|Year : 2020 | Volume
| Issue : 1 | Page : 68-72
Evaluation of incompatible crossmatch
Vidushi, Meena Sidhu, Saadat Nazir Shah
Department of Immunohematology and Blood Transfusion, GMC, Jammu, Jammu and Kashmir, India
|Date of Submission||05-Feb-2020|
|Date of Decision||25-Feb-2020|
|Date of Acceptance||17-Mar-2020|
|Date of Web Publication||17-Apr-2020|
Department of Immunohematology and Blood Transfusion, GMC, Jammu, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background and Objectives: Crossmatching is one of the bases of pretransfusion testing. Resolving problems in crossmatching should be carried out after proper planning and following departmental guidelines, and hence that time is not wasted, or blood withheld from patient unnecessarily. The aim of this study was to find the prevalence and cause of incompatible crossmatch and to formulate root cause analysis to help ensure safe transfusion. Materials and Methods: This was a prospective study conducted at a tertiary care hospital in North India, from December 2018 to November 2019. Request for blood components was received along with 2 ml labeled sample in ethylenediaminetetraacetic acid and plain tube. Crossmatching was done by column agglutination method in polyspecific (IgG + C3d) bead cards by ortho clinical diagnostic using semi-automated biovue. In case of any incompatible result, it was resolved using appropriate steps. Results: During the study period from December 2018 to November 2019, only 67 (0.65%) of the 10,320 samples received were found to be crossmatch incompatible and evaluated and appropriate donor units issued. The crossmatch incompatibility was much higher in the females (46, 68.7%) than the males (21, 31.3%). The direct antiglobulin test (DAT) was positive in nine patient samples, and the indirect antiglobulin test was found positive in 37 incompatible crossmatch units. Eleven cases of incompatible crossmatch were due to wrong blood in tube, seven due to contamination of reagents, and three due to DAT-positive donor units. Conclusion: In this study, alloimmunization (55.2%) was the most prevalent cause of incompatible crossmatch, and the most common alloantibody identified was anti-E. Incompatible crossmatch poses a challenge in the field of transfusion medicine. Root cause analysis is a systemic method for identifying all the contributing factors to a problem, so that the corrective action can be taken. A logical stepwise approach will enable the provision of safe transfusion.
Keywords: Antibody identification, antibody screening, direct antiglobulin test, incompatible crossmatch
|How to cite this article:|
Vidushi, Sidhu M, Shah SN. Evaluation of incompatible crossmatch. Glob J Transfus Med 2020;5:68-72
| Introduction|| |
One of the main responsibilities of transfusion services is to provide safe blood to the right patient at the right time. Crossmatching is one of the bases of pretransfusion testing. Crossmatching is done to ensure that transfused blood is compatible with patient to provide therapeutic benefit. Problems encountered during crossmatching should be resolved promptly. Resolving problems should be carried out after proper planning and following departmental guidelines, so that time is not wasted, or blood withheld from patient unnecessarily. If transfusion can be postponed, the resolution of problem is desirable before issuance of blood even though apparently compatible units are available. Sometimes, some nonspecific reaction may not themselves be dangerous to patient but may interfere with compatibility testing. Once these problems have been resolved, units which appeared incompatible may be shown to be suitable for transfusion; however, it is essential that problem should be completely resolved before blood transfusion when nonspecific agglutination is present.
The aim of the study was to find the prevalence and cause of incompatible crossmatch and to formulate root cause analysis to help ensure safe transfusion.
| Materials and Methods|| |
This was a prospective study conducted in a tertiary care hospital in North India from December 2018 to November 2019. Request for blood components was received along with 2 ml labeled sample in ethylenediaminetetraacetic acid and plain tube. Blood grouping was done by conventional tube technique using monoclonal antisera (Tulip diagnostic Pvt Ltd, India) and reverse grouping was done by in-house prepared A, B, O pooled cells, test validated by saline control. Any discrepancy encountered was resolved as per the departmental standard operating procedure (SOP). Crossmatching was done by column agglutination method in polyspecific (IgG + C3d) bead cards by ortho clinical diagnostic using semi-automated biovue. Tests were performed as per the manufacturer's instruction. Ten microliters of 4% donor red cell suspension, 40 μl of patient's serum, and 50 μl of Bliss were added in cassette, incubated at 37°C for 15 min, and centrifuged for 5 min.
In case of any incompatible result, it was resolved using appropriate steps as shown in [Figure 1]. Patient's clinical history, medication history, history of transfusion, pregnancy, or abortion (in females) were recorded.
The data were analyzed with the help of computer software SPSS for window version 17.0 (SPSS Inc., Chicago, Illinois, USA). The data were presented as percentage in tabular and appropriate diagrammatic form.
This study was approved by the institutional ethics committee.
| Results|| |
During the study period from December 2018 to November 2019, 10,320 sets of patient's samples were received in the blood bank for blood transfusion. Only 67 (0.65%) of these 10,320 were found to be crossmatch incompatible and evaluated and appropriate donor units issued. The crossmatch incompatibility was much higher in the females (46, 68.7%) than the males (21, 31.3%). An overall distribution of incompatibility ranges from neonates to elderly people, with a maximum incidence of 55% (n = 37) in the age group of 20–60 years, and minimum incidence of 2.9% (n = 2) was observed in the persons above 60 years of age [Figure 2].
Requisition for blood transfusion ranged from anemia due to cancer, autoimmune hemolytic anemia (AIHA), thalassemia, sickle cell disease, pregnancy to trauma, surgery, exchange transfusion, and dialysis. The causes of incompatibility observed are shown in [Figure 3].
The direct antiglobulin test (DAT) alone was positive in nine patient samples with 4+ reaction strength. Among seven patients with cold autoantibodies, crossmatch compatible units were given after performing tests at 37°C. In two patients with warm autoantibodies, antibody could not be isolated due to logistic constraints. Patients were transfused with least incompatible units along with steroids as they had no history of transfusion. No untoward reaction was observed.
Indirect antiglobulin test alone was found positive in 37 incompatible crossmatches. Antibody screening and identification was done. Single alloantibody was identified in 28 patients, multiple alloantibodies were found in seven patients, and in two patients, antibody screen came out to be negative. The most common alloantibody identified was anti-E. Patients with alloimmunization included multitransfused patients (thalassemia, sickle cell disease, renal failure, and hematological disorders) and pregnant females. One patient had naturally occurring anti-M reactive at room temperature. In patients with alloimmunization, antibody was identified, and antigen-negative blood unit was transfused. One sample was sent to immunohematology reference laboratory for antibody confirmation. Antibody profiles of incompatible crossmatch units are summarized in [Table 1].
Eleven cases of incompatible crossmatch were due to wrong blood in tube (WBIT), seven due to contamination of reagents, and three due to DAT-positive donor units.
Root cause analysis was formulated and is shown in [Figure 4].
| Discussion|| |
Pretransfusion testing includes reviewing blood sample acceptability, determining ABO group and RhD type, screening for red blood cell (RBC) antibodies, identifying the specificity of unexpected antibodies that are detected, selecting donor RBC units that are appropriate for the recipient's ABO and RhD type and unexpected antibody status, and performing a crossmatch between recipient and the unit to be transfused. The causes of incompatible crossmatch could be due to patient or donor unit factors and technical or clerical errors.
In our study, majority of incompatible crossmatches were found in females (69%) which is comparable to a study conducted by Bhatt et al. in the Western part of India and Bhattacharya et al. in the eastern part of India. In our study, alloimmunization (31%) was the most prevalent cause of incompatible crossmatch which is similar to the study conducted by Bhattacharya et al. (38%), whereas in contrast to study conducted by Bhatt et al., where AIHA (40%) was the most prevalent cause of incompatible crossmatch.
Multitransfused patients and pregnant females are at risk of forming alloantibodies to red cell antigens which can cause delayed hemolytic transfusion reaction and problems in finding compatible donor units, and in case of pregnant females, it can cause hemolytic disease of fetus and newborn. RBC alloimmunization results from disparity of antigens between donor and recipient. Recipient immune status, immunogenicity of the antigen, and dose of the antigen are the factors which play a significant role in alloimmunization. The rate of alloimmunization can be decreased by providing phenotype-matched blood. Blood to be transfused should always be matched at least with ABO, rhesus, and Kell system. Cost barrier is major issue in providing phenotype-matched blood.
In our study, we found three cases of incompatible crossmatch due to DAT-positive donor units. Now a days, there is emphasis on use of type and screen and electronic crossmatch instead of type and ccrossmatch in pretransfusion testing. These can miss DAT positive donor units unless DAT screening of donors is included in pretransfusion testing. Since these three units were discarded, we cannot comment on its effects if transfused. Similar cases of incompatible crossmatch due to DAT-positive donors were reported by Puri et al. There are no clear guidelines and policy for deferral of DAT-positive donors. However, DAT positivity is reported in 0.008% of donors. Mostly, blood donors with a positive DAT result appear to be perfectly healthy and have no obvious signs of hemolytic anemia. However, a careful evaluation may show evidence of increased red cell destruction.
In our institute, we have established protocol of documenting blood group twice before issuing blood unit to patient. This has helped in cases of WBIT or any clerical error and preventing mismatch blood transfusion reaction. A clerical error was found to be the most common cause of incompatible crossmatch in a study by Stainsby et al., in UK. “WBIT” is defined as events where blood is taken from the wrong patient and is labeled with the intended patient's details. Blood taken from the intended patient but labeled with another patient's details is called “mislabeled”. A College of American Pathologists Q-Probes Study in thirty institutions on 41,333 ABO blood typing specimens recorded aggregate rates of 7.4 instances of mislabeling and 0.43 instances of WBIT per 1000 specimens submitted. Mislabeling rates were lower in institutions requiring that specimens should be labeled with patients' birth dates than those that did not. To reduce the risk of error, the American Association of Blood Banks standards require that patient blood sample tubes have affixed to them, labels bearing at least two unique patient identifiers, and the dates on which specimens were collected.
Seven cases of incompatible crossmatch were found due to contamination of normal saline which was resolved by replacing it. Reagents should be stored and used as per the manufacturer's instructions or SOP.
| Conclusion|| |
Incompatible crossmatch poses a challenge in the field of transfusion medicine. The resolution of which requires a thorough evaluation of the patient's clinical condition and underlying pathology to identify the cause. Root cause analysis is a systemic method for identifying all the contributing factors to a problem, so that corrective action can be taken. A logical stepwise approach will enable the provision of safe transfusion.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]