mrmic

It's nice to be able to order commercially, but what's the fun in that? You should be able to contact a garden center, or maybe Google it these days, and get your seeds to make your own lectins! We did that in the 70s and 80s at our Immunohematology Reference Lab and was quite entertaining and challenging for the staff. I believe there is an AABB workshop book on Polyagglutination from 1980 that has some preparation and testing procedures. Very good reference book and I think even Dr. Bird had a chapter written on the development of lectins. We made a lot of the reagents that are commercially available today and I always thought it was good for the staff to research and prepare these reagents for a better understanding of their development.

Wow, it's been awhile since I have thought about En(a) antibodies! From what I remember from the 80s there were about 3 or 4 groups based on the antigen site's susceptibility to trypsin or ficin? I believe John Moulds and Wolfgang Dahr were working with some of these variations. Peter Issitt also had some excellent review publications on the MNS system. Can't remember the clinical significance with regards to pregnancy and HDN. I agree with Mr. Needs recommendations and hope that we see follow up information on this case. What were the titrations and/or doppler readings' results? Was the child affected and required treatments? Is nice to see this information on rare cases for future patients' medical care considerations.

"Run Forest, Run" But seriously, Mr Staley's last paragraph was very preceptive and to the point. Remember you were a staff tech too! Work at the bench periodically, walk through the lab and talk with the staff. Most techs want to do good, be heard, offer ideas and get a little recognition. And I'll end how I started, your days are "like a box of chocolates, you never know what your going to get". Surprises happen every day in transfusion service, that's why we're blood bankers, keep a sense of humor! Enjoy the ride.

As a "recommendation" I believe that leaves room for having another opinion. Even though I have seen only 1 case of TA-GVHD in 30 years of a pre-term neonate, that is one too many. And use of non-irradiated products would not be my recommendation.

Wow, since retirement and having time to review past posts, I found a missed opportunity to respond to Galvania's comment on my LISS/gel column comparison. I agree they are different "methods" however, atigen- antibody reactivity does take place in an ionic environment. That being said, the LISS tube test requires manually added LISS, while the column technologies the gel or bead matrix is prepared by the manufacturer for you. I haven't seen the actual composition of the different column matrixes and their ionic strength, but they must have one. Although, in the late 80's we could actually make our own columns, as originally described by LAPIERRE, and then by Luc Noel in " Micromethods en Immuno-Hematologie", Societe Nationals De Transfusion Sanguine, 1989. And even the tube LISS test can be improved by using a lighter red cell suspension and having a better serum to red cell ratio. If only our eyes were better! The standardized micro column matrixes have made this easier to read and sustain the agglutinates for longer readings. Oh, and no more subjective shaking the tube! It is nice that standardized pre-prepared tests cards/strips, cell suspensions are available to provide better reproducible tests among staff. So back to my comment and keep in mind that I'm just old and opinionated these days, I still look at the gel/bead columns as modified miniature LISS tube tests with basically the same principles as the standard LISS tube test when antigen-antibody reactions are the subject. At least that's what we thought when we made our own columns. So I hope we can respectfully agree to disagree.

Sorry, I cannot not have a question about this practice. Are you serious? A "neonate" is a general term. A neonate that is requiring transfusion is not a normal occurrence and "top-off" transfusions should not be considered normal practice. Transfusions should be considered carefully especially for neonates and the chance of TA-GVHD. Irradiated leukodepleted blood products should always be used. The risks of transfusion of irradiated red blood cells based on age of the unit prior to or afterwards of irradiation is another discussion and a medical decision based upon the patient issues and the data the medical staff wants to follow. But no one wants to speak with the family about TA-GVHD that could have been prevented.

Sorry I missed this discussion, it was very interesting. Since an email sent out re-opened this discussion I would just make a brief comment. HDN is a terrible outcome for the child especially, and also the mother and family. Not using antenatal RhIg is medical negligence. Not giving a potential D negative female/mother RhIg is close behind. It has always been a challenge with our anti-D reagents to deal with interpretation of weak reactivity and females of "child-bearing" age. And our testing methods have improved over the years. However, with the advances in molecular biology is serology really the best way to make this life-changing decision? Should prenatal molecular testing be standard? Thank you Mabel Adams for reminding us of one of our most important goals!

I somewhat remember that early on with the LUI freeze elution there were some attempts to elute non-ABO antibody specificities. At that time some suggested an additional source of protein and/or a minimal "LISS" environment might help with detecting these other antibody specificities. I'm not sure it worked out too well and other elution methods were much better. We just used for ABO elutes.

What? No one questioned NISS? I am impressed. Long Live NISS!

Inspectors are like a box of chocolates, you never know what you are going to get. I tend to agree with those who put forth do what you are comfortable doing for validation and/or QC. If you, your staff and pathologists are ok with your process then an Inspector (AABB or CAP) can have an opinion but they cannot tell you to stop or defend a deficiency. If your documentation has merit then you have a strong case of how you use your expired red cells or antisera for the care of your patients. We all do the best we can with what we have to work with.

Wow this is a late post. I just can't find the time to keep up sometimes. I certainly was not implying that either Duffy antibody would not be able to cause HDN but rather theoretically speaking given the circumstances it didn't quite give the picture of HDN. Again, even that is not a absolute. Looking back at all the comments and possible causes, which all had merit, I failed to see any reference to the possibility of an autoimmune issue and that there may be a possibility that the specificities are part of an newly development of autoantibody complex forming, i.e. mimicking specificities. Although these are normally seen within the Rh-Hr specificities, other specificities are not unheard of. Follow-up testing for cases like this rarely pan-out, if the infant clinically unaffected, the parents get their baby and disappear (sometimes and at least may not show up again until the next pregnancy). Too bad, would make a good abstract.... "My" thoughts or opinions for this site are based on previous experiences or readings (actual book in hand journals) and etc. Immunohematology Reference Laboratories see a variety of cases sent for consultations and that is what makes it so intriguing and challenging for us to give the clinician the information he/she needs to take care of their patient and that we are right there with him to help. We may not always have a specific answer but we can look for histories of similar cases and what the outcomes have been and give it our best educated interpretation of what might be happening and what transfusion recommendations we might propose. I'm about to retire and my ramblings will decrease (Yea goes the crowd). As far a the gel system, again my own thoughts/experiences we had in our Immunohematology Reference Lab, starting back even before Ortho commercially prepared system was as follows: Basically it is a micro-LISS-system with an optimized serum to cell ratio. Although we could not find a niche for using it on our investigations, we did start keeping it around to reproduce issues our hospitals were seeing with its use their routine transfusion service and to help provide educational information on what was happening and whether it had any clinical relevance. There was a lot of weak reactivity of various strengths referred to us by a variety of hospitals. Many these were related to the problems seen with the LISS tube system. Maybe even a little more since it much more sensitive based on how the method is set up commercially to work. Lastly, I believe that Malcolm Needs is truly an asset to this site and provides excellent information to all regarding such a variety of topics and also provides excellent references to support the information he provides. Thank you Mr. Needs! I hope you continue to provide your insight in this forum for many more years. mic

Since this is a accreditation agency group I would like to get an opinion on the requirement of the transfusion service's requirement to re-type the donor units. I do not know if this has been previously studied or written about in the past. Just thinking outside the box... If a donor center were to re-type the unit after the unit had been labeled and the unit tagged as such for the re-typed would the transfusion service be required to re-type the unit? You can't make an argument that you do not trust the donor center since you do not repeat HIV or etc. testing, and those tests are quite important. You cannot make an argument that you have found mis-typed units, because, that is the past, not after the proposed change in testing at the donor center; what is that per-cent? You cannot make an argument that the techs at the transfusion center never make a mistake; what is that per-cent? You cannot make a financial argument if there was a significant issue with the unit after transfusion the patient would sue everyone anyway. You can't say because it is a regulation, since those can be changed and that is what this is about. You can't make the argument that all rbc transfusions are fatal, because they are not. I might make techs uncomfortable about the change, but techs were uncomfortable when we went to LISS from albumin or physical crossmatch vs electronic crossmatch. What are your thoughts?

My initial answer would be no. Haven't seen this happen with a transfusion of 1 unit. Would have to recheck the whole process of the 1st sample (pre transfusion), starting from the collection (correct patient, correct collection site, correct person collecting, correct labeling, specimen handling, specimen testing, etc.etc)…. maybe there was an error along that path and not a immunohematological issue?

Anti-Fya and Anti-Fyb are not well known to cause significant HDFN. I have not seen one, at least. Was there any follow-up testing of the infant? What were the laboratory findings, i.e. bilirubin etc. ? It has been a few months now, have you had a chance to re-type the infant's red cells? Is there a chance that it really was a weak binding of Anti-Fya with Fya+ red cell antigens? If only a gel-card method of interpretation of a "weak positive" as being negative was used, I wouldn't necessarily be convinced that the infant is Fya-. Gel card methods do funny things sometimes.

"Does anybody know what time it is" Chicago, 1970. Does anybody know what titer it is? Simple question, answer not too simple. If you are following titers of a specific antibody for a specific reason (anti-D, pregnancy), it is important to establish the method you use is reproducible and that it correlates with what the physicians that are going to be using that information for. As has been pointed out with previous responses, the methods used for antibody enhancement may affect the endpoint results of the antibody titration. The physician is often attempting to make a decision for the care of the mother and her child, current or future. The laboratory should provide a interpretation of the results based on results they have laboratory data and based on histories of patients previously followed. Certainly, literature should be searched for information that has been shared regarding this subject, as the one previously mentioned, however, if your laboratory is involved in following titrations and clinical significance, it is probably important you established the data for your own laboratory.

I know this is a late response but re-reading some posts brings up old ponderings. I have always been interested in the non-immune stimulated antibody specificities (naturally occurring). When we have seen these in different patient populations, i.e. malignancies, pregnancies, and autoimmune anemias. There was some papers that put forth the term "mimicking" antibody specificities, we may occur from immune malignancies, drugs, herbs, etc., or due to a dilutional effect or specific enhancement methods. At the time we attempted to absorb and elute the antibody specificity in question with red cells that were negative for the antigen of the specificity in question. With some success but not 100%. Maybe the antibody was actually directed to some specific epitope that was part of or in common with the antigen in question? Is the ultimate test to transfuse the patient to determine if the red cell survival is affected by this apparent mis-match? I do not see a lot of red cell survival studies anymore. However, I will stop there. Only to say to Ms. Adams thank you for your non-immune stimulation of my old days immunohematology...…it is a naturally occurring problem I have reading BB posts......

I certainly agree with Mr. Blumberg and Mr. Needs as well as others, everyone brings up excellent points and explanations. My only comment I could put forth for consideration would be from a BB Pathologist I once worked with many years ago having observed similar cases. "Pregnancy is a disease".

I am interested if anyone has attempted to use one of the wireless temperature monitoring systems to monitor the coolers being used within the hospital? More hospital in the USA are looking at these systems for their refrigerator/freezer/room temperatures monitoring. That would seem to be an excellent monitoring and data documentation for the products outside BB's control.

It is all relative. Yes, antibodies' titers can rise and fall during pregancy whether or not the fetus is positive for the corresponding antigen(s). So titers may not be helpful in a subsequent pregnancy from a mother whom has shown to be an immune responder. But, it may be a one piece of the puzzle a physician can use to make decisions about the management of the pregnancy. It may be an opportunity for us to be part of the team, share our knowledge and experiences with the team, follow the immunohematology path, maybe learn something ourselves and share with our peers. I would be willing to follow the titers, it's Immunohematology, it's what we do, and maybe, just maybe, we might discover something relative. My soapbox for the day, just comments from my perspective as an old retired SBB.

WOW, don't see anti-JK3 too often! Have you already pursued family members and extended family members? Also, is there a ethnic group you may want to screen? We have had some success in the past in our area with Native Americans whom have had some members with a antibodies to a high antigens. Certainly would want that patient and or other family members start donating and freezing their donations for their and others' future. Technically, I agree with Mr. Needs approach with trying to resolve your immediate requirements. Good luck and best wishes for your patient's recovery.

I would be interested in the patient's history; male/female/ pregnancy/infections/drugs/drug use/medications/herb etc. use/transplants. Also, specimen information; standard clot tube/clot activator? / edta or other anticoagulant, time from collection to testing/ storage time? etc. Have new specimens been collected and retested by same and different methods or lot #s. I apologize in advance if this is asking for basic "given" items that were all ready looked at but before I would investigate unusual laboratory findings I am always interested in history first before finding out there were other contributing factors. laboratory question; are you able to remove the cells from the cell-typing gel-tube and elute anti-A from the cells. Will be watching to see your final decision on this case! Thanks for presenting it.

Sooooooo.........is is 1 positive reactive cell out of 3 selected cells ok? What next? Do you keep testing "homozygous or heterozygous" selected antigen positive cells til you get 3 negative? It's not just rulling out, it's looking for what's in. It is a good thing to have a Immunohematology Reference Lab partner to assist with multiple antibodies or antibodies to antigens of high frequency. Your blood supplier should have this service for you... Probability calculations do not always go hand to hand with antigen expression. 🐀 mic

😁 Something I remember!! Back in the "Reference" lab days when we could innovate on our feet without reimbursement issues, and probably some safety issues too. Malcolm, if I may address you informally, if not pardon me,. we did the same process as you described except, we found an old incubator we could adjust the temp and put our serofuge inside to centrifuge, running the plug wire up through the hole of the incubator that normally would have a black rubber stopper holding a glass thermometer! Good story, thanks for the memory. 🐀 mic

Still old school........why..........because I'm old.............. Is RBC genotyping our future? But first.............. Has research revealed if the extent of RBC antigen polymorphism higher than previously known by the number of antigen specificities? Are there serologically indistinguishable variants or subtypes identified, and if these variants are different from the wild type only by a very few amino acid substitutions, can these be functionally distinct and relevant in genotype matching for transfusion and hematopoietic stem cell transplantation? Which are clinically significant for transfusion purposes or hematopoietic stem cell transplantation or GVHD? These are similar issues that the HLA transplantation field has been discussing. Are blood bankers (Immunohematology field) today also discussing similar issues at regional and national meetings? I may be off track and need to get back involved with meeting to get "re-educated" and how far we have progressed over the last 20 years.

Gel testing is just a "miniature" tube system using a "controlled" % cell suspension and a Low ionic environment. Although the tube test can be similar, unless you are using the same %, concentrations and ratio, you might find it difficult to compare in-vitro results. Although the sensitivity may be slightly increased for some antigen-antibody reactivity, maybe those we don't want to see, it also has similar problems as other low-ionic methods with the Kell system. I agree with Ms. Adams comments. It is important that the OB/GYNs know how you are performing the titrations and if the method(s) correlates with clinical outcomes. This has been established with the tube method, maybe the tile as well, but I am not aware of references for the "gel" method. I believe, as long as the OB/GYN is aware that the "trigger" titer number for clinical intervention may be different for the gel method, however, the monitoring during pregnancy looking for a significant change in titer may be consistent with both methods. I also agree that use of other clinical data (Doppler etc.) is becoming a better standard of practice than amniocentesis and it is less risky for the mother and child. Although in suspected severe cases of HDN, amniocentesis may still be warranted. Better have your validations and IQCP ready...