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Asian Journal of Transfusion Science logoLink to Asian Journal of Transfusion Science
. 2019 May;13(Suppl 1):S19–S31.

Oral

PMCID: PMC6573577
Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 1: Determination of the correlation between hematopoietic progenitor cell count and flow cytometric CD34 cell enumeration in hemtopoietic progenitor cell harvest by apheresis

Aanchal Luthra 1, Aseem Kumar Tiwari 1, Dinesh Arora 1, Swati Pabbi 1, Geet Aggarwal 1

Background: The gold standard for estimation of Hematopoietic Progenitor Cells (HPC), to determine the Time-To-Initiate Harvest (TTIH) and Adequacy-Of-Harvest Dose (AOHD) is Flow cytometric CD34 cell enumeration. However, flowcytometer is available at very few centers in India, is expensive, requires trained staff and is time-consuming. The Sysmex XN-9000 cell-counter provides HPC count which is the count of immature and blast cells in a sample. Cell-counters are more widely available, cheaper, easy to perform and gives quicker results.

Aims: We have evaluated the correlation of HPC, Mono-Nuclear Cell (MNC) and White Blood Cell (WBC) count with flow cytometric CD34 cell enumeration at our center in 114 samples from data available from January 2016 to June 2018.

Methods: The gold standard for HPC count is flow cytometric CD34 cell enumeration. HPC count was estimated by XN-9000 in White Precursor Cell (WPC) channel which detects the abnormal membrane composition and nuclear content. HPCs are relatively resistant to permeabilization by WPC reagent. Samples were run simultaneously to determine the HPC count by flowcytometer and cell counter.

Results: 114 samples were evaluated. The correlation coefficients (r) for HPC, MNC, WBC counts and flow cytometric CD34 cell enumeration were 0.850, 0.649 and 0.422 respectively.

Conclusion: As the correlation between the HPC count and flow cytometric CD34 cell enumeration is very strong, we could use HPC count to estimate TTIH and AOHD in HPC (A). The correlation of MNC count with flow cytometric CD34 cell enumeration is good, so at places where advanced automated cell counters are not available, MNC count can serve as a supplementary method to determine TTIH. In a resource constrained country like India where flowcytometers are not available everywhere, HPC could replace or serve as an adjuvant to flow cytometric CD34 cell enumeration.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 2: Comparison of hematocrit change in preterm neonates with birth weight based versus formula based packed red blood cell transfusion

Rajbir Kaur Cheema 1, Ravneet Kaur 1, Suksham Jain 1, Deepak Chawla 1, Gagandeep Kaur 1

Background: Conventionally the packed red blood cell (PRBC) transfusion volume given to neonates is 10 ml/kg to 20 ml/kg. The weight based formulae underestimate the volume of PRBC required to achieve a target hematocrit (Hct) in preterm neonates.

Aim: The study was done to compare the rise in Hct after transfusing PRBC volume calculated either based on body weight or using formula considering Hct of blood bag and Hct of preterm neonates.

Materials and Methods: This prospective study included a total of 56 preterm neonates requiring transfusion for first time having ≤34 weeks of gestational age. Neonates were randomized using block randomization, to receive 15 ml/kg of PRBC transfusion (Group A) or transfusion based on formula (group B). Primary outcome of interest was post transfusion rise in hematocrit. Secondary outcome was effect of transfusion on neonatal morbidities in terms of retinopathy of prematurity, broncho-pulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, periventricular leukomalacia and death.

Results: Baseline variables (birth weight, gestation age, APGAR score and Score of neonatal acute physiology) pretransfusion hemodynamics and hematocrit of the bag were comparable in both groups. Mean volume of PRBC in group A was 18.39±5.16 ml, whereas in group B it was 28.5±7.1 ml, p=0.0001. Group B transfusions had statistically significant change in 24 hrs post transfusion hematocrit. Secondary outcomes were comparable in two groups. Four neonates died in group A and three in group B.

Conclusion: Post transfusion rise in Hct of patient in group B was significant as compared to group A but the need for re-transfusion was not decreased in group B despite transfusion of more volume of blood.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 3: Efficacy of plasma exchange in microangiopathic haemolytic anaemias: Experience from a tertiary care center of north India

Rekha Hans 1, Ratti Ram Sharma 1, Navneet Sharma 1, Surjit Singh 1, Neelam Marwaha 1

Background: Microangiopathic hemolytic anaemia (MAHA) encompasses a spectrum of disorders characterised by widely disseminated thrombosis in small blood vessels resulting in formation of schistocytes and concomitant thrombocytopenia. Plasma exchange (PE) needs to be considered as empirical and urgent life saving therapy in these disorders.

Methods: A retrospective analysis of all PE procedures performed in patients diagnosed as having MAHA done over a period of 9 years (2007-2016). Procedures were done on apheretic device (Cobe spectra, Terumo BCT, Lakewood Co. USA). Patients’ pre and post procedural hematological and renal parameters were analyzed by applying paired T test.

Results: PE was performed in 46 patients with diagnosis of MAHA (27- aHUS, 16 -TTP, 1 each of post stem cell transplantation drug induced thrombotic microangiopathy (TMA), post thyroidectomy TMA and post-partum TMA). The mean age of patient was 19.94±19.58 years with M:F as 1.5:1. Number of procedures per patient varied from 1 to 27. Post PE recovery was observed within 10-14 days with statistically significant increase in mean platelet count from 40.05±5.9 to 82.11±12.10 x103/μl (P=0.000) and significant decline in mean lactate dehydrogenase level from 2928.86±2079.92 to 657.20±388.76 IU/l (P=0.000). There was also significant decline in mean percentage of schistocytes in peripheral smear from 5.44±3.96% to 0.56±0.89% (P=0.000). The mean serum urea changed from 136.92±68.79 to 68.63±49.81 mg/dl and creatinine from 3.49±1.87 to 2.27±1.67 mg/dl (P=0.000 and 0.001 respectively) with significant increase in urine output from 0.71±0.53 to 1.06±0.33 ml/kg/hour (P=0.000). Adverse events were observed in 10 patients (21%), allergic reaction to replacement fluid (n=6) being the commonest followed by hypotension (n=2), rigors and chills (n=2). Overall survival rate at 6 months was 89%.

Conclusion: TPE had proven its usefulness as life-saving first line treatment modality in MAHA.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 4: Can we predict optimal timing of peripheral blood stem cells based on mononuclear cell count and preharvest CD34 count?

Rajeshwari Basavanna 1, Anitha Karani 1, Anand Deshpande 1

Background: Peripheral blood stem cell harvesting is most commonly used and preferred approach for stem cell collection for bone marrow transplant procedures. Many factors can influence stem cell mobilization and post-harvest CD34 count yield. To ensure that adequate CD34 cells are harvested, many parameters such as pre-harvest WBC count, platelet count, mononuclear cell and pre-harvest CD34 count are considered as predictive factors.

Aim: To correlate the predictive value of MNC count and pre-harvest CD34 count in obtaining sufficient post CD34 cell count and to review the impact of these parameters on the timing of the procedure.

Results: In this prospective study, 68 stem cell harvesting procedure were done on 47 donors/patients. Amongst them 36 were male and 11 females with an age range of 9-65 years (median:50). Autologous procedures were 34 and allogeneic procedures were 13. The diseases treated included Hodgkin's lymphoma (13), multiple myeloma (15) and non-Hodgkin's lymphoma (5). Of the 68 harvesting procedures done, adequate yield of CD34 cells (>3.0 x 106/kg) were obtained in 32 patients/donors by one procedure while 10, 4 and 1 patients required additional 2, 3 and 4 procedures respectively to obtain the same. Preharvest CD34 count was found to be most useful predictor of CD34 yield (Pearson correlation coefficient: 0.80) as compared to the preharvest MNC count (0.36). When the pre-harvest CD34 counts were >30/ul, the success rate of the procedure was 96% (26/27 procedures had adequate yield). Pre-harvest CD34 counts of 20-30/ul and <20/ul had successful yields in 37% (3/8) and 0%(0/24) respectively. 13 procedures were postponed in view of CD34 <10/uL.

Conclusion: Preharvest CD34 count is highly predictive of successfully harvesting adequate CD34 cells for BMT procedures. This can be reliably used to decide the timing of the stem cell harvesting as well as predict postharvest CD34 yield.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 5: Autologous platelet rich plasma for regenerative prolotherapy in chronic musculo-skeletal pain

Vinu Rajendran 1, Debasish Gupta 1, Rupa Sreedhar 1, Subin Sukesan 1

Background: Autologous Platelet Rich Plasma (PRP) when injected into injured tissues will release growth factors due to the activation of platelets which in turn promotes regeneration of tissues. PRP prolotherapy may open a gate of relief for those patients who are suffering from chronic musculo-skeletal pain.

Aims: To assess the effectiveness of Autologous PRP regenerative therapy on symptomatic pain relief and improvement of functional activity in patients with chronic musculo-skeletal pain.

Methods: This was a pre-post interventional study. Same participant acted as both control arm and test arm. Pre-procedural period was taken as control arm and post-procedural period was taken as test arm. 22 patients with chronic musculoskeletal pain were recruited. Visual Analogue Score (VAS) for pain and Functional Improvement Scoring (FIS) for activity were analyzed. Patients were given PRP prolotherapy at the diseased site and were followed up at the end of 2 weeks, 4 weeks, and 12 weeks. Pre and Post intervention data was analyzed and compared.

Results: There was significant improvement in VAS at 2 weeks, 4 weeks and 12 weeks following intervention. Improvement in FIS, sleep, mood and quality of life at 2 weeks, 4 weeks and 12 weeks was also noticed. Improvement in pain and functional activity was maximum at 4 weeks and started declining before 12 weeks following prolotherapy. There were no local or systemic adverse events following intervention.

Conclusion: Autologous PRP prolotherapy is found to have significant effect on pain relief in patients with chronic musculo-skeletal pain. It is also found to improve functional activity in these patients. It offers a curative approach rather than symptom relief and may help to delay or avoid surgical interventions. Repeat procedures after 2 months may be considered for desired therapeutic effect.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 6: Plerixafor use in autologous stem cell mobilization: Experience from tertiary care center of south India

Soumya Das 1,2, Smita Kayal 1,2, Abhishekh Basavarajegowda 1,2, Biswajit Dubashi 1,2

Background: Plerixafor (AMD3100) is approved for patients who show inadequate mobilization of CD34+ PBSCs. No such studies had been conducted in our institute evaluating the usage of Plerixafor for mobilization in autologous hematopoetic stem cell collection. The purpose of this study is to observe the overall profile of the patient's receiving the plerixafor and response to the same.

Methods: Patients who underwent autologous Hematopoietic Stem Cell Collection (aHSCC) using mobilization regime with plerixafor were reviewed from Jan, 2013 to Dec, 2017. An audit of the total no. of patients undergoing mobilization with plerixafor was assessed based on the clinical and laboratory parameters. Also the number of collection days required to obtain sufficient cells for indicated aHSCC and time to neutrophil and platelet engraftment following transplant to assess the quality of the stem cell harvested.

Results: Over last 5 years, a total of 78 patients had undergone aHSCC requiring 110 collections by apheresis technology. Out of which 22 patients (28%) required plerixafor to augment stem cell yield with a median age of 37.5 years (Range 14 – 65 years) requiring 33 apheresis collection. Among them 19 patients required plerixafor at the upfront, due to various reasons age >60 years (n=2), progressive disease (n=5), severe BM involvement (n=4), previous chemo- and/or radiotherapy (n=5), and chemotherapy affecting bone marrow (n=6). Among the upfront plerixafor group, 63% (n=12) patients successfully harvested with one collection with a CD34+ cell count of 2.6 X 106/kg. Remaining required two or more to complete the harvest with a CD34+ cell count of 1.7 X 106/kg. Among the remaining 21 patients who underwent the transplant, median number of days to polymorphonuclear leukocyte and platelet engraftment was 10.5 and 13.0, respectively.

Conclusion: Plerixafor was generally well tolerated. Mobilization of PB CD34+ cells was consistent with previous clinical trials.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 7: To evaluate the impact of plateletpheresis on hemostatic system in healthy donors

Arvind Kumar Yadav 1, Bhushan Asthana 1, RS Mallhi 1, Neerja Kushwaha 1, Amit Biswas 1

Background: Provision of Platelets for component therapy, assumes challenging proportions during war/mass casualty scenarios due to inherent logistic constraints of transporting platelets over long distances while ensuring short shelf life of 5 days and constant agitation enroute. One way to handle this issue is by performing plateletpheresis at the remote location itself from available donors, mostly healthy soldiers nearby. However, knowledge of effects of the procedure on hemostatic system of the donor following plateletpheresis is scarce.

Aim: To evaluate the hemostatic system, prior to and 24 hours after plateletpheresis and whether it poses any significant risk of hemorrhage to the donor (soldier) post procedure, on his subsequent injury, if any, in the combat/disaster zone.

Methods: 102 voluntary male donors were included in the study. Blood samples were collected before and 24 hours after plateletpheresis and were evaluated for platelet count, PT, APTT, TT, Fibrinogen, Factor V, VII, VIII, IX, X, vWF, AT, Protein C & Protein S using automated analyzers.

Results: All measured values were expressed as mean ± standard deviation and analyzed using a paired t-test, with level of significance, p < 0.05. Mean age of the donors was 25 ± 7 years. Following plateletpheresis, platelet count decreased from 267.8 x 109/L to 235.9 x109/L. Statistically significant prolongation of PT, APTT and TT was observed. Except Factor VII, VIII and vWF, all other factors showed statistically significant reduction in values. However, the reduced values were still within normal physiologic limits.

Conclusion: This study confirms that plateletpheresis does not significantly jeopardizes the haemostatic system of the donor, post procedurally, since the reduced values of several coagulation parameters still fall within normal physiological limits. Thus, a soldier can safely perform the duties of a combatant, 24 hours after plateletpheresis. Furthermore, the concept of “walking blood bank” can also be extrapolated for plateletpheresis.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 8: Donor granulocytapheresis collection at a tertiary care centre of northern India: Our experience

Divjot Singh Lamba 1,2, Satya Prakash 2, Rekha Hans 2, Ratti Ram Sharma 2, Neelam Marwaha 2

Background: Severe bacterial and fungal infection remains a persistent cause of morbidity and mortality in severely neutropenichemato-oncological patients.

Aim: To support severely neutropenic patients having life-threatening infections with granulocyte transfusions until successful resolution or hematopoietic reconstitution.

Methods: We present our experience on donor granulocytapheresis for 34 patients over a period of 9 years from 2010 to 2018. A total of 95 procedures were done in this period. Granulocyte collection was performed on donors fulfilling the donation criteria as per DGHS Technical Manual 2003. Donors were given G-CSF, 12 hours prior along with oral dexamethasone. Collection was done in Cobe-Spectra (Terumo BCT) using WBC kit.

Results: Donor and product profile – A total of 95 donors donated the units with median age of 26 years (IQR 23 – 31) without any adverse events. The median donor pre-hemoglobin was 14.6g/dl (IQR 13.9 to 15.4), and median pre-WBC count was 32300/ul (IQR 28000 – 37000). The median blood volume processed was 8000 ml (IQR 7000 - 9000) yielding a median TLC of 2.3 x 10^10/ unit (IQR 1.6 - 3.2) with a median granulocyte yield of 1.5 x 10^10/ unit (IQR 1.0 – 2.1). Patient profile – Products were transfused to a total of 34 hemato-oncological patients (M:F = 22:12). Median pre TLC count was 600/ul (IQR 300 – 800) and pre ANC was 80/ul (IQR 37 – 221). Post transfusion TLC was 600/ul (IQR 500 – 1000) and post ANC was 110/ul (IQR 39 – 292.5). Significant increase in TLC was observed after transfusion (p value < 0.043). 82.4% patients (28/34) recovered from underlying infection with rise in ANC > 500/ul.

Conclusion: Donor granulocytapheresis is safe and clinically useful adjunct in management of severely neutropenichemato-oncological patients not responding to antibiotics and antifungals.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 9: Effect of donor variables on yield in single donor plateletpheresis by haemonetics MCS plus

Ishan Joshi 1, Amit Sharma 1, RachanaNarain 1, Sunita Bundas 1, BS Meena 1

Background: Apheresis is a Greek word that means to separate or remove. In apheresis blood is withdrawn from a donor or patient in anticoagulant solution and separated into components. This study was planned to investigate the influence of donor demographic and laboratory factors on platelet yield.

Methods: The study included 100 healthy, plateletpheresis donors. All the donors were selected according to the guidelines laid down by Drugs and Cosmetics Act.8 Details of plateletpheresis were explained to each donor who gave due consent before the procedure. All donations were performed by Haemonetics MCS plus apheresis machine.

Results: The mean platelet yield was 3.16 ± 0.62 x 1011; 71 donors gave a platelet yield of more than 3 x 1011 per unit. Haemoglobin level was more than 14 g/dL in 85 donors. The mean BMI was 29.4±0.86 Kg/m2. A positive correlation was observed between pre donation platelet count and platelet yield (r = 0.284, p<0.01) and a negative correlation was observed between age (years) and platelet yield (r = –0.229, p<0.01) but no such correlation was noticed between platelet yield and haemoglobin (0.052), haematocrit (r = – 0.011), or blood group (r = – 0.098) of the donor. A positive correlation was also observed between BMI and platelet yield (r = 0.257, p<0.01).

Discussion: There are very few studies related to donor clinical and laboratory factors that may influence number of platelet yield. Identification of these factors would allow for better selection of donors resulting in higher platelet yield and consequently a lower number of donor exposures to the patients. Our study showed a significant negative correlation between the donor age and platelet yield (r = –0.229, p<0.01) but no such observation was reported in another study.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 10: Role of estimating serum ferritin levels in a repeated voluntary blood donor –Haemovigilance

Nishi Jaswal 1, Rakesh Jaswal 2

Background: It is seen that repeated blood donations can cause iron deficient anaemia in the voluntary blood donors. A study was conducted to estimate the serum ferritin levels among voluntary blood donors with different frequency of donations and compared with haemoglobin and haematocrit levels.

Methods: A cross-sectional study was conducted in 435 donors with different frequency of blood donation. The control group donated for the first time and the study group donated once, twice, thrice or four times in a year. The red cell parameters were measured by automatic cell count and estimation of serum ferritin was done by ELISA method.

Results: There were 86.20 % males and 13.79 % females. All the donors were included in the study. The distribution of donors was on the basis of the frequency of donation in a year. The first time donors were taken as controls which were 50.57 percent. The study groups were donors who donated once (28.5 %), twice (11.59%), thrice (6.43%) and four times (2.52%) in a year. A statistically significant correlation was seen between frequency of donation and serum ferritin levels. Distribution on the basis of number of donations per year and serum ferritin <15 ng/ml in the donors were 4.54 % in first time, 16.12% in once a year, 19.23 % in twice a year 28.57% in thrice year and 36.36 % in four times a year donations.

Conclusions: In our study, there was a definite correlation between serum ferritin levels and the frequency of blood donation in voluntary blood donors. Our study suggests that estimation of serum ferritin level is a mandatory tool for haemovigilance in the donors. We recommend iron supplementation and donor health education programme based on balanced nutritious diet for all donors.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 11: Extent of changes in pre donation and postdonation donor variables in single and double dose plateletpheresis and its implications on donor safety

Sreedevi Rajeswaran 1, N Rajakumar 1

Background: Proper selection of donors with good predonation platelet count is essential for achieving the optimal platelet yield in single donor plateletpheresis. Double dose plateletpheresis procedures are commonly done nowadays to reduce the immunogenicity and cost of the product.

Aim: The aim of this study was to assess the donor safety as this is an important area of concern in plateletpheresis.

Methods: 45 plateletpheresis procedures were done with COBE Spectra continuous flow cell separator. Statistical analysis was done to find out whether there was significant difference between pre and post donation donor hematological values after single and double dose collection.

Results: Average platelet yield achieved in single dose plateletpheresis was 3.4 +/- 0.28 X 10 11 platelets per unit. Mean pre-and post-donation platelet counts were 273,000/μL and 209,000/μLrespectively, mean Hb decreased slightly from 14.76 g/dL to 14.11 g/dL, mean red cell count was unchanged, whereas mean WBC counts dropped from 6543/μL to 6120/μL. Mean Hct decreased slightly from 44.7% to 44.2%, Double yield was collected in 16 procedures. Donors with preplatelet count >300,000/μl were subjected to double yield collection. Average yield achieved was 6.28 +/- 0.18 x 10 11 platelets. Mean post donation TPC was 167,000/μl, and no one had value <100,000/μl. WBC, RBC, HB, and HCT had similar trends as of single yield collection. Even though there was significant drop in donor platelet count after both single and double dose platelet collection, plateletpheresis procedure is relatively safe with no adverse effect.

Conclusion: Guidelines for high dose platelet collection should be individualized according to each transfusion medicine department's policy and need with special concern to donor safety and product quality. Post donation hematological parameters should be monitored in all those donors who are undergoing regular and high dose plateletpheresis for donor safety and to maintain optimal donor pool for plateletpheresis.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 12: Comparative study of adverse donor events in voluntary and replacement whole blood donors: Need of robust donor hemovigilance program

Lubna Naseer 1, Vijay Sawhney 1, Neeti Dutt 1

Background: Adverse donor reactions can lead to negative impact on donor retention in the time when need of blood transfusion is soaring up all over the world.

Aim: The aim of this study was to compare the frequency and severity of Adverse Events in voluntary and replacement whole blood donors.

Methods: A single centre retrospective study of all adverse donor events was conducted at Transfusion Medicine Department of Government Medical College, Jammu over a period of 1 year from April 2017 to March 2018. Selected donors were observed during and following donation for any adverse events. Blood donors were asked to report for any delayed adverse events.

Results: The overall reaction rate was 3.65% (641 out of 17527 donations) with higher rate in replacement donors (3.93%) than in voluntary donors (3.2%), in female donors (6.8%) than in male donors (3.6%). Most common type of reaction in both replacement and voluntary blood donors was mild vasovagal type (486 out of 641). Vasovagal reactions included dizziness in 312, fall in 51, injury due to fall in 2, pallor and perspiration in 402, palpitation in 8, chest tightness in 201, bladder incontinence in 1, nausea in 384, Vomiting in 12. Hematoma bruising in 115, Nerve injury in 7, Convulsions in 5 male donors, irritation due to skin preparation in 28 blood donors. Vasovagal type of reactions were seen more in females, low age and thin built, replacement donors, donors with fear and anxiety.

Conclusion: This study has increased our knowledge of risk factors associated with blood donation. And provided an insight into the importance of voluntary donation and need to increase the same and highlighting the need for specific guidelines for the management of higher risk donor groups.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 13: Comparative study of commercial and in-house prepared low ionic strength salt solution in a tertiary care hospital

Chhaya Keny 1, Darshan Adulkar 1

Background: Enhancing agents are used in Immunohematology techniques to potentiate antigen antibody reaction by reducing the net negative charge on the surface of red cells. Low Ionic Strength Salt Solution (LISS), Albumin, Polyethelene Glycol (PEG), Polybromide are few examples of enhancing agents. In our set up LISS is used as enhancing agent in immunological testing. LISS contain 0.2% sodium chloride, which results in an increased rate and degree of antibody uptake two to four times as compared to normal saline during sensitisation with an incubation time of 15 minutes.

Aims: The present study aims to compare serological and non-serological parameters of commercial and in-house prepared LISS. If results are comparable, in-house prepared LISS can be used for routine Immunohematology testing.

Methods: A total of 10000 samples were screened over a period of 4 months from April 2018 to July 2018 in Department of Transfusion Medicine, KEM hospital, Mumbai. Antibody screening was done by conventional tube technique (CTT) using pooled ‘O’ cells (In-house). Quality Control of In-house prepared LISS was done using following parameters. Nonserological parameters: Conductivity (3.6-3.7mmho/cm), Osmolarity (270-285 mmol). Serological parameters: Test for Hemolysis, Titer of AntiD (IgG). Results were compared with commercial LISS (Diamed GmbH Switzerland), and found comparable.

Conclusion: In-house prepared LISS had comparable results with commercial LISS. It is a cost effective alternative to use in routine immunohematological test procedures.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 14: Prediction of outcome in ABO incompatible neonates with respect to maternal Ig-G anti-A and anti-B titre in O group mothers

Shahida Noushad 1, D Meena 2, N Sasikala 1

Background: The fetus may inherit father's blood group whose antigen on red cells has corresponding antibodies in the mother resulting in maternal-fetal blood group incompatibility. As the incidence of Rh D alloimmunization has decreased after the introduction of anti-D prophylaxis, ABO-incompatibility is now the major cause of immune haemolytic disease of the newborn. Problems encountered from ABO maternal antibodies to the corresponding A or B antigens on the fetal red cells stimulated this study.

Aims: To evaluate predictors for risk of hyperbilirubinaemia in ABO-incompatible neonates with emphasize on maternal IgG anti-A/-B titres and to assess if maternal antibodies were associated with increased duration of phototherapy or repeated invasive treatment with IVIG or EXT.

Methods: Blood group O women admitted for labour at T.D. MCH, Alappuzha, from Jan 2017 to Jun 2018 were included. Offspring with blood group A or B had direct antiglobulin test performed and IgG anti-A/ -B levels measured in maternal plasma. Blood group A or B infants developing severe hyperbilirubinaemia, receivng phototherapy, immunoglobulin treatment or exchange transfusion were also noted.

Results: Of the 200 ABO incompatible pairs, 99 were O-A (49.5%) and 101 were O-B (51.5%). Maternal antibody-titres were significant predictor for hyperbilirubinemia (p<0.000), positive DAT (p<0.000), signs of hemolysis (p<0.000) and ICU admission. Ten neonates with blood group A or B received at least one immunoglobulin treatment and 2 received exchange transfusion. The need for invasive treatment (IVIG ± EXT) increased sharply for antibody titres ≥256 by tube technique.

Conclusion: Maternal IgG anti-A/-B titres contribute to the prediction of risk of severe hyperbilirubinaemia in ABO-incompatible neonates, in addition to blood-grouping and DAT testing.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 15: Significance of detection and resolution of blood group discrepancies

Sazia Samir 1, Ashish Jain 1, Neelam Marwaha 1, RR Sharma 1

Background: ABO discrepancies occur when the reactions in forward grouping are not corroborative to those in the reverse grouping which may be due to weak subgroups of A and B, missing or weak ABO antibodies or unexpected alloantibodies.

Aim: To determine the frequency of ABO discrepancies and their resolution to correctly identify the blood group of the donors.

Methods: This was a retrospective study on donor samples collected from 1st April, 2013 to 30th September, 2015 (two and a half years). For discrepant samples, the ABO and RhD grouping was repeated using tube technique using commercial antisera {anti-A, anti-B, anti-AB and anti-D, anti-D blend (IgM+IgG), anti-H anti-A1 lectins}. Adsorption-elution testing was done for detecting weak subgroups of A and B. Antibody screen (3-cell) and identification (11-cell) was done by gel technique (Bio-Rad, Switzerland).

Results: We detected 104 (0.072%) ABO discrepancies out of the total 144279 donor samples tested. Out of these, 135043 (93.6%) were RhD positive. The causes of ABO discrepancies were weak anti-B antibody (33/104; 31.73%), weak anti-A antibody and weak subgroups of A (24 each; 23.07% each) and weak subgroups of B (5/104; 4.8%). We found agglutination with O cells in 18 (17.3%) samples and 7 (38.88%) of them showed agglutination either at room temperature only or by an IAT as well and were RhD positive. The alloantibodies identified were anti-M in 5 donors and anti-Lea in 1, while the remaining 1 was ‘Bombay’ (Oh) phenotype. Among the 9236 (6.4%) RhD negative donors, the indirect antiglobulin test (IAT) was positive in 11 (0.12%) and the alloantibodies identified were anti-D (7), anti-D with anti-C (2), anti-D with anti-E (1) and anti-N (1).

Conclusion: The frequency of ABO discrepancies in our donor population is 0.072%. The presence of clinically significant antibodies re-emphasizes the testing with O cells during blood grouping.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 16: Comparison of ABO antibody titres by tube and column agglutination methods

Sabita Basu 1, Mahua Reddy 1, Debapriya Basu 1

Background: Outcome in ABO incompatible transplant is influenced by ABO antibody titers. Antibody titers determine the need for intervention in hemolytic disease of the newborn. Inter-laboratory variation in titration resultsis known to occur. This study was conducted to assess the conventional tube technique (CTT) and column agglutination technique (CAT) for antibody titration.

Aims: To compare the CTT with CAT for antibody titration. To assess IgM interference (if any) in IgG antibody estimation.

Methods: Twenty voluntary blood donors, each from blood group A, B and O were assessed for anti A and anti B antibody titers. A total of 80 titers were assessed, each for IgM and IgG (with and without IgM inactivation) by both CTT and CAT (Ortho BioVue system). Dithiothrietol (DTT) treatment was used for IgM inactivation. Results were analysed by applying wilcoxin rank sum test.

Results: IgM titer was more than IgG titer (with DTT treatment), for groups A, B, O (p<0.001). Higher titers were obtained by CAT as compared to the CTT method. IgG antibody titer with DTT treatment was less than IgG titer without DTT treatment, by both CAT and CTT methods (statistically very significant). The high IgG titers of non-DTT treated plasma wasnotedeven when using monospecific IgG AHG cards. The IgM and IgG titers (with and without DTT) amongst the three blood groups by CTT and CAT were: group O > A>B.

Conclusion: The study revealed that DTT treatment significantly reduced IgG titers by both CTT and CAT methods. IgM interfered with IgG estimation by CTTand also when mono-specific IgG card was used. Antibody titers by CAT were higher than by tube method. Variation in results due to different titration methods and whether IgM inactivation was done; could lead to inter-laboratory variation in results.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 17: Molecular characterization of rare D--/D-- variants in individuals of Indian origin

Swati Kulkarni 1, K Vasantha 1, Harita Gogri 1, Disha Parchure 1, Manisha Madkaikar 1

Background: The Rh system is the most polymorphic and immunogenic protein based blood group system with five main antigens: D, C, c, E, e. Rh antigens are of clinical importance because of their role in HDFN and HTR. Unusual Rh phenotypes such as Rhnull and D-- are rarely encountered in routine testing. D-- phenotype is a rare blood group characterized by the lack of expression of C, c, E and e on the red cells because of mutations in both alleles of the RHCE gene. The D antigen expression is exalted (up to 2,00,000 D antigenic sites per RBC) to the extent that IgG anti-D can agglutinate the RBCs in saline. Such individuals show presence of anti-Rh17 or anti-Hro.

Aim: To determine the molecular basis of D-- individuals (n=5) of Indian origin.

Methods: Five RhD positive postnatal women who had produced antibodies against all Rh antigens except D, leading to HDFN and fetal loss were referred to ICMR-NIIH for further evaluation. Extensive serological and molecular analysis was carried out.

Results: Serological testing with anti-C, anti-c, anti-E, and anti-e showed absence of C, c, E and e antigens, thus identifying the rare Rh variant as D--/D--. Flow cytometry confirmed absence of these antigens with exhalted expression of D antigen. Antibody screening and identification showed presence of anti-Rh 17. Molecular analysis by QMPSF showed gene conversion event between RHCE and RHD causing D-- phenotype. Most common hybrid was found to be RHCE-D (3-9)-CE followed by RHCE-D (3-8)-CE and RHCE-D (2-6)-CE.

Conclusion: This is the first study reporting molecular mechanism of D-- phenotype in Indian population. Identification of RHCE-null variants facilitates confirmation of D-- phenotypes in patients and donors, helping improve transfusion safety.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 18: Phenotype frequency of Rh and kell antigens among the blood donors of north India: A study on 21,000 donor samples

Prashant Pandey 1, Mukesh Kumar 1, Nitin Agarwal 1, Dharmender Kumar 1, Shweta Ranjan 1

Background: The Rh & Kell blood group system is the next most highly immunogenic blood group systems to ABO blood group system. Among all the minor blood group systems prevalence of alloimmunization is found to be highest against Rh & Kell antigens. This study was carried out with the aim to determine the phenotype frequency of Rh and Kell antigens in north Indian population.

Methods: During four years (May 2014 and June 2018) a total of 21000 blood donor samples tested for Rh (D, C, E, c, e) and Kell (K) antigens. The Rh & Kell antigen typing of donors was performed by hem-agglutination method (NEO, Gamma Immucor, USA). Monoclonal IgM antisera were used (Immucor Inc. Norcross, GA. US).

Results: There were a total of 21000 healthy blood donors samples which were tested for D, C, E, c, e & Kell(K) antigens. The most common Rh antigen observed in the study population was ‘e’ (98.88%) followed by ‘D’ (91.24%), ‘C’ (85.58%), ‘c’ (58.76%) and ‘E’ (18.47%). The frequency of the Kell antigen (K) was (2.79 %). According to nomenclature, the most common frequency observed was R1R1 (41.1%). The second commonest frequency observed was R1r (31.94%). Remaining were as follows: R1R2 (11.76%), R2r (5.25%), R2R2 (1.09%), R1Rz (0.1%), rr (7.81%), r’r (0.65%), r”r (0.27), r’r’ (0.03%). A rare phenotype r’r’ was found in one donor. Thus, phenotypically R1R1 (DCCee) group was the most common phenotype and r’r’ (dCCee) was least common.

Conclusion: Antigen typing and transfusion ABO and other 18 antigens is practically next to impossible and do not seem practical. But, typing and transfusion of Rh and Kell phenotype matched blood have been proven to be a good practical approach for transfusion especially among mutitransfused patients. Thus, In modern transfusion era, providing Rh and Kell phenotype matched blood can prevent alloimmunization to a large extent.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 19: A prospective observational study to analyse factors influencing plateletpheresis yields and posttransfusion platelet recovery

Swapnil Rai 1, Jayashree Sharma 1, Swarupa Bhagwat 1

Background: The currently observed sharp increase in demand of apheresis platelets has prioritized need for harvesting maximum platelet yield from donors and promoting optimum post-transfusion platelet recovery among patients.

Aims: (1) To evaluate donor parameters influencing plateletpheresis yields. (2) To compare mean 1 hour post-transfusion platelet increment, CCI (Corrected Count Increment) and PPR (Percent Platelet Recovery) among ABO identical, major incompatible, minor incompatible and bidirectional incompatible transfusions. (3) To determine incidence of platelet refractoriness. (4) To evaluate patient and product factors influencing CCI.

Methods: A prospective observational study of 15 months duration was conducted in Department of Transfusion Medicine at a tertiary care hospital. Eligible 200 plateletpheresis donors and 98 patients receiving those 200 platelet transfusions were enrolled and evaluated. P<0.05 was considered statistically significant.

Results: Pre-donation platelet count correlated positively; whereas MPV (mean platelet volume) and PDW (platelet distribution width) correlated negatively with platelet yield. Mean 1 hour post-transfusion platelet increment, CCI and PPR were 24 ± 11 x103/μL, 10631 ± 4765 and 27.76 ± 12.73% respectively. ABO identical platelet transfusions resulted in significantly higher mean platelet increments, CCI and PPR as compared to ABO major and bidirectional incompatible transfusions No significant difference in mean platelet increments, CCI and PPR was found between ABO identical and minor incompatible transfusions. Incidence of platelet refractoriness was 13.79%. Transfusion of 4 to 5 day old platelets were more likely to result in CCI <7500 as compared to 0 to 1 day old platelets. Patient with cardiac or other diagnosis were less likely to have CCI <7500 as compared to haematological diseases. CCI <7500 was more likely in presence of one or more non-immune patient factors (fever, bleeding, infection, sepsis, splenomegaly, disseminated intravascular coagulopathy).

Conclusion: Consideration of these significant factors can aid in implementation of efficacious platelet transfusion therapy, through coordination between clinicians and transfusion medicine specialists.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 20: Role of solid-phase platelet crossmatch in diagnosis of foetal neonatal allo-immune thrombocytopenia: A case series

P Amal Raj 1, Srivalli 1, Dolly Daniel 1

Introduction: Foetal and neonatal allo-immune thrombocytopenia (FNAIT) is major life-threatening condition which challenges clinicians. Early diagnosis of FNAIT would allow better outcomes with advent of newer treatment options like IVIG. With the current cost, HPA- typing, anti-HPA antibody detection and confirmation poses a financial challenge. The platelet cross-match using the solid phase red cell adherence (SPRCA) technique appears to be an interim solution for the diagnosis and management of FNAIT despite the inherent limitation of sensitivity. This case series describes 6 consecutive cases referred with a clinical suspicion of FNAIT.

Methods: For all 6 cases platelet crossmatch (PCXM) was performed using SPRCA technique using maternal plasma and paternal platelets. In the event of platelet transfusion requirement, PCXM was performed with maternal plasma and RDPs. Patients tested included 2 antenatal mothers with scans showing foetal intracranial haemorrhage, one with a previous history of NAIT, two infants aged 2 and 3 months with history of malena and one 7 day old neonate with history of per vaginal and umbilical bleeding. The latter had a normal coagulation profile with thrombocytopenia. All patients had a negative TORCH screen and normal maternal platelet count.

Results: All 3 antenatal mothers showed positive PCXM with paternal platelets. However, the two infants and the neonate showed negative PCXM with paternal platelets. Two of these who required platelet transfusion were found to have positive PCXM with RDPs.

Conclusion: PCXM proved to have the potential to diagnose FNAIT in the 3 antenatal patients tested. It might not be incorrect to conclude that FNAIT could be excluded in the 3 infants tested, given the negative PCXM, unusual time of presentation and a possibility of a multifactorial etiology for the thrombocytopenia and bleeding symptoms. However we acknowledge that the final diagnosis of FNAIT will require sensitive platforms for antiplatelet antibody screening and concomitant HPA-typing.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 21: Clinical outcome of neonates based on the age of red blood cells transfused – A prospective study

Lekshmi Sudev 1, Susheela Jacob Innah 1, Aboobacker Mohamed Rafi 1

Background: Red cell transfusion forms an important aspect of treatment administered to neonates in Neonatal ICU. Usual indication is to maintain desired hematocrit level in severely ill neonates and to treat symptomatic anemia in stable infants. Well characterized biochemical, structural, metabolic and physiologic changes occur within RBC during storage known as red cell storage lesion which affects effective oxygen delivery by transfused cells.

Aim: To assess association between age of red cells transfused and clinical outcome (lab parameters, oxygen requirement, intensive care requirement, hospital stay) among neonates.

Methodology: Depending on age of red cells transfused, clinical course in terms of laboratory parameters (Hb, HCT), oxygen requirement (FiO2), intensive care requirement and hospital stay are evaluated on days 1, 2, 3 and 4 following transfusion.

Results: Among 86 neonates, 23 (26.7%) had average increase in Hb and HCT. Majority were transfused with 0 day old blood followed by one day old blood. Neonates transfused with 3, 4 and 5 days old blood did not have an average increase in Hb& HCT. Decrease in oxygen requirement (FiO2) was also pronounced after transfusion with 0 day old blood followed by 1 day old blood. Statistical significance of morbidity outcomes (NEC, BPD, IVH) and mortality with regard to age of red cells could not be assessed. Incidence of neonatal transfusion reactions is nil and all transfusions were guideline based.

Conclusion: Study is in favor of transfusion of fresh red cells (<24 hours) to neonates especially preterm for a better clinical outcome with respect to increment in Hemoglobin and Hematocrit which in turn leads to better oxygenation and decrease in additional oxygen requirement during hospital stay. However gestational age at birth does have a significant impact on outcome with extreme prematurity itself being a significant factor contributing to the morbidity and mortality.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 22: Role of automated red cell exchange in methaemoglobinemia – Our center study

Paresh Vyasa 1, Chirag Shah 1

Background: Two cases of methaemoglobinemia where RBCX were done as a life saving procedure since first line of treatment methylene blue was contraindicated.

Case 1: Patient was 25 yrs old doctor who had P. Vivax malaria, took chloroquin for 3 days, started having weakness and breathing difficulty, shifted to ICU due to desaturation and breathing problem. On admission pulse 140/min, B.P. 84/70 mmHg, SPO270 % and cyanosis was present. On investigation found to be G-6PD deficiency. RBCX done since MB was contraindicated.

Case 2: Patient with h/o high grade fever since 5days, vomiting, oliguria having done 2 dialysis locally. On admission patient was tachypnic, hypoxic having cyanosis and pallor. On investigation Hb <5 gm %, altered RFT& LFT, high methaemoglobin and urine myoglobin. Since patient was having AKI, RBCX along with hemodialysis done.

Aim: To improve the tissue hypoxia by replacing red cells having methaemoglobin with simultaneous normal red cells infusion.

Methods: Automated red cell exchange done from central line access with the help of compatible leucodepleted red cell units. In both the cases, custom prime done with red cells. Isovolemic exchange was targeted. FCR were aimed to keep <50% and Hct at >30%. The whole procedures were done guarded and slowly as patients were on BiPaP and Norad infusion pump.

Results: In both cases, immediate post procedure SPO2 was significantly improved from 64% to 90% and 70% to 92% respectively.

Conclusion: These two cases calls for a heightened awareness of RBCX as a life saving procedure where first line of treatment is not possible.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 23: Therapeutic immunoadsorption and conventional plasma exchange: An exculpatory evidence

Soma Agrawal 1, Mohit Chowdhry 1, Sweta Nayak 2, Shiva Prasad Gajulapalli 1

Aim: To compare efficacy of immunoadsorption (IA) with conventional therapeutic plasma-exchange (cTPE) in ABO-incompatible (ABOi) renal transplant.

Methods: A prospective study was conducted for patients undergoing ABOi renal transplant from July-2015 to June-2017 (category-1, N=11) (IA±cTPE). Their data on rituximab conditioning, average length of stay (ALOS), number of cTPE/IA, antibody titers (AT), creatinine at discharge, patient and graft survival at 1 year were compared retrospectively with similar patients in period from February-2012 to June-2015 (category-2, N=29) (cTPE only). AT of patients started on cTPE (category 1) not decreasing to < 1 fold after 2 cTPE were shifted for IA. AT was determined at baseline, after each cTPE and daily till discharge. For patients undergoing IA, real time AT was done and IA stopped once the target titer (TT <1:8) was achieved. Post-transplant cTPE was done if, titers rebounded (≥1: 8). Intravenous- immunoglobulin (IVIG) was given after every cTPE/IA. For comparing costs, the procedure, IVIG and bed charges were assessed.

Results: In category-1, 7 patients (63.63%) were shifted to IA from cTPE. Mean cTPE procedures in category 1 and 2 is 3.5±2.4 and 4.8±2.5 respectively (p=0.206). Mean IA procedures in category-1 is 1.6±0.5. Number of patients requiring post-op cTPE was less in category-1 than category-2 i.e. N=5,45.5% vs N=20,69% respectively (p=0.171). Expense of IA in category-1 vscTPE in category-2 was statistically not significant (p=0.422) but had significant lesser ALOS (p=0.044) and rituximab conditioning days (p=0.043). Expenses when patient is undergoing both cTPE and IA (category-1) is significantly higher to category-2 (p=0.003). The two groups were comparable in AT at all times, creatinine value, graft and patient survival rates at 1 year.

Conclusion: Contrary to the general judgment of IA being expensive than cTPE, this study shows equivalent overall expenditures with comparable therapeutic outcomes and improved patient comfort by decreasing ALOS.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 24: Factors affecting the clinical outcome of massive transfusion - A prospective study

Divya Venugopal 1, Susheela J Innah 1, AM Rafi 1, Ramesh Bhaskaran 1

Introduction: Massivehemorrhage calls for massive transfusion (MT) in order to maintain adequate hemostasis. Nowadays Massive Transfusion Protocols (MTP) is the most appropriate treatment strategy.

Aim: To propose an ideal ratio of blood components after evaluating the relationship between ratios of blood components transfused and mortality.

Methods: MT was defined as receiving more than 4 Packed Red Blood Cell (PRBC) units within 1 hour with the anticipation of continued need. All such massively transfused patients above 13 years regardless of the cause of bleed were included in this prospective observational study from Dec-15 to Oct-17 totaling to 61patients. Subgroup categorization done and physician driven ratios were calculated. The ratios were grouped as High (>1), Equal (=1) and Low (<1) Ratios of FFP: PRBC and Platelet: PRBC.

Results and Discussion: 61 patients underwent MT with overall 7- day hospital mortality for patients treated with MTP as 8.1% with 100% mortality observed among penetrating trauma. Emergency admission was independent risk factor for mortality. Hypotension prior to the initiation of MT had a detrimental effect on survival. Efficient communication existed between treating physicians and transfusion medicine services. Majority of survivors received equal ratios of FFP: PRBC & Platelet: PRBC. All non-survivors received low ratios of FFP: PRBC and high ratios of Platelet: PRBC.

Conclusion: Providing a fixed ratio of blood components approximating a ratio of 1:1:1 of PRBC:FFP:Platelet during massive transfusion is associated with lower mortality in the present study. The need of the hour is prospective randomized trials & compliance to protocols.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 25: Correlation of the IgG subclasses with occurrence and severity of hemolytic disease of fetus and new born

Bharat Singh 1, Rahul Katharia 1, Mandakini Pradhan 1, Rajendra Chaudhary 1

Background: Hemolytic disease of fetus and new born (HDFN) is a leading cause of mortality and morbidity in the antenatal and neonatal periods. Maternal alloimmunization against paternal red cell antigens is the most important cause of HDFN. According to literature, HDFN cases with IgG1 and IgG3 have more severity when compared to IgG2 and IgG4. In present study, IgG subclass (IgG1 and IgG3) was identified using column agglutination test to evaluate the prevalence and clinical significance of IgG Subclasses in cases of HDFN. The findings might be helpful in early referral to higher centers and in determining prognosis of the case.

Methods: Fourty-eight alloimmunized (with anti-D alone) antenatal cases were studied. “DAT IgG1/IgG3 ID” card (Bio-Rad) was used in IgG subclass determination. Pregnancy outcome was classified into unaffected or mild/ moderate/ severe HDFN. Subclass prevalence was calculated and HFDN severity was correlated with IgG subclass in the study population.

Results: Subclass distribution among 48 alloimmunized (with anti-D) women was 24% for IgG1, 16.6% for IgG3, 41.6% for IgG1+IgG3 and 14.5% had neither IgG1 nor IgG. HDFN severity was significantly higher when IgG1 was present alone or in combination with IgG3 (p value < 0.01). Disease occurrence and severity was also significantly higher in case of IgG1 or IgG3 present, alone or in combination (p value < 0.01).

Conclusion: The presence of IgG1/IgG3 was significantly related to occurrence and severity of HDFN. Both disease occurrence and severity was significantly lower if neither IgG1 nor IgG3 was present. Therefore, alloimmunized antenatal women with IgG1/IgG3, alone or in combination require close and antenatal monitoring to detect HDFN features at early stage, timely and appropriate referral and intervention. We recommend IgG subclass determination by CAT to predict occurrence and severity of HDFN more accurately.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 26: Impact of iatrogenic blood loss and blood transfusion in critically ill patients

Anu Thomas 1, Susheela J Innah 1, Cherish Paul 1, Aboobacker Mohamed Rafi 1, Nithya M Baiju 1

Background: PRBC transfusions remain a cornerstone of critical care practice, but there is still a point of concern in the risk of anaemia and the benefits of red cell transfusion. Phlebotomy for routine and specialized laboratory investigations in critically ill patients contributes to a mean daily loss of 40 to 70 ml of blood.

Aims: (1) To study the mortality and morbidity of adult general ICU patients who required transfusion. (2) To study the association between length of ICU stay and number of units transfused. (3) To find out the association between volume of sample taken for investigation during ICU stay and the haemoglobin level.

Methods: A prospective observational study conducted in the department of Transfusion Medicine, Jubilee Mission Medical College, Kerala over 22 months in all patients who received transfusions under Critical Care unit. Demographic data and clinical data were recorded along with APACHE II score.

Results: The mean haemoglobin at the time of admission and discharge were 8.89 g/dl and 8.83 g/dl respectively. The mean phlebotomy volume loss during ICU stay was 15.8 + 1.456 ml/day. The mean PRBC units transfused during ICU stay were 3.68+ 2.52 units. Amongst the patients transfused those who received 7-9 units of PRBC had more length of hospital stay (14.50+5.260 days). Mortality (75%) was seen higher amongst those who were transfused with more than 10 units of PRBC.

Conclusion: Current study demonstrated that higher number of PRBC transfusion is associated with prolonged ICU stay and higher iatrogenic blood loss. However, given the risks associated with blood product administration and the intermittent shortage of blood supply, more attention is to be focussed on restrictive transfusion policies and pharmacological strategies to prevent and treat anaemia of critical illness.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 27: Retrospective analysis of massive transfusion practice in nontrauma related hemorrhagic shock in a tertiary care centre

AM Gayathri 1, S Sathyabhama 1, Debasish Gupta 1

Introduction: The desired effect of massive transfusion in critically bleeding patients is to prolong survival in the acute setting, allowing time to perform directed interventions to control the site of bleeding. This study intended to review the transfusion practice and outcomes of a massive transfusion protocol in a non-trauma population.

Aims and Objectives: To analyse retrospectively the massive transfusion practices and resultant outcome of patients over a period of two years.

Materials and Methods: This is a retrospective observational study of all patients who received a massive transfusion protocol for non-traumatic hemorrhagic shock over a two-year period (2016-2017). The primary outcome was in-patient hospital survival. Electronic medical records of 70 non-traumatic patients including both adult and paediatric cases that were admitted and had massive transfusion were assessed. Variables include age, sex, co-morbidities, drug intake, pre-surgical laboratory investigations, diagnosis and nature of surgical procedure, ratio of blood components transfused, post surgical laboratory parameters, period of ICU and hospital stay and recovery index.

Observation and Results: 0.78% of total surgical cases received massive transfusion. The diagnosis of the patient especially associated co-morbidities and the surgical procedure decide the outcome of the patient. All paediatric cases who underwent massive transfusion survived. The mean intra-operative blood product usage (PRBC: FFP: Platelet: Cryoprecipitate) ratio were found to be 2:2:1:1 among paediatric survivors and 7:4:2:2 among adult survivors and non- survivors. Similarly 24-hr post surgical blood usage among paediatric age group was 1:1:1:1 and 2:2:1:1 among adult survivors and 5:3:2:2 among non-survivors. Comparisons between pre and post surgical laboratory parameters were found to be statistically significant.

Conclusion: A revised massive transfusion protocol is mandatory in every surgical speciality in order to have a safe and judicious use of blood products and to have a better outcome and reduced hospital stays.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 28: Autoimmune hemolytic anemia - Laboratory predictors of clinical outcome, response and prognosis

Sanooja Pinki 1, Mathew Thomas 1

Background: The diagnosis of autoimmune hemolytic anemia (AIHA) is based on the clinical presentation and the serological evaluation of the autoantibody. The degree of hemolysis depends on the quantity, specificity, thermal aptitude and ability to fix complement and bind macrophages.

Aims: (1) To find the association between DAT strength and characterization of autoantibodies to in vivo hemolysis. (2) To analyze the trends in pre transfusion testing of AIHA cases. (3) To find the effect of PRBC transfusions in the patient outcome.

Methods: Prospective analysis of AIHA patients over 8 months. Patients with clinical and laboratory evidence of in vivo hemolysis and positive DAT were enrolled. Hemoglobin <9 g/dl, reticulocyte >2%, total serum Bilirubin >2mg/dl, LDH >500 IU/ml were the parameters taken to determine the severity of hemolysis. DAT positivity was proceeded to Auto control, monospecific characterization, Indirect Antiglobulin testing (IAT) following elution & adsorption if needed. Response, prognosis, hospital stay with best compatible transfusion were studied.

Results: Out of 183 DAT positive cases, 26 were due to AIHA. DAT alone was positive in 34.6%, DAT and IAT was positive in 64.5%; 26% accompanied by alloantibodies. 15% showed autoantibody with specificity (auto anti ce, auto anti c). 43% had blood grouping discrepancy, 81% resolved with pre warming, 19% needed cold adsorption and elution. Out of the 43%, warm and mixed AIHA constituted 36% each and cold AIHA represents 28% (p<0.032). 70% & 30% of severe hemolysis showed 4+ and 3+ DAT reaction respectively. 19 patients required transfusion, 174 crossmatches, 35 best compatible units were transfused. (CT ratio: 4.94). Mean hemoglobin increment is 0.99g/dL following transfusion. All had partial response during discharge; one had complete remission in follow up.

Conclusion: With reference to our experience, Specific policy, timely decisions and proper laboratory investigations, plays a decisive role in the management of AIHA patients.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 29: To study the prevalence of eighteen clinically significant blood group antigens in blood donors

Divya Setya 1, Aseem K Tiwari 1, Dinesh Arora 1, Subhasis Mitra 1

Background: International Society of Blood Transfusion (ISBT) recognizes more than 300 red cell antigens. Antibodies to 18 of these antigens are encountered frequently in laboratories, known to cause hemolysis on exposure to antigen positive red cells and hence are clinically significant. Data pertaining to prevalence of these antigens which helps in identifying rare phenotypes is limited for the Indian population. Being such a populous country, it is ironical that neither does India possess a national donor registry nor has it registered any rare donor with International rare donor registries.

Aim: To motivate and create a database of accessible, volunteer donors to provide blood in emergencies and to identify and register rare donors with rare donor registries like International Rare Donor Panel (IRDP).

Methods: This was a cross-sectional, analytical study conducted in the department of Transfusion Medicine of a large tertiary healthcare hospital from October 2016 to May 2018 with a planned sample size of 4800. A random systematic sampling method was used for including blood donors of either gender coming for blood donation who gave consent to participate in the study. All Direct and Indirect Antiglobulin Test (DAT and IAT) positive samples and all Infectious Disease Marker (IDM) positive samples were excluded from the study. Extended red cell antigen typing was performed and results were recorded in study proforma. Antigen, phenotype and gene frequencies were calculated.

Results: Out of the 6678 donors phenotyped, 1430 (21.41%) were first time donors, 1056 (15.81%) were voluntary donors and 680 (10.18%) were female donors. Antigen, phenotype and gene frequencies were comparable with published Indian data. Three donors with rare antigenic profiles were identified, one of whom have been registered with IRDP.

Conclusion: This study might help enhance the confidence of blood banks in finding appropriate units for patients with unexpected antibodies.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 30: Red cell allo-antibodies in healthy blood donors

Gopal Patidar 1, Kapil Singh 1, Afreen Karim Khan 1, Yashaswi Dhiman 1, Aanjli Hazarika 1

Background: Red cell alloantibodies in healthy blood donors is a rare observation. The prevalence of red cell allo- and autoantibodies has been reported among several populations including hospital-based patients, multi-transfused chronic haematological disorders patients, pregnant females and blood donors. In blood donors, red cell antibody screening test is still a less preferred practice in India.

Aims: Retrospective analysis of red cell alloantibodies in healthy blood donors at tertiary care hospital.

Methods: In this study we retrospectively analysed the red cell alloantibodies in healthy blood donors from October 2017 to July 2018. Antibody screening and identification test done by Bio-rad 3 cell and 11 cell red cell panels on gel column system.

Results: During study period from October 2017 to July 2018 total 18112 donors donated blood at our blood bank. Out of them we found a total of 17 (0.09%) alloantibodies and 1 (0.01%) auto antibody. In this both clinically significant (reacting at 37C) and clinically non-significant (cold antibodies) were detected. Out of 17 alloantibodies 7 were anti-M (3 warm reacting and 4 cold reacting), 3 anti-E, 3 anti-Lea and one each of anti- K, anti-N & Lea (combined), anti-Cw and one unidentified alloantibody detected. We also detected one autoantibody.

Conclusion: We had detected 0.09% of alloantibodies in healthy donor plasma. Presence of alloantibody in donor plasma can cause haemolytic transfusion reaction in recipient's body if large amount is transfused to them. So, alloantibodies in donor plasma testing we recommended that every blood bank should be testing for.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 31: Leukocytes filtration failure in red cells – Unusual cause

Rakhi Malvankar 1, Rajeshwari Basavanna 1, Diya Mansukhani 1, Shehnaz Khodaiji 1, Anand Deshpande 1

Background: Leukocytes in the blood units play no therapeutic role in transfusion and are responsible mainly for adverse transfusion reactions. One of the effective methods for leukodepletion of the blood components is using prestorage blood filters. Leukodepletion has a number of potential benefits for transfusion recipients such as reduced risk of febrile non-hemolytic transfusion reactions (FNHTR); CMV transmission and platelet refractoriness. Leukodepletion filter failure is relatively rare. We tried to evaluate the causes of the filter failures including process failures such as filter priming failure and non-process failures such as presence of HbS. In sickle cell trait slow filtration and filter occlusion is commonly seen. Sickle cell gene is known to be wide spread among people of Deccan plateau along with Kerala, Tamilnadu and Assam and not prevalent in western Maharashtra.

Aim: To evaluate the causes of leukocyte filtration failures in red cells.

Methods: Leukodepletion was carried out using Terumo Penpol, Fenwal and Macopharma inline filter blood bags. Sickling test (Sodium Metabisulfite) and chromatography technique (HPLC) were carried out for the leukocytes depletion filter failures.

Results: During 15 months period 11362 blood units were collected and filtered. There were 24 instances of filtration failures. Sickling test was positive in 18/24 cases. HPLC was carried out in 9 of these cases and it showed the presence of HbS (range of 30-38%). In 6 cases we could not determine the cause of filtration failure. Of the 18 donors which were sickling test positive, 11 were from Mumbai, 3 from eastern Maharashtra and 1 each from Gujarat, Odisha, Jharkhand and Chattisgarh.

Conclusion: Currently, Leucodepletion using inline filters is not a common practice in India. Though sickling test is not mandatory for blood screening for donors but if there is filtration failure possibility of sickling should be considered.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 32: Coagulation factor levels in fresh frozen plasma after storage at 1–6°C for 5 days: Feasibility of use

Arghyadeep Marik 1, Bhushan Asthana 1, RS Mallhi 1, Neerja Kushwaha 1, Amit Biswas 1

Background: Extending the shelf life of Thawed FFP beyond 24 hours enables us to manage inventory better, reduces the burden of demand Vs supply as well as minimizes wastage of Thawed FFP. It can also help in logistically supporting the transfusion services in making FFP readily available in mass casualty scenarios (war, natural calamity) in remote locations by reducing the time required for thawing FFP and the need for costly storage equipment.

Aim: The aim of this study was to compare the levels of Factors V, VII, VIII, IX, X, Fibrinogen and also PT, APTT and TT on thawed Fresh Frozen Plasma after prolonged storage for 5 days at a temperature of 1-6°C.

Methodology: The above mentioned Coagulation Factors were analysed in FFP at the time of product thaw and again after 120 hours of 1 to 6°C storage using fully automated coagulation analyser (STA Compact Max).

Results: All parameters were expressed as Mean ± Standard deviation and were analysed using paired t-test with level of significance, p<0.05. There was a significant decrease in activities of all measured coagulation factors with FV, VIII and IX showing the maximum decrease. However, all the FFP units retained factor activities above therapeutic range even after 5 days of storage at 1-6°C.

Conclusion: Although the levels of plasma clotting factors are reduced during storage, they are still maintained above the therapeutic range. In scenarios where maintaining FFP inventory is a logistical challenge and emergency massive demands of FFP are foreseen, the use of thawed FFP can be considered as a viable option with a robust transport system.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 33: Determination of optimal red cell inventory levels for a hospital based blood transfusion service

Anumole Jose 1, D Sushama 1, D Meena 1

Background: Appropriate inventory levels are key to effective inventory management which necessitates policy formulation based on institution specific data.

Aims: (1) To determine an institution specific optimal and minimum Packed Red Cell (PRC) inventory level for each ABO blood group. (2) To analyze the relationship between inventory levels and time expiry wastage of Packed Red Cell (PRC) units across the different ABO blood groups.

Methods: This is a retrospective study of 12 months duration in a tertiary care centre. By review of documents, the total number of Packed Red Cell (PRC) units issued during 12 months ( May 2017 –April 2018) was calculated. The total number of PRCs issued was divided with the total number of days in the study period, to derive Average Packed Red Cell Use Per Day. The Average Daily Use Estimate of PRC for eight blood groups was determined. A minimal and optimal inventory was determined by multiplying the average daily use by three and seven respectively. Issuable Stock Index (ISI) and Time Expiry Wastage as a Percentage of Issues (TAPI) were used to present stock and wastage data for each blood group and were compared to see if there is a correlation between these two variables.

Results: Average Packed Red Cell Use Per Day was 71, with mean percentage of blood use by blood group and Average Packed Red Cell Use Per Day by blood type was: O positive (39.3%;28), O negative (3.9%;3), A positive (23.6%;17), A negative (2.8%;2), B positive (21.9%;16), B negative (2.6%;2), AB positive (5.6%;4), AB negative (0.4%;0.2) respectively. Minimum and optimum inventory was O positive (84;196), O negative (9;21), A positive (51;119), A negative (6;14), B positive (48;112), B negative (6;14), AB positive (12;28), AB negative (0.6;1.4) respectively. Pearson correlation analysis demonstrated a positive correlation between ISI and TAPI.

Conclusion: Determination of optimum blood inventory levels through evidence based approach is imperative for effective and minimum-wastage inventory management.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 34: Performance evaluation of rapid diagnostic test against chemiluminescence immunoassays for the serological screening of hepatitis B surface antigen and antibody to hepatitis C virus among blood donors

Brinda Kakkar 1, Meenu Bajpai 1, Ekta Gupta 1, Guresh Kumar 1

Background: Serological screening of blood borne viruses (BBV) in donated blood can be done by either rapid diagnostic tests (RDTs) and/or enzyme linked immunosorbent assay (ELISA) or any other available sensitive immunoassay such as chemiluminescence immunoassay (CLIA). RDTs are preferred in centres with resource constraints or limited donations and apheresis donors where short turnaround time is required. As per literature it is known that RDTs have higher specificity but varied sensitivity.

Aim: To evaluate performance of two commercially available RDTs against CLIA (Architect i1000 SR, Abbott) for screening of HBsAg (RDT1 – Meriscreen HBsAg; RDT2 – Virucheck HBsAg) and anti-HCV (RDT3 – Tredro HCV AB; RDT4 – Qualpro HCV).

Methods: In this cross-sectional study, 1000 consecutive blood donors were screened from September 2017 to March 2018. Results obtained by both RDTs and CLIA were compared. In a subset of samples, two types of molecular techniques: real time PCR and transcription mediated amplification (TMA) were compared.

Results: Of the 1000 samples tested by CLIA, prevalence of HBsAg and anti-HCV was 3.2% and 0.6%, respectively. Sensitivity of RDT1 for HBsAg detection was 28.13% with 100% specificity, while RDT2 showed 28.13% sensitivity with 99.9% specificity. Sensitivity of RDT3 and RDT4 for anti-HCV detection was 16.67% with 100% specificity each. Further confirmation of viremia was done on CLIA reactive samples, HBV DNA was detected in 31.3% (10/32) by PCR and 21.9% (7/32) by TMA, while HCV RNA was detected in 16.6% (1/6) by both PCR and TMA. The concordance between PCR and TMA for HBV DNA and HCV RNA detection was 90.6% (κ 0.762; p=<0.001) and 100% (κ 1.000; p=0.014), respectively.

Conclusion: RDTs performed poorly for detection of HBsAg and anti-HCV among blood donors with low sensitivity and high specificity, thus, adding on to burden of transfusion services by compromising blood safety.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 35: Residual risk estimation of transmission of hepatitis B virus, hepatitis C virus and HIV in the donated blood in an Indian setting

Hem Chandra Pandey 1, Mariam Verghese 1, Arvind Rana 1, Rajkumar 1, Pankaj Jain 1

Background: Residual risk estimation of TTI helps in identifying the safety of blood transfusions, helping the clinicians to decide on allogenic transfusions versus alternative options as well as help policy makers in deciding to implement newer interventions to reduce the risk.

Aim: The aim of current study was to estimate the incidence rate and residual risk of transmission of HBV, HCV & HIV at our institute.

Methods: A retrospective study done at a tertiary care referral centre of north India. Data related to blood donor demographics as well as TTI testing (Chemiluminescence and ID-NAT) was collected from January 2015 to June 2017. Viral screening was done via automated chemiluminescence immunoassay (CLIA) analyser (Abbott i1000SR) and ID-NAT testing was done using TMA (ProcelixUltrio plus). Data was entered in Microsoft excel 2016 and analysed. The incident rate and residual risk were calculated by the method described by Busch and co-workers in 2005.

Results: A total of 106119 donors donated during study period. A total of 1335, 833 & 255 donors were reactive for HBV, HCV & HIV respectively with the respective NAT yield being 74, 12 & 1. Incidence rates for HBV, HCV & HIV were approx. 1080, 127 and 40 per 105 donors respectively. Residual risk of HBV, HCV and HIV was approx. 307, 4.5 and 3.2 per million donors respectively.

Conclusion: We found the residual risk and incident rate for HIV and HCV to be low whereas the same for HBV was found to be high despite testing by ID-NAT. Studies from other centres are needed to confirm our findings. There is need for country specific efforts to reduce this high risk of HBV transmission risk.

Asian J Transfus Sci. 2019 May;13(Suppl 1):S19–S31.

OP 36: Changing trends of syphilis testing among blood donors: What we know, what we do not know, and what we need to know

Trupti Barot 1, Harprit Singh 1

Aim: To evaluate the impact of treponemal specific vs. non-specific serological tests for syphilis in the setting of low prevalence syphilis with 100% non remunerated regular voluntary blood donor.

Methods: The retrospective study was carried out in Prathama Blood Centre, Ahmedabad from 01/01/2013 to 31/01/2018. A total of 1,56,311 non remunerated voluntary blood donors sample were analysed by Treponema pallidum hemagglutination assay with sensitivity and specificity are 98.5 % & 99.6% respectively. All TPHA positive samples were again retested by non specific Rapid plasma reagin test for identifying False Negativity.

Results: Out of 1, 56,311 non remunerated voluntary blood donors (95.80% male & 4.20% female), 477 donors (0.32%) were seroreactive by TPHA. We also tested all TPHA (specific test) positive samples with RPR (non specific) test and we found out of 477 only 276 samples (57.8%) shows seroreactivity with RPR test (male 98.9 % vs. female 1.09 %) which is statistically significant (p < 0.05) with false negativity value of 201/477 (42.14%). We again tested TPHA positive & RPR negative samples 201 with same specific treponema pallidum tests (TPHA) and we found 177 samples show seroreactivity (88.1%; p < 0.05) with good reproducibility of result.

Conclusion: This is the first study from Indian subcontinent showing Seroprevalence (via TPHA assay) of Syphilis in blood donors was 0.32%. Considering the limitations of RPR test which showed high rates of false negativity (as per our study) & high biological positivity (as per literature/WHO guidelines) which itself have adverse psychological effects (stress & anxiety) on donors. Hence more sensitive and treponemal specific tests like TPHA; FTA – ABS should be used, as recommended by ‘Screening Donated Blood for TTI – WHO Guidelines’ which will have huge impact on the blood screening practices.

Articles from Asian Journal of Transfusion Science are provided here courtesy of Wolters Kluwer -- Medknow Publications

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