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Transfusion Medicine Case Studies Patient GJ March 2010 John N. McLennan, MT(ASCP) Midwest Region American Red Cross Omaha, NE The need is constant. The gratification is instant. Give blood. TM Gertrude Jones presented to the emergency department complaining of shortness of breath and leg pain. She recently had a double mastectomy. Gertrude has a history of DVT’s in her left leg. Current hemoglobin: 7.0 g/dL Current hematocrit: 20.8% Gertrude’s transfusion history indicates that she is A Positive. She has received blood in the last 3 months, getting 8 units of packed red cells in the last 4 days. She has a history of anti-E. Crossmatch indicates that 8 of 8 units that are E antigen negative are incompatible. The sample was sent to the reference laboratory for further investigation. The need is constant. The gratification is instant. Give blood. TM 2 Case GJ Front Type Rh Reverse Type Anti-D A1 cells B Cells A Positive 4+ 0 4+ 0 3+ e Cw M N S s P1 Lea Leb K k Fya Fyb Jka Jkb Lua Lub LISS/AHG Anti-B LISS/37 Anti-A IS Interp. 1 R1R1 + + 0 0 + 0 + 0 0 + + 0 + + + + + + 0 0 + 0 0 0 2 R2R2 + 0 + + 0 0 + + + + + + 0 0 + + 0 + + 0 + 0 1+ 3+ 3 rr 0 0 + + 0 0 0 + 0 + 0 + 0 + 0 + 0 1+ 2+ 0 1+ 2+mf Blood Group System Rh D C E c MNSs 0 0 0 + + Auto The need is constant. The gratification is instant. Give blood. P Lewis Kell Duffy Kidd Lutheran TM 3 Case GJ With a positive auto-antibody in a recently transfused patient, a DAT and elution should be performed. Poly Positive IgG DAT 2+ mf IgG 3+ mf C3d Control 0 0 There is no specific order to perform testing. Since there were negative cells reactive at LISS/37 and LISS/AHG, testing with serum/plasma could be performed to determine the allo-antibody specificity. The elution could also be performed to determine what is coating the red blood cells. REMEMBER, the patient has been recently transfused, so there is a mixture of patient cells and transfused cells present in this sample. The need is constant. The gratification is instant. Give blood. TM 4 Case GJ Patient GJ is suspected to be having a delayed transfusion reaction. 2nd transfusion (antigen positive) Allo-antibody attaches to transfused red cells Positive DAT, reactive eluate: Delayed Transfusion Reaction Often, if the antibody screen is initially negative, transfusion with the antigen positive unit will trigger an Development of anamnestic response, causing the antibody to respond allo-antibody quite rapidly. This allo-antibody titer slowly decreases (over time) after the initial immune response, sometimes becoming undetectable in the serum. Initial transfusion (exposure to foreign antigen) The need is constant. The gratification is instant. Give blood. TM 5 Case GJ Rh D C E c MNSs P Lewis e Cw M N S s P1 Lea Leb Kell K k Duffy Kidd Lutheran Fya Fyb Jka Jkb Lua Lub LISS/AHG Blood Group System LISS/37 A panel was tested with the patient plasma to see if an antibody specificity could be determined. 1 RzR1 + + + 0 + 0 0 + 0 + + 0 + + + + 0 + 0 0 + 0 1+ 2 R1R1 + + 0 0 + + + 0 + + + + 0 0 + + 0 0 + 0 + 0 0 3 R1R1 + + 0 0 + 0 + + + 0 + 0 + 0 + 0 + + 0 0 + 0 0 4 R2R2 + 0 + + 0 0 + 0 + 0 0 + 0 + 0 + 0 0 + 0 + 1+ 3+ 5 R2R2 + 0 + + 0 0 + + 0 + 0 0 + 0 + 0 + 0 + 0 + 1+ 3+ 6 rr 0 0 0 + + 0 0 + + 0 + 0 + 0 + + + + + 0 + 1+ 3+ 7 rr 0 0 0 + + 0 0 + + + + 0 + 0 + + 0 + + 0 + 1+ 3+ 8 rr 0 0 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0 + 0 + 1+ 3+ The need is constant. The gratification is instant. Give blood. TM 6 Case GJ e Cw M N S s P1 Lea Leb K k Fya Fyb Jka Jkb Lua Lub LISS/37 LISS/AHG Additional cells were tested to complete the identification process 1 R1R1 + + 0 0 + + 0 + 0 + + + 0 0 + + 0 0 + 0 + 0 0 2 R1R1 + + 0 0 + 0 0 + + 0 0 0 + + + 0 + + + 0 + 0 0 3 rr 0 0 0 + + 0 + + 0 + 0 0 + 0 + + + + + 0 + 1+ 3+ 4 rr 0 0 0 + + 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 1+ 3+ Blood Group System Rh D C E c MNSs P Lewis Kell Duffy Kidd Lutheran All common allo-antibodies have been ruled out except anti-E and antic. It appears that the patient has developed anti-c. Now testing must be performed with the eluate to determine what antibody (ies) are coating the red cells. The need is constant. The gratification is instant. Give blood. TM 7 e Cw M N S s P1 Lea Leb K k Fya Fyb Jka Jkb Lua Lub Eluate/AHG Last Wash/AHG Case GJ 1 R1R1 + + 0 0 + 0 + 0 0 + + 0 + + + + + + 0 0 + 0 0 2 R2R2 + 0 + + 0 0 + + + + + + 0 0 + + 0 + + 0 + 2+ 0 3 rr 0 0 + + 0 0 0 + 0 + 0 + 0 + 0 + 2+ 0 Blood Group System Rh D C E c MNSs 0 0 0 + + P Lewis Kell Duffy Kidd Lutheran Eluate testing is treated just like plasma/serum testing. All common allo-antibodies must be ruled in/out with the eluate. A panel was performed to identify the antibody that is present in the eluate. The need is constant. The gratification is instant. Give blood. TM 8 Rh D C E c MNSs P Lewis e Cw M N S s P1 Lea Leb Kell K k Duffy Kidd Lutheran Fya Fyb Jka Jkb Lua Lub Last Wash/AHG Blood Group System Eluate/AHG Case GJ 1 RzR1 + + + 0 + 0 0 + 0 + + 0 + + + + 0 + 0 0 + 0 0 2 R1R1 + + 0 0 + + + 0 + + + + 0 0 + + 0 0 + 0 + 0 0 3 R1R1 + + 0 0 + 0 + + + 0 + 0 + 0 + 0 + + 0 0 + 0 0 4 R2R2 + 0 + + 0 0 + 0 + 0 0 + 0 + 0 + 0 0 + 0 + 2+ 0 5 R2R2 + 0 + + 0 0 + + 0 + 0 0 + 0 + 0 + 0 + 0 + 2+ 0 6 rr 0 0 0 + + 0 0 + + 0 + 0 + 0 + + + + + 0 + 2+ 0 7 rr 0 0 0 + + 0 0 + + + + 0 + 0 + + 0 + + 0 + 2+ 0 8 rr 0 0 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0 + 0 + 2+ 0 The need is constant. The gratification is instant. Give blood. TM 9 e Cw M N S s P1 Lea Leb K k Fya Fyb Jka Jkb Lua Lub LISS/37 LISS/AHG Case GJ 1 Rz R1 + + + 0 + + 0 + 0 + + + 0 0 + + 0 0 + 0 + 0 0 2 R1R1 + + 0 0 + 0 0 + + 0 0 0 + + + 0 + + + 0 + 0 0 3 rr 0 0 0 + + 0 + + 0 + 0 0 + 0 + + + + + 0 + 1+ 3+ 4 rr 0 0 0 + + 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 1+ 3+ Blood Group System Rh D C E c MNSs P Lewis Kell Duffy Kidd Lutheran All common allo-antibodies have been ruled out except anti-c. It appears that the patient has developed anti-c. If the patient had not been transfused so recently, a cell separation and complete phenotype would be performed. However, the patient received 8 units of PRBC’s in the past 4 days. There is a lot of circulating transfused cells in this patient’s sample, and cell separation and phenotyping would probably be unsuccessful. The need is constant. The gratification is instant. Give blood. TM 10 Case GJ Conclusion: • Anti-E historical per hospital record • Anti-c PEG/AHG and Eluate • Positive IgG-DAT • Due to recent multiple transfusions, phenotype was not performed • If required, transfuse A Positive red cells that are negative for E and c. The need is constant. The gratification is instant. Give blood. TM 11 Case GJ Patient management of a delayed hemolytic transfusion reaction include monitoring the patient and providing supportive care. Most frequently, a correction of the anemia is all that is required. This would be achieved by transfusing antigen negative blood. When a transfusion reaction is suspected, the patient’s physician and and the transfusion service director should be notified. This would allow for identification and treatment of any unrecognized hemolysis. The need is constant. The gratification is instant. Give blood. TM 12 Transfusion Medicine Case Studies Case PW March 2010 Presented by John N. McLennan, MT(ASCP) Midwest Region American Red Cross Omaha, NE The need is constant. The gratification is instant. Give blood. TM Pam Weeks is a patient at Large Hospital. She is a 2 year old African American female. She presented to the emergency department with a distended abdomen and severe abdominal discomfort. She had a liver transplant 8 months ago. She has received multiple transfusions in the last few months, with the most recent being 1 unit of packed red blood cells 4 weeks ago. Her current hemoglobin is 7.4 g/dL with a hematocrit of 23.3%. Large laboratory sent the sample to the reference lab for antibody identification. She is historically O Positive with a history of a warm autoantibody, not demonstrable in LISS media. The need is constant. The gratification is instant. Give blood. TM 14 Case PW Front Type Rh Reverse Type Interp. Anti-A Anti-B Anti-D A1 cells B Cells O Positive 0 0 4+ 4+ 3+ Blood Group System Kell Duffy Kidd Lutheran e Cw M N S s P1 Lea Leb K k Fya Fyb Jka Jkb Lua Lub PEG/AHG Lewis LISS/AHG P LISS/37 MNSs IS Rh 1 R1R1 + + 0 0 + 0 + 0 + 0 + 0 + 0 + + 0 0 + + + 0 2+ 0 w+ 2 R2R2 + 0 + + 0 0 0 + + + + + 0 0 + 0 + + + 0 + 0 2+ 0 1+ 3 rr 0 + 0 0 + + 0 + + + 0 + + 0 0 + 0 2+ 0 w+ 0 0 w+ w+ D C E c 0 0 0 + + Auto The need is constant. The gratification is instant. Give blood. TM 15 Case PW Poly IgG C3d Control 1+ 0 0 Positive IgG DAT Due to the formation of an antibody and the recent transfusions, an elution was performed on PW’s red cells. Blood Group System P Lewis Kell Duffy Kidd Lutheran e Cw M N S s P1 Lea Leb K k Fya Fyb Jka Jkb Lua Lub Last Wash PEG/IgG MNSs Eluate PEG/IgG Rh 1 R1R1 + + 0 0 + 0 + 0 + 0 + 0 + 0 + + 0 0 + + + 1+ 0 2 R2R2 + 0 + + 0 0 0 + + + + + 0 0 + 0 + + + 0 + 1+ 0 3 rr 0 + 0 0 + + 0 + + + 0 + + 0 0 + 1+ 0 D C E c 0 0 0 + + The eluate was broadly reactive with all cells tested, which is consistent with a warm-autoantibody. The need is constant. The gratification is instant. Give blood. TM 16 Case PW Warm auto reactivity is apparent in the serum and eluate with PEG enhancement. Confirmation can be performed by: Testing the DAT negative autologous cells against the serum Testing the eluate against the DAT negative autologous cells If a patient has been recently transfused and autologous cells are not available, the term “consistent with a warm autoantibody” will be used. This term is used when absolute confirmation by the above methods cannot be performed. The need is constant. The gratification is instant. Give blood. TM 17 Case PW A cell separation was performed. To ensure that any AHG testing will not be affected by the positive DAT, a DAT was performed on the separated cells. Since the cell separation had a positive DAT, EGA must be used to remove the IgG coating on the red cells IgG Cell Separated Cells 1+ EGA treated Cell Separation 0 The autologous cells (reticulocytes) that were harvested and chemically rendered DAT negative, are used for patient phenotyping. These cells can also be tested against the plasma and eluate to confirm the presence of a warm autoantibody. C E c e M N S s K Fya 0 0 + + + 0 0 + 0 0 The need is constant. The gratification is instant. Give blood. Fyb Jka Jkb 6% Albumin 0 + 0 0 TM 18 Case PW Patient serum PEG/AHG EGA Treated Cell Separation (DAT Negative autologous cells) 2+ Eluate PEG/AHG Last Wash PEG/AHG 2+ 0 All of the testing indicates that there is a warm auto-antibody present at PEG/AHG. It is not necessary to proceed any further with testing at PEG. PEG enhancement commonly enhances warm auto-antibody reactivity. Since we have negative reactivity with LISS enhancement, rule-out of the common allo-antibodies will be performed with LISS media. The need is constant. The gratification is instant. Give blood. TM 19 Case PW Rh MNSs Fya Fyb Jka Jkb Lua Lub LISS/AHG Blood Group System LISS/37 Because the patient had a negative antibody screen with LISS at AHG, a panel of cells was tested to insure all common allo-antibodies have been ruled out at LISS/AHG. + 0 + 0 + 0 + 2+ 0 0 + + + 0 + 0 + 2+ 0 0 + + + 0 + + 0 + 2+ 0 0 + 0 + 0 + + 0 0 + 2+ 0 0 + 0 + 0 + 0 + 0 0 + 2+ 0 0 0 + 0 + + + + + 0 + 2+ 0 P Lewis Kell e Cw M N S s P1 Lea Leb 1 R1R1 + + 0 0 + 0 + 0 + 0 + 0 + 0 2 R1R1 + + 0 0 + 0 0 + 0 + 0 0 + 3 R2R2 + 0 + + 0 0 0 + 0 + 0 + 4 R2R2 + 0 + + 0 0 + + + 0 + 5 r’r 0 + 0 + + 0 + 0 + + 6 r”r 0 0 + + + 0 + + + + D C E c K k Duffy Kidd Lutheran All common allo-antibodies have been excluded with LISS/AHG The need is constant. The gratification is instant. Give blood. TM 20 Case PW Now, the focus will be on testing for antibody identification at LISS/37. Auto-control was negative at LISS/37, indicating the probable presence of an allo-antibody. Since the phenotype of the patient has been established, testing of 2 phenotypically similar reagent red cells will aid in antibody identification. (phenotype: C-, E-, S-, K-, Fya-, Fyb-, Jkb-) Blood Group System Lewis Kell Duffy Kidd Lutheran LISS/AHG P LISS/37 MNSs IS Rh 1 R0r + 0 0 + + 0 + 0 0 + 0 0 + 0 + 0 0 + 0 0 + 0 2+ 0 2 R0r + 0 0 + + 0 + 0 0 + + 0 + 0 + 0 0 + 0 0 + 0 2+ 0 D C E c e Cw M N S s P1 Lea Leb K k Fya Fyb Jka Jkb Lua Lub The need is constant. The gratification is instant. Give blood. TM 21 Case PW Rh MNSs P Lewis Kell Duffy Kidd Lutheran Special Typing Blood Group System LISS/37 A panel of high incidence negative red cells was tested with the following results. (Testing only needs to be done at LISS/37) e Cw M N S s P1 Lea Leb K k Fya Fyb Jka Jkb Lua Lub 1 0 0 0 + + 0 + + 0 + + + 0 + + + 0 + + 0 + 2+ Joa- 2 + + 0 + + 0 + 0 + + 0 0 + 0 + 0 + 0 + 0 + 2+ Hy- 3 0 0 0 + + 0 + + 0 + 0 0 + 0 + + + + + 0 + 2+ Tja- 4 + + 0 0 + 0 + 0 + + 0 0 + 0 + 0 + 0 + 0 + 0 Kpb- 5 0 0 0 0 0 0 + 0 0 + 0 0 + 0 + + 0 + 0 0 + 2+ Rh Null D C E c The need is constant. The gratification is instant. Give blood. TM 22 Case PW Rh P Lewis Kell Duffy Kidd Lutheran e Cw M N S s P1 Lea Leb K k Fya Fyb Jka Jkb Lua Lub R1R1 + + 0 0 + + 0 0 + + 0 + 0 + + 0 + 0 0 + D C E 1 MNSs c + Special Typing Blood Group System LISS/37 Testing a Kpb negative cell was non-reactive at LISS/37. A second Kpb negative cell must be tested. 0 Kp b- Because Kpb negative cells are not commonly found on reagent grade red cell panels, the use of DTT treated cells can be used to rule-out all other common allo-antibodies, EXCEPT anti-K. The need is constant. The gratification is instant. Give blood. TM 23 Blood Group System Rh MNSs P Lewis Kell Duffy Kidd Lutheran DTT Treated LISS/37 Case PW e Cw M N S s P1 Lea Leb K k Fya Fyb Jka Jkb Lua Lub 1 R1R1 + + 0 0 + + + 0 + + + + 0 0 + + 0 0 + 0 + 0 2 R2R2 + 0 + + 0 0 + + + + + + 0 0 + 0 + 0 + 0 + 0 3 R1R1 + + 0 0 + 0 + 0 + 0 + + 0 0 + + + 0 + 0 + 0 4 R0r + 0 0 + + 0 + 0 + + + 0 + 0 + 0 + + 0 0 + 0 5 rr 0 0 0 + + 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 6 R2R2 + 0 + + 0 0 0 + 0 + + + 0 0 + + 0 + 0 0 + 0 7 R1R1 + 0 0 + + 0 0 + 0 0 + 0 0 0 + 0 0 + 0 0 + 0 8 rr 0 0 + 0 + + 0 + 0 + 0 0 + 0 0 + 0 D C E c 0 0 0 + + The need is constant. The gratification is instant. Give blood. TM 24 Case PW Initial conclusion: Warm auto-antibody at PEG/AHG with serum and eluate. Anti-Kpb at LISS/37. Honor anti-K (unable to rule out anti-K at LISS/37 due to unavailability of cells) The patient phenotype indicated patient PW was Kpb antigen negative, with testing being performed with unlicensed anti-sera. However, this phenotype is uncommon in African American individuals. The need is constant. The gratification is instant. Give blood. TM 25 Case PW Prevalence (%) Kpb Phenotype Whites Blacks A high prevalence in all populations. Kp(a+b+) 2.3 RARE This chart indicates 100% of Blacks Kp(a-b+) 97.7 100 Kp(a+b-) 2.3 RARE are antigen positive for Kpb The sample was submitted for molecular testing to determine if the anti-Kpb is allo or auto in nature. Molecular typing indicated that the patient is Kpb antigen positive, confirming the autoantibody specificity. Since there is an auto-antiKpb, antigen negative units do NOT need to be transfused. The need is constant. The gratification is instant. Give blood. TM 26 Consultation Request Form American Red Cross Biomedical Services Washington, DC 20006 Immunohematology Consultation Request for Completion using Computer Reference Lab contact numbers: Phone: 402 271 2580 x 2130 Midwest Region Omaha, NE 68105 CLIA # 28D0652588 Fax: 402 341 2578 See page 2 for instructions, sample types and tube labeling requirements Call Reference Laboratory before sending sample Reference Lab person contacted: Date/Time contacted: Submitting Facility Information Facility Name/ID: Request Date: Facility Address: City/State: Zip: Blood Bank Contact: Blood Bank Phone #: Requesting Physician: Blood Bank Fax #: Patient Information Patient Name: Patient ID: Birth Date/Age: Race: Specimen Date: ABO/Rh: Gender: M Diagnosis: F Hgb/Hct: Medications: Additional information: Transfusion History: No record Within last 3 months: No Yes ► Dates / products: Prior to last 3 months: No Yes ► Dates / products: Pregnancy History: Number: Known RBC antibody(ies) Anti -D Currently pregnant? No -C -c -E Yes -e -K ► Due date: -Fya -Fyb -Jka -Jkb -S -s Other (list): Test Request Routine ASAP STAT Note: STAT and/or after-hours charges may apply Patient not waiting, transfuse when available. Patient waiting, transfusion needed as soon as possible. Patient actively bleeding/life-threatening. Investigation Requested: (Check all that apply) ABO/Rh typing Incompatible crossmatch Positive DAT Suspected transfusion reaction Antibody identification Hemolytic Disease of the Fetus & Newborn Products Requested for this patient: (Check all that apply) OTHER SPECIFY: Product Attributes: (Check all that apply) Add any other facility-specific services offered. OTHER SPECIFY: PRESELECTED UNITS # units: Date needed: CMV-negative Leukoreduced Irradiated Hemoglobin S-negative RBC OTHER SPECIFY: Summary of Antibody Testing Results Tube: LISS Other: Gel Solid Phase The need is constant. The gratification is instant. Give blood. PEG ENZ IS 37C AHG CROSSMATCH RESULT I # Compatible Donors II # Incompatible Donors III AHG Used:Polyspecific IgG DAT: TM 27 Consultation Request Form 1. Obtain an appropriate sample and label it according to the instructions in the table below. 2. Prepare the sample for shipping according to the instructions in the table below. Sample and Tube Label Requirements Sample Type: Label Requirements: Sample Label MUST include: 2-3 7 ml EDAT tubes. IF a warm autoantibody is List regional requirements, for example, suspected, include additional EDTA tubes. Patient First and Last Name Do not submit samples collected with serum Patient ID Number (i.e., Hospital separator tubes. number, SSN, date of birth, etc) If recently transfused, include pre-transfusion red Date and time collected cell sample, if available No special preparation of the patient is needed prior to collecting samples NOTE: IMPROPERLY LABELED SAMPLES WILL NOT BE TESTED Shipping Instructions: Pack samples according to facility practice to prevent leaking or breakage in transit. Do not ship samples via first class mail. Please include return transportation for units requested in the facility specific area below. 3. Complete the form. 4. Contact the reference lab at the phone number on the top of the form prior to sending the sample. 5. Record the name of the person contacted and the date and time of the notification. 6. Follow any additional instructions noted in the ARC Facility-specific area below. 7. Submit the sample and a completed Consultation Request to the ARC. Facility Specific area (for ARC use) Please communicate return transportation instructions The need is constant. The gratification is instant. Give blood. TM 28 References: Roback, John D. (2008). AABB Technical Manual, 16th Edition. Maryland. American Association of Blood Banks. Reid, Marion and Christine Lomas-Francis. The Blood Group Antigen. Boston: Academic Press, 1997. Textbook of Blood Banking and Transfusion Medicine, Rudmann, et al, 2005, Chapter 15. The need is constant. The gratification is instant. Give blood. TM 29