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Case Study:
Jackie Ensley, MLS(ASCP)CMSBBCM
Immunohematology Reference Laboratory Manager
Kentucky Blood Center
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Objectives
1. To discuss a case study which required more complex antibody detection and identification
2. To review different methods of antibody detection
3. To discuss the transfusion recommendations and blood group involved with the case study
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3
HOSPITAL RESULTS
• April 2017 patient reported to hospital with no defined
antibody pattern: 1+ reactions in gel No reactions in tube at AHG
Needs 2 units
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PATIENT HISTORY
• Female, 45 years old, Caucasian
• Last Transfusion in 2014
• History: B Positive -No blood bank history at any of the larger surrounding hospitals
-Previously had non-specific gel reactivity
- Hgb 6.2
-Patient diagnosis includes anemia and cellulitis left leg
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ABO/Rh performed
DAT Performed
Anti-A Anti-B Anti-D A1 Cell B Cell ABO/Rh
0 4+ 4+ 4+ 0 B Positive
Poly/tube Anti-IgG/ tube Anti-C3/ tube
0√ 0√ 0√
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Reference Lab testing
Reference Lab testing
Phenotyping
Be sure to rule out anti-f, -K, -Fyb, -Jkb, -Leb, -M, -s
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Rh System Kell Duffy Kidd Lewis P MNS
D C c E e K Fya Fyb Jka Jkb Lea Leb P1 M N S s
+ + + + + 0 + 0 + 0 + 0 + 0 + + 0
Most likely R1R2
Reference Lab Testing – Plasma
Rh System Kell Duffy Kidd Lewis P MNS Lutheran
IS
AH
G-P
eG
Cell
D C c E e V Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub
I
+ + 0 0 + 0 0 + + 0 + 0 + + 0 + 0 0 + + 0 + + + 0 + 0 1+ II
+ 0 + + 0 0 0 0 + 0 + 0 + + + + + + 0 + + + + 0 0 + 0 0 AC
0 0
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Reference Lab Testing – Plasma
Rh System Kell Duffy Kidd Lewis P MNS
IS
AH
G-
Pe
G
Cell D C c E e K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s
1 0 0 + 0 + 0 + 0 + 0 + 0 0 + 0 0 + + 0 + 0 0 0 0
2 + + 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 0 + + 0 + 0 0
3 0 0 + + 0 + 0 0 + 0 + 0 + 0 + + 0 0 0 + 0 + 0 0
4 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + + 0 0 + 0 0
5 + + 0 0 + + + 0 + 0 + + 0 0 + 0 + + 0 + 0 + 0 0
6 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 0 + 0 + 0 + 0 0 0
Auto
+ + + + + 0 + 0 + 0 + 0 + 0 + + 0 0 0
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Reference Lab Testing – Plasma
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Rh System Kell Duffy Kidd Lewis P MNS Lutheran
GEL
Cell D C c E e K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub
1 + + 0 0 + 0 + 0 + 0 + + + + 0 + 0 + + + + + 0 + 1+
2 + + 0 0 + 0 + 0 + 0 + + + 0 + 0 + + + 0 + 0 0 + 2+
3 + 0 + + 0 0 + 0 + 0 + 0 0 + 0 0 + + + 0 + + + + 3+
4 + 0 + 0 + 0 + 0 + 0 + 0 + + 0 0 0 + 0 + + + 0 + 1+
5 0 + + 0 + 0 + 0 + 0 + + + + + + 0 + + + + + 0 + 1+
6 0 0 + + + + + 0 + 0 + + 0 0 + 0 + 0 + 0 + + 0 + 3+
7 0 0 + 0 + + + 0 + 0 + 0 + + + + 0 0 + 0 0 + 0 + 3+
8 0 0 + 0 + 0 + 0 + 0 + 0 + 0 + 0 + + + 0 + + 0 + 2+
9 0 0 + 0 + 0 + 0 + 0 + + 0 + + 0 + 0 0 + 0 + 0 + 0
10 0 0 + 0 + 0 + 0 + 0 + 0 + + 0 0 0 + + 0 + 0 0 + 2+
11 + 0 + 0 + + + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 1+
Auto
+ + + + + 0 + 0 + 0 + 0 + 0 + + 0 0
Reference Lab Testing – Plasma
Rh System Kell Duffy Kidd Lewis P MNS
AH
G-
Pe
G
GEL
Cell D C c E e K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s
1 0 0 + 0 + 0 + 0 + 0 + 0 0 + 0 0 + + 0 + 0 0 0 3+
2 + + 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 0 + + 0 + 0 3+
3 0 0 + + 0 + 0 0 + 0 + 0 + 0 + + 0 0 0 + 0 + 0 3+
4 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + + 0 0 + 0 1+
5 + + 0 0 + + + 0 + 0 + + 0 0 + 0 + + 0 + 0 + 0 2+
6 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 0 + 0 + 0 + 0 0 3+
Auto
+ + + + + 0 + 0 + 0 + 0 + 0 + + 0 0
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Additional cells are tested in the gel and range from 1+ to 3+ as well
• Let’s look at what we know:
Phase of reactivity: AHG
Strength/pattern of reactivity: almost all reactive, different strengths, weak in tube reacts best in gel
Patient history: previous history of non-specific gel reactivity
DAT/autocontrol: negative
Other info: B+
Serologic Problem Solving
So where do we go at this point?
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• Test phenotypically similar cell - negative for f, Fyb, Jkb, Leb, M, s
Positive
• Alloadsorption attempted
Unsuccessful
• Test with ficin treated cells
Negative
• Test with 0.2M DTT treated cells
Positive
Serologic Problem Solving
So where do we go at this point?
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Gerbich antibody
Chido/Rodgers antibody
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Testing Results
Ficin / papain - Sensitive
DTT 0.2M - Resistant
Almost all cells reactive
Different reaction strengths
Does not adsorb out
Reacts best in gel, not very well in tube
Pooled Plasma Inhibition
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Pooled Plasma Inhibition
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Original plasma reactivity
Control plasma
reactivity (6% albumin)
Pooled plasma reactivity
1+ 1+ 0
1+ 1+ 0
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Great!
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Gotcha!
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Anti-Ch
IgG Class
IAT Optimal
>90% Occurrence
FICIN SENSITIVE
DTT RESISTANT
Chido/Rodgers Fun Fact: Named after the first antibody producers, Chido and Rodgers.
21 From Human Blood Groups by Geoff Daniels
Chido/Rodgers - “HTLA”
• Reacts with majority of panel cells
• Frequently described as “reactive weakly by the antiglobulin test.” – Reactions are very weak and will break apart very
readily due to the weak attraction between the antigens and antibodies (low avidity).
– Repeated reactions may be irreproducible and not give the same strength or reactivity
• However, reactions of at least 1-2+ have also been seen using gel technique.
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Chido/Rodgers - “HTLA”
• These antibodies are not clinically significant
• Weak reactivity with high titers >64 are characteristic, but titers below 64 have also been seen.
**A high titer does not give us a specificity, but can help the lab determine if they are on the right track
with identification**
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Chido/Rodgers - “HTLA”
• Usually negative DAT, but each patient is different with unique history, diagnosis and treatment plans
• Reaction pattern suggests an antibody to a high-frequency antigen, and all or most cells are reactive at IgG.
• Reactions do not seem to fit a specific antibody or combination of antibodies pattern
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Chido/Rodgers - “HTLA”
• 1-2 phenotypically similar cells are run and are reactive
• Theoretically should not adsorb out of the plasma because of the low-avidity of the antibody
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Transfusions
• Antibody is not clinically significant
• Give compatible RBCs if able to but due to high prevalence of antigen may not be able to find crossmatch compatible
• May rarely see anaphylactic reactions with plasma products + platelets
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Resources
• Reid, Marion and Christine Lomas-Francis (2012). The Blood Group Antigen FactsBook, Elsevier.
• Daniels, G. (2013) Human Blood Groups, 3rd edition, Wiley-Blackwell, Oxford, UK.
Email me at [email protected]
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