Transfusing a 25yr old patient with an auto anti-e

[mrdth5]

My local reference lab did not make a recommendation whether to give e negative units or not, rather they deferred to the blood bank medical director.   The reference lab did mention during a phone conversation that transfusing e negative blood would greatly increase the risk of this patient developing an allo anti- E in the future which seems logical.

 

My MD decided not to screen for e but give AHG compatible units, or least incompatible.   I was wondering what others would give in this situation?

 

[tbostock]

We had this situation just last week. We recommend that these patients not be transfused unless life-threatening. Our patient had an 8 g/dL hemoglobin, so no way.

If there is clinical evidence of active hemolysis in the patient, most recommend giving the Anti-e neg blood, knowing that you will probably encourage a new Anti-E.

If no clinical evidence of hemolysis, you are better off giving E neg units. Read below for explanation.

https://www.cbbsweb.org/enf/2006/auto_e_bloodselect.html

[David Saikin]

whenever I have an "auto" anything I transfuse Rh phenotype specific rbcs (or recommend this when it is a referral).  Anytime I have NOT done this, I invariably see the Rh abs that the pt would develop.   I don't know how valid this is but it seems that once a pt is in the autoab mode, they tend to be more inclined to be sensitized. 

[bmarotto]

We do the same (Rh phenotype matched).  There have been a few cases over the years where the patient did not maintain the expected post transfusion hematocrit, or had increaszed RBC destruction, when e positive units were transfused.  The hematologist requested a trial of e negative, understanding the risk of being sensitized to E.  In some cases the patient did do better and in others it made no difference so we went back to Rh phenotype matched. 

[Malcolm Needs ☆]

We would recommend giving e+, E- units.

The thing is that the "anti-e" is almost certainly a mimicking specificity (the actual specificity being something like an anti-Rh17 or anti-Rh18). The "auto-anti-e" can probably be adsorbed out to extinction with e-, E+ red cells (although it will take more adsorptions than doing it with e+, E- red cells), but this will prove that it is quite okay to give e+, E- blood, and you will not run the risk of sensitising the patient to make a genuine allo-anti-E.

There will be very rare cases when e+ transfusions will not give some form of sustainable increase in Hb (i.e. less than a week, or the patient actually has a reaction to the transfusion), when you just have to give e-, E+ units, but these cases are very, very few and far between.

[Sophie1210]

I would probably recommend AHG compatible or least incompatible units. There is the risk of them developing the anti-E, but also e negative blood is hard to come by and I'd rather save it for people with a true anti-e.

[Joanne P. Scannell]

I would probably recommend AHG compatible or least incompatible units. There is the risk of them developing the anti-E, but also e negative blood is hard to come by and I'd rather save it for people with a true anti-e.

Problem is, giving 'least incompatible' just makes the tech feel better.  Patient-wise, grade of compatibility doesn't always correspond to clinical significance (that's a whole 'nother conversation).

 

Knowing that, if we have a patient whose auto antibody cannot be either removed (e.g. autoabsorption or differential absorption) or circumvented by other methods (e.g. less sensitive method, prewarming, etc.) so we can see 'what is under there', then we transfuse antigen-negative for the antigens that the patient does not possess.  In other words, we avoid potential antibodies/antibody formation and we 'ignore' auto-antibodies.

 

I say 'ignore' in semi-quote because if the patient is overtly hemolyzing (not all are fulminent), then it may be best to transfuse antigen-negative for the so named auto-antibody.

 

If we had this patient ... if we can't clear away the auto-antibody, we'd give antigen 'identical'.  (Noticing comments above, give E-neg only if he/she is E-neg.)  If he/she is in an acute hemolysis situation (i.e. rapidly hemolyizing and dropping hct, severely low hct) then we'd consider giving e-neg RBCs.

[tbostock]

I agree wholeheartedly with Joanne Croke about the "least incompatible" issue. I'm not a fan and no longer use the term here. We either give compatible units, or make our physician sign for incompatible.

[David Saikin]

 

I agree wholeheartedly with Joanne Croke about the "least incompatible" issue. I'm not a fan and no longer use the term here. We either give compatible units, or make our physician sign for incompatible.

 

I agree too - Least incompatible is like saying someone is "a little pregnant"!