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Comparing Platelet Compatibility to Red Cell Compatibility Protocols

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Comparing Platelet Compatibility to Red Cell Compatibility Protocols Review: comparing platelet compatibility to red cell compatibility protocols S. ROLIH Between 1971 and 1980, the number of platelet con- Incidence of Alloimmunization From centrates transfused in the United States increased from Transfusion 0.4 to 2.8 million units.1 That number increased to near- Each RBC or platelet transfusion has the potential to ly 5 million in 1987 and continues to increase in the influence the outcome of future transfusions of the 1990s. The increase in platelet transfusions has led to a same products by inducing the formation of alloanti- concomitant rise in the incidence of platelet alloimmu- bodies. For RBC transfusions, in which ABO and D nization. As a consequence, many transfusion services group-compatible units are routinely given, this is not a or blood product providers have developed platelet significant problem. Only 0.3 percent to 1.3 percent of compatibility protocols to select platelet components all RBC transfusion recipients produce alloantibodies, that will have acceptable survival when transfused to although in selected recipient populations, such as alloimmunized patients. Most serologists are familiar patients with thalassemia or sickle cell anemia, the with compatibility tests used to select red blood cells alloimmunization rate may be as high as 30 percent (RBCs) for transfusion. These tests are performed before because of chronic transfusions.2 Overall, decreased sur- transfusion, whether or not alloimmunization has vival of transfused RBCs due to alloimmunization occurs occurred. Platelet compatibility tests, in contrast, are infrequently. Once alloimmunization occurs, premature implemented only after alloimmunization and develop- loss of future transfused RBCs is prevented by the selec- ment of the refractory state. tion of antigen-negative donor RBCs, using relatively rapid and simple crossmatch tests. Purpose of RBC or Platelet Transfusions Many platelet transfusion failures are due to factors RBC transfusions are used to improve the oxygen-car- other than alloimmunization, such as the storage lesion rying capacity of the blood. They are administered most of the platelets transfused, hypersplenism, fever, or infec- frequently to ameliorate the consequences of acute tion. Alloimmunization occurs most frequently in chron- hemorrhage due to trauma or surgical procedures. ically thrombocytopenic patients who are transfused Transfusions are also used when there is considerable with multiple units of platelets for extended periods of underproduction of RBCs (such as in aplastic anemia), time, although there is contradictory data as to whether when the recipient’s own RBCs do not function nor- there is a direct relationship between transfusion dose mally (as in sickle cell anemia) or when the RBCs have and immune response.4 Dutcher et al.5 and Holohan et a greatly diminished life span (as in thalassemia major).2 al.6 report that 40 percent to 70 percent of leukemic RBCs are administered until the patient improves clini- patients become alloimmunized by transfusion with cally and the hemoglobin concentration is considered platelets. Alloimmunization rates are as high as 80 per- adequate. cent to 100 percent in aplastic patients, presumably Platelets are administered to stop or to prevent active because these patients do not receive immunosuppres- bleeding due to thrombocytopenia. Most often, platelets sive therapy, yet are repeatedly transfused with are transfused to patients with severe thrombocytopenia platelets.5,6 Platelet alloimmunization, if it occurs, begins secondary either to neoplastic conditions involving the within the first few weeks of replacement therapy.7 bone marrow or to chemotherapy.3 Occasionally, they Most of the antibodies involved in platelet alloimmu- are given to patients who have normal platelet counts nization and decreased platelet survival are directed but who produce platelets with abnormal function. toward HLA class I antigens. A smaller percentage IMMUNOHEMATOLOGY, VOLUME 11, NUMBER 4, 1995 133 S. ROLIH involves antibodies to platelet-specific antigens, and an transfusion, a CCI of 7,500/µL is considered the mini- even smaller percentage against ABH histoantigens. mum. At 18–24 hours, the desired minimum CCI is Making significant reductions in platelet alloimmuniza- 4,500/µL.9,10 When 1- and 24-hour CCIs are at or above tion rates has been difficult for two reasons. First, our the minimums, the outcome of transfusion is considered understanding of platelet antigen-antibody systems and reasonably good. CCIs below the minimum expected their clinical relevance is rudimentary, particularly when value at 1 hour are often used as a criterion for refrac- compared to our understanding of the clinical relevance toriness.3,11 of RBC-related antigen-antibody systems. Second, there Posttransfusion samples are not routinely collected in is no universally accepted platelet compatibility proto- many hospitals in the United States because of poor col or platelet antibody detection procedure. platelet management protocols, staff inconvenience, or staff shortage. Unfortunately, CCIs are therefore not cal- Initiating Compatibility Testing culated for many platelet recipients. Consequently, onset Certain tests are performed to determine RBC com- of the refractory state is often missed and refractory patibility, including ABO/D determination, antibody recipients may continue to receive platelet transfusions screening, and, when necessary, crossmatching using of decreasing benefit. O’Connell et al.12 studied the fea- 8 donor RBCs and recipient serum or plasma. These tests sibility of using a platelet count taken 10 minutes post- are performed before transfusion, hence the descriptive transfusion to calculate the CCI. The advantage of term “pretransfusion tests.” RBC compatibility testing substituting a 10-minute count is that staff are usually still also includes checking previous transfusion records for working with the patient, and are thus available to draw the recipient’s serologic history. If the patient was test- a sample. The data suggest that counts taken at 10 min- ed previously, results of current tests are compared with utes posttransfusion provide the same information as the those previously recorded, and the decision to transfuse 1-hour count. any RBC product is based on the entire record. The Using CCIs and clinical condition as indicators of poor antiglobulin phase of the crossmatch is required for transfusion response due to platelet alloimmunization is patients with a history of any clinically significant alloan- similar to relying solely on clinical condition and post- tibody, even if the current antibody detection test is neg- transfusion hematocrit values to identify the onset of ative. Blood lacking the implicated antigen(s) is selected RBC alloimmunization. It may be more practical to deter- for transfusion even if RBCs possessing that antigen are mine the onset of platelet alloimmunization by using 8 serologically compatible. rapid, inexpensive platelet antibody screening proce- In contrast to red cell compatibility tests, those for dures, as employed in RBC pretransfusion testing. Such platelets are not initiated until a patient fails to respond tests should not require the strict adherence to a time to two or more successive platelet transfusions, and non- schedule for sample withdrawal and would provide a immunologic mechanisms have been eliminated as the flexible, alternative, analytical tool to 1- or 24-hour post- cause. Transfusion response is evaluated in a manner transfusion platelet counts. However, it must be remem- that accounts for the number of platelets transfused, the bered that while the detection of antibodies to platelets patient’s blood volume, and the patient’s initial platelet can strengthen the diagnosis of refractoriness due to count. This is accomplished by comparing a corrected alloimmunization, it provides no precise correlation count increment (CCI) with an expected minimum since some antibodies are not clinically significant. response. The formula is as follows: Platelet antibody detection is currently an area of intense CCI = (Posttransfusion – pretransfusion platelet count x body interest, and many institutions are developing in-house surface area in M2) platelet antibody detection tests, and three types of tests Number of platelets transfused × 1011 are being marketed commercially. The timing of the pretransfusion platelet count is important when calculating the CCI. If the pretransfu- ABO and D Compatibility sion count is not taken immediately before transfusion, Compatibility between recipient and donor ABO the value used in the calculation may be misleading. groups is always a concern in RBC transfusions—to the The expected minimum CCI is dependent on the time extent that tests to demonstrate ABO compatibility are a interval between the transfusion and the posttransfusion required part of compatibility testing. Transfusion of platelet count. When the count is taken 1 hour after ABO-incompatible blood nearly always leads to rapid 134 IMMUNOHEMATOLOGY, VOLUME 11, NUMBER 4, 1995 Similarities—platelet and red cell serology intravascular destruction of RBCs due to the presence tional components. Essentially, products for platelet of complement-binding antibodies in the recipient’s transfusion are administered based on compatibility blood, and to the high density of A and B antigens on with only one group of antigens carried on the recipi- RBC membranes. Platelets also express A and B antigens, ent’s platelets. A similar
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