Red Cell Antigens

Individuals who lack a particular blood group antigen may produce

antibodies reacting with that antigen which may lead to a transfusion
reaction. ABO and Rh are clinically the most important.

Naturally occurring antibodies occur in the plasma of subjects who lack

the corresponding antigen. Most important are anti-A and anti-B, are
usually IgM and react optimally at cold temperatures.

Immune antibodies develop in response to the introduction, by

transfusion or transplacental passage during pregnancy, or red cells
possessing antigens that the subject lacks. These antibodies are
commonly IgG, and these immune antibodies react optimally at 37C.
Only IgG can pass transplacentally. Most important immune antibody
is the Rh, anti-D.

ABO system
A and B genes control the synthesis of specific enzymes responsible for
addition of single carb resides to a basic antigenic glycoprotein or
glycolipid.

Infections with blood transfusions

The main risk is from viruses that have long incubation periods and
especially those that are carried for many years by asymptomatic
individuals:
Hep A,B,C,D
Retroviruses: HIV and HTLV
Herpes viruses: CMV, EBV, HHV-8
Parvovirus B19
Bacteria: Treponema pallidum, Borellia burgdorferi, Brucella melitensis,
Yersinia enterocolitical, salmonella, Ricketssia Rickettsi (RMSF), Coxiella
burnetti (Q fever)
Protozoa: Plasmoida, trypanosome, Toxoplasma, Babesia, Leishmania
Prions: CJD

Blood group serology testing

Antiglobulin: Antihuman globulin is produced in animals following
injection of human globulin, purified complement or specific
immunoglobulin. When AHG is added to human RBCs coated with Ig or
complement, agglutination of the red cells indicates a positive test.

Cross-matching an pre-transfusion tests

From the patient: ABO and Rh blood group determined, serum is
screened for important antibodies by an indirect antiglobulin test on a
large panel of anti-genically typed group O red cells.
Complications of blood transfusion

Hemolytic transfusion reaction: May be immediate or delayed.

Associated with massive intravascular hemolysis, the result of
complement activating antibodies of IgM or IgG classes, usually with
ABO specificity.

Clinical features: Shock phase, after only a few milliliters or up to 1-2

hours after the end of a transfusion. Urticaria, pain in lumbar region,
flushing, headache, precordial pain, shortness of breath, fever,
hypotension. Moderate leukocytosis (15-20k) is usual.

Other transfusion reactions

Febrile reaction because of white cell antibodies: Human leukocyte

antibodies are usually the result of sensitization by pregnancy or
previous transfusion. Produce rigors, pyrexia and in sever cases
pulmonary infiltrates. Minimized by giving leukoreduced blood
(filtered).

Febrile or non-febrile, nonhemolytic: Hypersesitivity to donor plasma

proteins and if severe can result in anaphylactic shock. Immediate
treatment with antihistamines and corticosteroids.

Transfusion-related acute lung injury: Within 6 hours of an infusion as

pulmonary infiltrates with chest symptoms. Positive transfer of HLA
antibodies in donor plasma causing endothelial and epithelial injury.

Blood components:
Three components made by initial centrifugation of whole blood: red
cells, buffy coat and plasma.

RBCs stored at 4-6C for up to 35 days. After first 48, slow progressive
potassium loss from red cells into plasma. In cases where infusion of
potassium could be dangerous, fresh blood should be used.

Leukoreduced: Less than 5*10^6/L WBCs present. Reduce incidence

of febrile transfusion rxns and HLA alloimmunizations.

Packed RBCs (plasma-depleted) are treatment of choice for most

transfusions. In older subjects, a diuretic is often coadministered. RBC
substitues are under development, but not yet clinically valuable.
Synthetic O2-carrying substitues are often fluorinated hydrocarbons.

Platelet concentrates:
Should be kept above 5-10 for prophylaxis (serious risk of bleeding).
Use is indicated in bleeding associated with platelet disorders, count
should be kept above 50k.

Preparation from human plasma

Frozen plasma: prepared from single donor units, although pooled are
also available. Replacement of coag factors.

Cryoprecipitate: Thawing FFP at 4C and contains concentrated factor 8

and fibrinogen.

Blood replacement therapy

Vast majority in US from volunteer donors. Volume of a donated unit is
approximately 450mL.

FPP: Indications=evidence of coag factor deficiency with clinical

bleeding or need for an invasive procedure.

Transfusion of platelets: Normal platelet function, no clinical

spontaneous bleeding until below 30k-50k, often even lower than this.
Typically transfusion of six platelet concentrates raises platelet count
by 50-100k/uL.
The optimal transfusion threshold for perioperative transfusion was examined in the
Transfusion Trigger Trial for Functional Outcomes in Cardiovascular
Patients Undergoing Surgical Hip Fracture Repair (FOCUS) trial [28]. This trial
randomized 2016 patients with preexisting cardiovascular disease or cardiovascular risk
factors, to liberal versus restrictive postoperative transfusion after hip repair surgery. All
patients were 50 years (mean, 82 years) with a postoperative hemoglobin <10 g/dL.
The liberal transfusion group received immediate transfusion of one unit of packed RBCs
plus subsequent transfusions to raise the hemoglobin level to >10 g/dL whenever it fell
below this level. The restrictive transfusion group received single unit transfusions only if
they developed symptoms of anemia (defined as chest pain, orthostatic hypotension,
tachycardia unresponsive to fluid resuscitation, or congestive heart failure) or, in the
absence of symptoms, when the hemoglobin level fell below 8 g/dL.

The primary outcome of the study was death or an inability to walk 10 feet or across a
room without assistance at the 60-day evaluation. Secondary outcomes included a
combined outcome of in-hospital myocardial infarction, unstable angina, or death; and
later death for any reason. Results included the following [28,43]:
 The liberal and restrictive groups had similar rates of death or inability to walk 10-
feet unassisted at the 60-day evaluation (35.2 versus 34.7 percent, respectively;
OR 1.01; 95% CI 0.84-1.22). Similar results were found at 30-day follow-up.

The liberal and restrictive groups had similar rates of the composite endpoint of in-
hospital acute coronary syndrome or death (4.3 versus 5.2 percent, respectively;
OR 0.82; 99% CI 0.48-1.42). Separately, the endpoint of MI was lower in the liberal
group (2.3 versus 3.8 percent, OR 0.60; 99% CI 0.30-1.19), while the endpoint of
in-hospital death was higher in the liberal group (2.0 versus 1.4 percent, OR 1.44;
99% CI 0.58-3.56).

Mortality was similar for the liberal and restrictive groups.

At 60 days, rates of death were 7.6 and 6.6 percent, respectively (OR 1.17;
99% CI 0.75-1.83).

At approximately three years, rates of death were 43 and 41 percent,

respectively (HR 1.09; 95% CI 0.75-1.25).

The causes of death, and the proportion of deaths due to cardiovascular disease,
cancer, and infection were comparable between the liberal and restrictive groups.

A systematic review that included this trial and five others in patients with hip fracture
came to similar conclusions regarding the safety of a restrictive transfusion strategy in
this setting [44].

MostfacilitiesrelyonprotocolstodirectORhnegativeredcellstothosepatientswhowillreceivethe
greatestbenefitfromthem.Theseinclude:Womenofchildbearingpotential:forthisrecipientgroup,the
goalistoavoidalloimmunizationthatmightcomplicateafuturepregnancy.Theapplicableagevariesby
institution,but45or50yearsisthemostcommon.(Itmaybeinstructivetodeterminethefrequencyat
whichwomenaboveaproposedcutoffagegivebirthinahospitalscatchmentarea.)Youngmales:some
institutionsincludeboysunder16or18yearsinthegrouptoreceiveOnegativeredcellsiftheyhavenot
beenpreviouslybloodtypedwhentheirunderlyingcondition(mostlikelyamalignancy)ismorelikelyto
requirefuture,longtermtransfusionaspartoftheirmedicalcare.Whenemergencytransfusionisneeded
toapatientwhodoesnothaveacurrentpretransfusiontype,BloodworksNorthwestrecommends:O
negativeredcellunitsiftherecipientisafemaleundertheageof50years,oramaleundertheageof18
years;Opositiveredcellunitsforallotherpatients;andConversiontothepatientsABOandRhtype
andtypeassoonasthatcanbedetermined.LargeVolumeTransfusionsOccasionally,anOnegative
patientsufferslargevolumebloodlossandmultipleunits(morethansix)arerequiredtobetransfused.
Unlessthepatientisalreadyalloimmunized(thatis,hasantiDantibody)orisafemaleofchildbearing
potential,strongconsiderationshouldbegiventoconvertingthepatienttoreceivingOpositiveredcellsin
theinterestsofconservingtheOnegativeinventoryforthosewhohaveneedunderthedefinedprotocol.
EveniftheOnegativepatientultimatelymakesantiDaresponselikelytotakeatleast34monthsthe
patientisnotatimmediateriskofhemolysis.Ifsensitized(riskisapproximately20%),thepatientwould
thenreceiveOnegativeredcellsinthefuture.Thus,theonetimeuseofOpositivecellsposesno
immediateharmandlittlefuturerisktothepatient.ConservingONegativeRedCellResourcesCommon
PracticeTheprotocoldefinedaboveiscommonlypracticedininstitutionsbothlargeandsmallacrossthe
country.Intraumasituations,oneofthelargestandmostprestigiousemergencyfacilitiesontheeastcoast
theShockTraumaUnitattheUniversityofMarylandwidelypromotestheapproachofmaintaininga
stockof10Opositiveand2Onegativeredcellunitsforemergencyuse.(DuttonRPetal.JTrauma
2010;69:6206;DuttonRPetal.JTrauma2005;59:14459).TheShockTraumaUnithasconcludedthis
approachtoemergencytransfusionyieldsexcellentpatientoutcomesandisprudentresourcemanagement,
withlessthan10percentoftransfusedunitsbeingOnegativeandaverylowrateofRhsensitization.A
similarpracticeisdeployedattheUniversityofPittsburgh.Inafollowupanalysis(YazerMH,TriulziDJ.
DetectionofantiDinDrecipientstransfusedwithD+redbloodcells.Transfusion2007;47:21972201.),
onlyaboutoneinfiveRhnegativerecipientsofRhpositiveredcellsmadeantiD,furtherlimitingthe
longtermimpactoftransfusingRhpositivebloodtoanRhnegativerecipient.

In urgent/emergent situations, time may be insufficient to complete all components of

pretransfusion testing (eg, life-threatening anemia, brisk hemolysis, rapid bleeding).
Decisions regarding transfusion in such settings depend on assessment of the risks and
benefits of immediate transfusion versus completion of pretransfusion testing, including
compatibility testing. These decisions are made by the clinician caring for the patient
with involvement of transfusion medicine personnel. Importantly, "emergency release"
blood is always available for immediate, lifesaving transfusion.

Blood designated for emergency release is typically group O, Rh(D)-negative. At many

institutions, group O, Rh(D)-positive RBC units may be used for males and females who
are beyond childbearing age or when the usage is expected to be very high. The
designated RBC units are generally stored separately from other RBC units to allow
rapid access and to avoid potential mis-transfusion of non-group O blood. Specialized
modifications may not be available (eg, there may not be irradiated or cytomegalovirus-
safe RBC units).

Additional protocols to be followed during use of emergency release blood include

written indication on the released unit stating that compatibility testing has not been
completed, and written confirmation by the treating clinician that emergency release
blood is required.

After the blood has been released, compatibility testing can be performed on a
pretransfusion sample from the patient (if available). This is useful both for
crossmatching subsequent units and for notification of the treating clinician of any
unexpected results from the antibody screen and/or incompatibilities between the
emergency release unit(s) and the recipient. This information is also recorded in the
medical record.

The relatively low risk for hemolytic transfusion reactions in the setting of emergency
release RBC transfusions (released in the setting of no or incomplete pretransfusion
testing) was demonstrated in a retrospective review of 1002 emergency released RBC
units transfused to 262 patients. In this study, emergency release of RBCs was
associated with 0.1 percent risk of hemolytic transfusion reactions owing to pre-existing
non-ABO RBC antibodies (anti-c and probable anti-Jka) [12].

DLCO

A test of the diffusing capacity of the lungs for carbon monoxide (DLCO, also known as
transfer factor for carbon monoxide or TLCO), is one of the most clinically valuable tests
of lung function. The technique was first described 100 years ago [1-3] and applied in
clinical settings many decades later [4-6]. The DLCO measures the ability of the lungs to
transfer gas from inhaled air to the red blood cells in pulmonary capillaries. The DLCO
test is convenient and easy for the patient to perform. The ten seconds of breathholding
required for the DLCO maneuver is easier for most patients to perform than the forced
exhalation required for spirometry.

DEFINITIONS

DLCO The diffusing capacity for carbon monoxide (DLCO) is the product of the
carbon monoxide transfer coefficient (KCO) and the alveolar volume (VA). The
DLCO is also known as the transfer factor for carbon monoxide or TLCO.
VA The alveolar volume (VA) can be considered the number of contributing
alveolar units and is measured during the single breath DLCO by use of a tracer
gas (eg, helium).
KCO The carbon monoxide transfer coefficient (KCO is
approximately kCO/barometric pressure in mL/minute per mmHg) is often written
as DLCO/VA. It is an index of the efficiency of alveolar transfer of carbon monoxide.
kCO The permeability factor (kCO, minute-1) is the rate constant for alveolar-
capillary CO transfer (the rate of uptake of CO from alveolar gas).

PHYSIOLOGY The diffusing capacity of the lungs for carbon monoxide (DLCO) is
designed to reflect properties of the alveolar-capillary membrane, specifically the ease
with which oxygen moves from inhaled air to the red blood cells in the pulmonary
capillaries. The DLCO can be affected by factors that change the membrane properties
and also by changes in hemoglobin and capillary blood volume. The process of carbon
monoxide (CO) uptake can be simplified into two components: membrane conductance
(DM) and reactive conductance, the chemical reaction between CO and hemoglobin.
DM reflects the properties of diffusion across the alveolar capillary interface. Uptake of
CO by hemoglobin depends on the reaction rate (R) and the pulmonary capillary blood
volume (Vc). The two components occur in series and when conductances occur in
series, they are added as reciprocals. This relationship can be expressed as:

1/DLCO = 1/DM + 1/RVc

Diseases in which the uptake of oxygen is reduced cause parallel decreases in the
uptake of CO, as measured by the DLCO. Older textbooks suggest that thickening of the
alveolar-capillary membrane (in interstitial lung disease) and loss of alveolar membrane
surface area (in emphysema) are the primary causes of a low DLCO. However,
subsequent experimental data suggest these and most other diseases that influence the
DLCO do so by reducing the volume of red blood cells in the pulmonary capillaries. The
total volume of blood in the lungs in healthy adults at rest is less than 150 mL. Diseases
in which the alveolar-capillary surface area is reduced (eg, idiopathic pulmonary fibrosis
and emphysema) lead to a reduction in the blood volume in the lungs.

The volume of blood in the pulmonary capillaries and the DLCO are increased in the
following circumstances:

When pulmonary capillaries are recruited, as occurs during exercise

When the patient is in the supine position

During a Mueller (reverse Valsalva) maneuver

When a left-to-right cardiac shunt is present

Obstructive disease

The DLCO is an excellent index of the degree of anatomic emphysema in

smokers with airways obstruction. A low DLCO correlates highly with a low mean
density of lung tissue on lung CT scan and with the degree of anatomic
emphysema [10-12].

Smokers with airways obstruction but normal DLCO values usually have chronic
"obstructive" bronchitis but not emphysema.

Patients with airway obstruction from asthma typically have normal or high DLCO
values [13].
 Patients with cystic fibrosis have a normal DLCO until their disease becomes very
severe [14,15].

Patients with bronchiolitis obliterans usually have a reduced DLCO and may have
airflow limitation on spirometry.

Unlike the forced expiratory volume in one second (FEV1), the DLCO does not correlate
well with the degree of dyspnea in chronic obstructive pulmonary disease (COPD), and
following such patients with serial DLCO tests does not have well established clinical
value.

Restrictive disease The DLCO helps in the differential diagnosis of restrictive lung
disease, which is identified by reduced total lung capacity (TLC) and vital capacity (VC).
A low DLCO combined with reduced lung volumes suggests interstitial lung disease
(ILD) [16,17]. A normal DLCO associated with low volumes is consistent with an
extrapulmonary cause of the restriction, such as obesity, pleural effusion or thickening,
neuromuscular weakness, or kyphoscoliosis, although clinical evaluation and chest
imaging are needed for confirmation.

Another common application of the DLCO is for detection of mild (early or preclinical)
interstitial lung disease in high-risk patients, including those with [16,18-25]:

Sarcoidosis
Hypersensitivity pneumonitis (extrinsic allergic alveolitis)
Chest irradiation and cancer chemotherapy
Use of drugs known to have pulmonary toxicity
(eg, amiodarone, bleomycin, nitrofurantoin)
Rheumatic disease (eg, systemic sclerosis)