Weak alloantibody anti Jka missed on routine crossmatching: a case report illustrating the importance of “Type & Screen”

Weak alloantibody anti Jka missed on routine crossmatching: a case report illustrating the importance of “Type & Screen”

Case Report

Weak alloantibody anti Jka missed on routinecrossmatching: a case report illustrating theimportance of “Type & Screen”

Rajnath Makroo a,*, Aakanksha Bhatia b, Rosamma c

aDirector & Senior Consultant, Department of Transfusion Medicine, Indraprastha Apollo Hospitals,

Sarita Vihar, New Delhi, IndiabRegistrar, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, IndiacChief Technical Officer, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar,

New Delhi, India

a r t i c l e i n f o

Article history:

Received 7 January 2014

Accepted 17 February 2014

Available online xxx

Keywords:

Clinically significant

Hemolytic transfusion reactions

Dosage effect

Group and screen policy

a b s t r a c t

THE KIDD system of blood groups was discovered in 1951 by Allen, Diamond and Niedziela.

The Kidd antibodies are clinically significant antibodies and a number of hemolytic

transfusions reactions resulting from them have been reported. Kidd antibodies are at

times difficult to detect. They exhibit distinct dosage effect. We present here one such case

of alloantibody anti Jka, that could have easily been missed, if the “Group and Screen

policy” routinely practiced at our hospital was not in place.

Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Provision of safe blood for transfusion is the prime re-

sponsibility of every transfusion facility. This does not only

imply thorough testing for infectious markers, but also pro-

tection from hemolytic transfusion reactions resulting from

alloimmunization. Ever increasing efforts at improving blood

safety have led to incorporation of regular screening protocols

for detection of irregular immune antibodies at various

transfusion centers across the globe. The ultimate goal is to

identify the exact specificity of the antibody and provide the

corresponding antigen negative blood to the patients.

In most transfusion centers across India, detailed sero-

logical workup for such irregular antibodies is performed

either in cases where a blood group discrepancy is detected or

in cases of an incompatible/positive crossmatch. Since such a

practice is less time consuming and cost effective, it appears

to be the most practical approach, especially in the Indian

setting. However, there is a definite chance of missing certain

antibodies, some of which may be clinically significant. This

usually happens when the units that are cross matched lack

the particular antigen/s against which the patient has devel-

oped antibodies. Also at times the titer of the irregular anti-

body may be fairly low for causing a positive crossmatch.

Besides this there are several antigens and their

* Corresponding author.E-mail address: [email protected] (R. Makroo).

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier .com/locate/apme

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e3

Please cite this article in press as: Makroo R, et al., Weak alloantibody anti Jka missed on routine crossmatching: a case reportillustrating the importance of “Type & Screen”, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.02.004

http://dx.doi.org/10.1016/j.apme.2014.02.0040976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

corresponding antibodies that display a “Dosage Effect”

resulting in misleading crossmatch findings. Examples of

such antibodies are anti-Jka, anti-Jkb, anti-Fya, anti-Fyb, anti-C,

anti-E, and anti-c.1,2

THE KIDD system of blood groups was discovered in 1951

by Allen, Diamond and Niedziela.3 The Kidd antibodies are

clinically significant antibodies, usually IgG in nature and a

number of hemolytic transfusion reactions (HTRs), espe-

cially delayed HTRs resulting from them have been re-

ported.4 Kidd antibodies are at times difficult to detect. They

may directly agglutinate antigen positive cells; however the

reactions are generally weak. They exhibit distinct dosage

effect. The anti Jka reacts more strongly with Jk (aþb�) cells

than with Jk (aþbþ), while some anti Jka can only be

detected using Jk (aþb�) screening cells and thus all

screening and identification cell panels must contain at

least one such cell.5

We present here one such case of alloantibody anti Jka, that

could have easily beenmissed, had we not had been following

the “Group and Screen policy” routinely at our hospital.

2. Case report

A 17-year-old girl with epilepsy was admitted to our hospital.

CT showed a subdural hematoma, which required evacuation.

As a routine protocol her “Group and Screen” sample was

received at the department of Transfusion Medicine. Her

blood groupwas B Positive, and antibody screening performed

using the Solid Phase RedCell Adherence technology (Capture,

Immucor Inc. Norcross, GA) was negative. Two units of

crossmatch compatible packed red cells were issued for the

patient.

Two weeks later another request for two units of packed

red cells was received for this patient. As it had been over 72

hours since the previous transfusion episode, as per the

transfusion policy followed at our center, antibody screening

was repeated. To our dismay this time the antibody screen

performed using a four cell panel of Capture (Immucor Inc.

Norcross, GA.) was positive in one of the cells. The results are

shown in Table 1.

In the meanwhile, at the crossmatching counter two

random B positive units had already been cross matched for

the patient, both of which were compatible. Resisting the

tendency to issue crossmatch compatible blood looking at the

low hemoglobin levels of the patient and rising pressure from

the clinical side, we went ahead with antibody identification.

Appropriate samples were requested to be sent to the blood

bank for testing. The serological investigations performed

were as follows:

Direct Coomb’s Test e Positive (1þ).

Auto control e Positive (most likely due to positive DAT).

Antibody identificationwas run on the automated analyzer

Galileo (Immucor Inc. Norcross, GA). The results obtained are

shown in Table 2.

The reaction pattern clearly points towards an anti Jka.

Since the reaction strengths were only weak to 1þ, we

concluded that this patient had a weak alloantibody anti Jka.

Extended antigen typing of the patient could not be performed

since she was recently transfused.

Table

1e

Antibodysc

reenin

gch

art

e4ce

llpanel(Im

muco

rIn

c.Norcro

ss,GA).

Rh-H

rKell

Duffy

Kidd

Lewis

PMNSs

Luth

-eren

Xg

DC

cE

eF

VCw

KKpa

Kpb

Jsa

Jsb

Fya

Fyb

Jka

Jkb

Lea

Leb

P1

MN

Ss

Lua

Lub

Xga

1þ

þ0

0þ

00

þþ

þ0

þ0

þþ

þþ

þþ

0þ

þþ

0þ

0þ

01þ

2þ

0þ

þ0

00

00

þþ

þ0

þþ

00

þ0

þ0

þþ

00

0þ

þ0

30

0þ

0þ

þ0

00

þ0

þ0

þþ

0þ

00

þþ

þ0

þþ

0þ

01þ

40

0þ

0þ

þ0

00

þ0

þ0

þ0

þ0

þ0

þþ

0þ

0þ

0þ

þ0

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e32


Further, this case clearly exemplifies the dosage effect

shown by this antibody. In the cells where the Jka antigen is

present in a homozygous state (double dose), the reaction

strength is higher, while in the cells where the antigen is

present in heterozygous state (single dose), the reaction is

weak.

With these results in hand, we went back to the units that

had been crossmatched for the patient and typed them for the

Kidd antigens. The results of the antigen typing are shown in

Table 3.

The first unit was typed as Jka�Jkbþ and was thus

compatible. It was the second unit that was Jka þ Jkb þ but still

compatible that raised a question on issuing blood merely

based on crossmatch compatibilities. In the second unit the

Jka antigen was in heterozygous state and hence the results of

crossmatch were misleading.

3. Conclusion

The initial negative antibody screen in this case suggests

either absence of alloantibodies or the presence of very

weak existing alloantibodies before transfusion. The

detection of anti-Jka in post transfusion sample indicates

immunization due to transfused units. Had we relied on

crossmatch alone we could have transfused antigen positive

blood to this alloimmunized young lady, thereby adding fuel

to the fire. This case clearly illustrates the need of the “Type

and Screen” policy being incorporated in routine trans-

fusion practice.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

1. Makroo RN. Practice of Safe Blood Transfusion: Compendium ofTransfusion Medicine. 2nd ed. New Delhi, India: KongPoshPublications Pvt. Ltd.; 2009.

2. Reid ME, Lomas-Francis C. The Blood Group Antigen Facts Book.2nd ed. New York: Elsevier Academic Press; 2004.

3. Allen F, Diamond L, Niedziela B. A new blood group antigen.Nature. 1951;167:482.

4. Pineda AA, Vamvakes EC, Gorden LD, Winters JL, Moore SB.Trends in the incidence of delayed haemolytic and delayedserologic transfusion reactions. Transfusion.1999;39:1097e1103.

5. Daniels G. Human Blood Groups. 2nd ed. Blackwell Science Ltd;2002.

Table

2e

AntibodyIdentifica

tionch

art-14ce

llpanel(Im

muco

rIn

c.Norcro

ss,GA).

Rh-h

rKell

Duffy

Kidd

Lewis

PMNSs

Luth

-eren

Xg

DC

cE

ef

VCw

Kk

Kpa

Kpb

Jsa

Jsb

Fya

Fyb

Jka

Jkb

Lea

Leb

P1

MN

Ss

Lua

Lub

Xga

1þ

þ0

þþ

00

00

þ0

þ0

þþ

þþ

00

þþ

0þ

0þ

0þ

01þ

2þ

þ0

0þ

00

þ0

þ0

þ0

þþ

00

þ0

þþ

0þ

0þ

0þ

þ0

3þ

0þ

þ0

00

0þ

þ0

þ0

þþ

þ0

þ0

þþ

þ0

0þ

0þ

þ0

4þ

0þ

0þ

þþ

00

þ0

þ0

þ0

þþ

00

þþ

þþ

00

0þ

01þ

50

þþ

0þ

þ0

00

þ0

þþ

00

þþ

þ0

þ0

þþ

þþ

0þ

0w

60

0þ

þþ

þ0

00

þ0

þ0

þþ

00

þ0

þþ

þþ

0þ

0þ

þ0

70

0þ

0þ

þ0

00

þ0

þ0

þ0

þþ

þ0

0þ

þþ

0þ

0þ

þw

80

0þ

0þ

þ0

0þ

þ0

þ0

þ0

þþ

þ0

þ0

0þ

0þ

þþ

0w

90

0þ

0þ

þ0

00

þ0

þ0

þþ

00

þþ

0þ

þþ

0þ

0þ

00

10

00

þ0

þþ

00

0þ

0þ

0þ

00

þ0

þ0

þþ

þ0

þ0

þþ

1þ

11

00

þ0

þþ

00

0þ

0þ

0þ

þ0

þþ

þ0

00

þþ

þ0

þþ

w

12

00

þ0

þþ

00

0þ

þþ

0þ

þW

þ0

0þ

0þ

þþ

00

þ0

1þ

13

00

þ0

þþ

00

0þ

0þ

0þ

0þ

þ0

0þ

þþ

00

þþ

þ0

1þ

14

þþ

00

þ0

0þ

þ0

0þ

0þ

þþ

þþ

þ0

0þ

0þ

þ0

þ0

w Table 3 e Kidd antigen typing of the cross matched donorunits.

X match Donors Result Kidd typing

Patient Donor 1 Compatible Jka�JkbþDonor 2 Compatible Jka D JkbD

Donor 2 red cells are indicated in bold since they were compatible

inspite of being positive for Jka antigen.

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e3 3


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Weak alloantibody anti Jka missed on routine crossmatching: a case report illustrating the importance of “Type & Screen”