A rare case of a clinically significant anti-M alloantibody in a heart transplant recipient

INTRODUCTION

Anti-M antibodies are usually inactive at physiologic temperatures (37 °C). Rarely, these antibodies have been reported to react at physiologic temperatures, resulting in clinically significant hemolytic transfusion reactions or hemolytic disease of the fetus and newborn.

PATIENT AND METHODS

We describe a case of an acute hemolytic transfusion reaction due to an anti-M alloantibody reacting at physiologic temperatures in a critically ill patient.

RESULTS

Proper identification and management of anti-M antibody-mediated acute hemolysis rapidly improved and stabilized her hemoglobin.

CONCLUSION

Differentiation between anti-M antibody-mediated acute hemolysis and its differential diagnoses is of critical importance to guide therapeutic decisions in these rare clinical scenarios.

P-Null Phenotype Due to a Rare Frame-Shift Mutation and with Allo-Anti-PP1Pk Causing a Severe Hemolytic Transfusion Reaction: A Case Report with Clinical Management

INTRODUCTION

The identification of alloantibodies to high-frequency antigens (HFA) and subsequent transfusion management can be challenging and often poses a problem in finding the compatible blood for transfusion. The aim of this study was to investigate the specificity of the antibody to the HFA causing a hemolytic transfusion reaction (HTR) and procure the compatible blood unit for future transfusion.

CASE PRESENTATION

A 4-year-old female met with a head injury that led to intracranial bleeding and surgical intervention was required to remove blood clots. In the face of anemia, blood transfusion was planned. The pretransfusion tests on her blood sample revealed the presence of a pan-reactive alloantibody with hemolytic properties. She was transfused with 10 mL of the least incompatible red blood cells (RBCs) to which she reacted with signs of clinical hemolysis, i.e., chill, rigor, fever, and hemoglobinuria, on 3 different occasions. Despite her anemia, she was managed by medical intervention only. Her antibody reacted with all RBCs tested, except autologous and P-null (p phenotype) cells. Her RBCs did not react with anti-PP1Pk, which corroborated her phenotype as P-null. The genomic study revealed she was hemi- or homozygous or for a deletion of 26-bp in A4GALTexon 3, previously reported as causing the P-null phenotype and designated A4GALT*01N.019.

CONCLUSION

This report documents a rare case of the P-null phenotype with an alloanti-PP1Pk causing a severe HTR to transfusion of the trial dose of the least incompatible blood. The case is the first example of this specific A4GALTmutation found in India.

Red-cell alloimmunization profile in multi transfused patients: Findings and insights of a blood transfusion service

OBJECTIVES

Blood transfusion is a key intervention for decreasing morbidity and mortality in many cases and, besides its importance, potentially fatal consequences of incompatible transfusion are a great risk to patients. This study evaluated the incidence and specificity of erythrocyte alloantibodies in multi-transfused patients enrolled at an important Regional Blood Center.

MATERIALS/METHODS

This was a single-center retrospective cohort study that eveluated patients enrolled at a Regional Blood Center in a period of four years. A total of 29,128 patient samples were screened, out of which 79 (0.27%) were multiple-transfused patients with alloantibodies identified.

RESULTS

The most common alloantibody found was anti-E (22.55%) followed by anti-D (14.71%), anti-C (5.88%), anti-c (5.88%), anti-e (1.96%) and anti-C^w (0.98%). We also identified combinations of alloantibodies (25.32%), 5.88% of which showed an IgG autoantibody isolated or combined with alloantibodies. The most frequent reason for the need of blood transfusion included cases of surgery, emergency and urgency (36.71%).

CONCLUSIONS

A low rate of development of alloantibodies in multi-transfused patients was found, which could be a consequence of the implementation of red blood cell phenotyping for patients who may receive frequent transfusions, as in the case of some hematological neoplasms and hemoglobinopathies. However, the most common alloantibodies identified were against the Rh and/or Kell systems, with high clinical significance since both can cause delayed hemolytic transfusion reactions. Thus, the implementation of reliable antibody screening tests and the transfusion of phenotyped units for selected patients in all transfusion services represent important measures to increase transfusion safety.

Identifying and Understanding Transfusion Reactions in the Oncology Population

OBJECTIVES

To provide an overview of transfusion reactions, their underlying pathophysiology, clinical presentation, and recommendations for nursing management.

DATA SOURCES

We researched peer-reviewed journal articles, book chapters, Internet, and lecture proceedings.

CONCLUSION

Transfusion reactions are adverse reactions to blood products frequently seen in the oncology population and can significantly vary in severity and etiology. Oncology nurses are in a critical position to assist with prevention, early detection, and time-sensitive treatment of transfusion reactions.

IMPLICATIONS FOR NURSING PRACTICE

The oncology nurse's comprehensive understanding of possible transfusion reactions and management recommendations is key for optimal care of the oncology patient.

Incompatible crossmatch: First sign of a hemolytic transfusion reaction due to out-of-group platelet transfusion

Platelet (PLT) transfusion is undertaken in a variety of clinical settings with thrombocytopenia, with or without bleeding. Since PLTs are most often stored in donor plasma, group-specific PLT transfusions are preferred to out-of-group transfusions. PLTs adsorb ABO antigens over their surface from the plasma. In major ABO-incompatible PLT transfusions, anti-A/B from the patient plasma react with the ABO antigens on transfused PLTs and can potentially cause adverse reactions or PLT refractoriness. Transfusion of PLTs with major ABO incompatibility, though effective in preventing clinical bleeding, is associated with reduced posttransfusion PLT count increments. In minor incompatible PLT transfusion transfused, anti-A/B can cause hemolytic transfusion reaction (HTR) which is not always related to a high titer of anti-A/B in the donor. Although attempts are made to practice ABO identical PLT transfusion, most centers practice out-of-group random donor platelets (RDPs) as well as single-donorplatelets (SDP) transfusion. The limited PLT shelf life does not always permit ABO identical PLT transfusion. At our center, ABO-specific PLT transfusions are practiced where possible, and in case of minor ABO-incompatible transfusions, antibody titers are not done. Here, we report a case of HTR due to out-of-group SDP transfusion, detected in the laboratory after an incompatible red blood cell (RBC) crossmatch.

Molecular Detection of Glycophorins A and B Variant Phenotypes and their Clinical Relevance

Crossover or conversion between the homologous regions of glycophorin A (GYPA) and glycophorin B (GYPB) gives rise to several different hybrid glycophorin genes encoding a number of different glycophorin variant phenotypes which bear low prevalence antigens in the MNS blood group system. GP.Mur is the main glycophorin variant phenotype which causes hemolytic transfusion reaction (HTR) and hemolytic disease of the fetus and newborn (HDFN) in East and Southeast Asians. The detection of glycophorin variant phenotypes using serological methods is limited to phenotyping reagents that are not commercially available. Moreover, the red blood cells used for antibody identification are usually of the GP.Mur phenotype. The current Polymerase Chain Reaction (PCR)-based methods and loop-mediated isothermal amplification (LAMP) are available alternatives to phenotyping that allow for the specific detection of glycophorin variant phenotypes. This review highlights the molecular detection method for glycophorins A and B variant phenotypes and their clinical relevance.

Complement activation during intravascular hemolysis: Implication for sickle cell disease and hemolytic transfusion reactions

Intravascular hemolysis is a hallmark of a large spectrum of diseases, including the sickle cell disease (SCD), and is characterized by liberation of red blood cell (RBC) degradation products in the circulation. Released Hb, heme, RBC fragments and microvesicles (MVs) exert pro-inflammatory, pro-oxidative and cytotoxic effects and contribute to vascular and tissue damage. The innate immune complement system not only contributes to the RBC lysis, but it is also itself activated by heme, RBC MVs and the hypoxia-altered endothelium, amplifying thus the cell and tissue damage. This review focuses on the implication of the complement system in hemolysis and hemolysis-mediated injuries in SCD and in cases of delayed hemolytic transfusion reactions (DHTR). We summarize the evidences for presence of biomarkers of complement activation in patients with SCD and the mechanisms of complement activation in DHTR. We discuss the role of antibodies-dependent activation of the classical complement pathway as well as the heme-dependent activation of the alternative pathway. Finally, we describe the available evidences for the efficacy of therapeutic blockade of complement in cases of DHTR. In conclusion, complement blockade is holding promises but future prospective studies are required to introduce Eculizumab or another upcoming complement therapeutic for DHTR and even in SCD.

Fatal Acute Hemolytic Transfusion Reaction due to Anti-Wra

Background

The Wr^a blood group antigen is a low-frequency antigen. Antibody screening sets used in pretransfusion laboratory investigations usually do not contain a Wr(a+) cell. If subsequent cross-matching is performed without indirect antiglobulin test (IAT), Wr^a antibodies reacting with donor red blood cells (RBCs) will be missed. For reasonable economic and time-saving arguments the risk of missing the detection of a potential clinically relevant antibody is worldwide accepted.

Case Report

A 66-year-old women with a negative antibody screen rapidly deteriorated after she received two units of RBCs for symptomatic anemia after hip surgery. Diagnosis of a transfusion reaction was obscured by pre-existing and nonspecific symptoms. Laboratory investigation indicated acute hemolysis. Cross-matching in IAT was positive for the first unit, and an extended antibody identification panel showed reactivity with Wr(a+) cells. The patient did not respond to supportive therapy and died within 48 h after the start of transfusion.

Conclusion

This dramatic case provides further evidence on the clinical relevance of Wr^a blood group antibodies. In addition, it underlines the clinical importance of risk awareness in the blood transfusion chain and the possible complexity in relation to patient monitoring in daily transfusion practice.

Pre- and Post-Transfusion Alloimmunization in Dogs Characterized by 2 Antiglobulin-Enhanced Cross-match Tests

BACKGROUND

When dogs are transfused, blood compatibility testing varies widely but may include dog erythrocyte antigen (DEA) 1 typing and rarely cross-matching.

OBJECTIVES

Prospective study to examine naturally occurring alloantibodies against red blood cells (RBCs) and alloimmunization by transfusion using 2 antiglobulin-enhanced cross-match tests.

ANIMALS

Eighty client-owned anemic, 72 donor, and 7 control dogs.

METHODS

All dogs were typed for DEA 1 and some also for DEA 4 and DEA 7. Major cross-match tests with canine antiglobulin-enhanced immunochromatographic strip and gel columns were performed 26-129 days post-transfusion (median, 39 days); some dogs had an additional early evaluation 11-22 days post-transfusion (median, 16 days). Plasma from alloimmunized recipients was cross-matched against RBCs from 34 donor and control dogs.

RESULTS

The 2 cross-match methods gave entirely concordant results. All 126 pretransfusion cross-match results for the 80 anemic recipients were compatible, but 54 dogs died or were lost to follow up. Among the 26 recipients with follow-up, 1 dog accidently received DEA 1-mismatched blood and became cross-match-incompatible post-transfusion. Eleven of the 25 DEA 1-matched recipients (44%) became incompatible against other RBC antigens. No naturally occurring anti-DEA 7 alloantibodies were detected in DEA 7- dogs.

CONCLUSIONS AND CLINICAL IMPORTANCE

The antiglobulin-enhanced immunochromatographic strip cross-match and laboratory gel column techniques identified no naturally occurring alloantibodies against RBC antigens, but a high degree of post-transfusion alloimmunization in dogs. Cross-matching is warranted in any dog that has been previously transfused independent of initial DEA 1 typing and cross-matching results before the first transfusion event.

Rare antibody-associated hemolytic transfusion reaction and transfusion-related acute lung injury: a case report

BACKGROUND

Hemolytic transfusion reactions and transfusion-related acute lung injury (TRALI) are life-threatening complications associated with the transfusion of blood products. Hemorrhage is one of the most common surgical complications and the risk of bleeding is particularly acute in patients with hematologic deficiencies. Management of surgical bleeding can be divided into two phases. The first phase centers on immediate control of acute bleeding and the second phase focuses on keeping the patient stable and on reducing the sequelae associated with blood transfusions and blood loss.

CASE PRESENTATION

We present the case of a 53-year-old woman with long-standing immune thrombocytopenia who underwent repair of a symptomatic ventral hernia. On post-operative day one the patient developed hemoperitoneum, requiring exploratory laparotomy and massive transfusion of blood products. The patient's recovery was complicated by consistently low hemoglobin, hematocrit and platelets, prompting frequent transfusion of additional blood products. Shortly after activation of the massive transfusion protocol, the patient developed TRALI. Compounding the situation, on post-operative day sixteen the patient's serum started to show hemolysis: lactate dehydrogenase (LDH) levels rose to 1,845 IU/L, with haptoglobin at less than 5.8 mg/dL and with a high reticulocyte count (4.38%). Previous testing had shown that the patient was positive for most major antigens implicated in antibody formation and was only producing anti-E and anti-K antibodies (considered for all transfusions). Initial pre- and post-transfusion direct antiglobulin tests (DAT) were indeed negative. However, repeat DATs in the days following the noted serum changes were consistent with new allo-antibody formation. These findings prompted immediate withholding of all blood products and a thorough blood bank work up. Despite strong evidence for new allo-antibody formation, no specific known antibody could be identified. The patient recover well when blood products were withheld.

DISCUSSION

We present the case of a 53-year-old woman with long-standing immune thrombocytopenia who underwent repair of a symptomatic ventral hernia. On post-operative day one the patient developed hemoperitoneum, requiring exploratory laparotomy and massive transfusion of blood products. The patient's recovery was complicated by consistently low hemoglobin, hematocrit and platelets, prompting frequent transfusion of additional blood products. Shortly after activation of the massive transfusion protocol, the patient developed TRALI. Compounding the situation, on post-operative day sixteen the patient's serum started to show hemolysis: lactate dehydrogenase (LDH) levels rose to 1,845 IU/L, with haptoglobin at less than 5.8 mg/dL and with a high reticulocyte count (4.38%). Previous testing had shown that the patient was positive for most major antigens implicated in antibody formation and was only producing anti-E and anti-K antibodies (considered for all transfusions). Initial pre- and post-transfusion direct antiglobulin tests (DAT) were indeed negative. However, repeat DATs in the days following the noted serum changes were consistent with new allo-antibody formation. These findings prompted immediate withholding of all blood products and a thorough blood bank work up. Despite strong evidence for new allo-antibody formation, no specific known antibody could be identified. The patient recover well when blood products were withheld. Suspicion for hemolytic transfusion reactions should be high in patients with prior allo-antibody formation; these may present as acute hemolysis or as a delayed hemolytic transfusion reaction. Withholding blood products from these patients until compatible products have been identified is recommended. Moreover, TRALI is the leading cause of transfusion-related fatalities and should always be considered in transfusion settings.

CONCLUSIONS

Suspicion for hemolytic transfusion reactions should be high in patients with prior allo-antibody formation; these may present as acute hemolysis or as a delayed hemolytic transfusion reaction. Withholding blood products from these patients until compatible products have been identified is recommended. Moreover, TRALI is the leading cause of transfusion-related fatalities and should always be considered in transfusion settings.

Survey of Two New (Kai 1 and Kai 2) and Other Blood Groups in Dogs of North America

Background

Based upon serology, >10 canine blood group systems have been reported.

Objective

We surveyed dogs for dog erythrocyte antigen (DEA) 1 and 2 new blood types (Kai 1 and Kai 2), and some samples also were screened for Dal and DEA 3, 4, and 7.

Methods

Blood samples provided by owners, breeders, animal blood banks, and clinical laboratories were typed for DEA 1 by an immunochromatographic strip technique with a monoclonal antibody and analysis of band intensity. Both new antigens, the Dal and other DEAs (except DEA 7 by tube method), were assessed by a gel column method with either monoclonal or polyclonal antibodies. The same gel column method was applied for alloantibody detection.

Results

Of 503 dogs typed, 59.6% were DEA 1+ with 4% weakly, 10% moderately, and 45.6% strongly DEA 1+. Regarding Kai 1 and Kai 2, 94% were Kai 1+/Kai 2‐, 5% were Kai 1‐/Kai 2‐ and 1% were Kai 1‐/Kai 2+, but none were Kai 1+/Kai 2+. There was no relationship between Kai 1/Kai 2 and other blood types tested. Plasma from DEA 1‐, Kai 1‐, Kai 2‐ dogs, or some combination of these contained no detectable alloantibodies against DEA 1 and Kai 1 or Kai, respectively.

Conclusions and Clinical Importance

The new blood types, called Kai 1 and Kai 2, are unrelated to DEA 1, 3, 4, and 7 and Dal. Kai 1+/Kai 2‐ dogs were most commonly found in North America. The clinical relevance of Kai 1 and Kai 2 in canine transfusion medicine still needs to be elucidated.

Dangerous universal donors: the reality of the Hemocentro in Belo Horizonte, Minas Gerais

BACKGROUND

The term dangerous universal blood donor refers to potential agglutination of the erythrocytes of non-O recipients due to plasma of an O blood group donor, which contains high titers of anti-A and/or anti-B hemagglutinins. Thus, prior titration of anti-A and anti-B hemagglutinins is recommended to prevent transfusion reactions.

OBJECTIVE

The aim of this study was to estimate the frequency of dangerous universal donors in the blood bank of Belo Horizonte (Fundação Central de Imuno-Hematologia - Fundação Hemominas - Minas Gerais) by determining the titers of anti-A and anti-B hemagglutinins in O blood group donors.

METHOD

A total of 400 O blood group donors were randomly selected, from March 2014 to January 2015. The titers of anti-A and anti-B hemagglutinins (IgM and IgG classes) were obtained using the tube titration technique. Dangerous donors were those whose titers of anti-A or anti-B IgM were ≥128 and/or the titers of anti-A or anti-B IgG were ≥256. Donors were characterized according to gender, age and ethnicity. The hemagglutinins were characterized by specificity (anti-A and anti-B) and antibody class (IgG and IgM).

RESULTS

Almost one-third (30.5%) of the O blood group donors were universal dangerous. The frequency among women was higher than that of men (p-value=0.019; odds ratio: 1.66; 95% confidence interval: 1.08-2.56) and among young donors (18-29 years old) it was higher than for donors between 49 and 59 years old (p-value=0.015; odds ratio: 3.05; 95% confidence interval: 1.22-7.69). There was no significant association between dangerous universal donors and ethnicity, agglutinin specificity or antibody class.

CONCLUSION

Especially platelet concentrates obtained by apheresis (that contain a substantial volume of plasma), coming from dangerous universal donors should be transfused in isogroup recipients whenever possible in order to prevent the occurrence of transfusion reactions.

A case of acute hemolytic transfusion reaction due to anti-Di(a) antibody -A case report-

Many medical institutions in Korea have recently been performing an antibody screening test as one of the essential elements of a pre-transfusion test. The Di^a antigen is well known as one of the antigens with low incidence among Caucasians; however, it has been discovered with a relatively higher incidence among Mongoloid populations. The frequency of the Di^a antigen among the Korean population is estimated to be 6.4-14.5%. But in Korea, a screening panel of cells from abroad without Di^a positive cells has been commonly used when a patient has an unexpected antibody screening test. Here we report a case of acute hemolytic transfusion reaction due to Anti-Di^a antibody. To prevent other transfusion reaction by anti-Di^a antibody, addition of Di^a positive cells as unexpected antibody screening test is recommended.

[Diagnosis of acute transfusion reactions]

The erroneous transfusion of AB0-incompatible red cells may result in hemolysis and complement-mediated shock (acute hemolytic transfusion reaction, AHTR), leading to death in less than 10%. The mistake will be detected by re-checking the patient's and the blood product's identity. Evidence of the incompatible transfusion is supplied by serology and, in cases of a fatal outcome, by immunohistochemistry. Differential diagnoses to be distinguished from AHTR are other immunologically mediated events like the most important transfusion-related acute lung injury (TRALI), febrile non-hemolytic transfusion reaction (FNHTR), allergic transfusion reactions, along with a variety of nonimmunologic incidents like transfusion-transmitted bacterial infections, hypervolemia, and other rare events such as citrate reaction, air embolism, and foreign body embolism. If the outcome is lethal, the question of causality has to be answered by a comprehensive evaluation including the clinical data as well as serological, microbiological, autoptic, and histological findings.