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ABO confirmation testing required for red blood cell transfusion not platelet or plasma transfusion?


Clarest
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As per "standards", ABO confirmation testing is only required for red blood cell transfusion. So, I have seen some institutions just require ABO confirmation specimen for red blood cell not plasma or platelet transfusion, or for red blood cell and plasma but not platelet transfusion. Or they give multiple group A instead of AB plasma units for patients with unknown blood group during massive hemorrhage events and they claim there has been almost no transfusion reaction observed for giving group mismatched plasma units. I understand when there is a massive hemorrhage, a lot of transfused mismatched product could be bled out or diluted, or even our body's nature is busy coping with bleed instead of having strong immune response. I am still wondering if there is really so much difference of transfusing equal volume of  mismatched RBCs vs. plasma/platelets.

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Mismatched donor red cells (ABO antigens) would be hemolyzed by the patient's antibodies (anti-A, anti-B, anti-A,B), causing the dreaded ABO hemolytic reaction. The patient's antibodies are not going to be as dilute as donor antibodies until massively transfused and the patient is going to continue to produce antibodies to continue attacking donor cells. The red cell stroma from the destroyed mismatched donor cells would do the damage. The rationale with mismatched plasma is that the antibody source of the donor plasma is going to be diluted by the patient's blood volume and the amount transfused is going to be limited by the number of units transfused, enough that the impact on the patient's red cell antigens would be greatly minimized. There won't be as much antibody from the donor to react with the patient's red cells vs the patient antibody to react with mismatched donor cells. Maybe a positive DAT from mismatched plasma, hopefully a delayed removal of affected red cells instead of brisk hemolysis. Better than bleeding to death.

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17 minutes ago, AMcCord said:

Mismatched donor red cells (ABO antigens) would be hemolyzed by the patient's antibodies (anti-A, anti-B, anti-A,B), causing the dreaded ABO hemolytic reaction. The patient's antibodies are not going to be as dilute as donor antibodies until massively transfused and the patient is going to continue to produce antibodies to continue attacking donor cells. The red cell stroma from the destroyed mismatched donor cells would do the damage. The rationale with mismatched plasma is that the antibody source of the donor plasma is going to be diluted by the patient's blood volume and the amount transfused is going to be limited by the number of units transfused, enough that the impact on the patient's red cell antigens would be greatly minimized. There won't be as much antibody from the donor to react with the patient's red cells vs the patient antibody to react with mismatched donor cells. Maybe a positive DAT from mismatched plasma, hopefully a delayed removal of affected red cells instead of brisk hemolysis. Better than bleeding to death.

Sorry, but I disagree.  In most cases of ABO haemolytic transfusion reactions, it is not the ABO antibodies that cause the haemolysis that destroys the incompatible red cells, but activated complement that, in most cases, also causes "innocent bystander haemolysis", whereby the autologous red cells are also haemolysed.

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Per AABB, ABO and Rh type MUST be determined before any blood product transfusion (RBC, whole blood, Platelets, etc.), with exception only for emergent situations. Pretransfusion tests for allogeneic and autologous  transfusions shall include ABO group and Rh type on the patient sample. 

 

Sources: 

Cohn, Claudia S.,  Delaney, Meghan,  Johnson, Susan T. and  Katz, Louis M.. <em>Technical Manual, 20th edition</em>. https://ebooks.aabb.org/pdfreader/technical-manual-20th-edition50155278

Standards for Blood Banks and Transfusion Services, 33rd Edition, effective April 1, 2022 (Published: 9/9/2022

 

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21 hours ago, Malcolm Needs said:

Sorry, but I disagree.  In most cases of ABO haemolytic transfusion reactions, it is not the ABO antibodies that cause the haemolysis that destroys the incompatible red cells, but activated complement that, in most cases, also causes "innocent bystander haemolysis", whereby the autologous red cells are also haemolysed.

I may be mistaken but I seem to recall being taught that it was the ABO antibodies interaction with incompatible RBCs which caused the activated complement so without the ABO antibodies you don't get the hemolysis.

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1 hour ago, John C. Staley said:

I may be mistaken but I seem to recall being taught that it was the ABO antibodies interaction with incompatible RBCs which caused the activated complement so without the ABO antibodies you don't get the hemolysis.

That is true John, BUT it is STILL the complement (specifically the Membrane Attack Complex of C5b, activated C6, C7 and C8 molecules and about 6 activated C9 molecules) that causes the haemolysis, which is why autologous red cells are also destroyed.

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23 hours ago, Malcolm Needs said:

That is true John, BUT it is STILL the complement (specifically the Membrane Attack Complex of C5b, activated C6, C7 and C8 molecules and about 6 activated C9 molecules) that causes the haemolysis, which is why autologous red cells are also destroyed.

Malcolm we can do this for ever!!  The antibodies CAUSE the hemolysis by activating the compliment. 

Here's my analogy, without my finger pulling the trigger the gun doesn't go off and I don't get a bird in the bag. When I do pull the trigger did I kill the bird or did the lead shot kill the bird?  Or did the gun kill the bird? To address the hemolysis of autologous cells with the same analogy. Occasionally 2 birds are close together and both are killed with the same shot.  One was intended the other was not but I still pulled the trigger.  

Take one of the factors out of the equation and the end result does not happen or is significantly altered so the answer to all the questions is YES.  I think what we have here is a case of semantics.  Every step could be said to have CAUSED the end result.  

This is fun.  Let's discuss it over a pint some day.

:coffeecup:

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"I am still wondering if there is really so much difference of transfusing equal volume of  mismatched RBCs vs. plasma/platelets."

There's some truth to this.  The notion of universal donor red cells (group O) and plasma (group AB) turns out to be more of a relative thing than a virtue.  Group O red cells have 20-40 ml of donor plasma that is incompatible with 55% of recipients (groups A, B and AB, obviously).  This is usually not a huge problem, but when given in large amounts or from a high titer donor, hemolysis and organ failure can occur, including death.  When group AB plasma is given to groups O, A and B recipients, there is soluble antigen incompatible with all of these patients and observational studies show an increase in sepsis, organ failure (particularly lung) and death.  Thus we need to emphasize avoiding infusion of ABO incompatible antibody, cellular and soluble antigen.  This can be accomplished by giving ABO identical or washed group O cells and ABO identical plasma.  Platelets are a particular problem since inventory is limited.  ABO identical is best.  When ABO minor mismatched (group O platelets to a non-O patient) are transfused, the hemolytic transfusion reaction rate is about 1 in 700.  Of course, we may be missing harm to donor endothelial cells, for one thing, since they carry ABO antigens.  When ABO major mismatched platelets are administered (e.g., group A to a group O recipient) the increase in mortality/bleeding is about 20%, so harm to at least 1 in 5 patients. We need to stop doing this.

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Some of the platelet and endothelial injury and impaired hemostasis after ABO mismatched transfusions may be due to our transfusion practices of routinely using ABO non-identical transfusions. This involves infusing ABO incompatible cellular (platelet) and soluble (plasma, cryo) antigen and antibody (group O red cells and whole blood).  These antibodies and immune complexes have been modeled in vitro and interfere with endothelial integrity, platelet function, thrombin generation, and are pro-inflammatory.  When a greater effort is made to avoid ABO non-identical transfusions, mortality per unit of red cells transfused drops by 30% and mortality in cardiac surgery is decreased by 75%.

Refaai MA, Fialkow LB, Heal JM, Henrichs KF, Spinelli SL, Phipps RP, Masel E, Smith BH, Corsetti JP, Francis CW, Bankey PE, Blumberg N. An association of ABO non-identical platelet and cryoprecipitate transfusions with altered red cell transfusion needs in surgical patients. Vox Sang. 2011 Jul;101(1):55-60. doi: 10.1111/j.1423-0410.2010.01464.x. Epub 2011 Mar 18. PMID: 21414009; PMCID: PMC3115402.


McRae HL, Millar MW, Slavin SA, Blumberg N, Rahman A, Refaai MA. Essential Role of Rho-Associated Kinase in ABO Immune Complex-Mediated Endothelial Barrier Disruption. Biomedicines. 2021 Dec 7;9(12):1851. doi: 10.3390/biomedicines9121851. PMID: 34944667; PMCID: PMC8698390.
   

Refaai MA, Carter J, Henrichs KF, Davidson DC, Pollock SJ, Casey AE, Spinelli SL, Phipps RP, Francis CW, Blumberg N. Alterations of platelet function and clot formation kinetics after in vitro exposure to anti-A and -B. Transfusion. 2013 Feb;53(2):382-93. doi: 10.1111/j.1537-2995.2012.03718.x. Epub 2012 May 25. PMID: 22624532; PMCID: PMC3566315.
   

Refaai MA, Cahill C, Masel D, Schmidt AE, Heal JM, Kirkley SA, Blumberg N. Is It Time to Reconsider the Concepts of "Universal Donor" and "ABO Compatible" Transfusions? Anesth Analg. 2018 Jun;126(6):2135-2138. doi: 10.1213/ANE.0000000000002600. PMID: 29099432.
   

Blumberg N, Heal JM, Hicks GL Jr, Risher WH. Association of ABO-mismatched platelet transfusions with morbidity and mortality in cardiac surgery. Transfusion. 2001 Jun;41(6):790-3. doi: 10.1046/j.1537-2995.2001.41060790.x. PMID: 11399821.

Malvik N, Leon J, Schlueter AJ, Wu C, Knudson CM. ABO-incompatible platelets are associated with increased transfusion reaction rates. Transfusion. 2020 Feb;60(2):285-293. doi: 10.1111/trf.15655. Epub 2020 Jan 8. PMID: 31912889; PMCID: PMC7769037.

 

Magid-Bernstein J, Beaman CB, Carvalho-Poyraz F, Boehme A, Hod EA, Francis RO, Elkind MSV, Agarwal S, Park S, Claassen J, Connolly ES, Roh D. Impacts of ABO-incompatible platelet transfusions on platelet recovery and outcomes after intracerebral hemorrhage. Blood. 2021 May 13;137(19):2699-2703. doi: 10.1182/blood.2020008381. PMID: 33649761; PMCID: PMC9635530.

 

Inaba K, Branco BC, Rhee P, Holcomb JB, Blackbourne LH, Shulman I, Nelson J, Demetriades D. Impact of ABO-identical vs ABO-compatible nonidentical plasma transfusion in trauma patients. Arch Surg. 2010 Sep;145(9):899-906. doi: 10.1001/archsurg.2010.175. PMID: 20855762.

 

Shanwell A, Andersson TM, Rostgaard K, Edgren G, Hjalgrim H, Norda R, Melbye M, Nyrén O, Reilly M. Post-transfusion mortality among recipients of ABO-compatible but non-identical plasma. Vox Sang. 2009 May;96(4):316-23. doi: 10.1111/j.1423-0410.2009.01167.x. Epub 2009 Feb 24. PMID: 19254234.

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