBV (1.97%), HCV (0.29%), Syphilis (0.9%). Random samples tested by peripheral blood film were found to be negative for malarial parasite.
Conclusion: A decrease in trend in the prevalence of TTI has been seen in blood donors at our centre.
Prevalence of tranfusion transmitted infections among western Maharashtrian blood donor population and trends observed in a fourteen year study period
Ujjwal Dimri, J Philip, T Chatterjee, RS Mallhi
Department of Transfusion Medicine,AFMC, Pune, india
Background: Evaluation and monitoring of the prevalence of transfusion-transmissible infections among blood donors is a valuable index of blood safety, and of the prevalence of these infections in the general population.
Aim and Objectives: To study the prevalence and trends of transfusion transmissible infections among Western Maharashtrian blood donors in past 14 years (2000-2013). Study Design and Methods: 1,16,483 allogeneic donations from 2000 to 2013 screened for hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), malaria and syphilis were analyzed. The prevalence of HBV, HCV, and HIV infections per 1000 donations and 95% confidence interval were calculated.
Results: The prevalence of HBV, Syphilis and HIV decreased during the 14-year study from 2000 through 2013. The overall prevalence for entire study period, per 1000 donations, was 15.3% for HBV, 5.8% for HIV, 4.9% for HCV and 3.97% for syphilis. There was a significant decrease in hepatitis B surface antigen prevalence from 23.8% in 2000 to 10.3% in 2013. A similar significant decrease in the prevalence, from 13.1% in 2000 to 3.9% in 2013, of HIV was observed. Syphilis prevalence showed a significant decrease from 7.3% in 2000 to 1.06% in 2013. HCV prevalence showed a significant increase in blood donations from 3.9% in 2000 to 8.3% in 2013. Only 02 cases of malaria positive donation were found during the entire study period.
Conclusion: The trends of transfusion-transmitted infection prevalence in Western Maharashtra blood donors suggest that most of the blood safety measures employed in recent years in Western Maharashtra have been effective. The decline in HBV prevalence can also be attributed to an effective vaccination programme, while the rise in HCV can be attributed to lack of it. The rise in HCV detections can also be attributed to the better modalities of screening diagnostics available.
Prevalence of transfusion transmitted infections among multiple transfused thalassemic recipients in IBT&IH, Kolkata
Biplabendu Talukdar, 1 Suvro Sankha Datta
Departments of IBT&IH and 1 Transfusion Medicine, Tata Medical Center, Kolkata, West Bengal, India
Background: Voluntary non-remunerated blood donation is the main source of blood supply in our transfusion service. In west Bengal voluntary donation are poorly structured and safety of blood transfusion is still compromised.
Aims: To assess the prevalence rate of HIV, HBV and HCV infection among multiple transfused thalassemic recipients in southern Bengal.
Materials and Methods: Total four hundred and forty six (446) multi transfused thalassemic patients were included in our study. They used to get transfusion in regular interval from IBT&IH blood bank, Maniktala, Kolkata. All the blood units collected were tested using 3 rd generation ELISA. The patients were tested for HIV, HBV and HCV in six monthly basis and the incidence of sero-reactivity were calculated among them.
Result: In the 446 recipients thirty seven (37) that is 8.29% became serological positive for HIV, HbsAg and HCV. Among thirty seven serologically reactive recipients two (5.40%) were HIV positive, eleven (29.73%) were HbsAg positive and twenty six (70.27%) were HCV positive. Two of them (5.40%) had mixed infections, one had HIV with HCV and the other one had HCV with HbsAg.
Conclusion: The incidence of TTI is a matter of great concern. We had a significant number of patients with transfusion transmitted diseases (TTD) in this region. The present study emphasized on the fact that proper donor screening, testing of collected blood units using more sensitive tests like fourth generation ELISA or NAT can minimize the rate of TTD among multi transfused patients. Recruitment and retention of voluntary blood donor are also the keys to ensure safe transfusion practices.
Seroprevalence of infectious markers and their trends in blood donors over a period of 9 years
Vikas Hegde, RN Makroo, Mohit Chowdhry, Aakanksha Bhatia, NL Rosamma
Indraprastha Apollo Hospitals, New Delhi, India
Background and Objectives: Hepatitis B virus, Human Immunodeficiency virus, Hepatitis C virus and syphilis infections pose a great threat to blood safety. This study investigated the prevalence and the trends of serologic markers for transfusion transmissible infections (TTIs) among blood donors.
Materials and Methods: We examined whole blood donations collected from January 2005 through December 2013. Data of the donor parameters and infectious marker status of each donor was retrieved from the data base. The prevalence of positive serologic markers and their trends over years were analysed.
Results: The data of 180,477 donors who donated their blood during the study period was analyzed. Among them 173,019 (95.86%) were male donors and 7,458 (4.13%) were female donors. Replacement donations (174,939 (96.93%) represented the majority whereas, only 5,538 (3.06%) donations were from the voluntary donors (VD). The risk of blood being reactive was 3 times higher in male donors when compared with the female donors. The risk of blood being reactive for one or more infectious markers was 2.1 times higher in replacement donors when compared with the voluntary donors. Seropositivity of HIV, HBsAg, HBcAb, syphilis shows a significant decreasing trend (P < 0.05) over the period of time whereas the there was an increasing trend in HCV infection trend which was insignificant.
Conclusions: This study reflects the risk of TTIs has been decreased with respect to HIV, HBV and syphilis probably due to nationwide programmes (NACP, Hepatitis B vaccination), but the trends for HCV remains almost the same in blood donors. Therefore, improvements are needed to strengthen both safety and availability of blood.
Seroprevalence of transfusion transmissible infections among voluntary and replacement blood donors in a tertiary care hospital of Punjab
Dayanand Medical College & Hospital, Ludhiana, India
Background: Blood is a life saving source, but also an important mode of transmission of infections in the recipients. Voluntary blood collection and proper screening of blood are the cornerstones of transfusion medicine.
Aims: To know the seroprevalence of TTIs among voluntary and replacement blood donors in a tertiary care hospital.
Materials and Methods: From January 2008 to December 2013, a total of 187575 blood donor samples were tested by routine serological screening for Anti HIV-1,2 Anti HCV and HBsAg by (Vironostika HIV Ag/Ab, Hepanostika HCV Ultra and HBsAg ultra, bioMιrieux, France), VDRL by Immuno Chromatography Card method (Beacon Diagnostic) and Malaria by Rapid one step malaria LDH test (Microgene).
Results: Out of 187575 donors, 134391 (71.6%) were replacement and 53184 (28.4%) were voluntary. There were 131563 (70.1%) males and 2828 (1.5%) females in the age group of 18 to 60 years. It was observed that 492 (0.26%) were positive for HIV, 1937 (1.03%) for hepatitis B, 2867 (1.53%) for Hepatitis C, 3270 (1.74%) for VDRL and 11 (0.006%) for malaria. The seropositivity was more in replacement than voluntary donors. The prevalence of HCV and VDRL are higher in our study.
Conclusion: Strict quality control, proper counseling of donors and training of blood transfusion personnel, including deferral of suspected donors may help to prevent wastage of huge resources and maintaining high quality inventory. Efforts should be made to improve the number of female donors. More awareness should be spread among female population by holding educational talks in women's colleges, training and recruiting more female staff. Providing more privacy and comfort in the blood camps to encourage more females to donate blood should be done.
Seropositivity of HBsAg, HCV and HIV, syphilis among blood donors: A study on five years interval in medical college hospital
Om Bodariya, Atul Srivastava, Yukti Bhavsar, Ashok Ramanuj, J R Joshi, A S Agnihotri
C U Shah Medical College & Hospital, Surendranagar, India
Introduction: This study is conducted to evaluate the seroprevalance of HIV, HBsAG, HBV and syphilis among blood donors at blood bank of medical college hospital along the five years.
Materials and Methods: Study includes both voluntary and replacement donors. HIV, HBsAG and HCV were tested by ELISA methods approved by NACO and RPR was carried out for screening of Syphilis.
Results: The seroprevalance of HIV, HBsAG, HCV and Syphilis was 0.08%, 0.3%, 0.07% and 0.17% respectively in voluntary blood donors while seroprevalance of HIV, HBsAG, HCV and Syphilis was 0.31%, 1.18%, 0.16% and 1.12% respectively in replacement blood donors.
Conclusion: We observe that seroprevalance is higher in replacement donors than voluntary donors. These facts strongly indicate that we need more motivational and educational programmes to shift complete voluntary donation.
Changing trends in the prevalence of seropositivity for HIV, Hbsag, HCV, syphilis in blood donors at tertiary care hospital
Nirali Thakkar, MV Thaker, PH Shah, Lalji Valiya, SK Suri
Department of Pathology, Government Medical College, Bhavnagar, Gujarat, India
Background: 1% chance of transfusion associated problems including transfusion transmitted diseases. Study was carried out to know the Sero-prevalence of transfusion transmitted infections in blood donors in Bhavnagar.
Aims: To know the prevalence rate and trend of common Transfusion Transmitted diseases in blood donors at Blood Bank, Sir T General Hospital, Bhavnagar.
Materials and Methods: This retrospective study was carried out over a period of five year. Blood collection was carried out from voluntary donors as well as replacement donors. Total 34051 of blood donors were tested for detection of antibodies against HIV, HCV, syphilis, Hepatitis B antigen (HbsAg).
Results and Discussion: Total 34051 donors were screened. 24715 donors were voluntary donors and 9336 were replacement donors. Total donors reactive for different transfusion transmitted infections were 825 (2.42%) and from which were voluntary sero-reactive donors 424 (1.72%) and remaining 401 (4.32%) were replacement donors. Seroprevalence of HIV, HBV and HCV were decreased from 2007 to 2011, while of syphilis is increased during the same period because of use of more sensitive test method i.e. third generation ELISA as compared to RPR method of testing. Also increase in voluntary blood donation resulted in decreased seroprevalance.
Conclusion: Extensive screening of blood donors prior to blood donation by pre-donation counseling, encouraging voluntary blood donation by educating people, preventing repeat blood donation by post donation counseling of known seropositive donors are the main factors responsible for changing trend of seroprevalence of HIV, HBV and HCV and Syphilis.
Quality system of elisa on a unique way: For a small blood bank set-up
Ekta Pankhaniya, Chandni Karia, Sahjid Mukhida, Kamlesh Dharajiya
Rajkot Voluntary Blood Bank & Research Centre, Rajkot, India
Background: Blood safety is a major issue for the transfusion services. Measuring quality of TTI testing by Levey-Jennings (LJ) Charts in blood-banks is a better way, but a few ELISA kits do not support commercial as well as In-house prepared External Positive Controls (EPC). At that point, to ensure the quality of testing system is a challenging work for technical person. We share our experience to using kit controls and plotting of L J graph for routine testing.
Aim: To ensure quality system for ELISA by the L J Charts using the kit control, used for ELISA testing, where commercially available and in-house prepared EPC were not supported.
Materials and Methods: We are using commercially available and In-house prepared EPC for HIV and HBsAg testing. For HCV J. Mitra kits were not supported to L J Charts. We started to use kit control as an External Positive Control in routine testing. The E-ratio, mean, +2SD and -2SD confidence limits were calculated and plotted against day run. Interpretation of the graph was done by applying Westgard Rules.
Results: Kit controls were supplied by manufacturer with the kits for this study in enough quantity. Thus it was not required to prepare and store small aliquots. Results of 25 days run were collected and E-ratio, mean, SD (standard Deviation) were calculated. All results were within ±2SD limits. Any major adverse events were not noticed till date. Mandatory Westgard Rules have not yet been violated. The batch variation of the kits did not affect the EPC OD values.
Conclusion: When ELISA kits of some manufacturers do not support to L J Charts using by commercial and In-house prepared EPC, at that point of time, we can check the quality of ELISA testing by using kit control as an EPC. This method is very easy and reliable for small set-up blood bank where commercial EPC is not affordable as well as in-house EPC preparation is not feasible.
HIV, HBV, HCV, syphilis and malaria co-infection in over 100000 healthy blood donors in a tertiary care centre
Ravi C. Dara, Aseem Kumar Tiwari, Dinesh Arora, Ganesh Rawat, Vimarsh Raina
Medanta - The Medicity Hospital, Gurgaon, Haryana, India
Introduction: With the common modes of transmission, hepatitis B virus (HBV)/hepatitis C virus (HCV) co-infection is not uncommon in endemic areas and even amongst apparently healthy subjects like blood donors. Prevalence of co-infection of hepatitis viruses (HBV and HCV) with HIV and syphilis in India is unknown and might be underestimated. Individuals infected with one virus are concomitantly at risk of acquiring other parenterally or sexually transmitted viruses since HIV, HBV, and HCV share the similar routes of transmission.
Aim: To study the incidence of co-infection with human immunodeficiency virus (HIV)/hepatitis B virus (HBV)/hepatitis C virus (HCV)/ syphilis in an apparently healthy donor population.
Materials and Methods: During the study period from Jan 2010-July 2014 all the potential blood donors samples screened with serological tests for HIV, HbsAg, anti HBc (IgM), HCV using enhanced chemiluminescence assay while syphilis and Malaria by immuno-chromatography assay, which were reflex tested by supplementary assays.
Results: During the period of observation, out of 109105 blood donors tested co infection was observed in 62 donors with a co-infection rate of 1 in 1759 donors. 29% (15) were positive for (HBsAg + HCV). Co- infection rate of HIV + HCV, HCV + Syphilis, HBsAg + syphilis, HIV + Syphilis, HIV + HBsAg and HCV + malaria was 14% (9), 22% (14), 11% (7), 12.9% (8), 1.6% (1) and 1.6% (1) respectively. 4.8% (3) donors were positive for HCV and Anti Hbc IgM. One donor was positive for three infections (HCV + %HIV + Syphlis). Out of 62 co-infected donors 54 (87.09%) donors were first time donors while 8 (12.9%) were repeat donors with 21 donations at various blood banks.
Conclusion: Higher number of first time donors in our co-infection study emphasises that pool of regular repeat donors should be encouraged as they represents the best source of safe blood.
Third party quality control: Our experience with virotrol
J Ravishankar, Deepa Devi G, P Arumugam
The TN Dr MGR Medical University, Guindy, Chennai, india
Background: Third party quality controls in ELISA provide unbiased, independent assessment of analytical performance as they are unassayed; and analyte levels are weak/low reactive, with values typically in 1.5-3.0 S/Co (Sample/Cut-Off) range. But they must not be substituted for mandatory positive/negative calibrators. Use of a single multianalyte third party control like VIROTROL 1 (Biorad) helps in eliminating need to purchase individual controls. Virotrol 1 is also intended to provide a means of estimating precision.
Study: As a Regional Blood Transfusion centre, our blood bank lab receives ELISA kits regularly from other blood banks for Quality Control testing. Virotrol 1 (with antibodies to HIV-1, HTLV-1, HCV, HBc, CMV and HBsAg) is run in our lab with every ELISA run for quality control. This is followed by e-ratio calculation and plotting of results in Levey-Jenning chart.
Results: Eventhough Virotrol acts as a patient sample and gave low reactive results with anti-HCV on expected lines with manufacturer cutoff values; tests with HBsAg and anti- HIV kits were usually nonreactive in multiple manufacturer kits when using kit manufacturer cut off values.
Conclusion: Prior Virotrol runs with different manufacturer's ELISA kits is essential to know e-ratios of sample in individual kits and a mean of all values should be taken which will be the corrected e-ratio for Virotrol sample. When quality control tests are run with these data, we can find that a run which is nonreactive by standard cut off values will be weak reactive with corrected e-ratio. As levels of reactivity and specific performance characteristics will vary with different manufacturers' kits and assay procedures, the user should understand the limitations of external third party quality controls.
Sero-reactivity rate of transfusion transmitted infections (TTIs) and Co-infections among sero-reactive blood donors at tertiary care hospital
JK Upadhyay, HC Pandey, R Katharia, RK Chaudhary
Department of Transfusion Medicine, SGPGIMS, Lucknow, India
Introduction: Blood transfusion services routinely perform serological tests to screen for the presence of markers of HIV, HBV, HCV, Syphilis and Malaria as per the law. In addition to reducing the risk of transfusion transmission of these pathogens these data also provide an insight into the epidemiology of these infectious agents in the normal population. They also provide an idea as to where the donor screening needs further attention when it comes to ruling out the high-risk donors.
Materials and Methods: A retrospective analysis of the blood donation records was done for the period from Jan 2008 to Dec 2013 for a period of 6 years. The prevalence of various screened infections during this period was studied and analyzed.
Results: A total of 1,33,178 whole blood donations were done at our centre during the study period of which 3.69% donors were seroreactive for one of the markers tested. The sero-reactivity was 2.14% for HBV, 0.70% for HCV, 0.49% for HIV and 0.36% for syphilis. Reactivity among voluntary donors was 2.5% as compared to 3.82% among replacement donors. 1.16% of the seroreactive donors were found to be co-infected with more than one infectious agent. HBV was found to be associated in 79% of the co-infected donors. 98% of the co-infected donors were male and all of them were replacement donors.
Conclusion: We found that the reactivity rate among voluntary donors was less as compared to the replacement donors. The co-infections were also present in replacement donors only. The common mode of transmission of the studied pathogens is mostly responsible for co-infections and indicates high risk behavior as well as higher risk of exposure to these infectious agents. Efforts must also be undertaken to increase the voluntary donor base as voluntary donors are much more willing to share the high risk behavior as compared to replacement donors. This study further highlights the importance of good donor screening methods and need to increase the voluntary donor base.
Pattern of transmissible diseases in a rural voluntary blood bank: 10 years retrospective study
Deva Japa Ajith, M Mashhadi, Sanjeeth Peter
Gujarat Methodist Church Centre Care & Research Society Blood Bank, Nadiad, Gujarat, India
The primary responsibility of a Blood Transfusion Service (BTS) is to provide safe, and ensure to build and maintain a pool of safe, voluntary non-remunerated blood donors and take all necessary steps to ensure that the products derived from donated blood are efficacious for the recipient, with a minimal risk of any infection that could be transmitted through transfusion.
Materials and Methods: Blood units collected over a period of ten years, ie, 1 st January 2004 to 31 st December 2013 period were studied in a voluntary blood bank for the type of voluntary donation, number of seroreactive cases and the distribution of infections among the donors. All voluntary donated blood units that underwent only ELISA testing were included in this study. Fourth Generation HIV testing was carried out since the year 2007.
Results and Analyses: Out of 14,512 voluntary blood units collected, 17 (0.11%) were seroreactive for HIV, 92 (0.63%) were seroreactive for HBsAg, 31 (0.21%) were seroreactive for HCV and 6 7(0.46%) were seroreactive for Syphilis. An increasing trend of HBsAg and VDRL seroreactive units over the years have been identified. There is quality system thru education and training the staff to ensure the collection of donations from the lowest risk donors possible, with consideration given to the issue of sufficiency, balancing any risk of infection against the risk of blood shortages resulting from too stringent selection.
Conclusion: The BTS should provide clear and unambiguous guidance for the social workers involved in donor selection. The donors should be in good health at the time of donation and free from infections transmissible by blood and hence rigorous donor selection should be consistently applied to all blood donors either donating whole-blood, whether first-time or repeat donors. Selecting low risk donors, getting the right balance between safety and sufficiency is important in Blood Transfusion System.
Is RPR still valid as screening test for syphilis?
NR Ramesh Kumar, S Shanmugam
Lifeline Blood Bank & Research Centre, Tirunelveli, TN, India
Background: In India as per Drugs and Cosmetic Act the Mandatory tests for syphilis is VRRL/RPR (non-treponemal) before transfusion. This study aimed to compare the non-Treponemal test (RPR) vs Treponemal tests (ELISA).
Materials and Methods: A total of 4,560 voluntary blood donors samples were tested for syphilis by RPR (IMMUTREP) and by ELISA (Trepolisa 3.0- 3 rd generation ELISA kit to detect IgM, IgG and IgA treponemal antibodies).
Results: 75 of the donor's were repeatable reactive by ELISA method and 52 donor's were initial reactive by RPR method. All the ELISA positive sample was confirmed by TPHA method. Of the 75 reactive by ELISA method only 54 was reactive by RPR method, again retested for the 21 negative samples by same RPR reagent and found that 4 sample were reactive. In the 52 reactive samples by RPR method we found only 47 (90.4%) was reactive by ELISA method.
Conclusion: We found that 17 (22.7%) samples were false negative and 5 (9.6%) samples were false positive by RPR method. We found that 4 sample initially negative by RPR was due to improper rotation and timing. If we perform ELISA method for syphilis it will be easy to keep the print out of the ELISA reading, where as for RPR it is not possible. So we concluded that ELISA can be considered as a suitable test for screening of syphilis and should be made mandatory.
Notification of reactive transfusion transmitted infection screening results; turnout, follow-up and unaddressed issues
Rahul Chaurasia, Shamsuz Zaman, Kabita Chatterjee
AIIMS, New Delhi, India
Background: Transfusion safety begins with healthy donors. Fundamental part of preventing transfusion transmitted infections (TTI) is to notify and counsel reactive donors. Donor notification and counselling protects health, prevents secondary transmission of infectious diseases and provides feedback about the effectiveness of donor selection process.
Aims: To determine donor response rate following notification of reactive status and to assess prevalence of TTI among blood donors.
Materials and Methods: A total of 1,13,014 donations were screened for TTI viz. HIV, HBV, HCV and syphilis by serology (ELISA) along with individual donor Nucleic acid testing (ID-NAT). All reactive donors who gave consent were notified about their TTI reactive status by telephone or letter. Donors who reported back to the transfusion facility were retested and if found repeat reactive were referred to to Integrated counseling and testing centers for HIV, gastroenterology for HBV/HCV and STD clinic for syphilis for further confirmatory testing and management.
Results: We evaluated 2838 (2.51%) cases with reactive screening test results (1.38% HBV, 0.54% HCV, 0.27% HIV and 0.32% syphilis). Only 23.3% donors (662) responded to notification. The response among voluntary donors was better as compared to replacement donors (43.6% vs. 21.2%). Only 373 (56.3%) responsive donors followed their first attendance at referral specialities. Over six months, only 176 (6.2%) donors were undergoing treatment.
Conclusion: Transfusion safety rests heavily on the health of blood donors. Donors should undergo optimal pre-donation counselling so as to educate them about risk of TTI. It is the collective duty of transfusion facility to inform donors, allay their anxiety about reactive result and to advise them accordingly. There is also an urgent need to formulate nationally acceptable guidelines for notification and follow-up of reactive donors.
Evolving internal quality control strategies for transfusion transmitted infection (TTI) testing in blood bank: Our experience and lessons learnt
Mamta Mishra, Shweta Gupta, Rajesh Sawant, Anand Deshpande
P D Hinduja Hospital MRC, Mahim, Mumbai, India
Background: It is necessary to implement internal quality control(IQC) procedures as per good lab practices for continous and concurrent assessment of laboratory work and to ensure the correctness of the released results.
Aim: To study the feasibility of implementing robust IQC system capable of monitoring routine test performance as well as identifying errors due to other factors affecting the test results in our TTI laboratory.
Materials and Methods: Levey Jennings plot for manufacturers controls is used for routine quality analysis of our TTI tests. We prepared "In-house" control sample by dilution of positive sample and aliquoting them at an OD just above the cut-off OD of the kit control. Commercial, third party control was also run along with the kit and In-house control. The laboratory mean and its %CV was calculated for each control and were compared with each other. A note of any change in reagent, equipment (including trouble shooting details) and staff performing the test was done. LJ chart was plotted and interpreted as per Westgard's rules.
Results: Violation of Westrgard's mandatory rules was observed on 6 occasions with the kit control, 21 times with In-house control and 11 times with the commercial control. The lab mean for commercial control was found to be the most sensitive amongst the 3 controls in case of HBV and HCV testing. The monthly range of %CV for controls was 2.1% to 19.92% in HBV, 1.25% to 6.7% in HCV and 1.2% to 28.6% in HIV testing. The change in %CV correlated with changes in reagent lot.
Conclusion: Implementation of IQC in TTI testing is feasible. Atleast one additional control should be included along with the manufacturers control for early identification of changes in kit performances.
A two and half year study on Syphilis EIA II total antibody screening in the blood donor of a superspeciality hospital blood bank in Guwahati, Assam. First time in North-East India
Rupankar Sanyal, Deepa Bhuyan, DN Sarma
International Hospital, Guwahati, India
Introduction: Syphilis is a disease caused by a gram negative spirochete called Treponemapallidum. This spirochete is very thin, helicoidal and can live for 24-48 hours in blood. Blood transfusion is a potential route of Syphilis infection. It is a mandatory test in donor screening as per Indian drugs and cosmetics rule 1945, Schedule F Part XIIB. There are generally two types of Indirect diagnosis, that is Serology test, one non-treponemal test such as RPR, VDRL etc. and the other is treponemal test which can detect specific antibodies or anti- T. pallidum IgG, IgM and IgA.
Aim: In North-east India majority of the blood banks are doing Non-treponemal testthat isRPR orVDRL. Last two and half years, we are doing treponemal tests using BIO-RAD Syphilis EIA II Total Antibody. Our aim is to analyze the efficacy and dependability of EIA II total antibody testing in managing syphilis in the male replacement blood donor.
Materials and Methods: This study was conducted in the Blood Bank, International Hospital, Guwahati, Assam on 16,432 blood donor units from the month of January 2012 to August 2014.Therearethree recombinant antigens in a sandwich test which will detect T. pallidum specific IgG, IgM, and IgA. That means it detects antibodies in all stages of infection. The plastic wells are coated with a mixture of recombinant antigen. Specific antibodies in serum or plasma specimens combine with these antigens and with the same antigens conjugated to horseradish peroxidase, when conjugate is added to a well in which the specimen has been incubated. After unreacted materials has been removed by washing, the presence of bound enzyme indicating the presence in the specimen of specific antibodies is revealed by a colour change in the substrate-chromagen mixture. The intensity of the colour is compared to that in control wells to determine the presence or absence of specific antibody.
Result: From our study we found that percentage of Syphilis reactive blood unit is higher than the national percentage. Out of 16,342 unit of blood donation 309 units are found syphilis reactive That is 1.9% blood is syphilis reactive. From our study we found that the number of reactive sample is very high in Male Replacement Blood Donation. 276 male replacement blood donors were found reactive, which means 3% of Male replacement blood donor were reactive. We found 0.75% syphilis reactive in Female Replacement Blood Donor. There is 0.31% reactive in Voluntary Female Blood Donor. InVoluntary Male Blood Donor only 0.4% is syphilis reactive. From the year wise study it is found that Syphilis reactivity has slowed down from the year 2012 to 2014. In the year 2012 it is 2.07% and in the year 2013 it is 1.81% and now in the year 2014 it is come down to 1.73%.
Conclusion: The Treponemal tests are very specific and sensitive. It detects antibodies in all stage of infection including early and later stages. It was found that 2.07 to 1.73% of blood donation showed reactive in Syphilis EIA II total antibody testing. In our opinion total antibody testing for syphilis is needed for proper donor screening to practice safe blood banking. The study also reveals the safety of voluntary blood donation over replacement blood donation. 98% of the reactive units were the replacements type. The percentage of reactivity in both voluntary and replacement donors much more among male donors.
A study of hematological changes in malaria
Upasana R. Panchal, Ina Shah, Hansa Goswami, RN Gonsai
Department of Pathology, BJ Medical College, Civil Hospital, Ahemedabad, Gujarat, India
Background: In tropical countries like India, malaria remains a major health problem. The aim of this study was to assess the hematological changes which occur in different types of malarial infection, as it causes' significant complication. The hematological abnormalities that have been reported are anemia, thrombocytopenia, leucopenia, monocytosis, and eosinophilia. Majority of the complications are due to malarial consequences in high parasiteamia. Hematological changes play a key role in these lethal complications.
Objective: This study was conducted to estimate the predominance and severity of hematological changes in malarial infection.
Materials and Methods: This retrospective study included 200 cases diagnosed as malarial infection that were admitted in tertiary health care center, during the time interval of June 2011-September 2013. The diagnosis of malaria was confirmed on peripheral smear by thick and thin film stained slides with leishman's stain and antigen test (HRP2). Complete blood count (CBC) was done using automated CELL-DYNE 3700 counter.
Result: Amongst the 200 cases of malaria studied, 38% of the patient had plasmodium falciparum infection, were as 62% suffered from plasmodium vivax infection. 78% of the patient had thrombocytopenia, 76% of the patient had anemia, 18.50% of the Patient had leucopenia, 17.50% of the patient had monocytosis, 8.50% of the patient had eosinophilia. Basophil count were within limit. The incidence and severity of thrombocytopenia was slightly more in plasmodium falciparum infection than in plasmodium vivax.
Conclusion: Plasmodium falciparum as well as plasmodium vivax can cause significant hematological changes with high incidence of thrombocytopenia, anemia, leucopenia and monocytosis. Though the prevalence of thrombocytopenia is more in infection of plasmodium falciparum than in plasmodium vivax.
Enhancing blood safety through nat: The first blood bank experince from Eastern India
Sudipta Sekhar Das, Tirtha Pratim Sardar
Department of Transfusion Medicine Apollo Gleneagles Hospitals, Kolkata
Background: Transfusion-transmitted infections are a major problem associated with blood transfusion. Nucleic acid amplification testing (NAT) is not yet obligatory in India for blood donor screening. The primary benefit of NAT is the ability to reduce residual risk of infections by preventing window period (WP) donations.
Aims: Here we share our experience of screening our blood donors by The Roche cobas TaqScreen MPX Platform.
Materials and Methods: All btood donations between 23 November 2013 and 17 July 2014 and non-reactive for HBsAg, anti-HlV 1 & 2 and anti-HCV by CLIA were included in the study. NAT, for HBV-DNA, HCV-RNA and HIV-RNA in the minipool of 6 samples was performed using the Roche cobas TaqMan MPX assay. Individual sample of each positive pool was tested subsequently in the same platform. Each positive sample was then sent to referral PCR laboratory for the viral discrimination and quantitation. Sample positive for hepatitis-B virus (HBV) DNA was further screened for anti-HBc antibody & antibody to HBsAg (anti-HBs). All results were documented & recorded as per the SOP.
Results: Of the total 5681 blood donations during the study period, anti-HCV, HBsAg and anti HIV by CLIA were detected in 31 (0.54%), 28 (o.49%) and 11 (0.2%) donors respectively. A total of 5607 samples were tested for NAT of which 3 (0.05%) donors were found to be carriers of HBV DNA each with a viral load of <6 lU/ml. The NAT yield was observed to be 1 in 1869 donations. All these 3 NAT positive donors were sero-reactive for anti-HBc and 2 of them have developed borderline reactive anti-HBs antibody.
Conclusion: Introduction of NAT has successfully identified pre-serocoversion infectious blood donors and occult hepatitis B. Despite its cost effectiveness issues NAT will be a standard of blood donor screening in the future. With the implementation of NAT in our blood centre we could save 9 patients who would have otherwise received the infected blood components.
Seroprevalence of TTI infections in blood donors and role of strict donor selection criteria in reducing the blood discard due to Anti-HBc core positivity in a tertiary care hospital in Western India
Sunita Tulsiani, Anna Thomas, VP Antia
Breach Candy Hospital Blood Bank, Mumbai, Maharashtra, India
Background: Transfusion Transmissible Infections are a major challenge to the transfusion services all over the world. Two key strategies used to protect the blood supply are pre-donation donor assessment and laboratory testing of donations.
Aim: To determine the seroprevalence of HBsAg, HCV, HIV, TPHA and Anti HBc in blood donors at a blood bank of tertiary care hospital.
Materials and Methods: A retrospective study was done in the Department of Transfusion Medicine, Breach Candy Hospital, Mumbai from January 2009 to August 2014. All donors were selected as per the SOP based on Drug and Cosmetic Act and DGHS guidelines. As per SOP, donors with Hepatitis B and C were permanently deferred. Other donors with history of jaundice were deferred for 3 years after eliciting detailed history. However, for the past 2 years, this deferral period for jaundice was increased to 5 years. TTI testing was done by Abbot AXYSM till 2013 and later by ARCHITECT Chemiluminiscent microparticle immunoassays. Syphilis was done by RPR till 2013 and later by immumno-chromatographic assay.
Results: A total of 8416 donors were screened during the study period. The percent seroprevalence of HBV was 0.64, HCV was 0.79, HIV as 0.16, syphilis was 0.14, and Anti HBc was 7.6. It was observed that whenever HBsAg was reactive, Anti HBc was also reactive. By increasing the deferral period of jaundice from 3 years to 5 years, the discard due to anti HBc antibody was decreased from 9.4 to 6.6%.
Conclusion: The seroprevalence of TTI at our blood bank is low as compared to the National Prevalence. The low prevalence maybe due to the stringent criteria for donor screening and pre-donation counseling by a trained blood bank counselor. By following strict selection criteria for jaundice, discard due to anti-HBc core positivity was decreased.
Prevalence of HIV-I/II, HCV, HBs Ag and in blood donors of western region in India
Nirav Patel, Mamta Shah, Sangita Shah, Tarak Patel, Nidhi Bhatnagar, MD Gajjar, Nirav Patel
Department of Immunohaematology and Blood Transfusion, Civil Hospital, Ahmedabad, Gujarat, India
Introduction: The discovery of transfusion-transmitted infections (TTIs) has heralded a new era in blood transfusion practice worldwide with emphasis on two fundamental objectives, safety and protection of human life. Human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) are of great concern because of their prolonged viraemia and carrier or latent state. Knowing the prevalence of these viruses among blood donors will explain the extent to which these infections are present in India. Additionally, identifying safety issues in blood donation procedures will guide health actors to urgently develop and implement efficient strategies for ensuring blood safety.
Aims and Objective: To investigate the prevalence of HIV-I/II, HCV, HBs Ag and syphilis and co-infection in voluntary and replacement blood donors.
Materials and Methods: A prospective and retrospective study was done in the Department of IHBT, BJMC and Civil hospital Ahmedabad during January 2010 to October 2014. Donors were selected according to standard criteria recommended by National Aids Control Organization.
Result: In the present study, out of total 132257 blood donors, 131050 (99.08%) were males and 1207 (0.91%) were female which shows predominance of males as compared to females for the two studied years. The overall seroprevalence rate of HIV, HBV, HCV and syphilis was 12.45%, 47.82%, 20.35% and 19.38% respectively.
Discussion: The prevalence of TTIs among the Indian blood donors is reported to be ranging as follows; HBV −0.66% to 12%, HCV −0.5% to 1.5%, HIV −0.084% to 3.87%, and syphilis −0.85% to 3% respectively and in our study prevalence are HBV −0.78%, HCV −0.33, HIV −0.21, and syphilis −0.34% that are similar to other study.
Conclusion: Blood is still one of the main sources of transmission of hepatitis B, hepatitis C, HIV, and syphilis. Hence, strict selection of blood donors with the emphasis on getting voluntary donors and comprehensive screening of donors for TTIs using standard methods are highly recommended to ensure the safety of blood for recipient.
Glinically significant alloantibody to Lewis antigen: A potential cause of delayed hemolytic transfusion reaction
Lakshman Chandra, Sudipta Sekhar Das, Lakshman Chandra Ghosh
Apollo Gleneagles Hospitals, Kolkata, India
Background: Lewis antigens are produced by tissue cells, secreted into body fluids and then absorbed onto red cell membrane from plasma. There are three main Lewis phenotypes viz. Le (a+b-), Le (a-b+) and Le(a-b-). Lewis antibodies (anti-Le a and anti-Leo) are usually naturally occurring, predominantly of lgM class and are generally produced by Le (a-b-) individuals. Clinically significant antibodies to Lewis antigens reacting at 37 ° C are seldom encountered.
Aim: Here we share our experiences of managing two severely anaemic patients immunized with clinically significant anti-Le" alloantibody.
Materials and Methods: Two multi-transfused patients with symptoms of anemia and denied blood transfusions elsewhere visited our hematology out-patient department. In the current admission the treating physician immediately advised blood transfusions and due blood samples and completed requisitions were sent to the blood bank. Detailed immunohematological work-up has been performed as per departmental protocol.
Result: Though no blood group discrepancies were noted but anti-Lea antibody was detected using commercial panels in both the patients. Blood group of both the patients was "A" positive (Al subgroup). Interestingly in both the alloantibody had a wide thermal amplitude with decreasing agglutination strength (37 ° C > 22 ° C > 4 ° C). Both the patients revealed Le (a-b-) phenotype using special commercial Lewis antisera. In the first case when 10 group specific donor units were typed for Le a phenotype, 6 were found negative for Le a antigen. For the second old lady 5 Le a antigen negative units were obtained from a total of 10 group specific donor units. Presence of lgG class of Anti- Le a was confirmed using 0.01M dithiothreitol (DTT) treated serum.
Conclusions: Correct antibody detection enables to issue the patient the corresponding antigen negative blood and prevents further in vivo hemolysis and enhances significantly the therapeutic benefits.
Reviewing the blood cross-match ordering practices for elective surgeries at Dhiraj General Hospital: A tertiary care center
Shivangi Patel, Ashu Dogra, Purva Shinde, Komi Vyas, Rakesh Tandon
SBKS Medical Institute & Research Centre, Vaghodia, India
Background: There is always prior demand of blood and its products for patient undergoing elective surgeries which frequently overshoots the actual need resulting in unnecessary crossmatching.
Objective: Our primary aim was to audit the blood utilization in elective surgeries in our hospital over a period of 6 months and recommend a blood ordering schedule.
Materials and Methods: A retrospective study of patients who underwent elective surgeries over a period of 6 months (January 2014-June 2014) was done. The data collected include type of surgeries, number of units crossmatched and transfused. Thereafter crossmatch to transfusion ration (C:T),Transfusion probability (%T) and Transfusion index (TI) were calculated. We propose a blood ordering schedule based on surgical blood ordering equation.
Results: Total 1980 units were crossmatched for 960 patients but only 605 units were transfused to 450 patient i.e. 30% of the cross matched blood were utilized. The overall C/T was 3.2.
Conclusion: This study showed that requests for blood and its components were in excess of their utilization. Hence we recommend a save policy for these elective surgeries. Blood ordering schedule would provide an efficient way of blood utilization and better management of resources.
Resolution of difficulty in compatibility testing in a case of AIHA by DTT treatment of serum
Debapriya Basu, Krishnendu Mukherjee, BiplabenduTalukder, Suvro Sankha Datta
Medical College & Hospital, Kolkata, India
Background: We used to receive blood samples from AIHA patients for problem in compatibility testing. AIHA patients develop cold/warm autoantibody in their serum. These antibodies cause group discrepancy and problem in cross matching. Cold auto antibodies are generally IgM in nature.
Aim: DTT (Dithiothreitol) cleaves intermolecular disulfide bonds of IgM rendering the pentameric structure of IgM intomonomer and IgM becomes functionally ineffective.
Materials and Methods: 12 year old female patient presented with fever and cola coloured urine for seven days after receiving one unit AB+ PRBC. The patient was managed as a case of acute haemolytic transfusion reaction and the case was referred to us. We got the patient's blood sample and a blood group discrepancy was detected. Forward and reverse group showed AB+ and Bombay respectively. The discrepancy was resolved after warm saline wash of RBC and heating the serum at 37 degree Celsius for 30 minutes. In tube grouping blood group was O+. But several O+ units were found incompatible in tube method. The serum was treated with equal amount 0.01 (M)DTT for 30 minutes at 37 degree Celsius. One positive control was taken with patient's serum plus phosphate buffered saline along with the compatibility testing with DTT treated serum.
Results: After treatment of the serum with DTT it showed compatibility with O+ units. But the positive control (serum with PBS) did not show compatibility.
Conclusion: The abnormal IgM auto antibodies in the patient's serum were interfering in cross matching. The disulfide bonds of IgM molecules were cleaved by DTT which resolved the problem in compatibility. Thus treating the serum with DTT is a rational approach and should be initiated to resolve the problem of compatibility testing in presence of cold IgM autoantibodies.
Blood group resolution
Resolution of difficulty in compatibility testing
HLA antibodies screening of healthy donors using microlymphocytotoxicity test
Rinku V. Shukla, Tanvi Patel, Snehalata C. Gupte
Surat Raktadan Kendra and Research Centre, Surat, Gujarat, India
Background: Febrile non-hemolytic transfusion reactions (FNHTRs) may be due to antibodies against Human leukocyte antigens (HLA) in donor. They can trigger transfusion related acute lung injury (TRALI).
Aims: To determine prevalence of HLA antibodies in healthy donors of Surat.
Materials and Methods: A cell panel was prepared from 20 donors regularly donating blood. HLA A and B typing was done using Microlymphocytotoxicity (MLCT) test and used to detect HLA -A and B antibodies. The study included 511 donors. Their age, history of transfusion, obstetric history in female donors etc were noted. The serum samples were frozen at −30 ° C in 20 different aliquots for screening each sample with HLA panel cells. Lymphocytes were separated using density gradient technique and cryopreserved in liquid nitrogen and thawed when used. Cell viability was checked using trypan blue. The MLCT test was performed in Terrassaki plates. The reaction was scored (score 6 as positive and 8 as maximum positive) based on cell death in each well observed under phase contrast microscope.
Result: Out of 511 donors 340 were male and 171 female. Positive with score of 6 were 30/340 (8.8%) in males and 31/171 (18.1%) in females and score 8 was observed in 4 males (1.1%) and 7 females (4%).
Conclusion: The study observed higher inc
Bombay blood group: A case report from Chattisgarh, India
Prerna Mohan, Akhilesh Bhave, Rupma Ruha
Apollo Hospitals, Bilaspur, India
Background: Individuals with the rare Bombay phenotype (hh) do not express H antigen, the antigen which is present in blood group O. As a result, they cannot make A antigen or B antigen on their RBC, because A antigen and B antigen are made from H antigen. For this reason people who have Bombay phenotype can donate RBCs to any member of the ABO blood group system, but they cannot receive blood from any member of the ABO blood group system, but only from other people who have Bombay phenotype. Oh 1 or the Bombay blood group, is a rare blood type. This blood phenotype was first discovered in Bombay, in India, by Dr. Y. M. Bhende in 1952. This very rare phenotype is generally present in about 0.0004% of the human population, though in places such as Mumbai, locals can have occurrences as much as 1 in 10,000 of inhabitants and 1 in a million people in Europe. Given that this condition is very rare, any person with this blood group who needs an urgent blood transfusion will probably be unable to get it, as no blood bank would have any in stock.
Aim: It is very important, in order to avoid any complications during a blood transfusion, to detect Bombay phenotype individuals because the usual tests for ABO blood group system would show them as group O. Since Anti-H immunoglobulins can activate the complement cascade, it will lead to the lysis of RBCs provoking an acute hemolytic transfusion reaction. The confirmatory test for Bombay groups by using Anti-H lectin.
Materials and Methods: Apollo Hospitals Bilaspur is a 300 bedded largest tertialry care centre in Chattisgarh. A case of Bombay Blood group was admitted in our Hospital on 1-6-14. The patient was a young boy, 18yr old admitted with RTA with a Hb of 5.6 gm/dl. His Blood group came as "O" positive but was incompatible with O positive blood. The immune antibodies status was positive. Further testing of Red cells with Anti-H lectin confirmed the Blood group as "Oh", Rh positive. Not having the compatible blood in Blood Bank we started searching for Bombay Blood group compatible units for the patient. The patient belonged to Rajnagar colliery in Sidhi Daffai area of Anupur, Madhya Pradesh, and had a big family of three sisters. His father, sister and brother in law tested positive for Bombay Blood group and donated Blood. All of them belonged to the same area. Ultimately the patient was transfused with two units of Blood and discharged in a fit condition.
Result: This was our second case of Bombay Blood group, the first being in 2006 where a child was admitted with congenital heart disease, and was found to be case of Bombay Blood group. He also was a resident of Chttisgarh. His sister was the only one of 6 siblings who was found to be Bombay Blood group. He was however operated at Narayan Hridalaya with the help of a local NGO and is in a fit and fighting condition now.
Conclusion: A lot of NGO and websites are working on this but a nation wide directory for Bombay Blood group is the need of the HOUR.
Cold agglutinins: A clue to diagnosis?
A Yashovardhan, Ch Srinivasa Rao, Aparna Sharma
Narayana Mediclal College & Hospital, india
Cold agglutinin disease (CAD) is a subgroup of autoimmune hemolytic anemia (AIHA). This is usually associated with cold reactive autoantibodies. Pseudoneutropenia or low leukocyte count secondary to leukoagglutination is caused by ethylene diamine tetra acetic acid (EDTA) or cold agglutinins seen in benign and malignant disorders. In this paper, we report a case of secondary CAD due to Mycoplasma pneumonia in a 34 year old female patient who was admitted to hospital with fever, vomiting, respiratory distress and productive cough. As a part of routine investigation patient sample send to hematology for grouping. Forward grouping by tube method showed AB positive and reverse grouping showed agglutination with pooled A, B and O cells. Cold antibody test and direct coombs' test were positive. Observation of sample revealed autoagglutination. Prewarming of the sample, washing cells with warm saline and incubating reverse grouping tubes at 37 ° C resolved group discrepancy. Complete blood count (CBC) performed in three part automated hematology analyzer on sample collected in EDTA same day, revealed low hemoglobin level of 11.6 gm/dl, white blood cell (WBC) count of 5.9 × 10 9 /L and neutrophils of 0.5 × 10 9 /L. Peripheral smear shows leukocytes in clusters. We ask for sample in citrate anticoagulant, the CBC showed WBC count of 5.9 × 10 9 /L and neutrophils of 0.5 × 10 9 /L. Observation of sample revealed autoagglutination. At this time sample collected in pre-warmed EDTA tube, CBC showed WBC count of 5.3 × 10 9 /L and neutrophils of 3.9 × 10 9 /L. The patient was treated accordingly and get relieved from the symptoms. The specific problems that occur in the blood bank or laboratory due to cold agglutinins need to be kept in mind for the accurate diagnosis and treatment of the patient.
Alloimmunization with multiple antibodies in a multigravida pregnant female and neonatal outcome: A case report
Sachin Garg, Ashish Jain, S Prabakaran, Neelam Marwaha
Department of Transfusion Medicine, PGIMER, Chandigarh, India
Background: Hemolytic disease of fetus and newborn (HDFN) is a major cause of perinatal morbidity and mortality. We report a case of alloimmunization with multiple antibodies in a 35-year old multigravida female who visited our institute's antenatal clinic at 10 weeks of gestation. She had fetal hydrops or still births in previous six pregnancies, but never had a blood transfusion.
Aims: To detect and identify the alloantibodies.
Materials and Methods: Blood grouping (ABO and RhD), extended Rh phenotype (C,E,c,e) and antibody titration were performed using tube technique. Antibody screening, identification and direct antiglobulin test (DAT) were done using gel technology (Diacell, Diapanel and LISS-Coombs AHG cards, Biorad, Switzerland).
Results: Thepatientwas B RhD negative and her husband O RhD positive. The patient had anti-D, -C and -Fy b alloantibodies reactive in the AHG phase, thus clinically significant. She was negative for the corresponding antigens while her husband was positive for these three antigens. The anti-D titer was 1024. During the first intrauterine transfusion (IUT) at 21 +3 weeks, using O RhD negative packed RBCs (C and Fy b antigen negative) compatible in AHG phase with the patient's serum, the DAT on the fetalpre-IUT sample was 4+ and blood group O RhD positive. Thereafter, four more IUTs were performed. She delivered at 36 +3 weeks of gestation. The neonate had healthyindices: APGAR score- 8/9, birth weight- 2.4 kg and Hb- 14 gm/dL. The DAT of the neonate was negative, but the total serum bilirubin (TSB) was 10 mg/dL at 8 hours of life for which a double volume exchange transfusion (DVET) was performed and then he was discharged on day 12.
Conclusion: Antibody screening of pregnant females, especially those with bad obstetric history is significant for ensuring maternal and fetal monitoring during the antenatal period and giving appropriate IUT support.
Hereditary persistence of fetal hemoglobin (HPFH); A case report
Mahesh Yadav, DC Sharma, Sachin Singhal, S Iyanger, S Rai, LokeshTripathi, Bharat Jain
Gajra Raja Medical College, Gwalior, India
Background: Hereditary persistence of fetal hemoglobin (HPFH) is a benign condition in which significant fetal hemoglobin (HbF) production continues well into adulthood, disregarding the normal shutoff point after which only adult-type hemoglobin should be produced. This is usually caused by mutations in the β-globin gene cluster The percentage of incorrect expression might be as low as 10-15% or as high as 100% of the total hemoglobin, usually higher in homozygotes than in heterozygotes.
Case: A 50 years male, father of a β-thalassemia major patient, reported having Fetal Hemoglobin, 94.90% without any symptoms while being investigated for his family status of thalassemia.
Family History: Wife is a known case of Thalassemia minor with the history of 3 miscarriages. Family has an 8 month live baby with Thalassemia major. Investigations: Father- Hemoglobin HPLC/ Electrophoresis- HbF-94.90%, Hb A - 2.60%, HbA 2, Others- 0.50%. Hb conc.-15.10 gm% with erythrocytosis (RBC count- 6.37 million/mm 3 ). Child- Hemoglobin HPLC/ Electrophoresis- HbF-91.60%, Hb A - 6.0%, HbA 2-2.1, Others- 1.30%. Mother- Reported as β-thalassemia minor.
Discussion: By 6 months of age, a shift from gamma globin to beta globin(HBB) gene expression occurs, reducing the amount of fetal hemoglobin (Hb F; α2 γ2) produced so that the major form of hemoglobin present is Hb A (α2β2). Although residual amounts of Hb F are produced throughout life, the majority of healthy adults have less than 1 percent Hb F. Hereditary persistence of fetal Hb (HPFH) results from mutations within the beta globin gene cluster that alter normal hemoglobins witching. Heterozygotes for HPFH-associated deletions typically have high levels of Hb F (up to 30 percent) with normal red blood cell indices while Homozygous or Compound Heterozygous, when two deletions associated with HPFH are identified, individuals typically have Hb F levels approaching 100 percent with mild erythrocytosis.
Conclusion: Present case is a typical example of homozygous Hereditary Persistence of Fetal Hemoglobin (HPFH).
Incompatible blood transfusion after in vivo cross match
Reeta Rai, Poonam Das
Max Healthcare, Saket, New Delhi, India
Background: In non emergency situations an 'In-vivo or Biological' cross match can be performed by cautiously transfusing 25-50 ml serologically incompatible Red Cells over 15 minutes by watching patient's clinical response. After 30 minutes of transfusion, post transfusion specimen is examined for hemoglobin tinged serum. Approximately 2.5ml of incompatible blood hemolysis in an average adult will impart a red hue to plasma. In-Vivo cross match can indicate whether an acute reaction will occur after transfusion of individual unit.
Aim: To assess whether incompatible unit can be transfused safely after In-vivo cross matching.
Materials and Methods: 74 years female admitted for Bilateral Knee replacement surgery. Blood Bank received request for 2 units of PRC transfusion. Patient Blood Group - 'O' Positive and antibody screening using three cells panel was Positive. DCT and Auto control-Negative. No unit was found compatible. As patient was not in need of urgent transfusion, after discussion with Doctor I/C and keeping in view that patient might require transfusion during surgery, in-vivo cross matching was performed. 25 ml of least incompatible blood unit issued with instruction to clinician for slow and cautious transfusion. Post transfusion sample of patient taken after 30 minutes.
Result: There was no change in colour of plasma of post transfusion sample of patient. Patient was taken to OT next day and during surgery patient required transfusion. Unit with which in-vivo cross matching was performed, issued and transfusion was completed successfully.
Conclusion: In difficult circumstances, clinical picture of the patient should drive the decision to proceed for transfusion and decision should be jointly taken by Clinician and Blood Bank. If time permits, in-vivo survival study of radio labeled aliquot of incompatible cells can be determined, but is not widely available and impractical. Lack of hemolysis observed in post transfusion sample after In-vivo cross matching suggests that a catastrophic hemolytic transfusion reaction is unlikely and remainder of unit can be transfused slowly. However such assessment does not guarantee normal survival of transfused RBCs.
Prevalence of Rh and Kell phenotype in west Delhi donor population
Mausumi Swami, Amit K, Mausumi Swami
Deen Dayal Upadhyay Hospital, New Delhi, India
Background: Rh is the most important blood group system after ABO. At present, Rh blood group system consists of 50 defined blood-group antigens. The most important of these antigens for mother-fetus incompatibility and transfusion problems apparently are D,C,c, E and e. When an individual is identified as being Rh+ or Rh-, it is usually is in reference to the D antigen. The Kell antigen system (also known as Kell-Cellano system) is a group of antigens which are important determinants of blood type. The K antigen is one of the most clinically significant amongst the 25 Kell antigens. These antigens are the third most potent, after those of the ABO and Rh blood groups, at triggering an immune reaction.
Aim: This study was aimed to analyze frequency of Rh and Kell phenotype in the various ABO group donor population of west Delhi while providing Rh and Kell phenotype matched ieuco-reduced packed red blood cells for thalassemia cases registered with this centre.
Materials and Methods: The study conducted during the period of 01 st March 2014 to 31 st July 2014 on 2869 donor units collected in the camps and inhouse collections. Rh and Kell phenotyping was done by column gel agglutination method.
- Out of 2869 donors 126 were RhD positive being 95.61%.
- In this study most common antigen were e (98.81%) followed by D (95.61%) C (87.52%), c (56.67%), E(19.93%) and K(2.37%)
- Kell antigen in B group is 2.8%, overall being 2.37% and 1.96% B negative donors.
- C (5.17%) in O negative donors.
- Rh and Kell phenotyping is significant in rare D Negative donor population as (1) Kell positivity found in B Negative donor(2) C antigen prevalence in 0 Negative donors.
- In multiple transfusion cases phenotype matched cross-match should be atleast performed to avoid alloantibody formation.
Adverse blood transfusion reaction
Hardi Patel, Jasmin Jasani, Rakesh Tandon, Swapan Goswami, Rakesh Pasale, Ashu Dogra
SBKS MI & RC, Vaghodiya, India
Background: 24 YR/F with vomiting and headache x 2 weeks and admitted here with serial blood cultures showed growth of coagulase-positive Staphylococcus and diagnosed as Infective endocarditis. Patient underwent mitral valve replacement surgery. Post-operatively two units of PCV were transfused. During the administration of the 2nd unit her fever increased (39.4 ° C), and developed hoarseness of voice and facial edema. Transfusion of the second unit was stopped after receiving approximately 50% of the product. She was immediately treated with 25 mg of IV Benadryl with resolution of her symptoms.
Aim and Objectives: The aim of this study was to know the basic steps required to workup an acute transfusion reaction and formulate a diagnostic differential for an acute transfusion reaction.
Materials and Methods: Blood samples as well as urine samples from patient. Blood samples to be sent for culture are also needed.
Results: This case provides an opportunity to review the overall management of acute transfusion reactions. An acute or immediate reaction is diagnosed when symptoms occur during the infusion of blood or blood components, or up to 1-2 hours after the infusion is complete.
Conclusion: The patient's underlying history and baseline febrile status, the above constellation of symptoms was attributed to a "moderately severe allergic reaction to the transfused pcv".
Extended antigen matching in addition to Coomb's crossmatch leading to rise of hemoglobin in a thallassemic patient
Richa Gupta, Rachna Narain, Sunita Bundas, Richa Gupta, Varun Capoor, Parmendra Pachori, Mamta Soni
Department of Immunohaematology and Transfusion Medicine, SMS Medical College and Hospital, Jaipur, Rajasthan, India
Background: Transfusion support for thallassemic children is a challenge to blood banks, especially when the formation of alloantibodies hinders the crossmatching performed at Coomb's phase. Crossmatching a number of units to find one compatible unit is the usual resort.
Aim: To report the case of a thallassemic child for whom number of units crossmatched to find one compatible unit increased gradually with a delayed hemolysis and drop in haemoglobin after 5 days of transfusion. Providing extended red cell antigen matched units helped in improving the haemoglobin level of this patient.
Materials and Methods: Antibody screening and identification was performed on an automated analyser. Anti c and anti E were identified in the patient's serum. On her next visit to the blood bank, blood units negative for c and E antigens were crossmatched and supplied.
Result: The transfusion was uneventful. A rise in haemoglobin concentration was observed which sustained even after 10 days of transfusion.
Conclusion: In the case reported here, the patient was benefited by provision of extended antigen matched blood over and above Coomb's crossmatch. Similar transfusion practice is recommended forall multiply transfused patients from the first transfusion itself. Availability of already antigen typed units in the inventory decreases turnaround time and resources to find a compatible unit.
An unusual naturally occurring clinically significant anti-n in a renal cell carcinoma patient: A case report
Arun R, Deepthi Krishna
Sri Venkateshwara Institute of Medical sciences, Trupati, India
Background: The clinically significant antibodies are those reactive at 37 ° C in vitro and/or those reactive in the antihuman globulin (AHG) phase. Antibodies to N blood group antigensare typically IgM cold agglutinin inactive above a temperature of 20-25 ° C and thus not considered to be clinically significant. Though rare, sometimes these antibodies can be of clinical significance when the antibody detected is reactive at 37 ° C and AHG phase. Here we present a case of naturally occurring anti-N antibody reacting at AHG phase in a renal cell carcinoma patient.
Case Report: A 67 years old male came with complaints of obstructive lower urinary tract symptoms since 2 years. He was diagnosed to have right Renal cell carcinoma for which partial nephrectomy was planned. There was no history of previous transfusion or dialysis. Two units of packed red cells were requested. His blood group showed discrepancy. Pretransfusion testing with several units showed incompatibility. Antibody screening and identification was done which showed presence of anti-N that was reacting at AHG phase. Compatible blood was transfused without any adverse event.
Discussion: Anti-N antibodies can be naturally occurring or produced after an immunizing event. Our case had a naturally occurring anti-N as they were no immunizing stimulus like previous transfusion or dialysis. They can generally be ignored in transfusion practice and, if room temperature incubation is eliminated, they will not be detected. When anti-N active at 37 ° Care encountered, antigen-negative or red cells compatible by an indirect antiglobulin test should be provided. Our report highlights that the naturally occurring anti-N can react at 37 ° C thereby making it clinically significant and also the importance of detecting the thermal amplitude of antibodies so that untoward reactions can be prevented.
Distribution of abo blood groups in blood donors in tertiary care unit hospital, Bhavnagar district
Manju Vala, MV Thaker, PH Shah, SK Suri
Government Medical College, Bhavnagar, India
Background: Blood groups of people are determined genetically by the presence of specific antigens on the red blood cells. Although almost 400 blood grouping antigens have been reported, the ABO and Rh is recognized as the major clinically significant blood group antigens. Finding out blood groups is important for blood transfusion, prevalence of different diseases, genetic studies etc. Which are also known to vary from one population to another.
Aim: This study was carried out to determine the frequency and distribution of ABO and Rhesus blood groups in blood donors of Bhavnagar district Blood Bank in Sir T hospital.
Materials and Methods: The present retrospective study was carried out at blood bank, Sir T hospital, Bhavnagar. The study includes blood donor of age between 18-60 years. The distribution of ABO and Rh blood groups was studied among 47418 blood donors from period of January 2008 to June 2013.After blood donation, blood group was determined by forward and reverse blood grouping. Final blood group is confirmed only if both forward and reverse groups are identical. Rh negative blood groups were confirmed by antiglobulin technique. All weak D groups were considered as Rh positive.
Results and Discussion: Total 47418 donors were studied. Voluntary donors were 29622 (62.46%) and 17796 (37.53%) were replacement donors. Male to female ratio was 14.3:1. Most common blood group found was B (35.8%) followed by O (31.34%), A (23.57%)and AB (9.29%). No Bombay phenotype was detected. Total Rh positive were 93.85%and Rh Negative were 6.14%.
Conclusion: In the present study, commonest is 'B'blood group. This is followed by 'O', 'A' and 'AB' blood group. Regarding Rhesus blood group system Rh Negative were only 6.14%.
Red cell alloimmunization in repeatedly transfused patients
Dimel Bhuva, JH Vachhani
Department of IHBT, Government Medical College, Jamnagar, India
Introduction: Repeated Blood transfusions can result in the production of alloantibodies against one or more red cell antigens, which complicates subsequent transfusions. Antibodies must systematically be identified in the recipient's serum before every transfusion so that compatible blood can be provided. Otherwise problems might occur which sometimes could even threaten the patients' life.
Aims and Objective: The study was carried out to find out incidence of various red cell alloantibodies as well as auto-antibodies; to determine the type of antibody; to identify the factors such as frequency of transfusion, splenectomy status, donor ethnicity and gender and their association with the development of antibody in repeatedly transfused patients.
Materials and Methods: This prospective study was carried out for duration of 2 (two) years i.e. Aug 2011-July 2013 in Dept. of IHBT, Shree M. P. Shah Medical College, Jamnagar, Gujarat. Blood was taken from the patients of thalassemia major, sickle cell disease, chronic renal failure, Post partum hemorrhage, Aplastic anemia, Myelodysplastic syndrome with more than 10 red cell transfusions. The plasma/serum was used for antibody screening and antibody identification test. Three cell antibody screening was performed using antihuman globulin gel cards (ID-Card LISS/Coombs) and three cell panel (ID-DiaCell I,II,III-Asia). Those with positive antibody screening were analyzed further for antibody identification test using eleven cell panel (Set ID-Dia Panel).
Results: Antibody screening and identification was done in 2 consecutive set of samples (N = 300) which showed, nine (9) patients (3%) were alloimmunized. All repeatedly transfused patients had developed alloantibody before the starting of study period, no patient developed new alloantibody during study period.
Conclusion: Red cell alloimmunization should not be overlooked in repeatedly transfused patients. It should always be considered if the patient repeatedly suffers from haemolytic transfusion reactions, difficulty in finding compatible blood during cross match or patients not able to maintain haemoglobin at desired level in spite of regular transfusions. Alloantibodies should be identified and patients should be given corresponding antigen negative blood unit which will minimize the antibody mediated destruction of transfused red cells.
Prevalence of irregular antibodies to red cell antigens in donor population
Deepika Chenna, Shamee Shastry, Mohan Doss M
Department of IHBT, Kasturba Medical College, Manipal, India
Background: Screening of donor blood for presence of irregular antibodies to red cell antigens is done to avoid adverse reactions to recipients of plasma transfusion. Irregular antibodies can be naturally occurring or formed due to allo-immunization because of transfusion or previous pregnancy. They can be clinically significant (anti-Rh, anti-kidd) or non-significant (anti-M, anti-Le). The aim of this study was to study the prevalence of irregular antibodies among healthy blood donors.
Aim: To study the prevalence of irregular antibodies among healthy blood donors and their clinical significance.
Materials and Methods: Antibody screening of all blood donors is done using commercially available pooled cells (ID-Diacell pool from BIO-RAD)in our institution as part of routine testing. Those samples which came positive were identified using commercially available cell panels by column agglutination technique. Minor phenotyping of the donors for corresponding antigen was done. Data pertaining to age, gender, history of transfusion or pregnancy were all collected.
Results: Out of 26,804 donors screened for irregular antibody between January 2013 and August 2014, 15 (0.056%) donors were positive of which majority 14/15 (93.33%) had alloantibody and 1/15 (6.67%) had auto antibody. Among alloantibodies 92.9% (13/14) were naturally occurring and 7.1% (1/14) were immune mediated. Most frequent antibody was anti-Le a (4/14,28.6%). Others include anti-M, anti-Jk a],[ , anti-D, antiKp a . Antibodies status was indeterminate in 6 individuals of which 2 were against low incidence antigens and 4 against high incidence antigens. Prevalence was higher among female donors. All the antibodies were reacting at 37 ° C implicating their clinical significance.
Conclusion: 1 in 1785 donors had clinically significant antibodies. Hence adoption of sensitive and appropriate donor antibody screening technique is essential to prevent adverse transfusion reactions.
Strategies for donor red cell phenotyping based on prevalence of red cell alloantibodies: A study from tertiary care centre
Rajeshwari Basavanna, MP Chacko, J Mammen, SC Nair, D Daniel
CMC, Vellore, India
Background: Alloimmunization is a common complication of blood transfusion and pregnancy and is implicated in immunological adverse events related to transfusion. The prevalence of red cell antigens and alloantibodies vary among different populations. Data regarding their distribution and clinical consequence would help to take appropriate measures to minimize alloimmunization or prevent the complications.
Aim: The aim of this study is to determine the prevalence of alloantibodies in our patient population, and develop a strategy to minimize the risk of alloimmunization from transfusion initiation in high risk patients.
Materials and Methods: This is a retropective study of alloantibodies detected in our blood bank between 2008-2014 (September). Alloantibodies were identified using commercially available '11-cell' panel, after '3-cell' panel screeningwaspositive.
Results: Alloantibodies were detected in 253 (Male:87,Female:166) out of 2,000,27 subjects.139 were Rh negative (Male:38, Female:101) and 114 were Rh positive. The most common alloantibody identified in isolation in Rh negative subjects is anti-D (119/139, 85.6%). This was followed by a combination of Rh alloantibodies seen in 19/139(13.6%).These include 14 subjects with anti-D,C, 4 with anti-D,c and 1 with anti-D,C,E. In Rh positive samples Anti-E was the most common alloantibody noted in 48.3% (38.3% - single anti-E alloantibody and in combination with anti-c:10%). This was followed by Anti-Lea and Anti-M with 11.8% and 10.8% respectively. Discussion and
Conclusion: Anti-D continues to be the most common alloantibody identified in Rh-negative subjects while anti-E is most common in Rh-positive subjects. Substantial number of the study population had a combination of Rh alloantibodies implying a higher tendency to develop multiple alloantibodies after single antibody formation. Hence limited phenotyping of donor cells depending on the prevalence of alloantibodies should be considered in high risk group to minimize the risk of alloimmunization.
Serological red cell antigen phenotype in multiply transfused thalassemia patients: Comparison of pre and post transfusion phenotypes
Archana Tripathi, Priti Elhence, Lalit Dhantole, Anupam Verma, Prashant Agarwal
SGPGIMS, Lucknow, India
Background: Frequent Red blood cell (RBC) transfusions are necessary for management of thalassaemia patients. Alloimmunisation to RBC antigens is a major adverse effect of chronic transfusion therapy, and it can compromise the future transfusion care. Partial/extended red cell antigen phenotype matched RBC transfusions are recommended to minimize frequency of alloimmunisation. Phenotyping is also required for alloantibody specificity identification confirmation. This is usually carried out by classical serology techniques; however serological.
Aims: phenotype may not be the real phenotype in multiply transfused patients because of presence of transfused donor RBCor DAT + cells. To compare the extended red cell antigen phenotypes of 40 thalassemia patients before initiating the transfusion management to their serological phenotypes while on regular transfusions.
Materials and Methods: Forty thalassemia major patients (13 females/27 males, 2 to 22 years age) already phenotyped for red cell antigens before starting regular transfusion were enrolled in this study. These patients had received three to 161 RBC transfusions. Repeat extended RBC antigen phenotyping was done, compared to their original phenotypes and actual change was recorded. Phenotyping was done using commercially available monoclonal antisera and Antihuman Globulin Column Agglutination technology wherever relevant.
Results: Out of 40 patients 25 (62.5%) showed changes in Rh Cc and Ee antigens, 5(12.5%) showed changes in Kell K antigen, 32 (80%) patients in Kidd (Jk a],[b ), 22 (55%) patients for Duffy (Fy a],[b ) blood group system, 26 (65%) patients for M and N antigen and 18 (45%)for Ss antigen and 24 (60%) for Lewis (Le a],[b )blood group system from their original phenotype. DAT was positive in 8 (20%) of patients.
Discussion: The findings reaffirm the futility of use of serological phenotyping in multiply transfused patients, therefore we recommend extended phenotyping before embarking upon transfusion management orRed cell antigen genotyping in regularly transfused patients.
To study the prevalence of IgG subclasses (IgG1 and IgG3) in antenatal alloimmunized women in South India
Jui Choudhuri, MP Chacko, D Daniel
CMC, Vellore, india
Objective: To study the prevalence of IgG subclasses (IgG1 and IgG3) in antenatal alloimmunized women in South India and to correlate it with occurrence and severity of HDFN.
Materials and Methods: 85 antenatal women with a positive antibody screen were included. The antibodies identified and IgG subclass (IgG1/ IgG3) determined using the "DAT IgG1/IgG3 ID" card from DiaMed, BIO-RAD. Newborns were classified as "HDFN Present/Not" and further categorized into Mild/ Moderate/Severe. Prevalence of IgG1/IgG3 subclasses calculated and data compared using Pearson's chi-square test. HDFN severity correlated with IgG subclasses antibody titre levels and DAT.
Results: Prevalence of IgG subclasses was 20%, 4% and 25% for IgG1, IgG3, and IgG1+IgG3 respectively. 51% had neither. Among 57 newborns at risk of HDFN, a significant difference between disease severity and absence/presence of IgG1/IgG3 - either singly or in combination (P < 0.001), significance persisted in low and intermediate antibody titre level groups (P < 0.001). Binary logistic regression analysis showed the odds of severe HDFN to increase an additional seven times stepwise, the lowest being in patients with neither IgG1/IgG3, to having either one of them, to having both these subclasses together (P < 0.05, CI between 1.5-31.89). Strength of DAT correlated significantly with disease severity (P < 0.001).
Conclusion: The prevalence of IgG1/G3 subtypes is 49% in our population. The presence of IgG1/IgG3 subclass impacts significantly on severity of HDFN. This impact is evident even in low titres. DAT strength correlated significantly with severity of HDFN. Mothers with IgG1 /IgG3 subclass positivity require closer antenatal monitoring in order to ensure appropriate and timely antenatal/perinatal intervention and closer neonatal monitoring. Our study identified IgG subclass as an independent prognostic marker for HDFN. This test can easily be incorporated into routine clinical practice. It also significantly impacts on quality of clinical care.
Antibody reactivity in antibody screening positive patients: Conventional test tube method v/s two gel micro-column assay
Nehal Chotaliya, Jyoti Bhatt, Sahjid Mukhida, Kamlesh Dharajiya
Rajkot Voluntary Blood Bank and Research Centre, Rajkot, Gujarat, India
Background: Allo-immunization is a common effect of transfusion for multiple transfusion patients in current scenario. AHG phase compatible blood is good choice for transfusion but their all antibodies reactivity is major important part for compatibility testing, but it is also depend on sensitivity of compatibility testing method.
Aim: To compare both (conventional test tube method-CTT and Gel micro-column Assay- GMA) method for allo-immunized patient on compatibility testing.
Materials and Methods: Patient's serum samples that contained an RBC alloantibody with a singular specificity were identified by routine blood bank workflow. Parallel titration studies were performed on these samples by both the CTT method and GMA (ID-Micro column System anti-IgG+C 3 d gel card, Bio-Rad Laboratories Pvt. Ltd and ID-Micro Column System anti-IgG+C 3 d Glass Beads card-BR, Ortho Clinical Diagnostics-OCD).we also study titers of IgG antibodies to A and B by both method.
Result: 3 samples were including 1- Anti-D, 1-Anti-E antibody and 1- A and B antibodies are selected. All three samples are tested by both methods in serial dilution. Anti-D antibody's agglutination is not shown in CTT even at first dilution but in GMA react till three dilution in OCD and four dilutions in BR. Anti-E antibody's agglutination is shown till two dilutions in CTT and five dilution in OCD and seven dilutions in BR by GMA. For a natural occurring antibody anti-A and anti-B agglutination are shown till four dilution in CTT and seven dilution in GMA.
Conclusion: The Bio-Rad gel method was found to be a rapid and reliable procedure without controls. There was no requirement of wash phase in indirect antiglobulin test and sensitivity and specificity was comparable to spin tube method and Ortho Glass beads GMA method for Rh and ABO antibodies.
Impact of identifying partial DVI in neonatal setting: Experience from a tertiary care hospital
Siddharth Mittal, Jui C, P Amalraj, MP Chacko, D Daniel
CMC, Vellore, India
Introduction: Partial D, of which DVI is considered the most immunogenic, should be identified in the donor population. This is by virtue of its ability to alloimmunize Rh negative individuals. Donors should be tested with Anti-D which detects DVI. This avoids Partial D donor's blood being transfused to Rh negative patients. It is equally important to identify neonates with Partial D to initiate appropriate Anti-D prophylaxis to prevent alloimmunization in Rh negative mothers.
Aim: To study the frequency of Partial DVI phenotype in newborns and blood donors.
Materials and Methods: All blood donor samples are tested on the Microtitre plate (DiaMed-MP-Test, BIO-RAD) which is DVI negative and Column Agglutination technique (ID DiaClon ABD confirmation card, BIO-RAD) which is DVI positive. Forward grouping was done for all neonates for the past two months using the tube technique and CAT DVI positive card.
Result: Among 683 neonatal samples of which 50 were Rh-negative, 1 neonate showed positivity on the DVI positive card and negativity on DVI negative card and tube technique. The frequency in our study was found to be overall 0.15% in the neonatal population and 2.0% in Rh negative neonates alone. Molecular typing is awaited. Among donors, on a denominator of 94,464 over a period of three years, we have not identified any Partial D positive sample.
Discussion and Conclusion: Over one month of implementing this protocol for newborns we identified one neonatal sample as Partial D positive. This is of immense significance in preventing sensitization of Rh negative mothers and helps in offering timely Anti-D prophylaxis. Therefore in the context of preventing HDFN in subsequent pregnancies of an Rh negative mother who has a baby with D variant, our present protocol seems appropriate and a suitable measure.
Red cell alloimmunisation in multitransfused patients: A study in a tertiary care hospital of eastern India
Ansuman Sahu, Smita Mahapatra, Binoy Bhusan Sahu, Pankaj Parida
SCB Medical College and Hospital, Cuttack, Odisha, India
Background: Red cell alloimmunization is common among the transfusion recipients. Alloantibodies can pose serious clinical problem like delayed haemolytic reactions in multitransfused patients. They can also cause cumbersome in routine red serology and finding compatible PRC unit for the recipients.
Aims: This study aimed at studying the prevalence of RBC alloantibodies and their association between clinical, environmental and genetic characteristics of the recipient of erythrocyte transfusions.
Materials and Methods: Blood samples from 99 patients having thalassemia major, sickle cell disease and hemato-oncological disease were analysed for a period of six month from April, 2014 to September, 2014. All the samples are screened for antibody by using 3 cell panel by Column Agglutination Technology (CAT), if it comes positive subsequently the antibody was identified by 11 cell panel. Indirect Coombs Test (ICT) using pooled 'O' cell was done in each sample.
Results: Out of 99 all only two (2.02%) patients developed alloantibody detected by commercial cell panels. Other 4 (4.04%) patients developed antibody which are positive for conventional ICT using pooled 'O' cell. The alloantibodies identified were Anti Le a (1.01%), anti c (1.01%).
Discussion: We concluded that the finding of this study was comparable with other published work. The study also mandates carrying out immunohematology studies prior to every blood transfusion especially in cases that require multiple transfusions for a long period.
Type and screen policy for high risk patients in India: Where are we?
Fortis Escorts Heart Hospital, Delhi, India
Introduction: Pre-transfusion testing involves blood grouping (ABO and Rh) and major cross match (testing the recipient's serum/plasma against the donor's red blood cells) at 37 ° C to detect IgG antibodies. In the western countries, type and screen policy is routinely followed. By immediate-spin cross-match, ABO and Rh compatible blood can be issued from inventory in less than 10 minutes.
Aim: This study was conducted to assess implementation of type and screen policy in standalone blood banks in India and to assess compromise on blood safety, if any?
Materials and Methods: The study was carried out at the Standalone Blood Bank (Regional Blood Transfusion Centre) of North India during the period Jan 2012 to Apr 2012. Study was carried out in parallel to routine cross match using DiaMed ® ID System Gel cards (Column Agglutination Technology). Antibody screening was carried on Qwalys3, Diagast ® based on erythrocyte magnetization technology using commercial cell panel.
Results: Total 354 patients were included in the study. 2 samples were positive on antibody screening. Cross match was incompatible in 2 cases, out of which 1 sample was negative on antibody screening. No case was found with antibody screen negative but AHG cross match incompatible Table 1 and Table 2.
Conclusion: This study concluded safety level of 100% in high risk category patients. Type and screen policy can be implemented in Indian settings with no compromise on blood safety provided sufficient technical and infrastructural support is available at the centre.
Prevalence of Rh and Kell phenotypes in voluntary blood donors of Delhi/NCR
Shikha Gupta, Poonam Shrivastava, Rajesh Yadav
Lions Blood Bank, Delhi, India
Background: Rh is the most important blood group system after ABO. The five principal Rh antigens -D, C, c, E, and e and K (KEL1) are responsible for the majority of clinically significant antibodies resulting in haemolytic disease of foetus and newborn (HDFN) or hemolytic transfusion reactions. There is little data available for prevalence of these in Indian population.
Aims: To determine the frequencies of Rh antigens in voluntary blood donors of Delhi.
Materials and Methods: The study was carried out by Lions Blood bank, a Standalone RBTC blood bank in Delhi. All the 14280 donor units collected between 1.1.14 to 13.8.14 were phenotyped. The antigen typing of each donor's red blood cells was performed on NEO (Advanced fully automated Immunohaematology Analyser) Immucor, Rodermark, Germany that uses the microplate haemagglutination technique by using six standard antisera i.e anti-D, anti-C, anti-c, anti-E, anti-,e and anti-K. Agglutination of red blood cells at 37 C incubated phase of testing indicates the presence of appropriate antigen and no agglutination indicates a negative test.
Results: The prevalence of various phenotypes in voluntary blood donors is as follows D+ 94.34%, D- 5.66%, e + 98.13%, e- 1.87%, C + 85.95% C- 14.05%, c + 55.52%, c- 44.48%, E+ 20.30%, E- 79.7%, K + 2.26% and K- is 97.74%.
Conclusion: The prevalence of Rh and K antigens is derived from a large cohort of more than 14000 donors and would be helpful in calculating the number of units that would need to be tested to find the desired antigen combinations when providing blood for a patient with antibody/ies in NCR Delhi.
Should blood donors be routinely screened for irregular antibodies? Experience in a tertiary hospital in south India
Parmatma Tripathi, P Amalraj, MP Chacko, D Daniel
CMC, Vellore, India
Introduction: Current standards recommend that donor blood be screened for irregular antibodies. Screening of donors for antibodies exerts a strain on blood banks in terms of economy and labour. This study examines the frequency and nature of allo-antibodies discovered in donors in order to assess the value of such screening.
Objective: To study the frequency of clinically significant irregular antibodies in healthy blood donors.
Materials and Methods: Commercial, three and eleven cell panels are routinely used for antibody screening and identification in our centre. For this study, overall antibody prevalence and frequencies of the various antibody specificities which were discovered on screening in all donors over one year were calculated.
Results: 28,170 donors were screened of which 27,050 (96%) males. 39 donors (0.14%) were showed a positive screening test. The gender specific prevalence was 0.12% in males and 0.35% in females. 14 donors were negative on the eleven cell panel, and in 13, the antibody could not be identified. In the remaining 12 cases the following clinically significant antibodies were identified-Anti-Le(a) was most common (6 cases), followed by anti-Le(b) (2 cases), anti M (2 cases), anti C (1 case) and anti-e (1 case).
Discussion: We discovered an antibody prevalence of 0.14% in our donor population. At our current usage of plasma containing products, in the absence of screening, these figures approximately translate into an incident of passive immunisation occurring once a month. Known clinically significant antibodies were identified in approximately one third of the screen positive cases. The prevalence was thrice as much in female donors as compared to males. Though the antibody specificities could not be identified for almost 35%, with the panel available, the significance of these cannot be ignored. While reports of actual haemolytic transfusion reactions due to passive infusion are extremely rare, studies suggest that atypical antibodies can reduce the effectiveness of transfusion through destruction of recipient cells, and therefore should be avoided.
Bombay blood group: Are we still not doing it correctly!
Mitu Dogra, Veena Doda, Urvershi Kotwal, Satyam Arora
Dr Ram Manohar Lohia Hospital, New Delhi, India
Background: Bombay phenotype is frequently encountered in Indian scenario with variable presentations. A rare blood group which can easily be detected by basic blood group technique is still not detected or reported properly. Through our case report we have tried to highlight the incompetency of blood bank in India for not detecting and managing Bombay blood group donors as well as patients.
Case Report: A 2years old, male child was admitted in our hospital as a referred case with probable diagnosis of neuroblastoma having history of transfusion reaction at peripheral hospital where he was typed as O Rh D positive. His blood sample was sent to the blood bank for grouping and cross matching. Forward typing showed O blood group where as in reverse typing, his serum showed strong agglutination with A, B and O group control cells. Further his cells were checked with anti H lectin showing no agglutination. The blood group was finally interpreted as Bombay blood group with naturally occurring anti H antibodies in plasma that were IgM in nature with a titre of 1:32. A donor was traced in rare blood group directory of our own department and a unit was arranged. Two more units were then air lifted from other city and the case was managed.
Conclusion: This case highlights importance of both forward and reverse grouping in ABO typing and performing standard pretransfusion laboratory testing in blood bank. Since we are shifting from routine blood banking to automation, we are missing the role of O cells in reverse grouping as the cards meant for automated procedures lack this column. For effective management each blood bank should have rare blood group donors registered from amongst their regular voluntary donors and intra and inter state transfusion centre coordination. Moreover considering the rarity of Bombay blood group, it is desirable to develop cryopreservation facilities for rare blood donor units so that a lot of problems related to rare blood groups can be solved.
A case of alloanti: A 1 antibody in an A 2 B recipient reacting at 37 ° C
Rahul Chaurasia, Sham Suzzaman, Kabita Chatterjee
AIIMS, New Delhi, India
Background: A 1 and A 2 are two the most common subgroups of A. Qualitative and quantitative differences exist between A 1 and A 2 . During routine testing with monoclonal antisera-A, both A 1 and A 2 give a strong agglutination reaction and hence cannot be differentiated serologically. Use of A 1 lectin and H lectin are used for differentiating them.
Aim: We report a case of A 2 B group patient with anti-A 1 antibody reactive over wide thermal range which was detected during pretransfusion testing. A 3-year-old boy, known case of Gaucher's disease undergoing regular blood transfusions of AB Rh (D) positive blood at our centre in view of his hematological status. During his last pretransfusion testing, blood grouping discrepancy was reported.
Materials and Methods: Further immunohematological workup revealed patient's blood group as A 2 B Rh (D) positive with anti-A 1 antibody. The presence of anti-A 1 was confirmed after testing with two "O", "A 1"and "A 2" washed red cells. Anti-A 1 antibody was found to be reactive over a wide temperature range (4ΊC to 37ΊC). Titer on DTT treated serum with polyspecific AHG was 1:16 whereas of untreated serum was 1:64 (mixture of IgG + IgM).
Results: Since we don't routinely type donors for subgroups, we searched for A 2 B Rh (D) positive blood. Fortunately, after checking 10 units, one unit was successfully crossmatched and issued to the patient without any untoward affect.
Conclusion: Considering the lesser survival of A 1 red cells transfused to A 2 B or A 2 persons whose sera contain anti-A 1 , we propose to distinguish A 1 and A 2 subgroups in individuals with A and AB blood groups prior to blood transfusion, especially in those with anti-A 1 reactive at 37 ° C or with previous history of transfusion reactions following is O group blood transfusion.
Feto-maternal ABO incompatibility as a cause of hemolytic disease of newborn: Are we missing the obvious?
Satyam Arora, Veena Doda, Urvershi Kotwal, Mitu Dogra
Department of Transfusion Medicine, Dr RML Hospital & PGIMER, New Delhi, India
Introduction: Neonatal hyperbilirubinemia is the most common cause for early readmissions after patients discharge. Hemolytic jaundice is significant in 20% of newborns with jaundice. ABO and Rh incompatibility comprise two thirds of the total HDN in the western world. ABO HDN is confined to the 1% of group O women that have high-titre IgG antibodies whereas in general 15 to 25% of all maternal/fetal pairs are ABO incompatible. Here we discuss series of 17 cases of fetomaternal ABO incompatibility reported with HDN.
Aim: To study the clinical profile of patients with HDN, due to ABO incompatibility.
Materials and Methods: This study was a retrospective analysis of the fetomaternal ABO incompatibility reported to our department from January to March 2014. The cases referred to us were either with the features or suspicion of HDN after ruling out other causes of hemolysis. The clinical relevant data and immunohematological work up was analysed.
Results: Out of 100 requisitions of ABO incompatibility between mother and the baby, 17 babies had features of HDN with mean TSB at 15.1gm/dl. Out of 17 mothers, O-B scenario was in 12, A-B (4) and B-AB (1). DAT was positive in 9 babies and elute was reactive in 3 out of 9 for the corresponding antibody. Antibody titration of anti A and anti B was reported to be as high as 2048 (AHG phase). Antibody titration at >512 (AHG) was significantly associated with a positive DAT. On maternal screening two had positive IAT (anti D and Anti E). Of these 17 babies 4 required phototherapy two needed exchange transfusion and one received IVIG as well.
Conclusion: ABO incompatibility is a common presentation but HDN due to the incompatibility is rarely reported from our country. Our report is one of the first of its kind, highlighting the clinical and immunohematological profile of such patients.
Role of extended phenotyping in an alloimmunized patient
Kruti Patel, Maitery Gajjar, Hardik Raval, Nidhi Bhatnagar, Tarak Patel, Meghana Solanki
Department of Immunohematology and Blood Transfusion, BJ Medical College, Ahmedabad, Gujarat, India
Introduction: Red cell alloimmunization is an immune response against foreign RBC antigens, occurs due to blood transfusions and pregnancies. These antibodies may result in clinically significant hemolytic transfusion reactions, difficulty in compatibility and decrease in RBC survival.
Case Details: A 50 years old female patient, with a history of ostium secondum defect with Left to Right shunt, mild TR (tricuspid regurgitation) and mild MR(mitral regurgitation) was admitted in cardiology department for planned cardiac surgery. Patient's obstetric history was (G4 P3 A1 L3). One unit of red cell concentrate (RCC) was transfused two days prior to surgery to correct haemoglobin level. Fresh blood samples were received to keep four units compatible RCC ready for planned surgery. Antibody screening with three cell panel and eleven cell identification panel was panreactive with autocontrol negative. Her DAT and IAT were grade 4 positive. Specific alloantibody could not be identified. No compatible RCC unit was found due to possibility of multiple alloantibodies or alloantibody against high frequency antigen and surgery was postponed. Patient was given immunosuppressive therapy for three and half months, after which her DAT and IAT became negative. Phenotyping of patient, her brother, son and her husband was done. Phenotype matched blood from her brother was irradiated and transfused during surgery and transfusion was uneventful.
Conclusion: Alloimmunization can be decreased by providing phenotype matched blood. In alloimmunized patients, Autologus transfusion (predeposited, or intra- operative blood salvage) and phenotype matched blood transfusion can be used.
Red blood cell alloimmunization in thalassemia patients and factors affecting alloimmunization
Sangita Shah, Maitrey Gajjar, Nidhi Bhatnagar, Mamta Shah, Shital Soni, Megha Shah
Department of Immunohematology & Blood Transfusion, B J Medical College & Civil Hospital, Ahmedabad, india
Introduction: The recommended treatment for beta thalassemia major involves regular blood transfusions, usually administered every 2 to 5 weeks. Repeated blood transfusion can stimulate the patient's immune system and result in the formation of antibodies uaually IgG class. They can result in clinical hemolysis and complication of blood cross matching. Aims And
Objective: The purpose of this study was to determine the frequency of RBC alloantibodies and/or autoantibodies, the type of these antibodies, factors influencing on alloimmunization among multiple- transfused thalassemia major patients and effect of immunogenicity of RBC Antigens in development of alloimmunization.
Materials and Methods: This descriptive study was performed on 117 male and 68 female patients with thalassemia major who had received regular transfusion in Civil Hospital Ahmedabad, Gujarat, India from 1 January 2013 to 31 December 2013 between 0 to 12 years of age. ABO blood grouping and Rh(D) typing was done by fully automated blood grouping and matching system Qwalys 3 Diagast using electromagnetic technology. Initially antibody screening was done by using 3-cell panel of Biorad Corporation. In case of a positive screen, antibody identification was performed in the same phases as Ab screening, by using 11- cell panel. Phenotyping of Blood Donors done by the electromagnetic technology using Qwalys 3 Diagast.
Results and Observation: 10 patients (5.40%) of total 185 patients with thalassemia major developed alloantibodies against RBC Antigen. Among total alloimmunized patients, 7.35%were female and 4.27% were male. Majority of alloantibodies were directed against antigen in the Rh and Kell system. i. e. Anti c, Anti E and Anti K. The frequency of Anti-c and Anti-E is more. Frequency of Alloantibody is maximum in AB positive patients. From extended Antigen typing of voluntary donors coming in blood donation camp organized by our department were done during January 2013 to August 2013, we can see the frequency of D,C and e Antigens are more than frequency of c, E and K Antigens. Discusion: The present study was conducted to detect frequency of red cell alloimmunization and correlation of phenotyping and alloantibody positivity in transfusion dependent thalassemia patients in Gujarat. Frequency of red cell alloimmunization was 5.40% in this study. The most common alloantibody found were Anti-c and Anti- E These alloantibodies were mainly against Rh blood group system. Red cell alloantibody formation was not influenced by age at first transfusion, number of blood transfusion, splenectomy and leuckodepleted blood transfusion. In our study alloimmunized patients did not reveal any evidence of haemolytic transfusion reaction. The frequency of Antibody positivity in transfused patient is not directly proportional to frequency of antigen in the donor but it depends on immunogenicity of Antigen.
Conclusion: Red cell alloimmunization is an important development in patient with transfusion dependent thalassemia. Red cell alloantibody formation was not influenced by age at first transfusion, number of blood transfusions and spleenectomy. Females and group AB patients are showing more frequency of alloimmunization. The frequency of Antibody positivity in transfused patient is not directly proportional to frequency of antigen in the donor but it depends on immunogenicity of Antigen. Effect of leuckodepleted blood is still debatable. Routine pretransfusion matching of blood, other than ABO and RhD antigen is not recommended because of low rate of red cell alloimmunization and high cost associated with such testing.
Hemolytic disease of the newborn due to multiple red cell antibodies in Rh positive female
Veena Shenoy, 1 Rosemary Jacob Vatakencherry, L Saraswathy, 2 K Radhamany
Department s of Transfusion Medicine, 1 Physiology and 2 Obstetrics and Gynecology
- A 31 year old antenatal female (G2 P1 A1) presented to our hospital at 31 weeks for further management of her pregnancy. Caesarian section was planned at 31 weeks due to PIH,IUGR.
- Her sample was sent to blood bank for grouping and crossmatching. Blood group was O positive. On IAT crossmatch, the units were found to be incompatible (3+) indicating presence of clinically significant antibodies in her serum. Antibody screening (indirect coombs test) using 3 cell reagent panel detected presence of alloantibodies.
- No h/o transfusion. Autocontrol and DCT negative.
- Antibody identification using 11 cell panel showed presence of multiple red cell allo antibodies. Multiple antibodies are difficult to resolve: Repeated the test with another lot of 3 Cell panel, enzyme treatment of reagent cells, confirmation using antigen positive and negative cells.The antibodies present in this rh positive lady was anti c and anti kidd a. Confirmed by antigen phenotyping the lady and her husband. Titre (using O pos Homozygous antigen positive red cells) Anti c: 256, Anti Jka: 16
- Baby was delivered: Direct coombs test 3+.There was no hydrops at birth. Exchange transfusion was not needed. Only prbc transfusions needed. Responded well to phototherapy.
- Antibody screening has to be done in Rh positive females also as many antibodies to minor red cell antigen are known to cause Hemolytic disease of newborn (C, c, E, K, Jka, Duffy etc). Screening for non-RhD antibodies in all pregnant women has been implemented in most developed countries. And if alloimmunised, a close follow up of affected pregnancy is possible with interventions like intrauterine transfusions.
Blood group discrepancies due to weak subgroups of A: Two case reports
Indumole, Panicker, Veena Shenoy
Department of Transfusion Medicine, Amrita Institute of medical Sciences, Cochin, Kerala, India
Blood group discrepancies exist when reaction in forward grouping do not match the reaction in reverse grouping. Causes can be weakly reacting or missing antibody, weakly reacting or missing antigen, plasma abnormalities and due to miscellaneous causes. We report two cases of blood group discrepancy due to weak/missing antigen.
Case Report 1: A blood requisition for a ten year old girl who was being evaluated for anemia was received at blood bank. Cell grouping using Gel card (Dia- Med) revealed O Positive, serum grouping showed positive reaction with B cells only and hence 'A' group.
Resolution of Discrepancy: Cell group was repeated in conventional tube method, using two antisera from two different manufacturers. We tried to enhance the reaction by incubating the test 4 ° C for 30 min.Testing at 37 ° C and AHG phase also revealed same results. No reaction with Anti AB antisera. 4+ with Anti H. Patient serum was tested with A1cell and A1 lectin negative cell. No reaction with both. Adsorption and elution with Anti A serum was strongly positive, confirms presence of A antigen.
Interpretation: Sub group of A = ? A m / Aγ/ Ael A m / Aγ/ Ael characteristically unaggluttinated by Anti A or Anti AB. Anti H- strong positive. Anti B present. No Anti A1 Antibody. Detected only by Adsorbtion and elution with Anti A.Further confirmation of these sub groups can be done using molecular techniques and/or demonstration of A group transferases in the serum.
Case Report 2: 49 Year old female, diagnosed with gynecological malignancy, sample was sent for blood grouping to our department.Cell grouping showed weak mixed field reaction Anti 'A ' and Anti 'AB'.Reverse Grouping showed weak reaction with A cell and 4+ reaction with B cell and no reaction in O cell.
Resolution of Discrepancy: Repeated cell grouping at 4 ° C, Room temperature and 37 ° C gave the same reaction. Anti H gave +3 reaction with the patient cell.Patient's serum reacted with A 1 cell and no reaction with A1 lectin negative cell. Therefore anti A1 antibody is present. Adsorption and elution test with Anti A was strongly positive. Confirms presence of A antigen.
Interpretation: Sub group of A = A 3 A 3 red cell demonstrate a mixed field pattern of agglutination with Anti A and Anti AB reagents. (i.e. small agglutinates among many free RBCs). Anti A1 antibody is present in the serum of A3 individuals.
Discussion: Subgroups of A are phenotypes that differ from others with respect to the amount of A antigen carried on RBCs. The two principal subgroups of A are A1 (80%) and A2(20%). Subgroups weaker than A2 occur infrequently and characterized by decreasing numbers of A antigen sites and a reciprocal increase in H antigen. Weak subgroups result from expression of an alternate weak allele present at ABO locus. The genes responsible constitute less than 1% of the total pool of A genes.
Guillain-Barre syndrome in a patient with acute myocardial infarction with VSD repair treated with plasma exchange
Nidhi Bhatnagar, Nirav J Patel, Tarak Patel, Megha Shah, Mamta Shah, Maitrey Gajjar
Department of Immunohaematology and Blood Transfusion, Civil Hospital, Ahmedabad, Gujarat, India
Introduction: Guillain-Barre syndrome (GBS) is an acute, frequently severe progressive illness of peripheral nervous system that is autoimmune in nature. There is an association with Epstein Barr virus, Measles, Campylobacter jejuni (causing diarrhoea), HIV, and Cytomegalovirus, post vaccinal and post-surgical events. GBS after myocardial infarction (MI) with ventricular septal defect (VSD) is uncommon with high mortality rate if not treated promptly.
Case Report: A 60 year old male patient presented with complaint of acute onset of chest pain associated with nausea and perspiration. Next day he was operated for VSD. On post-surgical sixth day, patient had intermittent fever associated with night sweats followed by severe weakness of both upper and lower limbs. Patient had areflexicquadruparesis; nerve conduction test findings were suggestive of acute inflammatory demyelinating polyradiculoneuropathy, one of the variant of GBS. He was diagnosed as Guillain-Barre΄ syndrome on basis of Brighton case definitions. GBS is included in Category I indication for therapeutic plasma exchange as per ASFA (American Society for Apheresis). Total 5 cycles of TPE were performed on alternate day in a period of 10 days with removal of 200 ml/kg plasma after which neurological improvement was seen. Patient was extubated from ventilator and his muscle power improved from grade 0(complete paralysis) to grade-III (movement possible against gravity but not against resistance) (Grading of muscle power is as per Medical Research Council Scale) after completion of 5 cycle of TPE.
Discussion: GBS patients need constant monitoring and support of vital function. TPE involves the removal of injurious macromolecules from the plasma of patients with various medical conditions. TPE is relatively safe. It shortens the course of hospitalization and reduces the mortality and incidence of permanent paralysis. GBS patients need constant monitoring and support of vital function.
Conclusion: Thus we report a successful outcome of GBS post MI with VSD in a 60 year old male patient who was on ventilator treated successfully with therapeutic plasma exchange (TPE).
Rh and Kell phenotype of western region in India
Nirav J Patel, Nidhi Bhatnagar, Tarak Patel, Jaymin Bhatt, Vaidehi Patel, Maitrey Gajjar
Department of Immunohaematology and Blood Transfusion, Civil Hospital, Ahmedabad, Gujarat, India
Introduction: RH is the most important blood group system after ABO in transfusion medicine. The RH is the highly immunogenic and complex with numerous polymorphism and clinically significant alleles. The determination of Rh phenotypes can therefore be important during pregnancy, for previously transfused patients and for patients with known irregular antibodies. Knowledge of Rh phenotypes in given population is relevant for better planning and management of blood bank.
Aim and Objectives: To determine the incidence of Rh phenotypes in voluntary blood donors. To generate data for multipurpose future health utilities and prevention of alloimmunization. To make a strategy for giving safe blood to patients. Materials and Methods: The study was conducted on 1800 healthy voluntary donors at Department of Immunohematology and Blood Transfusion, Ahmedabad. ABO and Rh blood grouping was done by the erythrocyte magnetic technology using gropa2lys plate on fully automatic Immunohaematology analyser qwalys-3(Manufacture by Diagast). Extended phenotyping was also performed on the same platform using Duolys plate for D, C, c, E, e and K antigens.
Result: The most common Rh antigen observed in the study population was e (98.89%) followed by D (95.61%), C (89.22%), c (57.22%) and E (18.83%) and K (1.56).
Discussion: The antigen frequencies among Indian donors were compared with those published for other populations. The frequency of D antigen in Indian donor population was significantly higher than in the Caucasians (85%) and lower than in the Chinese (99%). The frequencies of C, c and E antigens were dissimilar to other ethnic groups while the e antigen was present in high frequency in Indians as also in the other ethnic groups.
Conclusion: By performing antibody screening adverse reactions reduced in all prospective patientsby transfusion. The knowledge of prevalence of different blood group antigens in any given population is always helpful in managing cases of alloimmunization in patients such as those with thalassemia, sickle cell anaemia, patients on dialysis, cancer patients, etc.
A Case Report: Delayed serological transfusion reaction due to anti-D in Rh D positive patient
S Aswin Kumar, Deepti Sachan
Department of Transfusion Medicine, Global Health City, Chennai, Tamil Nadu, India
Background: The Rh system is one of the most important and complex blood group systems. Rh antibodies are clinically significant and can cause HDN and Hemolytic transfusion reactions. Individuals with Partial D have missing portions of D antigen and can develop Anti-D antibody if exposed to missing epitopes. It has significant implications in transfusion and pregnancy. We present a case of delayed serological transfusion reaction due to anti D in Rh D positive woman.
Case Report: A 57 years old female from Kenya was admitted in our hospital as a case of stage IV recurrent Ca left breast, Hb 7.8 g/dl. Her Blood group was B Rh D positive. During crossmatching, all units were incompatible (1-2+); Direct antiglobulin test and auto control was also 2+ positive. Antibody screening using 3 and 11 cell panel using (DiaMed, Switzerland) showed weak positive. Acid Elution was done using acid elution kit (Diacidel, Biorad). Eluate showed the presence of Anti-D. On records, we found that patient received 2 units of B positive packed red cells at our hospital one week before. At that time, antibody screening was negative and all crossmatches were compatible. The patient probably developed anti-D after these transfusions. The decrease of hemoglobin and development of positive DCT after recent transfusion confirmed delayed serological transfusion reaction. Results for partial D confirmation and Rh genotype awaited.
Discussion: The Development of Anti D, due to transfusion of Rh D positive blood to a patient with Rh D variant, can cause delayed serologic transfusion reaction. Anti-D in partial D positive individuals is rarely reported. D variants are common in blacks and can cause severe hemolytic transfusion reaction or HDN. D variant should be distinguished serologically using monoclonal anti- D antiseras or by Rh Genotyping.
Clinical significance of anti-HLA Class I and Class II donor specific antibody (DSA) as a transplant monitoring tool: Review of 41 renal transplant cases
Suchita Jogale, R Sawant R, A Deshpande, R Sirsat 1 , A Almeida 1 , J Kothari 1
Departments of Nephrology, HLA Laboratory, and 1 Laboratory Medicine ],[ PD Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
Background: Monitoring renal transplant patients for presence or development of DSA plays crucial role in their management.
Aim: To review our data of renal transplant patients with respect to assessing the utility of Luminex anti-HLA Class I and Class II DSA as a post-transplant monitoring tool for graft survival.
Materials and Methods: Clinical and laboratory data of 87 prospective renal transplant patients was analyzed. CDC cross-match and Luminex DSA Class I and Class II was done in all patients. 41 patients transplanted during a period of 13 months were followed up for minimum one month and maximum 13 months period. 41 patients who went ahead for a transplant were followed up for development of acute rejection and graft survival. Post-transplant CDC and DSA was performed in cases with clinical suspicion of graft rejection or malfunction.
Results: 75 out of 87 patients were negative for CDC and DSA cross-match, while 8 patients had DSA positive and CDC negative status. Of the 41 patients transplanted with a negative CDC cross-match, one had a positive cross-match on Luminex. This patient had a borderline positive anti-HLA Class I antibodies. He developed acute rejection which was treated with serial plasmapheresis. Acute rejection free survival in recipients was 87.8% (36 out of 41). Overall graft survival for a follow up period of 7 months was 95.1% (39 out of 41). One patient developed de novo DSA Class II antibodies and was treated with IVIG. 3 out of 41 patients showed increase in creatinine from baseline pre-transplant mean 0.83 μmol/L (0.3 − 1.2 μmol/L). Renal biopsy was avoided on the basis of negative DSA and these patients responded to conservative therapy.
Conclusion: Patients with a negative CDC and DSA cross-match showed good renal allograft survival. Luminex testing enhanced the interpretation of CDC cross-match and had clinical utility in diagnosis and interpretation of acute rejection and avoidance of renal biopsy. Monitoring protocol for early detection of de novo anti-HLA DSA may be useful to treat patients before substantial damage to the graft occurs.
Delta - Beta thalassemia with refractory AIHA: A case report
Darshan G Adulkar, MD Gajjar, NM Bhatnagar, TR Patel, KK Patel
Department of IHBT, BJMC, Ahmedbad, India
Introduction: Autoimmune haemolytic anaemia (AIHA) disorder characterized by accelerated red cell destruction and/or decreased red cell survival secondary to the presence of auto-antibodies directed against self-antigens on red cells. Detection of red-cell-bound immunoglobulin's and/or complements by direct antiglobulin test (DAT) remains the crucial serological assay in the diagnosis of AIHA. Very few studies are available in the literature from India on refractory AIHA.
Case Report: A seven year old female patient with C/o fever, weakness and fatigability diagnosed as delta bete Thalassemia with severe hemolysis, transfused with 18 units of best matched red cells in the past 22 days. On Investigations, AIHA was confirmed and steroids were started along with 'E' antigen negative best matched leucoreduced blood transfusion. Patient was resistant to steroids and Rituximab and was started with IVIG. Patient was followed up till 3 months. No hemolysis and Hb of 12 gm% during her last visit.
Conclusion: Thorough immunohematological workshop would help to find autoantibody specificity and negative blood can be transfused. Phenotyping donors and patients would help to obtain phenotype specific blood units in such cases. Role of Rituximab is doubtful in steroid resistant AIHA.
Alloimmunization with anti-M antibody in a Rh D positive pregnant female causing fetal anemia: A case report
Anjali Chavan, Sachin Garg, Ashish Jain, RR Sharma, Neelam Marwaha
PGIMER, Chandigarh, India
Background: During the antenatal period, antibody screening is mostly done in RhD negative pregnant females in our country. We report a case of alloimmunization with anti-M antibody in a RhD positive multigravida pregnant female (G 6 P 1130 ) at 7 +2 weeks of gestation. It was reactive in anti-human globulin (AHG) phase, thus clinically significant.
Aims: To detect and identify the alloantibody and monitor fetal outcome.
Materials and Methods: Blood grouping (ABO and RhD), extended Rh typing (C,E,c,e) and antibody titration were performed using tube technique. Antibody screening, identification, antigen typing and direct antiglobulin test (DAT) were done using gel technique (Biorad, Switzerland). Enzyme treatment was done using 1% commercial papain (Biorad, Switzerland). The titer was also performed with patient's di-thiothreitol (DTT) treated serum.
Results: The cell grouping was B RhD positive, while in serum grouping there was 4+ agglutination with pooled O cells, thus it presented as an ABO discrepancy. On antibody screening and identification, anti-M was identified and was reactive at room temperature (RT) as well as at 37 ° C and in AHG phase. The reactivity of DTT treated serum was same at RT and 37 ° C, thus it was predominantly IgG type. The patient was M-N+ and her husband was M+N-. The titer of anti-M in untreated serum was 128 at RT and 256 in AHG phase, while that of DTT treated serum it was 8 at RT and 256 in AHG phase. Subsequently, the AHG phase titer remained at 256. An intrauterine transfusion (IUT) was performed at 25 +4 weeks gestation and the pre-IUT fetal sample revealed anemia (Hb = 8.2 gm/dL; hematocrit =23.5%). The group was AB RhD positive with M+N+ phenotype and positive DAT (1+).
Conclusion: This case presents a rare occurrence of IgG type of anti-M antibody in antenatal setting which lead to fetal anemia and also required an IUT.
Therapeutic plasma exchange in recurrent focal segmental glomerulosclerosis post renal transplantation: A case report in tertiary care hospital in north western India
Shivangini Kumari, Rachna Narain, Sunita Bundas, Richa Gupta, Varun Capoor, Parmendra Pachori, Mamta Soni
Department of IHBT, SMS Medical College, Jaipur, India
Background: Focal segmental glomerulosclerosis (FSGS) has been shown to recur after first renal allograft in 20-30% of the cases. It usually presents in the early post-operative period with re-emergence of proteinuria and progressive graft dysfunction. This differentiates it from denovo FSGS which usually presents after 12 months of transplantation.
Aim: To report the effect of Therapeutic Plasma Exchange (TPE) in obtaining remission in a patient withrecurrent Focal Segmental Glomerulosclerosis 3 months after renal transplantation.
Materials and Methods: TPE was performed for this patient on three consecutive days and then five more procedures on alternative days using Hemonitics MCS+. On each occasion 2500 ml plasma was extracted with 100% replacement. Replacement was done with 5% albumin and 2 units of group compatible plasma at the end. Along with plasmapheresis, 2 doses of Rituximab (500 mg) each at 2 weeks interval were also given.
Result: Laboratory investigations after eight procedures showed a drop in proteinuria from 4+ to 2+ and serum creatinine from 2.8 mg/dl to 1.6 mg/dl. The patient was then discharged with advice for regular follow up and two remaining doses of rituximab.
Conclusion: TPE along with rituximab therapy is an effective approach for obtaining remission in recurrent FSGS post renal transplantation, even after a delay of one month in diagnosis and start of therapy.
Need of guidelines for judicious use of apheresis platelets in clinical practice
Abhay G Jhaveri, Snehlata Gupta
Surat Raktadan Kendra and Research Centre, Surat, India
Background: Ours is a standalone blood bank catering about 500hospitals and nursing homes in and around city and district. About 350 to 400 units of apheresis platelets are issued each year. We tried to audit the usage of apheresis platelets.
Aims: The study was carried out to assess judiciousness of use of apheresis platelets.
Materials and Methods: Retrospective study was carried out for apheresis platelets issued (prepared on three different apheresis machines viz. Cobe Spectra, Amicus and Trima Accel) during last six years. The details were obtained from requisition slips.
Results: During last six years 2426 apheresis platelets were issued. Infection ranked as number one indication (30.13%) followed by hematological malignancies (13.69%). 3.71% of recipients had malaria. Out of infections, uncomplicated dengue accounted for 80.5% (24.24% of overall indications). Out of all these demands of uncomplicated dengue cases (where patient's platelet count was mentioned) 72.65% patients had platelet count of ≥10000/cmm. 91.45% patients had platelet count of ≥5000/cmm. ITP alone (without any associated complication) which is an absolute contraindication accounted for 1.32%. 16.67% of patients having malaria (without signs of bleeding) had platelet counts of >30000/cmm, 50% had platelet counts of >20000/cmm.
Conclusion: This study shows that one out of every four apheresis units used is actually grossly misused. Awareness is needed amongst general public as well as clinicians to stop misuse of apheresis platelets and thus in turn reduce misuse of resources and decrease unnecessary financial burden on the recipients. Professional bodies and government (statutory) agencies must come forward to provide guidelines appropriate for our need.
Immune thrombocytopenic purpura in pregnant patient managed with plasmapheresis: Case report
Dhara J Ardeshana, Shweta Upadhyay, Jitendra Vachhani
Department of Immunohematology and Blood Transfusion (IHBT), MP Shah Government Medical College, Jamnagar, Gujarat, India
Background: Immune thrombocytopenic purpura (ITP) known as Idiopathic thrombocytopenic purpura, is an acquired disorder. Immune mediated destruction of platelets and inhibition of platelet release from megakaryocyte. In adult, it is usually chronic disease. It is characterised by mucocutaneous bleeding and low platelet count with normal peripheral blood smear usually.
Aims: Management of pregnant patient having Immune Thrombocytopenic Purpura by plasmapheresis.
Materials and Methods: Female patient, 22 years old, 36kg weight, 7 months Primigravida, presented with bleeding gums, haematuria, petechia for two days. She admitted in medical ward GGH, Jamnagar. She had stable vitals at that times.
Results: On regular ANC, InitiallyHb-8 gm%, TC-9900, Platelets-3000/cumm, PSCM-Severe thrombocytopenia, dimorphic anemia, predominant macro-ovalocyes,PT-12sec, APTT-28 sec, LFT and RFT-Normal. She was given PCs and PCVs for thrombocytopenia and anaemia. No improvement after this.
Repeat Inv: Hb-7, Platelets-1500/cumm. She was not improved after methyl prednisolone inj. Again platelet-1000/cumm, ANA-++++, ANA Profile-only SS-A and RO-52 are positive, USG: Borderline splenomegaly, USG ANC: Live fetus, 25 weeks with asymmetrical IUGR of 4 weeks with 2 nd degree heart block. 2D echo: Normal, Bone marrow: Increased no of megakaryocytes with mature and young form many showing bluing of cytoplasm. Normal erythroid and myeloid series S/O ITP. She was given Inj. Dexona, tab. Azathioprine, IVIG-2g/kg*5days, but not improved, she diagnosed as Refractory ITP. Finally 6 Cycles of plasmapheresis done: Total WB processed-17374 ml, Total Plasma volume removed-7493 ml, Replacement fluid given [NS, Albumin (50 ml of 20%),FFP]-10510ml.
Conclusion: Finally after plasmapheresis platelet count-1.2 lac, LSCS done, a male live baby of 1.05 kg delivered died after 2 days due to CHB. No any intra and postpartum maternal complications.
Reducing the economic burden in management of Guillian-Barre syndrome
Sher Sankar Roy, RR Iyer, PH Shah, SK Suri
Department of Pathology, Government Medical College, Bhavnagar, Gujarat, India
Introduction: Guillain-Barrι syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy (AIDP), an autoimmune disease affecting the peripheral nervous system. Aims and Objectives: The present study was undertaken to emphasize the efficacy of plasmapheresis in treatment of adult GBS patients and to narrate methods of reducing the economic burden in the treatment of these patients.
Materials and Methods: A study was conducted on 12 adult patients of GBS admitted to Sir Takhtasinhji General Hospital, Bhavnagar from July 2012 to July 2014. All these patients were assessed on a six point disability scale. They were treated with Plasmapheresis over 10 days with REF627 kit from Haemonetics Corporation Limited on MCS+ apheresis machine. Improvement was noted by the change in the disability scale score after completion of the plasmapheresis cycles and the expense of various modes of treatment of GBS was also considered.
Results and Discussion: 9(75%) showed an improvement of one grade at the end of the treatment period. The cost per cycle of plasmapheresis in this set- up was Rs. 8000 per cycle i.e. on an average Rs. 40000 per patient. If TPE kit REF981E were used in its place, then the cost would be raised to Rs.14000 per cycle i.e. Rs.70000 per patient. Using 5% Human albumin would raise the cost by approximately Rs. 14000 per cycle i.e. Rs.70000 extra per patient. The cost of Intravenous Immunoglobulins per patient would fall between Rs. 264000 (44 kg) and Rs. 390000 (65 kg).
Conclusion: Plasmapheresis along with proper supportive measures is an efficacious mode of therapy in adult patients of GBS. This method can be made more cost-effective and economic burden reduced by using REF627 kit and 6% Hexastarch as replacement fluid on MCS+ Apheresis machine.
Guillain Barre syndrome: Treatment with therapeutic plasma exchange and physiotherapy and assessment of clinical features, outcomes and seasonal variation
Nehal Shah, Manisha Shrivatava, Seema Navaid
Bhopal Memorial Hospital and Research Centre, Bhopal, India
Background: Guillain-Barre syndrome (GBS) is an important cause of acute neuromuscular paralysis. Early diagnosis and aggressive treatment using Therapeutic Plasma Exchange (TPE) as a standard protocol along with physiotherapy can better the prognosis. The aim of this study is to analyze the clinical outcomes, recovery and seasonal variations in the patients with GBS treated with TPE as an Interventional treatment modality and physiotherapy as integral part of the treatment.
Materials and Methods: Medical records of 66 patients, referred to our center, diagnosed as GBS were retrospectively analyzed from the year 2002 to 2013. A predesigned proforma was used.
Results: In this study 41 (71.2%) patients were male. All 66 patients received 298 cycles of TPE. Good acceptance of TPE was seen in 53 (80.3%) patients. Out of all 34 patients received physiotherapy and clinical outcome improved in 26 (67%), 24 (71%) and 25 (74%) in terms of muscle strength MRC grading, Barthel Index and Katz index respectively. At the time of discharge out of 66 patients 50 (75.7%) showed clinical improvements in their muscle strength and 65 (99%) patients scored a higher functional outcomes and highest prevalence of GBS was found in S1 (Feb to April) and S2 (May to July) in 40 (60 %) patients.
Conclusion: Awareness amongst treating physicians, early diagnosis and treatment with TPE as standard treatment protocol and physiotherapy as supportive treatment reduces the period of the hospitalization, complications, disabilities, morbidity and mortality in patients with GBS and thereby improving the quality of life and is key for successful outcomes in resource confined countries.
To study the effects of gamma irradiation on single donor apheresis platelet units by assessment of biochemical parameters, platelet activation and platelet count
AK Biswas, J Philip, RS Mallhi
Department of Immunohaematology and Blood Transfusion, Armed Forces Medical College, Pune, Maharashtra, India
Background: The occurrence of TA-GvHD can be prevented by gamma irradiation of blood components. In India, there are no studies which have assessed the effect of gamma irradiation on the quality of apheresis derived single donor platelet (SDPs) concentrates.
Aims: To study the effects of gamma irradiation on SDP units, by measurement of cellular counts, functional indicators, and a panel of biochemical parameters, in order to assess pre-transfusion platelet quality.
Materials and Methods: SDPs were collected by a continuous flow apheresis technique (N = 400). The SDPs from each donor was divided into two parts, one gamma-irradiated with 25 Gy and the other used as a non-irradiated control. Swirling and morphological features, cellular counts, biochemical parameters including blood gas analysis, and platelet activation levels (CD62P: p-selectin) by flow cytometry were analyzed on Day 1 and on Day 5.
Results: Swirling, platelet morphology and pH were maintained during the shelf-life of both the irradiated and control products. There was significant decrease in platelet and WBC counts between the two groups on day 5. The mean biochemical parameters which decreased during storage in irradiated products (but not significantly) as compared to their controls were pO 2 , Na + , HCO3 - , and Ca 2+ . In contrast, the mean parameters which increased during storage in irradiated products (but not significantly) when compared to their controls were pCO 2 and K + . However, lactate increased and glucose decreased significantly in irradiated products over five day storage period. The mean proportion of platelets expressing CD62P over 5-day storage increased significantly.
Conclusion: On comparing irradiated and non-irradiated SDPs, the platelet and WBC count along with glucose levels were found to be significantly decreased on the fifth day in irradiated SDPs. In addition, CD62P expression and lactate were significantly increased in the irradiated SDPs. However, in all these SDPs, the quality control parameters were well above the FDA requirements and remained appropriate for transfusion to patients even on the fifth day after irradiation.
Therapeutic plasma exchange in the treatment of myasthenia gravis
Rajesh Kumar, Birinder S Paul, Sonia Gupta, Gagandeep Singh, Amarjit Kaur
Dayanand Medical College and Hospital, Ludhiana, Punjab, India
Background: Myasthenia gravis (MG) is a well known autoimmune disease characterized by antibodies against the acetylcholine receptor (anti-ACHR) on the post synaptic surface of the motor end plate. Plasma exchange is a therapeutic modality well established in MG with a positive recommendation based on strong consensus of class III evidence.
Aims: We analyzed the experience related to the indication, complication and outcome of TPE in MG.
Materials and Methods: A total of 35 patients of MG on ventilator were submitted to a total of 41 cycles and 171 session of TPE. It was performed using a single volume plasma exchange with intermittent cell separator (Hemonetics) by Femoral or central line access and scheduled preferably on alternate day interval. Immediate outcome was assessed shortly after each session and overall outcome at the time of discharge.
Results: About 31.8% of total MG patients had TPE performed with mean age of 32 years. The mean number of TPE session was 4.2 (SD ± 1.2), volume exchange was 2215 ml (SD ± 435), overall incidence of adverse reaction was 21.7%. Allpatients had immediate benefits of each TPE cycle. Good acceptance of procedure was observed in 78.3% of patients.
Conclusion: TPE was rational treatment for patients with myasthenia crisis and was used in association with immunosuppressor, it may be more effective if initiated earlier in the hospital course and in patients who had previously failed to respond to other treatment.
A critical review of plateletpheresis procedures in a tertiarycare multi-speciality hospital
Atul Shringare, Sangeeta Kalgutkar, Rajesh Sawant, Anand Deshpande
P D Hinduja Hospital & MRC, Mahim, Mumbai, India
Background: Donor selection, plateletpheresis procedure management and quality assurance of apheresis platelets are major aspects requiring ongoing monitoring for a robust plateletpheresis program.
Aim: To review plateletpheresis procedures, donor and apheresis parameters and identify areas for improvement.
Materials and Methods: Platelet donor parameters, plateletpheresis procedural parameters and quality records of apheresis platelets were retrieved and analyzed systematically. The key parameters analysed were donor CBC, height, weight and total blood volume (TBV), type of cell separator used, TBV processed, anticoagulant used, any adverse reactions related to the procedure, platelet content of product, time taken for platelet collection and post-procedure CBC of the donor.
Results: 854 plateletpheresis procedure parameters were analyzed (Cobe Spectra - 407 procedures Trima Accel- 447 procedures). Mean donor age 31.2 years (19-51 years), height 167.3 cm (151-222 cm) and weight 74.1 kg (54-113 kg). Pre-apheresis donor hematological parameters-mean Hb 14.3 g/dL (12.7-16.8 g/dL), hematocrit 43.6% (37.9-49.8 %) and platelet count 267 × 10 9 /L(183-429 × 10 9 /L). Mean blood volume processed was 3054 ml (2029-3970 ml) and anticoagulant used was 318 ml (208-405 ml). Average platelet yield of 4.31 × 10 11 (2.31-7.1 × 10 11 ) was obtained in a product volume of 252 ml (154-373 ml). Mean donor platelet count post procedure was 240 × 10 9 /L (111-336 × 10 9 /L) and the mean reduction in donor's platelet count was 70,000 (17,000-1,71,000/cumm). 4.6% of donors had a platelet count above 350 × 10 9 /L, thus qualifying for double platelet collection. Mean time taken for plateletpheresis procedure was 59.4 mins (44.5-76.5 mins). 17.6% of platelet products had a yield <3.0 × 10 11 and 17.3% had a yield >5.0 × 10 11 . 6 (1.6%) donors had severe vasovagal syncope and 8 procedures were abandoned due to flow related problems.
Conclusion: Donor platelet pheresis procedures were successfully performed by ensuring proper donor selection to obtain an optimum platelet yield in the product within optimum collection times. Adverse event reporting systems, donor recruitment and double yield platelet collections are the current areas of focus.
Role of plasmapheresis as an adjuvant to antibody mediated rejection management: Pilot study from a single centre
Sheetal Chandak, Aruna V Vanikar, Lovelesh Nigam
Blood Bank, IKD & Transplantation Sciences, Ahmedabad, India
Introduction: Antibodies are known to cause rejection of the transplanted organ. Plasmapheresis offers therapeutic benefit by clearing these antibodies from circulation. We carried out retrospective analysis of antibody mediated rejections (AMR) in our renal transplant recipients and evaluated the therapeutic efficacy of plasmapheresis.
Materials and Methods: This is a small pilot study of set of patients. We reviewed case files of patients who underwent therapeutic plasma exchange (TPE) in our department from January 2013 till June 2014. Patients with biopsy proven AMR subjected to plasmapheresis (Group-1) in our unit were considered for study. Serum creatinine (SCr) before and after plasmapheresis was evaluated and compared with controls who did not opt for plasmapheresis (Group-2). Three cycles of plasmapheresis were carried out on Cobe spectra Caridian BCT apheresis system. In total 1.5 times plasma volume was removed per cycle and replacement was carried out with crystalloids and colloids in ratio of 3:2 (0.9% saline and 20% human albumin).
Results: Total 161 biopsy proven rejections were documented. Of these 122 patients showed humoral rejection and 56 patients opted to undergo plasmapheresis. The mean age of the patients in group 1 was 31.4 years, M:F ratio was 3:1, and mean SCr before and after TPE was 3.88 mg/dL and 1.54 mg/dL respectively. The mean age of the patients in group 2 was 31.8 years, M:F 32:1 and mean SCr at the time of diagnosis and last follow up was 2.16 mg/dl and 2.11 mg/dl respectively.
Conclusion: Plasmapheresis is a useful adjuvant of anti-rejection therapy for AMR.
Therapeutic plasma exchange and physiotherapy in stiff person syndrome
Nehal Shah, Manisha Shrivatava, Seema Navaid
Bhopal Memorial Hospital and Research Centre, Bhopal, India
Background: Stiff-Person syndrome (SPS) is a rare neurological condition characterized by progressive muscle rigidity and stiffness with painful spasm of the muscle. The objective was to treat SPS with therapeutic Plasma exchange as disease modifying therapy and physiotherapy as supportive treatment modality in SPS patient.
Materials and Methods: Record of the patient with SPS referred to our institute for TPE was studied and outcome was analyzed in terms of Fatigue severity scale (FSS) and visual analog scale (VAS).
Results: We report a 32 years old male with continuous muscle stiffness in whole body more in right shoulder and hip and painful muscle spasm in facial muscle exaggerated by anxiety or emotional stress and worsened after onset. He was a known case of Ca rectum and hiatus hernia and underwent surgery one after the other. At hospitalization, he was fatigued easily and had severe body ache the FSS was 50 scoring agree to strongly agree and pain on VAS was 5/10. Neurological examination revealed diminished plantar reflexes. He could not walk for long due to stiffness. Electrophysiological and routine investigations were normal. High titers of anti-glutamic decarboxylase (GAD) antibodies (17.03U/ml) and carcinoembriyonic antigen (CEA) was 1.87 U/ml detected in serum, confirming the diagnosis. The SPS was unresponsive to pharmacotherapy with benzodiazepines. Five cycle plasma exchange therapy reduced the severity of clinical symptoms and decreased the anti-GAD antibody titer up to 7.0U/ml and CEA 1.42U/ml. Prolonged self stretching hold relax technique was initiated for two sessions a day which further decreased the stiffness and improved his FSS(30) and pain 7/10.
Conclusion: TPE in adjunction with physiotherapy improves the symptoms in SPS. To our knowledge this is the only case reported in central India.
Incidence of adverse events in plateletpheresis donors
Rimpreet Singh Walia, Kulbir Kaur, Suresh Kumar, Gopal Bahadur, Madan Gopal
Lifeline Blood Centre, Patiala, India
Background: Plateletpheresis procedures are generally well tolerated, however, they may sometimes be associated with adverse events. As a part of donor hemovigilance, such events must be carefully recorded, investigated and ways to reduce their recurrence must be formulated.
Aim: This study was undertaken to determine the incidence of adverse events in healthy plateletpheresis donors.
Materials and Methods: This prospective study included healthy plateletpheresis donors who donated platelets at Life Line Blood Centre, Patiala, Punjab from 1 st of April, 2013 to 24 th of September, 2014. During this period, the plateletpheresis procedures were performed either on Amicus (3.2 version, Fenwal) or Trima Accel (5.1 version, Terumo BCT). The donor adverse events were classified according to their nature, including, systemic, local or apheresis machine related.
Results: During the study period, a total of 477 plateletpheresis procedures were performed and out of these, 470 were performed on Amicus while 7 were performed on TrimaAccel cell separator. A total of 40 (8.34 %) adverse events were reported. Out of these 3 (0.63 %) were vasovagal reactions, 29 (6.07%) donors reported mild hypocalcemic symptoms and 6 (1.26%) donors had a local hematoma. In addition in 2 (0.42 %) of the procedures, leakage was reported due to a fault in theapheresis machine.
Conclusion: Plateletpheresis procedures are usually safe with a low incidence of adverse effects. The most common adverse effect reported was hypocalcemia followed by hematoma, which can easily be prevented by giving oral calcium tablets during the procedure and by careful selection of the vein, respectively.
Different presentations of thrombotic microangiopathy treated successfully with Ffp transfusion and therapeutic plasma exchange
L Nisha, NV Ramaswamy
Medical Trust Hospital, Kochi, India
1. A case of vaccine induced TMA: 2 months old male baby, admitted with purpuric spots following DPT vaccination on 45 th day. Investigations showed anemia, thrombocytopenia, high bilirubin, LDH and Retic count. Smear showed features of hemolysis and fragmented RBCs. Possiblity of TMA was considered and was started on FFP transfusion and predinisolone. Baby was discharged on 7 th day with normal counts but had a relapse after 5 days, again treated with FFP for 2 days, baby improved.
2. A case of Idiopathic TTP: Reshma, 19, FM presented with fever, headache, gum bleeding and transient LOC for 5 days. On admission, LP was done, CBC showed anemia and thrombocytopenia, peripheral smear showed florid schistiocytes and marked thrombocytopenia. Possibility of TMA was considered and was started on TPE initially OD followed by BD for 14 days in which she showed intermittent improvement but relapsed and Rituximab also was started. With TPE for 1 more week with 4 doses of Rituximab weekly, patient improved and discharged.
3. A case of secondary TTP- Post viral: Keerthy, 29, FM, presented with fever, abdominal pain, headache and diplopia. LP was done and other investigations sent showed Hb of 5.2, platelet count of 28000 and peripheral smear showed occasional schistiocytes, helmet cells, LDH 750 and creatinine of 2.8. In view of CNS and renal symptoms and findings, possibility of TTP was considered and was treated with TPE for 10days and Prednisolone for 5days. She was discharged with normal counts.
4. A case of secondary TTP? Drug induced. Post viral: Thomas, 64yrs, M, known c/o CVA, CAD, on clopidogrel, presented with echymotic patches for 2days. Investigations showed Hb 10.2, Platelet count 9000, LDH 795, T. Bilirubin 4.6. Peripheral smear showed schistiocytes, polychromasia etc. Retic count was 4%. Patient was treated with TPE for 13 days and prednisolone for 5 days, counts improved and discharged.
Role of plasmapheresis in management of neuromyelitis optica: A case report
Saurabh Lahre, Maitrey Gajjar, Nidhi Bhatnagar, Shital Soni, Tarak Patel, Nirav Patel
Department of IHBT, BJ Medical College, Ahmedabad, India
Introduction: Neuromyelitis Optica (NMO) is a variant of Multiple Sclerosis (MS) also knownas Devic's syndrome is an aggressive inflammatory disorder consisting most typically of attacks of acute Optic Neuritis(ON) and Myelitis, Myelitis can be severe and transverse and is typically longitudinally extensive involving three or more continuous vertebral segments.
Commonly encountered symptoms:
- Pain in eyes,
- Loss of vision,
- Weakness or Numbness in the arms and legs.
- Paralysis of arms and legs,
- Difficulty in controlling Bowel or bladder.
- Uncontrollable vomiting or hiccups.
Case Report: A 55 years old female patient with 55 kg body weight was admitted with gradual development of bilateral lower limb weakness since 15 days, sudden bilateral painless vision loss 4 months back, spontaneous urination and constipation since 15 days and high grade fever since 3 day. The patient had a normal power of grade 5 in upper limb and reduced power of grade 1 in lower limb, patient had diminished visual acquity upto light perception also patient couldn't sense bladder filling and required enema.
Result: After 5 cycles of Plasmapheresis total 11362 ml of plasma was removed (206 ml/kg), patients lower limb power increased to grade 4, visualacquity improved to around 4/6, patient could sense her bladder filling along with control in micturition and doesn't required enema.
Conclusion: Acute attacks of NMO are treated by high doses of glucocorticoids 1-2 g/d followed by taper. Plasmapheresis is done in acute cases which fail to respond to glucocorticoids. To prevent relapse Mycophenolatemofetil and anti-CD20 monoclonal antibodies (Rituximab) are used.
Effect of plateletpheresis on post donation serum thrombopoeitin levels and its correlation with platelet count in healthy voluntary donors
Rekha Hans, Rati Ram Sharma, Neelam Marwaha
Department of Transfusion Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Haryana and Punjab, India
Background: Thrombopoietin is a key cytokine in regulating platelet production and is regulated by a feedback mechanism between megakaryocytes and platelets. Thisfeedback mechanism is important in plateletpheresis donors to compensate for donation associated platelet loss. So, this study was conducted to study the changes in TPO levels during platelet recovery in plateletpheresis donors.
Aims and Objectives: To investigate changes in serum levels of thrombopoeitin in healthy donors undergoing plateletpheresis and its correlation with platelet recovery pattern.
Materials and Methods: Study comprised of 28 healthy plateletpheresis donors and was conducted in the Apheresis section of the Department of Transfusion Medicine, PGIMER, Chandigarhover a period of one year (2013-2014). Donors were screened as per DGHS criteria for plateletpheresis and procedures were performed on (TRIMA ACCEL, TERUMO BCT and AMICUS, FENWAL, USA). Platelet parameters (platelet count, Mean platelet volume and platelet distribution width) were estimated pre and post platelet collection, at 3 rd and 5 th day post donation. Serum TPO levels were determined by using quantitative sandwich enzyme-linked immunoassay (ELISA) technique (Raybiotech, USA) as per the protocol of the manufacturer.
Result: The serum TPO levels increased from a baseline of 204 ± 107 pg/ml to 245±114pg/ml post donation and remained elevated from baseline levels on day 3 and 5. The baseline donor platelet count was 226 ± 44 × 10 3 /μl and there was significant decline (30%) in post donation phase and remained below baseline on day 3 and 5. We observed an inverse relation of serum TPO with platelet count.
Conclusion: TPO plays a vital role in compensatory mechanism after platelet loss in healthy donors.
Therapeutic plasma exchange in treatment of pemphigus vulgaris: A case report
Aikaj Jindal, Rajesh Kumar, Amarjit Kaur, Sonia Gupta
Dayanand Medical College & Hospital, Ludhiana, India
Background: Pemphigus vulgaris (PV) is an autoimmune disease caused by antibodies directed against both desmoglein 1,3 resulting in the loss of cohesion between keratinocytes in the epidermis leading to extensive flaccid blisters and muco-cutaneous erosions.
Objective: The aim of case report is to assess the role of Therapeutic Plasma Exchange (TPE) in severe PV which was resistant to treatment.
Materials and Methods: TPE was performed using a single volume plasma exchange with intermittent cell separator (Haemonetics MCS plus, kit 980/790) machine by femoral access. It was scheduled on alternate-day intervals for five cycles. Replacement fluids used were isotonic sterile saline, 4% purified human albumin and Fresh Frozen Plasma.
Results: After TPE, Nikolsky sign became negative and no new lesions appeared. The exudation from the lesions reduced drastically. The lesions showed 60-70% re-epithelisation and 90% healing after the last cycle and oral lesions also healed completely.
Conclusion: TPE is a useful intervention in patients with PV who are not responding to standard therapy or who require unacceptably high doses of steroids or immunosuppressant. It may be considered as treatment option especially in developing countries like India as it is less costly and effective procedure for the management of severe PV.
Platelet volume indices and platelet apheresis
Arpit Patel, Jitendra Patel, Snehal Patel, Gopi Dobariya, Kruti Raja, AN Pandya
Department of IHBT, Government Medical College, Surat, India
Background: Platelet activity can be assessed by platelet volume indices (PVI) like MPV, PDW and P-LCR. In addition to donor's pre-donation platelet count and other variables, PVI have also influences on yield of platelet product. PVI are used as markers for the quality control of platelet concentrates, as these reflect storage induces shape changes and platelet-derived microparticles formation in platelets.
Aim: To develop an approach in blood bank professional, a habit of looking at platelet indices in hematology analyzer report of aphaeresis donors and QC samples of platelet aphaeresis products.
Materials and Methods: A retrospective data analysis was done for 422 platelet apheresis procedures conducted on CS 3000 plus with AMS cell separator, Fenwal and COM.TEC, Fresenius Kabi. Samples of the donors were collected before aphaeresis and 1 to 2 ml sample from each bag was collected in the satellite pouch attached to bag and analysis was done on day 0 and day 7. Platelet parameters were measured on automated hematology analyzers SYSMEX KX-21 and Horiba Micros 60. Statistical analysis was done by calculating 'r value' and a paired t test at 95 % confidence interval. A P value of < 0.05 was taken as significant.
Result: The mean platelet yield was 3.39 ± 0.88 × 10 11 /unit. The platelet yield correlated negatively (r value were -0.224, -0.045 and -0.159 respectively for correlation between MPV, PDW and PLCR with the yield, P < 0.0001). The mean values of PVI of SDP were significantly smaller than that of donor pre-donation samples (paired t test P value <0.05). The sizes of stored SDP on day 7 were significantly larger than that of day 0 (P value <0.05).
Conclusions: The platelet indices are useful to study selectively smaller platelet separation by automated cell separators, storage lesions and yield prediction.
Effect of fresh frozen plasma transfusion on prothrombin time in patients with mild and major coagulation abnormalities
Mary Sanshya, Meena D, Sasikala N
Department of Transfusion Medicine, Government TD Medical College, Allepy, Kerela, India
- FFP frequently transfused to patients with mild to moderate elevations in PT
- FFP transfusion appropriate when PT and APTT >1.5 times normal
- Requests for FFP most frequent inappropriate orders
Objectives of Study: To compare the change in PT INR in mild and major coagulation abnormalities. Study Design and Methods:
- Cohort study of all FFP transfusions for a period of 1 year (July 2013-July 2014)
- Any patient who received FFP with a pretransfusion PT 14-17 secs
- INR 1.1-1.85 (mild to moderate)
- Receiving FFP for a PT of >18 secs and
- INR >2 recorded separately (major)
- Effect of FFP lasts 6 to 8 hrs
- Follow up PT within 8 hrs included
- Pre (within 48 hrs before tx)
- Post transfusion PT INR (6-8 hrs post tx)
- 40, major coagulation abnormality
- 60, minor coagulation abnormality
Results: Major coagulation abnormality PT normalized in 97%, PT unchanged in 3%. Minor coagulation abnormality. PT unchanged in 98%, PT normalized in 2%.
Conclusion: FFP transfusion is not indicated or is not useful in mild coagulation abnormality.
Study of hemoglobinopathies and hemoglobin variants in anemic patients in a tertiary care centerusing hplc: A report of 6,500 cases
Amit Kumar Biswas, J Philip, T Chatterjee, RS Mallhi
Department of Immunohaematology and Blood Transfusion, Armed Forces Medical College, Pune, Maharashtra, India
Background: The hemoglobinopathies are a very heterogeneous group of congenital hemolytic anaemias, including hemoglobin (Hb) variants, thalassemia and hereditary persistence of fetal hemoglobin (HPFH). Cation exchange high performance liquid chromatography (HPLC-CE) has emerged as the method of choice for the initial screening of thalassemias and hemoglobinopathies and also for quantification of Hbslike HbA, HbA 2 and HbF.
Aim: The aim of this study was to determine the frequency of hemoglobinopathies in a tertiary care hospital in Western India, using the HPLC-CE.
Materials and Methods: This is a six year retrospective study conducted on 6,500 patients of anemia with suspected hemoglobinopathies. All the samples were analyzed on the Bio-Rad Variant II HPLC system and diagnosis was based on their retention times, their proportion of the total hemoglobin (%), and the peak characteristics. Statistical analysis was done with help of Microsoft Office Excel 2007 and data were expressed as percentages.
Results: A total of 6,500 cases were included in our study, out of these 740 (11.38%) cases showed abnormal Hb fractions. The major abnormality observed was of beta thalassemia trait (BTT) with a total of 522 cases (8.03%) followed by 43 (0.65%) cases of beta thalassemia major. Other hemoglobinopathies which were also identified are in the following proportions: HbE (total 67 (1.03%) cases including 41 HbE homozygous and 26 HbE heterozygous), HbS (total 85 (1.31%) cases including 34 HbS homozygous and 51 HbS heterozygous), HbD Punjab 13(0.18%) cases, Double heterozygous HbE-BTT (3 cases), Double heterozygous HbS-BTT (6 cases) and one case of HPFH.
Conclusions: The reliability of HbA 2 measurement by HPLC for the detection of beta thalassemias is of great advantage in a country like India, where the prevalence of HbA 2 is relatively high. In view of this, an early and precise diagnosis is very important for their clinical management and providing genetic counselling to prevent more serious hemoglobinopathies.
A case of ITP complicating pregnancy managed with TPO-mimetic drug elthrombopag olamine
Jyothis P, Susheela Innah, Kochuthresia JP, Aswath Kumar, Sereena Gilvas
Jubilee Mission Medical College, Thrissur, Kerela, India
Introduction: Immune thrombocytopenic purpura is a common acquired autoimmune disorder. The incidence of ITP during pregnancy is reported to be 1 to 2 per 1000 deliveries. Glucocorticoids are considered for initial therapy. Other treatment options include IVIgG, anti-Rh(D). TPO-mimetic drugs like Elthrombopag and romiplos time has been used successfully in many non-pregnant individuals with ITP, but studies and experiments regarding its effects on pregnancy is limited.
Case Report: 27 year old multigravida, known case of ITP with bad obstetric history of three abortions and one neonatal death with no living children presented at 26 weeks of gestation with complaints of spotting per vagina and petechial spots over the face and limbs. After two weeks of hospital stay the patient was not responding to steroid and immunosuppressant. Her platelet count was deteriorating and symptoms were worsening and she required frequent platelet transfusions. TPO mimetic drug Elthrombopag Olamine was started at 29 weeks of gestation. Her platelet count had never gone below 30,000/μl neither she required a platelet transfusion after starting elthrombopag. At 36 weeks of gestation she delivered an active male baby.
Discussion: Elthrombopag Olamine is a thrombopoietin receptor agonist indicated for the treatment of thrombocytopenia in patients with chronic immune thrombocytopenia who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy. Eltrombopag has been assigned to pregnancy category C by the FDA.
Conclusion: The role of a transfusion medicine specialist is not only to provide safer blood and blood products but also to minimize the usage of blood products as zero risk of TTI cannot be achieved even with advanced techniques like NAT.As transfusion medicine consultants we can recommend TPO mimetic drugs like Elthrombopag to patients with ITP and thereby we can reduce the risk of repeated platelet transfusions.
Pseudo-hemolytic transfusion reaction caused by rectus sheath hematoma
Shamee Shastry, Murlidhar V Pai 1 , Mohandoss M
Departments of Immunohematology and Blood Transfusion, 1 Obstetrics and Gynecology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
Introduction: The acute hemolytic transfusion reaction (AHTR) is one of the most feared complications of blood transfusion. However, few are not immunologically mediated. Some events may only simulate hemolytic transfusion reactions and they are categorized as 'Pseudo-hemolytic' transfusion reaction. We report one such event due to rectus sheath hematoma.
Case Report: We received the blood samples of a 24-years- old female patient for transfusion reaction work up. Her blood group was O positive and she had received blood transfusion following cesarean section on first post-operative day for anemia. Evening following transfusion, patient was found to have mild fever, decreased urine output and hypotension. Patient was brought to us on second postoperative day and on admission she appeared pale, blood pressure was 80/60 mm/Hg, pulse rate was 156/min, temperature 98.6 ° C and there was yellowish discoloration of sclera. Laboratory values showed drop in the post-transfusion hemoglobin level from 8.5 d/dL to 6.1 g/dL, her total bilirubin level was 3.9 with predominant direct bilirubin (3.5 mg/dL) and lactate dehydrogenase was 402 IU/L which increased to 507 IU/L on day 2. Bleeding and coagulation parameters were deranged. Evaluation was carried out as per our departmental standard operating procedure. Serum was icteric, direct antiglobulin test; antibody screening and elution studies were negative. Negative results were informed to the clinician immediately and the possibility of a hemolytic transfusion reaction was ruled out. Ultrasonography revealed gross ascites, bilateral pleural effusion and mild right sided hydronephrosis. On exploratory laprotomy rectus sheath hematoma (1000 gm clot) and hemoperitonium (~1 liter blood) were noticed and evacuated.
Conclusion: Reactions that are associated with blood transfusion may not always be due to transfusion per say. This case suggests that it is important to consider other differential diagnoses for such symptoms and even a negative result on transfusion reaction work-up shall be informed to the clinicians promptly.
Waldenstrφme macroglobulinemia: Its significance in transfusion medicine
Soumya Das, Shamee Shastry, Mohandoss Murugesan
Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
Background: Waldenstrφm's macroglobulinemia (WM) is a chronic lymphoproliferative disorder associated with IgM monoclonal gammopathy. Their clinical presentation ranges from being asymptomatic to hyperviscosity symptoms attributable to physiochemical properties of their paraproteins. Objectives: To emphasize the role of transfusion laboratory in the management of WM.
Materials and Methods: A 59-year-old female, presented with episodes of epistaxis and blurring of vision with central retinal venous occlusion. Patients EDTA blood sample for grouping was mucoid and turbid. Grouping by column agglutination technique was O positive with panreactivity in serum grouping. On slide, the sample exhibited rouleaux formation, and type III ABO discrepancy was suspected. Clinician was informed and advised for paraprotein level estimation. Immunohematology work up showed, DAT - negative, antibody screen - panreactive, cold agglutination test- negative and crossmatch - incompatible. Peripheral smear showed features of WM. Protein electrophoresis showed M-band in gamma region and IgM levels was 7256 mg/dL.
Results: The ABO discrepancy was resolved by conventional tube technique (CTT) and crossmatch was repeated in CTT. Two cycles of therapeutic plasma exchange (TPE) was performed (1.2 plasma volume each) with 50% crystalloids and plasma as replacement fluid. There was 82% reduction in the IgM levels (1326 mg/dL) after first TPE and 88% reduction (164 mg/dL) after the second procedure. Post TPE, patient improved symptomatically and rituximab was initiated.
Conclusion: Finding the reasons for group discrepancy or incompatible crossmatch help in patient's diagnosis and management. A significant reduction in IgM levels and improvement in hyperviscosity symptoms can be achieved with TPE in these patients.
Transfusion support in dengue patients: A study done in Salem district, Tamil Nadu
Suryatapa Saha, HM Prakash, Joshua Daniel, Poojitha Datla, Prathiba L, Thirumagal
Department of Transfusion Medicine, Vinayaka Mission's Kirupananda Variyar Medical College and Hospital (VMKV), Salem, Tamil Nadu, India
Background: Dengue is an infectious disease with a recurring incidence, especially in developing countries like India. The clinical spectrum of the disease ranges from dengue fever to dengue hemorrhagic fever. There is lack of evidence based guidelines for transfusion support in patients with dengue fever. This contributes to inappropriate use of blood components and blood centers constantly face the challenge of inventory management during dengue outbreak.
Aim: The aim of this study is to evaluate dengue patients as to when and whom to transfuse platelet and other blood components.
Materials and Methods: The present prospective study was conducted on 50 serologically confirmed dengue patients, admitted in the medicine department of a tertiary care hospital of Salem, Tamil Nadu from July 1 st to September 20 th , 2014.
Results: Out of 50 serologically confirmed dengue cases, number of patients having only thrombocytopenia (<1,00,000/cub.mm) was 45. No of patients having platelet count >1,00,000/cub.mm was 5. Among them, 10 cases had platelet count <30,000/cub.mm, 15 cases between (20,000-40,0000/cub.mm), 25 cases had platelet count between (40,000-1,80,000)/cub.mm. Out of 20 cases having platelet count >20,000/cub.mm, 15 cases had petechiae, mucocutaneous bleeding etc which necessitates the use of platelet transfusion, among them 2 cases had abnormal coagulation profile, so they received FFP transfusion besides platelets. The remaining 5 cases had platelet count >20,000 but no hemorrhagic manifestations and received inappropriate platelet transfusion. Out of 2 cases of FFP transfusion, one case expired due to dengu shock syndrome.
Conclusion: A centralized system of management with donor registries, guidelines and regular awareness programs can prevent the inappropriate transfusion of blood components.
Auto immune hemolytic anemia complicating viral b hepatitis: A case report
Deepthi Krishna G, Jothibai DS, Sreedhar Babu, Suresh B
Sri Venkateswara Institute of Medical Sciences, Tirupati, India
Background: Auto immune Hemolytic Anemia's (AIHAs) refer to a spectrum of disorders in which auto antibodies against antigens on erythrocyte membrane cause shortened survival of native as well as transfused red blood cells (RBCs). Viral Hepatitis is a major public health problem in India; here Hepatitis B Virus (HBV) endemicity is intermediate with a carrier frequency of 2-4%. AIHA is well documented in association with Hepatitis C. Here, we present a case of AIHA associated with Hepatitis B.
Case Report: A 66 years old female, diagnosed to have Hepatitis B elsewhere was referred to our tertiary care hospital with the complaints of yellowish discoloration of eyes and fever- for 1 month. Fever -High grade, associated with chills and rigors and easy fatigability. History of right upper abdominal pain, loss of appetite and usage of native medicine was obtained. No history of any bleeding or blood transfusions. She was pale, jaundiced and irritable. Laboratory tests revealed deranged liver function; HBsAg was positive. In view of the low hemoglobin levels (3.6 g/dl) O positive blood was requested. Cross matching was incompatible with several units; Direct Antiglobulin test (DAT) was positive by Column Agglutination Technology (CAT). Antibody screeningwas pan reactive; optimum reaction observed at 37 ° C. In this case, increased levels of Lactate Dehydrogenase (LDH), indirect bilirubin, reticulocytes, positive DAT and auto antibodies optimally reacting at 37 ° C are in favor of warm auto immune hemolytic anemia (WAIHA). However, best matched, 5 units of packed red cells were transfused sequentially under steroid coverage with significant improvement.
Conclusion: It is necessary that the prevalence of AIHA associated with HBV infection has to be studied in India. As widely stressed the "best suitable" blood unit is to be transfused as a life saving therapy.
Review of blood utilization for dengue cases in tertiary care hospital
Geetha Goudar, MS Bharati, MS Roselind
Department of Transfusion Medicine, Apollo Hospitals, Bangalore, Karnataka, India
Aim: Of this study was to validate the appropriate use of blood components like Single donor platelets (aphaeresis platelets) and Random platelet concentrate during the dengue epidemic. This study was retrospective for the dengue cases admitted in our hospital in the year 2013 which is 250 bedded tertiary care hospital. This study was undertaken to verify the adherence to guidelines while ordering platelet transfusions and capture prophylactic platelet transfusions in the serologically tested positive patients for dengue.
Materials and Methods: We evaluated clinical data, lab investigations, blood ordering and transfusion practices in 696 cases admitted as acute febrile illnessand serological confirmation of Dengue using NS1Ag, IgM, IgG by card/elisa method. The guidelines by WHO and Directorate of National vector borne diseases control programme 2008 for clinical management for Dengue, DSS, DHF and Indications of platelet transfusion was utilized to assess appropriate platelet transfusion.
Results: The 696 cases evaluated were serologically positive for Dengue, of these 4 were Dengue shock syndrome and 23 were dengue hemorrhagic fever. 2 cases each were also positive for malaria and leptospira, 1each for typhoid and chickengunya.3 female patients were pregnant with one diagnosed with haemoglobinopathy and IUD, and second with retained products of conception following MTP, third was normal first trimester pregnancy. Further the 696 cases were categorized into 4 on the basis of their platelet counts and 164 patients received platelet transfusions of which 10 received fresh frozen plasma, 2 received PRBCs. Only 81 patients of 164 had either rashes, petechia, epistaxis, hematuria, gum bleeding, brain hemorrhage. Rest 83 patients received transfusions as prophylaxis.
Discussion: 233 patients came under no risk category and none received any type of transfusions, 193 were in low risk of which 4.6% received transfusions and 3.1% had bleeding manifestation.160 were in high risk category 69% received transfusions and only 28% had bleeding manifestation. In the moderate risk of 110 patients 51% received transfusions 29% had bleeding manifestations. Overall 23.5% of patients received transfusions and 11.9 were prophylactic transfusions. Prophylactic platelet transfusion were given to all 12 patients with platelet count at level of <10,000/cumm and in absence of bleeding manifestations in 9 cases.
Conclusion: At the outset the guidelines for platelet transfusions were adhered, though the patients in high risk category were the largest group that received transfusions without bleeding from any site while they were hemodynamically stable. The guideline states that there is no need to give prophylactic platelets even at platelet count <20,000/cumm in absence of bleeding manifestations.Hence the exposure of such patients to unnecessary transfusion hazards could have been avoided.
Platelet refractoriness: Neonatal sepsis
K Hitesh Kumar, Pragathi Naik, G Sangeetha, M Sikinder Hayath
Kamineni Institute of Medical Sciences, Narketpally, Nalgonda, India
Background: Lack of response to platelet transfusion so that the expected post transfusion increment in platelet count is not attained is platelet refractoriness. Neonatal sepsis especially early neonatal sepsis is one of the most important non-immune causes of platelet refractoriness.
Aim: To analyse neonatal cases which had sepsis for platelet refractoriness and recovery from it.
Materials and Methods: 5 neonates with neonatal sepsis are studied. Detailed clinical history, laboratory investigations and treatment are evaluated. Among the 5 cases, klebsiella pneumonia was noticed in blood culture in 4 cases. In the 5 th case E. coli was noticed in pus culture. All the 5 cases revealed platelet refractoriness. Transfusion of platelet rich plasma, fresh frozen plasma, whole blood, packed cells were given.
Results: Post transfusion platelet counts after transfusions revealed platelet increment less than expected suggesting platelet refractoriness. Platelet counts improved later in four cases and one neonate died.
Conclusion: Neonatal sepsis is the majornon-immune cause of plateletrefractoriness. Commonest bacterial infection is Klebsiellapneumoniae followed by E. coli in the early neonatal sepsis cases analysed.
Comparison of use of platelet rich plasma and platelet rich fibrin in wound healing in periodontal surgery: A unique 'split mouth' trial
Maj Sudeep Kumar, Col Joseph Philip, Maj AK Biswas, AK Shreehari 1 , T Chatterjee, RS Mallhi
Departments of Immunohaematology and Blood Transfusion and 1 Dental Surgery, Armed Forces Medical College, Pune, Maharashtra, India
Background: Autologous platelet concentrates (PCs), namely platelet rich plasma (PRP) and platelet rich fibrin (PRF) have been used in periodontal regenerative surgery to achieve complete wound healing and regeneration of the periodontal unit. The seautologous PCs are a rich source of growth factors such as, platelet-derived growth factor, transforming growth factor-beta along with various other kinds of cytokines, which accelerate hard and soft tissue maturation and regeneration. The superiority of one source over the other has not been established. There are no studies conducted in India which has compared the efficacy PRP and PRF simultaneously in a patient.
Aim: To compare the effects of PRP and PRF in achieving wound healing and regeneration of the periodontal unit in periodontal surgery.
Materials and Methods: The study was conducted in tertiary care centre in collaboration with dept of dental surgery. Fourcases of chronic periodontitis with bilateral infrabony defects (IBD), were treated by means of autologous PRP on one side and autologous PRF on the other. The autolgous PCs i.e. PRP and PRF were prepared in-house manually. The clinical and radiological picture before intervention and following wound healing, six months post-operatively was compared.
Results: Both the preparations showed excellent results clinically and was verified radiologically.
Conclusion: The use of autologous PRF or PRP was equally effective in the treatment of IBDs, with uneventful healing of involved sites and significant bony fill. However, PRF had a few added advantages in the ease of its preparation with sustained slow release of growth factors over a week, minimal expense involved, lack of biochemical modifications involving extraneous thrombin, and the feasibility of it being used as point of care. Therefore PRF would appear to be a more practical method of using PC for healing in periodontal regenerative surgery.
An overview of granulocyte transfusions from an oncology center
Supriya Dhar, Suvro Sankha Datta, Sabita Biswas, Mammen Chandy
Tata Medical Center, Kolkata, India
Background: Granulocyte transfusions are a therapeutic option often used in oncology centers in patients with profound neutropenia. Granulocyte transfusions are infrequently used blood products and data for their use from India are limited. We describe here a retrospective analysis of granulocyte transfusions at our center over a one year period.
Materials and Methods: We analysed the granulocyte transfusion data of 6 patients who received a total of 13 products. Three patients received buffy coat granulocyte (BCG), total six products and three patients received apheresis granulocyte (AG), total seven products. The indications were ANC <0.5 × 10 9 /l with drug resistant invasive bacterial/fungal infection. Buffy coat granulocytes were obtained from group specific, cross match compatible, TTI nonreactive donors meeting all criteria for blood donation. These were obtained as a by product using the quadruple TAB-SAGM bag using TACE II machine and prepared after appropriate pooling. Cobe spectra cell separator was used for the second method where granulocyte apheresis was performed on a suitable donor primed with Dexamethasone and Inj. G-CSF 5 mcg/kg s/c 12 hours prior to procedure.
Result: The granulocyte content in the pooled BCG product ranged from 0.7 × 10 10 -1 × 10 10 and the RBC contamination ranged from 199-249 ml. In case of AG the content ranged from 0.7 × 10 10 -1.3 × 10 10 and the RBC contamination ranged 46.1-83.2 ml. Post transfusion counts were performed for increment. Five of the six patients had clinical improvement with increase in the ANC after product transfusion. Only one patient did not show any improvement even after three successive BCG transfusions.
Conclusion: Granulocyte transfusions are useful in managing drug resistant neutropenic patients. In case of non-availability of a suitable apheresis donor, Buffy coat granulocytes is a less expensive, viable, alternative and can be easily prepared.
Platelet transfusion therapy: An audit
Rashmi Sood, Gaurav Aroskar, Tarun Kumar
Saket City Hospital, Delhi, India
Introduction: Platelets, the fragments of cytoplasm derived from megakaryocytes, are essential in their contribution to primary hemostasis. Platelet Transfusion is indicated in various diseases with thrombocytopenia.
- To audit the Indications for platelet transfusions
- To audit the platelet transfusions which could have been avoided.
- To audit the prophylactic versus Therapeutic indications for transfusions.
- To establish platelet transfusion thresholds and policies, prior to common procedures.
- To audit for the effectiveness of platelet transfusion.
- To audit for the incidence of platelet refractoriness.
Materials and Methods: Retrospective data was collected to study the utilization patterns of the platelets prepared in a super-speciality hospital during a period of one year, starting July 2013 to July 2014. Number of patients transfused, indications for transfusions: Major user specialities, prophylactic and therapeutic transfusions, number of platelet units requested but non- issued, and number of units not utilized because of being TTI reactive, taken for quality control, discarded for expiry or red cell contamination or physical appearance, were studied.
Results: Major indications for platelet (RDPC) transfusion in one year of study period included Dengue, CAD, CKD, TCP, PUO, SDH, Stroke, Hypertension, Malaria, Septic Shock, DVD, Hepatic Encephalopathy, SLE, Atrial Septal Defect, Ventricular Septal Defect, Severe Aortic Regurgitation, Post-Partum Haemorrhage. All the platelet transfusions mentioned in the study were prophylactic and none was therapeutic. Platelets booked and transfused versus Platelets requested but not transfused included:
Dengue 9/1 PUO 1/3 SDH 3/1 Stroke 2/0 Hypertension 2/0 CKD 3/1 CAD 4/5 TVD 1/0 Malaria 2/0 Septic Shock 2/0 COPD 2/0 TCP 3/1 CKD 8/0 Hepatic Encephalopathy 1/0 SLE 0/1 ASD 0/2 VSD 0/1 Severe AR 0/1 PPH 0/1.
Total Platelets manufactured from July 2013 to July 2014: RDPC 1825 SDPC 90.
Total Platelets utilized from July 2013 to July 2014: RDPC: 691(37.86%) SDPC: 90(100%).
Month wise issue details: SDPC
Non Utilization of stock: Total PlateletsNot-Utilized: RDPC: SDPC 745: 0 = 40.82%: 0%
- being TTI reactive units: 511 (28%)
- 2.Units assessed for quality control: 52 (28%)
- Units wasted for problems in manufacturing: Red cell contamination: 1 = 0.054%
- Normal expiry date: 165 (9.04%)
- Transfusion Reactions due to Platelets: Three (3) times from RDPC and one (1) time from SDPC.
Conclusions: Platelet Transfusion practice needs to be audited from time to time in hospitals for better rational use of platelets. Platelet transfusion thresholds can be established for various diseases.
Transfusion associated circulatory overload: A case series in a tertiary care hospital
Naveen Agnihotri, Ajju Agnihotri
Fortis Hospital Shalimar Bagh, Delhi, India
Background: Transfusion associated circulatory overload (TACO) is an established but grossly under diagnosed and underreported complication of blood transfusion (BT).
Aim: We prospectively analyzed the definite, probable and possible TACO cases in our tertiary care setting.
Materials and Methods: All hospitalized patients who required a blood transfusion were included in the study. All the transfused patients were 'actively' monitored for any acute adverse reaction by using a uniquely coded blood issue form. All the blood transfusion reactions were analyzed according to the ISBT criteria and definition. TACO cases were further evaluated by examining patient records at bed side including imaging studies.
Results: A total of 6 TACO cases observed during the study period. A total of 21, 664 blood and components were transfused to 6942 different patients during the study period giving an incidence of 0.09% per patient transfused. Half of these TACO cases (3 out of 6) were picked up on detailed analysis by transfusion medicine physician and were missed by the reporting clinician.
Conclusion: Etiology of TACO is more complex than a mere circulatory overload and is still not completely understood. Although incidence of TACO is low, not all the cases are reported to the blood bank and a high degree of suspicion is required.
A study of knowledge, attitude and practice of nurses regarding blood transfusion: A tool to identify and bridge the gaps
Shamee Shastry, Mohandoss Murugesan
Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
Background: Blood transfusion is a multistep complex procedure involving several healthcare workers and nurses play a vital role in the safety of transfusion chain. There is limited data available on this subject. Hence we aimed to assess the knowledge and transfusion practice of the nursing staff and the factors influencing it.
Study Design and Methods: A cross-sectional survey was carried out on staff nurse in our tertiary care referral center. Questionnaire was designed to cover various aspects of blood transfusion. Questionnaire included 8 questions related to the knowledge, 9 questions related to transfusion practices and 3 questions about their attitude towards the existing practices of our hospital. Knowledge and practice scores were tabulated and gamma value was used to assess the strength of association. A score of 75% or above was considered good, score between 50-75% as average and a score below 50% was taken as poor knowledge or practice.
Results: The study group involved 426 out of 1200 staff nurses and majority had done diploma in general nursing and midwifery. Sixty one percent had an average and 27 percent had a good knowledge score. Sixty eight percent had a good practice score. The knowledge was found to influence practice score significantly. A unit increase in knowledge score corresponded to a 0.141 unit increases in practice score on evaluation, keeping other variables constant. The major gaps identified were with respect to the patient identification, labeling of sample, transportation of platelets, use of transfusion sets and ABO, Rh blood group shift.
Conclusion: The present study is one of the largest of its kind. This enabled us to identify the gaps in knowledge on various aspects of transfusion practices, which are currently being addressed in training programs and workshops for a better and safer tomorrow.
"Safe bedside transfusion practices" can prevent non-immune haemolytic transfusion reaction: A case report
Ashish Maheshwari, HK Dhawan, A Jain, L Singh, RR Sharma, N Marwaha
PGIMER, Chandigarh, India
We present here a case of non immune haemolytic transfusion reactions that occurred due to thermal injury (Cryoinjury) to packed red blood cell unit by improper storage in the ward refrigerator.
Case Report: A 47-year-old female, with a case of post total knee replacement with Hb 8.1gm/dl required one units of packed red blood cells (PRBC); same was cross matched and issued on post op day 1 from blood bank following all essential pre-release checks. Subsequently, on the day 3 a transfusion reaction was reported stating that patient had acute transfusion reaction with vomiting and cola coloured urine. In the blood bank all the essential clerical checks were carried out to rule out any clerical discrepancy at any stage from receiving of requisition to issue. On visual examination blood bag was showing gross haemolysis which was confirmed by centrifugation in tube showing pinkish supernatant. Patient's post-transfusion sample, pre-transfusion sample and attached tube segment of PRBC unit were also subjected to centrifugation in tube which showed clear supernatant in pre transfusion sample and pinkish supernatant in post transfusion sample. The tube segment attached to pre-transfusion sample before issue of blood showed clear supernatant which implies that blood unit was not haemolysed when it was issued from blood bank. Blood bag was sent for bacterial culture which was found to be negative. On subsequent look back as per patient's attendant it was found that PRBC unit was stored in the chiller compartment of ward refrigerator, patient's attendant also reported that after 15 minutes of starting transfusion patient felt anxiety, uneasiness, vomiting and abdominal pain but these symptoms were not recognised as transfusion reaction and transfusion was continued till one and half hour till patient passed cola coloured urine in the urinary bag by then 220 ml of haemolysed blood was transfused. Patient was managed appropriately and developed no sequel of transfusion reaction and discharged from hospital on post-op day 11.This was a case of non-immune haemolytic transfusion reaction where RBCs were lysed due to cryoinjury due to improper storage in ward. Also the clinical staff failed to recognise the early signs of transfusion reaction.
Conclusions: This case reemphasizes the need of "Safe Bedside Transfusion Practices ". Error due to storage and mishandling can be prevented by improving knowledge, attitude and practices of hospital clinical staff by their appropriate training which is an essential component of blood safety. This case also highlights the importance of retaining satellite tube segment of PRBC in blood bank before issue.
Acute hemolytic transfusion reaction caused by cold reacting anti Lewis antibody in a case of severe aplastic anaemia: A case report
Pragya K, Amalraj P, Mary PC, Dolly D
Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
Introduction: Hemolytic transfusion reactions caused by Antibodies against Lewis antigens are rarely reported. Anti -Lewis antibodies are not considered clinically significant most of the time. Red cells if compatible in tests at 37°C are considered to have normal in vivo survival.
Case Report: A 54 years old man, diagnosed case of very severe Aplastic Anaemia, awaiting bone marrow transplant, was transfused a unit of cross-match compatible blood for anaemia and febrile neutropenia. He had received multiple blood transfusions in the past. Following transfusion, the same evening he presented with complaints of high coloured urine. He was investigated and found to have features of hemolysis, namely hemoglobinuria, raised LDH, indirect hyperbilirubinaemia, increased reticulocyte counts and a weak direct Coomb's test positivity. Antibody screen was negative. The red cells were tested on a monospecific DAT card (BIO- RAD DC Screening I card) which showed positivity for C3d alone. This alerted us to the possibility of anti-Lewis antibody. A new sample was drawn and all tests performed at 4°C namely (antibody screen, cross match, antibody identification), which revealed an anti-Lewis a antibody. All the blood units to be transfused thereafter were phenotyped and only Lewis antigen negative units were transfused using a warmer. He was admitted and during this episode of hospital stay, he needed four more units of blood. When transfused with phenotyped blood lacking Lewis antigen through a warmer the transfusions were uneventful.
Discussion and Conclusion: Though episodes of Anti Lewis antibody mediated hemolysis are rare, few sporadic incidents have been reported. In view of this it is evident that presence of anti-Lewis antibody and its potential to cause acute hemolytic transfusion reaction cannot be ignored.
Triad of hypertension, convulsion and encephalopathy following blood transfusion: A report of a rare adverse transfusion reaction in a patient of Factor X deficiency with anemia
Anupam Verma, Archana Tripathi, Priti Elhence, Hemlata 1 , Shubha Phadke 2
Departments of Transfusion Medicine, 1 Anaesthesiology and 2 Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Background: There are very few reports in literature about post transfusion hypertension along with neurological complications developing in transfused patients mainly with hemoglobinopathies. To the best of our knowledge such a constellation of signs and symptoms is being reported for the first time in a patient with Factor X deficiency following plasma transfusion.
Case Report: A 18- year-female with known Factor X deficiency with menorrhagia developed severe hypertension (180/100 mmHg), generalized tonic clonic convulsions and encephalopathy along with red colored urine after 2 days of FFP transfusion. There was no history of hypertension, convulsions, any cardiovascular, renal or neurological disease before transfusion. She gave a history of FFP transfusion on every menstruation and also had episodes of nose bleed and hemarthrosisonce in the past. She had received 4 units of PRBC for anemia and 10 units of FFP for menorrhagia (with prolonged PT/APTT) from an outside hospital 15 days back. Initially it was suspected to be a case of hemolytic transfusion reaction due to red colored urine however, there was no hemoglobinemia (plasma Hb value of 0.05 g/dl) with no fever, chills or rigor and DAT was negative. Blood glucose, liver function tests were found to be deranged. Thromboelastography (TEG) done after 12 hours of clinical episode revealed plasmatic and platelet hypercoagulabilityin the patientthus no plasma transfusion was given [Figure 1]. However, PT and APTT during this period were slightly deranged (PT 16.6 s vs control 12.9 s APTT, 29.6 s vs control 27 s) towards hypocoagulable state. The Electroencephalography (EEG) showed features suggestive of encephalopathy while magnetic resonance imaging (MRI) showed subcortical edema in the brain consistent with diagnosis of posterior reversible encephalopathy. EEG and MRI done after 10 days of the clinical event were normal. Patient responded well to the anticonvulsants and antihypertensive agents prescribed and was discharged in a stable condition.
|Figure 1: TEG shows hypercoagulable tracing indicating a prothrombotic state|
Click here to view
Discussion: Hypertension, convulsions and encephalopathy occurring in a transfused patient is a serious life threatening blood transfusion reaction. Posttransfusion hypertension here was not due to volume overload (Transfusion associated circulatory overload) as hypertension occurred after 2 days of FFP transfusion. It is possible that initial rapid or aggressive PRBC transfusion to treat anemia initiated the hypertensive crises, which was aggravated by intensive FFP transfusion. Endothelial dysfunction leading to impaired vascular responsiveness to vasoconstrictors (epinepharine, norepinepharine, dopamine and angiotensin II) is seen in chronic anemic conditions. It is plausible that increased activity of vasoactive substances may have predisposed to this triad after blood transfusion in our patient.
Conclusion: Our report suggests that this triad may occur after aggressive red cell or plasma transfusion for rapid correction of anemia or coagulopathy respectively and a high degree of suspicion may help in arriving at the correct diagnosis and proper management. TEG may provide a better picture of overall hemostasis as compared to traditional coagulation tests for assessing adequacy or otherwise after FFP transfusion.
Rotational thromboelastometry: An expedient approach to the management of acquired bleeding disorders
Soonam John, Ramya V, Anup J Devasia, Mary Purna Chacko, Sukesh Chandran Nair
CMC, Vellore, India
Background: Acquired bleeding disorders are a major cause of mortality, both in the developed and developing countries. An acute haemorrhage should be managed immediately with blood products, factor concentrates or anti-fibrinolytics. Investigations to detect coagulopathies typically include baseline screening tests like prothrombin time, activated partial thromboplastin time, platelet count and fibrinogen level. These tests have a long turn around time which frequently lead to a blinded approach towards blood product support leading to under or over transfusion. In contrast, rotational thromboelastometry (ROTEM) which assesses hemostasis from the start of clot formation to fibrinolysis gives earliest results within ten minutes.
Aim: This study was done to establish a correlation between ROTEM parameters and standard coagulation profile in the context of acquired bleeding disorders.
Materials and Methods: A total of 138 subjects - 70 patients who presented with acquired bleeding disorders and 68 subjects diagnosed to be normal on the basis of a complete coagulation work up were included as the cases and controls respectively. All samples were subjected to standard coagulation profile and ROTEM analysis which included Clotting Time, Clot Formation Time, Alpha Angle, Maximum Clot Firmness and Maximum Lysis.
Results: The MCF correlated very well with serum fibrinogen levels (k value - 0.807; P < 0.000; Sensitivity - 88%; Specificity - 92%), and well with platelet count (k value - 0.793; P < 0.000; Sensitivity - 86%, Specificity-92%), whereas CFT showed moderate correlation with aPTT, platelet count and fibrinogen levels. Discussion and
Conclusion: ROTEM correlates well with standard coagulation parameters. ROTEM performed on whole blood showed interpretable results within 10 minutes, whereas standard coagulation profile required an average of 45-75 minutes. In view of the good correlation, it appears that ROTEM results can be safely used to implement early transfusion therapy for haemorrhage.
ABO-identical versus non-identical platelet transfusions: Comparison of therapeutic efficacy in oncology
Shweta Gupta, Rajesh Sawant, Anand Deshpande
P D Hinduja Hospital, Mumbai, India
Background: The significance of ABO matching for platelet transfusion has not been clearly defined. Therefore determining the clinical value of transfusing ABO -identical platelet is essential.
Aim: To compare the therapeutic efficacy of ABO-identical versus non-identical platelet transfusion in oncology patient population.
Materials and Methods: 729 Platelet transfusion episodes in 176 oncology patients were studied during period of six months. In a prospective, observational study, corrected count increment (CCI) and percentage platelet recovery (PPR) were calculated at 24 hours post transfusion. Choice of the platelet preparation i.e.; Random Donor Platelet (RDP) or Apheresis Platelet (SDP) was made by the treating clinician. The co-relation between ABO compatibility and platelet dose with CCI and PPR was studied. Chi-square test, Mann-Whitney test and Pearson correlation were used for statistical analysis of data.
Results: 729 transfusion episodes (518 RDP episodes and 211 SDP) in 176 oncology patients were studied. 25% were solid organ and 75% were haematological malignancy patients. Mean patient age was 39.6 (4 months-87) years, weight 55.4(3-103) kg, and height 157(43-194) cm. Dose of platelet was higher (P = 0.01) in SDP than RDP. 60.3% RDP and 62.5% of SDP transfusions were ABO identical. 96% of the transfusion episodes were prophylactic in nature. The mean pre-transfusion threshold for SDP was 17 × 10 9 /L whereas for RDP transfusion was 34 × 10 9 /L. Mean platelet increment with SDP transfusions was 30 × 10 9 /L whereas with RDP transfusion it was 16 × 10 9 /L. Statistically significant increase in PPR (P = 0.007) was seen with ABO- identical SDP transfusion. There was no statistical significant increment in CCI and PPR in ABO-identical vs ABO non-identical RDP transfusions.
Conclusion: ABO non-identical SDP transfusions lead to a statistically significant decrease in PPR at 24 hours post transfusion. The result of this pilot study showed marginally lower platelet increment with ABO-non identical platelet transfusions. This study shall continue in future to further analyse results in larger patient cohort.
An Audit on Clinical Usage of Blood & Components in Obstetrics in a Tertiary Care Hospital
Avila Sangtam, A Barindra Sharma, Barilin Passah, K Rachandra, A Meina Singh
Regional Institute of Medical Sciences, Imphal, Manipur, India
Introduction: Blood and component transfusion remains a lifesaving procedure in some of the obstetrics patients. In many hospitals of this country and especially in this part of the country, the transfusion practice is not audited adequately, more so in obstetrics practice. Evaluation of the transfusion practice in the hospital including obstetrics patients is required for developing protocols and improvement of transfusion services.
Aims: To evaluate pattern of clinical usage of blood and components in obstetrics patients.
Materials and Methods:
Study design: Prospective and cross sectional.
Setting and study period: Carried out in the Department of IHBT, RIMS, Imphal for a period of 6 months from January to June 2014.
Study material: Data related to bloodtransfusion in 160 obstetric patients obtained from blood Requisition forms, Master record, Issue register etc. The data included were number of transfusion in 6 month period, trimester wise, levels of Hb%, indications , component wise usage, single unit red cell transfusion etc.
Results: Out of 5887 blood and components issued during the study period, 241(4.09%) units were issue dto obstetrics patients. Maximum of transfused obstetric cases were in the age group of 26-35 years (54.37%) followed by the age group of 15-25 years (30%). The ABO and RhD distribution of the patients were 37.5%, 30%, 18.7% and 13.7% for O, A, B and AB respectively, all RhD positive. Transfusion in 65.62% and 4.38% of patients were done in the third and first trimesters. The Hb level of the patients requested for PRBC transfusion were as follows: <7 g/dl in 62.50%, 8-9 g/dl in 28.12%, 10 g/dl or above in 9.37% of the cases. Anaemia was noted in all the case and the commonest indication of the transfusion was acute blood loss with anaemia(68.12%). Requisition for components were maximum in 'immediate' 64.37%, followed by 'urgent category' with 28.13%, 'routine' 3.75% and 'G&S' in 3.75% of the cases.
Transfusion of blood and blood components in obstetrics emergencies
Spruha K Dhoakia, Sumit Bharadva, Dhara Ardeshna, Jitendra Vachhani
Department of Immunohematology and Blood Transfusion (IHBT), MP Shah Government Medical College, Jamnagar, Gujarat, India
Background: Obstetric hemorrhage is the leading cause of intensive care unit admission and one of the leading causes of death in the obstetric population. Massive transfusion is needed in almost all cases of obstetric hemorrhage. Transfusion therapy in obstetrics affects the pregnant woman, the developing fetus and the neonate. Causes of obstetric bleeding are (1) Antepartum Hemorrhage- Placenta previa, Placenta Abruption, Trauma and Uterine rupture and (2) Post partum Haemorrage- Uterine atony, Retained product of conception, Trauma, Clotting defects, Retained dead fetus, Eclampsia.
Aim: To estimate the percentage of Blood Component usage in obstetric haemorrhage.
Materials and Methods: This study was conducted by Blood Bank, Department of IHBT, G.G.Hospital and M.P. Shah Medical College, Jamnagar, Gujarat. Study period was May 2014 to October 2014. Cases that were studied included Post Partum Haemorrhage(PPH) and Abruptio Placenta that lead to Disseminated Intravascular Coagulation (DIC).
Result: Totally eight cases of obstetric haemorrhages were studied. Mortality observed in 20% of cases. Blood component usage: PRBC-16.%, WB-12.2%, FFP-46.4%, RDP-24.6%.
Discussion: The hightened state of coagulation in placental bed increases the vulnerability of pregnant female to thrombotic disorders. In abnormal pregnancies, this prothrombotic state further accelareted by pro inflammatory forces and release of procoagulant material. The spill over of localised coagulation activators from placenta initiates the biodegradation of fibrinogen and clotting factors, resulting in hemorrhage and microvascular thrombosis leads to DIC. Key to management is in early recognition to facilitate timely intervention. it is helpful to have a massive haemorrhage protocol outlined before an emergency occurs. Treatment includes supportive blood replacement therapy in addition to removal of placenta. Blood product replacement in massive obstetric haemorrhage: Control of bleeding, Restore the circulating blood volume, Control of exacerbating factors for abnormal coagulation, Blood products support like- Packed Red Blood Cells,Fresh Frozen Plasma, Platelate Transfusion etc according to patient's need.
Conclusion: Blood Component therapy is an integral part of the management of PPH. In this study, its found that FFP was mostly used in obstetric haemorrhage.
Blood utilization management in a transfusion service
G Deepa Devi, S Hamsavardhini, P Arumugam
Department of Transfusion Medicine, The TN Dr MGR Medical University, Chennai, India
Introduction: Blood collected from voluntary nonremunerated blood donors is a precious resource and should be used judicially. Every Transfusion service should establish both minimum and ideal inventory levels. Inventory level should be evaluated periodically and adjusted if needed. The ideal inventory level provides adequate supplies of blood for routine and emergency situations minimizing outdating. Both surpluses and shortages of blood products lead to insufficient use of resources.
Aim: To establish good inventory management practices in our blood transfusion center.
Materials and Methods: Calculation of Optimal Inventory was done using the following method. We collected weekly blood and component usage data over a 6 month period. We then determined the usage by ABO and Rh type for each week. To correct for unusual week to week variation (e.g. a large volume use for an emergency), the single highest usage for each type was not used in calculating the average weekly blood usage. We totaled the number of units of each ABO and Rh type, omitting the highest week in each column. We Divided each type by 25 (total number of weeks minus the highest week). This gave the average blood usage of each ABO and Rh type in our blood bank.
Results: By these simple calculations the department tries to meet out the demand supply ratio more optimally. We continuously evaluate the inventory practices using the outdate rates and the frequency of non availability of the particular blood group when needed by the patient. Daily stock details with details of date of expiry helps in managing the stock.
Conclusion: The final decisions, of course, must be the result of good judgment, and not the product of a mechanical set of formulas. Inventory level should be evaluated periodically and adjusted as needed. According to WHO routine hospital requires 7 blood units/bed/year and tertiary hospital requires 20 units/bed/year.
Unusual presentation of Hbq with macrocytosis
Cheryl Mazumder, Prakash Roplekar, Sudhamani, Rajiv Rao
D Y Patil University, School of Medicine, Navi Mumbai, India
Objectives: Generally HbQ(Quiescent dormant or inactive) is a rare α- chain varianta point mutation (GAC;CAC; Asp;His) at codon 74 of the α1-globin gene on chromosome 16p, presents as a heterozygous state along withα- thalassemia or β- thalassemia. Blood indices generally show normocytic normochromic picture or microcytic hypochromic picture, but this is a presentation with macrocytosis. It is a silent variant with no deleterious phenotypic effects or clinical manifestation.
Materials and Methods: Done on a cation exchange high performance liquid chromatography (CEHPLC) Bio Rad D10.
Result: The electrophoresis result shows Hb Q trait.
Conclusion: Apart from performing Hb electrophoresis on a normocytic normochromic and microcytic hypochromic, a macrocytic picture should also not be ignored for suspecting hemoglobinopathies.
Transfusion requirements in living donor liver transplantation
Rimpreet Singh Walia, R N Makroo, Sanjeev Aneja, Aakanksha Bhatia, Mohit Chowdhry
Lifeline Blood Centre, Patiala, Punjab, India
Background: Liver transplant is often associated with considerable bleeding and poses a challenge to the blood transfusion services.
Aim: This study was undertaken to analyse the average blood component consumption and the effectiveness of preoperative laboratory assessment and Model for End Stage Liver Disease (MELD) score in the estimation of transfusion requirements in Living Donor Liver Transplantation (LDLT).
Materials and Methods: This study was conducted at the Department of Transfusion Medicine and Department of Surgical Gastroenterology and Liver Transplant, Indraprastha Apollo Hospitals, New Delhi, from January 2009 to May 2012. Relevant data was obtained from the patient's case file. Univariate and stepwise regression analysis were employed to establish the significance of correlation of the preoperative laboratory variables, including hematocrit, platelet count, INR, total bilirubin, serum creatinine, blood urea and MELD score with the total consumption of Packed Red Cells (PRCs), cryoprecipitates, apheresis platelets and Fresh Frozen Plasma (FFP).Correlations were significant at P-value <0.05.
Results: A total of 509 patients were included. On an average, 8.44 units (SD = 6.11) of PRCs, 2.58 units (SD = 2.95) of cryoprecipitates, 0.81 units (SD = 1.16) of apheresis platelets and 2074.85 ml (SD = 1240.20) of FFP were consumed per LDLT. Stepwise discriminant analysis, identified those preoperative factors which have a significant predictive value for the total consumption of each blood component and these results were employed to construct separate prediction models for the utilization of each blood component and the respective R square values were determined. The blood component prediction models could be employed to accurately predict the total utilisation of PRCs, cryoprecipitates, FFP and apheresis platelets in 23, 22.6, 17.8 and 20.7 per cent of our patients, respectively.
Conclusion: Besides preoperative laboratory parameters and MELD score, other variables might also influence the blood component consumption in LDLTs.
A case report of multiple myeloma diagnosed by peripheral smear and bone marrow examination
Varsha Dhuliya, Meeta Nanavati, Hansa Goswami, RN Gonsai
Department of Pathology, BJ Medical College, Ahmedabad, Gujarat, India
Introduction: Multiple Myeloma is a debilitating malignancy that is a part of spectrum of diseases ranging from monoclonal gammopathy of unknown significance (MGUS) to plasma cell leukemia. It is a neoplasm of post-germinal centre, terminally differentiated B cells.
Case Report: A 50 year old man was admitted with complains of vertigo, loss of appetite, generalised weakness and backache since 5 Days to our department.
Investigation and Diagnosis: The following investigations are performed: Peripheral Smear Examination shows rouleaux formation, background staining and Plasmacytoid lymphocyte. ESR after 1 hour was 128 mm. Protein Electrophoresis Bone Marrow Examination revealed Hypercellular marrow with almost 50-55% cells were plasma cells and plasma blasts, having multinucleation, multilobation with few mott cells and flame cells. Bone marrow trephine biopsy shows hypercellularity and sheets of malignant plasma cells. USG report shows fatty changes in liver.
Conclusion: Although Multiple Myeloma's final diagnosis is done on the basis of many tests, Radiological opinion and Peripheral smear overview and Bone Marrow Examination. Out of these, Bone Marrow Plasmacytosis is the most important criterion of multiple myeloma, but still it is not a single diagnostic marker upto now.
Risk factors for bleeding among thrombocytopenic patients on intensive chemotherapy for acute myeloid leukemia: A time to event analysis
PS Shaiji, N Geetha
Government Medical College, Trivandrum, India
Background: Patients undergoing chemotherapy for acute myeloid leukemia are a risk group for thrombocytopenic bleeding. Severity of bleeding varies across and Platelet levels are not absolutely predictive of the occurrence of bleeding. Prevention as well as effective management of bleeding using drugs and blood products remains an important area in the supportive therapy of AML. We attempt to find out the risk factors associated with onset of bleeding in AML patients who are undergoing intensive chemotherapy in a Regional Cancer Center.
Aim and Objectives: 1. To find out the risk factors associated with bleeding in AML patients 2. To assess the frequencies of various categories of bleeding.
Materials and Methods: Patients with AML from January to December2011 were included. APML, Anticoagulant therapy or palliative chemotherapy were excluded. All patients underwent induction chemotherapy with Cytosine Arabinoside and Daunorubicin. Details noted were age, gender, body surface area, FAB type etc. Time to occurrence of first bleed, site, duration, grade and outcome of bleed also were recorded. Hb/WBC/platelet counts, presence of sepsis, temperature, administration of drugs and GCSF, RBC and platelet transfusions were recorded. Degree of bleeding was graded according to WHO. Kaplan Meier curves for time of onset of bleeding were plotted and compared with log-rank test. Cox's proportionalhazard model was used to analyse the factors associated with bleeding.
Results: Out of 81patients studied, all the patients experienced thrombocytopenia. 49.2% experienced bleeding manifestations. Major types of bleed were menstrual bleed, bleed from peripheral line, epistaxis, petechiae and conjunctival bleed.2 patients had experienced subarachnoid and intracerebral haemorrhage. Factors found to be significantly associated with early onset bleed are raised body temperature (Hazard Ratio 4.1, p.0001), GCSF Usage (HR 2.8, P = .000), Amphotericin (HR 2.9, P = .000), anemia = .002). Average number of RDPs used was 18 (SD4.2) in an induction.
Conclusion: Bleeding remains a significant problem in AML patients. Severe life threatening haemorhage also occurs infrequently. Special attention should be given to those with risk factors to minimize bleeding and its complications. Transfusion services should work towards providing timely supply of blood products to these patients.
Precaution to minimize the bacterial contamination in transfusion reaction
Nancy Geetha, Suresh Mitta, T Kippuraj
Masonic Blood bank and Component Center, Vellore, Tamil Nadu, India
Introduction: Blood transfusion is one of the most important procedure in patient care. When the blood/blood products are transfused after proper serology screening and compatibility testing, sometimes the recipient will feel difficulties during or after the transfusion. This reaction is known as transfusion reaction.
Materials and Methods: Transfusion Reaction divided into four types. They are 1) Febrile pyrogen reaction: Takes place due to the substances presents in blood or in anticoagulant or in blood bag tubing 2) Allergic reaction: Presence of some substances in donor blood to which the patient becomes allergic 3) Haemolytic reaction: Due tomismatching blood, wrong labeling and wrong identifications 4) Delayed transfusion reaction: Takes place after a week or months of transfusion. The following are the precautions to avoid the bacterial contamination 1) Handling the bag: The needle should not be exposed in the air the for more than 2 to 3 seconds. If exposed, aerobic organisms will grow and may lead into reaction. Hence, Select the prominent vein, clean the site thoroughly, open the needle and thus leads into reaction. Hence, Select the prominent vein, clean the site removes external dust, Betadine- germicidal, and final cleansing is done. Improper cleaning will lead in to contamination and thus leads into reaction To avoid such reaction, safety featured blood bag is used, in which special pouch is attached, where initial flow of (10-15ml)of blood is collected (can be used for screening and crossmatching, purpose) and the mid flow collection will go into the main blood bag. So even if there is skin contamination, it will not affect the main bag. 3) Pricking: Multiple pricking is one of the main causes for bacterial contaminations, which will lead to reaction. Try and avoid multiple pickings, or discard the early bag and use a fresh blood bag. 4) Penetrate: Never try to enter into main blood bag which is dangerous. Use the segments for crossmatching purpose, if by chance all segments get over, never enter into main bag. The whole unit will be contaminated and lead to reaction. It is better to discard the unit rather to take risk. 5) Storage: The blood or blood products are kept for longer period only in the blood bank refrigerator (BBR).Periodical cleaning of BBR is very essential, if not aerobic organism will grow and affect the plastic material which may be one of the reasons to have a reaction. It is suggested to clean BBR, once a month by using (1%) Microbac -Forte. (Aldehyde free surface disinfectant cleaner, which is effective against Bacteria, Mycrobacteria, Fungi, Viruses). To check the the effectiveness of cleaning, it is better to take culture swabs before cleaning had aerobic organisms grown, after cleaning shows no growth. 6) Timings: Tracking the timings is very essential like time of issuing blood, time of starting transfusion, time of stopping the transfusion (if any reaction occurs) and time of receiving the used bag. If a reaction takes place, the used bag should be sent o the blood bank for investigation immediately. Blood, being the rich and high media, organisms will grow if the used blood bag is kept in room temperature for long time, which will change the entire scenario.
Conclusion: Even the small negligence will lead into Transfusion Reaction, so take necessary precaution to get rid of Bacterial contamination of Transfusion reaction.
Transfusion support in A2 patients with anti: A 1 antibodies in a tertiary health care centre: A report of 3 cases
Jeeva Priya R
SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India
Background: A2 is rare subgroup. Because of weak antigenic power of A2 subgroup, haemolytic transfusion reaction is not severe and lethal under normothermic situations. However severe reaction may occur due to the presence of anti - A1 antibodies at lower temperatures ie 25 C, particularly observed in patients undergoing CABG under hypothermic CABG.
Case Report: Case Report 1: 36 year old female was admitted for complaints of lower abdominal pain, menorrhagia, giddiness. Patient was diagnosed to have fibroid uterus for which, she was posted for abdominal hysterectomy. Her HB was 5.6 g% and a blood request was sent from gynecology ward for 2 units of A Positive PRBCs. During cross matching, patient's blood group was found to be A2 positive with Anti A1 antibodies reactive at 37 C which was confirmed by both conventional tube technology and by gel technology. Hence the patient's blood was cross matched with compatible A2 positive blood. Transfusion of the first unit was uneventful. Patient developed severe chills and rigor after second unit PRBC transfusion, transfused after 2 days. Routine transfusion reaction workup was normal except weak positive DAT in post transfusion sample. Donor blood segment blood type was A2.Patient was further managed with hematinics. Case Report 2: 26 year old antenatal female 32 weeks gestation was admitted for management of anemia. Her HB was 7.5 g%. Blood request sent for 1 unit A Positive PRBC. During cross matching patient blood group was A2 with anti-A1 antibodies reactive at 37 C. Cross match compatible A2 blood was transfused uneventfully. Patient's blood was analysed post transfusion and found to have weak positive DAT. Hence second blood transfusion was avoided. In both the above said cases, donor's blood was clearly A2 positive. There was no co morbid medical conditions in both these patients. The reason for post transfusion DAT is not known. Case Report 3: 59 year old male admitted for triple vessel graft CABG required 4 units of AB negative blood with additional plasma and platelets during surgery. Patient's blood group was A2B negative with significant anti - A1 antibodies. Due to non availability of A2B negative blood, A1B negative blood which was in stock was cross matched and found to be compatible. Having in mind about the risk of developing lethal haemolytic transfusion reactions during cardio plegia, transfusion of A1B negative blood was denied inspite of it's compatibility. Options regarding alternative O Negative PRBC was discussed with the cardiothoracic surgeon and anaesthetist. Clinician opted out of operating the patient as transfusion across blood groups might pose allo- immunisation during subsequent surgeries.
Discussion: A blood group has common two phenotypes A1 and A2 with a prevalence of 80% and 20% respectively.A2 has weak antigenic power than A1, and hence observed as microscopic agglutination. Approximately 1-8% of A2 and 22-26% of A2B have anti - A1 antibodies. Anti A1 antibodies reactive at 37 C is clinically significant in producing haemolytic transfusion reaction. From the above cases, we came to conclusion that, recrossmatching and antibody detection should be done in A2 patients before every transfusion to prevent haemolytic transfusion reactions. It is important to monitor patients carefully for development of new antibodies. SOP s should be made regarding usage of alternative blood in case of emergency and in patients requiring large volume transfusions as in CABG. Separate blood inventory register for A2 and A2B blood should be maintained in the blood bank to prevent unnecessary wastage of negative group blood. In case of rare blood groups like A2B negative, blood conservation strategies utilising autologous blood transfusion with ANH are the recommended ways to prevent transfusion reactions.
Bed side transfusion practices: Touching the untouchables
Dheeraj Khetan, Rahul Katharia, Hemchandra Pandey, Ashish Jain, Lalit Dhantole, Persis Jaiswal, Sudarshana Gogoi, Rajesh Harsvardhan, HC Pandey, Rajendra Chaudhary
SGPGIMS, Lucknow, India
Background: Blood transfusion chain can be divided into three phases: Pre-analytical (patient bedside), analytical (steps done in transfusion services) and post- analytical (bedside). Bedside activities include multiple steps involving doctors, nurses and ward attendants and are prone to frequent errors. Majority (~70%) of events due to blood transfusion have been attributed to errors in bedside blood administration practices.
Aims: Audit of bedside transfusion practices (pre-analytical and post analytical phase) in pre-identified patient care areas was done to assess awareness and compliance to institute guidelines regarding requisition and administration of blood components.
Materials and Methods: Interview based questionnaire of ward staff and Observational survey of actual transfusion of blood components in total 26 wards of the institute was carried out over a period of one month (December 2013). All the collected data was coded (to maintain confidentiality) and analyzed using SPSS (v 20). For analysis, wards were divided into three categories- medical, surgical and others (including all Intensive care units).
Results: A total of 104 (33 resident doctors and 71 nursing) staff members were interviewed and observational survey could be conducted in 25 wards during the study period. In the pre-analytical phase, major issues were as follows: Lack of awareness for institute guidelines (80.6% not aware), improper sampling practices (67.3%) andprescription related (56.7%). In the post-analytical phase, major issues were found to be lack of consent for blood transfusion (72%), improper warming of blood component (~80%) and problems in storage and discarding of blood units.
Conclusion: There is need to create awareness about policies and guidelines of bed side transfusion among the ward staff. Regular audits are necessary for compliance to guidelines among clinical staff.
Does intravenous tranexamicacid reduce allogeneic blood transfusion in total hip and knee arthroplasty?
Ajju Agnihotri, Nischal Chugh, Saranjeet Kaur
Max Superspeciality Hospital, Shalimar Bagh, Delhi, India
Background: Total Knee or hip arthroplasty is known to be associated with significant blood loss. Thisnecessitates allogenic blood transfusions leading increased complications, increased hospital stay, increased cost and decreased patient satisfaction. Minimizing blood loss during and after surgery is therefore an important goal. Techniques such as use of antifibrinolytics, normovolemichemodilution or desmopress in have been used to reduce the need for allogenic blood transfusion.
Aim: This study aimstocompare the effect of antifibrinolytc agent- Tranexamicacid (TXA) in reducing allogenic blood transfusions in patients undergoing knee and hip arthoplasty.
Materials and Methods: This was a retrospective study performed from November 2012 to August 2014.Study period was divided into phase I and II based upon introduction of TXA after October 2013 for all patients. During Phase II-single dose of intravenous TXA (10 mg/kg) was given intraoperatively 10 minutes before incision. Blood utilization was compared amongst the two groups based upon their age, gender, hemoglobin and type of surgery.
Results: In phase I (without TXA) 38 out of total 61 patients (62.2%)were transfused 50 units of PRBC. In phase II (with TXA) only 19 out of total 80 patients (23.8%) were given 25 units of PRBC. There was a clinically significant reduction in the percentage of patients requiring blood transfusions after TXA. However, there was no difference in the number of PRBCs required per patient in cases requiring blood transfusion (1.31 unit per patient). Gender wise utilization of blood was also lower in the second group. For males blood utilization was reduced from 42.1% to 20% whereas in females the reduction was even more marked from 71.4% to 25.0%.
Conclusion: Intraoperative use of intravenous TXA in dose of 10 mg/kg significantly reduces allogenic blood transfusion in hip and knee arthroplasty patients.
Effectiveness of therapeutic phlebotomy in polycythemia patients
Soumya Das, Mohandoss Murugesan, Shamee Shastry
Department of Immunohaematology and Blood Transfusion, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
Introduction: Hyperviscosity that results from the expansion of total red cell volume in patients with polycythemia vera is the basis of prothrombotic state. Guidelines recommend aggressive therapeutic phlebotomy (TP) to lower the hematocrit below 45% in males and 42% in females.
Objectives: To study the profile of polycythemic patients undergoing TP in Kasturba Hospital, Manipal and to determine their hemoglobin, hematocrit and blood volume changes after the procedure.
Materials and Methods: The patients with polycythemia who underwent TP from September 2013 to July 2014 were included. The patient's demographic and clinical profiles were collected. Their hemoglobin, hematocrit and volume to be removed were noted. Randomly patients were selected in whom post procedure hemoglobin was determined and changes in hemoglobin concentration and blood volume were calculated. The change in hemoglobin concentration and clinical presentation was also studied.
Results: 134 patients (M-119, F-15) underwent 236 events of TP procedures. Median age was 49 years (22 to 88 years) and clinical presentation: Common ones were hypertension (28%), conjunctival congestion (21%), myalgia (20%), headache (18%), CVA (18%) and less common were erythromelalgia (1%), blurred vision (4%) and DVT (8%). Primary polycythemia was seen in 18 patients (JAK2 mutation - positive). 55% of patients had only one event and 4% had more than five events of TP. 56% of TP were done for acute presentations (with mean interval of 1.75 days) and the rest to reduce the hemoglobin concentration (mean interval of 41 days). The mean pre procedure hemoglobin was 17.6 ± 1.66 gm/dL and their drop in hemoglobin was 0.78 ± 0.5 gm/dL. Their pre-hematocrit was 54.2% and post-hematocrit was 52%. Mean volume of blood removed in each event was 304 ± 58.1 mL.The mean change in blood volume during TP in these patients was 0.199 ± 0.159 L.
Conclusion: Symptomatic improvements following TP were noted in 60% of patients. TP though commonly performed for reducing red cell mass in polycythemia had poor compliance from patients, resulting in failure to achieve desired levels.
Identifying borderline beta-thalassemia carriers: To determine hemoglobin A2 level by the HPLC system
Jignasa Gami, Heena Kashiyani, Kamlesh Dharajiya, Sahjid Mukhida
Rajkot Voluntary Blood Bank, Rajkot, India
Introduction: There are various methods for screening beta-thalassemia carriers. In primary screening methods, risk of false negative results for borderline A2 subjects is high. At our centre, we use High Performance Liquid Chromatography (HPLC) system for confirmatory test. To prevent thalassemia major birth, accurate screening for thalassemia is pre-requisite.
Aim: To detect and confirm borderline beta-thalassemia carriers for prevention of thalassemia major births.
Materials and Methods: We screened 15852 individuals for beta-thalassemia by using CBC as the primary screening test followed by HPLC, from Aug-2011 to July-2014. In screening, 293(1.84%) subjects defined as borderline where, HbA2 value between 3.4% to 3.9%, hemoglobin and mean corpuscular volume (MCV) normal or slightly reduced/elevated. Borderline HbA2 subjects were confirmed twice by HPLC on Bio-Rad Variant II machine.
Result: Out of 293borderline subjects 151 (51.5%) were detected negative for thalassemia in primary screening. In confirmatory test, 64 (21%) subject carried other heamoglobinopathies, while 79 (26%) subjects borderline, which need further testing. For borderline cases, Hb value varied from less than 7 gm/dl (8.5%), between 7-10 gm/dl (6.8%) and above 10 gm/dl (85%) while MCV value ranged below normal (<80) 26%, within normal (80-99) 59% and 12% elevated range. In study, 169 (57%) were males and 124 (43%) were females.
Conclusion: Majority of borderline HbA2 subjects had Hb and MCV values within the normal range. In primary thalassemia, screening chances to misdiagnose for borderline individuals is more. Only an effective thalassemia screening will help to prevent birth of thalassemia major babies. Thus confirmatory testing in such cases is essential.
ABO incompatible adult living donor liver transplantation: A case report
Deepti Sachan, Joy Varghese 1 , M Srinivas Reddy 2 K Ilan 3 , Gomathy Narasimhan 2 , K Venugopal 2 , Sanjay Govil 2 , Mohamed Rela 2
Department of Transfusion Medicine, 1 Hepatology, 3 Anethesiology and 2 Institute of Hepatobiliary and Liver Transplantation Surgery, Global Health City, Chennai, Tamil Nadu, India
Background: ABO-Incompatible liver transplantation (ABOiLT) is associated with high risk of acute humoral rejection due to preformed antibodies. It is performed only in cases lacking an available/compatible organ donoror in emergency situations and is done only in a few centers in India. We report asuccessful case of A 2 -O liver transplantation done in our transplant center.
Case Report: 51 year old male, known case of ethanol related end stage liver disease with hepatorenal syndrome and refractory ascitis, MELD 34, blood group O positive underwent (A 2 -O) ABOiLT with his wife as donor A 2 in May 2014. Anti-A Isoagglutinin titers were performed using double dilution method at saline phase (IgM) and IAT phase (IgG) at baseline to determine the risk of antibody mediated rejection. Baseline Anti-A IgM and IgG titer was 1:32 and 1:128 respectively. 2 sessions of 1 Plasma volumetherapeutic plasma exchange (TPE) were performed using a Optia Spectra cell separator to reduce isoaglutinin titres to IgG ≤16, IgM ≤8 before the transplantation. The replacement fluids for TPE used was fresh frozen plasma, 5% human albumin, and normal saline). Intraoperative 11 units of O positve Leucodepleted packed red cells, 11 units of A group Fresh frozen plasma and 7 units of cryoprecipitate was transfused. In addition to TPE, the immunosuppresive therapy included methyl prednisolone, tacrolimus, and Mycophenolate mofetil. During postoperative period, 2 more sessions of TPE was performedto reduce the ABO titers. Postoperative complications included MDR -Klebsiella infection sensitive to Tigecycline (POD10) and Tacrolimus induced neurotoxicity and required the alteration of immunosuppresion dose. The patient has now survived with more than 120 days after liver transplantation with normal liver function and no evidence of AMR.
Discussion: The A 2 Subgroup expresses lesser epitopes than the A 1 phenotype and shows less reactivity with Anti-A. It is found to be a safer option in ABOiLT with similar overall and graft survival. Transfusion Medicine plays an important role in ABOiLT for Blood group and Subtyping, ABO Isoagglutinintitre monitoring, plasmapheresis and transfusion support to these patients.
Red cell alloimmunization in patients undergoing liver transplantation: The challenges
Deepti Sachan, Aswin Kumar, Joy Verghese 1 , Ilan K 2 , Mohamed Rela
Departments of Transfusion Medicine, 1 Hepatology and 2 Anethesiology, Institute of Hepatobiliary and Liver Transplantation Surgery, Global Health City, Chennai, Tamil Nadu, India
Background: Orthotopic liver transplant is a life saving procedure for patients with end-stage liver disease. These patients are often multi-transfused due to haemostatic dysfunction/bleeding episodes and there is a risk of developing clinically significant alloantibodies towards blood transfusion. Supporting a liver transplant recipient with an alloantibody is challenging as they may require large amount of blood transfusion during the peri-transplantation period.
Aim: To assess the frequency and specificities of red cell alloimmunization in patients undergoing Liver transplant workup at our Institute.
Materials and Methods: 360 patients underwent orthotopic liver transplantation at Global Health city from August 2009 to August 2014. Pre transplant Immunohematological workup was carried out using three cell screening panel (ID Diacell, Biorad) and Polyspecific AHG cards. Antibody screening was performed on antibody screening positive samples using 11- cell panel (ID Panel, Biorad). Antigen typing was done using monoclonal antisera (Diaclon, Biorad). The clinical, crossmatch and transfusion records of the alloimmunized patients were reviewed.
Results: A total of 09 alloantibodies were identified in patients during pre transplant immunohematological workup with the overall prevalence of 2.7%. All had single antibodies. 2 patients had cold alloantibodies (Anti-M (N = 1), Anti-Lea (N = 1) which were not reacting at 37 C and titer <64; crossmatch compatible units were reserved and issued. Seven of them were clinically significant (Anti-Jka (N = 3), Anti-E (N = 2), Anti-Fya (N = 1), Anti-S (N = 1). A total of 396 (15-115 each patient) units were crossmatched and phenotyped to reserve 15 antigen negative units for each alloimmunized patient. The intraoperative blood transfusion was 49 units with an average of 5 units (range 0-10). There was no perioperative hemolysis or transfusion reaction in peri-operative period. The Turnaround Time for the reservation of 15 antigen negative units ranged from 4-72 hours. Intraoperative cell salvage was also used to reduce allogenic blood transfusion. Any incompatible units were not issued to these patients.
Conclusion: Transfusion therapy in alloimmunized patients is often challenging due to unpredicted and massive requirements of blood during transplant surgery. Proper and Timely antibody screening and identification, Adequate blood stock, availability of minor antisera, trained staff, and better communication with clinical team can help us to combat these challenges.
Management of a traumatic pharyngeal injury in a Hemophilia B patient under resource constraint scenario
Nittin Henry, Nithya S Baiju, AM Rafi, Susheela J Innah
Department of Transfusion Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
Case Report: 75% of Indian hemophilic patients are unable to afford the recommended Factor concentrates in India even with provision of factor concentrates at a subsidized rate. We are reporting a case of 1 year old hemophilia B patient who presented to us with traumatic pharyngeal injury. Patient was having severe form of Hemophilia B (<1%) and a hematoma with mild bleeding was identified on local examination. The patient's Factor IX deficiency was managed with recombinant Factor IX concentrates. Due to resource constraints we aimed replacement to 50% of normal Factor IX activity with tranexamic acid prior to surgery. Special care while giving general anesthesia and surgical procedure was advised. Post operative maintenance of Factor IX replacement also was restricted to one day post op. In developing countries like India we will have to manage patients with factor deficiencies now and again with management protocols that deviates from western guidelines.
Transfusion support in HSCT: A single centre retrospective analysis
Sabita Basu, Suvro Datta, Supriya Dhar, Mammen Chandy
Tata Medical Center, Kolkata, India
Background: Transfusion support in HSCT can be very demanding and challenging. We retrospectively analysed the first 100 days transfusion requirements among (HSCT) recipients with haematological as well as non-haematological malignancies.
Aims and Objectives: To analyse the transfusion requirements of various blood components in different types of HSCT.
Materials and Methods: This study included one hundred HSCT recipients who had received reduced intensity conditioning and were performed over 2 years. We divided the HSCT recipients into three groups: Autologous, allogenic and haplo-identical. Allogenic group was subdivided into matched related donor (MRD) and matched unrelated donor (MUD). The allo and haplo groups were then classified on the basis of the ABO compatibility as major, minor, bi-directional and group specific. We analysed the requirement of blood components within first 100 days of HSCT. Data was analysed using SPSS software.
Conclusion: Allo and haplo-HSCT required much more transfusion as compared to auto-HSCT. In the allo category, MUD required more transfusion support than MRD group. Transfusion requirements were significantly higher in major and bi-directional HSCT when compared with the minor and same blood group HSCT recipients.
BRDU: An in vivo marker of stem cell replication
Shoganraj S, Deepa D, Usha S
The TN Dr MGR Medical University, Guindy, Chennai, India
Stem cells when introduced into a tissue as a therapeutic mechanism to stimulate the repair of damaged tissue, its monitoring is possible by a marker BrdU, a thymidine analog. BrdU is 5-bromo-2-deoxyuridine, a modified deoxyuridine that is quite similar structurally to thymidine and therefore can be incorporated into a replicating DNA. The process of supplying a dividing cell with BrdU and incorporating into new DNA is called BrdU labeling. Antibodies specific for BrdU can then be used to detect the incorporated BrdU, thus indicating cells that were actively replicating their DNA. Binding of the antibody requires denaturation of the DNA, usually by exposing the cells to acid or heat. BrdU is not naturally found in cells - it must be added, so any cells undergoing cell division and DNA replication, at the time of BrdU addition will take up BrdU in its DNA and subsequent cells resulting from cell division of this first cell will also have BrdU in their DNA. Although BrdU is not re-introduced, the BrdU concentration per cell will be approximately one half with every cell division. Stem cells labeled with BrdU when introduced into new tissue, after a period of time the tissue can be stained histologically for the presence of BrdU in tissue cells. Any cell that has BrdU in its DNA is presumed to have derived from initial stem cells injected. Sometimes stem cells injected in tissues could die and release their BrdU into the surrounding space,and neighboring cells could take up this BrdU and label their DNA showing that all BrdU labeled cells to have arisen from the injected labeled stem cells which is still an ongoing research. Since BrdU can replace thymidine during DNA synthesis,it can cause mutations, but at labeling concentrations it does not cause any mutation. Hence it is widely preferred for in vivo studies of stem cell proliferation.
Collection, enumeration and cryopreservation of cord blood stem cell
Sakshi Sharma, Brig Paramjit Dhot, Jyotsna Madan, Parul Singhal, Brig R K Sehgal, Col Narendra Singh
Santosh Medical College, Ghaziabad, UP, India
Introduction: Cord blood as a source of haematopoietic stem cells has several advantages as it is easily available, involves non-invasive collection procedure and is better tolerated across the HLA barrier.
Aims and Objectives: The present study was carried out with a view to establish a HSC Bank in the department of Haematology, Santosh Medical College, Ghaziabad The aims were firstly, to develop techniques for collection of cord blood maximising the blood volume without compromising on the sterility and quality of stem cell yield. Secondly, to separate and enumerate the HSC in the cord blood and study the effect of cryopreservation on stem cell count and viability.
Materials and Methods: Consent of the pregnant mothers was taken. The umbilical vein was cannubated just above the clamp and more than 80 ml of cord blood was collected in the blood bag containing 22 ml of citrate phosphate dextrose anti-coagulant. Processing of the cord blood was done. 10% dimethyl sulphoxide was added. Total nucleated cell count was done. The cryobag was preserved in −86 degree centigrade deep freezer. Viability count of stem cells was done. Till date 54 cord blood samples have been stored.
Results: The average cord blood volume collected was 91 ml. Total nucleated cell count range from 14 × 10 7 ml to 27.5 × 10 7 ml. Viability of cord blood stem cells was 98.7%.
Conclusion: The present study was undertaken to standardize the collection, processing, enumeration and cryopreservation of cord blood stem cell for setting up a cord blood bank for cord blood transplantation. The initial results are encouraging and this has given impetus to our objective.
Immuno-hematologic consequencesin ABO incompatible allogeneic hematopoietic stem cell transplantation: An analysis
P Nagaraju, Shashank Ojha, SH Sumathi, SB Rajadhyaksha
Department of Transfusion Medicine, Tata Memorial Center Advanced Centre for Treatment, Research & Education in Cancer, Navi Mumbai, Maharashtra, India
Background: In modern era of allogeneichematopoietic stem cell transplantation [HSCT], ABO incompatibility though not a contraindication for successful transplant, presents with certain immunohematological challenges.
- To study immuno-hematological consequences of ABO Incompatible allogeneic HSCT with careful interpretation of ABO discrepancies and isoagglutinin titres.
- To determine the timeline for mixed red cell chimeric states with importance to transfusion support in such cases.
Materials and Methods: Retrospective analysis of all ABO incompatible HSCT was conducted from January 2008 to June 2014. Blood group and isoagglutinin titres (IgM and IgG), including baseline titres in both patient and donors were periodically followed up and analysed as per departmental standard operating procedures. The temporal ABO blood group disparities were addressed to provide transfusion support as per recommended guidelines. The isoagglutinins were further investigated and correlated amongst various categories using Mann-Whitney U test and ANOVA (with SPSS software 21).
Results: The analysis of ABO incompatible allogeneic HSCT (N = 73) included Major (N = 17), Minor (N = 35) and Bidirectional (N = 21) cases; of which majority were group O donors. The median baseline isoagglutinin titres of O blood group donors of minor HSCT were higher [Anti-A:IgM-32,IgG-64; Anti-B:IgM-32,IgG-64]. The mean (range) days of blood group switch to donor type in Major recipients were delayed significantly [60(28-110); P = 0.006]. Overall the mean (range) follow-up period of the HSCT patients was 110 days (28-249 days). The mean ± SD of packed red cell units transfused was highest in Major HSCT [2.9 ± 3.9] recipients (P = 0.37) whereas highest platelet transfusion was in recipients of minor HSCT [4.1 ± 6.5](P = 0.49).
Conclusion: The observed changes in ABO isoagglutinin titres and blood group switch might have clinical implications in the occurrence of immunohaematological complications and might also reflect recipients immunohaematological reconstitution after transplantation. These are relevant factors for patient blood management and blood inventory management.
Value addition to anti hla antibody detection through the luminex single antigen assay
R Shanthi, Anutha Augustin, Sam Arul doss, PC Mary, Dolly Daniel
Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
Introduction: The Complement Dependent Cytotoxicity (CDC) crossmatch described by Patel and Terasaki in the 1960s established the unquestionable role of antibodies detected on this platform in renal transplant outcomes. Newer platforms have since arrived on the scene. These with their increased sensitivity and specificity have proved to be useful adjuncts in pretransplant screening, as this case illustrates.
Case Report: A 34 year old married woman underwent workup for live related transplant with her mother-in-law (also a paternal aunt) as the prospective donor. The patient had a sensitization history of 6 blood transfusions, and 2 pregnancies. The donor was mismatched for A and B loci and a 2 antigen match for DR and DQ loci. CDC was consistently negative. However, Luminex crossmatch was showing weak class I positivity with an MFI of 1529. In view of the fact that the prospective donor was her motherin-law, she was considered to occupy a high risk bracket and this positivity, though weak could not be ignored. To confirm its significance we performed a Luminex Single Antigen assay. This showed the presence of a list of positive antibodies for both class I and class II antibodies. Further, looking into the typing of the donor, two of these, HLA A*11 and B*40 were discovered to be present in the donor. However they were associated with very low background corrected median fluorescent intensity (MFI).
Conclusion: The LSA in this particular case confirmed the presence of clinically significant donor specific antibody, yet objectively quantified the same as being at levels that could be managed safely with appropriate desensitization protocols.
How relevant is the single antigen bead assay kit to the Indian population
Anutha Augustin, Sam Aruldoss, R Shanthi, MP Chacko, D Daniel
Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
Background: Single antigen bead assay (SAB) is a sensitive platform, which uses recombinant beads of HLA allelic variants of class I and II epitopes, to identify antibodies against HLA alleles.
Objective: The study was performed to assess the robustness of the SAB assay in detecting HLA allelic specificities of the Indian population.
Materials and Methods: A comparison was made between the allelic specificities in 92 individuals of Indian origin and the specificities represented on the SAB assay.
Results: The High resolution typings obtained from 92 inviduals included 20 A alleles, 34 B alleles, 23 DRB1 alleles and 12 DQB1 alleles. 6/20 A alleles, 11/34 B alleles, 6/23 DRB1alleles and 1/12 DQB1alleles were not represented in the SAB assay. The six unrepresented A locus alleles were-A*02:11(13), A*02:06(9), A*02:16(4), A24:17(1), A*24:07(1), A*31:12(1)] present in 26 of 92 patients and eleven unrepresented B alleles [B*40:06(18), B*07:05 (13), B*35:03(13), B*13:01(2), B*15:17(4), B*38:02(3), BB*48:04(2), B*15:07(1), B*27:07(1), B*51:06(1), B*57:03(1)] were present in 49 of 92 patients with some patients having both their A and B alleles unrepresented. The six unrepresented DRB1 alleles [DRB1*12:02(6), DRB1*04:04(4), DRB1*13:02(4), DRB1*15:06(4), DRB1*10:02(1) and DRB1*08:02(1) were present in 20 of 92 patients, DQB1*05:02 was found to be present in 8 of 92 patients. Most of these alleles fit into the higher probability alleles in the API region group when data was sought from the HLA epitope registry.
Conclusion: A significant number of alleles at class I and class II loci identified from the Indian population were unrepresented in the SAB assay. This requires further study and follow-up. However in the interim it is critical that this assay be used with caution when used to identify antibodies to HLA specificities in the Indian population.
Mesenchymal stem cells: Cell biology and potential use in therapy: A review
Shailaja Mehta, Jasmin Jasani, RK Tandon, SS Goswami, RK Pasale, Ashu Dogra
Department of Pathology, SBKSMI & RC, Vadodara, India
Background: Within the bone marrow stroma there exists a subset of non-hematopoetic cells referred to as mesenchymal stem or mesenchymal progenitor cells. These cells can be ex vivo expanded and induced, either in vitro or in vivo, to terminally differentiate into osteoblasts, chondrocytes, adipocytes, tenocytes, myotubes, neural cells and hematopoietic supporting stroma. The multipotential of these cells, their easy isolation and culture, as well as their high ex vivo expansive potential make these cells an attractive therapeutic tool. In this work we will review the information dealing with the biology of mesenchymal progenitors as it has been revealed mainly by ex vivo studies performed with bone marrow derived cells.
Aim and Objectives: To provide an overall description of the MSC biology and to point out some areas where they are being introduced in the clinic.
Materials and Methods: 1. Simmons et al. developed a monoclonal antibody: Stro 1- used to isolate a pure population of cells with MSC characteristics. 2. Reyes et al. isolated a pleuripotent MSC population from CD45/glycoprotein.
Results: MSC have been employed in treatment of various therapy with beneficial results especially in large bone defect, ostegenesis imperfecta and myocardial infaraction.
Conclusion: MSC are one of the stem cells that are being introduced in the clinic for treatment of several degenerative diseases and they have several advantages including the ease of their isolation and culture and the stability of their phenotype in vitro.
A case report demonstrating the utility of multiple platforms in monitoring of desensitization in the HLA laboratory
Sam Arul Doss R, R Shanthi, MA Anutha, MP Chacko, D Daniel
Department of Transfusion Medicine and Immunohematology, Christian Medical College, Vellore, Tamil Nadu, India
Background: It is difficult to identify a compatible donor in a highly sensitized renal transplant recipient. In an attempt to ameliorate this situation, several desensitization protocols have been developed. However, in order to achieve acceptable transplant outcomes, antibody screening at the highest level of detection is essential in these scenarios as this case illustrates.
Case Report: A 33 year old female with end-stage renal disease underwent a workup towards live kidney transplant with her husband as the prospective donor. She has had two pregnancies, and no transfusions or prior transplants. Complement Dependent Cytotoxicity (CDC) crossmatches were initially negative, and later showed weak positivity. Luminex crossmatch showed consistent Class II positivity with Mean Fluorescence Intensity (MFIs) ranging from 2462 to 14093 and intermittent class I positivity ranging from 1443.5 to 2358.5. CDC crossmatch showed negative with a swap donor whereas the Class II still remained positive on Luminex crossmatch. Luminex single antigen assay (LSA) demonstrated a donor specific antibody directed at class II. On this basis, desensitization was started involving Rituximab (500 mg, 3 doses) and plasmapheresis (12 plasmapheresis and 1 double filtration plasmapheresis). As the Luminex platform demonstrated better pickup of the antibody, monitoring was done by Luminex crossmatch which was deemed more economical than the LSA. CDC was performed in parallel. After commencing Rituximab, CDC demonstrated IgG positivity of approximately 30% which was attributed to the drug and this was supported by Luminex crossmatch values which continued to fall. When the class II antibody levels reached 1888, LSA was performed for class II, which confirmed negativity. She shortly underwent transplant. Her post transplantation clinical course was uneventful. Post transplant Luminex crossmatches have been consistently negative for both class I and II.
Conclusion: This case report demonstrates the utility of multiple platforms in the monitoring of desensitization protocols.
Anti-Cd47: A miracle cure for cancer?
D Deepa, S Shoganraj, S Usha
The TN Dr MGR Medical University, Guindy, Chennai, India
Red Blood Cells are one of the most highly specialized cells in the body. Among the many proteins expressed on its membrane,CD47 (integrin associated protein), a transmembrane protein is involved in a range of cellular processes including apoptosis, migration, immune and angiogenic responses. CD47 partners with membrane integrins and also binds the ligands thrombospondin-1 and signal regulatory protein alpha. CD47 expression on the RBCS and many other cells protects them against phagocytosis. Young RBCS have more CD47 but it decreases slowly as it ages, which facilitates senescent RBCS to be destroyed. Irving Weismann, a biologist at Stanford university school of medicine discovered that leukemia cells produce higher levels of CD47. So, anti-CD47 could be used to destroy the cancer cells. To find out the effect of anti-CD47 antibodies, scientists exposed tumor cells to macrophages in two different Petri dish More Detailses, one without and other with anti-CD47 molecules. They observed that the macrophages ignored tumor cells in the former, but destroyed them in the latter. Researchers also observed the effect of anti-CD47 molecules in animals transplanted with certain tumors from human beings such as bladder and colonic cancer. They observed that few tumors disappeared, some shrunk and the animals remained free of cancer four months after cessation of the treatment. Based on animal studies, the human clinical trials (phase 1) of anti-CD47 have been planned on cancer patients. The human trials could be different as the microenvironment of a real tumor is a bit more complicated than the microenvironment of a transplanted tumour. Anti-CD47 could also attack the RBCS. But, researchers in animal studies found this effect to be short lived and compensated soon by newly produced RBCs. If this study is proven effective and safe, anti-CD47 could be the miracle molecule to treat majority of cancers in the near future.
Utility of HLA: Class II donor specific antibody (DSA) as a prognostic marker in renal allograft transplant recipient: A case report
J Suchita, R Sawant, A Deshpande, R Sirsat 1
Departments of Laboratory Medicine, HLA Laboratory, and 1 Nephrology, PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
Background: Before kidney transplantation, recipients are routinely screened for preformed anti-HLA antibodies (DSA) and prospective cross-match (CDC). Low immunological risk is indicated when the CDC cross-match result is negative and the patient does not have any significant DSA, both pre and post transplant. Clinical relevance of anti-HLA DSA detected by Luminex assay in the development of rejection after transplant has been the focus of the transplant community.
Case Report: A 50 years old male received live related renal allograft from his wife. There was a 1/6 (HLA -B*40) HLA antigen match between them. Pre transplant DSA and CDC cross-match were negative. Patient was on induction immunosuppression with Pangraf (3.5 mg). Patient's pre transplant creatinine was 5.8 μmol/L and decreased to 1.2 μmol/L at discharge from the hospital after transplant. On day-45 post transplant, patient's creatinine levels increased to 2.2 μmol/L. CDC cross-match was carried out which showed negative results, anti-HLA Class I DSA was negative (MFI = 270) and Class II DSA was borderline positive (MFI = 1041). Renal biopsy showed mild hydronephrosis changes and suggestive of acute humoral rejection. Patient was treated withplasmapheresis (5 sessions) and IVIG for acute humoral rejection and creatinine levels reverted to normal. On day 107 post transplant, DSA was repeated and was found to be negative for both Class I and Class II anti-HLA antibodies. The graft is surviving till date, with a negative DSA, normal creatinine levels, while CDC cross-match continues to be negative.
Conclusion: Anti-HLA Class II DSA positivity in the absence of a positive CDC cross-match can predict early rejection of renal allograft. There is a need to optimize DSA monitoring strategies post renal transplant.
Clinico-serologic co-relation in bidirectional ABO incompatible hematopoietic stem cell transplantation
Sabita Basu, Supriya Dhar, Suvro Datta, Rohith Chitrapur, Deepak Mishra, Mammen Chandy
Tata Medical Center, Kolkata, India
Background: The ABO blood group system is of prime significance in red cell transfusion and organ transplantation but not in allogenic hemopoietic stem cell transplantation (HSCT). 40-50% of HSC transplants are ABO incompatible.This incompatibility may be major, minor or bidirectional. Though there are descriptions of transfusion practice and protocols in ABO incompatible HSCT, there are considerable variations and transfusion support in these patients can be very challenging.
Aims: The immunohematologic observations in two cases of bidirectional ABO incompatible HSCT have been described and clinico-serologic correlation has been attempted.
Materials and Methods: In both the cases peripheral blood stem cell (PBSC) harvests were obtained using the Cobe spectra cell separator. Immunohematologic assessments in the donor and recipient were done as a part of pre HSCT evaluation. Both the standard tube technique and column agglutination method (Ortho Biovue micro bead system) was used. Antibody screen was done by column agglutination method using three cell panel (Surgiscreen cells). Iso-agglutinin titration was done by the master dilution method and standard validated techniques were used.
Results: The pattern of laboratory findings in the two cases were different and so were the clinical outcomes. While there was early engraftment in the first case, the second case developed pure red cell aplasia(PRCA) and this was well reflected in the immuno-hematologic assessments. There was a sharp rise in the anti donor isoagglutinin titer (2048) which coincided with the development of PRCA.
Conclusions: Immuno-hematologic assessment correlated well with the clinical picture and could be used to predict clinical outcome and onset of complications in ABO incompatible HSCT.
Determinants of stem cell yield in peripheral blood hematopoietic stem cell apheresis: A preliminary study at a tertiary care centre in south India
Veena Shenoy, Neeraj Sidharthan 2 , B Sreerekha 3 , K Pavithran
Departments of Transfusion Medicine and 3 Nanosciences, 2 Division of stem cell transplant, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
Background: Peripheral blood stem cell apheresis is increasingly used to obtain stem cells for autologous as well as allogenic transplants. The adequacy of stem cell collection is determined by products content of CD34 cells and mononuclear cells. If we can identify factors which can predict adequate CD 34 count in the apheresis product, it will be useful for planning the apheresis.
Aim: To find out the determinants in the donor which predict an adequate yield in the product obtained using hematopoetic stem cell apheresis.
Materials and Methods: Mobilization agents were growth factors(GCSF)/GCSF+ Chemotherapy agents. Apheresis was performed using Cobe spectra apheresis system, Terumo BCT as per protocol. The CD34 count estimation was done using flow cytometry following the ISHAGE recommendations. Pre CD 34 count, pre apheresis WBC count and CD 34 yield in the product was analysed retrospectively.
Results: Forty stem cell apheresis procedures were done for 25 patients with haematological malignancies. Eleven patients underwent autologous transplants and 14 patients allogenic transplants. CD34 positive cell count measured immediately prior to apheresis (pre-CD34) has a strong correlation with the amount of CD34 positive cells collected at the end of apheresis (P value: <0.000, r = 0.855). There is significant correlation between total CD34 cells collected and pre-harvest WBC count (P value: <0.014, r = 0.504).The correlation was significant when CD34 yield per kg recipient weight was considered (P value: <0.000, r = 0.859) and it is better than correlation with pre-harvest WBC count (r = 0.509, P = 0.000).
Conclusions: The pre-apheresis peripheral blood CD34(+) cell count is very useful in predicting PBSC yield.
Transfusion audit in bone marrow transplantation: A single centre experience
Shashank Ojha, P Nagaraju, SH Sumathi, SB Rajadhyaksha 1
Department of Transfusion Medicine, Tata Memorial Centre Advanced Centre for Treatment, Research & Education in Cancer, 1 Department of Transfusion Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
Background: Audit is a methodological and defined review of practices and policies to ensure safe and appropriate blood transfusion in order to reduce errors and accidents in scientific manner. Bone Marrow Transplantation (BMT) is a highly specialized activity where decisions concerning blood transfusions may affect outcome due to varying need vis-à-vis type and phase of transplantation, causative disease etc. This study was undertaken to review transfusion practices in BMT patients at our centre.
Aim: To analyze the blood component usage in BMT recipients through a well defined audit criteria.
Materials and Methods: All Packed Red Blood cells (PRBC) and Single Donor Platelets (SDP) transfusion in BMT patients from January 2008 to June 2014 were retrospectively analyzed and categorized on basis of type (Autologous/Allogeneic) and phase of transplant (Pre-transplant/Peri-transplant/Post- transplant), patient diagnosis and ABO-identical versus Out-of-Group transfusion.
Results: Total of 357 BMT patients (Autologous = 185, Allogeneic = 172) were transfused with 1099 PRBC and 2073 SDP. PRBC usage was more in allogeneic BMT (52.6%) compared to more SDP usage in autologous BMT (51.8%). Median (and Range) blood component usage was maximum in peri-transplant allogeneic BMT [PRBC = 2(0-13), SDP = 4(0-19)]. Patients of aplastic anemia required maximum transfusion [PRBC = 2(0-8), SDP = 4(0-15)]. ABO identical transfusion was more in autologous BMT [PRBC-100%, SDP-85.3%] compared to allogeneic BMT (PRBC-80%, SDP = 69.3%).
Conclusion: In BMT patients there is more requirement of SDP than PRBC. Transfusion requirement varies with type and phase of transplant along with causative disease. ABO identical transfusion is a major challenge in allogeneic BMT. Such audit helps in understanding the transfusion requirement in BMT patients vis-à-vis above mentioned factors.
Analysis of factors affecting stem cell yield in cord blood collection
Satya Prakash, Neelam Marwaha, R R Sharma, Ashish Jain, Jsswindwer Kalra
PGIMER, Chandigarh, India
Background: Umbilical cord blood become a valuable source for allogeneic hematopoietic stem cell transplantation. Ease of collection, ready availability and relatively lower graft-versus-host disease compared to peripheral blood stem cell favored umbilical cord blood stem cell transplantation.
Aim and Objective: Study was designed to assess the factors affecting stem cell yield in cord blood collections.
Materials and Methods: Study was conducted in Department of Transfusion Medicine and Obstetrics and Gynaecology, PGIMER, Chandigarh. A total of 200 cord blood units (CBU) were collected ex-utero from live birth deliveries in CPDA bag having anticoagulant: Cord blood ratio of 1:7 under aseptic condition. Before processing units were stored at 4 ° C.Volume reduction were done by 6% hydroxyethyl starch (HES) with ratio of HES: Cord blood were 1:5 and centrifugation was done to obtain cellular pellet. Differential cell counts were done through sysmex cell counter, viability testing by trypan blue exclusion test and CD34 and CD45 estimation were flow cytometry. First 100 units were cryopreserved with 10% DMSO and later 98 sample with 5% DMSO. Two sample were found to be HBsAg positive and not included in the study.
Result: Maternal factors like age, gravida, gestational age and method of delivery were not significant in relation to TNC, MNC and CD34+ counts. Birth weight of the new born were significantly correlated with placental weight (P value = 0.000), volume of CBUs (P value = 0.000), TNC (P value = 0.019) and MNC (P value = 0.029). Volume of the CBUs collected were significantly correlated with birth weight (P value = 0.000), Placental weight (P value = 0.000), absolute TNC counts (P value= 0.000), MNC counts (P value = 0.000) and Total CD34+ cell counts (P value = 0.000). Gender of the new born and gestational age at the time of delivery were not found to show any correlation with various parameters and cell counts. Percentage of DMSO used shown better viability with 5% as compared to 10% (P value = 0.000).
Conclusion: Volume of CBUs collectedwere the single most important factor of prognostic significance in relation to stem cell (CD34+ cell counts) yield however CBUs collected from pre-term deliveries should not be discarded as these CBUs were shown to have approximately equal amount of CD34+ cells. Cryopreservation with 5% DMSO found to have better viability in comparision to 10% DMSO.
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 1]
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