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Blood Banking and Transfusion Medicine Fellowship

This program involves the University of Minnesota Medical school, University of Minnesota Medical Center, Fairview, the Memorial Blood Centers of Minnesota, the American Red Cross North Central Blood Services of St. Paul, Hennepin County Medical Center, and the Veterans' Affairs Medical Center. This fellowship integrates the best aspects of these transfusion services and blood centers into an exceptionally balanced, yet diversified transfusion medicine experience. While rotations vary with individual trainee interests, the standard program includes: 6 months at Fairview-University, 1 month Memorial Blood Centers, 2 months American Red Cross, 6 weeks Veterans' Affairs Medical Center, and 6 weeks Hennepin County Medical Center. The fellows spend the majority of their time at their assigned institutions and participate weekly in conferences involving the entire transfusion medicine faculty. The fellowship is designed to prepare physicians for a career on either a hospital transfusion service or in a regional blood center. Substantial clinical involvement and extensive experience with laboratory problem solving and clinical consultation is provided. Complete laboratory training related areas such as immunology and coagulation is also available. As the fellow gains experience, more clinical duties and special projects are assigned. A second year of predominantly research is available for exceptional trainees.

Teaching Faculty

Teaching Facilities

University of Minnesota Medical Center, Fairview is a world leader in solid organ and hematologic stem cell transplantation and the treatment of hematological malignancies, including stem cell processing and freezing programs. The hospital has a broad range of active clinical services that extensively interact with the transfusion service, including cardiovascular surgery, obstetrics, neonatology, gynecology, and others. The Donor Center and Apheresis Unit provide peripheral blood stem cell collections, a busy therapeutic apheresis service, and carry out many developmental projects.

Memorial Blood Centers of Minnesota is an American Association of Blood Banks (AABB) Rare Donor Reference Laboratory, conducts parentage testing, performs transfusion-transmitted disease and clinical diagnostic testing for viral markers, serves as a local immunohematology reference laboratory, and provides expertise in the legal aspects of blood banking.

American Red Cross North Central Blood Services, St. Paul is a large, multi-service blood center that collects about 240,000 whole blood units annually, primarily in off-site mobile operations. The departments of hospital services and blood donor collections provide the fellow with insight into the regional management of blood resources. The blood center operates a large apheresis unit that collects products for both transfusion and research. The blood center also houses the ARC national neutrophil serology reference laboratory, a platelet cross match and platelet serology laboratory, a red cell serology laboratory, a cord blood bank, and a donor registry for the National Marrow Donor Program.

The Veterans' Affairs Medical Center provides a range of clinical services, including general and cardiovascular surgery, cancer therapy, and hematology. The fellow learns laboratory techniques directly at the bench under supervision, participates in the operation of a hospital-based blood donor program, and consults on clinical problems of transfusion medicine.

Hennepin County Medical Center provides advanced proficiency in trauma / massive transfusion practices, obstetric-associated transfusion practices, and the principles of a hospital transfusion service.

Requirements

In addition to the general Program requirements, candidates should be Board eligible or certified in clinical pathology, internal medicine, hematology, pediatrics, anesthesiology, or surgery at the time of matriculation.

Curriculum

General Goals and Objectives

The goal of the fellowship in Transfusion Medicine and Blood Banking is to provide comprehensive training in transfusion medicine, immunohematology, and blood banking. Following the fellowship, each fellow should be familiar with the basic principles of blood groups, compatibility testing, blood and blood component therapy, adverse effects of transfusion, blood donor recruitment and selection, blood collection, transmissible disease testing, apheresis including therapeutic apheresis, bone marrow and stem cell processing, parentage testing, laboratory administration, and total quality management. The fellow should have a working knowledge of the regulatory aspects involved in blood donor collection and transfusion medicine services. The fellow will obtain this comprehensive training by experience at five institutions. The material to be covered at each institution is shown in Table 1. In general, blood donor recruitment, donor selection, blood collection (whole blood and apheresis), component production transmissible disease testing, inventory management, and the organization and management of a community blood supply system will be provided at the ARC and MBCM. The patient oriented experiences are provided at the three hospital locations which complement each other. UMMCF is an academic medical center with major programs in solid organ and hematopoietic stem cell transplantation, oncology, cardiovascular surgery, obstetrics, and a neonatal ICU. HCMC is the city county hospital that serves as the primary trauma center and provides general medical care for a diverse population with a wide variety of medical, surgical, and pediatric problems. The VAMC is a general acute care facility that provides the fellow experience in consulting and the operation of a general community hospital type facility.

At UMMC, the fellow has extensive clinical involvement with component (especially platelet) use, blood components for surgery (due to large organ transplant service), therapeutic apheresis (done by blood bank donor center) and interaction with other clinical service residents and fellows such as hematology, marrow transplant, organ transplant, pediatrics and general surgery.

At HCMC, the fellow provides medical direction to the transfusion service under the supervision of the staff. This includes attending morning rounds, following up on appropriate cases, reviewing antibody workups, reviewing platelet transfusions and evaluating transfusion reactions. The fellow will also supervise the blood and component therapy of patients undergoing massive transfusion especially in the operating rooms or the emergency department.

Although five institutions are involved, there is good coordination and integration of fellowship training. Faculty from all of the institutions attend a weekly breakfast meeting along with the fellows and other trainees assigned to the blood banks including residents, medical students, hematology/oncology fellows, etc. Interesting or difficult cases from all the five institutions are discussed along with topics of interest in blood banking and transfusion medicine.

Specific Goals and Objectives

  1. Immunohematology Objectives

    After completing the fellowship, the fellow will be able to explain and perform basic tests, solve antibody problems and correlate laboratory findings with clinical significance in the following areas:

    1. Blood Groups
      1. ABO and other carbohydrate antigens (Lewis, P)
      2. Rh and other protein antigens (Kell, Duffy, Kidd, MNSs)
      3. Inheritance
      4. Clinical significance for transfusion or pregnancy
      5. Resolution of typing problems
    2. Pre-transfusion Testing
      1. Type and screen
      2. Compatibility tests including a complete crossmatch through the antiglobulin phase
      3. IgM and IgG antibodies
      4. Mechanisms of immune hemolysis
      5. Direct and indirect antiglobulin testing
      6. Alloantibody identification using panels
      7. Enhancement media including low ionic strength (LISS), enzyme, albumin and polyethylene glycol (PEG)
      8. Testing before non-red cell transfusion
      9. Potential role of the computer crossmatch
    3. Red Cell Serological Studies
      1. Autoantibody evaluation, cold and warm
      2. Autoimmune hemolytic anemias - treatment and transfusion
      3. Drug-related antibodies - evaluation and mechanisms
      4. Elution - purpose, methods, and interpretation
      5. Complex antibody problems - i.e. multiple, high frequency antigens, selection of appropriate components
      6. Prenatal screening and intrapartum monitoring
      7. Evaluation of hemolytic diseases of the newborn
        1. Fetal maternal hemorrhage, Rh immune globulin dose
        2. Exchange transfusion and/or intrauterine transfusion
    4. Platelet Serology
      1. Platelet antigen groups
      2. Drug-dependent platelet antibodies
      3. Autoimmune thrombocytopenia
      4. Neonatal alloimmune thrombocytopenia
      5. Post transfusion purpura
      6. Platelet antibody testing including platelet immunofluorescence and antigen capture assays (MAIPA)
    5. Neutrophil Serology
      1. Neutrophil-specific antigens
      2. Autoimmune neutropenia
      3. Drug-dependent neutrophil antibodies
      4. Neutrophil serology including immunofluorescence and agglutination assays

  2. Whole Blood Collection Objectives

    The fellow will be able to supervise and implement a blood donation program. A basic understanding of the following topics will be obtained:

    1. Blood Donation
      1. Basic strategies in donor recruitment (groups, individuals, volunteer versus paid)
      2. Collection settings - vans, mobiles, fixed sites
      3. Performance of donor interview and physical examination
      4. Donor safety issues
      5. Recipient safety issues
      6. Phlebotomy process
      7. Evaluation and treatment of donor reactions and injuries
      8. Autologous donation - candidates, frequency, common problem
      9. Directed donation - pros and cons of a directed donor program
      10. Minimal exposure transfusion program - candidates, frequency, common problems
      11. Therapeutic
      12. Ethical issues in donor screening and testing
    2. Blood Component Preparation and Testing
      1. Component preparation including labeling
      2. Donor testing
        1. Blood groups - ABO, Rh, antibody screen
        2. Infectious disease marker testing: syphilis, HBsAg, anti-HIV 1/2, ALT, anti-HBc, anti-HTLV-I/II, anti HCV, HIV antigen
        3. Confirmatory testing including anti-HIV western blots, and anti-HCV RIBA
        4. CMV antibody testing
        5. Nucleic acid amplification testing (NAT)
        6. New assay development
    3. Blood Donor Deferral Counseling
      1. Donor deferral registry and record keeping procedures
      2. Donor notification of positive results
      3. Donor counseling by phone or in person with particular emphasis on the implications for the donor's health
      4. Donor surveillance for a second reactive result such as ALT, anti-HTLV-I/II, HIV antigen
      5. Autologous donors
      6. Directed donors
      7. Confidentiality and requirements for reporting infectious disease markers to public health agencies
      8. Donor re-entry protocols as established by FDA
      9. Recipient lookback

  3. Blood Transfusion Objectives

    The fellow should be able to discuss standard laboratory and clinical practices, investigate problems and questions, and assess transfusion therapy in the following areas:

    1. Blood Component Therapy
      1. Storage - anticoagulation, temperature, expiration dates, red cell additive solutions, inventory levels
      2. Blood administration - specimen and patient identification, thawing, pooling, issuing, transport time and temperature, filtration
      3. Blood components - whole blood, packed red blood cells, platelet concentrates, apheresis platelets, plasma, cryopoor plasma, cryoprecipitate, and granulocytes
      4. Blood usage review - requirements, methods, transfusion committee activities, crossmatch to transfusion ratio, blood outdating and wastage
      5. Modified components - washed, irradiated, leukocyte-reduced, frozen/thawed deglycerolized red cells, CMV seronegative, HLA-matched platelets
      6. Management of platelet refractory patients including use of HLA matched and crossmatched platelets
      7. Support for solid organ and bone marrow transplant patients
      8. Intraoperative blood salvage - instrumentation, indications, and potential complications

    2. Adverse Effects of Transfusion

      The fellow will:

      1. be able to recognize and discuss pathophysiology, treatment, and prevention of the following: febrile, allergic, acute hemolytic, delayed hemolytic, anaphylactic, septic, transfusion-associated graft-versus-host disease, transfusion-related acute lung injury, and circulatory overload
      2. be able to manage massive transfusion including the appropriate and timely ordering of laboratory tests for monitoring the patient and recognizing the metabolic and hemostatic consequences of massive transfusion
      3. have a working knowledge of the effects of stored blood on recipients, including pediatric patients
      4. understand the available literature on immune suppression from transfusion and adverse effects of transfused leukocytes
    3. Transfusion-Related Infections
      1. HIV, hepatitis B and C, HTLV, CMV, parasites, and bacterial contaminants
        • current risks of transfusion
        • procedures to minimize risk for recipients
      2. Lookback procedures to identify transfusion recipients of potentially infectious units
        • HIV, HTLV-I and HCV require lookback
        • Lookback performed to limit transmission and initiate medical follow up of donor
      3. Indications for CMV seronegative blood
        • safety of the substitution of filtered cellular components for CMV seronegative

  4. Apheresis for Collection of Blood Components, Patient Therapy and Blood Hematopoietic Progenitor Cells

    The fellow will have an understanding of the basic concepts of apheresis and bone marrow/stem cell collection. The fellow will have a working knowledge of the variety of therapeutic apheresis instruments, procedures, and the appropriate indications.

    1. Donor Apheresis - The fellow will:
      1. have a basic understanding of the collection of platelets, plasma, leukocytes, and peripheral blood stem cells from normal donors.
      2. understand the donor eligibility requirements unique to apheresis.
      3. understand the different strategies for stimulating donors with hematopoietic growth factors or corticosteroids and the side effects of these medications.
      4. know the side effects and complications of normal donor apheresis and how to prevent or management these.
      5. understand the principles of operation of instruments used to collect blood components by apheresis.
      6. understand the unique requirements that apply to donors undergoing frequent (more often than every eight weeks) apheresis.
    2. Therapeutic Apheresis - The fellow will:
      1. Have a clear understanding of the appropriate indications for either cytapheresis or plasmapheresis.
      2. Act as a consultant and evaluate the patient before, during and after apheresis.
      3. Be able to design a treatment plan including use of replacement solutions.
      4. Understand and recognize the side effects and reactions related to therapeutic apheresis.
      5. Understand the operation of the instrumentation with regard to the separation and collection of various blood components.
    3. Bone Marrow/Stem Cells - The fellow will understand the:
      1. Procedures of harvesting of bone marrow and collection of peripheral blood stem cells by apheresis.
      2. Desired collection parameters including cell numbers and cell types.
      3. Role for allogeneic, autologous, or unrelated donor bone marrow or stem cells.

  5. Hematopoietic Cellular Engineering

    1. Hematopoietic Cellular Engineering - The fellow will:
      1. Understand the current theories and applications of hematopoietic transplantation, including advantages and disadvantages of bone marrow, peripheral blood, and umbilical cord blood-derived hematopoietic cells in transplantation.
      2. Understand the concepts of engraftment, ways in which it is measured, and use of cytokines to speed engraftment.
      3. Have a basic knowledge of the regulatory aspects of basic and advanced clinical cell engineering, including the role of the Food and Drug Administration.
      4. Understand the quality control aspects of a clinical cell engineering laboratory including cell enumeration, viability, functional evaluation, and detection of microbial contamination.
      5. Understand current theory and applications regarding collection, processing and storage of hematopoietic progenitor cells from marrow, peripheral blood, and umbilical cord blood.
      6. Understand techniques for thawing, washing and infusing cryopreserved hematopoietic cell grafts, including known adverse reactions. Will participate in these infusions.
      7. Understand the overall theory and methods of T-cell depletion, and related cell engineering methods to control or exploit graft-vs.-host disease.
      8. Understand current clinical methods and rationale underlying positive selection of CD34+ cells.
      9. Have a basic theoretical and practical understanding of selected cell engineering methods involving cell expansion, cell activation, and genetic modification.
    2. Umbilical Cord Blood Bank - The fellow will:
      1. Understand the role of cord blood in hematopoietic cell transplantation.
      2. Understand the structure and operation of a cord blood bank.
      3. Understand the medical evaluation and other criteria used to determine the suitability of cord blood for banking.
      4. Understand the ethical issues involved in cord blood banking including those relating to consent.
      5. Be knowledgeable of the methods used to process and store cord blood.
      6. Be familiar with techniques for thawing and transfusing cord blood.

  6. Parentage Testing

    The fellow will have an understanding of the legal, technical, and laboratory test systems employed in parentage and immigration testing.

    1. Specimen identification and chain of custody
    2. Test systems employed in parentage testing:
      1. ABO blood group
      2. Rh and other red cell antigens
      3. HLA typing
      4. DNA analysis
    3. Analysis and calculation of paternity index
    4. Legal implications of reporting system including testing protocol, affidavit, and deposition/testimony

  7. Coagulation

    It is expected that fellows will have completed a rotation or have spent time in a coagulation laboratory before beginning the fellowship. If not, the fellow will take the standard pathology coagulation rotation. The coagulation experience is designed to emphasize the recognition and management of coagulopathies and bleeding and thrombotic problems. The fellow will:

    1. Be knowledgeable about the management of bleeding or elective procedures in hemophilia patients.
    2. Be prepared to recognize, prevent, or manage the coagulopathy in massive transfusion.
    3. Be aware of the different coagulation factor concentrates, their indications, and disadvantages.
    4. Recognize and manage coagulopathies associated with a variety of clinical conditions such as cardiovascular bypass, renal disease, liver disease, ECMO devices, etc.
    5. understand the various strategies for managing coagulation factor inhibitors.
    6. Understand the inherited basis of some thrombotic disorders.

  8. Histocompatibility

    It is expected that the fellow will have completed a rotation in histocompatibility before beginning the fellowship. If not, the fellow will take the standard HLA rotation for pathology residents. The HLA experience for fellows is oriented to clinical decision-making regarding selection of organ and hematopoietic stem cell donors and donors for patients refractory to platelet transfusions. The fellow will:

    1. Understand the procedures used for serologic and molecular HLA typing.
    2. Understand the procedures used to crossmatch patients with potential kidney donors.
    3. Participate in the selection of one or more unrelated marrow donors.
    4. Understand the different kinds/extent of matched platelet donors and participate in the selection of donors for patients who are refractory to platelet transfusion.

  9. Quality Assurance and Administrative Management

    1. The fellow will understand how to insure that the transfusion service/blood bank or blood collection and processing facility is operating in conformity with the standards and requirements of the AABB, FDA, CAP, and JCAHO.
      1. Participate in CAP, AABB, FDA, state, or local inspection preparations or inspections occurring during the rotation
      2. Understand the role of individuals and institutions in the development of AABB Standards.
    2. Participate in ongoing quality management program.
      1. Understand federal regulations such as: CLIA, OSHA, and FDA good manufacturing practices
      2. Review ongoing quality control, proficiency testing, and competency evaluation activities
      3. Attend the quality program meetings and management meetings at each organization
    3. Participate in a program of continuous auditing of blood and blood component transfusions.
      1. Attend UMMCF transfusion committee meetings occurring during the rotation
      2. Participate in community hospital based transfusion committee meetings
      3. Perform blood usage audits as necessary
    4. Participate in continuing education program for technologists within the department.
      1. Present at the immunohematology conferences at UMMCF
      2. Present at the Laboratory Medicine and Pathology departmental pathology residents conference
      3. Present, if asked, at educational seminars such as Minnesota Association of Blood Banks and Quad Sates annual meetings

A general outline of the topics covered at each of the participating institutions is shown below.

Topic Covered UMMCF VAMC ARC MBCM HCMC
Blood groups •
RBC antibody investigation • • • •
Compatibility testing • •
Donor recruitment • •
Donor evaluation/selection • •
Blood collection • •
Component production • •
Donor apheresis • •
Autologous and directed donations • •
Component therapy • •
Clinical consultation • • •
Trauma massive transfusion •
Coagulation/bleeding • • •
Marrow transplantation •
Obstetrics •
Neonatal and pediatric transfusion • •
Transfusion reactions • • •
Therapeutic apheresis •
Therapeutic phlebotomy • • •
Intraoperative blood salvage • •
Hematopoietic stem cell processing •
HLA •
Parentage testing •
Transfusion committee • • •
Information systems • •
Administration & management • •
Blood utilization • •
Regional inventory management • •
Umbilical cord blood banking •
Platelet and neutrophil serology •