COMPREHENSIVE REVIEW NOTES AND Q&A GUIDE

(made for: PAMET-PASMETH INTERSCHOOL QUIZ SHOW Review)

Compiled by: RAC

IMMUNOHEMATOLOGY (Harmening 6th ed.)

CHAPTER 1
Each unit of whole blood collected contains approximately 450 mL of blood and 63 mL of anticoagulant preservative solution or
approximately 500 mL of blood and 70 mL of anticoagulant-preservative solution.
A donor can give blood every 8 weeks.
As of 2011, samples from donors of each unit of donated blood are tested by 10 screening tests for infectious diseases markers.
Glycolysis generates approximately 90% of the ATP needed by RBCs, and 10% is provided by the pentose phosphate pathway.
Seventy-five percent post-transfusion survival of RBCs is necessary for a successful transfusion.
ACD, CPD, and CP2D are approved preservative solutions for storage of RBCs at 1°C to 6°C for 21 days, and CPDA-1 is approved for 35 days.
Additive solutions (Adsol, Nutricel, Optisol) are approved in the United States for RBC storage for 42 days. Additive-solution RBCs have
been shown to be appropriate for neonates and pediatric patients.
RBCs have been traditionally glycerolized and frozen within 6 days of whole blood collection in CPD or CPDA-1 and can be stored for 10
years from the date of freezing.
Rejuvesol is the only FDA-approved rejuvenation solution used in some blood centers to regenerate ATP and 2,3-DPG levels before RBC
freezing.
Rejuvenation is used primarily to salvage O-type and rare RBC units that are at outdate or with specific anticoagulant-preservative
solution up to 3 days past outdate.
A platelet concentrate should contain a minimum of 5.5 1010platelets (in 90% of the sampled units according to AABB standards) in a
volume routinely between 45 and 65 mL that is sufficient to maintain a pH of 6.2 or greater at the conclusion of the 5-day storage period.
When platelet concentrates (usually 4 to 6) are pooled using an open system, the storage time changes to 4 hours. A new method of
pooling that uses a closed system allows the pool to be stored for 5 days from the date of collection.
Apheresis components contain 4 to 6 times as many platelets as a PC prepared from whole blood. They should contain a minimum of 3.0
x 1011 platelets (in 90% of the sampled units).
Platelet components are stored for up to 5 days at 20°C to 24°C with continuous agitation. When necessary, as during shipping, platelets
can be stored without continuous agitation for up to 24 hours (at 20°C to 24°C) during a 5-day storage period. Platelets are rarely stored
at 1°C to 6°C.
If a platelet bag is broken or opened, the platelets must be transfused within 4 hours when stored at 20°C to 24°C.
Self-Assessment Questions
1. What is the maximum volume of blood that can be collected from a 110-lb donor, including samples for processing?
a. 450 mL c. 525 mL
b. 500 mL d. 550 mL
2. How often can a blood donor donate whole blood?
a. Every 24 hours c. Every 8 weeks
b. Once a month d. Twice a year
3. When RBCs are stored, there is a “shift to the left.” This means:
a. Hemoglobin oxygen affinity increases, owing to an increase in 2,3-DPG.
b. Hemoglobin oxygen affinity increases, owing to a decrease in 2,3-DPG.
c. Hemoglobin oxygen affinity decreases, owing to a decrease in 2,3-DPG.
d. Hemoglobin oxygen affinity decreases, owing to an increase in 2,3-DPG.
4. The majority of platelets transfused in the United States today are:
a. Whole blood–derived platelets prepared by the platelet-rich plasma method.
b. Whole blood–derived platelets prepared by the buffy coat method.
c. Apheresis platelets.
d. Prestorage pooled platelets.
5. Which of the following anticoagulant preservatives provides a storage time of 35 days at 1°C to 6°C for units of whole blood and
prepared RBCs if an additive solution is not added?
a. ACD-A c. CPD
b. CP2D d. CPDA-1
6. What are the current storage time and storage temperature for platelet concentrates and apheresis platelet components?
a. 5 days at 1°C to 6°C c. 5 days at 20°C to 24°C
b. 5 days at 24°C to 27°C d. 7 days at 22°C to 24°C
7. What is the minimum number of platelets required in a platelet concentrate prepared from whole blood by centrifugation (90% of
sampled units)?
a. 5.5 x 1011 c. 3 x 1011
10
b. 3 x 10 d. 5.5 x 1010
8. RBCs can be frozen for:
a. 12 months. c. 5 years.
b. 1 year. d. 10 years.
 9. What is the minimum number of platelets required in an apheresis component (90% of the sampled units)?
a. 3 x 1011 c. 4 x 1011
11
b. 4 x 10 d. 3.5 x 1011
10. Whole blood and RBC units are stored at what temperature?
a. 1°C to 6°C c. 37°C
b. 20°C to 24°C d. 24°C to 27°C
11. Additive solutions are approved for storage of red blood cells for how many days?
a. 21 c. 35
b. 42 d. 7
12. One criterion used by the FDA for approval of new preservation solutions and storage containers is an average 24-hour post-
transfusion RBC survival of more than:
a. 50%. c. 65%.
b. 60%. d. 75%.
13. What is the lowest allowable pH for a platelet component at outdate?
a. 6 c. 6.8
b. 5.9 d. 6.2
14. Frozen and thawed RBCs processed in an open system can be stored for how many days/hours?
a. 3 days c. 24 hours
b. 6 hours d. 15 days
15. What is the hemoglobin source for hemoglobin-based oxygen carriers in advanced clinical testing?
a. Only bovine hemoglobin
b. Only human hemoglobin
c. Both bovine and human hemoglobins
d. None of the above
16. Which of the following occurs during storage of red blood cells?
a. pH decreases
b. 2,3-DPG increases
c. ATP increases
d. plasma K+ decreases
17. Nucleic acid amplification testing is used to test donor blood for which of the following infectious diseases?
a. Hepatitis C virus
b. Human immunodeficiency virus
c. West Nile virus
d. All of the above
18. Which of the following is NOT an FDA-approved test for quality control of platelets?
a. BacT/ALERT
b. eBDS
c. Gram stain
d. Pan Genera Detection (PGD) test
19. Prestorage pooled platelets can be stored for:
a. 4 hours. c. 5 days
b. 24 hours. d. 7 days
20. Which of the following is the most common cause of bacterial contamination of platelet products?
a. Entry of skin plugs into the collection bag
b. Environmental contamination during processing
c. Bacteremia in the donor
d. Incorrect storage temperature
CHAPTER 3
The immune system interacts with other host systems and maintains the host equilibrium. The two major roles for the IS are:
✓ Protection from pathogens and foreign substances
✓ Removal of abnormal and damaged host cells
The two major branches of the IS are:
✓ Innate, or natural—the nonspecific primitive IS
✓ Acquired, or adaptive—the specific, evolved IS
The basic mechanisms used by the IS are:
✓ Recognition of self and nonself organisms, cells, and tissues
✓ Removal of unwanted organisms, cells, and tissues (self or nonself)
✓ Repair of damaged host tissues
The acquired IS demonstrates diversity and uniqueness:
✓ Individual B and T cells have vast arrays of unique membrane molecules that can have configurations to match nearly any
antigen in the environment.
 ✓ Each individual lymphocyte has one unique receptor per cell that recognizes one epitope.
✓ Antibodies and T-cell receptors recognize and react only with the antigen that matches and fits their specific configuration.
✓ Selected T and B cells can remain dormant and later respond more rigorously upon second exposure of a previously
recognized antigen.
The acquired IS demonstrates tolerance: this indicates that immune responses against the host are either removed or downregulated.
There are three types of lymphocytes: T cells, B cells, and NK cells.
T cells (or lymphocytes) have the TCR, which is usually associated with the CD3 complex, and T cells require APCs to respond to antigens.
There are two well-characterized subpopulations of T cells distinguished by CD markers—T helper (TH, CD4-positive) and T cytotoxic (Tc,
CD8-positive) lymphocytes.
T helper lymphocytes have CD4 markers on their cell membranes, provide B-cell help to stimulate the immune response, release
lymphokines when stimulated, and recognize antigens in association with MHC class II molecules.
TClymphocytes have the CD8 marker on their membranes and can eliminate specific target cells without the help of antibody (cytotoxicity).
B lymphocytes (or cells) make up about 5% to 15% of circulating lymphocytes and are characterized by their membrane-bound antibodies
(or immunoglobulins)
Membrane-bound antibodies are manufactured by B cells and inserted into their cell membranes, where they act as antigen receptors.
Stimulated B cells differentiate into plasma cells to secrete humoral immunoglobulin; B cells receive T-cell help for antibody production
and for immunologic memory; a single B cell clone manufactures Ig of a single specificity for a specific antigen for its entire cell lifetime.
The primary, or original, immune response occurs after the first exposure to an antigen. The secondary, or anamnestic, immune response
happens after a second exposure with the same specific antigen.
Complement consists of a large group of different enzymatic proteins (convertases/esterases) that circulate in an inactive proenzyme
form. Once the cascade is started, they activate each other in a sequence to form products that are involved in optimizing phagocytosis
and cell lysis.
Complement can be activated through three pathways:
✓ The classical pathway is initiated by antigen antibody complexes and requires C1q for activation to proceed.
✓ The alternative pathway is activated by certain macromolecules on the cell walls of bacteria, fungi, parasites, and tumor cells
and requires C3b, serum factors B, D, properdin, and initiating factor.
✓ The lectin pathway is activated by binding of MBL to microbes.
All three pathways meet at a common point in the cascade and result in the formation of the membrane attack complex to remove
unwanted cells.
There are five classes (or isotypes) of immunoglobulins, all of which have a basic four-chain protein structure consisting of two dentical
light chains and two identical heavy chains. Disulfide (covalent) bonds link each light chain to a heavy chain and link the two heavy chains
to each other.
Antibody molecules are isotypic (based on heavy chain subtype), allotypic (based on one heavy chain mutation), or idiotypic (based on
hypervariable and variable regions of light and heavy chains) and are reflected in the Ig sequences.
Blood group antibodies may be characterized by such factors as epitope and variable region diversity (monoclonal or polyclonal), mode
of sensitization (naturally occurring or immune), expected or unexpected presence in routine serum samples, isotype class (IgM, IgG, or,
rarely, IgA), activity (warm or cold reactive or both, agglutinating or sensitizing), clinical significance, alloantibody or autoantibody
specificity, serum titer, and chemical reactivity (influence of enzymes, sensitivity to pH, DTT, or 2-ME reagents).
Self-Assessment Questions
1. Which of the following is not involved in the acquired or adaptive immune response?
a. Phagocytosis
b. Production of antibody or complement
c. Induction of immunologic memory
d. Accelerated immune response upon subsequent exposure to antigen
2. Which cells are involved in the production of antibodies?
a. Dendritic cells
b. T lymphocytes
c. B lymphocytes
d. Macrophages
3. Which of the following cells is involved in antigen recognition following phagocytosis?
a. B lymphocytes
b. T lymphocytes
c. Macrophages
d. Granulocytes
4. The role of the macrophage during an antibody response is to:
a. Make antibody
b. Lyse virus-infected target cells
c. Activate cytotoxic T cells
d. Process antigen and present it
5. Which of the following immunoglobulins is produced in the primary immune response?
 a. IgA
b. IgE
c. IgG
d. IgM
6. Which of the following immunoglobulins is produced in the secondary immune response?
a. IgA
b. IgE
c. IgG
d. IgM
7. Which of the following MHC classes are found on antigen presenting cells?
a. Class I
b. Class II
c. Class III
d. Class IV
8. Which of the following MHC classes encodes complement components?
a. Class I
b. Class II
c. Class III
d. Class IV
9. Which of the following immunoglobulins is most efficient at binding complement?
a. IgA
b. IgE
c. IgG
d. IgM
10. Which portion of the immunoglobulin molecules contains complement binding sites?
a. Heavy chain variable region
b. Light chain variable region
c. Heavy chain constant region
d. Light chain constant region
11. Which complement pathway is activated by the formation of antigen-antibody complexes?
a. Classical
b. Alternative
c. Lectin
d. Retro
12. Which of the following is known as the “recognition unit” in the classical complement pathway?
a. C1q
b. C3a
c. C4
d. C5
13. Which of the following is known as the “membrane attack complex” in the classical complement pathway?
a. C1
b. C3
c. C4, C2, C3
d. C5b, C6, C7, C8, C9
14. Which of the following immunoglobulin classes is capable of crossing the placenta and causing hemolytic disease of the newborn?
a. IgA
b. IgE
c. IgG
d. IgM
15. Which of the following refers to the effect of an excess amount of antigen present in a test system?
a. Postzone
b. Prozone
c. Zone of equivalence
d. Endzone
16. Which of the following refers to the presence of an excess amount of antibody present in a test system?
a. Postzone
b. Prozone
c. Zone of equivalence
d. Endzone
17. Which of the following refers to a state of equilibrium in antigen-antibody reactions?
a. Postzone
 b. Prozone
c. Zone of equivalence
d. Endzone
18. Which one of the following properties of antibodies is NOT dependent on the structure of the heavy chain constant region?
a. Ability to cross the placenta
b. Isotype (class)
c. Ability to fix complement
d. Affinity for antigen
19. Molecules that promote the update of bacteria for phagocytosis are:
a. Opsonins
b. Cytokines
c. Haptens
d. Isotypes
20. Select the term that describes the unique confirmation of the antigen that allows recognition by a corresponding antibody:
a. Immunogen
b. Epitope
c. Avidity
d. Clone
21. Which of the following terms refers to the net negative charge surrounding red blood cells?
a. Dielectric constant
b. Van der Waals forces
c. Hydrogen bonding
d. Zeta potential
Chapter 4
Self-Assessment Questions
1. The central dogma of molecular biology states that:
a. DNA is the genetic material
b. RNA is the genetic material
c. DNA is translated to mRNA
d. Proteins are transcribed from mRNA
2. Recombinant-DNA technology is possible because:
a. Restriction endonucleases cut RNA
b. Restriction endonucleases cut proteins
c. The genetic code is universal
d. Bacteria are difficult to culture
3. Agarose gel electrophoresis is a technique used for:
a. DNA synthesis
b. RNA synthesis
c. Separation of DNA molecules by size
d. Oligonucleotide synthesis
4. Restriction fragment length polymorphism (RFLP) is based on the use of the enzymes:
a. Reverse transcriptases
b. Bacterial endonucleases
c. DNA polymerases
d. RNA polymerases
5. The polymerase chain reaction (PCR):
a. Is carried out in vivo
b. Is used for peptide synthesis
c. Requires RNA polymerase
d. Is used for the amplification of DNA
6. Plasmids are:
a. Vectors used for molecular cloning
b. Antibiotics
c. Enzymes
d. Part of chromosomes
7. Some model organisms:
a. Simplify the study of human disease
b. Are used to produce recombinant proteins
c. Are prokaryotes and some are eukaryotes
d. All of the above
8. DNA sequencing:
 a. Is more difficult than peptide sequencing
b. Requires the use of RNA polymerase
c. Can never be automated
d. Is an enzymatic in vitro reaction
9. RFLP and SSP are techniques used for:
a. Protein isolation
b. RNA isolation
c. DNA typing
d. Protein typing
10. Recombinant DNA techniques:
a. Are not used in a clinical setting
b. Are useful research tools
c. Are not used in blood banking
d. Are useful only for research
11. Transcription mediated amplification:
a. Requires thermostable DNA polymerase
b. Is an isothermal procedure
c. Is an obsolete method currently replaced by SSOP
d. Utilizes probes labeled with fluorescent tags
12. Preseroconversion window:
a. Is the time when donors can be infected but do not yet test positive by serologic methods
b. May be narrowed by using molecular methods
c. Refers mainly to viral pathogens
d. All of the above
13. Red blood cell molecular antigen typing is useful in all listed situations except:
a. In screening RBC inventory for antigen-negative units
b. When reagent antibodies are weak or unavailable
c. In quantitative gene expression analysis
d. When resolving ABO discrepancies
Chapter 5
The antiglobulin test is used to detect RBCs sensitized by IgG alloantibodies, IgG autoantibodies, and complement components.
AHG reagents containing anti-IgG are needed for the detection of IgG antibodies because the IgG monomeric structure is too small to
directly agglutinate sensitized RBCs.
Polyspecific AHG sera contain antibodies to human IgG and the C3d component of human complement.
Monospecific AHG sera contain only one antibody specificity: either anti-IgG or antibody to anti–C3b-C3d.
Classic AHG sera (polyclonal) are prepared by injecting human globulins into rabbits, and an immune stimulus triggers production of
antibody to human serum.
Hybridoma technology is used to produce monoclonal antiglobulin serum.
The DAT detects in vivo sensitization of RBCs with IgG or complement components. Clinical conditions that can result in a positive DAT
include HDN, HTR, and AIHA.
The IAT detects in vitro sensitization of RBCs and can be applied to compatibility testing, antibody screen, antibody identification, RBC
phenotyping, and titration studies.
A positive DAT is followed by a DAT panel using monospecific anti-IgG and anti-C3d to determine the specific type of protein sensitizing
the RBC.
EDTA should be used to collect blood samples for the DAT to avoid in vitro complement attachment associated with refrigerated clotted
specimens.
There are multiple sources or error that can be introduced into the AHG procedure.
LISS, PEG, polybrene, and albumin can all be used as enhancement media for AHG testing, with each having their own advantages and
disadvantages.
Conventional tube testing, gel technology, enzym-linked technology, and solid-phase testing are available methods to use in AHG testing.
Method-dependent antibodies do exist and should be evaluated on a case-by-case basis.
Self-Assessment Questions
1. A principle of the antiglobulin test is:
a. IgG and C3d are required for RBC sensitization.
b. Human globulin is eluted from RBCs during saline washings.
c. Injection of human globulin into an animal engenders passive immunity.
d. AHG reacts with human globulin molecules bound to RBCs or free in serum.
2. Polyspecific AHG reagent contains:
a. Anti-IgG.
b. Anti-IgG and anti-IgM.
 c. Anti-IgG and anti-C3d.
d. Anti-C3d.
3. Monoclonal anti-C3d is:
a. Derived from one clone of plasma cells.
b. Derived from multiple clones of plasma cells.
c. Derived from immunization of rabbits.
d. Reactive with C3b and C3d.
4. Which of the following is a clinically significant antibody whose detection has been reported in some instances to be dependent on
anticomplement activity in polyspecific AHG?
a. Anti-Jka
b. Anti-Lea
c. Anti-P1
d. Anti-H
5. After the addition of IgG-coated RBCs (check cells) to a negative AHG reaction during an antibody screen, a negative result is observed.
Which of the following is a correct interpretation?
a. The antibody screen is negative.
b. The antibody screen needs to be repeated.
c. The saline washings were adequate.
d. Reactive AHG reagent was added.
6. RBCs must be washed in saline at least three times before the addition of AHG reagent to:
a. Wash away any hemolyzed cells
b. Remove traces of free serum globulins
c. Neutralize any excess AHG reagent
d. Increase the antibody binding to antigen
7. An in vitro phenomenon associated with a positive IAT is:
a. Maternal antibody coating fetal RBCs
b. Patient antibody coating patient RBCs
c. Recipient antibody coating transfused donor RBCs
d. Identification of alloantibody specificity using a panel of reagent RBCs
8. False-positive DAT results are most often associated with:
a. Use of refrigerated, clotted blood samples in which complement components coat RBCs in vitro.
b. A recipient of a recent transfusion manifesting an immune response to recently transfused RBCs.
c. Presence of heterophile antibodies from administration of globulin.
d. A positive autocontrol caused by polyagglutination.
9. Polyethylene glycol enhances antigen-antibody reactions by:
a. Decreasing zeta potential.
b. Concentrating antibody by removing water.
c. Increasing antibody affinity for antigen.
d. Increasing antibody specificity for antigen.
10. Solid-phase antibody screening is based on:
a. Adherence.
b. Agglutination.
c. Hemolysis.
d. Precipitation.
11. A positive DAT may be found in which of the following situations?
a. A weak D-positive patient
b. A patient with anti-K
c. HDN
d. An incompatible crossmatch
12. What do Coombs’ control cells consist of?
a. Type A-positive cells coated with anti-D
b. Type A-negative cells coated with anti-D
c. Type O-positive cells coated with anti-D
d. Type O-negative cells coated with anti-D
13. Which of the following methods requires the use of check cells?
a. LISS
b. Gel
c. Solid-phase
d. Enzyme-linked
14. Which factor can affect AHG testing, yet is uncontrollable in the lab?
a. Temperature
 b. Antibody affinity
c. Gravitational force in the centrifuge
d. Incubation time
15. If you had the authority to decide which primary AHG methodology to utilize at your lab, which method would you choose based on the
knowledge that the majority of the staff are generalists?
a. LISS
b. Polybrene
c. Solid phase or gel
d. Enzyme-linked
16. A 27-year-old group O mother has just given birth to a beautiful, group A baby girl. Since the mother has IgG anti-A in her plasma, it is
likely that the baby is experiencing some in vivo red cell destruction. Which of the following methods and tests would be most effective
at detecting the anti-A on the baby’s RBCs?
a. DAT using common tube technique
b. DAT using gel
c. IAT using common tube technique
d. IAT using gel
Chapter 6
ABO frequencies: group O, 45%; group A, 40%; group B, 11%; group AB, 4%.
ABO blood group system has naturally occurring antibodies that are primarily IgM.
ABO genes, like those of most other blood groups, are inherited in a codominant manner.
ABH-soluble antigens are secreted by tissue cells and are found in all body secretions. The antigens secreted depend on the person’s ABO
group.
ABO reverse grouping is omitted from cord blood testing on newborns, because their antibody titer levels are generally too low for
detection.
ABO RBC antigens can be glycolipids, glycoproteins, or glycosphingolipids; ABO-secreted substances are glycoproteins.
L-fucose is the immunodominant sugar responsible for H specificity.
N-acetylgalactosamine is the immunodominant sugar responsible for A specificity.
D-galactose is the immunodominant sugar responsible for B specificity.
The hhgenotype is known as the Bombay phenotype, or Oh, and lacks normal expression of the ABH antigens
Group O persons have the greatest amount of H substance; group A1B persons contain the least amount of H substance.
Approximately 80% of the individuals inherit the A gene phenotype as A1; the remaining 20% phenotype as A2or weaker subgroups.
Approximately 1% to 8% of A2persons produce anti A1 in their serum.
Glycoproteins in secretions are formed on type 1 precursor chains.
The ABH antigens on RBCs are formed on type 2 precursor chains.
Forward and reverse grouping normally yield strong (3+ to 4+) reactions.
Group A persons have anti-B in their serum; group B persons have anti-A in their serum; group AB persons have neither anti-A nor anti-
B in their serum; group O persons contain both anti-A and anti-B in their serum.
Approximately 78% of the random population inherit the Se gene and are termed secretors; the remaining 22% inherit the se gene and
are termed nonsecretors.
The Segene codes for the production of L-fucosyltransferase.
Self-Assessment Questions
1. An ABO type on a patient gives the following reactions:

What is the patient’s blood type?

2. The major immunoglobulin class(es) of anti-B in a group A individual is (are):
a. IgM.
b. IgG.
c. IgM and IgG.
d. IgM and IgA.
3. What are the possible ABO phenotypes of the offspring from the mating of a group A to a group B individual?
a. O, A, B
b. A, B
c. A, B, AB
d. O, A, B, AB
4. The immunodominant sugar responsible for blood group A specificity is:
a. L-fucose.
b. N-acetyl-D-galactosamine.
 c. D-galactose.
d. Uridine diphosphate-N-acetyl-D-galactose.
5. What ABH substance(s) would be found in the saliva of a group B secretor?
a. H
b. H and A
c. H and B
d. H, A, and B
6. An ABO type on a patient gives the following reactions:

The reactions above may be seen in a patient who is:

a. A1with acquired B.
b. A2B with anti-A1.
c. AB with increased concentrations of protein in the serum.
d. AB with an autoantibody.
7. Which of the following ABO blood groups contains the least amount of H substance?
a. A1B
b. A2
c. B
d. O
8. You are working on a specimen in the laboratory that you believe to be a Bombay phenotype. Which of the following reactions would you
expect to see?
a. Patient’s cells + Ulex europaeus = no agglutination
b. Patient’s cells + Ulex europaeus = agglutination
c. Patient’s serum + group O donor RBCs = no agglutination
d. Patient’s serum + A1 and B cells = no agglutination
9. An example of a technical error that can result in an ABO discrepancy is:
a. Acquired B phenomenon.
b. Missing isoagglutinins.
c. Cell suspension that is too heavy.
d. Acriflavine antibodies.
10. An ABO type on a patient gives the following reactions:

The results are most likely due to:

a. ABO alloantibody.
b. Non-ABO alloantibody.
c. Rouleaux.
d. Cold autoantibody.
Chapter 7
The Rh antibody was so named on the basis of antibody production by guinea pigs and rabbits when transfused with rhesus monkey RBCs.
Historically, Rh antibodies were a primary cause of HDFN, erythro-blastosis fetalis, and a significant cause of hemolytic transfusion
reactions.
Fisher-Race DCE terminology is based on the theory that antigens of the system are produced by three closely linked sets of alleles and
that each gene is responsible for producing a product (or antigen) on the RBC surface.
It is currently accepted that two closely linked genes on chromosome 1 control the expression of Rh; one gene (RHD) codes for the
presence of RhD, and a second gene (RHCE) codes for the expression of CcEe antigens. These genes interact with the RHAG gene on
chromosome 6 to form Rh antigens.
Rh antigens are characterized as nonglycosylated proteins in the RBC membrane, and do not appear on other tissues or in body fluids.
D antigen is highly immunogenic: exposure to less than 0.1 mL of Rh-positive RBCs can stimulate antibody production in an Rh-negative
person.
The most common phenotype in Caucasians is R1r (31%); the most common phenotype in African Americans is R0r (23%), followed by R0R0
at 19%.
A person who expresses no Rh antigens on the RBC is said to be Rhnull, and the genotype may be written as –––/–––.
 In the Wiener Rh-Hr nomenclature, it is postulated that the gene responsible for defining Rh actually produces an agglutinogen that
contains a series of three blood factors in which each factor is an antigen recognized by an antibody.
In the Rosenfield alpha/numeric terminology, a number is assigned to each antigen of the Rh system in order of its discovery (Rh1 = D, Rh2
= C, Rh3 = E, Rh4 = c, Rh5 = e).
The Rh antigens are inherited as codominant alleles.
A partial-D individual is characterized as lacking one or more pieces or epitopes of the total D antigen and may produce an alloantibody
to the missing fraction if exposed to RBCs with the complete D antigen.
Blood donor units for transfusion are considered Rh-positive if either the D or weak D test is positive; if both the D and weak D tests are
negative, blood for transfusion is considered Rh-negative.
Rh antibodies are IgG and can cross the placenta to coat fetal (Rh-positive) RBCs.
Rh-mediated hemolytic transfusion reactions usually result in extravascular hemolysis.
Self-Assessment Questions
1. The Rh system genes are:
a. RHD and RHCE.
b. RHD and LW.
c. RHD and RHAG.
d. RHCE and RHAG.
2. What Rh antigen is found in 85% of the Caucasian population and is always significant for transfusion purposes?
a. d
b. c
c. D
d. E
3. How are weaker-than-expected reactions with anti-D typing reagents categorized?
a. Rhmod
b. Weak D
c. DAT positive
d. Dw
4. Cells carrying a weak D antigen require the use of what test to demonstrate its presence?
a. Indirect antiglobulin test
b. Direct antiglobulin test
c. Microplate test
d. Warm autoadsorption test
5. How are Rh antigens inherited?
a. Autosomal recessive alleles
b. Sex-linked genes
c. Codominant alleles
d. X-linked
6. Biochemically speaking, what type of molecules are Rh antigens?
a. Glycophorins
b. Simple sugars
c. Proteins
d. Lipids
7. Rh antibodies react best at what temperature (°C)?
a. 15
b. 18
c. 22
d. 37
8. Rh antibodies are primarily of which immunoglobulin class?
a. IgA
b. IgD
c. IgG
d. IgM
9. Rh antibodies have been associated with which clinical condition?
a. Hemolytic disease of the fetus and newborn
b. Thrombocytopenia
c. Hemophilia A
d. Stomatocytosis
10. What do Rhnull cells lack?
a. Lewis antigens
b. Normal oxygen-carrying capacity
c. Rh antigens
 d. Hemoglobin
11. Convert the following genotypes from Wiener nomenclature to Fisher-Race and Rosenfield nomenclatures, and list the antigens present
in each haplotype.
a. R1r
b. R2R0
c. RzR1
d. rr
12. Which Rh phenotype has the strongest expression of D?
a. DCe/ce
b. DCe/DCe
c. DcE/DcE
d. D-
13. An individual has the following serologic reactions: D+C+E+c+e+f–.
What is the most probable genotype?
a. R1R2
b. Rory
c. Rzr
d. R1r”
14. Which of the following is the most common haplotype in the African American population?
a. DCe
b. DcE
c. Dce
d. ce
15. If a patient who is R1R1 is transfused with RBCs that are Ror, which antibody is he most likely to produce?
a. Anti-D
b. Anti-c
c. Anti-e
d. Anti-G
Chapter 8
Blood Group Technology
The ISBT terminology for RBC surface antigens provides a standardized numeric system for naming authenticated antigens that is
suitable for electronic data-processing equipment. This terminology was not intended to replace conventional terminology.
In the ISBT classification, RBC antigens are assigned a six-digit identification number: the first three digits represent the system,
collection, or series, and the second three digits identify the antigen. All antigens are catalogued into one of the following four groups:
✓ A blood group system if controlled by a single gene locus or by two or more closely linked genes
✓ A collection if shown to share a biochemical, serologic, or genetic relationship
✓ The high-prevalence series (901) if found in more than 90% of most populations
✓ The low-prevalence series (700) if found in less than 1% of most populations
Lewis Blood Group
Lewis blood group antigens are not synthesized by the RBCs. These antigens are adsorbed from plasma onto the RBC membrane.
The Le gene codes for L-fucosyltransferase, which adds L-fucose to type 1 chains.
The Le gene is needed for the expression of Lea substance, and Le and Se genes are needed to form Leb substance.
The lele genotype is more common among blacks than among whites and results in the Le(a–b–) phenotype.
Lewis antigens are poorly expressed at birth.
Lewis antibodies are generally IgM (naturally occurring) made by Le(a–b–) individuals.
Lewis antibodies are frequently encountered in pregnant women.
Lewis antibodies are not considered significant for transfusion medicine.
The P Group
The P blood group consists of the biochemically related antigens P, P1, Pk, PX2, NOR, and LKE.
P1 antigen expression is variable; P1 antigen is poorly developed at birth.
Anti-P1 is a common naturally occurring IgM antibody in the sera of P1– individuals; it is usually a weak, coldreactive saline agglutinin
and can be neutralized with soluble P1 substance found in hydatid cyst fluid.
Anti-PP1Pk is produced by the rare p individuals early in life without RBC sensitization and reacts with all RBCs except those of other p
individuals. Antibodies may be a mixture of IgM and IgG, efficiently bind complement, may demonstrate in vitro hemolysis, and can cause
severe HTRs. Anti-PP1Pk is associated with spontaneous abortions.
Alloanti-P is found as a naturally occurring alloantibody in the sera of Pk individuals and is clinically significant. Anti-P has also been
associated with spontaneous abortion.
Autoanti-P is most often the specificity associated with the cold-reactive IgG autoantibody in patients with paroxysmal cold
hemoglobinuria (PCH).
 The autoanti-P of PCH usually does not react by routine tests but is demonstrable as a biphasic hemolysin only in the Donath-Landsteiner
test.
The I and i Antigens
I and i antigens are not antithetical; they have a reciprocal relationship.
Most adult RBCs are rich in I and have only trace amounts of i antigen.
At birth, infant RBCs are rich in i; I is almost undetectable; over the next 18 months of development, the infant’s RBCs will convert from i
to I antigen.
Anti-I is typically a benign, weak, naturally occurring, saline-reactive IgM autoagglutinin, usually detectable only at 4°C.
Pathogenic anti-I is typically a strong cold autoagglutinin that demonstrates high-titer reactivity at 4°C and reacts over a wide thermal
range (up to 30° to 32°C).
Patients with M. pneumoniae infections may develop strong cold agglutinins with autoanti-I specificity.
Anti-i is a rare IgM agglutinin that reacts optimally at 4°C; potent examples may be associated with infectious mononucleosis.
The MNS Blood Group System
Anti-M and anti-N are cold-reactive saline agglutinins that do not bind complement or react with enzymetreated cells; both anti-M and
anti-N may demonstrate dosage.
Anti-S and anti-s are IgG antibodies, reactive at 37°C and the antiglobulin phase. They may bind complement and have been associated
with HDFN and HTRs.
The S–s–U– phenotype is found in blacks.
Anti-U is usually an IgG antibody and has been associated with HTRs and HDFN.
The Kell Blood Group
The Kell blood group antigens are well developed at birth and are not destroyed by enzymes.
The Kell blood group antigens are destroyed by DTT, ZZAP, and glycine-acid EDTA.
Excluding ABO, the K antigen is rated second only to D antigen in immunogenicity.
The k antigen is high prevalence.
Anti-K is usually an IgG antibody reactive in the antiglobulin phase and is made in response to pregnancy or transfusion of RBCs; it has
been implicated in severe HTRs and HDFN.
The McLeod phenotype, affecting only males, is described as a rare phenotype with decreased Kell system antigen expression. The McLeod
syndrome includes the clinical manifestations of abnormal RBC morphology, compensated hemolytic anemia, and neurological and
muscular abnormalities. Some males with the McLeod phenotype also have the X-linked chronic granulomatous disease.
The Duffy Blood Group System
Fya and Fyb antigens are destroyed by enzymes and ZZAP; they are well developed at birth. The Fy(a–b–) phenotype is prevalent in blacks
but virtually nonexistent in whites.
Fy(a–b–) RBCs resist infection by the malaria organism P. vivax.
Anti-Fya and anti-Fyb are usually IgG antibodies and react optimally at the antiglobulin phase of testing; both antibodies have been
implicated in delayed HTRs and HDFN.
The Kidd Blood Group System
Anti-Jka and anti-Jkb may demonstrate dosage, are often weak, and are found in combination with other antibodies; both are typically IgG
and reactive in the antiglobulin phase of testing.
Kidd system antibodies may bind complement and are made in response to foreign RBC exposure during pregnancy or transfusion.
Kidd system antibodies are a common cause of delayed HTRs.
Kidd system antibody reactivity is enhanced with enzymes, LISS, and PEG.
The Lutheran Blood Group System
Lua and Lub are antigens produced by codominant alleles; they are poorly developed at birth.
Anti-Luamay be a naturally occurring saline agglutinin that reacts optimally at room temperature.
Anti-Lub is usually an IgG antibody reactive at the antiglobulin phase; it is usually produced in response to foreign RBC exposure during
pregnancy or transfusion.
The Lu(a–b–) phenotype is rare and may result from three different genetic backgrounds; only individuals with the recessive type Lu(a–
b–) can make anti-Lu3.
Self-Assessment Questions
1. The following phenotypes are written incorrectly except for:
a. Jka+
b. Jka+
c. Jka(+)
d. Jk(a+)
2. Which of the following characteristics best describes Lewis antibodies?
a. IgM, naturally occurring, cause HDFN
b. IgM, naturally occurring, do not cause HDFN
c. IgG, in vitro hemolysis, cause hemolytic transfusion reactions
d. IgG, in vitro hemolysis, do not cause hemolytic transfusion reactions
3. The Le gene codes for a specific glycosyltransferase that transfers a fucose to the N-acetylglucosamine on:
 a. Type 1 precursor chain
b. Type 2 precursor chain
c. Types 1 and 2 precursor chains
d. Either type 1 or type 2 in any one individual but not both
4. What substances would be found in the saliva of a group B secretor who also has Lele genes?
a. H, Lea
b. H, B, Lea
c. H, B, Lea, Leb
d. H, B, Leb
5. Transformation to Leb phenotype after birth may be as follows:
a. Le(a–b–) to Le(a+b–) to Le(a+b+) to Le(a–b+)
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–)
d. Le(a+b+) to Le(a+b–) to Le(a–b–) to Le(a–b+)
6. In what way do the Lewis antigens change during pregnancy?
a. Lea antigen increases only
b. Leb antigen increases only
c. Lea and Leb both increase
d. Lea and Leb both decrease
7. A type 1 chain has:
a. The terminal galactose in a 1-3 linkage to subterminal N-acetylglucosamine
b. The terminal galactose in a 1-4 linkage to subterminal N-acetylglucosamine
c. The terminal galactose in a 1-3 linkage to subterminal N-acetylgalactosamine
d. The terminal galactose in a 1-4 linkage to subterminal N-acetylgalactosamine
8. Which of the following best describes Lewis antigens?
a. The antigens are integral membrane glycolipids
b. Lea and Leb are antithetical antigens
c. The Le(a+b–) phenotype is found in secretors
d. None of the above
9. Which of the following genotypes would explain RBCs typed as group A Le(a+b–)?
a. A/O Lele HH Sese
b. A/A Lele HH sese
c. A/O LeLe hh SeSe
d. A/A LeLe hh sese
10. Anti-LebH will not react or will react more weakly with which of the following RBCs?
a. Group O Le(b+)
b. Group A2 Le(b+)
c. Group A1 Le(b+)
d. None of the above
11. Which of the following best describes MN antigens and antibodies?
a. Well developed at birth, susceptible to enzymes, generally saline reactive
b. Not well developed at birth, susceptible to enzymes, generally saline reactive
c. Well developed at birth, not susceptible to enzymes, generally saline reactive
d. Well developed at birth, susceptible to enzymes, generally antiglobulin reactive
12. Which autoantibody specificity is found in patients with paroxysmal cold hemoglobinuria?
a. Anti-I
b. Anti-i
c. Anti-P
d. Anti-P1
13. Which of the following is the most common antibody seen in the blood bank after ABO and Rh antibodies?
a. Anti-Fya
b. Anti-k
c. Anti-Jsa
d. Anti-K
14. Which blood group system is associated with resistance to P. vivax malaria?
a. P
b. Kell
c. Duffy
d. Kidd
15. The null Ko RBC can be artificially prepared by which of the following treatments?
a. Ficin and DTT
 b. Ficin and glycine-acid EDTA
c. DTT and glycine-acid EDTA
d. Glycine-acid EDTA and sialidase
16. Which antibody does not fit with the others with respect to optimum phase of reactivity?
a. Anti-S
b. Anti-P1
c. Anti-Fya
d. Anti-Jkb
17. Which of the following Duffy phenotypes is prevalent in blacks but virtually nonexistent in whites?
a. Fy(a+b+)
b. Fy(a–b+)
c. Fy(a–b–)
d. Fy(a+b–)
18. Antibody detection cells will not routinely detect which antibody specificity?
a. Anti-M
b. Anti-Kpa
c. Anti-Fya
d. Anti-Lub
19. Antibodies to antigens in which of the following blood groups are known for showing dosage?
a. I
b. P
c. Kidd
d. Lutheran
20. Which antibody is most commonly associated with delayed hemolytic transfusion reactions?
a. Anti-s
b. Anti-k
c. Anti-Lua
d. Anti-Jka
21. Anti-U will not react with which of the following RBCs?
a. M+N+S+s
b. M+N–S–s
c. M–N+S–s+
d. M+N–S+s+
22. A patient with an M. pneumoniae infection will most likely develop a cold autoantibody with specificity to which antigen?
a. I
b. i
c. P
d. P1
23. Which antigen is destroyed by enzymes?
a. P1
b. Jsa
c. Fya
d. Jka
Chapter 9
The Diego system antigens are located on a major RBC protein, band 3, also known as the RBC anion exchanger (AE1).
Anti-Dia, anti-Dib, and anti-Wraare generally considered to be clinically significant; all have caused severe HTRs and HDFN. Anti-Wrais a
relatively common antibody.
Wrb expression requires the presence of a normal GPA (MNS system); alloanti-Wrb is extremely rare.
Yt antigens are GPI-linked RBC glycoproteins that are absent in individuals with PNH.
Anti-Yta is a fairly common antibody to a high-prevalence antigen that is sometimes clinically significant and sometimes insignificant.
The Xga antigen is found on the short arm of the X chromosome and is of higher prevalence in females (89%) than in males (66%). Although
it is usually IgG; some examples are naturally occurring.
Anti-Xga has not been implicated in HDFN or as a cause of HTRs.
Antibodies to Scianna system antigens are rare and little is known about their clinical significance. The rare null phenotype, Sc:–1,–2,–3,
has been observed in the Marshall Islands and New Guinea.
In addition to the Doa and Dob antigens, the Gya, Hy, and Joa antigens are assigned to the Dombrock system. Anti-Doa and anti-Dob have
caused HTRs but no clinical HDFN; these antibodies are usually weak and difficult to identify.
The Colton system is composed of the antithetical Coa and Cob antigens as well as the high-prevalence Co3 antigen; the antigens are
carried on aquaporin 1, an RBC water channel. The Colton antibodies have caused HTRs and HDFN.
LW has a phenotypic relationship with the D antigen; Rhnull RBCs type LW(a–b–).
 Anti-LW reacts strongly with D+ RBCs and can look like anti-D. DTT treatment of test RBCs will distinguish between these two antibodies
because the LW antigen is denatured by DTT, but the D antigen is not. In other words, anti-LW does not react with DTT-treated D+ RBCs
but anti-D does.
The antigens in the Chido/Rodgers system are located on the complement fragments C4B and C4A, respectively, that are adsorbed onto
RBCs from plasma.
The clinically insignificant anti-Ch and anti-Rg react weakly, often to moderate or high-titer endpoints in the antiglobulin test, and may
be tentatively identified by plasma inhibition methods.
Gerbich-negative phenotypes are very rare outside of Papua, New Guinea.
The Gerbich or Leach phenotypes have weak expression of Kell blood group antigens.
Gerbich antibodies are sometimes clinically significant for transfusion and sometimes insignificant.
Three cases of serious HDFN due to anti-Ge3 have been reported, associated with late onset anemia (after birth).
The Cromer antigens are carried on the decay-accelerating factor (DAF) and are distributed in body fluids and on RBCs, WBCs, platelets,
and placental tissue.
The rare anti-Cra and anti-Tca have been found only in black individuals; some examples have caused HTRs.
The Knops antigens are located on complement receptor 1 (CR1). Knops antibodies are clinically insignificant and have weak and nebulous
reactivity at the antiglobulin phase; they are not inhibited by plasma.
The Ina antigen is more prevalent in Arab and Iranian populations. Ina and Inb antigen expression is depressed on the dominant type Lu(a–
b–) RBCs.
JMH antibodies most often occur in individuals with acquired JMH– status. Anti-JMH in these individuals is not clinically significant.
Anti-Vel is most often IgG but can be IgM, and it has caused severe immediate HTRs and HDFN. When serum is tested, anti-Vel
characteristically causes in vitro hemolysis.
Anti-Ata has been found only in blacks; the antibody is usually IgG and has caused severe HTRs.
Anti-Jra is found more commonly in Japanese, but clinical significance is not well established, since it is a rare antibody; it has caused
HTRs and fatal cases of HDFN.
The CD59 antigen plays a key role in protecting against complement-regulated hemolysis by binding to C8 and C9.
Collections are antigens that have a biochemical, serologic, or genetic relationship but do not meet the criteria for a system.
Cost, Ii, Er, Globoside, Unnamed, and MN CHO are all blood group collections.
The MN CHO antigens are associated with the M or N antigen in the MNS (002) system and are expressed on GPA with altered levels of
sialic acid (NeuNAc) or GlcNAc.
Low-prevalence antigen/antibodies are usually detected when either an unknown maternal antibody causing HDFN is detected or an
unexplained incompatible crossmatch is found.
Low-prevalence antibodies are commonly found in serum that contains multiple antibodies.
Finding compatible blood for patients with low prevalence antibodies for transfusion is not difficult due to the low prevalence of the
antigen making compatible blood readily available.
Unlike low-prevalence antigens, finding compatible units negative for antigens in the 901 series can be challenging.
Six antigens currently make up the 901 series of the ISBT classification: Emm, AnWj, Sda, PEL, ABTI, and MAM.
Anti-Sda has characteristic shiny and refractile agglutinates under the microscope and is inhibited with urine from Sd(a+) individuals and
guinea pigs.
Haemophilus influenza uses the AnWj antigen as a receptor to enter RBCs.
The difficulty in identifying and finding compatible units makes antibodies to the high-prevalence antigens a potential transfusion risk.
HLA antigens are not considered a blood group antigen.
Chloroquine or EDTA/glycine-HCL can be used to remove the HLA antigens from RBCs.
Self-Assessment Questions
1. The antibody to this high-prevalence antigen demonstrates mixed-field agglutination that appears shiny and refractile under the
microscope.
a. Vel
b. JMH
c. Jra
d. Sda
2. What red blood cell treatment can be used to differentiate between anti-D and anti-LW?
a. Ficin
b. Trypsin
c. DTT
d. Papain
3. Which of the following has been associated with causing severe immediate HTRs?
a. Anti-JMH
b. Anti-Lub
c. Anti-Vel
d. Anti-Sda
4. Which of the following antibodies would more likely be found in a black patient?
 a. Anti-Cra
b. Anti-Ata
c. Anti-Hy
d. All of the above
5. Which of the following antigens is not in a blood group system?
a. Doa
b. LKE
c. JMH
d. Kx
6. A weakly reactive antibody with a titer of 128 is neutralized by plasma. Which of the following could be the specificity?
a. Anti-JMH
b. Anti-Ch
c. Anti-Kna
d. Anti-Kpa
7. An antibody reacted with untreated RBCs and DTTtreated RBCs but not with ficin-treated RBCs. Which of the following antibodies could
explain this pattern of reactivity?
a. Anti-JMH
b. Anti-Yta
c. Anti-Cra
d. Anti-Ch
8. The following antibodies are generally considered clinically insignificant because they have not been associated with causing increased
destruction of RBCs, HDFN, or HTRs.
a. Anti-Doa and anti-Coa
b. Anti-Ge3 and anti-Wra
c. Anti-Ch and anti-Kna
d. Anti-Dib and anti-Yt
9. Which antigen is the receptor for Haemophilus influenza?
a. AnWj
b. PEL
c. FORS
d. Kna
10. Which antigen is not absent or is weakened on RBCs of individuals with PNH?
a. Yta
b. Cra
c. CD59
d. Coa
11. Which of the following blood groups is carried on a structure that helps to maintain the RBC membrane integrity through interaction
with protein band 4.1?
a. Di
b. Kn
c. Ge
d. Vel
12. What is the name of the Knops system serologic null phenotype?
a. Gregory
b. Leach
c. Helgeson
d. McLeod
13. Which antigen when absent produces a null in the Dombrock system?
a. Hy
b. Joa
c. Dob
d. Gya
14. Which antigens are strongly expressed on placental tissue, allowing for the adsorption of antibodies?
a. Cromer
b. Knops
c. Diego
d. Vel
15. Which antigen was returned to the 901 series because there was no determined linkage to the SMIM1 gene?
a. JMH
b. Ata
c. ABTI
 d. MAM
16. The FORS blood group system was first thought to be part of what system due to the addition of N-acetylgalactosamine (GalNAc) to the
P antigen?
a. ABO
b. Lewis
c. P1PK
d. Globoside
17. What glycophorin expresses the MN CHO collection antigens that are associated with altered levels of sialic acid (NeuNAc) or GlcNAc?
a. GPA
b. GPB
c. GPC
d. GPD
18. What techniques can be used to remove the reactivity of Bg antigens?
a. EDTA/glycine-HCL
b. Platelet adsorption
c. Chloroquine treatment
d. All of the above
19. ABTI was thought to be classified with which antigen prior to it gaining system status?
a. Jra
b. FORS1
c. Vel
d. Lan
20. The Jr(a–) phenotype is found more commonly in:
a. Japanese.
b. African Americans.
c. South American Indians.
d. Caucasians.
Chapter 10
The purpose of the antibody screen is to detect unexpectedantibodies, which are found in approximately 0.8% to 2% of the general
population. The antibodies may be classified as immune (the result of RBC stimulation in the patient), passive (transferred to the patient
through blood products or derivatives), or naturally occurring (the result of environmental factors). Antibodies may also be classified as
alloantibodies, directed at foreign antigens, or autoantibodies, directed at one’s own antigens.
A clinically significant antibody is one that results in the shortened survival of RBCs possessing the target antigen. These antibodies are
typically IgG antibodies that react best at 37°C or in the AHG phase of testing and are known to cause hemolytic transfusion reactions
and/or HDFN.
Screen cells are commercially prepared group O RBC suspensions obtained from individual donors who are phenotyped for the most
commonly encountered and clinically significant RBC antigens.
RBCs from a homozygous individual have a double dose of a single antigen, which results from the inheritance of two genes that code for
the same antigen, whereas heterozygous individuals carry only a single dose each of two antithetical antigens (each gene codes for a
different antigen.)
Antibodies in the Kidd, Duffy, Lutheran, Rh, and MNSs blood group systems show dosage and yield stronger reactions against RBCs with
homozygous expression of their corresponding antigen.
Enhancement reagents, such as LISS and PEG, are solutions added to serum and cell mixtures prior to incubation at 37ºC to promote
antigen-antibody binding or agglutination.
Coombs’ control cells are reagent RBCs coated with human IgG antibody, which are added to all AHG negative tube tests to ensure
adequate washing occurred and that the AHG reagent is present and functional in the test system.
Gel and solid-phase adherence methods are alternatives to tube testing. These methods may be automated to increase efficiency.
The antibody exclusion method rules out possible antibodies based on antigens that are present on negatively reacting cells.
Conclusive antibody identification is achieved when the serum is reactive with at least three antigen-positive cells (i.e., reagent cells that
express the corresponding antigen) and negative with at least three antigen-negative cells (i.e., reagent cells that do not express the
correspond ing antigen). This can also be achieved using two antigen-positive cells and three antigen-negative cells or two antigen-
positive cells and two antigen-negative cells.
The DAT detects RBCs that were sensitized with antibody in vivo. Elution methods are used to free antibody from the cell surface to allow
for identification.
The relative quantity of an antibody can be determined by testing serial two-fold dilutions of serum against antigen-positive RBCs; the
reciprocal of the highest serum dilution showing agglutination is the antibody titer.
The calculation used to determine the number of random donor units that should be antigen-typed in order to theoretically provide the
requested number of antigen-negative RBC units for patients with an antibody involves dividing the number of antigen-negative units
requested by the frequency of antigen-negative individuals in the donor population
Chapter 11
Clerical error and ABO incompatibility are implicated in fatal transfusion reactions.
 Pretransfusion specimens, labels, and testing requests must contain two unique identifiers.
Writing must be legible and indelible.
Specimen draw date and time and the collecting individual must be traceable back to the collection of the patient sample.
Pretransfusion specimens must be collected within 3 days of the scheduled transfusion.
Review of records prior to transfusion is essential for safety.
Selection of donor unit is based on ABO grouping, Rh typing, current and historical antibody screening results, and any special
requirements.
Perform immediate spin, antiglobulin, or computer crossmatch based on current or historical serologic results.
Platelets, thawed plasma, and cryoprecipitate transfusions require a historical or current ABO grouping only. No compatibility testing
required
Emergency transfusions:
✓ Select uncrossmatched, group O, Rh-negative or Rh-positive red blood cell units based upon patient’s sex and age.
Massive transfusions:
✓ The American College of Surgeons recommends transfusion of red blood cells, thawed plasma, and platelets in a ratio of 1:1:1.
Neonatal transfusions:
✓ Select a group O, Rh-compatible red blood cell unit.
✓ Perform an antibody screen and any required compatibility testing with either an infant’s or mother’s specimen.
Intrauterine transfusion:
✓ Select a group O, Rh-negative red blood cell unit that is fresh, leukocyte-reduced, irradiated, negative for sickling hemoglobin,
and antigen-negative, if applicable
Self-Assessment Questions
1. Which is not included on a properly labeled specimen?
a. Two unique patient identifiers
b. Date and time of draw
c. Phlebotomist’s initials
d. Patient’s home address
2. How many days before a pretransfusion specimen expires?
a. 3 days
b. 7 days
c. 14 days
d. 1 month
3. 3.How many days must a pretransfusion specimen and donor unit segments be retained post-transfusion?
a. 3 days
b. 7 days
c. 14 days
d. 1 month
4. If a blood type cannot be resolved, what ABO group should be selected for a red blood cell transfusion?
a. Group A
b. Group B
c. Group O
d. Group AB
5. Which antibody specificity is not required in antibody detection tests?
a. K
b. Cw
c. Fya
d. S
6. A patient has a history of anti-Jka. The antibody screen is currently negative. Which red blood cell unit should be selected, and what
type of crossmatch should be performed?
a. Jk(a-) red blood cells, computer crossmatch
b. Jk(a-) red blood cells, antiglobulin crossmatch
c. Jk(a-) red blood cells, immediate spin crossmatch
d. ABO-compatible because the antibody screen is negative
7. Which is not true of rouleaux formation?
a. Mimics agglutination
b. Appears like a “stacking of coins”
c. Can be seen in the antiglobulin test
d. Can be dispersed by saline
8. A patient’s blood type is AB-negative, but there are no AB-negative red blood cell units available. What donor units could be selected?
a. A-negative
b. O-positive
c. B-positive
 d. All of the above
9. A patient requires 15 units of thawed plasma for an apheresis procedure. The patient’s blood type is O-negative. What donor units could
be selected?
a. O-negative
b. AB-positive
c. A-negative
d. All of the above
10. The American College of Surgeons recommends transfusion of red blood cells, thawed plasma, and platelets in what ratio for a massive
transfusion?
a. 2 units of red blood cells for every unit of platelets
b. 1 unit of red blood cells to 1 unit of thawed plasma to 1 unit of platelets
c. 1 unit of red blood cells to 3 units of thawed plasma
d. It’s an emergency. Give the surgeon whatever she wants
11. A patient’s antibody screen was positive and an anti-c was identified. Antiglobulin crossmatches were performed with c-negative units
and 1 of the 6 units was incompatible. What should be performed to resolve the incompatible crossmatch?
a. Give O-negative red blood cells
b. Retype the incompatible unit for the c antigen
c. Perform a DAT on the incompatible unit
d. Perform additional identification testing to include low-specificity antigens e. b, c, and d
12. 12. A mother, 30 weeks’ pregnant, has anti-K with a titer of 32. An intrauterine red blood cell transfusion is indicated. The donor unit
selected should be all of the following except:
a. O-negative
b. K-negative
c. Positive for sickling hemoglobin
d. Irradiated
13. A patient with sickle cell disease is B-positive with a positive antibody screen. The antibody identified is anti-D, and the autocontrol is
negative. What is a possible explanation?
a. The patient is weak D-positive
b. Autoantibody is present
c. Patient possesses the partial D phenotype
d. The patient has a positive DAT
Chapter 12
Advantages of CAT and solid-phase technologies over routine tube testing are as follows:
✓ Standardization, which means there is no tube shaking or resuspension of an RBC button to cause subjectivity in the
interpretation of the test.
✓ Stability, which means there are well-defined endpoints of the reaction.
✓ Decreased sample volume is needed for testing.
✓ Enhanced sensitivity and specificity are present.
CAT test points to remember:
✓ The principle of the CAT test is hemagglutination.
✓ In the CAT test, RBCs and serum or plasma are allowed to incubate together in a reaction chamber.
✓ Following incubation, controlled centrifugation drives the RBCs through a specially designed microtube filled with beads of
dextran-acrylamide gel.
✓ Agglutinated cells remain at the top of the tube or are trapped in the gel, depending on the size of the agglutinates.
✓ Unagglutinated cells move through the gel to the bottom of the tube.
✓ The gel test reactions are stable for observation or review for 2 to 3 days.
✓ CAT technology is currently approved for ABO forward and reverse grouping, Rh typing, DAT, antibody screening, antibody
identification, and compatibility testing.
✓ The major disadvantage of the CAT technology is the need to purchase special equipment: a centrifuge to accommodate the
microtube cards used for testing and a pipette for dispensing plasma or serum and RBC suspensions into the reaction chambers
of the microtubes.
SPRCA assay points to remember:
✓ The principle of SPRCA is based on solid-phase technology.
✓ In SPRCA tests, the target antigen is affixed to the bottom of the microplate wells.
✓ If the test plasma contains antibodies to the antigen, they attach to the fixed antigen, and indicator cells detect the attached
antibodies by forming a monolayer of RBCs.
✓ If the test plasma contains no antibodies to the antigen, there is no attachment to the fixed antigen, and the indicator cells
form a clearly delineated button at the center of the microplate well.
✓ Solid-phase reactions are stable for observation or review for 2 days.
✓ Solid-phase technology is currently approved for antibody screening, antibody identification, and compatibility testing.
 ✓ Advantages of solid-phase technology include the ease of use, because no predilution of reagents is required, and the ability
to test hemolyzed, lipemic, or icteric samples.
✓ Enhanced sensitivity increases the detection of weak alloantibodies.
✓ The major disadvantage of solid-phase technology is the need to purchase special equipment: a centrifuge that can spin
microplates, a 37°C incubator for microplates, and a light source for reading the final results.
Solid-phase protein A technology points to remember:
✓ IgG antibodies are captured in microwells that are coated with protein A.
✓ Solidscreen II, which uses solid-phase protein A technology, is an assay that uses traditional antiglobulin technique.
✓ Solid-phase protein A testing is available in the United States only as an automated technology on the TANGO infinity instrument.
Self-Assessment Questions
1. The endpoint of the CAT test is detected by:
a. Agglutination.
b. Hemolysis.
c. Precipitation.
d. Attachment of indicator cells.
2. The endpoint of the SPRCA test is detected by:
a. Agglutination.
b. Hemolysis.
c. Precipitation.
d. Attachment of indicator cells.
3. The endpoint of the solid-phase protein A assay is:
a. Agglutination.
b. Hemolysis.
c. Precipitation.
d. Attachment of cells to microwell.
4. Protein A captures antibodies by binding to the:
a. Fab portion of immunoglobulin.
b. Fc portion of immunoglobulin.
c. Surface of test cells.
d. Surface of indicator cells.
5. Mixed-field reactions can be observed in:
a. Gel.
b. SPRCA.
c. Protein A technology.
d. None of the automated technologies.
6. An advantage for both CAT and solid-phase technology is:
a. No cell washing steps.
b. Standardization.
c. Use of IgG-coated control cells.
d. Specialized equipment.
7. A disadvantage for both CAT and solid-phase technology is:
a. Decreased sensitivity.
b. Inability to test hemolyzed, lipemic, or icteric samples.
c. Inability to detect C3d complement–coated cells.
d. Large sample requirement.
8. A safety feature in the SPRCA test is:
a. Air bubble barrier.
b. Viscous barrier.
c. Color change of the LISS.
d. Use of IgG-coated control cells.
Chapter 13
An allogeneic blood donor should weigh at least 110 lbs (50 kg).
The minimum hemoglobin for a female whole blood donor is 12.5 g/dL.
The minimum hemoglobin for a male whole blood donor is 13.0 g/dL.
Persons who have had a blood transfusion are deferred for 12 months owing to risk of exposure to hepatitis, HIV, or other viral diseases.
The interval between whole blood donations is 8 weeks or 56 days.
The interval between plasmapheresis, plateletpheresis, or leukapheresis is at least 2 days.
Attenuated live viral vaccines such as smallpox, measles, mumps, yellow fever, and influenza carry a 2-week deferral.
A blood donor that has a positive serologic test for syphilis is deferred for 12 months.
Predeposit autologous donation refers to blood for the donor-patient that is drawn before an anticipated transfusion for surgery and
stored until used.
 An autologous donor must have a hemoglobin of at least 11.0 g/dL and a hematocrit of at least 33%.
A person who has received a nonhuman animal transplant of cells or tissues is permanently deferred from donating whole blood.
Males who have had sex with another male (MSM) in the past 12 months are deferred for 1 year.
Acute normovolemic hemodilution takes place in the operating room when 1 to 3 units of whole blood are collected and the patient’s
volume is replaced with colloid or crystalloid, then reinfused during surgical procedure, starting with the first unit collected.
Self-Assessment Questions
1. Which of the following information is not required for whole blood donation?
a. Name
b. Address
c. Transfusion history
d. Sex
e. Date of Birth
2. 2.Which of the following would be cause for deferral for a male donor?
a. Temperature of 99.2°F
b. Hematocrit of 37%
c. Spent 2 weeks in the United Kingdom in 1998
d. Weighs 80 kg
e. Received a blood transfusion 2 years ago
3. Which of the following would be cause for a permanent deferral?
a. Received a dura mater graft 9 months ago
b. Received hepatitis B immune globulin
c. Is currently on warfarin
d. Diagnosis of babesiosis
e. Traveled to Senegal 2 years ago
4. Immunization for rubella would result in a temporary deferral for:
a. 4 weeks.
b. 8 weeks.
c. 6 months.
d. 1 year.
e. 3 years.
5. Which of the following donors is acceptable?
a. Donor who had a first-trimester abortion 4 weeks ago
b. Donor whose husband is a hemophiliac who regularly received cryoprecipitate before 1989
c. Donor who was treated for gonorrhea 6 months ago
d. Donor who had a needle-stick injury 10 months ago
6. Which of the following tests is not required as part of the donor-processing procedure for allogeneic donation?
a. ABO
b. Rh
c. STS
d. Anti-HTLV-I
e. Anti-CMV
7. How long must a 2-unit RBC donor wait before donating red blood cells again?
a. 8 weeks
b. 16 weeks
c. 6 months
d. 12 months
8. What is the deferral period for Plavix?
a. 14 days after last dose
b. 1 month after last dose
c. 12 months after last dose
d. 48 hours after last dose
9. All of the following records must be kept for 10 years, except:
a. Unique ID of each unit.
b. Donor consent.
c. Request for blood or blood component.
d. A signed statement from requesting physician for emergency release.
10. What is the causative agent of Chagas disease?
a. Trypanosoma cruzi
b. Yersinia pestis
c. Treponema pallidum
d. Plasmodium falciparum
 11. Which of the following donors would be rejected for whole blood donation?
a. A male who had sex with another male in 1988
b. A female who had sex with a male in 1992
c. A male who had sex with another male last month
d. A female who had sex with a male 9 months ago
12. What does “infrequent” refer to when talking about a plasmapheresis program?
a. Donating no more frequently than once every 4 weeks
b. Donating once a year
c. Donating once every 6 months
d. Donating no more frequently than once every 8 weeks
13. A patient is having an exploratory laparotomy performed and donated blood for use in the patient’s upcoming surgery. Three units were
collected, with the last unit collected 2 days before surgery. Given this information, can the patient undergo surgery as planned?
a. Yes
b. No
14. Which of the following refers to a temporary deferral?
a. Donor received varicella zoster live attenuated vaccine
b. Donor had a confirmed positive test for HBsAg
c. Donor has a history of CJD
d. Donor was diagnosed with babesiosis
15. Which of the following carries a 12-month deferral?
a. Donor received Hepatitis B immune globulin
b. Donor received pituitary growth hormone from another human
c. Donor received the MMR vaccine
d. Donor spent 10 years in Africa
Chapter 14
The first and most important step in ensuring that transfused blood will not transmit a pathogenic virus is careful selection of the donor.
HAV is usually spread by the fecal-oral route in communities where hygiene is compromised.
On infection with HBV, the first positive test is HBV NAT and the first serologic marker to appear is HBsAg, followed by HBeAg and IgM
anti-HBc within the first few weeks of exposure.
HBIG is an immune globulin prepared from persons with a high titer of anti-HBs and is used to provide passive immunity to health-care
workers and others who are exposed to patients with HBV infection.
A combined vaccine for HAV and HBV is available to provide immunity.
HDV infection is common among drug addicts and can occur simultaneously with HBV infection; diagnosis depends on finding anti-HDV or
HDV RNA in the serum.
Of all HCV infections, 60% to 70% are asymptomatic. With the implementation of NAT testing for HCV, the window period has been reduced
to 10 to 30 days.
HCV is the leading cause of liver transplants in the United States.
HEV is an emerging agent associated with transmission through transfusion and is the leading cause of hepatitis in the United Kingdom.
Diagnosis of HIV-1 and HIV-2 infection is dependent on the presence of antibodies to both envelope and core proteins; HIV-positive persons
with fewer than 200 CD4+ T cells per microliter are considered to have AIDS in the absence of symptoms.
Transfusion-associated CMV infection is a concern for seronegative allogeneic organ transplant recipients and fetuses. Reactivation of a
latent infection can occur when an individual becomes severely immunocompromised.
The risk of CMV infection for low-birth-weight neonates is not as great as it was in the past due to better transfusion techniques and
management of their conditions.
The WB confirmation test detects the presence of antiHIV and determines with which viral proteins the antibodies react.
The window period for HIV can be shortened by using the polymerase chain reaction, which detects HIV infection before tests for antigen
or antibody are positive.
Bacterial contamination is the most frequent cause of transfusion-transmitted infection.
Because routine screening for parasitic infections is not currently available, many blood banks have added questions to their donor
questionnaire that address topics associated with risk for parasitic infection.
Pathogen inactivation methods are in use for plasma and platelet products and under development for red cell products. These methods
remove or reduce the residual risk of transfusion-associated disease due to the window period, virus variants, laboratory mistakes, and
new, emerging diseases.
Look-back is a process mandated by the FDA that directs collection facilities to notify donors who test positive for viral markers, to notify
prior recipients of the possibility of infection, and to quarantine or discard implicated components currently in inventory.
Self-Assessment Questions
1. The fecal-oral route is common in transmitting which of these hepatitis viruses?
a. HAV and HEV
b. HBV and HCV
c. HDV
 d. HGV
2. Which of the following is the component of choice for a low-birth-weight infant with a hemoglobin of 8 g/dL if the mother is anti-CMV
negative?
a. Whole blood from a donor with anti-CMV
b. RBCs from a donor who is anti-CMV negative
c. Leukoreduced platelets
d. Solvent detergent–treated plasma
3. Which of the following is an FDA-licensed screening test for HCV?
a. NAT + anti-HBc
b. RIBA
c. Lymph node biopsy
d. HCV RNA
4. Currently, which of the following does the AABB consider to be the most significant infectious threat from transfusion?
a. Bacterial contamination
b. CMV
c. Hepatitis
d. HIV
5. Which of the following is the most frequently transmitted virus from mother to fetus?
a. HIV
b. Hepatitis
c. CMV
d. EBV
6. Jaundice due to HAV is seen most often in the:
a. Adolescent
b. Adult
c. Child younger than 6 years old
d. Newborn
7. Currently, steps taken to reduce transfusion-transmitted CMV include:
a. Plaque reduction neutralization test
b. NAT testing
c. Leukoreduction
d. Minipool screening
8. HBV remains infectious on environmental surfaces for 1:
a. Day
b. Week
c. Month
d. Year
9. HBV is transmitted most frequently:
a. By needle sharing among IV drug users
b. Through blood transfusions
c. By unknown methods
d. By sexual activity
10. Which of the following is the most common cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma in the United States?
a. HAV
b. HBV
c. HCV
d. HDV
11. The first retrovirus to be associated with human disease was:
a. HCV
b. HIV
c. HTLV-I
d. WNV
12. All of the following statements are true concerning WNV except:
a. 1 in 150 infections results in severe neurological disease
b. Severe disease occurs most frequently in the over 50 age group
c. Deaths occur more often in those over 65 years who present with encephalitis
d. Fatalities occur in approximately 38% of infected individuals
13. The primary host for WNV is:
a. Birds
b. Horses
c. Humans
 d. Bats
14. Tests for WNV include all of the following except:
a. ELISA
b. NAT
c. Plaque reduction neutralization test
d. Immunofluorescent antibody assay
15. Individuals exposed to EBV maintain an asymptomatic latent infection in:
a. B cells
b. T cells
c. All lymphocytes
d. Monocytes
16. Fifth disease is caused by:
a. CMV
b. EBV
c. Parvovirus B19
d. HTLV-II
17. Transient aplastic crisis can occur with:
a. Parvovirus B19
b. WNV
c. CMV
d. EBV
18. Reasons why syphilis is so rare in the U.S. blood supply include all of the following except:
a. 4°C storage conditions
b. Donor questionnaire
c. Short spirochetemia
d. NAT testing
19. Nucleic acid amplification testing for HIV was instituted in donor testing protocols to:
a. Identify donors with late-stage HIV who lack antibodies
b. Confirm the presence of anti-HIV in asymptomatic HIV-infected donors
c. Reduce the window period by detecting the virus earlier than other available tests
d. Detect antibodies to specific HIV viral proteins, including anti-p24, anti-gp41, and anti-gp120
20. Screening for HIV is performed using the following technique:
a. Radio immunoassay
b. WB
c. Immunofluorescent antibody assay
d. NAT
21. The first form of pathogen inactivation was:
a. Chemical
b. Heat
c. Cold-ethanol fractionation
d. Anion-exchange chromatography
22. What is the most common parasitic complication of transfusion?
a. Babesia microti
b. Trypanosoma cruzi
c. Plasmodium species
d. Toxoplasma gondii
23. Which organism has a characteristic C- or U-shape on stained blood smears?
a. Trypanosoma cruzi
b. Plasmodium vivax
c. Plasmodium falciparum
d. Babesia microti
24. Which transfusion-associated parasite may have asymptomatic carriers?
a. Babesia microti
b. Trypanosoma cruzi
c. Plasmodium species
d. All of the above
25. Which disease is naturally caused by the bite of a deer tick?
a. Chaga’s disease
b. babesiosis
c. malaria
d. leishmaniasis
Chapter 15
Blood component manufacturing must be documented to ensure that the individuals who performed critical steps in manufacturing and
the equipment that was used is identifiable for each component made.
Equipment found in a component manufacturing laboratory includes centrifuges, plasma expressors, scales, sterile connection devices,
sealing devices, plasma freezers, refrigerators, platelet agitators, and environmental chambers. These devices should be carefully
selected and validated to ensure that they operate in accordance with regulatory requirements.
Whole blood is usually separated into components but has recently increased in popularity for transfusion in trauma due to research
presented by the U.S. military.
RBCs must be prepared by a method that separates the RBCs from the plasma and results in a hematocrit level of less than or equal to
80%. Leukoreduced RBCs should contain <5 ×106residual WBCs yet retain at least 85% of the original RBC content. The outdate of RBCs
depends on the anticoagulant/preservative and additive solution present.
Random-donor platelets must contain at least 5.5 ×1010 platelets; single-donor platelets must contain at least 3 ×1011platelets.
Leukoreduced products must contain <8.3 ×105or 5.0 ×106residual WBCs, respectively. Outdate is typically 5 days, although processes are
currently available to allow transfusion of platelets up to 7 days after collection.
FFP must be prepared within 8 hours of collection and is stored at –18°C for 12 months.
Cryoprecipitate is prepared from FFP and contains at least 80 units of antihemophilic factor and at least 150 mg of fibrinogen, and it is
stored at –18°C for 12 months. Because an adult dose of cryoprecipitate is usually 10 units, the individual components may be pooled at
the collection facility and refrozen or at the transfusion service after thawing.
Irradiated RBCs must be given a radiation dose of at least 25 Gy to the midplane of the canister, after which the expiration date of the
product changes to 28 days from the time of irradiation or maintains the original outdate, whichever comes first. The outdate of platelet
components is not changed by irradiation.
RBCs and platelets can be washed to remove the supernatant plasma and additive solution, which is then replaced with saline.
RBC and platelets can be divided into aliquots for patients who require smaller volumes to be transfused, such as infants and adults at
risk of transfusion associated circulatory overload. Plasma aliquots are usually prepared and frozen within 8 hours of collection at the
donor center.
Blood components can be pooled prior to transfusion to support individuals who need larger doses or specialized combinations of
components.
Human plasma may be used to manufacture a wide variety of therapeutic products, including clotting factors, immune globulins, and
albumin or other proteins. Because these carry a risk of disease transmission, recombinant or xenographic preparations are an
alternative for many products.
Blood components are most commonly labeled with ISBT 128, a specialized barcode language that includes definitions for the donation
identification number, blood type, product code, expiration date, and additional special labels.
Self-Assessment Questions
1. Which of the following lists the correct shelf life for the component?
a. Deglycerolized RBCs—24 hours
b. RBCs (CPD)—35 days
c. Platelet concentrate—10 days
d. FFP—5 years
e. RBCs (CPDA-1)—21 days
2. Each unit of cryoprecipitate prepared from whole blood should contain a minimum of how many units of AHF activity?
a. 40 IU
b. 80 IU
c. 120 IU
d. 160 IU
e. 180 IU
3. 3. Platelet concentrates prepared by apheresis should contain how many platelets?
a. 5.5 × 1010
b. 6 × 1010
c. 3 × 1011
d. 5.5 × 1011
e. 6 × 1011
4. 4. The required storage temperature for frozen RBCs using the high-glycerol method is:
a. 4°C
b. ≤–20°C
c. ≤–18°C
d. ≤–120°C
e. ≤–65°C
5. How does irradiation affect the shelf life of red blood cells?
a. Irradiation has no effect on the shelf life
b. The expiration date is 28 days from the date of irradiation or the original outdate, whichever is later
c. The expiration date is 28 days from the date of irradiation or the original outdate, whichever is sooner
 d. The expiration date is 25 days from the date of irradiation or the original outdate, whichever is later
e. The expiration date is 25 days from the date of irradiation or the original outdate, whichever is sooner
6. Once thawed, FFP must be transfused within __________ hours unless relabeled as thawed plasma:
a. 4
b. 6
c. 8
d. 12
e. 24
7. Quality control for nonadditive RBCs requires a maximum hematocrit level of:
a. 75%
b. 80%
c. 85%
d. 90%
e. 95%
8. AHF concentrates are used to treat:
a. Thrombocytopenia
b. Hemophilia A
c. Hemophilia B
d. von Willebrand’s disease
e. Factor XIII deficiency
9. Prothrombin complex concentrates are used to treat which of the following?
a. Factor IX deficiency
b. Factor VIII deficiency
c. Factor XII deficiency
d. Factor XIII deficiency
e. Factor V deficiency
10. RBCs that have been leukoreduced must contain less than ______ leukocytes and retain at least ______ of original RBCs.
a. 8 × 106/85%
b. 8 × 106/90%
c. 5 × 106/85%
d. 5 × 106/80%
11. Random-donor platelets that have been leukoreduced must contain less than ______ leukocytes.
a. 8.3 × 105
b. 8 × 106
c. 5 × 106
d. 3 × 1011
12. A single unit of FFP or PF24 should contain ______ mL of plasma.
a. 100–150
b. 200–400
c. 150–250
d. 50–150
13. Cryoprecipitate that has been pooled in an open system must be transfused within ______ hours.
a. 24
b. 6
c. 4
d. 8
Chapter 16
Transfusion therapy is used primarily to treat two conditions: inadequate oxygen-carrying capacity because of anemia or blood loss and
maintenance of hemostasis when the patient has insufficient coagulation proteins or platelets.
A unit of whole blood or RBCs in an adult should increase the hematocrit level 3% or hemoglobin level 1 g/dL.
RBCs are indicated for increasing the RBC mass in patients who require increased oxygen-carrying capacity.
Platelet transfusions are indicated for patients who are bleeding because of thrombocytopenia. In addition, platelets are indicated
prophylactically for patients who have platelet counts under 5,000 to 10,000/µL.
Each dose of platelets should increase the platelet count 20,000 to 40,000/µL in a 70-kg patient.
A plateletpheresis product is collected from one donor and must contain a minimum of 3 ×1011 platelets
Plasma contains all coagulation factors and is indicated for patients with multiple coagulation deficiencies that occur in liver failure, DIC,
vitamin K deficiency, warfarin overdose, and massive transfusion.
Cryoprecipitate contains at least 80 units of factor VIII and 150 mg of fibrinogen, as well as vWF, and factor XIII.
Factor IX is used in the treatment of persons with hemophilia B.
Immunoglobulin (IG) is used in the treatment of congenital hypogammaglobulinemia, to provide passive immunity for certain infections
such as hepatitis A and measles, and in certain autoimmune conditions such as immune thrombocytopenic purpura.
 Massive transfusion is defined as the replacement of one or more blood volume(s) within 24 hours, or about 10 units of blood in an adult.
Emergency transfusion warrants group O RBCs when patient type is not yet known.
Self-Assessment Questions
1. Leukocyte-reduced filters can do all of the following except:
a. Reduce the risk of CMV infection
b. Prevent or reduce the risk of HLA alloimmunization
c. Prevent febrile, nonhemolytic transfusion reactions
d. Prevent TA-GVHD
2. Albumin should notbe given for:
a. Burns
b. Shock
c. Nutrition
d. Plasmapheresis
3. Of the following, which blood type is selected when a patient cannot wait for ABO-matched RBCs?
a. A
b. B
c. O
d. AB
4. Which patient does notneed an irradiated component?
a. Bone marrow transplant recipient
b.Neonate weighing less than 1,200 g
c. Adult receiving an RBC transfusion
d. Adult receiving an RBC transfusion from a blood relative
5. RBC transfusions should be given:
a. Within 4 hours
b. With lactated Ringer solution
c. With dextrose and water
d. With cryoprecipitate
6. Which type of transplantation requires all cellular blood components to be irradiated?
a. Bone marrow
b. Heart
c. Liver
d. Kidney
7. Characteristics of deglycerolized RBCs include the following except:
a. Inexpensive
b. 24-hour expiration date after thawing
c. Used for rare antigen-type donor blood
d. Used for IgA-deficient recipient with history of severe reaction
8. Select the appropriate product for a bone marrow transplant patient with anemia:
a. RBCs
b. Irradiated RBCs
c. Leukoreduced RBCs
d. Washed RBCs
9. Which blood product should be selected for vitamin K deficiency?
a. Cryoprecipitate
b. Factor VIII
c. Factor IX
d. Plasma
10. Which fluid should be used to dilute RBCs?
a. 0.9% saline
b. 5% dextrose and water
c. Immune globulin
d. Lactated Ringer solution
Chapter 17
Allergic transfusion reactions and febrile nonhemolytic transfusion reactions are the most common adverse reactions, but transfusion-
related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are the most common transfusion reactions
associated with mortality.
Hemovigilance describes a process to standardize the definition of different transfusion reactions and data collection regarding the
incidence of transfusion reactions in order to improve the safety of blood transfusion.
Acute and delayed serologic transfusion reactions can be distinguished by the time of onset in relation to transfusion, predominant clinical
symptoms, and dominant pathophysiological mechanisms.
 Transfusion reactions in which respiratory symptoms predominate include TRALI, TACO, transfusion associated dyspnea, and severe
allergic reactions. However, these reactions also are associated with a variety of other signs and symptoms that overlap with other types
of reactions.
The pathophysiology of many types of reactions includes “two hits”: a predisposition of the recipient and transfusion of some mediator in
the transfused product that provokes the reaction.
Stored RBCs contain citrate, an anticoagulant that can cause hypocalcemia and can leak potassium from the cells into the supernatant
causing hyperkalemia, especially in neonates. In addition, RBCs and platelets undergo a variety of metabolic and morphological changes
called the “storage lesion,” but the clinical significance of these changes is still unknown.
Transfusion-associated graft-versus-host disease is a very rare, but devastating adverse effect of transfusion with a mortality rate of
90%, in which donor lymphocytes attack the recipient’s immune system.
Transfusion-transmitted bacterial infection (TTBI) is more often associated with platelet products than RBCs, and each of these products
is associated with a different set of microorganisms. S. aureus and gram positive organisms are most associated with platelets, while
gram-negative rods of the Enterobacteriaceae family are found more commonly with contamination RBCs.
Self-Assessment Questions
1. What component is most frequently involved with transfusion-associated sepsis?
a. Plasma
b. Packed red blood cells
c. Platelets
d. Whole blood
2. Fatal transfusion reactions are mostly caused by:
a. Serologic errors
b. Improper storage of blood
c. Clerical errors
d. Improper handling of the product
3. Early manifestation of an acute hemolytic transfusion reaction can be confused with:
a. Allergic reaction
b. Febrile nonhemolytic reaction
c. Anaphylactic shock
d. Sepsis
4. Pain at infusion site and hypotension are observed with what type of reaction?
a. Delayed hemolytic transfusion reaction
b. Acute hemolytic transfusion reaction
c. Allergic reaction
d. Febrile nonhemolytic reaction
5. Irradiation of blood is performed to prevent:
a. Febrile nonhemolytic transfusion reaction
b. Delayed hemolytic transfusion reaction
c. Transfusion-associated graft-versus-host disease
d. Transfusion-associated circulatory overload
6. The only presenting sign most often accompanying a delayed hemolytic transfusion reaction is:
a. Renal failure
b. Unexplained decrease in hemoglobin
c. Active bleeding
d. Hives
7. Which transfusion reaction presents with fever, maculopapular rash, watery diarrhea, abnormal liver function, and pancytopenia?
a. Transfusion-associated sepsis
b. Transfusion-related acute lung injury
c. Transfusion-associated graft-versus-host disease
d. Transfusion-associated allergic reaction
8. A suspected transfusion-related death must be reported to:
a. AABB
b. Federal and Drug Administration (FDA)
c. College of American Pathologists (CAP)
d. The Joint Commission (TJC)
9. Nonimmune hemolysis can be caused during transfusion by:
a. Use of small bore size needle
b. Use of an infusion pump
c. Improper use of a blood warmer
d. All of the above
10. Transfusion reactions are classified according to:
a. Signs or symptoms presenting during or after 24 hours
 b. Immune or nonimmune
c. Infectious or noninfectious
d. All of the above
11. With febrile nonhemolytic transfusion reactions:
a. They are self-limited
b. Fever resolves within 2–3 hours
c. Treatment is required
d. a and b are correct
e. All of the above
12. Absolute IgA deficiency is a classic example of a severe allergic reaction. A result indicating an absolute IgA deficiency is:
a. <0.05 mg/dL
b. <0.50 mg/dL
c. <0.50 gm/dL
d. <5 mg/dL
13. How are mild allergic transfusion reactions with isolated symptoms or hives and urticaria treated?
a. Transfusion is stopped and transfusion reaction workup is initiated
b. Transfusion is stopped and antihistamines administrated; when symptoms improve, transfusion is restarted
c. Stop transfusion and prepare washed red blood cells
d. Continue transfusion with a slower infusion rate
14. TRALI presents with the following symptoms:
a. Respiratory distress
b. Severe hypoxemia and hypotension
c. Fever
d. All of the above
15. Which of the following is characteristic of iron overload?
a. Delayed, nonimmune complication occurs
b. Chelating agents are used
c. Multiorgan damage may occur
d. All of the above
Chapter 18
In an apheresis procedure, blood is withdrawn from a donor or patient and separated into its components. One or more of the components
is retained, and the remaining constituents are recombined and returned to the individual.
The process of removing plasma from the blood is termed plasmapheresis; removing platelets is termed plateletpheresis or
thrombocytopheresis; removing RBCs is termed erythrocytapheresis; removing leukocytes is known as leukapheresis.
Apheresis equipment that uses intermittent flow centrifugation (IFC) requires only one venipuncture, in which the blood is drawn and
reinfused through the same needle. Once the desired component is separated, the remaining components are reinfused to the donor, and
one cycle is complete. Apheresis procedures performed on patients usually require many cycles to reach an acceptable therapeutic
endpoint.
Continuous flow centrifugation (CFC) procedures withdraw, process, and return the blood to the individual simultaneously. Two
enipuncture sites are necessary. The process of phlebotomy, separation, and reinfusion is uninterrupted.
Membrane filtration technology uses membranes with specific pore sizes, allowing plasma to pass through the membrane while the
cellular portion passes over it.
The most common anticoagulant used in apheresis is acid citrate dextrose.
Therapeutic apheresis is used to remove a pathological substance, to supply an essential or missing substance to alter the antigen–
antibody ratio, or to remove immune complexes.
The American Society for Apheresis (ASFA) has developed categories to define the effectiveness of therapeutic apheresis in treating a
particular condition or disease. Therapeutic apheresis is most appropriate for treating category I or II disorders.
In therapeutic plasmapheresis procedures, the replacement fluids used to maintain appropriate intravascular volume and oncotic
pressure include normal saline, FFP, cryo-reduced plasma, and 5% human serum albumin.
Complications of apheresis include vascular access issues, alteration of pharmacodynamics of medications, citrate toxicity, fluid
imbalance, allergic reactions, equipment malfunction (hemolysis), and infection. Fatalities have occurred (primarily patient rather than
donor).
Self-Assessment Questions
1. The most common anticoagulant used for apheresis procedures is:
a. Heparin
b. Sodium fluoride
c. Warfarin
d. Citrate
2. Therapeutic cytapheresis has a primary role in treatment of patients with:
a. Sickle cell disease and acute chest syndrome
b. Systemic lupus erythematosus to remove immune complexes
 c. Leukemia to help increase granulocyte production
d. Myasthenia gravis to increase antibody production
3. The minimum interval allowed between plateletpheresis component collection procedures is:
a. 1 day
b. 2 days
c. 7 days
d. 8 weeks
4. In plasma exchange, the therapeutic effectiveness is:
a. Greatest with the first plasma volume removed
b. Affected by the type of replacement fluid used
c. Enhanced if the unwanted antibody is IgG rather than IgM
d. Independent of the use of concomitant immune suppressive therapy
5. The replacement fluid indicated during plasma exchange for TTP is:
a. Normal (0.9%) saline
b. Hydroxyethyl starch (HES)
c. FFP
d. Albumin (human) 5%
6. The most common adverse effect of plateletpheresis collection is:
a. Allergic reaction
b. Hepatitis
c. Hemolysis
d. Citrate effect
7. Apheresis technology can be used to collect each of the following components except:
a. Leukocytes
b. Macrophages
c. Hematopoietic progenitor cells
d. Platelets
8. The anticoagulant added to blood as it is removed from a donor or patient during an apheresis procedure acts by:
a. Binding calcium ions
b. Increasing intracellular potassium
c. Binding to antithrombin III
d. Inactivating factor V
9. Peripheral blood stem cells are:
a. Responsible for phagocytosis of bacteria
b. Removed during erythrocytapheresis
c. Pluripotential hematopoietic precursors that circulate in the peripheral blood
d. Lymphocytes involved with the immune response
10. Which of the following can be given to an apheresis donor to increase the number of circulating granulocytes?
a. DDAVP
b. Hydroxyethyl starch (HES)
c. Immune globulin
d. G-CSF
Chapter 20
HDFN is the destruction of the RBCs of the fetus and neonate by IgG antibodies produced by the mother.
Only antibodies of the IgG class are actively transported across the placenta.
Usually, in RhD HDFN, the RhD-positive firstborn infant of an RhD-negative mother is unaffected because the mother has not yet been
immunized; in subsequent pregnancies, fetal cells carrying the Rh antigen immunize the Rh-negative mother and stimulate production
of anti-D.
In ABO HDFN, the firstborn infant may be affected as well as subsequent pregnancies in which the mother is group O and the newborn is
group A, B, or AB; the IgG antibody, anti-A,B in the mother’s circulation, crosses the placenta and attaches to the ABO-incompatible
antigens of the fetal RBCs.
Erythroblastosis fetalis describes the presence of immature RBCs or erythroblasts in the fetal circulation because the splenic removal of
the IgG-coated RBCs causes anemia; the term commonly used now is HDFN.
Although anti-D is the most antigenic of the Rh antibodies, anti-Kell is considered the most clinically significant of the non–Rh-system
antibodies in the ability to cause HDFN.
Prenatal serologic tests for obstetric patients include an ABO, Rh, and antibody screen during the first trimester of pregnancy.
A cord blood workup includes tests for ABO and Rh as well as DAT; the most important serologic test for diagnosis of HDFN is the DAT with
anti-IgG reagent.
RhIG administered to the mother within 72 hours following delivery is used to prevent active immunization by the RhD antigen on fetal
cells; RhIG attaches to fetal Rh-positive RBCs in maternal circulation, blocking immunization and subsequent production of anti-D.
 A Kleihauer-Betke test or flow cytometry is used to quantitate the number of fetal RhD-positive cells in the mother’s circulation as a
result of a fetomaternal hemorrhage.
Self-Assessment Questions
1. The etiology of HDFN is characterized by:
a. IgM antibody
b. Nearly always anti-D
c. Different RBC antigens between mother and father
d. Antibody titer less than 32
2. An important difference between the fetus and the newborn physiology is:
a. Bilirubin metabolism
b. Maternal antibody level
c. Presence of anemia
d. Size of RBCs
3. Kernicterus is caused by the effects of:
a. Anemia
b. Unconjugated bilirubin
c. Antibody specificity
d. Antibody titer
4. The advantage of middle cerebral artery peak systolic velocity Doppler (MCA-PSV) is that it is:
a. Able to measure fetal hemoglobin and hematocrit levels
b. Able to support antigen typing of fetal blood using DNA
c. Helpful for direct transfusion of fetal circulation
d. Noninvasive and decreases risk of adverse events
5. Blood for intrauterine transfusion (IUT) should be:
a. Irradiated, leukocyte reduced, more than 7 days old, HbS negative
b. Irradiated, leukocyte reduced, less than 7 days old, HbS positive
c. Irradiated, leukocyte reduced, less than 7 days old, HbS negative
d. Irradiated, leukocyte reduced, more than 7 days old, HbS positive
6. RhIG is indicated for:
a. Mothers who have anti-D due to allosensitization
b. Infants who are RhD-negative
c. Infants who have anti-D
d. Mothers who are RhD-negative
7. RhIG is given to RhD-negative mothers without regard for fetal RhD type in all of the following conditions except:
a. Ectopic pregnancy rupture
b. Full-term delivery
c. Amniocentesis
d. Induced abortion
8. A Kleihauer-Betke test or flow cytometry indicates 10 fetalcells per 1,000 adult cells. For a woman with 5,000-mL blood volume, the
proper dose of RhIG is:
a. One regular-dose (300 µg) vial
b. Two regular-dose vials
c. Three regular-dose vials
d. Four regular-dose vials
9. ABO HDFN is usually mild because:
a. ABO antigens are poorly developed in the fetus
b. ABO antibodies prevent the disease itself
c. ABO antibodies readily cross the placenta
d. ABO incompatibility is rare
10. A woman without prenatal care delivers a healthy term infant. A cord blood sample shows the infant is 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
Chapter 21
Immune hemolytic anemia is defined as shortened RBC survival mediated through the immune response, specifically by humoral antibody.
In alloimmune hemolytic anemia, patients produce alloantibodies to foreign RBC antigens introduced into their circulation, most often
through transfusion or pregnancy.
Alloimmune hemolytic anemia is self-limiting; when the foreign RBCs are cleared from circulation, RBC destruction stops.
In autoimmune hemolytic anemia (AIHA), patients produce antibodies against their own RBC antigens.
 In AIHA, the autoantibody is directed against the patient’s own RBCs; therefore, there is a consistent source of antibody and antigen present
for continuous RBC destruction.
In drug-induced immune hemolytic anemia, patients produce antibody to a particular drug or drug complex, with subsequent damage to
RBCs.
AIHA may be classified as cold-reactive (18%), warmreactive (70%), or drug-induced (12%); diagnostic tests include the DAT and
characterization of the autoantibody in the serum or eluate.
In AIHA, serum antibody will not be detected until the amount of antibody produced exceeds the number of RBC antigen sites available on
the patient’s own RBCs.
The common antibody specificity in both benign and pathological cold autoagglutinins is anti-I.
In CHD, the DAT will be positive because of complement coating of the RBCs; a cold antibody titer greater than 1,000 may cause visible
agglutination of anti coagulated blood at room temperature.
The classic antibody produced in PCH is called the Donath-Landsteiner antibody, and it has the specificity of autoanti-P. This biphasic
antibody binds to patient RBCs at low temperatures and fixes complement. Hemolysis occurs when coated cells are warmed to 37°C and
complement-mediated intravascular lysis occurs.
In WAIHA, most patients (67%) have both IgG and complement on their RBCs, but 20% have only IgG and 13% have only complement.
Warm-reactive autoantibodies are generally enhanced by enzyme techniques and often have a broad specificity within the Rh blood group
system.
When transfusing a patient with WAIHA, the primary concern is detection and identification of all alloantibodies that are masked by the
warm autoantibody.
In the immune complex drug mechanism, the soluble drug-antidrug complex nonspecifically adsorbs loosely to the RBC surface, yielding
a positive DAT with anti-C3 and sometimes with anti-IgG.
In the drug-adsorption (hapten) mechanism, drugs such as penicillin or cefotetan bind firmly to proteins of the RBC membrane. The DAT
will show reactivity with anti-IgG and often with anti-C3.
In the membrane modification drug mechanism, drugs such as the cephalosporins modify the RBCs so that plasma proteins can bind to
the membrane nonimmunologically. The DAT will often demonstrate reactivity with both anti-IgG and anti-C3.
In the autoantibody drug mechanism, the drug (e.g., alpha-methyldopa/Aldomet) induces production of an autoantibody that recognizes
RBC antigens. Both the autoantibody and eluate are reactive with normal RBCs. The DAT is reactive with anti-IgG.
Self-Assessment Questions
1. Immune hemolytic anemias may be classified in which of the following categories?
a. Alloimmune
b. Autoimmune
c. Drug-induced
d. All of the above
2. When preparing cells for a cold autoadsorption procedure, it is helpful to pretreat the cells with which of the following?
a. Dithiothreitol
b. Ficin
c. Phosphate-buffered saline at pH 9
d. Bovine albumin
3. The blood group involved in the autoantibody specificity in PCH is:
a. P.
b. ABO.
c. Rh.
d. Lewis.
4. Which of the following blood groups reacts best with an anti-H or anti-IH?
a. O
b. B
c. A2
d. A1
5. With cold-reactive autoantibodies, the protein coating the patient’s cells and detected in the DAT is:
a. C3.
b. IgG.
c. C4.
d. IgM.
6. Problems in routine testing caused by cold-reactive autoantibodies can usually be resolved by all of the following except:
a. Prewarming.
b. Washing with warm saline.
c. Using anti-IgG antiglobulin serum.
d. Testing clotted blood specimens.
7. Pathological cold autoagglutinins differ from common cold autoagglutinins in:
a. Immunoglobulin class.
b. Thermal amplitude.
 c. Antibody specificity.
d. DAT results on EDTA specimen.
8. Cold AIHA is sometimes associated with infection by:
a. Staphylococcus aureus.
b. Mycoplasma pneumoniae.
c. Escherichia coli.
d. Group A Streptococcus.
9. Many warm-reactive autoantibodies have a broad specificity within which of the following blood groups?
a. Kell.
b. Duffy.
c. Rh.
d. Kidd.
10. Valid Rh typing can usually be obtained on a patient with WAIHA using all of the following reagents or techniques except:
a. Slide and modified tube anti-D.
b. Chloroquine-treated RBCs.
c. Rosette test.
d. Monoclonal anti-D.
11. In pretransfusion testing for a patient with WAIHA, the primary concern is:
a. Treating the patient’s cells with chloroquine for reliable antigen typing.
b. Adsorbing out all antibodies in the patient’s serum to be able to provide compatible RBCs.
c. Determining the exact specificity of the autoantibody so that compatible RBCs can be found.
d. Discovering any existing significant alloantibodies in the patient’s circulation.
12. Penicillin given in massive doses has been associated with RBC hemolysis. Which of the classic mechanisms is typically involved in the
hemolytic process?
a. Immune complex.
b. Drug adsorption.
c. Membrane modification.
d. Autoantibody formation.
13. Which of the following drugs has been associated with complement activation and rapid intravascular hemolysis?
a. Penicillins.
b. Quinidine.
c. Alpha-methyldopa.
d. Cephalosporins.
14. A patient is admitted with a hemoglobin of 5.6 g/dL. Initial pretransfusion workup appears to indicate the presence of a warm
autoantibody in the serum and coating his RBCs. His transfusion history indicates that he received 6 units of RBCs 2 years ago after an
automobile accident. Which of the following would be most helpful in performing antibody detection and compatibility testing
procedures?
a. Adsorb the autoantibody using the patient’s enzymetreated cells.
b. Perform an elution and use the eluate for compatibility testing.
c. Crossmatch random units until compatible units are found.
d. Collect blood from relatives who are more likely to be compatible.
15. A patient who is taking Aldomet has a positive DAT. An eluate prepared from his RBCs would be expected to:
a. React only with Aldomet-coated cells.
b. Be neutralized by a suspension of Aldomet.
c. React with all normal cells.
d. React only with Rhnull cells.
16. One method that can be used to separate a patient’s RBCs from recently transfused donor RBCs is:
a. Chloroquine diphosphate treatment of the RBCs.
b. Reticulocyte harvesting.
c. EGA treatment.
d. Donath-Landsteiner testing.
17. Monoclonal antisera is valuable in phenotyping RBCs with positive DATs because:
a. Both polyspecific and monospecific antihuman serum can be used in antiglobulin testing.
b. Anti-C3 serum can be used in antiglobulin testing.
c. It usually does not require antiglobulin testing.
d. It does not require enzyme treatment of the cells prior to antiglobulin testing.
18. Autoadsorption procedures to remove either warm or cold autoantibodies should not be used with a recently transfused patient.
Recently means:
a. 3 days.
b. 3 weeks.
c. 6 weeks.
d. 3 months.
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