BLOOD

BANKING
Prepared by:
Beatrice M. Tumlos, RMT
 OVERVIEW

 Introduction
 ABO and Rh Blood Group Systems
 Other Major Blood Group Systems
 Minor Blood Group Systems
 Blood Donor Selection and Processing
 Blood Preservation and Banking
 Component Preparation
 Transfusion Therapy
 Transfusion Reaction
 Transfusion-transmitted Diseases
 Hemolytic Disease of the Newborn and Autoimmune Hemolytic Anemia
 Blood Bank Techniques and Procedures
Blood Bank Quality Management
 INTRODUCTION
I. Genetics
– study of transmission of inherited charateristics
– important in the study of antigens and inherited disorders
• DNA
– double helix
– 4 bases: adenine (A), thymine (T), cytosine (C), guanine (G)
• Gene
– a segment of DNA arranged along the chromosome at a specific position (locus)
• Alleles
– gene at a specific locus that differ in nucleotide sequence
o Homozygous alleles – identical
o Heterozygous alleles – non-identical
o Dosage Effect – homozygous genotype express itself with more antigen than the
heterozygous genotype
• Genotype
– total genetic composition of an individual, representing maternally and paternally derived
genes
• Phenotype
– Detectable or expressed characteristic of genes
 INTRODUCTION
• Antigens
– substances recognized as foreign by the body that has the ability to combine with an antibody
– usually, but not exclusively found on RBC membrane
o Immunogens – antigens capable of inducing an immune response
o Autoantigens – antigens derived from same individual
o Alloantigens – antigens from different individual of the same species
o Heteroantigens – antigens from different species

• Antibodies
– Protein substance secreted by plasma cells that is developed in response to, and interacting specifically with, an antigen
– Found in serum
o Immunoglobulins – 2 heavy chains + 2 light chains held together by disulfide bonds
REMEMBER!
IgG – Greatest plasma concentration; Goes across placenta
IgM – Mega (largest); best in coMplement fixation
IgA – sAliva, teArs (body secretions)
IgD – Don’t know function
IgE – allergEE
o Autoantibodies – made in response to body’s own antigens
o Alloantibodies – formed in response to antigens from individuals of the same species
o Heteroantibodies ( Xenoantibodies) – produced in response to antigens from another species
 ABO
BLOOD
GROUP
SYSTEM
 ABO BLOOD GROUP SYSTEM

• Described by Karl Landsteiner in 1900

• Most important blood group system in transfusion and transplantation
therapy
• Histo-blood group
• If A or B antigen is not present, person will make antibodies against the
missing antigens
• ABO antibodies are naturally occurring

A. Antigen Inheritance
– codominantly inherited
– Simple Mendelian Genetics = individual inherits one ABO gene from each parent and
these two genes determine which ABO antigens are present on RBC membrane
 ABO BLOOD GROUP SYSTEM
B. Antigen Formation
– Results from interaction of genes at three separate loci (ABO, Hh, Se)
– ABO genes code not for the production of antigens but for specific glycosyltransferases
– Paragloboside or glycan – basic precursor material for ABH antigens to which sugars are attached
a. H antigen – precursor structure on which A and B antigens are made

GENE GLYCOSYLTRANSFERASE IMMUNODOMINANT SUGAR ANTIGEN

H α-2-L- fucosyltransferase L-fucose H
A α-3-N-acetylgalactosaminyltransferase N-acetyl-D-galactosamine A
B α-3-D-galactosyltransferase D-galactose B
O ----------------------------------- ------------------------------- Unchanged H
b.

O > A2 > B > A2B > A1 > A1B

b. Se gene – controls presence of H substance in body secretions (saliva, urine, tear, amniotic fluid, milk,
bile, exudates, digestive fluids)
- Secretor: SeSe or Sese
o Group O secretor – has H antigen in secretions
o Group A secretor – has A and H antigens in secretions
o Group B secretor – has B and H antigens in secretions
o Group AB secretor – have A,B and H antigens on secretions
 ABO BLOOD GROUP SYSTEM
C. Antigen Development
- Begins in the sixth week of fetal life until 3 years of age
- Production initiated at birth (approx. 50%)
Phenotype Subgroups Possible Genotypes
D. Phenotypes and Genotypes A A1 A1A1, A1O, A1A2
A2 A2A2, A2O
B BB, BO
AB A1B A1B
A2B A2B
O OO
Bombay Oh
o Bombay Phenotype
- lack H gene and homozygous for h gene
- absence of A,B,H antigens
- initially typed as Group O but reacts strongly with O cells
- Confirmatory testing: Anti-H reagent (Ulex europeus)
- very rare (<200 cases worldwide)

E. ABO Antibodies
– Naturally occuring ; develop shortly after birth following exposure to ABO-like antigens in environment
– Mostly IgM = reacts best at room temperature
o Immune ABO antibodies – develop in response to ABO- incompatible RBCs; IgG = cross the placenta
 ABO BLOOD GROUP SYSTEM
F. Testing
a. Forward Grouping
– analyze patient cells for presence of ABO antigens
– Reagents: Anti-A1 (Dolichus biflorus) and Anti-B (Bandeiraea/ Griffonia simplicifolia)
– Positive reaction: Agglutination
Blood Group Anti-A Anti-B
A + -
B - +
AB + +
O - -

b. Reverse Grouping
– analyze patient serum or plasma for presence of ABO antibodies
– Adults = have antibodies in serum when corresponding antigen is absent on RBCs
– Neonates = not candidate for reverse typing
Blood Group A cells B cells
– Reagents: Known A1 and B RBC suspension
A
– Positive Reaction: Agglutination - +
B + -
AB - -
O + +
 ABO BLOOD GROUP SYSTEM
G. Acquired Antigens
ACQUIRED A ANTIGEN ACQUIRED B ANTIGEN
Occurrence Group O, B Group A
Disease Association Proteus mirabilis  Proteus vulgaris septicemia
 Escherichia coli O86
 Carcinoma of colon or rectum
 Intestinal obstruction
 Lower GIT infection

Blood Anti-A Anti-B A cells B cells

Group
Group AB + + - -
Acquired B + + - +
 ABO BLOOD GROUP SYSTEM
H. Typing Discrepancies
GROUP I GROUP II GROUP III GROUP IV
Weakly reacting/missing Weakly reacting/missing Plasma abnormalities Miscellaneous
antibodies antigens (Rouleaux Formation)
 Newborns  A/B Subgroups  Multiple Myeloma  Polyagglutination
 Elderly  Leukemia  Waldenstrom’s  Cold reactive
 Leukemic Px  Hodgkin’s disease macroglobulinemia antibodies
 Immunosuppressive  BGSS (carcinoma of  Plasma cell dyscrasias  Unexpected ABO
drugs stomach and pancreas)  High fibrinogen isogglutinins
 Congenital  Acquired B  Plasma expanders (eg.  Cis “AB phenotype”
agammaglobulinemia phenomenon Dextan, PVP)  Antibodies othe that
 Immunodeficiency  Low incidence antigens  Wharton’s jelly Anti-A, Anti-B
 BM/SC transplantation
 Px history  Incubate test mixutre  Cell washing 3x (saline)  Incubate @37C,
 Incubate px serum @RT (30 mins.) wash with saline
with reagents A1 and  Incubate @4C (15 @37C 3x and
B cells @RT (15-30 mins) with O cell and retyped
mins) Autocontrol  Red cells= 0.01M
 Add 1-2 drps serum DTT
 Incubate @4C (15  Serum=warm
mins) with O cell and reagent cells +
Autocontrol serum @37C,
retyped
 Cold autoabsorption
ABO BLOOD GROUP SYSTEM
Practice!
Anti-A Anti-B A cells B cells
Patient X 0 0 0 0

Group O
 Elderly
Group I Discrepancy
 Newborn
 Immunodeficiency
 Immunosuppressive drugs

 Check age of patient

 Increase incubation time for 30 mins
 Incubate at lower tempeature as 4C (15 mins)
with O cell and Autocontrol
ABO BLOOD GROUP SYSTEM
Practice!
Anti-A Anti-B A cells B cells O cells Autocont
rol
Patient Y 4+ 0 1+ 4+ 0 0

Group II Discrepancy Subgroup of A

 A2 with anti-A1

 React patient cells with Anti-A1 lectin

 Test serum against additional A1, A2
 Rh BLOOD GROUP SYSTEM
A.Genetics
o Two closely linked genes encode Rh antigens
• RhD: determines D expression (D/non-D)
• RhCE: determines C, c, E,e antigens (CE, Ce,cE,ce)
• Over 50 antigens
B. Nomenclature
o Fischer-Race (DCE) – Rh antigens were inherited as 3 closely linked set of alleles and each gene is
responsible for producing a product
o Wiener (Rh-hr) – Rh antigens were inherited as products of single gene at single locus that produced an
agglutinogen containing a series of blood factors and each factor is an antigen recognized by an antibody
o Rosenfield (Alpha Numeric) – Rh antigens are assigned numbers in order of its discovery
o International Society of Blood Transfusion (ISBT) – 6-digit number for each blood group specificity (first
3 digits:=System; last 3 digits= Antigenic Specificity)

FISCHER-RACE WIENER ROSENFIELD ISBT

D Rh0 Rh 1 004001
C rh’ Rh 2 004002
E rh” Rh 3 004003
c hr’ Rh 4 004004
e hr” Rh 5 004005
 Rh BLOOD GROUP SYSTEM
FISCHER-RACE WIENER
Gene Gene Agglutinogen
Dce R0 Rh0
DCe R1 Rh1
DcE R2 Rh2
DCE Rz Rhz
dce r rh
REMEMBER:
dCe r’ rh’
R or r = D/d
dcE r” 1 orrh”
‘ = Ce
2 or “ = Ce
dCE ry z orrhy
y = CE
 Rh BLOOD GROUP SYSTEM

CONVERT!

1. R1R2 1. R0r” 1. DcE/dce

a. DCE/Dce a. Dce/Dce a. R1R2

b. DcE/dCe b. Dce/dcE b. R0r’
c. DCe/DcE c. DcE/DcE c. r”r
d. dCe/Dce d. dCe/Dce d. R2r
 Rh BLOOD GROUP SYSTEM
C. D antigen
- The most clinically significant of all non-ABO antigens
- Highly immunogenic
- Only Rh antigen that undergoes routine testing
o Mechanisms of Weakened Expression of D antigen
1. Genetic Weak D
- D antigens expressed appear to be complete, but few in number
2. C Trans
- Position effect or Gene interaction effect
- Allele carrying D is in opposite position to allele carrying C
3. D Mosaic/Partial D
- one or more parts of D antigen is missing
o Testing for Weak D
- Perform AHG phase including a control (must be negative to be valid)

D. Other Rh Antigens
o C,c,E,e antigens – codominantly expressed, less immunogenic, typically occur in low frequency
o G antigens – produced by same Rh gene complexes that produce C and D antigens
Note: Most C-positive and D-positive RBCs are also G-positive

E. Immunogenicity
D>c>E>C>e
 Rh BLOOD GROUP SYSTEM
F. Rh Antibodies
- Immune antibodies – production is stimulated by pregnancy, incompatible blood transfusion/
transplantation
- mostly IgG (subclass 1 or 3) in nature and react optimally at 37C or AHG phase
- usually do not bind complement
- RBC destruction is extravascular
- clinically significant = HDFN AND HTR

G. Rh (D) Typing
- Routine testing is for D antigen only
- Currently, most testing now uses licensed monoclonal/polyclonal blend reagents
- Rh control required if high-protein reagents used

H. Unusual Phenotypes
o Rh Null
- Individuals whose RBCs lack all Rh antigens (---/---)
- Amorph gene
- Form anti-Rh 29 (total Rh)
o Rh deletions
- Rh complexes lacking alleles at Ee or Cc locus (D--/D--)
Note: D– RBCs have greatest amount of D antigen
 Rh BLOOD GROUP SYSTEM

EXERCISES!

1. All of the following will react with Anti-C except:

a.R1R1 DCe/DCe

b.R1r DCe/dce

c.R0R1 Dce/DCe

d.R0R0 Dce/Dce
Rh BLOOD GROUP SYSTEM

EXERCISES!
1. Reaction of patient RBCs with the following anti-sera:
Anti-D = +
Anti-C = +
Anti-E = -
Anti-c = -
DCe
Anti-e = +
Which of the ff. is the most probable genotype of patient?

a.rr dce/dce

b.rr’ dce/dCe

DCe/DcE
c.R1R2
DCe/DCe
d.R1R1
OTHER MAJOR
BLOOD GROUP
SYSTEMS
 OTHER MAJOR BLOOD GROUP SYSTEMS
1. Lewis
• Le gene codes for production of fucosyltransferase enzyme
• Antigens do not develop as integral parts of RBC membrane but are adsorbed from plasma
o Lewis Antigens
- develop gradually
- Cord blood and red cell from newborn infants phenotype as Le (a-b-)
- expression is affected by H, Se and Le genes
- decrease in expression during pregnancy
o Lewis Antibodies (Anti-Lea, Anti-Leb)
- usually IgM in nature
- react best at room temperature
- can bind complement = trigger in vitro hemolysis
- not associated with HDN
- enhanced by enzyme treatment
- appear transiently during pregnancy in Le(a-b-) women and disappear after delivery
- easily neutralized using commercial Lewis substance, serum or plasma

GENOTYPE ANTIGEN IN SECRETION RBC PHENOTYPE

ABH, lele, sese none ABH, Le (a-b-)
ABH, lele, SeSe/Sese ABH ABH, Le (a-b-)
ABH, Lele, sese ABH, Le (a+b-)
ABH, Lele, Sese/SeSe ABH, Le (a-b+)
 OTHER MAJOR BLOOD GROUP SYSTEMS

2. MNSs
- consists of five principal antigens (M, N, S, s, U)
o MN Antigens
- found in Glycophorin A
- differ in amino acid residue at positions 1 and 5
- well developed at birth M ag = Serine + Glycine
- easily destroyed by enzymes N ag = Leucine + Glutamic acid
- markers in Paternity testing
o Ss Antigens
- found in Glycophorin B S ag = Methionine
- differ in amino acid at position 29 N ag = Threonine
- well developed at birth
- less easily degraded by enzymes
- enhanced by enzyme treatment
- appear transiently during pregnancy in Le(a-b-) women and disappear after delivery
 OTHER MAJOR BLOOD GROUP SYSTEMS

o MNS Antibodies
- demonstrate dosage effect
• Anti-M
- mostly naturally occurring
- cold reactive saline agglutinins
- IgM or IgG
- usually do not bind complement
- do not react with enzyme treatment cells
- pH dependent = reacts best at pH 6.5
- other examples react only with RBCs exposed to glucose solutions
- rarely associated with HDN and HTR
• Anti-N
- Cold reactive IgM or IgG saline agglutinin
- do not bind complement
- seen in renal patients dialyzed on equipment sterilized with formaldehyde
 OTHER MAJOR BLOOD GROUP SYSTEMS

• Anti-S and Anti-s

- mostly IgG in nature
- reacts best at 37C and AHG phase
- Implicated with severe HTR with hemoglobinuria and HDN
• Anti-U
- rare but can be formed in S-s- individuals
- associated with severe HTR and HDN
- enhanced with enzyme treatment
o Testing
- use of lectin reagents
• Iberis amara = Anti-M
• Vicia graminea, Bauhinia species = Anti-N
 OTHER MAJOR BLOOD GROUP SYSTEMS

3. P
- structurally related to ABO antigens
- exist as glycoproteins and glycolipids
o Five Phenotypes

PHENOTYPE DETECTABLE ANTIGENS POSSIBLE ANTIBODIES

P1 P, P1 none
P2 P Anti-P1
p none

Anti-P
Anti-P, Anti-P1

o P1 Antigen
- found ion fetal cells (12 weeks) but weakens with gestational age
- deteriorates rapidly on storage
- P1-like antigen has been found in plasma and droppings of pigeon and egg white of turtledoves
- P1 substance has been identified in hydatid cyst fluid, extracts of Lumbricoides terrestris (common
earthworm) and Ascaris suum
 OTHER MAJOR BLOOD GROUP SYSTEMS

o Anti-P1
- common, naturally occurring IgM antibodies in sera of P2 individuals
- cold reactive saline agglutinin
- optimal reactivity is at 4C
- strongly observed in individuals infected with Echinococcus granulosus
- associated with Fascioliasis, Clonorchis sinensis and Opistorchis viverrini infections
- easily neutralized with commercially available P1 substance, Hydatid cyst fluid, pigeon droppings and
turtledove’s egg white
o Anti-P
- naturally occurring alloantibody in the sera of all Pk individuals
- very significant in transfusion = hemolytic with a wide thermal range of reactivity
- cold reactive IgG autoantibody seen in patients with Paroxysmal Cold Hemoglobinuria
- Biphasic activity (Cold= attaches red cells; Warm= lyses red cells)
- demonstrated by Donath Landsteiner test

Temperature Control Px whole blood

Normal px RT/4C No hemolysis No hemolysis
PCH 37C No hemolysis Hemolysis
o Anti-Pk
- Reported in in serum of P1 individuals with biliary cirrhosis and Autoimmune Hemolytic Anemia
 OTHER MAJOR BLOOD GROUP SYSTEMS

4. I
o I Antigens INFANTS ADULTS
i antigen Rich Trace
I antigen Undetectable Rich

• Rare i Adult or I negative Phenotype – individuals who do not change their i status after birth
o I Antibodies
- show dosage effect
1. Anti-I
- demonstrates strong reaction with adult cell and weak reaction with cord cells
- Not associated with HDN
- enhanced by enzymes
- common autoantibody that can be benign or pathologic

Benign Anti-I Pathologic Anti-I

Weak, naturally occurring saline-reactive IgM agglutinin Potent IgM at high titers
Reacts at 4C Broader thermal range (up to 30 or 32C)
Not associated with in vivo red cell destruction Attach in vivo = Autoagglutination and vascular occlusion
(Raynaud’s phenomenon) or intravascular hemolysis
Normal healthy individuals CAD (Cold Agglutinin Disease)
Primary Atypical Pneumonia (Mycoplasma pneumoniae)
 OTHER MAJOR BLOOD GROUP SYSTEMS

2. Anti-i antibodies
- rare, cold-reacting antibodies (4C)
- Mostly IgM but can also be IgG (associated with HDN)
- Associated with: Infectious Mononucleosis (EBV)
Diseases of RES (Alcoholic Cirrhosis, Myeloid Leukemia, Reticuloses)

3. Autoanti-I
- production is stimulated by micoorganisms carrying I-like antigen ont heir surface
eg. Listeria monocytogenes – from px with Cold Autoimmune Hemolytic Anemia has been
reported to absorb anti-I and stimulate its production in rabbits

o Testing for Anti-I or Anti-i

- done at 4C using Group O RBCs or cord RBCs
 OTHER MAJOR BLOOD GROUP SYSTEMS

5. Kell
- comprised of 21 high and low-incidence antigens (Major: K and k)
o Kell Antigens
- Immunogenic (K is rated second only to D in terms of immunogenicity)
- Well developed at birth
- Antigen Precursor:
McLeod Syndrome
(+) Acanthocytes

Kx
Chronic Granulomatous Disease

McLeod Phenotype
• Slow progressive muscular dystrophy
• Areflexia
• Choreiform movements
• Cardiomegaly (leading to Cardiomyopathy
• High CPK (MM Type)
• High Carbonic anhydrase III
- Destroyed and inactivated by Sulfhydryl reagents
 OTHER MAJOR BLOOD GROUP SYSTEMS
o Kell Antibodies
1. Anti-K
- common antibody encountered in Blood bank ( >90% of population is K-negative)
- usually an IgG antibody reactive in 37C and in AHG phase
- stimulated by antigen exposure (pregnancy and incompatible transfusion)
- implicated in severe HTR and HDN
- occasionally bind complement
- usually extravascular in vivo red cell destruction
2 Anti-k (Cellano)
- rare, but can cause HTR and HDN
3. Kpa (Penney), Jsa (Sulter), and Other Low Frequency Kell Antigens
- antibodies are rare because only so few people are exposed to the antigen
- often detected through unexpected incompatible crossmatches
4. Kpb (Rautenberg), Jsb (Matthews), and other High Frequency Kell Antigens
- antibodies are rare because so few people lack the antigen
5. Anti-Ku or Anti-KEL5
- antibodies to Ko (Knull) antigens
- considered clinically significant
- Testing of Ko cells: Treat normal RBCs with 2-AET (aminoethylisothiouronium)
 OTHER MAJOR BLOOD GROUP SYSTEMS

6. Duffy
- has four allelles responsible for major antigens (Fya, Fyb,Fy,Fyx)

o Duffy Antigens:
• Fya and Fyb - produced by codominant alleles; destroyed by common proteolytic enzymes
• Fyx - weakened form of Fyb
• Fy - no gene product

o 4 Phenotypes:
Fy (a+b-) = Chinese (90.8%)
Fy (a+b+) = Whites (49%)
Fy (a-b+)
Fy (a-b-) = African Black Race (68%); Resistant to Malaria due to Plasmodium vivax
* Fy6 = important for invasion for P. vivax
 OTHER MAJOR BLOOD GROUP SYSTEMS

o Duffy Antibodies (Anti-Fya and Anti-Fyb)

- commonly encountered antibody in blood bank
- usually IgG that react only at AHG phase
- Show dosage effect
- enhanced in a LIS medium
- often bind complement
- destroyed by proteolytic enzymes and heating to 56C
- associated with HTR; only Fya is occassionally implicated with HDN
 OTHER MAJOR BLOOD GROUP SYSTEMS

7. Kidd
Antigens (Jka and Jkb)
- detected on fetal red cells 11 weeks (Jka), 7 week (Jkb)
- well-develooed by birth
- enhanced by enzyme treatment

o Phenotypes:
1. Jk (a+b-)
2. Jk (a+b+)/Jk3 (+)
3. Jk (a-b+)
4. Jk (a-b-)/Jk3 (-) = high incidence in Polynesians including Filipinos, Indonesians,
Chinese and Japanese (produce Anti-Jk3)
 OTHER MAJOR BLOOD GROUP SYSTEMS

o Antibodies (Anti-Jka and Anti-Jkb)

- IgG1 and IgG3; binds complement
- show dosage effect
- have notorious reputation
- cause severe Delayed HTR and mild HDN
-Intravascular hemolysis
- detected in 37C and AHG phase
- difficult to detect, use enhancement techniques (enzymes, LISS, PEG)
- Drug-induced antibody due to intake of Methyldopa (Aldomet)

• Alloanti-Jk3 - IgG antibody that looks like an inseperable anti - JkaJkb.

- types as Jk (a-b-)
 OTHER MAJOR BLOOD GROUP SYSTEMS

8. Lutheran
- first recognized when Anti-Lua was discovered in the serum of a patient with lupus erythematosus
diffuses.
- following the transfusion of unit of blood carrying the low incodence antigen, it was named
Lutheran (a misinteroretation of the donor's name Lutera .

o Antigens (Lua and Lub)

- poorly feveloped at birth and do not reach adult levels until age 15

o Four Phenotypes: o Antibodies

1. Lu (a+b-) 1. Anti-Lua
2. Lu (a+b+) - mostly naturrally occuring saline agglutinin; reacts best at RT
3. Lu (a-b+) -maybe IgA, IgM, IgG
4. Lu (a-b-) - gives Mixed field agglutination
2. Anti-Lub
- mostly IgG (IgG4)
-reacts at 37C and AHG phase
-mild HTR and HDN
 Duffy the
OTHER
PRIKLMAJOR BLOOD
Monkey andGROUP SYSTEMS
or th Kidd PILA
KLIRP Luvs to eat KIDD
MNS
Enhanced
Naturally Enhanced Destroyed
Dosage by Warm Activates
Occurring by Enzyme by Enzyme
effect Acidificatio Antibodies Complement
antibodies Treatment Treatment
n

ABO P Duffy Rh P

MN Rh other
Lewis Rh than D I
Kell

MN I Kidd M Lewis

Duffy
P1 Kidd Lutheran ABO
Duffy

Lewis MNS Kidd Kidd

 OTHER MAJOR BLOOD GROUP SYSTEMS

Anti- • Paroxysmal ColdHemoglobinuria

P

• Infectious mononucleosis
Anti-i
• Cold Agglutinin disease
Anti-I • Primary Atypical Pneumonia
• McLeod Phenotype
Anti- • X-linked Chronic Granulomatous Disease
K
Anti- • Drug-induced antibody formation after Methyldopa
Jka/A (Aldomet) intake
nti-Jkb
MINOR BLOOD GROUP
SYSTEMS
 MINOR BLOOD GROUP SYSTEMS
1. Gerbich
- 3 high incidence antigens (Ge2, Ge3, Ge4)
- 4 low incidence antigens (Wb, Lsa, Ana, Dha)
- inherited on Chromosome 2, expressed on Glycophorin C/D
- Leach Phenotype (GE:-2,-3,-4) = Elliptocytosis
2. Cromer
- 8 high incidence antigens (Cra, Tca,Tcab, Dra, Esa, IFC, UMC, WESb)
- 3 low incidence antigens ( Tcb, Tcc,, WESa)
- carried by Decay Accelerating Factor (DAF)
- seen mostly in black individuals
- Paroxismal Nocturnal Hemoglobinuria = weak/absent Cromer-related ags
3. Knops
- 5 antigens (Kna, Knb, McCa, SIa, Yka)
- located on Chromosome 1; Complement receptor 1 (CR1)
4. Indian
- 2 antithetical antigens (Ina, Inb)
- carried by CD44 marker
 MINOR BLOOD GROUP SYSTEMS
5. Diego
- 2 antigens (Dia,Dib)
- Racial marker of Mongolian ancestry (NCS American Indians, Japanese, Chinese)
- Antigens are located on the Anion Exchange molecule (AE-1) = integral transport protein for the
anion exchange of bicarbonate and chloride in red cell membrane
- Defect in AE-1 = Hereditary Spherocytosis, Congenital Acanthocytosis, South East Asian Ovalocytosis
6. Cartwright
- 2 antigens (Yta,Ytb)
- majority is Yt (a+)
7. Colton
- 3 antigens (Coa, Copb, Coab)
- rare antibodies, but can cause HTR
8. Dombrock
- 2 antigens (Doa, Dob)
- rare antibodies, but can cause HTR
 MINOR BLOOD GROUP SYSTEMS
9. Xg
- 1 antigen (Xga) = 2 Phenotypes: Xg (a+) and Xg (a-)
- X-linked;more common in women
- Ag is destroyed by enzyme treatment
10. HLA (Human Leukocyte Antigen; Bennett Goodspeed)
- Bga = HLA-B7
Bgb = HLA-B17
Bgc = HLA-A28
11. Sda
- antibodies exhibit characteristic Mixed field agglutination
- easily neutralized with urine
12. High Titer, Low Avidity (HTLA)
- Antigens: High frequency
- Antibodies: Exhibit reactivity at high dilutions of serum, but the strength of agglutination is weak
- Includes: a. Chido (Ch) and Rogers (Rg)– linked to HLA genes
- associated with C4d component (C4A=Rg;C4B=Ch) on chromosome 6
- denatured by proteolytic enzymes and neutralized by plasma or serum
b. Cost-Sterling (Csa)
c. York (Yka)
d. Knops (Kn)
e. McCoy (McCa)
f. John Milton Hagen (JMH)
BLOOD DONOR SELECTION
& PROCESSING
BLOOD DONOR SELECTION & PROCESSING

DONATION PROCESS
 BLOOD DONOR SELECTION & PROCESSING
BASIC QUALIFICATIONS OF A POTENTIAL BLOOD DONOR

ALLOGENIC AUTOLOGOUS
Appears to be in No signs and symptoms of
good health active infection
Age: 18-65 years old
No age limit
Weight: >110 lbs. (50 kg)
No strict weight requirement
Oral Temp: < 37.5C (99.5F)
(Every pound below 110 lbs. = -4 mL)
Pulse: 50-100 bpm
BP: 90-160 mmHg
60-100 mmHg
Hemoglobin: > 12.5 g/dL
Hematocrit: > 38% Hemoglobin: >11 g/dL
Frequency: Hematocrit: > 33%
8 weeks = WB donations
16 weeks = 2-unit red cell collection Frequency: Not more frequent than every
4 weeks = infrequent apheresis 3 days (72 hrs)
2 days = plasma, platelet or leukapheresis Last donation completed 3 days before surgery
(not to exceed 24x/yr)
BLOOD DONOR SELECTION & PROCESSING
MEDICAL HISTORY QUESTIONNAIRE
BLOOD DONOR SELECTION & PROCESSING
MEDICAL HISTORY QUESTIONNAIRE
BLOOD DONOR SELECTION & PROCESSING
DEFERRAL

PERMANENT
Men who have sex with other man anytime since 1977
Hemophiliacs
Intravenous drug abusers
Persons who engagediinsex for money or drugs anytime since 1977
Confirmed AIDS (+)
Viral Hepatitis after age 11
Confirmed (+) for Hepatitis (HBsAg, Anti-HBc,HcAb)
Confirmed (+) for HTLV
Malignant Solid Tumors
Hematological malignancies; Chemotherapeutic agents
Serious abnormal bleeding tendencies
Chronic cardiopulmonary, liver or renal disease
TakenTegison(Etretrnate) for Psoriasis
HxofBabesiosis,Chaga’sDisease
Received Clotting factor concentrates
Risk factor forCreutzfeld-JakobDisease (or immediate family member)
BLOOD DONOR SELECTION & PROCESSING
DEFERRAL

TEMPORARY
Cold

Flu

Tuberculosis

Syphilis

Curable heart, lung, kidney and GI tract diseases

Treatment with antibiotics

 BLOOD DONOR SELECTION & PROCESSING
DEFERRAL

3 YEARS 1 YEAR
After HBIg administration
Immigrant/refugee coming from an After rabies vaccination
area endemic for Malaria Rape victims
(after departure) Healthcare workers with percutaneous exposure to blood and
body fluids
Close contact with Viral hepatitis (+) px

Tattoo

Sexual contact with prostitute

Jail Incarceration for 72 consecutive hourrs

Diagnosed with Malaria Received transfusion of blood components
(after becoming Travel to areas endemic for Malaria
( w/ or w/o prophylactic therapy)
asymptomatic) Hx of tx and infx of Syphilis,Gonorrhea
Leishmania risk due to travel to Iraq in the last 3 years
(from departure)
 BLOOD DONOR SELECTION & PROCESSING
DEFERRAL
120 6 2 1
2 48
DAY MONTH MONTH MONT
WEEKS HOURS
S S H
S
Symptoms German Yellow fever
of measles vacc.
headache (Rubella)
and fever vacc. Measles
with high (Rubeola)
West Nile Existing Recent After
vacc.
After
virus risk Pregnanc
y for the blood cessation of
Isotretinoin
Oral Polio
Hema-
vacc.
120 days
past 6 donatio (Accutane)
for acne tx pheresis
from weeks n Mumps
recovery After vacc.
from cessation of
WNV Finasteride
(Proscar) for Smallpox
infection BPH tx vacc.
 BLOOD DONOR SELECTION & PROCESSING

DONOR TESTING
o ABO and Rh phenotype
o Antibody screen
o HbsAg
o Anti-HCV
o Anti-HBc
o HCV NAT
o Anti-HIV-1/2
o HIV NAT
o Anti-HTLV-I/II
o Syphilis: RPR or Hemaagglutination
o West Nile Virus Nucleic Acid Testing
o IgG antibody to Trypanosoma cruzi (Chaga’s disease)
 BLOOD DONOR SELECTION & PROCESSING

AUTOLOGOUS DONATION
- Donor is also the recipient of blood
- Safest blood that a individual can receive

1. Predeposit Autologous Donation

- blood is withdrawn before an anticipated transfusion and stored until use

2. Intraoperative Autologous Transfusion

- blood is collected during surgical procedure and usually reinfused immediately

3. Immediate Preoperative Hemodilution (Acute Normovolemic Hemodilution)

- 1-3 units of whole blood are collected and the patient’s volume is replaced by colloid (1:1) or crystalloid (3:1), then the
blood collected is reinfused during the surgical procedure

4. Postoperative Blood Salvage

- a drainage tube is placed in the surgical site and postoperative bleeding is salvaged, cleaned and reinfused

DIRECTED DONATION
- the unit collected is directed toward a specific patient
- usually from a family member or a friend
- must be irradiated to prevent GVHD
- tag used has distinct color (eg. Yellow, salmon)
 BLOOD DONOR SELECTION & PROCESSING
APHERESIS DONATION
- collection of specific blood component while returning the remaining whole blood components back to the patient
- uses Automated cell separator device whose centrifugal force separates blood into components based on differences in density
- used to collect plasma, platelets, leukocytes, red cells, stem cells
- Objective: Collect large volumes of the intended component

1. Plasmapheresis
- first product collected by apheresis methods
- Serum Total Protein: at least 6.0 g/dL
Red cell loss: not exceed 25 mL/week or 200 mL/8 weeks
- Infrequent/Occassional donor – undergoes no more than 1 procedure in a 4-wk period
Serial donor – donates more frequently than 4 weeks but not more than every 48 hrs and <2 donations in a 7 day period
- must be tested for total serum/plasma protein levels, , Quantitative Ig levels and SPE every 4 mons.

2. Plateletpheresis
- 75% platelet transfusions are pheresis-derived platelets
- equiv. to 6-8 RDP
- Indications: Px alloimmunized and refractory to RDP
- Platelet count: at least 150 x 10^9/L
- Interval: at least 2 days (not exceeding more than 2x/week or more than 24x/year)
- Deferral: Aspirin, Feldene ingestion w/in 3 days = 48 hours
Plavix (Clopidogrel), Ticlid (Ticlodipine) = 14 days
>100 mL of red cells were not able to return to donor = 8 weeks
 BLOOD DONOR SELECTION & PROCESSING

3. Leukapheresis
- only effective way to collect leukocytes, specifically granulocytes
- Drugs/Sedimenting agents:
o Hydroethyl starch (HES) = common sedimenting agent that enhances separation of white cell from red cells during
centrifugation
o Prednisone or Daxamethasone (corticosteroid) = pulling granulocytes from marginal pool into general circulation
o Growth Factors (Recombinant Hematopoietic Growth factors) = can produce 4-8x the volume of cells in each collection;
well-tolerated by donors
- Tests: ABO, Rh, HLA type

4. Double RBC Pheresis

- can be autologous or allogenic
- Male donor: 130 lbs., 5’1”
Female donor: 150 lbs., 5’5”
Hemoglobin(Done by Quantitative Mtd.): 40%
- Interval: 16 weeks upon completion
Note: If discontinued prior to completion and total red cell loss is <200 mL = 8 weeks
If discontinued prior to completion and total red cell loss is >300 mL = 16 weeks
 BLOOD DONOR SELECTION & PROCESSING

WHOLE BLOOD COLLECTION

A. Donor Identification
- Alpha numeric system used to link the donor to the donor record, pilot tubes, blood container
and all components to be made
- Donor name and Donor identification numbers must match
B. Aseptic Technique
- Alcohol-Iodine-Alcohol
- Iodine Allegy = Clorhexidine gluconate
- Area is scrubbed at least 4 cm in all directions from the site for a min. of 30 seconds
C. Blood Collection Procedure
- Tourniquet: 40-60 mmHg
- Mixing of Blood and anticoagulant: every 45 sec.
D. Post-donation Instructions
- Remain at rest for a few mins. in an area where they can be observed by the BB staff
- Give instructions to follow for the next 24 hours
BLOOD DONOR SELECTION & PROCESSING
 BLOOD DONOR SELECTION & PROCESSING
COMMON DONOR REACTIONS
COMMON DONOR REACTIONS COMMONLY PREVENTION & MANAGEMENT
ATTRIBUTED TO
Weakness, Tingling sensation, Anxiety, • Elevate donor’s feet to 45 angle for few mins.
Palpitations, Lightheadedness Hypoglycemia Then lower to 20 angle
• Apply cold, wet towels to neck and forehead
• Let donor breathe paper bag
• Provide juice before donation
• Discontinue donation
Fainting Anxiety, • Discontinue donation
Hypoglycemia • Administer glucose solution
Convulsion Anxiety, Underlying • Discontinue donation
disease • Maintain Airway
Jet-like pulsating bleeding with Inadvertent puncture • Discontinue immediately
bright red blood of artery • Apply pressure over puncture site at least 10mins.
Shooting pain followed by numbness Inadvertent punture • Reassure
and tingling in the forearm of median nerve • Apply support to arm
Hematoma Very fragile veins, • Discontinue if large
Unskilled • Apply pressure at least 5 mins
Phlebotomist, • Apply cold packs
Uncooperative donor • Reassure donor
BLOOD PRESERVATION
AND BANKING
 BLOOD PRESERVATION AND BANKING
1943
A. Anticoagulants and Red Cell Additives
Loutit and Mollison
Approved Preservatives Preservation Period introduced Acid-
citrate-dextrose
Acid-citrate-dextrose (ACD) 21 days
(ACD)
Citrate-phosphate-dextrose (CPD) 21 days
1957
Citrate-phosphate-adenine (CPDA-1) 35 days Gibson introduced
Citrate-phosphate-double dextrose (CP2D) 21 days Citrate-phosphate-
dextrose (CPD) which
Citrate-phosphate-adenine-2 (CPDA-2) 42 days
was less acidic
 BLOOD PRESERVATION AND BANKING
B. Additive Solutions

Saline
42 days
Adsol (AS-1)
Adenine Nutricel (AS-3)
Glucose Optisol (AS-5)
Mannitol
C. Rejuvenation Solutions
- used in blood centers to regenerate ATP and 2,3-DPG
- Red cells stored in liquid state for fewer than 3 days after their outdate are
rejuvenated for 1-4 hours at 37C with the solution
- PIGPA: Phosphate, Inosine, Glucose, Pyruvate, Adenine
PIPA: Phosphate, Inosine, Pyruvate, Adenine
o Rejuvesol – only FDA approved rejuvenation solution in US
 BLOOD PRESERVATION AND BANKING
STORAGE LESIONS
- biochemical changes that occur during the storage of red blood cells

DECREASE INCREASE
pH Plasma Hemoglobin
ATP Lactic acid
2,3-DPG K (Potassium)
Plasma sodium
BLOOD COMPONENTS
AND TRANSFUSION
THERAPY
PREPARATION OF BLOOD COMPONENTS

A. Centrifugation

B. Temperature C. Time of Preparation

FFP = within 8 hrs

Platelet Concentrate = 20-24C
FP24 = within 24 hrs
Other Blood components = 1-6C
Platelets (from WB) = within 24 hrs
 BLOOD COMPONENTS AND TRANSFUSION THERAPY

BLOOD COMPONENTS
COMPONENT INDICATIONS STORAGE TRANSPOR SHELF-LIFE
T

Whole blood Volume expansion and RBC mass in 1-6C 1-10C Depending on
acute blood loss (33.8-42.8F) preservative

PRBCs Increase RBC mass of asymptomatic, 1-6C 1-10C Open System: 24

normovolemic patients hrs
Closed System:
depending on
preservative
Leukopoor Increase RBC mass in patients with 1-6C 1-10C Open System: 24
RBCs recurrent FNHTR due to leukocyte hrs
antibodies, HLA alloimmunization, Closed System:
susceptible to CMV depending on
preservative

Washed Increase RBC mass of symptomatic 1-6C 1-10C 24 hours

RBCs anemic patients with hx of allergic,
febrile, urticarial, and anaphylactic
reactions
 BLOOD COMPONENTS AND TRANSFUSION THERAPY
BLOOD COMPONENTS
COMPONENT INDICATIONS STORAGE TRANSP
ORT
SHELF-LIFE
Frozen Storage of rare blood and autologous -65C or 10 years
RBCs units -120C
METHOD FROZEN STORED FREEZING
AT
AT EQUIPMENT
High Glycerol (40% glycerol; Slow freezing) -80C -65C Mechanical freezer
Low Glycerol (20% glycerol; Fast freezing) -196C -120C Liquid N2
Agglomeration (Glycerol, glucose, fructose, EDTA) -80C -65C Mechanical Freezer
Platelet For bleeding due to thrombocytopenia 20-24C w/ 5 days
concentrate or throbmbocytopathy agitation
Platelet Thrombocytopenic px alloimmunized 20-24C w/ 5 days
(Pheresis) to HLA or platelet antigen agitation
FFP Correct multiple coagulation factor -18C 1 year
deficiencies, Reverse effect of -65C 7 years
Warfarin (Coumadin) Thawed and stored at
1-6C =24 hrs
 BLOOD COMPONENTS AND TRANSFUSION THERAPY
BLOOD COMPONENTS
COMPONENT INDICATIONS STORAGE SHELF-LIFE
Cryoprecipit Fibrinogen deficiency, Hemophilia A, -18C or colder 1 year
ate von Willebrand’s disease and Factor After thawing= 6 hrs
XIII deficiency After pooling= 4 hrs
Granulocytes Px with granulocyte dysfunction or 20-24C w/o agitation 24 hours
(Pheresis) myeloid hypoplasia who are
unresponsive to antibiotics
Factor VIII Px with Hemophilia A 1-6C Check vial
conc. (lyophilized/freeze
dried)
Factor IX Px with Hemophilia B or specific factor 1-6C Check vial
conc. deficiencies (lyophilized/freeze
dried)
Plasma For hypovolemic shock (replace loss of 2-10C 5 years
Protein colloids), severe burns, pressure support
Fraction during hypotensive episodes, HDN
(Albumin) (binds bilirubin)
 BLOOD COMPONENTS AND TRANSFUSION THERAPY

IRRADIATION
- Done to blood components containing viable lymphocytes
- Prevent proliferation of transfused T lymphocytes in recipients at risk of acquiring TA-GVHD
- AABB and FDA recommendation: Minimum of 25 Gy dose of gamma radiation to the central
portion , with no less than 15 Gy delivered to any part of the bag
- Cesium-137 or Cobalt-60
- Indications:
o Fetuses receiving intrauterine transfusion
o Immunosuppressed px
o Recipients of BM transplant
o Px with congenital immunodeficiency
o Px with hematologic/oncologic disorders
o Recipeint of blood from first degree relative (Direct Donation)
- Shelf life: 28 days after irradiation or at the end of the storage period, whichever comes
first
 BLOOD COMPONENTS AND TRANSFUSION THERAPY

VIRAL INACTIVATION
- Mostly done in plasma products
1. UV Irradiation
2. Heating in Liquid State
3. Heating in Lyophilized Form
TRANSFUSIO
N
REACTIONS
 TRANSFUSION REACTIONS

TRANSFUSION REACTIONS
- Adverse effect that occurs during of after the administration of
blood or blood components

IMMEDIATE/ACUTE DELAYED
 Less than 24 hours  More than 24 hours
Immunologic Non- Immunologic Non-
Immunologic Immunologic
• Hemolytic • Bacterial • Hemolytic • TA-
• FNHTR Cotamination • TA-GVHD Hemosiderosis
• Allergic • TACO • Post-transfusion • Disease
• Anaphylactic • Physical or Purpura Transmission
• TRALI Chemical
Hemolysis
 IMMEDIATE,
IMMUNOLOGIC
TRANSFUSION
REACTIONS
 TRANSFUSION REACTIONS

ACUTE HEMOLYTIC TRANSFUSION REACTION

 Caused by even a small volume of incomatible boold (at least 10 mL)
 usually due to ABO incompatibilities
 Intravascular hemolysis (Hemoglobinemia & Hemoglobinuria)
 fever, chills, hemoglobinuria, DIC, renal failure
Prevention/Management: Discontinue transfusion immediately
 TRANSFUSION REACTIONS

FEBRILE NON-HEMOLYTIC TRANSFUSION REACTION (FNHTR)

 Increase in temperature of 1C or more that is associated with transfusion and cannot be
explained by any other medical condition
 Caused by HLA class I antigens on transfused WBC or platelets
 Most common type of transfusion reactions
Prevention/Management: Leuko-reduced RBCs (<5 x 10^6 WBC, 85% recovered RBC)
 TRANSFUSION REACTIONS

ALLERGIC TRANSFUSION REACTION

 Reaction between recipient antibodies and transfused donor soluble plasma proteins
 Second most common type of transfusion reaction
 Associated with urticaria
Prevention/Management: Washed RBCs, Administer Anti-Histamines before transfusion
 TRANSFUSION REACTIONS

ANAPHYLACTIC REACTION
 Occurs after infusion of only few milliliters of blood
 Due to reaction between Anti-IgA and IgA in transfused products
 IgA-deficient recipient with Anti-IgA
 Very severe allergic reaction and is life threatening
Prevention/Management: Washed RBCs
 TRANSFUSION REACTIONS

TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI)

 Also known as Non-cardiogenic Pulmonary Edema (NCPE)
 Attributed to administration of donor plasma containing high concentrations of leukoagglutinins
directed against recipient leukocytes
 Acute respiratory distress, hypoxemia, pulmonary edema, fever hypotension (same with ADULT
Respiratory Distress Syndrome)
Prevention/Management: Leuko-reduced RBCs (<5 x 10^6 WBC, 85% recovered RBC)
 IMMEDIATE,
NON- IMMUNOLOGIC
TRANSFUSION
REACTIONS
 TRANSFUSION REACTIONS

BACTERIAL CONTAMINATION
 Principal Causes: Transient bacteremia in asymptomatic donors & contamination of collection equipment
during the manufacturing process
 Common in Platelet concentrate
 RBC units: Yersinia enterocolitica, Pseudomonas fluorescens & Pseudomonas putida, (>80%)
 Propionibacteriyum acnes – common isolate from human skin that is the most common bacterial
contaminant in RBCs (Kunishima)
 Platelet units: Staphylococcus epidermidis, Bacillus cereus
 Gram (-) = Ref. temp.
 Gram (+) = Room temp.
Prevention/Management: Proper collection, handling and processing of blood units and donor screening
 TRANSFUSION REACTIONS

TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD

 Iatrogenic cause
 Associated with the rapid infusion of large volumes of blood products
 Administration of blood without equivalent blood loss
 Individuals at risk: Children, Elderly px, Px with cardiac diseases
Therapy: Therapeutic phlebotomy, 0xygen therapy, Intravenous diuretics
 TRANSFUSION REACTIONS

PHYSICAL OR CHEMICAL HEMOLYSIS

 Causes: Mechanical damage (infusion of blood through a small bore needle), Osmotic or
Chemical damage (addition of hypotonic/hypertonic solutions or drugs), Thermal trauma
(freezing blood without cryoprotective agent or warming blood above 50C)
Therapy: Proper collection, handling and processing of blood units and avoiding physical traumas
 DELAYED, IMMUNOLOGIC
TRANSFUSION REACTIONS
 TRANSFUSION REACTIONS

DELAYED HEMOLYTIC TRANSFUSION REACTION

 Associated with secondary or amnestic response to an antigen
 May not be recognized for days, weeks, or months after transfusion until a rapid decline in px
hematocrit is noticed
 usually due to IgG antibodies (Rh, Kell, Kidd, Duffy)
 extravascular hemolysis
 fever, mild jaundice
Prevention/Management: Discontinue transfusion immediately
 TRANSFUSION REACTIONS

TRANSFUSION ASSOCIATED-GRAFT VERSUS HOST DISEASE (TA-GVHD)

 Occurs when certain susceptible, immunocompromised recipients are transfused with blood or
blood components containing immunocompetent lymphocytes
 Presents high mortality rate
Prevention/Management: Irradiated blood component
 TRANSFUSION REACTIONS

POST TRANSFUSION PURPURA (PTP)

 Rare transfusion reaction usually seen in older female px previously immunized to
platelet antigens through pregnancy and/or transfusion
 Mild to severe thrombocytopenia with clinical bleeding
Therapy: Exchange transfusion, Corticosteroids, Intravenous immunoglobulin
 DELAYED,
NON-IMMUNOLOGIC
TRANSFUSION
REACTIONS
 TRANSFUSION REACTIONS

TRANSFUSION-ASSOCIATED HEMOSIDEROSIS (IRON OVERLOAD)

 Excess iron accumulates in the mitochondria of cells in organs (liver, heart, endocrine gland)
 Patients At risk: Thalassemia major, Sickle cell anemia, Hemoglobinopathies, Aplastic anemia
Therapy: Iron-chelating agents (Deferroxamine, Desferioxamine)
Neocytes (Retics) = longer life span
PRBC (<7 days old) and washed (Aplastic anemia)
 TRANSFUSION REACTIONS

DISEASE TRANSMISSION
 Hepatitis B, C, D virus
 CMV
 EBV
 HTLV I and II (seen increasingly in drug abusers)
 HIV
 Treponema pallidum (killed when placed in Ref temp. for 3 days)
 Plasmodium sp.
 Babesia microti
 Trypanosoma cruzi
 Toxoplasma gondii
Prevention: Volunteer blood (RA 7719)
Comprehensive blood donor selection (PE + Interview + Serology tests)
TRANSFUSION REACTIONS

Citrate Toxicity  Chronic transfusion of large amount of

blood
 Results to induced hypocalcemia
Hypothermia  Due to transfusing cold blood

Hyperkalemia  From the increased potassium levels in

banked blood
 TRANSFUSION REACTIONS

When Transfusion Reaction is Suspected:

1. Transfusion must be stopped
2. The IV line must e kept open in case there will be a immediate treatment
3. The attending physician and the blood bank must be notified as soon as possible
 TRANSFUSION REACTIONS
WORK-UP:

 Clerical check for discrepancies of the compatibility tag on blood bag, blood bag label,
and patient identification
 A post-transfusion sample from the patient is centrifuged, and the serum/plasma is
examined for icterus or hemolysis and compared with pretransfusion sample
 Perform DAT on post-transfusion EDTA specimen
Post-transfusion DAT (+); Pretransfusion DAT (-) = Antigen-antibody incompatibility
 Gram stain of the blood bag and culture, if necessary, to determine the presence of
bacterial contamination
 Repeat ABO/Rh typing, Antibody screen and Crossmatch, if necessary, RBC panel
 Examination of Post=transfusion urine
 Determination of post-transfusion PT, PTT, Platelet count, Fibrinogen, Fibrin split
products (suspected DIC)
 Measurement of Hct/Hb at frequent intervals if hemolysis is observed
 Measurement of Serum bilirubin on post-transfusion samples drawn after 5-7 hours
 Measurement of Haptoglobin
TRANSFUSION-
TRANSMITTED
DISEASES
 TRANSFUSION-TRANSMITTED DISEASES

A. Hepatitis
1. Hepatitis A – infection through blood transfusion is very rare
2. Hepatitis B – accounts for 10% of cases; has been greatly reduced by mandatory testing of
all donor units for HBsAg
3. Hepatitis C – accounts for more than 80% of cases; all donor units must be tested for Hepa C
4. Hepatitis D – seen in conjunction with Hepa B

B. HIV 1 and 2
- testing is required in all donor units
- Improved testing techniques have greatly reduced the risk of transmission of HIV through
transfusion

C. HTLV I and II
- antibodies have been identified in some intravenous drug abusers
 TRANSFUSION-TRANSMITTED DISEASES

D. CMV
- concerns the low-birth-weight neonates and immunocompromised patients
- Transmitted by leukocytes
- Prevention: Leuko-depleted donor units

E. Malaria
- risk of transmission is very rare
- Persons with history of disease are temporarily exluded from blood donation

F. Babesiosis
- risk of transmission is extremely rare

G. Syphilis
- rarely trasnmitted because the period that viable spirochetes can be found in the blood is
very brief
- Do not survive in ref. temperature for 3 days
- FDA requires syphilis testing on all donor units
HEMOLYTIC DISEASE OF
THE NEWBORN (HDN)
HEMOLYTIC DISEASE OF THE NEWBORN
- aka Erythrobladtosis fetalis
- occurs when the mother is alloimmunized to antigen(s)
found on RBCs of fetus = destruction of fetal RBCs
(hemolysis)
- anemia and hyperbilirubinemia
- Antibodies: ABO, Rh, MNS, Kell, Duffy, Kidd, Lutheran
- ABO HDN= most common; milder
Rh HDN = most severe
A. Pathophysiology of HDN
B. Laboratory Evaluation
Primary Indicators of Severity:
• Hyperbilirubinemia
• Degree of Anemia
1. ABO-HDN
- characterized by weakly (+) or negative DAT
- very mild/absent anemia
- increased spherocytes and reticulocytes
- mild jaundice ( does not appear for 24-48 hrs post-delivery)
- Mostly seen in Group A1 or B infants who have Group O mothers

2. Rh-HDN
- (+) DAT
- anemia is present
- increased reticulocytes
- jaundince appears within 24 hrs with increased bilirubin levels
C. Assessment of Fetomaternal Hemorrhage
1. Qualitative Test: Rosetting Test
- distinguishes Rh-positive fetal RBcs from Rh-negative maternal RBCs
- maternal RBCs are added with Anti-D
- D positive test cells are then added and form rosettes with any Anti-
D coated fetal cells present
2. Quantitative Test: Kleihauer-Betke Stain
- distinguishes Hemoglobin F- c9ntaininh fetal rbcs from those adult
cells that contain Hemoglobin A
- alcohol-fixed blood smear--> treated with acid buffer to elute Hgb A--
>counterstain
= Hgb F containing cells will stain and Hgb A containing cells appear as
ghost cells
D. Treatment
1. Intrauterine transfusion - to correct anemia in the fetus
2. Early delivery (34 weeks gestation) and when Fetal lung maturity has been determined
3. Transfusion - to correct anemia in the newborn in mild cases
4. Exchange transfusion -in severe cases:
• To decrease bilirubin levels
• To correct anemia
• To remove infant's sensitized RBCs
• To decrease concentration of incompatible antibodies
○ Donor Blood Cell Characteristics:
a. Must be group-specific or must be negatibr for the antigen against which the mother's antibodies are
directed
b. Should be Group O or same ABO group as the mother and infant, if both are the same
c. Must not jave unexpected antibodies
d. Must be less than 7 days old
e. Should be negative for CMV
f. Should be negative for Hb S
E. Prevention
- the only type of HDN preventable is that caused by Anti-D
- administer Rh immune globulin (RhIG) within 72 hrs after del8very of the first D positive
infant from D negative mother
- RhIG: made of purified, concentrated antiD gamma globulin

○ Criteria for Administering RhIG:

a. Mother is D-negative
b. Mother must have no detectable anti-D in her serum
c. Infant must br D-positive
d. Cord bloof is DAT (-)
e. The amount of RhIg to be given is determined by Kleihauer-Betke test:
No. of fetal cells/ 1000 adult cells x 5,000 = mL fetal whole blood /30 = No. of vials to give
Note: 1 vial= given if no fetal cells are detected
AUTOIMMUNE HEMOLYTIC
ANEMIAS (AIHA)
- Autoantibodies: may be responsible for decreased RBC survival and may interfere
with pretransfusion testing
1. Warm AIHA
- majority of cases
- ab usually IgG and react best at 37C
- DAT (+)
- If Antobody screen (+) = perform Adsorption and Elution

2. Cold AIHA
- second most common type
- usually IgM
- usually harmless
- eg. Cold Agglutinin disease, Paroxysmal Cold Hemoglobinuria
3. Mixed type AIHA
- cause severe hemolysis
- feature both warm and cold AIHAs
- DAT (+)
- presence of IgG and C3d on rbcs

4. Drug-induced IHA
- DAT (+)
a Drug adsorption
- penicillin
- IgG antibodies
b. Immune complex
- quinine, quinidine
-activate complement C3d
c. Membrane modification
- cephalothin
-modify rbc membrane and alloe the nonspecific adsorption of protein
d. Drug-induced hemolytic anemia
- DAT usually (+)
- Procainamide, levodopa, methyldopa, mefenamic acid
BLOOD BANKING TECHNIQUES
 BLOOD BANKING TECHNIQUES
COMPATIBILITY TESTING
A. Patient identification
- Px must have a wristband with identification information
- tubes are labelled at bedside immediately after sample is drawn (Px name, time and date
of collection, name of phlebotomist)
B. Collection
- Serum = preferred sample
- Avoid hemolysis and must not be drawn from an IV site unless absolutely necessary (stop
infusion, flush the line with normal saline and discard the first 5-10 mL of blood drawn)
C. Age of Specimen
- Fresh sample
- Previously transfused patient and/or Pregnant = not older than 72 hrs
D. Sample Storage
- AABB: 1-6C for at least 7 days following transfusion
 BLOOD BANKING TECHNIQUES
COMPATIBILITY TESTING
1. Homologous Transfusion
A. Selection of Donor
○ ABO and Rh on donor units
○ ABO and Rh on recipient
○ Antobody screening of recipient
○ Antibody identification (if unexpected antibody is identified)
○ Autocontrol
○ Crossmatch
• Major crossmatch: "PSDR"; to determine ABo compatibility of donor cells
• Minor crossmatch: "PRDS"; no longer required
- tested in three phases:
1. Immediate Spin - saline at Room temp.
2. Incubation at 37C with enhancement medium
3. Antiglobulin phase after washing
2. Autologous Transfusion
○ ABO and Rh on autologous units
○ ABO and Rh on recipieNT
○ Antibody screening and major crossmatch
(Not required, but the IS phase is often performed

3. Neonatal Transfusion
○ ABO and Rh on the infant
○ Antibody screen on infant or the mother
• If negative antibody screen, no need for crossmatch
• If donor cells are not Group O, the infant must be tested for Anti-A
and Anti-B abs; if either is present, ABO-compatible rbcs must be used.
Selection of Donor Units according to ABO and Rh:
○ ABO group - most important consideration for selecting donir units for
transfusion
1st choice: always the same ABO grouo
2nd choice: ABO compatible donor units given as PRBCs
○ Rh type - second most important
Rh positive px: may recive either Rh (+) or Rh (-) units
Rh negative px: must receive Rh (-) rbcs; can receive Rh (+) given that Anti-D is
not present
○ Group O negative RBCs - the compo ent of choice for neonatal transfusion ;
Grouo specific blood may be given if mother and infant have the same ABO type.
○ Emrgency situations:
Preferred: O negative PRBC
 GEL TECHNOLOGY
- uses microtubule filled with dextran acrylamide gel
- usually for antibody screening
1. Add 50 mL of 0.8% sRBCs
2. Add 25 mL of patient serum
3. Incubate for 15.mins at 37C
4. Centrigufe for 10 mins

4+ Solid band of agglutinated red cells at the top of gel column; No red cells are visible in the bottom of microtube
3+ Predominant amount of agglutinated red cells towards the top of gel column with few agglutinates staggered below
the thicker band; Majority of agglutinates are observed in the top half of gel column
2+ Red cell agglutinates dispersed throughout the gel column with few agglutinates at the bottom of microtubes;
Agglutinates are distributed through the upper and lower halves of the gel
1+ Red cell agglutinates predominantly observed in lower half of gel column with red cells; Reactions may be weak, with
few agglutinates remaining in the gel area just above the red cell pellet in the bottom of microtube
Neg Red cells forming a well-delineated pellet in the bottom of microtube; Gel above red cell pellet is clear and free of
agglutinates
MF Layer of red cell agglutinates at the top of gel column accompanied by a pellet of unagglutinated cells in the bottom
of the microtube
ANTIBODY SCREEN
Performed to detect antibodies in:
• Patients requiring transfusion
• Obstetric patients
• Patients with suspected transfusion reaction
• Blood and plasma donors
- Includes 37C incubation and use of Antiglobulin test
A. Reagents:
• Screening cells: Group O RBCs that provide specific antigens (usually distributed in 2
or 3 vial sets
• Enhancement media: increases sensitivity of a test system
• AHG reagents: detects clinically significant antibodies
- must contain anti-IgG when used for antibody detection and compatibility testing
o Polyspecific AHG – contains both anti-IgG and anti-C3d/C3b; used in DAT testing
o Monospecific AHG – contains either anti-IgG or anti-C3d/C3b; used in differential
DAT testing, Antibody detection and identification
o Coombs Control cells – required for control of negative AHG tests
- verifies that adequate washing was performed and that AHG was added
- must react when added to negative AHG tests
ANTIBODY SCREEN
4+ Solid agglutinate, clear supernatant background

3+ Several large agglutinates, clear supernatant background

2+ Medium-sized agglutinates, clear supernatant background

1+ Small agglutinates, turbid supernatant background

Neg No agglutination of hemolysis

W+ Tiny agglutinates, turbid supernatant backround

B. Limitations of Antibody Screen
• Will not detect antibodies when the titer has dropped below the sensitivity level of the
screening method being used
• Will not detect antibodies to low-frequency antigens that are not present on any of the
screening cells

C. Factors Affecting Sensitivity

o Cell-to-serum ratio
• Antibody Excess (Prozone): False negative
• Antigen Excess (Postzone): False negative
o pH
• best at neutral pH of 6.8 to 7.2
o Temperature
• Clinically significant antibodies react at 37C or at AHG phase
oLength of Incubation
• Too little = not enough cells are sensitized
• Too long = bound antibody may dissociate
• Depends on media used (follow manufacturer’s instructions)
ANTIBODY IDENTIFICATION
A. Patient History
o Transfusion and Pregnancy history – may indicated recent antibody stimulation
o Recent Drug Therapy – eg. IV Ig, RhIg, Anti-lymphocyte globulin
o Age, Sex, Race and Diagnosis – eg. Anti-U in African race

B. Reagents
o Antibody Identification Panel – collection of 11 to 20 group O RBCs with various
antigen expression
o Screen cells profile sheets – lot specific
o Autocontrol – patient’s rbcs are tested against patient’s serum
C. Panel Interpretation
o Phase of Reactivity
• Low temperature/ Immediate Spin phase = IgM
• 37C/ AHG phase = IgG
• Reaction at more than one phase = combination of IgM and IgG

PHASE ROOM TEMP. 37C AHG

Antibodies Cold Autoabs (I, H, Potent Cold (IgM) Rh, K, Fy, Jk, S, s,
IH),M,N,P1,Lea.Leb,Lua Autoabs, Warm Abs Lub,Xga
(D,E,K)
Ig class IgM IgG IgG

o Clinically
Reaction
significant
No
Strength – clue to number of Yes
antibodies present Yes

• Varying strengths = suggest more than one antibody or dosage

o Exclusion – “Rule-outs”
• Performed in cells showing homozygous expression of antigen
QUALITY MANAGEMENT IN
BLOOD BANK
QUALITY MANAGEMENT IN BLOOD BANK
MONITORING OF INSTRUMENTS OR EQUIPMENT
TRANSFUSION SERVICES
Refrigerators and Freezers Daily (every after 4 hours)
Centrifuge
 Speed timer (Tachometer) Quarterly
 Temperature (Refrigerated) Monthly
 Disinfection Weekly
Cell washers (speed, timer) Quarterly
Blood warmers Quarterly
Mercury thermometers Annually
Alarm Activation (refrigerators, freezers) Monthly
Heating blocks Daily when in use
Water baths Daily when in use

Platelet incubators (enclosed, monitored Daily

chambers)
Platelet incubators (ambient temp storage) Every 4 hours
QUALITY MANAGEMENT IN BLOOD BANK
MONITORING OF INSTRUMENTS OR EQUIPMENT

DONOR FACILITY
Donor unit agitators Daily when in use
Scales Daily when in use
Balances Daily when in use
Hemoglobinometer Daily when in use
Microhematocrit centrifuges Daily when in use