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   Table of Contents - Current issue
Coverpage
January-June 2019
Volume 4 | Issue 1
Page Nos. 1-127

Online since Monday, April 22, 2019

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GUEST EDITORIAL  

Massive transfusion needs during war or other casualties Highly accessed article p. 1
Sangeeta Pathak
DOI:10.4103/GJTM.GJTM_30_19  
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REVIEW ARTICLES Top

Review of existing legislative instruments for blood systems of Countries in the WHO Eastern Mediterranean Region p. 6
Cees Theodoor Smit Sibinga, Yetmgeta Eyayou Abdella, Frank Konings
DOI:10.4103/GJTM.GJTM_8_19  
Blood transfusion is an essential part of health-care systems; contributes to saving millions of lives; improves patient expectancy and quality of life; and supports medical and surgical procedures. Blood and blood products-whole blood, red blood cells, platelets, and plasma were added to the WHO Model List of Essential Medicines (EMs) in 2013. Effective blood regulation is crucial for establishing blood products as EMs which requires countries to implement an appropriate regulatory framework and functioning regulatory authority (RA). There are numerous situations, for example, in the less developed world, where these prerequisites have barely been implemented. Existing legislative tools of the Eastern Mediterranean Region countries were collected, analyzed for relevance and appropriateness for the regulation of blood products, associated substances and relevant medical devices. Literature search on matching combinations of regulatory system/framework, legislation, regulation, with production and use of blood products resulted in few references on national and international legislation. The WHO recommendations and EU Directives were used as reference. Formal legislative and regulatory documents issued by nine countries from 1960 to 2017 were reviewed. Most are descriptions of RA, operational establishments, and specific requirements. None comply with the WHO/EU recommended format and contents; will not support effective regulatory oversight to promote and enhance the quality, safety, and availability of blood and blood products. National authorities should provide effective leadership and governance in developing a national blood system (NBS), fully integrated into the national health system. Essential functions of NBS include an appropriate regulatory framework; legislation, regulations, and nonlegislative instruments administered by an RA. These should spell out ethics, principles and boundaries, standard setting, and organization of NBS to ensure and sustain an adequate supply of quality-assured blood products and safe clinical use.
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Application of flow cytometry in transfusion medicine p. 16
Rajesh B Sawant
DOI:10.4103/GJTM.GJTM_26_19  
Flow cytometry-based testing approaches have no longer remained restricted to the research laboratories. With widening of its horizons in the field of diagnostics in oncology and transplantation medicine, the flow cytometer-based testing approach is now relevant to many aspects of the field of transfusion medicine. Two of the most important applications of flow cytometry in transfusion medicine are the enumeration of CD34-positive cells in the peripheral blood and stem cell product and the enumeration of residual white blood cell counts in blood product as a quality control measure. The flow cytometer-based crossmatch for detection of donor-specific anti-human leukocyte antigen antibodies is also gaining popularity in the field of histocompatibility and immunogenetics. The utility of this platform in the field of immunohematology is also increasing and looks promising for clinical decision-making in the near future.
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ORIGINAL ARTICLES Top

Comparative analysis of platelet storage lesion in whole-blood-derived platelets stored in autologous plasma versus platelets stored in platelet additive solution using flow cytometric assay of CD62 and Annexin V p. 21
Subhashish Das, M L Harendra Kumar
DOI:10.4103/GJTM.GJTM_24_19  
Background: Platelets storage lesions remain a challenge in regular blood transfusion services. Flow cytometric study based on the expression of platelets activation markers in the stored platelets is a good method to study such lesions. Materials and Methods: Buffy-coat-derived platelet concentrates were stored under standard conditions for 7 days. The expression of activation antigens CD62p and Annexin V on total platelets and populations of small, medium-sized and large platelets was analyzed by flow cytometry during storage on days 0, 5 and 7. Results: There was significant difference in Annexin V expression between PAS and non- PAS group on Day 0, Day 5 and Day 7. The same observation was noted with regard to CD62 estimations. Conclusion: Our study confirm the beneficial effects of platelet additive solution as highlighted by the flow cytometric assay of CD62 and Annexin V. Evaluation of the level of expression of various activation markers on different platelet populations could be an additional valid tool in quality control of platelet concentrates, and could be a novel approach towards better platelet inventory management.
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On-site and off-site adverse donor reactions in voluntary whole blood donors: A study from a tertiary care oncology center p. 28
Priti D Desai, Anisha A Navkudkar, Sunil B Rajadhyaksha
DOI:10.4103/GJTM.GJTM_4_19  
Aim: The aim of this study was to analyze the frequency of on-site and off-site adverse donor reactions and its correlation with contributory factors if any. Materials and Methods: A prospective observational study was conducted from October 2016 to November 2016. A total of 1000 voluntary whole blood (WB) donors who consented to participate in the study were contacted telephonically the next day of donation. Donors were asked a structured questionnaire and information was documented. Results: Of the 1000 voluntary WB donors, 948 responded to the phone calls. Of these 948, 79 (8.33%) donors experienced adverse reactions. Of the 79 donors, 33% (26/79) reactions occurred on-site, whereas 67% (53/79) reactions occurred off-site (P < 0.05). Of the total on-site reactions, 92% (24/26) were vasovagal reactions (VVRs) and 8% (2/26) were hematomas (P < 0.001). Of the total off-site reactions, 47% (23/53) were vasovagal and 53% (30/53) were hematomas. Of the 79 donors, 60% (47/79) experienced VVR and 40% (32/79) experienced hematomas. Of the 32 hematoma reactions, 94% (30/32) were noticed off-site, whereas 6% (2/30) occurred on-site (P < 0.001). Majority of hematomas took more than 7 days to resolve. Conclusion: Maximum reactions occurred off-site, and hence donor follow-up after the donor has left the donation site is important. Postdonation follow-up proves to be an efficient tool to acquire information about adverse donor reactions. The next day telephonic follow-up was helpful as donor recall of the off-site reactions was better, which otherwise would have gone unreported.
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Surrogate markers and their correlation to bacterial contamination and other quality parameters in random-donor platelets by platelet-rich plasma method p. 33
Priyatesh Dwivedi, Abhishekh Basavarajegowda, Apurba Sankar Sastry
DOI:10.4103/GJTM.GJTM_5_19  
Introduction: Bacterial contamination in platelet concentrates (PCs) occurs more frequently than other blood components because of several factors such as storage in oxygen permeable blood bags at 20°C–24°C with continuous agitation which facilitates bacterial growth compared to other blood components which are kept frozen or refrigerated which inhibits bacterial proliferation in them. The purpose of the study was to assess the incidence of bacterial contamination of random-donor PCs and factors associated with its contamination and see how well the surrogate markers such as pH and swirling correlate with the same. Methodology: This was a cross-sectional study which included randomly chosen 500 random-donor platelets (RDPs) in blood bank prepared by platelet-rich plasma method. The samples chosen for the study were from the RDPs on the 5th day of storage after their preparation. pH, platelet count, and swirling in platelets, which act as surrogate markers for bacterial contamination, were checked on the RDP units. About 1–3 ml of PCs was inoculated from the RDP units into labeled culture bottles (BD Bactec Peds Plus/F). Results: Among a total of 499 random-donor PCs that were cultured in the automated BACTEC system for the study, none of them were culture positive. Thirty RDP units in the study were visibly lipaemic whereas 93 RDP units were visibly reddish in appearance. PCs having volumes <40 ml or >70 ml did not affect the swirling, pH, and platelet counts. There was a statistically significant difference between mean pH with RDP units having swirling Grade 2 and 3 and platelet counts with RDP units having swirling Grade 1 and 2. Conclusion: Bacterial contamination though poses a significant risk is a very rare event in a meticulously prepared and stored PCs. Surrogate markers though useful in resource-constrained settings does not correlate optimally with the quality indicators.
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Spectrum of alloimmunization among multitransfused beta-thalassemia major patients p. 39
Usman Waheed, Muhammad Arshad, Muhammad Saeed, Akhlaaq Wazeer, Ahmed Farooq, Abida Arshad, Hasan Abbas Zaheer
DOI:10.4103/GJTM.GJTM_52_18  
Introduction: The development of alloantibodies is a major problem among thalassemia major individuals due to periodic blood transfusions. The current study assessed the frequency and specificity of erythrocytes alloimmunization and also the variables affecting the extent of alloimmunization in repeatedly transfused thalassemia patients. Materials and Methods: This prospective, cross-sectional study was conducted at the Department of Blood Transfusion Services and Thalassemia Centre of Pakistan Institute of Medical Sciences from August 2017 to February 2018. Of the 475 thalassemia major patients, alloantibodies were screened and identified by 3-red cell antigen panel and afterward by an extended 11-cell antigen panel. The data analysis was done through SPSS version 20.0. Chi-square test was employed. Results: Alloantibodies were detected in 77 (16.2%) patients, 5 (6.5%) patients were found with double alloantibodies. Anti-D (31.1%) and Anti-E (29.9%) antibodies had the highest incidence and were found in 24 and 23 patients, independently. Anti-K antibody was observed in 11 (14.3%) and Anti-C in 3 (3.9%) patients. Anti-C (2.6%), Anti-E (2.6%), and Anti-Kpa (2.6%) all were found in two patients, individually. Similarly, Cw (1.3%), k (1.3%), Jka (1.3%), Anti-Fyb (1.3%), and Anti-s (1.3%) antibodies were detected in one patient each. Alloantibodies were common in males, splenectomized patients, in those who initiated their transfusions before 2 years of age, in patients receiving nonleukoreduced blood and in B and O blood group patients. Conclusion: The proper management and prudence are needed for thalassemia patients due to hemolytic nature of these alloantibodies. New techniques should be introduced to reduce the incidence of red blood cell alloimmunization.
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Slump of trends in transfusion-transmissible infectious diseases: Is syphils alarming in Pakistan? p. 45
Maqsood Ahmad, Muhammad Saeed, Aamir Hanif, Usman Waheed, Muhammad Arshad, Noor Ul Ain, Farhan Rasheed, Shahida Hussain
DOI:10.4103/GJTM.GJTM_46_18  
Aims: This study was planned to evaluate the trends of transfusion-transmissible infectious diseases (TTID). Setting and Design: This cross-sectional retrospective study was conducted on donor community attending Transfusion Medicine Department, Punjab Institute of Cardiology, Lahore, Pakistan from January 1, 2012, to December 31, 2016. Subject and Methods: A total of 79,774 blood donors were processed for HbsAg anti-HCV, anti-human immunodeficiency virus (HIV), syphilis, and malaria detection by rapid immune chromatographic technique. Statistical Analysis: The data analysis was done through SPSS 20.0. Chi-square test was employed. Results: Males and females were 91% and 9%, respectively. The mean age was 44 ± 10 years, the prevalence of TTID was 4.0%, and year-wise decreasing trends were observed as 4.4%, 4.2%, 3.7%, 3.9%, and 3.9%, respectively, in 2012–2016. Overall Co-infection was 0.36%, HBV+HCV co-infection was most common. The seroprevalence of HBV, HCV, syphilis, malaria, and HIV was 0.9%, 1.7%, 1.1%, 0.1%, and 0%, respectively. Year-wise seroprevalence of HCV was 2.1%, 1.8%, 1.7%, 1.7%, and 1.3%; HBV was 1.2%, 0.8%, 0.8%, 1.0%, and 1.0%, syphilis was 0.8%, 0.8%, 0.9%, 1.4%, and 1.5%, and malaria was 0.1%, 0.03%, 0.1%, 0.1%, and 0.05% in 2012–2016, respectively, and no single case of HIV was detected. Conclusion: Raising trends for syphilis among blood donors underscore the concern about growing infection of this disease in the community as these blood donors represent the highly selective community. The zero prevalence of HIV in Pakistani population supports the growing awareness of this life-threatening disease. HBV and HCV infections still continue to be a menace to the society because, in spite of decreasing trend, burden of the disease is still high in general community.
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Revisit of efficiency of blood usage – Need for continuous audit p. 52
Soumee Banerjee, Parimala Puttaiah, Sitalakshmi Subramanian
DOI:10.4103/GJTM.GJTM_12_19  
Background: The most common indices assessing blood usage are crossmatch-to-transfusion (C/T) ratio, transfusion probability (%T), Transfusion Index (TI), nonusage probability (NUP), and wastage as percentage of issue (WAPI). This study, in a South Indian tertiary care hospital, audits blood utilization efficiency and revisits it after implementing corrective measures for deficiencies identified by the first audit highlighting the importance of continuous surveillance and proper measures in efficient blood utilization. Materials and Methods: Blood utilization over 6 months, assessed by C/T ratio, TI, %T, and NUP indicated inefficient blood usage (high C/T ratio). After initiating appropriate measures, reaudit over 1 month assessed effect on blood usage. The total duration was from December 2017 to November 2018. Request forms packed red blood cells provided patient demographics, number of units requested, and indication. Blood bank records provided number of units crossmatched and issued against each request. Results: Initial audit: total requests- 4450, C:T ratio-3.6, TI-0.5, %T- 32% and NUP- 72%. Reaudit: Total requests-948 (medical 52%, surgical 48%), Overall monthly WAPI- 0.1%, C:T ratio-2.4 (medical 1.3, surgical 3.5), %T-63.5%(medical 84%, surgical 43%), TI-1 (medical 1.4, surgical 0.6), NUP- 24% (medical- 11%, surgical 37%) C/T ratio – no subspecialty crossed the highest acceptable value (2.5) except gynecology and obstetrics (4.1) and pediatric surgery (2.75). All departments met the lowest acceptable %T (30%) except G&O (25.2%). All departments met minimum TI (0.5) except G&O (0.3), pediatric surgery (0.47), and surgical super specialties (0.3). Conclusion: Initial audit showed inefficient blood utilization. Appropriate steps taken to improve this included the establishment of standard protocols. Reaudit showed efficient blood utilization in medical departments and the need for further revision in practices for surgical departments. Hence, continuous monitoring is vital in ensuring effective blood usage.
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To evaluate hemoglobin thresholds of elective surgical patients and blood typing policy for reducing the erythrocyte transfusion in a hospital setting p. 58
Sankalp Sharma, Dhananjay Prasad, Saurabh Lehre
DOI:10.4103/GJTM.GJTM_51_18  
Introduction: The existing methods to quantify blood requirement in elective surgical procedure are the baseline hemoglobin (Hb) and hematocrit of patients. The risk-based scoring systems available are maximum allowable surgical blood loss and maximum surgical blood ordering schedule employ retrospective data evaluation or patient-specific variables, respectively. The aim of the present study was to evaluate a single institutional data for analyzing red blood cell (RBC) requirement among various surgical diagnoses. The study also evaluated RBC threshold for blood transfusions and efficacy of blood typing policy toward reducing unnecessary transfusions in an institution. Study Design and Methods: This study is a retrospective data evaluation from a single institution of blood transfusion patterns among elective surgical patients. Results: The blood transfusions in surgical diagnoses (n = 259) got integrated under 16 categories. The overall crossmatch-to-transfusion ratio was 1.4, average Hb before transfusion was 9.0 g/dl across the surgical categories, and average erythrocyte transfusion per patient for the various clinical diagnoses was 0.4 blood units. The effective Blood usage was 73.2% of requisitions received and blood typing was performed in 46.3% of total requisitions. Blood typing policy showed a statistically significant improvement in the blood transfusion of crossmatched units in the hospital. A per-unit reduction of blood cost in patients was also observed. Conclusions: The blood transfusion across the surgical categories showed similar Hb thresholds before transfusion. Blood typing policy improved EBU and reduced unnecessary crossmatches and transfusion costs among the patients.
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Patients' involvement and the improvement of patient blood management Highly accessed article p. 65
Ali Akbar Pourfathollah, Gharib Karimi, Mehdi Tabrizi Namini, Sakineh Yousefi Darestani, Mahmoud Hadipour Dehshal
DOI:10.4103/GJTM.GJTM_20_19  
Introduction: Patient blood management (PBM) is of prime importance today for the preservation and conservation of health resources and for patient safety. To fulfill the goal of appropriate use of blood and blood components, all the shareholders involved in patient treatment, particularly patients themselves should play an effective role. Materials and Methods: The present research aims to evaluate the status of patients' rights, patient awareness-raising efforts, and the consequent informed consent for transfusion order purposes in hospitals. To this end, the interview was conducted on 181 patients under surgery. The data were finally analyzed using SPSS software version 23. Results: In the present study, 109 men and 72 women were interviewed, of whom only 15 patients (8.25%) were aware of the likelihood of blood transfusion pre- or perioperative and further only 5 (2.76%) had received the adequate information on (dis) advantages of blood transfusion. Finally, after we provided precise information about (dis) advantages of blood transfusion and the alternatives, it came out to be known that the patients' decision out of the four choices of (1) homologous transfusion, (2) preoperative anemia treatment, (3) postoperative anemia treatment, and (4) autologous transfusion is estimated to be significant before they were given information compared with that of after. Discussion: The status of information sharing with patients and that of the patient informed consent procedure in Iran hospitals are weak and require serious reconsideration as far as patients' rights are concerned. Informing patients on (dis) advantages of blood transfusion and the alternatives can be a very effective measure in PBM success in Iran.
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Performance evaluation of VITROS syphilis Treponema pallidum agglutination assay in blood donor samples by using centers for disease control and prevention reverse sequence algorithm p. 69
Amardeep Pathak, Manushri Sharma, Narender Tejwani, Anurag Mehta
DOI:10.4103/GJTM.GJTM_37_18  
Background: VITROS syphilis Treponema pallidum agglutination (VSTPA) assay is a treponemal assay for the detection of antitreponemal antibody in the human serum or plasma using enhanced chemiluminescence technology. Centers for Disease Control and Prevention (CDC) has offered reverse sequence algorithm for screening syphilis. Aim and Objective: This study was undertaken to evaluate the performance of VSTPA assay over the nontreponemal (rapid plasma regain [RPR]) as well as treponemal assay based on immunochromatography principle, which is commonly used in blood transfusion centers, using CDC reverse sequence algorithm. Material and Methods: A total number of 33,367 donor samples were screened for the syphilis infection using either VSTPA assay or syphilis rapid card test and the syphilis reactivity rate was compared between both assays. Results: While screening with syphilis rapid card test, the percentage of reactivity observed was 0.36% whereas with VSTPA assay, the reactivity was increased to 0.87%. As per the CDC reverse sequence algorithm, the seroreactive samples in VSTPA assay were subjected to nontreponemal RPR test. The discordant samples which showed “nonreactive” in RPR assay were sent for syphilis confirmatory test based on fluorescent treponemal antibody absorption (FTA-ABS) test. In the reverse algorithm study, 40% of samples with discordant results were confirmed as “Positive” in FTA-ABS test confirming the superior sensitivity of VSTPA assay over nontreponemal RPR assay as well as treponemal syphilis rapid card test. Conclusion: Automation of syphilis screening using VSTPA assay helps in consolidation of the assay with other transfusion transmittable infections, namely, HIV, HBsAg, and anti-HCV screening assay on chemiluminescence platform which is highly valuable for optimizing workflow, efficiency with excellent sensitivity, and reliable specificity.
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Red cell alloimmunization in multi-transfused, oncology patients: Risks and management p. 74
Sadhana Mangwana, Atin Kacker, Nikhil Simon
DOI:10.4103/GJTM.GJTM_11_19  
Introduction: Repeated blood transfusion can result in the development of alloantibodies against one or more red cell antigens. Risk of alloimmunization is high in patients receiving multiple transfusions in hemoglobinopathies, hematologic malignancies, and cancer patients receiving chemotherapy. Materials and Methods: A study was undertaken to know risk of alloimmunization in multi-transfused, oncology patients and its management in a tertiary care oncology hospital over 3 years' period receiving multiple transfusions and subjected to antibody screening by 3-cell panel and antibody identification by 11 or 14 cell panels, wherever required, using solid phase red cell adherence technology. Results: 8115 units of leukodepleted, packed red blood cells (RBCs) were given to 5886 admissions. Of these, 18 patients (0.30%) developed red cell alloimmunization. Of these, 17 (94.5%) were female and only 1 (5.5%) was male patient, with 78% (14) solid organ malignancies and 22% (4) hematological malignancies. Three patients (16.6%) had concurrent warm autoantibodies with alloantibodies while 5 patients (28%) had multiple alloantibodies. About 68% of alloantibodies belonged to Rh blood group system followed by Duffy, Kidd, Kell, and MNS systems. Maximum alloantibodies (36%) were anti-E alloantibody. Conclusion: It is vital to detect the appearance of new alloantibodies or disappearance of old alloantibodies to prevent hemolytic transfusion reaction during or after allogeneic transfusion. Regular screening for the development of alloantibodies in multi-transfused patients and providing leukoreduced, Rh phenotyped and antigen-matched blood is recommended for better management of these patients. The prevention of RBC alloantibody formation in multi-transfused patients extends life expectancy and reduces the requirement of blood transfusion.
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SHORT ARTICLES Top

The anti-Mia antibody – Report of four cases in a tertiary care hospital with review of literature p. 79
Sangeeta Pahuja, Shivali Sehgal, Geetika Sharma, Manisha Singh, Ramvilash Yadav
DOI:10.4103/GJTM.GJTM_2_19  
Anti – Mia antibody is antibody reacting with Mi III phenotype of the Miltenberger (Mi) subsystem. It is rarely reported in the West, however, it is common in Chinese and South East Asian populations. Very few cases have been reported in India. Here, we report 4 cases of the Anti - Mia antibody picked up on antibody screening of samples (which was performed using Asia ID-Diacell I-II-III Asia (Mia +) 3 cell panel). Patients: In all the four cases, ICT was positive. Antibody screening and Identification was done with 3 cell panel (ID-Diacell I-II-III (Asia)) and 11 cell panel (ID-DiaPanel) respectively. Antibody screening showed reaction in “Asia” cell (carrying Mia Antigen) of 3 cell panel. Antibody identification by 11 cell panel was negative ruling out antibodies of Rh, Kell, Duffy, Kidd, Lewis, P, Lutheran and MNS systems. Reaction with the “Asia” cell suggested the presence of Anti-Mia antibody which was confirmed by obtaining the same result when screening was repeated with 2 different lots of 3 cell panel. Discussion and Conclusion: The Miltenberger (Mi) subsystem comprises of a group of phenotypes of red cells that carry low frequency antigens associated with the MNSs blood group system. The Anti- Mia antibody was first described in 1951 in the serum of Mrs Miltenberger. Anti- Mia antibody is clinically significant and can cause Hemolytic disease of newborn (HDN) and mild to moderate haemolytic transfusion reactions (HTR). Most of the antibody screening and identification panels used in India are imported and represent the Western population. They do not have representation of the Mia antigen on their red cells. This leads to missing out of the Anti- Mia antibody which may cause HDN and HTR leading to significant consequences. Thus, the Mia antigen should be incorporated in our screening panels.
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Impact of awareness on routine antenatal antibody screening: A prospective study p. 84
Soumya Das, Shamee Shastry, Poornima B Baliga
DOI:10.4103/GJTM.GJTM_25_19  
Introduction: A screening test is performed to detect potential health disorders or diseases in people who do not have any symptoms of disease. The major objective of a screening program is to reduce morbidity, mortality and the disease burden. Antenatal antibody screening in India is mainly focused on the detection of anti-D in RhD-negative mother. Hemolytic disease of the fetus and newborn can also be caused by the antibodies directed against other minor red cell antigens among RhD-positive women. Hence, the study was planned to analyze the influence of creating awareness among clinicians and patients towards implementing the universal antibody screening for pregnant women. Materials and Methods: The obstetricians as well as the patients were made aware of the benefits of the screening test at regular intervals during the study period regarding the universal antenatal antibody screening. Results: During the study period, a total of 2336 samples from antenatal cases were screened for red cell antibodies. A positive outcome was evident by the rise in number of RhD-positive samples received in the laboratory for antenatal antibody screening from 18.2% during the prestudy phase to 72.8% in the second phase of the study after the intervention. Conclusion: In a developing country like India, extra efforts should be put by the transfusion service in collaboration with hospital transfusion committee to sensitize the obstetricians about the need and obvious benefits of performing antibody screening in all antenatal cases.
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CASE REPORTS Top

Oblivious of the yellow world – A newborn's telltale: ABO hemolytic disease of newborn p. 87
Daljit Kaur, Poonam Sidana, Gaurav Mandhan, Kamlesh Kanodia
DOI:10.4103/GJTM.GJTM_45_18  
The increased destruction of fetal red cells can be immune (allo- or autoantibodies) or nonimmune (hemoglobinopathies, enzyme defects, and membrane defects) in nature and can cause shortened life span of red cells leading to hemolytic disease of the fetus and newborn. Maternofetal ABO incompatibility is common but rarely leads to severe anemia due to poorly developed A or B antigens on fetal red blood cells and neutralization of antibody by tissue and soluble ABO blood group substances in plasma, while RhD hemolytic disease of newborn (HDN) occurring due to D-antigen sensitization in D-negative mothers may lead to severe HDN. Here, we report a case of an inborn neonate who was admitted in neonatal intensive care unit of our hospital at day 1 of life with severe hyperbilirubinemia and needed exchange transfusion.
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Management of a complicated case of liver transplant patient with multiple alloantibodies p. 90
Nitin Agarwal, Prashant Pandey, Mukesh Kumar, Anurag Kumar
DOI:10.4103/GJTM.GJTM_49_18  
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.
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Systematic approach in identification and management of multiple alloantibody: A case of triple alloantibody p. 93
Samrat Thapa, Latha Jagannathan, Ankit Mathur, T V Kumar Reddy, Santanu Chakraborty
DOI:10.4103/GJTM.GJTM_41_18  
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.
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Severe hemolytic crisis due to cold agglutinins associated with Mycoplasma pneumoniae infection that complicated the compatibility tests p. 96
Sanmukh R Joshi, Ankita Sheladiya, Hiren Dhanani, Pramod Godiwala
DOI:10.4103/GJTM.GJTM_29_18  
The cold agglutinins (CAs) associated with Mycoplasma infection may give rise to autoimmune hemolytic anemia (AIHA), and in rare cases, results in severe crises requiring hospitalization. The present case was this kind with severe hemolytic crises due to clinically significant CA that had caused the life-threatening AIHA in association with the infection by Mycoplasma pneumoniae. The blood specimens were collected in the warm environment to obviate spontaneous autoagglutination. Autoimmune nature of the CA involved was established by the direct antiglobulin test (DAT) using reagents obtained from commercial sources. The serological specificity of the CA was ascertained by titration by saline tube test against the red blood cells (RBCs) from the adults and the newborn infants as well as the hemagglutination inhibition study using human milk as a source of the soluble I antigen. The patient's clinical and other details were obtained from the hospital records. A 20-year-old male admitted to the hospital with a severe hemolytic crisis that required blood transfusion. DAT on his RBCs was positive due to the presence of C3d complement fraction, in concurrence with a high-titer CAs with anti-I specificity and positive serological test for M. pneumoniae. A severe hemolytic crisis was evident by sudden drop in hemoglobin, presence of reticulocytes and erythroblasts in circulation. The patient was conservatively treated with antibiotics, steroid, and blood transfusions with improvement in condition and was discharged after 7 days of hospitalization. He was followed up for the next 3 months through which he continued to be in good condition. The investigations showed a rare case of the CA, with anti-I specificity, causing severe hemolytic crisis in association with M. pneumoniae infection that required hospitalization.
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Resolution of blood group discrepancy and transfusion support to a nontransfusion-dependent thalassemia patient with anti-C and anti-N alloantibodies p. 101
Debasish Mishra, Rashmita Panigrahi, Gopal Krushna Ray, Dibyajyoti Sahoo
DOI:10.4103/GJTM.GJTM_30_18  
Nontransfusion-dependent thalassemia (NTDT) patients generally do not require regular blood transfusion, but may be transfused before surgery. Blood group discrepancy exists when forward grouping and reverse grouping do not match. Pretransfusion testing includes ABO/Rh typing, antibody screening, and cross-matching. Forward grouping and reverse grouping were done using monoclonal anti-A, anti-B, and anti-D (Tulip Diagnostics, Goa, India) and in-house prepared 5% A, B, and O cell by conventional tube test method, respectively. Antibody screening and identification were done using 3-cell panel and 11-cell panel (Ortho Clinical Diagnostics, USA), respectively. In our case, we found a discrepancy in reverse grouping and incompatibility due to anti-c and anti-N alloantibodies. Three units of O positive, c and N antigen negative blood units were transfused to this patient. The patient was also managed by hematinics, antibiotic, and bed rest. Antiglobulin cross-matching must be done in all types of compatibility testing of RBC units. Rh and K phenotype-matched PRBC reduced the chances of alloimmunization. Proper coordination between the physician and specialist in transfusion medicine is required in case of alloantibody formation.
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A successful pregnancy occurred after isolating the offending antibody(s) and choosing appropriate sperm donor of similar phenotype p. 105
Sourav Mukherjee, Durba Biswas, Prasun Bhattacharya, Amit Biswas, Kushal Chatterjee
DOI:10.4103/GJTM.GJTM_55_18  
Sensitization against Rh(D )is the most common cause of haemolytic disease of fetus and newborn (HDFN). Now a days, a widespread use of antenatal and postnatal Rh immunoglobulin has resulted in marked decrease in prevalence of Rh(D) alloimmunization. Fetal loss due to other red cell antigens gain importance as there are no prophylactic immunoglobulin are available. Here, we present a case of primary infertility associated with non Rh(D) alloimmunization which was detected in a 30 year old housewife during her ongoing infertility treatment. The antibody identification workup showed patient is having multiple alloantibodies , probable anti-c, and anti-Fya. The extended phenotype shows that the husband is mismatched with the wife's phenotype in “c” and Fya. Also the probable antibody in the mother's serum are anti-c and anti-Fya which are noted to cause HDFN as per literature.
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Role of red blood cell exchange for treatment of acquired methemoglobinemia in a patient of aniline dye poisoning p. 108
Dolly Gohel, Nidhi Bhatnagar, MD Gajjar, Tarak Patel, Nihar Chaudhari
DOI:10.4103/GJTM.GJTM_7_19  
Typical indication for red blood cell (RBC) exchange is sickle cell disease and its related complications. However, one of the miscellaneous indications of RBC exchange is for the patients of methemoglobinemia who are refractory to treatment by methylene blue. Acquired methemoglobinemia is more common than any genetic causes. Acquired methemoglobinemia is caused by toxins that oxidize heme iron, notably nitrate and nitrite-containing compounds. For patients failing to respond to the standard treatment with methylene blue or in whom its use is contraindicated, hyperbaric oxygen or RBC exchange is indicated. We report a case which was refractory to methylene blue.
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How a transfusion medicine consultation became a life-saving intervention for an E-Beta thalassemia patient: A case report from Kolkata, West Bengal p. 111
Biplabendu Talukdar, Soumyarupa Majee, Prasun Bhattacharya, Subrata Das, Rony Roy Chaudhury, SK Sabib
DOI:10.4103/GJTM.GJTM_16_18  
Bedside transfusion practice is a challenge for Transfusion Medicine practitioners in multi-transfused patients who have irregular antibody(s) against donors red cell antigens. Apart from ABO and Rh, there are more than 300 identified blood group antigens present on the surface of red cell membrane. We present a patient of E-Beta thalassemia in 36 weeks of gestation who is nontransfusion-dependent thalassemic. She had received two units of concentrated red blood cells (RBCs) 2 years back during the birth of her first child by cesarean section. She was severely pale when she attended the obstetrics outpatients' department for her second pregnancy. Urgent transfusion of two units of ABO-matched packed RBCs worsened the anemia and jaundice. Instead of hemoglobin increment, fall of Hb with cola colored urine occurred within a short period. Antibody identification was done, and antibody negative red cell transfusion was given which helped the obstetrician for safe delivery and well-being of the mother.
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Blocked D in RhD hemolytic disease of fetus and newborn p. 114
Rajeswari Subramaniyan
DOI:10.4103/GJTM.GJTM_54_18  
A 3-day-old term neonate was admitted to our hospital for the evaluation of neonatal jaundice. The neonate was born to an RhD-negative multiparous mother who had never received anti-D prophylaxis. The neonate's direct antiglobulin test was 4+. Blood group was B, and Rh D typing was negative using tube technique and positive (2+) using gel card. The mother had anti-D, and anti-D titers were 1:1024. After heat elution, RhD typing of the neonate was positive using tube (2+) and gel technique (4+). The eluate was shown to have anti-D. As the red cells of the neonate were saturated with maternal anti-D, commercial monoclonal anti-D could not bind to D antigen which resulted in false-negative D typing in the neonate. Such blocking phenomenon is rare. The discrepancy was identified while using two different techniques (tube and gel) which aided in early diagnosis and tailored an appropriate treatment. The neonate improved after the initiation of a combination of intravenous immunoglobulin and phototherapy.
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LETTERS TO EDITOR Top

Possible transmission of human immunodeficiency virus through blood transfusion in Pakistan p. 117
Usman Waheed, Hasan Abbas Zaheer
DOI:10.4103/GJTM.GJTM_9_19  
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Purple blood: An incidental finding in a blood administration set p. 118
Remi Remakanth
DOI:10.4103/GJTM.GJTM_6_19  
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Association with ABO blood group with olfactory function p. 119
Subhashish Das
DOI:10.4103/GJTM.GJTM_53_18  
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A step toward bloodless medicine and surgical practice will lead to rational use of blood: A literature review p. 120
Ashishkumar Nathabhai Kanani, Jitendra H Vachhani, Shweta B Upadhyay
DOI:10.4103/GJTM.GJTM_50_18  
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Leukocyte reduction filters: A source of peripheral blood leukocytes for research and drug production p. 122
Shirin Ferdowsi, Ali Akbar Pourfathollah
DOI:10.4103/GJTM.GJTM_27_19  
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SPECIAL COMMUNICATIONS Top

The genotype distribution of hepatitis C virus in blood donors in Fuzhou p. 124
Lin Hongkeng, Jiang Weimei, Lin Shou
DOI:10.4103/GJTM.GJTM_31_19  
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Retrospectrive analysis of Rh(D) negative patients needing emergency rescue transfusion using “matched transfusions” p. 126
Liang Jing, Yang Li-Ping, Liu Wen, Liu Jing-Han, Lan Jiong-Cai
DOI:10.4103/GJTM.GJTM_32_19  
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