Transfusion Medicine Clinical Fellowship Program -
Training Objectives and Duties

Mission Statement
Environmental Description
Clinical and Research Training
Training Objectives and Duties
Evaluation

Transfusion Service / Coagulation Rotation

Transfusion Services

  1. Master basic blood group serology and develop familiarity with techniques (manual and automated) to perform ABO & Rh typing, antibody screen, antibody identification, crossmatching and direct antiglobulin test.
  2. Perform clinical investigation and laboratory interpretation of transfusion reactions.
  3. Know the indications for each blood component, its content and potential adverse effects.
  4. Know indications for CMV-negative/safe, irradiated, and leukocyte-reduced blood products.
  5. Become familiar with the principles of transfusion support of organ transplantation and bone marrow transplantation.
  6. Become familiar with the regulatory agencies that oversee transfusion services (AABB, FDA, CLIA, State, CAP)The transfusion medicine fellow is expected to participate in activities involving the department of Quality Assurance.
  7. Know the acute, delayed, and chronic complications of transfusion, their pathogenesis, diagnosis, treatment, and prevention including: acute and delayed hemolysis, fever chill reactions, allergic reactions, anaphylaxis, TRALI, TAGVHD and septic transfusion reactions
  8. Understand the role of cytokines in mediating acute transfusion reactions
  9. Be familiar with the laboratory evaluation of transfusion reactions
  10. Be familiar with transfusion transmitted infections including HIV, hepatitis, HTLV, bacteria, CJD, syphilis, malaria, babesia, and Chagas disease.
  11. Know the pathogenesis, management, and diagnosis of hemolytic disease of the newborn.
  12. Be familiar with blood component support for the fetus and the newborn.
  13. Be familiar with blood component support during pregnancy.
  14. Be familiar with major clinically significant red cell antigen systems (ABO, Rh, Kell, Kidd, Duffy, MNSS), their frequency, frequency of antibodies to these antigens, clinical significance and transfusion management. Be familiar with the commonly encountered clinically insignificant antibodies, including Lewis, P,I, and HTLA, and their transfusion management.
  15. Be familiar with the laboratory investigation of warm, cold, and drug-induced hemolytic anemias, their clinical features, laboratory investigation, and management.
  16. Act as a consultant for clinicians on issues of Blood Banking/Transfusion Medicine.
  17. Serve as a teaching and clinical resource for residents in pathology

Coagulation

  1. Develop familiarity with interpreting coagulation profiles in liver disease, vitamin K deficiency heparin effect, DIC, lupus anticoagulant, von Willebrand's disease, hemophilia, blocking inhibitors, and hypercoagulable states. Develop familiarity with the management of patients with active DIC or other coagulopathies.
  2. Obtain medical histories for interpretation of coagulation studies. Fellows are expected to provide guidance to the residents.
  3. Understand the diagnosis and significance of Factor V Leiden and Prothrombin variant mutations.
  4. Develop familiarity with the interpretation of platelet aggregation studies and bleeding time and their role in the diagnosis of acquired and inherited platelet dysfunction disorders.
  5. Understand the appropriate use and interpretation of coagulation tests. Understand, in a general fashion the underlying coagulation mechanisms evaluated by various tests.
  6. Be familiar with the various testing methods used in coagulation, i.e., clotting endpoint, chromogenic assays, laurell rockets, ELISA and molecular assays.

Hemophilia

  1. Understand the diagnosis, natural history, and management of patients with hemophilia A and B.
  2. Recognize the presentation, symptomatology, and appropriate management of hemorrhagic problems of hemophilia: hemarthroses, hematomas, retroperitoneal hematomas, CNS hemorrhage, GI bleeding.
  3. Understand the incidence, natural history, and management of the complications including hepatitis (A-G), HIV infection, inhibitors, and orthopedic disabilities.
  4. Understand the diagnosis, natural history, and management of patients with von Willebrand's Disease.
  5. Develop a working knowledge of the blood products indicated for hemophilia and von Willebrand's management, including calculations and appropriate treatment doses and safety of each product. Fellows will be able to provide initial therapeutic recommendations for outpatient and emergency factor replacement.
  6. Understand the genetics of hemophilia and von Willebrand's disease, diagnostic tests available, and appropriate counseling for family members.
  7. Understand treatment modalities for vonWillebrand's disease and indications for treatment including prophylaxis.
  8. Be familiar with gene therapy and its potential role in future patient management.

Blood Services Rotation

Fellows spend 1-2 months in the blood program gaining exposure to all aspects of blood recruitment, collection, manufacturing (processing), and distribution. The fellows observe these activities in a cGMP environment. Rotation requirements include the following:
  1. Observe a donor through the interview process, examination, arm preparation, and phlebotomy.
  2. Observe blood donations at both a fixed site and mobile site for donor collection.
  3. Following whole blood units through processing into individual components in the component laboratory.
  4. Rotate through Product Management where storage, inventory management, and hospital component distribution occurs.
  5. Rotate through special donations to observe the scheduling and special features required to manage an autologous, directed, and marrow donor program.
  6. Rotate through the donor counseling area
  7. Review the regulatory requirements for blood center operations with the Quality Unit.
  8. Observe donors undergoing donor apheresis of platelets and if possible granulocytes
  9. Review with apheresis coordinator the development of an HLA matched donor pool and indications for HLA matched platelets. The fellow will participate in the selection of HLA matched platelets for refractory patients.
  10. The fellow will discuss the National Marrow Donor Program with the coordinator

Goals /Objectives

  1. Understand the strategies for donor recruitment and the methods use to recruit donors.
  2. Become familiar with donor motives including altruism, reward, and test seeking.
  3. Know the criteria for donor eligibility and assessment methods used at donation (interview and examination)
  4. Understand the rationale for each question in the donor screening process and the deferral requirements.
  5. Understand the rationale and methods used for each test performed on a unit of blood.
  6. Be able to categorize the steps in the donation process designed to protect the recipient and those designed to protect the donor.
  7. Recognize the adverse reactions to donation and their management.
  8. Know the processes required to manage an autologous/directed donation program.
  9. Understand how autologous donation differs from allogeneic donation.
  10. Know the rationale for autologous donation and the appropriate indications.
  11. Understand the role of directed donations and their advantages and disadvantages.
  12. Understand the concept of "crossover" and the application to autologous and directed units
  13. Become familiar with the steps in component processing including separation techniques, anticoagulation, preservatives, storage and quality requirements.
  14. Know the labeling requirements for each component and the requirements to "release" a unit and the shipping conditions.
  15. Become familiar with the regional demands for blood and how local collections and imports are used to meet demand.
  16. Understand the steps taken to manage blood shortages and emergencies.
  17. Know the reasons for product recalls and management of the process.
  18. Become familiar with the donor counseling function including donor notification policies, donor deferral, and counseling.
  19. Understand the consequences and methods for handling abnormal test results.
  20. Know rational and requirements for "lookback" and post transfusion surveillance.
  21. Understand the concept of cGMP and know the relevant sections of the FDA Code of Federal Regulations and the AABB Standards.
  22. Be familiar with the indications for HLA-matched platelets and techniques for HLA typing and antibody screening, and management of donor plateletpheresis.
  23. Know the indications for granulocyte therapy, and management of donor granulocytapheresis.
  24. Become familiar with the National Marrow Donor Program.

Apheresis Rotation

1-2 months. Fellows engage in the following activities on the apheresis rotation:
  1. Review the various apheresis instruments with the nurses
  2. Observe the performance of therapeutic plasmaphereis and cytopheresis procedures with the nurses.
  3. Fellows discuss with the nurses and attendings the indications for therapeutic apheresis, complications, fluid replacement and treatment course.
  4. Fellows follow all patients on the service either by attending the procedure or discussing the case with the nurse. Fellows report to the attending any changes in clinical status and the progress of therapy.
  5. Fellows observe the collection of stem cells by apheresis and follow patients who are undergoing multiple collections.
  6. Fellows will observe a therapeutic phlebotomy

Goals and Objectives

  1. Understand the principles of apheresis technology, including continuous and discontinuous centrifugation, filtration, and immunoadsorption.
  2. Know the complications associated with apheresis and their management.
  3. Know which disease can be effectively treated with therapeutic plasmapheresis and the appropriate replacement fluids.
  4. Know the indications for therapeutic leukopheresis, plateletpheresis and erythrocytapheresis.
  5. Become familiar with apheresis techniques for hematopoietic stem cell collection.
  6. Understand the indications and techniques used for therapeutic phlebtomy.

Hematopoietic Stem Cell Laboratory Rotation

Fellows will spend a week in the laboratory with the HSC laboratory supervisor. Fellows will observe the processing, enumeration, freezing and storage of autologous and allogeneic stem cell collections. Fellows will review the Standards for accreditation of the HSC laboratory with the supervisor. The fellow will observe CD34 measurements by flow and will review CD34 reports for decisions on additional collections.The fellow will observe an infusion of HSC.

Goals and Objectives

  1. Become familiar with the different modalities available for the collection of hematopoietic stem cells (HSC) from peripheral blood,bone marrow, and cord blood.
  2. Understand the use of CD34 in assessing the adequacy of collection
  3. Understand the method of CD34 enumeration by flow cytometry.
  4. Become familiar with the different ways of processing the stem cell collection, i.e. removal of RBCs or plasma for ABO incompatible allo-BMT, T cell depletion, purging.
  5. Become familiar with the freezing and storage of HSCs.
  6. Become familiar with the HSC thawing and infusion process and complications of infusion.

Viral Testing Rotation

Fellows spend up to one week in the Donor Testing Laboratory with the supervisor or technologists observing the methods used to perform viral testing. The fellow will discuss with staff the testing algorithms and the use of screening and confirmatory tests in donor testings.

Goals and objectives

  1. Understand the interaction of the CAP, AABB, CLIA, and FDA in the regulation of patient and donor testing.
  2. Learn the biology and natural history of hepatitis A to G. HIV-1, HIV-2, HTLVI/II, and West Nile Virus
  3. Understand the algorithms for EIA viral testing and learn limitations of current assays.
  4. Become familiar with supplemental tests and when to use them.
  5. Become familiar with polymerase chain reaction based assays for viral testing.

Histocompatibility Rotation

For one week, fellows rotate through the HLA laboratory at the University of Pittsburgh. He/she observe serological and molecular methods for class I and class II typing. Fellows will discuss with staff the use of HLA typing in the platelet donor, stem cell, and organ transplant setting.

Goals and Objectives

  1. Understand when and why serologic, cellular, and DNA assays are important to the transplant patient.
  2. Understand which techniques for HLA typing are useful in each type of solid organ transplant.
  3. Understand how various techniques for antibody screening and crossmatching are important in evaluating the donor and recipient.
  4. Understand the relevance of allelic mismatches defined by DNA techniques in bone marrow transplantation.
  5. Understand the clinical relevance and techniques for monitoring bone marrow engraftment.
  6. Obtain an overview of the type of cases, problems, and challenges facing a clinical histocompatibility laboratory.

Conferences and Meetings

Name of Conference Frequency Department Responsible
Stem Cell Transplant Transfusion Meeting Weekly Hematology
Medical Grand Rounds Weekly Medicine
Hemophilia Meeting Weekly Hemophilia Center
Medical Staff Meeting Bi-Weekly ITxM
Coagulation Staff Meeting Bi-Weekly ITxM
  1. The fellow can participate in providing recommendations to the transplant service house staff for transfusion support, particularly platelet transfusions.
  2. Passive participation.
  3. Fellows are exposed to hemophilia patients and their management.
  4. Active participation. The fellow may submit agenda items for discussion and is expected to actively contribute to the discussions. Fellows present journal club articles during medical staff meetings 2-3 times/year in rotation with pathology residents. Administration issues are discussed.

Teaching Responsibilities

The Fellow is expected to conduct daily morning rounds with the trainees and attendings. These rounds involve evaluation of difficult red cell serologic studies, discussion of transfusion reactions and consultations on blood product usage from the clinical staff. The fellow provides didactic lectures for trainees that will cover: ABO and Rh serology, component therapy, transfusion reactions, use of specialized blood products, hemolytic disease of the newborn, and hemolytic anemias. Fellows also serve as a continuing medical education resource for the Blood Bank technical staff.