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 Table of Contents  
SHORT ARTICLE
Year : 2017  |  Volume : 2  |  Issue : 2  |  Page : 159-162

Red cell autoantibodies: Selection of blood for transfusion


1 Department of Transfusion Medicine, Sri Balaji Action Medical Institute, New Delhi, India
2 Department of Transfusion Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication11-Sep-2017

Correspondence Address:
Sadhana Mangwana
Department of Transfusion Medicine, Sri Balaji Action Medical Institute, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_23_17

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  Abstract 


Introduction: Transfusion of serological safe blood is an essential requirement in transfusion medicine. Development of anti- red blood cell antibodies remains a major problem. Materials and Methods: A study was conducted on 24237 donors and 25155 patients between August 2013 and July 2016 to determine the prevalence of RBC autoantibodies and management of autoantibody screen positive cases. Results: 19 donors (0.078%) were identified with RBC autoantibodies. 16 of 19 donors showed warm autoantibodies (WAAs), one showed cold autoagglutinin and two showed autoantibodies; type not identified. Ten patients (0.039%) were identified with autoantibodies, of which nine showed warm autoantibodies and one showed cold autoagglutinin. Conclusion: Autoantibodies are mostly formed against the high incidence antigens and therefore react with red cells of random donors' blood, causing difficulty in interpretation of cell typing, compatibility testing, antibody detection and antibody identification. There are wide variations in testing and RBC selection practices in patients with WAAs, further studies are required to evaluate and compare different testing algorithms and transfusion strategies.

Keywords: Alloantibodies, alloimmunization, direct antiglobulin test, warm autoantibodies


How to cite this article:
Mangwana S, Bedi N, Simon N. Red cell autoantibodies: Selection of blood for transfusion. Glob J Transfus Med 2017;2:159-62

How to cite this URL:
Mangwana S, Bedi N, Simon N. Red cell autoantibodies: Selection of blood for transfusion. Glob J Transfus Med [serial online] 2017 [cited 2019 Aug 17];2:159-62. Available from: http://www.gjtmonline.com/text.asp?2017/2/2/159/214276




  Introduction Top


Transfusion of serological safe blood is an essential requirement in blood transfusion services. The most important determination for any transfusion is to exclude the presence of potentially clinically significant alloantibodies in patient's blood before selecting red blood cells (RBCs) for transfusion. Patients who have warm autoantibodies (WAAs) in their serum have a higher rate of alloimmunization.[1],[2],[3] Exclusion of newly formed alloantibodies is of primary concern in patients with WAAs that have been transfused. Autoantibodies are directed against the individual's own RBCs which can result in clinical hemolysis and difficulty in cross-matching blood. The formation of autoantibodies against RBCs has been documented in previous studies.[4],[5] This circulating humoral antibody may shorten the duration of RBC survival.[6]

Monitoring for evidence of RBC destruction due to alloantibodies is difficult in patients who already have autoimmune hemolytic anemia (AIHA). Patients with warm-reactive autoantibodies may or may not have apparent hemolysis or severe anemia. Uncommonly, antibodies that appear to exhibit antigenic specificity on RBC panels fail to maintain specificity following alloadsorption (i.e., they mimic antigenic specificity). Understanding both the pitfalls and the proper pathways to establish the diagnosis and to interpret the clinical significance of these mimicking antibodies is important for the patient management.[7]

Aim

The purpose of this study was to determine the prevalence of RBCs autoantibodies among the patients and healthy donor population in our institute and management of autoantibody screen positive cases for their transfusion demands.


  Materials and Methods Top


All patients' and donors' samples received in immunohematology laboratory at the Department of Transfusion Medicine from August 2013 to July 2016 were reevaluated retrospectively. All donors were screened as per guidelines under D and C act. During this period, 24,237 donors and 25,155 patients with varied diagnosis were screened for antibodies and subsequent identification. As pretransfusion protocol, serum/plasma was analyzed for detection of new antibody to RBC antigen using standard methods by Solid Phase Red Cell Adherence Technology (Capture, Immucor Inc., Norcross, GA, USA). Patients' history, age and sex were also taken. A volume of 4 ml sample for antibody screen testing was received in ethylenediaminetetraacetic acid tube with each blood requisition for patients. Antibody screen with positive results was further subjected to identification. Elution and adsorption methods were employed in patients with suspected autoantibody. A commercial warm autoantibody removing medium (W.A.R.M.; ZZAP) was used for the eluates and adsorbed sera to detect the specificity of the autoantibody. Adsorb sera was tested again with screen cells. Polyspecific direct antiglobulin test (DAT) was performed on all patients using 0.8% cell suspension of patient's RBC with antihuman globulin. Patients with negative screen test results were transfused by selecting ABO compatible unit and putting cross-match with adsorb sera using column agglutination technology (Diamed, Switzerland).


  Results Top


Of the total 24,237 donors, 19 (0.078%) were identified with RBC autoantibodies. Out of these 19 donors, 16 (84%) showed WAAs, one showed cold autoagglutinin and two showed autoantibodies; type not identified. All 19 donors (100%) were males. Donors' age ranged from 22 to 65 years with a mean of 36.15 years of which 53% donors (10) were up to 30 years of age. Of the 19 donors, 10 (53%) showed positive DAT, rest 9 (47%) showed only positive autocontrol. The frequency of different blood groups among donors with autoantibodies is shown in [Figure 1].
Figure 1: Frequency of different blood group among the donors with autoantibody

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Out of the total 25,155 patients, 13 patients (0.039%) were identified with autoantibodies. The majority (85%) showed warm reactive autoantibodies either alone or with alloantibodies. Patients' age ranged from 30 to 70 years (mean age – 53.15 years). Ten of 13 patients (77%) were identified with only autoantibodies. Of these ten patients, nine patients showed WAAs, and one showed cold auto agglutinin. Their age ranged from 28 to 90 years with a mean age of 54 years. Autoantibodies prevalence was more in women (60%) than in men (40%). Clinical conditions associated with the presence of autoantibodies and correlation with DAT and history of blood transfusion are shown in [Table 1].
Table 1: Patients' diagnoses and clinical correlation

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Alloimmunization (23%) was observed more in women with a high frequency of antibodies against Rh system (anti-c, anti-E). One of the multiply transfused patients initially developed WAAs but later alloimmunized with the development of alloantibodies (anti-c, anti-E). All the four alloimmunized (three anti-E, two anti-C, and one anti-M) patients were females either with obstetric event or with multiple transfusions.


  Discussion Top


Autoantibodies are mostly formed against the high-incidence antigens and therefore react with red cells of most random donors' blood, causing difficulty in interpretation of cell typing, compatibility testing, antibody detection, and antibody identification. The prevalence of autoantibodies in our study is very low as compared to different studies in different population as shown in [Table 2]; with the majority of autoantibodies as warm reactive autoantibodies. Warm reactive antibodies are usually polyclonal IgG antibodies; however, IgA or monoclonal IgM antibodies are also seen occasionally. Complement (C3) may also accompany these antibodies.
Table 2: Comparison of the prevalence of autoantibodies in different studies

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A variety of novel immune modulating agents and therapies have been developed leading to the autoantibody development. When RBC autoantibodies are detected, it would be useful to predict the behavior of these antibodies to plan therapy and provide appropriate patient follow-up. Adsorbed serum may be used to screen and select units for transfusion. Using the adsorbed serum may provide some assurance that the correct unit is selected and avoid incompatibility, but this practice can also provide a false sense of security for the transfusion of these patients. The unit is still incompatible with the patient's circulating autoantibody. Resolving these serologic problems is important; however, a delay in a transfusion for these patients because of serologic incompatibility may cause greater harm. The relationship of autoantibody and its hemolytic potential is not well defined, and the clinical presentation of patients with warm antibodies is highly variable, ranging from asymptomatic to severe anemia. An individual with autoantibodies upon blood transfusion may possibly lead to suppression of erythropoiesis of autologous cell, rise in autoantibody titer, increase risk of hemolysis, and increased risk of alloimmunization. Five of 13 patients (38%) showed positive DAT, and seven of 13 patients (54%) received transfusions of RBCs. There are few studies of patients with thalassemia, carcinoma, myelodysplastic syndrome, sickle cell disease having WAAs and proportion of patients experiencing hemolysis.[9],[10],[12],[13],[14] In the present study, no evidence of hemolysis was encountered.

Our data showed a low autoimmunization rate in donors (0.078%) and patients (0.039%) population in our hospital. The alloimmunization rate (23%) in our patients is lower than in previous reports where alloantibodies prevalence ranged from 27% to 40%.[15],[16],[17],[18] In the present study, finding of one patient (8%) initially developing warm autoantibody, alloimmunized on repeated blood transfusion, is in accordance with literature review which ranged from 3.1% to 37%.[8]

The most common alloantibodies specificities in a patient with WAAs include antigens from Rh (50%) and Kell (20%) antigen system,[19] with anti-E alloantibodies being the most common. Similar findings are observed in this study. The presentation of patients with WAAs is highly variable and may range from patients who are asymptomatic without RBC destruction to severe and life-threatening anemia.

In case of transfusion requirement to the patient with autoantibodies, clinicians should be reassured about the thorough investigation for clinically significant alloantibodies detection. Transfusion decision should be collective by both clinician and transfusion medicine physician after assessing transfusion risk versus benefit to patient and to provide least amount of blood for adequate oxygenation. Transfusion should be very slow with constant monitoring of vital signs for any sign of hemolysis. In patients with WAAs without underlying alloantibodies, phenotype-matched RBCs should be given: At least for Rh and K blood group antigens. Policies should be made based on the presence of a diagnosis of AIHA, urgency of transfusion, ability to detect alloantibodies, results of pre transfusion testing, and availability of antigen negative units. There are differences in practice based on geographical location, hospital size, and available testing. Since there is paucity in literature regarding testing algorithms, further studies are required to evaluate and compare different testing algorithms and transfusion strategies, especially in the era of RBC genotyping, discovery of variations in blood group antigens and various transfusion practices. The focus should be on feasibility and cost-effectiveness of routine phenotyping/genotyping in selecting RBCs for transfusion especially in resource constrained countries.


  Conclusion Top


The presence of autoantibodies complicates pre-transfusion and compatibility testing and poses difficulties in detection of alloantibodies by pan reactivity. It is vital to detect the appearance of new alloantibodies or disappearance of old alloantibodies to prevent hemolytic transfusion reaction during or after allogenic transfusion. Collaborative decision to transfuse these high-risk patients should occur only in patients with life-threatening anemia or to improve oxygen carrying capacity with constant monitoring for any evidence of hemolysis. In patients without sign and symptoms of hemolytic anemia transfused with allogenic RBCs will have a similar life expectancy as that of autologous RBCs. Scientific investigations to identify clinically significant WAAs, with or without alloantibodies would guide practice in testing and RBC selection strategies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Leger RM, Garratty G. Evaluation of methods for detecting alloantibodies underlying warm autoantibodies. Transfusion 1999;39:11-6.  Back to cited text no. 1
    
2.
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4.
Singer ST, Wu V, Mignacca R, Kuypers FA, Morel P, Vichinsky EP, et al. Alloimmunization and erythrocyte autoimmunization in transfusion-dependent thalassemia patients of predominantly Asian descent. Blood 2000;96:3369-73.  Back to cited text no. 4
    
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Ho HK, Ha SY, Lam CK, Chan GC, Lee TL, Chiang AK, et al. Alloimmunization in Hong Kong Southern Chinese transfusion-dependent thalassemia patients. Blood 2001;97:3999-4000.  Back to cited text no. 5
    
6.
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7.
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8.
Makroo RN, Bhatia A, Hegde V, Chowdhry M, Thakur UK, Rosamma NL, et al. 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. 8
[PUBMED]  [Full text]  
9.
Ansari S, Voosogh P, Moshtaghian S. Assessment of frequency of alloimmunization and erythrocyte autoimmunization in transfusion dependent thalassemia patients. Acta Med Iran 2008;46:137-40. Available from: http://www.acta.tums.ac.ir/index.php/acta/article/view/3458. [Last accessed on 2016 Jul 26].  Back to cited text no. 9
    
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Dhawan HK, Kumawat V, Marwaha N, Sharma RR, Sachdev S, Bansal D, et al. Alloimmunization and autoimmunization in transfusion dependent thalassemia major patients: Study on 319 patients. Asian J Transfus Sci 2014;8:84-8.  Back to cited text no. 11
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Castellino SM, Combs MR, Zimmerman SA, Issitt PD, Ware RE. Erythrocyte autoantibodies in paediatric patients with sickle cell disease receiving transfusion therapy: Frequency, characteristics and significance. Br J Haematol 1999;104:189-94.  Back to cited text no. 14
    
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Ziman A, Cohn C, Carey PM, Dunbar NM, Fung MK, Greinacher A, et al. Warm-reactive (immunoglobulin G) autoantibodies and laboratory testing best practices: Review of the literature and survey of current practice. Transfusion 2017;57:463-77.  Back to cited text no. 19
    


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