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Unit 14 Hemotherapy and Organ
Transplantation
Terry Kotrla, MS, MT(ASCP)BB
Hemotherapy Introduction
Indications for transfusion must be defined.
Transfuse appropriate product.
Products most frequently used:
Red blood cells
Apheresis platelets
Fresh frozen plasma
Cryoprecipitate
Additional considerations:
Irradiated
CMV negative
Red Blood Cells
Used to treat symptomatic anemia.
Criteria for selection
ABO compatible
Negative 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 Cells
Indications for use:
Oncology patients
Trauma victims
Cardiac, orthopedic and other selected surgeries.
End-stage renal disease
Premature infants
Diseases such as sickle cell, thalassemia, aplastic anemia, etc.
Additional considerations
Immunosuppressed give CMV negative
Risk of TA-GVHD give irradiated
Apheresis Platelets
Used to treat thrombocytopenia
Function includes
Maintenance of vascular integrity
Initial arrest of bleeding by platelet plug formation.
Stabilization of hemostatic plug through contribution to fibrin
formation.
Criteria for selection
ABO compatible if possible
If ABO compatible not available limit exposure.
D negative for D negative recipients, can give RhIG
Apheresis Platelets
Indications for use:
Chemotherapy or radiation therapy patients.
Post-hematopoietic progenitor cell transplant recipients
Peri- or post-operative bleeding
Thrombocytopenic purpura
Thrombocytopenia due to other causes
Additional considerations
Immunosuppressed give CMV negative
Risk of TA-GVHD give irradiated
Fresh Frozen Plasma
Used to replace clotting factors including labile factors V and
VIII.
Criteria for selection
MUST be ABO compatible.
Crossmatching NOT necessary.
ABO selection
Think of ABO antibodies in PATIENT.
AB universal donor.
Group O universal recipient, WHY?
Fresh Frozen Plasma
Preparation
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 hours
After 24 hours can be relabeled “thawed plasma” and used for 5
days if not needed for Factor V or VIII.
Fresh Frozen Plasma
Indications for use
Clotting factor concentrates not available.
Massive transfusion.
Patients on warfarin who are bleeding.
Plasmapheresis
Severe liver disease
DIC
Rare specific plasma protein deficiencies.
Two units frequently ordered.
Cryoprecipitate
What is it?
Insoluble precipitate which forms when FFP is thawed at 1-6C.
Contains concentrated levels of Factor VIII and fibrinogen.
Criteria for selection
Due to small volume ABO group does not matter UNLESS
patient is an infant or small child.
ABO compatibility considerations same as FFP.
Cryoprecipitate
Preparation
NEVER thaw until order to give is confirmed.
Must be thawed at 37C.
Protect ports.
For adult patient pool 6-10 units for therapeutic dose
Expiration
Frozen 1 year.
Thawed 6 hours
Pooled 4 hours
Cryoprecipitate
Indications for use:
Massive transfusion
DIC
Fibrinogenemia
VonWillebrand’s disease
Massive Transfusion Protocol
Massively 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 RBCs
4 units FFP
1 unit apheresis platelets
Continue until lab results are within normal limits.
Transplantation
Solid organs
Kidney
Liver
Lungs
Intestine
Pancreas
Heart
Living donor tissue and cell allografts
Hematopoietic progenitor cells: bone marrow or peripheral blood
Cord blood
Tissue Allografts: bone, heart valves, tendons, etc.
Transplantation
Solid Organ Compatibility testing
MUST be ABO compatible for solid organ transplants.
MUST be HLA compatible
Progenitor 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 role
Accurate ABO typing of donor
Supply 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 antigenpresenting cells for helper T cells
For 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 Qualifications
List of individuals waiting for organs far exceeds supply.
Most cases <60 yr old
Disqualified if:
Recent MI
Active infection
Malignancy
Substance abuse
Limited life expectancy from unrelated disease
Time Factors - FYI
Once harvested organs must be transplanted quickly
Kidney – 48 hours
Pancreas – 24 hours
Liver – 12 hours
Corneas – 8 hours
Heart 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 Support
Liver transplant require the most blood components.
Problem if patient has alloantibodies
Use antigen negative first 5-10 units
Switch 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 Support
Transfusion support for other types of transplants usually not
a problem.
Follow protocol at your institution.
Products
Irradiated
CMV negative
Marrow Transplantation
Types
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.
Procedure
Destroy patient’s bone marrow totally.
Infuse HLA matched HPC or bone marrow.
Monitor for engraftment.
Marrow Transplantation
Indications
Hematologic malignancies
Severe immunodeficiency
Aplastic anemia
Hemoglobinopathies
Malignant diseases are the most common indication.
Success rate depends on
Patient’s disease and stage of disease
Degree of prior treatment
Age and condition of patient
Degree of HLA match between patient and donor.
Transfusion Support for Marrow
Transplant
Refer 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 Challenges
Challenges 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.
References
AABB Technical Manual 16th edition, 2008
Basic & Applied Concepts of Immunohematology, Blaney and Howard,
2009
Massive 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/a
ppropriate.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