The need is constant. The gratification is instant. Give blood. TM Transfusion Medicine Case Studies Patient GJ March 2010 John N. McLennan, MT(ASCP) Midwest

The need is constant.The gratification is instant.Give blood.TM

Transfusion Medicine Case StudiesPatient GJMarch 2010

John N. McLennan, MT(ASCP)

Midwest Region American Red Cross

Omaha, NE


Gertrude Jones presented to the emergency department complaining of shortness of breath and leg pain. She recently had a double mastectomy. Gertrude has a history of DVT’s in

her left leg.

Current hemoglobin: 7.0 g/dL Current hematocrit: 20.8%

Gertrude’s transfusion history indicates that she is A Positive. She has received blood in the last 3 months, getting 8 units of

packed red cells in the last 4 days. She has a history of anti-E.

Crossmatch indicates that 8 of 8 units that are E antigen negative are incompatible.

The sample was sent to the reference laboratory for further investigation.

2


Case GJ

3

Front Type Rh Reverse Type

Interp. Anti-A Anti-B Anti-D A1 cells B Cells

A Positive 4+ 0 4+ 0 3+

Blood Group System

Rh MNSs P Lewis Kell Duffy Kidd Lutheran

D C E c e Cw M N S s P1 Lea Leb K k Fya Fyb Jka Jkb Lua Lub

1 R1 R1 + + 0 0 + 0 + 0 0 + + 0 + + + + + + 0 0 + 0 0 0

2 R2 R2 + 0 + + 0 0 + + + + + + 0 0 + + 0 + + 0 + 0 1+ 3+

3 rr 0 0 0 + + 0 0 + + 0 0 0 + 0 + 0 + 0 + 0 + 0 1+ 2+

Auto 0 1+ 2+mf


With a positive auto-antibody in a recently transfused patient, a DAT and elution should be performed.

There is no specific order to perform testing. Since there were negative cells reactive at LISS/37 and LISS/AHG, testing with serum/plasma could be performed to determine the allo-antibody specificity. The elution could also be performed to determine what is coating the red blood cells.

REMEMBER, the patient has been recently transfused, so there is a mixture of patient cells and transfused cells present in this sample.

4

Case GJ

Poly IgG C3d Control

Positive IgG DAT 2+ mf 3+ mf 0 0


5

Case GJ

This allo-antibody titer slowly decreases (over time) after the initial immune response, sometimes becoming undetectable in the serum.

Often, if the antibody screen is initially negative, transfusion with the antigen positive unit will trigger an anamnestic response, causing the antibody to respond quite rapidly.

Patient GJ is suspected to be having a delayed transfusion reaction.


A panel was tested with the patient plasma to see if an antibody specificity could be determined.

6

Case GJ

Blood Group

System



1 Rz R1 + + + 0 + 0 0 + 0 + + 0 + + + + 0 + 0 0 + 0 1+

2 R1 R1 + + 0 0 + + + 0 + + + + 0 0 + + 0 0 + 0 + 0 0

3 R1 R1 + + 0 0 + 0 + + + 0 + 0 + 0 + 0 + + 0 0 + 0 0

4 R2 R2 + 0 + + 0 0 + 0 + 0 0 + 0 + 0 + 0 0 + 0 + 1+ 3+

5 R2 R2 + 0 + + 0 0 + + 0 + 0 0 + 0 + 0 + 0 + 0 + 1+ 3+

6 rr 0 0 0 + + 0 0 + + 0 + 0 + 0 + + + + + 0 + 1+ 3+

7 rr 0 0 0 + + 0 0 + + + + 0 + 0 + + 0 + + 0 + 1+ 3+

8 rr 0 0 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0 + 0 + 1+ 3+


7

Case GJ

All common allo-antibodies have been ruled out except anti-E and anti-c. It appears that the patient has developed anti-c. Now testing

must be performed with the eluate to determine what antibody (ies) are coating the red cells.

Blood Group System



1 R1 R1 + + 0 0 + + 0 + 0 + + + 0 0 + + 0 0 + 0 + 0 0

2 R1 R1 + + 0 0 + 0 0 + + 0 0 0 + + + 0 + + + 0 + 0 0

3 rr 0 0 0 + + 0 + + 0 + 0 0 + 0 + + + + + 0 + 1+ 3+

4 rr 0 0 0 + + 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 1+ 3+

Additional cells were tested to complete the identification process


Case GJ

Eluate testing is treated just like plasma/serum testing. All common allo-antibodies must be ruled in/out with the eluate. A panel was performed to identify the antibody that is present in the eluate.

8

Blood Group System



1 R1 R1 + + 0 0 + 0 + 0 0 + + 0 + + + + + + 0 0 + 0 0

2 R2 R2 + 0 + + 0 0 + + + + + + 0 0 + + 0 + + 0 + 2+ 0

3 rr 0 0 0 + + 0 0 + + 0 0 0 + 0 + 0 + 0 + 0 + 2+ 0


9

Case GJ

9

Case GJ

Blood Group

System



1 Rz R1 + + + 0 + 0 0 + 0 + + 0 + + + + 0 + 0 0 + 0 0

2 R1 R1 + + 0 0 + + + 0 + + + + 0 0 + + 0 0 + 0 + 0 0

3 R1 R1 + + 0 0 + 0 + + + 0 + 0 + 0 + 0 + + 0 0 + 0 0

4 R2 R2 + 0 + + 0 0 + 0 + 0 0 + 0 + 0 + 0 0 + 0 + 2+ 0

5 R2 R2 + 0 + + 0 0 + + 0 + 0 0 + 0 + 0 + 0 + 0 + 2+ 0

6 rr 0 0 0 + + 0 0 + + 0 + 0 + 0 + + + + + 0 + 2+ 0

7 rr 0 0 0 + + 0 0 + + + + 0 + 0 + + 0 + + 0 + 2+ 0

8 rr 0 0 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0 + 0 + 2+ 0


1010

Case GJ

All common allo-antibodies have been ruled out except anti-c. It appears that the patient has developed anti-c.

If the patient had not been transfused so recently, a cell separation and complete phenotype would be performed. However, the patient received 8 units of PRBC’s in the past 4 days. There is a lot of circulating transfused cells in this patient’s sample,

and cell separation and phenotyping would probably be unsuccessful.

Blood Group System



1 Rz R1 + + + 0 + + 0 + 0 + + + 0 0 + + 0 0 + 0 + 0 0

2 R1 R1 + + 0 0 + 0 0 + + 0 0 0 + + + 0 + + + 0 + 0 0

3 rr 0 0 0 + + 0 + + 0 + 0 0 + 0 + + + + + 0 + 1+ 3+

4 rr 0 0 0 + + 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 1+ 3+


Conclusion:• Anti-E historical per hospital record

• Anti-c PEG/AHG and Eluate

• Positive IgG-DAT

• Due to recent multiple transfusions, phenotype was not performed

• If required, transfuse A Positive red cells that are negative for E and c.

11

Case GJ


Patient management of a delayed hemolytic transfusion reaction include monitoring the patient and providing supportive care. Most frequently, a correction of the anemia is all that is required. This would be achieved by transfusing antigen negative blood.

When a transfusion reaction is suspected, the patient’s physician and and the transfusion service director should be notified. This would allow for identification and treatment of any unrecognized hemolysis.

12

Case GJ


Transfusion Medicine Case StudiesCase PW

March 2010

Presented by John N. McLennan, MT(ASCP)

Midwest Region American Red Cross

Omaha, NE


Pam Weeks is a patient at Large Hospital. She is a 2 year old African American female. She presented to the emergency department with a

distended abdomen and severe abdominal discomfort.

She had a liver transplant 8 months ago. She has received multiple transfusions in the last few months, with the most recent being 1 unit of

packed red blood cells 4 weeks ago.

Her current hemoglobin is 7.4 g/dL with a hematocrit of 23.3%.

Large laboratory sent the sample to the reference lab for antibody identification. She is historically O Positive with a history of a warm

autoantibody, not demonstrable in LISS media.

14


Case PW

15

Front Type Rh Reverse Type

Interp. Anti-A Anti-B Anti-D A1 cells B Cells

O Positive 0 0 4+ 4+ 3+


Case PW

Due to the formation of an antibody and the recent transfusions, an elution was performed on PW’s red cells.

16

Poly IgG C3d Control

Positive IgG DAT 1+ 0 0

The eluate was broadly reactive with all cells tested, which is consistent with a warm-autoantibody.


Warm auto reactivity is apparent in the serum and eluate with PEG enhancement. Confirmation can be performed by:

Testing the DAT negative autologous cells against the serum

Testing the eluate against the DAT negative autologous cells

If a patient has been recently transfused and autologous cells are not available, the term “consistent with a warm autoantibody” will be used. This term is used when absolute confirmation by

the above methods cannot be performed.

17

Case PW


A cell separation was performed. To ensure that any AHG testing will not be affected by the positive DAT, a DAT was performed on the separated cells.

18

Case PW

C E c e M N S s K Fya Fyb Jka Jkb6%

Albumin

0 0 + + + 0 0 + 0 0 0 + 0 0

Since the cell separation had a positive DAT, EGA must be used to remove the IgG coating on the

red cells

IgG

Cell Separated Cells 1+

EGA treated Cell Separation 0

The autologous cells (reticulocytes) that were harvested and chemically rendered DAT negative, are used for patient phenotyping. These cells

can also be tested against the plasma and eluate to confirm the presence of a warm autoantibody.


19

Case PW

Patient serumPEG/AHG

EluatePEG/AHG

Last WashPEG/AHG

EGA Treated Cell Separation (DAT Negative autologous cells) 2+ 2+ 0

All of the testing indicates that there is a warm auto-antibody present at PEG/AHG.

It is not necessary to proceed any further with testing at PEG. PEG enhancement commonly enhances warm auto-antibody reactivity.

Since we have negative reactivity with LISS enhancement, rule-out of the common allo-antibodies will be performed with LISS media.


Because the patient had a negative antibody screen with LISS at AHG, a panel of cells was tested to insure all common allo-antibodies

have been ruled out at LISS/AHG.

20

Case PW

All common allo-antibodies have been excluded with LISS/AHG

Blood Group System



1 R1 R1 + + 0 0 + 0 + 0 + 0 + 0 + 0 + 0 + 0 + 0 + 2+ 0

2 R1 R1 + + 0 0 + 0 0 + 0 + 0 0 + 0 + + + 0 + 0 + 2+ 0

3 R2 R2 + 0 + + 0 0 0 + 0 + 0 + 0 + + + 0 + + 0 + 2+ 0

4 R2 R2 + 0 + + 0 0 + + + 0 + 0 + 0 + 0 + + 0 0 + 2+ 0

5 r’r 0 + 0 + + 0 + 0 + + 0 + 0 + 0 + 0 + 0 0 + 2+ 0

6 r”r 0 0 + + + 0 + + + + 0 0 + 0 + + + + + 0 + 2+ 0


Now, the focus will be on testing for antibody identification at LISS/37.

Auto-control was negative at LISS/37, indicating the probable presence of an allo-antibody. Since the phenotype of the patient has been

established, testing of 2 phenotypically similar reagent red cells will aid in antibody identification. (phenotype: C-, E-, S-, K-, Fya-, Fyb-, Jkb-)

21

Case PW


22

Case PW

A panel of high incidence negative red cells was tested with the following results. (Testing only needs to be done at LISS/37)

Blood Group System



1 0 0 0 + + 0 + + 0 + + + 0 + + + 0 + + 0 + 2+ Joa -

2 + + 0 + + 0 + 0 + + 0 0 + 0 + 0 + 0 + 0 + 2+ Hy-

3 0 0 0 + + 0 + + 0 + 0 0 + 0 + + + + + 0 + 2+ Tja -

4 + + 0 0 + 0 + 0 + + 0 0 + 0 + 0 + 0 + 0 + 0 Kpb -

5 0 0 0 0 0 0 + 0 0 + 0 0 + 0 + + 0 + 0 0 + 2+ Rh Null


Testing a Kpb negative cell was non-reactive at LISS/37. A second Kpb negative cell must be tested.

23

Case PW

Because Kpb negative cells are not commonly found on reagent grade red cell panels, the use of DTT treated cells can be used to rule-out all other common

allo-antibodies, EXCEPT anti-K.

Blood Group System



1 R1 R1 + + 0 0 + + 0 + 0 + + 0 + 0 + + 0 + 0 0 + 0 Kpb -


24

Case PW

Blood Group System



1 R1 R1 + + 0 0 + + + 0 + + + + 0 0 + + 0 0 + 0 + 0

2 R2 R2 + 0 + + 0 0 + + + + + + 0 0 + 0 + 0 + 0 + 0

3 R1 R1 + + 0 0 + 0 + 0 + 0 + + 0 0 + + + 0 + 0 + 0

4 R0 r + 0 0 + + 0 + 0 + + + 0 + 0 + 0 + + 0 0 + 0

5 rr 0 0 0 + + 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0

6 R2 R2 + 0 + + 0 0 0 + 0 + + + 0 0 + + 0 + 0 0 + 0

7 R1 R1 + 0 0 + + 0 0 + 0 0 + 0 0 0 + 0 0 + 0 0 + 0

8 rr 0 0 0 + + 0 0 + 0 + + 0 + 0 + 0 0 + 0 0 + 0


Initial conclusion:

Warm auto-antibody at PEG/AHG with serum and eluate.

Anti-Kpb at LISS/37.

Honor anti-K

(unable to rule out anti-K at LISS/37 due to unavailability of cells)

The patient phenotype indicated patient PW was Kpb antigen negative, with testing being performed with unlicensed anti-sera. However, this phenotype is

uncommon in African American individuals.

25

Case PW


Kpb

A high prevalence in all populations.

This chart indicates 100% of Blacks

are antigen positive for Kpb

The sample was submitted for molecular testing to determine if the anti-Kpb is allo or auto in nature.

Molecular typing indicated that the patient is Kpb antigen positive, confirming the autoantibody specificity. Since there is an auto-anti-

Kpb, antigen negative units do NOT need to be transfused.

26

Case PWPrevalence (%)

Phenotype Whites Blacks

Kp(a+b+) 2.3 RARE

Kp(a-b+) 97.7 100

Kp(a+b-) 2.3 RARE


Consultation Request Form

27

Reference Lab contact numbers: Phone: 402 271 2580 x 2130 Fax: 402 341 2578

See page 2 for instructions, sample types and tube labeling requirements

Call Reference Laboratory before sending sample

Reference Lab person contacted: Date/Time contacted:

Submitting Facility Information Facility Name/ID: Request Date:

Facility Address: City/State: Zip:

Blood Bank Contact:

Blood Bank Phone #: Requesting Physician:

Blood Bank Fax #:

Patient Information Patient Name: Patient ID:

Birth Date/Age: Race: Gender: M F

Specimen Date: ABO/Rh:

Diagnosis: Hgb/Hct:

Medications:

Additional information:

Transfusion History: No record

Within last 3 months: No Yes ► Dates / products:

Prior to last 3 months: No Yes ► Dates / products:

Pregnancy History: Number: Currently pregnant? No Yes ► Due date:

Known RBC antibody(ies) Anti -D -C -c -E -e -K -Fya -Fyb -Jka -Jkb -S -s

Other (list):

Test Request Note: STAT and/or after-hours charges may apply

Routine Patient not waiting, transfuse when available. ASAP Patient waiting, transfusion needed as soon as possible.

STAT Patient actively bleeding/life-threatening.

Investigation Requested: (Check all that apply)

ABO/Rh typing Positive DAT Antibody identification

Incompatible crossmatch Suspected transfusion reaction Hemolytic Disease of the Fetus & Newborn

OTHER SPECIFY:

Products Requested for this patient: (Check all that apply) Product Attributes: (Check all that apply)

PRESELECTED UNITS

# units:

Date needed:

Add any other facility-specific services offered. OTHER SPECIFY:

CMV-negative Leukoreduced Irradiated Hemoglobin S-negative RBC

OTHER SPECIFY:

Summary of Antibody Testing Results

Tube: LISS PEG ENZ

Other:

Gel Solid Phase

IS 37C AHG

I

II

III

AHG Used:Polyspecific IgG

CROSSMATCH RESULT

# Compatible Donors

# Incompatible Donors

DAT:


28

1. Obtain an appropriate sample and label it according to the instructions in the table below.

2. Prepare the sample for shipping according to the instructions in the table below.

Sample and Tube Label Requirements Sample Type: 2-3 7 ml EDAT tubes. IF a warm autoantibody is suspected, include additional EDTA tubes.

Do not submit samples collected with serum separator tubes.

If recently transfused, include pre-transfusion red cell sample, if available

No special preparation of the patient is needed prior to collecting samples

Label Requirements: Sample Label MUST include:

List regional requirements, for example, Patient First and Last Name Patient ID Number (i.e., Hospital

number, SSN, date of birth, etc) Date and time collected

NOTE: IMPROPERLY LABELED SAMPLES WILL NOT BE TESTED

Shipping Instructions:

Pack samples according to facility practice to prevent leaking or breakage in transit. Do not ship samples via first class mail. Please include return transportation for units requested in the facility specific area below.

3. Complete the form.

4. Contact the reference lab at the phone number on the top of the form prior to sending the sample.

5. Record the name of the person contacted and the date and time of the notification.

6. Follow any additional instructions noted in the ARC Facility-specific area below.

7. Submit the sample and a completed Consultation Request to the ARC.

Facility Specific area (for ARC use)

Please communicate return transportation instructions

Consultation Request Form


References:Roback, John D. (2008). AABB Technical Manual, 16th

Edition. Maryland. American Association of Blood Banks.

Reid, Marion and Christine Lomas-Francis. The Blood Group Antigen. Boston: Academic Press, 1997.

Textbook of Blood Banking and Transfusion Medicine, Rudmann, et al, 2005, Chapter 15.

29

Documents

The need is constant. The gratification is instant. Give blood. TM Transfusion Medicine Case Studies Patient GJ March 2010 John N. McLennan, MT(ASCP) Midwest