EAST 2017 #11: Use of Incompatible (Type A) Plasma For Massive Transfusion

Type AB plasma is considered “universal donor” plasma, as it contains no antibodies to red cells with either A or B antigens on their surface. Unfortunately, only about 4% of the US population have this blood type and can provide the product. Due to this shortage, some trauma centers have decided to use Type A plasma initially for massive transfusion, and switch to type specific plasma once patient blood has been typed and screened.

This works, since only about 13% of the population have red cells with B antigens on the surface. But are there any adverse effects in those patients who receive potentially incompatible plasma? The EAST Multicenter Study group performed a retrospective study using trauma registry and blood bank data from 5 trauma centers. They looked at adult patients who received plasma as part of the massive transfusion protocol (MTP) over a 4+ year period. Incompatible type A plasma transfusion was defined to occur if a patient had either Type B or AB blood.

Here are the factoids:

  • There were a total of 1212 patients in the study; 93% were compatible and 7% were incompatible type A initial transfusions
  • The usual trauma demographics were seen (young, male) and the average ISS was 25 (they triggered an MTP, remember?)
  • By chance, the incompatible group had a slightly higher ISS (29) and penetrating injury rate (45% vs 33%)
  • The incompatible group received significantly more plasma during the first 4 hours and during the first day
  • There was no difference in mortality sepsis, ARDS, thromboembolic events, or renal failure
  • Regression analysis showed that incompatible plasma was not a predictor of mortality or morbidity
  • There was one hemolytic reaction and one occurrence of TRALI, both in the compatible group

Bottom line: This is the largest study around on the topic, and it does not show any significant problems (at least the ones that were studied) with giving incompatible plasma in acute trauma. How can this be, you ask? Remember, only the first one or two units (the first MTP pack) is potentially incompatible. Hopefully, by the time the second pack is delivered, the blood has been typed. And these patients are potentially receiving multiple units of typed plasma after the initial transfusion which dilutes the incompatible, and multiple transfusions overall which may blunt their immune response. 

This is an important paper that all centers should consider as they update their massive transfusion protocols!

Questions and comments for the authors/presenters:

  1. The abstract states that 5 centers participated, but the tables only list 4. Please explain this.
  2. It is not stated explicitly whether all centers used type A plasma initially. Is this the case?
  3. This is important work! Have any other centers converted to initial use of type A plasma?

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: Use of incompatible type A plasma transfusion in patients requiring massive transfusion protocol: outcomes of an EAST multicenter study. Paper #16, EAST 2017.

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  • Neil Blumberg

    Evidence that AB plasma is not safe as universal donor plasma

    Vox Sang. 2009 May;96(4):316-23. doi: 10.1111/j.1423-0410.2009.01167.x. Epub 2009 Feb 24.

    Post-transfusion mortality among recipients of ABO-compatible but non-identical plasma.
    Shanwell A1, Andersson TM, Rostgaard K, Edgren G, Hjalgrim H, Norda R, Melbye M, Nyrén O, Reilly M.

    BACKGROUND AND OBJECTIVES:

    The
    consequences of ABO-compatible non-identical plasma for patient outcome
    have not been studied in randomized clinical trials or large cohort
    studies and use varies widely in the absence of evidence-based policies.
    We investigated if transfusion with compatible instead of identical
    plasma confers any short-term survival disadvantage on the recipients.

    MATERIALS AND METHODS:

    The
    cohort of all 86 082 Swedish patients who received their first plasma
    transfusion between 1990 and 2002 was followed for 14 days and the risk
    of death in patients exposed to compatible non-identical plasma compared
    to recipients of only identical plasma.

    RESULTS:

    After
    adjustment for potential confounding factors, there was an increased
    mortality associated with exposure to ABO-compatible non-identical
    plasma, with the excess risk mostly confined to those receiving 5 or
    more units (relative risk, 1.15; 95% confidence interval, 1.02-1.29).
    Stratification by blood group indicated higher risks in group O
    recipients, especially when the compatible plasma was from a group AB
    donor.

    CONCLUSIONS:

    This
    study suggests that ABO-compatible non-identical plasma is less safe
    than identical plasma. Subanalyses by blood group suggest a role for
    circulating immune complexes. Our findings may have policy implications
    for improving transfusion safety.This is an interesting, but not surprising finding.

    So-called universal
    donor AB plasma is actually incompatible withj 95% of recipients. It
    contains large amounts of soluble antigen that can react with anti-A and
    anti-B in the plasma of group O, A and B individuals. These immune
    complexes can interfere with platelet function, clot formation and are
    associated with increased mortality in observational studies. A plasma
    has antibody that reacts with 15% of individuals who are group B and AB,
    and antigen incompatible with 45% of patients of group O, but is
    identical with the 40% of patients who are group A. Since hemolysis is
    not the major risk of transfusion in this setting, as compared with
    increased bleeding, thrombosis and multi-organ failure (all potentially
    made worse by immune complexes), one would expect A plasma to be safer
    than AB plasma. It would be interesting to compare recipients by blood
    group. We would expect group A recipients to do the best in this
    setting receiving A plasma. Group AB would be expected to do the worst,
    with group O and B somewhere in between, or at least worse than the A
    recipients.

    Presented
    to the AABB in 2016 and published in Sept 2016 TRANSFUSION. Evidence
    that group O red cells are probably not safe as universal donors,
    possibly due to the small amount of anti-A and anti-B present when given
    in larger amounts.

    TITLE: Transfusion of ABO non-identical red cells and mortality in patients undergoing massive transfusion
    AUTHORS (FIRST NAME, LAST NAME): Majed Refaai1, Kelly Henrichs1, Christine Cahill1, Scott Kirkley1, Amy
    Schmidt1, Debra Masel1, Paul Bankey2, Mark Gestring2, Amanda Lippa1, Neil Blumberg1
    INSTITUTIONS (ALL):
    1. Transfusion Medicine, University of Rochester Medical Center, Rochester, NY, United States.
    2. Surgery, University of Rochester Medical Center, Rochester, NY, United States.
    PRESENTATION TYPE: Oral or Poster Presentation
    CURRENT CATEGORY: Scientific
    ABSTRACT BODY:
    Background/Case Studies: Massive transfusion often requires use of ABO non-identical red cells. ABO non-identical
    transfusions are associated with increased bleeding, organ failure and mortality. We investigated whether ABO nonidentical
    transfusions in massively transfused patients are associated with increased mortality.
    Study Design/Methods: 24 hour(h) and overall hospital mortality in 403 patients undergoing massive transfusion at a
    single Level 1 trauma center from 2008-2014, as well as recipient ABO blood group and number of ABO non-identical
    transfusions were determined and differences tested by Chi square.
    Results/Findings: Overall 24h survival (68%) and discharged alive (53%) did not differ by ABO blood group
    (O=192;A=143;B=51;AB=17). Receipt of 1-4 ABO non-identical transfusions was not associated with inferior survival
    (n=73)(75% 24h and 65% overall survival) vs. (n=288)(69% and 53%) in recipients of only ABO identical. However
    receipt of 5+ ABO non-identical transfusions (primarily RBC) (n=42) was associated with poor survival at both 24h
    (48%; p=0.006) and overall (31%; p=0.0015). We analyzed subsets of patients receiving comparable numbers of
    transfusions to evaluate whether receipt of ABO non-identical was confounded with total transfusions. The receipt of
    5+ ABO non-identical components was consistently associated with increased mortality across strata of total
    transfusions. We examined those surviving at least 24h (n=275) to evaluate if receipt of ABO non-identical
    transfusions was confounded with early fatal hemorrhage. In patients surviving 24h, the adverse association with 5+
    ABO non-identical transfusions remained significant. Patients received 5+ ABO non-identical RBCs due to being
    group AB (mean=13 RBCs), and, to a lesser extent, group A (1.6) or B (2.1). Group O patients rarely received nonidentical
    transfusions (exclusively platelets). Amongst 24h survivors, group O individuals (n=129) had reduced overall
    mortality (18%) compared with non-Os (n=146)(27%) (p=0.053). Mortality was highest in group AB (n=14) (43%), then
    group A (n=101) (28%) and group B (n=31)(16%) (p=0.06).
    Conclusion: Larger numbers (5+) of ABO non-identical RBCs are associated with greater mortality than receipt of ABO
    identical RBC only, or 1-4 ABO non-identical RBCs. Group AB & A recipients had increased mortality among 24h
    survivors. Whether this is due to a biologic effect or confounding is not ascertainable from our data. However these
    results are consonant with the relative potency of anti-A/-B antibodies. The superior survival of group O patients, who
    have low FVIII/vWF levels, is unexpected, providing evidence the increased mortality in group A/AB patients may be
    antibody-mediated. Transfusion of ABO identical or plasma-reduced O rbcs are potential testable strategies to
    improve survival after massive transfusion.

    An association of ABO non-identical platelet and cryoprecipitate transfusions with altered red cell transfusion needs in surgical patients.

    Refaai MA, Fialkow LB, Heal JM, Henrichs KF, Spinelli SL, Phipps RP, Masel E, Smith BH, Corsetti JP, Francis CW, Bankey PE, Blumberg N.Vox Sang. 2011 Jul;101(1):55-60.

    ABO-immune complex formation and impact on platelet function, red cell structural integrity and haemostasis: an in vitro model of ABO non-identical transfusion.

    Zaffuto BJ, Conley GW, Connolly GC, Henrichs KF, Francis CW, Heal JM, Blumberg N, Refaai MA.Vox Sang. 2016 Apr;110(3):219-26. doi: 10.1111/vox.12354.

    Neil Blumberg MD

    University of Rochester Medical Center

    Rochester, NY

    • TheTraumaPro

      Neil, interesting paper. Although they include a cohort of trauma patients, they don’t reveal how many there are. I’ll read this thoroughly soon and probably post something about it.