B patient with O plateletpheresis

[Antrita]

I have a B positive chemo patient that requires packed cells and platelpheresis 1 or twice a week. It is very rare for me to have a B platelet. His response to both packed cells and platelets is not so good. I am thinking of switching him to O positive packed cells. Does anyone have thoughts, experience etc. with this situation.

Thanks

Antrita

[John C. Staley]

Couple of questions:

First, how difficult would it be to get B plts?

Second, which has a direct bearing on the first question, how much notice do you get prior to the plt transfusion?

It always amazes me how giving incompatible FFP is virtually taboo but we don't seem to hesitate at all giving the same volume of incompatible plasma if it is associated with plts.

[scodina]

Are you having trouble getting B red cells also? Can you tell me a little more about your suggestion to give O red cells instead of B? Just curious. Thanks!

[kim]

Is this patient only having issues getting a bump off plt's? Maybe the patient has plt antibodies??

[jhaig]

Is the patient refractory?

Have you done a corrected count increment (CCI)?

You could also set up a standing order with your supplier if getting the correct product is an issue.

[Antrita]

As for notice - I get very little of it. We have an minimum care satellite hospital where most of the transfusion patients go. Many times they are there before I get the patient's specimen. I rarely have more than 2 plateletpheresis and it is extremely rare for either of them to be a B or AB.

My question about the packed cells is with all the A and O plasma this patient is getting would O cells have a longer survival since I'm giving his B antibodies with his platelets. Some of our plateletpheresis are greater than 300ml.

Antrita

[John C. Staley]

I would have my medical director chat with the patient's physician and explain that you are potentially causing this patient more harm than good. If this patient is not critical and you can get B platelets shipped in within 24 hours that would be your best option especially if the transfusions are prophalytic and not to try to stop active bleeding.

As noted above there are other possibilities but my philosophy has always been to try to rule out the most likely first and then go hunting for unicorns.

[Mabel Adams]

What fun is that, John? I have a long tradition of hunting for unicorns--haven't found any yet, though.

[Antrita]

More clarification. My blood product provider will not provide type specific plateletpheresis because of their 5 day expiration date. The patient does not have a platelet antibody and we have now sent out a specimen on him for HLA matched platelets.

Why I am asking about the red cells is because his hemoglobin doesn't rise much after transfusion. I am not sure if this is strictly because of his chemotherapy or if the fact we are giving him Anti-B plasma with every plateletpheresis. My thought was by O cells would have a longer survival time in the Anti-B plasma.

I went to a conference one time and the speaker was talking how every Blood Bank should have a policy about how to give incompatible blood. He had a hypothetical case where there was no O red cells so the patient was to be transfused with B cells. He said in this case, you would want to also transfuse B plasma to dilute the patients anti-B antibodies. I can't imaging this ever happening. What I am thinking is the reverse should also be true.

Also, I don't have any problem getting B red cells.

Antrita

[L106]

Antrita,

That's unfortunate that your blood provider will not honor a request for a group-specific plateletpheresis if you give them something like a day advanced notice "because of the platelets' 5-day expiration date." NEWS FLASH.......The majority of other blood suppliers are dealing with the same 5-day expiration date limit, yet they will honor (or at least try to honor) such a reasonable request.

That point aside......... Whether it is important to use only group-specific platelets has always been a controversial issue. We often transfuse non-group-specific platelets when the urgency and/or inventory dictates it. Yes, once in a while we see a patient develop a weakly Positive DAT (for example, due to Anti-B in Group O platelets attaching to the patient's Group B red cells.) However, it has been our experience that this rarely results in a significant amount of red cell destruction.

Nevertheless, it certainly would do no harm to use Group O red cell units for the next 2 or 3 transfusion episodes and monitor the patient's response. Evaluate the data and decide whether the patient fared better with Group O or Group B donor units. Worth a try!

Donna

[Mabel Adams]

Novel concept about giving ABO incompatible blood. I would think that giving B FFP would also provide some B substance that might adsorb out some anti-A,B and anti-B. Makes you want to give AB plasma in case there would be more A & B substance in it. Or give the plasma first. I guess creating immune complexes would be the least of anyone's worries in that situation.

[bbbirder]

It is too bad that your blood supplier won't give you what you are asking for. Can you find another source?

I would think Group A platelets would be better than group O, since the anti-B wouldn't be as potent. What about pooled platelets? Some patients do better with those than single donor.

If a patient has platelet or HLA antibodies, you really can't worry about the ABO type but instead need to give 'matched' platelets.

Perhaps the patient isn't responding for other reasons? Spleen problems?

Good luck.

Linda Frederick

[jhaig]

Why is your supplier so worried about expiration dates? The 5-day limit has been is use forever and it's not like they're going to expire on your shelf. They're going to be used so there should be no concern about the units going to waste.

I was going to mention splenic sequestration, but I was beaten to the punch:D

[Debbie]

How about AB platelets - just eliminate the risk of ANY ABO antibodies altogether. I can't imagine that your blood supplier wouldn't change your standing order to give you one unit of AB platelets for a short period of time.

Try another supplier!! Many blood centers out there are willing to do this, let them know that!

[kharbert]

Thank you, John for bringing this up!

I wonder about the same thing. I got a stunning 2 minutes of silence when I asked about this at an ASCLS meeting. I believe one of the fatalities reported to the FDA in FY 2005 was due to an A patient receiving O apheresis platelets. (Fatalities Reported to FDA Following Blood Collection and Transfusion. Annual Summary for Fiscal Years 2005 and 2006)

Also, according to this article, there are places that only transfuse ABO compatible platelets.

Mark K. Fung, MD, PhD, FCAP; Katharine A. Downes, MD, FCAP; Ira A. Shulman, MD, FCAP. Transfusion of Platelets containing ABO-Incompatible Plasma a survey of 3156 North American Laboratories Arch Pathol Lab Med—Vol 131, June 2007

Good question, John!

[adiescast]

The other option, if you have the centrifuge, is to reduce the plasma load in the ABO incompatible platelet pheresis right before you give it.

By the way, we started matching ABO types for platelet pheresis about two years ago. It is not always possible to do, but it makes sense. As John said, no one would ever casually give a plasma out of type the way we as an industry have done with platelets (both pheresis and pooled).

I am assuming, since it was not mentioned, that the patient has not developed a positive DAT?