Neil Blumberg

Also, were any of the transfused units antigen positive? This is the quickest way to get a negative indirect antiglobulin test ;).

Was the patient transfused? If not, hyper hemolysis is less likely. Sounds like mechanical causes are most likely.

Patient should be monitored for a delayed hemolytic transfusion reaction for about 10-14 days, not necessarily in hospital. Most common signs are fever and progressive anemia. sometimes dark urine or jaundice. Patient education before discharge if earlier than this is essential.

No, not an error.

If the donor passes your screening questions and seems clinically fine overall, there is literally no need to worry about these issues, either in terms of donor or recipient safety. The history and physical exam are by far the most important information in evaluation of patients or donors.

Not yet available. Being developed by Grifols. Probably months to a year away from FDA approval. You can contact them about becoming a testing site for licensure I'd guess. Until it's licensed you won't be able to use it in patient care, just research/validation.

Thanks Malcolm. Not pedantry at all. These exceptions are relevant and potentially important, particularly for ABO.

Ideally one avoids infusing plasma containing antibodies to recipient antigen. Of course it’s always a bad idea to transfuse antigen to which the recipient has antibodies. We often forget that after transplant all of the recipient cells except the blood cells and immune cells are of the original phenotype. We often forget that after transplant all of the recipient cells, except the blood cells and immune cells are of the original phenotype. In this case group AB cells might be safest with no incompatible antigen or antibody. Group A would be my next choice and I would wash or plasma reduce to get rid of the anti-B which will interact with the recipients endothelial cells, soluble antigen and all non-hematopoietic cells of the recipient. Some folks would use group O red cells which I think is probably the worst possible choice given the potential anti-A and anti-B. Washing or volume reduction would minimize this risk.

When you have incompatible antigen or antibody, low level hemolysis occurs, probably with complement activation. This is not at levels clinically evident, but inflammation occurs. Inflammation potentiates (increases) B cell activation and provides one mechanism by which ABO non-identical red cell transfusion (without washing) increases rbc alloimmunization to other antigens being presented. It is known to the case, both from clinical observations (referenced in my previous post) and from animal models which provide evidence that the presence of inflammation increases alloimmunization to red cells and other antigens. It's the mechanism by which adjuvants in vaccines increase immunization to microbial antigens in vaccines, by the way. Inflammation. Not a good thing if you are not infected and receiving transfused antigen :). But useful if you are trying to get a beneficial immune response to an antigen.

Whole blood only makes sense for patients with life threatening bleeding. Red cells are safer for patients who have major anemia/minor and/or slow bleeding. Whole blood will put many patients who are not hypovolemic into cardiac failure/pulmonary edema, and are, in general more toxic than red cells alone.

If you need copies of these reprints or have further questions, happy to help.

Perhaps this is one rare physician who actually reads the medical literature on the subject or has thought things through. The history of this is very simple. Based upon the experience of severe or fatal hemolytic transfusion reactions to whole blood, it was discovered that when a patient's ABO type was unknown, and urgent transfusion was life saving, group O was the least likely to result in disaster. When group O red cells became available during the middle of the last century, with modest amounts of plasma left, it was decided by the then experts that this could be used for non-urgent, routine transfusions of all patients. So-called universal donor O red cells. The problem, with the 100% accuracy of hindsight, was that we had no evidence this is was good, much less optimal practice. But it was convenient. It meant blood banks didn't have to stock all 8 Rh and ABO types, so it was good for us in the transfusion service. It wasn't good for patients. Why is that? Well, there is residual incompatible plasma with anti-A and anti-B in all group O red cells that haven't been washed or thoroughly volume depleted. Well, you might ask, and all of us have assumed for decades, that a few dozen milliliters of incompatible plasma is not a big deal. The answer, now known to some extent, is that it is a big deal for some patients who are groups A, AB and probably B. This small residual plasma can on rare occasions cause severe hemolysis. It's 100% severe if it happens to you as a patient. This has been known for decades. What is new is the data that recipients of ABO mismatched red cells (Group O in general) have a higher rate of red cell alloimmunization to other red cell antigens, (Transfusion 2012 Mar;52(3):635-40. doi: 10.1111/j.1537-2995.2011.03329.x; 2025 Mar;65(3):588-603. doi: 10.1111/trf.18135. higher rates of febrile and allergic reactions, (Transfusion 2012 Mar;52(3):635-40.doi: 10.1111/j.1537-2995.2011.03329.x.) higher rates of HLA alloimmunization, and perhaps overall higher rates of mortality (Transfusion. 2016 Mar;56(3):550-7.doi: 10.1111/trf.13376). So, if you are a recipient, you want ABO identical transfusions, or compatible red cells that have had all or almost all of the plasma removed, as by washing, for example.

We have educated our multiple myeloma specialists to send a type and screen before administering the first dose of a daratumumab (Darzalex). Our standard operating procedure is to have a panel of three cord blood cells (we have a large OB service) that is a laboratory developed test of sorts. Cord cells do not express CD38 at interfering levels. As it turns out we have made more of an issue of this than it warrants. Patients who have negative antibody screens essentially never develop new antibodies to red cells after being started on daratumumab probably because it potential inhibits B cells function. Minimal B cell function apparently yields little ability to make antibodies to red cell antigens, which are relatively weak alloantigens, especially when there is no adjuvant or inflammation in the recipient. That said, a manufacturer is making a soluble CD38 analog that will inhibit the anti-CD38 activity and make testing easier from what I've read. DTT treatment is also reasonable. But the good news is that patients on this drug do not make new antibodies. There are literature references to this, and we have probably tested about 500 patients with no new alloantibodies. Mostly non-transfused patients, obviously.

As far as I know there is no FDA requirement for two people to issue blood. Obviously some hospitals have only one person working night shift in the lab, so that isn't happening realistically. There is a traditional requirement for two people to identify the recipient and the transfused product, but this is only if positive patient identification is not used these days.

Understood, but the most important thing to realize is that minor variations are of no clinical significance when they occur. Dealing with unrealistic or irrational or foolishly rigid accreditation or regulation inspectors is a serious but separate issue :).