Preparation of RBCs for Thalassemia patient with multiple antibodies Detection and Identification of Alloantibodies to Red Cell Antigens Iranian Blood Transfusion Organization Mostafa Moghaddam MS, CLS ( ASCP ) BB Head of Immunohematology Reference Laboratory ISBT member of RARE Donor Working Party ISBT member of Immunohematology Working Party

Requirements of IBTO (AABB) Standards for an Detection and Identification of unexpected Antibodies to Red Cell Antigens جستجو و شناسائي آنتي باديهاي غيرمنتظره عليه آنتي ژنهاي گلبول قرمز خون Requirements of IBTO (AABB) Standards for an Antigen negative Blood Transfusion Request 1.Positive identification of the recipient and the recipient blood samples. 2. ABO group and Rh (D) typing of the recipient's blood 3. Red cell antibody detection tests for clinically significant antibodies using the recipient’s serum/plasma ( Antibody Screening ) 4. Comparison of current findings on the recipient’s sample with records of previous results

5. Confirmation of the ABO group of red cell components . Detection and Identification of unexpected Antibodies to Red Cell Antigens جستجو و شناسائي آنتي باديهاي غيرمنتظره عليه آنتي ژنهاي گلبول قرمز خون 5. Confirmation of the ABO group of red cell components . 6. Confirmation of the Rh type of Rh negative red cell components 7. Selection of components of ABO group / Rh type and appropriate antigen negative RBC unit for the recipient 8. Performance of a serologic or computer cross match 9. Labeling of products with the recipient’s identifying information

react at 37ºС or in the antihuman globulin (AHG) phase Detection and Identification of unexpected Antibodies to Red Cell Antigens Clinically significant alloantibodies react at 37ºС or in the antihuman globulin (AHG) phase are usually IgG antibodies cause a transfusion reaction decrease survival of RBCs

Detection and Identification of unexpected Antibodies to Red Cell Antigens جستجو و شناسائي آنتي باديهاي غيرمنتظره عليه آنتي ژنهاي گلبول قرمز خون Antibody Screen Definition : Testing the patient’s serum/ plasma with group ‘’O” reagent red cells in an effort to detect atypical antibodies Small percentage of general population has detectable RBC antibodies 0.2 - 2 Percent Thalassemia/Sickle cell patients 6-35% Heart surgery patients 10% Renal disease patients 7% Incubation at 37ºС Use of an antiglobulin test IBTO (AABB) requirement states that method used to detect clinically significant antibodies must include

Groups that an antibody screen test is required Detection and Identification of unexpected Antibodies to Red Cell Antigens جستجو و شناسائي آنتي باديهاي غيرمنتظره عليه آنتي ژنهاي گلبول قرمز خون Groups that an antibody screen test is required 1. As part of pre transfusion testing on the recipient Thalassemia & Sickle cell 2. Routine prenatal testing for obstetric patients evaluate HDN candidacy for RhIG 3. Donors of allogenic blood and blood products stem/ progenitor cells

Methods Tube technique - Gel technique Solid phase technique Automation Methods Tube technique - Gel technique Solid phase technique

More is no better in Blood Transfusion

Providing blood for Thalassemia patient with Anti-M & Anti-Jkb and more A blood sample from a female patient with Hg 2.5 g/dl was received by IRL .Patient was suffering from serious multiple blood transfusion reactions including severe confusion and mild syncope. Name M.D Age 26 years old City Isfahan Diagnosis Splenomegaly-anemia /candidate for splenectomy

Providing blood for Thalassemia patient ABO O Rh(D) Positive Antibody Screen test Auto control test Positive(weak+) Antibody ID Anti-M and Anti-Jkb DAT PS1 PS2 Anti-IgG Anti-C3d Control 12.18.2014 0 / 2+ W+/3+ 4+ 11.05.2015 w+/w+ 0/w+ W+ C c E e K k Fya Fyb Jka Jkb M N S s Patient phenotype Dec 2014 4+ Mf(3+) Mf(2+) Nov 2015 3+

Patient’s Chronological Medical History Medical decisions Outcome Reason Number of RBCs transfused Important dates Blood transfusion stopped Transfusion reaction reported ? 2 RBCs 9 yrs old 2 more rbcs infused patient suffered severe AHT reaction including confusion and mild syncope Hg  4.5 g/dl and  2.5 in few days Hg  to 2.5g/dl after one week Gallstone removed post endoscopy 4 WRBCs 25 yrs old Oct 2014 Resting at home with Hg 3.7 g/dl contacted blood center in Isfahan IRL in Tehran splenectomy requested 2 more Nov 2014 splenectomy was performed successfully on Dec 20 2014 Hg 5.9 g/dl transported to Isfahan blood center M- Jkb- C- K- 3RBCs were prepared Dec 6-13 2014 No Transfusion since then Hg 7.5g/dl No transfusion reaction One unit was prepared RBC M- , Jkb- ,C- K- Dental surgery 1 RBC Oct 3 2015 C 32% M 22% Jkb 28% Fya 17% s 11% = 0.0003% Only one unit RBC has been found patient needs C-, K-, M- , JKb- , Fya- , s- anti-M not reacting this time anti-Jkb reconfirmed anti-s also was identified Plastic surgery Requested 5 RBCs Nov 16 2015

+ Should Transfusion of thalassemia patients be matched using phenotype –matched RBC donor units? Disease What Antigens Name of Laboratory 61 sickle patients 1830 LRBC C, E , K neg HTR dropped 90% reduction of alloimmunization from 3% to 0.5 Transfusion 2001 Sickle cell anemia K, C, E, S, Fya or Fybneg 40 patient Ag matched No alloantibody 46 patients No Ag matched 16 developed antibodies Transfusion 1994 Sickle cell patients 12year study 351 patient received 8939 LRBC 29.1 % developed at least 1 or more antibodies C , c, E, e and K Ag neg prevent all antibodies in 53.3 patients C , c, E , e, K ,S , Fya and Jkb prevent all antibodies in 70.8 patients Transfusion 2002

+ Should Transfusion of thalassemia patients be matched using phenotype –matched RBC donor units? Disease What Antigens Name of organization thalassemia K neg Canada Ontario Hospital sickle cell anemia D, C, c, E, e, K neg U.S.A Ohio Blood Bank K neg for female under 45 years no antigen negative RBCs for patient with no antibody Australian Blood Bank LRBCs avoid providing stored RBC drived cytokines sickle , thalassemia GI bleed ,AML but not for ALL or CLL D , C, c E, e , K , phenotyping Fya , Fyb , Jka or Jkb is waste of time New York Blood Bank Vox 1983 Sickle & thalassemia Full phenotype tested at diagnosis give C, c ,D, E, e , K Ag neg R◦ should receive R◦ & rr on emergency no matching for Duffy , Kidd, M, N,S British Committee For Standardization Hematology 1996 Transfusion Medicine

Very Rare Blood Type in Iranian Rare Donor Data Base 2009-2015 Oh Bombay Kpb- Lu (a- b- ) Fy (a-b-) Jk(a-b-) RzRz RzR1 RzR2 r'' r'' r' r' D - - k-(Cellano) Rh null K null P null (Allo-Anti-P) P1 pK In(b-) Total number of donors identified 26 1 8 19 2 3 9 13 12

Alternative for Incompatible Transfusion Events Countries Cristalloid Colloid Small volume transfusion Corticosteroids IVIG Radiation therapy Eculizumab (Soliris ,complement inhibitor) Volum expander Albumin –Dextran Autologous RBCs Erytropoetin Plasma Exchange Blood substitute (research phase) Brazil China Finland France Germany Italy Iran Japan Singapore Sweden Switzerland The Netherlands UK US

چرخه سازگـاری و خون سـالم = آزمایشگـاه رفرانس ایمونوهمـاتولوژی ImmunohematologyReference Laboratory = Compatibility Wheel and Safe Blood and if any one saved a life, it would be as if he saved the life of the whole people 32 maedeh