Content

1 Mechanism 2 Direct Coombs test

2.1 Examples of diseases that give a positive direct Coombs test

2.1.1 Examples of alloimmune hemolysis 2.1.2 Examples of autoimmune hemolysis 2.1.3 Drug-induced immune-mediated hemolysis

2.2 Laboratory method 3.1 Examples of clinical uses of the indirect Coombs test

3 Indirect Coombs test 3.1.1 Blood transfusion preparation 3.1.2 Antenatal antibody screening 3.2.1 First stage 3.2.2 Second stage 3.2.3 Titrations

3.2 Laboratory method

4 Coombs reagent 5 Enhancement media 6 History of the Coombs test 7 References 8 External links

Mechanism

Schematic showing the direct and indirect Coombs tests.

The two Coombs tests are based on the fact that anti-human antibodies, which are produced by immunizing non-human species with human serum, will bind to human antibodies, commonly IgG or IgM. Animal anti-human antibodies will also bind to human antibodies that may be fixed onto antigens on the surface of red blood cells (also referred to as RBCs), and in the appropriate test tube conditions this can lead to agglutination of RBCs. The phenomenon of agglutination of RBCs is important here, because the resulting clumping of RBCs can be visualised; when clumping is seen the test is positive and when clumping is not seen the test is negative. Common clinical uses of the Coombs test include the preparation of blood for transfusion in cross-matching, screening for atypical antibodies in the blood plasma of pregnant women as part of antenatal care, and detection of antibodies for the diagnosis of immune-mediated haemolytic anemias. Coombs tests are done on serum from venous blood samples which are taken from patients by venepuncture. The venous blood is taken to a laboratory (or blood bank), where trained scientific technical staff do the Coombs tests. The clinical significance of the result is assessed by the physician who requested the Coombs test, perhaps with assistance from a laboratory-based hematologist.

Direct Coombs test

The direct Coombs test (also known as the direct antiglobulin test or DAT) is used to detect if antibodies or complement system factors have bound to RBC surface antigens in vivo. The DAT is not currently required for pre-transfusion testing but may be included by some laboratories.

[edit] Examples of diseases that give a positive direct Coombs test

The direct Coombs test is used clinically when immune-mediated hemolytic anemia (antibodymediated destruction of RBCs) is suspected. A positive Coombs test indicates that an immune mechanism is attacking the patient's own RBC's. This mechanism could be autoimmunity, alloimmunity or a drug-induced immune-mediated mechanism.

Hemolytic disease of the newborn

Hemolytic disease of the newborn, also known as Hemolytic disease of the fetus and newborn, HDN, HDFN, or Erythroblastosis fetalis,[1] is an alloimmune condition that develops in a fetus, when the IgG molecules (one of the five main types of antibodies) produced by the mother pass through the placenta. Among these antibodies are some which attack the red blood cells in the fetal circulation; the red cells are broken down and the fetus can develop reticulocytosis and anaemia. This fetal disease ranges from mild to very severe, and fetal death from heart failure (hydrops fetalis) can occur. When the disease is moderate or severe, many erythroblasts are present in the fetal blood and so these forms of the disease can be called erythroblastosis fetalis (or erythroblastosis foetalis).

Contents
1 Symptoms 2 Causes 3 Serological diagnoses 4 Diagnosis 5 Treatment 6 Complications 7 Similar conditions

Symptoms
Hemolysis leads to elevated bilirubin levels. After delivery bilirubin is no longer cleared (via the placenta) from the neonate's blood and the symptoms of jaundice (yellowish skin and yellow discolouration of the whites of the eyes) increase within 24 hours after birth. Like any other severe neonatal jaundice, there is the possibility of acute or chronic kernicterus. Profound anemia can cause high-output heart failure, with pallor, enlarged liver and/or spleen, generalized swelling, and respiratory distress. The prenatal manifestations are known as hydrops fetalis; in severe forms this can include petechiae and purpura. The infant may be stillborn or die shortly after birth.[citation needed]

Causes

Antibodies are produced when the body is exposed to an antigen foreign to the make-up of the body. If a mother is exposed to a foreign antigen and produces IgG (as opposed to IgM which does not cross the placenta), the IgG will target the antigen, if present in the fetus, and may affect it in utero and persist after delivery. The three most common models in which a woman becomes sensitized toward (i.e., produces IgG antibodies against) a particular antigen are:
Fetal-maternal hemorrhage can occur due to trauma, abortion, childbirth, ruptures in the placenta during pregnancy, or medical procedures carried out during pregnancy that breach the uterine wall. In subsequent pregnancies, if there is a similar incompatibility in the fetus, these antibodies are then able to cross the placenta into the fetal bloodstream to attach to the red blood cells and cause hemolysis. In other words, if a mother has anti-RhD (D being the major Rhesus antigen) IgG antibodies as a result of previously carrying a RhD-positive fetus, this antibody will only affect a fetus with RhD-positive blood. The woman may receive a therapeutic blood transfusion. ABO blood group system and the D antigen of the Rhesus blood group system typing are routine prior to transfusion. Suggestions have been made that women of child bearing age or young girls should not be given a transfusion with Rhcpositive blood or Kell1-positive blood to avoid possible sensitization, but this would strain the resources of blood transfusion services, and it is currently considered uneconomical to screen for these blood groups. HDFN can also be caused by antibodies to a variety of other blood group system antigens, but Kell and Rh are the most frequently encountered. The third sensitization model can occur in women of blood type O. The immune response to A and B antigens, that are widespread in the environment, usually leads to the production of IgM anti-A and IgM anti-B antibodies early in life. On rare occasions, IgG antibodies are produced. In contrast, Rhesus antibodies are generally not produced from exposure to environmental antigens.

Serological diagnoses
ABO system ABO hemolytic disease of the newborn can range from mild to severe, but generally it is a mild disease. anti-A antibodies anti-B antibodies

Rhesus system rhesus D hemolytic disease of the newborn (often called Rh disease) is the most common form of severe HDN. The disease varies from mild to severe. rhesus E hemolytic disease of the newborn is a mild condition rhesus c hemolytic disease of the newborn can range from a mild to severe disease - is the third most common form of severe HDN rhesus e hemolytic disease of the newborn - rare rhesus C hemolytic disease of the newborn - rare

antibody combinations (ie anti-Rhc and anti-RhE antibodies occurring together) - can be severe anti-Kell hemolytic disease of the newborn anti-K 1 antibodies - disease ranges from mild to severe - over half of the cases are caused by multiple blood transfusions - is the second most common form of severe HDN anti-K
2

Kell system

,anti-K

and anti-K

antibodies - rare

Other blood group antibodies (Kidd, Lewis, Duffy, MN, P and others).

Diagnosis
The diagnosis of HDN is based on history and laboratory findings: Blood tests done on the newborn baby
Biochemistry tests for jaundice Peripheral blood morphology shows increased reticulocytes. Erythroblasts (also known as nucleated red blood cells) occur in moderate and severe disease. Positive direct Coombs test (might be negative after fetal interuterine blood transfusion) Positive indirect Coombs test

Blood tests done on the mother

Treatment
Before birth, options for treatment include intrauterine transfusion or early induction of labor when pulmonary maturity has been attained, fetal distress is present, or 35 to 37 weeks of gestation have passed. The mother may also undergo plasma exchange to reduce the circulating levels of antibody by as much as 75%. After birth, treatment depends on the severity of the condition, but could include temperature stabilization and monitoring, phototherapy, transfusion with compatible packed red blood, exchange transfusion with a blood type compatible with both the infant and the mother, sodium bicarbonate for correction of acidosis and/or assisted ventilation. Rhesus-negative mothers who have had a pregnancy with/are pregnant with a rhesus-positive infant are given Rh immune globulin (RhIG) at 28 weeks during pregnancy and within 72 hours after delivery to prevent sensitization to the D antigen. It works by binding any fetal red cells with the D antigen before the mother is able to produce an immune response and form anti-D IgG. A drawback to pre-partum administration of RhIG is that it causes a positive antibody screen when the mother is tested, which can be difficult to distinguish from natural immunonological responses that result in antibody production.

Complications
Complications of HDN could include kernicterus, hepatosplenomegaly, inspissated (thickened or dried) bile syndrome and/or greenish staining of the teeth, hemolytic anemia and damage to the liver due to excess bilirubin.

Similar conditions
Similar conditions include acquired hemolytic anemia, congenital toxoplasma and syphilis infection, congenital obstruction of the bile duct and cytomegalovirus infection.

Rh disease
Rh disease (also known as Rh (D) disease, Rhesus disease, RhD Hemolytic Disease of the Newborn, Rhesus D Hemolytic Disease of the Newborn or RhD HDN) is one of the causes of hemolytic disease of the newborn (also known as HDN). The disease ranges from mild to severe. When the disease is mild the fetus may have mild anaemia with reticulocytosis. When the disease is moderate or severe the fetus can have a more marked anaemia and erythroblastosis (erythroblastosis fetalis). When the disease is very severe it can cause morbus haemolyticus neonatorum, hydrops fetalis, or stillbirth.

Serology
During any pregnancy a small amount of the baby's blood can enter the mother's circulation. If the mother is Rh negative and the baby is Rh positive, the mother produces antibodies (including IgG) against the Rhesus D antigen on her baby's red blood cells. During this and subsequent pregnancies the IgG is able to pass through the placenta into the fetus and if the level of it is sufficient, it will cause destruction of Rhesus D positive fetal red blood cells leading to development Rh disease. It may thus be regarded as insufficient immune tolerance in pregnancy. Generally Rhesus disease becomes worse with each additional Rhesus incompatible pregnancy. The main and most frequent sensitizing event is child birth (about 86% of sensitized cases), but fetal blood may pass into the maternal circulation earlier during the pregnancy (about 14% of sensitized cases)[1]. Sensitizing events during pregnancy include miscarriage, therapeutic abortion, amniocentesis, ectopic pregnancy, abdominal trauma and external cephalic version. The incidence of Rh disease in a population depends on the proportion that are rhesus negative. Many non-caucasian peoples have a very low proportion who are Rhesus negative, so the incidence of Rh disease is very low in these populations. In Caucasian populations about 1 in 10 of all pregnancies are of a Rhesus negative woman with a Rhesus positive baby. It is very rare for the first Rhesus positive baby of a Rhesus negative woman to be affected by Rh disease. The first pregnancy with a Rhesus positive baby is significant for a rhesus negative woman because she can be sensitized to the Rh positive antigen. In Caucasian populations about 13% of Rhesus negative mothers are sensitized by their first pregnancy with a rhesus positive baby. If it were not for modern prevention and treatment, about 5% of the second Rhesus positive infants of Rhesus negative woman, would result in still births or extremely sick babies and many babies who managed to survive would be severely ill. Even higher disease rates would occur in the 3rd and subsequent Rhesus positive infants of rhesus negative woman. By using anti-RhD immunoglobulin (Rho(D) Immune Globulin) the incidence is massively reduced . Rh disease sensitization is about 10 times more likely to occur if the fetus is ABO compatible with the mother than if the mother and fetus are ABO incompatible.

Prevention Most Rh disease can be prevented by treating the mother during pregnancy or promptly (within 72 hours) after childbirth. The mother has an intramuscular injection of anti-Rh antibodies (Rho(D) Immune Globulin), sold under the brand name RhoGAM. This is done so that the fetal Rhesus D positive erythrocytes are destroyed before her immune system can discover them. This is passive immunity and the effect of the immunity will wear off after about 4 to 6 weeks (or longer depending on injected dose) as the anti-Rh antibodies gradually decline to zero in the maternal blood. It is part of modern antenatal care to give all Rhesus D negative pregnant women an anti-RhD IgG immunoglobulin injection at about 28 weeks gestation (with or without a booster at 34 weeks gestation). This reduces the effect of the vast majority of sensitizing events which mostly occur after 28 weeks gestation. Anti-RhD immunoglobulin is also given to non-sensitized Rhesus negative women immediately (within 72 hours - the sooner the better) after potentially sensitizing events that occur earlier in pregnancy.

Blood tests
Maternal blood
The Kleihauer-Betke test or flow cytometry on a postnatal maternal blood sample can confirm that fetal blood has passed into the maternal circulation and can also be used to estimate the amount of fetal blood that has passed into the maternal circulation. The indirect Coombs test is used to screen blood from antenatal women for IgG antibodies that may pass through the placenta and cause hemolytic disease of the newborn. The direct Coombs test is used to confirm that the fetus or neonate has an immune mediated hemolytic anemia. Full blood count - the hemoglobin level and platelet count are important Bilirubin (total and indirect)

Fetal blood (or umbilical cord blood)

Management
Antenatal
Ultrasound - to detect and monitor hydrops fetalis Quantitative analysis of maternal anti-RhD antibodies - an increasing level is a sign of fetal Rh disease Intrauterine blood transfusion Intraperitoneal transfusion - blood transfused into fetal abdomen Intravascular transfusion - blood transfused into fetal umbilical vein This is more modern and more effective than intraperitoneal transfusion. A sample of fetal blood can be taken from the umbilical vein prior to the transfusion.

Early delivery (usually after about 36 wks gestation)

Postnatal

Phototherapy for neonatal jaundice in mild disease Exchange transfusion if the neonate has moderate or severe disease (the blood for transfusion must be less than a week old, Rh negative, ABO compatible with both the fetus and the mother, and be cross matched against the mothers serum)

[edit] History of medical advances in Rh disease

The Rhesus blood type was first discovered in 1937 by Karl Landsteiner and Alexander S. Wiener.[2] In 1939 Philip Levine and Rufus E. Stetson[3] published their findings about a family who had a stillborn baby who died of hemolytic disease of the newborn. The mother was aged 25 and it was her second pregnancy and she suffered blood loss at the delivery. Both parents were blood group O and the husband's blood was used to give the mother a blood transfusion, but the mother suffered a severe transfusion reaction. They investigated this transfusion reaction. Since the mother and the father were both blood group O, they concluded that there must be a previously undiscovered blood group antigen that was present on the husband's RBCs but was not present on the mother's RBCs and that the mother had formed antibodies against the new blood group antigen. This suggested for the first time that a mother could make blood group antibodies because of immune sensitization to her fetus's RBCs. They did not name this blood group antigen, but it was subsequently found to be the Rhesus factor. The first treatment for Rh disease was an exchange transfusion, which was invented by Dr. Alexander S. Wiener. That procedure was further refined by Dr, Harry Wallerstein,[4] a transfusionist. Although the most effective method of treating the problem at the time, it was only partially ameliorative in cases where damage to the neonate had already been done. Children with severe motor damage and/or retardation could result. However, it is estimated that in the two decades it was used approximately 200,000 lives were saved, and the great majority were not brain damaged. Ronald Finn, in Liverpool, England applied a microscopic technique for detecting fetal cells in the mother's blood. It led him to propose that the disease might be prevented by injecting the atrisk mother with an antibody against fetal red blood cells. He proposed this for the first time to the public on February 18, 1960. A few months later, he proposed at a meeting of the British Genetical Society that the antibody be anti-RhD. Nearly simultaneously with him, William Pollack, then of Ortho Pharmaceutical Corporation, and researchers John Gorman and Vincent Freda[5] of New York City's Columbia-Presbyterian Medical Center, having come to the same realization, set out to prove it by injecting a group of male prisoners at Sing Sing Correctional Facility with antibody provided by Ortho, obtained by a fractionation technique developed by Dr Pollack (who also provided Dr. Finn with several vials of antibody during a visit by Dr. Finn to Ortho). Animal studies had previously been conducted by William Pollack, using a rabbit model of Rh. This model, named the rabbit HgA-F system, was a perfect animal model of human Rh, and enabled Dr. Pollack's team to gain experience in preventing hemolytic disease in rabbits by giving specific HgA antibody, as was later done with Rh-negative mothers. One of the needs was a dosing experiment that could be used to determine the level of circulating Rh-positive cells in an Rh-negative pregnant female derived from her Rh-positive fetus. This was first done in the rabbit system, but subsequent human tests at the University of Manitoba conducted under Dr.

Pollack's direction confirmed that this result matched the human dosing perfectly. The dose is 20 G of antibody for 1mL of Rh-positive red cells. Sir William Liley performed the first successful intrauterine transfusion in 1963. In ABO hemolytic disease of the newborn (also known as ABO HDN) maternal IgG antibodies with specificity for the ABO blood group system pass through the placenta to the fetal circulation where they can cause hemolysis of fetal red blood cells which can lead to fetal anemia and HDN. In contrast to Rh disease, about half of the cases of ABO HDN occur in a firstborn baby and ABO HDN does not become more severe after further pregnancies. The ABO blood group system is the best known surface antigen system, expressed on a wide variety of human cells. For Caucasian populations about one fifth of all pregnancies have ABO incompatibility between the fetus and the mother, but only a tiny minority develop symptomatic ABO HDN[1]. The latter only occurs in mothers of blood group O because they can produce enough IgG antibodies to cause hemolysis. Although very uncommon, cases of ABO HDN have been reported in infants born to mothers with blood groups A[2][3] and B[4].

Causes
Environmental exposure Anti-A and anti-B antibodies are usually IgM and do not pass through the placenta, but some mothers "naturally" have IgG anti-A or IgG anti-B antibodies, which can pass through the placenta. Exposure to A-antigens and B-antigens, which are both widespread in nature, usually leads to the production of IgM anti-A and IgM anti-B antibodies but occasionally IgG antibodies are produced. Fetal-maternal transfusion Some mothers may be sensitized by fetal-maternal transfusion of ABO incompatible red blood and produce immune IgG antibodies against the antigen they do not have and their baby does. For example, when a mother of genotype OO (blood group O) carries a fetus of genotype AO (blood group A) she may produce IgG anti-A antibodies. The father will either have blood group A, with genotype AA or AO, or more rarely, have blood group AB, with genotype AB. Blood transfusion It would be very very rare for ABO sensitization to be caused by therapeutic blood transfusion as a great deal of effort and checking is done to ensure that blood is ABO compatible between the recipient and the donor.

[edit] Moderating factors

In about a third of all ABO incompatible pregnancies maternal IgG anti-A or IgG anti-B antibodies pass through the placenta to the fetal circulation leading to a weakly positive direct Coombs test for the neonate's blood. However, ABO HDN is generally mild and short-lived and only occasionally severe because:

IgG anti-A (or IgG anti-B) antibodies that enter the fetal circulation from the mother find A (or B) antigens on many different fetal cell types, leaving fewer antibodies available for binding onto fetal red blood cells.

Fetal RBC surface A and B antigens are not fully developed during gestation and so there are a smaller number of antigenic sites on fetal RBCs.

[edit] Diagnosis
Routine antenatal antibody screening blood tests (indirect Coombs test) do not screen for ABO HDN. If IgG anti-A or IgG anti-B antibodies are found in the pregnant woman's blood, they are not reported with the test results, because they do not correlate well with ABO HDN. Diagnosis is usually made by investigation of a newborn baby who has developed jaundice during the first day of life.

[edit] Treatment
Neonatal jaundice caused by ABO HDN is usually successfully treated with phototherapy, unless the ABO HDN is uncommonly severe. Treatment of moderate or severe HDN caused by ABO antibodies is similar to that for Rh disease.

[Hemolytic anemiaHemolytic disease of the newborn (anti-Kell ) is the second most common
1

cause of severe hemolytic diseases of newborns (HDN) after Rh disease. Anti-Kell1 is becoming relatively more important as prevention of Rh disease is also becoming more effective. Hemolytic disease of the newborn (anti-Kell1) is caused by a mismatch between the Kell antigens of the mother and fetus. About 91% of the population are Kell1 negative and about 9% are Kell1 positive. A fraction of a percentage are homozygous for Kell1. Therefore, about 4.5% of babies of a Kell1 negative mother are Kell1 positive. The disease results when maternal antibodies to Kell1 are transferred to the fetus across the placental barrier. These antibodies can cause severe anemia by interfering with the early proliferation of red blood cells as well as causing alloimmune hemolysis. Very severe disease can occur as early as 20 weeks gestation. Hydrops fetalis can also occur early. The finding of anti-Kell antibodies in an antenatal screening blood test (indirect Coombs test) is an indication for early referral to a specialist service for assessment, management and treatment.

Contents

Cause
Mothers who are negative for the Kell1 antigen develop antibodies after being exposed to red blood cells that are positive for Kell1. Over half of the cases of hemolytic disease of the newborn owing the anti-Kell antibodies are caused by multiple blood transfusions, with the remainder due to a previous pregnancy with a Kell1 positive baby.

Prevention
Suggestions have been made that women of child bearing age or young girls should not be given a transfusion with Kell1 positive blood. Donated blood is not currently screened (in the U.S.A.) for the Kell blood group antigens as it is not considered cost effective at this time. It has been hypothesized that IgG anti-Kell1 antibody injections would prevent sensitization to RBC surface Kell1 antigens in a similar way that IgG anti-D antibodies (Rho(D) Immune

Globulin) are used to prevent Rh disease, but the methods for IgG anti-Kell 1 antibodies have not been developed at the present time.

Management
It can be detected by routine antenatal antibody screening blood tests (indirect Coombs test) in a similar way to Rh disease. The treatment of hemolytic disease of the newborn (anti-Rhc) is similar to the management of Rh disease.

anti-Kell2, anti-Kell3 and anti-Kell4 antibodies

Hemolytic disease of the newborn can also be caused by anti-Kell2, anti-Kell3 and anti-Kell4 IgG antibodies. These are rarer and generally the disease is milder. Hemolytic disease o the newborn (anti-Rhc) can range from a mild to a severe disease. It is the third most common cause of severe HDN. Rh disease is the most common and hemolytic disease of the newborn (anti-Kell) is the second most common cause of severe HDN. It occurs more commonly in women who are Rh D negative.

Contents
[hide]

1 Causes 2 Prevention 3 Management 4 References 5 See also

[edit] Causes
A Rhc negative mother can become sensitised by red blood cell (RBC) Rhc antigens by her first pregnancy with a Rhc positive fetus. The mother can make IgG anti-Rhc antibodies, which are able to pass through the placenta and enter the fetal circulation. If the fetus is Rhc positive alloimmune hemolysis can occur leading to HDN. This is similar as for Rh disease, which is usually caused when a RhD negative mother is sensitised by her first pregnancy with a RhD positive fetus. Sensitization to Rhc antigens can also be caused by blood transfusion.

[edit] Prevention
It has been suggested that women of child bearing age or young girls should not be given a transfusion with Rhc positive blood (or Kell 1 positive blood for similar reasons). This would require a lot of extra work in blood transfusion departments and it is considered not economical to do the blood group screening at the present time. It is theoretically likely that IgG anti-Rhc antibody injections would prevent sensitization to RBC surface Rhc antigens in a similar way that IgG anti-D antibodies (Rho(D) Immune Globulin) are used to prevent Rh disease, but the methods for IgG anti-Rhc antibodies have not been developed at the present time.

[edit] Management
It can be detected by routine antenatal antibody screening blood tests (indirect Coombs test) in a similar way to Rh disease. The treatment of hemolytic disease of the newborn (anti-Rhc) is similar to the management of Rh disease. Blood transfusion is the process of transferring blood or blood-based products from one person into the circulatory system of another. Blood transfusions can be life-saving in some situations, such as massive blood loss due to trauma, or can be used to replace blood lost during surgery. Blood transfusions may also be used to treat a severe anaemia or thrombocytopenia caused by a blood disease. People suffering from hemophilia or sickle-cell disease may require frequent blood transfusions. Early transfusions used whole blood, but modern medical practice commonly uses only components of the blood.

Contents

Precautions
[edit] Compatibility

The key importance of the Rh group is its role in Hemolytic disease of the fetus and newborn. When an Rh negative mother carries a positive fetus, she can become immunized against the Rh antigen. This usually is not important during that pregnancy, but in the following pregnancies she can develop an immune response to the Rh antigen. The mother's immune system can attack the baby's red cells through the placenta. Mild cases of HDFN can lead to disability but some severe cases are fatal. Rh-D is the most commonly involved red cell antigen in HDFN, but other red cell antigens can also cause the condition. The "positive" or "negative" in heard blood types such as "O positive" is the Rh-D antigen.
[edit] Transfusion transmitted infections

A number of infectious diseases (such as HIV, syphilis, hepatitis B and hepatitis C, among others) can be passed from the donor to recipient. Among the diseases that can be transmitted via transfusion are:
HIV-1 and HIV-2 Human T-lymphotropic virus (HTLV-1 and HTLV-2) Hepatitis C virus (responsible for >90% of post-transfusion hepatitis) Hepatitis B Treponema pallidum Malaria Chagas Disease variant Creutzfeldt-Jakob Disease or "Mad Cow Disease" has been shown to be transmissible in blood products. No test exists for this, but various measures have been taken to reduce risks.

When a person's need for a transfusion can be anticipated, as in the case of scheduled surgery, autologous donation can be used to protect against disease transmission and eliminate the problem of blood type compatibility. "Directed" donations from donors known to the recipient were a common practice during the initial years of HIV. These kinds of donations are still common in developing countries.
[edit] Processing of blood products prior to transfusion

Donated blood is usually subjected to processing after it is collected, to make it suitable for use in specific patient populations. Examples include:
Component separation: red cells, plasma and platelets are separated into different containers and stored in appropriate conditions so that their use can be adapted to the patient's specific needs. Red cells work as oxygen transporters, plasma is used as a supplement of coagulation factors, and platelets are transfused when their number is very scarce or their function severely impaired. Blood components are usually prepared by centrifugation. Leukoreduction, also known as Leukodepletion is the removal of white blood cells from the blood product by filtration. Leukoreduced blood is less likely to cause alloimmunization (development of antibodies against specific blood types), and less likely to cause febrile transfusion reactions. Chronically transfused patients Potential transplant recipients Patients with previous febrile nonhemolytic transfusion reaction Patients with hereditary immune deficiencies Patients receiving blood transfusions from relatives in directeddonation programs Patients receiving large doses of chemotherapy, undergoing stem cell transplantation, or with AIDS (controversial).

Tests for certain quality control issues such as disease or contamination.

[edit] Neonatal transfusion

To ensure the safety of blood transfusion to pediatric patients, hospitals are taking additional precaution to avoid infection and prefer to use specially tested pediatric blood units that are guaranteed negative for Cytomegalovirus. Most guidelines recommend the provision of CMVnegative blood components and not simply leukoreduced components for newborns or low birthweight infants in whom the immune system is not fully developed.[9] These specific requirements place additional restrictions on blood donors who can donate for neonatal use. Neonatal transfusions typically fall into one of two categories:
"Top-up" transfusions, to replace losses due to investigational losses and correction of anemia. Exchange (or partial exchange) transfusions are done for removal of bilirubin, removal of antibodies and replacement of red cells (e.g., for anemia secondary to thalassemias and other hemoglobinopathies).[10]

[edit] Pre-Transfusion compatibility testing Main article: Cross-matching

The terms type and screen are used for the testing that (1) determines the blood group (ABO compatibility) and (2) screens for alloantibodies.[11] It takes about 45 minutes to complete (depending on the method used). The blood bank technologist also checks for special requirements of the patient (e.g. need for washed, irradiated or CMV negative blood) and the history of the patient to see if they have a previously identified antibody. A positive screen warrants an antibody panel/investigation. An antibody panel consists of commercially prepared group O red cell suspensions from donors that have been phenotyped for commonly encountered and clinically significant alloantibodies. Donor cells may have homozygous (e.g. K+k-), heterozygous (K+k+) expression or no expression of various antigens (K-k+). The phenotypes of all the donor cells being tested are shown in a chart. The patient's serum is tested against the various donor cells using an enhancement method, e.g. Gel or LISS. Based on the reactions of the patient's serum against the donor cells, a pattern will emerge to confirm the presence of one or more antibodies. Not all antibodies are clinically significant (i.e. cause transfusion reactions, HDN, etc.). Once the patient has developed a clinically significant antibody it is vital that the patient receive antigen negative phenotyped red blood cells to prevent future transfusion reactions. A direct antiglobulin test (DAT) is also performed as part of the antibody investigation.[12] Once the type and screen has been completed, potential donor units will be selected based on compatibility with the patient's blood group, special requirements (e.g. CMV negative, irradiated or washed) and antigen negative (in the case of an antibody). If there is no antibody present or suspected, the immediate spin or CAC (computer assisted crossmatch) method may be used. In the immediate spin method, two drops of patient serum are tested against a drop of 3-5% suspension of donor cells in a test tube and spun in a serofuge. Agglutination or hemolysis in the test tube is a positive reaction and the unit should not be transfused. If an antibody is suspected, potential donor units must first be screened for the corresponding antigen by phenotyping them. Antigen negative units are then tested against the patient plasma using an antiglobulin/indirect crossmatch technique at 37 degrees Celsius to enhance reactivity and make the test easier to read. If there is no time the blood is called "uncross-matched blood". Uncross-matched blood is Opositive or O-negative. O-negative is usually used for children and women of childbearing age. It is preferable for the laboratory to obtain a pre-transfusion sample in these cases so a type and screen can be performed to determine the actual blood group of the patient and to check for alloantibodies.

[edit] Procedure
Blood transfusions can be grouped into two main types depending on their source:
Homologous transfusions, or transfusions using the stored blood of others. These are often called Allogeneic instead of homologous. Autologous transfusions, or transfusions using the patient's own stored blood.

Donor units of blood must be kept refrigerated to prevent bacterial growth and to slow cellular metabolism. The transfusion must begin within 30 minutes after the unit has been taken out of controlled storage.

Blood can only be administered intravenously. It therefore requires the insertion of a cannula of suitable caliber. Before the blood is administered, the personal details of the patient are matched with the blood to be transfused, to minimize risk of transfusion reactions. Clerical error is a significant source of transfusion reactions and attempts have been made to build redundancy into the matching process that takes place at the bedside. A unit (up to 500 ml) is typically administered over 4 hours. In patients at risk of congestive heart failure, many doctors administer a diuretic to prevent fluid overload, a condition called Transfusion Associated Circulatory Overload or TACO. Acetaminophen and/or an antihistamine such as diphenhydramine are sometimes given before the transfusion to prevent other types of transfusion reactions.

[edit] Blood donation

Main article: Blood donation

Blood is most commonly donated as whole blood by inserting a catheter into a vein and collecting it in a plastic bag (mixed with anticoagulant) via gravity. Collected blood is then separated into components to make the best use of it. Aside from red blood cells, plasma, and platelets, the resulting blood component products also include albumin protein, clotting factor concentrates, cryoprecipitate, fibrinogen concentrate, and immunoglobulins (antibodies). Red cells, plasma and platelets can also be donated individually via a more complex process called apheresis. In developed countries, donations are usually anonymous to the recipient, but products in a blood bank are always individually traceable through the whole cycle of donation, testing, separation into components, storage, and administration to the recipient. This enables management and investigation of any suspected transfusion related disease transmission or transfusion reaction. In developing countries the donor is sometimes specifically recruited by or for the recipient, typically a family member, and the donation immediately before the transfusion.
[edit] Risks to the recipient Main article: Transfusion reaction

There are risks associated with receiving a blood transfusion and these must be balanced against the benefit which is expected. The most common adverse reaction to a blood transfusion is a febrile non-hemolytic transfusion reaction, which consists of a fever which resolves on its own and causes no lasting problems or side effects. Hemolytic reactions include chills, headache, backache, dyspnea, cyanosis, chest pain, tachycardia and hypotension. Blood products can rarely be contaminated with bacteria; the risk of severe bacterial infection and sepsis is estimated, as of 2002, at about 1 in 50,000 platelet transfusions, and 1 in 500,000 red blood cell transfusions.[13] There is a risk that a given blood transfusion will transmit a viral infection to its recipient. As of 2006, the risk of acquiring hepatitis B via blood transfusion in the United States is about 1 in 250,000 units transfused, and the risk of acquiring HIV or hepatitis C in the U.S. via a blood transfusion is estimated at 1 in 2,000,000 (2 million) units transfused.[citation needed] These risks were much higher in the past before the advent of second and third generation tests for transfusion

transmitted diseases. The implementation of Nucleic Acid Testing or "NAT" in the early 2000s has further reduced risks, and confirmed viral infections by blood transfusion are extremely rare in the developed world. Transfusion-associated acute lung injury (TRALI) is an increasingly recognized adverse event associated with blood transfusion. TRALI is a syndrome of acute respiratory distress, often associated with fever, non-cardiogenic pulmonary edema, and hypotension, which may occur as often as 1 in 2000 transfusions.[14] Symptoms can range from mild to life-threatening, but most patients recover fully within 96 hours, and the mortality rate from this condition is less than 10%. [15] Although the cause of TRALI is not clear, it has been consistently associated with anti HLA antibodies. Because anti HLA strongly correlate with pregnancy, several transfusion organisations (Blood and Tissues Bank of Cantabria, Spain, National Health Service in Britain) have decided to use only plasma from men for transfusion. Other risks associated with receiving a blood transfusion include volume overload, iron overload (with multiple red blood cell transfusions), transfusion-associated graft-vs.-host disease, anaphylactic reactions (in people with IgA deficiency), and acute hemolytic reactions (most commonly due to the administration of mismatched blood types). Concerns about whether transfusion risks are heightened by storage time have also been emerging, although there is no consensus on the significance of blood age.[16][17] Relatedly, questions have been raised regarding the uncertain and inconsistent efficacy of transfusions for certain vulnerable patient groups such as the critically ill.[18] Scientists working at the University of Copenhagen reported in the journal Nature Biotechnology in April 2007 of discovering enzymes, which potentially enable blood from groups A, B and AB to be converted into group O. These enzymes do not affect the Rh group of the blood.