Severe donor reaction as a hazard of replacement blood donation.

Blood donation is generally considered to be a safe procedure, but occasionally adverse reactions of varying severity may occur predonation, donation, or postdonation phases. Various studies have reported the incidence of adverse donor reaction as 0.6%-5.6%. Donor reactions are classified into mild, moderate, and severe types or immediate and delayed. Although delayed reactions account for <2% of total adverse donor reactions, 27.6% are severe with or without injury. Herein, we report a case of potentially preventable delayed Grade 2 vasovagal reaction in a 56-year-old replacement blood donor.

Amber coloured plasma-Case for illustration.

INTRODUCTION: Abnormal colour of plasma is infrequently identified during processing of blood and blood components. Common reasons include haemolysis, medications or diet related. Sometimes, the aetiology is unknown. It is a dilemma for every transfusion specialist encountering this situation. Effort should be made to find the aetiology of discolouration of plasma, so that the blood donor can be suitably advised, and a decision can be made regarding the use of blood products. MATERIALS AND METHODS: We encountered two cases of orange coloured (amber coloured) plasma in our regular blood donors. All the common reasons for abnormal plasma discolouration were evaluated, including the donor's medication and diet. Spectrophotometry along with Liquid Chromatography-Mass Spectrometry (LC-MS) in both the positive and negative ion modes with literature search helped in arriving at a conclusion. RESULTS: Haemolysis was ruled out by estimation of plasma haemoglobin. Spectrophotometric analysis of the coloured plasma samples showed a peak, which was absent in normal coloured plasma. This was further investigated using Liquid Chromatography-Mass Spectrometry (LC-MS) in both the positive and negative ion modes. There was no significant difference between the coloured and normal samples in the positive ion mode. But in the negative ion mode, there was a peak observed at 110.5 and 191 m/z value in the profile of the coloured samples in comparison with the normal sample. Literature review shows the peak was corresponding to the presence of quinic acid residues-a substance found in coffee, and potentially excreted into the plasma of an individual with high coffee consumption. CONCLUSION: Reporting unusual causes associated with plasma discolouration is important. Present guidelines forbid issue of abnormal coloured blood and blood components for transfusion. Further such reports are necessary to confirm the safety of recipients receiving such units. This is the first case report to our knowledge of quinic acid discolouring blood products.

Autologous versus allogeneic blood transfusion: A comparative study of the peri-operative outcomes in a tertiary care hospital in South India amidst the COVID-19 pandemic.

Autologous blood transfusion is known to have advantages over allogeneic transfusion. The COVID-19 pandemic intensified the already existing shortage of allogeneic blood supply. We carried out a study during this period with the aim to elicit the effects of autologous blood collection and transfusion, to compare the peri-operative outcomes of autologous and allogeneic transfusion practices and also to assess the influence of the autologous transfusion programme in the Blood Centre inventory. It was prospective observational comparative study among neurosurgical and vascular surgical patients in a tertiary care centre in South India. 141 patients were allocated into Group I (n = 71) who received autologous transfusion and those who received conventional allogeneic transfusion were clustered as Group II (n = 72) for analysis. We employed Acute Normovolemic Hemodilution (ANH), Pre-deposit Autologous Donation (PAD) and Intra-operative Cell Salvage (ICS) as various modalities for autologous blood collection. In our study, 43 (60.6%) from Group I received exclusive autologous blood transfusion, whereas 28 (39.4%) required additional allogeneic transfusion. No significant difference in hemoglobin, hematocrit, platelet count and INR were observed between the groups post transfusion. Significant difference was observed in the thoracoabdominal aortic aneurysm (TAAA) patients with respect to duration of ICU stay (2.7 ± 1.1 days in Group I and 6.2 ± 0.8 days in Group II; p = 0.002) and re-exploration due to bleeding (16.7% in Group I and 40% in Group II; p = 0.048). Autologous blood transfusion is safe and effective. It can be employed as routine practice and also during any acute shortage or pandemic.

Addressing concerns and suggestions of blood donors: An assured way for donor motivation, recruitment, and retention.

The World Health Organization and National Blood Transfusion Council, Government of India, advocate regular repeat nonremunerated voluntary blood donors as the safest of all donors to meet the blood requirements of the country. Recruitment and retention of individuals as voluntary blood donors requires the adoption of novel and varied strategies protecting the voluntary nonremunerated nature of blood donation. In this review article, we are focusing on how addressing the donor suggestions and concerns has created a win-win situation for blood donors and blood transfusion services.

Leukoreduced red cell concentrates: Are they meeting the quality standards?

BACKGROUND: Leukocytes are responsible for producing both immune and nonimmune adverse reactions, and therefore, various methods have been developed to remove them from the blood components before transfusion. AIM: The aim of this study was to analyze the quality parameters in leukoreduced red cell concentrates (RCCs) and investigate the efficiency of leukocyte removal and red cell recovery in the leukoreduction methods followed in our center. MATERIALS AND METHODS: The study evaluated the quality parameters in 112 RCCs prepared using buffy-coat reduction by the Terumo automatic component extractor II+ system, manual saline washing, and leukofiltration using the Leucolab filter system. RESULTS: With analysis, leukofiltration was found to be the most efficient in reducing leukocyte content in RCCs, achieving a mean leukoreduction of 99.99%. Buffy-coat reduction and saline washing achieved a leukoreduction of 78.54% and 82.67%, respectively. While filtration showed the least red cell recovery of 81.93% compared to 90.57% in buffy-coat reduction and 91.87% in saline washing methods. An analysis of hemoglobin content showed that none of the buffy-coat removed RCCs processed from 350-ml collections and underwent poststorage leukofiltration could meet the European Standards for minimum hemoglobin content. CONCLUSION: Filtration is found to be the better method for leukoreduction of RCCs. It is suggested to perform a single method of leukoreduction preferably leukofiltration for maximum red cell recovery.

Autologous blood transfusion in a neurosurgical patient with multiple alloantibodies.

There are many challenges to obtain antigen-negative, crossmatch compatible blood for a patient with multiple alloantibodies. We present a case report of a 31-year-old female patient with a recurrent pontine cavernoma who was to undergo a neurosurgical procedure. We identified alloantibodies anti-Fya and anti-c in her blood sample. To meet her intraoperative blood requirement, we attempted with autologous blood transfusion using both predeposit autologous donation and acute normovolemic hemodilution. Autologous blood alone was sufficient despite anticipating surgical blood loss and a postoperative surgical site infection.

Investigating non-immune haemolytic transfusion reactions in surgical patients.

OBJECTIVE: To perform a Root Cause Analysis (RCA) to identify the cause for Acute Haemolytic Transfusion Reaction (AHTR) in five patients who received red cell transfusions. BACKGROUND: The occurrence of red coloured urine following blood transfusion carries the possibility of an immune or non-immune mediated haemolytic transfusion reaction (HTR). Non-immune haemolysis can be due to thermal, osmotic, or mechanical injury to red blood cells. The authors report five cases of non-immune HTR that occurred in surgical patients in the peri-operative period. METHODS: AHTR was reported to the Transfusion Medicine Department, in five patients who underwent surgery and received a blood transfusion in the peri-operative period. Transfusion reaction workup and RCA were performed to identify the cause for AHTR. RESULTS: The initial presentation was red coloured urine and suspicion of an immune HTR. Immunohaematology workup ruled out an immune mediated haemolysis and further analysis revealed the possibility of mechanical red cell destruction in all these cases. CONCLUSION: Multiple factors can result in non-immune destruction of red cells. Possibility of non-immune haemolysis should be considered while evaluating haemolytic transfusion reactions.

Assessment of Lewis negative phenotype as a risk factor for multivessel disease in patients with acute coronary syndrome.

INTRODUCTION: Acute coronary syndrome is a manifestation of coronary artery disease caused by decreased blood flow to the heart musculature resulting in ischaemia and infarction of the heart. The Lewis (Le) blood group system comprise mainly Lewis a & b antigens which are secreted in plasma and are expressed on red cells, platelets and endothelium. This study assesses the risk of multivessel disease in acute coronary patients with lewis negative (a- b-) phenotype. MATERIALS AND METHODS: The study included 183 patients diagnosed with acute coronary syndrome and who underwent coronary angiography to detect stenosis of the coronary vessels. The severity of the disease was classified based upon the number of vessels stenosed and their blood sample was phenotyped for Lewis antigens. The patients' risk factors, GRACE score and management were included for the study and multivariate logistic regression was carried out for analysis. RESULTS: The prevalence of Lewis (a- b-) was 27.4% and there was a significant association with multivessel disease (P<0.05). However, there was no association of lewis (a- b-) with any of the risk factors causing coronary disease. The adjusted odds ratio of triple vessel disease in lewis (a- b-) was 2.6, female gender was 0.6 and patients with diabetes mellitus was 3.1, respectively. The GRACE score showed a significant association with ABO blood group (P<0.05) but not with lewis (a- b-). DISCUSSION: Lewis negative patients are more likely to develop triple vessel disease compared to other lewis blood groups. This warrants further studies to investigate the link between lewis system and atherothrombosis.

Molecular characterization of rare D--/D-- variants in individuals of Indian origin.

BACKGROUND: Rh antigens are critical in haemolytic disease of the foetus and newborn (HDFN). The D-- phenotype is a rare blood group characterised by the lack of expression of C, c, E and e antigens at the surface of red blood cells because of mutations in both RHCE alleles inactivating the expression of a "normal" protein. The aim of the study was to determine the molecular basis of D-- individuals of Indian origin. MATERIALS AND METHODS: Ten Rh D-positive postnatal women who had produced antibodies against all Rh antigens, except D, leading to HDFN and foetal loss, were investigated. Extensive serological and molecular (polymerase chain reaction [PCR] using sequence-specific primers), quantitative multiplex PCR of short fluorescent fragments (QMPSF), and Sanger sequencing analyses were carried out. RESULTS: Serological testing with anti-C, anti-c, anti-E, and anti-e reagents showed absence of the four antigens in all ten index cases, as well as in three siblings. Flow cytometry indicated absence of these antigens with a typical exalted expression of the D antigen, thus confirming the rare D-- phenotype. Molecular analysis by QMPSF suggested homozygous CE-D hybrid alleles causing the D-- phenotype: RHCE-D(3-9)-CE (n = 11), RHCE-D(3-8)-CE (n=1), and RHCE-D(2-6)-CE (n=1). DISCUSSION: For the first time, we report the molecular basis of the D-- phenotype in the Indian population. Identification and characterisation of RHCE-null variants by molecular methods can help resolve transfusion-related problems in these individuals. Family studies of index cases helped to identify rare blood donors and offer counselling to females of child-bearing age on the complications involved in such pregnancies.

Patient blood management in a neurosurgical patient with anti-e antibody.

The successful application of patient blood management approach in a 48-year-old neurosurgery patient planned for meningioma excision and requiring transfusion is described. The patient had multiple past immunizing events and developed antibody against a high-frequency antigen "e" of the Rh blood group system. With the joint effort from transfusion medicine specialist, anesthesiologist, and surgeon, the patient was successfully managed using the preoperative autologous blood donation program.

A comparative analysis of factors influencing haemoglobin content in RBC units.

BACKGROUND AND OBJECTIVES: The increment in a patient's haemoglobin level is based upon the haemoglobin content of the transfused RBC units. The total haemoglobin present in the blood bags can vary because of the blood donor, processing method, volume and type of bag used. The study is done to analyse the factors causing variation of haemoglobin content in RBC units. MATERIALS AND METHODS: A total of 260 RBC units were tested for the haemoglobin content and analysed with the donor variables (age, gender, weight & capillary haemoglobin). The blood bags were then separated into two groups based on the donor capillary haemoglobin (normal 12.5-15.0 g/dL vs high 15.1-18.0 g/dL), volume (350 vs 450 mL), processing method (Platelet rich plasma vs buffy coat) and further analysis was carried out. RESULTS: The mean haemoglobin content was 54.7 g ranging from 34.2-80 g per unit. The factors which significantly influenced (p < 0.0001) were capillary haemoglobin, gender and weight of donor, volume of blood collected and the processing method. There was a significant difference (p < 0.0001) in haemoglobin content between the two groups in all the three categories (capillary haemoglobin, volume and processing method). Regression analysis showed all three of them contributed to 80 % variability of haemoglobin content in the RBC unit. CONCLUSION: The marked variation of haemoglobin content in our study revealed that there is a need for standardizing RBC unit. Labelling of units with haemoglobin content and transfusion based on it will result in better patient care.

D--phenotype due to RHD-RHCE hybrid transcript in a case of severe haemolytic disease of newborn with anti-Rh 17(Hrₒ) antibodies.

BACKGROUND: D antigen is one among the most immunogenic antigens and is the most common cause of Haemolytic Disease of Fetus and Newborn (HDFN). The D-phenotype is a rare Rh variant in which none of the RhCE antigens are expressed on the red cell surface. Individuals having D-phenotype are capable of producing a rare alloantibody named as anti-Rh17(Hr° ) in response to pregnancy or transfusion and has the potential to react with C/c and E/e antigens causing severe haemolytic transfusion reaction (HTR) and haemolytic disease of fetus and newborn (HDFN). CASE REPORT: We have encountered a case of severe HDFN with an accidental discovery of D- phenotype of the mother with anti-Rh-17 antibodies. D- phenotype has been confirmed with molecular typing along with genotyping of all family members. CONCLUSION: Rare phenotypes like D- individuals especially if allo-immunised are of great concern at times of transfusion requirements. Hence, proper identification of these individuals are important to contribute them to the rare donor pool and to adopt adequate patient blood management strategies.

Case series investigation on the Lewis system antibodies encountered during a routine screening in a tertiary care hospital-based blood center.

BACKGROUND: Anti-Lewis antibodies, usually do not react at 37°C, hence are clinically insignificant. However, on rare occasions, these antibodies have been reported as the cause for hemolytic transfusion reaction (HTR). AIM: We report our experience on the 6 cases of anti-Lewis antibodies that reacted at room temperature (RT) and at 37°C. MATERIALS AND METHODS: Standard serological methods were employed in detection and identification of antibodies. Demographic and clinical details were obtained from the records on the subjects under study. RESULTS: These were found among the patients and the blood donors of varied age groups and gender (21 to 65 years). Also, they were found among the patients with varied clinical diagnosis. The 2 patients in second trimester had anti-Le a or anti-Le b and other 2 male patients had anti-Le ab or anti-Le b with wide thermal amplitude were found during the course of pre- transfusion compatibility tests including antibody screening and cross-matching. Two male donors typed Le (a-b-) had anti-Le ab with wide thermal amplitude. Lewis antigen negative RBC units were provided for transfusion in the situation. CONCLUSION: Although antibodies to Lewis blood group antigens often react at lower temperatures and therefore remain clinically insignificant, some of them, on rare circumstances, may react at higher temperature of 37°C and may produce hemolytic episode or at least yield reduce survival of incompatible red cells in transfusion recipients. On safer side, the antigen-negative unit may be used in transfusion. The donors' registry with detailed phenotype profile may go a long way to provide blood for transfusion in emergency situations.

A case of severe donor reaction leading to grievous injury.

Adverse events of variable severity may occur occasionally following whole blood donation. We are reporting a case of severe donor reaction leading to grievous injury. A first-time male voluntary blood donor donated blood in our blood donation camp. The donation was uneventful, and he left the premise after 20 min of postdonation observation and advice. Several minutes later, he fell on the road and injured himself complicated with severe delayed vaso-vagal reaction. The donor had lacerated wound over the chin, fracture neck of the left mandible, fracture left lower incisor and left lower molar tooth. Appropriate medical care was catered to the donor with full medical support from Department of Transfusion Medicine and was fully recovered from the injury. Blood collection team must take up the responsibility of the management of all complications related to blood donation.

Detection of a rare subgroup of A phenotype while resolving ABO discrepancy.

Weaker subgroups of ABO blood group system give rise to discrepancies between forward and reverse grouping and cause diagnostic difficulties in routine blood banking. Weaker subgroups of A blood group that have been reported so far include A3, Aend, Ax, Am, Ay, and Ael. We report a case of a 54-year-old patient whose red cells showed a discrepancy between cell and serum grouping on initial testing. Serological investigation included absorption elution tests and saliva testing after performing initial blood grouping. Molecular genotyping of the ABO gene was performed by DNA sequencing of exons 6 and 7 of the ABO gene. The serological characteristics of the patient's red cells were similar to Ax subtype. The patient was a secretor and only H substance was present in the saliva. Serum did not show the presence of anti-A1. Molecular genotyping confirmed the ABO status as Aw06/O13. The weak A phenotype identified in the propositus had serological characteristics similar to Ax and showed the ABO genotype Aw06/O13. Although Aw06 allele has been previously reported in the Indian population, this is the first study to report O13 allele in the Indian population.