ICID > Clinical Management > Haematology > Irradiation of Blood Components  
 

Irradiation of Blood Components 

  •  
  • 1. Indications
  • 2. Clinical Management
  • 3. Patient Information
  • 4. Audit
  • 5. Evidence Base
  • 6. Appendices
  • 1. Indications

    1.1 Background

    Cellular blood components are irradiated to prevent transfusion-associated Graft-vs-host disease (TA-GVHD). TA-GVHD is a potential complication of transfusion of any blood component containing viable T lymphocytes where there is a degree of disparity in histocompatibility antigens between donor and patient.

    The risks of TA-GVHD are highest in recipients with immunodeficiency or immunosuppression, although TA-GVHD has not been described in patients infected with the human immunodeficiency virus. In immunocompetent individuals, sharing of an HLA haplotype with the donor appears to be a major contributory factor.

    These cellular blood components are irradiated by either X-ray or irradiation and are identified by an approved overstick label which should include the date of irradiation and any reduction in shelf life. The effectiveness of this process must be checked by examining the RAD-SURE label on each pack - the central opaque portion will have changed from 'NOT IRRADIATED' to 'IRRADIATED'.

    Recommendation. The minimum dose achieved in the irradiation volume should be 25Gy, with no part receiving more than 50Gy (Grade 1 recommendatin; level B evidence) 

    1.2   Indications for Irradiated Cellular Products

    1.2.1     Paediatric Practice

    1.2.1.1  Intrauterine (IUT) and  neonatal exchange transfusion (ET)

    All blood for intrauterine transfusion (IUT) should be irradiated. It is essential to irradiate blood for neonatal exchange transfusion (ET) if there has been a previous IUT or if the donation comes from a first- or second-degree relative. For other neonatal ET cases, irradiation is recommended provided this does not unduly delay transfusion. For IUT and ET, blood should be transfused within 24 hours of irradiation and, in any case, by 5 days or less from collection.

    1.2.1.2 Top-up transfusion

    It is not necessary to irradiate red cells for routine ‘top-up’transfusions of premature or term infants unless either there has been a previous IUT, in which case irradiated compounds should be administered until 6 months after the expected delivery date(40 weeks gestation), or the donation has come from a first-or second degree relative (2C)

    1.2.1.3  Platelet transfusions

    Platelets transfused in utero to treat alloimmune thrombocytopenia should be irradiated  and any subsequent  red cell or platelet transfusions irradiated until 6 months after the expected date of delivery (40 weeks gestation) There is no need to irradiate other platelet transfusions for pre –term or term infants, unless they have been donated  by first- or second degree relatives

    1.2.1.4  Granulocyte transfusions

    All granulocyte transfusions should be irradiated for recipients of any age, and transfused as soon as possible after irradiation.

    1.2.1.5  Congenital immunodeficiencies in infants and children

    All severe T lymphocyte immunodeficiency syndromes should be considered as indications for irradiation of cellular blood components. Once a diagnosis of immunodeficiency has been suspected, irradiated components should be given while further diagnostic tests are undertaken. A clinical immunologist should be consulted for advice in cases where there is uncertainty.

    1.2.1.6  Acquired immunodeficiency states in childhood

    There is no indication  for routine irradiation  of cellular blood components for infants or children who are suffering from a common viral infection, who are HIV positive, or who have  AIDS. However, this should be kept under review. There is also no indication for routine irradiation of cellular blood components for adults who are HIV positive or who have AIDS.

    1.2.1.7  Cardiac surgery in neonates and infants

    There is no need to irradiate red cells or platelets for infants undergoing cardiac surgery unless clinical or laboratory features suggest  a coexisting T lymphocyte immunodeficiency syndrome

    1.2.2  Haematology and Stem Cell Transplant Patients – Children and Adults

    1.2.2.1  Acute leukemia

    It is not necessary to irradiate red cells or platelets for adults or children with acute leukemia, except for HLA-matched platelets or donations from first- or second-degree relatives, unless patients have received purine analogues (see 1.2.3.1).

    1.2.2.2  Allogeneic stem cell transplantation

    All recipients of allogeneic haemopoietic stem cell transplantation (SCT) must receive irradiated blood components from the time of initiation of conditioning chemoradiotherapy

    Irradiated components should be continued while the patient continues to receive graft-versus- host disease (GvHD) prophylaxis, i.e usually for 6 months post transplant, or until lymphocytes are>1 x 109 / l If chronic GvHD is present  or if continued immunosuppressive treatment is required, irradiated blood components should be given indefinitely.

    Allogeneic blood transfused to bone marrow and peripheral blood stem cell donors 7 days prior to or during the harvest should also be irradiated

    1.2.2.3  Autologous bone marrow/peripheral blood stem cell recipients

    Patients undergoing  bone marrow or peripheral blood stem cell ‘harvesting’  for future autologous  re-infusion should receive irradiated cellular blood components during and for 7 days before the bone marrow/ stem cell harvest to prevent collection  of viable allogeneic T lymphocytes which can potentially withstand cryopreservation

    All patients undergoing  autologous bone marrow transplant or peripheral blood stem cell transplant  should receive irradiated cellular blood components from initiation  of conditioning chemo/radiotherapy until 3 months post- transplant (6 months if total body irradiation was used in conditioning)

    1.2.3  Other Patient Groups

    1.2.3.1  Purine analogues

    Patients treated with purine analogue drugs (Fludarabine,Cladribine and deoxycoformycin) should receive irradiated blood components indefinitely.

    The situation with other purine analogues such as Bendamustine and clofarabine is unclear, but use of irradiated blood components is recommended as these agents have a similar mode of action

    1.2.3.2 Biological Agents

    Irradiated blood components should be used after alemtuzumab (anti- CD52) therapy. Their use after rituximab(anti -CD20) is not recommended at this time. As  new potent immunosuppressive drugs and biological agents are introduced into practice there is a need for a regular review of these recommendations.

    1.2.3.3 Hodgkin's disease

    All adults and children  with Hodgkin’s lymphoma at any stage of the disease should have irradiated red cells  and platelets for life.

    1.2.3.4  Acquired immunodeficiency

    It is not necessary to irradiate  blood components for patients undergoing routine surgery, those with solid tumours, HIV infection, autoimmune diseases or after solid organ transplantation (unless alemtuzumab) (anti –CD52) has been used in the conditioning regime). The effects of new regimes of chemo – and immunotherapy entering clinical practice must continue  to be monitored (Grade 2  recommendation: level C evidence)

    1.2.3.5 Aplastic anaemia.

    In view of the recent switch from horse anti- thymocyte globulin (ATG) to the more immunosuppressive rabbit ATG, we now recommend use of irradiated blood components for aplastic anaemia patients receiving immunosuppressive therapy with ATG( and / or alemtuzumab)

    Irradiaated components are recommended for all patients receiving  immunosuppressive therapy with anti- thymocyte globulin(ATG)

    We cannot make a firm recommendation as to how long irradiated products should continue to be used after ATG administration but the 2009 BCSH guidelines recommend continuing at least until the lymphocyte count>1x109/l.

    1.2.3.6  Donations from family members and HLA-selected donors

    All transfusions from first- or second-degree relatives should be irradiated, even if the patient is immunocompetent. Likewise, all HLA-matched components should be irradiated, even if the patient is immunocompetent.

    1.2.4  Which components should be irradiated

    For at-risk patients, all red cell, platelet and granulocyte transfusions should be irradiated, except cryopreserved red cells after deglycerolization. It is not necessary to irradiate fresh frozen plasma, cryoprecipitate or fractionated plasma products.

    Red cells may be irradiated at any time up to 14 days after collection, and thereafter stored for a further 14 days from irradiation. Where the patient is at particular risk from hyperkalaemia, e.g. intrauterine or neonatal exchange transfusion, it is recommended that red cells be transfused within 24 hrs of irradiation or cells are washed.

    Platelets can be irradiated at any stage during storage and can thereafter be  stored up to their  normal shelf life after collection..

    Granulocytes for all recipients should be irradiated before issue, and thereafter transfused with minimum delay.

    Irradiated components not used for the intended recipient can be safely returned to stock to be used for recipients who do not require irradiated components. The reduction in shelf life must be observed.

    All irradiated units should be labelled as such using an approved bar code label. Each unit  should be monitored using a radiation-sensitive device, and the result permanently recorded, manually or by computer.

    1.2.5 Ensuring  irradiated components are supplied and transfused

    Patients at risk of TA-GvHD should be made aware of their need for irradiated blood components and provided with appropriate written information  and an alert- card for clinical staff. We endorse the recommendations from SHOT (www.shotuk.org) relating to improved clinical and laboratory awareness, documentation and communication  of special requirements for transfusion, including irradiated components. Initiatives to improve laboratory and clinical information management systems ( including IT links with Pharmacy and diagnostic services to highlight “at risk” patients) should be incorporated into local policies and regularly audited. Poor communication between centres involved  in “shared care” of patients is a well reported hazard and the development of a standardised national system for recording and transferring details of special transfusion requirements is an urgent requirement. In this Trust, patients requiring irradiated blood components will be sent a letter including an NHSBT information leaflet and alert card. This will be sent from Blood Transfusion.

    1.3  Aim/purpose

    To prevent transfusion associated graft-versus-host disease.

    1.4  Patient/client group

    As above


    2. Clinical Management

    2.1 Staff & equipment

    It is incumbent upon the Consultant responsible for the  patient to inform the Blood Transfusion Laboratory of the need for irradiated products.

    The Blood Transfusion Laboratory will inform the Transfusion Practitioner, who will send the patient a letter including an NHSBT information leaflet and alert card, and will also keep a database of patients requiring irradiated products.

    Nurses should check that blood is irradiated before administration in "at risk" patients.

    Pharmacy should not issue purine analogues without informing Blood Transfusion that the patient will require irradiated components.  This information must be recorded in the patient's Blood Transfusion records on Telepath.

    2.2 Method/procedure

    Transfusion associated graft-versus-host-disease

    2.3 Potential complications / Risk management

    Transfusion associated graft-versus-host-disease.

     2.4 After care

    Patients requiring irradiated blood components should sent a letter including an NHSBT information leaflet and alert card. This will be sent from Blood Transfusion 


    3. Patient Information


    4. Audit

    4.1 Audit indicators

     

    Aspect of Care

    %

    Exceptions

    Definition

    1. All recipients of allogeneic bone marrow or peripheral blood stem cells from time of conditioning therapy until at least 6 months post-transplant or until graft-versus-host disease prophylaxis has been withdrawn will have their blood components irradiated

    100%

    None

     

    2. All allogeneic bone marrow or peripheral blood stem cell donors should receive irradiated blood components if needed within the week prior to, or during, harvesting.

    100%

    None

     

    3. All autologous bone marrow or peripheral blood stem cell recipients (from one week before harvest or stem cell collection until 6 months post-transplant) will have their blood components irradiated

    100%

    None

     

    4. All donations from HLA-matched donors or first or second degree relatives will have their blood components irradiated.

    100%

    None

     

    5. All patients with Hodgkin's disease will have their blood components irradiated.

    100%

    None

     

    6. Patients with congenital immunodeficiency states will have their blood components irradiated.

    100%

    None

     

    7. All intrauterine transfusions (IUT) or exchange transfusions in neonates will receive irradiated blood components

    100%

    None

     

    8. Top-up transfusions in neonates (if there has been an IUT or if the donor is a first or second degree relative) will receive irradiated blood components

    100%

    None

     

    Components that require Gamma-irradiation

     

     

     

    9. For at risk patients, all red cell, platelet, and granulocyte transfusions should be irradiated,

    100%

    Cryopreserved red cells after deglycerolization.

    It is not necessary to irradiate fresh frozen plasma, cryoprecipitate or fractionated blood products.

    10. Red cells may be irradiated at any time up to 14 days after collection and thereafter stored for a further 14 days from irradiation.

    100%

    None

     

    11. When red cells are used for IUT or exchange transfusion, they should be transfused within 24 hours of irradiation because of risks of hyperkalaemia.

    100%

    None

     

    12. The Consultant responsible for the patient should inform the blood bank of the need for irradiated products.

    100%

    None

     

    13. Nurses should check that blood is irradiated before administration in "at risk" patients.

    100%

    None

     

    14.  Pharmacy should not issue purine analogies without informing Blood Transfusion that patient will require irradiated products.

    100%

    None

     

    15.  Patients to be sent an information sheet and alert card

    100%

    None

     

    4.2 Audit design

    See appendix 1 for data collection form.

    4.3 User involvement

    4.4 Risk management

     

    5. Evidence Base

    References

    1. Department of Health (2002) Better Blood Transfusion, appropriate use of blood. Health Service Circular (HSC 2002/009) HMSO London

    2. Blood Safety and Quality Regulations (2005)

    3. National Patient Safety Agency NPSA/2008/SPN14

    4. British Committee for Standards in Haematology (BSCH) (2009) The administration of blood and blood components and the management of transfused patients. 

    5. British Committee for Standards in Haematology (BSCH) (2004) Guidelines for compatibility procedures in blood transfusion laboratories.  Transfusion Medicine 14, 59-73.

    6. McClelland D.B.L., et al.  (2007) Handbook of Transfusion Medicine (4th edn).  The Stationary Office: http://www.tso.co.uk

    7. The Retention and Storage of pathological Records and Specimens, 4th Edition 2009.  Guidance from the Royal College of Pathologists and the Institute of Biomedical Science.

    8. Contreras M. (1998) ABC of Transfusion (3rd edn).  British Medical Journal Publishing Group: London.

    9. British Committee for Standards in Haematology (BSCH) (2004) Guidelines for the Use of Fresh Frozen Plasma, Cryoprecipitate and Cryosupernatent British Journal of Haematology 126: 11-28, with amendments in 2005 and 2007.

    10. British Committee for Standards in Haematology (BSCH) (2010) Guidelines on the use of irradiated blood components  British Journal of Haematology 152: 35 - 51

    11. Gray, A. Illingworth ,J. (2004) Right Blood, right patient, right time. RCN guidance for improving transfusion practice. Royal College of Nursing, London

    12. Department of Health (2009) Reference Guide to Consent for Examination or Treatment. Deparment of Health, Electronic version only

    13. Department of Health (2007) Better Blood Transfusion, Safe and appropriate use of blood.  HSC 2007/001.  Electronic version only

    14. Transfusion guidelines for neonates and older children (2004) British Journal of Haematology 124 433 – 453.  With amendments 2005 and 2007.

    15. Neonatal Transfusion Practice, Murray NA & Roberts IAG, Arch Dis Child FetNeon Ed 2004, 89:F101-F107

    16. British Committee for Standards in Haematology. Guidelines for the use of Platelet Transfusions. , British Journal of Haematology. 2003: 122: 10-23

    Appendix x

    British Committee for Standards in Haematology. (2006) Guidelines on the Management of Massive Blood Loss.  British Journal of Haematology 135, 634 - 641


    6. Appendices

    Appendix 1 Data Collection Form  Irradiation of Blood Components DCF

     

     



    Document Owner Effie Grand 
    Department
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