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   Table of Contents - Current issue
Coverpage
July-December 2019
Volume 4 | Issue 2
Page Nos. 129-248

Online since Thursday, October 17, 2019

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EDITORIAL  

Transfusion Medicine has Emerged: Redefining the Role of the Transfusion Specialists in the Changing Scenario p. 129
Shivaram Chandrashekar
DOI:10.4103/GJTM.GJTM_59_19  
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REVIEW ARTICLES Top

Risk mitigation in blood transfusion services – A practical approach at the blood center level p. 132
Shivaram Chandrashekar, Ambuja Kantharaj
DOI:10.4103/GJTM.GJTM_58_19  
Hemovigilance is a set of surveillance procedures starting from the donor vein and ending with the patient vein, aimed at reducing the risks associated with transfusion which could be donor related, recipient related, or process related. Donor-related risks include local and systemic complications which need a variety of interventions to ensure safe blood donation and are mainly aimed at preventing local trauma and fall or injury after a blood donation resulting from a vasovagal reaction. Recipient-related risks are hemolytic and nonhemolytic in nature and may present with fever, rash, or dyspnea besides other features. Appropriate mitigation measures are needed for each of them, especially the more ominous ones like transfusion-related acute lung injury/transfusion-associated circulatory overload. Process-related risks are the leading cause of risks associated with transfusion. Human errors can be mitigated by the use of technology such as barcoding, radio-frequency identification, digital transporter boxes, and having effective protocols and checklists in place.
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Platelet refractoriness p. 140
B Sunil Rajadhyaksha, D Priti Desai, A Anisha Navkudkar
DOI:10.4103/GJTM.GJTM_45_19  
Platelet transfusion support is extensively required for hemato-oncology patients who are multiply transfused. Platelet refractoriness can represent a significant clinical condition that complicates the platelet transfusion support in such patients. It remains a challenge associated with an increased bleeding risk, longer hospital stays, and increased morbidity and mortality. Causes for refractoriness are broadly divided into nonimmune and immune causes. Approximately two-thirds of refractory episodes are due to nonimmune factors while one-third are due to immune factors. Common formulae to assess platelet refractoriness include corrected count increment (CCI), posttransfusion platelet increment, and percentage platelet recovery. Measurement of CCI is one of the best parameters to differentiate between immune and nonimmune causes. In nonimmune factors which are associated with increased platelet consumption, treating the underlying cause and increasing the frequency of transfusion should be considered. However, in immune factors which are due to increased destruction of platelets owing to alloimmunization, other strategies such as ABO-identical/ABO-compatible fresh platelets, human leukocyte antigen-matched platelets, and crossmatched platelet transfusions should be considered. The newer approach includes epitope-matched platelet transfusion which is still in amateur stage. The strategies in the prevention of alloimmunization include leukoreduction of blood components, reducing donor exposure by providing single-donor platelets, and providing ABO-compatible platelets from the beginning of the treatment. This review will address the causes of platelet refractoriness and practical approach to the diagnosis, management, and its prevention.
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ORIGINAL ARTICLES Top

Platelet compatibility and platelet antibodies detection: A step towards resolving dilemma in management of platelet refractoriness in oncology patients p. 148
Sadhana Mangwana, Atin Kacker, Nikhil Simon
DOI:10.4103/GJTM.GJTM_51_19  
Background: Platelet refractoriness complicates the provision of platelet transfusions- a critical and essential part in management of thrombocytopenia in Oncology patients. Platelet refractoriness poses challenge due to alloimmunization to HLA (Class I) and human platelet antigens (HPAs) and is associated with adverse clinical outcomes and increases health care costs. Aim: A prospective, observational study was planned in medical oncology patients having thrombocytopenia to analyse result of platelet compatibility with post-transfusion platelet count increment and to ascertain presence of platelet antibodies as causative factor in platelet refractory patients. Methods: Eighty oncology patients having thrombocytopenia in a tertiary care centre; both solid organ and hematological malignancies, requiring platelet transfusion were included in this study. ABO-compatible, leucoreduced, random donor platelets with less than 72 hours storage and platelet cross matched were transfused. In case of platelet refractoriness and presence of platelet incompatibility, platelet antibody screening test was performed using SPRCA technique. A P-value < 0.05 was considered statistically significant. Results: Study population was 18-85 years with maximum number of cases (31.3 %) in 60-70 years age group with equal number of both genders. 80% cases showed platelet cross-match compatibility, while 20% were platelet cross-match incompatible. Amongst incompatible platelet cross matches, 87.5% cases showed presence of platelet alloantibodies and all cases except one showed platelet refractoriness. Platelet yield in compatible platelet cross match was higher than in patients with incompatible platelet cross match (P-value < 0.001). Previous exposure in the form of Pregnancy (61% cases) and history of transfusion (54% cases) played a vital role in platelet refractoriness and development of platelet alloantibodies. Patients treated with chemotherapy (78.8%) had significant risk of platelet refractoriness and platelet alloimmunization. Conclusion: Platelet cross matching along with testing for anti-platelet antibodies using SPRCA method is an effective, useful tool and rapid, first-line approach for selecting compatible platelets from the local inventory as compared to HLA-matched platelets in the treatment of thrombocytopenic cancer patients. Blood services must be aware of the measures to prevent alloimmunization and correct identification of refractoriness to provide adequate transfusion support for oncology patients reducing hospital length of stay and minimizing health care cost.
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The least incompatible crossmatch red blood cell transfusion by biological compatibility test p. 154
Senem Maral, Sule Mine Bakanay, Sema Akıncı, Aysun Senturk Yıkılmaz, Pinar Comert, Imdat Dilek
DOI:10.4103/GJTM.GJTM_37_19  
Introduction: Pretransfusion testing is an essential serological test to protect the recipient from hemolysis and provide compatible blood product. The final step is the crossmatching test which is done by the transfusion center. Although all products are crossmatched in same cases, compatible products may not be available. Aims and Objectives: This study aimed to determine the safety and efficacy of the least incompatible crossmatched erythrocyte transfusion, through the use of biological in vivo crossmatch testing. Materials and Methods: The study included twenty patients who required transfusion and for whom appropriate red blood cell (RBC) could not be found. Totally, 69 units of least incompatible RBC transfusion from crossmatch incompatible products was administered by applying the “in vivo compatibility” test. Patients were observed during the transfusion with respect to acute hemolytic reactions that could develop. The biochemical hemolysis parameters were examined before and at 24 h after transfusion. Results: All transfusions were completed successfully with no complications or symptoms observed in any case. A statistically significant increase in hematocrit (Hct) and hemoglobin was seen post transfusion (P < 0.001). As parameters of hemolysis, lactate dehydrogenase and bilirubin levels were found to be statistically normal (not increased) (P = 0.453 and 0.946, respectively). Conclusions: Biological in vivo compatibility testing seems to be a safe, predictive, and bedside feasible test, which could be lifesaving for many patients.
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NATSpert ID TripleH: A novel individual donor multiplex nucleic acid amplification test to reduce risk of transfusion-transmitted infections: Two-year experience of a blood bank in central India p. 158
Sheela M Mundhada, Gautam R Wankhede, Shefali Desai, Dakhave Minal
DOI:10.4103/GJTM.GJTM_54_19  
Background: In India serological screening is mandatory for all donated blood for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) while Nucleic Acid Amplification Testing (NAT) is not a mandatory screening test. There is a risk of transfusion-transmitted infections (TTI) during window period using serology. Aims and Objectives: The aim of this study was to analyse NAT screening using an indigenously developed, Indian manufactured Individual Donor NAT (ID-NAT) and compare it with serology. Materials and Methods: All blood donations between June 2017-March 2019 were screened serologically for HBV, HCV and HIV at an Indian blood bank. Blood donations also underwent ID-NAT screening using the NATSpert ID TripleH detection assay based on real time PCR. The results were analysed to identify yield cases. Results: In the study, 30,772 blood donor samples were screened serologically out of which 214 were reactive. 30,558 serologically non-reactive blood donations and 77 randomly selected, serologically reactive blood donations were screened using NATSpert. Out of 30,635, 85 donor samples were reactive on the NATSpert which included 77 serology positive and 8 NAT yield cases. The NAT yield found was 2 each for HBV/HIV and 4 of HCV. Conclusion: The NATSpert ID TripleH offers a statistically significant advantage over EIA in ability to detect TTI in blood donors (P < 0.05, Fishers Exact Test). The NAT yield of 1:3829 was in line with other Indian studies. NATSpert assay will provide a significant improvement in blood safety and offer a cost benefit compared to the imported products.
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Adverse effects of intermittent flow therapeutic plasmapheresis in neurology patients in a resource constrained setting p. 163
Sukanya Baruah, Sundar Periyavan
DOI:10.4103/GJTM.GJTM_1_19  
Introduction: Therapeutic plasma exchange (TPE) aims at removing harmful substances from patient's plasma. It has become a treatment option in a variety of neurological disorders with good outcome. In the last decade, there has been an increase in the number and spectrum of indications for therapeutic apheresis. Aims and Objectives: To analyse the complications of plasmapheresis patients with varied neurological disorders in a tertiary care neurocentre to evaluate the safety of the procedure. Materials and Methods: A retrospective analysis of complications in all patients who underwent TPE for various neurological disorders in the Transfusion Medicine Department from April 2013 to May 2014 was carried out. Patient record files and TPE protocol forms were analysed to collect the data about various complications during the procedure. Results: A total of 1912 procedures were carried out on 399 patients. Guillain Barre Syndrome was the most common indication. A total of 145( 36.3%) patients had adverse reactions. Mild reactions like rash (40%), chill and rigor (21%), cramps (6.8%) were found in 98 cases (68%). Moderate reactions included hypotension (17.9%), access site pain and hematoma (7.5%), vasovagal attack (3.44%), seizure (1.37%) etc. Severe life threatning reactions were not seen in any of the cases. Conclusion: Our results advocate TPE as a safe and effective procedure in neurological disorders. Most complications are mild and can be managed effectively. Complications can be further reduced by careful patient monitoring, use of prophylactic calcium and use of albumin as replacement fluid.
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“Prevalence of Inhibitors in Hemophilia Patients and its Clinical Implications”: A Study of 276 Patients in Western India p. 168
Sangita Darshan Shah, Tarak R Patel, Nidhi M Bhatnagar, Maitrey D Gajjar, Mamta Chintan Shah, Sujata Tripathi
DOI:10.4103/GJTM.GJTM_35_19  
Introduction: Hemophilia is an X-linked congenital bleeding disorder caused by a deficiency of coagulation factor VIII (FVIII) in hemophilia A (HA) or factor IX (FIX) in hemophilia B (HB). Accurate diagnosis of hemophilia by factor assay to demonstrate deficiency of FVIII or FIX is essential for appropriate management. Inhibitor development results in partial or complete lack of the efficacy of replacement therapy, and it makes the management of patients more difficult with an increased risk of morbidity, serious bleeding, and disability, resulting in a substantial impact on patient's quality of life and health-care costs, compared to patients without inhibitors. Aims and Objectives: To assess the incidence of inhibitor development in HA and HB patients along with its consequences. Materials and Methods: The present study was carried out at a tertiary care teaching hospital in Western India. A total of 276 patients of hemophilia were included in the study. FVIII, FIX, and inhibitor screening were carried out in all patients sample as routine testing. Patients who were found positive in inhibitor screening were further evaluated for quantitative assay (Bethesda assay). Results: Out of total 276 patients, 243 patients of HA and 33 patients of HB were observed. The incidence of inhibitor development is 20.57% in HA and 6.06% in HB. The maximum number of patients and maximum number of inhibitors was between the age group of 11 and 30 years. There was more number of patients with severe disease as compared to mild and moderate forms. The concentration of inhibitor >5 BU was seen in 76% of HA patients and 100% of HB patients with inhibitor. Sixty-one patients came for follow-up. In three patients, inhibitor disappeared. The incidence of complications was more in patients who had developed inhibitor which increases the cost of treatment and increases the social suffering of the patients. Conclusion: Inhibitor development affect the severity and treatment of the disease significantly and there by increases the suffering and cost to the patient.
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Critical audit of fresh frozen plasma transfusion practices in obstetric and gynecology departments in a tertiary care hospital – Where and what needs to be improved? p. 175
Vandana Puri, Ipsita Dhal, Kalpana Singh, Geetika Sharma, Preeti Rai, Sunita Sharma
DOI:10.4103/GJTM.GJTM_49_19  
Introduction: Fresh frozen plasma (FFP) prepared from whole blood contains plasma proteins and all the coagulation factors including factor V and factor VIII. Many FFP transfusion guidelines have been published till now. However, the administration is inappropriate without any scientific basis or clinical indication in many hospital settings. Aims and Objectives: A retrospective study was carried out between February 2016 and August 2016 in the regional blood transfusion center of our institution to assess the appropriate usage of FFP in obstetrics and Gynecology. It was done using the FFP transfusion guidelines based on the British Committee for Standards in Hematology and College of American Pathologists. Materials and Methods: Blood bank requisition forms received from patients of obstetrics and gynecology department during this period were screened. Indications for transfusion requests were studied and further divided into appropriate and inappropriate requests. Results: A total of 901 units of FFP were issued to 250 patients during this period. Appropriate usage of FFP was found in 67% and inappropriate usage in 33% of the 250 patients evaluated. Bleeding related to surgery with deranged coagulation profile constituted the most common appropriate indication for FFP infusion, and severe anemia was the most inappropriate indication for FFP use. Conclusion: The usage of FFP requires a proper understanding and knowledge about the appropriate and inappropriate usages. It also involves training and supervising the medical staff at regular intervals. Computerized audit programs are required to do a prospective monitoring of the FFP issue and usage in any clinical setting. Further studies are required on the usage of FFP specifically in obstetric and gynecology patients to improve the utilization of this precious blood product.
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Allogenic blood transfusion requirements and effects of storage age of blood units on postoperative period in cardiac surgeries: An analytical study p. 180
Basudev Pokhrel, Abhishekh Basavarajegowda, Sai Chandran, Debdatta Basu, Tanveer Rehman
DOI:10.4103/GJTM.GJTM_47_19  
Introduction: The clinical use of blood with regard to cardiac surgeries should be justifiable as it is associated with significant transfusion requirements, and tends to put a great burden on the blood inventory. Storage of red blood cell (RBC) induces various biochemical, biomechanical, and immunological changes that affect red cell viability, deformability, oxygen-carrying capacity, microcirculatory flow, and hence cause various adverse outcomes related to transfusion. Aim of Study: We made an effort to investigate the patterns of usage of allogenic blood products and the effect of volume and storage age of transfused RBCs with morbidity and mortality after cardiac surgery. Methodology: This was a cross-sectional analytical study conducted from January 2016 to June 2017, including all patients undergoing elective open-heart cardiac surgery at a tertiary care hospital. Records were reviewed for the details of blood components issued such as date of collection, date of transfusion, date of expiry and number of units of blood components transfused, details of the surgery, demographic details, postoperative length of stay (PLOS), and complications. Results: A total of 75 patients were included in this study. The majority of the surgeries (60%) were done for rheumatic heart disease. The difference in the transfusion patterns of various blood products with respect to the types of surgery, age or gender was statistically not significant. There was an association between increased PLOS (considered to be >11 days which is the mean) and mean unit age of the transfused packed RBCs (pRBCs) and the difference was statistically significant using the Chi-square test. Conclusion: There is a wide variation in transfusion practices in patients undergoing cardiac surgery. There is no significant association between the number of pRBCs transfusions and postoperative neurological, pulmonary, and other complications when number of pRBCs units ≤4.
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Platelet additive solution suspended apheresis platelets: A new perspective for safe transfusion practice in patients with liver disease p. 186
Suryatapa Saha, Deepti Sachan, Deepti Krishna, Raghuram
DOI:10.4103/GJTM.GJTM_33_19  
Introduction: Thrombocytopenia is one of the most common complications in chronic liver disease and perioperative transplant patients requiring multiple units of platelets transfusion. Aim: This study was undertaken to find out the effectiveness of platelet additive solution (PAS) suspended apheresis platelets in such patients and to compare the in vitro quality of PAS suspended, and plasma suspended apheresis platelets. Materials and Methods: This is a prospective study conducted in the Transfusion Medicine Department of multiorgan transplant center in South India from April 2016 to April 2017. AntiA and antiB isoagglutinin titers were analyzed in O group SSP+ suspended apheresis platelet concentrates (PCs) and response of both SSP+ suspended, and plasma suspended apheresis PCs were analyzed in patients by checking the corrected count increment (CCI). Results: Among 200 single donor platelet (SDP) products, 111 (55.5%) were SSP suspended and 89 (44.5%) were plasma suspended. There were no adverse transfusion reactions in SSP+ suspended PCs. Among 24 individuals with paired plasma suspended and SSP+ suspended SDP products, no statistically significant difference was found in CCI at 24 h. There was a statistically significant difference between pre- and post-anti-A and anti-B titers (P < 0.001). Ten donor units (23.2%) had titer ≥64 for anti-A and anti-B. Conclusion: The ex vivo storage of SDP in PAS offers several advantages in the harvesting of additional plasma for use as transfusable product and reduction of allergic reactions besides maintaining the quality control of platelets.
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Comparison of conventional immunochromatographic assay with new automated-Treponema pallidum hemagglutination assay for screening of syphilis in blood donors p. 191
Devi Prasad Acharya, Aseem K Tiwari, Geet Aggarwal, Dinesh Arora, Ravi C Dara, Gunjan Bhardwaj, Gautam Kumar Gupta
DOI:10.4103/GJTM.GJTM_55_19  
Introduction: Serological tests for syphilis contributed greatly to the detection of Treponema pallidum infection in blood donors and especially in those who were missed during the medical selection. Although several different treponemal assays have been evaluated in India, the debate that which treponemal test-formats would be suitable for a particular blood transfusion service is far from settled. Aims and Objectives: The study was undertaken with an objective of comparing conventional immunochromatographic assay (ICA) with new automated T. pallidum hemagglutination assay (a-TPHA) in over 10,000 consecutive blood donor samples with fluorescent treponemal antibody-absorption assay (FTA-Abs) as the gold standard to resolve the discordant samples. Materials and Methods: The study was conducted in the Department of Transfusion Medicine in a large tertiary care hospital in India. Consecutive blood donors from July 2014 to January 2015 were evaluated simultaneously for antitreponemal antibodies by solid-phase ICA (SD BIOLINE Syphilis 3.0, Alere Medical Pvt. Ltd., USA), a-TPHA (Immucor Diagnostics, USA) and FTA-Abs (Biocientifica SA, FTA-Abs, Argentina). Performances of both the assays were evaluated using statistical tools. Results: A total of 10,129 donor samples were evaluated. A total of 113 (1.1%) donor samples were reactive for syphilis; either on ICA or a-TPHA or both. Ninety-one of these 113 reactive samples were reactive on FTA-Abs, giving seroprevalance of syphilis as 0.9%. a-TPHA was superior to ICA in terms of sensitivity, specificity, positive predictive value, negative predictive value, and Youden's index. Conclusion: The new “a-TPHA” is a superior assay to ICA as the screening assay for syphilis in blood donors.
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Evaluation of the automated fluorescent immunoassay system anti-hepatitis C virus assay for the detection of hepatitis C virus infection Highly accessed article p. 198
Usman Waheed, Min-woong Hwang, Noor e Saba, Sooncheol Hong, Muhammad Saeed, Akhlaaq Wazeer, Muhammad Arshad, Javaid Usman, Hasan Abbas Zaheer
DOI:10.4103/GJTM.GJTM_39_19  
Introduction: Hepatitis C has emerged as a fatal epidemic in the country in the past two decades. One of the major risk factors remains unsafe blood transfusions. Aims and Objectives: The present study evaluated the performance of a newly developed automated fluorescent immunoassay system (AFIAS anti-hepatitis C virus [HCV] assay) in comparison with the Architect anti-HCV assay for the detection of anti-HCV antibodies in the blood donor samples. Methodology: This cross-sectional study was conducted in the Department of Pathology and Blood Transfusion Services, Shaheed Zulfiqar Ali Bhutto Medical University, PIMS, Islamabad. About 3–5 ml blood was collected from 282 blood donors and was processed for the detection of anti-HCV by the Architect anti-HCV assay and AFIAS anti-HCV assay during the period January–October 2016. All those samples which were indeterminate by the Architect anti-HCV assay (with 1–5 value in the signal-to-cutoff) were further examined by the AFIAS anti-HCV assay. Architect anti-HCV assay was considered as gold standard. We compared the results of individual specimen; discrepant results specimens were further tested by third-party test, the Elecsys anti-HCV II assay on Cobas e411 by Roche. Sensitivity (level of detection [LOD]) of the AFIAS anti-HCV assay with 10 widely used rapid immune-chromatographic diagnostic tests (RIDTs) for anti-HCV was evaluated. We assessed the imprecision of the AFIAS anti-HCV assay. To measure the variation of the intra-assays (within days), 12 replicate tests were performed with known concentrations of anti-HCV. Results: The results obtained by the AFIAS anti-HCV assay showed similarity with those obtained by the Architect anti-HCV assay when tested with 282 blood specimens. When examining the results of an individual specimen by these two assays, 126 and 151 specimens showed identical positive and negative results, respectively; overall identity was 98.23%. Only five specimens showed comparatively different results. In comparison to RIDT, the AFIAS anti-HCV assay is 20–40 times more sensitive. Conclusion: The AFIAS anti-HCV assay will be useful in small-to-medium-sized laboratories for testing ready to use single sample test. It showed good agreement with the Architect anti-HCV assay and is useful for the detection of HCV infection. It is a superior alternative for low-sensitive RIDT anti-HCV assay.
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Assessment and association of coagulation factors (FVIII and fibrinogen) with the mode of collection and storage of fresh frozen plasma p. 204
Rajendran Loganathan, Rajendra G Kulkarni, Rakhee Kar, B Abhishekh, Debdatta Basu
DOI:10.4103/GJTM.GJTM_41_19  
Background: Indian Drugs and Cosmetics Act and Rules 1945 states that 1% or 4 units/month of any components prepared and stored should meet specific quality control parameter. Currently, our blood center relies on nonancillary tests such as prothrombin time (PT)/activated PT test for quality check of fresh frozen plasma (FFP). However, the guidelines advice to check the levels of labile coagulation factors, routinely. Aim: This study was conducted to establish coagulation factor assay and assess conditions such as collection, transportation, time of preparation, and storage conditions to assess the level of clotting factors FVIII and fibrinogen in FFP and to identify the association of the levels of clotting factors FVIII and fibrinogen in FFP with its mode of collection and storage. Materials and Methods: A cross-sectional study was carried out delimiting inclusion criteria as the FFP to be prepared from whole blood collected in-house or at outdoor blood collection drives blood with varying duration of storage within 12 months; the exclusion criteria on units that were discarded reasons due to leaking in bags found positive for transfusion transmitted infections. The sample size was calculated based on logistics, budget, and convenient sampling technique. Statistical analysis was carried out using software IBM PASW statistics (SPSS) version 19.0, and independent Student's one-way analysis of variance for levels of statistical significance was considered at P < 0.05 among the parameters such as clotting factors among the different blood groups. Results: There was no significant difference observed on different modes of collection between the levels of FVIII and fibrinogen. However, the difference between FVIII levels with different time-lapse of component processing was statistically significant (P = 0.002). However, regarding fibrinogen such a difference was not a significant difference. Conclusion: Heat-labile factors were maintained as per the DGHS criteria when FFP was prepared within 4 h and stored for 6 months.
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Investigation of HLA-DRB1*15:03 and HLA-DRB1*09:01 alleles to determine predisposition to development of ABO antibodies (Anti-A and Anti-B) amongst blood donors of type “O” in Southern Iran p. 208
Bentolhoda Mozafari, Ali Akbar Pourfathollah, Leila Kohan
DOI:10.4103/GJTM.GJTM_56_19  
Introduction: Agglutination in red blood cells can be associated with a number of complications. These complications are related to the amount of antibody titer produced. Some genetic factors, such as HLA-DRB1*15:03 and HLA-DRB1*09:01 alleles, are involved in the production of antibody titers. Aims and Objectives: The aim of this study was to investigate the causative allele of the high and dangerous titer antibodies (anti-A and anti-B) among blood donors in Bandar Abbas. Methods: Antibody A and B levels were measured by titration on 121 serum samples of blood type O donors in 2 incubations at room temperature and anti-human globulin tube method. Titers higher than 512 and the same number of participants with a titer of <64 were selected and whether or not genotypes 901 and 1503 were found. After titration, sample DNAs were extracted, and then, amplification-refractory mutation system–polymerase chain reaction was used to determine allelic polymorphism. Results: The antibody titer was found to be elevated in this study, but there was no significant relationship between the presence or absence of genotype 901 (HLA-DRB1*9:01) and genotype 1503 (HLA-DRB1*15:03) and the high titer of anti-A and anti-B antibodies. Discussion and Conclusion: Finally, studies have shown that a critical titer should be determined for antibodies to the ABO blood system in order to provide blood transfusion safety. However, the higher the titers of anti-A and anti-B, the safety of transfusion medicine is also provided.
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Incidence and frequency of various red blood cell antibodies and the experience of providing antigen-negative transfusion support for patients at a tertiary care super specialty hospital p. 214
Ruhi Mehra, Minal Rane, Ujwala D'Mello, Rajesh B Sawant
DOI:10.4103/GJTM.GJTM_52_19  
Introduction: The presence of red blood cell (RBC) auto and/or alloantibodies can pose a serious challenge of finding transfusion support for such patients. Aim and Objectives: The aim of this study was to assess the frequency and type of unexpected RBC antibodies in the patient population of a tertiary care super specialty hospital and analyze the transfusion support and its effectiveness in these patients. Methodology: This was a retrospective cross sectional study based on data contained in all blood requests, received over a period of 39 months inclusive of demographic,laboratory and clinical variables. Results: Among the 25,338 patients screened, 122 (0.48%) had alloantibodies and 19 (0.07%) had autoantibodies. Of the 141 patients with atypical antibodies, 109 (77.30%) were female and 32 (22.69%) were male. Antibodies directed against the antigens from various blood group systems were as follows: Rh – 54.5%, MNS – 21.8%, and Lewis – 13.6%. Anti-D (32.8%), Anti-M (16.4%), and Anti-E (10.9%) were the most prevalent. Multiple alloantibodies were seen in 2 (1.41%) cases and autoantibodies coexisting with an alloantibody in 9 (6.38%) cases. Discussion: RBC alloimmunization rate is lower (0.41%) in our hospital in comparison with published reports. Higher alloimmunization in female patients in the age group of 20–40 years mainly associated with a history of pregnancy and comparatively lower rate in males and strongly associated with a history of transfusion in the age group of 40–60 years has been reported in literature. Conclusion: RBC alloimmunization rate (0.55%) in general patients treated in our hospital is lower as compared to other reported rates in our country. The provision of RBC phenotype-matched (Rh and Kell) blood for patients likely to get multiple transfusions right from the beginning may reduce the alloimmunization rates further.
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Prevalence of irregular red blood cell antibodies among healthy blood donors in South India p. 219
Deepti Sachan, G Deepthi Krishna, Suryatapa Saha, Raghuram Prasath
DOI:10.4103/GJTM.GJTM_22_19  
Background: Although antibody screening is mandatory according to the National Blood Policy of India, the prevalence of irregular red cell antibody and its specificities are not much reported in South Indian population. Aims and Objectives: The objective of this study is to find the prevalence of irregular red cell antibodies and positive direct antiglobulin test (DAT) in healthy blood donors in South India population. Materials and Methods: This is a retrospective observational study conducted in the department of transfusion medicine from April 2011 to March 2018 (7 years) at a tertiary care referral center, Chennai, Tamil Nadu. Red cell antibody screening of all voluntary blood donors was performed using commercial O cells (ID DiaCell Pool, DiaMed, Cressier sur Morat, Switzerland). Positive sera were further investigated to identify the irregular erythrocyte antibody by commercially available red cell panel (ID-DiaPanel, Diamed-ID Microtyping System). Results: A total of 40,629 donors were screened for the presence of irregular erythrocyte antibodies. A total of 57 (0.14%) donors showed the presence of irregular antibodies, in which 41 (71.9%) were alloantibodies. Most frequent alloantibodies identified were of MNS blood group system with anti-M being the highest (n = 15, 36.58%), followed by Rh blood group system. Sixteen (0.039%) donors were DAT positive, which were detected during routine crossmatching. Conclusion: Implementation of red cell antibody screening in all the blood donors routinely helped us understand the prevalence of antibodies in our region and its importance in providing compatible blood products and to avoid transfusion reactions.
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Use of liver enzymes as a surrogate marker for monitoring treatment of hepatitis C virus disease p. 224
Chhavi Rajvanshi, Aseem Kumar Tiwari, Pranav Dorwal, Simmi Mehra
DOI:10.4103/GJTM.GJTM_36_19  
Introduction: Hepatitis C virus infects 3% people globally, that causes significant morbidity and mortality. For diagnosis and monitoring of treatment of HCV infection; biochemical markers and HCV RNA are tested. Aim of the Study: We tried to find out whether there is an association of liver enzymes (AST, ALT) and anti HCV antibody with the HCV viral load in patient's serum. Material and Methods:238 consecutive patients with suspected or confirmed Hepatitis C viral disease were included in this study. All consecutive samples of patients for two years were tested for HCV RNA quantification using real time PCR (viral load). Serum aminotransferase (AST, ALT) and anti-HCV antibody levels were also recorded and compared with the viral load. Correlation coefficient was used to study association between different parameters. Results: Significant positive correlation was found between liver enzymes (AST, ALT) and HCV viral load. Conclusion: There is a significant correlation between liver enzymes and RNA viral load. Therefore, viral load may be substituted with test for liver enzymes during monitoring of treatment, at least partially, and this could result in substantial cost savings.
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Frequency of irregular red cell antibodies in blood donor population p. 227
Prathibha Bharathan, Ashish Jain, Neelam Marwaha
DOI:10.4103/GJTM.GJTM_28_19  
Introduction: Irregular red blood cell (RBC) antibodies may occur in blood donors and potentially can lead to transfusion reactions or decreased survival of transfused RBCs. Therefore, it is necessary to know the prevalence of alloantibodies in donors and their clinical significance. Aims and Objectives: The study was aimed to determine the prevalence of RBC alloantibodies in blood donors. Materials and Methods: ABO typing and RhD typing were performed using the fully automated immunohematology analyzer (Qwalys 3, Diagast, France). For RhD-negative samples, a “weak D” testing was also performed by tube technique using a blend (immunoglobulin M [IgM] + IgG) of anti-D antisera (Tulip Diagnostics, Goa, India). Antibody screening (3-cell panel) and identification (11-cell panel) were done by gel technique (LISS-Coombs AHG Card, Bio-Rad, Switzerland). The antibody titer was done using the tube technique. Results: During the study period, a total of 2310 donor samples were tested. Out of these, 2299 (99.56%) were male and 11 (0.44%) were female. ABO distribution was found to be maximum for blood group B (34.5%), followed by O (33.3%), A (22%), and AB (10.3%). Among the total donors, 2085 (90.3%) were RhD positive. All the RhD-negative samples were negative on “weak D” testing. Antibody screen was positive for only one sample (0.043%); the alloantibody identified was anti-M, which was reactive in anti-human globulin phase as well, and the titer was 1. It was from a male donor who had no history of transfusion. One sample (0.04%) showed autoantibody weak positive (wk+), and there was one ABO discrepancy (0.04%), which was due to weak subgroup of A. Conclusion: The prevalence of RBC alloantibodies is 0.043% (1/2310) in our donor population. As the sample size was small, larger studies are needed to determine the actual prevalence of alloantibodies in donors.
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CASE REPORTS Top

Anti-D antibody in a D-positive patient: Autoantibody or development of alloantibody after platelet transfusion p. 231
Sadhana Mangwana, Vivek Gangwar
DOI:10.4103/GJTM.GJTM_29_19  
Rh D (D or RH 1) is next clinically important blood group after ABO blood group system. Although most people are either D+ or D−, there are a large number of individuals having different forms of D variants; weak D, partial D, or DEL phenotypes. We present a case report of a 32-year-old male with a history of cough and cold for 5 days with development of petechial rashes all over the body from day 1 and afebrile and marked thrombocytopenia. He was transfused with multiple platelet concentrates. Initially, there was an absence of irregular red cell antibodies, but after 72 h of transfusion, he developed autoanti-D antibody. An accurate D-antigen identification is important and essential for pretransfusion evaluation to prevent antibody formation, and a partial D variant might be suspected when typing for the D antigen showing weaker-than-normal reactions. This case emphasizes that some partial D variants are likely to be missed by routine serological tests.
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A case report of neonatal alloimmune thrombocytopenia: The utility of platelet crossmatch studies in the diagnosis and management p. 234
HA Venkatesh, Abhishek Paul, Ambuja Kantharaj, Shivaram Chandrashekar
DOI:10.4103/GJTM.GJTM_50_19  
Alloimmune thrombocytopenia is the most common cause of severe thrombocytopenia and intracranial bleed in the perinatal period, resulting from placental transfer of maternal platelet antibodies directed against the paternal-derived fetal platelet antigens. It is estimated to occur in 1 in 2500 births but continues to be an underdiagnosed and underreported condition in our country. Detection of human platelet antigen-specific antibody in the maternal serum and platelet genotyping are the gold standards in the diagnosis. This case report highlights the utility of platelet crossmatch studies in the diagnosis and management of neonatal alloimmune thrombocytopenia.
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Resolution by adsorption-elution method and transfusion support to a patient of thalassemia intermedia with anti-c alloantibody p. 237
Debasish Mishra, Prabodh Kumar Dash, Satya Prakash, Somnath Mukherjee
DOI:10.4103/GJTM.GJTM_34_19  
Transfusion support remains the mainstay of supportive treatment for thalassemia patients in spite of recent advances such as stem cell transplantation and gene therapy. Thalassemia intermedia (TI) patients generally do not require regular transfusion support but can develop severe anemia, requiring frequent transfusion during the period of stress such as infection and pregnancy. The genetic disparity of red blood cell antigens between donor and recipient leads to sensitization and resulting development of alloantibodies. Red cell alloimmunization leads to incompatiblity and delays in issue of compatible units. Majority of these alloantibodies were against Rh and Kell blood group. Here we report a case of 28 years old TI who developed anti-c following multiple transfusions since the age of 18 years. The patient was transfused with c antigen-negative, A positive anti-human globulin cross-matched blood unit. Thus, we emphasize to include antibody screening routinely in multi-transfused patients and provision of at least Rh phenotype-matched blood to prevent further alloimmunization.
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Interference of daratumumab with compatibility testing in blood bank p. 240
Rani Premkumar, Siva Deepthi
DOI:10.4103/GJTM.GJTM_10_19  
Plasma cell myeloma accounts for 1% of malignant tumors and 10%–15% of hematopoietic neoplasms. Daratumumab (DARA), a novel targeted immunotherapy drug, was approved by the Food and Drug Administration to treat relapsed/refractory multiple myeloma. DARA, which is a CD38-targeted immunomodulatory drug, also cross-reacts with red cells and sensitizes them, causing difficulties and delay in the blood bank. To avoid delay in view of patient care, proper communication with blood bank professionals is required. We present a case of relapsed/refractory multiple myeloma in a 45-year-old male who required transfusions due to anemia and severe thrombocytopenia.
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SPECIAL COMMUNICATIONS Top

Flow cytometry method for platelet-specific antibody detection by acid treatment through human leukocyte antigen-1 removal p. 243
Qin-Qin Ma, Hui-Jun Zhu, Li Rui-Shu, Fu Min, Lu Ping
DOI:10.4103/GJTM.GJTM_61_19  
Background: Platelet (PLT) transfusion has been a crucial for clinical blood transfusion and bleeding prophylaxis. Identification of antibody against PLT-specific antigen is important for accurately diagnosing posttransfusion purpura, neonatal alloimmune thrombocytopenia, and platelet refractoriness due to PLT-specific antibodies. However, the presence of anti-human leukocyte antigen (HLA) antibody makes the detection of PLT-specific antibody more complex. Materials and Methods: The influence of treatment of PLTs with phosphate-buffered solution (PBS) or citric acid at pH 3.0 on the expression of human-specific antigen and HLA Class I was tested by flow cytometry. PLTs were treated with citric acid at room temperature for 5 min, and all solutions were precooled at 4°C. Results: Acid treatment reduced more than 90% of HLA Class I complexes when compared with PBS-treated ones on the surface of PLT membrane without any significant cell damage. The antigenicity of HLA Class I was lowered with time, but the antigenicity residue was little with PLT fragments after more than 5 min. However, human-specific antigen involving CD61 was not decreased after appropriate acid treatment, which was confirmed by corresponding monoclonal antibody. The use of standard serum from National Institute of Biological Standards and Control (NIBSC) containing only anti-human PLT antigen-1a antibody or anti-HLA antibody-positive control was applied to confirm the effect of acid treatment on PLT antigen. Conclusion: These findings suggested that acid treatment method could be useful for detecting PLT-specific antibodies, guiding clinical transfusion.
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The role of platelets in the process of lung cancer A549 cell growth and its related mechanism p. 247
Li Juan, Zhangfei Wang, Man Fang, Yiqin Luo
DOI:10.4103/GJTM.GJTM_62_19  
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