1. The need is constant. The gratification is instant. Give blood. TM Transfusion Medicine Case Studies Patient GJ March 2010 John N. McLennan, MT(ASCP) Midwest Region American Red Cross Omaha, NE

2. 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. 2

3. The need is constant. The gratification is instant. Give blood. TM Case GJ 3 Front TypeRhReverse Type Interp. Anti-A -B -DA 1 cellsB Cells A Positive4+0 03+ IS LISS/37 LISS/AHG Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran DCEceC w MNSsP 1 Le a b KkFy a b Jk a b Lu a b 1 R 1 R 1 ++00+0+00++0++++++00+00 0 2 R 2 R 2 +0++00++++++00++0++0+01+3+ 3 rr000++00++000+0+0+0+0+01+2+ Auto 01+ 2+ mf

4. The need is constant. The gratification is instant. Give blood. TM With a positive auto-antibody in a recently transfused patient, a DAT and elution should be performed. 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. 4 Case GJ PolyIgGC3dControl Positive IgG DAT 2+ mf 3+ mf 0 0

5. The need is constant. The gratification is instant. Give blood. TM 5 Initial transfusion (exposure to foreign antigen) Development of allo-antibody 2 nd transfusion (antigen positive) Allo-antibody attaches to transfused red cells Positive DAT, reactive eluate: Delayed Transfusion Reaction Case GJ This allo-antibody titer slowly decreases (over time) after the initial immune response, sometimes becoming undetectable in the serum. Often, if the antibody screen is initially negative, transfusion with the antigen positive unit will trigger an anamnestic response, causing the antibody to respond quite rapidly. Patient GJ is suspected to be having a delayed transfusion reaction.

6. The need is constant. The gratification is instant. Give blood. TM A panel was tested with the patient plasma to see if an antibody specificity could be determined. 6 Case GJ LISS/37 LISS/AHG Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran DCEceC w MNSsP 1 Le a b KkFy a b Jk a b Lu a b 1 R z R 1 +++0+00+0++0++++0+00+0 1+ 2 R 1 R 1 ++00+++0++++00++00+0+0 0 3 R 1 R 1 ++00+0+++0+0+0+0++00+0 0 4 R 2 R 2 +0++00+0+00+0+0+00+0+1+3+ 5 R 2 R 2 +0++00++0+00+0+0+0+0+1+3+ 6 rr 000++00++0+0+0+++++0+1+3+ 7 rr 000++00++++0+0++0++0+1+3+ 8 rr 000++0+00+00++00+0+0+1+3+

7. The need is constant. The gratification is instant. Give blood. TM 7 Case GJ All common allo-antibodies have been ruled out except anti-E and anti- c. 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. LISS/37 LISS/AHG Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran DCEceC w MNSsP 1 Le a b KkFy a b Jk a b Lu a b 1 R 1 R 1 ++00++0+0+++00++00+0+0 0 2 R 1 R 1 ++00+00++000+++0+++0+0 0 3 rr000++0++0+00+0+++++0+1+3+ 4 rr 000++0+0+0+0+0++++00+1+3+ Additional cells were tested to complete the identification process

8. The need is constant. The gratification is instant. Give blood. TM Case GJ 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. 8 Eluate/AHG Last Wash/AHG Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran DCEceC w MNSsP 1 Le a b KkFy a b Jk a b Lu a b 1 R 1 R 1 ++00+0+00++0++++++00+ 0 0 2 R 2 R 2 +0++00++++++00++0++0+2+ 0 3 rr000++00++000+0+0+0+0+2+ 0

9. The need is constant. The gratification is instant. Give blood. TM 9 Case GJ 9 Eluate/AHG Last Wash/AHG Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran DCEceC w MNSsP 1 Le a b KkFy a b Jk a b Lu a b 1 R z R 1 +++0+00+0++0++++0+00+0 0 2 R 1 R 1 ++00+++0++++00++00+0+0 0 3 R 1 R 1 ++00+0+++0+0+0+0++00+0 0 4 R 2 R 2 +0++00+0+00+0+0+00+0+2+0 5 R 2 R 2 +0++00++0+00+0+0+0+0+ 0 6 rr 000++00++0+0+0+++++0+2+0 7 rr 000++00++++0+0++0++0+2+0 8 rr 000++0+00+00++00+0+0+2+0

10. The need is constant. The gratification is instant. Give blood. TM 10 Case GJ 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. LISS/37 LISS/AHG Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran DCEceC w MNSsP 1 Le a b KkFy a b Jk a b Lu a b 1 R z R 1 +++0++0+0+++00++00+0+0 0 2 R 1 R 1 ++00+00++000+++0+++0+0 0 3 rr000++0++0+00+0+++++0+1+3+ 4 rr 000++0+0+0+0+0++++00+1+3+

11. The need is constant. The gratification is instant. Give blood. TM 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. 11 Case GJ

12. The need is constant. The gratification is instant. Give blood. TM 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. 12 Case GJ

13. The need is constant. The gratification is instant. Give blood. TM Transfusion Medicine Case Studies Case PW March 2010 Presented by John N. McLennan, MT(ASCP) Midwest Region American Red Cross Omaha, NE

14. 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. 14

15. The need is constant. The gratification is instant. Give blood. TM Case PW 15 Front TypeRhReverse Type Interp. Anti-AAnti-BAnti-DA 1 cellsB Cells O Positive004+ 3+ Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran IS LISS/37 LISS/AHG PEG/AHG DCEceCwCw MNSsP1P1 Le a Le b KkFy a Fy b Jk a Jk b Lu a Lu b 1 R1R1R1R1 ++00+0+0+0+0+0++00+++02+0 w+ 2 R2R2R2R2 +0++000+++++00+0+++0+02+0 1+ 3 rr000++0+00++0+++0++00+02+0 w+ Auto 00w+

16. The need is constant. The gratification is instant. Give blood. TM Case PW Due to the formation of an antibody and the recent transfusions, an elution was performed on PW’s red cells. 16 PolyIgGC3dControl Positive IgG DAT 1+0 0 Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran Eluate PEG/IgG Last Wash PEG/IgG DCEceCwCw MNSsP1P1 Le a Le b KkFy a Fy b Jk a Jk b Lu a Lu b 1 R1R1R1R1 ++00+0+0+0+0+0++00+++1+0 2 R2R2R2R2 +0++000+++++00+0+++0+ 0 3 rr000++0+00++0+++0++00+1+0 The eluate was broadly reactive with all cells tested, which is consistent with a warm-autoantibody.

17. The need is constant. The gratification is instant. Give blood. TM 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. 17 Case PW

18. The need is constant. The gratification is instant. Give blood. TM 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. 18 Case PW CEceMNSsKFy a Fy b Jk a Jk b 6% Albumin 00+++00+000+00 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.

19. The need is constant. The gratification is instant. Give blood. TM 19 Case PW Patient serum PEG/AHG Eluate PEG/AHG Last Wash PEG/AHG EGA Treated Cell Separation (DAT Negative autologous cells) 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.

20. The need is constant. The gratification is instant. Give blood. TM 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. 20 Case PW All common allo-antibodies have been excluded with LISS/AHG LISS/37 LISS/AHG Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran DCEceC w MNSsP 1 Le a b KkFy a b Jk a b Lu a b 1 R 1 R 1 ++00+0+0+0+0+0+0+0+0+2+ 0 2 R 1 R 1 ++00+00+0+00+0+++0+0+2+ 0 3 R 2 R 2 +0++000+0+0+0+++0++0+2+ 0 4 R 2 R 2 +0++00+++0+0+0+0++00+2+ 0 5 r’r 0+0++0+0++0+0+0+0+00+2+ 0 6 r”r 00+++0++++00+0+++++0+2+ 0

21. The need is constant. The gratification is instant. Give blood. TM 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-, Fy a -, Fy b -, Jk b -) 21 Case PW Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran IS LISS/37 LISS/AHG DCEceCwCw MNSsP1P1 Le a Le b KkFy a Fy b Jk a Jk b Lu a Lu b 1 R0rR0r+00++0+00+00+0+00+00+02+0 2 R0rR0r+00++0+00++0+0+00+00+0 0

22. The need is constant. The gratification is instant. Give blood. TM 22 Case PW A panel of high incidence negative red cells was tested with the following results. (Testing only needs to be done at LISS/37) LISS/37 Special Typing Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran DCEceC w MNSsP 1 Le a b KkFy a b Jk a b Lu a b 1 000++0++0+++0+++0++0+2+Jo a - 2 ++0++0+0++00+0+0+0+0+2+Hy- 3 000++0++0+00+0+++++0+2+Tj a - 4 ++00+0+0++00+0+0+0+0+0Kp b - 5 000000+00+00+0++0+00+2+Rh Null

23. The need is constant. The gratification is instant. Give blood. TM Testing a Kp b negative cell was non-reactive at LISS/37. A second Kp b negative cell must be tested. 23 Case PW Because Kp b 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. LISS/37 Special Typing Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran DCEceC w MNSsP 1 Le a b KkFy a b Jk a b Lu a b 1 R 1 R 1 ++00++0+0++0+0++0+00+0Kp b -

24. The need is constant. The gratification is instant. Give blood. TM 24 Case PW DTT Treated LISS/37 Blood Group System RhMNSsPLewisKellDuffyKidd Lutheran DCEceC w MNSsP 1 Le a b KkFy a b Jk a b Lu a b 1 R 1 R 1 ++00+++0++++00++00+0+0 2 R 2 R 2 +0++00++++++00+0+0+0+0 3 R 1 R 1 ++00+0+0+0++00+++0+0+0 4 R 0 r+00++0+0+++0+0+0++00+0 5 rr000++0+0+0+0+0++++00+0 6 R 2 R 2 +0++000+0+++00++0+00+0 7 R 1 R 1 +00++00+00+000+00+00+0 8 000++00+0++0+0+00+00+0

25. The need is constant. The gratification is instant. Give blood. TM Initial conclusion : Warm auto-antibody at PEG/AHG with serum and eluate. Anti-Kp b 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 Kp b antigen negative, with testing being performed with unlicensed anti-sera. However, this phenotype is uncommon in African American individuals. 25 Case PW

26. The need is constant. The gratification is instant. Give blood. TM Kp b A high prevalence in all populations. This chart indicates 100% of Blacks are antigen positive for Kp b The sample was submitted for molecular testing to determine if the anti-Kp b is allo or auto in nature. Molecular typing indicated that the patient is Kp b antigen positive, confirming the autoantibody specificity. Since there is an auto-anti- Kp b, antigen negative units do NOT need to be transfused. 26 Case PW Prevalence (%) PhenotypeWhitesBlacks Kp(a+b+)2.3RARE Kp(a-b+)97.7100 Kp(a+b-)2.3RARE

27. The need is constant. The gratification is instant. Give blood. TM Consultation Request Form 27

28. The need is constant. The gratification is instant. Give blood. TM 28 Consultation Request Form

29. The need is constant. The gratification is instant. Give blood. TM References: Roback, John D. (2008). AABB Technical Manual, 16 th 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. 29