Manual of Transfusion Medicine Ramadas Nayak, Rakshatha Nayak
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
A antigens 45
common structure for 42
formation of 42
A genes 54
A1 and B red cells 75
A2 red cells 48
ABO 41, 55, 59, 60, 235, 258, 387
agglutinins, reduced titer of 172
and D grouping, controls for 85
antibody
acquired 58
less common 57
monoclonal 70
titers 56b
antigens 47, 57, 57f, 59
and antibodies, clinical significance of 58
characteristics of 41
poor development of 399
typing 70
blood group 33, 61, 70t, 72, 72b, 73f, 399
alleles of 54
antigen and phenotype 75
production of 52f
red cells 71
system 33t, 38, 41, 45fc, 54t, 98, 99, 190
compatibility 265
agglutination indicates 227
compatible blood 233
discrepancies 86, 86b, 87, 87b, 88fc, 89t, 90, 90t, 91, 91t, 92t, 94t, 95fc
resolution of 86, 93
summary of 94
expression, anomalous 50
genes 44
genetic loci controlling expression of 43
group 69, 72, 76, 224, 225, 233, 235, 390, 393, 400
blood selection 393t
determination 335
interpretation of 72t
methods of 71
system, genetic features of 53
hemolytic disease of fetus and newborn 234, 397
incompatibility 228, 296, 380, 399, 531, 531t
minor 531
incompatible
antibodies, transfusion of 303
organ, transplantation of minor 320
red cells, transfusion of 303
phenotypes 45
reagents 469
serum testing 75, 75t
subgroups 90
system 40, 59
inheritance patterns 55f
type 75, 282
Abortions 550
Accelerate graft rejection 510
Accreditation 488
Acetylglucosamine 46
Acid elution test 397f
Acid-base
disorders 239
disturbances 292
Acid-citrate-dextrose 163, 169, 288
Acquired immunodeficiency syndrome 23, 141, 346, 349, 445, 571
transfusion-transmitted 443
Activate complement system 297
Activated partial thromboplastin time 268
Acute graft-versus-host disease 516
Acute hemolytic transfusion reaction 302, 303, 304fc, 321, 333, 337, 337b, 341fc
signs of immune-mediated 303b
symptoms of immune-mediated 303b
Acute immune mediated transfusion reactions 328
Acute intravascular hemolytic transfusion reaction 337f
Acute lung injury
immune transfusion-associated 309
transfusion-related 252, 303, 309, 312t, 340, 481, 494, 517
Acute nonhemolytic transfusion reactions 302, 306
Acute normovolemic hemodilution 413
Acute respiratory
disease 569
distress syndrome 309, 311
Acute transfusion reaction 302, 303fc, 317t
evaluation of 339fc, 340fc
nonimmunological 312
type of 317
Acute transplant rejection 119
Adaptive immune cells 2
response 2, 5
components of 5
Additive solutions 169, 270
composition of 166t
Additive system 165, 248
advantages of 166
Adenine 26, 165, 166
Adenosine triphosphate 513
binding cassette 135
Adhesion molecules, interactions of 287
Adipocytes 520
Adoptive cell transfer 536
Adsorption 211
allogeneic 212
commercial reagents for 212
homologous 212
technique, uses of 213b
Adverse reaction 333b, 532
Adverse transfusion
incident 439
reaction 300, 330
recognizing of 333
Agammaglobulinemia
acquired 56
congenital 56
Agarose gel electrophoresis 375
Agglutination 11, 68, 194, 198, 225, 228, 229
based methods 17
first stage of 66
grading system 187t
reactions 77
grading of 183
strengths of 87
second stage of 66
stages of 11
temperature of 13
weaker 86
Aggressive immunotherapy 324
classification system 561t
embolism 239
pollution of 445
Albumin 245
infusion 327
reagents 232
Alcohol, denatured 367
Alleles 31, 37, 41, 505
multiple 31, 33
types of 31, 31f
Allelic antigens 100, 129
five sets of 125
Allergic reaction 292, 308, 309, 338
following transfusion 308b
mild 308, 310
Allergic transfusion 331
reaction 307, 310t, 340
Alloadsorption 201
Alloantibody 20, 91, 127, 190, 231, 400, 508
clinically significant 206
detection of 10
formation of 117
Allogeneic donation 139
Allogeneic hematopoietic progenitor cell
harvest 523
transplantation 527
Allogeneic stem cell transplantation 533, 533f
Allografts 495
rejection of 515
Alloimmunization 104, 381, 535
factors influencing rate of 327
Alpha numeric terminology 100
American Association of Blood Bank 226, 451, 489
American Society for Apheresis Categorization of Apheresis Indications 287t
Amino acid 7
Aminophylline 293
Amniocentesis 104, 389
indications for 389
Amorph 46
Amorphic gene 43
Amplicon, production of 502
Amplification 372
Amplifier molecule 376
Anamnestic immune response 9
Anaphylactic reactions 292, 293, 307, 308, 332
Anaphylactic response 308, 310
Anaphylactoid 308, 310
Anaplasma phagocytophilum 428
Anemia 146, 250, 381, 405
acute 409
alloimmune hemolytic 410
aplastic 527, 530
chronic 325
requiring transfusion support 409
risk for 36
severe 250
Angioedema 308
localized 308
Angiotensin converting enzyme 314
inhibitors 327
Anguilla anguilla 69
Animal anatomical waste 447
Animal immune system 175
Antecubital veins 148f
Anti-A and anti-B 58
A and B group 56
in O group 56
Anti-A reagents, commercial 49
Anti-A1 57
lectin 71, 71f
Antibiotic therapy 316
Antibody 3, 5, 12, 41, 57, 69, 71, 82, 114, 122, 128, 203, 210, 218, 225, 350, 353, 387, 515
absence of 21
acquired 20, 85, 103
additional 91
against
additives 232
Rh antigens 103
anticomplement 175
antigen reaction 83
circulating 207
classification 79
clinically significant 190
complete 7
concentration levels 215
dependent cell-mediated cytotoxicity test 388
detection 114, 188, 191, 514
and identification 68
methods 190, 193
purpose of 188b
reagents for 191
development of 56, 327
dose-dependent 189
enhancement of 116
excessive 12
exclude presence of 399
exclusion 206
formation 4
forming B lymphocytes 64
high prevalence 205
high-titer 58
identification 188, 198, 199b, 200b, 207, 208b, 215, 218
panel sheet 202f
preanalytic phases of 200
reagents for 198
red cell panels, features of initial 198
results of 203
IgG type of 383
immune complex 11
incomplete 7, 11, 173, 179
Indian 132
interactions 79
layers of 361
low prevalence 205
mediated graft rejection 516
molecule 64, 67
naturally occurring 190, 201
nature of 104
original 98
passive 201
plasma for 211
potentiators 66
mechanism of 69t
type of 69
private 509
producing cells 105
production of 5, 379
reactions in vitro 10
reactive 225t
reagents, commercial 62
resolution 188
responses
primary 10f
secondary 10f
salient features of 9t
screening 94, 188, 197t, 225, 236, 387, 405, 426, 427, 510f
gel method for 195f
indications for 191b
purpose of 191
test 10, 188, 231
separating multiple 215
serum for 211
significance of 114, 219
sources of neutralization substances for 210t
specificity of 188, 386
temperature for 217
testing 565
titration 215, 387
types of 56, 354, 379, 510
warm 201
weak 85
weakly reactive 12, 191
Anticoagulant 521, 551
acid citrate dextrose A 166
citrate dextrose 278
solution 282f
preservative
amount of 243
solutions 163, 165t
Anticoagulation 276
Anti-Cromer antibodies 131
Anti-D
monoclonal reagents 105, 106b
production of 99
Anti-Dombrock antibodies 127, 128
Antifibrinolytic agents 239
Antigen 3, 49, 67, 99, 120, 135, 350, 353, 386, 492
antibody 21
binding 15
complex 11, 49
ratio 12, 17
reaction 14, 15, 58, 61, 205
antithetical 124
authenticated 101
binding fragment, formation of 6f
characteristics of 3
dosage 204
endogenous 495
excessive 12
exogenous 22, 496
expression 113, 118, 121, 125, 127, 128, 130, 189, 189t
functions 495, 496
gradient of 49f
heterozygous 189
high-frequency 203
high-prevalence 193, 218
identification red cell panels 198
in common, presence of 217
interactions 79
low-frequency 203
low-prevalence 218
mixtures 365
negative
blood donors 36
red blood cells 234
number of 498t
per cell 42
normal 102
phenotypes 192
positive reagent red cells 203
presentation 495, 496
processing of 5
specific
dendritic cells, autologous 536
T-cells 493
systems, dozen of 19
typing, methods of 208
Antigenic
determinant 3
exposure 380, 383
Antiglobulin 83
crossmatch 229
method of 229
requirements 226f
drops of 108, 182
phase 228
reagents 61, 183, 192
conventional polyspecific 175
quality control of 185
serum, addition of 102
techniques, applications for indirect 184t
test 96, 104, 105, 127, 173, 178, 180f, 181, 182, 183f, 185, 186t, 187, 426f
advantages of 186t
direct methods of 180f
disadvantages of 186t
history of 173
indirect 67, 79, 102, 114, 179, 181, 183t, 184, 227, 228
interpreting positive direct 205t
materials required indirect 182
principles of 179b
procedure, indirect 185t
quality control for 185
sources of error in 185
technique indirect 182
types of 178
uses of direct 181
uses of indirect 182
Antigram 192
Anti-H 57
reagents 71f
Antihemophilic factor 264, 420
concentrate of 557
Antihuman globulin 7, 102, 173175, 190, 225
cards 78
preparation of 175
reagent 15, 63, 174, 174f, 469
serum 551, 582
technique, indirect 229
test 173, 178, 427
sensitivity of 187
Antihuman leukocyte antigen antibody 513
Anti-Kell autoantibodies 117
Anti-Rh antibodies, reactivity of 104
Antiseptic solution 148
Antisera 61, 62, 72
commercial 69, 71
Antiserum 11, 83, 500, 501
against human 11
Anti-trypanosoma cruzi 481
Anuria 332
Anxiety 332
Apheresis 274, 276, 277f, 281, 281b, 284, 521
adverse effects of 292b
basic principles of 275f
blood components 294t
donation 140
donors 293
general requirements for 280b
granulocytes 168
indications for 275, 275b
licensing 444
machine 276, 277
methods of 276
monitoring for 558
physiology of 276
procedures 292
red blood cells 254
time needed for 284
types of 274, 577
Apnea 328
Apoptosis 527
Armed forces transfusion services 589
Arrhythmia, cardiac 306
Artery
accidental puncture of 154
disease, coronary 570
forceps and scissors 148
Artificial oxygen carriers, potential benefits of 415b
Aseptic precautions 316
Autoadsorption 201, 212f
Autoantibody 3, 20, 92, 124, 127, 190, 196, 201, 508
warm 68
Autoanti-P 123
Autoclaving 448
Autoimmune diseases 494
Autoimmune hemolytic anemia 35, 84, 104, 117, 179, 181, 239, 342, 410
diagnosis of 184
severe 130
Autologous blood 412b, 539
donation 411
preoperative 240
transfusion 328, 411
advantages of 411b
contraindications for 412b
disadvantages of 412b
Autologous control
positive 196
result of 205
Autologous donation, preoperative 328
Autologous hematopoietic progenitor cell transplant 533, 534
indications for 532b
Autologous red cell phenotype 200, 207, 216
Autologous transfusion 240
types of 412, 413b
Automation 422
advantages of 422
use of 423
Auto-Rh antibody 104
Autosomal dominant and X-linked recessive 121
Autosomal recessive 119
phenotype 121
Avidin-linked detection system 505
Azide methemoglobin 157
Azurophilic granules 5
B
B antigen 45
acquired 85, 88, 89t
acquisition of 50
common structure for 42
formation of 42
B cell 4, 63
functions of 5
isolation of 502
lymphomas 536
malignancies 535
B genes 54
B lymphocytes 3, 5, 64, 495, 512
stimulation of 515
B phenotype
acquired 50
inherited 50
Babesia microti 357
Babesiosis 288, 443
Bacteria 243
gram-negative 172
gram-positive 172
retaining filters 559
Bacterial contamination 307, 331, 472
sources of 314
suspected 481
Band aids 148
Bandeiraea simplicifolia 50
Barcode label system 423
Basic immunoglobulin structure 6f
Basic test procedure 364
Bead-chip technology 35
Bilirubin
conjugated 381
metabolism of 382f
Bind oxygen 403
Biologic false positives 355
Biomedical waste 436, 444, 445
categories of 447t
containers/bags, label for 448f
disposal option for 447t, 448b
generation of 445
management 446
scientific management of 446, 446fc
Biotechnology 447
Birth canal 347
Bleeding 259
disorder, diagnosis of 268fc
Blood 346
acute loss of 244
agitator 547
and blood products
in blood bank, quality control of 473t
quality control of 472
artificial 414
bacterial contamination of 314b
bags 162
primary 162
quality of 162
selection of 434
system 162
traceability of 434
types of 163, 163t
bank 20, 61t, 138, 369, 422, 425, 425b, 426b, 428, 429, 429t, 433, 468b, 475b, 538, 539, 545, 553, 555, 558, 578
accommodation for 545, 581
audits in 488
by drugs controller, licensing of 443
document control system in 477
enzyme used in 115
equipment used in 471t
information systems 424
license for operation of 541
licensing of 443, 545t, 578
licensing policy and legal framework for 578
modernization of 586, 587
policy 336
prerequisite for grant of license for 579
quality control of reagents in 469t
quality management system for 452f
reagents, licensing of 61
registers in 475
regulations and legal framework 538
renewal of license for operation of 542
requirements for operation of 545
safety for 488
size of 444
staff requirement in 546t
supplies required for 581
system 538
technician 546
technology 567
banking
and transfusion services 442
applications of molecular genetics to 34, 370
challenges in 441
genetic principles in 30
historical overview of 22
recent advances in 425
basic principles in 138
borne disease 445, 470, 486
brain barrier 383
cell 43
ex vivo generation of 417
lineages of 520
processor 253
serology 138
center 138, 538, 539
operation of 539
policy 336
staff requirement in 546t
well equipped 441
clinical use of 442
collecting container 548
collection 138, 141, 147, 148b, 159b, 434, 468
bag 148, 162
equipment 149
for components 246
monitor 150f
of whole blood, process of 148
perioperative 413
process of 149f
room 545, 550, 581
set 242, 243f
technique of 472
triple plastic bag for 163f
compatible 188
component 140, 242, 245, 269, 269t, 270f, 275, 281, 306, 316, 475, 539, 545, 553, 555, 558
availability of 441
categories of 555, 577
expiration of 168t
issue register 476
preparation of 246, 246f, 248b, 545
processing of 554, 577
quality control of 472
remove particular 275
separation of 434
transfusion of 347, 405, 517
uses of 245t
container 581, 583
weighing device 547
derivative 418
donation 155t, 438, 549
adverse reactions to 152
camps 444, 554, 555b
criteria for 549
deferment of 550t
program 443
types of 139
donor 36, 350fc, 359, 367, 438
prospective 573
record 552
register 582
registration 475
selection 431, 568
errors during collection of 222
establishments 138
functions of 414, 414b
genotyping, advantages of 84
group 19, 33, 38, 70, 79, 101, 112b, 209, 304, 427, 553t, 565
A 45
AB 47
alloantibodies 20
and compatibility testing 431
and labeling 431
antibodies 76
antigen 3, 17, 19, 399
autoantibodies 20
B 45
chimera 85
effect on 209t
genetics 25
infant's 393
interpretation of 73f
O 46, 52
reagents 468
secretors 47t
selection for transfusion 405
serology 1
serums 548
slide method interpretation of 73f
system 38, 39t, 40, 41, 42f, 44, 54, 79, 112, 115, 122, 122t, 135, 191
hematocrit of 394
in cold room, storing of 167
in refrigerator, storing of 167
issue of 434
loss 250
acute 139
iatrogenic 404
massive transfusion of 312
mixers 148
preservation 162
aims of 162b
pressure 147, 311
processing 468
production of 473
products 138, 251, 284b, 419, 431, 539, 543
bacterially contaminated 305
manufacture of 539, 540, 542, 544, 561
requirements for manufacture of 558, 559, 563
testing of 562
quality control in collection of 467
rapid transfusion of 312
rational use of 431
recovery, perioperative 328
safe administration of 432
safety
elements of 444
program, evolution of 586
sample 179, 186, 221, 222b, 390, 432
depicting location of cellular components 9f
large number of 76
selected for exchange transfusion 393
selection of 393, 577
separation, flow pathway of 278f
shield statutes 443
specimen, acceptability of 222
stock register 582
storage of 162, 166
substitutes 414
transfusion 138, 296, 338t, 347, 353, 387, 392, 400, 414b, 436, 437, 516
adverse effects of 296
complications of 302b
crossmatching for 182
history of 386, 550
process similar to 531
reactions 300
service 22, 538
sets 581
therapy 138
transmissible by 569
transmissible
diseases 545
infections, testing 470
transport of 162, 432
type 40
unit 393, 405
arrangement of 167
utilization monitoring 485
vending machine 430
vessels 347
volume of 150, 165, 394, 412
whole blood, staff requirement in 546t
within hospital, transport of 167
Body's own antigens 3
Bombay blood group 51, 94, 95t
Bombay phenotype, salient features of 53b
Bone marrow 59, 132
autologous 526
collection 522b
derived hematopoietic progenitor cells 520
examination 323
transplant 56
Bovine albumin 14, 65, 68, 548
Brain 134
natriuretic peptide 311, 313, 340
assay of 313
Breastfeeding 146, 550
Breath sounds, abnormal 311
Bromelain 68
Bronchospasm 308
Buffy coat 528
concentration 528
method 257, 257fc
pooling set 258
reinfusion of 289
removal method 257
C
Calcium hypochlorite 367
Campylobacter jejuni 60
Cancer 59, 146, 530
immunotherapy 535
Candida vaginitis 114
Carbohydrate
antigens 13, 40
chains 42
Carbon dioxide 103
Card before test 367f
Card test 355
Cardiac arrest 531
Cardiac disease 311
Cardiac surgery
bleeding during 402b
previous history of 402
Cardiovascular diseases 570
Cardiovascular support 340
Cartwright antibodies 126
Cartwright antigens 125
Cartwright blood group system 125
Catadromous fish 69
CD59
antibodies 136
antigen 136
blood group system 136
Cell
abnormal 64
allogeneic 495
cycle 27
major phases of 27, 27f
dehydration 529
depletion 528
division 25, 27
types of 27
dual populations of 80
effector 4
enrichment 529
expansion 529
free hemoglobin solutions 415
free plasma 247
mediated immunity 5
membrane 4, 41, 42
shape 169
mixed 80
panel
preservation of 192
selected 209
populations 530
purging 529
and reduction 529
selection systems 528
surface 492
to-serum ratio 12
transfusions 492
Cellular
antigen systems 429
blood components 323f
concentration of 309
irradiation of 324b
elements, effect on 169
immunity 5
immunodeficiency 322
congenital 324
loss 276
therapeutics 430
therapy 430, 519
Centers for Disease Control and Prevention 312
Central nervous system 383, 409, 570
Central venous
access 523
catheter 314
Centrifugation 246, 248, 254, 279, 423, 500, 527
duration of 247
methods of 277
speed of 247
Centrifuge 470
blood bags 255
bowl, cross-section of 278f
post-transfusion 335
Cerebral artery peak systolic velocity, middle 388, 391
Cervical secretions 47
Chagas disease 145, 481
Chemical
cryoprotective 529
removal 36
waste 447
Chemiluminescent immunoassay 369, 444
Chemotherapy, high-dose 324
Chest X-ray 311
Chido/Rodgers
antibodies 130
antigens 129
blood group system 129
Chills 306, 532
Chimera, artificial 85
Chimeric antigen receptors 536
Chimerism 530
artificially induced 90
Chlamydia trachomatis 378
Chlorine 367
Chloroform 210
Cholera 146, 550
Choriocarcinoma 125
Chromatography, affinity 279, 280f
Chromosome 25, 493
autosomal 19, 25
components of 25
homologous 29
number of 28, 29
structure of 26f
Chymotrypsin 117, 128
Circulatory disorders 146
Cirrhosis, alcoholic 125
Cis-Ab phenotype 50
Citrate 164, 165
anticoagulants 189
phosphate-dextrose 163, 169
adenine 163, 169, 551
dextrose 163
solution 581
phosphate-double dextrose 169
toxicity 238, 292, 326, 523
Citric acid 164, 166
Closed system bag 148
Clostridium 300
Coagulation 60, 239
abnormalities 239
cascade, activation of 300
disorder 269
factor
concentrate, disadvantages of 411
reduced levels of 239
Coagulopathy 294
transfusion treatment of 267
Coding region 30
Codons 30
Cold
agglutinin 57
alloantibodies 91, 92t, 93t, 203
antibodies 81, 91
autoantibodies 91, 92t, 93t, 217
hemagglutinin disease 342
Collected sample, appearance of 223
Colloids 419, 420
advantages of 420t
artificial 419
disadvantages of 420t
solutions 419
Colon cancer 536
Colony stimulating factors 418
Color codes 468
Color Doppler middle cerebral artery peak systolic velocity 388
Colorectal carcinoma 89
Colored band indicating test 356f, 367f
Colton antibodies 128
Colton antigen 128
Colton blood group system 128
Colton system 112
Column agglutination 78
system, uses of 79, 79b
technology 17, 78, 78f, 80, 81f, 108, 183f, 195, 230f, 426f
systems 426
test 78
Communicable disease 445
Community acquired hemolytic-uremic syndrome 124
Compatibility 431
test 183, 220, 235
components of 220
record 476
Compatible plasma, replacement of 578
Complement activation, consequences of 297
Complement system 20, 497
activation, pathways of 21
functions of 21f
Complete blood count 527
Complex antibody
identification 216
problems 68
Compliment activation releases vasoactive amines 298f
Component separation, principle of 275
Computer crossmatch 229
advantages of 230b
Computer system validation 464
Conjugation 417
Continuous medical education 455
Conventional tube testing 186
Coombs antiglobulin test 179
Coombs control cells 178, 187, 194
Coombs crossmatches 339
Coombs phase tests 79
Coombs reagent 179
Coombs serum 551, 582
Coombs test 23, 104, 173, 180
history of 173
Copper sulfate 468
solution, preparation of 156
specific gravity method 156
Cord blood 516, 532
bilirubin 390
collection 524
product, processing 525
Cord cells 124
Cord hemoglobin value 390
Cord red blood cells 189, 189t
Cordocentesis 388
Corticosteroids 282, 309
Cotton wool swabs 148
Creutzfeldt-Jakob disease 366
Cromer antibodies 131
Cromer antigens 130
Cromer blood group 136
system 130
Crossmatch 431
interpretation of 226t, 229
procedures 226
techniques 226, 226b
testing 220, 225
limitations of 230
purposes of 226
types of 226
Cryo-poor plasma 245
Cryoprecipitate 245, 247, 269, 271, 369, 406, 557
bag of 265t
indications for 265, 265b
pooling of 266
production of 266f
salient features of 264b
thawing of 265
Cryoprecipitated antihemophilic factor 264, 266, 267, 270, 411, 472
Crystalloid 419, 420
advantages of 420t
disadvantages of 420t
solutions 419
Cyanmethemoglobin method 157, 159f
Cyanosis 328
Cylinder enzyme-linked immunosorbent assay 363
Cytapheresis 274, 280
Cytokine 4, 5, 306, 497, 529
production 514
release of 307
side effects of 523
Cytomegalovirus 251, 252, 320, 357, 393, 420, 525, 535
infection 404, 575
status 141
transmission 535
Cytopenia 331
Cytosine 27
Cytotoxic reactions 495
Cytotoxicity
complement-dependent 501t
D
D antigen 98, 101, 102, 386
absence of 99
detection of 102
partial 103
D phenotype 102
Dane particle 350
Data handling, automation of 424b
Deep freezer 267f
Delated nonimmunological iron overload 325
Delayed transfusion reaction 302, 318, 326t
etiology of 318fc
Dendritic cell 2, 4, 5, 495, 519, 535, 536
use of 535
vaccine 536b
Dengue fever 443
Deoxyribonucleic acid 25, 26, 26f, 37, 370
based molecular typing 502
based techniques, advantages of 502
duplex, denaturation of 373
isolation of 503
location of 26
preparation and amplification of 503
synthesis 513
virus, hepatotropic 349
Deoxyribose sugar moiety 27
Detect weak antibodies 305
Dextrose 164166
D-galactosyltransferase 45
Diabetes 146, 571
Diagnostic kits and reagents, register for 553
Dichloromethane 214
Dideoxyribonucleoside triphosphate 506
Diego antibodies 125
Diego antigens 125
Diego blood group system 125
Diego system 112, 137
Diffuse intravascular coagulopathy 318
Digestive system 572
Dimethyl sulfoxide 529
Diphtheria 79, 146, 550
Direct antiglobulin techniques, applications for 184t
Direct antiglobulin test 79, 102, 178, 179, 184, 194, 195, 214, 318, 335, 337, 340, 341, 344, 379, 390, 400, 429
procedure 178t, 185t
Direct solid phase test systems 83
Disinfection 487
Disposable blood collection bags, types of 150, 151t
Disposable sterile bleeding sets 581
Disseminated intravascular coagulation 268, 300, 341, 406, 411
Document
control 477
elements of 477b
maintenance 478
Documentation control system, pyramid of 477f
Dolichos biflorus 48, 50
Dombrock antibodies 128
Dombrock antigens 127
Dombrock blood group system 112, 127, 127t, 128
Donath-Landsteiner test 123, 123f
Donation, autologous 139
Donor
ABO group selection 233t
additional qualifications of 550
adverse
events 479
reactions, number of 484
and blood unit records, retention of 474
and donation, types of 139
apheresis 275, 279
autologous 523, 526
blood
collection, record of 475
processing of 160
product, antibody in 517
product, T cells in 517
repeat testing of 224
screening of 431
commercial paid 139
counseling of 431
cytapheresis 275, 280
eligibility 147
erythrocytapheresis 283
granulocytoapheresis 281
hemoglobin estimation of 156
hemovigilance 438
human leukocyte antigen antigens 517
leukocytapheresis 281
leukocyte infusion 534
lymphocyte 254
infusion 534
physical assessment of 146
plasmapheresis 275, 285
plateletapheresis 281
post-donation
instructions to 153
management of 152
preparation of 254
professional 139, 540
recipient crossmatch 507
record 475
number of incomplete 484
red cells 87, 228f, 337
registration of 141
sample 338
screening 140, 140f
selection 138, 140, 144, 280282, 434, 467
and registration 475
criteria for 283
requires 141
specific antibody 513
suitability of 556
testing 357
treatment of 282
types of 139
units, selection of appropriate 233
Dopamine 293
Dot blot assay 363
Double red blood cell collections
advantages of 284b
disadvantages of 284b
Double red cell
collection 283
automated 283
donation 283
Drabkin solution 159
constituents of 158t
detergent-modified 158
Drug-induced hemolysis, investigation of 184
Drugs and Cosmetics
Act 444, 538, 565
and Rules 538
Amendment Rules 565
Rules 539, 566
Dry heat sterilisation 448
Duffy antigens 118
Duffy blood group system 118, 137
Duffy glycoprotein 119
Duffy system 112
phenotypes in 118t
Dysfibrinogenemia 269
Dyspnea 310, 331
E
Edema, conjunctival 308
Electrolytes 292
effect on 170
Electronic crossmatch 229
Electrophoretic separation 375
Elevated lactate dehydrogenase 337
Elution 208, 210, 390
partial 211
technique
principle of 210f
uses of 210b
total 211
Emergency drugs 148, 153
Empty satellite bag 269
Encapsulation 417, 448
Encoding genes 118
Encountering during donation, problems 153
Endocrine disorders 571
Endogenous pyrogens, release of 306
Endothelial cells 59, 119, 515, 520
Endothelium 310
Endotoxins 315
Endotracheal intubation 293
Enzyme 15, 68, 209, 548
enhance cold 68
immunoabsorbent assays 369
immunoassay 17, 350fc, 357, 358, 365, 368, 369
advantages of 358b
labeled anti-human immunoglobulin antibody 364
linked antiglobulin test 359
linked fluorescence assay 444
linked immunosorbent assay 17, 19, 350, 359, 363, 428, 508, 551, 552
applications of 359, 359b
competitive 362, 363f
indirect 360
procedures, advantages of 359b
technique, advantages of 511
test 511
types of 359
uses of 359
linked immunosorbent
crossmatch assays 508, 511
spot 514
substrate 511
test method, one-stage 209
treatment 209t, 216
reactivity with 209
Epidermis 135
Epilepsy 146
Epinephrine 293, 309
Epithelial membrane 59
Epitope 3
Epstein-Barr virus 64, 251, 357
infections 125
Equipment
maintenance of 470
quality control of 470
selection of 457
validation for new 457
Erythema 308
Erythroblastosis fetalis 324, 385fc
Erythroblasts 381
Erythrocyt apheresis 566
Erythrocytapheresis 274
benefits of 283
Erythrocyte magnetized technology 427
Erythroid membrane associated protein 127
Erythro-magnetic technology 427
Erythropheresis 578
Erythropoiesis, accelerated 381
Erythropoietin 403, 404, 418
low 403
response 403
Escherichia coli 123, 315
Ethanol 367
Ether 210]
Ethyl alcohol 367
Ethylenediaminetetraacetic acid 552
Ex utero collection 524
Exchange transfusion 234, 244, 341, 392394, 400
advantages of 393b
criteria for 392
Exons 30
Exotic disease 443
External proficiency exercise 470
External quality assessment 489
scheme 442
benefits of 490b
External quality assurance 472
Extravascular hemolysis 22, 300
consequences of 301f
Extrinsic pathway, activation of 300
F
Fab fragments 7
Faint muscular twitching/spasms 155
False reactions 227
False-negative
reactions 94, 96
test, causes of 185, 338
False-positive
reactions 94, 197
causes of 197b
tests, causes of 185
Fascioliasis 122
Febrile nonhemolytic transfusion reaction 252, 303, 306, 307b, 307t, 494, 517
Febrile reaction 307, 332
Fetal
antigen 383
circulations 380
deoxyribonucleic acid testing 388
genotyping 389
hemoglobin 397f
maturity 389
red blood cells 403
premature destruction of 379
red cells, immune destruction of 381
Rh hemolytic disease, pathogenesis of 384f
spleen 382f
Fetomaternal hemorrhage 380, 395, 396
amount of 385
detection of 396f
Fever 303f, 304, 306, 331, 532
development of 320
Fibrin
degradation products 268
sealant 267
Fibrinogen 245
level 268
replacement of 269
Ficin 68, 134, 209
Filtration 279
Fisher-race
DCE terminology 110
haplotype 100
notations 100
Flow centrifugation, continuous 278
Flow cytometry 19, 507, 508, 511
Fludarabine therapy 324
Fluid
phase assays 17fc
shifts 276
Fluorescein isothiocyanate 511
Fluorescent
caps 502
treponemal antibody 19, 356
test 356
Flushing 532
Food and Drug Administration 369, 457, 489
Foreign antigen 1
Foreign red cells 200
Forensic investigations 493, 494
Formalin 501
Fraction antigen binding 7
Fragmented blood transfusion service 444
Free hemoglobin, false-positive test for 337
Free plasma hemoglobin 337
Freezing hematopoietic progenitor cells, preparation for 529
Fresh blood 179
Fresh frozen plasma 168, 242, 245, 260, 261f, 266f, 269, 271, 285, 406, 420, 432, 436, 557, 577
indications for 261, 262b
Fresh whole blood 244
Frozen red blood cells 252
Fucosyltransferase 43, 48
Fully automated
immunohematology analyzer 426f
transfusion-transmitted infection system 428f
Fungal infection 406
G
Galactose 46
Gamma
globulin 146, 550
irradiation 324
Gastric juice 47
Gastrointestinal cell cancers 114
Gastrointestinal symptoms 308
Gastrointestinal tract 4, 47
lower 89
Gel based testing 17
Gel card 78, 426
features of 78
method 183
technology 78, 108
interpretation of 81f
Gel filled microtube 79
Gel low-ionic antiglobulin test 185
Gel method 186, 195f
Gel test 183
antibody screen 195f
specific 185
types of 183
Genes 25, 30, 37
activation 514
alleles of 32
block of 99
groups of 514
location of 126, 497f
loci of 493
regions of 30
structure of 30
Genetic code 30
Genetic disease 527
Genetic forms 347
Genetic locus 31, 37
Genital fluids 347
Genitourinary tract 47
Genotype 32, 36, 41, 44, 99, 101
determination of 54
types of 32
Gerbich antigens 130
Gerbich blood group system 130
Gerbich null phenotype 130
Germ cell division 27
GIL antibodies 135
GIL antigens 134
GIL blood group system 134
Glass bead
matrix 80f, 81f
technology 426
Glass microbead
matrix 78, 79, 183f, 229
appearance of 78f
technology 17
Glass slide 35
Glassware 447
Globoside blood group system 122
Glucose 166
Glutaraldehyde 367
Glycan 42
Glycerol 253
cryoprotectant, process of removal of 253
Glycine 67
acid 131, 210
Glycolipid 40, 42
Glycophorin A 115
Glycophorin B 115
Glycoprotein 40, 494
acetylcholinesterase 125
molecules 42
primarily 42
Glycosylphosphatidylinositol 40, 125
Glycosyltransferase 44, 113
enzymes 45, 48t
Gonads, germ cell of 28
Good manufacturing practices 548, 589
Graft
alloantigens 515
autologous 534
cells, killing of 515
disease, risk of 529
rejection 534
versus-host disease 251, 406, 408, 534
Gram stain and culture 316
Granulocyte 169, 324, 406, 519, 532
collection 406
colony-stimulating factor 520, 521
components 324
concentrate 245, 270, 271, 557, 576
preparation of 271b
volume of 282
macrophage colony stimulating factor 271, 520
stimulation 284
transfusion 281, 324
complications of 271, 272b
indications for 271, 271b
yield, increase 282
Granulocytopheresis 280
Graves’ disease 571
Gravity leukopheresis 271
Group B red cells 70
Group O
cells 46
donors 191
reagent screen cells 71
red blood cells 198
Rh-negative packed cells 235
Group red blood cells antigens 70
Guanine 26
Guinea pigs 98
H
H antigen 4446
amount of 53
common structure for 42
concentration of 44, 44f
formation of 42, 43
H blood group system antigens 41
H gene 43, 51
H influenzae type B 132
H transferase 51
Hairy cell leukemia 286, 288
Haploid cells 29
Haplotype 101
Haptens 3
Haptoglobin 298, 299
levels 320
low 337
Headache 523
Heart
disease 146, 570
coronary 60
hypertensive 570
lung transplants 407
surgery 139
transplants 407
Heat freeze-thaw 210
Heavy chain, types of 7t
Heavy spin 247, 248
centrifugation 254
Helicobacter pylori 60, 114
Hemagglutination 11, 17, 81, 203
assays 425
uses of 425b
grading of 15t
indirect 356
reaction 79
reversed passive 552
scoring of 15t
testing 34
Hemapheresis 274
Hematocrit 394
centrifuge 547
level 147
Hematologic cells, ex vivo manipulation of 535
Hematologic malignancy 251, 311, 324, 536
Hematological parameters 400
Hematological tests 79
Hematoma 153, 155
Hematopoietic cells 495
Hematopoietic graft
cryopreservation of 529
recipients 530
Hematopoietic growth factors 283, 417
Hematopoietic progenitor cell 59, 140, 284, 370, 429, 519, 520, 526, 526t, 533
advantages of collection of 522b
by bone marrow collection, risks of 521
collection 284, 520
benefits of 521
procedure 523
disadvantages of collection of 522b
donor concerns 523
dose 521
mobilization 522
side effects of 523
processing methods, specialized 528
products 520b
processing 527
reinfusion of 531
terminology of 520
transplant, types of 525
transplantation 324, 407, 494, 519
goals of 520b
indications for 525, 526b
purpose of 520b
transfusion therapy for 535
washing of 528
Hematopoietic stem cell 519, 520, 526, 578
transplantation 96, 502, 516, 520
complications of 533
sources of 520b
Hematuria 332
Hemiglobincyanide 159t
Hemo-cue blood hemoglobin
apparatus 157f
system 157
Hemoglobin 147, 156, 157, 300, 337, 381, 414, 415
based oxygen carriers 415, 416, 416b
concentration 159, 159f
content 565
determination 550, 551b, 581
estimation
methods of 156
sources of errors in 157
into plasma 299
level after transfusion 244
types of 415
Hemoglobinemia 298, 300, 306, 337
Hemoglobinometer 547
Hemoglobinopathy, test for 525
Hemoglobinuria 298, 300, 306, 332, 337
asymptomatic 305
Hemolysin 16
Hemolysis 15, 58, 59, 194, 196, 198, 203, 225, 228, 229, 294, 296, 319, 320, 331, 381, 531
absence of 227
acute 337f
after birth 382
alloantibody-induced 342
elevated liver enzymes, low platelet count 342
types of 296
Hemolytic anemia 250
drug-induced 410
Hemolytic disease 58
of fetus and newborn 7, 59, 98, 104, 114, 181, 182, 188, 225, 379, 382f, 383, 387t, 398t, 393, 400, 429
cause of 110
classification of 379, 380b
diagnosis of 184
risk of 84
Hemolytic properties 57
Hemolytic reaction 98
serious 531
symptoms of 298f
Hemolytic transfusion reactions 14, 58, 104, 218, 335, 338, 341fc, 342b
control 305b
delayed 117, 318, 319, 320b, 321, 321t
investigation of 181, 184
Hemolytic uremic syndrome 342, 409, 420
Hemolyzed plasma 334f
Hemophilia 139, 411
A 411
B 411
Hemostatic abnormalities 239
Hemostatic disorders 410, 411
Hemovigilance 436, 438
goal of 436
reporting 483
system 438
terminology in 438
Hepa filters 559
Heparin 171
effect of 402
Hepatitis 352f, 366
A 146
acute 352f, 353f
B 146, 244, 370, 445, 582
acute 353
infection 145
positive test for 145
surface antigen 565
virus 349, 352f, 357, 437, 525
C 244, 445
antibody 565
virus 352, 357, 437, 486
chronic 352f, 353f
infection 571
Heteroantibodies 3
Heterohybridomas 64
Heterozygotes hypercholesterolemia 292
Hexose molecule, basic structure of 42f
Highly decentralized blood banks 441
Hinge region 6
Histocompatibility complex 3
gene
major 493
polymorphism of major 493, 497
major 497f, 536
molecules, major 492
restriction, major 493, 495
Histocompatibility testing 502, 515
and matching, techniques of 498
Histone 26
Hodgkin's disease 534
Hodgkin's lymphoma 324, 532
Homologous chromosomes, pair of 29, 37
Homozygous 32, 33, 45, 51, 189
antigen 189
expression 189, 198
Hook effect 362
Hospital blood bank 450
activities of 451b
Hospital transfusion committee 472, 487
goals of 487b
Host disease, risk of 529
Host factors 386
Human alloantisera 501
Human anatomical waste 447
Human antibody molecules 175
Human B lymphocytes 64, 511
Human blood 538, 543
components 539
for components of blood products, processing of whole 540, 541
for manufacture or blood products, processing of whole 540, 541
group 38
system 98
operation of whole 564
processing of whole 542
testing of whole 582
Human cell cultures 511
Human derived coagulation factor concentrates, infusion of 328
Human embryonic stem cells 417
Human erythrocyte antigen 35
Human globulins 173
Human immunodeficiency virus 123, 141, 244, 346, 347, 350fc, 357, 437, 486, 525, 548
1 antibody tests 349
antibodies tests 552
antigen testing 349
infected whole blood 347
infection 349f, 350b, 571
transmission of 347
isolation 349
properties of 347
related infections 587
structure of 348f
testing facilities 586
Human immunoglobulin molecules 177
Human leukocyte antigen 140, 251, 310, 340, 342, 503, 514, 516, 517, 524, 525
allele 505, 506
alloimmunization 535
and sex, mismatched for 534
antibody 517
detection of 511
formation of 509
identification of 510
methods of detecting 510
screen 512
specific 501
techniques for detection of 509
classification of 494
codominant expression of 497
complex 493, 496f, 497f
detection 499
evaluation 508
haplotype 493, 497
identical siblings 516
inheritance 497
matched platelet 324
concentrates 324
molecular techniques 502
nomenclature for 497, 498
specific antibodies
after immunization 509
in pregnancy 509
in transfusion 509
in transplantation 509
system 492
techniques for detection of 498
testing to identify 499
types of donor 514
typing 498, 515
method for 500
procedures 503
sera trays 501
Human major histocompatibility complex 493
Human mesenchymal stem cells 125
Human neutrophil antigen 310, 340
antibodies 517
Human peripheral lymphoid cells 5
Human platelet antigen 324, 517
Human polyclonal origin, high-protein reagents of 105
Human proteins, family of 173
Human red blood corpuscles 555
Human resources 454
Human retrovirus, nontransforming 347
Humoral immunity 5
Humoral rejection 516
Hybrid cells 64
Hybridoma 64, 64f, 70, 176
cell line 64
technology 63, 177f
Hydatid cyst disease 122
Hydroclaving 448
Hydrogen
bonds 27
peroxide 367
Hydrolysis 448
Hydrops fetalis 381, 382
Hydroxyethyl starch 280, 283, 290, 293, 419
solution 271
Hyperactive immune system 2
Hyperbilirubinemia 298, 320, 337, 381, 382
Hyperkalemia 238, 306
Hyperleukocytosis 287
Hyperparasitemia 288
Hypersensitivity reaction, stimulation of delayed 515
Hypertriglyceridemia 159
Hyperventilation 155
Hypocalcemia 238, 292
risk of 523
Hypochlorite solution 486
Hypofibrinogenemia 239, 406
Hypogammaglobulinemia
acquired 56
congenital 56
Hypokalemia 238, 523
Hypomagnesemia 523
Hypoplastic anemia 250
Hypotension 293, 308, 331, 531
treatment of 293
Hypotensive transfusion reaction 439
Hypothermia 238, 239, 402, 404
Hypotonia 328
Hypovolemia 244, 250, 293
Hypoxemia 310
I
I blood group
antigens 124
system 124
Iberis amara 50
Immature dendritic cells 135
Immune
alloantibodies 190
reconstitution 532
serum globulin 242
thrombocytopenic purpura 268
Immune hemolytic
anemias 410
reaction 336
Immune-mediated
acute hemolytic transfusion reaction, causes of 304
hemolytic transfusion reaction 343
Immune response 493, 495
primary 8, 10t, 319
secondary 9, 10t, 319
Immune system 2, 3
cell of 4
components of 4
role of 2
types 2
Immunity 1
Immunization 146, 147, 550
active 397
passive 397
Immunoadsorption 280
Immunoblot 364
Immunocompromised state 324
Immunodominant sugars 43, 44
Immunoelectroblot 364
Immunoelectrophoresis 16
Immunofluorescence assay 350
Immunogen 3
Immunogenicity 3, 19
Immunoglobulin 3, 6, 9t, 12, 17, 69, 245
A antibodies 8, 173
class 56, 386
digestion of 7
molecule 7t
structure of 6
types of 6, 7, 386
Immunoglobulin G 340
antibodies 7, 66, 83
weak 203
isotype 130
monoclonal anti-D 107
sensitized red cells 178
preparation of 178
Immunoglobulin M
antibody 7, 66, 173
molecules 66
anti-D monoclonal reagent 105
anti-HbC indicates recent infection 352
isotype 116
monoclonal anti-D/saline agglutination test 107
Immunohematology 1, 10, 434
automation in 422
transfusion therapy 138
Immunologic status 403
Immunological disorders 20, 526
Immunology, basic concepts of 1
Immunomagnetic beads 501
Immunomagnetic selection 528
Immunosuppressive therapy 56
Immunotherapy 535
In utero collection 524
In vitro
bacterial contamination 96
serologic reactions 56
technique 502
Incompatible fluids 342
Incubation time, increased 213
Infections 534
bacterial 50, 406, 481
chronic 353
markers tests, record of 476
Infectious agents 461
risk of exposure to 461
Infectious disease 145, 355, 434, 446, 460, 490, 572
markers 280
test kits 460, 470
testing for 468, 526
Inflammatory reaction 515
Inflate blood pressure cuff 149
Influenza 146
Innate immune cells 2
Intermittent flow centrifugation 277, 278f
International Hemovigilance Network 437
functions of 437b
International Society of Blood Transfusion 101, 112, 437, 439b, 489
Intestinal obstruction 89
Intracellular infections 495
Intracellular pathogens 5
Intracellular red cell parasite 320
Intraoperative collection 413
Intraoperative hemodilution 328
Intrauterine transfusion 235, 324, 391
indications for 391b
Intravascular hemolysis 22, 119, 296, 297, 302t
causes of 296b, 300b
consequences of 299f
Intravenous
antihistamines 309
drug abusers 347
fluid infusion 223
immune globulin 325, 391, 392
Intrinsic pathway, activation of 300
Ionic strength 14
saline
low 104, 193, 548
normal 193
solution, low 66, 228
Iron overload 410
Irradiated blood components, indications for 254, 254b
Irradiation, method of 254
Isoantibody 69
Isopropyl alcohol 367
Itching 308, 332
J
Jaundice 320, 571
John Milton Hagen
antibodies 134
antigens 134
blood group system 134
protein 134
Jr antibodies 135
Jr antigen 135
Jr blood group system 135
Jumbo plasma 285
K
K and K antigens 117
K antigens 117
Kell and Kx blood group systems 116
Kell antibodies 117, 118
Kell antigens 116, 117, 386
Kell blood group antigens 137
Kell glycoprotein 117
Kell phenotypes 116b
Kell system 112
Keratinocytes 323
Kernicterus 383
Kidd antibodies 120
Kidd antigen 119
expression of 119
Kidd blood group 23
system 119, 137
Kidd system 112, 119
phenotypes in 119t
Kidney disease 146, 572
severe 171
Kits, quality control of 470
Kleihauer-Betke acid-elution test 395
Kleihauer-Betke test 396
Knops antibodies 131
Knops antigens 131
Knops blood group system 131
Knops resides 131
KX antigen 117
L
Labels and label control 478
Labile coagulation factors, amount of 243
Labor, premature induction of 391
Laboratory centrifuge 471
Laboratory information management systems 424
Lactate dehydrogenase 320, 337, 340
Lactic dehydrogenase 318, 340, 341
Lan antibodies 135
Lan antigen 135
Lan blood group system 135
Landsteiner's rule 69
Landsteiner-Eiener blood group system 129
Landsteiner-Wiener blood group system phenotypes 129b
Langerhans cells 495
Lattice formation 11
Lectin 68, 548
pathway 21
Leishmaniasis 79
Leptospira 300
Lethargy 328
Leukapheresis 282, 521, 523, 540, 558, 577, 578
products 532
Leukemia 90, 91, 129, 523, 534
acute
lymphoblastic 287, 535
myelogenous 287, 532, 534
chronic lymphocytic 56, 535
relapse of 534
Leukemogenesis 289
Leuko reduced blood components, transfusion of 251b
Leukocytapheresis 288
Leukocyte 132, 140, 251, 332, 492
and tissue 492
antibody 510
concentrates 540
filter, modified 473
functions, maintain 139
poor red cells 473
reduced components 251, 472
reduction 251
categories of 252
disadvantages of poststorage 252b
filter 251, 408
poststorage 252
prestorage 252, 307
Leukodepleted red cells 575
Leukodepletion 251
benefits of prestorage 252b
Leukoreduced single donor platelets 578
Leukoreduction 251, 323
method of 251
poststorage 252
prestorage 252
Levy-jennings chart 444
Lewis antibodies 113
Lewis antigens 113, 114
Lewis blood group 137
biological role of 114
system 113
Lewis system 112
antigens 16
phenotypes of 113b
L-fucose 43
L-fucosyltransferase enzyme 43
Licenses, cancellation and suspension of 543, 580
Licensing procedure 583
Light spin 247, 255
centrifugation 254
Lipid envelope 348
Lipoprotein
apheresis, selective removal of low-density 292
high-density 292
low-density 60
Liposome-encapsulated hemoglobin, advantages of 417b
Lips, edema of 308
Liquid plasma 169, 263
Liquid-phase techniques 193
tubes and microplates 193
Live attenuated vaccines 573
Liver
biopsy 323
disease 571
chronic 237, 571
failure 571
fluke 122
transplant, complications of 407
transplantation 407
Locus 37, 41
Low-ionic strength solution, disadvantages of 67
Luminex 504
analyzer 513
based technique 510
single antigen 513
technique 508
Lung disease 146, 570
Lutheran antibodies 121
Lutheran antigens 120, 121
Lutheran blood group system 120, 137
Lutheran system 112, 120
phenotypes in 120t
Lymphocytapheresis 274, 289
Lymphocyte 4, 5, 169, 274, 501503, 515, 519
antibody secreting 64
culture, mixed 513
indicates 501
lysis of 501
microcytotoxicity test 499
preparation 499
amount of 514
reaction, mixed 513
separation 500f
use of 512
Lymphocytotoxic human leukocyte antigen antibodies 510
Lymphocytotoxicity 499
Lymphoid
line 519
tissue, mucosa-associated 4
Lymphoma 129
relapse of 534
Lymphotoxin 497
Lyophilized synthetic platelets 417
M
M and N antigens 115
Macroglobulin 494
Macrophages 35, 495
Macroscopic tests 367
Maculopapular rash 308, 323
Magnetic beads 500
Malaria 60, 119, 147, 244, 288, 357
antigen test 367, 367f
detection of 367
history of 550
infection 135
Malarial adhesion protein 133
Malarial antibody, tests for 367
Malarial parasite 565
Malignant cells 519
Mandatory screening tests 369
Mannitol 165, 166
Mannose-binding lectin 21
Manual tube testing 17
Massive bleeding, management of 237
Massive blood transfusions 262
Massive fetomaternal hemorrhage 395
Massive intravascular hemolysis 297
Massive transfusion 35, 234, 236, 237, 238t
complications of 237
Master formula records 563
Maternal antibody, effect of 385
Maternal circulations 380
Maternal liver 381, 382f
Mature lymphocytes 4
McLeod syndrome 117, 137
Measles 79, 146
Mechanical mixing device 150f
Medical laboratory technology, postgraduate diploma in 568
Medical termination of pregnancy 386
Meiosis 28
sites of 28
stages of 29, 29f
Melanoma, advanced 536
Membrane attack complex 16, 22f, 297, 298f
Membrane filtration 279
Memory cells 4
Mendelian dominant fashion 40
Meningitis, bacterial 130
Menstrual bleeding, excessive 146
Mesenchymal stem 520
cells 123
Metabolic alkalosis 239, 523
Metabolic complications 238, 328
Metabolism, inborn error of 526
Metabolize citrate 404
Metallic body implants 447
Methemalbumin 157, 339
Methylated spirit 367
Methylene chloride 210
Microangiopathic hemolytic anemia 409
Microbial pathogens 123
Microbiological tests, separate room for 486
Microbiology 447
Microchimerism 535
Microglobulin polypeptide 494
Microhemagglutination assay 356
Microlymphocytotoxicity 499, 500f
complement-dependent 507, 507f, 510, 510f
typing, complement-dependent 499
Micropinocytosis 135
Micropipette 107f
Microplate
method 76, 77f, 78f
technique 108
Microtiter 501
plate wells 361
Microtyping system 78, 426
Microvascular bleeding 239
Microvascular hemorrhage 238
Ministry of Health and Family Welfare 538, 563
Miscarriage 386
Mislabeling errors 478
Missed antibody, causes of 231b
Mitochondrial deoxyribonucleic acid 26
Mitosis 25, 27
phases of 28, 28f
sites of 28
Mitotic phase 27
Mixed-field
agglutination 196, 202
appearance 96
reactions 90, 208
causes of 90
Molecular blood grouping 72, 84, 85
applications of 84
Molecular forces, types of 27
Molecular genetics 33
Molecular immunohematology 33
Molecular methods 208
Molecular techniques 428
Molecular testing
applications of 34, 34t, 429t
clinical applications of 35
Molecule 4, 175
Monoclonal antibody 6265, 65t, 64f, 175, 361
products 62
reagents 63
disadvantages of 65
use of 65
Monoclonal anti-D
antibodies 105
reagents 105, 106
Monoclonal antihuman globulin production 175
Monoclonal antisera 105
Monoclonal blends 106
Monoclonal murine antibody 64f
Monocytes 519
Monohydrate 166
Mononuclear cell
component suspension, preparation of 288
count 522
Mononuclear phagocyte 319
system, macrophages of 300
Mononuclear phagocytic system 179
Mononucleosis, infectious 125
Monospecific antihuman globulin 176
reagents 175
Mother's blood group 393
Multicomponent apheresis donation 284
Multiple antibody 196, 203, 216
resolution 216
Multiple component systems 278
Multiple myeloma 56, 93, 159, 523, 532, 534
Multiple platelet apheresis products 281
Multiplex immunoassay (luminex) 512
Mumps 146
Murine monoclonal blends 49
Muscle pain 523
Mutilation 448
Myalgia 523
Mycoplasma pneumoniae 124, 201
Myeloablative transplants 530
Myelodysplastic syndrome 526
Myeloid line 519
Myeloma cells 63, 64
N
N-acetyl-D-galactosamine sugar 45
N-acetylgalactosamine 45, 89
N-acetylgalactosaminyltransferase 45
Naïve lymphocytes 4
National AIDS Control Organization 538, 587
role of 442
National Blood Policy 436, 441444, 538
National Blood Transfusion Council 442, 539
National Institute of Virology 539
Natural killer cells 5, 519
Nausea 154, 523, 532
Needle-related injuries 153, 154
Negative cells 501
Negative control cells 208
Negative indirect test 83
Negative test 228
Neisseria gonorrhoeae 378
Neocytopheresis 284
Neonatal transfusion 236, 328, 403, 407b
Nephrotic syndrome 133
Nephrotoxic free hemoglobin 528
Neuroblastoma 324
Neurologic ischemia 531
Neurologic toxicity 531
Neutral gel 185
Neutralization 16
techniques 209
Neutropenia, severe 406
Neutrophils 310
engraftment of 532
Newborn transfusions 392
Nonagglutinating antibody 83, 173
Noncoding region 30
Nonconformance management 479
Nonconformance reporting 481
Nonconformance type 480t
Nonexpressed genes 36
Non-governmental Organizations 538
Nonhematologic malignancies 536
Nonhemolytic transfusion reaction 343
Non-Hodgkin's lymphoma 523, 532, 534, 535
Non-human leukocyte antigen antibodies 508
Nonimmune hemolysis 342
Nonimmune mediated
hemolysis 305
hemolytic transfusion reaction 343
red cell hemolysis, causes of 305
Noninfectious
complications 302
conditions 355
Noninfectious waste 445
Non-ionic detergent 158
Nonlive vaccines 573
Nonmyeloablative
conditioning 530
transplant 534
Nonremunerated donors 467
Nonsecretors 47, 60
Nonself antigen 8
Non-serological crossmatch 226, 229, 230
Nontreponemal antibody-screening tests 354
Nucleated cell 494
total 525
Nucleic acid 368, 370
amplification
test 23, 349, 350fc, 350fc, 369, 370, 372f, 428
techniques of 372b
extraction of 372
probe 502
sequence 506
based amplification 372, 377
types of 26
Nucleic acid test 34, 370, 371, 378, 429, 444, 525
advantages of 371b
applications of 371, 372b
benefits of 371b
techniques of 372
Nucleocapsid protein 348
Nucleotide
chain of 26
sequence 504
unit, structure of 26, 27f
O
O gene 32, 43, 46
Occupational hazard 445
OK antigens 133
OK blood group system 133
Oligonucleotide 504
probes 504
reverse sequence-specific 504
sequence-specific 503
Oligosaccharide 42
chains, type 1 43
Oliguria 332
Oncofetal antigens 125
Oncology 408
Opsonization 297
Oral polio vaccine 146
Organ systems 308
Organ transplantation 493, 498, 514
Organic solvents 214
Original licence 585f
Oropharyngeal airway 153
Osmotic fragility 169
Osteoblasts 520
Osteogenic progenitor cells 520
Ovalocytosis 130
Ovarian cyst fluid 47
Oxygen 293
and mask 153
carriers, artificial 414
delivery, immediate restoration of 416
exchange for 380
saturation 311
therapeutics 414
Oxygenating pump, time of 402
P
P blood group 122, 137
antibodies 122
antigen 122
expression 122
biological role 123
physiologic role of 123
Packed cells 256f
Packed red blood cell 138, 245, 247, 271, 318
features of 251b
frozen 556
Packed red cells 255f
Pain 332
Pancreatic cancer 59
Pancytopenia 535
Panel reactive antibody 508, 511
Papain 11, 68, 134, 209
Para-Bombay blood group 52
Paragloboside 42
Parasite 172
causing 481
Parenteral transmission 347
Paresthesias 328
Paroxysmal cold hemoglobinuria 123
Paroxysmal nocturnal hemoglobinuria 79
detection of 82
Particle agglutination assays 364
advantages of 364t
disadvantages of 364t
Particle gel immunoassay 82
test 357
Parvovirus
B19, receptor for 123
infection 79
Passenger lymphocyte syndrome 531, 532
Paternal samples, testing of 36
Pathogen reduction technology 428
Pathologenic humoral factors, removal of 289
Pediatric transfusion 236, 403
Pedigree chart 55f
Peptic ulcer, chronic 146
Percutaneous umbilical blood sampling 388
Perfluorocarbon emulsions 415
Perfluorocarbons
advantages of 416b
disadvantages of 416b
Perfluorochemical emulsions 415
Performing test, time period of 387
Perinatal period 380
Perinatal spread 347
Perinatal transmission 347
Periodic competency assessment 456
Periorbital area, edema of 308
Peripheral blood 5, 520, 522, 526
lymphocytes 499, 500
progenitor cells 520, 521
smears, microscopic examination of 367
stem cells 284, 577
Peripheral lymphoid
organs, T cell zones of 4
tissues 5
Peripheral organs 4
Permanent chimera 85
Permanent deferral 144
Pertussis 146
pH 214
effect of 13, 170
reduction of 214
Pharmacogenomic applications 493, 494
Phenotype 32, 36, 41, 72, 99, 101, 114, 125, 202
weak 50
Phlebitis and cellulitis, mild 153
Phlebotomy 148, 149, 153, 166, 169, 269
donor care after 152
inspection of site of 147
Phosphate
buffered saline 548
diester bonds 27
molecule 27
Photoactivable drug 289
Photoactivation by ultraviolet A light 289
Photochemotherapy, extracorporeal 288
Photometric devices 78
Photopheresis 288
extracorporeal 288, 288t
Phototherapy 392, 400
Phycoerythrin 505
Physical examination requirements 147t
Phytohemagglutinin 513
Pilot samples 556
Pilot tubes 148
Placenta 59, 114, 134
during pregnancy, role of 380
umbilical cords 524
Placental trophoblasts 131
Plague 146, 550
Plasma 12, 53, 168, 172, 198, 263, 334, 369, 557, 560
antibody in 99
by additive solution, replacement of 172
cells 3, 5, 515
citrate level 238
cold insoluble portion of 264
collection of 558
components 260
selective removal of 291
containing blood components 58
cryoprecipitate reduced 265
derivative 245, 245t
infusion of 327
products 260
dextrose 170
double 284
excess 289
exchange 275, 285
mechanisms of action of 289
expanders 232
expresser 248, 249f
from blood, separation of 165
frozen 169, 269
individual 560
K+ 170
less 250
normal 334f
products 285
transfusion of 235
protein fraction 245
pyrolysis 448
regain, rapid 354, 355
removal 307
significant volumes of 332
substitutes 419
testing 87, 91, 94
transfusion 407
triple 284
Plasmapheresis 274, 275, 391, 540, 558, 577
donors, criteria for 285
Plasmodium
falciparum 60
infection 130
vivax 119
Plastic bags, types of 171, 171t
Plastic closed bag system 246f
Plastic collection bag 242
Plasticized polyvinyl chloride 162
Platelet 59, 167, 168, 170, 245, 258, 269, 274, 284, 369, 406, 432, 494, 519
additive solutions 171, 172b
advantages of 171, 172b
advantages of 281b
alloimmunization 327
apheresis of 258, 558
collection of 140, 278, 282f
components 254
concentrate 170, 245, 247, 251, 255, 256f, 257, 258, 271, 473, 556
advantages of 257
indications for 259, 259b
preparation of 256fc, 257, 257fc
production of 256f
transfusions 315
count 239, 259
minimum 281
disorders 139
dysfunctional 269
engraftment of 532
delayed 535
functions of 254b, 402
irradiated 168
leukocytes 260
pooled 259
poor plasma 256f
removal of 254
preservation 171
refractoriness 494, 517
causes of 259b
rich plasma 245, 247, 255f, 256f, 270
centrifugation of 254
method 256fc
selection for refractory 493
shelf life of 171, 171t
sources of 254
substitutes 417
therapy 251
transfusion 259b, 407, 510, 535
efficacy of 259
poor response to 492
refractoriness 327
salient features of 260b
units 472
platelet count in 472
Plateletpheresis 274, 280, 281, 540, 558, 577, 578
Poisonous diluents 159
Polar body 29
Policies and process documents 474, 478
Policy document 477
Polyacrylamide gel electrophoresis 375
Polyagglutination 94
Polybrene 15, 193
Polyclonal antibody 62, 65, 65t, 175
blends 105
products 62
reagents 63, 65
Polyclonal antihuman
globulin
production 175
reagents 176f
immunoglobulin G 63
Polyclonal antiserum 63
Polyclonal immune response 63, 63f
Polycythemia vera 121
Polyethylene glycol 15, 67, 104, 417
Polygonal anti-D reagents 106
Polymerase chain reaction 35, 358, 371, 372, 374f, 502, 503
components of 374t
primer 502
products
analysis of 375
detection of 375
sequence-specific
oligonucleotides hybridization 503
primers typing 505
testing 502
Polymerization 417
Polymorphism 493, 506
Polymorphonuclear neutrophils 2
Polyspecific antihuman globulin 175
reagents 174
Polyspecific reagent 192
Pooled buffy coat, platelet extraction from 257
Pooled platelet concentrate, advantages of 257
Population genetics 33
Positive cells 501
Positive control cells 208
Positive direct antiglobulin test, causes of 181t
Positive indirect test 83
Positive reaction 18, 77, 79, 199, 203
reaction strength of 203
Positive test 228
Positivet lymphocytes 513
Postcentrifugation 423
Post-donation care 152
Postnatal management of infant 392
Post-transfusion
blood sample 334, 335, 338
purpura 318, 324, 327
reaction blood and urine samples 334
serum hemoglobin 336
urine sample 335, 338
Post-transplant immunological monitoring 513
Postzone effect 12, 17
Potassium 404
cyanide 158
dihydrogen phosphate 158
ferricyanide 158
Potency 61
Potent hemolysin 123
Potential phenotype exclusion 217
Povidone iodine 367
Preamplifier molecule 376
Preanalytic information 200
Preanalytical modules 423
Precentrifugation 423
Preexisting disease 312
Prematurity, anemia of 403
Presyncope 153
Pre-transfusion
antibody screen 201
blood sample 335
compatibility testing 79
sample 335
testing 220, 224t, 234, 412, 428
protocol 221b
Primer extension 374
Prion disease 366
Procedure documents 477
Process document 477
Process validation 463
Professional antigen-presenting cells 495
Proficiency testing 485
program 472
Progenitor cell 524
collection 521
cryopreserved 531
lineage-restricted 519
product 408
Prolymphocytic leukemia 286, 288
Pronase 128
Protease enzyme 128
Proteasomes 495
Protein 26
antigens 13
chains 494
complement 174, 175
concentration of 65
increased precipitation of 67
molecules 68
reagent
control, low 65
low 105
synthesis 30
Proteolytic enzyme 11, 68, 83
Prothrombin time 268
Prozone 12
phenomenon 17
Pruritus 308
Psychiatric diseases 570
Public health hazard 446
Pulmonary capillaries 118
Pulmonary edema 310, 311
Pulmonary wedge pressure 313
Pulse 147
Punnett square 54, 55f
Purified human immunoglobulin 175
Purines 26
Purkinje cells 118
Pyridoxylated hemoglobin polyoxyethylene 417
Pyrimidines 27
Pyrogenic reaction 338
Pyrogens 306
Pyruvate kinase deficiency 300
Q
Quality assurance 451, 464
audits 488
components of 465t
elements of 465b
Quality control 62, 247, 250, 258, 265, 451, 466, 470, 487, 562
documentation, components of 467b
internal 467
tests 475
type and frequency of 466
versus validation 466
Quality incidents and exceptions 488
Quality indicators 484
Quality management 451
system 451, 452, 453b
Quality manager 482
Quality manual 474, 478
Quality program 451
Quality system 451
scheme 442
Quantitative method 283
Quick-fix solution, initial 482
R
Rabies vaccination 550
Radiation therapy 324
Radioimmunoassay 365
Radioimmunoprecipitation assay 358
Random donor 260
platelets 258, 498
RAPH blood group system 133
Rash 331
Reaction
negative 18, 77, 199, 203
phase of positive 204
severe 308, 310
strength and phase of 196
Reagent anti-D 102
Reagent cells, antigenic profile of 192
Reagent control 65
Reagent group O red cells 191
Reagent product insert 61
Reagent red blood cell 70
Reagent red cell 61, 62, 65, 76, 79, 82, 198, 200b, 201, 218
Reagin antibodies 354
Reagin test, automated 355
Recipient adverse events 480
Recipient blood sample 221
Recipient hemovigilance 438
Recipient leukocyte antibodies 306
Recipient red cells 222
Recombinant coagulation factors 430
Recombinant immunoblot assay 358
Record, protection of 474
Records management 478
Red blood cell 1, 13, 32, 40, 66, 98, 102, 164, 166, 168, 220, 246, 253, 270, 274, 284, 379, 403, 420
alloimmunization 327
and plasma 166
components 247
deglycerolized 253
disorders 526
engraftment 532
delayed 531
exchange 274
groups 38
hematocrit 472
low volume 165
membrane 14
loss of lipid in 169
phenotype 101
sensitization of 11f
separation of 248
transfusion 315, 405, 407, 410
indications for 405
Red cell 7, 41, 49, 71, 75, 77, 82, 101, 102, 105, 135, 179, 211, 252, 369, 432
additive solutions 165
adherence 78
agglutination of 11
antibody 41, 49, 91, 190, 198
detection 79
identification panels 198
identification studies 337
antigen 10, 19, 35t, 38, 40, 42, 58, 68, 69, 198, 319
and antibody 9f
detection of 183
expression 189
inheritance of 40
phenotyping of 183
apheresis 283, 286
clumping of 12f
components, types of 575
concentrate 245, 247, 473
crossmatching of 282
defect, intrinsic 305
destruction of 305
during storage 165
exchange 288, 341, 410
exposure of 305
genotype analysis 429
grouping 70
ionic charge 13
irradiated 575
lysis 22f, 297, 298f
membrane 38, 66, 68
contains antigen 9f
panel 104
phenotype 59
prediction of 35
population of 96
preparations 76
procedure in 211
rapid destruction of 303
reagent panel 199
reduction 527, 528
sample 198
significant number of 332
storage of 163
substitute 414, 415, 415b
testing 87
transfusion of incompatible 58
typing 34
washed 253, 473
Red Cross Society 538
Refrigerated centrifuge 247, 249f, 471, 547
Regulatory regions 30
Rejuvenation solution 167
Remedial action 482
Renal damage 532
Renal disease
chronic 408, 408t
end-stage 133
Renal dysfunction 294, 409
Renal failure 304, 306, 332, 531
prevention of 341
Renal graft rejection 114
Renal injury develops 337
Renal medulla 119
Renal transplant 407
Renewal of licence 586f
Repeat compatibility test 337
Replacement donors 139
Replacement fluid 269, 285, 289, 291
Residual leukocyte counts 472
Respiratory
diseases 570
distress 308
epithelium 134
symptoms 308, 331
Restarting transfusion 309
Retention, record 474
Reticulocyte typing 208
Reticuloendothelial system 22
Reverse-transcriptase polymerase chain reaction 375
Rh antibodies 103
characteristics of 103
production, causes of 103
Rh antigen 101, 103, 379
Rh antisera 469
Rh blood group 102f
system 98, 99, 100, 101
Rh compatibility 258
Rh deficiency syndrome 103
Rh genes 98
Rh group 235, 387
Rh grouping
controls for 106
methods of 106b
techniques 106
Rh haplotype 100
Rh hemolytic disease of fetus and newborn 234
Rh immunization, antenatal management of 391
Rh immunoglobulin 201, 379, 394
injection 258
prophylaxis of 104
Rh inheritance, normal pattern of 99f
Rh negative 99, 101, 102
blood 233
phenotype 103
Rh positive
blood 98, 234
cells, normal 102
Rh system 110
basic genetics of 98
biochemistry 103
discovery of 98
Rh terminologies 101
Rh types 224, 225, 233, 390, 400
sera 582
Rh typing reagents, types of 105
Rhesus monkeys into rabbits 98
Rhesus system 40, 98
Rheumatic heart disease 570
Ribonucleic acid 30f, 370, 375
small amount of 26
viruses 347
Rigors 306
Room temperature, reactive at 124
Root cause analysis 440, 454
Rosenfield nomenclature 101
Rosette technique 395
Rouleaux 93, 197
characteristics of 197
Rouleaux formation 85, 93t, 228, 231
causes of 197
Routine antigen typing 208
Routine blood bank 101, 136
quality control procedures 466
R-phycoerythrin 511
Rubber ball 149
Rubella 146
Rule out hemolysis 315
Rule out hemolytic transfusion reaction 307
S
Safe blood transfusion 430
ethical issues in 443
Safe transfusion, no standards for 444
Saline
equal volume of 93
normal 306f, 469
room temperature technique 74
washed red cells 575
Saliva 47
Salk polio 146
Salt-poor albumin 67
Sample collection
errors 327
test tubes for 148
tubes 222
Sample tubes 147
Sandwich enzyme linked immunoassay 361
technique 361f
Scianna antigens 126, 127
Scianna blood group system 126
Screen cell sample, number of 196
Screening assays, principles of 358
Screening cells 65
pooled 192
Screening method 357
Sealing blood collection bag 152f
Sedimentation agents, using 527
Sedimentation method 250
Sedimented blood sample 247
Self-antigens 207
Semiautomated immunohematology analyzer 426f
Seminal fluid 47
Sensitization, risk of 394
Sensitized cells 173
Separate sterile room 524
Septicemia, gram-negative 89
Seroconversion window 370
Serologic crossmatch 231
Serologic cross-matching 17
Serologic rotators 547
Serologic screening test, presumptive 355
Serologic testing 342, 386, 412
Serological crossmatch 226
techniques 227
Serological test 357
principles of 227
Serological typing 499
Serum 12, 69, 87
bilirubin 400
concentration 392
cell ratio 12, 13
proteins, group of 6
reactivity, matching of 204
testing 87
Settle method 364
Severity of disease 399
Sex chromosomes 25
Sexual contact 353
Sexual transmission 347
Sexually transmitted
disease 353
infections 572
Sézary cell syndrome 286, 288
Shiga toxins, receptors for 123
Shock 304
causes of 309
prevent 139
Short tandem repeats 506
Shredding 448
Sialic acid 13
Sialic acid rich glycoprotein 115
Sialoglycoprotein 115
Sickle cell 79
anemia 121, 325, 409, 530
disease 288, 409b
Simply transfusion reactions 300
Single antibody 196
specificity 203
Single donor
apheresis platelets 260
plasma 245, 264
Single donor platelet 140, 258, 281, 578
collection of 282f
kit 282f
modified 578
Single nontraumatic venepuncture 255
Single nucleotide polymorphisms 34
Single unit leukopheresis 271
Single-nucleotide polymorphisms 208, 502
Skin biopsy 323
Slide technique 72, 106
Small blood volumes 278
Smallpox 146
Society of blood transfusion 437
Sodium
azide 157
biphosphate 165
chloride 67, 166
deoxycholate 157
dihydrogen monophosphate 166
hypochlorite 367
nitrite 157
Soil, pollution of 445
Soiled waste 447
Solid organ transplantation 407
Solid phase
adherence tests 185, 195
assays 17, 18, 18f
immunoassay 358
immunosorbent assays 358
red cell adherence
assay 82
assays technology 84f
methods 228
technology, advantages of 82
test systems, types of 82
Solid support nitrocellulose membrane 365
Solid tumors 324
Solvent-detergent plasma 263
Somatic cell 25
division 27
Sophisticated thermocyclers 377
Spermatozoa 29, 29f
Spherocytes 103
Sphygmomanometer 148
cuff 152
Spillage 487
Spin
crossmatch, immediate 227, 228f, 425
phase, immediate 193
technique, immediate 74
types of 247, 247t
Spirochete 172
treponema pallidum 353
Spleen 134
Spontaneous agglutination 65
Stable cyanmethemoglobin 157
Stacked coin appearance 197
Stacked coins 93
Standard basic immunohematology testing 320
Standard blood grouping 551
Standard numerical nomenclature 40
Standard operating procedure 62, 461, 432, 474, 478, 548
advantages of 463b
system 482
usual contents of 463b
State licensing authority 585
Stem cell 519b
transplantation, autologous 533b
Sterile connecting device 245
Sterile products, manufacture of 561t
Sterilization-cum-washing 545
Stethoscope 148
Stimulate immunocompetent 513
Stock solution, preparation of 156
Stomatocytes 103
Stomatocytosis, hereditary 300
Stop transfusion immediately 333
Storage area 560
Storage equipment 458
Storage lesion 169
Storage of blood, refrigerator for 470
Strand displacement assay 372
Streptococcus
pyogenes 132
suis 124
Stromal cells 520
Stronger reaction 204
Subsequent pregnancy 385
Sulfhydryl reducing agents 128, 129, 131
Supplier qualifications 459
Supportive therapy 333
Surgery, cardiac 402
Surgical procedures 570
Suspension array technology 19
Syngeneic hematopoietic progenitor cell transplantation 526
Syphilis 244, 353, 357
diagnosis of 79
laboratory diagnosis of 353
serology reagents 548
Systemic inflammatory response syndrome 531
Systemic reactions 154
T
T cytotoxic cells 4
T helper cells 4
T lymphocytes 4, 496, 512
subsets of 4
T pallidum hemagglutination assay 356, 356f
T pallidum particle agglutination test 357
Table top centrifuge 75f
Tachycardia 310, 331
Target antigen 82, 211
Target cell 495
Tattoo 550
T-cell
activation of 517
depleted marrow and leukemia, use of 516
depletion 530
disadvantages of 530
mediated graft rejection 515
sensitization in vivo or ex vivo of 535
Technical resource group 588
Technical supervisor 546
Techniques targeting T-cells 530
Telomere 26
Temperature and humidity 560
Temperature and pulse determination 550, 581
Temperature dependent methods 214
Temporary central storage 448
Temporary donor deferral 145t
Test method validation 464
Test plasma 96
Test tube racks 148
Tetanic spasms 155
Tetanus 146, 550
Thalassemia 325, 410
Thawed fresh frozen plasma, appearance of 263f
Thawed plasma 169, 263
Thawing 266, 528, 530
bath 262f
Therapeutic apheresis 275, 279, 286, 293, 328
indications of 286
Therapeutic cytapheresis 275, 286, 578
indications of 286b
Therapeutic erythrocytapheresis 288
Therapeutic leukapheresis 286
Therapeutic leukocytapheresis 287
Therapeutic plasma
exchange 269, 274, 289, 290t, 291t, 409
complications of 291, 291b
pheresis 275, 578
Therapeutic platelet apheresis 286
Therapeutic procedures 444
Thrombocythemia 287
Thrombocytoapheresis 274
Thrombocytopenia 239, 409
heparin-induced 79
Thrombocytosis 286, 287
reactive 286
Thromboplastin time, partial 294
Thrombotic thrombocytopenic purpura 285, 342, 409, 420
Thymine 27, 134
Thyroid
disease 571
disorders 571
tumors, malignant 571
Tile technique 72, 106
Tissue
injury 239
transplantation 493
typing 515
Titer level 215
uses of 215
Tongue
depressor 153
edema of 308
Total-body irradiation 530
Toxic reactions 495
Toxoids 146, 573
Traditional tube method 224
Trained healthcare professionals, shortage of 441
Training and competency testing 487
Transcription mediated
amplification 372, 377
assay 372
Transcription-based amplification 377
Transfected human leukocyte antigen deficient human lymphoid cells 511
Transferring blood, process of 138
Transfused donor red cells, acute intravascular destruction of 303
Transfused red cells 51, 57
Transfusing blood products 234
Transfusion 96, 208, 409
chronic 35
discontinuation of 340
duration, extension of 312
hazards 436
hemosiderosis 325
history of 223b
laboratory, quality assurance in 487
practice, quality control in 472
procedures, clinical 432
recipient 316
regulation and legislation 538
related acute lung injury 311, 340
diagnosis of 311b
services 138
strategies 240
support 420t
therapy 402
transmitted infections, screening blood donors for 357
Transfusion associated
acute lung injury, pathogenesis of 309
circulatory overload 303, 311, 312, 313t, 340
graft versus host disease 318, 322, 325t, 535
hypotension 313
infection 481
mortality 311
sepsis 303, 314, 316b, 314, 340
Transfusion medicine 1, 1f, 58, 138, 296, 300, 314b, 425, 450, 567
branches of 138
common antibodies in 204t
quality control in 467
requirements in 458
types of antibodies in 190
Transfusion reaction 129, 181, 205, 302b, 326, 330, 331b, 335, 335b, 336b, 344fc, 492
immediate 331
recognition of 331
record of 476
reporting form 438
summary of 343t
types of 307, 333, 517
Transfusion-transmitted
disease 302, 346, 357, 443, 464, 472
risk for 140
infections 172
relevant 141
infectious agents 346t
viral disease 320
Transmissible spongiform encephalopathies 366
Transmission
congenital 351
mode of 351, 353
route of 347
Transplacental transmission 353
Transplant
preparing products for 530
rejection of 515
related complications 532
Transplantation 407, 408
allogeneic 140, 535
autologous 140, 532
fresh products 529
Transplanted organs, rejection of 492
Treponema pallidum immobilization 356
Treponemal antibodies 356
Treponemal tests 356
Trichomonas vaginalis 378
Trisodium citrate 166
True agglutination and rouleaux formation 197
Trypan blue 501
Trypanosoma cruzi 357
infection 145
Trypsin 128
Tube
antibody screen test 194f
method 73, 74f
procedure of 193
techniques 106
test 76, 107, 183
protocols 199
techniques 193
Tumor 495
cells 530, 536
lysis syndrome 287
necrosis factor 497
Two-stage enzyme 193
test method 209
Typhoid 146, 550
U
Ultraviolet A 288
Umbilical cord blood 520, 525b, 526
collection, features of 524b
derived hematopoietic progenitor cell 524
processing 525
Umbilical cord hematopoietic progenitor cells, advantages of 524b
Unacceptable Quality control 467
Unconjugated bilirubin 381
Unique equipment identification 457
Unique sequences, specific for 505
Unit using sterile technique 312
Universal donor 23
high-titer 58
Universal leukocyte reduction 251
Universal precautions in blood bank 486b
Universal recipient 23
Universal red cells 16
Unrelated donors 527
Upper airway involvement 309
Urinary tract infection 114
Uroepithelial cell cancers 114
Urticaria 293, 308
Urticarial reactions
mild 309
severe 309
Urticarial response 308, 310
Uvula, edema of 308
V
Vaccination 146, 147
and inoculation 573
approach 536
Vaginal secretions 47
Validation, type of 457
Vasoactive amines 297
Vasovagal
reaction 293
syncope 154
Venepuncture 468
site of 155
Venereal disease research laboratory 16, 246, 354, 552
Venipuncture 149
Vibrio cholerae 60
Vicia graminea 50
Viral core 348
Viral inactivation process 561
Viral infections 5, 201, 481
Viral load tests 378
Viral replication, active 352
Viral transmission 347
Virtual blood bank 429
Virus, direct inoculation of 347
Visible agglutination 11
Visual check for hemolysis 335
Visual hemolysis 336
Vital staining 501
Vital stains 501
Volume expansion 293
Voluntary blood donor 431, 566
Voluntary donors 467
Voluntary nonremunerated donors 139, 431
Vomiting 154, 523, 531
von Willebrand disease 268, 410
von Willebrand factor 245, 269
W
Waldenström's macroglobulinemia 93, 159
Waste
and infectious materials, disposal of 558
chemicals 445
sharps 447
types of 447
Water
bath
and incubator 471
thawing in 262
pollution of 445
West Nile virus 525
Western blot 350, 358, 364, 365
Wharton's jelly 85
White blood cell 1, 246
disorders 526
Whole blood 243, 473, 557
by blood bank 577
collection 524
donation 139
indications for 244b
testing of 552
transfusion of 139
Whole human blood 540, 543
Wiener haplotype, modified 100
Wiener terminology 100
modified 100
Working solution, preparation of 156
World Health Organization 437
X
X chromosomes 25
Xenoantibodies 3
Xylene 214
Y
Y chromosome 25
Yellow fever 146
Yt system 112
Z
Zygosity 34
×
Chapter Notes

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Basic Immunology Related to Blood Group SerologyCHAPTER 1

CHAPTER OUTLINE
  • Immune system
  • Terminologies used in immunology
  • Components of immune system
  • Immunoglobulins
  • Immune response
  • Immunohematology
  • Traditional laboratory testing methods
  • Nontraditional laboratory testing methods
  • Blood group antigens
  • Blood group alloantibodies and autoantibodies
  • Complement system and blood banking
  • Historical overview of blood banking/blood transfusion service (BTS)
 
INTRODUCTION
Immunity is defined as a resistance (defense mechanism) exhibited by host against invasion by any foreign antigen, including microorganisms. Immunology is the branch of medicine and biology concerned with immunity. Immunohematology is an integral part and plays an important role in transfusion medicine.
  • Immunohematology deals with the serologic, genetic, biochemical and molecular study of antigens associated with membrane structures on the cellular constituents of blood (red blood cells [RBCs], white blood cells [WBCs], and platelets). It also deals with the immunologic properties and reactions of blood components and constituents.
  • Transfusion medicine (Fig. 1.1) includes the transfusion of blood, its components, and derivatives.
Basic concepts of immunology: For understanding the principles of immunohematology, it is necessary to know the basic concepts of immunology.
zoom view
Fig. 1.1: Various components of transfusion medicine.
2
These include the antigens, antibodies, antigen-antibody reactions and complement affecting the antigen-antibody reaction. The application of immunohematology principles in the clinical laboratory is usually carried out in the blood bank or transfusion services department. Immunohematologists perform and interpret various serologic and molecular assays which help in the diagnosis, prevention, and management of immunization associated with transfusion, pregnancy, and organ transplantation.
 
IMMUNE SYSTEM
 
Role of Immune System
The immune system plays two main roles in the human body.
  1. It provides the immune mechanism which protects the body against external foreign substances. The immune response is a highly evolved system and is necessary for survival. It rapidly responds to any foreign material or pathogens that invade the body and can initiate a series of events to eliminate this foreign material or pathogens.
  2. It plays an important role in the identification and destruction of abnormal cells. These abnormal cells may be malignant cells, cells infected with microorganism or cells coated with antibodies. It has an ability to distinguish between self and nonself antigens.
Immune system is like a double-edged sword. Though immune system is protective in most of the situations, sometimes a hyperactive immune system may cause fatal diseases.
 
Types
The immune system consists of two lines of defense namely innate and adaptive immune response/immunity.
 
Innate (Natural/Native) Immune Response
Its salient features are:
  • First line of defense present by birth.
  • Provides immediate initial protection against an invading pathogen. It is triggered by substances which indicate potential danger to a host. These substances are common to many pathogens, such as bacterial lipopolysaccharide or viral nucleic acid.
  • Does not depend on the prior contact with foreign antigen or microbes.
  • Lacks specificity, but highly effective.
  • Triggers the adaptive immune response.
  • No memory and no self/nonself recognition are seen.
  • Innate immune cells: These include monocyte-derived macrophages, neutrophils (polymorphonuclear neutrophils [PMNs] and dendritic cells [DCs]).
 
Adaptive Immune Response
If the innate immune system fails to provide effective protection against invading microbes, the adaptive immune system is activated. Thus, it is the second and more complex immune response that may follow the innate response. It specifically targets antigens present in the immunizing substance. It is characterized by the development of antigen-specific antibody and T cell responses. Three characteristic features are: (1) specificity, (2) diversity and (3) memory. Other salient features are:
  • Second line of defense acquired during life.
  • Capable of recognizing both microbial and nonmicrobial substances.
  • Takes more time (days to weeks) to develop and is more powerful than innate immunity.
  • Long-lasting protection.
  • Prior exposure to antigen is present.
  • Adaptive immune cells: T and B lymphocytes, and null cells.
 
TERMINOLOGIES USED IN IMMUNOLOGY
Transfusion medicine needs sound knowledge of antigens and antibodies. For understanding the immune system, it is essential to know some essential terms used in immunology.3
  • Antigen (Ag): Any substance (usually foreign or a nonself) that is recognized as foreign by the body and capable of inducing immune response (antibody formation) in an immunocompetent individual. These antigens bind specifically to an antibody or cell-surface receptors of T lymphocytes. All antigens are not capable of eliciting an immune response. Blood group antigens are present on the surface of RBCs.
  • Immunogen: It is a substance capable of provoking an antibody-mediated immune response when it is introduced into an immunocompetent host to whom it is foreign. The terms antigen and immunogen are often used synonymously. The immune response is initiated by the presentation of an antigen (initiates formation of and reacts with an antibody) or immunogen (initiates an immune response). The term antigen is more commonly used in blood banking because the primary testing is the detection of antibodies to blood group antigens.
  • Immunogenicity: The ability of an antigen to elicit an immune response is known as its immunogenicity. The immunogenicity of an antigen is depends on:
    • Characteristics of antigens: These include degree of foreignness, molecular size and configuration, temperature, pH, and ionic environment and antigenic complexity (depends on the number of available epitopes or antigenic determinants).
    • Host's genetically determined immune responsiveness.
  • Antibody (Ab): If a foreign antigen is introduced into an immunocompetent individual, a protein produced in response to it is called an antibody. Antibody is an immunoglobulin that is produced and secreted by activated B lymphocytes (plasma cells derived from B lymphocytes) after stimulation by a specific immunogen. Immunoglobulin proteins consist of two identical heavy chains and two identical light chains. The light chains recognize a particular epitope on an antigen and facilitate clearance of that antigen.
    While all antibodies are immunoglobulins, not all immunoglobulins are antibodies. Immunoglobulin molecules for which no complementary material or antigen has been recognized are simply called immunoglobulins, not antibodies.
    • Alloantibodies: They are formed in response to antigens from individuals of the same species. These are the type of antibodies involved in transfusion reactions.
    • Heteroantibodies (xenoantibodies): They are antibodies produced in response to antigens from another species.
    • Autoantibodies: They are made in response to the body's own antigens.
  • Antigen-presenting cell (APC): APC is any cell that can process and present antigenic peptides in association with class II major histocompatibility complex (MHC) molecules and deliver a costimulatory signal necessary for T cell activation. The professional APCs include macrophages, DCs, and B cells. Nonprofessional APCs, which function in antigen presentation only for short periods include thymic epithelial cells and vascular endothelial cells.
  • Epitope (antigenic determinant): It is a portion/site of an immunogen/antigen that is recognized and combines specifically with an antibody of B lymphocyte or antigen receptor of a T lymphocyte (T-cell receptor [TCR]-MHC combination or TCR ligand-CD1 complex).
  • Haptens: They are well-defined molecules that are too small to be immunogenic (i.e. they cannot stimulate antibody production) by themselves but can induce an antibody response when attached to (coupled with) a carrier protein. The hapten molecules have a molecular weight (MW) less than 10,000 daltons (D). The carrier protein should have a MW greater than 10,000 D.
  • Immune system: It is a collective term for all the cells and tissues involved in 4immune activity (host defense system). Included in this system are the cells of the immune system, the thymus, lymph nodes, spleen, bone marrow, portions of the liver, gastrointestinal tract (GIT) and mucosa-associated lymphoid tissue.
  • Receptor: It is a molecule or cell membrane protein molecule whose configuration allows it to form a tightly fitting complex with another molecule of complementary shape (ligand which is molecule that binds to a receptor).
  • Cytokine: It is a low molecular weight protein secreted from an activated cell that affects the function or activity of other cells. Cytokines regulate the intensity and duration of the immune response by exerting a variety of effects on lymphocytes and other immune cells that express the appropriate receptor.
  • Clone: It is a population of genetically identical cells derived from successive divisions of a single progenitor cell (a cell that originates from a stem cell and differentiates into a more specialized cell).
 
COMPONENTS OF IMMUNE SYSTEM
Immune system is made up of special cells, proteins, tissues and organs.
 
Organs Involved in Immune System
They may be central organs or peripheral organs.
  • Central organs: Bone marrow, liver and thymus.
  • Peripheral organs: Lymph nodes and spleen.
The mucosal-associated lymphoid tissues (i.e. GIT-associated and bronchus-associated lymphoid tissues) also play an important role by involving both central and peripheral functions.
 
Cells of the Immune System
Cells of immune responses (lymphocytes and other cells) migrate among lymphoid and other tissues and the vascular and lymphatic circulations.
  1. Lymphocytes are the primary cells involved:
    1. Naïve lymphocytes
    2. T lymphocytes
    3. B lymphocytes
    4. Natural killer (NK) cells
  2. Dendritic cells
  3. Macrophages.
 
Naïve Lymphocytes
These are mature lymphocytes which have not encountered the antigen (immunologically inexperienced). After the lymphocytes are activated by recognition of antigens, they differentiate into:
  • Effector cells: They perform the function of eliminating microbes.
  • Memory cells: They live in a state of heightened awareness and are better able to combat the microbe in case it infects again.
 
T Lymphocytes
T (thymus-derived) lymphocytes develop from precursors in the thymus.
Distribution: Mature T cells are found in:
  • Peripheral blood where it constitutes 60–70% of lymphocytes
  • T cell zones of peripheral lymphoid organs namely paracortical region of lymph node and periarteriolar sheaths of spleen.
Subsets of T lymphocytes: Naïve T cells can differentiate into two major subtypes namely (1) CD4 and (2) CD8.
  1. T helper cells: These cells have a cell surface marker called CD4 and hence are also called CD4+ cells. They help B cells in antibody formation; constitute two-thirds of circulating T cells. They recognize antigen presented by class II human leukocyte antigen (HLA) molecules.
  2. T cytotoxic cells: These cells have the surface marker CD8 and hence are called CD8+ cells. They constitute one-third of circulating T cells and recognize antigens in context of class I HLA molecules.5
 
B Lymphocytes
B (bone marrow-derived) lymphocytes develop from precursors in the bone marrow.
Distribution
  • Peripheral blood: Mature B cells constitute 10–20% of the circulating peripheral lymphocyte population.
  • Peripheral lymphoid tissues: Lymph nodes (cortex), spleen (white pulp), and mucosa-associated lymphoid tissues (pharyngeal tonsils and Peyer's patches of GIT).
Functions of B cells: All the mature, naïve B cells express membrane-bound immunoglobulins on their surface that functions as B-cell receptors (BCRs) for antigen. B cells recognize antigen via these BCRs.
  • Production of antibodies: The primary function of B cells is to produce antibodies. After stimulation by antigen and other signals, B cells develop into plasma cells. These cells secrete antibodies which are the mediators of humoral immunity.
  • Antigen-presenting cell: B cells also serve as APCs and are very efficient at antigen processing.
 
Dendritic Cells
As the name suggests these cells have numerous fine cytoplasmic processes that resemble dendrites. These are important APCs in the body.
 
Macrophages
Macrophages are a part of the mononuclear phagocyte system.
Processing of antigen: In adaptive immune response, macrophages process the antigens present in the phagocytosed microbes and protein antigens. After processing, the antigen is presented to T cells and thus, they function as APCs in T cell activation.
 
Adaptive Immune Responses
It can be classified into two main divisions.
  1. Humoral immunity: In this type, immunity is mediated by soluble protein products called antibodies produced by B lymphocytes and helper T cells. Antibody is capable of reacting with the specific antigen responsible for its production. Macrophages also participate in the effector phase of humoral immunity. Macrophages get activated by interferon-gamma (IFN-γ).
  2. Cell-mediated immunity (cellular immunity): Cellular immunity is mediated T lymphocytes, macrophages and their soluble products called cytokines. It is localized reaction to organism, usually intracellular pathogens. Macrophages are main effector cells in certain types of cell-mediated immunity, the reaction that serves to eliminate intracellular microbes. In this type of response, T cells activate macrophages and increase their capability to kill ingested microbes. Macrophages efficiently phagocytose and destroy microbes which are opsonized (coated) by immunoglobulin G (IgG) or C3b through their respective receptors. Cell-mediated cytotoxicity is important in lysis of virus infected cells and rejection of allograft and tumor cells. Other cytotoxic cells involved in cell-mediated immune response are natural cells (NK). These NK cells are able to attack the target cells and kill them.
 
Components of Adaptive Immune Response
 
Natural Killer Cells
  • Nonphagocytic large (little larger than small lymphocytes) granular (numerous cytoplasmic azurophilic granules) lymphocytes.
  • Comprise about 5–15% of human peripheral lymphoid cells.
Function: Natural killer cells provide defense against many viral infections and other intracellular pathogens and also has antitumor activity, causing lysis of cells with which they react. Killing of the cells is performed without prior exposure to or activation by these microbes or tumors. Because of this ability, NK cells act an early line of defense against viral infections and few tumors.6
Major histocompatibility complex molecules (Discussed in chapter 23).
 
IMMUNOGLOBULINS
The function of the immune system is to defend the body from externally derived agents and from potentially dangerous self-constituents. The main effector cells of specific immunity are lymphocytes. The lymphocytes possess receptors capable of discriminating one antigen from another (based on differences in their molecular configuration).
Immunoglobulins are a group of serum proteins.
Antibodies: Immunoglobulins for which a corresponding antigen can be identified are called antibodies.
Immunoglobulins: They lack corresponding antigen are simply called immunoglobulins and are not antibodies.
 
Types of Immunoglobulins
There are five classes of immunoglobulins designated as: (1) IgM, (2) IgG, (3) IgA, (4) IgD, and (5) IgE. Of these, IgM, IgG and IgA (rarely) antibodies are produced against RBC antigens and mainly involved in blood group serology.
 
Structure of Immunoglobulin Molecule (Fig. 1.2)
Immunoglobulin consists of amino acid molecules linked by peptide bonds forming amino acid chains.
Heavy and light chains: All immunoglobulins share the same basic structure consisting of four chain molecules. The basic immunoglobulin unit consists of two identical heavy chains and two identical light chains held together by disulfide bonds. Immunoglobulin molecules are proteins and therefore have two terminal regions namely (1) the amino (-NH2) terminal and (2) the carboxyl (-COOH) terminal.
  • Light chains: The light chains belong to two antigenetically different isotypes, i.e. (1) Kappa (K) and (2) Lambda (λ). In any immunoglobulin molecule, the two light chains are always identical, being either Kappa or Lambda.
  • Heavy chains: The heavy chains are different for each class of immunoglobulins (Table 1.1).
  • Disulfide bond: Each light chain is joined to one heavy chain by a disulfide bond. One or more disulfide bonds link the two heavy chains in an area of considerable flexibility called the hinge region. The four chains bound by covalent (disulfide) and noncovalent bonds give “Y” configuration.
    zoom view
    Fig. 1.2: Schematic representation of basic immunoglobulin (IgG) structure. The inset shows formation of antigen-binding fragment (Fab) and constant fragment (Fc) after enzymatic cleavage of the IgG molecule by papain.
    7
    Table 1.1   Types of heavy chain in different immunoglobulin molecules.
    Type of immunoglobulin
    Type of heavy chain
    IgA
    Alpha (α)
    IgG
    Gamma (Γ)
    IgM
    Mu (µ)
    IgD
    Delta (δ)
    IgE
    Epsilon (ϵ)
    • Variable region: The portion near the amino terminus or N-terminus of both light and heavy chains of immunoglobulins is called variable region. The antigenic specificity of the immunoglobulin molecule lies in this portion. They are termed variable because they are structured according to the great variation in antibody specificity.
    • Constant portion: The carboxyl region of all heavy chains and the light chains has a relatively constant amino acid sequence and is called as the constant region. The five isotypes of heavy chains and two of light chains are determined by the amino acid sequences of the constant portion.
 
Digestion of Immunoglobulins
Digestion of an immunoglobulin molecule with the proteolytic enzyme papain results in cleavage or splitting of the heavy chain at the hinge region. This produces three separate fragments namely: two Fab and one Fc fragments (Fig. 1.2 inset).
  • Two Fab fragments: These fragments are identical and consist of one light chain linked to the N-terminal half of the heavy chain. These N-terminal fragments retain the specificity of the antibody and are called Fab fragments (fraction antigen binding). Structurally and functionally, the Fab fragments consist of the portions of the immunoglobulin from the hinge region to the amino terminal end and are the regions responsible for binding antigen.
  • One Fc fragment: The Fc fragment is that portion of the immunoglobulin molecule from the carboxyl region to the hinge region (from both heavy chains) still joined to one another by the hinge region disulfide bonds. This is the nonantibody protein fragment capable of crystallization and is called Fc fragment. Fc fragments on IgG antibody is responsible for complement fixation, for placental transfer, monocyte binding by Fc receptors on cells and reaction with antihuman globulin (AHG).
 
Individual Immunoglobulin Classes
 
IgM Antibodies (Fig. 1.3)
These antibodies readily and very strongly agglutinate the red cells carrying the corresponding antigens in saline. Therefore, they are known as complete antibodies. IgM exists in serum as a pentamer and cannot cross the placental barrier. They activate complement through the classic pathway and markedly enhance the inflammatory and phagocytic defense mechanisms. The optimal temperature is room temperature (i.e. 20–24°C).
 
IgG Antibodies (Fig. 1.4)
Immunoglobulin G antibodies are also called “incomplete antibody”, because they do not cause agglutination of red cells with corresponding antigen in saline. They can readily cross the placenta and responsible for hemolytic disease of newborn (HDN). It tends to combine with and remain attached to cell surface antigens, where its presence can be detected in vitro by antiglobulin testing. In vivo, cells or particles coated with IgG undergo markedly enhanced interaction with cells that have receptors for the Fc portion of gamma chains, especially neutrophils and macrophages. The optimum temperature for reaction of IgG is 37°C. IgG antibodies account for the majority of the clinically significant antibodies directed against blood group antigens.8
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Fig. 1.3: IgM pentamer (polymer formed from five molecules of a monomer) immunoglobulin molecule (joined together).
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Fig. 1.4: Monomer containing only one immunoglobulin unit (e.g. IgG, IgD and IgE molecule).
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Fig. 1.5: IgA dimer composed of two identical simpler monomers (Ig) are joined together.
There are four subclasses of IgG: (1) IgG1, (2) IgG2, (3) IgG3, and (4) IgG4.
  • Most IgG antibodies contain all four subclasses. However, some are predominantly or exclusively composed of a single subclass.
  • The subclasses have different biologic properties.
    • All bind to the crystallizable fragment (Fc) receptors on macrophages. All can cross the placental barrier. All except IgG4 are capable of binding to complement through the classic pathway.
    • IgG1 and IgG3 bind complement much more efficiently than IgG2.
    • IgG1 constitutes 65–70% of the total IgG found in serum.
 
IgA Antibodies (Fig. 1.5)
It serves no physiologic function. Most of the IgA mass and all of its physiologic significance exist in mucosal secretions. It is important to know that people deficient in IgA may have anti-IgA. IgA antibodies against RBC antigens usually occur with IgG and IgM antibodies having the same specificity. These IgA antibodies neither cross the placental barrier nor do they fix complement. IgA antibodies can cause agglutination in saline.
The location of cellular components, red cell antigen and antibody in a blood sample is depicted in Figure 1.6.
The salient features of antibodies (immunoglobulins) are presented in Table 1.2.
 
IMMUNE RESPONSE
Immune response after exposure to an antigen is influenced by the host's previous history with the foreign material. There are two types of immune responses: (1) primary and (2) secondary.
Primary immune response: It is the response of the body when an immunocompetent individual is exposed for first time to a foreign antigen (nonself antigen). In this, there is a lag period/phase, i.e. the time between exposure to the antigen and appearance of detectable antibody. It can vary from a few days to weeks or even months. It depends on factors like nature and quantity of the antigen, route of administration and protein synthesizing capacities of the host. The antibody that appears in the blood after first contact with an antigen is always IgM type.9
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Fig. 1.6: Blood sample depicting the location of cellular components, red cell antigen and antibody. The serum or plasma contains the antibody, whereas the red cell membrane contains the antigen.
After some days, IgG becomes detectable. If there is no further exposure to the antigen, the level of circulating IgM antibody peaks and then declines, while IgG antibody persists for longer time. Apart from immune responses, the primary immune response generates memory cells. These memory cells contribute to the immune response on second or subsequent exposure to the same antigen (i.e. secondary or anamnestic immune response).
Anamnestic or secondary immune response: Even if the antigen that caused the primary response disappears from the body, circulating T cells and memory B cells continue to persist. When there is a subsequent or second contact with the same antigen, memory B cells respond far more rapidly than unstimulated cells. There is no lag period and the dose of the antigen can be very small. The memory cells exhibit rapid proliferation of the IgG secreting progeny. This is called anamnestic or secondary response. Within a short time (within hours or a day), the level of circulating IgG antibody rises sharply. The IgG response may be as much as 100 times greater than the primary response. The affinity of antibody molecules for the antigens will also be greater than in primary response.
Antibody level and time of development of primary and secondary antibody responses are shown in Figure 1.7.
Table 1.2   Salient features of antibodies (immunoglobulins).
Features
IgM (millionaire's antibody)
IgG (subtypes: IgG1, IgG2, IgG3, IgG4)
IgA
IgE (reaginic/
homocytotropic antibody)
IgD
Approximately % of total Ig
5%
80% (maximum)
15%
Trace
Trace
Molecular weight (Daltons [Da])
900,000 (maximum)
150,000
150,000 to 300,000
190,000
180,000
Type of heavy chain
µ
γ
α
ε
d
Structure
Pentamer (maximum size)
Monomer
Dimer (in glandular secretions), monomer (in serum)
Monomer
Monomer
Complement activation
Yes
(classical pathway)
Yes
(classical pathway)
Activates alternate complement pathway
No
No
Transport across placenta
No
Yes
No
No
No
Half-life (days)
5
21
6
2
3
Main function
Primary immune response
Secondary immune response
Functions as B-cell receptor
Mucosal immunity
Highly effective at neutralizing toxins
Allergic diseases, defense against parasite infection and anaphylactic reaction
Unknown
10
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Fig. 1.7: Antibody level and time of development of primary and secondary antibody responses.
Differences between primary and secondary immune response are presented in Table 1.3.
 
IMMUNOHEMATOLOGY
 
Red Cell Antigen-Antibody Reactions in Vivo
 
Transfusion, Pregnancy and Immune Response
During transfusion and pregnancy, a patient is exposed to many potentially foreign antigens present on red cells, white cells, and platelets. These foreign antigens have immunogenic potentiality. These foreign antigens may activate the immune system of the patients or patient may be “sensitized”, with the resultant production of circulating antibodies. The antibodies produced in response to transfusion and pregnancies are classified as alloantibodies.
Antibody screen test: It is performed on the recipient to detect any existing red cell alloantibodies before transfusion.
  • Detection of alloantibody: If a red cell alloantibody is found, a test is done to identify the specificity of the antibody.
  • Specificity of alloantibody: Once the specificity is identified, donor units lacking the red cell antigen are selected for transfusion.
  • Importance: Detecting and identifying alloantibodies in the patient before transfusion are important to avoid the formation of antigen-antibody complexes in vivo (within the patient's body), which would reduce the survival of the transfused cells.
Immunization during pregnancy: Immunization may also occur during pregnancy due to entry of fetal blood cells into the maternal circulation at delivery. Alloantibody may develop as an immune response to RBC, WBC, or platelet antigens of fetal origin. Routinely females are screened during the first trimester of pregnancy for the presence of red cell alloantibodies. These red cell alloantibodies can destroy fetal red blood cells before or after delivery. The destruction of red cell may lead to clinical complications due to anemia and high levels of bilirubin in the fetus or newborn.
 
Red Cell Antigen-Antibody Reactions in Vitro
The combination of antibody with antigen produces a variety of observable results. Antigen-antibody reactions are important in immunohematology. In blood group serology (immunohematology), the most common reactions are as follows:
Table 1.3   Differences between primary and secondary immune response.
Features
Primary response
Secondary response
Cells that mediate the response
Circulating T lymphocytes
Memory B cells
Lag period
Long: Weeks to months
Usually 5–10 days
Short: Hours to days
Usually 1–3 days
Antibody isotype
IgM first; followed by IgG
Usually IgM > IgG
IgG response and under certain situations IgA or IgE
Peak response
Smaller
Larger
Dose of antigen required to elicit response
Higher the dose faster the response
Even minute doses produce 100-fold increased response
11
  • Agglutination: Hemagglutination
  • Hemolysis
  • Neutralization
  • Precipitation
 
Agglutination and Hemagglutination
Antigen-antibody reactions occurring in laboratory testing (in vitro) are detected by visible agglutination of the RBCs (hemagglutination) or development of hemolysis at the completion of testing (a positive result).
Hemagglutination: It produces the clumping of red cells that result when antibody molecules combine with antigenic determinants on adjacent red cells. This brings RBCs together and forms a visible aggregate.
  • A positive reaction in immunohematologic testing is indicated by agglutination. A positive result indicates that an antigen-antibody immune complex was formed, and the specificity of the antibody matched the antigen in the test system.
  • A negative reaction in immunohematologic testing is indicated by no agglutination. Negative result/reaction suggests that there is no formation of antigen-antibody complex and indicates that the antibody in the test system is not specific for the antigen.
Agglutination is the end point for most test involving red cells and blood group antibodies. It is the primary and most common reaction observed in routine transfusion practice.
 
Stages of agglutination
Agglutination occurs in two stages namely (1) sensitization and (2) visible agglutination (lattice formation).
Sensitization (or antibody binding/attachment to red cells): In the first stage of red cell agglutination, there is simple coating or binding of an antibody to an antigen on the red cell membrane. This stage needs an immunologic recognition between the antigen and antibody. During this recognition stage, the antigen-binding sites of the antibodies become closely associated with the antigenic determinants (epitopes) on the RBC membrane (Fig. 1.8). The antibodies and antigens are held together loosely by noncovalent bonds. This does not produce clumping or visible agglutination of red cells in saline. Since no visible agglutination is seen, an additional step is needed to produce visible agglutination or to otherwise measure the reaction by the use of albumin, proteolytic enzymes, or AHG reagent. This stage depends on factors such as the pH, temperature of the reaction, incubation time, and ionic strength of the suspension medium.
Visible agglutination (Lattice formation): After the red cells have been sensitized with antibody molecules, visible agglutination (Fig. 1.9) occurs when several RBCs are physically joined together by the union of antigen with antibody. This stage depends on factors such as distance between red cells, optimal concentrations of antigen and antibody, and time and speed of centrifugation.
  • Enhancement of contact: The use of proteolytic enzymes (e.g. papain or ficin) can increase/enhance cell-to-cell contact of RBCs.
  • Adding antiserum: RBCs sensitized by incomplete antibodies (antibodies that will not react in saline) agglutinate when antiserum against human IgG is added (antiglobulin/Coombs test).
 
Factors affecting agglutination
Agglutination is a reversible chemical reaction. Various factors can affect reactivity of antigen-antibody RBC agglutination reactions. These factors can be manipulated to enhance (or decrease) agglutination.
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Fig. 1.8: Sensitization of RBCs with antibodies.
12
zoom view
Fig. 1.9: Agglutination is the clumping of red cells together because of interactions with specific antibodies.
Agglutination reactions are affected by the concentration of the reactants (antigen and antibody) and by factors such as pH, temperature, and ionic strength. The surface charge, antibody isotype, RBC antigen dosage, and the use of various enhancement media, AHG reagents, and enzymes are all important in antigen-antibody reactions. The most important factors are discussed in the following sections:
 
Antigen-Antibody ratio (cell-to-serum ratio) (Fig. 1.10)
Amount of available antigen and antibody affects hemagglutination.
  • Equivalence: For agglutination reactions to occur, it is necessary to have optimal proportions of antigen and antibody, i.e. equal amount/proportions of antigen-antibody. Any deviation from this ratio decreases the efficiency of the reaction and a loss of the zone of equivalence between antigen and antibody ratio. Thus, adding equal volumes of serum and 2–5% suspension of red cells is sufficient and is recommended for all routine blood banking procedures. The recommended ratio in red cell serology is one drop of serum to one drop of 2–5% red cells (or 2 drops of serum to 1 drop of the RBC suspension). It gives the proper balance between antigen and antibody to allow sensitization and agglutination to occur. This ratio may be altered, depending on the test method used.
  • Prozone: It occurs when antibody molecules are in excess than that of available antigenic sites. This results in false-negative reactions. When antibody (immunoglobulin) is present in the test system in excess (when compared to antigen concentration), false-negative reactions occur as a result of prozone.
  • Antigen excess (postzone): When the antigen is in excess, false-negative reactions occur due to postzone effect. In both prozone and postzone effect, the agglutination may not occur. This can give rise to false-negative results.
  • The antigen-antibody test systems can be manipulated to overcome the effects of excessive antigen or antibody. If this is suspected following steps will help to correct it.
    • Excessive antibody: If the problem is due to excessive antibody, the plasma or serum may be diluted with the appropriate buffer.
    • Excessive antigen: The problem of excessive antigen can be solved by increasing the serum-to-cell ratio, which increases the number of antibodies available to bind with each RBC.
    • Weakly reactive antibody: If the antibody is weakly reactive (weak expression of antigen on RBCs—dosage effect), increasing the antibodies present can increase the test's sensitivity.13
      zoom view
      Fig. 1.10: Diagrammatic representation of the effects of varying concentrations of antigen and antibody on lattice formation.
      In such cases, the serum-cell-ratio may be doubled (2 drops serum and 1 drop 2–5% red cell). This provides more antibodies to react with the available antigens. While investigating adverse transfusion reactions, it may be desirable to increase the serum-cell-ratio by as much as 10- to 20-fold. This should be done only when enhancing media or potentiators have not been included in the test system.
 
Effect of pH
The ideal pH for antigen-antibody reactions in which most antibodies react best at a neutral pH. It ranges between 6.5 and 7.5, which is similar to the pH of normal plasma or serum. The pH values below 6 or above 8 reduce the reactivity. Stored saline has a pH of 5.0–6.0, hence buffered saline is preferred in serologic testing. However, some anti-M show enhanced reactivity at a pH of 6.5 and acidifying the test system may help in distinguishing anti-M from other antibodies.
 
Temperature and phase of reactivity
The optimal temperature at which an antibody reacts can provide useful clues to antibody identity. Depending on the thermal specificity, most antibodies form two broad categories:
  1. Those reactive at “cold” temperature (e.g. 4–25°C). IgM antibodies react best at 4–25°C.
  2. Those reactive at “warm” temperature (e.g. 30–37°C). IgG antibodies react best at 30–37°C.
Temperature of agglutination is determined by the nature of antigen and the type of reaction and not by the class of antibody. Binding with carbohydrate antigens (as with ABO antigen-antibody reactions) occurs best at low temperatures, while bindings with protein antigens (as with Rh antigen-antibody reaction) occurs best at 37°C due to the protein nature of the antigen. Antibodies that react in vitro only at temperature below 30°C rarely cause destruction of transfused antigen-positive red cells and are considered clinically insignificant. When performing pretransfusion compatibility testing, the focus is on clinically significant antibodies. They generally react at 37°C or with the anti-IgG in the AHG reagent.
 
Red cell ionic charge
Red blood cells have a negative charge at this surface which makes RBCs to repel each other. The negative charge is due to sialic acid molecules on the surface of RBCs. This natural repulsive force which holds the RBC apart is called zeta potential. This is protective and keeps RBCs from adhering to each other in the peripheral blood. The distance which keeps 14the RBCs apart is very small but sufficient to prevent the small IgG molecules to bridge the gap and agglutinate the red cells. However, large IgM molecules bridge the gap and bring the red cells together causing agglutination of RBCs.
 
Ionic strength
In normal saline, Na+ and Cl ions cluster around and partially neutralize opposite charges on antigens and antibody molecules. This interferes with the association of antibodies with antigen. A decrease in the ionic strength of the medium of suspension, increases the association of Ab with Ag. The use of low ionic strength solutions (LISS), or low salt media contains 0.2% sodium chloride and they decrease the ionic strength of medium.
 
Incubation time (length of incubation)
Incubation time is also important for antigen-antibody reactions. If incubation time is too little (less contact time), only few sensitized RBCs will be detected by routine methods. If the incubation time is allowed to continue for too long, bound antibody may begin to dissociate from the RBCs. Incubation time is different for different blood group antibodies. Incubation time also depends on temperature and medium in which the reaction takes place. Optimum incubation time for most blood group reactions in saline environment is 30–60 minutes at 37°C. Weak reactive antibodies may require longer time. Addition of enhancement agents or potentiators may shorten the incubation time. For example, enhancement agents like LISS or polyethylene glycol (PEG) can reduce the incubation time to 10–15 minutes at 37°C.
 
Freshness of serum and RBCs
Best antigen-antibody reaction occurs with fresh serum and freshly prepared red cells. If serum is not immediately used, it should be stored at −20°C or lower.
 
Enhancement media
Agglutination reactions for IgM antibodies and their corresponding RBC antigens are easily observed in saline medium and these antibodies usually do not need enhancement or modifications to react strongly with antigens. IgG antibodies react best at 37°C and are generally responsible for hemolytic transfusion reactions and HDN. Hence, detection of IgG antibodies is clinically more significant than IgM. Many enhancement techniques or potentiators are available to discover the presence of IgG antibodies. Many of the enhancement media act by reducing the zeta potential of RBC membranes. Reducing the zeta potential allows the more positively charged antibodies to get closer to the negatively charged RBCs. Thus, enhancement techniques or potentiators increase RBC agglutination by IgG molecules. Various methods for enhancement are:
  • Physical methods: Centrifugation and agitation enhance antigen-antibody reaction.
    1. Centrifugation: It is an effective method to enhance agglutination reactions. It reduces the reaction time by increasing the gravitational forces on the reactants, brings the cells close together and increases the chance of association between antibody and antigen. During centrifugation, sensitized RBCs overcome their natural repulsive effect (zeta potential) for each other and agglutinate more efficiently. High-speed centrifugation is one of the most efficient methods used in blood banking. However, centrifugation should not cause packing of cells too tightly, which may lead to false-positive reactions.
    2. Agitation: Another method of enhancing antigen-antibody reaction often employed by the shakers used for rapid plasma reagin (RPR) and Western blot testing.
  • Chemical methods:
    1. Bovine albumin (22% or 30% concentration): It increases the dielectric constant of the medium and reduces the zeta potential (i.e. reduce electric repulsion between cells). It also affects the surface tension between cells, 15thus causing antibody-coated cells to agglutinate. Thus, by reducing zeta potential and surface tension, albumin enhances antigen-antibody binding. Bovine albumin does not cause agglutination of noncoated cells.
    2. Enzymes: Papain is the proteolytic enzyme most commonly used in blood group serology. Others include bromelin, ficin, and trypsin. These enzymes act by:
      • Lowering the zeta potential: Sialic acid is the major contributor of the net negative change at the red cell surface which keeps cells separated from each other in an ionic suspending medium. Enzymes cleave sialic acid molecules and reduce the negative charge on RBCs.
      • Cleaving of protein also increases the surface tension between cells thus predisposing to agglutination.
      • They cause spicule formation on the red cell. This increases the potential number of contact points.
        Note: Certain red cell antigens can undergo denaturation by enzyme treatment, e.g. M, N, S, Fya, and Fyb. Thus, it is important not to use enzyme treatment while detecting any of these antigens.
    3. Antihuman globulin (AHG) reagent: AHG causes agglutination of sensitized/coated cells. AHG bridges the gap between the IgG molecules attached to the red cells and enhances their agglutination. This is the most common as well most sensitive method used to detect antigen-antibody reaction in immunohematology.
The direct AHG test is used to determine if RBCs are coated with antibody or complement or both.
Polyethylene glycol and polybrene are macromolecule additives used with LISS to enhance agglutination reactions. PEG is more effective than albumin, LISS, or polybrene for detection of weak antibodies. These reagents have been used in automated and manual testing systems.
Grading and scoring of hemagglutination are presented in Table 1.4.
 
Hemolysis
In immunohematology laboratory, apart from agglutination as an indicator of an antigen-antibody reaction, red cell hemolysis in the tube is also an indicator of the activity of an antigen and antibody (antigen-antibody reaction) in vitro.
  • Hemolysis (Fig. 1.11) is the rupture or breakdown of red cells with release of intracellular hemoglobin. In vitro, hemolysis requires activation of complement cascade. Complement system gets activated when there is antigen-antibody complex (immune complex). Hemolysis does not occur if the antigen-antibody reaction takes place in serum that lacks complement (stored blood) or in anticoagulant that chelates/binds to Ca++ and Mg++ (both Ca++ and Mg++ necessary for complement activation). Hence, for demonstration of hemolysis fresh serum samples (without anticoagulants) should be used.
    Table 1.4   Grading and scoring of hemagglutination.
    Grade
    Appearance
    Score
    4+
    Red cell button—one solid aggregate with a clear background
    10
    3+
    Several medium to large aggregates with a clear background
    8
    2+
    Many small to medium aggregates with a clear background
    5
    1+
    Many small aggregates with a turbid background with many free red cells
    3
    + or w
    Few small aggregates with many unagglutinated cells
    2
    ±m or +m
    Aggregates visible only under microscopic examination
    1
    0
    Negative—absence of aggregates (no agglutination)
    0
    R
    Rouleaux (nonspecific aggregation that appears like a stack of coins and disappears with addition of saline)
    NA
    H
    Hemolysis—presence of free hemoglobin in the serum
    10
    16
    zoom view
    Fig. 1.11: Diagrammatic appearance of normal RBC and ruptured/hemolyzed RBC.
  • Hemolysin: Antibodies that have the capacity to activate complement on reacting with antigens on red cells and cause hemolysis are called hemolysins.
  • Many blood group antibodies on reacting with the antigens on red cells activate the complement and produce membrane attack complex (MAC). MAC causes damage to RBC membrane leading to destruction of RBCs. This in turn releases the intracellular fluid in the RBCs into the serum.
  • In the test system, hemolysis is identified by the pink or red coloration of the supernatant fluid after tubes are centrifuged. IgM antibodies predominantly activate complement while IgG rarely does so.
  • Some red cell antibodies characteristically produce hemolysis in vitro, such as antibodies to the Lewis system antigens and anti-Vel.
Note: Testing for hemolysin is mandatory prior to release of the so-called universal red cells/whole blood of group “O” to a recipient with non-O (A, B, AB) group.
 
Neutralization (Inhibition)
Soluble form of blood group antigens can also combine with soluble blood group antibody. It will result in full or partial neutralization (inhibition) of antibody. There is no formation of a visible precipitate. In this reaction, if the strength of the antibody diminishes or if it disappears completely, an antigen-antibody reaction can be assumed to have taken place.
Missing or weak antigens/antibodies can often be detected with the help of neutralization reactions.
 
Precipitation (Fig. 1.12)
When soluble antibody reacts with soluble antigen and forms an insoluble, usually visible complex, the reaction is called as precipitation. Such complexes are seen in test tubes as a sediment or ring and in agar gels as a white line. Precipitation is the end point of procedures such as immunodiffusion and immunoelectrophoresis. Examples for precipitation reactions are venereal disease research laboratory (VDRL) and RPR tests performed in the blood bank to screen for syphilis.
  • Antigen and antibody should be present in optimal proportions for the occurrence of precipitation. In an ideal reactive condition, an equivalent amount of antigen and antibody binds.
    zoom view
    Fig. 1.12: Diagrammatic reorientation of appearances of solution, suspension and precipitate.
    17
  • Prozone phenomenon (refer pages 12 and 13): If there is excess of unbound Ab (immunoglobulin), there will be very few Ag sites to combine with the molecules and the lattice structure is not formed. Ag-Ab complexes are formed but do not accumulate sufficiently to form a visible lattice. An excess of leads of antibody leads to a phenomenon called a prozone. It is important to rule out prozone phenomenon while screening for atypical antibodies like anti-D in a woman giving a sample for indirect antiglobulin test, during antenatal checkup.
  • A surplus of antigen leads to a postzone effect (refer page 13).
 
TRADITIONAL LABORATORY TESTING METHODS
These include hemagglutination (a special type of agglutination), precipitation, agglutination inhibition, and hemolysis.
Other techniques which are used to quantify antigen or antibody with the use of a radioisotope, enzyme, or fluorescent label—such as radioimmunoassay (RIA), enzyme-linked immunosorbent assay (ELISA) or enzyme immunoassay (EIA), Western blotting (WB), and immunofluorescence (IF).
In transfusion medicine, much laboratory testing involves detection and identification of antibodies in patient's plasma. These assays can be mainly divided into: (1) fluid-phase assays (agglutination-based methods) and (2) solid-phase assays.
 
Fluid-Phase Assays (Agglutination-Based Methods)
 
Uses of Agglutination-Based Tests in Blood Bank
Agglutination is used for:
  • Serologic cross-matching (donor RBCs incubated with recipient plasma or serum)
  • Screening for unexpected antibodies (reagent RBCs of known blood group antigen composition incubated with recipient plasma or serum)
  • Blood group antigen phenotyping of the donor or recipient (test RBCs are incubated with monoclonal antibodies or reagent-quality antisera of known specificity).
 
Methods (Refer Pages 71-84 of Chapter 4)
  • Manual tube testing: Agglutination detected by adhesion of RBCs to one another in post-centrifuge pellet.
  • Microtiter plate: Agglutination visualized by spread pattern of RBCs in individual wells.
  • Column agglutination technique:
    • Gel-based testing: After agglutination is allowed to take place, the reaction mixture is centrifuged through a gel-matrix (usually composed of dextran-acrylamide). Unagglutinated RBCs pass through the gel, whereas larger, agglutinated RBCs are retained at the top or within the matrix. Details are presented in Chapter 4.
    • Glass microbeads technology (refer pages 78-82)
Agglutination reaction tests are sensitive and easy to perform. However, the formation of agglutination depends on antigen-antibody ratio (refer Fig. 1.10 on page 13).
 
Solid-Phase Assays
In these assays, a specific antigen or antibody is immobilized on a solid matrix, usually made of plastic. It can be used for either antigen detection or antibody detection. A solution containing antigen/antibody (depends on which has to be tested, i.e. if antigen in the testing sample to be tested then antibody and vice versa) is placed on the well; polystyrene (or other plastic used) directly absorbs antigen/antibody from the solution and irreversibly binds to antigen/antibody to the plastic. The well is washed, the analyte is added and incubated with the antigen/antibody-coated solid phase, and its adherence is measured.
 
Solid-Phase Assays for Phenotyping RBCs (Fig. 1.13)
Antibodies specific for a known blood group antigen are coated onto the round bottom of the microtiter plates.18
zoom view
Fig. 1.13: Solid-phase assays for phenotyping RBCs.
RBCs to be analyzed are added to the microplate wells, allowed to adhere and then the microplate is centrifuged.
  • Positive reaction: Specific binding of RBC to the antibodies results in dispersion of the RBCs over the surface of the entire well. This indicated the presence of antigen on the RBCs.
  • Negative reaction: No binding of RBC antigens to the antibodies on the well of microtiter plates. The red cells cluster together as a “button” at the bottom of well.
 
Solid-Phase Assays for Detecting Antibodies to RBC Antigens (Fig. 1.14)
In this test, antigen-coated RBCs (or red cell fragments) are coated onto the microtiter plate wells. Patient's serum to be tested is added. It is incubated and washed. If the patient serum contains antigen-specific antibodies, they will bind to antigen-coated red cells in the microtiter plate. Then indicator red cells (coated with antihuman IgG) are added.
zoom view
Fig. 1.14: Solid-phase assays for detecting antibodies to RBC antigens.
19
  • Positive reaction: It is characterized by diffuse adherence of the indicator red cells to the well.
  • Negative reaction: It is characterized by clustering of indicator red cells in a button.
 
Enzyme-Linked Immunosorbent Assay
Discussed on pages 359-63 of Chapter 16.
 
NONTRADITIONAL LABORATORY TESTING METHODS
 
Western Blot
Discussed on pages 364-5 of Chapter 16.
 
Flow Cytometry
Recent techniques to study immunologic reactions are fluorescence-assisted cell sorting (FACS) and flow cytometry. Flow cytometry has revolutionized the analysis of cell populations.
Principle: In flow cytometry, antibodies tagged with a fluorescent dye (i.e. fluorescent tag-labeled antibodies) against cell surface molecules are used. These antibodies are incubated with target population of cells. These “stained” cells are then passed through a flow cytometer. As the cells coated with fluorescent-labeled antibody travel in the flow cytometer, the cells are exposed to lasers which excite the fluorescent tags. This causes emission of a brightly fluorescent color of a specific wavelength that can be detected by sensors in the flow cytometer. Fluorescence is assessed on cell-by-cell basis. This allows visualization and quantification of minor population cells present in a complex mixture.
 
Suspension Array Technology
Suspension array technology (SAT) combines the specificity of solid-state antigen/antibody interaction (ELISA) with the sensitivity of flow cytometry. In transfusion medicine, it is used for identification of HLA-specific alloantibodies for screening platelet donors and blood group genotyping.
 
BLOOD GROUP ANTIGENS
The term blood group is not only used for genetically encoded red cell antigens but also to the immunologic diversity expressed by other blood constituents, including leukocytes, platelets, and plasma.
Location of gene and mode of inheritance: Most blood group genes (few exceptions) are located on the autosomal chromosomes and their inheritance follows Mendelian laws of inheritance. A majority of blood group alleles also demonstrate codominance. In codominance, the products of both alleles of a gene pair exert an observable effect and are thus equally dominant (e.g. the alleles A and B of the blood group system ABO; O is recessive to A and B). That means genetic heterozygotes at a particular locus will express both gene.
Many membrane-associated structures on blood cells act as antigens because they are capable of reacting with a complementary antibody or cell receptor. A majority of these antigens are capable of eliciting an antibody-mediated immunologic response and are thus are immunogenic (refer page 3). Each antigen can have a variety of different epitopes or specific antigenic determinants page 3. Epitopes are discrete, immunologically active regions of the antigen. The epitopes can interact with specific lymphocyte membrane receptors or secreted complementary antibody.
About a dozen of antigen systems are significant and are commonly important in the transfusion medicine. Individuals who lack certain antigens, when exposed to them may form antibodies. These antibodies may be detected on routine testing in the blood bank products.
 
Immunogenicity
An antigen capable of eliciting an immune response is called as immunogenicity. Blood group antigens greatly vary in their capability to elicit an immune response. The most immunogenic are A, B, and RhD antigens. Hence, all blood to be transfused must be 20matched for these antigens between the blood donor and the recipient. About 50–75% of D-negative individuals would produce anti-D if transfused with only one unit of D-positive blood. Apart from AB and D antigen, K followed by Fya antigens are also immunogenic.
 
BLOOD GROUP ALLOANTIBODIES AND AUTOANTIBODIES
Majority of clinically significant blood group antibodies are IgG or IgM type and occasionally an IgA type.
 
Classification of Blood Group Antibodies
Blood group antibodies can be classified as:
Alloantibody: This reacts with a foreign antigen not present on the patient's own RBC. Identification of alloantibodies and selection of compatible blood components are the most important functions of a transfusion medicine service.
  • Naturally occurring antibodies: These antibodies that are present in our body in the absence of an apparent stimulus. Some alloantibodies to RBC antigens are called naturally occurring. The antigenic stimulus for this is unknown and these antibodies may appear regularly in the serum of persons who lack the corresponding antigen. For example in the ABO blood group system. These antibodies are commonly of IgM type and occur in serum without any specific red cell antigenic stimulus (e.g. anti-A, anti-B, anti-P).
    These antibodies are present in individuals who lack that particular antigen. They develop in infancy by 4–8 months and are maintained with little variation throughout the life. They again reduce in old age. Other naturally occurring antibodies are produced only in a small number of individuals.
  • Acquired antibodies: Most blood group alloantibodies are produced as the result of immunization to foreign RBC antigens. The immunization may occur either during previous transfusion of blood components or following pregnancy. These antibodies are usually IgG type. Examples include Rh antibodies like anti-D and anti-Kell produced by external sensitization.
Autoantibody: It reacts with an antigen on the patient's own cells.
 
COMPLEMENT SYSTEM AND BLOOD BANKING
The complement system or complement, is a complex group of over 20 circulating serum and cell membrane proteins that play a number of biologic roles. They play most important role in immunohematology in that they are able to lyse the cell membranes of antibody-coated RBCs. They have a multiple function within the immune response. Their primary roles include immune adherence, phagocytosis, direct lysis of cells and bacteria, as well as assisting with opsonization to facilitate phagocytosis. Their peptide fragment split products play roles in inflammatory responses such as increased vascular permeability, smooth muscle contraction, chemotaxis, migration, and adherence. It is often involved in blood group reactions and immunological disorders. Complement plays an important role in the sensitization and destruction of transfused RBCs by alloantibody or the destruction of autologous RBCs by autoantibody. Complement is also important in immunohematologic testing. The complement components are unstable and heat liable. Hence, it is important for serum specimens to be fresh for blood bank testing.
The complement system is a group of plasma proteins synthesized in the liver, and are native precursor components. They are sequentially numbered from C1 to C9. The number refers to their discovery date, not to their activation sequence. The four unique serum proteins of the alternative pathway are designated by letters: factor B, factor D, factor P (properdin), and IF (initiating factor). Complement components circulate in inactive 21form as proenzymes, with the exception of factor D of the alternate pathway. The cleavage products of complement proteins are distinguished from parent molecules by adding suffixes from “a” to “e” as they are cleaved (e.g. C3a and C3b).
 
Pathways of Complement System Activation (Fig. 1.15)
The complement proteins may be activated in a cascade of events. The decisive step in complement activation is the proteolysis of the third component, C3. Cleavage of C3 can occur by any one of the three pathways: (1) the classical, (2) alternative, and (3) lectin pathways.
  1. Classical pathway: It is activated by antigen-antibody (Ag-Ab) complexes. The antibodies involved are IgM, IgG1, or IgG3 antibody and get activated when the C1 component binds to the Fc portion (refer page 6) of the antibody molecule.
  2. Alternative pathway or properdin system: It is triggered by microbial surface molecules (e.g. endotoxin, or lipopolysaccharides/LPS), complex polysaccharides, cobra venom, and other substances and does not require specific antibody for activation. Thus, they get activated in the absence of antibody.
  3. Lectin pathway: It directly activates C1 when plasma mannose-binding lectin (MBL) binds to mannose on microbes. MBL in turn activates proteins of the classical pathway.
 
Role of Complement in RBC Destruction
The reactions that take place from C5 to C9 are termed the membrane attack complex and result in lesions on the RBC surface. These lesions allow the rapid passage of ions, and the cell lyses from osmotic pressure changes. When antibody binds to intrinsic (self) RBC antigens on the RBC membrane, it activates the complement by classic pathway.
zoom view
Fig. 1.15: Different pathways of activation and functions of the complement system. All pathways of activation lead to cleavage of C3.
22
Complement may also be activated on RBCs when an exogenous antigen (nonself, e.g. drugs like penicillin which acts as hapten) adsorbed to its cell surface. For example, penicillin-coated RBCs and forms antipenicillin antibodies.
RBC-antibody complexes usually activate complement by the classical pathway. Antibody-coated RBCs are removed by cells of the mononuclear phagocyte system.
 
Intravascular Hemolysis (Fig. 1.16)
Intravascular RBC hemolysis is usually caused by antibodies directed against the ABO antigens. Rarely, hemolysis may be due to other IgM blood group antibodies or some complement-fixing IgG antibodies (e.g. anti-Kidd antibodies). Intravascular lysis occurs when large amounts of complement are rapidly activated. It results in complete activation of complement cascade and generation of the terminal membrane attack complex (C5–9). This complex polymerizes to form pores in the RBC membrane and the extracellular fluid enters the cell. The RBCs swell and burst by osmotic lysis.
 
Extravascular Hemolysis
Majority of extravascular hemolysis is due to IgG antibodies against RBC antigen. When IgG antibodies bind RBCs, it activates the complement and the complement-coated RBCs are removed from the circulation and are destroyed in the RE (reticuloendothelial) system.
 
Historical Overview of Blood Banking/Blood Transfusion Service (BTS)
  • The first attempt for blood transfusion was made in 1492. During this, to save life of a Pope Innocent VIII (who was in coma), an attempt was made by orally administering blood from 3 healthy boys. However, it resulted in death of all of them.
  • In 1628, English physician William Harvey discovered the circulation of blood.
  • During 1665–1667, Dr Richard Lower (England) and Dr Jean-Baptiste Denys, an eminent physician of King Louis XIV of France recorded successful blood transfusion in animals and reported transfusions from lambs to humans. After this, transfusing the blood from animals to humans was prohibited by law, delaying the advances in transfusion medicine for about 150 years.
  • In 1795, in Philadelphia, an American Physician, Philip Syng Physick, performed the first human blood transfusion, although he does not publish this information.
  • In 1818, James Blundell, a British obstetrician transfused human blood to a female with postpartum hemorrhage. During 1825–1830, he performed ten transfusions, of which five were beneficial to the patients.
  • In 1840, Samuel Armstrong Lane and Blundell, undertook first successful whole blood transfusion to treat a case of hemophilia.
    zoom view
    Fig. 1.16: Red cell lysis through membrane attack complex (MAC). Binding of IgG or IgM antibody to an antigen promotes complement fixation. Activation of complement leads to formation of MAC which causes cell lysis. Example—transfusion of A group blood to individual with B group.
    23
  • Clotting was the main obstacle for transfusion of blood. In 1869, Braxton Hicks recommended the use of sodium phosphate as a nontoxic anticoagulant.
  • Karl Landsteiner (Australian physician) discovered the major milestone by identifying ABO group in 1901. He also explained the rational for blood incompatibility and hemolytic transfusion reaction. Landsteiner won the Nobel Prize for Medicine for this discovery in 1930. The discovery of the ABO blood group system marked the beginning of modern blood banking and transfusion medicine. Landsteiner noted the presence of agglutinating antibodies in the serum of individuals who lacked the corresponding ABO antigen.
  • AB blood group was discovered in the year 1902 by A Decastello and A Sturli.
  • In 1907, Hektoen suggested that the safety of transfusion can be improved by cross-matching.
  • In 1912, Roger Lee (physician) from Massachusetts General Hospital coined the term “Universal Donor” and “Universal Recipient”.
  • The Rh blood group system was discovered by Karl Landsteiner, Alexander Wiener, Philip Levine and RE Stetson in 1940.
  • Successful blood transfusion was achieved in 1914. Huston reported the use of sodium citrate and glucose as diluents and anticoagulant solution for transfusion.
  • In 1915, sodium citrate was used by Richard Lewisohn to prevent clotting of blood. This has helped the process of collection of blood from donors and storage easier.
  • In 1916, Rous and Turner introduced citrate-dextrose solution as anticoagulant for blood collection. This has resulted in more practical and safer transfusion of blood.
  • MNS system was discovered in the year 1927. P blood group system was also discovered in the same year.
  • Early in 1932, the first blood bank was established in Leningrad Hospital, Russia to combat blood loss in World War II.
  • Dr Charles Drew first described the techniques in blood transfusion and establishment of blood bank.
  • In 1930–1940 another major blood group Rh blood group system was discovered by Karl Landsteiner.
  • In 1940, Edwin Cohn developed fractionation—plasma, albumin, protein.
  • In 1943, P Beeson first published the transfusion-transmitted hepatitis.
  • In 1945, Coombs, Mourant, and Race described the use of AHG (Coombs test) for detection of incomplete antibodies.
  • Kell blood group was discovered in the year 1946. This blood group was named after Mrs Keller, the mother of first child to be affected with HDN. Kidd blood group was named after Mrs Kidd whose serum contained the antibody and antigen was named “JK” after woman's child John Kidd, who suffered HDN.
  • In 1948, developed the plastic bag for blood collection.
  • Duffy group was detected in 1950. Mr Duffy was a hemophilia patient.
  • Bombay blood group was discovered by Dr YM Bhende and colleagues in the year 1952.
  • In 1962, antihemophilic factor was discovered and use of component was understood.
  • In 1964, plasmapheresis was introduced.
  • In 1965, cryoprecipitate was first used.
  • In 1971, HBsAg antigen detection test was introduced for safe blood transfusion.
  • In 1981, reported the first case of acquired immunodeficiency syndrome (AIDS). The causative agent for AIDS was identified on 1983. In 1985, ELISA screening test for HIV antibodies was available.
  • In 1985, donated blood screening for HIV was started.
  • In 1998, it was made mandatory to test for hepatitis C for blood transfusion.
  • Recent advances:
    • Nucleic acid amplification test for detecting genetic materials of viruses even before antibodies develop.24
    • Blood components are prepared and used for transfusion.
    • Recombinant thrombopoietin available.
    • Hemopoietic stem cell transplantation.
    • Automation in blood banking and apheresis.