성균관의대 삼성서울병원
조 덕
1. 2016 수혈가이드라인 - 백혈구제거 혈액제제 - 방사선 조사 혈액제제 - 세척 혈액제제
2. 수혈부작용: ATRs
3. RhD 음성자(Asia type DEL) 수혈 4. Daratumumab and Blood-
compatibility Testing
leukocyte reduced & irradiated blood
components
Leukocyte reduction filter
In US
< 5.0 X 10^6 / Unit
In UK/EUR
< 1.o X 10^6 / Unit
In Korea
국내 백혈구제거 혈액제제 정도관리 자료
2016 수혈가이드라인
cardiac sugery
Hematol Oncol Stem Cel Ther 2008;106-123
Prestorage
Generally within 72 hr of collection
Post-storage
In transfusion service
At bedside (less common)
Eight Patients with Hypotensive Reactions to Transfusion.
Hypotensive Transfusion Reactions in Pts Taking Angiotensin-Converting–Enzyme Inhibitors
The pathogenesis of these reactions
involves bradykinin generation as blood is filtered over certain leukoreduction filters.
ACE inhibitors prevent bradykinin
breakdown; thus, patients receiving ACE
inhibitors are exposed to higher bradykinin levels.
Quiz 1
다음 중 백혈구제거혈액제제 사용의
적응증가 가장 거리가 먼 것은?
Immunological effects
- Presentation of foreign HLA antigens to host immune system
- Leads to anti-HLA antibodies
- Platelet refractoriness - Issues with transplants
https://vimeo.com/82044463
Non-immune causes
– fever, sepsis, splenomegaly, DIC, medications – hypersplenism etc
Immune causes
–
Alloimmunization to HLA and/or plateletspecific antigen due to prior exposure from
pregnancy, transfusions and/or transplantation
적십자사 혈액수혈연구원 이선아
Quiz 2
현재 대한적십자사에서 일반 혈소판이 아닌 HLA matched 혈소판을 신청할 경우 환자에 게 추가로 시행할 필수 검사는?
leukocyte reduced & irradiated blood
components
2016 수혈가이드라인
Rare (0.1 to 1% of those susceptible)
Attack on host tissues by transfused T- lymphocytes
Damage to skin, liver, GI tract, mucus memb., Bone marrow
Nearly always fatal in less than 1 mon
2016 수혈가이드라인
2016 수혈가이드라인
Father immune system;
Ignore transfused child 1’s lymphocytes
Child 1’s lymphocyte kills Father’s tissues
Effects of irradiation on potassium levels in RBCs
Pre-stored RBC that has been irradiated
3 days prior
Continuous AutoTransfusion System (CATS) to wash RBCs, in order to lower the high potassium (K+) level in the
packed RBCs unit, during massive transfusion following transfusion-induced hyperkalemic cardiac arrest.
3 log reduction !!
AABB 18th
Quiz 3
다음 중 방사선 조사 후 24시간 이내에 방사 선조사 적혈구를 수혈해야하는 경우가 아닌 것은?
수혈부작용
Anaphylactic Transfusion Reaction
ATRs present with mild to severe anaphylactic reactions and lead to dyspnea, shock, loss of
consciousness, tachycardia, and in rare cases, death.
Patients with IgA deficiency,
anhaptoglobinemia, and C3 and C4 deficiencies are at an increased
risk of developing ATRs
Allergic transfusion is most common transfusion reaction – occurs in all types of product but less common with pRBCs
Anaphylactic reactions occur in 1:20,000 to 1:47,000 components transfused
Anaphylactic reactions associated with IgA
deficiency or haptoglobin deficiency, especially in
Asian patients; incidence 1:1000 recipientsA 50-yr-old Korean woman was diagnosed with relapsed
AML-M3. She developed thrombocytopenia during chemotherapy and an anaphylactic transfusion reaction on the 4th and 5th platelet transfusions immediately after the transfusion of the platelet
concentrates was initiated.
No detectable serum haptoglobin.
Anhaptoglobinemia occurs because of an allelic
deletion in the Hp gene cluster.
The presence of an antibody against haptoglobin was
detected by performing ELISA.
is an effective way of eliminating the plasma component
. Platelet washing can also be achieved by centrifugation and resuspension in saline by the manual method
or by using washing instrument such as Cobe 2991
Not encouraged: PNH, AIHA etc
Quiz 4
다음 중 세척혈소판 혹은 세척적혈구 수혈의 적응증은?
53/3 1
RhD 음성 환자가
혈소판 수혈을 지속적으로 받아야 할 상황
Case
Anti-D 발생을 예방하기 위하여 (특히, 가임기 여성)
1. 산모에게 RHIG 투여 (임신, 출산 등) 2. D-환자에게 D-음성 적혈구의 수혈
3. D+혈소판 수혈받은 D- 환자에게 RHIG 투여
수혈의학 4판
Asia type DEL
RhD (-): 0.15%
RhD variant: rare - weak-D 형 - Partial-D 형
- DEL 형 : 15% (Asian type DEL type)
RhD & D variants 빈도
KJBT, 2007, 이 혜련 등 Kim JY, 2005, Transfusion
수혈의학 4판
61/3 1
RhD 음성(실은 D변이형) 혈액 수혈 후 항-D가 발생한 환자 발생!
Problem !
68세 D 음성 (ccddee) 여자 환자,
복부대동맥 수술 시
D 음성 RBCs 2 unit 혈액을 수혈 후
수술 전에 없었던 항-D 항체 발생
Kim et al. KJLM 2009
64세 러시아 D 음성 (ccddee) 환자,
전립선 암 수술
D 음성 RBCs 2 unit 혈액을 수혈 후
수술 전에 없었던 항-D 항체 발생
RhD 검사법
RhD typing
Weak D typing
Adsoption_Elution Test
RHD genotyping
DEL - Elution
D(-) 환자에게 D+ 혈액 수혈
2006, KJBT
2010, NEJM
Non-cde만 유전자 검사!
..cde인 경우 Weak D 검사도 안해도 됨 (이론상)
D 변이형 환자의 수혈
29 yr, Male
left isomerism with complex congenital heart disease
수술 기왕력이 4회
수술시 Massive transfusion 가능성 있음
Asia type DEL (c. 1227 G>A) 확인
submitted
0 20 40 60 80 100 120
0 2 4 6 8 10 12 14 16 18 20
Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Hemoglobin g/dL Platelet x10³/μL
1
3 2
6 4
11
7
2 1
2 1 5
RhD- SDP Unit RhD+ SDP Unit RhD- RBC Unit RhD+RBC Unit Rhogam
1500 IU Heart
Transplantation
- + - - - - - -
Ab screening
Anti-D
Hb PLT
Figure 1. Laboratory findings and blood transfusion record of the case during admission
Quiz 5
Asia type DEL 형에 관한 설명이다. 틀린 것 은?
MM 환자가 적혈구 수혈 요청함.
교차시험에서 모두 양성으로 공급할 혈액이 없다고 보고됨
Case
comfirmed by flow cyometry that CD 38 is weakly expressed on human RBCs
Surface expression of RBC CD38 appears to be relatively low, potentially explaining the weak agglutination reactions seen in vitro. Despite
binding to RBCs, DARA did not cause significant hemolysis in the five treated patients.
To date, no transfusion-related adverse events have been observed in approximately 2000 patients who have been treated with daratumumab in the clinical
development program.
Transfusion. 2015 Jun;55(6 Pt 2):1545-54.
-
Despite binding to RBCs, DARA did not cause significant hemolysis in the five treated Pts.- Clinicians should inform patients of the risk of delayed or incompatible blood transfusions when they are being treated with daratumumab.
Quiz 6
( ) 투여 중인 환자의 정보를 혈액은행과 공유하지 않을 경우 혈액요청시 출고가 지연 되거나 안될 수가 있다. ( ) 안에 적합한 약제는?
