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I believe the old saying is, "If the computer ain't happy, ain't nobody happy!!"

Giving O units (or A2) keeps our computer happier on patients with documented anti-A1. Of course, that is the prime objective these days, right? We bow to our computers!

I worked in Red Cell Immunohaematology for most of my 43 years before retirement, including two times at the International Blood Group Reference Laboratory (IBGRL), and for over a decade at one of the NHS Blood and Transplant Centres in London. During that time, I saw some pretty weird Kidd antibodies, but never came across an example of one that reacted with red cells with Jk(a) heterozygous expression, but not with Jk(a) homozygous expression. One such "weird" type (although I never saw one) was the extremely rare, dominant inhibitor type In(Jk), similar, but, of course, not identical to In(Lu). These red cells usually type as Jk(a-b-), but their true Kidd type can be ascertained by Adsorption and elution tests.. These red cells are also more resistant to haemolysis by 2M Urea than red cells with "normal" expression of the Kidd antigens, but less resistant to haemolysis by 2M Urea than true "amorphic" Jk(a-b-) red cells. There are approximately 14, 000 copies of the Kidd carrier molecule per red cell (quite a small number, when compared with some other carrier molecules, such as the D antigen). The amino acid residue that defines either the Jka or Jkb antigens is very close to the red cell membrane in the 4th extracellular loop but is largely “hidden” by the 3rd extracellular loop (steric hindrance). Both facts may contribute to the weak reactions between Kidd antibodies and Kidd antigens. Schematic of the Kidd carrier molecule (after Wester ES, Storry JR, Olsson ML. Characterization of Jk(a+weak): a new blood group phenotype associated with an altered JK*01 allele. Transfusion 2011; 15: 380-392. DOI: 10.1111/j.1537-2995.2010.02795.x. In this paper, Wester et al also describe weakened forms of both the Jka and the Jkb antigens, but in each case, the amino acid substitution is remote from position 280 of the mature protein. In addition, an individual with the Trp171Arg mutation with weak Jk(a) expression has produced an anti-Jk3 or anti-Jk3-like antibody, and so they may be “dangerous patients” (Whorley T, Vage S, Kosanka J, Lose SR, Sandquist AR, Copeland TR, Westhoff CM. JK alleles associated with altered Kidd antigen expression. Transfusion 2009; 41 (Suppl.): 48A-49A (abstract). Lastly (for now anyway!), most foetal red cells sensitised by maternal antibodies react only with anti-IgG, but I (and a colleague Grant Webb) have both noticed, but not published, occasions when such red cells also react with anti-C3d and, in one case, only anti-C3d (see genuine photographs below)..

Forgot to add, Plasmalyte is also FDA approved for use with blood components. No data :). In our OR, there is no normal saline at all, just Ringer's Lactate and Plasmalyte, the latter used for blood component administration. Plasmalyte is slightly more expensive than normal saline, but also somewhat less toxic.

I haven't seen a rebuttal but the FY system is reported to be a problem with storage. It was reported by : Williams D, Johnson CL, Marsh WL. Duffy antigen changes on red blood cells stored at low temperature. Transfusion. 1981 May-Jun;21(3):357-9. doi: 10.1046/j.1537-2995.1981.21381201813.x. PMID: 7233520.

I went back to your original post and it clearly said "Trigger" for some posters. My lab only uses the microscope for FMH screening tests and rarely (like once in a blue moon) looking for mixed field during post-transfusion reaction investigations. I would consider it to be looking for Zebras, as Malcom said, to want to see rouleaux or a cold-reactive antibody by letting tubes "sit before looking under the microscope" (slightly adulterated version, my apologies). I didn't see any mention of "only for ABO discrepancies" or even "reverse type". I've seen cold reactive antibodies look like rouleaux and rouleaux that gave the same appearance as cold reactive antibodies. Some are helped to be clearer with saline replacement, some not. That's probably where I stopped looking at these things under a microscope. We predominantly test using automated gel method with tube usually being the "come to the rescue" method to not see just those things you were talking about. Do I saline replace or pre-warm the test components for those things? If I need to, but I try not to wake the sleeping beasts so I don't see them in the first place.

If there ARE extra reactions in the back type, then they do need to be resolved IF, and I mean IF, they look as if they could signify that the forward ABO type is false. That having been said, I STILL would not go looking for rouleaux or agglutination that was not present when the tests are read at their normal incubation period and temperature. Why would you want to look for a herd of Zebra, when you hear a herd of Horses (thank you John C Staley - or, at least, I think it was you who used to say this to me on a regular basis - apologies if it was not - but it was a great comment!)?

I think we're confusing ourselves. I was referring to the original post which suggested a modification of procedure in order to enhance rouleaux/colds. Serological assays are typically read "without undue delay", i.e., immediately. If some techs have a practice to "let tubes sit before looking at them", that could be construed as deviating from the procedure, unless they have some bizarre and very specific local instruction to do so.

Transfus Apher Sci. 2023 Jun;62(3):103641. doi: 10.1016/j.transci.2023.103641. Epub 2023 Jan 13. Association of crystalloid fluid infusion with intravascular hemolysis and organ dysfunction in hematopoietic stem cell transplant patients Melissa R Holloway 1, Thomas Fountaine 2, Kelly Henrichs 3, Tate Feeney 4, Jeffrey Andolina 5, Kristen O'Dwyer 6, Jane Liesveld 7, Neil Blumberg 8, Eric Huselton 9 Affiliations expand PMID: 36653255 DOI: 10.1016/j.transci.2023.103641 Abstract Endothelial cell activation and injury is common after hematopoietic stem cell transplant (HSCT) and is associated with many post-transplant complications. An underexplored mechanism of endothelial cell damage in this population is the infusion of normal saline (NS, 0.9 % sodium chloride) and other crystalloids, as NS use is associated with adverse outcomes in other patient populations. We hypothesized that the infusion of unbalanced crystalloids during HSCT may lead to changes in biomarkers commonly associated with red blood cell (RBC) hemolysis in patients before and after infusion, and that markers of endothelial and end-organ damage during admission may be associated with markers of hemolysis and total crystalloid use. Samples were collected from 97 patients. From pre-fluid infusion to post-fluid infusion, mean haptoglobin decreased (11.7 ug/ml vs 8.4 ug/ml; p < 0.0001), hemopexin decreased (549 vs 512 μg/ml; p = 0.005), and red cell distribution width (RDW) decreased (15.7 vs 15.6; p = 0.0009). During admission (mean 19.4 days, SD 9.9), all markers of tissue and organ damage, including mean creatinine, lactate dehydrogenase (LDH), blood urea nitrogen (BUN), total bilirubin, AST, and ALT, increased from admission to peak levels (p < 0.0001). On linear regression, fluid volume (ml/kg) of crystalloid infusion positively predicted post-fluid infusion cell-free hemoglobin (r(96) = 0.34, p < 0.0001), free heme (r(96) = 0.36, p < 0.0001), and peak LDH during admission (r(75) = 0.23, p = 0.041), and negatively predicted post-fluid infusion hemopexin (r(96) = - 0.34, p < 0.0001). Unbalanced crystalloids may contribute to hemolysis and endothelial damage in HSCT patients. Alternatives such as buffered crystalloid solutions (PlasmaLyte, Lactated Ringer's) may be worth investigating in this population.

The preferred solution for administration of blood components should be Plasmalyte. Less hemolysis in vitro. Normal saline is toxic to patients and should never be used, in my opinion. Causes a metabolic acidosis and kidney injury. Ringer's lactate is fine too, but as you note, is forbidden (based upon no data whatever) by FDA. The only patients who might benefit from normal saline are those with a metabolic hypochloremic alkalosis, which is very rare. Our enthusiasm for normal saline was entirely misplaced. Randomized trials show it to be harmful and increase mortality in critically ill patients. Balanced Crystalloids versus Saline in Critically Ill Adults. Semler MW, Self WH, Rice TW.N Engl J Med. 2018 May 17;378(20):1951. doi: 10.1056/NEJMc1804294.PMID: 29768150 Free PMC article. BACKGROUND: Both balanced crystalloids and saline are used for intravenous fluid administration among critically ill adults. ...METHODS: In a pragmatic, cluster-randomized, multiple-crossover trial in five intensive care units at an academic center, we assigned 15,802 adul … Balanced Crystalloids versus Saline in Noncritically Ill Adults. Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, Slovis CM, Lindsell CJ, Ehrenfeld JM, Siew ED, Shaw AD, Bernard GR, Rice TW; SALT-ED Investigators.N Engl J Med. 2018 Mar 1;378(9):819-828. doi: 10.1056/NEJMoa1711586. Epub 2018 Feb 27.PMID: 29485926 Free PMC article. Clinical Trial. BACKGROUND: Comparative clinical effects of balanced crystalloids and saline are uncertain, particularly in noncritically ill patients cared for outside an intensive care unit (ICU). METHODS: We conducted a single-center, pragmatic, multiple-crossover trial comparing balan … Balanced Crystalloids versus Saline in Critically Ill Adults. Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, Guillamondegui OD, May AK, Weavind L, Casey JD, Siew ED, Shaw AD, Bernard GR, Rice TW; SMART Investigators and the Pragmatic Critical Care Research Group.N Engl J Med. 2018 Mar 1;378(9):829-839. doi: 10.1056/NEJMoa1711584. Epub 2018 Feb 27.PMID: 29485925 Free PMC article. Clinical Trial. BACKGROUND: Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes. METHODS: In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five …

We had to purchase a set of screening cells from a different vendor for DTT treating cells for Darzalex patients because when we validated it, the Duffy antigen we were testing didn't survive the process consistently. It was fine on Alba cells but not on Immucor cells.

Could be an antigen within the Knops Blood Group System. They are notorious for "going off" on older red cells, but the antibodies are not renowned for being clinically significant.

Your guess is as good as anyone else's. . I suspect the FDA will continue doing regulatory stuff until told to stop by Congress or some court. I'd assume they will regulate LDTs as they have proposed.

Good morning, Blood Bankers. I work at a Level 1 Trauma center and we just purchased 4 of these coolers. Has anyone had a successful validation plan? If so do you mind sharing. TIA. I am trying to find the most efficient way to validate and make sure we are covering every extreme possible.

Yes. And worse, some cells react differently, including having no reactivity, as compared with cells of the same degree of zygosity. Thus the possibility of Kidd antibodies needs to be seriously considered when the recipient is negative for one or both antigens and the panel is reactive but without clearcut specificity for Jka or Jkb.

No worries, any questions are helpful.

Saline review for TRASCI final[1].pdf

I did come across one article where the author recommended changing guidelines for the use of Lactated Ringers in transfusion but only in times of "Rapid Infusion" such as during trauma. I would suspect there would be too many clots in the tubing otherwise. I would imagine there needs to be much more study on this with specific guidelines created. I work in a small hospital and like that it is black and white to NOT use the Lactate Ringers. With the Blood Bank being responsible for all transfusions, I wouldn't want to be a part of a situation where someone used a solution when it was not indicated that resulted in a bad outcome. I'll embrace change when the Circular says otherwise What articles has the OR read and offered? Is the surgeon previously military? Just wondering where they saw that Lactated Ringers has been used....

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They can't all be hard. Also, as a reminder, I could really use help with new questions, I have a very small reserve.

You are quite right Jason. I also remember a similar paper, written by Jill Storry, entitled "Long term preservation of red cell antibody identification panels in low ionic strength solution." This was published in Medical Laboratory Sciences 1987; 44 (4): 350-355, but was based on the winning Margaret Kenwright award presentation at the Annual Scientific Meeting of the British Blood Transfusion Society, London, UK on 4th September 1986. This was when Jill was a Senior Medical Laboratory Scientific Officer at the South Western Regional Transfusion Centre of the National Blood Transfusion Service in Southmead Road, Bristol. She has done rather well for herself since then, now being a Professor at Lund University. Unfortunately, I don't have a DOI for this paper. At the time, I was working at Mayday Hospital in Croydon, London, and wrote to her to clear up a couple of queries I had. In early January 1988 she wrote back to me and, in this reply, she stated, "Can I also draw your attention to the fact that the original trial (her original trial) was done using frozen re-constituted red cells. It has subsequently been pointed out to me that when using fresh cells for screening purposes there is significant loss of Fy(a) and Fy(b) antigens over a two week period. This phenomenon has been well documented (see below) and is due to the release of proteases upon leucocyte aminoglycoside interaction. Gentamicin is of course, an aminoglycoside antibiotic. We have overcome this problem completely by leucocyte depletion using a Sepacell 500 filter, and I hope to submit a short communication to the IMLS journal describing the results of this modification." I haven't got a reference for this. The paper to which Jill was referring to in her letter was: Malyska H, Kleeman JE, Masouredis SP, Victoria EJ. Effects on Blood Group Antigens from Storage at Low Ionic Strength in the Presence of Neomycin. Vox Sanguinis 1983; 44 (6): 375-384. DOI: 10.1111/j.1423-0410.1983.tb03660.x All that having been said, I would be surprised if all screening cells and antibody identification cells were not now leukodepleted. In addition, of course, apart from certain areas of Asia, neither the Fy(a), nor the Fy(b) antigens can be regarded as high prevalence antigens, and those antigens within the Duffy Blood Group System that can be regarded as high prevalence (Fy3, Fy5 and Fy6) are vey different to both Fy(a) and Fy(b), and so it is doubtful that these would weaken substantially upon storage.

Some of you more "experienced" people will remember the little saws that we used to score the microhematocrit tubes so we could break off the part with the immature red cells for antigen typing someone who had been recently transfused. What the heck were those saws meant for originally? I feel like they came with something else in the lab. Were they for general chemistry glass tubing? Also, what tool works well now for scoring the plastic-coated glass microhematocrit tubes since those little saws aren't available? I found a few centimeters of staples (ready to be put in a stapler) could work. Hack saw blade?

Harbor freight mini files are your friend.

We used a "Machinist File" to cut glass crit tubes back in the day for baby Bilis. You can get them for less than $10 at Grangier or other suppliers.

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For some reason I remember them being simple knives. Something like this, it just needed to score the glass, or now, plastic covered glass.

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Route 1, that is how I got my SBB. I went to Rush University in Chicago.

In order to qualify for the SBB certification through route 1, you need to have completed a program that is accredited by CAAHEP. This means that the program meets certain standards of quality. If you're interested in learning more about CAAHEP, you can check out this article on what CAAHEP is and why it matters: What is CAAHEP?

Malcolm, I've up graded that from Zebras to Unicorns. Thanks for remembering.

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Wow, we crushed this goal! Great work!

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I believe most of these tests will fall under 1976-Type LDTs which fall under enforcement discretion. The immunohematology tests that may fall the new rule would be modifications to manufacturers' instructions (i.e., you use the reagent/test in another method, you use a different specimen type or extend the specimen acceptable time limit).

"the presenter stated specifically that NOTHING has been grandfathered. " I think the presenter is mistaken. The FDA specifically noted that the area of rare reagents and cells, and similar testing would not be subject to LDT enforcement. Of course, all the opinions in the world matter not a bit until the FDA actually acts or does not act. I cannot imagine they want to be inspecting every tertiary care hospital and blood center reference laboratory for this purpose. And most of the things we are discussing in the transfusion service and immunohematology lab are not used to provide diagnostic results to practitioners, but rather used for internal resolution of therapeutic decisions. Quite different from your average laboratory test which provides quantitative or semi-quantitative result to physicians and other practitioners who make decisions based upon lab results. Perhaps a nuance, but a real difference. If the FDA insists we validate the use of a potent anti-HPA1 anti-platelet antibody in our decision making, we're out of luck :). Ain't happening. Interestingly, much of what we do in clinical medicine has not been "validated" or subjected to FDA-like regulation. Such as using autologous or allogeneic stem cell transplants, liver transplants, using a stethoscope or looking at a patient's retina with an ophthalmoscope. No validation. No data to speak of at all.

I attended a webinar presentation on this and the presenter stated specifically that NOTHING has been grandfathered. There are some items that the FDA has said it would still use enforcement discretion, but was very much above my understanding.

Yup. What Neil said. We do not give RhIg prophylaxis for women of childbearing age if they have received Rh Pos red cells, but will offer it for Rh pos platelets. Once a full unit of red cells is in, it's a lot to mitigate, and if they're getting 1 unit of Rh pos red cells, they're usually getting MTP and many more Rh pos products. Plus, treatment for anti-D in pregnancy has gotten pretty sophisticated, it's certainly not pleasant for mom, but it can be done. The patient has to survive first!

2024-08935.pdf (federalregister.gov) I have not read it all but some BB tests seem to be out of scope such as the use of rare antisera/red blood cells when no reagent is commercially available as well adsorption techniques, Donath Landsteiner test, Drug Induced hemolysis tests and the Monocyte Monolayer Assay... not an exhaustive list but I might have missed while going though quickly these 500+ pages.

I think most blood bank reagents and tests have been grandparented in. The FDA knows there is no alternative to these home brew reagents and testing procdures.

There are no data to answer your questions, as far as I know. It's important to make sure that the fetal cell quantitation is not measuring maternal cells with increased fetal hemoglobin, as this would overestimate the RhIgG dose needed. This is not a problem with some methods (anti-Rh(D) quantitation of fetal cells but can be a problem with acid elution (K-B) staining, for examples. If there is convincing evidence these are fetal cells, give the correct dose IV even if many vials. IM injections are cruel and unusual punishment if IV injectables are available. For patients who are not planning future pregnancies, this should be discussed with the patient. For sick patients who have received transfusions, we do not infuse RhIgG except for younger women (<40-50) who plan future pregnancies and have a prognosis for survival. Hemolysis from RhIgG can be a problem at high doses of RhIgG and large transfusion volumes. On balance we usually elect not to give RhIgG to women who have received entire or multiple units of Rh(D) positive red cells. It's a complex clinical decision with little science to guide us.

Another inspector who is a bureaucratic and clinically ignorant rigid thinker. My sympathies. There is no reason to document early infusion rates, and these vary by patient due to clinical condition. This is just a guideline and not a requirement, as the inspector would know if they had any bedside clinical practice experience. Just say it's a rough guideline, not a requirement, and clinical judgement will determine the infusion rate for each patient.