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Susila S, Ilmakunnas M, Lauronen J, Vuorinen P, Ångerman S, Sainio S. Low titer group O whole blood and risk of RhD alloimmunization: Rationale for use in Finland. Transfusion 2024; 64 Suppl 2:S119-S125. [PMID: 38240146 DOI: 10.1111/trf.17700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Prehospital low-titer group O whole blood (LTOWB) used for patients with life-threatening hemorrhage is often RhD positive. The most important complication following RhD alloimmunization is hemolytic disease of the fetus and newborn (HDFN). Preceding clinical use of RhD positive LTOWB, we estimated the risk of HDFN due to LTOWB prehospital transfusion in the Finnish population. STUDY DESIGN AND METHODS We collected data on prehospital transfusions in Tampere and Helsinki University Hospital areas. Using the mean of reported alloimmunization rates in trauma studies (24%) and a higher reported rate representing trauma patients of 13-50 years old (42.7%), we estimated the risk of HDFN and extrapolated it to the whole of Finland. RESULTS We estimated that in Finland, with the current prehospital transfusion rate we would see 1-3 cases of severe HDFN due to prehospital LTOWB transfusions every 10 years, and fetal death due to HDFN caused by LTOWB transfusion less than once in 100 years. DISCUSSION The estimated risk of serious HDFN due to prehospital LTOWB transfusion in the Finnish population is similar to previous estimates. As Finland routinely screens expectant mothers for red blood cell antibodies and as the contemporary treatment of HDFN is very effective, we support the prehospital use of RhD positive LTOWB in all patient groups.
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Affiliation(s)
- Sanna Susila
- Finnish Red Cross Blood Service, Vantaa, Finland
- Emergency Medical Service and Emergency Department, Päijät-Häme wellbeing services county, Lahti, Finland
| | - Minna Ilmakunnas
- Finnish Red Cross Blood Service, Vantaa, Finland
- Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Meilahti Hospital Blood Bank, Department of Clinical Chemistry, HUS Diagnostic Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Pauli Vuorinen
- Emergency Medical Services, Centre for Prehospital Emergency Care, Pirkanmaa wellbeing services county, Tampere, Finland
| | - Susanne Ångerman
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Hughey S, Kotler J, Cole J, Jewett F, Checchi K, Lin A. Whole blood transfusion among allied partnerships: unified and interoperable blood banking for optimised care. BMJ Mil Health 2023:e002516. [PMID: 37709507 DOI: 10.1136/military-2023-002516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/25/2023] [Indexed: 09/16/2023]
Abstract
Whole blood transfusion is being increasingly used for trauma resuscitation, particularly in military settings. Low-titre group O whole blood simplifies the logistical challenges and maximises the benefits of blood transfusion when compared with component therapy in austere battlefield conditions. Screening protocols and blood testing requirements for prescreened donors in walking blood banks (WBBs), which are used for emergency transfusions, are established by both the USA and most partner nations, though they are not necessarily uniform across these combined forces. Interoperability and standardisation of blood bank resources and protocols across allied forces in multinational military operations, including uniformity in screening processes, collection methods and storage is essential to the provision of safe and effective blood product transfusions in this austere setting. Predeployment screening, multinational training exercises and universal WBB sets with instructions in multiple languages can help enhance the interoperability of combined multinational operations and create a more efficient WBB system. Standardisation of blood collection, nomenclature, equipment and screening practices will allow for the most optimal utilisation of whole blood resources across a multinational battlefield.
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Affiliation(s)
- Scott Hughey
- Anesthesiology and Pain Medicine, US Naval Hospital Okinawa, Okinawa, AP, Japan
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - J Kotler
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Department of Orthopedic Surgery, US Naval Hospital Okinawa, Okinawa, Japan
- 3d Medical Battalion, III Marine Expeditionary Force, Okinawa, Japan
| | - J Cole
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Michaud Role 2 Expeditionary Medical Facility, Camp Lemonniere, Djibouti, Djibouti
| | - F Jewett
- Department of Pathology, US Naval Hospital Okinawa, Okinawa, AP, Japan
| | - K Checchi
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Department of Surgery, US Naval Hospital Okinawa, Okinawa, Japan
| | - A Lin
- 3d Medical Battalion, III Marine Expeditionary Force, Okinawa, Japan
- Department of Cardiology, US Naval Hospital Okinawa, Okinawa, Japan
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Seheult JN, Callum J, Delaney M, Drake R, Dunbar NM, Harm SK, Hess JR, Jackson BP, Javanbakht A, Moore SA, Murphy MF, Raval JS, Staves J, Tuott EE, Wendel S, Ziman A, Yazer MH. Rate of D-alloimmunization in trauma does not depend on the number of RhD-positive units transfused: The BEST collaborative study. Transfusion 2022; 62 Suppl 1:S185-S192. [PMID: 35748692 DOI: 10.1111/trf.16952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/12/2022] [Accepted: 01/17/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Evidence indicates the life-saving benefits of early blood product transfusion in severe trauma resuscitation. Many of these products will be RhD-positive, so understanding the D-alloimmunization rate is important. METHODS This was a multicenter, retrospective study whereby injured RhD-negative patients between 18-50 years of age who received at least one unit of RhD-positive red blood cells (RBC) or low titer group O whole blood (LTOWB) during their resuscitation between 1 January, 2010 through 31 December, 2019 were identified. If an antibody detection test was performed ≥14 days after the index RhD-positive transfusion then basic demographic information was collected, including whether the patient became D-alloimmunized. The overall D-alloimmunization rate, and the rate stratified by the number of units transfused, were calculated. RESULTS Data were collected from nine institutions. Five institutions reported fewer than 10 eligible patients each and were excluded. From the remaining four institutions, all from the USA, there were 235 eligible patients; 77 (random effects estimate: 32.7%; 95% CI: 19.1-50.1%) became D-alloimmunized. Three of the institutions reported D-alloimmunization rates ≥38.6%, while the remaining institution's rate was 12.2%. In both random and fixed-effects models, the rate of D-alloimmunization was not significantly different between those who received one RhD-positive unit and those who received multiple RhD-positive units. CONCLUSION In this large, multicenter study of injured patients, the overall rate of D-alloimmunization fell within the range previously reported. The rate of D-alloimmunization did not increase as the number of transfused RhD-positive units increased. These data can help to inform RhD type selection decisions.
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Affiliation(s)
- Jansen N Seheult
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pathology and Pediatrics, George Washington University Medical School, Washington, District of Columbia, USA
| | - Rosanna Drake
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Sarah K Harm
- Department of pathology, University of Vermont Medical Center, Burlington, Vermont, USA
| | - John R Hess
- Transfusion Service, Harborview Medical Center and the Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Bryon P Jackson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ayda Javanbakht
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Sarah A Moore
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Michael F Murphy
- National Health Service Blood and Transplant, and Oxford Biomedical Research Centre, Oxford, UK
| | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico
| | - Julie Staves
- National Health Service Blood and Transplant, and Oxford Biomedical Research Centre, Oxford, UK
| | - Erin E Tuott
- Transfusion Service, Harborview Medical Center and the Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Alyssa Ziman
- Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, California, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Ringel F, Schoenfeld H, El Bali S, Sehouli J, Spies C, Salama A. Safety of Uncrossmatched ABO-Compatible RBCs in Alloimmunized Patients with Bleeding: Data from Two Decades: Results of a Systematic Analysis in 6,109 Patients. Transfus Med Hemother 2021; 49:234-239. [PMID: 36159957 PMCID: PMC9421688 DOI: 10.1159/000520649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction: Uncrossmatched ABO-compatible red blood cells (RBCs) are generally recommended in patients with life-threatening massive bleeding. There is little data regarding RBC transfusion when patients are transfused against clinically significant alloantibodies because compatible RBCs are not immediately available. Methods/Patients: All patients reviewed in this study (n = 6,109) required emergency blood transfusion and were treated at the Charité – Universitätsmedizin Berlin between 2001 and 2015. Primary uncrossmatched O Rh(D)-positive or -negative RBC units were immediately transfused prior to complete regulatory serological testing including determination of ABO group, Rhesus antigens, antibody screening, and crossmatching. Results: Without any significant change in the protocol of emergency transfusion of RBCs, a total of 63,373 RBC units were transfused in 6,109 patients. Antibody screening was positive in 413 patients (6.8%), and 19 of these patients received RBC units against clinically significant alloantibodies. None of these patients appeared to have developed significant hemolysis, and only one patient with anti-D seems to have developed signs of insignificant hemolysis following the transfusion of three Rh(D)-positive units. One patient who had anti-Jka received unselected units and did not develop a hemolytic transfusion reaction. Conclusion: Transfusion of uncrossmatched ABO-compatible RBCs against alloantibodies is highly safe in patients with life-threatening hemorrhage.
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Affiliation(s)
- Frauke Ringel
- Department of Gynecology with Center for Oncological Surgery, Campus Virchow-Klinikum, Charité − Universitätsmedizin Berlin, Berlin, Germany
- Institute of Transfusion Medicine, Campus Virchow-Klinikum, Charité − Universitätsmedizin Berlin, Berlin, Germany
- *Frauke Ringel,
| | - Helge Schoenfeld
- Institute of Transfusion Medicine, Campus Virchow-Klinikum, Charité − Universitätsmedizin Berlin, Berlin, Germany
- Institute of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité − Universitätsmedizin Berlin, Berlin, Germany
- Labor Berlin, Charité Vivantes GmbH, Berlin, Germany
| | - Said El Bali
- Institute of Transfusion Medicine, Campus Virchow-Klinikum, Charité − Universitätsmedizin Berlin, Berlin, Germany
| | - Jalid Sehouli
- Department of Gynecology with Center for Oncological Surgery, Campus Virchow-Klinikum, Charité − Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology, Division of Operative Intensive Care Medicine, Campus Virchow-Klinikum, Charité − Universitätsmedizin Berlin, Berlin, Germany
| | - Abdulgabar Salama
- Department of Gynecology with Center for Oncological Surgery, Campus Virchow-Klinikum, Charité − Universitätsmedizin Berlin, Berlin, Germany
- Institute of Transfusion Medicine, Campus Virchow-Klinikum, Charité − Universitätsmedizin Berlin, Berlin, Germany
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Transfusion Preparedness in the Labor and Delivery Unit: An Initiative to Improve Safety and Cost. Obstet Gynecol 2021; 138:788-794. [PMID: 34619726 DOI: 10.1097/aog.0000000000004571] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/05/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate patient safety, resource utilization, and transfusion-related cost after a policy change from universal type and screen to selective type and screen on admission to labor and delivery. METHODS Between October 2017 and September 2019, we performed a single-center implementation study focusing on risk-based type and screen instead of universal type and screen. Implementation of our policy was October 2018 and compared 1 year preimplementation with 1 year postimplementation. Patients were risk-stratified in alignment with California Maternal Quality Care Collaborative recommendations. Under the new policy, the blood bank holds a blood sample for processing (hold clot) on patients at low- and medium-risk of hemorrhage. Type and screen and crossmatch are obtained on high-risk patients or with a prior positive antibody screen. We collected patient outcomes, safety and cost data, and compliance and resource utilization metrics. Cost included direct costs of transfusion-related testing in the labor and delivery unit during the study period, from a health system perspective. RESULTS In 1 year postimplementation, there were no differences in emergency-release transfusion events (4 vs 3, P>.99). There were fewer emergency-release red blood cell (RBC) units transfused (9 vs 24, P=.002) and O-negative RBC units transfused (8 vs 18, P=.016) postimplementation compared with preimplementation. Hysterectomies (0.05% vs 0.1%, P=.44) and intensive care unit admissions (0.45% vs 0.51%, P=.43) were not different postimplementation compared with preimplementation. Postimplementation, mean monthly type and screen-related costs (ABO typing, antibody screen, and antibody workup costs) were lower, $9,753 compared with $20,676 in the preimplementation year, P<.001. CONCLUSION Implementation of selective type and screen policy in the labor and delivery unit was associated with projected annual savings of $181,000 in an institution with 4,000 deliveries per year, without evidence of increased maternal morbidity.
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Yazer M, Triulzi D, Sperry J, Corcos A, Seheult J. Rate of RhD-alloimmunization after the transfusion of RhD-positive red blood cell containing products among injured patients of childbearing age: single center experience and narrative literature review. ACTA ACUST UNITED AC 2021; 26:321-327. [PMID: 33775237 DOI: 10.1080/16078454.2021.1905395] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To determine the rate of RhD-alloimmunization in injured RhD-negative patients in the age range of childbearing potential who were transfused with at least one unit of RhD-positive red blood cells (RBC) or low titer group O whole blood (LTOWB). METHODS Injured RhD-negative patients between the ages of 13-50 at an American Level 1 trauma center who were transfused with at least one unit of RBCs or LTOWB during their resuscitation and who had an antibody detection test performed at least 14 days afterwards were included. RESULTS Over a 20-year period, 96 study-eligible patients were identified, of which 90/96 (93.8%) were male. The median age of these 96 patients was 33 (5th-95th percentiles: 19-49) years. The majority of these patients (71/96, 74.0%) had an injury severity score (ISS) greater than 15. Overall, 41/96 (42.7%; 95% CI: 32.7%-53.2%) of these patients became alloimmunized after receipt of a median of 3 (5th-95th percentiles: 1-35) units of RhD-positive RBCs and/or LTOWB. There was no association between receipt of leukoreduced RBCs or receipt of LTOWB and the RhD-alloimmunization rate. DISCUSSION The rate of RhD-alloimmunization in this study was at the higher end of rates that have been reported. None of the previous studies focused exclusively on trauma patients in the childbearing age range. CONCLUSION The 42.7% rate of RhD-alloimmunization in a predominantly male trauma population could probably be extrapolated to women in the same age range when estimating their risk of RhD-alloimmunization following RhD-positive transfusion.
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Affiliation(s)
- Mark Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Darrell Triulzi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jason Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alain Corcos
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jansen Seheult
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
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Group A emergency-release plasma in trauma patients requiring massive transfusion. J Trauma Acute Care Surg 2021; 89:1061-1067. [PMID: 32890339 DOI: 10.1097/ta.0000000000002903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Both groups A and AB plasma have been approved for emergency-release transfusion in acutely bleeding trauma patients before blood grouping being performed. The safety profile associated with this practice has not been well characterized, particularly in patients requiring massive transfusion. METHODS This secondary analysis of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios trial examined whether exposure to group A emergency-release plasma (ERP) was noninferior to group AB ERP. We also examined patients whose blood groups were compatible with group A ERP versus patients whose blood groups were incompatible with group A ERP. Outcomes included 30-day mortality and complication rates including systemic inflammatory response syndrome, infection, renal injury, pulmonary dysfunction, and thromboembolism. RESULTS Of the 680 patients predicted to receive a massive transfusion, 584 (85.9%) received at least 1 U of ERP. Of the 584 patients analyzed, 462 (79.1%) received group AB and 122 (20.9%) received group A ERP. Using a hazard ratio (HR) of 1.35 as the noninferiority margin, transfusion with group A versus group AB ERP was not associated with increased thromboembolic rates (HR, 0.52; 95% confidence interval [CI], 0.31-0.90). Mortality (HR, 1.15; 95% CI, 0.91-1.45) and nonfatal complication rates (HR, 1.24; 95% CI, 0.87-1.77) were inconclusive. In the subgroup analysis, transfusion with incompatible ERP (group B or AB patients receiving group A ERP) was not associated with increased nonfatal complications (HR, 1.02; 95% CI, 0.80-1.30). There were no reported hemolytic transfusion reactions. CONCLUSION The use of ERP is common in patients requiring massive transfusion and facilitates the rapid balanced resuscitation of patients who have sustained blood loss. Group A ERP is an acceptable option for patients requiring massive transfusion, especially if group AB ERP is not readily available. LEVEL OF EVIDENCE Therapeutic/Care Management, level IV; Prognostic, level III.
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Critical decision points in the management of acute trauma: a practical review. Int Anesthesiol Clin 2021; 59:1-9. [PMID: 33560038 DOI: 10.1097/aia.0000000000000317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Successful emergency transfusions require early recognition and activation of resources to minimize treatment delays. The initial goals should focus on replacement of blood in a balanced fashion. There is an ongoing debate regarding the best approach to transfusions, with some advocating for resuscitation with a fixed ratio of blood products and others preferring to use viscoelastic assays to guide transfusions. Whole-blood transfusion also is a debated strategy. Despite these different approaches, it generally is accepted that transfusions should be started early and crystalloid infusions limited. As hemodynamic stability is restored, endpoints of resuscitation should be used to guide the resuscitation.
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Affiliation(s)
- Michael S Farrell
- Department of Surgery, University of California San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA 94110, USA; Zuckerberg San Francisco General Hospital, San Francisco, CA, USA. https://twitter.com/mfarrellmd
| | - Woon Cho Kim
- Department of Surgery, University of California San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA 94110, USA; Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Deborah M Stein
- Department of Surgery, University of California San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA 94110, USA; Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
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van Turenhout EC, Bossers SM, Loer SA, Giannakopoulos GF, Schwarte LA, Schober P. Pre-hospital transfusion of red blood cells. Part 1: A scoping review of current practice and transfusion triggers. Transfus Med 2020; 30:86-105. [PMID: 32080942 PMCID: PMC7317877 DOI: 10.1111/tme.12667] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/18/2019] [Accepted: 01/16/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The primary aim of this scoping review is to describe the current use of pre-hospital transfusion of red blood cells (PHTRBC) and to evaluate criteria used to initiate PHTRBC. The effects on patients' outcomes will be reviewed in Part 2. BACKGROUND Haemorrhage is a preventable cause of death in trauma patients, and transfusion of red blood cells is increasingly used by Emergency Medical Services (EMS) for damage control resuscitation. However, there are no guidelines and little consensus on when to initiate PHTRBC. METHODS PubMed and Web of Science were searched through January 2019; 71 articles were included. RESULTS Transfusion triggers vary widely and involve vital signs, clinical signs of poor tissue perfusion, point of care measurements and pre-hospital ultrasound imaging. In particular, hypotension (most often defined as systolic blood pressure ≤ 90 mmHg), tachycardia (most often defined as heart rate ≥ 120/min), clinical signs of poor perfusion (eg, prolonged capillary refill time or changes in mental status) and injury type (ie, penetrating wounds) are common pre-hospital transfusion triggers. CONCLUSIONS PHTRBC is increasingly used by Emergency Medical Services, but guidelines on when to initiate transfusion are lacking. We identified the most commonly used transfusion criteria, and these findings may provide the basis for consensus-based pre-hospital transfusion protocols.
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Affiliation(s)
| | - Sebastiaan M. Bossers
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Stephan A. Loer
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Georgios F. Giannakopoulos
- Department of Trauma SurgeryAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lothar A. Schwarte
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Patrick Schober
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
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Abstract
Transfusion of uncrossmatched erythrocytes is lifesaving in patients who are severely bleeding when crossmatched erythrocytes are unavailable. The hemolysis risk after uncrossmatched erythrocyte administration to appropriate patients is very low.
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12
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Harris CT, Totten M, Davenport D, Ye Z, O'Brien J, Williams D, Bernard A, Boral L. Experience with uncrossmatched blood refrigerator in emergency department. Trauma Surg Acute Care Open 2018; 3:e000184. [PMID: 30402556 PMCID: PMC6203135 DOI: 10.1136/tsaco-2018-000184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/20/2018] [Accepted: 08/14/2018] [Indexed: 12/05/2022] Open
Abstract
Background Uncrossmatched packed red blood cell (PRBC) transfusion is fundamental in resuscitation of hemorrhagic shock. Ready availability of uncrossmatched blood can be achieved by storing uncrossmatched blood in a blood bank refrigerator in the emergency department (ED), but could theoretically lead to inappropriate uncrossmatched use. Methods This retrospective study was performed at a level I trauma center from January 2013 to March 2014. Possibly inappropriate transfusion was defined as patients who received at least one unit of blood from the ED refrigerator and no more than two units of PRBC in the first 24 hours. Deaths within the first 24 hours were excluded. Patients who received blood from the ED refrigerator who received ≤2 units total in 24 hours were compared with those who received >2 units. Results 158 adults received blood from the ED refrigerator. 140 (88.6%) were trauma patients. 37 (23.4%) received massive transfusion (MT). 42 (26.6%) deaths were excluded. 29 patients received ≤2 units and 87 received >2 units in the first 24 hours. The ≤2 units group had a higher systolic blood pressure (116 mm Hg vs. 102 mm Hg, p=0.042), lower base deficit (6.4 mEq/L vs. 9.4 mEq/L, p=0.032), higher hematocrit (34% vs. 30%, p=0.024), lower rate of MT protocol activation (27.6% vs. 58.6%, p=0.005), and lower rates of transfusion of fresh frozen plasma (17.2% vs. 54.0%, p=0.001) and platelets (13.8% vs. 39.1%, p=0.012). Appropriately transfused patients were more likely to have evidence of shock with active, non-compressible hemorrhage. Potentially inappropriate uses were more likely in patients either without evidence of hemorrhage or without signs of shock. Discussion Storing uncrossmatched blood in the ED is an effective way to get PRBCs transfused quickly in hemorrhaging patients and is associated with a low rate of unnecessary uncrossmatched transfusion. Provider education and good clinical judgment are imperative to prevent unnecessary use. Level of evidence Level III, therapeutic.
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Affiliation(s)
- Charles T Harris
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Michael Totten
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Daniel Davenport
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Zhan Ye
- Department of Pathology and Laboratory Medicine, University of Kansas, Lawrence, Kansas, USA
| | - Julie O'Brien
- Department of Pathology and Laboratory Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Dennis Williams
- Department of Pathology and Laboratory Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Andrew Bernard
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Leonard Boral
- Department of Pathology and Laboratory Medicine, University of Kentucky, Lexington, Kentucky, USA
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13
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Mayer B, Müller J, Candela-García MJ, Manteau AC, Weinstock C, Pruß A. Evaluation of the New Lateral Flow Card MDmulticard® Basic Extended Phenotype in Routine Clinical Practice. Transfus Med Hemother 2018; 45:341-346. [PMID: 30498412 DOI: 10.1159/000486606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 01/03/2018] [Indexed: 11/19/2022] Open
Abstract
Background Transfusion emergencies and critical situations require specifically designed devices to simplify and optimize the standard procedures. In addition, matching antigens over and above ABO-Rh-K would be beneficial. Methods Routine blood samples were collected in four immunohematology centers and tested with the new MDmulticard Basic Extended Phenotype for the simultaneous detection of the Duffy, Kidd, and Ss antigens, according to the principle of the lateral flow. Results were compared with those obtained using routine serology methods. Discrepancies were analyzed by molecular techniques/genotyping. Results 310 samples were tested (167 donors; 75 patients; 28 subjects with positive direct antiglobulin test (DAT); 15 newborns; 25 previously transfused patients). The 285 samples with non-mixed-field reaction yielded 1,710 antigen results with 8 discrepancies (0.47%) six of which in DAT-positive subjects: three false-positive (Fya) for MDmulticard, and two false-positive (Fya) plus three false-negative (Fyb) for the reference methods (MDmulticard PPA for donors/patients/newborns: 99.82%; negative percent agreement: 100%; sensitivity: 100%; specificity: 99.39%, positive predictive value: 99.75%; negative predictive value: 100%). The MDmulticard detected mixed-field in 15 antigen reactions from 13 transfused patients, undetected by the comparative method, with the opposite result in 8 antigens (5 patients). Conclusion The MDmulticard Basic Extended Phenotype met the criteria prescribed for the testing of donor, patient, DAT-positive, and newborn samples in transfusion laboratory routine.
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Affiliation(s)
- Beate Mayer
- Institute of Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Müller
- German Red Cross Blood Service Baden-Württemberg - Hesse, Institute for Clinical Transfusion Medicine and Immunogenetics, Ulm, Germany
| | | | | | - Christof Weinstock
- German Red Cross Blood Service Baden-Württemberg - Hesse, Institute for Clinical Transfusion Medicine and Immunogenetics, Ulm, Germany
| | - Axel Pruß
- Institute of Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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14
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Flommersfeld S, Mand C, Kühne CA, Bein G, Ruchholtz S, Sachs UJ. Unmatched Type O RhD+ Red Blood Cells in Multiple Injured Patients. Transfus Med Hemother 2018; 45:158-161. [PMID: 29928169 DOI: 10.1159/000485388] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 11/13/2017] [Indexed: 12/18/2022] Open
Abstract
Background Immediate supply of red blood cell (RBC) concentrates is crucial in the initial treatment of exsanguinating patients in the emergency room. General shortage of RhD- RBCs has led to protocols in which patients with unknown blood groups are initially transfused with group O, RhD+ RBCs. Limited data are available regarding the safety of such an approach. Methods Transfusion protocols for all multiple injured patients from the regional polytrauma database were retrospectively analyzed over a period of 5 years. Data on side effects were retrieved from the local safety update registry. Follow-up data were obtained from patients with identified RhD-incompatible transfusions. Results In total, 823 patients were registered as multiple injured in the database. An immediate transfusion of 259 units (mean number of units 4, range 1-6) group O, RhD+ RBCs was initiated in 62 of them. 14 of these patients were RhD- and received 60 units of RhD-incompatible RBCs in the emergency room. In the later course RhD- patients received additional 185 incompatible transfusions (13; 1-31). The overall seroconversion rate was 50%. No adverse outcome due to incompatible transfusion was observed. Conclusions Initial supply with group O, RhD+ RBCs in multiple injured patients appears to be safe. Significant numbers of RhD- units can be saved for use in other patients.
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Affiliation(s)
- Sabine Flommersfeld
- Center for Transfusion Medicine and Hemotherapy, University Hospital Gießen and Marburg, Marburg Campus, Marburg, Germany
| | - Carsten Mand
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Gießen and Marburg, Campus Marburg, Marburg, Germany
| | | | - Gregor Bein
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Gießen, Germany
| | - Steffen Ruchholtz
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Gießen and Marburg, Campus Marburg, Marburg, Germany
| | - Ulrich J Sachs
- Center for Transfusion Medicine and Hemotherapy, University Hospital Gießen and Marburg, Marburg Campus, Marburg, Germany.,Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Gießen, Germany
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15
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Fiorellino J, Elahie AL, Warkentin TE. Acute haemolysis, DIC and renal failure after transfusion of uncross-matched blood during trauma resuscitation: illustrative case and literature review. Transfus Med 2018; 28:319-325. [PMID: 29460456 DOI: 10.1111/tme.12513] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 01/18/2018] [Indexed: 11/28/2022]
Abstract
AIMS/OBJECTIVES The aims of this study were to report a patient with acute haemolytic transfusion reaction (HTR) after transfusing uncross-matched red blood cell (RBC) units and to identify the frequency of this complication. BACKGROUND Uncross-matched RBC units are commonly transfused in emergencies, but the frequency of acute HTR is unknown. METHODS We describe a male stabbing victim who received three units of uncross-matched RBC units complicated by acute intravascular HTR, disseminated intravascular coagulation (DIC) and renal failure. We identified 14 studies evaluating the frequency of acute HTR post-emergency transfusion of uncross-matched RBC units. RESULTS Acute HTR was shown by haemoglobinuria, free-plasma haemoglobin and methemalbumin, with anti-K and anti-Fya eluted from recipient red cells; acute DIC featured severe hypofibrinogenemia, thrombocytopenia, elevated fibrin D-dimer and multiple bilateral renal infarcts. Two of the three transfused units reacted with pre-existing RBC alloantibodies [anti-K (titre, 128), anti-Fya (titre, 512)], explained by transfusion 25 years earlier. Our literature review found the frequency of acute HTR following emergency transfusion of uncross-matched RBC units to be 2/3998 [0·06% (95% CI, 0·01-0·21%)]. CONCLUSIONS Although emergency transfusion of uncross-matched blood is commonly practiced at trauma centres worldwide, with low risk of acute HTR (<1/1000), our well-documented patient case demonstrates the potential for acute HTR with severe complications.
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Affiliation(s)
- J Fiorellino
- Department of Anesthesiology, McMaster University, Hamilton, Ontario, Canada
| | - A L Elahie
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
| | - T E Warkentin
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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16
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Yazer MH, Cap AP, Spinella PC, Alarcon L, Triulzi DJ. How do I implement a whole blood program for massively bleeding patients? Transfusion 2018; 58:622-628. [PMID: 29332316 DOI: 10.1111/trf.14474] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 11/21/2017] [Accepted: 11/21/2017] [Indexed: 12/14/2022]
Abstract
Building on the successful military experience, interest has been rekindled in transfusing whole blood (WB) early in the resuscitation of traumatically injured civilians, often before their ABO group is known. WB efficiently provides treatment for shock and coagulopathy, as well as platelet hemostatic function, to patients losing large volumes of blood. Unlike group O uncrossmatched red blood cells (RBCs), group O WB contains a substantial amount of plasma, which is incompatible with the RBCs of all non-group O recipients. Thus, when implementing a WB program, it is important to decide how to mitigate the risk of immune-mediated hemolysis. Other questions that a hospital needs to answer before implementing a WB program include determining which patients will be eligible for this product, how many units eligible patients can receive, for how long it should be stored and under what conditions, and how to monitor for adverse events. The donor center needs to consider if the WB should be leukoreduced, how to comply with the AABB's transfusion-related acute lung injury risk mitigation standard, and into which storage solution it should be collected. This report describes the multidisciplinary approach taken to implementing a civilian WB program at a multihospital health care system in the United States.
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Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, and the Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA-FT Sam Houston, Texas
| | - Philip C Spinella
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St Louis, St Louis, Missouri
| | - Louis Alarcon
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Darrell J Triulzi
- Department of Pathology, University of Pittsburgh, and the Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
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17
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Clavier B, Pouget T, Sailliol A. Evaluation of a lateral flow-based technology card for blood typing using a simplified protocol in a model of extreme blood sampling conditions. Transfusion 2017; 58:313-316. [PMID: 29193130 DOI: 10.1111/trf.14420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/10/2017] [Accepted: 10/16/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Life-threatening situations requiring blood transfusion under extreme conditions or in remote and austere locations, such as the battlefield or in traffic accidents, would benefit from reliable blood typing practices that are easily understood by a nonscientist or nonlaboratory technician and provide quick results. STUDY DESIGN AND METHODS A simplified protocol was developed for the lateral flow-based device MDmulticard ABO-D-Rh subgroups-K. Its performance was compared to a reference method (PK7300, Beckman Coulter) in native blood samples from donors. The method was tested on blood samples stressed in vitro as a model of hemorrhage cases (through hemodilution using physiologic serum) and dehydration (through hemoconcentration by removing an aliquot of plasma after centrifugation), respectively. RESULTS A total of 146 tests were performed on 52 samples; 126 in the hemodilution group (42 for each native, diluted 1/2, and diluted 1/4 samples) and 20 in the hemoconcentration group (10 for each native and 10% concentrated samples). Hematocrit in the tested samples ranged from 9.8% to 57.6% while hemoglobin levels ranged from 3.2 to 20.1 g/dL. The phenotype profile detected with the MDmulticard using the simplified protocol resulted in 22 A, seven B, 20 O, and three AB, of which nine were D- and five were Kell positive. No discrepancies were found with respect to the results obtained with the reference method. CONCLUSION The simplified protocol for MDmulticard use could be considered a reliable method for blood typing in extreme environment or emergency situations, worsened by red blood cell dilution or concentration.
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Affiliation(s)
- Benoît Clavier
- French Military Blood Transfusion Institute, Clamart, France
| | - Thomas Pouget
- French Military Blood Transfusion Institute, Clamart, France
| | - Anne Sailliol
- French Military Blood Transfusion Institute, Clamart, France
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18
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19
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Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: Outcomes of an Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg 2017; 83:25-29. [PMID: 28452877 DOI: 10.1097/ta.0000000000001532] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With a relative shortage of type AB plasma, many centers have converted to type A plasma for resuscitation of patients whose blood type is unknown. The goal of this study is to determine outcomes for trauma patients who received incompatible plasma transfusions as part of a massive transfusion protocol (MTP). METHODS As part of an Eastern Association for the Surgery of Trauma multi-institutional trial, registry and blood bank data were collected from eight trauma centers for trauma patients (age, ≥ 15 years) receiving emergency release plasma transfusions as part of MTPs from January 2012 to August 2016. Incompatible type A plasma was defined as transfusion to patient blood type B or type AB. RESULTS Of the 1,536 patients identified, 92% received compatible plasma transfusions and 8% received incompatible type A plasma. Patient characteristics were similar except for greater penetrating injuries (48% vs 36%; p = 0.01) in the incompatible group. In the incompatible group, patients were transfused more plasma units at 4 hours (median, 9 vs. 5; p < 0.001) and overall for stay (11 vs. 9; p = 0.03). No hemolytic transfusion reactions were reported. Two transfusion-related acute lung injury events were reported in the compatible group. Between incompatible and compatible groups, there was no difference in the rates of acute respiratory distress syndrome (6% vs. 8%; p = 0.589), thromboembolic events (9% vs. 7%; p = 0.464), sepsis (6% vs. 8%; p = 0.589), or acute renal failure (8% vs. 8%, p = 0.860). Mortality at 6 (17% vs. 15%, p = 0.775) and 24 hours (25% vs. 23%, p = 0.544) and at 28 days or discharge (38% vs. 35%, p = 0.486) were similar between groups. Multivariate regression demonstrated that Injury Severity Score, older age and more red blood cell transfusion at 4 hours were independently associated with death at 28 days or discharge; Injury Severity Score and more red blood cell transfusion at 4 hours were predictors for morbidity. Incompatible transfusion was not an independent determinant of mortality or morbidity. CONCLUSION Transfusion of type A plasma to patients with blood groups B and AB as part of a MTP does not appear to be associated with significant increases in morbidity or mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.
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20
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Injury severity, sex, and transfusion volume, but not transfusion ratio, predict inflammatory complications after traumatic injury. Heart Lung 2017; 46:114-119. [DOI: 10.1016/j.hrtlng.2016.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 10/25/2016] [Accepted: 12/11/2016] [Indexed: 01/28/2023]
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21
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Abstract
Pretransfusion testing is reviewed for the anesthesiologist, with an emphasis on the electronic crossmatch and transfusion of uncrossmatched erythrocytes when testing is incomplete.
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22
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A₁A₂BO and Rh gene frequencies among six populations of Jammu and Kashmir, India. Transfus Apher Sci 2014; 50:247-52. [PMID: 24485956 DOI: 10.1016/j.transci.2014.01.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 10/26/2013] [Accepted: 01/06/2014] [Indexed: 11/23/2022]
Abstract
A study was undertaken to record gene frequencies of ABO blood groups, their subtypes and Rh antigen for six different endogamous groups including a tribal population. The ABO phenotypic frequency varies among six different populations showing significant difference (p<0.0005). Gujjar and Bakarwal (a tribal population) shows highest (42.29%) of B blood phenotypes. A1 is the highest among Syeds (39.31%), O blood group frequency highest among Mughals (43.23%) and A1B and A2B are rare phenotypes showing very low frequency among all populations. The pattern of allele frequencies (p<0.025) is in order of I(O)>I(B)>I(A1)>I(A2), except Syeds (I(O)>I(A1)>I(B)>I(A2)). The rhesus protein (Rh) phenotypic frequency (p<0.01) shows significant increase in Rh(D) positive (87.86% in Syed to 96.03% in Khan) among all populations. The Rh allele (p<0.05) and genotype (p<0.02) frequencies shows a significant difference. Heterozygosity for Rh protein is less than homozygosity among six populations. The result from this study provides information on the genetic variation in blood antigens and rhesus protein among human populations inhabiting Jammu and Kashmir.
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