Specific Requirements

AIMS Specific requirements your patients have for transfusion and how this is managed Classify which patients require: Irradiated components CMV negative components Washed components Phenotype selected components HLA or HPA selected components Learning Outcomes Describe the risks of not requesting specific requirements Describe the recommendations from SHOT regarding specific requirements not met and explain ways that errors can be avoided

Specific Requirements What are specific requirements?

Why are Specific Requirements important? Prevention of transfusion associated Graft versus Host Disease IRRADIATION Prevention of CMV infection or reactivation CMV NEGATIVE Prevention of red cell antibody production PHENOTYPE MATCHED Increase platelet increments post transfusion HLA/HPA SELECTED Prevent anaphylactic reactions WASHED

Irradiation Prevention of Transfusion associated-graft versus Host Disease Ta- GvHD is a result of engraftment and proliferation of alloreactive donor lymphocytes = cytokine release and tissue damage Results: Skin rash, fever, diarrhoea, renal dysfunction and bone marrow failure 1-2 weeks after transfusion >90% mortality rate

Who requires irradiated blood components? Intrauterine transfusions Patients receiving HLA-selected platelets (Transfusions from 1 st or 2 nd degree relatives) Transfusions for neonates that have received transfusions in utero, and neonatal exchanges Recipients of allogeneic stem cell transfusions until GvHD prophylaxis is complete or lymphocytes >1x10 9 /L Auto stem cell transplants (pre to 3 months post) Hodgkin lymphoma Drugs: purine analogues, Campath, ATG

Irradiation applies to which blood components? Cellular Components

Irradiation Case Study Patient with chronic lymphocytic leukaemia and chronic anaemia admitted to ED required urgent transfusion of 2 RBC and 1 PLT Specific requirements box not ticked on request form Sample processed and components issued 1 st unit of blood in progress when patient asked if blood was irradiated Nurse said no and transfusion stopped Nurse contacted laboratory no notification for irradiated components Units recalled and irradiated components issued SHOT report 2013

Irradiation New BSH Irradiated Guidelines due soon Abstract at BSH 2018: Elliot J, Addison J et al. Outcome of failure to irradiate cellular components: a retrospective review of SHOT reports 2010-2016 Br J Haematol 2018; 181 (Suppl.1):143. Detailed analysis of 554 reports between 2010-2016 established that the range of non-irradiated components transfused was 1-486 Patient who received 486 non-irradiated blood/blood components was a patient with Hodgkin Lymphoma

CMV Negative Type of herpes virus 50-60% of population have been exposed to virus without symptoms and therefore CMV positive Transmission of CMV in blood components can lead to a primary infection or reactivation

Who requires CMV negative Blood Components? Intrauterine transfusions Neonates up to 28 days post expected delivery date Elective transfusion in pregnancy Granulocytes if patient is CMV seroneg Do not delay emergency transfusion if CMV negative components not available

CMV Negative applies to which blood components? Cellular Components

CMV Case Study A pregnant woman (gestation 19 weeks) was having a liver transplant The red cells requested and transfused were not CMV negative because the blood transfusion laboratory was unaware the patient was pregnant The requestor did not select CMV negative or indicate that the patient was currently pregnant on the request form This was discovered when documented on the second request form after the initial red cells had already been administered There was no historical record in the transfusion laboratory for this patient SHOT report 2014

Phenotyped Red Cells Antigen matched Helps prevent development of antibodies Helps prevent transfusion reactions Different levels of matching depending on patient type

Who requires phenotyped blood? Patients with red cell antibodies to prevent a transfusion reaction Sickle Cell Disease and Thalassaemia to prevent the production of antibodies K negative red cells for women of child bearing age (<50) - to prevent the production of antibodies that might cause severe haemolytic disease of the foetus and newborn

Where to find this information on a red cell unit?

Phenotype Case Study A child with sickle cell disease received 2 units of red cells that were compatible but not phenotyped matched, and a further 2 units 6 years later, again not phenotype matched Six months later following a further request it was noted that the patient had developed anti-c Further testing identified the patient as C-negative (R0r=cDe/cde) and that she had initially been transfused a C-positive unit The BMS had failed to follow the standard operating procedure (SOP) to have a phenotype performed in the first instance prior to red cell issue SHOT report 2014

HLA/HPA Platelets Selected platelets to patients HLA/HPA type Most commonly used for patients that have poor response to platelet transfusions due to antibodies Should be used for patients with inherited platelet defects i.e. Glanzmanns Thrombasthenia Neonatal alloimmune thrombocytopenia antibodies from mothers circulation bind to babies platelets and remove from circulation Single donor (apheresis)

Washed Components Indicated for patients with recurrent or severe allergic or febrile reactions to red cells Severely IgA-deficient patients with anti- IgA antibodies for whom red cells from an IgA deficient donor are not available

HEV negative Components Patients awaiting solid organ transplant (SOT) from 3 months prior to date of planned elective SOT or from the date of listing for a solid organ transplant Patients who have had SOT for as long as the patient is taking immunosuppressants Patients with acute leukaemia from diagnosis (unless/until decision made not to proceed with stem cell transplant) Patients awaiting allogeneic stem cell transplant from 3 months prior to the date of planned transplant and up to 6 months following transplant, or for as long as the patient is immunosuppressed Extra corporeal procedures only included if within above indications

Other requirements Virally inactivated, non-uk sourced FFP & cryoprecipitate for those born after 01/01/1996 prevention of vcjd Apheresis platelets for those born after 01/01/1996 prevention of vcjd Red Cell units <5 days old for neonatal exchange/large volume transfusions reduce risk of hyperkalaemia

Red cells for IUT / Exchange 1. Group O (usually D Neg, C Neg, E Neg) 2. Antigen negative for maternal antibodies + K negative 3. Donor has donated in the last 2 years 4. PANTS negative and High Titre for anti-a and -B negative 5. HbS negative 6. CMV negative 7. Less than 5 days old 8. CPD not SAGM preservative 9. Hyperconcentrated (IUT >0.7, exchange 0.5-0.6) 10. Irradiated (24 hour expiry)

What requirements need prescribing? Irradiation CMV negative (other than for neonates) Washed HLA matched HEV negative

The Transfusion Lab automatically select... Phenotyped units they must be informed of the patients diagnosis i.e. sickle cell disease MB or SD FFP (MB Cryoprecipitate) for patients born after 01/01/1996 Red cells <5 days old for neonatal exchanges/large volume transfusions

Risk of not prescribing requirements Irradiation and CMV negative requirements should be included as part of the written instruction of blood components The SHOT report 2017 highlighted 225 cases where patients specific requirements weren t met most common (37% n=83) is irradiated blood not given (51% in 2015)

SHOT reports Specific Requirements Not Met SHOT Report 2017 PHB Bolton-Maggs (Ed) D Poles et al. on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group. The 2017 Annual SHOT Report (2018).

SHOT Recommendation Incorrect Blood Component Transfused All professional staff participating in transfusion must perform independent and careful checks. A simple 5-point aide memoire at the final step would remind staff to check for the correct patient identifiers, and the prescription for the correct component and confirmation of specific requirements

Patient Involvement & Shared Care Inform the patient of specific requirements Antibody cards given to patients with red cell antibodies Irradiated leaflet and card to patients who need irradiated blood components If patient transferred, the clinical and laboratory team at referral hospital must be informed