carolyn swickard

The Ko phenotype is incredibly rare in all ethnic groups, but, some cases have been published involving a transient loss of Kell antigens, and the concurrent appearance of apparent antibodies directed against one or more of the antigens within the Kell Blood Group System.
"Naturally Occurring" cases of anti-K are not unknown, but, once again are very rare.  A few of these have appeared in the literature, such as:
Morgan P, Bossom EL.  "Naturally Occurring" Anti-Kell (K1):  Two Examples.  Transfusion 1963; 3: 397-398.
Marsh WL, Nichols ME, Oyen R, Thayer RS, Deere WL, Freed PJ, Schmelter SE.  Naturally occurring anti-K stimulated by E. Coli enterocolitis in a 20-day-old child.  Transfusion 1978; 18: 149-154.
Kanel GC, Davis I, Bowman JE.  "Naturally-occurring" anti-K1:  Possible association with mycobacterium infection. Transfusion 1978; 18: 472-473.
Algora M, Barbolla L, Contreras M.  Naturally occurring anti-D, anti-K, anti-Fya and anti_Leab.  Vox Sanguinis 1991; 61: 141.
In each case, you will notice, there is either an accompanying infection, or, in the last case a form of neoplasm.  This may fit with your patient, if the early gastric cancer has allowed the escape of, for example, E coli into his circulation.
I was also interested in the fact that you tested the patient's red cells, and found them to be phenotypically K-k-, but genotypically KEL: -1, 2, -3, 4, -6, 7.  Did you also test the red cells with anti-Kpa, anti-Kpb, anti-Jsa and anti-Jsb, to ensure that these antigens were not detected?  I am not asking this to be facetious, but because there have been examples of an apparent lack of the k antigen due to amino acid residue substitutions either at position 193, usually threonine for the k antigen, or very close to position 193 (see Millard GM, Lopez GH, Turner EM, Lizarazu ME, Roots NM, Liew Y-W, Flower RL, Hyland CA.  Modified expression of the KEL2 (k) blood group antigen attributed to p.Leu196Val amino acid change three residues from the K/k antigen polymorphism site: implications for donor screening.  Transfusion 2019; 59: 1156-1158 and Yazdanbakhsh K, Lee S, Yu Q, Reid ME.  Identification of a defect in the intracellular trafficking of a Kell blood group variant.  Blood 1999; 94 (1): 310-318).  However, the amino acid residue substitutions can be "geographically remote" from position 193 affecting the expression of the k, and other Kell antigens (see Velliquette RW, Hue-Roye K, Lomas-Francis C, Gillen B, Schierts J, Gentzkow K, Peyrard T, von Zabern I, Flegel WA, Rodberg K, Debnath AK, Lee Soohee, Reid ME.  Molecular basis of two novel and related high-prevalence antigens in the Kell blood group system, KUCI and KANT, and their serological and spatial association with K11 and KETI.  Transfusion 2013; 53: 2872-2881)).
To complicate matters further, some anti-k reagents may give weak or negative reactions, while others give apparently normal reactions.  I remember a case I was involved in myself.  We were following a woman with anti-D during her pregnancy.  She was K+k+, and her partner was D+, K-.  Upon delivery, her baby typed as K+k- in our hands (which excluded the father, unless he had a Ko haplotype).  Sadly, he was no longer available to check his red cells again.  I sent a sample of the baby's blood down to the IBGRL, and they made the baby a straightforward K+k+.  Anyway, to cut a long story short, they were using an anti-k from a different clone to the one we were using, so I sent Joyce Poole some of the anti-k we were using, and Lo and Behold, they also got a negative reaction!  I asked if they would perform a KEL gene sequence, and they did find a mutation, miles away from where the KEL2 locus was found, and yet it affected the expression of the k antigen.  Sadly, I can't remember exactly the location of the mutation, and, because we couldn't type Dad again (or sequence his KEL gene, we couldn't prove it was inherited, and so could not write up the case.
So, what to do?
1.  Retest the patient's k antigen using a selection of anti-k reagents with different clones.
2.  If you haven't already done this, test for the expression of the Kp(a), Kp(b), Js(a) and Js(b) antigens, to see if the patient is, at a phenotypic level either a Ko or a Kmod.
3.  It might be worthwhile performing adsorption and elution tests, IF these are negative.
4.  It COULD, POSSIBLY, be worthwhile just checking that the patient has a normal XK gene at position XP21.1, as, of course, it is possible to have the McLeod phenotype without having McLeod syndrome (in other words, these people do not have Chronic Granulomatous Disease [CGD]) - we had a   donor like this where I worked (the only one in the UK).
5.  If transfusion is required in the meantime, give K- IAT cross-match compatible blood.
SORRY FOR THE VERY LONG POST.

I don't think the posters in this thread were talking about "repeating" panels - they were talking about "running" a panel with the same method when you get equivocal results on your primary method.  If using solid phase  - run a solid phase panel.  If running gel - run a gel panel, etc.  Don't just step down to tubes (or a weaker method) without giving the primary method (and usually more sensitive method) a chance to show you what it is trying to show you.
For your next question - working with the specimen might have some validity if you have centrifuge problems or are running clots (red tops) for screens instead of EDTA (purple tops) specimens.  Make sure your spin speeds and times will clear the white cells in a EDTA tube.  Make sure you follow Immucor instructions on degrees of lipemia and hemolysis that are allowed.  Otherwise - if you are running the same lot # of strips on 2 different ECHOs - I would be surprised if they give different answers.
Does that help?

Does your system allow you to "GROUP" all of the individual products(codes) under single headings (RBC, FFP, CRYO, PLTPH, etc)?  If so - then that is probably how you then build the Ordering screens to limit the Drs to the seeing the Groups only.  Anything special they have to put in comments - or your system may allow some questions and answers in the Order screens.  That is how Meditech does it and I think that is how Safe-Trace did it too.  You see all the product codes in Blood Bank - but the Order screens don't - that would be complete chaos!!  The system on your side also has to recognize the Groups so you don't have to line up each special product to a special order - also chaos!

I don't think the posters in this thread were talking about "repeating" panels - they were talking about "running" a panel with the same method when you get equivocal results on your primary method.  If using solid phase  - run a solid phase panel.  If running gel - run a gel panel, etc.  Don't just step down to tubes (or a weaker method) without giving the primary method (and usually more sensitive method) a chance to show you what it is trying to show you.
For your next question - working with the specimen might have some validity if you have centrifuge problems or are running clots (red tops) for screens instead of EDTA (purple tops) specimens.  Make sure your spin speeds and times will clear the white cells in a EDTA tube.  Make sure you follow Immucor instructions on degrees of lipemia and hemolysis that are allowed.  Otherwise - if you are running the same lot # of strips on 2 different ECHOs - I would be surprised if they give different answers.
Does that help?

One other thing I do is to have you select 5 components which have final disposition.  Then see that every person that dealt with that component had a competency for what they did - including those who transfused.

You don't need to keep those records about irradiation.  You are not performing it.
As an inspector I almost always look at standards which I have been cited for.  (I always disliked when the inspector said: "I knew I'd have to look really hard to find something in Dave's lab).  That's not my style.  I only dig if what I am finding merits such.
I always look to verify you have corrected any prior deficiencies (these are given to us as part of the packet).
I observe your staff and attempt to correlate what they are doing with what your policy/procedure says they should do.  I also ask your staff (without a senior staff member accompanying me) about their work environment, employer, ability to attend CE programs.
I want to see your quality stuff, especially any reports which you should have generated based on your QP.  If you don't have anything it will be a long day for both of us.
I will want to observe a transfusion or at least speak w a nurse about transfusions.  Nursing training for transfusion and knowledge of reactions - this will be from Nursing Ed/Admin
I don't want to review your procedure manual unless you ask me to look at specific items or you have added something new.  I do want to see your table of contents so I can see what you do - I may take a peek at something there that piques my interest (I may also ask you if I might have a copy if it is something I'd like to bring to my own operation).
There are lots of funny stories but you'll have to be inspected by me to hear them. (actually, most of them are quite sad as they involve citations).
I tell your staff to relax because when I go back to work I do the same thing they do.
 
I was an AABB inspector/assessor for 20+yrs.  Still a CAP Team Leader.
 

Sorry all; I was supposed to post a paper about this myself, and forgot all about it (mind like a sieve).  I also thought it derived from the Netherlands, but got that wrong too- it was a paper from the USA.  Anyway, it was:
Santhanakrishnan M, Tormey CA, Natarajan P, Liu J, Hendrickson JE.  Clinically significant anti-KEL RBC alloantibodies are transferred by breast milk in a murine model.  Vox Sanguinis 2016; 111: 79-87.  DOI: 10.1111/vox.12387.

Here is a link to excellent resources regarding studies and risks for Low Titre O Whole blood. https://www.strac.org/blood. I think this may help answer a lot of questions.
Here in San Antonio, I have seen great results from pre-hospital (ambulance and helicopter) use of cold-stored LTOWB.  Patients who have received units have arrived stable where, in the past, would have surely been an MTP activation.  Our local trauma centers are using it, up to 8 units before switching to components. The results have been positive. 

You should probably get used to the DTT procedure.  Hemo-BioScience offers the reagent in small aliquots that can be used easily without bothering with trying to manufacture the stuff.  There are several threads on this already on this site.  Do a search and see the discussions.   I had posted our procedure in one - let me know if it is not accessible now and I can send it to you.
The cord panel method would be nice if you are doing a lot of pts, and at least the cells will last a while.  DDT treated cells will not last long at all.  
 
 

You should probably get used to the DTT procedure.  Hemo-BioScience offers the reagent in small aliquots that can be used easily without bothering with trying to manufacture the stuff.  There are several threads on this already on this site.  Do a search and see the discussions.   I had posted our procedure in one - let me know if it is not accessible now and I can send it to you.
The cord panel method would be nice if you are doing a lot of pts, and at least the cells will last a while.  DDT treated cells will not last long at all.  
 
 

What are you referring to with "95% of recipients of AB plasma have antibody to the soluble antigen present"?  
Even with low titer O Pos WB units aren't you going to see just as much formation of antigen-antibody complexes as you do with a non-type specific platelet pheresis?  The volume of plasma will be about the same and will contain anti-A, anti-B and anti-A,B,  correct?
What about the Trauma centers that are using A plasma - is that any better?
 

sorry - fighting a cold - at least I got it right once!!!!

If you use DDT, you won't last long either!!!!!!!!!!  SORRY, I couldn't resist it!!!!!!!!!!

Does the O.R ever tell you that the Pt's armband is "inaccessible" because it is "under the patient and contained within the sterile field"?  We use an armband system for our BB patients and we get told that occasionally when we need to transfuse in O.R. and they didn't get the armband number before they covered up the pt.  The RN usually winds up crawling under the pt's table.  What does your O.R do in that case?  Especially since they are having to do a barcode read of that band?
We use coolers for our O.R. deliveries (one pt per room) and I never want to even discuss the introduction of an O.R. refrigerator.   Anything giving in the O.R. is documented in the anesthesiologist"s records, which are also part of the electronic record.

DTT SOP.pdf
 
This procedure is based on the HemoBioscience SOP and the AABB SOP.  Works for us.
Prior threads on this topic have indicated that the DTT treated cells will not last long, so we do this only at need.

Amen! 
Our nurses take vitals before, at 15 mins, at 1 hour, and at end (<4hrs).  Don't know where it came from but that is our policy.

I liked the first vitals being taken just before the blood was picked up. This prevented many a wasted unit. Not sure if this policy was regulatory or if common sense had broken out. 

All the DTT treated cells were still positive so that should rule out Darazalex.  I wonder about the new one anti-CD47?  Has anyone run into it yet and do we have any way of coping with it yet?  Does it have a name yet?
I was thinking anti-Fy3 or anti-U because of the ficin testing results, but the phenotyping is wrong for that, isn't it?
 
 
 

There is also clotting to worry about.  I have had to watch for and account for clotting in every ABORh slide test I have ever performed from a fingerstick (healthfairs and quick ones done for "can you tell me what my blood type is, pleeeease?").  How does the company recommend performing the test?  If from a fingerstick - how much blood is needed, where does it go, how fast might it air dry and give erroneous results, what happens if it clots?  All questions that would have to be answered before it could be put into service.

We are starting to phase in the molecular testing for discrepant RHD testing.  (Rh neg/Weak D pos and/or weak reactions with standard FDA approved Anti-D reagents (- which may be what Sunshine is doing - only we put them in the computer as Weak D pos)).  We are going to be taking the recommendations of the 2015 workgroup ("time to phase in RHD genotyping....)" and getting a more definitive answer for ourselves and our OB doctors that is safe for our patients and less of a strain on our Rh neg blood supply. 
Can anyone share a procedure with some of the correct technical terms to help us get through this morass?  AuntiS? or JoyG? - seems like you already have it working.  We may go a head and build it in the computer reflex testing too, but that will be for another day since Meditech may take some convincing!?
 

Some good materials here as well => https://www.bbguy.org/2016/06/17/want-g-wiz/

1. The AABB Tech Manual, the AABB Standards, Harmening's book is good, Issit's "Applied Group Serology" is excellent; Mollison's "Blood Transfusion is Clinical Medicine" is excellent;  Blood Bank Guy - a very useful site; this forum - always useful.  The AABB website.  National websites (AUS, New Zealand Canada) for their blood services.  ARC and UBS (now Vitalent) - our big national blood suppliers.
2.  Get a set pattern of working set up that you can follow (within the ways your Blood Bank likes to do things: tubes, automated, computerized, etc.);  ALWAYS do the work the same way - keep things in the same order always - your tubes, your results, your units as you work with them and label them.  I have trained people who I watch do things in a completely random order, especially as they load the centrifuge - then they had to straighten out every thing to read it and enter it in the computer.  Waste of time and very confusing - it will get you in BIG trouble someday when you are in a hurry.   At the same time - things will change overtime - new computer, new instrument, etc. - be adaptive to change.  If you need to set up a new pattern because it is more efficient or works better with a new instrument (especially computers) - be willing to change and adapt.
3.  Always keep an eye on processes - make sure they follow the Standards and are being done correctly.  Watch for inappropriate procedural drift - don't just change the procedure to "your" way just because you think it works better - it may be the other way for a good reason.  If not - talk it out and see if you can initiate change.  Blood bankers can be slow to change, but they follow rules for VERY good reasons.
4.  You just always wish you knew more.  Patients don't always follow the "rules" and situations can be very fluid in trying to get the right products to the right patient at the right time - and YOU will be the one holding the line on staying within safety rules (and yes, they do scream at you sometimes.)  Most Drs and many RNs do not know a lot about Blood Bank - you will answer many questions.  Always try to keep learning.  Remember always  - there is a patient at the other end of that conversation and they need your help.  You may be the only one with the right and safe answer, but you have to find a way to help the patient 1st.
Best of luck - enjoy the adventure.
 

1. The AABB Tech Manual, the AABB Standards, Harmening's book is good, Issit's "Applied Group Serology" is excellent; Mollison's "Blood Transfusion is Clinical Medicine" is excellent;  Blood Bank Guy - a very useful site; this forum - always useful.  The AABB website.  National websites (AUS, New Zealand Canada) for their blood services.  ARC and UBS (now Vitalent) - our big national blood suppliers.
2.  Get a set pattern of working set up that you can follow (within the ways your Blood Bank likes to do things: tubes, automated, computerized, etc.);  ALWAYS do the work the same way - keep things in the same order always - your tubes, your results, your units as you work with them and label them.  I have trained people who I watch do things in a completely random order, especially as they load the centrifuge - then they had to straighten out every thing to read it and enter it in the computer.  Waste of time and very confusing - it will get you in BIG trouble someday when you are in a hurry.   At the same time - things will change overtime - new computer, new instrument, etc. - be adaptive to change.  If you need to set up a new pattern because it is more efficient or works better with a new instrument (especially computers) - be willing to change and adapt.
3.  Always keep an eye on processes - make sure they follow the Standards and are being done correctly.  Watch for inappropriate procedural drift - don't just change the procedure to "your" way just because you think it works better - it may be the other way for a good reason.  If not - talk it out and see if you can initiate change.  Blood bankers can be slow to change, but they follow rules for VERY good reasons.
4.  You just always wish you knew more.  Patients don't always follow the "rules" and situations can be very fluid in trying to get the right products to the right patient at the right time - and YOU will be the one holding the line on staying within safety rules (and yes, they do scream at you sometimes.)  Most Drs and many RNs do not know a lot about Blood Bank - you will answer many questions.  Always try to keep learning.  Remember always  - there is a patient at the other end of that conversation and they need your help.  You may be the only one with the right and safe answer, but you have to find a way to help the patient 1st.
Best of luck - enjoy the adventure.
 

1. The AABB Tech Manual, the AABB Standards, Harmening's book is good, Issit's "Applied Group Serology" is excellent; Mollison's "Blood Transfusion is Clinical Medicine" is excellent;  Blood Bank Guy - a very useful site; this forum - always useful.  The AABB website.  National websites (AUS, New Zealand Canada) for their blood services.  ARC and UBS (now Vitalent) - our big national blood suppliers.
2.  Get a set pattern of working set up that you can follow (within the ways your Blood Bank likes to do things: tubes, automated, computerized, etc.);  ALWAYS do the work the same way - keep things in the same order always - your tubes, your results, your units as you work with them and label them.  I have trained people who I watch do things in a completely random order, especially as they load the centrifuge - then they had to straighten out every thing to read it and enter it in the computer.  Waste of time and very confusing - it will get you in BIG trouble someday when you are in a hurry.   At the same time - things will change overtime - new computer, new instrument, etc. - be adaptive to change.  If you need to set up a new pattern because it is more efficient or works better with a new instrument (especially computers) - be willing to change and adapt.
3.  Always keep an eye on processes - make sure they follow the Standards and are being done correctly.  Watch for inappropriate procedural drift - don't just change the procedure to "your" way just because you think it works better - it may be the other way for a good reason.  If not - talk it out and see if you can initiate change.  Blood bankers can be slow to change, but they follow rules for VERY good reasons.
4.  You just always wish you knew more.  Patients don't always follow the "rules" and situations can be very fluid in trying to get the right products to the right patient at the right time - and YOU will be the one holding the line on staying within safety rules (and yes, they do scream at you sometimes.)  Most Drs and many RNs do not know a lot about Blood Bank - you will answer many questions.  Always try to keep learning.  Remember always  - there is a patient at the other end of that conversation and they need your help.  You may be the only one with the right and safe answer, but you have to find a way to help the patient 1st.
Best of luck - enjoy the adventure.
 

1. The AABB Tech Manual, the AABB Standards, Harmening's book is good, Issit's "Applied Group Serology" is excellent; Mollison's "Blood Transfusion is Clinical Medicine" is excellent;  Blood Bank Guy - a very useful site; this forum - always useful.  The AABB website.  National websites (AUS, New Zealand Canada) for their blood services.  ARC and UBS (now Vitalent) - our big national blood suppliers.
2.  Get a set pattern of working set up that you can follow (within the ways your Blood Bank likes to do things: tubes, automated, computerized, etc.);  ALWAYS do the work the same way - keep things in the same order always - your tubes, your results, your units as you work with them and label them.  I have trained people who I watch do things in a completely random order, especially as they load the centrifuge - then they had to straighten out every thing to read it and enter it in the computer.  Waste of time and very confusing - it will get you in BIG trouble someday when you are in a hurry.   At the same time - things will change overtime - new computer, new instrument, etc. - be adaptive to change.  If you need to set up a new pattern because it is more efficient or works better with a new instrument (especially computers) - be willing to change and adapt.
3.  Always keep an eye on processes - make sure they follow the Standards and are being done correctly.  Watch for inappropriate procedural drift - don't just change the procedure to "your" way just because you think it works better - it may be the other way for a good reason.  If not - talk it out and see if you can initiate change.  Blood bankers can be slow to change, but they follow rules for VERY good reasons.
4.  You just always wish you knew more.  Patients don't always follow the "rules" and situations can be very fluid in trying to get the right products to the right patient at the right time - and YOU will be the one holding the line on staying within safety rules (and yes, they do scream at you sometimes.)  Most Drs and many RNs do not know a lot about Blood Bank - you will answer many questions.  Always try to keep learning.  Remember always  - there is a patient at the other end of that conversation and they need your help.  You may be the only one with the right and safe answer, but you have to find a way to help the patient 1st.
Best of luck - enjoy the adventure.