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

[marilynm]

Autoantibodies can have almost any blood group specificity. We actually investigated a patient with an autoantibody showing D specificity. The reference is the ARC Immunohematology journal: Immunohematology 1994;10:117-119 by Dzik W, Blank J, Lutz P, Hirose TG, Lomas C and Moulds. M titled "Immune hemolysis following transfusion: a mimicking autoanti-D in a D- patient with alloanti-D." Our patient was D negative but it can occur in D positive patients. There are several references in our paper on autoantibody showing anti-D specificity in D positive patients. Once you have ruled out recent transfusions, medications, etc. then the explanation would be autoantibody.

Mmoulds

[Ann Viernes]

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??????.

In addition to the possible scenarios already posted, consider organ transplant (or BMT) from an Rh negative donor with an anti-D. Passenger lymphocytes from the transplanted organ can continue to produce anti-D for many months after the transplant. We had such a patient who experienced brisk hemolysis for months, with a compensated anemia, very high retic count. The key here is to communicate with the organ transplant department to discover the donor's name and hospital and communicate with the blood bank at that hospital regarding donor's blood type and antibody screen results. In BMT transplants, eventually the Rh negative hematopoietic cell line will convert the patient to Rh Negative, but not so in the solid organ transplants.

[rcurrie]

Shily, you beat me to the punch. Sounds like it could be anti-LW.

BC

[marilynm]

I do not think this is anti-LW. I do not see how strong the reactions were, but if they were strong then Rh D negative cells would react, if it were anti-LW.

However, it could be ruled out by testing D negative cord cells, as they would react if it were anti-LW, as D neg cord cells have stronger LW antigen then D neg adult cells. Also, DTT-treating the reactive D positive cells would show if it was anti-LW, as they would be nonreactive DTT-treated.

I think this is autoantibody mimicing anti-D specificity.

Marilyn m

[Marilisa]

Did you perform a DAT on the patient? A positive DAT may interfere with the patient's D typing. Also, a check of the patient's history may determine that she has received WinRho and/or Rhogam. Did you titer the antibody? The strength may also help you determine if the antibody is actively acquired or passively acquired.

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

[marilynm]

I assume your lady is Indian? I think we need to look up what category of partial D has been found in your population. Also, whose anti-D are you using? I do not think it is D VI as they usually do not give a 4+ reaction with anti-D.

Marilynm

[Immunohematologist]

I had something similiar to this happen to me. I work at a reference lab, which does not get any patient information besides name, age and sex. So, it is pretty difficult to determine what problem you could be facing with a patient. Our machine basically runs the show, you put the samples on, it does type and screen, and the panels. At the end of the day, i see a sample that is Rh positive with an Anti-D antibody. Ever since this, I have been researching to try to figure out how this could be since there was no error in handling. We use the capture plates, not gels, but I did run a titer on a gel and it was 1:2. All reactions for the panel were 4+ and clearly could not be any other antibody except D. I repeated the type on tubes, and it had a 2+ reaction for D4, screening cells were 2+ and 3+ so, all the reactions were quite strong. We don't have the ability to do elutions or anything fancy like that, but I was just curious of what this could be. I too, thought it may be an auto Anti-D but I don't know for sure.

[marilynm]

In reply to Immunohematologist, what is critical with your case is "what is the DAT or what does the auto control do?" If the DAT and/or autocontrol are negative, then you have a partial D with alloanti-D. If the DAT and/or autocontrol are positive then you probably have auto antibody with anti-D specificity.

I work in a Reference Laboratory, but whenever we have an antibody and no information on the patient was supplied, we call the referring laboratory and request at least transfusion and pregnancy history.

In the past, when I was in charge of a reference lab that got samples from screening labs we would call them and have them call the doctor to get the information we needed. It was not easy and not always successful, but we always gave it a try.

I do not like reporting out "anti-D in a D positive person" unless I know a history.

Marilynm

[jayinsat]

This looks like a passively acquired anti-D due to rhogam. If she did not receive WinRHo(D) she probably got RhoGam. Yea, I know she's Rh+ and not a candidate for RhoGam, but obgyn offices make those mistakes all the time! We work closely with a hematology/oncology group and we see a lot of their rh+ patients with auto-anti-D due to WinRho(D). You call the office and half the time the nurses don't have a clue what you are talking about when you ask them if the patient received WinRho(D). Only when you speak to the treating physician (the one who ordered it) do you get straight answers (if you can figure that out). I'm willing to bet that your patients received WinRho(D), Rhogam or IVIG. A D variant is very possible but with a positive Direct Coombs, it's probably passively acquired. BTW, you can get passively acquired C and E with WinRho too!

Hope that helps.

[KECIA]

I agree with everyone she could be a Partial D IVa. This D phenotype is associated with the production of an allo-Anti-D. These individuals with partial D phenotypes should be considered Rh neg for transfusion purposes and are candiates for RHIG if they have not made Anti-D. Severe HDN has not been reported, but the pregency should be monitored for HDN of the fetus. Further send her specimen out for molecular testing to confirm.

[Brenda K Hutson]

I came across this once and when I ruled out other thoughts/possibilities that came to mind, I spoke with Dr. Garratty about the possiblity of it being a partial D. I then sent it to his Lab and he confirmed that it was in a fact a Partial D.

Brenda Hutson, CLS(ASCP)SBB

[Malcolm Needs ☆]

Nobody seems to have mentioned that, if it was a patient of Black ethnicity, it could be a partial D III, with a genuine alloanti-D.

This partial D type (or types actually, as there are more than one - about 5 or 6 now, if I remember correctly) types positive with ALL anti-D reagents, and can only be distinguished by genotyping.

[irshadaad]

Why we will not consider anti-G

Edited October 28, 2009 by irshadaad

[irshadaad]

Partial d individuals can produce -anti d.......we have got two such cases

[Malcolm Needs ☆]

Why we will not consider anti-G

I think this is because there is no mention throughout of the presence of an apparent anti-C.

With very few exceptions, all C+ red cells are also G+, and, in fact most weak to moderate anti-Gs will tend to react more strongly with C+ red cells (such as R1R1 and r'r) than with D+ red cells (such as R2R2 and Ro); this, despite the fact that, of the common Rh types (excluding things like D-- and D..) R2R2 expresses the highest number of D antigen sites.

When an anti-G is present on its own, reactions will always mimic an apparent anti-C+D. Of course, as the cell that often stimulates the production of the anti-G is an r'r, there is often a true anti-C (or anti-Ce) element to the antibody as well.

[crummer]

D vii

[jcdayaz]

This is a very real phenomenom. It does happen. If a person is missing part of the D antigen then they can most certainly form antibodies against that antigen. It is called "partial D"...or older school terminology is "mosaic D". It is important to identify and then transfuse with Rh neg blood.

It is important to rule out Anti-G as previously mentioned.....but that typically presents like a combo of Anti -D,C. Not only Anti-D.

[Robert]

Might the patient have received Anti-D immunoglobulin to treat I.T.P. in the past?

[Malcolm Needs ☆]

Might the patient have received Anti-D immunoglobulin to treat I.T.P. in the past?

How much in the past? Almost all of the anti-D would be on the recipient's red cells and he/she would have a fairly hefty positive DAT.

:confused:

[Max]

We had 4 cases of anti-D in D+.

One was a patient in treatment woth anti-Rh immunoglobulin for an ITP.

Two were "partial" (as we call them) D identified with molecular biology: one variant DNB and the other variant III.

The second "partial" case was an Afro-american woman, she hand two pregnancy before the third that was when the immunization was discovered. The Ab title peaked 1:128 , but the pregnancy was unevenfful and the baby was born DAT+ but ok.

The last case happened just yesternay in a cardio-surgery patient that received 15 or so units in the last 18 days. We are still working on him.

[BankerGirl]

We have had two such patients this month so far (a very rare phenomenon for us!). The first was a surgical patient with a history of blood transfusion in Germany, and the second was a case of ITP-treated Rh Immune globulin. In the second case, the patient required a crossmatch four days after the RhIg and, surprise, the IAT and DAT were positive. The antibody ID came out as a clear anti-D, but what surprised me is that the elution showed a pan agglutinin, not anti-D. I guess this goes to prove that you can't always predict--which is why we do the testing, huh?

[Malcolm Needs ☆]

We have had two such patients this month so far (a very rare phenomenon for us!). The first was a surgical patient with a history of blood transfusion in Germany, and the second was a case of ITP-treated Rh Immune globulin. In the second case, the patient required a crossmatch four days after the RhIg and, surprise, the IAT and DAT were positive. The antibody ID came out as a clear anti-D, but what surprised me is that the elution showed a pan agglutinin, not anti-D. I guess this goes to prove that you can't always predict--which is why we do the testing, huh?

When was the second patient recognised? The reason I ask is that, some years ago, before we got worried about such things, the anti-D we used was not just anti-D, but a mixture of antibodies, but which were mostly anti-D, which itself, had to be of a certain "strength".

I can't remember exactly how many there were, but we once did an "antibody identification" on a sample of anti-D immunoglobulin, and we detected about 6 different antibody specificities!

I think I am correct in saying that such a "soup" of antibodies is no longer allowed, but it could be the reason that your elution was pan-reactive. The other reason could be that the patient already had an "enzyme only" auto-antibody, that would react by IAT if eluted.

I don't know; I am only throwing in suggestions!

:confused::confused:

By the way, I believe I have cited this particular website before (but at my age memory is anything but perfect), for those interested in Weak and Partial D types that are known to produce alloanti-D, put "rhesusbase" into your search engine for a spectacularly useful site (although it does require updating).

Edited November 19, 2009 by Malcolm Needs

[BankerGirl]

Malcom,

We just gave the ITP patient the RhIg 10 days ago. I did not do the workup, as it was my day off, and I can't find the panel sheets just now, but it would be interesting to see if there is any difference in the reactions with the Rh positive cells, versus the Rh negative ones. You have me currious now, so I am going to have to find out what happened to those panel sheets!

[Malcolm Needs ☆]

Of course, the other complication that I have just thought of (and you will not thank me for this!) is that an auto-anti-LW (which is actually more common than a lot of people think) will sometimes mimic an anti-D by IAT, but will look like an pan-reacting auto-antibody by enzyme technique, with slightly less strong reactions with the D- red cells. However, when you do an eluate, it will also look pan-reactive by IAT, as the anti-LW comes away from the LW antigen on the D- red cells relatively easily, giving an antibody that reacts well with all red cells.

You could try an ABO compatible, rr, cord cell with the original plasma, and see if that reacts by IAT, as the LW antigen is particularly strong on cord cells.

I told you that you wouldn't thank me; more work and no guarantee of success, as it may not be an auto-anti-LW at all!!!!!!!!!!

Sorry.

:redface::redface:

[jcdayaz]

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??????.

To the extent of my experience, I have never seen/heard of Auto-Anti-D. I have seen multiple presentations of D variant patients forming Anti-D (although a farely rare phenomenon). If your patient is D variant, then it is not unexpected for him to form Anti-D. D, as we all know, is very immunogenic. If this is the case, we do not classify the Antibody as "Auto-Anti-D"--we would classify it as "D variant with Anti-D". We would not bother to have the D variant identified....we would simply transfuse Rh negative blood.

You do want to confirm/exclude the presence of WinRho infusion. WinRho would also explain your dilemma. The presence of WinRho has given me multiple problems!