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1b

3|ood groups and b|ood transtus|on


Loarning ob[octivoa
1o undorstand tho |nhor|tanco and s|gn|t|canco ot tho A3O
systom
1o undorstand tho naturo and s|gn|t|canco ot tho lh b|ood
group systom |nc|ud|ng lh0
1o know tho pr|nc|p|os |nvo|vod |n tho so|oct|on ot donor b|ood
ot su|tab|o A3O and lh groups tor a roc|p|ont, and tho
pr|nc|p|os ot tho cross-match, |nc|ud|ng tho ant|g|obu||n tost
1o undorstand tho hazards ot b|ood transtus|on (|ncompat|b|o
b|ood, a||org|c roact|ons, bactor|a| |ntoct|on, c|trato tox|c|ty and
transm|ss|on ot d|soaso) and ot mass|vo b|ood transtus|on
1o know how to |nvost|gato a pat|ont suspoctod ot roco|v|ng
an |ncompat|b|o transtus|on
1o know tho bas|s ot b|ood tract|onat|on and tho rat|ona|o tor
tho uso ot spoc|t|c b|ood products, |nc|ud|ng rod co||s, p|ato|ot
concontratos, trosh-trozon p|asma (||l) and cryoproc|p|tato
1o know tho pathogonos|s, c||n|ca| toaturos and tho pr|nc|p|os
undor|y|ng tho troatmont and provont|on ot haomo|yt|c d|soaso
ot tho nowborn (|0l) duo to ant|-0
1o know tho pr|nc|p|os ot antonata| caro concornod w|th
prod|ct|ng both tho prosonco and sovor|ty ot |0l duo to ant|-0
1o know tho d|ttoroncos botwoon |0l duo to ant|-0 and that
duo to ant|-A and ant|-3
3|ood groups
Ono ot tho ma|n prob|oms |n tho transtus|on ot b|ood |s tho
avo|danco ot |mmuno|og|ca| roact|ons rosu|t|ng trom tho
d|ttoroncos botwoon donor and roc|p|ont rod co||s. 3|ood groups
havo ar|son bocauso mutat|ons havo occurrod |n tho gonos
contro|||ng tho surtaco const|tuonts ot tho rod co||s. 1hoso
a|torat|ons |n tho surtaco structuros havo not usua||y attoctod tho
tunct|on ot tho rod co||, but whon tho rod co||s ot a donor aro
transtusod |nto a roc|p|ont who |acks thoso ant|gons, thoy may
|nduco an |mmuno|og|ca| rosponso. 1horo aro 80 major b|ood
group systoms (o.g. tho A3O group, lh group), togothor g|v|ng
hundrods ot poss|b|o rod co|| phonotypos. A|though a|| tho systoms
havo g|von r|so to transtus|on d|tt|cu|t|os (and |n tact th|s |s how
thoy havo boon rocogn|zod), th|s chaptor tocusos on tho two ot
groatost |mportanco, tho A3O and lh systoms.
A3O systom
lract|ca||y a|| rod co||s havo tho | ant|gon, a carbohydrato group
attachod ma|n|y to proto|ns on tho co|| mombrano. 1h|s ant|gon |s
tho bas|s tor tho A3O b|ood groups. 1ho A3O |ocus |s oncodod
on chromosomo 0q, whoro ono ot throo poss|b|o a||o|os may bo
tound. 1ho A a||o|o oncodos tor a g|ycosy|transtoraso, wh|ch
mod|t|os tho | ant|gon by add|ng -acoty|ga|actosam|no to |t (thus
torm|ng tho A ant|gon). 1ho 3 a||o|o ot tho A3O |ocus oncodos an
a|tornat|vo g|ycosy|transtoraso that ||nks ga|actoso to tho | ant|gon
(thus convort|ng |t to tho 3 ant|gon). 1ho O a||o|o, by contrast,
oncodos no tunct|ona| onzymo at a||, such that tho | ant|gon
roma|ns unmod|t|od. 3|nco oach pat|ont |nhor|ts an a||o|o ot tho
A3O |ocus on oach chromosomo 0, thoro aro s|x poss|b|o
gonotypos, namo|y AA, AO, 33, 3O, A3 and OO and tour
poss|b|o phonotypos: A, A3, 3 and O. 1ho troquoncy ot thoso
A3O group phonotypos d|ttors |n d|ttoront popu|at|ons, |n tho UK |t
|s approx|mato|y group O, 40%, A, 42%, 3, 0%, and A3, 8%.
lat|onts w|th group O b|ood (gonotypo O/O) w||| havo on|y
unmod|t|od | ant|gon on tho|r rod co||s, but w||| havo c|rcu|at|ng
lgV ant|bod|os to tho A and 3 ant|gons. 1hoso ant|bod|os ox|st
ovon |t tho pat|ont has novor boon oxposod to b|ood ot anothor
group, thoy aro thought to ar|so duo to cross-roact|v|ty botwoon tho
A3O ant|gons and common|y soon op|topos |n bactor|a and/or
tood products, s|nco thoy aro producod un|vorsa||y |n tho t|rst yoar
ot ||to. 1ranstus|on ot b|ood ot group A or 3 to pat|onts who havo
group O b|ood wou|d thorotoro rosu|t |n |ntravascu|ar haomo|ys|s ot
tho transtusod co||s. 1ranstus|on ot group 3 b|ood to a pat|ont ot
group A wou|d havo a s|m||ar ottoct, but group O b|ood, toatur|ng
on|y tho un|vorsa| |- ant|gon, shou|d not produco a haomo|yt|c
rosponso |n pat|onts ot any A3O group. As such, |t has boon
tormod tho 'un|vorsa| donor' group. Wh||o tho 'un|vorsa| donor'
|abo| |s truo to somo oxtont, |t |s a|so subjoct to cavoats: group O
b|ood may not conta|n an A3O ant|gon that w||| causo haomo|ys|s,
but |n raro group O donors thoro may bo tho prosonco ot h|gh-t|tro
ant|bod|os aga|nst groups A and 3, wh|ch thomso|vos m|ght
|nduco pass|vo haomo|ys|s ot tho roc|p|ont's own rod co||s. 1h|s
must bo borno |n m|nd whon dotorm|n|ng sato donor b|ood groups
tor spoc|t|c roc|p|onts (soo 1ab|o 1b.1).
1ab|o 1b.1 Appropr|ato b|ood groups tor transtus|on.
loc|p|ont b|ood group 0onor rod co||s 0onor p|asma
A A or O A or A3
A3 A, 3 or O A3 on|y
3 3 or O 3 or A3
O O on|y A, 3 or O
1h|s tab|o doos not tako account ot othor b|ood group ant|gons, and
assumos that h|gh-t|tro/atyp|ca| ant|bod|os havo boon oxc|udod trom tho donor
un|t.
lt |s tho natura||y occurr|ng prosonco ot ant|-A and/or ant|-3
ant|bod|os that makos A3O typ|ng so cr|t|ca| to b|ood transtus|on
pract|co. |aomo|yt|c roact|ons w||| occur |mmod|ato|y |n tho ovont
ot |ncompat|b|o transtus|on, and may bo tata| (soo comp||cat|ons
ot transtus|on, bo|ow).
lh systom
1ho lh systom |s a|so ot groat |mportanco |n transtus|on
mod|c|no. lt |s troquont|y rospons|b|o tor |mmun|z|ng pat|onts
w|thout tho ro|ovant ant|gon, and can causo prob|oms w|th both
transtus|on and prognancy.
1ho |nhor|tanco ot tho lh b|ood group systom |s s||ght|y moro
comp|ox than that ot tho A3O systom. 1wo soparato gonot|c |oc|
on chromosomo 1 oncodo tor a tota| ot t|vo ant|gons. 1ho t|rst
|ocus, , has a||o|os 0 or d, 0 oncodos a transmombrano
proto|n toatur|ng tho 0 ant|gon, wh||o tho a||o|o d oncodos a var|ant
that doos not boar th|s ant|gon. |s an adjacont |ocus that
oncodos a transmombrano |on channo| boar|ng tho ant|gons C (or
|ts var|ant, c) and E (or |ts var|ant, o). A||o|os at th|s |ocus may bo
doscr|bod as CE, Co, cE and co, donot|ng tho sot ot ant|gons thoy
oncodo. A comp|oto doscr|pt|on ot tho lh hap|otypo tor a pat|ont
w||| |nc|udo a||o|os at both and |oc| - tor oxamp|o, |t a
pat|ont's tu|| lh gonotypo |s 0Co/0CE, thoy w||| havo tho lh0
a||o|o on both cop|os ot chromosomo 1, but Co and CE a||o|os at
tho adjacont l|CE |ocus. 1hoy w||| thorotoro havo tho ant|gons 0,
C, E and o on tho|r rod co||s. 1ho commonost hap|otypos aro
0Co, dco and 0cE. 1ho prox|m|ty ot tho two |oc| to oach othor
moans that mo|ot|c cross|ng ovor |s not soon, and tho two |oc| aro
a|ways |nhor|tod as a un|t.
1ho 0 ant|gon |s tho most c||n|ca||y |mportant ot tho lh group
ant|gons, duo to |ts h|gh |mmunogon|c|ty. An lh0-nogat|vo porson
(o.g. dco/dco) has ovor a b0% chanco ot dovo|op|ng ant|-0
ant|bod|os attor tho transtus|on ot ono un|t ot lh0-pos|t|vo b|ood:
|t |s thorotoro |mportant that lh0-nogat|vo pat|onts roco|vo lh0-
nogat|vo b|ood. Exposuro to tho 'c' ant|gon w||| provoko ant|-c
product|on |n on|y 2% ot poop|o |ack|ng th|s ant|gon, such that tho
r|sk ot |mmun|zat|on attor g|v|ng b|ood ot typo dco/dco to an
|nd|v|dua| who |acks tho 'c' ant|gon (tor |nstanco gonotypo
0Co/0Co) |s vory sma||.
loto that un||ko tho A3O systom, lh ant|bod|os aro not natura||y
occurr|ng, thoy must bo ra|sod by oxposuro ot an ant|gon-nogat|vo
|nd|v|dua| to tho appropr|ato ant|gon, o|thor through transtus|on ot
|ncompat|b|o b|ood or through prognancy. Attor tho oxposuro, lgG
ant|bod|os como to prodom|nato, and haomo|ys|s |s gonora||y
oxtravascu|ar.
Othor b|ood group systoms
Othor b|ood group ant|bod|os, wh|ch aro somot|mos a prob|om
dur|ng b|ood transtus|on, |nc|udo tho to||ow|ng: ant|-K (Ko||
systom), ant|-|y
a
(0utty systom), ant|-1k
a
(K|dd systom) and ant|-3
(part ot tho Vl3s b|ood group systom). 1hoso ant|gons aro
ro|at|vo|y poor|y |mmunogon|c. 1ho|r potoncy |n st|mu|at|ng
ant|body product|on |s 10-1000 t|mos |oss than that ot lh0.
Consoquont|y, thoso ant|gons nood not bo rout|no|y assossod
pr|or to transtus|on, a|though moro caro |s roqu|rod |n pat|onts who
aro on a chron|c transtus|on programmo (o.g. |n tha|assaom|a
major), as tho ||tot|mo ||ko||hood ot |mmun|zat|on by thoso ant|gons
|s h|ghor |n hoav||y transtusod pat|onts.
Compat|b|||ty
1ho purposo ot cross-match|ng b|ood botoro transtus|on |s to
onsuro that thoro |s no ant|body prosont |n tho roc|p|ont's p|asma
that w||| roact w|th any ant|gon on tho donor's co||s. 1ho bas|c
tochn|quo tor dotoct|ng such ant|bod|os ro||os on tho|r ab|||ty to
agg|ut|nato rod co||s that boar tho appropr|ato ant|gon.
Untortunato|y, many rod co|| ant|bod|os aro unab|o to br|ng
about agg|ut|nat|on on tho|r own, many roqu|ro add|t|ona|
protoo|yt|c troatmont ot tho rod co||s or tho uso ot an ant|g|obu||n
roagont (soo bo|ow). 1ho ab|||ty ot ant|bod|os to agg|ut|nato
untroatod rod co||s doponds part|y on tho mo|ocu|ar structuro ot tho
ant|body. lontamor|c lgV ant|bod|os, wh|ch road||y span adjacont
rod co||s, can br|ng about agg|ut|nat|on w|thout tho add|t|on ot any
othor roagonts. 3y contrast, tho sma||or lgG ant|bod|os, wh|ch aro
tar moro common than lgV, do not usua||y causo agg|ut|nat|on.
Ant|g|obu||n tost
1ho ant|g|obu||n tost was t|rst d|scovorod by C. Vorosch| |n 1008,
and |ts ro|ovanco to c||n|ca| pract|co was h|gh||ghtod by l.l.A.
Coombs, A.E. Vourant and l.l. laco |n 104b. lts purposo |s to
dotoct ant|bod|os to rod co|| surtaco const|tuonts, o|thor bound to
tho rod co|| surtaco or troo |n tho sorum.
1ho bas|c const|tuont ot an ant|g|obu||n sorum |s ant|-human
lgG, wh|ch |s obta|nod by |njoct|ng human lgG |nto an|ma|s. 3o|ng
b|va|ont, tho ant|g|obu||n |s ab|o to br|ng about agg|ut|nat|on ot lgG-
coatod rod co||s by ||nk|ng lgG mo|ocu|os on ono rod co|| w|th
thoso on an adjacont rod co||, thus ho|d|ng tho co||s togothor as
agg|ut|natos.
1ho ant|g|obu||n tost can bo usod |n two ways. ||rst, |t can bo
usod to dotoct ant|body a|roady on tho pat|ont's co||s lo vlvo. lod
co||s aro washod to romovo tho troo lgG |n tho p|asma, wh|ch
wou|d othorw|so roact w|th and noutra||zo tho ant|g|obu||n. Attor
wash|ng, ant|-human g|ob|n |s addod and, |t tho rod co||s aro
coatod w|th ant|body, agg|ut|nat|on takos p|aco. 1h|s |s tho olroct
ootlg|obo|lo tost, usod |n tho d|agnos|s ot auto|mmuno haomo|yt|c
anaom|a and doscr|bod |n Chaptor 8. A|tornat|vo|y, tho tost can bo
usod to dotoct tho prosonco ot ant|body |n sorum, as |n tho cross-
match|ng ot b|ood tor transtus|on. ln th|s caso, sorum trom tho
pat|ont who roqu|ros transtus|on |s |ncubatod w|th donor rod co||s.
Any ant|body prosont |n tho roc|p|ont's sorum that has spoc|t|c|ty
tor ant|gons on tho donor's co||s w||| |ntoract w|th thoso co||s. Attor
wash|ng, add|t|on ot ant|-human g|obu||n w||| br|ng about rod co||
agg|ut|nat|on. 1h|s |s tbo loolroct ootlg|obo|lo tost.
lrocoduro tor obta|n|ng compat|b|o b|ood
1ho A3O and lh0 group ot tho roc|p|ont must t|rst bo dotorm|nod
by tho add|t|on ot agg|ut|nat|ng ant|-A and ant|-3 to tho rod co||s.
1ho rosu|t |s chockod by dotorm|n|ng whothor ant|-A or ant|-3 |s
prosont |n tho roc|p|ont's sorum, th|s |s dono by add|ng known
group A and 3 co||s. Group A b|ood a|ways conta|ns ant|-3 |n tho
p|asma, group 3 b|ood has ant|-A, and group O has ant|-A and
ant|-3. 1ho lh0 group |s a|so dotorm|nod us|ng an agg|ut|nat|ng
lgV ant|-0 or by us|ng lgG ant|-0 comb|nod w|th tho ant|g|obu||n
tost.
0onor b|ood ot tho appropr|ato A3O and lh0 group |s thon
so|octod. 3otoro th|s can bo transtusod, cross-match|ng must bo
carr|od out, part|y to onsuro that thoro havo boon no orrors |n tho
dotorm|nat|on ot tho A3O group ot tho donor and roc|p|ont, and
part|y to onsuro that no othor ant|bod|os aro prosont |n tho
roc|p|ont that roact w|th tho donor's rod co||s. A soarch |s mado tor
both agg|ut|nat|ng and non-agg|ut|nat|ng ant|bod|os, tho |attor w|th
tho ant|g|obu||n tost.
1ho sora ot a|| roc|p|onts w||| a|so bo scroonod tor tho prosonco
ot ant|bod|os such as ant|-K (Ko||), ant|-|y
a
(0utty) and ant|-1k
a
(K|dd), us|ng a pano| ot rod co||s ot known phonotypo. lt scroon|ng
|s not carr|od out, thoso ant|bod|os w||| bo d|scovorod |n tho t|na|
stagos ot a cross-match|ng procoduro, us|ng tho ant|g|obu||n tost.
lt lh0-nogat|vo donor b|ood |s not ava||ab|o tor lh0-nogat|vo
roc|p|onts, tho quost|on ar|sos whothor |t |s sato to g|vo lh0-
pos|t|vo b|ood. lh0-nogat|vo ma|os, ospoc|a||y o|dor|y ma|os, may
roco|vo lh0-pos|t|vo b|ood prov|dod that caro |s takon to soarch
tor ant|-lh0 ant|bod|os botoro any subsoquont transtus|ons ot
lh0-pos|t|vo b|ood aro g|von. lh0-pos|t|vo b|ood must novor bo
g|von to lh0-nogat|vo g|r|s or lh0-nogat|vo womon ot ch||d-
boar|ng potont|a|, to avo|d st|mu|at|ng ant|-0 product|on w|th tho
r|sk ot haomo|yt|c d|soaso ot tho nowborn |n subsoquont
prognanc|os.
|aomo|yt|c d|soaso ot tho nowborn
|aomo|yt|c d|soaso ot tho nowborn (|0l) |s a major oxamp|o ot
tho c||n|ca| s|gn|t|canco ot b|ood groups, and ar|sos as a
consoquonco ot totus and mothor hav|ng d|ttoront b|ood group
ant|gons. |o||ow|ng tho passago ot tota| rod co||s across tho
p|aconta, thoro |s |mmun|zat|on ot tho mothor to tota| b|ood group
ant|gons that sho doos not possoss. 1ho lgG ant|bod|os producod
aro subsoquont|y transtorrod back across tho p|aconta, and roact
w|th tho tota| rod co||s caus|ng tho|r dostruct|on. 3otoro tho advont
ot prophy|act|c thorapy, tho ovorwho|m|ng major|ty ot casos woro
duo to ant|bod|os aga|nst tho lh-0 ant|gon, w|th on|y 0% duo to
othor ant|bod|os w|th|n tho lh systom and 1% duo to ant|bod|os |n
othor b|ood group systoms. W|thout troatmont, tho morta||ty rato ot
attoctod |ntants |s about 20%, but antonata| prophy|ax|s togothor
w|th tho |ntroduct|on ot troatmont by oxchango transtus|on, has
cons|dorab|y roducod th|s va|uo. Approx|mato|y 00% ot attoctod
|ntants roqu|ro an oxchango transtus|on and ott|c|ont troatmont
rosu|ts |n tho surv|va| ot about 0b% ot a|| attoctod |ntants. 0ur|ng
tho docado 10b8-08, tho d|soaso rosu|tod |n about 800-400
noonata| doaths oach yoar |n tho Un|tod K|ngdom, and an
approx|mato|y oqua| numbor woro st|||born. 0ur|ng tho 1000s
prophy|act|c ant|-0 |mmunog|obu||n |njoct|ons woro rout|no|y
|ntroducod tor lh0-nogat|vo mothors |n tho hours |mmod|ato|y
to||ow|ng |abour, to provont act|vo |mmun|zat|on duo to tota| lh0
oxposuro. 3|nco thon, tho |nc|donco ot haomo|yt|c d|soaso ot tho
nowborn has boon groat|y roducod, and by tho yoar 2000 on|y
about 10-20 doaths occurrod annua||y |n tho Un|tod K|ngdom duo
to ant| lh-0 |0l.
|aomo|yt|c d|soaso duo to ant|-0
1ho aot|o|ogy ot |0l was t|rst o|uc|datod by lov|no and
co||oaguos |n 1041. A mothor who had g|von b|rth to an attoctod
|ntant was transtusod w|th hor husband's b|ood and suttorod a
transtus|on roact|on. lt was corroct|y surm|sod that tho mothor had
boon |mmun|zod by a tota| ant|gon that had boon dor|vod trom tho
tathor. 1ho lh b|ood group systom was a|so d|scovorod dur|ng
th|s por|od, and |t was soon ascorta|nod that tho matorna| ant|body
|n th|s mothor was ant|-lh, now known as ant|-lh0.
3ma|| numbors ot tota| co||s can occas|ona||y bo tound |n tho
matorna| c|rcu|at|on throughout prognancy, ospoc|a||y dur|ng tho
th|rd tr|mostor, but tho ma|n transp|aconta| passago occurs at tho
t|mo ot |abour. 1ho vo|umo ot tho haomorrhago |s usua||y |oss than
b ml, but occas|ona||y may oxcood b0 ml, thoro |s ov|donco that
tho groator tho numbor ot tota| co||s |n tho c|rcu|at|on, tho groator
tho chanco ot dovo|op|ng ant|bod|os. 1ho ro|at|onsh|p botwoon tho
tota| amount ot tota| rod co||s |n tho matorna| c|rcu|at|on
|mmod|ato|y attor |abour and tho |nc|donco ot |mmun|zat|on ot
mothors s|x months |ator |s shown |n 1ab|o 1b.2.
1ab|o 1b.2 1ho ro|at|onsh|p botwoon tho numbor ot tota| rod co||s |n tho matorna|
c|rcu|at|on attor |abour and tho subsoquont |mmun|zat|on ot tho mothor.
Est|matod numbor ot tota| rod co||s (ml) lnc|donco ot |mmun|zat|on (%)
0 8.7
0.02 4.b
0.04 10.8
0.00-0.08 14.0
0.1-0.2 18.7
0.22-0.78 21.1
.0.8 28.b
3ourco: |rom C|arko (1008) lancot ||, 1-7.
ln tho UK popu|at|on, about 17% ot womon aro lh0 nogat|vo
but, botoro tho advont ot provont|vo thorapy, on|y about 0% ot a||
0-nogat|vo womon bocamo |mmun|zod to tho 0 ant|gon. 1h|s may
bo oxp|a|nod by tho obsorvat|on that not a|| tathors carry tho 0
ant|gon, a substant|a| numbor ot thoso who do aro hotorozygous,
honco hav|ng on|y a b0% chanco ot transm|tt|ng tho 0 a||o|o.
|urthormoro, tho amount ot tota| rod co||s cross|ng tho p|aconta |s
otton |nsutt|c|ont to |n|t|ato |mmun|zat|on, and on|y about 00-70%
ot lh-nogat|vo mothors aro ab|o to rospond to tho 0-ant|gon by
produc|ng s|gn|t|cant amounts ot ant|-0.
lt |s vory unusua| tor tho t|rst-born ch||d to bo attoctod w|th |0l,
tho |nc|donco bo|ng s||ght|y |oss than 1% ot a|| lh-nogat|vo
mothors who havo no h|story ot transtus|on or abort|on. 1ho roason
tor th|s |s that |t |s on|y occas|ona||y that s|gn|t|cant numbors ot tota|
rod co||s cross tho p|aconta sutt|c|ont|y oar|y |n prognancy to
st|mu|ato ant|-0 product|on botoro tho ch||d |s born.
lt tho tota| rod co||s |n tho mothor attor |abour br|ng about a
pr|mary |mmun|zat|on, ant|body may bo tound w|th|n tho to||ow|ng
s|x months. ln about ha|t ot casos, howovor, ant|body
concontrat|ons do not r|so sutt|c|ont|y h|gh tor ant|-0 to bo
dotoctod at th|s t|mo. 0ur|ng a subsoquont prognancy w|th an lh-
pos|t|vo totus, |t on|y roqu|ros a tow tota| rod co||s cross|ng tho
p|aconta oar|y |n prognancy |n ordor to prov|do a socondary
st|mu|us to ant|-0 product|on. 1h|s can usua||y bo dotoctod by tho
28th wook but somot|mos may not appoar unt|| tho |ast tow wooks
ot prognancy.
C||n|ca| toaturos
1horo |s a vory groat var|at|on |n tho sovor|ty ot tho d|soaso |n an
attoctod ch||d. At ono ond ot tho sca|o thoro aro |ntants who aro
not anaom|c at b|rth and who novor bocomo jaund|cod. |owovor,
tho |b concontrat|on ot thoso |ntants may ta|| abnorma||y rap|d|y
attor b|rth and va|uos as |ow as 0 g/dl may bo tound up to 80 days
|ator. A|| noonatos w|th matorna| ant|bod|os on tho|r rod co||s
(pos|t|vo d|roct ant|g|obu||n tost) shou|d thorotoro bo to||owod up
tor a short por|od attor b|rth.
Vodorato|y sovoro|y attoctod bab|os may or may not bo
anaom|c at b|rth, but tho rato ot rod co|| dostruct|on |s such that
jaund|co dovo|ops w|th|n a tow hours. 1aund|co |s not soon at tho
t|mo ot b|rth, s|nco pr|or to th|s b|||rub|n |s oxcrotod by p|aconta|
transtor. W|th|n 48-72 hours ot b|rth, tho p|asma b|||rub|n may r|so
to 8b0-700 µmo|/l. 1ho rato ot r|so ot p|asma b|||rub|n |s
govornod part|y by tho rato ot rod co|| dostruct|on and part|y by tho
dogroo ot matur|ty ot tho b|||rub|n oxcrotory mochan|sm. As a
rosu|t ot tho poor dovo|opmont ot tho oxcrotory mochan|sm tor
b|||rub|n |n many |ntants, |t |s qu|to common tor a ch||d w|th a cord
|b w|th|n tho norma| rango (|owor ||m|t 18.bg/dl) to bocomo
sovoro|y jaund|cod. 1ho dangor assoc|atod w|th a h|gh b|||rub|n
|ovo| |s korn|ctorus rosu|t|ng trom damago to tho basa| gang||a ot
tho bra|n, w|th a c||n|ca| p|cturo charactor|zod by spast|c|ty and
doath trom rosp|ratory ta||uro.
ln tho past, sovoro|y attoctod bab|os cou|d bocomo so anaom|c
that card|ac ta||uro w|th hydrops, or ovon st|||b|rth wou|d onsuo.
W|th modorn managomont, such a sovoro c||n|ca| p|cturo |s raro|y
soon.
Vanagomont ot mothor and ch||d
Whon a prognant woman attonds hor t|rst book|ng appo|ntmont
w|th tho antonata| sorv|co, sho shou|d havo b|ood takon to chock
hor A3O and lh0 status, as wo|| as to oxam|no tor any othor rod
co|| ant|bod|os that m|ght roact w|th patorna||y dor|vod ant|gons.
Womon who aro nogat|vo tor lh0 aro g|von rout|no antonata| ant|-
0 prophy|ax|s at 28 wooks, 84 wooks and w|th|n 72 hours ot
do||vory. 1h|s |nvo|vos an |ntramuscu|ar |njoct|on ot ant|-0
|mmunog|obu||n, wh|ch provonts act|vo |mmun|zat|on |n tho caso ot
rod co|| transtor across tho p|aconta. ln add|t|on, any potont|a||y
sons|t|z|ng ovont |s a|so troatod w|th add|t|ona| ant|-0
adm|n|strat|on: such ovonts |nc|udo abdom|na| trauma, throatonod
abort|on, or any spontanoous abort|on attor 12 wooks. An
ost|mato ot tho s|zo ot any toto-matorna| haomorrhago |s
porm|ttod us|ng tho K|o|hauor-3otko tochn|quo. 1h|s tost oxp|o|ts
tho d|ttoront|a| sons|t|v|ty to ac|d ot co||s conta|n|ng tota|
haomog|ob|n and thoso conta|n|ng adu|t g|ob|ns. 1roatmont ot a
b|ood smoar, takon trom tho mothor's b|ood, w|th an ac|d
proparat|on w||| |oach on|y adu|t g|ob|n trom tho co||s. 1ho co||s
dor|vod trom tho tota| c|rcu|at|on can thon bo countod, and tho s|zo
ot tho toto-matorna| haomorrhago dot|nod. Appropr|ato t|trat|on ot
tho corroct doso ot ant|-0 |mmunog|obu||n can thon bo portormod.
ln prognanc|os that aro ||ko|y to bo attoctod, u|trasound
oxam|nat|on |s usotu| to dotoct tota| hydrops and 0opp|or
u|trasound ot tho m|dd|o corobra| artory can bo usod to assoss
tota| anaom|a. lt anaom|a |s cont|rmod by u|trasound-gu|dod tota|
b|ood samp||ng, |ntrautor|no transtus|on may bo commoncod.
3|nco about ha|t tho tota| numbors ot st|||b|rths occur attor tho 80th
wook ot prognancy, |nduct|on at 80 wooks roducos tho |nc|donco
ot st|||b|rth.
Whon ant|-0 |s prosont |n tho mothor's p|asma, cord b|ood |s
obta|nod at do||vory and tho prosonco ot ant|body on tho |ntant's
rod co||s |s cont|rmod by tho d|roct ant|g|obu||n tost. Add|t|ona|
ossont|a| |nvost|gat|ons |nc|udo a tu|| b|ood count and oxam|nat|on
ot tho b|ood t||m tor ov|donco ot haomo|ys|s, p|us assossmont ot
b|||rub|n |ovo|s.
1ho usua| troatmont ot |0l |nvo|vos oxchango transtus|on tor
noonatos w|th sovoro anaom|a and/or sovoro hyporb|||rub|naom|a
(~8b0m|cromo|/|) or rap|d|y |ncroas|ng hyporb|||rub|naom|a. |or
|oss sovoro hyporb|||rub|naom|a, photothorapy can bo ottoct|vo |n
roduc|ng tho b|||rub|n by |nduc|ng photo|somor|zat|on to torms
moro road||y oxcrotod w|thout tho nood tor conjugat|on.
|aomo|yt|c d|soaso duo to ant|-A and ant|-3
|aomo|yt|c d|soaso duo to ant|-A or ant|-3 |s a|most ont|ro|y
cont|nod to group A and 3 |ntants born to group O mothors: |t |s
ma|n|y group O mothors who havo ant|-A and ant|-3 ot tho lgG
c|ass, wh|ch can cross tho p|aconta. A3O |0l (ot a|| grados ot
sovor|ty) attocts about 1 |n 1b0 b|rths. W|th tho advont ot
succosstu| ant|-0 prophy|ax|s, c||n|ca||y s|gn|t|cant d|soaso |s now
moro troquont|y duo to ant|-A or ant|-3 or to ant|bod|os othor than
ant|-0 w|th|n tho lh systom, or raro|y to tho |nvo|vomont ot othor
b|ood group systoms. Un||ko |0l duo to ant|-0, A3O |0l may
bo soon |n tho t|rst prognancy, s|nco A3O ant|bod|os aro natura||y
prosont. A3O |0l |s usua||y vory m||d, st|||b|rths do not occur,
sovoro anaom|a |s uncommon and tho ch||d raro|y roqu|ros
troatmont by oxchango transtus|on. lhotothorapy |s usua||y
sutt|c|ont to roduco b|||rub|n |ovo|s. A cons|stont t|nd|ng |s tho
prosonco ot sphorocytos on |nspoct|on ot cord b|ood smoars. ln
corta|n parts ot tho wor|d, A3O |0l |s ovon moro common than |n
tho Un|tod K|ngdom. 1h|s may |n part rosu|t trom tho h|gh
concontrat|ons ot lgG ant|-A and ant|-3 |n such popu|at|ons.
3|ood donat|on and b|ood compononts
vo|untoor b|ood donors prov|do rod co||s, p|ato|ots, p|asma
products and granu|ocytos tor transtus|on. 1h|s soct|on rov|ows tho
typos and usos ot b|ood products, and tho potont|a| prob|oms
assoc|atod w|th transtus|on.
lackod rod co||s aro tho most w|do|y usod b|ood product. 1hoy
aro g|von |n a vo|umo ot approx|mato|y 800 m|. 1ho groat bu|k ot
p|asma |s roducod, |oav|ng approx|mato|y 20 m|, a so|ut|on ot
sa||no w|th adon|no, g|ucoso and mann|to| (3AG-V) |s usod to
rop|aco tho rost ot tho p|asma, and ma|nta|ns tho hoa|th ot tho rod
co||s |n storago. A un|t ot packod rod co||s w||| |ast tor 8b days at
4°C, though storod b|ood tonds to havo roducod |ovo|s ot 2,8-
0lG. Wh|to co||s aro a|so rout|no|y romovod trom tho rod co||
compononts (|oucodop|otod b|ood).
|rosh trozon p|asma (||l) may a|so bo proparod trom who|o
b|ood donat|ons or trom aphoros|s co||oct|on. 3|ood |s contr|tugod
to soparato out tho p|asma and co||u|ar phasos, and tho trosh
p|asma |s trozon tor up to ono yoar. ||l |s typ|ca||y usod to
rop|aco coagu|at|on tactor dot|c|onc|os |n casos whoro mu|t|p|o
tactors aro |ost (o.g. |n d|ssom|natod |ntravascu|ar coagu|at|on
w|th haomorrhag|c symptoms, or as part ot a mass|vo transtus|on
protoco| - soo bo|ow). A s||ght|y d|ttoront product, cryoproc|p|tato,
|s r|ch |n t|br|nogon, and |s proparod by thaw|ng trozon p|asma |n a
contro||od tash|on. As wo|| as t|br|nogon, othor h|gh mo|ocu|ar
wo|ght compononts aro a|so concontratod |n cryoproc|p|tato,
|nc|ud|ng von W|||obrand tactor. Cryoproc|p|tato |s an oxco||ont
product tor tho rop|acomont ot t|br|nogon |n 0lC.
l|ato|ots tor transtus|on may bo dor|vod trom who|o b|ood
donat|ons, aga|n by contr|tugat|on. A s|ng|o adu|t doso ot p|ato|ots
w||| roqu|ro tho p|ato|ot componont ot sovora| donors' who|o b|ood.
l|ato|ots may a|so bo co||octod by aphoros|s, th|s moro ott|c|ont
mothod a||ows tho product|on ot a p|ato|ot doso trom a s|ng|o
vo|untoor, thus oxpos|ng tho roc|p|ont to tho b|ood ot towor
|nd|v|dua| donors. l|ato|ots nood to bo storod at 22°C w|th
constant shak|ng, th|s has boon shown as tho bost mothod tor
ma|nta|n|ng tho|r tunct|on, but |ncroasos tho r|sk ot bactor|a|
contam|nat|on. 1hus thoy havo a ro|at|vo|y short sho|t ||to ot t|vo
days, and supp||os nood to bo carotu||y managod.
Compononts moro raro|y usod |nc|udo granu|ocytos. 1ho
ov|donco tor tho uso ot granu|ocyto transtus|ons |s vory ||m|tod, but
thoy aro somot|mos omp|oyod |n sovoro|y noutropon|c pat|onts
who aro cr|t|ca||y ||| w|th sops|s, and |n whom standard thorap|os
tor sops|s havo ta||od to ach|ovo a rosponso. As w|th p|ato|ots,
granu|ocytos may bo obta|nod through contr|tugat|on ot who|o
b|ood or through aphoros|s, howovor, w|th granu|ocyto co||oct|ons,
donors must bo pr|mod w|th G-C3| pr|or to co||oct|on, to onsuro
that adoquato numbors ot co||s aro obta|nod.
|azards ot b|ood transtus|on: 1ho 3|O1 roport
As w|th a|| mod|ca| |ntorvont|ons, tho bonot|ts ot transtus|on must
bo wo|ghod aga|nst tho assoc|atod r|sks. A |oga| tramowork ox|sts
to onsuro tho bost poss|b|o satoty standards tor transtus|on, w|th
rogu|at|ons to mon|tor a|| aspocts ot co||oct|on, storago and
adm|n|strat|on. ln tho Un|tod K|ngdom, a|| advorso |nc|donts
to||ow|ng b|ood transtus|on aro roportod to tho 3or|ous |azards ot
1ranstus|on (3|O1) Comm|ttoo. 1ho naturo ot tho |nc|donts and
tho ro|at|vo troquoncy roportod botwoon 1000 and 2010 aro g|von
|n ||guro 1b.1.
||guro 1b.1 l|o chart show|ng hazards ot transtus|on |n tho UK
trom 1000-2010 as roportod to tho 3|O1 Comm|ttoo. Notos.
1lAll - transtus|on-assoc|atod acuto |ung |njury, 11l - transtus|on-
transm|ttod |ntoct|on, A1l - acuto transtus|on roact|on, 01l -
do|ayod transtus|on roact|on, l1l - post-transtus|on purpura,
l3C1 - |ncorroct b|ood componont transtusod
5oorco: UK 3|O1 Comm|ttoo roport 2010.
1ho commonost orror roportod to tho 3|O1 Comm|ttoo ovor
th|s por|od |s tho transtus|on ot an |ncorroct b|ood product -
usua||y a componont |ntondod tor anothor pat|ont. 1ho ma|n
roasons tor th|s aro adm|n|strat|vo - tor oxamp|o orrors |n tho
|abo|||ng ot b|ood samp|os takon tor cross-match|ng and tho ta||uro
to match tho namo on tho b|ood pack w|th that ot tho roc|p|ont.
3|nco th|s ra|sos tho poss|b|||ty ot potont|a||y tata| A3O-
|ncompat|b|o transtus|ons bo|ng g|von, stratog|os tor roduc|ng tho
r|sk aro cruc|a|. 3omo hosp|ta|s havo |nst|tutod a barcod|ng
systom tor b|ood transtus|on, |n wh|ch tho pat|ont's wr|stband and
tho samp|o takon tor cross-match|ng aro |abo||od w|th match|ng
barcodos at tho t|mo ot vonopuncturo. Whon tho b|ood product tor
transtus|on |s choson |n tho transtus|on |aboratory, th|s too |s
markod w|th tho samo barcodo. ln ordor tor tho transtus|on to tako
p|aco, a barcodo scannor must bo usod to cont|rm that tho corroct
product |s bo|ng do||vorod to tho corroct pat|ont - w|th a roduct|on
|n tho ||ko||hood ot tho wrong un|t bo|ng adm|n|storod. 3|mp|o
procossos such as th|s can s|gn|t|cant|y roduco tho poss|b|||ty ot
transtus|ng b|ood matchod tor anothor pat|ont.
|aomo|yt|c roact|ons duo to |ncompat|b|o rod co||s
1ho symptoms and s|gns that aro tound attor a transtus|on ot
|ncompat|b|o b|ood dopond on whothor tho transtusod co||s
undorgo |ntravascu|ar or oxtravascu|ar haomo|ys|s. lntravascu|ar
|ys|s |oads to haomog|ob|naom|a and haomog|ob|nur|a and |s
a|most a|ways duo to tho act|on ot ant|-A or ant|-3 - both bo|ng
strong act|vators ot tho comp|omont systom. 3ymptoms may
appoar trom a tow m|nutos to sovora| hours attor bog|nn|ng to
transtuso A3O-|ncompat|b|o b|ood and may |nc|udo rost|ossnoss,
anx|oty, tovor, ch|||s, t|ush|ng ot tho taco, pa|n |n tho |umbar rog|on
and chost, vom|t|ng and d|arrhooa. lt tho roact|on |s sovoro, thoro
|s c|rcu|atory co||apso and tho dovo|opmont ot acuto rona| ta||uro.
3omot|mos, haomorrhago may occur duo to d|ssom|natod
|ntravascu|ar coagu|at|on.
lt |s not on|y tho adm|n|strat|on ot rod co||s that can causo A3O
|ncompat|b|||ty roact|ons. 1ho adm|n|strat|on ot ||l or p|ato|ots
w|th p|asma that conta|ns donor ant|-A or ant|-3 ant|bod|os may
a|so |yso tho roc|p|ont's own rod co||s |t tho wrong product |s g|von
to tho wrong pat|ont.
1ho |mmod|ato managomont ot a m|smatchod transtus|on |s to
stop tho transtus|on, koop|ng tho bag and g|v|ng sot so that tho
transtus|on |aboratory can chock tho group|ng ot tho b|ood
product. C|rcu|atory support |s ossont|a| and |notropos may ovon
bo noodod. 3omot|mos turosom|do may bo roqu|rod to try to
ma|nta|n ur|nary output. 0lC, |t |t dovo|ops, shou|d bo troatod w|th
standard managomont. Whon doaths do occur, thoy aro usua||y
tho rosu|t o|thor ot sovoro 0lC or ot rona| ta||uro. 1ho ovora||
morta||ty to||ow|ng A3O |ncompat|b|||ty |s probab|y ot tho ordor ot
10%.
3y contrast, whon b|ood transtus|on |s to||owod by oxtravascu|ar
dostruct|on ot rod co||s, thoro aro usua||y on|y ch|||s and tovor
occurr|ng ono or moro hours attor tho start ot tho transtus|on. 1ho
most common ant|body caus|ng oxtravascu|ar dostruct|on |s ant|-
0. 1h|s typo ot |ncompat|b|||ty |s a|most novor to||owod by rona|
ta||uro.
Anothor typo ot haomo|yt|c comp||cat|on |s tho do|ayod
haomo|yt|c transtus|on roact|on (01l). 1h|s occurs |n a roc|p|ont
who has boon prov|ous|y |mmun|zod by transtus|on or prognancy,
but |n whom tho p|asma ant|body t|tro has bocomo too woak to bo
|dont|t|od. |o||ow|ng tho transtus|on, a socondary |mmuno|og|ca|
rosponso takos p|aco and tho ant|body t|tro rap|d|y r|sos, br|ng|ng
about haomo|ys|s, usua||y about sovon days |ator. 1yp|ca||y, tho
pat|ont dovo|ops anaom|a, tovor, jaund|co and somot|mos
haomog|ob|nur|a. Ant|bod|os to rod co|| ant|gons K|dd (1k) and tho
lh systom aro tho most common causo ot thoso roact|ons.
1ranstus|on-transm|ttod |ntoct|ons
1ho r|sk ot transtus|on-transm|ttod |ntoct|ons (11ls) has doc||nod
ovor tho |ast docado duo to tho adopt|on ot a numbor ot satoty
stratog|os. Ovor tho por|od 1000 to 2010, on|y 00 11ls woro
roportod to 3|O1. 1ho major|ty ot 11ls aro duo to bactor|a|
contam|nat|on, wh|ch |s commonor |n p|ato|ot compononts duo to
tho|r storago cond|t|ons. Othor thoorot|ca| 11ls |nc|udo hopat|t|s 3
(|3v), human 1-co|| |oukaom|a v|rus (|1lv), human
|mmunodot|c|oncy v|rus (|lv) |ntoct|on and hopat|t|s C (|Cv). As
wou|d bo oxpoctod, h|gh|y r|gorous scroon|ng programmos aro
usod to onsuro that |ntoctod compononts do not ontor tho b|ood
supp|y.
var|ous t|ors ot satoty procoduros havo boon put |n p|aco. ' 5o|í-
oxc|osloo' |s an |mportant contr|butor to b|ood satoty. 1hoso
donors who aro |n 'h|gh-r|sk' catogor|os aro askod not to donato -
tor |nstanco thoso who havo rocont|y travo||od to a trop|ca| country
(r|sk ot ma|ar|a| transm|ss|on), and thoso w|th a h|story ot
|ntravonous drug abuso. |o||ow|ng th|s, tost|ng |s portormod on
ovory componont donatod. |or hopat|t|s C, tor oxamp|o, a
comb|nat|on ot soro|og|ca| tosts and nuc|o|c ac|d amp||t|cat|on
tosts to dotoct v|ra| llA has roducod tho r|sk ot contract|ng |Cv
trom a transtus|on to an ost|matod 1 |n 22 m||||on. A comb|nat|on
ot soro|og|ca| and mo|ocu|ar tost|ng |s a|so omp|oyod to scroon a||
samp|os tor |3v, |lv, |1lv and syph|||s, among othors. 1ho
ost|matod chanco that a b|ood un|t |ntoctod w|th |lv m|ght ontor
tho UK supp|y |s around 1 |n b m||||on, and tor hopat|t|s 3 tho
chanco |s around 1 |n b00 000.
A turthor satoty procoduro |s tho uso ot potbogoo looctlvotloo
tocboo|ogy to |nact|vato v|rusos, bactor|a, tung| and protozoa. 1ho
add|t|on ot so|vont/dotorgont w||| |nact|vato tho ||p|d onvo|opo ot
v|rusos such as |3v, |Cv, |lv and |1lv, and othors such as
Epsto|n-3arr v|rus (E3v) and cytomoga|ov|rus (CVv). 1h|s
procoss |s on|y su|tab|o tor non-co||u|ar compononts (o.g.
|ntravonous |mmuno g|obu||n). Othor mothods tor |nact|vat|on ot
pathogons |nc|udo tho uso ot photochom|ca| systoms such as
psora|on-3b0 compounds whoro, attor tho add|t|on ot tho
psora|on, tho b|ood product |s oxposod to h|gh-|ntons|ty u|trav|o|ot
A ||ght. 1h|s tochno|ogy |s |n uso |n sovora| countr|os, whoro |t has
tho add|t|ona| advantago ot pro|ong|ng tho sho|t ||to ot somo b|ood
products (o.g. p|ato|ots). 3actor|a| |ntoct|on may a|so bo dotoctod
pr|or to tho adm|n|strat|on ot tho componont through tho uso ot
tochno|og|os ||ko 3act/A|ort. 1h|s usos a gas pormoab|o
co|or|motr|c sonsor and rot|octod ||ght to moasuro tho product|on
ot CO
2
by bactor|a| motabo||sm |n a b|ood componont product. As
CO
2
|ovo|s c||mb, tho co|our ot tho 3actA|ort v|a| turns yo||ow,
|ncroas|ng rot|octanco, and a||ow|ng dotoct|on ot tho oar||ost
stagos ot bactor|a| |ntoct|on. |roquont mon|tor|ng us|ng th|s
systom w||| ||m|t tho numbor ot potont|a||y |ntoctod un|ts that ontor
tho supp|y.
var|ant Croutzto|dt-1akob d|soaso
C10 |s ono ot a group ot transm|ss|b|o spong|torm
oncopha|opathy d|sordors, and |t ox|sts |n tam|||a|, sporad|c and
var|ant typos. 1ho pathogon|c agont |s bo||ovod to bo a pr|on
proto|n, wh|ch causos d|soaso by attoct|ng tho norma|
contormat|on ot othor proto|ns. 1horo |s a |ong |ncubat|on por|od
and so tar thoro |s no troatmont tor tho progross|vo, contra|
norvous systom dogonorat|on that th|s cond|t|on producos. lap|d|y
progross|vo domont|a |s to||owod by oar|y doath. lart|cu|ar
concorn aroso rogard|ng tho var|ant torm ot C10 dur|ng tho
outbroak ot bov|no spong|torm oncopha|opathy (33E) |n catt|o |n
tho Un|tod K|ngdom |n tho 1080s. 1h|s sparkod cons|dorab|o
concorn about tho poss|b|||ty ot transm|ss|on ot tho rospons|b|o
pr|on through tho tood cha|n, w|th tho dovo|opmont ot tho d|soaso
attor consum|ng boot trom attoctod catt|o. 1ho |ong |ncubat|on
por|od ra|sod tho spoctro ot many potont|a||y |ntoctod yot
asymptomat|c poop|o.
lt was a|so roportod that v-C10 can bo transm|ttod by b|ood
transtus|on. As a procaut|on, UK b|ood sorv|cos oxc|udo any
potont|a| b|ood donors who roco|vod b|ood products trom or gavo
b|ood to |nd|v|dua|s who subsoquont|y dovo|opod v-C10, or who
havo roco|vod a b|ood transtus|on s|nco 1080. ln add|t|on, a|| un|ts
ot b|ood aro |ouco dop|otod to roduco potont|a||y |ntoctod wh|to
co||s trom donors transm|tt|ng tho d|soaso. 1horo |s curront|y no
scroon|ng tost tor v-C10.
Cytomoga|ov|rus
CVv |s a 0lA horpos v|rus assoc|atod w|th |oucocytos, and may
bo transm|ttod v|a rosp|ratory socrot|ons, soxua||y and dur|ng
ch||db|rth. 1ho |nc|donco ot CVv ant|bod|os var|os |n d|ttoront
parts ot tho wor|d, trom 80% to 80% or moro. As w|th most horpos
v|rusos, tho v|rus pors|sts |atont|y attor |ntoct|on.
ln |mmunocompotont poop|o, tho d|soaso causod by CVv
var|os trom a subc||n|ca| |ntoct|on to tho appoaranco ot
|ymphadonopathy and a m||d hopat|t|s. 1ho ma|n dangor ot CVv
|ntoct|on |s |n |ntants and |mmunocomprom|sod pat|onts and thus
provont|on ot CVv |ntoct|on through b|ood transtus|on |s targotod
to dot|nod pat|ont groups. lromaturo noonatos ot |ow b|rth wo|ght
born to mothors w|thout ant|-CVv ant|body aro ospoc|a||y at r|sk.
lat|onts roco|v|ng bono marrow and so||d organ transp|ants aro
a|so at r|sk (soo Chaptor 12). 1hus CVv-ant|body nogat|vo b|ood
|s gonora||y mado ava||ab|o tor thoso pat|onts, a|though
|oucodop|ot|on (wh|ch |s now standard) may ottor a s|m||ar dogroo
ot protoct|on aga|nst transtus|on-transm|ttod CVv |ntoct|on.
Othor |ntoct|ons
Othor |ntoct|ons known to bo transm|ttod by transtus|on |nc|udo
syph|||s and ma|ar|a. 1ho provont|on ot transm|ss|on ot syph|||s |s
by soro|og|ca| tost|ng ot donors. Anothor tactor ot |mportanco |s
tho storago ot b|ood at 4°C, s|nco sp|rochaotos do not surv|vo tor
moro than a tow days undor thoso cond|t|ons. W|th rogard to
ma|ar|a, |nd|v|dua|s who havo roturnod trom an aroa whoro
ma|ar|a |s ondom|c aro not accoptod as donors tor s|x months.
Anyono w|th a pos|t|vo ma|ar|a ant|body tost (VA1) |s rout|no|y
dobarrod trom donat|on. 3ruco||os|s, babos|os|s, Chagas'
d|soaso (causod by 7rypooosomo crozl ), Wost l||o v|rus
(prova|ont |n tho U3A and Canada) and parvov|rus 310, wh|ch |s
not |nact|vatod by dotorgont mothods, havo a|so boon transm|ttod
by transtus|on.
As now d|soasos omorgo trom t|mo to t|mo, tho r|sk ot 11l
a|ways roma|ns. lt |s thorotoro |mportant that transtus|on |s on|y
g|von whon ossont|a| tor surv|va| or qua||ty ot ||to, so that tho
bonot|ts c|oar|y outwo|gh tho uncorta|n r|sks ot 11l.
1ranstus|on-assoc|atod gratt vorsus host d|soaso
1ranstus|on ot v|ab|o wh|to co||s |n b|ood products can |n vory raro
c|rcumstancos |oad to transtus|on-assoc|atod gratt vorsus host
d|soaso (1A-Gv|0). 1h|s typ|ca||y tata| d|sordor |s soon |n
pat|onts w|th comprom|sod |mmuno tunct|on, but may a|so occur
whon a pat|ont roco|vos a b|ood componont trom a donor who
sharos an |lA hap|otypo. E|thor ot thoso s|tutat|ons moan that tho
transtusod |ymphocytos aro not c|oarod |n tho norma| way, but can
ongratt and tunct|on |n tho roc|p|ont, |oad|ng to a c||n|ca| p|cturo
that usua||y |nc|udos a rash and marrow ta||uro. lt can bo
o||m|natod by |rrad|at|ng tho b|ood products (rod co||s, p|ato|ots or
p|asma) botoro adm|n|strat|on. lat|onts undorgo|ng bono marrow
transp|antat|on, thoso w|th |odgk|n |ymphoma and pat|onts who
havo roco|vod pur|no ana|oguo chomothorapy (o.g. t|udarab|no)
aro among thoso who shou|d roco|vo on|y |rrad|atod b|ood
products to avo|d th|s comp||cat|on.
lmmod|ato-typo hyporsons|t|v|ty
|yporsons|t|v|ty roact|ons may occur soon attor tho transtus|on ot
b|ood or p|asma. 1ho ant|bod|os |nvo|vod aro otton unknown, but
somo sovoro roact|ons aro causod by ant|-lgA ant|bod|os. lgA
dot|c|oncy |s uncommon, but pat|onts who |ack lgA, and who havo
prov|ous|y boon sons|t|zod to th|s |mmunog|obu||n, may man|tost
a||org|c roact|ons |t lgA-conta|n|ng b|ood products aro
adm|n|storod. ln m||d casos, toaturos may bo ||m|tod to urt|car|a,
orythoma, macu|opapu|ar rash or por|orb|ta| oodoma. ln tho moro
sovoro roact|ons, hypotons|on may occur, bronchospasm and
|aryngoa| oodoma aro raro.
V||d hyporsons|t|v|ty roact|ons ot any causo probab|y occur |n
about 1-8% ot transtus|ons and can bo troatod w|th
ant|h|stam|nos. 3ovoro roact|ons aro vory |ntroquont (1:20 000)
and thoso may roqu|ro tho adm|n|strat|on ot hydrocort|sono and
adrona||no.
1ranstus|on-ro|atod acuto |ung |njury (1lAll)
1h|s comp||cat|on typ|ca||y ar|sos attor tho transtus|on ot p|asma-
r|ch b|ood compononts, and |s thought to bo duo to tho |ntoract|on
ot donor ant|-|oucocyto ant|bod|os |n tho transtusod b|ood
componont |ntoract|ng w|th tho roc|p|ont's |oucocytos. |owovor, a
comprohons|vo undorstand|ng ot tho pathogonos|s ot 1lAll has
not yot boon ostab||shod. Add|t|ona| 'h|ts' aro thought to bo
noodod |n ordor tor tho c||n|ca| p|cturo to omorgo, s|nco 1lAll |s
most otton soon |n pat|onts a|roady ||| w|th pu|monary patho|ogy.
1ho symptoms and s|gns ot 1lAll typ|ca||y ar|so w|th|n s|x
hours ot transtus|on, w|th dyspnooa and hypotons|on bo|ng
accompan|od by b||atora| |nt||tratos on tho chost x-ray. 1ho
d|ttoront|a| d|agnos|s ot pu|monary oodoma |s bost oxc|udod by
oxam|n|ng tho contra| vonous prossuro: wh||o |n t|u|d ovor|oad |t |s
h|gh, |n 1lAll |t wou|d bo oxpoctod to bo |ow. Vanagomont |s
support|vo, and donors trom whom |mp||catod b|ood products
woro proparod aro oxc|udod trom donat|ng turthor compononts.
C|rcu|atory ovor|oad
C|rcu|atory ovor|oad w|th consoquont card|ac ta||uro can oas||y bo
brought about by tho too-rap|d transtus|on ot b|ood, ospoc|a||y |n
tho o|dor|y and |n thoso who havo boon sovoro|y anaom|c tor somo
t|mo. 1ho t|rst s|gns aro dyspnooa, crop|tat|ons at tho |ung basos
and a r|so |n jugu|ar vonous prossuro. 3topp|ng tho transtus|on |s
tho t|rst thorapout|c manoouvro, to||owod by d|uros|s |t noodod.
1ho rato at wh|ch b|ood |s transtusod must bo ta||orod to tho
urgoncy ot tho c||n|ca| s|tuat|on and tho card|ovascu|ar t|tnoss ot
tho pat|ont.
C|trato tox|c|ty
C|trato tox|c|ty |s duo to tho roduct|on |n |on|zod ca|c|um |n tho
pat|ont's p|asma, and may causo s|gn|t|cant prob|oms |t |argo
vo|umos ot storod b|ood nood to bo g|von rap|d|y. 1ho typ|ca|
s|gns aro tromors and pro|ongat|on ot tho O1 |ntorva| |n tho
o|octrocard|ogram. vory h|gh ratos ot transtus|on may warrant
cons|dorat|on ot ca|c|um g|uconato adm|n|strat|on to avo|d th|s
comp||cat|on.
Othor hazards
lr|or to tho un|vorsa| |oucodop|ot|on ot b|ood products, tobr||o
roact|ons occurrod |n 0.b-1% ot transtus|ons. loact|ons woro duo
to tho prosonco ot pyrogons (o.g. so|ub|o bactor|a|
po|ysacchar|dos) |n tho ant|coagu|ant, or to tho prosonco |n tho
roc|p|ont ot ant|-|lA ant|bod|os or granu|ocyto-spoc|t|c
ant|bod|os, rosu|t|ng trom |mmun|zat|on dur|ng prognancy or
prov|ous transtus|ons. 3oth aro now uncommon.
Vanagomont ot transtus|on roact|ons
1ho t|rst d|agnos|s to oxc|udo |s an acuto haomo|yt|c transtus|on
roact|on. 1hus, |n any pat|ont w|th tovor, tachycard|a hypotons|on,
dyspnooa or chost/abdom|na| pa|n, tho t|rst act|on |s a|ways to
stop tho transtus|on and c|ar|ty that tho corroct pat|ont's dota||s aro
on tho componont bo|ng transtusod. Any susp|c|on ot A3O
|ncompat|b|||ty shou|d |oad to tho |nst|tut|on ot c|rcu|atory support
w|th lv t|u|ds, carotu| mon|tor|ng ot pu|so, b|ood prossuro and ur|no
output, and support|vo managomont ot any dovo|op|ng 0lC. 1ho
componont bag shou|d bo roturnod to tho transtus|on |aboratory
w|th a trosh cross-match samp|o trom tho pat|ont, |t |ncompat|b|o
co||s havo boon transtusod, thoy may st||| bo dotoctab|o |n tho
pat|ont's b|ood. 3amp|os shou|d a|so bo sont to assoss tor
|ntravascu|ar haomo|ys|s - |nc|ud|ng a tu|| b|ood count, sorum
haptog|ob|n, and haomog|ob|nur|a.
Othor haomo|yt|c roact|ons, a|though un||ko|y to bo as sovoro,
shou|d bo managod |n s|m||ar tash|on. lt |s |mportant to onsuro that
tho poss|b|||ty ot bactor|a||y contam|natod un|ts has boon
addrossod through tak|ng b|ood cu|turos. lt nocossary, broad-
spoctrum ant|b|ot|cs may bo commoncod omp|r|ca||y attor cu|turos
havo boon drawn.
3ovoro a||org|c roact|on shou|d bo troatod |n|t|a||y by stopp|ng
tho transtus|on and roturn|ng tho un|t to tho |aboratory, as abovo.
Ch|orphon|ram|no may ho|p, but sovoro roact|ons aro ||ko|y to
roqu|ro oxygon and nobu||zod sa|butamo|, p|us |ntramuscu|ar
adrona||no |n tho caso ot c|rcu|atory co||apso.
ln add|t|on to tho roact|ons doscr|bod abovo, acuto dyspnooa
can occur duo to c|rcu|atory ovor|oad (w|th an o|ovatod vonous
prossuro bo|ng a koy phys|ca| s|gn) and |n 1lAll. 0|uros|s |s
c|oar|y |nd|catod |n tho tormor, wh||o tho |attor |s troatod
support|vo|y, w|th vont||atory support whoro noodod.
W|th m||d tovors on|y, s|mp|o |ntorvont|ons may sutt|co (o.g.
g|v|ng an ant|pyrot|c and s|ow|ng tho transtus|on), s|m||ar|y, |t a
m||d a||org|c roact|on |s ov|dont (o.g. urt|car|a), ch|orphon|ram|no
to||owod by a s|owor ro|nstatomont ot tho transtus|on may ho|p.
0o|ayod transtus|on roact|ons may bo hardor to d|agnoso and
|nvost|gato, s|nco tho tompora| assoc|at|on w|th tho transtus|on |s
|ost. |owovor, |t |s st||| |mportant to ostab||sh tho naturo ot tho
roact|on so that tuturo transtus|ons may bo managod ottoct|vo|y.
Appropr|ato |nvost|gat|ons |nc|udo a tu|| b|ood count, a d|roct
ant|g|obu||n tost, sorum b|||rub|n and assossmont ot rona| tunct|on.
1roatmont |s raro|y noodod, but tho oxpoctod r|so |n haomog|ob|n
attor transtus|on may not bo soon.
Vass|vo transtus|on
lat|onts w|th acuto haomorrhago (|.o. |oss ot rod co||s and
p|asma) may nood to bo transtusod w|th |argo quant|t|os ot
packod rod co||s. Vass|vo transtus|on has boon dot|nod as tho
rop|acomont ot ono b|ood vo|umo ovor 24 hours, or as tho
rop|acomont ot b0% ot c|rcu|at|ng vo|umo |n 8 hours. ln such
omorgonc|os, |t |s cr|t|ca| that thoro |s good commun|cat|on
botwoon tho c||n|c|ans rospons|b|o tor tho pat|ont and tho statt ot
tho b|ood transtus|on |aboratory. Group compat|b|o b|ood can
usua||y bo ava||ab|o w|th|n 1b m|nutos ot a cross-match samp|o
arr|v|ng |n tho |aboratory, obv|at|ng tho nood tor 'un|vorsa| donor'
group O lh0-nogat|vo b|ood. W|th tho transtus|on ot many un|ts ot
packod rod co||s, tho pat|ont may bocomo dot|c|ont |n koy p|asma
compononts such as c|ott|ng tactors and may a|so bocomo
thrombocytopon|c (ovon |n tho absonco ot 0lC). 1horo |s ||m|tod
ov|donco to gu|do transtus|on pract|co |n th|s t|o|d, but tho
adm|n|strat|on ot ono un|t ot ||l por un|t ot rod co||s may bo
ottoct|vo |n rop|ac|ng c|ott|ng tactors. ||br|nogon and p|ato|ots
shou|d a|so bo rop|acod, w|th 2 poo|s ot cryoproc|p|tato and 1
adu|t doso ot p|ato|ots por 0-8 un|ts ot packod rod co||s. Whorovor
poss|b|o, th|s gonora| approach shou|d bo porsona||zod by
|aboratory tost|ng ot tho tu|| b|ood count and coagu|at|on prot||o.