Anti D antibodies in a D positive patient ! Input please !

[geekay]

I would appreciate inputs from the members in the following scenario please !

Blood sample of a pregnant lady walking into the hospital for the first time is received in the Blood Bank and

the test for anti D typing shows 4+ reaction. But was not compatible with D positive blood.

Later on , antibody identification reveals anti D antibodies.

(For transfusion, "D negative" blood is given as "D positive" blood was incompatible.)

In my career for the first time, I am coming across such a situation .

How do we explain such a scenario of anti D antibodies in a "D positive " patient ? :eyepoppin

I have my explanation, but I would appreciate inputs from the members also please !

in anticipation,

and with wishes to all,

engeekay2003 :disbelief:disbelief:disbelief

[Eagle Eye]

Are you using GEL? you may have patient with catogory IV??

[geekay]

Hi aakupaku,

we use manual technique only. and the test tube showed 4+ positivity in the reaction with anti-D antiserum.

and the antibody identification in manual tube technique, showed anti D antibody.

with wishes and thanks friend,

engeekay2003

[David Saikin]

Patient probably is missing part of the D mosaic and has made antibodies to the missing portion(s). I have a pt who is a D(VI) with anti-D.

[Eagle Eye]

I forgot to ask you the most important question. Is your aotocontrol/DAT positive? If yes, what is the specificity you identified in your eluate?

You can have patient who is on WinRHo(form of Anti-D,IV IgG)? In that case your autocontrol will be positive and your eluate will have anti-D specificity. So medication history is very important.

If AC/DAT is negative,

You should send patient's cells for molecular testing (if available) to determine if patient is partial D.

[BSIPHERD]

Does the patient have positive DAT?

[DHarts]

Okay, I will throw my hat in the ring! Has the patient received an Immune globulin injection??? Check the medical record. I have seen this in the past numerous times.

Dawn

[Yanxia]

And sometimes LW system antibodies looks like anti-D.

[LaraT23]

Has anyone thought about her making abs to her baby? If the patient is partial D and the baby isn't, she could be hemolyzing the fetal cells. The D mosaic should have come up weak D pos shouldn't it? I say do the abs with DTT treated cells to distiguish from LW and check that auto control!

[galvania]

I guess I should have read this thread before replying to the Positive Du thread. My reply to that thread is relevant here. I would go for a DIV or a DVI. As far as I know, all the 'strong? DVI samples have And I would agree with Lara - the baby is in danger here.

[marilynm]

There are several considerations besides those already suggested, but if the autocontrol is negative then she is probably a partial D, lacks part of the D antigen and has produced alloanti-D.

It is important to know what the source of the Anti-D reagent is that was used and what clones are in it.

Also, what is the race of the person? Has she had previous pregnancies or has she been transfused. You need to find out what stimulated the anti-D. And, of course, the baby could be at risk if it is D positive.

It is probably not a D VI, as most of these partial D category do not give a 4+ reaction with commercial anti-D on IS.

I guess it is important also to know if you did the D typing in tube or gel or solid phase.

MarilynM

[marilynm]

One more point, there is a partial D kit out there that can help classify some partial D cells by serology before you go to molecular. MKMoulds

PS I saw that you do tube and not gel D typing, so ignore my question on that point.

MKMoulds

[marilynm]

You can also test D negative cord cells to rule out anti-LW, as they would react if it were anti-LW and not anti-D. Make sure the cord cells have a negative DAT,etc, so they would not give a false positive reaction. This is probably easier then testing DTT treated cells, for a small lab.

MKMoulds

[LaraT23]

You can also test D negative cord cells to rule out anti-LW, as they would react if it were anti-LW and not anti-D. Make sure the cord cells have a negative DAT,etc, so they would not give a false positive reaction. This is probably easier then testing DTT treated cells, for a small lab.

MKMoulds

Could you also use O neg cells from a banked unit? That might be easier to get your hands on....

[marilynm]

The reason you test D negative cord cells is because cord cells have stronger LW antigen then adult D negative cells, and I am assuming in her testing that D negative panel cells were nonreactive. It really also depends on the strength of the antibody. If it is very strong (2-3+), then adult D neg cells would react with an anti-LW. If it is weak, then they might not. But D neg cord cells would react with anti-LW.

MKMoulds

[LaraT23]

mkmoulds:

Do you have a reference for that? the cord LW thing. I am sure it would be something I need to look in to for my SBB, and am not finding anything helpful in the technical manual! Thanks in advance.

[marilynm]

A very good reference for cord cells and LW antigen, as well as LW in general is the ARC journal Immunohematology, 1992;8:87-93 by JR Storry titled "Review: the LW blood group system". She gives quite a few of the original references to the studies done by Jane Swanson and others.

MKMoulds

[apmdas]

I would appreciate inputs from the members in the following scenario please !

Blood sample of a pregnant lady walking into the hospital for the first time is received in the Blood Bank and

the test for anti D typing shows 4+ reaction. But was not compatible with D positive blood.

Later on , antibody identification reveals anti D antibodies.

(For transfusion, "D negative" blood is given as "D positive" blood was incompatible.)

In my career for the first time, I am coming across such a situation .

How do we explain such a scenario of anti D antibodies in a "D positive " patient ? :eyepoppin

I have my explanation, but I would appreciate inputs from the members also please !

in anticipation,

and with wishes to all,

engeekay2003 :disbelief:disbelief:disbelief

The patient who was pregnant was possibly alloimmunised by her foetus to provide non 'D' Rh antibodies. Though the 'D' antigen is the most potent in production of anti 'D' antibodies i.e. most immunogenic, followed by anti 'C' and anti 'E' which was responsible for the incompatibility of Rh 'D' positive blood. What you have detected are possibly the anti C or anti E antibodies. These need to be checked for as they are usually igG, may cross the placental barrier. The pregnant lady needs to have the antibody identification and the evaluation and more careful monitoring of the foetus.

[ckcheng]

D positive patient with anti-D most likely

(1) D variant form anti-D against the subunit the patient missing thru pregnant or transfusion. Check the reagent you are using, patient DAT, and I recommend you send it to the reference lab if you have no idea what it is.

(2) D positive ITP patient treat with anti-D. Check medical record, talk with the doctor, and perform DAT.

(3) IVIG or plasma products transfused contains small amount of anti-D.

D positive patient with anti-D like antibody could be anti-LW just like what Yanxia said. It reacts strong with D positive cells and weak with D negative cell. Extreme hard to find LW negative cell for transfusion.

Hope it helps.

CK Cheng, MSc, SBB(ASCP), CQA(ASQ)

HONG KONG

[Kimster]

She may have ITP and is being treated with Rho(D) Immune Globulin. It is used only in Rh positive patients for ITP.

[madhu]

No answers,,,in fact a query of my own. I had a patient..a 34 year old male, admitted with fever, jaundice and anaemia, Blood group O Pos, the D antigen confirmed by use of 2 different anti-D's. His auto control and DAT were positive and serum sample showed antibody identified as anti-D. the eluate also gave the pattern of anti-D clearly. All D neg cells were negative.All these tests were done by gel.His DAT with monospecific AHG was positive only with IgG. The only units compatible for him were O neg and he was transfused with these without any event....does this confirm an auto anti-D??????.

[ckcheng]

Before you draw any conclusion it is an auto-D, please check

(1) Patient may received anti-D for the treatment of ITP which subsequently shows hemolysis. Check medical record, and call the physician to ask for further info before you draw any conclusion.

(2) Also, it may patient is a D variant, which produce anti-D to the subunit(s) he missed after transfusion. Check transfusion history record. DAT should show mix-field reaction in this case.

(3) LW antibodies may react just like anti-D. That is strong with D pos cells, but neg (may be weakly pos) with D neg cels, howevere, it is NOT common.

Hope it helps.

CK Cheng, MSc, SBB(ASCP), CQA(ASQ)

HONG KONG

Aug 28, 2008

[apmdas]

Hi Madhu.

Before proceeding further, please find out

1. history of transfusion

2. history of drug intake

3. was Anti E and Anti C of the CDE complex excluded

4. method of elution of antibody in serum

Regards,

Mohan

[Eoin]

I have seen this a number of times. I agree. Further full investigation needed. Mostly they have had Anti-D gammaglob somewhere else. I have seen what we considered at the time to be a true auto - anti-D, but that was back in the late 70's, so typing sera for D was still fairly crap then. Would love to have the patient again (was male incidentally). Experience showed if given D Pos blood, he haemolysed it but did significantly better when given D Neg blood. Can not remember his underlying condition (come on guys, it was 38-40 years ago).

Quick investigation engeekay2003.

Good luck

Eoin. PS do tell us the outcome.

[madhu]

Since the patient is no longer reachable, I can only tell what I received from the hospital - No drug history was received.

Elution- I did a cold acid elution.

Were Anti-C and Anti-E excluded- yes- used an extended panel of D Neg cells.

No previous history of transfusion as informed by the hospital.....

I cannot do much on his sample now but it has always baffled me...Can I confirm it as an auto-Anti-D? if not then how do i explain his reactions???

Again, he was transfused with D neg cells without event...