Terry Kotrla, MS, MT(ASCP)BB

Unit 14 Hemotherapy and Organ Transplantation

Hemotherapy IntroductionIndications for transfusion must be defined.Transfuse appropriate product.Products most frequently used:

Red blood cellsApheresis plateletsFresh frozen plasmaCryoprecipitate

Additional considerations:IrradiatedCMV negative

Red Blood CellsUsed to treat symptomatic anemia.Criteria for selection

ABO compatibleNegative for antigens that patient has

clinically significant, alloantibodies to.Infant – compatible with baby and mother

and lack antigens to which mother has clinically significant antibodies.

Red Blood CellsIndications for use:

Oncology patientsTrauma victimsCardiac, orthopedic and other selected

surgeries.End-stage renal diseasePremature infantsDiseases such as sickle cell, thalassemia,

aplastic anemia, etc.Additional considerations

Immunosuppressed give CMV negativeRisk of TA-GVHD give irradiated

Apheresis PlateletsUsed to treat thrombocytopeniaFunction includes

Maintenance of vascular integrityInitial arrest of bleeding by platelet plug

formation.Stabilization of hemostatic plug through

contribution to fibrin formation.Criteria for selection

ABO compatible if possibleIf ABO compatible not available limit exposure.D negative for D negative recipients, can give

RhIG

Apheresis PlateletsIndications for use:

Chemotherapy or radiation therapy patients.Post-hematopoietic progenitor cell transplant

recipientsPeri- or post-operative bleedingThrombocytopenic purpuraThrombocytopenia due to other causes

Additional considerationsImmunosuppressed give CMV negativeRisk of TA-GVHD give irradiated

Fresh Frozen PlasmaUsed to replace clotting factors including

labile factors V and VIII.Criteria for selection

MUST be ABO compatible.Crossmatching NOT necessary.

ABO selectionThink of ABO antibodies in PATIENT.AB universal donor.Group O universal recipient, WHY?

Fresh Frozen PlasmaPreparation

NEVER thaw until order to give is confirmed.Thaw at 37C for 30-45 minutes – several

methods available.Must use protective overwrap to protect

ports from contamination.Expiration

24 hoursAfter 24 hours can be relabeled “thawed

plasma” and used for 5 days if not needed for Factor V or VIII.

Fresh Frozen PlasmaIndications for use

Clotting factor concentrates not available.Massive transfusion.Patients on warfarin who are bleeding.PlasmapheresisSevere liver diseaseDICRare specific plasma protein deficiencies.

Two units frequently ordered.

CryoprecipitateWhat is it?

Insoluble precipitate which forms when FFP is thawed at 1-6C.

Contains concentrated levels of Factor VIII and fibrinogen.

Criteria for selectionDue to small volume ABO group does not

matter UNLESS patient is an infant or small child.

ABO compatibility considerations same as FFP.

CryoprecipitatePreparation

NEVER thaw until order to give is confirmed.Must be thawed at 37C.Protect ports.For adult patient pool 6-10 units for

therapeutic doseExpiration

Frozen 1 year.Thawed 6 hoursPooled 4 hours

CryoprecipitateIndications for use:

Massive transfusionDICFibrinogenemiaVonWillebrand’s disease

Massive Transfusion ProtocolMassively bleeding patients need EVERYTHING.Massive transfusion protocols have been studied

and are proven to reduce mortality rates.Numbers will vary according to institution but

standardizes the protocol to transfuse components.

Example for adult:6 units RBCs4 units FFP1 unit apheresis platelets

Continue until lab results are within normal limits.

TransplantationSolid organs

KidneyLiverLungsIntestinePancreasHeart

Living donor tissue and cell allograftsHematopoietic progenitor cells: bone marrow or

peripheral bloodCord blood

Tissue Allografts: bone, heart valves, tendons, etc.

TransplantationSolid Organ Compatibility testing

MUST be ABO compatible for solid organ transplants.

MUST be HLA compatibleProgenitor cells or bone marrow

ABO doesn’t matter.MUST be HLA compatible

Other tissues (bone, etc.) only stored, no compatibility testing necessary – bone and cornea most common.

Transfusion service roleAccurate ABO typing of donorSupply blood appropriate blood components.

Human Leukocyte Antigens (HLA)Complex array of genes and their

molecular products involved in immune regulation and cellular differentiation.

HLA antigens found on surface membranes of all NUCLEATED cells.

Second in importance to only ABO for solid organ transplant survival.

Human Leukocyte Antigens (HLA)HLA found on surface of nucleated cells which includes

WBC.Function of HLA is to help identify and in turn, fight

“foreign stuff”2 types of HLAsome for MHC I and MHC II (MHC genes

are on chromosome 6)Most important HLA are types A, B (MHC I) and DR (MHC

II)MHC I present antigens to cytotoxic T cells and MHC II

use antigen-presenting cells for helper T cellsFor this reason, it is important to have closely matched

HLA between donor and recipient to avoid rejection, i.e., to avoid donor cells being presented to recipient immune system by MHC for destruction.

Recipient QualificationsList of individuals waiting for organs far

exceeds supply.Most cases <60 yr oldDisqualified if:

Recent MIActive infectionMalignancySubstance abuseLimited life expectancy from unrelated

disease

Time Factors - FYIOnce harvested organs must be

transplanted quicklyKidney – 48 hoursPancreas – 24 hoursLiver – 12 hoursCorneas – 8 hoursHeart and lungs – 6 hours

Recipients closest to location of donor and who “match” are first ones offered organ.

United Network for Organ Sharing (UNOS) is clearing house http://www.unos.org/

Transfusion SupportLiver transplant require the most blood

components.Problem if patient has alloantibodiesUse antigen negative first 5-10 unitsSwitch to unscreened or partially matched

units.Use antigen negative last 5-10 units.Requires close communication between

physician and transfusion service.May use preop plasmapheresis to reduce

titer of clinically significant antibodies.

Transfusion SupportTransfusion support for other types of

transplants usually not a problem.Follow protocol at your institution.Products

IrradiatedCMV negative

Marrow TransplantationTypes

Autologous hematopoietic progenitor cells (HPC)(not really a transplant but a “rescue”).

Allogeneic hematopoietic progenitor cells.Bone marrow

Purpose is to reconstitute patient’s heamtopoietic system after destruction of the recipient’s.

ProcedureDestroy patient’s bone marrow totally.Infuse HLA matched HPC or bone marrow.Monitor for engraftment.

Marrow TransplantationIndications

Hematologic malignanciesSevere immunodeficiencyAplastic anemiaHemoglobinopathies

Malignant diseases are the most common indication.

Success rate depends onPatient’s disease and stage of diseaseDegree of prior treatmentAge and condition of patientDegree of HLA match between patient and

donor.

Transfusion Support for Marrow TransplantRefer to page 310 in textbook.Transfusion service staff must carefully

follow protocol and determine phase patient is in.Phase I compatible with recipient.Phase II compatible with recipient and donor.Phase III compatible with donor.

Marrow Transplantation – Transfusion Service ChallengesChallenges for transfusion service after successful

transplant with ABO marrow different than original.During transition mixed field results and ABO

discrepancies will occur, indicates successful engraftment.

Historical type will be one type, current sample will be another after successful engraftment.

History is CRUCIAL in these situations.Must have patient redrawn to verify no collection

error occurred.Must document from medical records when

transplant was performed.

ReferencesAABB Technical Manual 16th edition, 2008Basic & Applied Concepts of Immunohematology,

Blaney and Howard, 2009Massive Transfusion Protocols, 2009,

http://www.cinj.org/documents/MTP.pdf Massive Transfusion for Trauma is Appropriate, 2005,

http://www.itaccs.com/traumacare/archive/05_03_Summer_2005/appropriate.pdf

Transfusion Support in Solid-Organ Transplantation, 2001, http://www.itxm.org/tmu/tmu2001/tmu4-2001.htm

Role of Transfusion Services in Organ and Tissue Transplantation http://tinyurl.com/3ojbr9l

End of Unit 14