mrmic

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
 

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".  

Found a bb tech locally to take them all!😁

Retired SBB.  I have several Immunohematology books from the 70s and 80s published by AABB for workshops and seminars.  Also, others such as published for other Immunohematologists, for example P.Issitt and others in the field.
If anyone may have any interest in owning these hardback books I would gladly share.  It would be sad to just recycle, which I have seen happen to other previous medical books.
If you would like me to list any particular year's books, titles or authors just leave a reply to this post or to me separately.
After a month or so if there is no interest, they are off to be recycled! 🤔

Found a bb tech locally to take them all!😁

Found a bb tech locally to take them all!😁

Found a bb tech locally to take them all!😁

Found a bb tech locally to take them all!😁

Retired SBB.  I have several Immunohematology books from the 70s and 80s published by AABB for workshops and seminars.  Also, others such as published for other Immunohematologists, for example P.Issitt and others in the field.
If anyone may have any interest in owning these hardback books I would gladly share.  It would be sad to just recycle, which I have seen happen to other previous medical books.
If you would like me to list any particular year's books, titles or authors just leave a reply to this post or to me separately.
After a month or so if there is no interest, they are off to be recycled! 🤔

Thank you Malcolm I appreciate your comment.  I probably just need to accept the life of books in these times of the availability of resources via digital methods and the ever expanding clouds.  At least the technology of recycling has also become more efficient and the books can have new value in their new existence!
I must say I do appreciate the technology that has allowed forums such as this one to exist.  I enjoy seeing the interests in Immunohematology continue in the newer generations of "blood bankers" and the advancement of laboratory methods.

Thank you Malcolm I appreciate your comment.  I probably just need to accept the life of books in these times of the availability of resources via digital methods and the ever expanding clouds.  At least the technology of recycling has also become more efficient and the books can have new value in their new existence!
I must say I do appreciate the technology that has allowed forums such as this one to exist.  I enjoy seeing the interests in Immunohematology continue in the newer generations of "blood bankers" and the advancement of laboratory methods.

Retired SBB.  I have several Immunohematology books from the 70s and 80s published by AABB for workshops and seminars.  Also, others such as published for other Immunohematologists, for example P.Issitt and others in the field.
If anyone may have any interest in owning these hardback books I would gladly share.  It would be sad to just recycle, which I have seen happen to other previous medical books.
If you would like me to list any particular year's books, titles or authors just leave a reply to this post or to me separately.
After a month or so if there is no interest, they are off to be recycled! 🤔

A VERY good friend of mine, Phil Learoyd, has just started up a new site devoted to the history of blood transfusion. I've had a brief look at it, and it looks to be fantastic, and would thoroughly recommend it to anyone interested in the subject.   It can be found on https://www.historyofbloodtransfusion.co.uk/

I know that some of the early work on ABO-mismatched solid organ transplantation, viz-a-viz ABO antibodies was carried out by Professor Patrick Mollison and his co-workers, and he showed that, whereas inhibition of IgM ABO antibodies is reasonably easy by, in the early days, transfusion of FFP to adsorb the antibodies in vivo, the same is not true of IgG ABO antibodies.  He and his co-workers found the inhibition of these antibodies was much more difficult, and this was almost certainly because only 40% of IgG antibodies are intravascular, as so they "rebound" when inhibited or removed from the intravascular area, whereas almost all of the IgM antibodies are intravascular, and so "rebound" is less likely.

I agree with everyone!
However, the specific antibody ID methods and/or the titration methods alone do not affect the decision process for the pregnancy. 
A significant antibody identified or a significant change in the titration result does.
But, only does if there have been reported cases of harm to the mother and/or infant based on the specific antibody identification and using the specific method of titration.
A lot of the literature in the (ancient?) past showing correlation with potential harm to the infant were done with saline and/or dilutions of percentages of bovine albumin.  Some of us "old farts" still remember those old reports.
With all the new reagents or methods that are available now, it requires BB technologists to help initiate the investigation and follow up with the physians to report cases of a positive or negative outcomes of pregnancies with the different laboratory methods.  Based on that knowledge, the technologist can select the best antibody identification and titration methods for following pregnancies and the physician can make the best medical plan of action for the pregnancy.
So the best place to start; researching literature then working with obgyn physicians in your area to correlate the best laboratory methods with the best patients' outcomes.

Interesting issue.  I agree with what you have presented.  Trying to create communication with the transplant team is the best direction to go. In my past experiences with transplant/BB issues we found it better for the BB Supervisor and the BB medical director to meet with the Chief of the  transplant service.  Inquire why these tests are being ordered and why we are concerned about the tests being ordered.  If there was a reason the transplant physians were ordering these tests, maybe we could help them by suggesting the best laboratory tests to help achieve their goal.  (Research or treatment monitoring, etc.)
If the Chief of service agrees with your concerns regarding the testing, he/she will discuss with his transplant team.  Orders from the top - down within the service works best for getting the team to change their ordering practice.  
In addition, by offering the willingness of the laboratory to help the the transplant team accomplish their goal, if approved by the Chief of the service,  we (the laboratory) comes across as not to be telling what they are doing wrong but to offer our help to order the necessary, correct tests that would help their goal.
Good Luck

I agree with everyone!
However, the specific antibody ID methods and/or the titration methods alone do not affect the decision process for the pregnancy. 
A significant antibody identified or a significant change in the titration result does.
But, only does if there have been reported cases of harm to the mother and/or infant based on the specific antibody identification and using the specific method of titration.
A lot of the literature in the (ancient?) past showing correlation with potential harm to the infant were done with saline and/or dilutions of percentages of bovine albumin.  Some of us "old farts" still remember those old reports.
With all the new reagents or methods that are available now, it requires BB technologists to help initiate the investigation and follow up with the physians to report cases of a positive or negative outcomes of pregnancies with the different laboratory methods.  Based on that knowledge, the technologist can select the best antibody identification and titration methods for following pregnancies and the physician can make the best medical plan of action for the pregnancy.
So the best place to start; researching literature then working with obgyn physicians in your area to correlate the best laboratory methods with the best patients' outcomes.

of course it could just simply be that the hospital lab made an error grouping it as a false positive.  As this is a question designed for new students, I doubt whether the level of scientific understanding required is very high at this stage.  It would depend what theory the students had done up until the point that the question was set

Perhaps the monoclonal anti-D reagents had been taken out of the fridge, and not allowed to come to room temperature before being used.  Most, if not all, monoclonal anti-D grouping reagents will detect an I-like or i-like antigen on D Negative red cells (see Thorpe SJ, Boult CE, Stevenson FK, Scott ML, Sutherland J, Spellerberg MB, Natvig JB, Thompson KM.  Cold agglutinin activity is common among human monoclonal IgM Rh system antibodies using the V4-34 heavy chain variable gene segment.  Transfusion 1997; 37: 1111-1116, and Thorpe SJ, Ball C, Fox B, Thompson KM, Thorpe R, Bristow A.  Anti-D and anti-i activities are inseparable in V4-34-encoded monoclonal anti-D: the same framework 1 residues are required for both activities.  Transfusion 2008; 48: 930-940).
What it should NOT be, under any circumstances, is that the anti-D reagents at the Central Blood Bank fails to detect an epitope that is detected by the hospital's anti-D reagent.

Maybe anti-P1, rather than anti-P.

Just a question - along with mrmic - What is the average daily temperature in your lab?  If this antibody is, at least partially, a "Cold" and you have a LOT of reactions like this, as you stated, it just may be too cold in your lab.  Try a strict Prewarm test, as suggested by Malcom and if that helps, consider reducing the amount of Room Temp exposure your average specimen encounters and see if you can cut the reactions down.  We have almost no RT exposure in our testing anymore (Immucor ECHO) but we used to have more extraneous reaction problems in the winter when our lab grew colder (think blue fingers!).  Just a suggestion.
Does anyone think this (second panel) may be an anti-P?  It is not showing the whole pattern, but I have seen several that didn't.

I would get more history first.
Transfused when? How much and/or how often? With what, rbcs, plasma, platelets, Immunoglobulin? Why? Diagnosis? Meds? Age of patient? Pregnancies if female? Previous antibody test results and methods utilized?  Any results of extended rbc testing previously done available? Any other lab results suggesting rbc destruction or decreased rbc survival of transfused red cells?
DAT negative but autocontrol positive? Could transfused red cells be present?  Early production of cold reactive auto or allo antibodies showing up?  As previously suggested try prewarming saline technique with no enhancement media, 45-60 min incubation with IgG reading only.  Could be cold and warm reactive auto or allo antibodies present.
Based on patient and testing histories should help with making a decision on what to do serologically.
It's a little troublesome if this type of reactivity is seen often in BB?  Unless there is some common issue with these patients, it may be something with regards to the actual methods or techniques used in the lab and not really a patient issue at all.

Definitely enough story lines for a mini-series!
These are all possible stories that could happen to any of us. 
Being in direct contact with physicians (who know everything) and nurses (who believe policy is not practice) and providing products that could be life saving or harmful to patients and parts of the process is out of BBs control can be very stressful for technologists.  And sometimes is hard to get new technologists to work in our field.
With providing administration with some of these "real" scenarios and the possible medical-legal-pr implications I was able to acquire an additional salary % for techs working full time in the transfusion service.  When other department techs thought it was unfair, I asked them to apply for a BB position (no takers).  Might be worth a try if you need techs.
Thanks to all who are sharing your experiences. 

I think we need to add an OMG emoji to our selections!

I just had to share this story...When I worked in a large teaching hospital we had a team of Transfusion Nurses who were responsible for drawing most samples and administering the transfusions. Occasionally, however, physicians (or interns/residents) would draw the samples. One afternoon we received an unlabeled sample drawn by a physician via courier. We contacted the physician and informed him a new sample would have to be drawn. He said he would come to the transfusion service and label it right away. We told him that was unacceptable, however, he insisted. While he was on his way, we put together several samples without labels and placed them in a rack. When he arrived, we presented the rack to him and told him to select the sample to label. He actually tried to feel each tube to find the warmest one and said that was the sample he sent. Obviously we did not allow the sample to be labeled.  The story has been told many times!!!