TRANSFUSION BIOLOGY & THERAPY

ANN MEREDITH GARCIA TRINIDAD, MD, MCMMO, FPCP, FPSMO

Internal Medicine – Medical Oncology
ABO antigens

Image credit: Wikipedia

 ABO antigens & antibodies

(isoagglutinins)

Image credit: BC Open Textbooks

 ABO antigens & antibodies

(isoagglutinins)

Image credit: BC Open Textbooks

 ABO antigens & antibodies

(isoagglutinins)

Image credit: BC Open Textbooks

 ABO antigens & antibodies

(isoagglutinins)

Image credit: BC Open Textbooks

Rh system

Image credit: SlideShare (Rick Presley)

Rh system

Image credit: Lumen Learning

Rh system

Image credit: Lumen Learning

 Lewis system

*Most common cause of incompatibility during pretransfusion screening

*Usually IgM and cannot cross the placenta

Image credit: SlideShare (Ferdie Fatiga)

 Pretransfusion testing
TEST TARGET FEATURES
“Forward type” ABO and Rh – Uses antisera directed against the A, B,
phenotype and D antigens
“Reverse type” Isoagglutinins – Should correlate with the ABO
phenotype
Alloantibody screen Antibodies – Performed by mixing patient serum with
against other type O RBCs that contain the major
RBC antigens antigens of most blood group systems and
whose extended phenotype is known
Cross-matching – Ordered when there is a high probability
that the patient will require a pRBC
transfusion
– Blood selected must be ABO compatible
and lack antigens for which the patient has
alloantibodies
Blood components

Hard spin

RD
platelets

Image credit: eClinpath

Blood components

Hard spin

RD
platelets

Image credit: eClinpath

Blood components

Image credit: Bangalore Medical Services Trust

Blood components

Harrison’s Principles of Internal Medicine 19E

 Blood components
Whole blood – Provides both oxygen-carrying capacity and volume expansion
– Ideal component for patients who have sustained acute hemorrhage
of ≥25% total blood volume loss
– Typically used only in emergency settings
Packed RBCs – Increases oxygen-carrying capacity
– Target levels = 70-100 g/L
– 1 unit = 10 g/L (Hgb), 3% (Hct)
Platelets – Threshold for prophylactic platelet transfusion = 10,000/μL in
patients without fever or infections
– Threshold to prevent spontaneous hemorrhage = 5,000/μL
– Target level for invasive procedures = 50,000/μL
– 2 units of transfused RD/m2 BSA ≈ 10,000/μL
Fresh-frozen plasma – Contains stable coagulation factors and plasma proteins: fibrinogen,
antithrombin, albumin, and proteins C and S
– For correction of coagulopathies, including the rapid reversal of
warfarin; supplying deficient plasma proteins; and treatment of TTP
– Acellular (does not transmit intracellular infections)
Cryoprecipitate – Source of fibrinogen, factor VIII (1:80), and von Willebrand factor
(VWF)
 Blood components
Whole blood – Provides both oxygen-carrying capacity and volume expansion
– Ideal component for patients who have sustained acute hemorrhage
of ≥25% total blood volume loss
– Typically used only in emergency settings
Packed RBCs – Increases oxygen-carrying capacity
– Target levels = 70-100 g/L
– 1 unit = 10 g/L (Hgb), 3% (Hct)
Platelets – Threshold for prophylactic platelet transfusion = 10,000/μL in
patients without fever or infections
– Threshold to prevent spontaneous hemorrhage = 5,000/μL
– Target level for invasive procedures = 50,000/μL
– 2 units of transfused RD/m2 BSA ≈ 10,000/μL
Fresh-frozen plasma – Contains stable coagulation factors and plasma proteins: fibrinogen,
antithrombin, albumin, and proteins C and S
– For correction of coagulopathies, including the rapid reversal of
warfarin; supplying deficient plasma proteins; and treatment of TTP
– Acellular (does not transmit intracellular infections)
Cryoprecipitate – Source of fibrinogen, factor VIII (1:80), and von Willebrand factor
(VWF)
 Blood components
Whole blood – Provides both oxygen-carrying capacity and volume expansion
– Ideal component for patients who have sustained acute hemorrhage
of ≥25% total blood volume loss
– Typically used only in emergency settings
Packed RBCs – Increases oxygen-carrying capacity
– Target levels = 70-100 g/L
– 1 unit = 10 g/L (Hgb), 3% (Hct)
Platelets – Threshold for prophylactic platelet transfusion = 10,000/μL in
patients without fever or infections
– Threshold to prevent spontaneous hemorrhage = 5,000/μL
– Target level for invasive procedures = 50,000/μL
– 2 units of transfused RD/m2 BSA ≈ 10,000/μL
Fresh-frozen plasma – Contains stable coagulation factors and plasma proteins: fibrinogen,
antithrombin, albumin, and proteins C and S
– For correction of coagulopathies, including the rapid reversal of
warfarin; supplying deficient plasma proteins; and treatment of TTP
– Acellular (does not transmit intracellular infections)
Cryoprecipitate – Source of fibrinogen, factor VIII (1:80), and von Willebrand factor
(VWF)
 Blood components
Whole blood – Provides both oxygen-carrying capacity and volume expansion
– Ideal component for patients who have sustained acute hemorrhage
of ≥25% total blood volume loss
– Typically used only in emergency settings
Packed RBCs – Increases oxygen-carrying capacity
– Target levels = 70-100 g/L
– 1 unit = 10 g/L (Hgb), 3% (Hct)
Platelets – Threshold for prophylactic platelet transfusion = 10,000/μL in
patients without fever or infections
– Threshold to prevent spontaneous hemorrhage = 5,000/μL
– Target level for invasive procedures = 50,000/μL
– 2 units of transfused RD/m2 BSA ≈ 10,000/μL
Fresh-frozen plasma – Contains stable coagulation factors and plasma proteins: fibrinogen,
antithrombin, albumin, and proteins C and S
– For correction of coagulopathies, including the rapid reversal of
warfarin; supplying deficient plasma proteins; and treatment of TTP
– Acellular (does not transmit intracellular infections)
Cryoprecipitate – Source of fibrinogen, factor VIII (1:80), and von Willebrand factor
(VWF)
 Blood components
Whole blood – Provides both oxygen-carrying capacity and volume expansion
– Ideal component for patients who have sustained acute hemorrhage
of ≥25% total blood volume loss
– Typically used only in emergency settings
Packed RBCs – Increases oxygen-carrying capacity
– Target levels = 70-100 g/L
– 1 unit = 10 g/L (Hgb), 3% (Hct)
Platelets – Threshold for prophylactic platelet transfusion = 10,000/μL in
patients without fever or infections
– Threshold to prevent spontaneous hemorrhage = 5,000/μL
– Target level for invasive procedures = 50,000/μL
– 2 units of transfused RD/m2 BSA ≈ 10,000/μL
Fresh-frozen plasma – Contains stable coagulation factors and plasma proteins: fibrinogen,
antithrombin, albumin, and proteins C and S
– For correction of coagulopathies, including the rapid reversal of
warfarin; supplying deficient plasma proteins; and treatment of TTP
– Acellular (does not transmit intracellular infections)
Cryoprecipitate – Source of fibrinogen, factor VIII (1:80), and von Willebrand factor
(VWF)
Adverse reactions to blood transfusion

Harrison’s Principles of Internal Medicine 19E

 Immune-mediated:
Acute hemolytic transfusion reactions

Image credit: The Immune System

 Immune-mediated:
Acute hemolytic transfusion reactions

Image credit: Wikimedia

 Immune-mediated:
Delayed hemolytic transfusion reactions

Image credit: Basicmedical Key

 Immune-mediated:
Febrile nonhemolytic transfusion reactions

*Most frequent reaction associated with the transfusion of

cellular blood components
Image credit: ResearchGate
 Immune-mediated:
Allergic and anaphylactic reactions

Image credit: Kuby Immunology

 Immune-mediated:
Allergic and anaphylactic reactions

Image credit: Wikimedia

 Immune-mediated:
Transfusion-related acute lung injury

*Most common cause of transfusion-related fatalities

Immune-mediated:
Alloimmunization

Image credit: Blood Journal

 Nonimmunologic reactions
REACTION FEATURES
Fluid overload – Dyspnea, oxygen desaturation ,
(transfusion-associated bilateral infiltrates on chest X-ray,
circulatory overload) systolic HPN, elevated BNP levels
Hypothermia – Rapid infusion of cold blood
components  can result in cardiac
dysrhythmias
Electrolyte toxicity – RBC leakage during storage 
increased K+
– Chelation of calcium by citrate 
hypocalcemia from multiple rapid
transfusions
Iron overload – Endocrine, hepatic, and cardiac
*1 u pRBC = 200-250 mg of manifestations after 100 units of
iron pRBCs (20 g of iron)
Hypotensive reactions – Transient hypotension among
patients on ACE inhibitors caused by
bradykinin in blood products
Immunomodulation – Caused by allogeneic blood
transfusion
MANAGEMENT/PREVENTION
– Monitoring the rate and volume of
the transfusion
– Diuretic
– In-line warner
– Fresh or washed RBCs for neonatal
transfusions
– Calcium infusion if symptomatic
– Alternative therapies (e.g., EPO)
– Judicious transfusion
– Chelating agents (deferoxamine,
deferasirox)
– None
– Leukocyte-depleted cellular
products
Infectious complications

Image credit: World Health Organization

 Infectious complications

VIRUSES BACTERIA* OTHERS

 HCV  Yersinia  Plasmodium
 HIV  Pseudomonas  Babesia
 HBV  Serratia  Trypanosoma
 West Nile virus  Acinetobacter  A. phagocytophilum
 CMV  Escherichia  Dengue virus
 HTLV-1  Coagulase-negative  Chikungunya virus
 Parvovirus B19 staphylococci  Yellow fever virus
 Variant Creutzfeldt-
Jakob disease

*Most bacteria do not grow well at cold temperatures; thus, PRBCs and FFP are not common sources
of bacterial contamination.
*Platelet concentrates, which are stored at room temperature, are more likely to contain skin
contaminants such as gram-positive organisms.
Adverse reactions to blood transfusion

Image credit: Yilin Zhang

Adverse reactions to blood transfusion
No error
found No Febrile nonhemolytic
Plasma (FNHTR)
hemolysis?
Severe
Clerical Yes symptoms
Fever/chills check
Bacterial
contamination
T
Acute hemolytic (AHTR)
R Error
A found
N No other Mild allergic
S Hives/itching symptoms
F
U
S Review Severe, hypotension Anaphylaxis
I Dyspnea clinical Risk group Volume overload
picture Unexplained TRALI
O
N
AHTR
Rule out Bacterial contamination
Hypotension – Error Anaphylaxis
– Plasma hemolysis TRALI
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