Tag: Donor Immunohematology

Donor ABO/D typing, antibody screening, antibody identification, ABO antibody titration

Washed RBCs

drzeyd

Note:  This is an updated version of a previous post.

Principle:

Washing RBCs removes plasma and reduces the leukocyte count only by 1 log.  For leukodepletion, we must rely on filtration to reduce the WBCs to less than 1 x 106 per unit according to CE rules.  Red cells or platelets in additive solution contain only minimal plasma (about 35 ml).  There are few definite indications for washing RBCs and it should be rarely necessary.

Policy:

Washing RBCs should only be done in the following circumstances:

  1. Deglycerolization of frozen RBCs.
  2. Severe allergic or anaphylactic reactions to plasma proteins
  3. IgA deficiency with anti-IgA
  4. Paroxysmal nocturnal hemoglobinuria PNH—relative indication (often these patients receive RBCs before the diagnosis of PNH is confirmed)
  5. Transfusing a previously irradiated RBC unit for pediatric use if more than 24 hours has passed since it was irradiated.
  6. Any other time when so designated by a transfusion medicine consultant.

Note:

  1. If anyone requests washed RBCs and it does not fit into one of the above categories, contact the transfusion medicine consultant.
  2. Washed RBCs are NO substitute for leukodepleting RBCs by filtration NOR can they be used in place of irradiation for prophylaxis against transfusion-associated-graft-versus-host disease TAGVHD.  Using the Reveos automated component processing system, all components are leukodepleted—RBCs are released in SAGM.

Reference:

Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, MD, USA

Interpretation of Donor Ortho Blood D Blood Group Reagents

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Principle:

For the purpose of typing blood donors, we want to detect weak and partial D types and consider them as D-positive since even a portion of the D molecule is immunogenic and sensitization to it may cause anti-D hemolytic disease of the newborn.

Background:

Ortho Diagnostics Reagents use three different monoclonal antibody cocktails that react variably with the antigen D (Rh1)—these are found on TWO (2) cards:  Anti-A/B/A,B/D/CDE and Anti-DVI:

Anti-D/Anti-RH1—IgM monoclonal antibody clone D7B8 can detect most examples of weak and partial D including weak D types 1, 2, 3, 4.0, and D categories II, III, IV, V, VII, DBT, and R0Har.  It does NOT detect category VI.  Retest positive reactions of 2+ or less by an alternate method.  It may show different serologic activity compared to other D typing reagents.

Anti-CDE/Anti-RH1,2,3—IgM monoclonal blend of clone MS24 (anti-C), clone MAD2 (Anti-D), and clone C2 (Anti-E) can detect most cells expressing C, D, or E antigens.  Most examples of partial D including DVI and weak D express C or E antigens and will be detected directly by the included anti-D or indirectly by the anti-C or anti-E in the cocktail.  It does NOT detect Rh:33 (R0Har).

Anti-DVI/Anti-RH1 will agglutinate cells with a DVI phenotype, analogous to our previous DVI+ reagents.

Policy:

  1. Follow the manufacturer’s instruction for storage, handling, and usage of all reagents.
  2. If the D-control is positive, the reactions are indeterminate, repeat by another method.
  3. For donors, run all three anti-D reagents listed—do not use the patient typing algorithm or reagents.
  4. Use the following table for interpretation and further actions if needed:
Pattern #Anti-D/D7B8Anti-CDEAnti-DVID-Interpretation
1PositivePositivePositiveD-positive
2PositivePositiveNegativeDo additional testing
3PositiveNegativeNegativeDo additional testing
4NegativeNegativePositiveDo additional testing
5PositiveNegativePositiveDo additional testing
6NegativePositivePositiveD-positive, probable DVI variant
7NegativePositiveNegativeD-negative, probable rare genotypes r’ and/or r’’
8NegativeNegativeNegativeD-Negative

If the reaction is 2+ or less with the Ortho anti-D/D7B8 reagent or 1+ with either the CDE or DVI reagents is patterns 2, 3, 4, or 5 above, repeat by another manufacturer’s reagents, including DVI+ and DVI- sensitivities.

Medinfo-Ortho interface settings for Blood Donor Center:

Anti-D/D7B8Anti-CDED-Interpretation
3,41,2,3,4D-positive
3,40Indeterminate
00Indeterminate
01,2,3,4Do DVI REFLEX
REFLEX DVI If DVI-pos, then D-positive
REFLEX DVI If DVI-neg, then D-negative
00D-negative
~~Indeterminate

~ means any other result

Note all of the following:

  1. No reagents may be able to detect all D variants.
  2. ~ means any other value for that reagent (e.g. anti-D/D7B8 reactions 1, 2, mf, hemolyzed)
  3. Note that this new algorithm makes a 2+ reactivity with Anti-D/D7B8 as indeterminate.

References:

  1. Product Insert, Anti-A/B/A,B/D/CDE/Control Card, Revised January, 2015, Ortho Clinical Diagnostics, High Wycombe, Buckinghamshire/UK
  2. Publication J55650_EN, Instructions for Use, Blood Grouping Reagent Ortho Sera Anti-D(DVI) (Anti-RH1), Version 2.0, 2015-07-30, Alba Bioscience, Edinburgh, UK
  3. Standards for Blood Banks and Transfusion Services, 29th Edition, AABB, Bethesda, MD, USA

Further Thoughts on Inter-Depot Transfer, Blood Delivery, Type and Antigen Matching

drzeyd

In my recent post, I provided sample flows and parameter mapping for delivery of blood components.  The final components from the component preparation center may be sent to various depots (freestanding location and/or hospital blood banks.  There should be complete traceability for every step (from donor reception, collection, testing, and processing) transport between locations, and finally the exact storage site, which might include which refrigerator/freezer/incubator and even shelf/position number for each component is stored.  The end of that document showed rules for type/antigen matching.

For disaster planning, rapid inventory enumeration by type is very important.  This can be very time-consuming manually.  With our Medinfo Hematos blood bank system, we could quickly get total inventory across the Qatar or by hospital in less than one minute.  We could also quickly find antigen-matched units across the system and reserve it at any one site for another if necessary.

Smart blood bank dispensing refrigerators, as offered by Haemonetics and Angelatoni, may also serve as depots and take the place of a hospital blood bank for some dispensing.  These solutions can also capture vital information about the storage conditions of the components and prevent release if the storage criteria are not met.  They can also interface with blood bank computer systems and use the main system’s logic for the dispensation rules.  In Medinfo, they can be added as a hospital blood bank site.

Upon receipt at the hospitals from the blood processing center, the forward ABO and D typing must be confirmed.  We used D reagents which detected partial D so we would call such donor units as D-positive.  However, if a patient type reagent insensitive to partial D types is used, it is possible for a unit to be typed as D-negative whereas in the donor center it might be D-positive.  Sometimes, nothing types consistently as D-positive:  all you can say is that with a particular reagent and lot number, there is or isn’t reactivity.

The greatest complexity is for RBCs since potentially so many antigens exist.  Criteria for matching/ignoring certain antigens must be made.  Critically significant antibodies such as the Kell, Duffy, Kidd, and certain Rh (D and c) must be antigen matched.  A robust blood bank computer system can enforce these rules.

For other components, antigen/typing may be less important.  In fact, in most situations, any type of platelets can be given to anyone (except neonates).  Despite the potentially incompatible plasma, there is rarely significant hemolysis.  In fact, if pooling platelets without regard to blood types is done, a platelet transfusion is a common cause of a positive direct antiglobulin test DAT—something that is not clinically significant.  No one died of a positive DAT by itself for this reason.

Specific rules for compatible plasma types are important, but nowadays, low-titer group A plasma may be used like universal AB plasma.  The challenge is to be able to perform the ABO titration (specifically anti-B) quickly—titration can be a slow process, even with automated equipment.  A similar situation for low-titer, universal group O whole blood requires both anti-A and anti-B titration (I will return to this topic in a future post).  With Medinfo, I can define rules (e.g. IgM titer < 1:64) to accept these units as a universal type for all ABO groups.

Special rules can be built into the software so that production, transfer, storage, and release of COVID convalescent plasma CCP are only performed at special quarantine sites by designated personnel.  This means there can be dedicated transport pathways built into the inter-depot transfer process to keep this inventory separate at all times.

Logistics and Processes for a COVID-19 Convalescent Plasma Program

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I prepared the following plan for a CCP program for HMC Qatar in March, 2020.  The workflow is divided into four (4) modules:

  1. Registration/Interview/Physical Examination/Apheresis Collection
  2. Donor Marker Testing and Immunohematology Testing
  3. Production/Aliquoting/Pathogen-Inactivation/Storage
  4. Product Thawing/Product Release

Module 1:

  1. Collection/registration/screening must be in a separate area from regular blood and apheresis donations.
  2. Donors must provide consent.
  3. ISBT specimen labels must be used on each tube collected.
  4. We need a minimum of two apheresis nurses, one for the registration/screening/post-donation observation and one for the actual apheresis procedure.
  5. If there will be multiple serial donors, then we need a waiting area (each donor at least 2 meters apart).
  6. Donor screening must be in sound-proof area so that other waiting donors cannot hear the interview/questionnaire process.
  7. Amount that can be collected depends on body weight:  500 ml for <80 kg and 600 ml for >= 80 kg, collection may occur twice per week
  8. Collection time includes 15 minutes for registration/interview/physical examination, 60-75 minutes and 15 minutes for cleanup/disinfection before the next case, approximately 2 hours per donation.
  9. A post-donation observation area (minimum 15 minutes after collection) with apheresis nurse nearby in case of reactions is needed if there will be multiple donors.
  10. Specimens will

Module 2:

  1. Donor testing and donor immunohematology will be done with other donor specimens in our regular location

Module 3:

  1. Apheresis collection must be processed and stored separately from regular blood/apheresis donations.
  2. Processing will occur only after the results are shown to meet all criteria.
  3. Pre-collection testing (test-only donation) would permit processing without waiting for results.
  4. Storage at minus 80C may be for a minimum of six (6) years but this may be extended if needed.
  5. All acceptable components will have a final ISBT label—no products without the ISBT label will be transfused.  The ISBT label indicates that the unit meets all donor criteria for convalescent plasma.

Module 4:

  1. Product modification (thawing) and release (sign out from blood bank) must be in a separate area(s) from the regular hospital blood bank.
  2. Release of convalescent plasma follows the same process as regular component release
  3. Transfusion of convalescent plasma at the patient’s bedside follows same process as regular component transfusion
  4. Nursing and other staff performing the transfusion must pass competency assessment.
  5. Plasma will be transfused as ABO-identical or compatible unless low ABO-titer group A is used.
  6. Plasma must be free of clinically significant antibodies

Workflow Considerations:

  1. Donors must be restricted to the waiting, collection, or post-donation observation areas.
  2. Donors must NOT pass through production, testing, or component release areas (just as they are currently restricted in the Blood Donor Center and HMC hospital blood banks/transfusion services).

Logistics:

  1. Throughput is a maximum of 4 donors (2000 to 2400 ml plasma) per eight-hour shift with one apheresis nurse and one donor apheresis (Trima) machine.
  2. The processes are scalable with additional staff and machines (e.g. with 3 machines and nurses, then 12 donors and 6000 to 7200 ml of plasma collected).
  3. Thawing of 1-2 units of plasma takes up to one hour.  Contact the quarantine blood bank at least one hour before the desired pick-up time.
  4. The four modules above can be in separate areas not adjacent to one another.  Modules 1, 3, and 4 must be quarantine areas where access is limited.  Module 2 can be performed with regular donor specimens using standard precautions.
  5. We can provide training for transfusion of blood components and competency assessment to any location transfusing this product.

Information Technology:

  1. All modules will be connected to the Medinfo Hematos IIG dedicated blood bank computer system.
  2. All records of collection/production/testing/storage/modification/release will be stored therein.
  3. All ordering of convalescent plasma components will be through Medinfo.
  4. External test results (e.g. future antibody titering) can be added to the component information.
  5. Links to the Hospital Information System (Cerner) may be considered after the Medinfo processes are fully functional.

International Perspective

drzeyd

When I first moved overseas from the United States, I brought the perspective of my American training and experience.  I saw everything in my new blood bank through those eyes.

Yet, most of my staff were not American or even North American.  Few were even native in English, and most of those  were not American.  They had different qualifications, many of which would not have been accepted by the American schemes.  Still, they functioned well.

I also worked with the US military technologist staff during Gulf War One.  Some did not even have a Bachelor’s degree;  yet, they performed the work well.

I used many technologies that were not yet (or never) US FDA approved such as gel or glass bead typings and pooled buffy coat platelet production.  There were rare reagents I could buy off the shelf (e.g. anti-Tja/PP1Pk).

Later, I adopted pathogen-reduction technology (Mirasol), automated component production (Atreus then Reveos), and platelet additive solution.  I achieve a level of good manufacturing practice that would have been difficult to achieve by the FDA-approved methods.

My perspective had changed.  In the Middle East, I studied many frameworks and came to the conclusion that the best approach was to customize them to our local needs.  My particular experience was to start with one framework, i.e. Council of Europe CE, and then localize it.

To do this, I could not use an American turnkey blood bank software for either the donor or patient operations.  I needed a flexible system that could be customized to my needs.  Again, I chose a CE-marked system, Medinfo Hematos IIG that had already been adapted to many frameworks.

It is much easier to work solely within one system such as FDA.  However, if I had done that, I would have lost so much flexibility and not had a system optimized for local conditions.  I would not have used Mirasol, Reveos, Diamed, and many other reagents.

One big disappointment at such international meetings is the perspective by one country’s regulatory agency that they feel its regulations and framework will work well overseas.  I would wager that those people were not well acquainted with international conditions.

Another frustration was attending another international meeting in which the presenters apologized for the source of information since it came from a foreign country (France) and not their own (United States).

No country has a monopoly on what is best for everyone.  To share our experiences and compare is so valuable.  No one assume his way is the best.  In my career, I have had the richest experiences studying other perspectives and my organizations have benefited greatly from the exchange.  We can all learn from each other.  We are citizens of the world.

Medinfo COVID Convalescent Plasma Workflow Revisited

drzeyd

It now has been over eight 8 months since I prepared the CCP workflow in Medinfo.  It was built on the framework of the manual CCP process including donor prescreening with an abbreviated donor questionnaire.  It was really quite simple and used the donor and patient modules to create quarantine areas for donor screening, collection, processing, and hospital patient blood bank release.

Here are my current comments on the process:

Donor Qualification:

I would still exclude malaria and HTLV from the donor questionnaire and would update to UDQ 2.1.  Since these donors have recovered from a potentially life-threatening illness, I would keep the Hgb threshold at 11 g/dl.

Donor Collection:

In the future, I would consider using one of the soon-to-be-released portable devices that continuously monitor vital signs with pO2 and EKG lead to rule out asymptomatic pulmonary or cardiac problems.

I would also consider using low-ABO-titer, group A, universally to meet the demand for group B and AB patients.

Donor Testing:

There is still no need to segregate and separately test CCP donor specimens from regular blood donor specimens.  I would perform SARS-CoV-2 antibody testing and set a threshold for qualifying donors—that threshold will be based on the manufacturer’s recommendations.  However, if the treating physician wanted to use a low-titer unit, I would permit this.

Donor Processing:

There is no need to change this from the current processes.  Keep the CCP processing separate from the regular operations.

CCP Plasma Release:

I would keep the quarantine release and restrict it to the locations used for treating COVID-19 patients

Medinfo Software Modifications:

I would record the IgG and IgM titers for SARS-CoV-2 antibodies in each donation record.  This would include testing and entering the results on donations prior to this testing.  ISBT labels should include this antibody titer.

Hospital Information Software Modifications:

Set up restricted CCP ordering for the actual treating physicians only.  Also provide the ISBT code and shortened descriptors to it if necessary (certain HIS vendors still cannot read ISBT codes natively).

The original CCP workflow is attached for reference.

Manual Collection of COVID-19 Convalescent Plasma

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This process was originally done in the first phase of CCP collection.  I have updated it to include SARS-CoV-2 antibody testing.

Principle:

Due to the pandemic, we will initially MANUALLY collect an experimental, investigational-use-only plasma product from apheresis donors and treat it with Mirasol.  THIS IS A EMERGENCY INTERIM PROCESS UNTIL THE MEDINFO HEMATOS IIG PROCESSES ARE PREPARED AND VALIDATED.

Policy:

  1. Good Manufacturing Practice applies:
    1. Manufacturers’ recommended processes for equipment and materials usage applies.
    1. All staff engaged in these processes must be competency assessed successfully.
  2. Pre-Screening:
    1. Clinical staff will use the prescreening document to select donors for pre-donation screening.
  3. Quarantine:
    1. All processes (day 0, day 1, day 2, and product modification and release) will be done in quarantine areas SEPARATE and DISTINCT from regular Transfusion Medicine activities.  This includes:
      1. Separate space and equipment must be provided.
        1. Equipment for this project may NOT be used for regular, non-quarantine processes
    2. Non-Transfusion Medicine staff will not be permitted in operational areas.
    3. Prospective donors will not be permitted in the processing, testing, storage, or blood bank work areas.
  4. Donation Process:
    1. Day 0:  Registration, check donor deferral database, questionnaire, physical exam including arm check, and specimen collection using ISBT specimen labels
    2. Use latest manual donor questionnaire.
    3. Day 1:  Donor marker and immunohematology testing, review of results, accept or reject donor for actual plasmapheresis
    4. Day 2:  Collect manufacturer’s recommended volume of plasma (500 ml if < 80 kg, 600 ml if >= 80 kg), aliquot, pathogen-inactivate (Mirasol), freeze at minus 80C
  5. Testing:
    1. Testing will be performed with regular blood donor specimens using ISBT specimen labels
    2. Testing must be done by donor-specific processes (not those for clinical patients)
      1. Exclude malaria and HTLV testing.
    3. Testing must be directly interfaced to Medinfo Hematos IIG donor module
    4. CCP COVID antibody testing:
      1. SARS-CoV-2 antibody testing to be performed to determine cut-off for donor eligibility for CCP collection.
      2. Use of donors with antibody levels below threshold is at the discretion of the treating clinician.
  6. Processing:
    1. Aliquoting, pathogen-inactivation, and labelling may proceed if the pre-donation screening results are acceptable.
  7. Storage:
    1. Long-term in minus 80C quarantine freezer
    2. Short-term at 1-6 C just after thawing in quarantine refrigerator
    3. Standard temperature monitoring and alarms apply
  8. Labelling:
    1. The backup manual labelling process applies
    2. The ISBT specimen label will the donor unit number
      1. Outdate will be 6 years if the product is stored at -65C, 1 year if stored at -18C
  9. Product Release:
    1. Orders must be on the PAPER requisition (old Blood Bank Order Form) with a patient prescription and signed by a physician designated to treat COVID patients.
      1. No orders in Cerner
    2. Thawing plasma at 37C upon receipt of order by Transfusion Medicine staff
    3. Signing out component to clinical unit by Transfusion Medicine Staff to locations treating COVID-19 patients.
  10. Information Technology:  Medinfo Hematos IIG customized software to be implemented as soon as possible for all processes
  11. Not covered:  Transfusion Medicine is NOT responsible for:
    1. Triage of request for convalescent plasma
    2. Pickup and transport of components

References:

  1. Level 1-4 documents for donation, testing, processing, and release of blood components
  2. COVID-19 Plasma Donor Prescreening Document, 8/4/20

COVID-19 Convalescent Plasma CCP Series Introduction

drzeyd

I will be posting a detailed series about the manual and software-enhanced COVID-19 processes that I set up in Qatar at HMC Doha in March-April 2020.

In this series I will provide you with screen shots of my Medinfo Hematos IIG software design for each step in the process:  collection, processing, testing, inter-depot transfer, and hospital transfusion service/blood bank release.

This GMP-compliant software-enhanced system is based on the manual system I set up in early March 2020 at HMC.

I want to thank Medinfo Hematos IIG for their rapid response to building this parallel system based on my standard processes in so short a time (two weeks) and my special thanks to the software engineering team at Vital Health Technologies, the agent for Medinfo in Qatar.

To start the series, I am providing the basic workflow for the system.  As is normal in Medinfo software design, a full mapping of the processes are made.  This workflow shows the new CCP ISBT codes and the quarantine collection and processing steps.  The donor testing (marker and immunohematology) processes are similar to those for regular donor units.

This is basically the same process both manually and in the software.  I always say:

A good software process is based on a good manual process!!

Please note the following workflow for our initial discussion.