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cold auto workflow


tkakin

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I am questioning my original work flow for processing cold auto antibodies. 

Currently it is set up that if you suspect a cold antibody we will perform a 3 cell tube screen with auto control and test at IS, 4C, 37C, and IgG.  If the patient is reacting at IS and/or 4C with all cells tested, and not at 37 or IgG, we report as  a cold auto antibody without sending specimen to the reference lab.

Recently we had a positive gel screen = mixed field in both of the 2 cells of the Ortho Gel screen.  The cold antibody was also interfering with the blood type.  Patient was positive with the IS and 4C phases, and negative with the 37 and IgG phases of the tube screen.  

The tech was having some trouble resolving the blood type, so it was sent to the reference lab (using Grifols gel) and they found the Cold auto and an Anti-E (mixed field reactivity with all E pos cells in panel).  I repeated the tube screen, had another tech do the tube screen and it repeated negative at 37 and IgG.  

Is it wrong to not send Cold autos for a full panel workup?

 

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No, it isn't.

In the UK Reference Laboratories, we tended just to screen to see if the antibody reacted at 30oC or not.  If it did, as per Petz LD and Garratty G.  Immune Hemolytic Anemias, 2nd edition, Churchill-Livingstone, 2004, then it was considered to be clinically significant.  We would do nothing else at all.  The titre of the antibody was thought to be irrelevant, as it was unusual, although not unique, to find a cold auto-antibody reacting at 30oC (or above) that was not a high titre.  We certainly did not spend any time at all determining the specificity of the antibody.  As I believe I have said before, not only was the specificity regarded as totally irrelevant, but if the specificity turned out to be anti-H, anti-I or anti-HI (as it usually was), we would not recommend the transfusion of Oh units or adult ii units and, as far as I know, there has never been a donor who is both Oh AND an adult ii!!!!!!!!!

In your own case, if the anti-E was not reacting at 37oC, especially with a monospecific anti-IgG reagent, it is not going to be clinically significant, and I really doubt if it was a true anti-E (it is much more likely to be a mimicking anti-E, and I don't blame your Reference Laboratory for one minute for not going on to prove that).

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