gagpinks

I would agree with your first point Scott, but only because the sample being used is a plain tube, and, therefore, the liquid phase would be serum, rather than plasma.  If, on the other hand, the sample was in an EDTA anticoagulated tube, and the liquid phase would, therefore, be plasma, you no longer see in vitro haemolysis, as EDTA will chelate the Ca++, Mn++ and Mg++, all of which are required as cofactors at the beginning of the classic complement pathway.
 
I certainly agree with your second point, unless, as Anna says, there is in vivo haemolysis in the original sample (which is very often seen in cases of CHAD, even if the sample is kept at 37oC).

I am wondering why the cord cells were tested with anti-C3? I believe it is not a common practice to test the cord with anti-C3 I just saw one too a few months ago, mine is a peripheral draw on a new born rather than cord, anti-IgG and -C3 pos.  I looked it up on Issitt's textbook. His references indicates that HDN due to complement activaton is an argument that has been challenged, as "C3 coating can be found on normail cord samples". I think if Hb and bili are normal C3 coating probably is not significant??  
 

Both my friend and colleague Grant Webb and I have seen this with Kidd antibodies, but have not formally published this (see a couple of slides from one of my lectures), but none resulted in clinically significant HDFN (otherwise, of course, we would have published).
In my own case, dothandar, the reason we tested with anti-C3d was because we only had cassettes that contained an anti-C3d (see the photographs), and we only saw the positive DAT by anti-C3d by pure accident!
Reports of a Kidd antibody, causing a.pptx

1)  Yes, the auto-anti-LW would look like an anti-D, rather in the same way that allo-anti-LW looks like a anti-D.  Both react far more strongly with D Positive than D Negative red cells, unless the D Negative red cells are from cord or neonatal blood, and yes, there would also be a concomitant weakening of the antigen.
2)  This was the finding of Giles and Lundsgaard with their LW case.  I repeat that I have not seen this myself, but given that LW, Rh and RHAG (amongst other antigens) are all part of the Band 3 macromolecule and, as such, if the expression of one is affected, the expression of the others will also be affected. 

I am a little confused by your question, in as much as, in one place you say that the patient has the Partial D Type DAR, but in another you say that the patient has the Dw antigen, sometimes known by its trivial name Weil, or more properly as Rh23, which is a low prevalence antigen associated with Partial DV Type 4.  I think you mean that your patient has the DAR D Type, and that the D antigen is typing weakly.  Am I correct in thinking this?  I hope so, otherwise it doesn't make sense (at least, to me).
Turning to the CdeS type, there are several (at least 8) of these in terms of genetic background.  All have one thing in common, and that is a Leucine to Valine substitution at position 245 of the mature position, due to a point mutation in exon 5 of the RHCcEe gene.  Five of these also have the Tryptophan to Cysteine substitution at position 16, resulting in the expression of (normally) the C antigen, due to a point mutation in exon 1.  However, 74% of C-, c+ Black Americans with normal expression of c have Cysteine at position 16.
The thing is though, that any C antigen that is expressed is weakened, and some anti-C reagents do not react with it.  On the other hand, because there are at least 4 amino acid residues that are involved in the expression of the C and/or c antigen (at positions 16, 60, 68 and 120), it is more than possible (in fact, probable) where mutations are present, that the c antigen is expressed at a normal strength, whilst the C antigen is also expressed in the weakened form.  Indeed, the C antigen itself is a Partial C antigen, and such an individual can produce a form of anti-C, rather in the same way that an individual with a Partial D can produce a form of anti-D.
So, to cut a long story short, this is why the individual will express the c and e antigens in the cis position, even though they also express the C and e antigens (in a manner of speaking) in the cis position, and why the ce (compound) antigen can also be expressed.

Most warm auto-antibodies have a specificity within the Rh Blood Group System, although some others, more rarely, have a specificity outside of this system, such as auto-anti-Wrb.
Most of the auto-antibodies from within the Rh Blood Group System mimic anti-e, anti-E, anti-C, anti-c or a combination (or even a compound antibody, such as anti-Ce or anti-Rh7), but, in reality, they are actually weak forms of anti-Rh17 and/or anti-Rh18, although strong examples are not unknown).  As they are usually mimicking antibodies, they can usually be adsorbed out with red cells that do not actually express the actual antigen on their surface (for example, an apparent anti-e can be adsorbed out using R2R2 red cells).
PLEASE DO NOT try to identify them yourself, as the actual specificity is not significant, but will take an awful lot of time and you will require some VERY rare red cells, such as Rhnull, D--/D-- and the like, and these should be reserved for when they are required to identify the specificity of rare allo-antibodies, such as anti-Hr, anti-HrB or anti-Rh29, where a true specificity may well be vital to identify.
In contrast, most "cold" auto-antibodies are true specificities.
For more information, you would find it hard to beat reading, Petz LD and Garratty G.  Immune Hemolytic Anemias, 2nd edition, Churchill-Livingstone, 2004, although I would advise you to be selective, as it is a very detailed book!

Uk guidelines suugest, "Any senisitizing event before 20 weeks not required KB test however lady required Rhogam .  After 20 weeks, any senisitizing event required KB as well as anti-D depending on the bleed.

Even better, if they could be published in the Case Studies section of this site (no patient names, of course - or, come to that, hospital names).  That way, we could all learn, as none of us knows everything!

I agree entirely David, for the USA and others, BUT, have a look at the flag besides gagpinks' name; it is the Union Flag.  This means that she is working in the UK.  In the UK, all of the units are typed for ABO, D, C, c, E, e, K and, now, Hep E by the various blood services, so there is no added cost to selecting Rh and Kell antigen matched units of blood.

Quality Systems are big, hairy and ravenous. They eat paper, printer cartridges and lots of time. They are hard to see unless you have "audit glasses" on.

Hi Nicola
Agree with Malcolm. I am sure  I am sure you mean running panel on IH1000.
We run all our panel on IH 1000 and we interpret manually.  To do this we run few known controls such as Weak antiD, Fya, S c ,K and AB serum. We also did few serial dilution for control and run on analyser to see any weak reaction. We also run some known patient to compare the result. We also performed intra comparison with these control to compare the result. We kept reagent on board for 48 hours run and control  to see there is no difference in result after 72 hours because you can keep on board only for 48 hours. And there is no temperature control on analyser. Of course you take part in NEQAS to measure your performance. 
I hope this might be useful

It's great having Malcolm in the lab to fire questions at! He really is a walking, talking Transfusion textbook and a true gentleman.

The chances are that this bleed is a chronic, rather than an acute bleed, and, I suspect that there is a certain amount of "accommodation" going on, rather like there is in the case of an ABO solid-organ mis-match.  At the same time, however, it must be remembered that the A antigen on the red cells of a foetus is very much weaker than the A antigen of an adult (the number of antigen sites per red cell are much lower than the number of antigen sites per adult red cell) as a result of the "A transferase" being very inefficient during foetal life, and with these two factors "coming together", as it were, I am not that surprised.  I am more surprised, if anything, that you can still detect such a large volume of group A red cells.

Sadly, I doubt whether this was done by the NHSBT RCI laboratory.  Such testing is usually deemed "too expensive" under "LEAN" rules!

Thanks Malcolm 
I was doing one of the IPEX excercise and there was case where baby had DAT positive due to maternal antibody. Therefore result on phenotypes( Fya  Fyb)  are not reliable.  In this case you can use chloroquine phosphate to de nature Off antibodies.  So I thought they might be using for all above cases. I knew about DTT and ZZAP. But never came across about CDP. 

I think that this is very possible.  We have seen some thawed plasma look like egg drop soup after several hours in the refrigerator.  If you place it back in the water bath for about 5 minutes, cryoprecipitate will go back in solution and should be fine to transfuse.  If it still looks the same after warming, then you shouldn't use it.

The reaction with anti-D may well be enhanced - but not for the right reasons!
Thorpe et al1, 2 reported that monoclonal anti-D molecules possess a V4-34 moiety, that is also present in anti-I and  anti-i.  As a result, if papain-treated D- red cells are tested with such antisera, or untreated D- red cells are tested with such antisera that have not been brought to room temperature, they may agglutinate, and you will get a false positive - which is the very last thing you want.
1.  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.
  2.  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.

That is what my former supervisor used to say (he was a tech for over 50 years)!  Get the titer up where you can work with it!  God rest him!

I like that ! None of this wishy-washy, barely reactive stuff.

I agree with Malcolm. In theory, there may be examples of anti-K that only react with K+k- cells, but in practice it's a very rare event.
One of my former colleagues/mentors once said that one shouldn't worry about missing a weak antibody. If the patient were unfortunate to be transfused antigen-positive blood, the former weak antibody would be super-strong next time around !!! Problem solved.

I have seen about two cases of this in 43 years in blood transfusion.  Yes, they exist - but so does Rhnull!!!!!!!!

In my opinion (and that of the BCSH Guidelines) you do not need a K+k- red cell to rule out anti-K.
If you look at the antigen profile of the red cells you use every day as screening cells, they will not have a K+k- cell, and yet you are ruling out the presence of anti-K (and any other antibodies directed against the major blood group antigens) with each sample that gives negative reactions with these red cells.  In addition, if you look at the screening cell profile that the BCSH Guidelines recommend, they say that the K antigen MUST be represented, but NOT that these cells must be K+k-.

I just answered this question.


My Score PASS  

Well, in the very old days (about three months before I retired, according to me ex-work mates!) the only way we had for performing a type and screen/crossmatch was to use samples that had been kept warm, so I can't see that things would have changed that much (and we didn't kill "too many" of our patients)!

OK, so I presume you are  diluent 2 to make your crossmatch suspensions?  Well, Diluent 2 is not identical to the buffer used for the cell suspension in the screening cells.  so it may be that this patient is reacting against something in the red cell suspension buffer which is common to both biorad and Capture - although I have never seen one reacting that strongly before.
On the other hand, it certainly does look like a cold antibody.  Are you doing both screen and XM manually or on an instrument?  And how exactly are you preparing your blood bag segments?