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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 2  |  Issue : 1  |  Page : 59-63

Protocol evolved for the management of red cell alloimmunization


Department of Transfusion Medicine, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Andheri (W), Mumbai, Maharashtra, India

Date of Web Publication22-Mar-2017

Correspondence Address:
Nidhi Mehta
Department of Transfusion Medicine, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Andheri (W), Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_45_16

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  Abstract 

Alloimmunization is a detrimental effect of transfusion therapy which makes availability of compatible blood difficult due to increased incidence of development of alloantibody and autoantibody, which can lead to mild-to- fatal adverse reactions. This case report illustrates the effective resolution of a case with multiple alloantibodies using advanced immuno-haematological workup with rare antisera. This report also re-emphasizes the need for universal antibody screening and identification for both donors and patients as part of pre-transfusion testing. The assessment of need for transfusion helped in deriving an effective plan of action for supportive care to the patient against the fear of hemolytic reaction. The provision of right and compatible (antigen negative) blood helped in management of patient during chemotherapy. This case emphasizes the indispensable need of devising and maintaining a Rare Blood Donor Register in developing nations. The Rare blood donor registry will help revolutionize the current transfusion practices, and will provide better means of managing critical care patients with single/ multiple antibodies.

Keywords: Alloimmunization, antibody identification, blood transfusion, irregular antibodies, rare blood donors


How to cite this article:
Mehta N, Chakraborty IR, Rane M, Gupta M. Protocol evolved for the management of red cell alloimmunization. Glob J Transfus Med 2017;2:59-63

How to cite this URL:
Mehta N, Chakraborty IR, Rane M, Gupta M. Protocol evolved for the management of red cell alloimmunization. Glob J Transfus Med [serial online] 2017 [cited 2020 Aug 6];2:59-63. Available from: http://www.gjtmonline.com/text.asp?2017/2/1/59/202716


  Introduction Top


Red blood cell (RBC) transfusion continues to play a significant role as lifesaving modality. Delayed hemolytic transfusion reaction (DHTR) is a life-threatening adverse effect of blood transfusion, seen after 5–7 days posttransfusion (can be 4–16 days or up to 4 weeks), mainly as a consequence of anamnestic response to previous antigenic stimulation. Alloimmunization, i.e., development of alloantibody against the foreign RBC, is one of the most important complications of blood transfusions in multiple-transfused patients.[1] Alloimmunization further complicates the transfusion therapy due to (1) difficulty in getting compatible blood (2) increase in the incidence of additional alloantibody and autoantibody development, (3) DHTR, and (4) life-threatening hyperhemolysis syndrome. The most important unexpected RBC alloantibodies in transfusion practice, in terms of frequency of occurrence, are directed toward the Rh (D, C, E, c, and e) and Kell (K) antigens, followed by antigens of Duffy, Kidd, MNS and other minor blood group systems. The development of red cell alloantibodies depends on many factors such as the frequency of antigen in population, whether or not it is an effective immunogen, presence of nonhuman sources of antigen similar to blood group antigen, and amount of antigen exposure. These antibodies can cause acute HTR and DHTR as well as hemolytic disease of the fetus and newborn (HDFN).[2],[3],[4],[5] Pretransfusion antibody screening of patient's sample before cross-match is an essential component of compatibility testing in many countries. However, it is yet to make a mark in the Indian hospital setup as proven in the limited literature that is available.[6],[7]

Unlike other adverse effects of transfusion, DHTRs remain difficult to prevent because (1) there are no tests available to identify patients with evanescent antibodies, (2) sharing of antibody results between facilities is not widely available/practiced, and (3) systematic follow-up testing after transfusion to detect newly formed antibodies is rare. Moreover, treatment options are limited, consisting primarily of supportive care and replacing cleared RBCs via simple transfusion.[8] Blood bank serological findings may include a positive direct antiglobulin test (DAT) (IgG and/or C3) and new antibody in serum. The implicated antibody is often not detectable in pretransfusion specimens due to low concentration but quickly becomes detectable posttransfusion indicating anamnestic antibody response. The anamnestic response may not cause hemolysis and the patient appears asymptomatic with no clinical findings despite the positive serological findings.


  Case Report Top


A 52-year-old female patient, postmenopausal for 4 years, known case of metastatic serous adenocarcinoma of ovary and hemoglobin (Hb) E hemoglobinopathy, was admitted in our institute with complaints of abdominal distension for 1½ months duration, associated with abdominal pain and constipation. The patient had two normal, uneventful deliveries with no history of transfusion during the course of pregnancy.

Ultrasonography revealed hepatosplenomegaly with complex cystic mass lesion measuring 10.1 cm × 9.2 cm × 5.5 cm close to the posterior wall of the uterus. She gives a past transfusion history of two units of packed RBC (PRBC) in her prior hospitalization. She developed high-grade fever posttransfusion of the second unit during the same episode.

Patient's blood samples were received for blood grouping and cross-matching at our institute.

Blood grouping

Blood grouping by forward and reverse typing was O positive by CAT [Figure 1] and [Table 1].
Figure 1: Rh Kell phenotyping and blood grouping

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Table 1: Blood grouping of repeat sample

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Direct antiglobulin test/indirect antiglobulin test

Patient sample was DAT negative and indirect antiglobulin test positive (3+).

Retrospective history revealed previous history of transfusion with PRBC 20 years back, following diagnosis of anemia. However, no further records were available for the same. Gynecology resident was asked to send repeat samples for advanced immune-hematological workup. All repeat samples were tested as per the departmental standard operating procedure.

Irregular antibody screening

Serum was screened for irregular antibodies using commercially available three-cell reagent panel which showed strong, consistent agglutination in screening cells (II and III), suggesting the presence of multiple antibodies (anti E, c, K, k, Kp a, Fy a, JK b, Le b, M, N, S, Lu a) [Figure 2].
Figure 2: Irregular antibody screening using III-cell panel

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Antibody identification

The sample was further processed for antibody identification using commercially available eleven-cell reagent panel. The consistency in strength of reaction (4+) in cells 3, 4, 6, 9, and 11 led to possibility of underlying alloantibodies against antigens S, M, E, and JK b [Figure 3].
Figure 3: Antibody identification using XI-cell panel

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Select cells

Select cells from a separate eleven-cell panel were used to rule out the presence of anti-M and anti-JK b [Table 2].
Table 2: Select cells from ortho resolve Panel A

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Rh Kell phenotyping

Rh Kell phenotyping was carried out on pretransfusion sample and results were interpreted as CCee Kell negative. Patient being E antigen negative strengthens possibility of the presence of E antibody [Figure 1].

Extended antigen phenotyping

Pretransfusion sample was tested with rare antisera Jk b, M, E, and S antisera by conventional test tube technique for typing of with positive and negative controls, and the results confirmed the presence of anti-S [Table 3]. However, anti-E could not be ruled out. All compatible units thus selected were S and E antigen negative.
Table 3: Extended antigenic phenotyping

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Antibody titers

E antibody titers were not tested.

In this case, the anti-S antibody found was both IgG (1:2048) and IgM (1:256) (incomplete anti-S).[9]


  Discussion Top


Based on evidence of low Hb (i.e., 5.6 g/dl), there was a need for urgent blood transfusion. Ten units of blood were cross-matched, out of which five were compatible in saline and coombs phase. Over a period of 5 days, total six units RBC was transfused. Out of six transfusions, three resulted in febrile reaction. DAT was negative on posttransfusion sample which ruled out the presence of autoantibodies. While pretransfusion Hb was 5.6 as seen in [Figure 4], posttransfusion Hb remained in range of 6.3–6.9, thereby ruling out any hemolytic reaction. Patient completed two cycles of chemotherapy.
Figure 4: Repeat sampling of hemoglobin E, hematocrit, indirect bilirubin

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Overall, 1% of patients in general population and 18.6% in multitransfused patients develop RBC alloantibodies.[10],[11] The global incidence of RBC alloantibodies has been estimated in 0.8% of blood donors and 1%–2% in hospital patients.[12] Schonewille et al.[13] found in retrospective multicentric studies that 20%–25% of 653 immunized nonhematology patients and that 22% of 115 immunized hemato-oncology patients formed additional RBC, clinically relevant antibodies against Rh, Kell, Duffy, Kidd, and MNS systems after repetitive transfusion episodes.

MNS antibodies display dosage (they react stronger against cells which are homozygous vs. heterozygous for the antigen in question). Anti-M and anti-N antibodies are naturally occurring, cold-reacting IgM-class antibodies, whereas anti-S, anti-s, and anti-U antibodies are acquired following multiple exposure (via pregnancy or past transfusion with blood products) and are warm-reacting IgG-class antibodies.[14] They are capable of producing HTRs and HDFN and are thus clinically significant. Some examples of “incomplete” anti-S can be detected much more readily by incubating serum and red cells at room temperature rather than at 37°. Although most examples of “immune” anti-S were incomplete IgG antibodies, two examples behaving as saline agglutinins were found to be IgM.[9]

The significant history of multiple transfusions in our patient helped understanding major reason for the presence of alloimmunization. Because only 11% of light-skinned and 3% of dark-skinned are S-, it can be difficult to provide blood for a patient with anti-s. S-Units are much easier to find (45% of light-skinned and 69% of dark-skinned are S-). Antibodies to low-prevalence antigens are commonly found in reagent anti-S; these can cause discrepant antigen typing results.[15] In one series of 175,000 pregnancies in the Oxford region of England, anti-S antibody was detected in 22 pregnancies in 19 women. Previous blood transfusions were thought to be the case of sensitization in 13 women. Only four tested DCT positive and only one infant required exchange transfusion.[2],[16]


  Conclusion Top


This case highlights the importance of antibody screening and identification as a part of pretransfusion testing in identifying irregular antibodies for donors as well as patients. This case also highlights the importance of extended phenotyping especially in case of multiple antibodies.

It is imperative for blood banks to make a quick assessment regarding the need for transfusion against the fear of hemolytic reactions for each and every patient and to derive a plan of action to provide transfusion services as a supportive care to their clinical management. This case emphasizes the indispensable need of devising and maintaining a Rare Blood Donor Register [17] in developing nations which will help revolutionize the current transfusion practices that are being followed. This will help in providing a better means of managing critical care patients with single/multiple antibodies. However, due to varied distribution of blood groups in the general population in such countries, 100% donor screening with extended phenotyping will prove to be an immense challenge to the limited resources and growing cost and logistics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Eder AF, Chambers LA. Noninfectious complications of blood transfusion. Arch Pathol Lab Med 2007;131:708-18.  Back to cited text no. 1
    
2.
Pitan C, Syed A, Murphy W, Akinlabi O, Finan A. Anti-S antibodies: An unusual cause of haemolytic disease of the fetus and newborn (HDFN). BMJ Case Rep 2013;2013. pii: bcr2012006547.  Back to cited text no. 2
    
3.
Singer ST, Wu V, Mignacca R, Kuypers FA, Morel P, Vichinsky EP. Alloimmunization and erythrocyte autoimmunization in transfusion-dependent thalassemia patients of predominantly Asian descent. Blood 2000;96:3369-73.  Back to cited text no. 3
    
4.
Pahuja S, Pujani M, Gupta SK, Chandra J, Jain M. Alloimmunization and red cell autoimmunization in multitransfused thalassemics of Indian origin. Hematology 2010;15:174-7.  Back to cited text no. 4
    
5.
Makroo RN, Bhatia A, Hegde V, Chowdhry M, Thakur UK, Rosamma NL. Antibody screening & identification in the general patient population at a tertiary care hospital in New Delhi, India. Indian J Med Res 2014;140:401-5.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Luzo AC, Pereira FB, de Oliveira RC, Azevedo PR, Cunha RD, Leonardi MI, et al. Red blood cell antigen alloimmunization in liver transplant recipients. Transplant Proc 2010;42:494-5.  Back to cited text no. 6
    
7.
Thakral B, Saluja K, Sharma RR, Marwaha N. Red cell alloimmunization in a transfused patient population: A study from a tertiary care hospital in North India. Hematology 2008;13:313-8.  Back to cited text no. 7
    
8.
Tormey CA, Stack G. Limiting the extent of a delayed hemolytic transfusion reaction with automated red blood cell exchange. Arch Pathol Lab Med 2013;137:861-4.  Back to cited text no. 8
    
9.
Klein HG, Anstee DJ. Mollison's Blood Transfusion in Clinical Medicine. 11th ed., Ch. 6. NJ, USA: Wiley-Blackwell; 2014. p. 222.  Back to cited text no. 9
    
10.
Rosse WF, Gallagher D, Kinney TR, Castro O, Dosik H, Moohr J, et al. Transfusion and alloimmunization in sickle cell disease. The Cooperative Study of Sickle Cell Disease. Blood 1990;76:1431-7.  Back to cited text no. 10
    
11.
Dara RC, Tiwari AK, Pandey P, Arora D. Approach to a case of multiple irregular red cell antibodies in a liver transplant recipient: Need for developing competence. Asian J Transfus Sci 2015;9:94-7.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Cheng CK, Lee CK, Lin CK. Clinically significant red blood cell antibodies in chronically transfused patients: A survey of Chinese thalassemia major patients and literature review. Transfusion 2012;52:2220-4.  Back to cited text no. 12
    
13.
Schonewille H, van de Watering LM, Brand A. Additional red blood cell alloantibodies after blood transfusions in a nonhematologic alloimmunized patient cohort: Is it time to take precautionary measures? Transfusion 2006;46:630-5.  Back to cited text no. 13
    
14.
15.
Harmening DM. Modern Blood Banking and Transfusion Practices. 6th ed., Ch. 8. Philadelphia, United States: F.A. Davis Company; 2012. p. 188-9.  Back to cited text no. 15
    
16.
Mayne KM, Bowell PJ, Green SJ, Entwistle CC. The significance of anti-S sensitization in pregnancy. Clin Lab Haematol 1990;12:105-7.  Back to cited text no. 16
    
17.
Kaur R, Jain A. Rare blood donor program in the country: Right time to start. Asian J Transfus Sci 2012;6:1-2.  Back to cited text no. 17
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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