Olle Berséus MD, PhD Ass.professor Department for Transfusion Medicine Örebro University Hospital Sweden

Transcription

1 Olle Berséus MD, PhD, Ass.professor Department for Transfusion Medicine Örebro University Hospital Sweden Medical advisor in transfusion medicine to the Swedish Armed Forces.

2 Safety of low titer group O Whole blood Olle Berséus 2016 RDCR Symposium June Bergen References of importance to the presentation can be found in Transfusion 2013; 53: 114S-123S

3 Why group O whole blood? The transfusion of ABO-incompatible red cells constitutes a MAJOR INCOMPATIBILITY The transfused cells may undergo a rapid haemolysis and cause a severe (even fatal) transfusion reaction. This hazard is avoided by the use of group O red cells

4 Blood group O plasma contains free antibodies against A and B red cells As the amount of plasma is limited in the transfusion unit the severity of an eventual transfusion reaction is more moderate and very seldom fatal. The transfusion of incompatible plasma constitutes a MINOR INCOMPATIBILITY

5 Adverse patient effects from transfusion of ABO-incompatible plasma (1) Immediate effects Formation of A-/B-immuncomplexes Agglutination and hemolysis of the red cells Activating mononuclear cytotoxic cells Formation and release of acute phase reactants (complement factors, cytokines) Activation and aggregation of platelets Activation of the coagulation system (DIC?) Delayed effects Late effects

6 Adverse patient effects from transfusion of ABO-incompatible plasma (2) Delayed effects within 2h (up to 4 days) Febrile reactions Increased osmotic fragility of the red cells Persistent heme induced activation of the inflammatory respone Persistent thrombocytopenia Coagulopathies and increased fibrinolysis Part in the pathogenesis of transfusion related acute lung injury (TRALI) Immunomodulation in the recipient

7 Adverse patient effects from transfusion of ABO-incompatible plasma (3) Late effects (>50 years) Possibility of an increased incidence of persistent microchimerism Donor white cells can be found in the circulation of the recipient in about 50% of transfused patients with a major trauma and massive bleeding No effect of leucocyte reduction of the transfused blood unit Utter GH. Transfusion 2012; 52: 926-8

8 Reports of hemolytic reactions by transfusion of group O blood to non-group O recipients 1911 Ottenberg proposes group O blood donors as universal donors non military publications with case reports of severe hemolytic reactions after a transfusion of group O blood or plasma to non-group O recipients has been found and reviewed. Antibody titres varied from 16 to >8000 (IgM / IgG) Volume of infused plasma varied from 25 ml to 800 ml All patients recovered except for 2 fatalities

9 Military experiences of the transfusion of group O blood to non-group O recipients World War II Group O blood used universally in US armed forces In 1944 reports of haemolytic reactions in blood units with high titres anti-a/b. There after only low titre * group O blood units were being sent to the military hospitals. No further reports of haemolytic reactions reported within spite of more than transfusions * Anti- A and or anti-b saline titre < 250 Berséus 2013

10 Military experiences of the transfusion of group O blood to non-group O recipients Korean War Only low titre group O blood used. During 1952 >60000 transfusions. No hemolytic reactions reported. Severe IHTR after return to recipient s blood group. After massive transfusion continue group O blood. Berséus 2013

11 Military experiences of the transfusion of group O blood to non-group O recipients Vietnam war Low titre group O blood used universally. From 1965 all blood groups used at major military hospitals, group O blood in the periphery > transfusions Only 1 report of an IHTR from transfusion with group O blood (A high titre unit by mistake released from hospital the patient had uneventful recovery) Berséus 2013

12 Platelet transfusions containing ABO-incompatible plasma Summary of 25 case reports (30 pat.) : 21 patients with systemic malignacies 2 fatalities 4 surgical patients 0 fatalities 5 other 0 fatalities In all patients but one the transfused plasma the anti-a / anti-b titres were above 100 (saline) and 400 (antiglobulin). All patients with less than 200 ml transfused plasma had anti-a / anti-b titres above 1000 (antiglobulin). Berséus et al, Transfusion 2013; S-23S Berséus 2013

13 Summary of the literature review Reviewing literature there is no safe low titer level with the titration techniques being used. In most laboratories there is a large uncontrolled variation in the anti-a/-b titers owing to the individual reactivity between the antigen presented on the test cell and the corresponding plasma antibody. In a primary healthy patient the risk for a clinically significant acute complication mediated by the transfusion of incompatible plasma seems very low even when a considerable amount of antibody is being transfused. All reviewed cases with a fatal outcome have occurred in patients with an severe ongoing systemic disease.

14 Nature of ABO blood group immunization (1) Age 0 3 months No ABO blood group antibodies present. 3 months Bacterial A and B blood group substances from the normal intestinal bacterial flora induces the formation of A- and or B- antibodies of the IgM-class (the natural antibodies )

15 Nature of blood group immunization (2) After: pregnancy, Active immunization with the production of specific blood group antibodies of both IgM and IgG class transfusion of a blood product, vaccination.

16 Vaccination mediated A and B immunization Elevated levels of both IgM and IgG class anti-a and/ or anti-b have been reported after vaccinations with bacteria or virus derived vaccines against: tetanus, typhoid, diphteria, plague, meningococcus, hemophilus influenza, influenza virus A/B. The stimulative activity varies with the different brands of the same vaccine Very high levels of IgM and IgG class anti-b has been described in a group A donor after per oral intake of a commercial probiotic containing lactobacillus

17 Booster effects on anti-a/b by vaccines (1) In order to evaluate the risk for a booster effect on the synthesis of the anti ABO antibodies in blood donors from the military vaccination program of today, all crew members of the Swedish naval vessel HMS Carlskrona were investigated before and after the seven months deployment to the Indian Ocean during 2013.

18 Booster effects on anti-a/b by vaccines (2) 98 males, 22 females, age years, all healthy. Plasma samples taken before the vessel was leaving were frozen and later titrated in duplicated pairs with samples taken 8-10 months after the return to Sweden. Titration for anti-a and -B (IgM and IgG) was performed in gel columns on microcards. The vaccination program included vaccines against: Cholera, Hepatis A and B, Influensa A and B type, Meningococcus, Measles, Mumps, Pertussis, Polio, Rubella, TBE, Tetanus, Typhus, Yellow Fever.

19 Booster effects on anti-a/b by vaccines (3) No individual showed any significant change in their A- or B- antibody titer for either IgM and IgG type. Maximal difference in the paired samples were 1 dilution step (6 individuals). 6 individuals were high titer and showed the same titer in both samples.

20 Quantification of anti-a and anti-b Titration: in a saline medium (only IgM) with antiglobulin (IgG and/or IgM) Technique: agglutination, in test tubes agglutination, separation in gel tubes manual or automated Flow cytometry: specific quantification of antibody technically complicated, expensive Gold standard

21 Quantification of anti-a and anti-b Titration: in a saline medium (only IgM antibodies) with antiglobulin method (IgG and/or IgM antibodies) Technique: agglutination in test tubes agglutination and separation in gel tubes Flow cytometry: specific quantification of the antibody technically complicated and expensive Gold standard No functioning standardization or reference value No generally approved method for laboratory routine titrations

22 Low titer group O blood in Sweden Anti-A and anti- B Titer IgM < 1:100 agglutination in saline Titer IgG < 1:400 agglutination in AHG after inactivation of IgM with dithiothreitol (DTT) Titration is performed with a manual gel technique on microcards using randomly chosen A 1 and B red cells as reagents.

23 Reproducibility of the gel technique On six consecutive days a cold stored (+4 O C) group O plasma sample was titrated against identical daily prepared A 1 and B red cells in a freshly prepared dilution serie. All the corresponding gelcards showed the same picture. The A 1 IgM dilution serie day 1 and day 6 are shown.

24 Antigen reactivity of different red cells A high titer (anti-a+b) group O plasma sample was titrated for anti-a and -B (IgM and IgG) against 10 randomly chosen A 1 and B red cells. The titer for IgM differed 4 dilution steps with the A1-cells and 5 steps with the B-cells. The titer for IgG differed 5 dilution steps with both the A 1 -cells and B-cells. 3 of the A 1 -cells classified the donor as low titer 2 of the B-cells classified the donor as low titer

25 Antibody reactivity of different donors Titration of 40 group O plasmas against 2 high reactive cells group A 1 (Ax,Ay) and group B (Bx,By). The diagram shows the difference in dilution steps between the two cells Donors shifting low / high titer IgM: A cells 5, B cells 3 IgG: A cells 5, B cells 2 Only 1 donor had a shift in both A and B cells IgM IgG No of plasmas A-cells B-cells A-cells B-cells No=2x40 No=2x40 No=2x40 No=2x Difference in dilution steps Difference in dilution steps

26 High titres of anti-a and anti-b in group O donors at the Örebro Blood Center Titration of aniti-a resp. anti-b with gel-technique in saline medium (IgM) and with antiglobulin (IgG) Cut off value for IgM <1/100 and for IgG <1/400 Regular plt-apheresis donors (11/248) 4,4 % Regular active military personnel (1/33) 3 % Swedish Special Forces 27 % Berséus 2013

27 Final conclusion (1) In emergency life saving support the risks for an IHTR or other severe adversive effects from the transfusion of group O blood or plasma to a nongroup O recipient constitutes a minor risk which with good margins is outweighed by the benefit. Whenever possible all universal donors should be screened for low titres of anti-a and anti-b (IgM and IgG) in order to eliminate the risk of donors with very high titers.

28 Final conclusion (2) For non emergency situation the above mentioned screening for anti-a and anti-b of both IgM and IgG classes should be mandatory. For prematures non compatible blood and blood components should be tested against the red cells of the recipient.