Acute renal failure with hemolysis in a D-mismatched transfusion recipient treated with RhIG

Transfusing selected RhD negative patients with RhD positive packed red cell concentrates resulted in lower frequency of anti-D development and saved almost two thousand RhD negative concentrates during 5 years

BACKGROUND

The Blood Bank at Oslo University Hospital implements restrictions when the stocks of blood groups O and A RhD negative packed red blood cell concentrates (PRBCCs) drop below 60 units due to high demand and low donor availability. Restrictions entail transfusing RhD negative male patients and women >50 years with RhD positive units, to provide RhD negative units to those who should not receive RhD positive units. Earlier studies have reported that up to 50% of RhD negative patients developed anti-D after RhD positive blood transfusion. We aimed to investigate the rate of anti-D alloimmunization using this restriction strategy in our population.

STUDY DESIGN AND METHODS

This retrospective study was performed at Oslo University Hospital between 2006 and 2011. Antibody screen results were included throughout 2019 for the patients readmitted to the hospital.

RESULTS

607 RhD negative mostly cancer patients and patients having surgery for cardiovascular conditions received 1926 RhD positive PRBCCs. Post-transfusion antibody screen was available for 401 patients (66.1%), and 76 patients (22.2%) developed anti-D. In 15 of the 76 patients (19.7%), anti-D became evanescent in the follow-up.

DISCUSSION

The proportion of anti-D immunisation in RhD negative patients receiving RhD positive PRBCCs in this study was consistent with findings from other reports. To our knowledge, this is the first study reporting a high proportion of evanescence of anti-D. Transfusing selected RhD negative patients with RhD positive PRBCCs when RhD negative stocks are low, contributed saving 1926 RhD negative PRBCCs during the study period of 64 months.

Management of Wrong Blood Transfusion to an RhD Negative Woman in Labor

Blood transfusion is life-saving in massive hemorrhage. Before pre-transfusion tests with ABO and RhD typing results are available, O RhD negative packed red blood cell (PRBC) units are used without cross-matching in emergency. RhD negative girls and women of child-bearing age should always receive RhD negative blood transfusions to prevent RhD-alloimmunization because anti-D-related hemolytic disease of fetus and newborn (HDFN) can result in mild to severe anemia, and in a worst-case scenario death of an RhD positive fetus and/or newborn. However, "wrong blood to wrong patient" happens unintentionally. Here we report an emergency blood transfusion with one unit of RhD positive PRBCs to an RhD negative young woman when estimated blood loss was 2500 mL during delivery and surgical removal of retained placenta. Realizing the mistake, management with high dose anti-D immunoglobulin (Ig) was initiated to remove the RhD positive red blood cells (RBCs) from the patient's circulation. Such mitigation is recommended only for girls and women of child-bearing age. Follow-up was performed by flow cytometry until RhD positive RBCs were no longer detected. Ten months after the delivery, antibody screening was negative. However, we still do not know whether we managed to prevent RhD-alloimmunization.