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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 93-95

Systematic approach in identification and management of multiple alloantibody: A case of triple alloantibody


Department of Transfusion Medicine, Bangalore Medical Services Trust, Rotary TTK Blood Bank, Bengaluru, Karnataka, India

Date of Web Publication22-Apr-2019

Correspondence Address:
Mr. Samrat Thapa
Department of Transfusion Medicine, Bangalore Medical Services Trust, Rotary TTK Blood Bank, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_41_18

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  Abstract 


Alloimmunization is an adverse consequence of exposition to red blood cell antigens through transfusion, pregnancy, or transplantation. Alloimmunization to red cell antigens creates problem not only in immunohematological testing but also causes difficulty in finding compatible blood for those patients who develop multiple alloantibodies. Moreover, the development of multiple alloantibodies can significantly complicate transfusion therapy and/or provokes hemolytic transfusion reactions, the severity of which can vary from mild to extremely severe. We are presenting an interesting case with multiple alloantibodies. Patient's samples were investigated for antibody screening using commercially available three cell panels, and the antibody was identified using different lots of identification panel. Red cell phenotyping was done with minor blood group antisera. After workup, antigen-negative compatible blood was provided for transfusion.

Keywords: Alloimmunization, antibody identification, multiple alloantibodies


How to cite this article:
Thapa S, Jagannathan L, Mathur A, Reddy T V, Chakraborty S. Systematic approach in identification and management of multiple alloantibody: A case of triple alloantibody. Glob J Transfus Med 2019;4:93-5

How to cite this URL:
Thapa S, Jagannathan L, Mathur A, Reddy T V, Chakraborty S. Systematic approach in identification and management of multiple alloantibody: A case of triple alloantibody. Glob J Transfus Med [serial online] 2019 [cited 2019 Sep 16];4:93-5. Available from: http://www.gjtmonline.com/text.asp?2019/4/1/93/256757




  Introduction Top


Red cell antibodies other than naturally occurring anti-A or anti-B are called unexpected red cell antibodies. There are two types of unexpected red cell antibodies: “alloantibodies” and “auto-antibodies.” When someone produces antibody against the antigen that he/she lacks, the antibody is called as alloantibody. Therefore, by definition, alloantibodies react only with allogenic red cells that express corresponding antigen.[1]

Antibody identification studies determine the specificity and significance of red blood cell antibodies. This information is important when selecting donor units for transfusion and for monitoring potential cases of hemolytic disease of newborn. A majority of patient samples with unexpected alloantibodies contains single alloantibody and are relatively simple to identify. Identification studies for samples containing multiple alloantibodies may be very complex and require a great deal of time and expertise on the part of investigator.[2]

When a serum contains multiple antibodies, it may be difficult to interpret the results of testing performed on a single panel of reagent red cells. The presence of multiple antibodies may be suggested by a variety of test results.

  1. The observed pattern of reactive and nonreactive tests does not fit that of a single antibody
  2. Reactivity is present at different test phases
  3. Unexpected reactions are obtained when attempts are made to confirm the specificity of a suspected single antibody
  4. No discernible pattern emerges.[3]


We report a case of alloimmunized patients with multiple antibodies and the challenges faced during pretransfusion testing.


  Case Report Top


A newborn baby diagnosed with neonatal hyperbilirubinemia was referred for exchange transfusion. Mother, 32–year-old, had no history of transfusion but had two pregnancies before.

Mother's blood group was found to be B Rh (D) negative. The antibody screening (Surgiscreen, Ortho-Clinical Diagnostics) of the mother's serum showed panagglutination with varying grades of reactions. Furthermore, DAT and Autocontrol (AHG polyspecific card, Ortho-Clinical Diagnostics) were negative by column agglutination technique.

On further investigation of mother's serum, the 11 cell panel (Resolve Panel A, Ortho-Clinical Diagnostics) was negative only for two cell #6 and #10, as shown in [Table 1], suggesting the antibody against D, C, Fy a, Jk a, Le a, S, and M. Anti-Le a and Anti-S were ruled out using select cells (Resolve Panel B, Ortho-Clinical Diagnostics). Anti-Fy a and Anti-M were ruled out after phenotyping (Bioclone, Ortho-Clinical Diagnostics) were found to be positive for corresponding antigens. Furthermore, negative phenotyping for D, C, and Jk a confirmed the presence of those antibodies. For further confirmation, husband's sample was phenotyped for D, C, and Jk a antigen and was found to be positive.
Table 1: Mother's serum reaction grading with donor cells at antihuman globulin phase

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All 17 units of B- and O-negative red cells available in stock were typed for Jk a, and two units were found to be negative for Jk a and C as well. One of these was issued, and the patient's condition improved with reduction in posttransfusion bilirubin levels.


  Discussion Top


Patients with multiple alloantibodies need detailed investigation which requires a lot of resources such as rare antiseras, several identification panels, and skilled workforce as well as a good blood inventory. On many occasions, while dealing with a multiple antibodies cases, one identification panel would not be sufficient to conclude the antibodies present. Although most of the time the configuration of antigens present in panel cells will be supportive toward the investigation, in some cases it may not.

In addition, providing an appropriate donor unit, which lacks the entire corresponding antigen, needs a good knowledge of the incidence of antigens so that the number of units to be crossmatched can be determined. For example, in case Anti-Jk a is identified, if the patient required two units of compatible blood, how many units need to be tested to find them? Since we know that 81.5% of the Indian population is Jk a positive [4] or that 18.5% are Jk a negative, the number of random units needed for antigen screening is calculated by dividing the number of antigen-negative units desired by the incidence of antigen-negative individuals in donor population, that is, approximately 11 units.[5] But suppose, we have anti-E present along with anti-Jk a, the number of units to be screened would be the required number of units divided by the incidence of antigen-negative individuals of both antigens multiplied. As the incidence of E antigen is 20% in Indian population [4] or that 80% are negative for E antigen, the calculation goes like,

2/0.185 × 0.8 = 13.5 – approximately 14 units

This case highlights the challenges faced during the investigation of the patient's sample with multiple alloantibodies and drudgery in finding a compatible unit. To conclude the whole study, we would like to highlight two points:

  1. Extended phenotyping plays a major role in the identification of antibody as well as finding a compatible donor unit when multiple antibodies are suspected
  2. A nationwide registry of voluntary donors with extended antigen phenotyping and rare type is highly recommended as it would not be possible to supply a patient with multiple antigen-negative bloods by random screening of blood bank's inventory.


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.
Fung MK, Grossman BJ, Hillyer CD, Westhoff CM. Identification of Antibodies to Red Cell Antigens. Technical Manual. 18th ed.. USA: American Association of Blood Banks; 2014. p. 391.  Back to cited text no. 1
    
2.
Harmening DM. Detection and identification of antibodies. Modern Blood Banking and Transfusion Practices. 3rd ed.. New Delhi: Jaypee Brothers Medical Publishers; 1994. p. 242.  Back to cited text no. 2
    
3.
Brecher ME, Leger RM, Linden JV, Roseff SD. Technical Manual. 15th ed.. USA: American Association of Blood Banks; 2005. p. 423.  Back to cited text no. 3
    
4.
Makroo RN, Bhatia A, Gupta R, Phillip J. Prevalence of Rh, Duffy, Kell, Kidd and MNSs blood group antigens in the Indian blood donor population. Indian J Med Res 2013;137:521-6.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Harmening DM. Detection and identification of antibodies. Modern Blood Banking and Transfusion Practices. 5th ed.. New Delhi: Jaypee Brothers Medical Publishers; 2005. p. 257.  Back to cited text no. 5
    



 
 
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