Warm auto ????

[John C. Staley]

We've had a patient coming in at least one a week for a transfusion (2-4 units). He has a warm auto antibody with no underlying alloantibody. We don't perform absorptions at my facility and send them to a reference lab. My question is how extensive of a work up do you do for each transfusion episode? This has been going on for about 6 months and he has never produced an alloantibody after many units.

[janet]

We have the same scenerio.....we are transfusing phenotypically matched (or as close to as possible) so we are assured no antibodies are produced. We do the full work up every 3 days (more when the patient is not in a crisis episode and not requiring daily transfusions).

I have asked the same question, 'why am I doing all this work when he still reacts with everything'. It just makes me feel better to know if something happens I went throught the motions and found nothing was different.

[Cathy]

In the past, we have gotten approval from our Medical Director and the patient's physician, to extend the Type and Screen for up to two weeks. Each patient would have to be handled on a case by case basis.

[Sandy Smietana]

We send the patient sample out to be worked up. If there are no underlying antibodies we give least incompatible crossmatched blood on a Release Form requiring the patient physician's signiture. We provide blood for transfusion for the 72 hours the patient sample is viable with no additional workup regardless of the number of units requested. If additional blood is needed after the sample expires, we send a new sample out for another antibody workup. We do basically the same thing if the patient has clinically significant antibodies - provide antigen negative least incompatible blood for the 72 hours the clot is viable requesting the patient's physician signiture on a Release Form. For patients with no history of clinically significant antibodies,we do not antigen type the patient to give blood that matches the patient phenetypically nor will we give Anti-e negative blood if the patient has an Auto Anti-e. We've

found this is a waste of resources - reagents and staff and the patient doesn't respond any differently to the transfused product. This is a situation that has to be decided by your Medical Director. We've never had any problems with the physicians accepting our protocols. Our patients usually have Hematology Consults and the Hematologists are comfortable with the protocol

It will be interesting to see what other people are doing in this situation.

Sandy Smietana

[Jane]

We have had several of these patients in the recent past and we also do not perform absorptions. Our reference lab (ARC) recommended that the full workup be repeated every 2 weeks (with the thinking that they wouldn't respond with a new allo antibody sooner than this) unless their DAT changed in strength. We still did redid our stuff every 3 days (antibody screen, DAT, etc.) It did take us longer than 3 days to get blood the first time one of these patients was worked up because she did have several underlying antibodies so on that one our pathologist decided to extend the XM expiration.

[janet]

Our reference lab is unable to autoabsorb after the patient is transfused. How are others who do autoabsorptions capable of doing this? Do you use donor cells phenotypically matched to the patient's?

That is my reasoning for giving phenotypically matched....if you haven't stimulated them, they can't make it!

[adiescast]

We do homologous adsorptions, so my situation is different. We repeat the adsorption every 30 days unless the DAT or the screen is stronger (Ha! most of them start at 4+!) if there are no underlying antibodies on the first adsorption. If there are underlying antibodies, we will repeat the adsorption more frequently.

[GSD2SABSAL]

This is a very difficlut question and there are many different opinions on the subject.

When we encounter these patients, we sometimes ( depending the the frequency and amount of units transfused) , extend the work-up for up to 2 weeks as long as the DAT reaction is consistent. If possible we try to phenotype the patient and provide a phenotypically matched product, although many times this is not possible. Given that the body may respond to these antigens at any point and given the fact that we don't want to make our job more difficult down the road, it is prudent to do this. We have had patients as you describe that have developed three or four antibodies after multiple transfusions. Others do not develop any. This policy is typically made after some lengthy conversations with the blood bank director.