Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online:583
  • Home
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 90-92

Management of a complicated case of liver transplant patient with multiple alloantibodies


1 Department of Transfusion Medicine, Jaypee Hospital, Noida, Uttar Pradesh, India
2 Immucor India Pvt Ltd., New Delhi, India

Date of Web Publication22-Apr-2019

Correspondence Address:
Dr. Nitin Agarwal
Department of Transfusion Medicine, Jaypee Hospital, Noida, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_49_18

Rights and Permissions
  Abstract 


The focus of transfusion services is now shifting toward the prevention of alloimmunization and delayed hemolysis, especially in multi-transfused patients. Here, we present a complex case of a multitransfused chronic liver disease patient, alloimmunized with multiple Rh antibodies posted for a liver transplant. Our blood bank successfully managed this patient and was able to supply the required blood components on time to save his life. A 28-year-old male patient was admitted to our hospital for the liver transplant. Blood bank could not find compatible blood units for the patient. The patient antibody screen was positive and the pattern was suggestive of anti-E antibody, but few other antibodies such as C, K, Fyb, and N could not be ruled out. Eluate showed the same result on antibody screening. The patient serum was alloadsorbed with “rr” blood using conventional tube technique. Adsorbed patient serum showed the pattern of hidden anti-C and we confirmed that patient serum contained anti-E and anti-C antibodies. As “e” antigen is a high prevalence antigen, we could not find an e negative unit and only C negative unit could be provided to the patient without any untoward incidence.

Keywords: Adsorption, alloimmunization, antibody identification, anti-C, anti-e, elution, multiple alloantibodies


How to cite this article:
Agarwal N, Pandey P, Kumar M, Kumar A. Management of a complicated case of liver transplant patient with multiple alloantibodies. Glob J Transfus Med 2019;4:90-2

How to cite this URL:
Agarwal N, Pandey P, Kumar M, Kumar A. Management of a complicated case of liver transplant patient with multiple alloantibodies. Glob J Transfus Med [serial online] 2019 [cited 2019 Nov 15];4:90-2. Available from: http://www.gjtmonline.com/text.asp?2019/4/1/90/256762




  Introduction Top


With a decrease in the risk of viral transmission and immediate hemolysis after blood transfusion, the focus of transfusion services is now shifting toward the prevention of alloimmunization and delayed hemolysis, especially in multi-transfused patients. Leukodepletion and availability of extended matched blood are a step toward the prevention of alloimmunization while quick and accurate identification of alloimmunizing antibody and providing corresponding antigen-negative blood go a long way in the prevention of hemolysis in the patient.

Here, we present a complex case of a multitransfused chronic liver disease patient, alloimmunized with multiple Rh antibodies posted for a liver transplant. Our blood bank successfully managed this patient and was able to supply the required blood components on time to save his life.


  Case Report Top


A 28-year-old male patient with 5 years history of chronic liver disease due to hepatitis B virus was admitted to our hospital for the liver transplant. The patient has had few episodes of upper gastrointestinal bleed in the past and had been multiply transfused on various occasion (there was no transfusion history in the past 100 days). He required further transfusions as he had low hemoglobin; and therefore, a demand for red blood cells (RBCs) was sent to our department. Blood bank could not find compatible blood units on anti human globulin (AHG) crossmatch by column agglutination technique using cards by Ortho Diagnostics. On further investigation, his antibody screen was positive using fully-automated immunohematology analyzer Galileo-NEO (Immucor, Norcross, USA). The sample was further processed for antibody identification (solid-phase Capture Ready ID) which showed the presence of multiple alloantibodies. The pattern was suggestive of anti-E antibody, but there was suspicion of multiple antibodies as 13 of 14 cells were reactive and other antibodies such as C, K, Fy b, and N could not be ruled out. Elution was performed on his red cells using Gamma Elukit-II (Immucor, USA), but the eluate showed the same result on antibody screening and suggested the presence of multiple antibodies. Therefore, his serum was alloadsorbed with “rr” blood using conventional tube technique hoping that anti-E would be fully adsorbed. Antibody identification on adsorbed patient serum showed the pattern of hidden anti-C, and we confirmed that patient serum contained anti-E and anti-C antibodies. Two different lots of Capture Ready ID and an 11 cell panel of liquid cells (Panocell-10) were used to rule out antibodies. Antigen typing of eluted RBCs was performed, and the patient was found to be C and e antigen negative. This further substantiated our results. The patient was given a total of five units of ABO-compatible, C antigen-negative packed RBCs, and best-matched blood in the AHG phase. As “e” antigen is a high prevalence antigen, we could not find an e negative unit and only C negative unit could be provided to the patient. However, we followed the patient regularly, and there were no signs of in vivo hemolysis after a month of follow-up. [Table 1] summarizes the advanced serological workup for this patient.
Table 1: Advanced serological workup of the patient

Click here to view



  Discussion Top


Although blood transfusion nowadays is very safe with the inventions of newer technologies and acceptance of better procedures, patients are still at risk of transfusion-related complications such as RBC alloimmunization and delayed hemolysis. It is often difficult to find compatible blood for patients with RBC alloimmunization and can be associated with delayed hemolytic transfusion reactions.[1],[2] Patients with chronic liver disease and candidates for liver transplant are more likely to be multi-transfused and are, therefore, at the high risk of alloimmunization.[3] The patients with chronic liver disease already have hemostatic dysfunction and may require urgent blood transfusion during pre-, intra-, or post-operative period. The presence of alloantibodies may complicate transfusion therapy in these patients. Alloantibodies may also affect liver transplant outcomes and can contribute to higher incidences of early death.[4] Various Indian and international studies have shown that multiply transfused patients are more at risk of alloimmunization and quoted antibody development in 3%–50% of transfused patients after RBC transfusion depending on the various risk factors such as heterogeneity of donor and patient populations, leukodepletion of blood, and number of transfusions.[5],[6],[7]

Of all alloantibodies detected in these patients, Rh (D, C, E, c, e) and Kell antibodies have been found to be the major culprits in most of the patients. Our patient was also found to be alloimmunized with multiple alloantibodies to Rh system such as anti-E and anti-C. Universal antibody screening in all such multi-transfused patients as part of pretransfusion testing will help to identify atypical antibodies and appropriate transfusion support can be planned well in time.[8]

The liver is a highly vascular organ and extensive bleeding can occur during liver transplant, especially so in patients with portal hypertension due to end-stage liver disease. As this patient had alloantibodies and providing antigen-negative units could be challenging for blood bank due to limited inventory, the transplant team was well informed in time to be extra cautious to restrict blood loss during surgery. This patient required only five units of blood during the surgery and could be well managed by our blood bank.

It has been proposed repeatedly that providing Rh and kell matched blood is able to protect many patients from alloimmunization.[9] Boyd et al. reported mortality in three alloimmunized liver transplant patients who were issued antigen-positive units.[10] It is, therefore, a prudent strategy to phenotype all blood units available in the blood bank to provide matched blood units on time whenever there is an emergency requirement.

As “e” antigen is a high-frequency antigen, and its frequency in Indian population has been found to be almost 100%,[11],[12],[13] we could not found “e” negative blood for our patient. Only “C” antigen negative blood was given to the patient, and he did not show any signs of hemolysis after 1 month of follow-up. According to the published literature, anti-D has the most and anti-”e” has the least chances of hemolysis among all antibodies against Rh antigens.[14]

Early serological workup in all multi-transfused patients with prompt communication between clinical and transfusion department is the key to successful management of these patients. An advanced immunohematology laboratory should not only be able to identify an immunizing antibodies in the patient serum but also should be able to provide antigen-negative units on time to prevent further hemolysis and delay in the management of the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schonewille H, Haak HL, van Zijl AM. Alloimmunization after blood transfusion in patients with hematologic and oncologic diseases. Transfusion 1999;39:763-71.  Back to cited text no. 1
    
2.
Aygun B, Padmanabhan S, Paley C, Chandrasekaran V. Clinical significance of RBC alloantibodies and autoantibodies in sickle cell patients who received transfusions. Transfusion 2002;42:37-43.  Back to cited text no. 2
    
3.
Murthy TV. Transfusion support in liver transplantation. Indian J Anaesth 2007;51:13-9.  Back to cited text no. 3
  [Full text]  
4.
Au WY, Liu CL, Lo CM, Fan ST, Lam MF, Lam CK. Red blood cell alloantibodies and liver transplantation in Chinese patients. Transplantation 2003;76:324-6.  Back to cited text no. 4
    
5.
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. 5
    
6.
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. 6
    
7.
Makroo RN, Arora JS, Chowdhry M, Bhatia A, Thakur UK, Minimol A. Red cell alloimmunization and infectious marker status (human immunodeficiency virus, hepatitis B virus and hepatitis C virus) in multiply transfused thalassemia patients of North India. Indian J Pathol Microbiol 2013;56:378-83.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
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. 8
    
9.
Michail-Merianou V, Pamphili-Panousopoulou L, Piperi-Lowes L, Pelegrinis E, Karaklis A. Alloimmunization to red cell antigens in thalassemia: Comparative study of usual versus better-match transfusion programmes. Vox Sang 1987;52:95-8.  Back to cited text no. 9
    
10.
Boyd SD, Stenard F, Lee DK, Goodnough LT, Esquivel CO, Fontaine MJ. Alloimmunization to red blood cell antigens affects clinical outcomes in liver transplant patients. Liver Transpl 2007;13:1654-61.  Back to cited text no. 10
    
11.
Thakral B, Saluja K, Sharma RR, Marwaha N. Phenotype frequencies of blood group systems (Rh, Kell, Kidd, Duffy, MNS, P, Lewis, and Lutheran) in North Indian blood donors. Transfus Apher Sci 2010;43:17-22.  Back to cited text no. 11
    
12.
Makroo RN, Bhatia A, Gupta R, Phillip J. Prevalence of Rh, Duffy, Kell, Kidd & MNSs blood group antigens in the Indian blood donor population. Indian J Med Res 2013;137:521-6.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Kahar MA, Patel RD. Phenotype frequencies of blood group systems (Rh, Kell, Kidd, Duffy, MNS, P, Lewis, and Lutheran) in blood donors of South Gujarat, India. Asian J Transfus Sci 2014;8:51-5.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Mollison PL, Engelfriet CP, Contreras M. Blood Transfusion in Clinical Medicine. 10th ed. Oxford: Blackwell Science; 1997.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Tables

 Article Access Statistics
    Viewed335    
    Printed54    
    Emailed0    
    PDF Downloaded13    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]