2682_Ch01_001-025 28/05/12 12:22 PM Page 21

COMPILED BY SHAIRA RAE BILLENA

Chapter 1 Red Blood Cell and Platelet Preservation: Historical Perspectives and Current Trends 21

storing and shipping platelets at 20°C to 24°C, especially the enzymatic galactosylation of cold-stored platelets to modify
chance for bacterial proliferation. Refrigeration would signif- specifically one type of membrane protein. The addition
icantly reduce the risk of bacterial contamination, allowing of uridine diphosphate galactose is the vehicle for the
for longer storage. Many approaches have been attempted modificaiton.89
without success, although early results showed some prom-
ise. The approaches primarily involve adding substances to Frozen Platelets
inhibit cold-induced platelet activation, as this is thought to
be the key storage lesion. Two reports concluded that platelets Although considered a research technique and not licensed by
stored at 1°C to 6°C could conceivably have satisfactory in the FDA, frozen platelets are used occasionally in the United
vivo viability and function if the surface of the platelets were States as autologous transfusions for patients who are refrac-
modified to prevent the enhanced clearance (unsatisfactory tory to allogeneic platelets. Platelets are collected by apheresis,
viability) from circulation.88,89 the cryopreservative dimethyl sulfoxide (DMSO) is added, and
Based on animal studies, it was suggested that cold- the platelets are frozen at –80°C. The frozen platelets can be
induced spherical platelets can remain in the circulation if stored for up to 2 years. Prior to transfusion, the platelets are
abnormal clearance is prevented. Spherical platelets, mani- thawed and centrifuged to remove the DMSO. Although in
fested as a result of cold storage, have been assumed to be a vivo recovery after transfusion is only about 33%, the platelets
trigger for low viability. The specific approach involves the seem to function effectively.5

SUMMARY CHART
Each unit of whole blood collected contains approxi- Research is being conducted to improve on the current
mately 450 mL of blood and 63 mL of anticoagulant- additive solutions.
preservative solution or approximately 500 mL of Research is being conducted to develop procedures to
blood and 70 mL of anticoagulant-preservative reduce or inactivate pathogens.
solution. RBC substitutes under investigation include hemoglo-
A donor can give blood every 8 weeks. bin-based oxygen carriers and perfluorocarbons.
As of 2011, samples from donors of each unit of do- A platelet concentrate should contain a minimum of
nated blood are tested by 10 screening tests for infec- 5.5 ! 1010 platelets (in 90% of the sampled units
tious diseases markers. according to AABB standards) in a volume routinely
Glycolysis generates approximately 90% of the ATP between 45 and 65 mL that is sufficient to maintain a
needed by RBCs, and 10% is provided by the pentose pH of 6.2 or greater at the conclusion of the 5-day
phosphate pathway. storage period.
Seventy-five percent post-transfusion survival of RBCs When platelet concentrates (usually 4 to 6) are pooled
is necessary for a successful transfusion. using an open system, the storage time changes to
ACD, CPD, and CP2D are approved preservative solu- 4 hours. A new method of pooling that uses a closed
tions for storage of RBCs at 1°C to 6°C for 21 days, and system allows the pool to be stored for 5 days from the
CPDA-1 is approved for 35 days. date of collection.
Additive solutions (Adsol, Nutricel, Optisol) are ap- Apheresis components contain 4 to 6 times as many
proved in the United States for RBC storage for platelets as a PC prepared from whole blood. They
42 days. Additive-solution RBCs have been shown to should contain a minimum of 3.0 ! 1011 platelets (in
be appropriate for neonates and pediatric patients. 90% of the sampled units).
RBCs have been traditionally glycerolized and frozen Platelet components are stored for up to 5 days at 20°C
within 6 days of whole blood collection in CPD or to 24°C with continuous agitation. When necessary, as
CPDA-1 and can be stored for 10 years from the date during shipping, platelets can be stored without con-
of freezing. tinuous agitation for up to 24 hours (at 20°C to 24°C)
Rejuvesol is the only FDA-approved rejuvenation so- during a 5-day storage period. Platelets are rarely
lution used in some blood centers to regenerate ATP stored at 1°C to 6°C.
and 2,3-DPG levels before RBC freezing. If a platelet bag is broken or opened, the platelets must
Rejuvenation is used primarily to salvage O-type and be transfused within 4 hours when stored at 20°C to
rare RBC units that are at outdate or with specific 24°C.

t
anticoagulant-preservative solution up to 3 days past
outdate.
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22 PART I Fundamental Concepts

7. What is the minimum number of platelets required in a

Review Questions
platelet concentrate prepared from whole blood by cen-
trifugation (90% of sampled units)?
1. What is the maximum volume of blood that can be col-
lected from a 110-lb donor, including samples for a. 5.5 ! 1011
processing? b. 3 ! 1010
c. 3 ! 1011
a. 450 mL
d. 5.5 ! 1010
b. 500 mL
c. 525 mL 8. RBCs can be frozen for:
d. 550 mL a. 12 months.
2. How often can a blood donor donate whole blood? b. 1 year.
c. 5 years.
a. Every 24 hours
d. 10 years.
b. Once a month
c. Every 8 weeks 9. What is the minimum number of platelets required in
d. Twice a year an apheresis component (90% of the sampled units)?
3. When RBCs are stored, there is a “shift to the left.” This a. 3 ! 1011
means: b. 4 ! 1011
c. 2 ! 1011
a. Hemoglobin oxygen affinity increases, owing to an
d. 3.5 ! 1011
increase in 2,3-DPG.
b. Hemoglobin oxygen affinity increases, owing to a de- 10. Whole blood and RBC units are stored at what
crease in 2,3-DPG. temperature?
c. Hemoglobin oxygen affinity decreases, owing to a de- a. 1°C to 6°C
crease in 2,3-DPG. b. 20°C to 24°C
d. Hemoglobin oxygen affinity decreases, owing to an c. 37°C
increase in 2,3-DPG. d. 24°C to 27°C
4. The majority of platelets transfused in the United States 11. Additive solutions are approved for storage of red blood
today are: cells for how many days?
a. Whole blood–derived platelets prepared by the a. 21
platelet-rich plasma method. b. 42
b. Whole blood–derived platelets prepared by the buffy c. 35
coat method. d. 7
c. Apheresis platelets.
d. Prestorage pooled platelets. 12. One criterion used by the FDA for approval of new preser-
vation solutions and storage containers is an average
5. Which of the following anticoagulant preservatives pro- 24-hour post-transfusion RBC survival of more than:
vides a storage time of 35 days at 1°C to 6°C for units of a. 50%.
whole blood and prepared RBCs if an additive solution b. 60%.
is not added? c. 65%.
a. ACD-A d. 75%.
b. CP2D
c. CPD 13. What is the lowest allowable pH for a platelet compo-
d. CPDA-1 nent at outdate?
a. 6
6. What are the current storage time and storage tempera- b. 5.9
ture for platelet concentrates and apheresis platelet c. 6.8
components? d. 6.2
a. 5 days at 1°C to 6°C
b. 5 days at 24°C to 27°C 14. Frozen and thawed RBCs processed in an open system
c. 5 days at 20°C to 24°C can be stored for how many days/hours?
d. 7 days at 22°C to 24°C a. 3 days
b. 6 hours
c. 24 hours
d. 15 days
2682_Ch01_001-025 28/05/12 12:22 PM Page 23

Chapter 1 Red Blood Cell and Platelet Preservation: Historical Perspectives and Current Trends 23

15. What is the hemoglobin source for hemoglobin-based 8. Harmening, DM: Clinical Hematology and Fundamentals of
oxygen carriers in advanced clinical testing? Hemostasis, 5th ed. FA Davis, Philadelphia, 2009.
9. Mohandas, N, and Chasis, JA: Red blood cell deformability,
a. Only bovine hemoglobin membrane material properties and shape: Regulation of trans-
b. Only human hemoglobin mission, skeletal and cytosolic proteins and lipids. Semin
c. Both bovine and human hemoglobins Hematol 30:171–192, 1993.
d. None of the above 10. Mohandas, N, and Evans, E: Mechanical properties of the genetic
defects. Ann Rev Biophys Biomol Struct 23:787–818, 1994.
16. Which of the following occurs during storage of red 11. Koch, CG, Li, L, Sessler, DI, et al: Duration of red cell storage
blood cells? and complications after cardiac surgery. N Engl J Med
358(12):1229–1239, 2008.
a. pH decreases 12. Dumont, LJ, and AuBuchon, JP: Evaluation of proposed FDA
b. 2,3-DPG increases criteria for the evaluation of radiolabeled red cell recovery
c. ATP increases trials. Transfusion 48(6):1053–1060, 2008.
d. plasma K+ decreases 13. Hod, EA, Zhang, N, Sokol, SA, et al: Transfusion of red blood
cells after prolonged storage produces harmful effects that are
17. Nucleic acid amplification testing is used to test donor mediated by iron and inflammation. Blood 115(21):4284–
blood for which of the following infectious diseases? 4292, 2010.
14. Luten, M, et al: Survival of red blood cells after transfusion: A
a. Hepatitis C virus comparison between red cells concentrates of different storage
b. Human immunodeficiency virus periods. Transfusion 48(7):1478–1485, 2008.
c. West Nile virus 15. Zeiler, T, Muller, JT, and Kretschmer, V: Flow-cytometric de-
d. All of the above termination of survival time and 24-hour recovery of trans-
fused red blood cells. Transfus Med Hemother 30:14–19, 2003.
18. Which of the following is NOT an FDA-approved test 16. Valeri, CR: Preservation of frozen red blood cells. In Simon,
for quality control of platelets? TL, Dzik, WH, Snyder, EL, Stowell, CP, and Strauss, RG (eds):
Rossi’s Principles of Transfusion Medicine, 3rd ed. Williams &
a. BacT/ALERT Wilkins, Baltimore, 2002.
b. eBDS 17. Ozment, CP, and Turi, JL: Iron overload following red blood
c. Gram stain cell transfusion and its impact on disease severity. Biochim
d. Pan Genera Detection (PGD) test Biophys Acta 1790(7):694–701, 2009.
18. Beutler, E: Red cell metabolism and storage. In Anderson, KC,
19. Prestorage pooled platelets can be stored for: and Ness, PM (eds): Scientific Basis of Transfusion Medicine.
WB Saunders, Philadelphia, 1994.
a. 4 hours. 19. Simon, TL, Snyder, EL, Stowell, CP, et al (eds): Rossi’s Princi-
b. 24 hours. ples of Transfusion Medicine, 4th ed. Wiley-Blackwell, Malden,
c. 5 days. MA, 2009.
d. 7 days. 20. Weinberg, JA, McGwin, G Jr, Marques, MB, et al: Transfusions
in the less severely injured: Does age of transfused blood affect
20. Which of the following is the most common cause of outcomes? J Trauma 65(4):794–798, 2008.
bacterial contamination of platelet products? 21. Offner, PJ, Moore, EE, Biffl, WL, Johnson, JL, and Silliman, CC:
Increased rate of infection associated with transfusion of old
a. Entry of skin plugs into the collection bag
blood after severe injury. Arch Surg 137(6):711–716, 2002.
b. Environmental contamination during processing 22. Vandromme, MJ, et al: Transfusion and pneumonia in the
c. Bacteremia in the donor trauma intensive care unit: An examination of the temporal
d. Incorrect storage temperature relationship. J Trauma 67(1):97–101, 2009.
23. Högman, CF: Additive system approach in blood transfusion
birth of the SAG and Sagman systems. Vox Sang 51:1986.
References 24. Högman, CF: Recent advances in the preparation and storage
1. Parks, D: Charles Richard Drew, MD 1904–1950. J Natl Med of red cells. Vox Sang 67:243–246, 1994.
Assoc 71:893–895, 1979. 25. Yasutake, M, and Takahashi, TA: Current advances of blood
2. Kendrick, DB: Blood Program in World War II, Historical Note. preservation—development and clinical application of additive
Washington Office of Surgeon General, Department of Army, solutions for preservation of red blood cells and platelets.
Washington, DC, 1964, pp 1–23. Nippon Rinsho 55:2429–2433, 1997.
3. United States Department of Health and Human Services: 2009 26. Jain, R, and Jarosz, C: Safety and efficacy as AS-1 red blood cell
National Blood Collection and Utilization Survey Report. Re- use in neonates. Transfus Apheresis Sci 24:111–115, 2001.
trieved August 2011 from http://www.hhs.gov/ash/bloodsafety/ 27. U.S. Department of Health and Human Services, Food and
2009nbcus.pdf. Drug Administration. Code of Federal Regulations, Title 21—
4. New York Blood Center. Blood Statistics. Retrieved August 30, Food and Drugs, Blood Products 600–680. U.S. Government
2011 from www.nybloodcenter.org/blood-statistics.do?sid0= Printing Office, Washington, DC, 2010.
85&page_id=202#bone. 28. Valeri, CR, et al: A multicenter study of in-vitro and in-vivo
5. Roback, J, Combs, M, Grossman, B, and Hillyer, C: Technical values in human RBCs frozen with 40% (wt/vol) glycerol and
stored after deglycerolization for 15 days at 4°C in AS-3: as-

t
Manual, 16th ed. American Association of Blood Banks,
Bethesda, MD, 2009. sessment of RBC processing in the ACP 215. Transfusion
6. Stramer, S: Current risks of transfusion-transmitted agents—a 41:933–939, 2001.
review. Arch Pathol Lab Med 131:702–707, 2007. 29. Klein, HG, Glynn, SA, Ness, PM, and Blajchman, MA: Research
7. Zou, S, et al: Current incidence and residual risk of hepatitis B opportunities for pathogen reduction/inactivation of blood
infection among blood donors in the United States. Transfusion components: Summary of an NHLBI workshop. Transfusion
49:1609–1620, 2009. 49:1262–1268, 2009.
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42 PART I Fundamental Concepts

Common Steps in Modern Genetics 2. There must be a way to visualize and locate the molecular
Techniques species to be studied. This is often done with probes that
act as signals or beacons that will bind specifically to the
Over the past three decades, the knowledge of genetics has molecule being analyzed; for example, DNA, by interac-
advanced exponentially. Understanding the biochemical and tion with parts of the molecule, such as hybridization
biophysical nature of DNA, RNA, and peptides and proteins with the hydrogen bonds of DNA. The probes can be syn-
has allowed techniques to be developed to study these im- thesized with radiolabels, chemiluminescence molecules,
portant molecules in great detail and to define the ways in fluorochromes, or nanoparticles.
which they interact in cells, groups of cells, complex multi- 3. A method to separate out different species and subspecies
cellular organisms, and even in an entire human being. Most being studied, such as different sequences of DNA, must
of the techniques used in molecular biology (the science of be available. An example of this involves running nucleic
studying and manipulating genetic material) are based on acids through gels, binding them to columns, hybridizing
the biochemical and biophysical properties of genes and them to membranes, or binding them to other molecules.
chromosomes. 4. A method to quantify the isolated and studied species has
The following steps are common to most techniques used to be used to get differences in amount as exact as possi-
in molecular biology: ble in the process studied. Changes in optical density
1. Any material that is to be studied must first be isolated when exposed to UV radiation, radioisotope emission lev-
intact without structural damage. This is often done with els, fluorescence energy detection, chemiluminescence
chemicals that interact with one part of the cellular ma- emission that can be detected with optical imaging
terial and not another. The methods to do this can be instruments can all be used to obtain data.
based on pH changes, salt gradients, detergent lysis, and Several techniques used in molecular biology are reviewed
enzyme activation. in Chapter 4.

SUMMARY CHART
Genetics is defined as the study of inheritance or the cannot be passed on to another generation. Some
transmission of characteristics from parents to offspring. mutations are silent and have no consequence on the
It is based on the biochemical structure of chromatin, organism in which they occur and therefore have no
which includes nucleic acids and the structural proteins selective pressure against them in the population.
that constitute the genetic material as well as various en- Transcription is an enzymatic process whereby genetic
zymes that assist in genetic processes such as replication. information in a DNA strand is copied into an mRNA
All living organisms have specific numbers of chromo- complementary strand. Eukaryotic mRNA is modified
somes. Humans have 22 pairs of autosomes and one after it is made by various processing steps, such as the
set of sex chromosomes, females (XX) and males (XY), removal of introns and addition of a poly-A tail to the
giving a total of 46 chromosomes in diploid cells. 3a end. These processing steps take place in the nu-
Mendel’s law of independent assortment states that fac- cleus of the cell before the mRNA is exported to the
tors for different characteristics are inherited independent cytoplasmic ribosomes for translation.
of each other if they reside on different chromosomes. Translation is the complex process by which mRNA,
Human chromosomes are composed of the genetic which contains a mobile version of the DNA template
material chromatin, a complex of the nucleic acid poly- encoding the genes for an organism, is turned into pro-
mer DNA wrapped around highly basic proteins called teins, which are the functional units of an organism and
histones. The helical structure of DNA allows a lot of in- the cells that it consists of. Translation occurs on the
formation to be packaged in a very small amount of space. ribosomes, and additional steps may be necessary to get
Replication of DNA is semiconservative and is accom- a specific protein into its final correct form, such as pro-
plished via the enzyme DNA polymerase, which pro- teins that require disulfide linkages and proteins that are
duces a complementary duplicate strand of nucleic positioned within the cell membrane. Proteins are made
acid. Therefore, each strand of DNA can act as a tem- of strings of amino acids and are always read in an amino
plate to be copied to make the opposite strand. DNA terminal (left) to carboxyl terminal (right) direction.
has a direction and is always read and written in the 5a The polymerase chain reaction (PCR) is an in vitro
(left) to 3a (right) direction unless specified differently method for enzymatic synthesis and amplification of spe-
for certain applications. cific DNA sequences using a pair of primers, usually
Mutation refers to any structural alteration of DNA in short nucleotide sequences, that hybridize to opposite
an organism (mutant) that is caused by a physical or DNA strands and flank the region of interest. Various
chemical agent (mutagen). Mutations can be beneficial modifications have made the PCR reaction more efficient
or deleterious. Some mutations are lethal and therefore and specific and allow more complex analysis.
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Chapter 2 Basic Genetics 43

9. Transcription can be defined as:

Review Questions
a. Introduction of DNA into cultured cells.
1. Which of the following statements best describes mitosis? b. Reading of mRNA by the ribosome.
c. Synthesis of RNA using DNA as a template.
a. Genetic material is quadruplicated, equally divided
d. Removal of external sequences to form a mature RNA
between four daughter cells
molecule.
b. Genetic material is duplicated, equally divided
between two daughter cells 10. When a male possesses a phenotypic trait that he passes
c. Genetic material is triplicated, equally divided to all his daughters and none of his sons, the trait is said
between three daughter cells to be:
d. Genetic material is halved, doubled, then equally a. X-linked dominant.
divided between two daughter cells b. X-linked recessive.
2. When a recessive trait is expressed, it means that: c. Autosomal dominant.
d. Autosomal recessive.
a. One gene carrying the trait was present.
b. Two genes carrying the trait were present. 11. When a female possesses a phenotypic trait that she
c. No gene carrying the trait was present. passes to all of her sons and none of her daughters, the
d. The trait is present but difficult to observe. trait is said to be:
3. In a pedigree, the “index case” is another name for: a. X-linked dominant.
b. X-linked recessive.
a. Stillbirth.
c. Autosomal dominant.
b. Consanguineous mating.
d. Autosomal recessive.
c. Propositus.
d. Monozygotic twins. 12. DNA is replicated:
4. Which of the following nitrogenous bases make up DNA? a. Semiconservatively from DNA.
b. In a random manner from RNA.
a. Adenine, leucine, guanine, thymine
c. By copying protein sequences from RNA.
b. Alanine, cytosine, guanine, purine
d. By first copying RNA from protein.
c. Isoleucine, lysine, uracil, leucine
d. Adenine, cytosine, guanine, thymine 13. RNA is processed:
5. Proteins and peptides are composed of: a. After RNA is copied from DNA template.
b. After protein folding and unfolding on the ribosome.
a. Golgi bodies grouped together.
c. Before DNA is copied from DNA template.
b. Paired nitrogenous bases.
d. After RNA is copied from protein on ribosomes.
c. Nuclear basic particles.
d. Linear arrangements of amino acids. 14. Translation of proteins from RNA takes place:
6. Which phenotype(s) could not result from the mating a. On the ribosomes in the cytoplasm of the cell.
of a Jk(a+b+) female and a Jk(a-b+) male? b. On the nuclear membrane.
c. Usually while attached to nuclear pores.
a. Jk(a+b–)
d. Inside the nucleolus of the cell.
b. Jk(a+b+)
c. Jk(a–b+) 15. Meiosis is necessary to:
d. Jk(a–b-) a. Keep the N number of the cell consistent within
7. Exon refers to: populations.
b. Prepare RNA for transcription.
a. The part of a gene that contains nonsense mutations.
c. Generate new DNA sequences in daughter cells.
b. The coding region of a gene.
d. Stabilize proteins being translated on the ribosome.
c. The noncoding region of a gene.
d. The enzymes used to cut DNA into fragments.
References
8. PCR technology can be used to: 1. Watson, JD, and Crick, FHC: Molecular structure of nucleic
a. Amplify small amounts of DNA. acids: A structure for deoxyribose nucleic acid. Nature 171:737,
b. Isolate intact nuclear RNA. 1953.
c. Digest genomic DNA into small fragments. 2. Garrett, RH, and Grisham, CM: Structure of nucleic acids. In
Garret, RH, and Grisham, CM: Biochemistry, 4th ed. Brooks/Cole,
d. Repair broken pieces of DNA.

t
Cengage Learning, Boston, 2010, pp 316–353.
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74 PART I Fundamental Concepts

SUMMARY CHART
The immune system interacts with other host systems Membrane-bound antibodies are manufactured by
and maintains the host equilibrium. The two major B cells and inserted into their cell membranes, where
roles for the IS are: they act as antigen receptors.
• Protection from pathogens and foreign substances Stimulated B cells differentiate into plasma cells to
• Removal of abnormal and damaged host cells secrete humoral immunoglobulin; B cells receive
The two major branches of the IS are: T-cell help for antibody production and for immuno-
• Innate, or natural—the nonspecific primitive IS logic memory; a single B cell clone manufactures Ig of
• Acquired, or adaptive—the specific, evolved IS a single specificity for a specific antigen for its entire
The two major arms of the acquired IS are: cell lifetime.
• Humoral, mediated by B cells and antibody The primary, or original, immune response occurs after
production the first exposure to an antigen. The secondary, or
• Cellular, mediated by T cells and lymphokines anamnestic, immune response happens after a second
The basic mechanisms used by the IS are: exposure with the same specific antigen.
• Recognition of self and nonself organisms, cells, and Complement consists of a large group of different
tissues enzymatic proteins (convertases/esterases) that circulate
• Removal of unwanted organisms, cells, and tissues in an inactive proenzyme form. Once the cascade is
(self or nonself) started, they activate each other in a sequence to form
• Repair of damaged host tissues products that are involved in optimizing phagocytosis
The acquired IS demonstrates diversity and uniqueness: and cell lysis.
• Individual B and T cells have vast arrays of unique Complement can be activated through three pathways:
membrane molecules that can have configurations • The classical pathway is initiated by antigen-
to match nearly any antigen in the environment. antibody complexes and requires C1q for activa-
• Each individual lymphocyte has one unique recep- tion to proceed.
tor per cell that recognizes one epitope. • The alternative pathway is activated by certain
• Antibodies and T-cell receptors recognize and react macromolecules on the cell walls of bacteria, fungi,
only with the antigen that matches and fits their parasites, and tumor cells and requires C3b, serum
specific configuration. factors B, D, properdin, and initiating factor.
• Selected T and B cells can remain dormant and later • The lectin pathway is activated by binding of MBL
respond more rigorously upon second exposure of to microbes.
a previously recognized antigen. All three pathways meet at a common point in the
The acquired IS demonstrates tolerance: this indicates cascade and result in the formation of the membrane
that immune responses against the host are either attack complex to remove unwanted cells.
removed or downregulated. There are five classes (or isotypes) of immunoglobu-
There are three types of lymphocytes: T cells, B cells, lins, all of which have a basic four-chain protein struc-
and NK cells. ture consisting of two identical light chains and two
T cells (or lymphocytes) have the TCR, which is usually identical heavy chains. Disulfide (covalent) bonds link
associated with the CD3 complex, and T cells require each light chain to a heavy chain and link the two
APCs to respond to antigens. heavy chains to each other.
There are two well-characterized subpopulations of Antibody molecules are isotypic (based on heavy chain
T cells distinguished by CD markers—T helper (TH, subtype), allotypic (based on one heavy chain muta-
CD4-positive) and T cytotoxic (Tc, CD8-positive) tion), or idiotypic (based on hypervariable and variable
lymphocytes. regions of light and heavy chains) and are reflected in
TH lymphocytes have CD4 markers on their cell mem- the Ig sequences.
branes, provide B-cell help to stimulate the immune Blood group antibodies may be characterized by such
response, release lymphokines when stimulated, and factors as epitope and variable region diversity (mon-
recognize antigens in association with MHC class II oclonal or polyclonal), mode of sensitization (naturally
molecules. occurring or immune), expected or unexpected pres-
TC lymphocytes have the CD8 marker on their mem- ence in routine serum samples, isotype class (IgM,
branes and can eliminate specific target cells without IgG, or, rarely, IgA), activity (warm or cold reactive
the help of antibody (cytotoxicity). or both, agglutinating or sensitizing), clinical signifi-
cance, alloantibody or autoantibody specificity, serum
B lymphocytes (or cells) make up about 5% to 15% of
titer, and chemical reactivity (influence of enzymes,
circulating lymphocytes and are characterized by their
sensitivity to pH, DTT, or 2-ME reagents).
membrane-bound antibodies (or immunoglobulins)
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Chapter 3 Fundamentals of Immunology 75

9. Which of the following immunoglobulins is most effi-

Review Questions
cient at binding complement?
1. Which of the following is not involved in the acquired or a. IgA
adaptive immune response? b. IgE
c. IgG
a.Phagocytosis
d. IgM
b.Production of antibody or complement
c.Induction of immunologic memory 10. Which portion of the immunoglobulin molecules
d.Accelerated immune response upon subsequent expo- contains complement binding sites?
sure to antigen a. Heavy chain variable region
2. Which cells are involved in the production of antibodies? b. Light chain variable region
c. Heavy chain constant region
a. Dendritic cells
d. Light chain constant region
b. T lymphocytes
c. B lymphocytes 11. Which complement pathway is activated by the forma-
d. Macrophages tion of antigen-antibody complexes?
3. Which of the following cells is involved in antigen recog- a. Classical
nition following phagocytosis? b. Alternative
c. Lectin
a. B lymphocytes
d. Retro
b. T lymphocytes
c. Macrophages 12. Which of the following is known as the “recognition
d. Granulocytes unit” in the classical complement pathway?
4. The role of the macrophage during an antibody response a. C1q
is to: b. C3a
c. C4
a. Make antibody
d. C5
b. Lyse virus-infected target cells
c. Activate cytotoxic T cells 13. Which of the following is known as the “membrane
d. Process antigen and present it attack complex” in the classical complement pathway?
5. Which of the following immunoglobulins is produced in a. C1
the primary immune response? b. C3
c. C4, C2, C3
a. IgA
d. C5b, C6, C7, C8, C9
b. IgE
c. IgG 14. Which of the following immunoglobulin classes is
d. IgM capable of crossing the placenta and causing hemolytic
disease of the newborn?
6. Which of the following immunoglobulins is produced in
the secondary immune response? a. IgA
b. IgE
a. IgA
c. IgG
b. IgE
d. IgM
c. IgG
d. IgM 15. Which of the following refers to the effect of an excess
amount of antigen present in a test system?
7. Which of the following MHC classes are found on
antigen presenting cells? a. Postzone
b. Prozone
a.Class I
c. Zone of equivalence
b.Class II
d. Endzone
c.Class III
d.Class IV 16. Which of the following refers to the presence of an
excess amount of antibody present in a test system?
8. Which of the following MHC classes encodes complement
components? a. Postzone
b. Prozone
a.Class I

t
c. Zone of equivalence
b.Class II
d. Endzone
c.Class III
d.Class IV
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76 PART I Fundamental Concepts

17. Which of the following refers to a state of equilibrium 3. Sunshine, G, and Coico, R: Immunology: A Short Course,
in antigen-antibody reactions? 6th ed. John Wiley & Sons, Hoboken, 2009.
4. Stites, DP, Parslow, TG, Imboden, JB, and Terr, AI (eds):
a. Postzone Medical Immunology, 10th ed. McGraw-Hill, New York, 2001.
b. Prozone 5. Nance, SJ, Arndt, PA, and Garratty, G: Correlation of IgG
c. Zone of equivalence subclass with the severity of hemolytic disease of the newborn.
d. Endzone Transfusion 30:381, 1990.
6. Rieben, R, et al: Antibodies to histo-blood group substances A
18. Which one of the following properties of antibodies is and B: Agglutination titers, Ig class, and IgG subclasses in
NOT dependent on the structure of the heavy chain con- healthy persons of different age categories. Transfusion 31:607,
1991.
stant region? 7. Sokol, RJ, et al: Red cell autoantibodies, multiple immunoglob-
a. Ability to cross the placenta ulin classes, and autoimmune hemolysis. Transfusion 30:714,
b. Isotype (class) 1990.
c. Ability to fix complement 8. Kerr, WG, Hendershot, LM, and Burrows, PD: Regulation of
IgM and IgD expression in human B-lineage cells. J Immunol
d. Affinity for antigen
146:3314, 1991.
19. Molecules that promote the update of bacteria for 9. Klein, HG, and Anstee, DJ (eds): Red cell antibodies against
self-antigens, bound antigens and induced antigens. In Molli-
phagocytosis are: son’s Blood Transfusion in Clinical Medicine, 11th ed. Wiley-
a. Opsonins Blackwell, Oxford, UK, 2007, pp 253–298.
b. Cytokines 10. Klein, HG, and Anstee, DJ (eds): ABO, Lewis and P groups and
c. Haptens Ii antigens. In Mollison’s Blood Transfusion in Clinical Medi-
cine, 11th ed. Wiley-Blackwell, Oxford, UK, 2007, pp 114–162.
d. Isotypes
11. Turgeon, ML: Fundamentals of Immunohematology, 2nd ed.
20. Select the term that describes the unique confirmation Lippincott Williams & Wilkins, Philadelphia, 2003.
12. Schleuning, M, et al: Complement activation during storage of
of the antigen that allows recognition by a correspon- blood under normal blood bank conditions: Effects of pro-
ding antibody: teinase inhibitors and leukocyte depletion. Blood 79:3071,
a. Immunogen 1992.
b. Epitope 13. Issitt, PD, and Anstee, DJ: Applied Blood Group Serology,
4th ed. Montgomery Scientific, Durham, NC, 1998, pp 34–35.
c. Avidity
14. Kutt, SM, et al: Rh Blood Group System Antigens, Antibodies,
d. Clone Nomenclature, and Testing. Ortho Diagnostic Systems, Raritan,
NJ, 1990, pp 13–14.
21. Which of the following terms refers to the net negative 15. Stevens, CD: Clinical Immunology and Serology: A Laboratory
charge surrounding red blood cells? Perspective, 3rd ed. FA Davis Company, Philadelphia, 2009.
a. Dielectric constant 16. Ammann, AJ: Mechanisms of immunodeficiency. In Stites, DP,
b. Van der Waals forces Terr, AI, and Parslow, TG (eds): Basic and Clinical Immunology,
8th ed. Appleton & Lange, Norwalk, 1994.
c. Hydrogen bonding
d. Zeta potential

References
1. Waytes, AT, et al: Pre-ligation of CR1 enhances IgG-dependent
phagocytosis by cultured human monocytes. J Immunol
146:2694, 1991.
2. Roback, J, Combs, M, Grossman, B, and Hillyer, C: Technical
Manual, 16th ed. CD-ROM. American Association of Blood
Banks, Bethesda, MD, 2009.
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Chapter 4 Concepts in Molecular Biology 97

Extensive Blood Group Typing of Donors Determining the Frequency of Blood Group
for Alloimmunized Patients Polymorphisms in a Population
Patients with multiple antibodies may require extensive test- Genotyping databases can be used to predict the possibility
ing to find compatible blood for transfusion. It is now possible of finding a specific allele in a given population once a
to genotype potential donors and the patient to prevent further similar population has been analyzed at the genotype level.
immunization and to characterize the donor at a more specific Because most blood group alleles are the result of a single
level.53 DNA testing can be done in place of extensive family nucleotide polymorphism, screening of blood samples for
studies to determine the genotype. Sequencing of the entire allele frequency can be relatively easy and done by simple
gene of interest, often required to obtain sufficient informa- DNA-based methods. Several different methods employed
tion, may be labor-intensive. The amount of work may be less- for this include RFLP and SSP-PCR (single or multiplex),
ened if exon sequencing is done first and if RFLPs can be done real-time quantitative PCR, sequencing and microarray tech-
on certain areas of the gene at the beginning of the study. nology using DNA probes on chips.
Focused sequencing with comparisons to antigenic profiles
can also be used. Having extensive information on the Blood Group Typing of Patients With Autoimmune
patients’ and the potential donors’ genotypes allows transfu- Hemolytic Anemia and Other Diseases
sion to take place in a safer environment. Knowing the anti- Patients with autoimmune hemolytic anemia and other con-
gens that the patient does not have based on genotyping ditions such as sickle cell anemia can have trouble obtaining
prevents further alloantibodies from being made from the compatible donor units. They are often sensitized to many
transfusion of blood that is positive for these antigens. Because antigens and have a rapid turnover of red cells, requiring
red cells have lost their nuclei, white cells can be used for frequent transfusion. Because they can have a complex pop-
genotyping and other normal adult diploid cells. ulation of red cells, with autologous cells mixed with trans-
fused cells from more than one donor, genotyping methods
Screening of Blood Donors to Find Rare are an excellent way to type these donors. A small amount
Blood Group Phenotypes of patient white cells or cheek cells can be used to determine
Using DNA-based methods to screen blood donors allows for the genotype using standard DNA-based methods, and the
a high-throughput system screening in comparison with serol- subsequent patient phenotype can be determined from the
ogy-based methods. Blood group antisera often are not readily genotype.
available for rare blood group phenotypes or are prohibitively Although crossmatching may not provide totally com-
expensive to use on a large scale. Genotyping with PCR tech- patible results, especially with autoimmune diseases, at
niques allows for the probes (or primers) to be synthesized at least alloantigens can be ruled out when transfusion is
low cost and used in DNA-based methods, as long as informa- required, thereby preventing further alloimmunization in
tion about the sequence of the gene is known. Different alleles an already-difficult-to-transfuse patient. In addition to
can be tested at the same time in the multiplex PCR assays or saving the time required for repeated adsorptions, elu-
on microarrays. Once known, the genotype information can tions, and extensive phenotyping in these patients and in
be put into a database and does not require repeated testing, donor units, the information obtained by DNA-based
which saves considerable time and money. A rare donor profile methods is highly accurate and easy to obtain. It is a
can be generated, linking potential donors to potential recipi- permanent record of the patient’s genetic profile, and it is
ents for better recruitment in cases of emergency. For patients necessary information in cases where transplant may be
requiring donor units with rare phenotypes, the costs and time considered. It is also a permanent record of the donor’s
involved in genotyping such donor units are acceptable. profile when performed.

SUMMARY CHART
The central dogma of molecular biology: DNA m RNA The structure of DNA determines its function. The
m protein. sequence of nucleotides of one strand determines the
Proteins have structural, enzymatic, and gene-regulatory sequence of its complementary strand, the basis for
function. Through these mechanisms, the genotype of the semiconservative way of replication.
a cell is translated into its phenotype. A gene is transcribed into precursor RNA, and the
DNA is the genetic material. spliced mRNA is translated into the amino acid
DNA is a double helix, consisting of two antiparallel sequence of the coded protein. The sequence of
strands of stacked nucleotides paired through hydro- mRNA unequivocally determines the sequence of the
gen bonds. Adenine (A) always pairs with thymine (T), protein.
and cytosine (C) always pairs with guanine (G).

Continued
2682_Ch04_077-100 22/05/12 11:40 AM Page 98

98 PART I Fundamental Concepts

SUMMARY CHART—cont’d
Recombinant DNA is the DNA of one organism “cut Genomic and cDNA libraries are collections of clones
and pasted” into a carrier vector. The foreign gene containing the genetic material of a cell.
introduced in a host organism is functional because the Base pairing between complementary strands of DNA or
genetic code is universal. RNA (hybridization with a labeled probe) is used to de-
By DNA cloning, recombinant genes of complex animals, tect specific nucleic acid sequences in complex mixtures.
such as humans, are introduced into simple organisms, Southern blotting, Northern blotting, and dot blotting
such as bacteria, and other model organisms, such as are hybridization-based techniques for nucleic acid
mice, allowing structural and functional studies. sequence-specific recognition.
Restriction endonucleases, bacterial enzymes that rec- The polymerase chain reaction (PCR) is an in vitro
ognize and cut specific DNA sequences, are fundamen- method for DNA amplification.
tal tools for DNA cloning. Molecular polymorphism is studied at the genetic
Gel electrophoresis separates nucleic acids by size. level by DNA typing. Methods for DNA typing
The most common host cell is the bacterium E. coli. relevant for transfusion medicine are restriction
Plasmids, the most commonly used vectors, are inde- fragment length polymorphism, allele-specific oligonu-
pendently replicating circular DNA molecules modified cleotide probe hybridization, allele-specific PCR
to provide the host cell with resistance to antibiotics amplification, DNA sequencing, and DNA profiling
(selectable marker) and one or more restriction enzyme (DNA fingerprinting).
sites for inserting the recombinant gene. PCR and TMA are used for the early detection of
By reverse transcription, mRNA is transcribed into transfusion-transmitted pathogens.
complementary DNA (cDNA). Other therapeutic uses of molecular biology are gene
Automated fluorescent DNA sequencing based on the therapy and the clinical use of recombinant proteins,
Sanger dideoxy, chain termination method is a stan- such as interferons, coagulation factors, and growth
dard laboratory procedure. factors.
DNA sequencing of a cloned cDNA corresponding to Molecular RBC antigen typing is used to either confirm
a given gene is the easiest way to determine the amino serologic testing or in cases where serology is not possible
acid sequence of a protein. or is not sensitive enough or where discrepancies occur.

5. The polymerase chain reaction (PCR):

Review Questions
a. Is carried out in vivo
1. The central dogma of molecular biology states that: b. Is used for peptide synthesis
c. Requires RNA polymerase
a. DNA is the genetic material
d. Is used for the amplification of DNA
b. RNA is the genetic material
c. DNA is translated to mRNA 6. Plasmids are:
d. Proteins are transcribed from mRNA a. Vectors used for molecular cloning
2. Recombinant-DNA technology is possible because: b. Antibiotics
c. Enzymes
a. Restriction endonucleases cut RNA
d. Part of chromosomes
b. Restriction endonucleases cut proteins
c. The genetic code is universal 7. Some model organisms:
d. Bacteria are difficult to culture a. Simplify the study of human disease
3. Agarose gel electrophoresis is a technique used for: b. Are used to produce recombinant proteins
c. Are prokaryotes and some are eukaryotes
a. DNA synthesis
d. All of the above
b. RNA synthesis
c. Separation of DNA molecules by size 8. DNA sequencing:
d. Oligonucleotide synthesis a. Is more difficult than peptide sequencing
4. Restriction fragment length polymorphism (RFLP) is b. Requires the use of RNA polymerase
based on the use of the enzymes: c. Can never be automated
d. Is an enzymatic in vitro reaction
a. Reverse transcriptases
b. Bacterial endonucleases
c. DNA polymerases
d. RNA polymerases
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Chapter 4 Concepts in Molecular Biology 99

9. RFLP and SSP are techniques used for: 12. Brenner, S, Jacob, F, and Meselson, M: An unstable intermediate
carrying information from genes to ribosomes for protein
a. Protein isolation synthesis. Nature 190:576–581, 1961.
b. RNA isolation 13. Nirenberg, M, and Leder, P: RNA codewords and protein
c. DNA typing synthesis. Science 145:1399–1407, 1964.
d. Protein typing 14. Temin, HM, and Mizutani, S: RNA-dependent DNA polymerase
in virions of Rous sarcoma virus. Nature 226:1211–1213, 1970.
10. Recombinant DNA techniques: 15. Baltimore, D: RNA-dependent DNA polymerase in virions of
a. Are not used in a clinical setting RNA tumour viruses. Nature 226:1209–1211, 1970.
16. Sharp, PA: RNA interference—2001. Genes Dev 15:485–490,
b. Are useful research tools 2001.
c. Are not used in blood banking 17. Yamamoto, F, et al: Cloning and characterization of DNA
d. Are useful only for research complementary to human Histo-blood group A transferase
mRNA. J Biol Chem 265:1146–1151, 1990.
11. Transcription mediated amplification: 18. Sambrook, J, and Russell, DW: Molecular Cloning: A Labora-
a. Requires thermostable DNA polymerase tory Manual, 3rd ed. Cold Spring Harbor Laboratory Press,
b. Is an isothermal procedure Cold Spring Harbor, NY, 2001.
19. Alberts, B, et al: Molecular biology of the cell, 4th ed. Garland
c. Is an obsolete method currently replaced by SSOP Publishing, New York, 2002.
d. Utilizes probes labeled with fluorescent tags 20. Nathans, D, and Smith, HO: Restriction endonucleases in the
analysis and restructuring of DNA molecules. Ann Rev
12. Preseroconversion window: Biochem 44:273–293, 1975.
a. Is the time when donors can be infected but do not 21. Wagner FF, and Flegel, WA: RHD gene deletion occurred in the
yet test positive by serologic methods Rhesus box. Blood 95:3662–3668, 2000.
b. May be narrowed by using molecular methods 22. Kirsanov, KI, Lesovaya, EA, Yakubovskaya, MG, and Belitsky,
GA: SYBR Gold and SYBR Green II are not mutagenic in the
c. Refers mainly to viral pathogens
Ames test. Mutat Res 699(1-2):1–4, 2010.
d. All of the above 23. Logdberg, L, Reid, M, and Zelinski, T: Human blood group
genes 2010: Chromosomal locations and cloning strategies
13. Red blood cell molecular antigen typing is useful in all revisited. Transfus Med Rev 25(1):36–46, 2011.
listed situations except: 24. International Human Genome Sequencing Consortium: Initial
a. In screening RBC inventory for antigen-negative units sequencing and analysis of the human genome. Nature
b. When reagent antibodies are weak or unavailable 409:860–921, 2001.
25. Gaspar, HB: Bone marrow transplantation and alternatives for
c. In quantitative gene expression analysis
adenosine deaminase deficiency. Immunol Allergy Clin North
d. When resolving ABO discrepancies Am 30(2):221–236, 2010.
26. Saiki, RK, Gelfand, DH, Stoffel, S, Scharf R, Higuchi, R, Horn,
References GT, et al: Primer-directed enzymatic amplification of DNA
with a thermostable DNA polymerase. Science 239:487–491,
1. Crick, F: Central dogma of molecular biology. Nature 1988.
227(5258):561–563, 1970. 27. Busch, MP, and Kleinman, SH: Nucleic acid amplification
2. Griffith, F: The significance of pneumococcal types. J Hyg testing of blood donors for transfusion-transmitted diseases.
(Lond) 27(2):113–159, 1928. Report of the Interorganizational Task Force on nucleic acid
3. Avery, OT, MacLeod, CM, and McCarty M: Studies on the amplification testing of blood donors. Transfusion 40:143–159,
chemical nature of the substance inducing transformation of 2000.
pneumococcal types. Induction of transformation by a des- 28. Kraj, B, and Nadder, T: Blood donor screening process and
oxyribonucleic acid fraction isolated from Pneumococcus type infectious disease testing using molecular methods. Advance
III. J Exp Med 1;79(2):137–158, 1944. for Medical Laboratory Professionals, 17–20, October 8, 2007.
4. Hershey, AD, and Chase, M: Independent functions of viral 29. Sanger, F, Nicklen, S, and Coulson, AR: DNA sequencing
protein and nucleic acid in growth of bacteriophage. J Gen with chain-terminating inhibitors. Proc Natl Acad Sci USA
Physiol 36(1):39–56, 1952. 74:5463–5467, 1977.
5. Chargraff, E, Magasanik, B, Visher, E, Green, C, Doniger, R, and 30. Southern, EM: Detection of specific sequences among DNA
Elson, D: Nucleotide composition of pentose nucleic acids from fragments separated by gel electrophoresis. J Mol Biol 98:
yeast and mammalian tissues. J Biol Chem 186(1):51–67, 1950. 503–517, 1975.
6. Watson, JD, and Crick, FHC: Molecular structure of nucleic 31. Brown, PO, and Botstein, D: Exploring the new world of the
acids: A structure for deoxyribose nucleic acid. Nature genome with DNA microarrays. Nat Genet 21:33–37, 1999.
171:737–738, 1953. 32. Hashmi, G, et al: A flexible array format for large-scale,
7. Breslauer, KJ, et al: Predicting DNA duplex stability from the rapid blood group DNA typing. Transfusion 45(5):680–688,
base sequence. Proc Natl Acad Sci USA 83(11):3746–3750, 2005.
1986. 33. Montpetit, A, et al: High-throughput molecular profiling of
8. Lewin, B: Genes VIII. Prentice Hall, New York, 2004, p 392. blood donors for minor red blood cell and platelet antigens.
9. Pauling, L, Itano, HA, et al: Sickle cell anemia a molecular Transfusion 46(5):841–848, 2006.
disease. Science 110(2865):543–548, 1949. 34. Bennett, EP, et al: Genomic cloning of the human histo-blood
10. Ingram, VM: Gene mutations in human hemoglobin: The group ABO locus. Biochem Biophys Res Commun 206(1):
chemical difference between normal and sickle cell hemoglobin. 318–325, 1995.
Nature 180:326–328, 1957. 35. Lyondagger, E, Millsondagger, A, Phan, T, and Wittwer, CT:
11. Keller, EB, Zamecnik, PC, and Loftfield, RB: The role of micro- Detection and Identification of base alterations within the
somes in the incorporation of amino acids into proteins. region of factor V Leiden by fluorescent melting curves. Mol
J Histochem Cytochem 2(5):378–386, 1954. Diagn 3(4):203–209, 1998.
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Chapter 5 The Antiglobulin Test 115

CASE STUDIES Case 5-2

Case 5-1 A 34-year-old white male is admitted for an exploratory
laparotomy. A type and screen is ordered prior to his
You are working second shift at a Midwestern suburban
scheduled surgery. ABO and Rh typing reveal the patient
hospital. Although you were trained in school using gel
is O-positive, and the blood bank technologist performed
technology, your lab utilizes the conventional tube testing
an antibody screen using the patient serum and a two-cell
method using LISS as an enhancement medium, because
screen using gel technology. One of the cells in the antibody
the medical director refuses to adopt gel as the primary
screen is weakly reactive, so you proceed with an anti-
AHG methodology. About an hour before the end of your
body identification using a ten-cell panel. However, only
shift, the phlebotomist brings you a routine type and
two cells are weakly reactive (1+) and show no pattern of
screen for a patient just admitted to the medical surgical
reactivity. A second panel is run and yields similar results.
floor. Because you are confident you can finish before
You decide to run an antibody identification panel using
your shift ends, you decide to proceed with testing. The
the conventional tube testing method with LISS as your
patient types as an A-positive. The antibody screen results
enhancement medium. All reactions are negative using
were negative in all phases of testing. Therefore, check
LISS, including the cells that were previously positive.
cells were added to all tubes and the reactions after cen-
trifuging were also negative. 1. Can the antibody screen be interpreted as negative?
2. Provide an explanation for the observed results.
1. Can the antibody screen be interpreted as negative?
3. Are there additional tests that should be conducted to
2. What steps must be taken to resolve the problem?
complete testing on this patient? If so, which tests
3. What is the most likely cause for the discrepant
should be run?
results?
4. What are other causes for the results?

SUMMARY CHART
The antiglobulin test is used to detect RBCs sensitized The IAT detects in vitro sensitization of RBCs and
by IgG alloantibodies, IgG autoantibodies, and com- can be applied to compatibility testing, antibody
plement components. screen, antibody identification, RBC phenotyping, and
AHG reagents containing anti-IgG are needed for titration studies.
the detection of IgG antibodies because the IgG A positive DAT is followed by a DAT panel using
monomeric structure is too small to directly aggluti- monospecific anti-IgG and anti-C3d to determine the
nate sensitized RBCs. specific type of protein sensitizing the RBC.
Polyspecific AHG sera contain antibodies to human EDTA should be used to collect blood samples for
IgG and the C3d component of human complement. the DAT to avoid in vitro complement attachment
Monospecific AHG sera contain only one antibody associated with refrigerated clotted specimens.
specificity: either anti-IgG or antibody to anti–C3b-C3d. There are multiple sources or error that can be intro-
Classic AHG sera (polyclonal) are prepared by injecting duced into the AHG procedure.
human globulins into rabbits, and an immune stimulus LISS, PEG, polybrene, and albumin can all be used as
triggers production of antibody to human serum. enhancement media for AHG testing, with each having
Hybridoma technology is used to produce monoclonal their own advantages and disadvantages.
antiglobulin serum. Conventional tube testing, gel technology, enzyme-
The DAT detects in vivo sensitization of RBCs with linked technology, and solid-phase testing are available
IgG or complement components. Clinical conditions methods to use in AHG testing.
that can result in a positive DAT include HDN, HTR, Method-dependent antibodies do exist and should be
and AIHA. evaluated on a case-by-case basis.
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116 PART II Blood Groups and Serologic Testing

8. False-positive DAT results are most often associated with:

Review Questions
a. Use of refrigerated, clotted blood samples in which
1. A principle of the antiglobulin test is: complement components coat RBCs in vitro.
b. A recipient of a recent transfusion manifesting an
a. IgG and C3d are required for RBC sensitization.
immune response to recently transfused RBCs.
b. Human globulin is eluted from RBCs during saline
c. Presence of heterophile antibodies from administra-
washings.
tion of globulin.
c. Injection of human globulin into an animal engenders
d. A positive autocontrol caused by polyagglutination.
passive immunity.
d. AHG reacts with human globulin molecules bound to 9. Polyethylene glycol enhances antigen-antibody reactions
RBCs or free in serum. by:
2. Polyspecific AHG reagent contains: a. Decreasing zeta potential.
b. Concentrating antibody by removing water.
a. Anti-IgG.
c. Increasing antibody affinity for antigen.
b. Anti-IgG and anti-IgM.
d. Increasing antibody specificity for antigen.
c. Anti-IgG and anti-C3d.
d. Anti-C3d. 10. Solid-phase antibody screening is based on:
3. Monoclonal anti-C3d is: a. Adherence.
b. Agglutination.
a. Derived from one clone of plasma cells.
c. Hemolysis.
b. Derived from multiple clones of plasma cells.
d. Precipitation.
c. Derived from immunization of rabbits.
d. Reactive with C3b and C3d. 11. A positive DAT may be found in which of the following
situations?
4. Which of the following is a clinically significant antibody
whose detection has been reported in some instances to a. A weak D-positive patient
be dependent on anticomplement activity in polyspecific b. A patient with anti-K
AHG? c. HDN
d. An incompatible crossmatch
a. Anti-Jka
b. Anti-Lea 12. What do Coombs’ control cells consist of?
c. Anti-P1 a. Type A-positive cells coated with anti-D
d. Anti-H b. Type A-negative cells coated with anti-D
5. After the addition of IgG-coated RBCs (check cells) to a c. Type O-positive cells coated with anti-D
negative AHG reaction during an antibody screen, a d. Type O-negative cells coated with anti-D
negative result is observed. Which of the following is a 13. Which of the following methods requires the use of
correct interpretation? check cells?
a. The antibody screen is negative. a. LISS
b. The antibody screen needs to be repeated. b. Gel
c. The saline washings were adequate. c. Solid-phase
d. Reactive AHG reagent was added. d. Enzyme-linked
6. RBCs must be washed in saline at least three times before 14. Which factor can affect AHG testing, yet is uncontrollable
the addition of AHG reagent to: in the lab?
a. Wash away any hemolyzed cells a. Temperature
b. Remove traces of free serum globulins b. Antibody affinity
c. Neutralize any excess AHG reagent c. Gravitational force in the centrifuge
d. Increase the antibody binding to antigen d. Incubation time
7. An in vitro phenomenon associated with a positive 15. If you had the authority to decide which primary AHG
IAT is: methodology to utilize at your lab, which method would
a. Maternal antibody coating fetal RBCs you choose based on the knowledge that the majority of
b. Patient antibody coating patient RBCs the staff are generalists?
c. Recipient antibody coating transfused donor RBCs a. LISS
d. Identification of alloantibody specificity using a panel b. Polybrene
of reagent RBCs c. Solid phase or gel
d. Enzyme-linked
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Chapter 5 The Antiglobulin Test 117

16. A 27-year-old group O mother has just given birth to a 23. Lachman, PJ, and Muller-Eberhard, HJ: The demonstration in
beautiful, group A baby girl. Since the mother has IgG human serum of “conglutinogen-activating-factor” and its
effect on the third component of complement. J Immunol
anti-A in her plasma, it is likely that the baby is experi- 100:691, 1968.
encing some in vivo red cell destruction. Which of the 24. Muller-Eberhard, HJ: Chemistry and reaction mechanisms of
following methods and tests would be most effective at complement. Adv Immunol 8:1, 1968.
detecting the anti-A on the baby’s RBCs? 25. Cooper, NR: Isolation and analysis of mechanisms of action of
an inactivator of C4b in normal human serum. J Exp Med
a. DAT using common tube technique
141:890, 1975.
b. DAT using gel 26. Case, J, et al: International reference reagents: Antihuman glob-
c. IAT using common tube technique ulin, an ISBT/ICSH Joint Working Party Report. Vox Sang
d. IAT using gel 77:121, 1999.
27. Brown, DL, et al: The in vivo behaviour of complement-coated
red cells: Studies in C6-deficient, Ce-depleted and normal
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papers/monoanti.htm. 37. Stroup, M, and MacIlroy, M: Evaluation of the albumin
12. Kohler, G, and Milstein, C: Continuous cultures of fused cells antiglobulin technique in antibody detection. Transfusion
secreting antibody of predefined specificity. Nature 256:495, 5:184, 1965.
1975. 38. Low, B, and Messeter, L: Antiglobulin test in low-ionic strength
13. Lachman, PJ, et al: Use of monoclonal antibodies to characterize salt solution for rapid antibody screening and cross-matching.
the fragments of C3 that are found on erythrocytes. Vox Sang Vox Sang 26:53, 1974.
45:367, 1983. 39. Moore, HC, and Mollison, PL: Use of a low-ionic strength
14. Holt, PDJ, et al: NBTS/BRIC 8: A monoclonal anti-C3d anti- medium in manual tests for antibody detection. Transfusion
body. Transfusion 25:267, 1985. 16:291, 1976.
15. Voak, D, et al: Monoclonal antibodies—C3 serology. Biotest 40. Shirley, R, et al: Polyethylene glycol versus low-ionic strength
Bull 1:339, 1983. solution in pretransfusion testing: A blinded comparison study.
16. Mollison, PL: Blood Transfusion in Clinical Medicine, 7th ed. Transfusion 34:5, 1994.
Blackwell Scientific, Oxford, 1983, p 502. 41. Barrett, V, et al: Analysis of the routine use of polyethylene
17. Garratty, G, et al: An IgA high titre cold agglutinin with an un- glycol (PEG) as an enhancement medium. Immunohematology
usual blood group specificity within the Pr complex. Vox Sang 11:1, 1995.
25:32, 1973. 42. Jorgensen, J, et al: The influence of ionic strength, albumin and
18. Petz, LD, and Garratty, G: Acquired Immune Hemolytic Anemias. incubation time on the sensitivity of indirect Coombs’ test. Vox
Churchill Livingstone, New York, 1980, p 193. Sang 36:186, 1980.
19. Polley, MJ, and Mollison, PL: The role of complement in the 43. Voak, D, et al: Low-ionic strength media for rapid antibody
detection of blood group antibodies: Special reference to the detection: Optimum conditions and quality control. Med Lab
antiglobulin test. Transfusion 1:9, 1961. Sci 37:107, 1980.
20. Polley, MJ, et al: The role of 19S gamma-globulin blood group 44. Bruce, M, et al: A serious source of error in antiglobulin testing.
antibodies in the antiglobulin reaction. Br J Haematol 8:149, Transfusion 26:177, 1986.
1962. 45. Green, C, et al: Quality assurance of physiological saline used
21. Stratton, F, et al: The preparation and uses of antiglobulin for blood grouping. Med Lab Sci 43:364, 1968.
reagents with special reference to complement fixing blood 46. Voak, D, et al: Antihuman globulin reagent specification: The
group antibodies. Transfusion 2:135, 1962. European and ISBT/ICSH view. Biotest Bull 3:7, 1986.
22. Stratton, F, et al: Value of gel fixation on Sephadex G-200 in the 47. Mallory, D, et al: Immunohematology Methods and Procedures.
analysis of blood group antibodies. J Clin Pathol 21:708, 1968. American National Red Cross, Washington, D.C., 1993, pp 40–41.
2682_Ch06_119-148 28/05/12 12:26 PM Page 146

146 PART II Blood Groups and Serologic Testing

SUMMARY CHART
ABO frequencies: group O, 45%; group A, 40%; group Group O persons have the greatest amount of H
B, 11%; group AB, 4%. substance; group A1B persons contain the least amount
ABO blood group system has naturally occurring of H substance.
antibodies that are primarily IgM. Approximately 80% of the individuals inherit the A
ABO genes, like those of most other blood groups, are gene phenotype as A1; the remaining 20% phenotype
inherited in a codominant manner. as A2 or weaker subgroups.
ABH-soluble antigens are secreted by tissue cells and Approximately 1% to 8% of A2 persons produce anti-
are found in all body secretions. The antigens secreted A1 in their serum.
depend on the person’s ABO group. Glycoproteins in secretions are formed on type
ABO reverse grouping is omitted from cord blood test- 1 precursor chains.
ing on newborns, because their antibody titer levels The ABH antigens on RBCs are formed on type 2
are generally too low for detection. precursor chains.
ABO RBC antigens can be glycolipids, glycoproteins, Forward and reverse grouping normally yield strong
or glycosphingolipids; ABO-secreted substances are (3+ to 4+) reactions.
glycoproteins. Group A persons have anti-B in their serum; group B
L-fucose is the immunodominant sugar responsible for persons have anti-A in their serum; group AB persons
H specificity. have neither anti-A nor anti-B in their serum; group O
N-acetylgalactosamine is the immunodominant sugar persons contain both anti-A and anti-B in their serum.
responsible for A specificity. Approximately 78% of the random population inherit
D-galactose is the immunodominant sugar responsible the Se gene and are termed secretors; the remaining
for B specificity. 22% inherit the se gene and are termed nonsecretors.
The hh genotype is known as the Bombay phenotype, The Se gene codes for the production of L-fucosyltrans-
or Oh, and lacks normal expression of the ABH antigens. ferase.

4. The immunodominant sugar responsible for blood group

Review Questions
A specificity is:
1. An ABO type on a patient gives the following reactions: a. L-fucose
b. N-acetyl-D-galactosamine
Patient Cells With Patient Serum With c. D-galactose
d. Uridine diphosphate-N-acetyl-D-galactose
Anti-A Anti-B A1 cells B cells
5. What ABH substance(s) would be found in the saliva of
4+ 4+ Neg Neg a group B secretor?
a. H
What is the patient’s blood type?
b. H and A
a. O c. H and B
b. A d. H, A, and B
c. B
d. AB 6. An ABO type on a patient gives the following reactions:

2. The major immunoglobulin class(es) of anti-B in a group Patient Cells With Patient Serum With
A individual is (are):
Anti-A Anti-B Anti-A1 A1 cells B cells
a. IgM
b. IgG 4+ 4+ Neg 2+ Neg
c. IgM and IgG
d. IgM and IgA The reactions above may be seen in a patient who is:
3. What are the possible ABO phenotypes of the offspring a. A1 with acquired B
from the mating of a group A to a group B individual? b. A2B with anti-A1
c. AB with increased concentrations of protein in the
a. O, A, B
serum
b. A, B
d. AB with an autoantibody
c. A, B, AB
d. O, A, B, AB
2682_Ch06_119-148 28/05/12 12:26 PM Page 147

Chapter 6 The ABO Blood Group System 147

7. Which of the following ABO blood groups contains the 9. Klein, HG, and Anstee, DJ: Mollison’s Blood Transfusion in
least amount of H substance? Clinical Medicine, 11th ed. Blackwell Publishing, Malden, MA,
2005.
a. A1B 10. American Association of Blood Bank Standards, 26th ed.
b. A2 American Association of Blood Banks, Bethesda, MD, 2009.
c. B 11. Olsson, ML, and Chester, MA: Polymorphism and recombi-
d. O nation events at the ABO locus: A major challenge for
genomic ABO blood grouping strategies. Transfus Med
8. You are working on a specimen in the laboratory that 11:295–313, 2001.
you believe to be a Bombay phenotype. Which of the 12. Chester, MA, and Olsson, ML: The ABO blood group gene: A
locus of considerable genetic diversity. Transfus Med Rev
following reactions would you expect to see? 15:177–200, 2001.
a. Patient’s cells + Ulex europaeus = no agglutination 13. Yamamoto, F, Clausen, H, White, T, Marken, J, and Hakamori
b. Patient’s cells + Ulex europaeus = agglutination S: Molecular genetic basis of histo-blood group ABO system.
c. Patient’s serum + group O donor RBCs = no Nature 345:229–233, 1990.
14. Cohen, M, Hurtado-Ziola, N, and Varki, A: ABO blood group
agglutination glycans modulate sialic acid recognition on erythrocytes. Blood
d. Patient’s serum + A1 and B cells = no agglutination 114:3668–3676, 2009.
15. Donghaile, DO, Jenkins, VP, McGrath, R, et al: Defining the
9. An example of a technical error that can result in an molecular mechanisms responsible for the ABO high expresser
ABO discrepancy is: phenotype. Blood (ASH Annual Meeting Abstracts) 114:2119,
a. Acquired B phenomenon. 2009.
b. Missing isoagglutinins. 16. Yamamoto, F: Cloning and regulation of the ABO genes. Trans-
fus Med 11:281–294, 2001.
c. Cell suspension that is too heavy.
17. Seltsam, A, et al: Systematic analysis of ABO gene diversity
d. Acriflavine antibodies. within exons 6 and 7 by PCR screening reveals new ABO alle-
les. Transfusion 43:428–439, 2003.
10. An ABO type on a patient gives the following reactions: 18. Olsson, ML, Irshaid, NM, Hosseini-Maaf, B, et al: Genomic
analysis of clinical samples with serologic ABO blood grouping
Patient Cells discrepancies: Identification of 15 novel A and B subgroup
With Patient Serum With alleles. Blood 98:1585–1593, 2001.
19. Seltsam, A, Hallensleben, M, Kollmann, A, and Blasczyk, R:
Anti-A Anti-B A1 cells B cells O cells Autocontrol The nature of diversity and diversification at the ABO locus.
4+ Neg 2+ 4+ 2+ Neg Blood 102:3035–3042, 2003.
20. Hosseini-Maaf, B, Hellberg, A, Chester, MA, and Olsson, ML:
An extensive polymerase chain reaction-allele-specific poly-
These results are most likely due to: morphism strategy for clinical ABO blood group genotyping
a. ABO alloantibody. that avoids potential errors caused by null, subgroup, and
hybrid alleles. Transfusion 47(11):2110–2125, 2007.
b. Non-ABO alloantibody.
21. Blumenfeld, OO: The ABO gene—more variation! Blood
c. Rouleaux. 102:2715, 2003.
d. Cold autoantibody. 22. Svensson, L, Pettersson, A, and Henry, SM: Secretor genotyping
for A385T, G428A, C571T, 685delTGG, G849A, and other
mutations from a single PCR. Transfusion 40:856–860, 2000.
References 23. Watkins, WM: The ABO blood group system: Historical back-
1. 2009, F. R. (n.d.): Vaccines, Blood & Biologics; U.S. Food and Drug ground. Transfus Med 11:243–265, 2001.
Administration. Fatalities reported to FDA following blood col- 24. Yan, L, Zhu, F, Liu, Y, Xu, X, and Hong, X: Sequences variations
lection and transfusion: Annual summary for fiscal year 2009. in 5'-flanking region of ABO gene and correlation with ABO
Retrieved March 22, 2010, from www.fda.gov/BiologicsBlood- alleles in the indigenous Chinese. Vox Sang 94(3):227–233,
Vaccines/SafetyAvailability/ReportaProblem/TransfusionDona- 2008.
tionFatalities/ucm204763.htm. 25. Fujitani, N, et al: Expression of H type 1 antigen of ABO
2. Landsteiner, K: Uber agglutinationserscheinungen normalen histio–blood group in normal colon and aberrant expressions
menschlichen blutes. Wien Klin Wschr 14:1132–1134, 1901. of H type 2 and H type 3/4 antigens in colon cancer. Glycoconj
3. Roback, D, Combs, MR, Grossman, BJ, and Hillyer, CD: Tech- J 17:331–338, 2000.
nical Manual, 16th ed. American Association of Blood Banks, 26. Hosoi, E, Hirose, M, and Hamano, S: Expression levels of
Bethesda, MD, 2008. H-type alpha (1,2)-fucosyltransferase gene and histo-blood
4. Garratty, G, Glynn, SA, and McEntire, R: ABO and Rh (D) phe- group ABO gene corresponding to hematopoietic cell differen-
notype frequencies of different racial/ethnic groups in the United tiation. Transfusion 43:65–71, 2003.
States. Transfusion 44:703–706, 2004. 27. Mizuno, N, Ohmori, T, Sekiguchi, K, et al: Alleles responsible
5. Daniels, G, and Bromilow, I: Essential Guide to Blood Groups. for ABO phenotype-genotype discrepancy and alleles in indi-
Blackwell Publishing, Malden, MA, 2007. viduals with a weak expression of A or B antigens. J Forensic
6. Simon, TL, Snyder, EL, Stowell, CP, Strauss, RG, Solheim, BG, Sci 49(1):21–28, 2004.
and Petrides, M (eds): Rossi’s Principles of Transfusion Medi- 28. Seltsam, A, and Blasczyk, R: Missense mutations outside the
cine, 4th ed. Wiley-Blackwell, Malden, MA, 2009. catalytic domain of the ABO glycosyltransferase can cause
7. Dumont, LJ, AuBuchon, JP, Herschel, L, Roger, J, White, T, and weak blood group A and B phenotypes. Transfusion
Stassinopoulos, A: Random healthy donor sera show varying ef- 45(10):1663–1669, 2005.
fectiveness in hemolyzing ABO Incompatible red blood cells. 29. Novaretti, MCZ, Domingues, AE, Pares, MMNS, et al: Rapid
Blood (ASH Annual Meeting Abstracts) 108(11):958, 2006. detection of 871G>A mutation by sequence specific PCR
8. Murphy, MF, and Pamphilon, DH: Practical Transfusion Medi- in ABO*A301 blood donors. Blood (ASH Annual Meeting
cine, 3rd ed. Wiley-Blackwell, Hoboken, NJ, 2009. Abstracts) 104:4098, 2004.
2682_Ch07_149-171 22/05/12 11:43 AM Page 169

Chapter 7 The Rh Blood Group System 169

SUMMARY CHART
The Rh antibody was so named on the basis of anti- in order of its discovery (Rh1 = D, Rh2 = C, Rh3 = E,
body production by guinea pigs and rabbits when Rh4 = c, Rh5 = e).
transfused with rhesus monkey RBCs. Rh antigens are characterized as nonglycosylated
Historically, Rh was a primary cause of HDFN, erythro- proteins in the RBC membrane.
blastosis fetalis, and a significant cause of hemolytic The most common phenotype in whites is R1r (31%);
transfusion reactions. the most common phenotype in blacks is R0r (23%),
Fisher-Race DCE terminology is based on the theory followed by R0R0 at 19%.
that antigens of the system are produced by three The Rh antigens are inherited as codominant alleles.
closely linked sets of alleles and that each gene is re- A partial-D individual is characterized as lacking one
sponsible for producing a product (or antigen) on the or more pieces or epitopes of the total D antigen and
RBC surface. may produce alloantibody to the missing fraction if
A person who expresses no Rh antigens on the RBC is exposed to RBCs with the complete D antigen.
said to be Rhnull, and the phenotype may be written Blood donor units for transfusion are considered
as –––/–––. Rh-positive if either the D or weak-D test is positive;
In the Wiener Rh-Hr nomenclature, it is postulated if both the D and weak-D tests are negative, blood for
that the gene responsible for defining Rh actually transfusion is considered Rh-negative.
produces an agglutinogen that contains a series of blood Most Rh antibodies are IgG immunoglobulin and react
factors in which each factor is an antigen recognized optimally at 37°C or following antiglobulin testing;
by an antibody. exposure to less than 0.1 mL of Rh-positive RBCs can
It is currently accepted that two closely linked genes stimulate antibody production in an Rh-negative person.
control the expression of Rh; one gene (RHD) codes Rh-mediated hemolytic transfusion reactions usually
for the presence of RhD, and a second gene (RHCE) result in extravascular hemolysis.
codes for the expression of CcEe antigens.
Rh antibodies are IgG and can cross the placenta to
In the Rosenfield alpha/numeric terminology, a num- coat fetal (Rh-positive) RBCs.
ber is assigned to each antigen of the Rh system

Review Questions 5. How are Rh antigens inherited?

a. Autosomal recessive alleles
1. The Rh system was first recognized in a case report of: b. Sex-linked genes
a. A hemolytic transfusion reaction. c. Codominant alleles
b. Hemolytic disease of the fetus and newborn. d. X-linked
c. Circulatory overload. 6. Biochemically speaking, what type of molecules are Rh
d. Autoimmune hemolytic anemia. antigens?
2. What antigen is found in 85% of the white population a. Glycophorins
and is always significant for transfusion purposes? b. Simple sugars
a. d c. Proteins
b. c d. Lipids
c. D 7. Rh antibodies react best at what temperature (°C)?
d. E
a. 22
3. How are weaker-than-expected reactions with anti-D b. 18
typing reagents categorized? c. 15
a. Rhmod d. 37
b. Weak D 8. Rh antibodies are primarily of which immunoglobulin
c. DAT positive class?
d. Dw
a. IgA
4. Cells carrying a weak-D antigen require the use of what b. IgM
test to demonstrate its presence? c. IgG
a. Indirect antiglobulin test d. IgD
b. Direct antiglobulin test
c. Microplate test
d. Warm autoadsorption test
2682_Ch07_149-171 22/05/12 11:43 AM Page 170

170 PART II Blood Groups and Serologic Testing

9. Rh antibodies have been associated with which of the References

following clinical conditions? 1. Levine, P, and Stetson, RE: An unusual case of intragroup
a. Erythroblastosis fetalis agglutination. JAMA 113:126, 1939.
b. Thrombocytopenia 2. Landsteiner, K, and Wiener, AS: An agglutinable factor in
c. Hemophilia A human blood recognized by immune sera for rhesus blood.
Proc Soc Exp Biol (NY) 43:223, 1940.
d. Stomatocytosis 3. Levine, P, et al: The role of isoimmunization in the pathogen-
10. What do Rhnull cells lack? esis of erythroblastosis fetalis. Am J Obstet Gynecol 42:925,
1941.
a. Lewis antigens 4. Race, RR, et al: Recognition of a further common Rh genotype
b. Normal oxygen-carrying capacity in man. Nature 153:52, 1944.
c. Rh antigens 5. Mourant, AE: A new rhesus antibody. Nature 155:542, 1945.
d. MNSs antigens 6. Stratton, F: A new Rh allelomorph. Nature 158:25, 1946.
7. Levine, P: On Hr factor and Rh genetic theory. Science 102:1,
11. What antigen system is closely associated phenotypically 1945.
with Rh? 8. Race, RR: The Rh genotypes and Fisher’s theory. Blood 3 (Suppl
2):27, 1948.
a. McCoy 9. Wiener, AS: Genetic theory of the Rh blood types. Proc Soc Exp
b. Lutheran Biol (NY) 54:316, 1943.
c. Duffy 10. Rosenfield, RE, et al: A review of Rh serology and presentation
d. LW of a new terminology. Transfusion 2:287, 1962.
11. Lewis, M: Blood group terminology 1990. Vox Sang 58:152,
12. Anti-LW will not react with which of the following? 1990.
12. Tippett, PA: A speculative model for the Rh blood groups. Ann
a. Rh-positive RBCs Hum Genet 50:241, 1986.
b. Rh-negative RBCs 13. Cherif-Zahar, B, Bloy, C, Le Van Kim, C, et al: Molecular
c. Rhnull RBCs cloning and protein structure of a human blood group Rh
d. Rh:33 RBCs polypeptide. Proc Natl Acad Sci USA Aug;87(16):6243–6247,
1990.
13. Convert the following genotypes from Wiener nomen- 14. Le van Kim, C, Mouro, I, Cherif-Zahar, B, et al: Molecular
clature to Fisher-Race and Rosenfield nomenclatures, cloning and primary structure of human blood group RhD
and list the antigens present in each haplotype. polypeptide. Proc Natl Acad Sci USA Nov 15;89(22):10925–
10929,1992.
a. R1r DCe/dce Rh:1,2,-3,4,5 15. Arce, MA, Thompson, ES, Wagner, S, et al: Molecular cloning of
b. R2R0 DcE/Dce Rh:1,-2,3,4,5 RhD cDNA derived from a gene present in RhD-positive, but not
c. RzR1 DCE/DCe Rh:1,2,3,-4,5 RhD-negative individuals. Blood Jul 15;82(2):651–655, 1993.
d. ryr dCE/dce Rh:-1,2,3,4,5 16. Ridgewell, K, Spurr, NK, Laguda, B, et al: Isolation of cDNA
clones for a 50 kDa glycoprotein of the human erythrocyte
14. Which Rh phenotype has the strongest expression of D? membrane associated with Rh (rhesus) blood group antigen
expression. Biochem J 287:223–228, 1992.
a. R1r 17. Colin, Y, Cherif-Zahar, B, Le Van Kim, C, et al: Genetic basis
b. R1R1 of the RhD-positive and RhD-negative blood group polymor-
c. R2R2 phism as determined by Southern analysis. Blood 78:2747–
d. D– 2752, 1991.
18. Singleton, BK, Green, CA, Avent, ND, et al: The presence of an
15. Which of the following most commonly causes an RHD pseudogene containing a 37 base pair duplication and
individual to type RhD positive yet possess anti-D? nonsense mutation in Africans with the RhD-negative blood
group phenotype. Blood 95(1):12–18, 2000.
a. Genetic weak D 19. Shao, CP, Maas, JH, Su, YQ, et al: Molecular background of
b. Partial D Rh D-positive, D-negative, D (el) and weak D phenotypes in
c. C in trans to RHD Chinese. Vox Sang 83:156–161, 2002.
d. D epitopes on RhCE protein 20. Blumenfeld, OO, and Patnaik, SK: Allelic genes of blood group
antigens: A source of human mutations and cSNPs docu-
16. An individual has the following Rh phenotype: mented in the Blood Group Antigen Gene Mutation Database.
D+C+E+c+e+. Using Fisher-Race terminology, what is Hum Mutat Jan;23(1):8–16, 2004.
their most likely Rh genotype? 21. Avent, ND, Butcher, SK, Liu, W et al: Localization of the C
termini of the Rh (rhesus) polypeptides to the cytoplasmic face
a. DCE/Dce of the human erythrocyte membrane. J Biol Chem 267:15134–
b. DCE/dce 15139, 1992.
c. DCe/dcE 22. Avent, ND, Liu, W, Warner, KM, et al: Immunochemical analy-
d. DCe/DcE sis of the human erythrocyte Rh polypeptides. J Biol Chem
271:14233–14239, 1996.
17. Which of the following is the most common Rh pheno- 23. Hughes-Jones, NC, Gardner, B, and Lincoln, PJ: Observations
type in African Americans? of the number of available c, D, and E antigen sites on red cells.
Vox Sang 21:210, 1971.
a. Dce/dce 24. Westhoff, CM, and Wylie, DE: Transport characteristics of
b. DcE/dce mammalian Rh and Rh glycoproteins expressed in heterolo-
c. DCe/dce gous systems. Transfus Clin Biol 13:132–138, 2006.
d. Dce/dCe
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210 PART II Blood Groups and Serologic Testing

SUMMARY CHART
Blood Group Terminology RBCs except those of other p individuals. Antibodies
The ISBT terminology for RBC surface antigens provides may be a mixture of IgM and IgG, efficiently bind com-
a standardized numeric system for naming authenti- plement, may demonstrate in vitro hemolysis, and can
cated antigens that is suitable for electronic data pro- cause severe HTRs. Anti-PP1Pk is associated with
cessing equipment. This terminology was not intended spontaneous abortions.
to replace conventional terminology. Alloanti-P is found as a naturally occurring alloantibody
In the ISBT classification, RBC antigens are assigned in the sera of Pk individuals and is clinically significant.
a six-digit identification number: The first three Autoanti-P is most often the specificity associated with
digits represent the system, collection, or series, the cold-reactive IgG autoantibody in patients with
and the second three digits identify the antigen. All paroxysmal cold hemoglobinuria (PCH).
antigens are catalogued into one of the following The autoanti-P of PCH usually does not react by routine
four groups: tests but is demonstrable as a biphasic hemolysin only
v A blood group system if controlled by a single gene in the Donath-Landsteiner test.
locus, or by two or more closely linked genes
The I and i Antigens
v A collection if shown to share a biochemical, sero-
logic, or genetic relationship I and i antigens are not antithetical; they have a recip-
v The high-prevalence series (901) if found in more rocal relationship.
than 90% of most populations Most adult RBCs are rich in I and have only trace
v The low-prevalence series (700) if found in less amounts of i antigen.
than 1% of most populations At birth, infant RBCs are rich in i; I is almost unde-
Lewis Blood Group tectable; over the next 18 months of development, the
infant’s RBCs will convert from i to I antigen.
Lewis blood group antigens are not synthesized by the
Anti-I is typically a benign, weak, naturally occurring,
RBCs. These antigens are adsorbed from plasma onto
saline-reactive IgM autoagglutinin, usually detectable
the RBC membrane.
only at 4°C.
The Le gene codes for L-fucosyltransferase, which adds
Pathogenic anti-I is typically a strong cold autoagglu-
L-fucose to type 1 chains.
tinin that demonstrates high-titer reactivity at 4°C and
The Le gene is needed for the expression of Lea sub- reacts over a wide thermal range (up to 30°–32°C).
stance, and Le and Se genes are needed to form Leb
Patients with M. pneumoniae infections may develop
substance.
strong cold agglutinins with autoanti-I specificity.
The lele genotype is more common among blacks
Anti-i is a rare IgM agglutinin that reacts optimally
than among whites and results in the Le(a–b–)
at 4°C; potent examples may be associated with infec-
phenotype.
tious mononucleosis.
Lewis antigens are poorly expressed at birth.
Lewis antibodies are generally IgM (naturally occurring) The MNS Blood Group System
made by Le(a–b–) individuals. Anti-M and anti-N are cold-reactive saline agglutinins
Lewis antibodies are frequently encountered in pregnant that do not bind complement or react with enzyme-
women. treated cells; both anti-M and anti-N may demonstrate
Lewis antibodies are not considered significant for dosage.
transfusion medicine. Anti-S and anti-s are IgG antibodies, reactive at 37°C
and the antiglobulin phase. They may bind complement
The P Blood Group and have been associated with HDFN and HTRs.
The P blood group consists of the biochemically The S–s–U– phenotype is found in blacks.
related antigens P, P1, Pk and LKE. Anti-U is usually an IgG antibody and has been asso-
P1 antigen expression is variable; P1 antigen is poorly ciated with HTRs and HDFN.
developed at birth.
The Kell Blood Group System
Anti-P1 is a common naturally occurring IgM anti-
body in the sera of P1– individuals; it is usually The Kell blood group antigens are well developed at
a weak, cold-reactive saline agglutinin and can birth and are not destroyed by enzymes.
be neutralized with soluble P1 substance found in The Kell blood group antigens are destroyed by DTT,
hydatid cyst fluid. ZZAP, and glycine-acid EDTA.
Anti-PP1Pk is produced by the rare p individuals early Excluding ABO, the K antigen is rated second only to
in life without RBC sensitization and reacts with all D antigen in immunogenicity.
2682_Ch08_172-215 22/05/12 11:44 AM Page 211

Chapter 8 Blood Group Terminology and the Other Blood Groups 211

SUMMARY CHART—cont’d
The k antigen is high prevalence. Other Blood Groups and Antigens
Anti-K is usually an IgG antibody reactive in the The Diego system antigens are located on a major RBC
antiglobulin phase and is made in response to preg- protein, band 3, also known as the RBC anion ex-
nancy or transfusion of RBCs; it has been implicated changer (AE1).
in severe HTRs and HDFN.
Anti-Dia, anti-Dib, and anti-Wra are generally consid-
The McLeod phenotype, affecting only males, is de- ered to be clinically significant; all have caused severe
scribed as a rare phenotype with decreased Kell system HTRs and HDFN. Anti-Wra is a relatively common
antigen expression. The McLeod syndrome includes antibody.
the clinical manifestations of abnormal RBC morphol-
Wrb expression requires the presence of a normal GPA
ogy, compensated hemolytic anemia, and neurological
(MNS system); alloanti-Wrb is extremely rare.
and muscular abnormalities. Some males with the
McLeod phenotype also have the X-linked chronic Anti-Yt a is a fairly common antibody to a high-
granulomatous disease. prevalence antigen that is sometimes clinically signif-
icant and sometimes insignificant.
The Duffy Blood Group System The Xga antigen is found on the short arm of the
Fya and Fyb antigens are destroyed by enzymes and X chromosome and is of higher prevalence in females
ZZAP; they are well developed at birth. The Fy(a–b–) (89%) than in males (66%). Although it is usually IgG,
phenotype is prevalent in blacks but virtually nonex- anti-Xga has not been implicated in HDFN or as a
istent in whites. cause of HTRs.
Fy(a–b–) RBCs resist infection by the malaria organism Antibodies to Scianna system antigens are rare and
P. vivax. little is known about their clinical significance. The
Anti-Fya and anti-Fyb are usually IgG antibodies and rare null phenotype, Sc:–1,–2,–3, has been observed in
react optimally at the antiglobulin phase of testing; the Marshall Islands and New Guinea.
both antibodies have been implicated in delayed HTRs In addition to the Doa and Dob antigens, the Gya, Hy,
and HDFN. Joa antigens are assigned to the Dombrock system.
Anti-Doa and anti-Dob have caused HTRs but no
The Kidd Blood Group System clinical HDFN; these antibodies are usually weak and
Anti-Jka and anti-Jkb may demonstrate dosage, are difficult to identify.
often weak, and found in combination with other The Colton system is composed of the antithetical Coa
antibodies; both are typically IgG and reactive in the and Cob antigens as well as the high-prevalence Co3
antiglobulin test. antigen; the antigens are carried on aquaporin 1, a red
Kidd system antibodies may bind complement and are cell water channel. The Colton antibodies have caused
made in response to foreign RBC exposure during HTRs and HDFN.
pregnancy or transfusion. LW has a phenotypic relationship with the D antigen;
Kidd system antibodies are a common cause of delayed Rhnull RBCs type LW(a–b–).
HTRs. Anti-LW reacts strongly with D+ RBCs and can look
Kidd system antibody reactivity is enhanced with like anti-D. DTT treatment of test RBCs will distin-
enzymes, LISS, and PEG. guish between these two antibodies because the LW
antigen is denatured by DTT, but the D antigen is not.
The Lutheran Blood Group System In other words, anti-LW does not react with DTT-
Lua and Lub are antigens produced by codominant treated D+ RBCs but anti-D does.
alleles; they are poorly developed at birth. The antigens in the Chido/Rodgers system are located
Anti-Lua may be a naturally occurring saline agglutinin on the complement fragments C4B and C4A, respec-
that reacts optimally at room temperature. tively, that are adsorbed onto RBCs from plasma.
Anti-Lub is usually an IgG antibody reactive at the The clinically insignificant anti-Ch and anti-Rg react
antiglobulin phase; it is usually produced in response to weakly, often to moderate or high-titer endpoints in
foreign RBC exposure during pregnancy or transfusion. the antiglobulin test and may be tentatively identified
The Lu(a–b–) phenotype is rare and may result by plasma inhibition methods.
from three different genetic backgrounds; only indi- Gerbich-negative phenotypes are very rare outside of
viduals with the recessive type Lu(a–b–) can make Papua, New Guinea.
anti-Lu3.
Continued
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212 PART II Blood Groups and Serologic Testing

SUMMARY CHART—cont’d
Gerbich antibodies are sometimes clinically significant JMH antibodies most often occur in individuals with
for transfusion and sometimes insignificant. Only acquired JMH– status. Anti-JMH in these individuals
three cases of serious HDFN due to anti-Ge3 have been is not clinically significant.
reported. Anti-Vel is most often IgG but can be IgM, and has
The Cromer antigens are carried on the decay acceler- caused severe immediate HTRs and HDFN. When
ating factor and are distributed in body fluids and on serum is tested, anti-Vel characteristically causes in
RBCs, WBCs, platelets, and placental tissue. vitro hemolysis.
The rare anti-Cra and anti-Tca have been found only in Anti-Ata has been found only in blacks; the antibody
black individuals; some examples have caused HTRs. is usually IgG and has caused severe HTRs.
The Knops antigens are located on complement Anti-Jra is found more commonly in Japanese, but
receptor 1 (CR1). Knops antibodies are clinically in- clinical significance is not well established, since it
significant and have weak and “nebulous” reactivity at is a rare antibody; it has caused HTRs and a fatal case
the antiglobulin phase; they are not inhibited by plasma. of HDFN.
The Ina antigen is more prevalent in Arab and Iranian Anti-Sda has characteristic shiny and refractile agglu-
populations, with Ina and Inb antigen expression tinates under the microscope and is inhibited with
being depressed on the dominant type Lu(a–b–) urine from Sd(a+) individuals.
RBCs.

5. Transformation to Leb phenotype after birth may be as

Review Questions
follows:
1. The following phenotypes are written incorrectly a. Le(a–b–) to Le(a+b–) to Le(a+b+) to Le(a–b+)
except for: b. Le(a+b–) to Le(a–b–) to Le(a–b+) to Le(a+b+)
c. Le(a–b+) to Le(a+b–) to Le(a+b+) to Le(a–b–)
a. Jka+
d. Le(a+b+) to Le(a+b–) to Le(a–b–) to Le(a–b+)
b. Jka+
c. Jka(+) 6. In what way do the Lewis antigens change during
d. Jk(a+) pregnancy?
2. Which of the following characteristics best describes a. Lea antigen increases only
Lewis antibodies? b. Leb antigen increases only
c. Lea and Leb both increase
a. IgM, naturally occurring, cause HDFN
d. Lea and Leb both decrease
b. IgM, naturally occurring, do not cause HDFN
c. IgG, in vitro hemolysis, cause hemolytic transfusion 7. A type 1 chain has:
reactions a. The terminal galactose in a 1-3 linkage to subterminal
d. IgG, in vitro hemolysis, do not cause hemolytic trans- N-acetylglucosamine.
fusion reactions b. The terminal galactose in a 1-4 linkage to subterminal
3. The Le gene codes for a specific glycosyltransferase that N-acetylglucosamine.
transfers a fucose to the N-acetylglucosamine on: c. The terminal galactose in a 1-3 linkage to subterminal
N-acetylgalactosamine.
a. Type 1 precursor chain.
d. The terminal galactose in a 1-4 linkage to subterminal
b. Type 2 precursor chain.
N-acetylgalactosamine.
c. Types 1 and 2 precursor chain.
d. Either type 1 or type 2 in any one individual but not 8. Which of the following best describes Lewis antigens?
both. a. The antigens are integral membrane glycolipids
4. What substances would be found in the saliva of a b. Lea and Leb are antithetical antigens
group B secretor who also has Lele genes? c. The Le(a+b–) phenotype is found in secretors
d. None of the above
a. H, Lea
b. H, B, Lea
c. H, B, Lea, Leb
d. H, B, Leb
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Chapter 8 Blood Group Terminology and the Other Blood Groups 213

9. Which of the following genotypes would explain RBCs 17. Which of the following Duffy phenotypes is prevalent
typed as group A Le(a+b–)? in blacks but virtually nonexistent in whites?
a. A/O Lele HH Sese a. Fy(a+b+)
b. A/A Lele HH sese b. Fy(a–b+)
c. A/O LeLe hh SeSe c. Fy(a–b–)
d. A/A LeLe hh sese d. Fy(a+b–)

10. Anti-LebH will not react or will react more weakly with 18. Antibody detection cells will not routinely detect which
which of the following RBCs? antibody specificity?
a. Group O Le(b+) a. Anti-M
b. Group A2 Le(b+) b. Anti-Kpa
c. Group A1 Le(b+) c. Anti-Fya
d. None of the above d. Anti-Lub

11. Which of the following best describes MN antigens and 19. Antibodies to antigens in which of the following blood
antibodies? groups are known for showing dosage?
a. Well developed at birth, susceptible to enzymes, a. I
generally saline reactive b. P
b. Not well developed at birth, susceptible to enzymes, c. Kidd
generally saline reactive d. Lutheran
c. Well developed at birth, not susceptible to enzymes,
20. Which antibody is most commonly associated with
generally saline reactive
delayed hemolytic transfusion reactions?
d. Well developed at birth, susceptible to enzymes,
generally antiglobulin reactive a. Anti-s
b. Anti-k
12. Which autoantibody specificity is found in patients with c. Anti-Lua
paroxysmal cold hemoglobinuria? d. Anti-Jka
a. Anti-I
21. Anti-U will not react with which of the following RBCs?
b. Anti-i
c. Anti-P a. M+N+S+s–
d. Anti-P1 b. M+N–S–s–
c. M–N+S–s+
13. Which of the following is the most common antibody d. M+N–S+s+
seen in the blood bank after ABO and Rh antibodies?
22. A patient with an M. pneumoniae infection will most
a. Anti-Fya
likely develop a cold autoantibody with specificity to
b. Anti-k
which antigen?
c. Anti-Jsa
d. Anti-K a. I
b. i
14. Which blood group system is associated with resistance c. P
to P. vivax malaria? d. P1
a. P
23. Which antigen is destroyed by enzymes?
b. Kell
c. Duffy a. P1
d. Kidd b. Jsa
c. Fya
15. The null Ko RBC can be artificially prepared by which d. Jka
of the following treatments?
24. The antibody to this high-prevalence antigen demon-
a. Ficin and DTT
strates mixed-field agglutination that appears shiny and
b. Ficin and glycine-acid EDTA
refractile under the microscope:
c. DTT and glycine-acid EDTA
d. Glycine-acid EDTA and sialidase a. Vel
b. JMH
16. Which antibody does not fit with the others with respect c. Jra
to optimum phase of reactivity? d. Sda
a. Anti-S
b. Anti-P1
c. Anti-Fya
d. Anti-Jkb
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214 PART II Blood Groups and Serologic Testing

25. Which of the following has been associated with causing 5. Roback, JD, Combs, MR, Grossman, BJ, and Hillyer, CD (eds):
severe immediate HTRs? Technical Manual, 16th ed. Bethesda, MD: AABB, 2008.
6. Mourant, AE. A “new” human blood group antigen of frequent
a. Anti-JMH occurrence. Nature 158:237–238,1946.
b. Anti-Lub 7. Daniels, G: The Human Blood Groups, 2nd ed. Blackwell
c. Anti-Vel Science, Oxford, 2002.
d. Anti-Sda 8. Grubb R. Correlation between Lewis blood group and secretor
character in man. Nature 162:933,1948.
26. Which of the following antibodies would more likely be 9. Reid, ME, and Lomas-Francis, C: The Blood Group Antigen
found in a black patient? Facts Book, 2nd ed. Academic Press, San Diego, CA, 2003.
10. Levine, P, Bobbitt, OB, Waller, RK, et al: Isoimmunization by a
a. Anti-Cra new blood factor in tumor cells. Proc Soc Exp Biol Med
b. Anti-Ata 77:403–405, 1951.
c. Anti-Hy 11. Sanger, R: An association between the P and Jay systems of
d. All of the above blood groups. Nature 176:1163–1164, 1955.
12. Matson, GA, Swanson J, Noades, J, et al: A “new” antigen and
27. Which of the following antigens is not in a blood group antibody belonging to the P blood group system. Am J Hum
system? Genet 11:26–34, 1959.
13. Arndt, PA, Garratty, G, Marfoe, RA, et al: An acute hemolytic
a. Doa transfusion reaction caused by an anti-P1 that reacted at 37°C.
b. Vel Transfusion 38:373–377, 1998.
c. JMH 14. Hellberg, A, Poole, J, and Olsson, ML: Molecular basis of the
d. Kx globoside-deficient Pk blood group phenotype. J Biol Chem
277:29455–29459, 2002.
28. A weakly reactive antibody with a titer of 128 is neutral- 15. Yoshida, H, Ito, K, Kusakari, T, et al: Removal of maternal
ized by plasma. Which of the following could be the antibodies from a woman with repeated fetal loss due to
P blood group incompatibility. Transfusion 34:702–705,1994.
specificity? 16. Tippett, P, Sanger, R, Race, RR, et al: An agglutinin associated
a. Anti-JMH with the P and the ABO blood group systems. Vox Sang
b. Anti-Ch 10:269–280, 1965.
c. Anti-Kna 17. Lund, N, Olsson, ML, Ramkumar, S, et al: The human Pk histo-
blood group antigen provides protection against HIV-1 infec-
d. Anti-Kpa
tion. Blood 113:4980–4991, 2009.
29. An antibody reacted with untreated RBCs and DTT- 18. Marsh, WL, and Jenkins, WJ: Anti-i: A new cold antibody.
Nature 188:753, 1960.
treated RBCs but not with ficin-treated RBCs. Which of 19. Yu, L, Twu, Y, Chang, C, et al: Molecular basis of the adult i
the following antibodies could explain this pattern of phenotype and the gene responsible for the expression of
reactivity? the human blood group I antigen. Blood 98:3840–3845,
a. Anti-JMH 2001.
20. Yu, L, Twu, Y, Chou, M, et al: The molecular genetics of the
b. Anti-Yta
human I locus and molecular background explain the partial
c. Anti-Kpb association of the adult i phenotype with congenital cataracts.
d. Anti-Ch Blood 101:2081–2088, 2003.
21. Curtain, CC, Baumgarten, A, Gorman, J, et al: Cold haemag-
30. The following antibodies are generally considered clin- glutinins: Unusual incidence in Melanesian populations. Br J
ically insignificant because they have not been associ- Haematol 11:471–479, 1965.
ated with causing increased destruction of RBCs, HDFN, 22. Booth, PB, Jenkins, WL, and Marsh, WL: Anti-IT: A new anti-
or HTRs. body of the I blood group system occurring in certain Melane-
sian sera. Br J Haematol 12:341–344, 1966.
a. Anti-Doa and anti-Coa 23. Garratty, G, Petz, LD, Walerstein, RO, et al: Autoimmune
b. Anti-Ge3 and anti-Wra hemolytic anemia in Hodgkin’s disease associated with anti-IT.
c. Anti-Ch and anti-Kna Transfusion 14:226–231, 1974.
d. Anti-Dib and anti-Yt 24. Greenwalt, TJ, Sasaki, T, Sanger, R, et al: An allele of the S(s)
blood group genes. Proc Natl Acad Sci 40:1126–1129, 1954.
25. Fukuda, M: Molecular genetics of the glycophorin A gene
References cluster. Semin Hematol 30:138–151, 1993.
1. Issitt, PD, and Anstee, DJ: Applied Blood Group Serology, 26. Palacajornsuk, P: Review: Molecular basis of MNS blood group
4th ed. Montgomery Scientific, Durham, NC, 1998. variants. Immunohematology 22:171–182, 2006.
2. Garratty, G, Dzik, W, Issit, PD, et al: Terminology for blood 27. Reid, ME, Storry, JR, Ralph, H, et al: Expression and quantita-
group antigens and genes—historical origins and guidelines in tive variation of the low-incidence blood group antigen He on
the new millennium. Transfusion 40:477–489, 2000. some S–s– red cells. Transfusion 36:719–724, 1996.
3. Storry, JR, Castilho, L, Daniels, G, et al: International Society of 28. Darnborough, J, Dunsford, I, and Wallace, JA: The Ena antigen
Blood Transfusion Working Party on red cell immunogenetics and antibody: A genetical modification of human red cells affect-
and blood group terminology: Berlin report. Vox Sang 101: ing their blood grouping reactions. Vox Sang 17:241–255, 1969.
77–82, 2011. 29. Furuhjelm, U, Myllylä, G, Nevanlinna, HR, et al: The red cell
4. Daniels, GL, Fletcher, A, Garratty, G, et al: Blood group termi- phenotype En(a-) and anti-Ena: Serological and physiochemical
nology 2004: From the International Society of Blood Transfu- aspects. Vox Sang 17:256–278, 1969.
sion committee on terminology for red cell surface antigens. Vox 30. Jung, HH, Danek, A, and Frey, BM: McLeod syndrome:
Sang 87:304–316, 2004. A neurohaematological disorder. Vox Sang 93:112–121, 2007.
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236 PART II Blood Groups and Serologic Testing

primary importance to remove the warm autoantibody to

CELL IS RT 18°C 4°C
detect the alloantibody. It is not necessary to determine
A1 0 0 1+ 2+ the specificity of the autoantibody, although many seem
A2 1+ 2+ 4+ 4+ to be directed against Rh antigens.
B 0 0 2+ 3+ Warm autoantibodies are IgG antibodies that are found
coating the patient’s RBCs and that are free in the patient’s
O adult 2+ 3+ 4+ 4+
serum. Adsorption techniques are used to remove the an-
O cord 0 0 1+ 2+ tibody from the serum.
Auto 0 0 1+ 2+ Finding RBC units that are compatible with a patient
who has a warm autoantibody may be difficult. If after
Figure 9–19. Cold antibody screen performed on an AB patient with
the absorption no clinically significant antibodies are de-
autoanti-IH.
tected, an immediate spin crossmatch to detect ABO
incompatibility is all that is necessary. If clinically significant
purpose. A cold panel consisting of group O adult cells antibodies are present, then antigen-negative units should
(H and I antigens), group O cord cells (H and i antigens), be crossmatched using an antiglobulin technique. The
group A1 adult cells (I antigen), and an autocontrol may warm autoantibody frequently interferes with this testing,
be tested at 4°C to determine the specificity of the cold making interpretation of results difficult.
autoantibody (see Figs. 9–18 and 9–19). Some transfusion medicine experts believe that repeat-
ing the full warm autoantibody workup is unnecessary if
1. Why is a cold autoantibody suspected in this case?
the patient’s serologic picture has remained unchanged
2. Why may a technologist test cord blood cells in a case
when compared with previous results.48,49 They advocate
such as this?
transfusing the patient with units that are phenotypically
3. How might a technologist avoid interference from cold
matched for Rh and K antigens in order to minimize the
autoantibodies?
risk of alloimmunization. Refer to Figure 9–14.
Case 9-5 This panel was performed on a male lymphoma pa-
tient who was last transfused 2 years ago. He has not
Warm-Reacting Autoantibodies received any transplants and is not currently on any
medications.
Warm-reacting autoantibodies are some of the most
challenging to work up. Warm autoantibodies are 1. What does the pattern of reactivity in the original
uncommon, but they may occur secondary to chronic panel (PEG/IgG column) suggest?
lymphocytic leukemia, lymphoma, systemic lupus ery- 2. How can you differentiate this pattern from that of an
thematosus, and other autoimmune diseases or as a result antibody to a high-prevalence antigen?
of drug therapy. Suspect a warm autoantibody when all 3. What type of adsorption procedure is recommended
cells, including the autocontrol, are reactive at the AHG in this case?
phase and at the same strength. If an underlying alloanti- 4. Are any alloantibodies present in this specimen?
body is present, cells that possess that antigen may react 5. How would you prepare red blood cell products for
stronger than those that are antigen-negative. It is of this patient?

SUMMARY CHART
The purpose of the antibody screen is to detect unexpected Screen cells are commercially prepared group O red
antibodies, which may be found in approximately 0.2% blood cell suspensions obtained from individual
to 2% of the general population. The antibodies may be donors who are phenotyped for the most commonly
classified as immune (the result of RBC stimulation in the encountered and clinically important RBC antigens.
patient), passive (transferred to the patient through blood RBCs from a homozygous individual have a double
products or derivatives), or naturally occurring (the result dose of a single antigen, which results from the inher-
of environmental factors). Antibodies may also be itance of two genes that code for the same antigen,
classified as alloantibodies, directed at foreign antigens, whereas heterozygous individuals carry only a single
or autoantibodies, directed at one’s own antigens. dose each of two different antigens. (Each gene codes
A clinically significant antibody is one that results in for a different antigen.)
the shortened survival of RBCs possessing the target Antibodies in the Kidd, Duffy, Lutheran, Rh, and MNSs
antigen. Clinically significant antibodies are IgG blood group systems show dosage and yield stronger
antibodies that react best at 37°C or in the AHG reactions against RBCs with homozygous expression
phase of testing. They are known to cause hemolytic of their corresponding antigen.
transfusion reactions and HDFN.
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Chapter 9 Detection and Identification of Antibodies 237

SUMMARY CHART—cont’d
Enhancement reagents, such as LISS and PEG, least three antigen-negative cells (i.e., reagent cells that
are solutions added to serum and cell mixtures in the do not express the corresponding antigen), and the
IAT to promote antigen-antibody binding or aggluti- patient’s RBCs phenotype negative for the correspon-
nation. ding antigen.
Coombs’ control cells are RBCs coated with human The DAT detects RBCs that were sensitized with anti-
IgG antibody, which are added to all AHG-negative body in vivo. Elution methods are used to free anti-
tube tests to ensure that there was an adequate washing body from the cell surface to allow for identification.
step performed and that the AHG reagent is present The calculation used to determine the number of ran-
and functional in the test system. dom donor units that should be antigen typed in order
Gel and solid phase adherence methods are alterna- to provide the requested number of antigen-negative
tives to tube testing. These methods may be automated RBC units for patients with an antibody involves
to increase efficiency. dividing the number of antigen-negative units requested
The antibody exclusion method rules out possible an- by the frequency of antigen-negative individuals in the
tibodies based on antigens that are present on nega- donor population.
tively reacting cells. The relative quantity of an RBC antibody can be deter-
Conclusive antibody identification is achieved when the mined by testing serial twofold dilutions of serum
serum containing the antibody is reactive with at least against antigen-positive RBCs; the reciprocal of the
three antigen-positive cells (i.e., reagent cells that highest serum dilution showing agglutination is the
express the corresponding antigen), negative with at antibody titer.

3. A request for 8 units of packed RBCs was received for

Review Questions patient LF. The patient has a negative antibody screen,
but one of the 8 units was 3+ incompatible at the AHG
1. Based on the following phenotypes, which pair of cells
phase. Which of the following antibodies may be the
would make the best screening cells?
cause?
a. Cell 1: Group A, D+C+c–E–e+, K+, Fy(a+b–),
a. Anti-K
Jk(a+b–), M+N–S+s–
b. Anti-Lea
Cell 2: Group O, D+C–c+E+e–, K–, Fy(a–b+),
c. Anti-Kpa
Jk(a–b+), M–N+S–s+
d. Anti-Fyb
b. Cell 1: Group O, D–C–c+E–e+, K–, Fy(a–b+),
Jk(a+b+), M+N–S+s+ 4. The physician has requested 2 units of RBCs for patient
Cell 2: Group O, D+C+c–E–e+, K–, Fy(a+b–), DB, who has two antibodies, anti-L and anti-Q. The fre-
Jk(a+b–), M–N+S–s+ quency of antigen L is 45%, and the frequency of antigen
c. Cell 1: Group O, D+C+c+E+e+, K+, Fy(a+b+), Q is 70% in the donor population. Approximately how
Jk(a+b+), M+N–S+s+ many units will need to be antigen-typed for L and Q to
Cell 2: Group O, D–C–c+E–e+, K–, Fy(a+b–), fill the request?
Jk(a+b+), M+N+S–s+ a. 8
d. Cell 1: Group O, D+C+c–E–e+, K+, Fy(a–b+), b. 12
Jk(a–b+), M–N+S–s+ c. 2
Cell 2: Group O, D- C–c+E+e–, K–, Fy(a+b–), d. 7
Jk(a+b–), M+N–S+s–
5. Anti-Sda has been identified in patient ALF. What
2. Antibodies are excluded using RBCs that are homozygous substance would neutralize this antibody and allow
for the corresponding antigen because: detection of other alloantibodies?
a. Antibodies may show dosage a. Saliva
b. Multiple antibodies may be present b. Hydatid cyst fluid
c. It results in a P value of .05 for proper identification c. Urine
of the antibody d. Human breast milk
d. All of the above
2682_Ch09_216-240 22/05/12 11:45 AM Page 238

238 PART II Blood Groups and Serologic Testing

6. Patient JM appears to have a warm autoantibody. She was 9. What additional cells need to be tested to be 95% confi-
transfused 2 weeks ago. What would be the next step per- dent that the identification is correct?
formed to identify any alloantibodies that might be in her a. Three e-negative cells that react negatively and one
serum? additional e-positive cell that reacts positively
a. Acid elution b. One additional E-positive cell to react positively and
b. Warm autoadsorption using autologous cells one additional K-positive cell to react positively
c. Warm differential adsorption c. Two Jkb homozygous positive cells to react posi-
d. RESt™ adsorption tively and one Jkb heterozygous positive cell to react
negatively
7. What is the titer and score for this prenatal anti-D titer?
d. No additional cells are needed
(Refer to Figure 9–20.)
a. Titer = 64; score = 52 10. Using the panel in Figure 9–21, select cells that would
b. Titer = 1:32; score = 15 make appropriate controls when typing for the C antigen.
c. Titer = 64; score = 21 a. Cell number 1 for the positive control and cell number
d. Titer = 32; score = 52 2 for the negative control
b. Cell number 1 for the positive control and cell number
For Questions 8 through 10, refer to Figure 9–21.
6 for the negative control
8. Select the antibody(ies) most likely responsible for the c. Cell number 2 for the positive control and cell number
reactions observed: 4 for the negative control
a. Anti-E and anti-K d. Cell number 4 for the positive control and cell number
b. Anti-Fya 5 for the negative control
c. Anti-e
d. Anti-Jkb

Figure 9–20. Anti-D titer results for

Saline Question 7.
Dilution 1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024 control
Results 4+ 4+ 3+ 2+ 1+ 1+ 0 0 0 0 0 0

Donor Cell
D C c E e Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub Xga IS 37 AHG CC
number

R1R1 1 + + 0 0 + 0 0 + 0 + 0 + + + + 0 0 + + + + + + 0 + + 0 0 0 3+

R1r 2 + + + 0 + + + + 0 + 0 + + 0 0 + 0 + 0 + 0 + + 0 + + 0 0 3+

R1R1 3 + + 0 0 + 0 0 + 0 + 0 + 0 + + + 0 + + 0 + 0 + 0 + + 0 0 0 3+

R2R2 4 + 0 + + 0 0 0 + 0 + 0 + + 0 + + 0 + + + 0 + 0 0 + + 0 2+ 3+

r’r 5 0 + + 0 + 0 0 + 0 + 0 + 0 0 0 + + 0 + + 0 + + 0 + 0 0 0 0 3+

r”r’’ 6 0 0 + + 0 0 0 + 0 + 0 + + 0 0 + 0 0 + 0 + 0 + 0 + + 0 2+ 3+

rr K 7 0 0 + 0 + 0 + + 0 + 0 + + 0 0 + 0 + + 0 + 0 + 0 + + 0 0 3+

rr 8 0 0 + 0 + 0 0 + 0 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 0 3+

rr 9 0 0 + 0 + 0 0 + 0 + 0 + + 0 + 0 0 + + + + 0 + + + 0 0 0 0 3+

R1r 10 + + + 0 + 0 0 + 0 + 0 + + 0 + + 0 + + + 0 0 + 0 + + 0 0 0 3+

R0 11 + 0 + 0 + 0 0 + 0 + 0 + + + 0 + 0 + + + 0 0 + 0 + + 0 0 0 3+

Patient 0 0 0 3+
Cells

Figure 9–21. Panel study for Questions 8–10.

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Chapter 9 Detection and Identification of Antibodies 239

11. Which of the following methods may be employed to 11. Ciavarella, D, Pate, L, and Sorenson, E: Serologic comparisons
remove IgG antibodies that are coating a patient’s red of antibody detection and titration methods: LISS, PeG, gel
(abstract). Transfusion 42:108S, 2002.
blood cells? 12. Yamada, C, Serrano-Rahman, L, Vasovic, LV, Mohandas, K, and
a. Adsorption Uehlinger, J: Antibody identification using both automated
b. Elution solid-phase red cell adherence assay and a tube polyethylene
c. Neutralization glycol antiglobulin method. Transfusion 48:1693, 2008.
13. Bouix, O, Ferrera, V, Delamaire, M, Redersdorff, JC, and Roubi-
d. Titration
net, F: Erythrocyte-magnetized technology: An original and
12. A technologist has decided to test an enzyme-treated innovative method for blood group serology. Transfusion
48:1878, 2008.
panel of RBCs against a patient’s serum. Which of the 14. Schonewille, H, Haack, HL, and van Zijl, AM: RBC antibody
following antibody pairs could be separated using this persistence. Transfusion 40:1127, 2000.
technique? 15. Tormey, CA, and Stack, G: The persistence and evanescence
a. Anti-Jka and anti-Jkb of blood group alloantibodies in men. Transfusion 49:505,
2009.
b. Anti-S and anti-Fya
16. South, SF: Use of the direct antiglobulin test in routine testing.
c. Anti-D and anti-C In Wallace, ME, and Levitt, JS (eds): Current Application and
d. Anti-Jka and anti-Fya Interpretation of the Direct Antiglobulin Test. American Asso-
ciation of Blood Banks, Arlington, VA, 1988, p 25.
13. An antibody demonstrates weak reactivity at the AHG 17. Issitt, PD, and Anstee, DJ: Applied Blood Group Serology,
phase when using a tube method with no enhancement 4th ed. Montgomery Scientific Publications, Durham, NC,
reagent and monospecific anti-IgG AHG reagent. When 1998, p 470.
repeating the test, which of the following actions may 18. Fisher, RA: Statistical methods and scientific inference, 2nd ed.
Oliver and Boyd, Edinburgh, Scotland, 1959.
increase the strength of the positive reactions? 19. Harris, RE, and Hochman, HG: Revised p values in testing
a. Adding an enhancement reagent, such as LISS or PEG blood group antibodies. Transfusion 26:494, 1986.
b. Decreasing the incubation time from 30 minutes to 20. Kanter, MH, Poole, G, and Garretty, G: Misinterpretation and
10 minutes misapplication of p values in antibody identification: The lack
of value of a p value. Transfusion 37:816, 1997.
c. Employing the prewarm technique
21. Roback, J (ed): Technical Manual, 16th ed. American Associa-
d. Decreasing the incubation temperature to 18°C tion of Blood Banks, Bethesda, MD, 2008, p 894.
22. Kosanke, J, and Arrighi, S: Antigen typing red cells that are re-
References sistant to IgG reduction (abstract). Transfusion 40:119S, 2000.
23. Roback, J (ed): Technical Manual, 16th ed. American Associa-
1. Giblett, ER: Blood group alloantibodies: An assessment of some tion of Blood Banks, Bethesda, MD, 2008, p 896.
laboratory practices. Transfusion 17:299, 1977. 24. Morelati, F, Revelli, N, Musella, A, et al: Automated red cell
2. Boral, L, and Henry, IB: The type and screen: A safe alternative phenotyping (abstract). Transfusion 41:110S, 2001.
and supplement in selected surgical procedures. Transfusion 25. Lowe, L: Use of MTS IgG gel cards for red blood cell antigen
17:163, 1977. typing (abstract). Transfusion 42:109S, 2002.
3. Standards for Blood Banks and Transfusion Services, 26th ed. 26. Bennett, PR, Le Van Kim, C, Dolon, Y, et al: Prenatal determi-
American Association of Blood Banks, Bethesda, MD, 2009. nation of fetal RhD type by DNA amplification. N Engl J Med
4. International Standards for Cellular Therapy Product Collec- 329:607–610, 1993.
tion, Processing, and Administration Accreditation Manual, 27. Palacajornsuk, P, Halter, C, Isakova, V, et al: Detection of blood
4th ed. Foundation for the Accreditation of Cellular Therapy/ group genes using multiplex SNaPshot method. Transfusion
Joint Accreditation Committee—ISCT and EBMT, Omaha, 49:740, 2009.
NE, and Barcellona, Spain, 2008, p 183. 28. Wagner, FF, Bittner, R, Petershofen, EK, Doescher, A, and Müller,
5. Judd, WJ, Luban, NLC, Ness, PM, et al: Prenatal and perinatal TH: Cost-efficient sequence-specific priming–polymerase chain
immunohematology: Recommendations for serologic manage- reaction screening for blood donors with rare phenotypes. Trans-
ment of the fetus, newborn infant, and obstetric patient. Trans- fusion 48:1169, 2008.
fusion 30:175, 1990. 29. Karpasitou, K, Drago, F, Crespiatico, L, et al: Blood group geno-
6. Issitt, PD, and Anstee, DJ: Applied Blood Group Serology, typing for Jka/Jkb, Fya/Fyb, S/s, K/k, Kpa/Kpb, Jsa/Jsb, Coa/Cob, and
4th ed. Montgomery Scientific Publications, Durham, NC, Lua/Lub with microarray beads. Transfusion 48:505, 2008.
1998, p 47. 30. Aster, RH, Miskovich, BH, and Rodey, GE: Histocompatibility
7. Klein, HG, and Anstee, DJ: Mollison’s Blood Transfusion in antigens of human plasma; localization to HLD-3 lipoprotein
Clinical Medicine, 11th ed. Blackwell Scientific Publications, fraction. Transplantation 16:205, 1973.
Oxford, England, 2005, p 312. 31. Yuan S: Immunoglobulin M red blood cell alloantibodies are
8. Issitt, PD, and Anstee, DJ: Applied Blood Group Serology, frequently adsorbed by rabbit erythrocyte stroma. Transfusion
4th ed. Montgomery Scientific Publications, Durham, NC, 50(5):1139–1143, 2010.
1998, p 132. 32. Roback, J (ed): Technical Manual, 16th ed. American Associa-
9. Standards for Blood Banks and Transfusion Services, 26th ed. tion of Blood Banks, Bethesda, MD, 2008, p 893.
American Association of Blood Banks, Bethesda, MD, 2009. 33. Landsteiner, K, and Miller, CP: Serologic studies on the blood
10. Kosanke, J, Dickstein, B, and Davis, K: Evaluation of incuba- of primates: II. The blood group of anthropoid apes. J Exp Med
tion times using the ID-Micro Typing system (abstract). Trans- 42:853, 1925.
fusion 42:108S, 2000.
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256 PART II Blood Groups and Serologic Testing

findings indicate yet another method for performing com-

patibility testing. CASE STUDIES
Finally, an automated flow cytometry system is cur-
Case 10-1
rently being developed and investigated for pretransfusion
compatibility testing. A study comparing flow cytometry Labor and delivery orders 4 units of packed red blood
with column agglutination and standard tube testing for cells stat on a 32-year-old white female with the following
ABO, Rh typing, and antibody detection revealed a system results: ABO/Rh—A-positive; antibody screen—no unex-
equivalent for each methodology. It is also quite comparable pected antibodies detected; history—no unexpected an-
in many aspects, including sensitivity, accuracy, and speci- tibodies in two previous deliveries at this facility, and no
men turnaround time.81,82 previous red cell transfusions recorded.
As information technology continues to grow, all aspects
of patient care, including compatibility testing, may be 1. What crossmatch options do you have?
computerized. In addition to performing an electronic cross- 2. Which do you choose and why?
match, computer systems now include electronic identifica-
Case 10-2
tion of the patient, automated testing, and electronic transfer
of data. The success of these systems depends on interfacing Pretransfusion testing results on a presurgical patient with
automated testing instruments with bar-code readers and a a 3-unit crossmatch order are as follows: ABO/Rh—
laboratory computer.83 B-positive; unexpected antibody screen—no unexpected
Our knowledge of compatibility testing is in a dynamic antibodies detected; 3 RBC units crossmatched—unit 1,
state, and we look forward to continuing developments in compatible at AHG; unit 2, compatible at AHG; and unit 3,
technical procedures to streamline and safeguard transfusion incompatible at AHG using gel column methodology.
practice. The challenge of modern blood banking will be to
merge new technology with the assurance of beneficial 1. What can account for the incompatible unit? Explain?
results and positive outcomes for the patient. 2. How would you resolve this situation?

SUMMARY CHART
Most fatal transfusion reactions are caused by clerical corresponding antigen on the donor RBCs, donor hav-
errors. ing a positive DAT, abnormalities in patient serum
Samples and forms must contain patient’s full name such as increased protein concentration (rouleaux) or
and unique identity number. contaminants in test system.
Writing must be legible and indelible. Emergencies:
Date of collection must be written on sample. v May have to select uncrossmatched, group O, Rh-
negative packed RBCs.
Sample must be collected within 3 days of scheduled
transfusion.
v May want to give uncrossmatched, group O, Rh-
positive packed RBCs if male patient or female
A blood bank specimen must have two unique patient patient is beyond childbearing years.
identifiers—the date of collection and initials or sig- v May be able to provide type-specific, uncross-
nature of the person who collected the sample. matched RBCs.
Confirm blood type of donor. Plasma products units:
Check patient records (history) for results of previous v No compatibility testing required.
tests. Perform ABO grouping, Rh typing, and antibody Transfusion to fetus:
screening on patient. v Compatibility testing performed using mother’s
Select donor unit based on ABO group and Rh type of sample.
patient; further consider presence of antibodies in pa- v Donor unit must lack antigen against maternal
tient by antigen-typing donor unit for the correspon- antibody.
ding antigen. v Group O Rh-negative donor selected when fetal
Perform immediate spin or antiglobulin crossmatch type is unknown or when type is known but is not
based on current or historical serologic results. compatible with mother’s type.
Electronic crossmatch can replace immediate spin Transfusion to infant:
crossmatch when two blood types are on file for the v Maternal sample can be used for compatibility testing.
patient and antibody screen is negative. v Initial sample from infant typed for ABO (front
Positive results in the crossmatch may be caused by type) and Rh.
incorrect ABO grouping of patient or donor, alloanti- v Donor unit selected should be compatible with
body or autoantibody in patient reacting with the both mother and baby.
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Chapter 10 Pretransfusion Testing 257

7. The purpose of the immediate spin crossmatch is to:

Review Questions
a. Ensure survival of transfused RBCs
1. Pretransfusion testing: b. Determine ABO compatibility between donor and
recipient
a. Proves that the donor’s plasma is free of all irregular
c. Detect cold-reacting unexpected antibodies
antibodies
d. Meet computer crossmatch requirements
b. Detects most irregular antibodies on the donor’s RBCs
that are reactive with patient’s serum 8. Which does not represent requirements set forth by the
c. Detects most errors in the ABO groupings AABB for the performance of a computer crossmatch?
d. Ensures complete safety of the transfusion a. Computer system must be validated on-site.
2. Which is not true of rouleaux formation? b. Recipient antibody screen must be positive.
c. Two determinations of the recipient ABO and Rh
a. It is a stacking of RBCs to form aggregates.
must be performed.
b. It can usually be dispersed by adding saline.
d. Computer system must have logic.
c. It can appear as an ABO incompatibility.
d. It cannot cause a false-positive immediate spin 9. You have just received a request and sample for pretrans-
crossmatch. fusion testing. Which is the most appropriate to do first?
3. What type of blood should be given in an emergency a. Perform the ABO grouping and Rh typing
transfusion when there is no time to type the recipient’s b. Complete the crossmatch
sample? c. Perform the IAT to see if the patient is going to be a
problem
a. O Rh0 (D)-negative, whole blood
d. Check the records for prior type and screen results
b. O Rh0 (D)-positive, whole blood
on the patient
c. O Rh0 (D)-positive, packed cells
d. O Rh0 (D)-negative, packed cells 10. Blood donor and recipient samples used in crossmatch-
ing must be stored for a minimum of how many days
4. A patient developed an anti-Jka antibody 5 years ago. The
following transfusion?
antibody screen is currently negative. To obtain suitable
blood for transfusion, which procedures apply? a. 2
b. 5
a. Type the patient for the Jkb antigen as an added part to
c. 7
the crossmatch procedure.
d. 10
b. Crossmatch random donors with the patient’s serum,
and release the compatible units for transfusion to the 11. Which is true regarding compatibility testing for the in-
patient. fant younger than 4 months old?
c. Type the patient and donor units for the Jka antigen, a. A DAT is required.
and then crossmatch the Jka negative units with the b. A crossmatch is not needed with the infant’s blood
patient serum. when unexpected antibodies are present.
d. Computer-crossmatch Jka negative donor units. c. Maternal serum cannot be used for antibody
5. A 26-year-old B Rh0 (D)-negative female patient requires detection.
a transfusion. No B Rh0 (D)-negative donor units are d. To determine the infant’s ABO group, RBCs must be
available. Which should be chosen for transfusion? tested with reagent anti-A, anti-B, and anti-A,B.
a. B Rh0 (D)-positive RBCs 12. A nurse just called to request additional RBC units for a
b. O Rh0 (D)-negative RBCs patient for whom you performed compatibility testing 4
c. AB Rh0 (D)-negative RBCs days ago. She would like you to use the original speci-
d. A Rh0 (D)-negative RBCs men, as you keep it for 7 days anyway. Your most appro-
priate course of action would be to:
6. Having checked the patient’s prior history after having
received the specimen and request, you: a. Check to see if there is enough of the original
specimen
a. Do not have to repeat the ABO and Rh if the name and
b. Perform the compatibility testing on the original
hospital number agree
specimen
b. Do not have to repeat the indirect antiglobulin test
c. Request more information in case the patient has de-
(IAT) if the previous IAT was negative
veloped a clinically significant unexpected antibody
c. Have to perform a crossmatch only if one has not been
d. Indicate that a new specimen is necessary because the
done within the last 2 weeks
patient has been recently transfused
d. Have to compare the results of your ABO, Rh, and IAT
with the previous results
2682_Ch10_241-259 22/05/12 11:46 AM Page 258

258 PART II Blood Groups and Serologic Testing

13. A crossmatch is positive at AHG phase with polyspecific 21. Mollison, PL: Blood Transfusion in Clinical Medicine, 9th ed.
AHG reagent but is negative with monospecific anti-IgG Blackwell Scientific, Oxford, England, 1993, p 225.
22. Roback, J (ed): Technical Manual, 16th ed. American Associa-
AHG reagent. This may indicate the antibody: tion of Blood Banks, Bethesda, MD, 2008, p 453.
a. Is a weak anti-D 23. Standards, op cit, p 35, 5.15.1.1.
b. Is a clinically insignificant Lewis antibody 24. Roback, J. (ed): Technical Manual, 16th ed. American Associ-
c. Can cause decreased survival of transfused RBCs ation of Blood Banks, Bethesda, MD, 2008, p 453
25. Alexander, D, and Henry, JB: Immediate spin crossmatch in
d. Is a Duffy antibody
routine use: A growing trend in compatibility testing for red
14. The emergency room requests 6 units of packed RBCs cell transfusion therapy. Vox Sang 70:48, 1996.
26. Walker, RH: On the safety of the abbreviated crossmatch.
for a trauma patient prior to collection of the patient’s In Polesky, HF, and Walker, RH (eds): Safety in Transfusion
specimen. The most appropriate course of action is to: Practices; CAP Conference, Aspen, 1980. College of American
a. Release group O RBCs to ER with trauma patient Pathologists, Skokie, IL, 1982, p 75.
identification on each unit sent 27. Shulman, IA, et al: Experience with the routine use of an
abbreviated crossmatch. Am J Clin Pathol 82:178, 1984.
b. Refuse to release units until you get a patient sample
28. Dodsworth, H, and Dudley, HAF: Increased efficiency of
c. Indicate necessity for signed patient waiver for transfusion practice in routine surgery using pre-operative
incomplete pretransfusion testing antibody screening and selective ordering with an abbreviated
d. Explain need of patient’s ABO group prior to issuing crossmatch. Br J Surg 72:102, 1985.
blood 29. Garratty, G: Abbreviated pretransfusion testing. Transfusion
26:217, 1986.
15. Which is not an example of the most common form of 30. Freidberg, RC, et al: Type and screen completion for scheduled
error associated with fatal transfusion reactions? surgical procedures. Arch Pathol Lab Med 127, 2003.
31. Judd, WJ: Are there better ways than the crossmatch to demon-
a. Phlebotomist labels patient A tubes with patient B strate ABO incompatibility? Transfusion 31:192, 1991.
information 32. Shulman, IA, and Calderon, C: Effect of delayed centrifuga-
b. Technologist enters results of patient A testing into tion or reading on the detection of ABO incompatibility by
patient B field the immediate-spin crossmatch. Transfusion 31:197, 1991.
33. Perkins, JT, et al: The relative utility of the autologous control
c. Wrong RBC unit is tagged for transfusion
and the antiglobulin test phase of the crossmatch. Transfusion
d. Antibody below detectable levels during pretransfusion 30:503, 1990.
testing 34. CFR, op cit, part 606, section 160.
35. Green, TS: Rouleaux and autoantibodies (or things that go
References bump in the night). In Treacy, M (ed): Pre-Transfusion Testing
for the 80s. American Association of Blood Banks, Washington,
1. Roback, J (ed): Technical Manual, 16th ed, American Association DC, 1980, p 93.
of Blood Banks, Bethesda, MD, 2008. 36. Bartholomew, JR, et al: A prospective study of the effects of
2. Linden, JV, et al: Transfusion error in New York State: An dextran administration on compatibility testing. Transfusion
analysis of 10 years experience. Transfusion 40:1207, 2000. 26:431, 1986.
3. Carson, TH: Standards for Blood Banks and Transfusion 37. Golde, DW, et al: Serum agglutinins to commercially pre-
Services, 26th ed. American Association of Blood Banks, pared albumin. In Weisz-Carrington, P: Principles of Clinical
Bethesda, MD, 2009, p 32, 5.11.2. Immunohematology. Year Book Medical, Chicago, 1986,
4. Ibid, p 3, 2.1.2 p 214.
5. Ibid, pp 32, 33, 5.11.2–4. 38. Judd, JW: Requirements for the electronic crossmatch. Vox
6. Ibid, p 33, 5.11.2.3, 5.11.3. Sang 74:409, 1998.
7. Ibid, p 34, 5.13.3.2. 39. Ibid.
8. Ibid, p 21, 5.6.3. 40. Butch, SH, et al: Electronic verification of donor-recipient com-
9. Ibid, p 33, 5.11.4. patibility: The computer crossmatch. Transfusion 34:105,
10. Code of Federal Regulations (CFR), Title 21, Food and Drugs. 1994.
Office of the Federal Register, National Archives and Records Serv- 41. Shulrman, IA, et al: North American Pretransfusion Testing
ice, General Services Administration, Part 610, section 40, revised Practices, 2001–2004. Results from the College of American
June 11, 2001, and Part 640, section 5 revised August 6, 2001. Pathologists Interlaboratory Comparison Program Survey Data,
11. Standards, op cit, pp 29–31, 5.8, and pp 33, 34, 5.13. 2001–2004, p 986.
12. Ibid, p 29, 5.8.3.1. 42. Judd, JW: Requirements for the electronic crossmatch. Vox
13. Ibid, p 33, 5.12. Sang 74:409, 1998.
14. Ibid, p 63, 6.2.5. 43. Ibid p 36, 5.15.2.
15. Ibid, p 34, 5.13.3.2 44. Standards, op cit p 36, 5.15.2.1–5.
16. Ibid, p 33, 5.13.2. 45. CFR, op cit, part 606, section 160.
17. Garratty, G: Evaluating the clinical significance of blood group 46. Standards, op cit, p 37, 5.16.
alloantibodies that are causing problems in pretransfusion 47. Ibid.
testing. Vox Sang 74:285, 1998. 48. Ibid.
18. Giblett, ER: Blood group alloantibodies: An assessment to some 49. Ibid.
laboratory practices. Transfusion 17:299, 1977. 50. Ibid, p 38, 5.17.5.
19. Spielmann, W, and Seidl, S: Prevalence of irregular red cell 51. Roback, J (ed): Technical Manual, 16th ed. American Associa-
antibodies and their significance in blood transfusion and tion of Blood Banks, Bethesda, MD, 2008, p 441.
antenatal care. Vox Sang 26:551, 1974. 52. Ibid.
20. Aygun B, et al: Clinical significance of RBC alloantibodies and 53. Standards, op cit, pp 30, 31, 5.8.5.
autoantibodies in sickle cell patients who received transfusion. 54. Ibid, p 45, 5.1.6A.
Transfusion 42:37, 2002. 55. Ibid, p 29, 5.8
2682_Ch11_260-272 22/05/12 11:46 AM Page 271

Chapter 11 Overview of the Routine Blood Bank Laboratory 271

BLOOD UTILIZATION REVIEW REPORT

PERIOD:
Parameter Result Goal Comment
Statistics
C:T Ratio 1.5 Concern at ! 2.0
# Physicians C:T ! 1.5 0 See attached for physician names
Patients transfused NA
Patients receiving ! 1 component NA
Massive transfusions NA
Breakdown of units given: RBC – NA
PLT -
FFP –
CRYO -
Tissue products implanted NA
T&S converted for surgery " 5% of TYSC
Wasted units 0
ABO and/or RH type change (POS units to NEG patients) " 5%
(NEG units to POS patients) NA
ABO change NA
Lookback investigations 1 NA
Reactions
Transfusion reaction workups 3% total
transfusions
Inventory control
Units received/units transfused "2
Returned to supplier NA
Expired units 0
Component usage
__ patients receiving red cells were Did not meet screening NA Chart reviews being performed by
reviewed. criteria of HGB " 8.0 medical director
All patients receiving components Did not meet screening NA Chart reviews being performed by
were reviewed criteria of PT ! 13; PTT ! 30; medical director
PLT " 20

Figure 11–13. Sample Blood Utilization Report. This report helps the blood bank monitor effective use of blood products, including the number of physicians whose
C:T ratio exceeds the hospital standard, and possible inappropriate transfusions. This report is typically reviewed by the blood bank medical director and a medical peer
review committee.

SUM M ARY CHART

The goal of every blood bank laboratory is to provide Blood and blood components must be stored and
quality service and safe blood products. shipped under conditions that ensure their viability.
All blood bank laboratory operations are regulated Every donor unit is tested to determine ABO group and
by law. Rh type, including weak D when indicated. Units are
Personnel employed by blood bank laboratories must also tested for selected viral markers.
be qualified by education, training, or experience. The type of Rh-negative units must be confirmed because
A primary source of operational information is the SOP of potential sensitization that may occur if Rh-positive
manual. blood is transfused to an Rh-negative recipient.
Hemapheresis is a process that uses an apheresis Manual tube procedures are being replaced by emerg-
machine to selectively remove components from donor ing technologies, including gel-based methods and
blood. automation.
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272 PART II Blood Groups and Serologic Testing

6. Which of the following may not be used as a patient

Review Questions
identifier?
1. What is the shipping temperature requirement for a. Patient’s full name
plasma? b. Patient’s date of birth
c. Patient’s medical record number
a. 1°F to 6°F or higher
d. Patient’s room number
b. 1°C to 6°C or lower
c. #18°F or higher 7. Which of the following is not an enhancement media that
d. #18°C or lower may be used in antibody screening and identification?
2. Antibody serial titration studies are most often associated a. Albumin
with which of the following blood bank test groupings? b. Low ionic strength solution (LISS)
c. Normal saline
a.Prenatal evaluation
d. Polyethylene glycol
b.Type and screen
c.Type and crossmatch 8. Which of the following methods may be useful in
d.Blood unit processing investigating a positive DAT?
3. The prewarm technique is most useful in investigating a. Elution techniques
which types of blood bank problems? b. Removal of cell-bound antibody using chloroquine
a.ABO discrepancies diphosphate
c. Drug studies
b.Rh discrepancies
d. All of the above
c.Warm antibodies
d.Cold antibodies
References
4. It is most important to perform weak-D testing in which
1. American Association of Blood Banks: “About Blood and Cellular
of the following blood bank test groupings? Therapies.” Available at www.aabb.org.
a. Type and screen 2. United States Department of Health and Human Services: 2009
b. Type and crossmatch National Blood Collection and Utilization Survey Report, 2011.
Available at www.hhs.gov/bloodsafety.
c. Cord blood evaluation
3. Standards for Blood Banks and Transfusion Services, 27th ed.
d. Prenatal evaluation American Association of Blood Banks, Bethesda, MD, 2011.
4. Roback, John D, et al: Technical Manual, 16th ed. American
5. Which of the following is a method for determining
Association of Blood Banks, Bethesda, MD, 2008.
approximate volume of fetal-maternal bleed? 5. Code of Federal Regulations, Title 21 CFR Parts 640.
a.Kleihauer-Betke test Washington, DC: US Government Printing Office, 2009
b.Eluate testing (revised annually).
6. The Joint Commission Edition, Quality System Assessment for
c.Nucleic acid amplification testing
Nonwaived Testing, January 2010.
d.Antibody screening
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Chapter 12 Other Technologies and Automation 285

SUMMARY CHART
Advantages of gel and solid-phase technologies over v Solid-phase technology is currently approved for
routine tube testing are: antibody screening, antibody identification, and
v Standardization: There is no tube shaking or resus- compatibility testing.
pension of an RBC button to cause subjectivity in v Advantages of solid-phase technology include the
the interpretation of the test. ease of use, because no predilution of reagents is
v Stability: There are well-defined endpoints of the required, and the ability to test hemolyzed, lipemic,
reaction. or icteric samples. Enhanced sensitivity increases
v Decreased sample volume needed for testing the detection of weak alloantibodies.
v Enhanced sensitivity and specificity v The major disadvantage of solid-phase technology
Gel test points to remember: is the need to purchase special equipment: a cen-
v The principle of the gel test is hemagglutination. trifuge that can spin microplates, a 37°C incubator
v In the gel test, RBCs and serum or plasma are for microplates, and a light source for reading the
allowed to incubate together in a reaction chamber. final results.
v Following incubation, controlled centrifugation Solid-phase protein A technology points to remember:
drives the RBCs through a specially designed mi- v IgG antibodies are captured in microwells that are
crotube filled with beads of dextran-acrylamide gel. coated with protein A.
v Agglutinated cells remain at the top of the tube or v Solidscreen II, which uses solid-phase protein A
are trapped in the gel, depending on the size of the technology, is an assay that uses traditional
agglutinates. antiglobulin technique.
v Unagglutinated cells move through the gel to the v Solid-phase protein A testing is available only in
bottom of the tube. the United States as an automated technology on
v The gel test reactions are stable for observation or the TANGO optimo instrument.
review for 2 to 3 days. Solid-phase immunosorbent assay (ELISA) points to
v Gel technology is currently approved for ABO remember:
forward and reverse grouping, Rh typing, DAT, v The MACE products provide well-characterized
antibody screening, antibody identification, and monoclonal antibodies immobilized in microwells
compatibility testing. that are used to capture glycoproteins from
v The major disadvantage of the gel technology is the platelets supplied by the user.
need to purchase special equipment: a centrifuge v MACE is used primarily for compatibility testing.
to accommodate the microtube cards used for test- v The PAK products provide well-characterized
ing and a pipette for dispensing plasma or serum platelet glycoproteins that are either immobilized
and RBC suspensions into the reaction chambers directly or captured by monoclonal antibodies to
of the microtubes. wells of a microwell plate.
SPRCA assay points to remember: v PAK is used to detect and differentiate between
v The principle of SPRCA is based on solid-phase antibodies that bind to platelet-specific glycoproteins
technology. (IIb/IIIa, Ib/IX, Ia/IIa, and IV) and class I HLA,
v In SPRCA tests, the target antigen is affixed to the primarily for compatibility testing.
bottom of the microplate wells. Luminex-based assay points to remember:
v If the test plasma contains antibodies to the anti- v Luminex-based assay is a bead-based assay that
gen, they attach to the fixed antigen, and indicator uses florescence and flow cytometry to test for
cells detect the attached antibodies by forming a platelet/HLA antibodies.
monolayer of RBCs. v Luminex assay uses a mixture of 100 different
v If the test plasma contains no antibodies to the colored beads, each bead coated with a different
antigen, there is no attachment to the fixed anti- protein.
gen, and the indicator cells form a clearly delin- v The flow cytometer distinguishes between each
eated button at the center of the microplate well. of the 100 beads by the amount and color of the
v Solid-phase reactions are stable for observation or internal dyes.
review for 2 days.
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286 PART II Blood Groups and Serologic Testing

10. A safety feature in the SPRCA test is:

Review Questions
a. Air bubble barrier
b. Viscous barrier
1. The endpoint of the gel test is detected by:
c. Color change of the LISS
a. Agglutination
d. Use of IgG-coated control cells
b. Hemolysis
c. Precipitation
References
d. Attachment of indicator cells
1. Shulman, IA, Maffei, LM, and Downes, KA: North American
2. The endpoint of the SPRCA test is detected by: pretransfusion testing practices, 2001–2004: Results from
a. Agglutination the College of American Pathologists Interlaboratory Compar-
ison Program survey data, 2001–2004. Arch Path Lab Med
b. Hemolysis
129:984–989, 2005.
c. Precipitation 2. College of American Pathologists. CAP survey final critique
d. Attachment of indicator cells J-B, 2005.
3. Lapierre, Y, Rigal, D, Adams, J, et al: The gel test: A new way
3. The endpoint of the solid-phase protein A assay is: to detect red cell antigen-antibody reactions. Transfusion
a. Agglutination 30:109–113, 1990.
b. Hemolysis 4. ID-Micro Typing System. Question and answer guide. Ortho
Diagnostic Systems, Raritan, NJ, 1996.
c. Precipitation
5. Package insert for MTS buffered gel card. Pompano Beach, FL.
d. Attachment of cells to microwell Micro Typing Systems, 2008.
6. Package insert for MTS Anti-D (Monoclonal)(IgM) card.
4. Protein A captures antibodies by binding to:
Pompano Beach, FL. Micro Typing Systems, 2008.
a. Fab portion of immunoglobulin 7. Package insert for MTS Monoclonal Rh phenotype card.
b. Fc portion of immunoglobulin Pompano Beach, FL. Micro Typing Systems, 2009.
c. Surface of test cells 8. Package insert for MTS Anti-IgG card, Pompano Beach, FL.
Micro Typing Systems, 2008.
d. Surface of indicator cells
9. Chan, A, Wong, HF, Chiu, CH, et al: The impact of a gel system
5. The endpoint of the solid-phase immunosorbent assay on routine work in a general hospital blood bank. Immunohe-
matology 12:30–32, 1996.
(ELISA) is:
10. A new era begins: Introducing ID-MTS, ID-Micro Typing
a. Agglutination System (product brochure). Ortho Diagnostics Systems, Raritan,
b. Hemolysis NJ, November 1995.
c. Color change in the substrate 11. Package insert for ID-Tipmaster Repetitive Dispense Pipetor,
Pompano Beach, FL. Micro Typing Systems, 2011.
d. Attachment of indicator cells
12. Package insert for Biohit/MTS Electronic Pipettor. Biohit,
6. Mixed-field reactions can be observed in: Neptune, NJ. Ortho-Clinical Diagnostics, 2011.
13. Rosenfield, RE, Kochwa, SE, and Kaczera, Z: Solid phase
a. Gel serology for the study of human erythrocyte antigen-antibody
b. SPRCA reactions. Proceedings, Plenary Session, 25th Congress, Inter-
c. Protein A technology national Society Blood Transfusion, Paris, 1978.
d. Luminex 14. Plapp, FV, et al: Blood antigens and antibodies: Solid phase
adherence assays. Lab Manage 22:39, 1984.
7. The endpoint of the luminex assay is change of: 15. Moore, HH: Automated reading of red cell antibody identifica-
tion tests by a solid phase antiglobulin technique. Transfusion
a. Electrical charge on the RBCs
24:218–221, 1985.
b. Color of the liquid substrate 16. Capture (solid phase technology). Product brochure, Immucor,
c. Color of indicator on beads Norcross, GA, 2009.
d. Density of the indicator substrate 17. Capture (solid phase technology). Package insert for Capture-
R Ready-ID Extend I & II. Immucor, Norcross, GA, 2008.
8. An advantage for both gel and solid-phase technology is: 18. Rolih, S, et al: Solid phase red cell adherence assays. La Trans-
a. No cell washing steps fusione del Sangue 36:4, 1991.
19. Galileo Echo instrument (solid phase automation). Product
b. Standardization
brochure, Immucor, Norcross, GA, 2007.
c. Use of IgG-coated control cells 20. Galileo Neo instrument (solid phase automation). Product
d. Specialized equipment brochure, Immucor, Norcross, GA, 2010.
21. King, BF, and Wilkinson, BJ: Binding of human immunoglobulin
9. A disadvantage for both gel and solid-phase technology is: G to protein A in encapsulated Staphylococcus aureus. Infect
a. Decreased sensitivity Immun 33:666–672, 1981.
b. Inability to test hemolyzed, lipemic, or icteric samples 22. Solidscreen II (solid phase protein A technology), package
insert, Biotest AG, 2008.
c. Inability to detect C3d complement–coated cells
d. Large sample requirement
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Chapter 13 Donor Screening and Component Preparation 327

SUMMARY CHART
An allogeneic blood donor should weigh at least Postoperative salvage is an autologous donation in
110 lb (50 kg). which a drainage tube is placed in the surgical site
The pulse rate of a potential blood donor should be be- and postoperative bleeding is salvaged, cleaned, and
tween 50 and 100 beats per minute. reinfused.
The hemoglobin/hematocrit level of an allogeneic All whole blood units should be stored at 1°C to 6°C;
blood donor should be at least 12.5/38%. those units destined for platelet production should
A donor must be permanently deferred if he or she be stored at 20°C to 24°C until platelets have been
has had a confirmed positive test for HBsAg after the removed.
11th birthday. Donor units must be tested for the following viral
The deferral period for persons who have been treated markers: STS, anti-HIV-1/2, HIV-antigen, anti-HTLV
for malaria is 3 years following therapy. I/II, HBsAg, anti-HBc, and anti-HCV.
Persons who have had a blood transfusion are deferred RBCs must be prepared by a method that separates the
for 12 months owing to risk of exposure to hepatitis, RBCs from the plasma and results in a hematocrit level
HIV, or other viral diseases. of less than or equal to 80%.
A platelet pheresis donor should not have taken aspirin Irradiated RBCs must be given a radiation dose of at
for 3 days before donation because it decreases platelet least 25 Gy to the midplane of the canister, after which
function. the expiration date of the product changes to 28 days
from the time of irradiation or maintains the original
The interval between whole blood donations is
outdate, whichever comes first.
8 weeks or 56 days.
Leukocyte-reduced RBCs are products in which the
A person with a history of hemophilia A or B, von
absolute leukocyte count is less than 5 × 106.
Willebrand disease, or severe thrombocytopenia must
be permanently deferred from donating blood. Random-donor platelets must contain at least 5.5 ×
1010 platelets; single-donor platelets must contain at
Attenuated live viral vaccines such as smallpox,
least 3 × 1011 platelets; each carries a shelf-life of
measles, mumps, yellow fever, and influenza (live
5 days.
virus) carry a 2-week deferral.
FFP must be prepared within 8 hours of collection
Attenuated live viral vaccines such as German measles
for CPD, CPDA-1, and CP2D; it is stored at –18°C for
(rubella) and chickenpox (varicella zoster) carry a
12 months.
4-week deferral.
Cryoprecipitate is prepared from FFP and contains
A blood donor who has a positive serologic test for
at least 80 units of antihemophilic factor and
syphilis must be deferred for 12 months.
150 to 250 mg of fibrinogen; this product is indi-
Donors who have tested positive for the HIV antibody cated for hemophilia A, factor XIII deficiency, and
must be indefinitely deferred. hypofibrinogenemia.
Predeposit autologous donation refers to blood for the RhIg is a solution of concentrated anti-Rho(D), which
donor-patient that is drawn before an anticipated is manufactured from pooled hyperimmunized donor
transfusion (e.g., surgery) and stored until use. plasma. It is used to prevent Rho(D) immunization of
An autologous donor must have a hemoglobin of at an unsensitized Rh-negative mother after an abortion,
least 11 g/dL and a hematocrit level of at least 33%. miscarriage, amniocentesis, or delivery of an Rh-
Intraoperative autologous transfusion occurs when positive or Rh-unknown infant.
blood is collected during a surgical procedure and is One unit of random-donor platelets typically increases
usually reinfused immediately. the platelet count in a 70-kg adult by 5,000 to
Acute normovolemic hemodilution takes place in the 10,000/ML; 1 unit of apheresis platelets should increase
operating room when 1 to 3 units of whole blood are the platelet count in a 70-kg adult by 30,000 to
collected and the patient’s volume is replaced with col- 60,000/ML.
loid or crystalloid. The blood is reinfused during the
surgical procedure.
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328 PART III Transfusion Practice

8. Each unit of cryoprecipitate prepared from whole blood

Review Questions
should contain approximately how many units of AHF
activity?
1. Which of the following information is not required for
whole blood donors? a. 40 IU
b. 80 IU
a.Name
c. 120 IU
b.Address
d. 160 IU
c.Occupation
e. 180 IU
d.Sex
e.Date of birth 9. Platelet concentrates prepared by apheresis should con-
tain how many platelets?
2. Which of the following would be cause for deferral?
a. 5.5 × 1010
a. Temperature of 99.2°F
b. 6 × 1010
b. Pulse of 90 beats per minute
c. 3 × 1011
c. Blood pressure of 110/70 mm Hg
d. 5.5 × 1011
d. Hematocrit level of 37%
e. 6 × 1011
e. None of the above
10. The required storage temperature for frozen RBCs using
3. Which of the following would be cause for permanent
the high-glycerol method is:
deferral?
a. 4°C
a. History of hepatitis after 11th birthday
b. –20°C
b. Positive hepatitis C test result
c. –18°C
c. Positive HTLV-I antibody
d. –120°C
d. Positive anti-HBc test result
e. –65°C
e. All of the above
11. How does irradiation affect the shelf-life of red blood
4. Immunization for rubella would result in a temporary
cells?
deferral for:
a. Irradiation has no effect on the shelf-life.
a. 4 weeks
b. The expiration date is 28 days from the date of irra-
b. 8 weeks
diation or the original outdate, whichever is later.
c. 6 months
c. The expiration date is 28 days from the date of irra-
d. 1 year
diation or the original outdate, whichever is sooner.
e. no deferral required
d. The expiration date is 25 days from the date of irra-
5. Which of the following donors is acceptable? diation or the original outdate, whichever is later.
a. Donor who had a first-trimester therapeutic abortion e. The expiration date is 25 days from the date of irra-
4 weeks ago diation or the original outdate, whichever is sooner.
b. Donor whose husband is a hemophiliac who regularly 12. Once thawed, FFP must be transfused within:
received cryoprecipitate before 1989
a. 4 hours
c. Donor who was treated for gonorrhea 6 months ago
b. 6 hours
d. Donor who had a needlestick injury 10 months ago
c. 8 hours
6. Which of the following tests is not required as part of the d. 12 hours
donor processing procedure for allogeneic donation? e. 24 hours
a.ABO 13. Quality control for RBCs requires a maximum hemat-
b.Rh ocrit level of:
c.STS
a. 75%
d.Anti-HTLV I
b. 80%
e.Anti-CMV
c. 85%
7. Which of the following lists the correct shelf-life for the d. 90%
component? e. 95%
a.Deglycerolized RBCs—24 hours 14. AHF concentrates are used to treat:
b.RBCs (CPD)—35 days
a. Thrombocytopenia
c.Platelet concentrate—7 days
b. Hemophilia A
d.FFP—5 years
c. Hemophilia B
e.RBCs (CPDA-1)—21 days
d. von Willebrand disease
e. Factor XIII deficiency
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Chapter 13 Donor Screening and Component Preparation 329

15. Prothrombin complex concentrates are used to treat 6. Friedland, GH, et al: Lack of transmission of HTLV-III/LAV in-
which of the following? fection to household contacts of patients with AIDS or AIDS
related complex with oral candidiasis. N Engl J Med 314:344,
a. Factor IX deficiency 1986.
b. Factor VIII deficiency 7. Kaur, P, and Basu, S: Transfusion-transmitted infections:
c. Factor XII deficiency Existing and emerging pathogens. J Post Grad Med 51:146,
d. Factor XIII deficiency 2005.
8. Soendjojo, A, et al: Syphilis d’emblee due to a blood transfu-
e. Factor V deficiency
sion. Br J Veneral Dis 58:149, 1982.
16. How is the antibody screen test different for donors than 9. Risseeuw-Appel, IM, and Kothe, FC: Transfusion syphilis:
A case report. Sex Transm Dis 10:200, 1983.
for patients? 10. Chambers, RW, et al: Transfusion of syphilis by fresh blood
a. In donors, a 2-cell screen is used. components. Transfusion 9:32, 1969.
b. In donors, a 3-cell screen is used. 11. Director, Center for Biologics Evaluation and Research, Food
c. In donors, a pooled cell is used. and Drug Administration: Recommendations for the deferral
of current and recent inmates of correctional institutions as
d. There is no difference in testing.
donors of whole blood, blood components, source leukocytes,
17. RBCs that have been leukoreduced must contain less and source plasma. Memorandum to all registered blood and
plasma establishments, June 8, 1995.
than ______ and retain at least ______ of original 12. Food and Drug Administration. Guidance for Industry. Revised
RBCs. preventive measures to reduce the possible risk of transmission
a. 8 × 106/85% of Creutzfeldt-Jakob disease (CJD) and variant Creutzfeldt-
b. 8 × 106/90% Jakob disease (vCJD) by blood and blood products. May 2010.
Available at www.fda.gov/cber/guidelines.htm.
c. 5 × 106/85%
13. Zayas, CF, et al: Chagas disease after organ transplantation—
d. 5 × 106/80% United States, 2001. MMWR Weekly 51:210, 2002.
14. Stramer, SL, et al: Blood donor screening for Chagas disease—
18. Random-donor platelets that have been leukoreduced United States, 2006–2007. MMWR 56: 141, 2007.
must contain less than ______ leukocytes. 15. Food and Drug Administration. Guidance for Industry. Rec-
a. 8.3 × 105 ommendations for management of donors at increased risk
b. 8 × 106 for human immunodeficiency virus type 1 (HIV-1) group O
infection. August 2009. Available at www.fda.gov/cber/
c. 5 × 106
guidelines.htm.
d. 3 × 1011 16. Petrides, M, Stack, G, Cooling, L, and Maes, LY: Practical Guide
to Transfusion Medicine, 2nd ed. Bethesda, MD, 2007.
19. A single unit of FFP or PF24 should contain ______ mL 17. Walther, WG: Incidence of bacterial transmission and transfu-
of plasma. sion reactions by blood components. Clin Chem Lab Med
a. 100–150 46:919, 2008.
b. 200–400 18. Thaler, M, et al: The role of blood from HLA-homozygous
donors in fatal transfusion-associated graft vs. host disease.
c. 150–250
N Engl J Med 321:25, 1989.
d. 50–150 19. Food and Drug Administration. Guidance for Industry
and FDA review staff: Collection of platelets by automated
20. Cryoprecipitate that has been pooled must be transfused methods. December 2007. Available at www.fda.gov/cber/
within ______ hours. guidelines.htm.
a. 24 20. Allain, JP, et al: Transfusion-transmitted infectious diseases.
b. 6 Biologicals 37:71, 2009.
21. Alter, HJ: Detection of antibody to hepatitis C virus in prospec-
c. 4
tively followed transfusion recipients with acute and chronic
d. 8 non-A, non-B hepatitis. N Eng J Med 321:1494, 1989.
22. Hjelle, B: Transfusion-transmitted HTLV-I and HTLV-II. In
Rossi, EC, et al: Principles of Transfusion Medicine, 2nd ed.
References Williams & Wilkins, Baltimore, MD, 1995.
1. Price, TH (ed): Standards for Blood Banks and Transfusion Serv- 23. Centers for Disease Control and Prevention. Detection of West
ices, 26th ed. AABB, Bethesda, MD, 2009. Nile Virus in blood donations—United States, 2003. MMWR
2. Roback, JD (ed): Technical Manual, 16th ed. AABB, Bethesda, 52:769, 2003.
MD, 2008. 24. Food and Drug Administration Guidelines for Industry: An
3. Food and Drug Administration. Donor History Questionnaire Approved Circular of Information for the use of human blood
user brochure. DHQ v1.3 May 2008. Available at www.fda.gov/ and blood components, 2009. (available at www.fda.gov/cber/
BiologicsBloodVaccines/BloodBloodProducts/Questions. guidelines.htm)
4. Food and Drug Administration. Guidance for Industry. Recom- 25. King, KE (ed): Blood Transfusion Therapy: A Physician’s Hand-
mendations for deferral of donors and quarantine and retrieval book, 9th ed. American Association of Blood Banks, Bethesda,
of blood and blood products in recent recipients of smallpox MD, 2008.
vaccine (Vaccinia virus) and certain contacts of smallpox vaccine 26. Heddle, NM, and Kelton, JG: Febrile nonhemolytic transfusion
recipients. December 2002. Available at www.fda.gov/cber/ reactions. In Popovsky, MA: Transfusion Reactions. American
guidelines.htm. Association of Blood Banks, Bethesda, MD, 1996.
5. Kleinman, S: Blood donor screening and transfusion safety. In 27. Heddle, NM, et al: A prospective study to identify the risk
Linden, JV, and Bianco, C (eds): Blood Safety and Surveillance. factors associated with acute reactions to platelet and red cell
Marcel Dekker, New York, 2001. transfusions. Transfusion 33:794, 1993.
2682_Ch14_331-351 22/05/12 11:49 AM Page 348

348 PART III Transfusion Practice

Laboratory findings during the first 48 hours: became anuric. He was then transferred to the intensive
• Anemia care unit (ICU).
• Thrombocytopenia
Negative direct antiglobulin test (DAT)
• Normal prothrombin time (PT) and partial thrombo-
plastin time (PTT) Peripheral smear: decreased platelets, rare nucleated RBC,
• Normal D-dimer and fibrinogen 2+ schistocytes.
• Elevated LDH Decreased ADAMTS 13
• Decreased haptoglobin 1. What are the top five possible diagnoses for this case?
2. What is the most likely diagnosis for this patient and
Hospital Course
why?
Overnight, the patient became increasingly agitated, re- 3. What are the main symptoms in cases of this type?
fused oral intake, and pulled out his intravenous 4. What is the main treatment for this disease?
catheter. His urine output decreased significantly and he

SUMMARY CHART
In an apheresis procedure, blood is withdrawn from a Membrane filtration technology uses membranes with
donor or patient and separated into its components. specific pore sizes, allowing plasma to pass through the
One or more of the components is retained, and the membrane while the cellular portion passes over it.
remaining constituents are recombined and returned The most common anticoagulant used in apheresis is
to the individual. acid citrate dextrose.
The process of removing plasma from the blood is Therapeutic apheresis is used to remove a pathological
termed plasmapheresis; removing platelets is termed substance, to supply an essential or missing substance
plateletpheresis or thrombocytopheresis; removing to alter the antigen–antibody ratio, or to remove
RBCs is termed erythrocytapheresis; removing leuko- immune complexes.
cytes is known as leukapheresis. The American Society for Apheresis (ASFA) has devel-
Apheresis equipment that uses intermittent flow oped categories to define the effectiveness of therapeu-
centrifugation (IFC) requires only one venipuncture, tic apheresis in treating a particular condition or
in which the blood is drawn and reinfused through disease. Therapeutic apheresis is most appropriate for
the same needle. Once the desired component is treating category I or II disorders.
separated, the remaining components are reinfused In therapeutic plasmapheresis procedures, the replace-
to the donor, and one cycle is complete. Apheresis ment fluids used to maintain appropriate intravascular
procedures performed on patients usually require volume and oncotic pressure include normal saline, FFP,
many cycles to reach an acceptable therapeutic cryo-reduced plasma, and 5% human serum albumin.
endpoint.
Complications of apheresis include vascular access
Continuous flow centrifugation (CFC) procedures issues, alteration of pharmacodynamics of medications,
withdraw, process, and return the blood to the individ- citrate toxicity, fluid imbalance, allergic reactions, equip-
ual simultaneously. Two venipuncture sites are neces- ment malfunction (hemolysis), and infection. Fatalities
sary. The process of phlebotomy, separation, and have occurred (primarily patient rather than donor).
reinfusion is uninterrupted.

2. Therapeutic cytapheresis has a primary role in treatment

Review Questions
of patients with:
1. The most common anticoagulant used for apheresis a. Sickle cell disease and acute chest syndrome.
procedures is: b. Systemic lupus erythematosus to remove immune
a.Heparin. complexes.
c. Leukemia to help increase granulocyte production.
b.Sodium fluoride.
d. Myasthenia gravis to increase antibody production.
c.Warfarin.
d.Citrate.
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Chapter 14 Apheresis 349

3. The minimum interval allowed between plateletpheresis References

component collection procedures is: 1. McLeod, B: Therapeutic apheresis: History, clinical application,
a. 1 day. and lingering uncertainties. Transfusion (in press), 2009.
b. 2 days. 2. Hester, J: Apheresis: The first 30 years. Transfus Apher Sci
c. 7 days. 24:155, 2001.
3. Malchesky, PS, et al: Apheresis technologies and clinical appli-
d. 8 weeks. cations: The 2007 international apheresis registry. Ther Apher
4. In plasma exchange, the therapeutic effectiveness is: Dial 14(1):52, 2009.
4. Chen, Y, et al: Effect of acute citrate load on markers of bone
a. Greatest with the first plasma volume removed metabolism in healthy volunteers. Vox Sang 97:324, 2009.
b. Affected by the type of replacement fluid used 5. Bell, AM, et al: Severe citrate toxicity complicating volunteer
c. Enhanced if the unwanted antibody is IgG rather apheresis platelet donation. J Clin Apheresis 22:15, 2007.
than IgM 6. Tomita, T, et al: Vasovagal reactions in apheresis donors. Trans-
fusion 42(12):1561–1566, 2002.
d. Independent of the use of concomitant immunosup- 7. Reiss, RF, Harkin, R, Lessig, M, et al: Rates of vaso-vagal reac-
pressive therapy tions among first time teenaged whole blood, double red cell,
and platelet pheresis donors. Ann Clin Lab Sci 39(2):138–143,
5. The replacement fluid indicated during plasma exchange 2009.
for TTP is: 8. Price, TH: Centrifugal equipment for the performance of ther-
a. Normal (0.9%) saline. apeutic hemapheresis procedures. In MacPherson, JL, and
b. Hydroxyethyl starch (HES). Kaspirisin, DO (eds): Therapeutic Hemapheresis, vol 1. CRC
Press, Boca Raton, FL, 1985: 123.
c. FFP. 9. Price, TH (ed): Standards for Blood Banks and Transfusion
d. Albumin (human) 5%. Services, 26th ed. American Association of Blood Banks,
Bethesda, MD, 2009.
6. The most common adverse effect of plateletpheresis 10. Rock, G, Tittley, P, and McCombie, N: Plasma collection using
collection is: an automated membrane device. Transfusion 26:269, 1986.
a. Allergic reaction. 11. Burgstaler, EA: Blood component collection by apheresis. J Clin
b. Hepatitis. Apheresis 21:142, 2006.
12. Code of federal regulations. Title 21 Parts CFE 606, 610.
c. Hemolysis. Washington, DC: US Government Printing Office, 2006
d. Citrate effect. (revised annually).
13. Balint, B, et al: Apheresis in donor and therapeutic settings:
7. Apheresis technology can be used to collect each of the Recruitments vs. possibilities—a multicenter study. Transfus
following components except: Apher Sci 33:181, 2005.
a. Leukocytes. 14. Eder, AF, and Benjamin, RF: Safety and risks of automated
b. Macrophages. collection of blood components. In Eder, AF, and Goldman, M
(eds): Blood Donor Health and Safety. AABB Press, Bethesda,
c. Hematopoietic progenitor cells. MD, 2009, pp 103–121.
d. Platelets. 15. Rossmann, SN: Talking with the donor: Information, consent,
and counseling. In Eder, AF, and Goldman, M (eds): Blood Donor
8. The anticoagulant added to blood as it is removed Health and Safety. AABB Press, Bethesda, MD, 2009, pp 1–20.
from a donor or patient during an apheresis procedure 16. FDA Guidance for Industry and FDA Review Staff, February 13,
acts by: 2001, Technical correction: Recommendations for collecting
a. Binding calcium ions. red blood cells by automated apheresis methods.
17. FDA Memorandum, March 10, 1995, Revision of FDA memo-
b. Increasing intracellular potassium. randum of August 27, 1982: Requirements for infrequent
c. Binding to antithrombin III. plasmapheresis donors.
d. Inactivating factor V. 18. Moog, R: Feasibility and safety of triple dose platelet collection
by apheresis. J Clin Apheresis 24:238, 2009.
9. Peripheral blood stem cells are: 19. Picker, SM, et al: Prospective comparison of high-dose platelet-
a. Responsible for phagocytosis of bacteria. pheresis with the latest apheresis systems on the same donors.
b. Removed during erythrocytapheresis. Transfusion 46:1601–1608, 2006.
20. FDA Guidance for Industry and FDA Review Staff, December 17,
c. Pluripotential hematopoietic precursors that circulate 2007, Collection of platelets by automated methods.
in the peripheral blood. 21. Alex, J, Roberts, B, and Raife, T: Postdonation platelet counts
d. Lymphocytes involved with the immune response. are safe when collecting platelets with the Trima Accel using a
postdonation platelet count target of r50,000 platelets/µL.
10. Which of the following can be given to an apheresis donor J Clin Apheresis 24:215, 2009.
to increase the number of circulating granulocytes? 22. Atallah, E, and Schiffer, CA: Granulocyte transfusion. Curr
a. DDAVP Opin Hematol 13:45-49, 2006.
23. Price, TH: Granulocyte transfusion therapy. J Clin Apheresis
b. Hydroxyethyl starch (HES) 21:65–71, 2006.
c. Immune globulin 24. King, KE (ed): Blood Transfusion Therapy: A Physician’s Hand-
d. G-CSF book, 9th ed. AABB, Bethesda, MD, 2008.
2682_Ch15_352-366 22/05/12 11:51 AM Page 365

Chapter 15 Transfusion Therapy 365

CASE STUDIES 9 g/dL, hematocrit 27%, WBC 15,000/µL, and platelet

count 5,000/µL. The hematologist plans to perform a bone
Case 15-1 marrow biopsy and aspiration.

A 55-year-old man is contemplating surgery for severe 1. What blood component(s) is (are) indicated? Why?
arthritis in the right hip. 2. Describe how the dose is calculated. What laboratory
result is desired?
1. What should be known to determine how many units 3. The patient receives chemotherapy, and 2 weeks
of RBCs should be crossmatched? later the hemoglobin is 6.8 g/dL and the hematocrit
2. How can it be determined if the patient can donate 20%. The patient complains of shortness of breath
blood (autologous predeposit) for use during surgery? when hurrying to the bus stop. The physician decides
3. The patient has a history of bleeding after a tonsillec- to order RBC transfusion. What dose of RBCs is
tomy at age 7 years. What tests should be done to indicated? How is this determined?
further study this potential problem?
4. If the patient is found to have von Willebrand’s Case 15-4
disease, which blood product might be necessary?
A 45-year-old man is admitted to the emergency depart-
Case 15-2 ment vomiting blood. His hemoglobin is 8 g/dL, platelet
count 80,000, PT/INR 18/2, fibrinogen 125 mg/dL. The
A 45-year-old woman complains of tiredness and weak- physician orders 4 units of RBCs, 4 units of plasma, and
ness. She appears pale. Laboratory results are as follows: 1 pool of platelets stat.
hemoglobin 6.2 g/dL, hematocrit 20%, MCV 75 fL, MCHC
28%. On further questioning, she reports excessive men- 1. Which blood group(s) should be selected for the RBC
strual bleeding, sometimes lasting for several weeks. transfusions?
2. For FFP and platelets, which blood type(s) should be
1. Does this patient need a transfusion? Justify your selected?
answer.
2. If the intern decides to give one unit of RBCs, what His type and screen is B positive with positive antibody
would be the resulting hemoglobin and hematocrit screen. The ED nurse calls and informs the blood bank
levels? that the massive transfusion protocol has been started.
3. Which components should be prepared?
Case 15-3
4. Which blood group and Rh type should be selected?
A 22-year-old woman presents with easy bruising and 5. What should be done about the positive antibody
fatigue. A complete blood count reveals hemoglobin screen?

SUMMARY CHART
Transfusion therapy is used primarily to treat two con- Plasma contains all coagulation factors and is indicated
ditions: inadequate oxygen-carrying capacity because for patients with multiple coagulation deficiencies that
of anemia or blood loss and insufficient coagulation occur in liver failure, DIC, vitamin K deficiency,
proteins or platelets to provide adequate hemostasis. warfarin overdose, and massive transfusion.
A unit of whole blood or RBCs in an adult should in- Cryoprecipitate contains at least 80 units of factor VIII
crease the hematocrit level 3% or hemoglobin level and 150 mg of fibrinogen, as well as vWF, and factor
1 g/dL. XIII.
RBCs are indicated for increasing the RBC mass in pa- Factor IX is used in the treatment of persons with
tients who require increased oxygen-carrying capacity. hemophilia B.
Platelet transfusions are indicated for patients who are Immunoglobulin (IG) is used in the treatment of con-
bleeding because of thrombocytopenia. In addition, genital hypogammaglobulinemia and patients exposed
platelets are indicated prophylactically for patients to hepatitis A or measles.
who have platelet counts under 5,000 to 10,000/µL. Massive transfusion is defined as the replacement of
Each dose of platelets should increase the platelet one or more blood volume(s) within 24 hours, or
count 20,000 to 40,000/µL in a 70-kg human. about 10 units of blood in an adult.
A plateletpheresis product is collected from one donor Emergency transfusion warrants group O RBCs when
and must contain a minimum of 3 × 1011 platelets. patient type is not yet known.
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366 PART III Transfusion Practice

9. Which blood product should be selected for vitamin K

Review Questions
deficiency?
1. Leukocyte-reduced filters can do all of the following a. Cryoprecipitate
except: b. Factor VIII
c. Factor IX
a. Reduce the risk of CMV infection
d. Plasma
b. Prevent or reduce the risk of HLA alloimmunization
c. Prevent febrile, nonhemolytic transfusion reactions 10. Which fluid should be used to dilute RBCs?
d. Prevent TA-GVHD a. 0.9% saline
2. Albumin should not be given for: b. 5% dextrose and water
c. Immune globulin
a. Burns
d. Lactated Ringers solution
b. Shock
c. Nutrition
References
d. Plasmapheresis
1. King, KE (ed): Blood Transfusion Therapy: A Physician’s Hand-
3. Of the following, which blood type is selected when a book, 9th ed. AABB, Bethesda, MD, 2008.
patient cannot wait for ABO-matched RBCs? 2. Circular of Information for the Use of Human Blood and Blood
a. A Products. AABB, America’s Blood Centers, American Red
Cross, Washington, DC, January 2010.
b. B 3. Ferraris VA, et al: Perioperative blood transfusion and blood
c. O conservation in cardiac surgery: The society of thoracic
d. AB surgeons and the society of cardiovascular anesthesiologists
clinical practice guideline. Ann Thorac Surg 83:S27, 2007.
4. Which patient does not need an irradiated component? 4. Weiskopf, RB, et al: Oxygen reverses deficits of cognitive func-
a. Bone marrow transplant recipient tion and memory and increased heart rate induced by acute
b. Neonate weighing less than 1,200 g severe isovolemic anemia. Anesthesiology 96:871, 2002.
5. Carson, TH (ed): Standards for Blood Banks and Transfusion
c. Adult receiving an RBC transfusion Services, 27th ed. AABB, Bethesda, MD, 2011.
d. Adult receiving an RBC transfusion from a blood 6. Quraishy, N, et al: A compendium of transfusion practice
relative guidelines. American National Red Cross, Washington, DC,
2010.
5. RBC transfusions should be given: 7. Slichter, SJ: Evidence-based platelet transfusion guidelines.
a. Within 4 hours Hematology 127:172, 2007.
b. With lactated Ringer’s solution 8. British Committee for Standards in Haematology: Guidelines
for the use of fresh-frozen plasma, cryoprecipitate and cryosu-
c. With dextrose and water pernatant. Brit J Haematol 126:11–28, 2004.
d. With cryoprecipitate 9. McVay, PA, and Toy, PTCY: Lack of increased bleeding after
liver biopsy in patients with mild hemostatic abnormalities.
6. Which type of transplantation requires all cellular blood Am J Clin Pathol 94:747, 1990.
components to be irradiated? 10. Mannucci, PM: Hemophilia: Treatment options in the twenty-
a.Bone marrow first century. J Thrombosis Haemostasis 1:1349–1355, 2003.
b.Heart 11. Knezevic, I, and Kruskall, MS: Intravenous immune globulin:
An update for clinicians. Transfusion 43:1460, 2003.
c.Liver 12. Roberts, HR: Recombinant factor VIIa (Novoseven) and the
d.Kidney safety of treatment. Semin Hematol 38:48, 2001.
13. Mayer, SA, et al: Efficacy and safety of recombinant factor VII
7. Characteristics of deglycerolized RBCs include the for acute intracerebral hemorrhage. N Eng J Med 358:2127,
following except: 2008.
a. Inexpensive 14. Laupacis, A, et al: Prevention of posttransfusion CMV in the
b. 24-hour expiration date after thawing era of universal WBC reduction: a consensus statement. Trans-
fusion 41:560, 2001.
c. Used for rare antigen-type donor blood 15. Shivdasani, RA, et al: Graft-versus-host disease associated with
d. Used for IgA-deficient recipient with history of severe transfusion of blood from unrelated HLA-homozygous donors.
reaction N Eng J Med 328:755, 1993.
16. Sazama, K: Reports of 355 transfusion-associated deaths: 1976
8. Select the appropriate product for a bone marrow trans- through 1985. Transfusion 30:583, 1990.
plant patient with anemia: 17. AuBuchon, JP (ed): Guidelines for Blood Utilization Review.
a. RBCs AABB, Bethesda, MD, 2001.
18. Simon, TL, et al: Practice parameter for the use of red blood
b. Irradiated RBCs cell transfusions. Arch Pathol Lab Med 122:130, 1998.
c. Leukoreduced RBCs
d. Washed RBCs
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Chapter 16 Adverse Effects of Blood Transfusion 387

The transfusion was stopped two-thirds of the way culture were performed on the unit of blood implicated
through. The nursing personnel performed a clerical with the reaction, and two sets of blood cultures were
check by verifying the patient identification band to the drawn from the patient.
transfusion record and the unit crossmatch tag to confirm
Gram stain-unit of blood: Gram-positive cocci in clusters
that the blood component was given to the correct
patient. The patient’s physician was notified. The nurse, Transfusion Service Physician Follow-up:
who had monitored the patient during past transfusions, The transfusion service physician was immediately noti-
expressed her concern to the physician regarding the fied of the gram-stain results. The results were relayed to
severity of the reaction when compared to previous reac- the patient’s physician, who started the patient on broad-
tions observed. The physician requested a transfusion spectrum antibiotic treatment until identification and sen-
reaction workup. A properly labeled postreaction sample sitivity of the cultures were complete. Shortly after, the
was drawn and sent along with the unit of blood, attached blood center was notified of the transfusion service physi-
tubing, and solutions to the transfusion service for a cian’s preliminary findings, and all available donor prod-
transfusion reaction workup. The patient was treated with ucts were discarded. The following day, culture results
Tylenol and discharged with instructions to continue revealed positive growth in both the patient and the unit
monitoring her temperature. of blood, and the organism was identified as Staphylococ-
Transfusion Service Evaluation cus aureus. A follow-up written notification prepared by
The laboratory technologist examined both pre- and the transfusion service physician was sent to the blood
postreaction samples, the blood bag, and the tubing for center for donor evaluation. Further investigation by the
clerical errors. The attached solution was verified to be blood center revealed that the donor arm was not cleaned
0.9% normal saline, and historic patient records were per standard operating procedures, which led to contam-
checked and verified. No defects were revealed. Repeat ination of the unit. The blood center phlebotomist was
testing was performed on the postreaction sample with retrained on proper cleansing techniques.
the following results: Interpretation
Postreaction Sample: This case represents a transfusion-associated sepsis due
Blood type: O-negative to a failure to follow standard operating procedures for
DAT: Neg the arm preparation prior to donation, most likely result-
Hemolysis: No hemolysis ing in contamination of the unit from the skin flora of the
donor.
Three hours later, the patient returned to the emer-
gency department with an increase in temperature and a 1. What laboratory workup is performed to diagnose
decrease in blood pressure. The transfusion service physi- transfusion-associated sepsis?
cian was consulted, and further testing of the unit of 2. What symptoms usually present with transfusion-
blood was ordered. Immediately, a gram stain and blood associated sepsis?

SUMMARY CHART
Transfusion reactions are classified according to postreaction sample from the acute transfusion reac-
symptom time interval. Less than 24 hours: acute tion evaluation or test will need to be followed with
transfusion reactions; greater than 24 hours: delayed comparison to the pretransfusion testing results. If
transfusion reactions. Both further classify into immune necessary, additional testing in duplicate (pre- and
or nonimmune. postreaction samples) could include repeat basic
The transfusion reaction workup is designed to rule in immunohematology testing, eluate, and antigen typing
or rule out hemolysis. to identify the cause of the immune hemolysis.
Acute transfusion reaction evaluation or testing Non-immune hemolysis occurs when the RBC suffers
includes clerical check, examination for visual hemol- mechanical or chemical damage and is manifested as
ysis, DAT, and patient ABO group confirmation. an asymptomatic hemoglobinuria
Acute transfusion reactions include acute hemolytic Transfusion-associated sepsis occurs when bacteria are
reactions, transfusion-associated sepsis, febrile non- introduced to the patient via a contaminated blood
hemolytic reactions, allergic reactions, TRALI, and TACO. product, manifested by an increase in body tempera-
Immune hemolysis occurs when previously formed ture or more than 2°C, rigors, and hypotension. When
IgM (ABO) or IgG (non-ABO) antibodies in the recip- this condition is suspected, additional testing includes
ient recognize the corresponding donor RBC antigen gram staining and cultures of the blood component
and result in complement-mediated intravascular and the patient. Isolation of the same organism is key
hemolysis. Evidence of immune hemolysis in the for the diagnosis.

Continued
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388 PART III Transfusion Practice

SUMMARY CHART—cont’d
Febrile nonhemolytic reactions occur when the recip- graft-versus-host disease, post-transfusion purpura,
ient is exposed to the donor cytokines present in the and iron overload.
WBC or plasma and is manifested by an increase in Delayed serologic/hemolytic reactions occurs second-
body temperature of more than 1°C with or without ary to an anamnestic or primary immune response
chills. Workup must exclude hemolytic (transfusion directed to red cell antibodies that may (delayed
reaction workup testing) and septic reactions (symp- hemolytic transfusion reaction) or may not (delayed
toms and patient evaluation). serologic transfusion reaction) be associated with clin-
Allergic reactions can be mild (hives or itching) or se- ical evidence of shortened red cell survival of the trans-
vere (anaphylaxis) and are mainly caused by the release fused RBCs. Besides standard basic immunohematology
of histamine from the interaction between the allergen testing (ABO/Rh, antibody screen and when indicated
present in the donor plasma and the recipient preformed antibody identification), additional testing will include
IgE antibodies. A classic example of a severe allergic re- DAT and, when indicated, an eluate and antigen typing
action is the one seen due to the presence of anti-IgA of the units recently transfused.
antibodies in a patient with absolute IgA deficiency. Transfusion-associated graft-versus-host disease occurs
TRALI occurs most frequently when donor leukocyte when the transfusion-derived donor lymphocytes
antibodies react with the WBCs in the recipient’s lung attack and destroy the recipient immune system, caus-
vasculature, damaging the endothelium and causing ing pancytopenia and death. It is prevented by the
noncardiogenic pulmonary edema. High plasma volume gamma irradiation of blood components for transfu-
blood components from parous female donors are the sion to patient populations at risk.
most commonly associated blood components. There- Post-transfusion purpura is an acquired profound throm-
fore, focus is on prevention achieved by using only male bocytopenia that occurs when a patient with preformed
plasma components or plasma components collected platelet antibodies is transfused with a blood component
from WBC antibody–negative female donors. containing the platelet antigen and sharing specificity
TACO occurs when the patient’s cardiovascular system is with the preformed antibodies, leading to the destruction
unable to handle the transfused volume, resulting in con- of the donor and recipient platelets. Anti-HPA-1a is the
gestive heart failure. This is an underreported complica- most common implicated antibody specificity.
tion of transfusion, often responsive to patient diuresis. Iron overload occurs due to long-term accumulation
Delayed transfusion reactions include delayed of iron in the body tissues from multiple RBC transfu-
serologic/hemolytic reactions, transfusion-associated sions. This causes organ damage.

4. Pain at infusion site and hypotension are observed with

Review Questions
what type of reaction?
1. What component is most frequently involved with a. Delayed hemolytic transfusion reaction
transfusion-associated sepsis? b. Acute hemolytic transfusion reaction
c. Allergic reaction
a. Plasma
d. Febrile nonhemolytic reaction
b. Packed red blood cells
c. Platelets 5. Irradiation of blood is performed to prevent?
d. Whole blood a. Febrile nonhemolytic transfusion reaction
2. Fatal transfusion reactions are mostly caused by? b. Delayed hemolytic transfusion reaction
c. Transfusion-associated graft-versus-host disease
a. Serologic errors
d. Transfusion-associated circulatory overload
b. Improper storage of blood
c. Clerical errors 6. The only presenting sign most often accompanying a
d. Improper handling of the product delayed hemolytic transfusion reaction is?
3. Early manifestation of an acute hemolytic transfusion a. Renal failure
reaction can be confused with? b. Unexplained decrease in hemoglobin
c. Active bleeding
a. Allergic reaction
d. Hives
b. Febrile nonhemolytic reaction
c. Anaphylactic shock
d. Sepsis
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Chapter 16 Adverse Effects of Blood Transfusion 389

7. Which transfusion reaction presents with fever, macu- 15. Which of the following is characteristic of iron overload?
lopapular rash, watery diarrhea, abnormal liver function, a. Delayed, nonimmune complication
and pancytopenia? b. Chelating agents are used
a. Transfusion-associated sepsis c. Multiorgan damage may occur
b. Transfusion-related acute lung injury d. All of the above
c. Transfusion-associated graft-versus-host disease
d. Transfusion-associated allergic reaction References
8. A suspected transfusion-related death must be 1. Eder, AF, and Chambers, LA: Noninfectious complications of
reported to? blood transfusion. Arch Pathol Lab Med 131:708–718, 2007.
2. Mazzei, CA, Popovsky, MA, and Kopko, PM: Noninfectious
a. AABB complications of blood transfusion. In Roback, JD (ed): Tech-
b. Federal and Drug Administration (FDA) nical Manual, 16th ed. AABB Press, Bethesda, MD, 2009,
c. College of American Pathologists (CAP) pp 715–749.
d. The Joint Commission (TJC) 3. Fuller, AK, Uglik, KM, Savage, WJ, et al: Bacterial culture
reduces but does not eliminate the risk of septic transfusion
9. Nonimmune hemolysis can be caused during transfusion reactions to single-donor platelets. Transfusion 49:2588–2593,
by: 2009.
4. Hendrickson, JE, and Hillyer, CD: Noninfectious serious
a. Use of small bore size needle. hazards of transfusion. Anesth Analg 108:759–769, 2009.
b. Use of an infusion pump. 5. Chapman, CE, Stainsby, D, Jones, H, et al: Ten years of
c. Improper use of a blood warmer. hemovigilance reports of transfusion-related acute lung injury
d. All of the above in the United Kingdom and the impact of preferential use of
male donor plasma. Transfusion 49:440–452, 2009.
10. Transfusion reactions are classified according to: 6. Gauvin, F, Lacroix, J, Robillard, P, et al: Acute transfusion
reactions in the pediatric intensive care unit. Transfusion
a. Signs or symptoms presenting during or after 46:1899–1908, 2006.
24 hours. 7. Domen, RE: Adverse reactions associated with autologous
b. Immune or nonimmune. blood transfusion: Evaluation and incidence at a large academic
c. Infectious or noninfectious. hospital. Transfusion 38:296–300, 1998.
d. All of the above 8. Callum, J, and Nahirniak, S: Adverse effects of human-derived
plasma derivatives. In Popovsky, MA (ed): Transfusion Reac-
11. With febrile nonhemolytic transfusion reactions: tions, 3rd ed. AABB Press, Bethesda, MD, 2007, pp 501–523.
9. McLeod, BC, Sniecinski, I, Ciaravella, D, et al: Frequency of
a. They are self-limited. immediate adverse effects associated with therapeutic aphere-
b. Fever resolves within 2 to 3 hours. sis. Transfusion 39:282–289, 1999.
c. Treatment is required. 10. Price, TH (ed): Standard for Blood Banks and Transfusion Serv-
d. A and B are correct ice, 26th ed. AABB, Bethesda, MD, 2009.
e. All of the above 11. College of American Pathologists Laboratory Accreditation
Program checklists. Northfield, IL: College of American Pathol-
12. Absolute IgA deficiency is a classic example of a severe ogists, 2009.
allergic reaction. Results indicating an absolute IgA 12. Code of Federal Regulation. Title 21 CFR Part 606-660.
Washington, D.C.: U.S. Government Printing Office, 2008.
deficiency: 13. Davenport, RD: Management of transfusion reactions. In
a. < 0.05 mg/dL Mintz, PD (ed): Transfusion Therapy Clinical Principles
b. < 0.50 mg/dL and Practice, 2nd ed. AABB Press, Bethesda, MD, 2005,
c. < 0.50 gm/dL pp 515–539.
14. Ramirez-Arcos, S, Goldman, M, and Blajchman, MA: Bacterial
d. < 5 mg/dL contamination. In Popovsky, MA (ed): Transfusion Reactions,
13. How are mild allergic transfusion reactions with isolated 3rd ed. AABB Press, Bethesda, MD, 2007, pp 163–206.
15. Fung, MK, Downes, KA, and Shulman, IA: Transfusion of
symptoms or hives and urticaria treated? platelets containing ABO incompatible plasma: A survey of
a. Transfusion is stopped and transfusion reaction 3156 North American Laboratories. Arch Pathol Lab Med
workup is initiated. 131:909–916, 2007.
b. Transfusion is stopped and antihistamines adminis- 16. Josephson, CD, Mullis, NC, Van Demark, C, et al: Significant
number of apheresis-derived group O platelet units have a
trated; when symptoms improve, transfusion is “high titer” anti-A/A,B: Implications for transfusion policy.
restarted. Transfusion 44:805–808, 2004.
c. Stop transfusion and prepare washed red cells. 17. Cooling, LL, Downs, TA, Butch, SH, et al: Anti-A and anti-B
d. Continue transfusion with a slower infusion rate. titers in pooled group O platelets are comparable to apheresis
platelets. Transfusion 48:1206–1213, 2008.
14. TRALI presents with the following symptoms: 18. Davenport, RD: Hemolytic transfusion reactions. In Simon, TL,
a. Respiratory distress Dzik, WH, Snyder, EL, Stowell, CP, and Strauss, RG (eds):
Rossi’s Principles of Transfusion Medicine, 3rd ed. Lippincott,
b. Severe hypoxemia and hypotension Williams & Wilkins, Philadelphia, 2002, pp 815–828.
c. Fever 19. Sweeney, J: Additive solutions for platelets: Is it time for North
d. All of the above America to go with the flow? Transfusion 49;199–201, 2009.
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Chapter 17 Cellular Therapy 401

SUMMARY CHART
The categories of HPC donors are autologous (self), Freezing of HPCs requires the slow addition of DMSO
allogeneic (another person, related or unrelated), and and freezing in a controlled-rate freezer at 1°C to
syngeneic (twin or triplet). 3°C/min.
HPC donors are assessed by history and physical, lab Myeloablative conditioning completely destroys the
tests, EKG, chest x-ray, and donor health history. bone marrow and the immune system. Nonmyeloab-
The National Marrow Donor Program (NMDP) re- lative conditioning partially destroys bone marrow and
cruits donors, stores data, and searches for donors re- the immune system.
quested by recipient institutions. Major ABO incompatibility in HPC transplantation is
A recipient has a 25% chance of an HLA match with a when the donor’s RBCs are incompatible with the re-
sibling. cipient’s antibody.
Umbilical cord blood donation requires the consent, Minor ABO incompatibility is when the donor’s plasma
history, and lab testing of the mother. is incompatible with the recipient’s RBCs.
HPC-M is the collection of bone marrow by aspiration. Engraftment is defined as PMNs greater than 500/ML
The donor undergoes general or epidural anesthesia (about 10 days) and platelets greater than 20,000/ ML
and may need RBC transfusion. (about 15 days), and recipient is no longer RBC trans-
HPC-A is the collection of HPCs from the peripheral fusion dependent (90 to 100 days).
blood by leukapheresis. The HPCs are mobilized by Graft-versus-host disease is defined as donor T cells
cytokine. attacking the recipient’s cells and tissues.
Transplantation is used to treat leukemia, lymphoma, Acute GVHD occurs during the first 100 days after
and multiple myeloma. transplant; chronic occurs after 100 days.
Allogeneic transplantation is not routinely used for Donor lymphocyte infusion is used to treat relapse of
nonmalignant diseases because of the serious risks. chronic myelogenous leukemia.
HPC products are tested for CBC, WBC differential, In HPC transplant recipients, leukocyte-reduced and
CD34+ cells, and viability. irradiated cellular products are selected to reduce the
Bacterial and fungal cultures are required after thawing. risk of HLA alloimmunization, CMV transmission, and
GVHD. CMV seronegative cellular blood products may
HPCs are stored at 20°C to 25°C or 4°C and –196°C.
also be selected.
DMSO is used as a cryoprotectant.
The blood type selected for blood transfusion must be
Viability can be determined by dye exclusion or by compatible with both the donor and the recipient.
flow cytometry.

4. Graft-versus-host disease (GVHD) is primarily caused by:

Review Questions
a. Neutrophils.
1. Which of the following terms describe an HPC transplant b. T lymphocytes.
where the donor and recipient may be unrelated? c. B lymphocytes.
d. Monocytes.
a. Allogeneic
b. Autologous 5. The minimum number of CD34+ cells required in an
c. Syngeneic HPC-apheresis collection to ensure timely engraftment is:
d. Hematopoietic a. 2 × 102 CD34+ cells/kg.
2. Stem cells from HPC donors may be mobilized with: b. 2 × 104 CD34+ cells/kg.
c. 2 × 106 CD34+ cells/kg.
a. Plerixafor.
d. 2 × 108 CD34+ cells/kg.
b. Granulocyte colony-stimulating factor (G-CSF).
c. Chemotherapy. 6. The mother of a cord blood donor is tested for:
d. All of the above a. ABO.
3. Which choice is an advantage of an HPC transplant using b. HIV.
umbilical cord blood? c. Antibody screen.
d. All of the above
a. Recipient weight of no concern
b. Donor screening and testing abbreviated
c. Higher risk of GVHD
d. No significant risk to the donor or mother
2682_Ch17_391-402 22/05/12 11:56 AM Page 402

402 PART III Transfusion Practice

7. The cellular marker used to quantify the collection of 6. Burt, RK, Loh, Y, Pearce, W, et al: Clinical applications of
HPCs is: blood-derived and marrow-derived stem cells for nonmalignant
diseases. JAMA 299:925–936, 2008.
a. CD4. 7. Bitter, RE, Schofer, C, Weipoltshammer, K, et al: Recruitment
b. CD33. of bone marrow derived cells by skeletal and cardiac muscle in
c. CD34. adult dystrophic mdx mice. Anat Embryol 199:391–396, 1999.
d. CD59. 8. Petersen, BE, Bowen, WC, Patrene, KD, et al: Bone marrow as
a potential source of hepatic oval cells. Science 284:1168–1170,
8. The recommended dose of gamma radiation administered 1999.
to a blood product to reduce the risk of graft-versus-host 9. Cogle, CR, Yachnis, AT, Laywell, ED, et al: Bone marrow trans-
differentiation in brain after transplantation: A retrospective
disease is: study. Lancet 363:1432–1437, 2004.
a. 1,500 cGy to any point within the canister. 10. Padley, D (ed): Standards for Cellular Therapy Product Serv-
b. 1,500 cGy to the midplane of the canister. ices, 4th ed. AABB, Bethesda, 2009.
c. 2,500 cGy to the midplane of the canister. 11. Klein, MA, Kadidlo, McCollough, J, et al: Microbial contamina-
tion of hematopoietic stem cell products: Incidence and clinical
d. 2,500 cGy to any point within the canister.
sequelae. Biol Blood Marrow Transplant 12:1143–1149, 2006.
9. During HPC processing, cultures must be performed: 12. Larghero, J, Rea, D, Esperou, H, et al: ABO-mismatched mar-
row processing for transplantation: Results of 114 procedures
a. At initial testing. and analysis of immediate adverse events and hematopoietic
b. Before freezing. recovery. Transfusion 46:309–402, 2006.
c. After thawing. 13. Berz, D, McCormack, EM, Winer, ES, et al: Cryopreservation
d. After infusion. of hematopoietic stem cells. Am J Hematol 82:463–472, 2007.
14. Worel, N, Greinix, HT, Schneider, B, et al: Regeneration of ery-
10. HPC products are required to be tested for: thropoiesis after related and unrelated donor BMT or peripheral
blood HPC transplantation: A major ABO mismatch means
a. Hepatitis C. problems. Transfusion 40:543–560, 2000.
b. Epstein-Barr virus. 15. Sauer-Heilborn, A, Kadidlo, D, and McCullough, J: Patient care
c. Variant CJD. during infusion of hematopoietic progenitor cells. Transfusion
d. Herpes simplex virus. 44:507–516, 2004.
16. Camels, B, Lemarie, C, Esterni, B, et al: Occurrence and sever-
11. Which of the following terms describe an HPC trans- ity of adverse events after autologous hematopoietic cell infu-
plant where donor and recipient are the same person? sion are related to the amount of granulocytes in the apheresis
product. Transfusion 47:1268–1273, 2007.
a. Allogeneic
17. Bittencourt, H, Rocha, V, Chevret, S, et al: Association of CD34
b. Autologous cell dose with hematopoietic recovery, infections, and other
c. Syngeneic outcomes after HLA-identical sibling bone marrow transplan-
d. Hematopoietic tation. Blood 99:2726–2733, 2002.
18. Goker, H, Haznedaroglu, IC, and Chao, NJ: Acute graft-
12. Which of the following terms describe an HPC trans- versus-host disease: Pathobiology and management. Exp
plant where donor and recipient are identical twins? Hematol 29:259–277, 2001.
19. Lee, SJ, Vogelsang, G, and Flowers, MED: Chronic graft-versus-
a. Allogeneic
host disease. Biol Blood Marrow Transplant 9:215–233, 2003.
b. Autologous 20. Slichter, SJ: Leukocyte reduction and ultraviolet B irradiation
c. Syngeneic of platelets to prevent alloimmunization and refractoriness to
d. Hematopoietic platelet transfusions: The trial to reduce alloimmunization to
platelets study group. N Engl J Med 337:1861–1869, 1997.
21. Kaminski, ER, Hows, JM, Goldman, JM, and Batchelor, JR:
References Pretransfused patients with severe aplastic anaemia exhibit
1. Code of Federal Regulations, CFR—Title 21 Part 1271. Human high numbers of cytotoxic T lymphocyte precursors probably
cells, tissues, and cellular and tissue-based products. Washing- directed at non-HLA antigens. Br J Haematol 76:401–405,
ton, DC, U.S. Government Printing Office, 2010. 1990.
2. Grewal, SS, Barker JN, Davies SM, et al: Unrelated donor 22. Goodrich, JM, Bowden, RA, Fisher, L, Keller C, Schoch, G,
hematopoietic cell transplantation: Marrow or umbilical cord and Meyers, JD: Ganciclovir prophylaxis to prevent cy-
blood? Blood 101:4233–4244, 2003. tomegalovirus disease after allogeneic bone marrow transplant.
3. Wagner, JE, Barker, JN, Defor, TE, et al: Transplantation of un- Ann Intern Med. 118:173–178, 1993.
related donor umbilical cord blood in 102 patients with malig- 23. Winston, DJ, Ho, WG, Bartoni, K, et al: Ganciclovir prophylaxis
nant and nonmalignant diseases: Influence of CD34 cell dose of cytomegalovirus infection and disease in allogeneic bone
and HLA disparity on treatment related mortality and survival. marrow transplant recipients: Results of a placebo-controlled,
Blood 100:1611–1618, 2002. double-blind trial. Ann Intern Med 118:179–184, 1993.
4. Attal, M, Harrousseau, JL, Facon, T, et al: Single versus double 24. Broeckh, M, Nichols, WG, Papanicolaou, G, et al: Cytomegalovirus
autologous stem cell transplantation for multiple myeloma. in hematopoietic stem cell transplants: Current status, known
N Engl J Med 349:2495–2502, 2003. challenges, and future strategies. Biol Blood Marrow Transplant
5. Lenhoff, S, Hjorth, M, Holmberg, E, et al: Impact on survival of 9:543–558, 2003.
high dose therapy with autologous stem cell support in patients 25. Lee, TH, Paglieroni, T, Ohto, H, et al: Survival of donor leuko-
younger than 60 years with newly diagnosed multiple myeloma: cyte subpopulations in immunocompetent transfusion recipi-
A population based study. Nordic Myeloma Study Group. Blood ents: Frequent long-term microchimerism in severe trauma
95:7–11, 2000. patients. Blood 93:3127–3139, 1999.
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Chapter 18 Transfusion-Transmitted Diseases 423

SUMMARY CHART
The first and most important step in ensuring that Transfusion-associated CMV infection is a concern for
transfused blood will not transmit a pathogenic virus seronegative allogeneic organ transplant recipients and
is careful selection of the donor. fetuses. Reactivation of a latent infection can occur when
HAV is usually spread by the fecal-oral route in com- an individual becomes severely immunocompromised.
munities where hygiene is compromised. The risk of CMV infection for low-birth-weight neonates
On infection with HBV, the first serologic marker to is not as great as it was in the past due to better transfu-
appear is HBsAg, followed by HBeAg and IgM anti-HBc sion techniques and management of their conditions.
within the first few weeks of exposure. The WB confirmation test detects the presence of anti-
HBIG is an immune globulin prepared from persons HIV and determines with which viral proteins the
with a high titer of anti-HBs and is used to provide pas- antibodies react.
sive immunity to health-care workers and others who The window period for HIV can be shortened by using
are exposed to patients with HBV infection. the polymerase chain reaction, which detects HIV in-
A combined vaccine for HAV and HBV is available to fection before tests for antigen or antibody are positive.
provide immunity. Bacterial contamination is the most frequent cause of
HDV infection is common among drug addicts and can transfusion-transmitted infection.
occur simultaneously with HBV infection; diagnosis Because routine screening for parasitic infections is not
depends on finding anti-HDV or HDV RNA in the currently available, many blood banks have added
serum. questions to their donor questionnaire that address
Of all HCV infections, 60% to 70% are asymptomatic. topics associated with risk for parasitic infection.
With the implementation of NAT testing for HCV, the Pathogen inactivation methods are under development
window period has been reduced to 10 to 30 days. to remove the residual risk of transfusion-associated
HCV is the leading cause of liver transplants in the disease due to the window period, virus variants,
United States. laboratory mistakes, and new, emerging diseases.
Diagnosis of HIV-1 and HIV-2 infection is dependent Look-back is a process mandated by the FDA that
on the presence of antibodies to both envelope and directs collection facilities to notify donors who test
core proteins; HIV-positive persons with fewer than positive for viral markers, to notify prior recipients of
200 CD4+ T cells per µL are considered to have AIDS the possibility of infection, and to quarantine or dis-
in the absence of symptoms. card implicated components currently in inventory.

4. Currently, which of the following does the AABB consider

Review Questions
to be the most significant infectious threat from transfusion?
1. The fecal-oral route is common in transmitting which of a. Bacterial contamination
these hepatitis viruses? b. CMV
c. Hepatitis
a. HAV
d. HIV
b. HBV
c. HDV 5. Which of the following is the most frequently transmitted
d. HCV virus from mother to fetus?
2. Which of the following is the component of choice for a a. HIV
low-birth-weight infant with a hemoglobin of 8 g/dL if b. Hepatitis
the mother is anti-CMV negative? c. CMV
d. EBV
a. Whole blood from a donor with anti-CMV
b. RBCs from a donor who is anti-CMV negative 6. Jaundice due to HAV is seen most often in the:
c. Leukoreduced platelets a. Adolescent.
d. Solvent detergent–treated plasma b. Adult.
3. Which of the following tests is useful to confirm that a c. Child younger than 6 years old.
patient or donor is infected with HCV? d. Newborn.
a. ALT + anti-HBc
b. Anti-HIV 1/2
c. Lymph node biopsy
d. RIBA
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424 PART III Transfusion Practice

7. Currently, steps taken to reduce transfusion-transmitted 15. Individuals exposed to EBV maintain an asymptomatic
CMV include: latent infection in:
a. Plaque reduction neutralization test. a. B cells.
b. NAT testing. b. T cells.
c. Leukoreduction. c. All lymphocytes.
d. Minipool screening. d. Monocytes.

8. HBV remains infectious on environmental surfaces for 1: 16. Fifth disease is caused by:
a. Day. a. CMV.
b. Week. b. EBV.
c. Month. c. Parvovirus B19.
d. Year. d. HTLV-II.
9. HBV is transmitted most frequently: 17. Transient aplastic crisis can occur with:
a. By needle sharing among IV drug users. a. Parvovirus B19.
b. Through blood transfusions. b. WNV.
c. By unknown methods c. CMV.
d. By sexual activity d. EBV.
10. Which of the following is the most common cause of 18. Reasons why syphilis is so rare in the United States
chronic hepatitis, cirrhosis, and hepatocellular carci- blood supply include all of the following except:
noma in the United States? a. 4°C storage conditions.
a. HAV b. Donor questionnaire.
b. HBV c. Short spirochetemia.
c. HCV d. NAT testing.
d. HDV
19. Nucleic acid amplification testing for HIV was instituted
11. The first retrovirus to be associated with human disease in donor testing protocols to:
was: a. Identify donors with late-stage HIV who lack antibodies.
a. HCV b. Confirm the presence of anti-HIV in asymptomatic
b. HIV HIV-infected donors.
c. HTLV-I c. Reduce the window period by detecting the virus
d. WNV earlier than other available tests.
d. Detect antibodies to specific HIV viral proteins,
12. All of the following statements are true concerning
including anti-p24, anti-gp41, and anti-gp120.
WNV except:
a. 1 in 150 infections results in severe neurologic 20. Screening for HIV is performed using the following
disease. technique:
b. Severe disease occurs most frequently in the over-50 a. Radio immunoassay
age group. b. WB
c. Deaths occur more often in those over 65 years who c. Immunofluorescent antibody assay
present with encephalitis. d. NAT
d. Fatalities occur in approximately 38% of infected
21. The first form of pathogen inactivation was:
individuals.
a. Chemical.
13. The primary host for WNV is: b. Heat.
a. Birds. c. Cold-ethanol fractionation.
b. Horses. d. Anion-exchange chromatography.
c. Humans.
22. What is the most common parasitic complication of
d. Bats.
transfusion?
14. Tests for WNV include all of the following except: a. Babesia microti
a. ELISA. b. Trypanosoma cruzi
b. NAT. c. Plasmodium species
c. Plaque reduction neutralization test. d. Toxoplasma gondii
d. Immunofluorescent antibody assay.
2682_Ch18_403-426 22/05/12 11:58 AM Page 425

Chapter 18 Transfusion-Transmitted Diseases 425

23. Which organism has a characteristic C- or U-shape on 17. Halasz, R, et al: GB virus C/hepatitis G virus. Scand J Infect
stained blood smears? Dis 33:572, 2001.
18. Nunnari, G, et al: Slower progression of HIV-1 infection in
a. Trypanosoma cruzi persons with GB virus C coinfection correlates with an intact
b. Plasmodium vivax T-helper 1 cytokine profile. Ann Intern Med 139:26, 2003.
c. Plasmodium falciparum 19. Zanetti, AR, et al: Multicenter trial on mother-infant transmis-
d. Babesia microti sion of GBV-virus. J Med Virol 54:107, 1998.
20. Sathar, MA, et al: GB virus C/hepatitis G virus (GBV-C/HGV):
24. Which transfusion-associated parasite may have asymp- Still looking for a disease. Int J Exper Pathol 81:305, 2000.
tomatic carriers? 21. Jarvis, LM, et al: The effect of treatment with alpha-interferon
on hepatitis G/GBV-C viraemia. The CONSTRUCT Group.
a. Babesia microti Scand J Gastroenterol 33:195, 1999.
b. Trypanosoma cruzi 22. Centers for Disease Control and Prevention: HIV/AIDS
c. Plasmodium species Prevalence Estimates, United States, 2006. Available at
d. All of the above www.cdc.gov/mmwr/preview/mmurhtm/mm5739a2.htm.
Accessed August 11, 2010.
25. Which disease is naturally caused by the bite of a deer tick? 23. Centers for Disease Control and Prevention: HIV and AIDs
in the United States. Available at www.cdc.gov/hiv/resources/
a. Chagas’ disease factsheets/us.htm. Accessed August 11, 2010.
b. Babesiosis 24. American Red Cross: Blood Testing. Available at www.
c. Malaria redcross/blood.org/learn-about-blood/what-happens=
d. Leishmaniasis donated-blood/blood-testing. Accessed August 11, 2010.
25. Centers for Disease Control: Advancing HIV prevention:
New strategies for a changing epidemic—United States, 2005.
References Available at www.cdc.gov/hiv/topics/prev_prog/AHP/default.
1. American Association of Blood Banks: Standards for blood htm. Accessed August 11, 2010.
banks and transfusion services, 26th ed. AABB, 2009. 26. Manns, A, Hisada, M, and La Grenade, L: Human
2. Centers for Disease Control and Prevention: Detection of West T-lymphotropic virus type I infection. Lancet 353:1951, 1999.
Nile virus in blood donations—United States, 2003. MMWR 27. Matsuoka, M: Human T-cell leukemia virus type I and adult
59:25, 2010. T-cell leukemia. Oncogene 22:5131, 2003.
3. Roback, JD (ed): Technical Manual, 16th ed. American Asso- 28. Nagai, M, and Osame, M: Human T-cell lymphotropic virus
ciation of Blood Banks, Bethesda, MD, 2008. type I and neurological diseases. J Neurovirol 9:228, 2003.
4. Bishop, ML, et al: Clinical Chemistry Techniques, Principles 29. Murphy, EL, et al: Increased prevalence of infectious diseases and
and Correlations, 6th ed. Lippincott, Williams & Wilkins, other adverse outcomes in human T lymphotropic virus types
Baltimore, MD, 2010. I- and II-infected blood donors. J Infect Dis 176:1468, 1997.
5. Lemon, SM: Type A viral hepatitis: Epidemiology, diagnosis, 30. American Association of Blood Banks: Dual enzyme immuno
and prevention. Clin Chem 43;8:1494, 1994. assay (EIA) approach for deferral and notification of anti-
6. Soucie, JM, et al: Hepatitis A virus infections associated with HTLV-I/II EIA reactive donors. Association Bulletin #99–9.
clotting factor concentrates in the United States. Transfusion Available at www.aabb.org/members_only/archives/association_
38:573, 1998. bulletins/ab99–9.htm. Accessed on August 11, 2010.
7. Miller, LE: Serology of viral infections. In Stevens, CD (ed): 31. Prowse, CV: An ABC for West Nile virus. Transfus Med 13:1, 2003.
Clinical Immunology and Serology: A Laboratory Perspective, 32. Petersen, LR, Marfin, AA, and Gubler, DJ: West Nile virus.
2nd ed. FA Davis Company, Philadelphia, 2003, p 324. JAMA 290:524, 2003.
8. Centers for Disease Control and Prevention: Hepatitis A Infor- 33. Centers for Disease Control and Prevention: West Nile virus
mation for the Public. Available at www.cdc.gov/hepatitis/ statistics, surveillance and control archive. Available at
A/afap.htm#transmission. Accessed July 30, 2010. www.cdc.gov/ncidod/dvbid/westnile/surv&control.htm. Accessed
9. Centers for Disease Control and Prevention: Hepatitis B virus. August 13, 2010.
Available at www.cdc.gov/hepatitis/resources/professionals/ 34. Centers for Disease Control and Prevention: Acute flaccid
pdfs/ABCTable_BW.pdf. Accessed August 9, 2010. paralysis syndrome associated with West Nile virus infection—
10. Centers for Disease Control and Prevention: Surveillance Mississippi and Louisiana, July–August 2002. MMWR 51:825,
for Acute Viral Hepatitis—United States, 2007. Available at 2002.
www.cdc.gov/mmwr/PDF/ss/ss5803.pdf. Accessed August 9, 35. Centers for Disease Control and Prevention: West Nile virus:
2010. Overview of West Nile virus. Available at www.cdc.gov/ncidod/
11. Lox, ASF, and McMahon, BF: AASLD practice guidelines: dvbid/westnile/qa/overview.htm. Accessed August 13, 2010.
Chronic hepatitis B. Hepatology 34:1225, 2001. 36. Petersen, LR, and Marfin, AA: West Nile virus: A primer for
12. Marcellin, P, et al: Adefovir dipivoxil for treatment of hepatitis clinicians. Ann Intern Med 137:173, 2002.
B antigen-positive chronic hepatitis B. N Engl J Med. 348:808, 37. Centers for Disease Control and Prevention: Epidemic/
2003. Epizootic West Nile virus in the United States: Guidelines
13. Gerlach, JT: Acute hepatitis C: High rate of both spontaneous for surveillance, prevention, and control. Available at www.cdc.
and treatment-induced viral clearance. Gastroenterology gov/ncidod/dvbid/westnile/lab_DiagnosticTesting.htm. Accessed
125:80, 2003. August 16, 2010.
14. Centers for Disease Control and Prevention: Hepatitis E virus. 38. Busch, MP, et al: Screening the blood supply for West Nile virus
Available at www.cdc.gov//hepatitis/HEV?HEVfaq.htm#section1. RNA by nucleic acid amplification testing. N Engl J Med
Accessed August 9,2010. 353:460–467, 2005.
15. Alter, H, et al: The incidence of transfusion associated hepatitis 39. Centers for Disease Control and Prevention: Dispatch:
G virus infection and its relation to liver disease. N Engl J Med Update: Detection of West Nile virus in blood donations—
336:747, 1997. United States, 2003. MMWR 52:2003. Available at www.cdc.
16. Heringlake, S, et al: Association between fulminant hepatic gov/mmwr/preview/mmwrhtm/mm5232a3.htm. Accessed
failure and a strain of GB virus C. Lancet 348:1626, 1996. August 16, 2010.
2682_Ch19_427-438 22/05/12 11:59 AM Page 437

Chapter 19 Hemolytic Disease of the Fetus and Newborn (HDFN) 437

the infant’s hemoglobin is reported as 4.3 g/dL and biliru- The results indicate the cord blood specimen is all
bin as 3.9 mg/dL. Typing results of this specimen are as adult blood and the heel-stick specimen is nearly all adult
follows: blood.
Anti-A Anti-B Anti-D DAT 2. How could that happen?
0 0 0 +/–
Further testing is done on the heel-stick specimen:
1. What is the infant’s blood type? Why is the infant so
Anti-A Anti-B RBC Eluate
anemic? What further testing is indicated?
4°C0 + Anti-D
Further testing shows the following:
These results indicate that the infant is B-positive and
Cord Blood Heel-stick has HDFN caused by anti-D.
Anti-I 4+ 3+
Kleihauer-Betke 0/1,000 23/1,000

SUMMARY CHART
HDFN is the destruction of the RBCs of the fetus and Although anti-D is the most antigenic of the Rh anti-
neonate by IgG antibodies produced by the mother. bodies, anti-Kell is considered the most clinically sig-
Only antibodies of the IgG class are actively trans- nificant of the non-Rh-system antibodies in the ability
ported across the placenta. to cause HDFN.
In Rh HDFN, the Rh-positive firstborn infant of Prenatal serologic tests for obstetric patients include
an Rh-negative mother is unaffected because the an ABO, Rh, and antibody screen during the first
mother has not yet been immunized; in subsequent trimester of pregnancy.
pregnancies, fetal cells carrying the Rh antigen A cord blood workup includes tests for ABO and Rh
immunize the Rh-negative mother and stimulate pro- as well as DAT; the most important serologic test for
duction of anti-D. diagnosis of HDFN is the DAT with anti-IgG reagent.
In ABO HDFN, the firstborn infant may be affected RhIG administered to the mother within 72 hours fol-
as well as subsequent pregnancies in which the lowing delivery is used to prevent active immunization
mother is group O and the newborn is group A, B, by the Rh(D) antigen on fetal cells; RhIG attaches to
or AB; the IgG antibody, anti-A,B in the mother’s cir- fetal Rh-positive RBCs in maternal circulation, blocking
culation, crosses the placenta and attaches to the immunization and subsequent production of anti-D.
ABO-incompatible antigens of the fetal RBCs. A Kleihauer-Betke test or flow cytometry is used to
Erythroblastosis fetalis describes the presence of imma- quantitate the number of fetal Rh-positive cells in
ture RBCs or erythroblasts in the fetal circulation be- the mother’s circulation as a result of a fetomaternal
cause the splenic removal of the IgG-coated RBCs causes hemorrhage.
anemia; the term commonly used now is HDFN.

3. Kernicterus is caused by the effects of:

Review Questions
a. Anemia.
1. HDFN is characterized by: b. Unconjugated bilirubin.
c. Antibody specificity.
a. IgM antibody.
d. Antibody titer.
b. Nearly always anti-D.
c. Different RBC antigens between mother and father. 4. The advantages of cordocentesis include all of the follow-
d. Antibody titer less than 32. ing except:
2. The main difference between the fetus and the newborn is: a. Allows measurement of fetal hemoglobin and hemat-
ocrit levels
a. Bilirubin metabolism.
b. Allows antigen typing of fetal blood
b. Maternal antibody level.
c. Allows direct transfusion of fetal circulation
c. Presence of anemia.
d. Decreases risk of trauma to the placenta
d. Size of RBCs.
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438 PART III Transfusion Practice

5. Middle cerebral artery-peak systolic velocity is used to: References

a. Measure bilirubin. 1. Geifman-Holtzman, O, et al: Female alloimmunization with
b. Determine fetal blood type. antibodies known to cause hemolytic disease. Obstet Gynecol
c. Determine change in optical density. 89:272–275, 1997.
d. Assess for anemia. 2. Klein, HG, and Anstee, DJ: Mollison’s Blood Transfusion in
Clinical Medicine, 11th ed. Blackwell Scientific, London, 2005,
6. Blood for intrauterine transfusion should be all of the pp 496–545.
following except: 3. Bowman, JM: The prevention of Rh immunization. Transfus
Med Rev 2:129–150, 1988.
a. More than 7 days old. 4. Klein, HG, and Anstee, DJ: Mollison’s Blood Transfusion in
b. Screened for CMV. Clinical Medicine, 11th ed. Blackwell Scientific, London, 2005,
c. Gamma-irradiated. pp 163–208.
d. Compatible with maternal serum. 5. Vaughan, JI, et al: Inhibition of erythroid progenitor cells by
anti-Kell antibodies in fetal alloimmune anemia. N Engl J Med
7. RhIG is indicated for: 338:798–803, 1998.
6. Vengelen-Tyler, V: The serological investigation of hemolytic
a. Mothers who have anti-D. disease of the newborn caused by antibodies other than
b. Infants who are Rh-negative. anti-D. In Garratty, G (ed): Hemolytic Disease of the New-
c. Infants who have anti-D. born. American Association of Blood Banks, Arlington, VA,
d. Mothers who are Rh-negative. 1984, pp 145–172.
7. Moise, KJ: Management of Rhesus alloimmunization in preg-
8. RhIG is given without regard for fetal Rh type in all of nancy. Obstet Gynecol 100:600–611, 2002.
the following conditions except: 8. Judd, WJ, Johnson, ST, and Storry, JR: Judd’s Methods in
Immunohematology, 3rd ed. AABB, Bethesda, MD, 2008.
a. Ectopic pregnancy rupture. 9. Finning, K, et al: Fetal genotyping for the K (Kell) and Rh C,
b. Amniocentesis. E, c, and E blood groups on cell-free DNA in maternal plasma.
c. Induced abortion. Transfusion 47:2126–2133, 2007.
d. Full-term delivery. 10. Mari, G, et al: Noninvasive diagnosis by Doppler ultrasonog-
raphy of fetal anemia due to maternal red-cell alloimmuniza-
9. A Kleihauer-Betke test or flow cytometry indicates tion. Collaborative group for Doppler assessment of the blood
10 fetal cells per 1,000 adult cells. For a woman with velocity in anemic fetuses. N Eng J Med 342:9–14, 2000.
5,000 mL blood volume, the proper dose of RhIG is: 11. Oepkes, D, et al: Doppler ultrasonography versus amniocen-
tesis to predict fetal anemia. N Engl J Med 354:156–164,
a. One regular-dose vial. 2006.
b. Two regular-dose vials, plus one. 12. Schumacher, B, and Moise, KJ: Fetal transfusion for red
c. One regular-dose vial, plus one. blood cell alloimmunization in pregnancy. Obstet Gynecol
d. Two microdose vials. 88:137–150, 1996.
13. Maisels, MJ, and McDonagh, AF: Phototherapy for neonatal
10. RhIG is indicated in which of the following circumstances? jaundice. N Engl J Med 358:920–928, 2008.
14. Brinc, D, et al: Immunoglobulin G-mediated regulation of the
a. Mother D-positive, infant D-positive murine response to transfused red blood cells occurs in
b. Mother D-negative, infant D-positive the absence of active immunosuppression: Implications for
c. Mother D-positive, infant D-negative the mechanism of action of anti-D in the prevention of
d. Mother D-negative, infant D-negative haemolytic disease of the fetus and newborn? Immunology
124:141–146, 2008.
11. ABO HDFN is usually mild because: 15. Kennedy, MS: Perinatal issues in transfusion practice. In
a. ABO antigens are poorly developed in the fetus. Roback, JD (ed): Technical Manual, 16th ed. AABB, Bethesda,
2008, pp 625–637.
b. ABO antibodies prevent the disease. 16. Herschel, M, et al: Isoimmunization is unlikely to be the cause
c. ABO antibodies readily cross the placenta. of hemolysis in ABO-incompatible but direct antiglobulin test-
d. ABO incompatibility is rare. negative neonates. Pediatrics 110:127–130, 2002.
17. Kennedy, MS: Rho(D) immune globulin. In Rayburn, W, and
12. A woman without prenatal care delivers a healthy Zuspan, FP (eds): Drug Therapy in Gynecology and Obstetrics,
term infant. A cord blood sample shows the infant is 3rd ed. CV Mosby, St. Louis, 1991, p 297.
A-positive with a positive DAT. The workup of the
unexpected finding should include:
a. Anti-C3 antiglobulin test.
b. ABO testing of the mother.
c. Direct antiglobulin testing of the mother’s specimen.
d. ABO and Rh typing of the father.
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470 PART III Transfusion Practice

Cefotetan-Treated RBCs Untreated RBCs

37°C IAT 37°C IAT
Patient’s serum 1:100 4+ 4+ 0 0✓
Patient’s eluate 1:20 0 3+ 0 0✓
Last wash 1:20 0 0✓ 0 0✓
Positive control 3+ 3+ 0 0✓
Negative control 0 0✓ 0 0✓

Anticefotetan was identified in the patient’s serum and eluate. The patient must be warned that she should never receive
cefotetan again. Renal failure and fatality were seen in 19% of such cases in one study.7

SUMMARY CHART
Immune hemolytic anemia is defined as shortened The classic antibody produced in PCH is called the
RBC survival mediated through the immune response, Donath-Landsteiner antibody, and it has the specificity
specifically by humoral antibody. of autoanti-P. This biphasic antibody binds to patient
In alloimmune hemolytic anemia, patients produce al- RBCs at low temperatures and fixes complement.
loantibodies to foreign RBC antigens introduced into Hemolysis occurs when coated cells are warmed to 37°C
their circulation, most often through transfusion or and complement-mediated intravascular lysis occurs.
pregnancy. In WAIHA, most patients (67%) have both IgG and
Alloimmune hemolytic anemia is self-limiting; when complement on their RBCs, but 20% have only IgG
the foreign RBCs are cleared from circulation, RBC and 13% have only complement.
destruction stops. Warm reactive autoantibodies are generally enhanced
In autoimmune hemolytic anemia (AIHA), patients by enzyme techniques and often have a broad speci-
produce antibodies against their own RBC antigens. ficity within the Rh blood group system.
When transfusing a patient with WAIHA, the primary
In AIHA, the autoantibody is directed against the
concern is detection and identification of all alloanti-
patient’s own RBCs; therefore, there is a consistent
bodies that are masked by the warm autoantibody.
source of antibody and antigen present for continuous
RBC destruction. In the immune complex drug mechanism, the soluble
drug-antidrug complex nonspecifically adsorbs loosely
In drug-induced immune hemolytic anemia, patients
to the RBC surface, yielding a positive DAT with anti-C3
produce antibody to a particular drug or drug com-
and sometimes with anti-IgG.
plex, with subsequent damage to RBCs.
In the drug-adsorption (hapten) mechanism, drugs
AIHA may be classified as cold reactive (18%), warm
such as penicillin or cefotetan bind firmly to proteins
reactive (70%), or drug-induced (12%); diagnostic
of the RBC membrane. The DAT will show reactivity
tests include the DAT and characterization of the
with anti-IgG and often with anti-C3.
autoantibody in the serum or eluate.
In the membrane modification drug mechanism, drugs
In AIHA, serum antibody will not be detected until
such as the cephalosporins modify the RBCs so that
the amount of antibody produced exceeds the num-
plasma proteins can bind to the membrane nonim-
ber of RBC antigen sites available on the patient’s
munologically. The DAT will often demonstrate reac-
own RBCs.
tivity with both anti-IgG and anti-C3.
The common antibody specificity in both benign and
In the autoantibody drug mechanism, the drug (e.g.,
pathological cold autoagglutinins is anti-I.
alpha-methyldopa/Aldomet) induces production of an
In CHD, the DAT will be positive because of comple- autoantibody that recognizes RBC antigens. Both the
ment coating of the RBCs; an antibody titer greater autoantibody and eluate are reactive with normal
than 1,000 may cause visible agglutination of antico- RBCs. The DAT is reactive with anti-IgG.
agulated blood at room temperature.
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Chapter 20 Autoimmune Hemolytic Anemias 471

9. Many warm reactive autoantibodies have a broad speci-

Review Questions
ficity within which of the following blood groups?
1. Immune hemolytic anemias may be classified in which a. Kell
of the following categories? b. Duffy
c. Rh
a. Alloimmune
d. Kidd
b. Autoimmune
c. Drug-induced 10. Valid Rh typing can usually be obtained on a patient
d. All of the above with WAIHA using all of the following reagents or
techniques except:
2. When preparing cells for a cold autoadsorption proce-
dure, it is helpful to pretreat the cells with which of the a. Slide and modified tube anti-D
following? b. Chloroquine-treated RBCs
c. Rosette test
a. Dithiothreitol
d. Monoclonal anti-D
b. Ficin
c. Phosphate-buffered saline at pH 9 11. In pretransfusion testing for a patient with WAIHA, the
d. Bovine albumin primary concern is:
3. The blood group involved in the autoantibody specificity a. Treating the patient’s cells with chloroquine for
in PCH is: reliable antigen typing
b. Adsorbing out all antibodies in the patient’s serum to
a. P
be able to provide compatible RBCs
b. ABO
c. Determining the exact specificity of the autoantibody
c. Rh
so that compatible RBCs can be found
d. Lewis
d. Discovering any existing significant alloantibodies in
4. Which of the following blood groups reacts best with an the patient’s circulation
anti-H or anti-IH?
12. Penicillin given in massive doses has been associated
a.O with RBC hemolysis. Which of the classic mechanisms
b.B is typically involved in the hemolytic process?
c.A2
a. Immune complex
d.A1
b. Drug adsorption
5. With cold reactive autoantibodies, the protein coating the c. Membrane modification
patient’s cells and detected in the DAT is: d. Autoantibody formation
a. C3 13. Which of the following drugs has been associated with
b. IgG complement activation and rapid intravascular hemoly-
c. C4 sis?
d. IgM
a. Penicillins
6. Problems in routine testing caused by cold reactive b. Quinidine
autoantibodies can usually be resolved by all of the c. Alpha-methyldopa
following except: d. Cephalosporins
a. Prewarming 14. A patient is admitted with a hemoglobin of 5.6 g/dL.
b. Washing with warm saline Initial pretransfusion workup appears to indicate the
c. Using anti-IgG antiglobulin serum presence of a warm autoantibody in the serum and coat-
d. Testing clotted blood specimens ing his RBCs. His transfusion history indicates that he
7. Pathological cold autoagglutinins differ from common received 6 units of RBCs 2 years ago after an automobile
cold autoagglutinins in: accident. Which of the following would be most helpful
a. Immunoglobulin class in performing antibody detection and compatibility
b. Thermal amplitude testing procedures?
c. Antibody specificity a. Adsorb the autoantibody using the patient’s enzyme-
d. DAT results on EDTA specimen treated cells.
b. Perform an elution and use the eluate for compatibil-
8. Cold AIHA is sometimes associated with infection by: ity testing.
a. Staphylococcus aureus c. Crossmatch random units until compatible units are
b. Mycoplasma pneumoniae found.
c. Escherichia coli d. Collect blood from relatives who are more likely to
d. Group A Streptococcus be compatible.
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472 PART III Transfusion Practice

15. A patient who is taking Aldomet has a positive DAT. An 13. Garratty, G, Petz, LD, and Hoops, JK: The correlation of cold
eluate prepared from his RBCs would be expected to: agglutinin titrations in saline and albumin with haemolytic
anaemia. Br J Haematol 35:587, 1977.
a. React only with Aldomet-coated cells 14. Engelfriet, CP, et al: Autoimmune hemolytic anemias: Serolog-
b. Be neutralized by a suspension of Aldomet ical studies with pure anti-immunoglobulin reagents. Clin Exp
c. React with all normal cells Immunol 3:605, 1968.
d. React only with Rhnull cells 15. Rosse, WF: Quantitative immunology of immune hemolytic
anemia: The relationship of cell-bound antibody to hemolysis
16. One method that can be used to separate a patient’s and the effect of treatment. J Clin Invest 50:734, 1971.
RBCs from recently transfused donor RBCs is: 16. De Angelis, V, et al: Abnormalities of membrane protein com-
position in patients with autoimmune haemolytic anaemia.
a. Chloroquine diphosphate treatment of the RBCs Br J Hematol 95:273, 1996.
b. Reticulocyte harvesting 17. Gilliland, BC, Baxter, E, and Evans, RS: Red cell antibodies in
c. EGA treatment acquired hemolytic anemia with negative antiglobulin serum
d. Donath-Landsteiner testing tests. N Engl J Med 285:252, 1971.
18. Garratty, G: Autoimmune hemolytic anemia. In Garratty, G
17. Monoclonal antisera is valuable in phenotyping RBCs (ed): Immunobiology of Transfusion Medicine. Marcel Dekker,
with positive DATs because: New York, 1994, p 493.
19. Stratton, F, et al: Acquired hemolytic anemia associated with
a. Both polyspecific and monospecific antihuman serum IgA anti-e. Transfusion 12:197, 1972.
can be used in antiglobulin testing 20. Sturgeon, P, et al: Autoimmune hemolytic anemia associated
b. Anti-C3 serum can be used in antiglobulin testing exclusively with IgA of Rh specificity. Transfusion 19:324,
c. It usually does not require antiglobulin testing 1979.
21. Hoppe, PA: The role of the Bureau of Biologics in assuring
d. It does not require enzyme treatment of the cells prior
reagent reliability. In Considerations in the Selection of
to antiglobulin testing Reagents. American Association of Blood Banks, Washington,
DC, 1979, p 1.
18. Autoadsorption procedures to remove either warm or 22. Garratty, G, and Petz, LD: An evaluation of commercial
cold autoantibodies should not be used with a recently antiglobulin sera with particular reference to their anticomple-
transfused patient. Recently means: ment properties. Transfusion 11:79, 1971.
a. 3 days 23. Roback, JD (ed): Technical Manual, 16th ed. American
Association of Blood Banks, Bethesda, MD, 2008.
b. 3 weeks
24. Reid, ME: Autoagglutination dispersal utilizing sulfhydryl
c. 6 weeks compounds. Transfusion 18:353, 1978.
d. 3 months 25. Storry, JR, Olsson, MI, and Moulds, JJ: Rabbit red blood cell
stroma bind immunoglobulin M antibodies regardless of blood
group specificity (letter). Transfusion 46:1260, 2006.
26. Judd, WJ: Controversies in transfusion medicine: Prewarmed
References tests: Con Transfusion 35:271, 1995.
27. Chaplin, H, et al: Clinically significant allo-anti-I in an
1. Allan, J, and Garratty, G: Positive direct antiglobulin tests in I-negative patient with massive hemorrhage. Transfusion 26:57,
normal blood donors (abstract). Proceedings of the Interna- 1986.
tional Society of Blood Transfusion, Montreal, 1980. 28. Marsh, WL: Aspects of cold-reactive autoantibodies. In Bell,
2. Izui, S: Autoimmune hemolytic anemia. Curr Opin Immunol CA (ed): A Seminar on Laboratory Management of Hemolysis.
6:926, 1994. American Association of Blood Banks, Washington, DC, 1979,
3. Barthold, DR, Kysela, S, and Steinberg, AD: Decline in suppres- p 79.
sor T cell function with age in female NZB mice. J Immunol 29. Combs, MR, et al: An auto-anti M causing hemolysis in vitro.
112:9, 1974. Transfusion 31:756, 1991.
4. Banacerraf, B, and Unanue, ER: Textbook of Immunology. 30. Garratty, G: Target antigens for red-cell-bound autoantibodies.
Williams & Wilkins, Baltimore, 1979. In Nance, ST (ed): Clinical and Basic Science Aspects of
5. Kirtland, HH, Horwitz, DA, and Mohler, DN: Inhibition of Immunohematology. American Association of Blood Banks,
suppressor T cell function by methyldopa: A proposed cause Arlington, VA, 1991, p 33.
of autoimmune hemolytic anemia. N Engl J Med 302:825, 31. Lyckholm, LJ, and Edmond, MB: Seasonal hemolysis due to
1980. cold-agglutinin syndrome. N Engl J Med 334:437, 1996.
6. van Loghem, JJ: Concepts on the origin of autoimmune 32. Aoki, A, et al: Cardiac operation without hypothermia for
diseases: The possible role of viral infection in the etiology of the patient with cold agglutinin. Chest 104:1627, 1993.
idiopathic autoimmune diseases. Semin Hematol 9:17, 1965. 33. Shirey, RS, et al: An anti-i biphasic hemolysin in chronic parox-
7. Petz, LD, and Garratty, G: Immune Hemolytic Anemias, 2nd ed. ysmal cold hemoglobinuria. Transfusion 26:62, 1986.
Churchill Livingstone, Philadelphia, 2004. 34. Judd, WJ, et al: Donath-Landsteiner hemolytic anemia due to
8. Hillman, RS, and Finch, GA: Red Cell Manual, 7th ed. FA an anti-Pr-like biphasic hemolysin. Transfusion 26:423, 1986.
Davis, Philadelphia, 1996. 35. Reid, M: Association of red blood cell membrane abnormalities
9. Roback, JD (ed): Technical Manual, 16th ed. American with blood group phenotype. In Garratty, G (ed): Immunobi-
Association of Blood Banks, Bethesda, MD, 2008. ology of Transfusion Medicine. Marcel Dekker, New York,
10. Okuno, T, Germino, F, and Newman, B: Clinical significance 1994, p 257.
of autologous control (abstract). American Society Clinical 36. Salloum, E, and Lundberg, WB: Hemolytic anemia with
Pathologists 16, 1984. positive direct antiglobulin test secondary to spontaneous
11. Lau, P, Haesler, WE, and Wurzel, HA: Positive direct antiglob- cytomegalovirus infection in healthy adults. Acta Hematol
ulin reaction in a patient population. Am J Clin Pathol 65:368, 92:39, 1994.
1976. 37. Benraad, CEM, Scheerder, HAJM, and Overbeeke, MAM:
12. Judd, WJ, et al: The evaluation of a positive direct antiglobulin Autoimmune haemolytic anaemia during pregnancy. Eur J
test in pretransfusion testing. Transfusion 20:17, 1980. Obstet Gynecol Reprod Biol 55:209, 1994.
2682_Ch21_475-494 22/05/12 12:01 PM Page 491

Chapter 21 The HLA System 491

ischemic time is the amount of time there is no blood the HLA matching between donor and recipient may
flow through the organ. The single most important HLA play an important role in live-donor lung transplantation
pretransplant test is the HLA-antibody screen. Recipients (2% to 3%) in an attempt to improve post-transplant con-
with no preformed HLA antibodies receive transplants ditions and graft survival rates.85 Virtual crossmatching also
without crossmatching. Those with preformed HLA anti- plays an important role in those sensitized patients awaiting
bodies require either pretransplant crossmatches to deter- lung transplantation.
mine recipient-donor compatibility or donor HLA phenotype
to perform virtual crossmatching. Pancreas and Islet Cell Transplantation
The primary indication for pancreas transplantation is di-
Liver Transplantation abetes. The majority of pancreas transplants performed are
Orthotopic liver transplantation has become an established simultaneous pancreas and kidney transplants (81%), with
and successful therapeutic modality for patients with pancreas following kidney (12%) and pancreas alone (5%).
end-stage liver disease. Immunologic factors in recipient/ HLA matching, as reported by one of the largest pancreas
donor matching for liver transplantation and recipient transplant centers, has a major effect on graft survival,86
presensitization have largely been ignored in the past particularly in the pancreas after kidney and pancreas
because of the liver’s unique abilities to act as a sink for alone transplants. Because of increased risks of myocardial
anti-HLA antibodies and to regenerate itself if destroyed complications with pancreas transplantation, islet cell
by antibody. The consequences of HLA presensitization transplantation has been actively pursued. Although islet
and ABO incompatibility were recently underlined in cell transplantation is technically simple, difficulty has
three reports.82–84 In the first, a retrospective analysis of been encountered in achieving sustained engraftment in
preformed HLA antibodies demonstrated 1-year graft humans due to insufficient cell numbers. To overcome
survival rate of 40% in the presensitized individuals as this, sufficient islet mass is attained by transplanting islets
compared with 83% in the nonsensitized individuals. In from two donor pancreases when cell numbers are low. To
the second, survival of patients with emergency ABO- date, the effect of HLA matching has not been studied, but
incompatible transplants was 30% compared with 76% in data are being stored for future analyses.
patients with emergency ABO-compatible grafts and 80%
in patients with elective ABO-compatible grafts. United Network for Organ Sharing
In an effort to provide solid organs (a rare commodity)
Lung Transplantation equitably, the United Network for Organ Sharing (UNOS)
An overall review of the indications for lung transplantation was established in 1986. This organization received the
during the past several years reveals that emphysema and federal contract to operate the national Organ Procure-
cystic fibrosis account for the majority of double-lung trans- ment and Transplantation Network (OPTN) and to de-
plants. The major indications for single-lung transplantation velop an equitable scientific and medically sound organ
include pulmonary fibrosis (33%) and emphysema (41%). allocation system. The OPTN is charged with developing
In addition, single-lung transplants for primary hyperten- policies that maximize use of organs donated for trans-
sion are being performed instead of heart-lung transplanta- plantation, ensuring quality of care for transplant patients,
tion. As with hearts, short cold ischemic times for lungs and addressing medical and ethical issues related to organ
preclude prospective histocompatibility testing. However, transplantation in the United States.

SUMMARY CHART
The HLA genetic region is a series of closely linked The HLA genotype represents the association of the
genes located on the short arm of chromosome 6 that alleles on the two C6 chromosomes as determined
determine major histocompatibility factors—that is, by family studies, and the term haplotype refers to the
surface antigens or receptors that are responsible for allelic makeup of a single C6 chromosome.
recognizing and eliminating foreign tissues. The majority of HLA alloantibodies are IgG and can be
The HLA class I region encodes genes for the classic grouped into private antibodies (binding to an epitope
transplantation molecules HLA-A, HLA-B, and HLA-C; unique to one HLA gene product), public antibodies
the class II region encodes genes for the molecules (binding to epitopes shared by more than one HLA
HLA-DR, HLA-DP, and HLA-DQ; the class III region gene product), or cross-reactive (binding to struc-
encodes genes for C2, C4, Bf (complement factors), turally similar HLA epitopes) antibodies.
21-hydroxylase, and tumor necrosis factor.

Continued
2682_Ch21_475-494 22/05/12 12:01 PM Page 492

492 PART IV Leukocyte Antigens and Relationship Testing

SUMMARY CHART—cont’d
Techniques of histocompatibility testing include anti- The general strategies employed by transplantation
gen and allele typing; HLA antibody detection and immunologists include use of immunosuppressive
identification, in which recipient serum is tested drugs, reduction of graft “foreignness,” and induction
against a panel of cells or a panel of single antigens; of tolerance.
and crossmatching, in which specific donor cells and Platelet refractoriness is manifested by the failure to
recipient sera are tested for compatibility. The ability achieve a rise in circulating platelet count 1 hour after
to perform “virtual” crossmatches due to the specific infusion of adequate numbers of platelets.
and sensitive single antigen screening assay has refined TRALI is the most severe adverse outcome from trans-
pretransplant histocompatibility testing and improved fusion manifested by fever, hypoxemia, and pulmonary
organ allocation algorithms. This has led to improved edema.
clinical outcomes.

7. What is the molecular technique that detects undefined

Review Questions
alleles?
1. The HLA genes are located on which chromosome? a. Restriction fragment length polymorphism
b. Sequence-specific primer typing
a. 2
c. Sequence-specific oligonucleotide typing
b. 4
d. Direct nucleotide sequencing
c. 6
d. 8 8. What represents the association of the alleles on the two
C6 chromosomes as determined by family studies?
2. The majority of HLA antibodies belongs to what im-
munoglobulin class? a.Haplotype
b.Genotype
a. IgD
c.Phenotype
b. IgE
d.Xenotype
c. IgG
d. IgM
References
3. What is the test of choice for HLA antigen testing? 1. Dausset, H: Leukoagglutinins: Leukoagglutinins and blood
a. Agglutination transfusion. J Vox Sang 4:190, 1954.
b. Molecular 2. Dausset, J: Iso-leuco-anticorps. Acta Haematol 20:156, 1958.
c. Cytotoxicity 3. Marsh, SGE, et al: Nomenclature for Factors of the HLA
System. Tissue Antigens 75:291, 2010.
d. ELISA 4. Kissmeyer-Nielson, F, et al: Hyperacute rejection of kidney
4. Of the following diseases, which one has the highest rel- allografts associated with preexisting humoral antibodies
against donor cells. Lancet 1:662, 1966.
ative risk in association with an HLA antigen? 5. Bjorkman, PJ, et al: Structure of the HLA class I histocompat-
a. Ankylosing spondylitis ibility antigen, HLA-A2. Nature 329:506, 1987.
b. Juvenile diabetes 6. Brown, JH, et al: Three-dimensional structure of the human
c. Narcolepsy class II histocompatibility antigen HLA-DR1. Nature 364:33,
1993.
d. Rheumatoid arthritis 7. Townsend AR, et al: The epitopes of influenza nucleoprotein
5. Why is HLA matching not feasible in cardiac transplan- recognized by cytotoxic T lymphocytes can be defined with
short synthetic peptides. Cell 44:959, 1986.
tation? 8. Babbit, BP, et al: Binding of immunogenic peptides to Ia histo-
a. No HLAs are present on cardiac cells compatibility molecules. Nature 317:359, 1985.
b. No donors ever have HLA antibodies 9. Little, AM, and Parham, P: Polymorphism and evolution of
c. Total ischemic time is too long HLA class I and II genes and molecules. Rev Immunogenet
1:105, 1999.
d. Total ischemic time is too short 10. Kohler, G, and Milstein, C: Derivation of specific antibody
6. DR52 molecules are the product of which alleles? producing tissue culture and tumor lines by cell fusion. Eur J
Immunol 6:611, 1976.
a. DRA and DRB1 11. Dausset, J, et al: Un nouvel antigene du systeme HL-A (Hu-1),
b. DRA and DRB3 1’ antigene 15 allelle possible des antigenes 1, 11, 12. Nouv
c. DRA and DRB4 Rev Fr Hematol 8:398, 1968.
d. DRA and DRB5 12. Kissmeyer-Nielsen, F, Svejgaard, A, and Hange, M: Genetics of
the HL-A transplantation system. Nature 291:1116, 1968.
2682_Ch22_495-508 22/05/12 12:04 PM Page 507

Chapter 22 Relationship Testing 507

2. The fifth genetic system tested (D3S1358) represents a(n):

Case 22-2 a. RBC antigen system tested by agglutination
b. RBC enzyme system
A white trio consisting of a mother, child, and alleged
c. DNA polymorphism tested by RFLP
father is tested to establish paternity. The following results
d. STR-DNA polymorphism tested by PCR
are obtained:
3. Among the following statements relating to the inter-
Genetic System Mother Child Alleged Father pretation of these results, choose the one that is true:
ABO A O B a. The alleged father is excluded due to a direct exclusion
MNSs MNs MNs NSs at D3S1358.
D10S28/Hae III 3.34, 2.98 3.34, 4.52 1.95, 4.52 b. The alleged father may be excluded due to an
D2S44/Hae III 3.42, 4.24 2.90, 3.42 2.90, 3.11 inconsistency at D3S1358.
D3S1358 15, 16 15, 17 14, 18 c. A mutation may have occurred at D3S1358.
FGA 21, 22 22, 25 20, 25 d. The alleged father is excluded due to a direct exclu-
TH01 6, 9.3 9, 9.3 7, 9 sion in the ABO system.
1. The fourth genetic system tested (D2S44/Hae III)
represents a(n):
a. RBC antigen system tested by agglutination
b. RBC enzyme system
c. DNA polymorphism tested by RFLP
d. STR-DNA polymorphism tested by PCR

SUMMARY CHART
Relationship (parentage testing) refers to the testing of STR present on the Y chromosome can verify only
genetic markers that are inherited to determine the male lineage.
presence or absence of a biological relationship. Mitochondrial DNA can verify only maternal lineage.
The ultimate goal of relationship (parentage testing) is The term mismatch is used when the bands between
to confirm a specific biological relationship with the the child and the alleged father do not match; a mini-
individual in question, usually a father or a mother or mum of two mismatches is required before an opinion
sometimes a sibling. of nonpaternity (or nonmaternity) is rendered.
The blood group systems used most often in paternity A direct exclusion occurs when a marker is detected
testing are ABO, Rh, MNSs, Kell, Duffy, and Kidd. in the child and is absent in the mother and the alleged
The HLA complex represents the most polymorphic father or when the alleged father’s phenotype demon-
genetic system in the human genome; only antigens strates two markers and the child has neither one
expressed by the A and B loci are considered for of them.
relationship testing with non-DNA-based typing. An indirect exclusion occurs when a single marker is
RFLP refers to polymorphisms of the DNA that can be detected in the child and a different single marker is
detected by restriction enzymes; polymorphisms detected detected in the alleged father.
in relationship testing relate to the presence of VNTR. False direct exclusions can occur as the result of muta-
In PCR, the DNA fragment of interest is amplified in tions that are significant enough to alter the final prod-
amount thousands of times, and the resulting product uct, lack of precursor substance, suppressor activity at
is normally identified directly through fluorescence re- a locus unlinked to the one tested, or chimeric state of
sulting from fluorescently labeled primers incorpo- one of the tested individuals.
rated in the PCR reaction. False indirect exclusions occur secondary to the pres-
STRs have repeats that are 4 to 5 bp long. ence of silent alleles (e.g., Fy).
2682_Ch22_495-508 22/05/12 12:04 PM Page 508

508 PART IV Leukocyte Antigens and Relationship Testing

3. Histocompatibility Testing 1972. Proceedings of the 5th Inter-

Review Questions national Conference. Evian. Munksgaard, Copenhagen, 1973.
4. Jeffreys, AJ, Wilson, B, and Thein, SL: Hypervariable “minisatel-
1. Among the combinations of attributes described below, lite” regions in human DNA. Nature 314:67, 1985.
select the one that would not be suitable for a genetic 5. Brinkman, B, et al: Mutation rate in human microsatellites:
Influence of the structure and length of the tandem repeat.
system used in parentage testing analysis.
Am J Hum Genet 62:1408, 1998.
a. The system has multiple alleles in Hardy-Weinberg 6. Krings, M, et al: Neanderthal DNA sequences and the origin of
equilibrium. modern humans. Cell 90:19, 1997.
b. The system has a high mutation rate. 7. Ivanov, P, et al: Mitochondrial DNA sequence heteroplasmy in
the grand duke of Russia: Giorgig Romanov establishes the
c. Databases of allele frequencies are available for all
authenticity of remains of Tsar Nicholas II. Nat Genet 12:417,
ethnic groups tested by the laboratory. 1996.
d. All systems selected are genetically independent from 8. Edwards, M, and Allen, RW: Characteristics of mutations at the
each other. D5S818 locus studied using a tightly linked marker. Transfusion
44:83–90, 2004.
2. In which of the following genetic systems is the allele 9. Brenner, CH: A note on paternity computation in cases lacking
frequency distribution continuous (not discrete)? a mother. Transfusion 33:51, 1993.
a. DNA polymorphisms by RFLP
b. DNA polymorphisms by PCR Bibliography
c. RBC antigens AABB: Guidance for Standards for Parentage Testing Laboratories,
d. RBC enzymes 5th ed. American Association of Blood Banks, Bethesda, MD,
2002.
3. A false direct exclusion in RBC antigen genetic systems AABB: Standards for Parentage Testing Laboratories, 5th ed. American
can be caused by: Association of Blood Banks, Bethesda, MD, 2001.
Allen, RW, Wallhermfechtel, M, and Miller, WV: The application of
a.A silent allele
restriction fragment length polymorphism mapping to parentage
b.A lack of precursor substance testing. Transfusion 30:552, 1990.
c.An alternate untested allele Annual report summary for relationship testing laboratories. American
d.Weak reagents Association of Blood Banks, 2008. Available at www.aabb.org/sa/
facilities/Documents/rtannrpt08.pdf.
4. Among the following organizations, which one offers an Brinkmann, B, Klintschar, M, Neuhuber, F, Huhne, J, and Rolf, B:
accreditation program for parentage testing laboratories? Mutation rate in human microsatellites: Influence of the
structure and length of the tandem repeat. Am J Hum Genet
a. AABB
62:1408–1415, 1998.
b. ASCP Committee on DNA Forensic Science: The Evaluation of Foren-
c. FDA sic DNA Evidence: An Update. National Academic Press,
d. HCFA Washington, DC, 1996, pp 53–54.
Edwards, M, and Allen, RW: Characteristics of mutations at the
D5S818 locus studied using a tightly linked marker. Transfusion
References
44:83–90, 2004.
1. Bernstein, F: Ergebnisse einer biostatischen zusammenfassenden Polesky, HF: Parentage testing: Use of DNA polymorphisms and
Betrachtung über die erblichen Blutstrukturen des Menschen. other genetic systems. In Henry, JB (ed): Clinical Diagnosis and
Klin Wschr 3:1495, 1924. Management by Laboratory Methods, 20th ed. WB Saunders,
2. Smithies, O: Zone electrophoresis in starch gels: Group varia- Philadelphia, 2001, pp 1390–1401.
tions in the serum proteins of normal human adults. Biochem J Walker, RH: Molecular biology in paternity testing. Lab Med
61:629, 1955. 23:752, 1992.
2682_Ch23_509-525 22/05/12 12:04 PM Page 524

524 PART V Quality and Compliance Issues

SUMMARY CHART
Blood bank compliance with federal regulations and cGMP requires that facilities design their processes
accreditation requirements is mandated by the FDA, and procedures to ensure that blood components are
the Joint Commission, the AABB, and the CAP. manufactured consistently to meet the quality standards
Compliance inspections measure the state of the facility’s appropriate for their intended use.
program with respect to the applicable requirements at Process validation challenges all activities in a new
a single point in time and are usually conducted every 1 process before implementation to provide a high degree
to 2 years. of assurance that the process will work as intended.
Quality control procedures in blood banking may Routine QC procedures, review of records, and capture
include daily testing of the reactivity of blood typing of nonconformances when the process did not perform
reagents, positive and negative controls in infectious as expected are routine process control measures that
disease testing, calibration of serologic centrifuges, and monitor whether a process is functioning as needed.
temperature monitoring of refrigerators, freezers, and Nonconformance management is a name for processes
thawing devices. that detect, report, evaluate, and correct events in
Quality assurance is a set of planned actions to provide blood bank operations that do not meet the facility’s
confidence that processes and activities that influence or other requirements.
the quality of the product or service are working as An internal audit reviews a specific facility process and
expected individually and collectively. determines—by examining documents and records,
A QMS provides a framework for uniformly applying interviews, and observations—whether the facility is
quality principles and practices across all blood bank meeting applicable requirements and its own policies,
operations, starting with donor selection and proceeding processes, and procedures.
through transfusion outcomes. A process improvement team is a group of people
Process control is a set of activities that ensures a given who represent different activities in a given process
process will keep operating in a state that is continuously and who have been brought together to identify and
able to meet process goals without compromising the implement ways to solve process problems.
process itself.

5. Which one statement below is correct?

Review Questions
a. A process describes how to perform a task.
1. A QMS is: b. A procedure simply states what the facility will do.
c. A procedure informs the reader how to perform a task.
a. Synonymous with compliance.
d. A policy can be flowcharted.
b. Active and continuous.
c. Part of quality control. 6. A blank form is a:
d. An evaluation of efficiency. a. Record.
2. QSEs are applied to: b. Procedure.
c. Flowchart.
a. Just the blood bank’s management staff.
d. Document.
b. Blood bank quality control activities.
c. Only blood component manufacturing. 7. An example of a remedial action is:
d. The blood bank’s path of workflow. a. Applying the problem-solving process.
3. cGMP refers to: b. Starting a process improvement team.
c. Resolving the immediate problem.
a. Regulations pertaining to laboratory safety.
d. Performing an internal audit.
b. Validation of testing.
c. Nonconformance reporting. 8. The PDCA cycle is used for:
d. Manufacturing blood components. a. Problem resolution.
4. Internal and external failure costs are: b. Process control.
c. Validation.
a. Readily identifiable in facility reports.
d. Auditing.
b. Controlled through prevention and appraisal.
c. Built into the facility’s operating budget.
d. Part of prevention and appraisal.
2682_Ch23_509-525 22/05/12 12:04 PM Page 525

Chapter 23 Quality Management 525

9. The difference between the blood bank and laboratory 9. American Association of Blood Banks: Technical Manual, 16th
QMSs is that: ed. Bethesda, MD, 2008.
10. Food and Drug Administration, Center for Biologics Evalua-
a. The laboratory has a different path of workflow. tion and Research: Guideline on Quality Assurance in Blood
b. The blood bank does not include computer systems. Establishments (Docket No. 91N-0450). Food and Drug
c. The QSEs are different. Administration, Rockville, MD, 1995.
d. The blood bank excludes testing. 11. Department of Health and Human Services: Code of Federal
Regulations, Title 45, Parts 160 and 164. U.S. Government
10. The QSEs for the blood bank QMS can be used for the Printing Office, Washington DC, revised annually.
laboratory because: 12. Centers for Medicare and Medicaid Services: Code of Federal
Regulations, Title 42, Parts 430 to end. U.S. Government
a. The paths of workflow are identical. Printing Office, Washington, DC, revised annually.
b. Both the laboratory and blood bank experience 13. Scholtes, PR, et al: The Team Handbook, 3rd ed. Goal-QPC,
accreditation inspections. Salem, MA, 2003.
c. The QSEs are universal. 14. McCloskey, LA, and Collet, DN: TQM: A Primer Guide to Total
Quality Management. GOAL/QPC, Methuen, MA, 1993.
d. The QSEs are required by international standards.
15. International Organization for Standardization: ISO 9001:2008
Quality management systems—Requirements. International
References Organization for Standardization, Geneva, 2008.
16. International Organization for Standardization: ISO 15189:2007
1. Food and Drug Administration, Center for Biologics Evaluation
Medical laboratories—Particular requirements for quality and
and Research: Guideline on General Principles of Process Vali-
competence. International Organization for Standardization,
dation. Food and Drug Administration, Rockville, MD, 2011.
Geneva, 2007.
2. Food and Drug Administration, Department of Health and
17. Clinical and Laboratory Standards Institute: A Quality Man-
Human Services: Code of Federal Regulations, Title 21, Parts
agement System Model for Laboratory Services; Approved
200–299. U.S. Government Printing Office, Washington, DC,
Guideline, GP26, 4th ed. Wayne, PA, 2011.
revised annually.
18. Campanella, J (ed): Principles of Quality Costs: Principles,
3. Food and Drug Administration, Department of Health and
Implementation, and Use, 3rd ed. American Society for Quality
Human Services: Code of Federal Regulations, Title 21, Parts
Press, Milwaukee, WI, 1999.
600–799. U.S. Government Printing Office, Washington, DC,
revised annually.
4. The Joint Commission: Comprehensive Accreditation Manual Bibliography
for Hospitals. Joint Commission Resources, Oakbrook Terrace,
Berte, LM (ed): Transfusion Service Manual of SOPs, Training
IL, 2010.
Guides and Competence Assessment Tools, 2nd ed. American
5. The Joint Commission: Comprehensive Accreditation Manual
Association of Blood Banks, Bethesda, MD, 2007.
for Laboratories and Point-of-care Testing. Joint Commission
Clinical and Laboratory Standards Institute: Training and Competence
Resources, Oakbrook Terrace, IL, 2010.
Assessment, 3rd ed. Approved guideline GP21-A3. Clinical and
6. College of American Pathologists: Inspection Checklists for
Laboratory Standards Institute, Wayne, PA, 2009.
Laboratory Accreditation. College of American Pathologists,
Laboratory Documents: Development and Control. Approved
Northfield, IL, 2010.
guideline GP2A-5. CLSI, Wayne, PA, 2006.
7. American Association of Blood Banks: Standards for Blood Banks
Tague, NR: The Quality Toolbox, 2nd ed. ASQC Press, Milwaukee,
and Transfusion Services, 27th ed. American Association of
2005.
Blood Banks, Bethesda, MD, 2011.
8. International Organization for Standardization: ISO 9000:2005
Quality management systems—Fundamentals and vocabulary.
International Organization for Standardization, Geneva, 2005.
2682_Ch26_556-570 22/05/12 12:06 PM Page 567

Chapter 26 Laboratory Information Systems 567

offer challenges to the system. The goal is to make sure that involves pushing the system to its physical limits. This might
the system repeatedly performs intended functions and does be accomplished by allowing large volumes of data to be en-
not perform unintended functions. The types of testing that tered into the system via all available input devices.
should be performed are: Not every type of test case may be appropriate for each
function to be tested. For example, boundary test cases will
• Normal testing
probably not be applicable in a donor registration function.
• Boundary testing
Another kind of validation testing is parallel testing. This
• Invalid test cases
involves running two systems in parallel and comparing the
• Special test cases
outputs of both. For a blood bank switching from a manual
• Stress testing
to a computerized system, every procedure would be per-
Normal testing uses typical blood bank inputs to produce formed manually and in the computer.
normal, or routine, outputs. Boundary testing involves Validating a blood bank information system is a very
forcing the system to evaluate data that are slightly below or lengthy and labor-intensive process, but it provides great
slightly above valid ranges. This kind of testing might be benefits if undertaken in a thorough manner. Extensive test-
used for disease test results. Invalid test cases assess the ing will identify potential problems in the way that the blood
system’s ability to recognize and reject incorrect inputs. Exam- bank intends to use the system. Sometimes workarounds
ples of invalid inputs include entering Q for an ABO inter- have to be created, but when it is done as part of validation
pretation or entering a blood product code that has not been testing, staff members can be properly trained before going
defined in the static database file. Special test cases are those “live” on the new system or software. The creation and
that make the system react to unusual inputs. A special performance of comprehensive and detailed validation test
case could be designed to see how the system responds when cases require allocation of significant resources to the project,
more than one person attempts to add or edit special trans- but the end result—a well-validated blood bank information
fusion instructions in the same patient’s record. Stress testing system—is worth the resource costs.

SUMMARY CHART
Blood bank information systems assist in the manage- A blood bank information system can have numerous
ment of data and can allow tracing of a blood component specific applications related to the management of
through all processing steps from donation through donors, patients, and blood components.
transfusion (final disposition). User codes and passwords prevent unauthorized use
A computer system is composed of three main compo- of the system and provide a means for capturing the
nents: hardware, software, and people. identity of each person who performs a task on the
Hardware components perform functions related to information system.
input and output, processing, and storage of data. Control functions assist in making decisions at critical
Software tells the computer what to do with the infor- points in the selection of donors and release of blood
mation it has received. components for transfusion.
Application software allows users to perform tasks that When results must be corrected or amended, they
are specific to blood bank operations. must be clearly designated as such on printed reports
Donor, patient, and blood component information is and monitor displays used by patient caregivers.
maintained in databases, which are divided into files A blood bank must have documented evidence of val-
and further subdivided into individual records. idation of its system as well as written procedures for
Static database files define the terminology that the all aspects of system management in order to comply
blood bank will use and provide a dictionary of coded with regulatory and accreditation requirements.
terms that the system can use to sort data. Blood bank SOPs must address computer tasks related
Operating system software controls the hardware, to blood bank technical duties and must address
manipulates the application software, and coordi- computer-specific procedures such as computer down-
nates the flow of information between the disks and time, backup of software programs and data, system
memory. maintenance, security, error management, and person-
nel training.
The system manager oversees the maintenance of the
system’s hardware and software, including adding or On-site software validation must provide documented
deleting items from the static database files, assigning evidence that provides a high degree of assurance that
access codes to new users, implementing software up- the system will function consistently as expected
grades from the vendor, and investigating and reporting under the unique combination of hardware, databases,
problems encountered by the users. environment, SOPs, and people at the site.
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568 PART V Quality and Compliance Issues

7. Preventing the issue of an incompatible blood compo-

Review Questions
nent is an example of:
1. Components of an information system consist of all of a. Inventory management.
the following except: b. Utilization review.
c. System security.
a. Hardware
d. Control function.
b. Software
c. Validation 8. Information is stored in a collection of many different
d. People files called the:
2. To be in compliance with regulatory and accreditation a. Database.
agency requirements for blood bank information systems, b. Configuration.
blood banks must maintain SOPs for all of the following c. Hardware.
except: d. Disk drive.
a. Vendor validation testing 9. Application software communicates with this type of
b. Computer downtime software to retrieve data from the system disks:
c. System maintenance a. Interface
d. Personnel training b. Operating system
3. A validation test case that assesses the system’s ability to c. Security
recognize an erroneous input is called: d. Program
a. Normal 10. Validation testing for software should consider all of the
b. Boundary following items except:
c. Stress a. Data entry methods
d. Invalid b. Control functions
4. An example of interface software functionality is: c. Performance of testing in production database
d. Invalid data
a. The entry of blood components into the blood bank
database 11. Complete the truth table below for a negative antibody
b. The transmission of patient information from the HIS screen using two screening cells (SCI, SCII) at the
into the blood bank system immediate spin (IS), 37°C (37), and antihuman globulin
c. The printing of a workload report (AHG) phases.
d. Preventing access to the system by an unauthorized
user Phase SCI SCII Interpretation
5. Backup copies of the information system: IS
a. Can be used to restore the information system data and
0 0 Negative
software if the production system is damaged. 37°C 0 0
b. Are used to maintain hardware components.
c. Are performed once a month.
AHG 0 0
d. Are created any time changes are made to the system. CC + +
6. User passwords should be:
a. Shared with others.
b. Kept confidential.
c. Posted at each terminal.
d. Never changed.
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Chapter 26 Laboratory Information Systems 569

12. During validation testing, a computer user entered the 3. The computer will beep and display **Unit Has Been
following results for an antibody screen test: Transfused** when a blood component that has already
been transfused is entered.
SCI IS 37 AHG CC Interpretation 4. The Transfusion History screen display will indicate the
patient has been transfused and will display the date of
Result 0 0 0 + Negative the last transfusion.
After the user verified the entries, the monitor displayed 5. Printed reports will indicate relevant units were
the following message: “Invalid test results.” What assigned transfused status
caused the error message to display? Test Cases
Name of Section C. ________________________________
a. An invalid entry was made in the check cells (CC) Section D
column. 1. Attempt to assign transfused status to the following
b. The truth table was set up incorrectly.
units:
c. The interpretation does not correlate with the test
a. Quarantined blood component
entries. b. Selected (but not issued) blood component
d. The interface to the laboratory computer system is
c. Transfused blood component
down. 2. Selection of units from issued inventory list
13. The following test plan has been created to validate 3. Manual entry of issued blood components
the blood bank computer function used to update the Data Entry Methods
Name of Section D. ________________________________
status of blood units that have been transfused. The Section E
test plan contains each of the sections, lettered A through
1. Operator will input blood component information and
H, required for a thorough test plan. Evaluate each sec-
select blood components.
tion and, using the list below, assign a name to each
2. Operator will input selected patient information.
section.
3. Blood bank computer will update the patient and unit
Section Names record.
• Acceptance • Data entry methods Documentation Methods
Name of Section E. ________________________________
• Acceptance criteria • Documentation methods
Section F
• Control functions • Result review
• Test cases The following screen displays and printed reports will be
• Corrective action
verified for accuracy:
Test Plan Function: Assigning Transfused Status Screen Displays Printed Reports
Section A Patient Information Patient History Report
Description: This function is used to change the status of Unit Information Transfusion Listing
issued units to a transfused status. All records pertaining Unit History
to the unit and patient will be updated: Transfusion History
Control Functions
Name of Section A. ________________________________ Result Review
Name of Section F. _________________________________
Section B Section G
1. Preventing the assignment of transfused status to a The acceptability of the results of each test case will be
quarantined blood unit. determined by the blood bank manager and documented
2. Preventing the assignment of transfused status to a on the validation documentation form.
blood unit that has already been transfused. Corrective Action
Name of Section G. ________________________________
3. Preventing the assignment of transfused status to a Section H
blood component that has not been issued. If the software does not perform as expected, the problem
Acceptance Criteria
Name of Section B. ________________________________ must be recorded on a computer problem report and the
Section C supervisor alerted. A remedial action plan will be devised
1. The computer will beep and display **Unit Has Not with the assistance of the blood bank computer system
Been Issued** when a blood unit number that has not vendor.
been issued is entered. Acceptance
Name of Section H. ________________________________
2. The computer will beep and display **Unit Is in Blood bank director signature:____ Date:_____________
Quarantined Status** when a blood component that Comments: _____________________________________
is in quarantine status is entered.