Global Journal of Transfusion Medicine

: 2019  |  Volume : 4  |  Issue : 2  |  Page : 154--157

The least incompatible crossmatch red blood cell transfusion by biological compatibility test

Senem Maral1, Sule Mine Bakanay2, Sema Akıncı2, Aysun Senturk Yıkılmaz2, Pinar Comert2, Imdat Dilek2,  
1 Department of Hematology, Ankara Diskapi Yildirim Beyazit Research and Training Hospital, Ankara, Turkey
2 Department of Hematology, Ankara Ataturk Research and Training Hospital, Ankara, Turkey

Correspondence Address:
Dr. Senem Maral
Department of Hematology, Ankara Diskapi Yildirim Beyazit Research and Training Hospital, Ankara


Introduction: Pretransfusion testing is an essential serological test to protect the recipient from hemolysis and provide compatible blood product. The final step is the crossmatching test which is done by the transfusion center. Although all products are crossmatched in same cases, compatible products may not be available. Aims and Objectives: This study aimed to determine the safety and efficacy of the least incompatible crossmatched erythrocyte transfusion, through the use of biological in vivo crossmatch testing. Materials and Methods: The study included twenty patients who required transfusion and for whom appropriate red blood cell (RBC) could not be found. Totally, 69 units of least incompatible RBC transfusion from crossmatch incompatible products was administered by applying the “in vivo compatibility” test. Patients were observed during the transfusion with respect to acute hemolytic reactions that could develop. The biochemical hemolysis parameters were examined before and at 24 h after transfusion. Results: All transfusions were completed successfully with no complications or symptoms observed in any case. A statistically significant increase in hematocrit (Hct) and hemoglobin was seen post transfusion (P < 0.001). As parameters of hemolysis, lactate dehydrogenase and bilirubin levels were found to be statistically normal (not increased) (P = 0.453 and 0.946, respectively). Conclusions: Biological in vivo compatibility testing seems to be a safe, predictive, and bedside feasible test, which could be lifesaving for many patients.

How to cite this article:
Maral S, Bakanay SM, Akıncı S, Yıkılmaz AS, Comert P, Dilek I. The least incompatible crossmatch red blood cell transfusion by biological compatibility test.Glob J Transfus Med 2019;4:154-157

How to cite this URL:
Maral S, Bakanay SM, Akıncı S, Yıkılmaz AS, Comert P, Dilek I. The least incompatible crossmatch red blood cell transfusion by biological compatibility test. Glob J Transfus Med [serial online] 2019 [cited 2020 Oct 28 ];4:154-157
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Full Text


Interaction between antigens on the donor erythrocytes and recipient antibodies, or antigens on recipient erythrocytes and antibodies in the donor plasma, results in the destruction of erythrocytes.[1],[2]

Pretransfusion compatibility testing, which consists of essential serological tests, is performed to provide appropriate blood components and protect the recipient from hemolysis.[3] During pretransfusion testing, if no compatible crossmatch red blood cell (RBC) is found, clinicians may avoid transfusion, and consultation with the hematology department is generally required. However, in critical patients who are deeply anemic or bleeding massively, urgent transfusion is necessary.[4]

In this study, the least incompatible RBC product was selected by the transfusion center and transfused to patients byin vivo compatibility test.

This study aimed

This study aims to determine the safety and efficacy of the least incompatible crossmatched erythrocyte transfusion, through the use of biological in vivo crossmatch testing.

 Materials and Methods


The study included twenty transfusion-naïve patients, 12 female and 8 male patients, for whom crossmatch compatible RBC could not be found in blood banking reserve.

All the patients had no previous history of transfusion, or hematological disease. The reasons of transfusion were preoperative and/or postoperative anemia, autoimmune hemolytic anemia, and ongoing bleeding.

In vivo test

All procedures in the laboratory and selection of the RBC products were made by the technician on duty. RBC concentrates were suspended in saline-adenine-glucose-mannitol. None of the patients had any premedication such as steroids or antihistamines before transfusion. From the selected incompatible unit, 20-ml blood was collected in a 20 cc syringe (Hayat®) and infused intravenously to the patients in 10 min via the antecubital vein. The patients were observed for any signs of acute hemolysis for 20 min before the initiation of the transfusion of the residual blood. The transfusions were started from another vascular access and finished as rapidly as tolerated, with the complete transfusion not exceeding 4 h. Each transfusion was observed by medical professionals to identify any evidence of acute hemolysis. The signs and symptoms of acute transfusion reaction were looked for, i.e., dyspnea, headache, hypotension, back pain, fever, tachycardia, and chills, and these were recorded together with the time of occurrence by the observer.

If any symptoms indicating hemolysis were observed, the transfusion was stopped and another selected unit of blood was used. Pre- and post-transfusion hemoglobin (Hb) and Hct levels were compared to determine the increase as a result of the transfusion. Biochemical markers indicating hemolysis include lactate dehydrogenase (LDH), and total and indirect bilirubin levels were recorded to evaluate the hemolytic state. The same laboratory tests were performed after 24 h of transfusion in order to look for any signs of hemolysis.

Statistical analysis

Statistical analyses were made using SPSS software version 24.0 (IBM Corp., SPSS Statistics for Windows, Armonk, NY, USA). Kolmogorov–Smirnov test was used to determine the normality of the variables. The parametric variables were presented as mean ± standard deviation and nonparametric variables as median and interquartile range. Categorical variables were presented as percentage (%). The Wilcoxon test was used for comparing nonparametric variables; paired sample t- test was used to compare the parametric variables. All statistical tests were two sided, and P ≤ 0.05 was considered statistically significant.

Ethical approval

Written informed consent was obtained from the patients. Approval for the study was granted by the ethics committee of our hospital. All procedures were conducted in accordance with the principles of the Helsinki Declaration.


The study included twenty patients, eight males (40%) and twelve females (60%), with a mean age of 52.70 ± 16.26 years (range: 28–81 years).

All the transfusions (n = 69) were observed for acute hemolytic reactions, and a record was made of signs of acute hemolytic transfusion reactions (AHTRs). Multiple units of transfusion (range: 1–12 units) were experienced for certain patients. No complications or signs were observed in any of the transfusions, and all the transfusions were completed successfully.

The demographic data of the participants and the transfusion units are presented in [Table 1], and the biochemical and hematological parameters are shown in [Table 2]. After transfusion, the mean Hb level increased to 8.01 ± 1.53 g/dl from 6.14 ± 1.34 g/dl. A statistically significant increase in Hct and Hb was seen post transfusion (P = 0.001) [Table 2]. As indicators of hemolysis, LDH and total and unconjugated bilirubin levels were not determined to have significantly increased post transfusion (P = 0.453, P = 0.946, and P = 0.476, respectively).{Table 1}{Table 2}


Many antigens and antibodies against erythrocytes may cause adverse AHTRs. The aim of the pretransfusion testing is avoiding hemolysis and providing a compatible blood product.[5] There must be an investigation of the history of the use of certain drugs that can induce hemolysis, lymphoproliferative disorders, autoimmune diseases or immunodeficiency disorders, pregnancy or prior transfusion, and difficulties in finding blood for family members. The patients included in our study were investigated for transfusion history. All patients were transfusion naïve, and no significant history was determined for disease and medication that may cause difficulties during transfusion.

Compatibility testing certainly includes the determination of ABO and Rh types, antibody screening, and a crossmatching test. The final step, the crossmatching test, refers to the selection and testing of a specific donor unit of RBCs for transfusion to the recipient. Transfused RBC units do not need to be antigenically identical to the recipient's RBCs, but should not provoke clinically significant hemolysis in the recipient. However, if patients have a history of a clinically significant antibody or an antibody identified in a current specimen, units negative for the corresponding RBC antigen should be crossmatched with an antihuman globulin crossmatch.[6]

Previously, Petz discussed the use of ABO-matched least incompatible units as an acceptable alternative to performing an adequate serological evaluation before transfusion.[6]

Duringin vivo crossmatch test, infusion of 20 ml of blood was started at a rate of 2 ml/min and a pause of 20 min was given to observe the patient for hemolytic signs. In clinical practice, the rate of well-matched blood transfusion should be 1–2 ml/min in the first 15 min and then should be continued as soon as possible at the rate of 4 ml/min to determine hemolytic status. In clinical practice, only 10 ml of blood transfusion is sufficient for acute hemolysis to occur due to transfusion.[7] Symptoms are mostly observed within a few minutes of starting the transfusion. Fever and chills are mostly seen as initial findings. Dyspnea, back pain, and uncomfortable feelings may also develop. Therefore, the method of testing, the infusion rate, and the observation period are sufficient to detect acute hemolytic symptoms.

There are two reports in literature of a limited number of patients, which have predicted hemolysis with incompatible blood transfusion byin vivo testing. One method involves 1.0-ml intravenous infusion of Cr51-labeled RBC and observation of RBC survival.[8] The other study reported the infusion of a trace of blood and observation of rapid signs of hemolytic transfusion reaction.[9] Both studies showed that selected units were available and hemolysis may be ignored, similar with our results.

In the current study, adequate levels of increased Hb were determined after transfusion. Biochemical parameters which indicate hemolysis were found to be significant but clinically did not correlate with hemolytic transfusion reaction. This silent hemolytic status could be ignored in cases where the Hb was increased to the target level.

Prior studies have investigated the risk of uncrossmatched group-specific or group O red blood transfusion.[4],[10] This may be an alternative way to increase Hb when cross-compatible units are not available and transfusion is urgent. In Turkey, depending on the institutional policy, several transfusion centers choose to transfuse group O, Rh (D)-negative RBC to increase Hb levels. We suggest, after seeking RBC in the bank reserve, transfusing the selected least incompatible RBC with biological crossmatch testing.


Acute transfusion-related hemolytic reactions are a serious situation. When pretransfusion tests result as crossmatch incompatible, clinicians should not avoid transfusion if it is urgently required. The biologicalin vivo compatibility test is safe, is predictive, and can be feasibly applied at the bedside, which may be lifesaving for many patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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