Solving Blood Bank Case Studies, is easy as…

Deborah Baudler MS, MT(ASCP)SBB

ASCLS-MO/STL CLMA Spring Conference

April 6, 2016

Objectives

• 1. Identify common problems that occur in day to day blood banking

• 2. Discuss various techniques for problem-solving

• 3. Apply new knowledge to case studies for resolution

You have been called to join this elite investigative team of Super Immunohematologists!

ARE YOU READY?

“The science of deduction and analysis is one which can only be acquired by long and patient study...”

Sherlock Holmes

The tricks to problem-solving…

Having the Knowledge and Resources

Let’s Narrow Down the List…

• ABO Discrepancies

• Weak Positive Antibody Screen……no antibody identified

• Miscellaneous Reactivity showing up on the antibody panel

• Incompatible Crossmatch when antibody screen is negative

• Antibody that doesn’t “behave” as it should

The most common problem is…

• Telephone rings so you didn’t notice that the A1 and B cells were reversed in your rack

• Red cell suspensions are too heavy or too light

• Reagents expired or contaminated?

Other possibilities…

• Got interrupted and forgot to add patient plasma

• In a hurry… forgot to set timer so incubation time too short or too long

• Didn’t notice a fibrin clot in specimen

• Interpretations not accurately recorded

Many times, the solution is easy…

• Start over, hoping the problem will just go away

• Shake the tubes harder

• Rock, paper, scissors…

• Pretend the weak reactions don’t really exist

• Call your blood bank supervisor at 2 am to see if she/he is reading a good book

• Leave it for the next shift to resolve!

Sometimes the problems are real, now what?

• For complete identification of antibodies:• 1. Rule out using homozygous cells

• 2 Exceptions: • Anti-K [1 heterozygous cell]• Anti-C and Anti-E when Anti-D [2-3 heterozygous cells]

• 2. Consider the phases of reactivity

• 3. Consider the strengths of reactivity

• 4. Is there a matching pattern?

• 5. Is everything else ruled out?

• 6. Is there any extra reactivity that is not accounted for?

• 7. Is the 0.05 p-value or 95% confidence limit met?

• 8. Is the patient antigen negative for corresponding antibody(ies)?

Let’s review a few rules…

Let’s explore some Case Studies…

Case 1

• 82 yr. old woman arrives by ambulance from local nursing home

• Medical history: Type 1 diabetic, slipped and fell after dinner

• Hgb is 6.8 g/dl, Hct is 20%

• X-rays reveal a broken right hip

Case 1

• ER doctor orders a 2 unit crossmatch STAT!

• Her blood type results:

• What’s her blood type?

Anti-A Anti-B Anti-D A1 cell B cell

0 4+ 3 + 4+ 1+

Oh No!

D C c E e K Fya Fyb Jka Jkb M N S s IS AHG cc

1 + 0 + 0 + 0 + + + 0 0 + + 0 0 0 √

2 + 0 + + 0 + 0 + 0 + + + 0 + 0 0 √

3 0 + + 0 + 0 + 0 + + + 0 + + 2+ 2+ nt

• Next thing you know, her antibody screen comes up positive, YIKES!

• Let’s do the Cross-out Technique

Case 1

• Which Antibodies Could Possibly be Present?

D c E e K Fyb Jka Jkb N S s IS AHG cc

1 + 0 + 0 + 0 + + + 0 0 + + 0 0 0 √

2 + 0 + + 0 + 0 + 0 + + + 0 + 0 0 √

3 0 + + 0 + 0 + 0 + + + 0 + + 2+ 2+ nt

C Fya M

The panel results… for Case 1?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub IgG

Gel

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 2+

2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0

4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + W+

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 2+

6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + + + 0 0 + 1+

7 0 + 0 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 0

80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 2+

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 + 0 0 0 + + 0 0 + 0

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 0

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + + + 0 0 + w+

PC 0

Let’s do the cross outs

The panel results… for Case 1?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub IgG

Gel

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 2+

2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0

4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + W+

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 2+

6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + + + 0 0 + 1+

7 0 + 0 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 0

80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 2+

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 + 0 0 0 + + 0 0 + 0

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 0

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + + + 0 0 + w+

PC 0

M

What do we know…

•Antibody identified as Anti-M and patient phenotypes M Neg

•Anti-M can possess both IgM and IgG components

•IgM antibodies can cause ABO discrepancies

•To resolve discrepancy: test group B, M Neg cells with patient plasma

Anti-A Anti-B Anti-D A1 cells B cells

0 4+ 3+ 4+ 0

Case 2

D C c E e K Fya Fyb Jka Jkb M N S s IS AHG cc

1 + 0 + 0 + 0 + + + 0 0 + + 0 0 0 √

2 + 0 + + 0 + 0 + 0 + + + 0 + 0 0 √

3 0 + + 0 + 0 + 0 + + + 0 + + 0 0 √

• 33 yr. old woman is admitted for delivery of her 3rd child

• Blood type is A Negative and antibody screen is currently Negative

• She has a history of an anti-K

Case 2

• It’s been over 24 hrs. and labor has not progressed after her membranes ruptured at home

• The OB doctor requests 2 units of blood to be crossmatched since he is prepping for a C-section

• One of the 2 K-negative units is incompatible in the Coomb’sphase of testing

• A DAT is performed on the reactive unit and it is negative

• What should you do next?

The panel results… for Case 2?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG

Gel

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 2+

2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0

4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 0

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0

6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0

7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 0

80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 0

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 0

PC 0

What next?

• Find 2 more Cw select cells to run to confirm antibody ID

• Cw results in a single amino acid change most often found on the RhCe protein• Cw is located on the first extracellular loop of the RhCE

gene

• Anti- Cw may show dosage

• Will it be hard to find a 2nd compatible unit?

Transfusion. 2004 Nov;44(11):1663-73.

So far so good!

Case 3

• It’s 8 pm on a quiet Friday night in St. Louis

• Next you hear over the loud speaker… “phlebotomy to Trauma 1”

• 38 yr. old male arrives by ambulance, bleeding from multiple stab wounds, impacting several internal organs

• The ER doctor orders 2 O Neg uncrossmatched units after phlebotomy draws his specimen

• The specimen arrives with an order to Type and Cross 5 units of prbcs and thaw 2 units of FFP to be transfused during surgery

Case 3

D C c E e K Fya Fyb Jka Jkb M N S s IS AHG cc

1 + + 0 0 + + + 0 + + 0 + + 0 0 1+ nt

2 + 0 + + 0 0 0 + 0 + + + 0 + 0 0 √

3 0 + + 0 + 0 + + + 0 + 0 + + 0 0 √

His Type and Screen results are below:

Anti-A Anti-B Anti-D A1 cells B cells

0 0 4+ 4+ 3+

The panel results… for Case 3?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG

Gel

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + W+

2+ + 0 0 + 0 0 + + 0 + 0 + + + + + 0 + + + + 0 + 0 + 0

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0

4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + 0

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0

6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0

7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 1+

80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 1+

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 0

PC 0

Let’s do the cross outs

The panel results… for Case 3?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG

Gel

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + W+

2+ + 0 0 + 0 0 + + 0 + 0 + + + + + 0 + + + + 0 + 0 + 0

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0

4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + 0

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0

6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0

7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 1+

80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 1+

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 0

PC 0

Everything is ruled out, now what?

What Should You Do?

Things to consider when you have weak reactivity…• Get the Patient’s Medical History

• Possible Solutions: • Check lot number of antigrams!• Repeat antibody screen and ID by a second method• Check expiration dates of reagents• Increase serum/cell ratio• Increase incubation time• Perform an enzyme panel• Contact the manufacturer

• How should this be reported?

The panel results… for Case 3?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG

Gel

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + W+

2+ + 0 0 + 0 0 + + 0 + 0 + + + + + 0 + + + + 0 + 0 + 0

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0

4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + 0

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0

6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0

7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 1+

80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 1+

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 0

PC 0

Highlight the positives, looking for a pattern or dosage

Additional suggestions…

• Medical history confirmed patient had received 2 units of red cells 2 months ago due to a drive-by shooting

• The antigram and reagents were ok

• The panel was repeated using additional drops of serum and PEG, no improvement

• An enzyme panel was completely negative

• We tried all the above suggestions and still NOTHING! UGH!!

• Let’s try an eluate!

• When a patient forms a new antibody, it attaches to transfused cells

• For a DAT to become positive: >200 molecules of IgG on red cell

• Purpose of an eluate:• Removes an antibody that’s coating the red cell

• Concentrates antibody

• Allows identification of newly forming or weak antibodies

• Can be positive even when DAT is negative

• In this case the DAT was weak positive

Benefits of an Eluate

The panel results… for Case 3?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub

IgG

eluate cc

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 1+ nt

2+ + 0 0 + 0 0 + + 0 + 0 + + + + + 0 + + + + 0 + 0 + 1+ nt

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0 √

4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + 0 √

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0 √

6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 2+ nt

7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 2+ nt

80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0 √

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 2+ nt

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 2+ nt

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 0 √

PC

An Anti-Fya was identified. Case solved!

After surgery…

• The patient received 2 units of Fya neg blood and was transferred to the county jail after he recovered from his wounds.

• 27 yr. old man is medevac to your facility from a small community hospital. The patient has been in a motor vehicle accident and is bleeding internally. He is being prepped for the OR.

Case 4

• So you perform a STAT Type and Screen

• While the antibody screen is incubating, you record the following results for the blood type:

• Any problems?

Case 4

Anti-A Anti-B Anti-D A1 cells B cells

2+mf 2+mf 2+mf 4+ 4+

• The patient’s antibody screen results are Negative!

• Now what?

Case 4

D C c E e K Fya Fyb Jka Jkb M N S s IS AHG cc

1 + 0 + 0 + 0 + 0 + 0 0 + + 0 0 0 √

2 + 0 + + 0 + 0 + 0 + + 0 0 + 0 0 √

3 0 + 0 0 + 0 + + + + + + + + 0 0 √

• Check Medical History

• Patient received:

• 10 units Group O Negative rbcs

• 4 Group O Single Donor Platelets

Case 4

• Patient’s ABO discrepancy was due to massive transfusion of out of group blood products.

• Important Clue: Mixed-field agglutination

• Information from transferring hospital confirmed that patient was AB Positive

• What blood type of rbcs should be transfused?

Resolution to Case 4

Ready for Another Case?

Case 5

• 22 yr. old sickle cell patient

• Transfusion history: received numerous units of red cells since the age of 14 yr.

• She is in the out patient center awaiting a 2 unit transfusion

• Her blood type is A Positive and she has been phenotypically matched for Rh and K.

Anti-C Anti-c Anti-E Anti-e Anti-K

4+ 3+ 3+ 4+ 0

Case 5

D C c E e f K Fya Fyb Jka Jkb M N S s Gel

AHG

1 + + 0 0 + 0 0 + + + 0 0 + + 0 0

2 + 0 + + 0 0 + 0 + 0 + + + 0 + 0

3 0 0 + 0 + + 0 + 0 + + + 0 + + 2+

• Her antibody screen comes up positive!

The panel results… for Case 5?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG

Gel

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 0

2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0

4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 2+

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 2+

6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0

7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 2+

80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 2+

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 2+

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 2+

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 2+

PC 0

Let’s do the cross outs

The panel results… for Case 5?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG

Gel

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 0

2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0

4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 2+

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 2+

6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0

7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 2+

80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 2+

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 2+

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 2+

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 2+

PC 0

Resolution for Case 5?

• The f antigen is expressed when c and e are made by the same gene

• It is present on all R0 (Dce) and r (dce) haplotypes

• Anti-f is often a component of anti-c or anti-e

• It is clinically significant and can cause mild HTR and mild HDFN

• Patients with anti-f can be transfused with c or e neg. red cell units• R1R1 or R1R2 will be given c negative, R2R2 will be given e negative

• Our sickle cell patient safely received 2 c negative units without any complications

Case 6

• 56 yr. old man with a history of ITP (Idiopathic Thrombocytopenia Purpura)

• Hgb: 7.5

• Platelets: 10,000

• Physician orders 2 units of red cells

Case 6

D C c E e K Fya Fyb Jka Jkb M N S s IS AHG cc

1 + + 0 0 + + + 0 + + 0 + + 0 0 2+ nt

2 + 0 + + 0 0 0 + 0 + + + 0 + 0 2+ nt

3 0 + + 0 + 0 + + + 0 + 0 + + 0 0 √

His Type and Screen results are below:

Anti-A Anti-B Anti-D A1 cells B cells

0 4+ 3+ 4+ 0

The panel results… for Case 6?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG

Gel

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 3+

2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 3+

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 3+

4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 3+

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0

6 0 0 + + + 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0

7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 0

80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 0

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 3+

PC 1+

Let’s do the cross outs

The panel results… for Case 6?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG

Gel

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 3+

2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 3+

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 3+

4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 3+

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0

6 0 0 + + + 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0

7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 0

80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 0

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 3+

PC 1+

What to do next?

Select Cell Panel for Case 6

Vial D C c E e C

w

K k K

p

a

Js

a

F

y

a

F

y

b

Jk

a

Jk

b

L

e

a

L

e

b

P1 M N S s L

u

a

X

g

a

Pt

AHG

1 0 + + 0 + 0 + + 0 0 + 0 + 0 0 + + + + + 0 0 0 0

2 0 + + 0 + 0 0 + 0 0 + + 0 + + 0 + + 0 0 + 0 + 0

3 0 0 + + + 0 0 + 0 0 0 + 0 + 0 + + 0 + 0 + 0 + 0

4 0 0 + + + 0 0 + 0 0 0 + 0 + 0 + + 0 + 0 + 0 + 0

•To rule out Anti-E and Anti-C when Anti-D is present

Anti-D when the Patient is Rh Positive?

• How is that possible?

• Transfusion history: received 6 B positive units in last 3 years

• No bone marrow or stem cell transplant

• Medications: WinRho

• What’s that?

Resolution for Case 6

• Large dose of anti-D

• Used to treat patients with ITP in Rh Positive patients along with corticosteroids

• Pathophysiology: anti-D will attach to red cells and trick spleen into removing them instead of antibody-coated platelets

• Transfusion requirements?

Case 7

• A 30 yr. old man admitted for a relapse of acute leukemia.

• Transfusion history: Received 2 units of leuko-reduced packed red blood cells without incidence last year.

• On this admission, the physician orders 2 units of red cells since his hematocrit is 18%.

• 3 days later the patient’s Hct is 15% with no signs of bleeding. The patient receives 2 more crossmatch compatible units.

• His type and screen results are below:

Anti-A Anti-B Anti-D Rh ct. A1 cells B cells SCIAHG

SCII AHG

SCIIIAHG

4+ 0 3+ 0 0 2+ 0 + 0 + 0 +

Case 7

• During the transfusion of the fourth unit, the patient develops fever, chills and hemoglobinuria.

• A transfusion reaction workup is ordered.

• The post-transfusion specimen was slightly icteric after centrifugation.

• The post-transfusion specimen DAT is weakly positive with Anti-IgG and Anti-C3d.

• What should be done next?

The panel results… for Case 7?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub

Poly

AHG

eluate

cc

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 2+ nt

2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0 √

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 2+ nt

4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 1+ nt

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 1+ nt

6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0 √

7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 2+ nt

80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0 √

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 2+ nt

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 2+ nt

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 1+ nt

PC

Let’s do the cross outs

The panel results… for Case 7?

Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub

Poly

AHG

eluate

cc

1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 2+ nt

2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0 √

3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 2+ nt

4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 1+ nt

50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 1+ nt

6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0 √

7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 2+ nt

80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0 √

9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 2+ nt

10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 2+ nt

11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 1+ nt

PC

Case 7

• Kidd antibodies can bind complement, so weak reactivity can be enhanced with Polyspecific AHG

• Common cause of delayed transfusion reactions due to rapidly decreasing titers

Case 7

• Both units phenotyped Jka positive

• 91% of Blacks and 77% of Caucasians are Jka

positive

• Jka and Jkb are well developed at birth

• Kidd antigens are not destroyed by enzymes or DTT

• Kidd antibodies are IgG

• Anti-Jka and Anti-Jkb reactivity can be enhanced by PEG, LISS, enzymes or by increasing the serum to 4 drops

Congratulations! You are now among the Elite Group of Blood Bankers!

Additional Blood Bank Resources

• Blood Bank Guy [Dr. Joe Chaffin] = bbguy.org

• Transfusion Medicine Question of the Day• http://transfusionnews.com/path-questions/

• One of the editors and co-founders is Dr. Ronald Jackups [WUSTL]