CP SERVICE REVIEW4-5-2010LMROC 3-29 TO 4-4

Nicole Cipriani

Saturday/Sunday

3 TTP patients JB 59 year old male s/p liver transplant and HepC

microangiopathic hemolytic anemia Plts 53 72 92

RS 73 year old male angioimmunoblastic T cell lymphoma confusion, multi-organ failure Plts 66 30

LM 29 year old female with chronic relapsing TTP left sided weakness ADAMTS13 activity: <5% (nml >67%) ADAMTS13 inhibitor: 1.4 units (nml <0.4) Plts 8 17

Chronic Relapsing TTP

To be discussed May 24

Choose your adventure

* Transfusion Reaction

* Transfusion-related infectious disease

Case 1

13 year old male with history of hypertrophic obstructive cardiomyopathy

3-17-2010 ICD placement Morrow procedure (resection of subaortic

muscle) Complicated by

Postoperative bleed LV dysfunction LVAD Additional surgeries

Blood Products Received

44 units RBC 28 units FFP 9 packs Platelets 5 units Cryo

3-17 to 4-1

Transplant Candidate

HIV ELISA Non-reactive

Hepatitis C virus antibody Reactive x5 (3-28 to 4-2) 10 days prior nonreactive (3-18)

Hepatitis C viral load None detected (3-30) (Real time PCR for Hepatitis C RNA)

EBV IgG capsid antibody Positive

NO additional known risk factors for

HCV.

Test Blood Donors ?

Postgrad Med J. 1994 Aug;70(826):572-5.

Prevalence of antibodies to hepatitis C virus after blood transfusion in heart surgery.

Barcena R, Gonzalez A, Martin-de-Argila C, Ulibarrena C, Graus J, Grande LA.Department of Gastroenterology, Ramon y Cajal Hospital, Alcalá de Henares University, Madrid, Spain.

We studied the frequency and time of appearance of antibodies to the hepatitis C virus (HCV) retrospectively in the sera of 127 patients who underwent heart surgery between 1983 and 1986. They received blood from volunteer donors hepatitis B surface antigen (HBsAg) negative with normal serum alanine-aminotransferase levels. A prospective follow-up was carried out every 15 days for at least 6 months from the moment of the transfusion. Of the ten patients who developed biochemical criteria of post-transfusional non-A non-B hepatitis, six seroconverted to anti-HCV (60%). Of the other 117, two were already positive before transfusion (1.51%), one patient showed antibodies only in the first post-transfusional serum (passive transfer), and another two patients with no evidence of post-transfusional hepatitis developed HCV antibodies on the 90th day, remaining indefinitely (afterwards seroconversion without hepatitis); both patients' earlier sera were anti-HCV negative. Four (40%) of the ten patients with post-transfusional hepatitis did not develop any serum markers to known hepatotropic agents. Although these findings do not exclude a viral infection by these viruses, they are consistent with the involvement of an unidentified non-A, non-B, non-C agent.

PMID: 7524052

J Pediatr. 1994 Sep;125(3):463-5.

Passive transfer of hepatitis antibodies during intravenous administration of immune globulin.

Karna P, Murray DL, Valduss D, Mattarella N, Dyke JW, Maier GA.Department of Pediatrics and Human Development, Michigan State University, East Lansing.

We studied the effect of intravenous immune globulin (IVIG) infusion on the levels of hepatitis B and C antibodies in 10 premature babies. All four tested lots of a commercially purchased IVIG preparation were found to contain substantial amounts of hepatitis B core and hepatitis C antibodies. Our results show that passive transfer of hepatitis B and C virus antibodies occurred after IVIG infusion, and that the levels were dependent on the quantity of IVIG given. When assessing neonates for hepatitis, the factor of receipt of blood products, including IVIG, needs to be considered to interpret laboratory results.

PMID: 8071759

Anti-Hepatitis C Antibodies

Passive transfer of antibodies only ? Seroconverson without hepatitis ? Subclinical infection ?

Case 2

85 year old female left breast lymphoma (extranodal marginal zone) CAD, CHF, diabetes upper GI bleed

Transfused 7 units 3-2 5 units 3-1 (+ 4 FFP) 2 units 2-26

No history of transfusion reaction Newly dropping hematocrit Type and Screen 3-29-10

Hemoglobin: 2-7-10 to 4-3-10

3-2-10Last T

2-16-10First T

Lab Workup

Type: B pos Screen: 2+ and 3+ Panel: 1+ to 4+ in 8/11 cells Auto-control: 2+ DAT: negative Eluate: 3+ and 4+ to screen cells Eluate Panel: >C & >E Antisera to patient RBC:

C = mixed field E = negative

Mixed field = Some patient cells (C

neg)+

Some transfused cells (C pos)

Concise Rh System

Antigen Allelic Partner Antibodies

D (none) Naturally occurring

C c Acquired

E e Acquired

Delayed Transfusion Reactions Production of antibodies against

antigens on RBCs of transfused blood (or pregnancy) May take days – months – years to form

antibodies 1-1.6% of transfusions form antibodies

If transfused another unit with those antigens May result in delayed hemolysis

Delayed Transfusion Reactions

Type Signs Mechanism Timeline

DHTR (Hemolytic)1:2500 Ts

Fever, anemia, leukocytosis, hemoglobinemia, hemosiduria, LDH & bili

Extravascular hemolysis

Days to weeks

DSTR (Serologic)1:1250 Ts

Unexplained anemia, no response to additional transfusions* NO laboratory evidence of hemolysis

Presence of alloantibodyNO lab hemolysis

Days to weeks, Abs may become undetectable over months to years

Red Cell Parasite Fever Intravascular hemolysis

Days to weeks

GVHD Fever, rash, GI symptoms

NO hemolysis Days to weeks* DHTR/DSTR antigens: Kidd > Duffy > Kell > MNS* DAT can be negative if no/few transfused red cells remain

Hemoglobin: 2-7-10 to 4-3-10

3-2-10Last T

2-16-10First T

Also: LDH &

bilirubin Haptoglobin

+ Coombs

DELAYED HEMOLYTIC TRANSFUSION REACTION

Acute Transfusion Reactions

Type Signs Mechanism Treatment

Hemolytic Fever, chills, hypotension

ABO incompatibility, Intra- or Extra-vascular hemolysis

Lasix, Morphine, Pressors

Febrile Nonhemolytic

Fever chills Cytokines in unit,Abs to donor WBCs

LeukoreduceAntipyretics

Allergic Hives, flushing anaphylactic

Abs to donor plasma proteins

Antihistamine

TRALI ARDS Donor Abs to patient WBCs

SupportiveDefer donor

TACO SOB, HTN Volume overload

Lasix, Oxygen

Sepsis Fever, chills, hypotension

Bacteria in donor blood

Antibiotics

Thank you