BLOOD TRANSFUSION SUPPORT IN STEM CELL TRANSPLANT

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BLOOD TRANSFUSION SUPPORT IN STEM CELL TRANSPLANT

• Salwa Hindawi
• Director of Blood Transfusion Services
• KAUH, Jeddah
• Saudi Arabia

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Introduction

• Bone Marrow Transplant can be either
• Allogeneic
• Autologous
• PBSCT
• Cord Blood

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Diseases Treatable by BMT

• Non-Hodgkin's Lymphoma Hodgkins Disease
  Multiple Myeloma Acute Leukemias Chronic
  Leukemias Myelodysplasia Testicular Cancer
  Aplastic Anemia

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Role of transfusion services
Basic transplant issues that impact blood bank
policies. Recognize common serologic problems
encountered in transplant recipients Appropriate
blood products when transfusion is needed.
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Basic transplant issues

• Recipient-Donor ABO compatibility.
• ABO and Rh compatibility are not required for
  the successful outcome of BMT

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BASIC TRANSPLANT ISSUES

• Special Blood Requirement
• Irradiated
• CMV Negative
• Leukocyte-Reduced
• Saline-washed or volume reduced

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Pre-Transplant Considerations

• Is this a major or minor ABO incompatibility?
• How high the patients antibody titers against
  the donors ABO group?
• How high the donors antibody titers against the
  patients ABO group?
  
• Will the patient require special conditioning?
  Will the HPC collection require processing?
  

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RECIPIENT-DONOR ABO COMPATIBILITY
Compatible transplant Immunohemtologic
complications Major incompatibility Minor
incompatibility Major minor incompatibility
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Recipient- Donor ABO Compatibility

•  ABO Major Mismatch Recipient is O-Donor is A
•   -Acute hemolysis at infusion.
•   -Delayed hemolysis from persistent patient
  antibodies.
•   -Delayed onset of hematopoiesis.
• ABO Minor Mismatch Recipient is A- Donor is O
•   -Acute hemolysis at infusion.
•    -Delayed hemolysis from donor antibodies.
• ABO Major-Minor Mismatch Recipient is A-Donor is
  B

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ABO COMPATIBILITY
DONOR
Blood Group O A B AB
O Compatible Major Major Major
A Minor Compatible Major and minor Major
B Minor Major and minor Compatible Major
AB Minor Minor Minor Compatible
RECIPIENT
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TRANSFUSIONS FOLLOWING BONE MARROW TRANSPLANTATION

• beginning with preparative regimen
• ABO compatibility is not required between bone
  marrow donor and recipient.
• Compatible transplant
• no special requirements
• Minor incompatibility
• recipient type plasma and platelet until
  recipient cells have disappeared

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TRANSFUSIONS FOLLOWING BONE MARROW TRANSPLANTATION

• Major incompatibility
• recipient type red cells until recipient
  isoagglutinins have disappeared
• Major and minor incompatibilities
• group AB plasma, group AB or washed platelets
  until recipient cells gone group O red cells
  until recipient isoagglutinins have disapeared.

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Blood Selection when recipient/donor are not ABO
identical
Patient ABO Donor ABO RBC FFP 1st Choice plt 2nd Choice plt
O A B AB O O O A,AB B,AB AB B,O A,O A,B,O
A O B AB O O A,O A,AB AB AB B,O B,A,O A,B,O
B O A AB O O B,O B,AB AB AB A,O A,B,O B,A,O
AB O A B O A,O B,O AB AB AB A,B,O A,B,O A,B,O
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NON-ABO MISMATCHES

• major Rh-incomp.,patient anti-D antibodies
  against engrafted donor Rh RBCs.
• Mismatches involving Rh system may cause
  hemolysis, do not affect survival.
• Kidd,M,N and S.

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Complications Related to Blood Transfusion

• Haemolysis
• Alloimmunization to red cell antigens
• Infection (CMV)
• Graft-Verses Host Disease (GVHD)

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Passenger B lymphocyte syndrome

• Delayed hemolysis 7-14 days post transplant
• Mediated by donor lymphocytes carried in the HSC
  component
• Immune hemolysis of the recipients red cells as
  results of anti A and/or anti B production
• PBSC at greater risk than marrow
• Abrupt onset may be severe with signs of IV
  hemolysis

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Passenger B lymphocyte syndrome

• Worsen with transfusion ,due to hemolysis of
  transfused group O RBCs .
• Methotrexate as anti-proliferative agent use to
  suppress the proliferation of donor lymphocytes
  in HSC inoculum.

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PROPHYLAXIS

• Transfusion of Group O red cells
• Occasional red cell exchange transfusion is
  indicated to replace the recipients incompatible
  red cells with Group O.
• Recipient ABO plts type

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Marrow Processing

• Red cell depletion and/or plasma depletion ONLY
  performed on BM collection.
• Red cell depletion Recipient has Ab against
  Donor red cells.
• To avoid hemolysis of donor red blood cells in
  HPC collection.
• Plasma depletion Donor has AbS against Recipient
  red cell .
• To avoid hemolysis of red blood cells in
  recipients circulation.

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Leucodepletion of Blood Components
Alloimmunization Prevention of Febrile Non
Haemolytic Transfusion Reaction. Replacement of
CMV negative blood components.
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Irradiation of blood products

• All cellular components should be gamma
  irradiated (25 Gy or 2500 cGy) this inactivates
  the T lymphocytes in the donor unit and prevents
  graft versus host disease in an immunocompromised
  recipient.
• Start at conditioning
• for 6month in Allogeneic BMT
• 3 month for Autologous BMT

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Indications for Gamma Irradiated Blood Components

• congenital immunodeficiency syndromes.
• intrauterine transfusions.
• All neonates who received intrauterine
  transfusion.
• transfusions from all blood relatives.
• bone marrow transplant recipients.

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Cord Blood

• The multipotent-stem-cell-rich blood found in the
  umbilical cord has proven useful in treating the
  same types of diseases as those treated using
  bone marrow stem cells and PBSCs.
• Umbilical cord blood stem cell transplants are
  less prone to rejection than either bone marrow
  or peripheral blood stem cells.
• Umbilical cord blood lacks well-developed immune
  cells
• the cells have not yet developed the features
  that can be recognized and attacked by the
  recipient's immune system

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Conclusions

• Bone marrow transplantation (BMT) is rapidly
  expanding as a practical and therapeutic
  modalities.
• the transfusion medicine professional must take
  into account the series of immunohematological
  changes and complications that may arise in such
  patients.
• We must apply techniques, methods, and approaches
  not routinely used in the general blood-banking
  environment.

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Thanks