|Year : 2019 | Volume
| Issue : 1 | Page : 90-92
Management of a complicated case of liver transplant patient with multiple alloantibodies
Nitin Agarwal1, Prashant Pandey1, Mukesh Kumar1, Anurag Kumar2
1 Department of Transfusion Medicine, Jaypee Hospital, Noida, Uttar Pradesh, India
2 Immucor India Pvt Ltd., New Delhi, India
|Date of Web Publication||22-Apr-2019|
Dr. Nitin Agarwal
Department of Transfusion Medicine, Jaypee Hospital, Noida, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
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 20];4:90-2. Available from: http://www.gjtmonline.com/text.asp?2019/4/1/90/256762
| Introduction|| |
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|| |
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.
| Discussion|| |
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., 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. 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. 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.,,
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.
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. Boyd et al. reported mortality in three alloimmunized liver transplant patients who were issued antigen-positive units. 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%,,, 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.
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
Conflicts of interest
There are no conflicts of interest.
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