Accepting RBCs with alloantibodies

[dcharland]

My supplier wants to provide us with donor units from individuals whose plasma contains unexpected anitbodies. I do not want to accept these units. What are other institutions experience with these types of units?

[Yanxia]

Wash the cells.

[Malcolm Needs ☆]

I wouldn't want them, and I certainly wouldn't go to the expense of washing them.

[harev]

I suggest review of the literature regarding use of red cell products from donors with antibodies particularly the first reference from a large teaching facility. It is not uncommon to give out-of-group red cells which gives a much high-titiered antibody, anti-A, anti-B, anti-A,B, than would occur with use of red cells with unexpected atnibodies. Facilities in this area successfully use these products without problems. This avoids wasting products in particular Rh Negative red. About 50% of the antibodies found in donors are anti-D or anti-D + -C.

1. Combs MR, Bennett DH, Telen MJ. Large-scale use of red blood cell units containing alloantibodies. Immunohematology 2000; 16: 120-123.

2. Harbin K, Prihoda L. Alloantibody Titers in AS-1 Leukocyte-Reduces Donor Units. Transfusion 2003; 43: 32A (S105-040F).

3. Prihoda L, Spruell M, Sapp C, Plett M. Use of Donor Red Blood Cells Containing Alloantibody. Transfusion 2003; 43: 32A (S106-040F).

[Shaundrey]

We choose not to take units with alloantibodies. Our blood center keeps trying to give them to us but we keep saying no. I got one in for a patient once and even had the unit washed to remove the antibody and the unit was incompatible with several patients. There I was stuck with an expensive product that I couldn't use on anyone.

[Ellen Zeigler]

If the red cells have been prepared using an additive solution (adenine-saline, eg AS-1, AS-3, etc) there is minimal residual plasma left on the red cell. As the second approach - In the US they should be labeling with the antibody specificity. There are a lot of O negs out there with anti-D, C that you might readily be able to use.

[Malcolm Needs ☆]

I suggest review of the literature regarding use of red cell products from donors with antibodies particularly the first reference from a large teaching facility. It is not uncommon to give out-of-group red cells which gives a much high-titiered antibody, anti-A, anti-B, anti-A,B, than would occur with use of red cells with unexpected atnibodies. Facilities in this area successfully use these products without problems. This avoids wasting products in particular Rh Negative red. About 50% of the antibodies found in donors are anti-D or anti-D + -C.

1. Combs MR, Bennett DH, Telen MJ. Large-scale use of red blood cell units containing alloantibodies. Immunohematology 2000; 16: 120-123.

2. Harbin K, Prihoda L. Alloantibody Titers in AS-1 Leukocyte-Reduces Donor Units. Transfusion 2003; 43: 32A (S105-040F).

3. Prihoda L, Spruell M, Sapp C, Plett M. Use of Donor Red Blood Cells Containing Alloantibody. Transfusion 2003; 43: 32A (S106-040F).

Yes, actually, I'm looking at this with a UK-centric mind, and I do agree with both you and Ellen Zeigler, and, indeed, have used such units myself in the past.

The problem in the UK is that anybody who has themselves been transfused is then banned from donating blood because of the risk from variant Creutzfeldt-Jacob disease, and, of course, any donor with an antibody (unless it is through pregnancy) will have been transfused.

All units of blood in the UK are also leukodepleted and plasma reduced, but most are also tested for high-titre ABO antibodies, so, if it were not for the risk of vCJD, I'd probably be in totalfavour of using these units, but I still wouldn't go to the expense of washing them.

:redface::redface:

[keisterkid]

I work for a large blood center that washes all of our antibody positive units. There is no difference in pricing. We don't want to waste a usable product, our clients don't haven't complained (knock on wood).

[Malcolm Needs ☆]

I work for a large blood center that washes all of our antibody positive units. There is no difference in pricing. We don't want to waste a usable product, our clients don't haven't complained (knock on wood).

I'm sorry keisterkid, you may not pass on the cost, but there is a cost.

There is the cost of the maintenance of the cell washer, there is the cost of the liquid consumables, such as the saline, there is the cost of the electricity to run the cell washer, there is the cost of the sterile bag into which the washed blood goes, there is the cost of the sterile docking tubing, there is the cost of the sterilising of all of these, there is the cost in terms of time of the person undertaking the washing, there is the cost of the labeling of the new bag, etc, etc.

The fact that there is no difference in pricing is not down to the fact that there is no cost, but the fact that your clients do not complain is down to the fact that you do not pass on the cost; but ask your finance people if there is a cost.

In no way am I saying that it is not a usable product (see my immediate previous post), but don't pretend that washing these units does not have a cost.

:mad::mad::mad::mad::mad:

[dherbert]

Great thread here guys - I was wondering though after reading the references that harev gave to us (thankyou!) what the practice is in the UK re: these units with unexpected alloantibodies. I presume from the papers that the US mostly discards these units but what about the UK? It sounds like they might also be discarded, from one of Malcom's comments about not wanting them either. (And I am talking about donors with low tire antibodies eg 2 or 4 and from pregnancy perhaps rather than transfusion to avoid the whole permanent deferral issue?)

regards

Denise

[SusanM]

We occasionally receive units with other antibodies, as was stated earlier the majority are anti D or C,D. We do not wash them. We do try not to use them on 'repeat customers' as we have had cases where the antibody can then be detected in the recipient. But we have not had any other problems in giving them.

[Malcolm Needs ☆]

Great thread here guys - I was wondering though after reading the references that harev gave to us (thankyou!) what the practice is in the UK re: these units with unexpected alloantibodies. I presume from the papers that the US mostly discards these units but what about the UK? It sounds like they might also be discarded, from one of Malcom's comments about not wanting them either. (And I am talking about donors with low tire antibodies eg 2 or 4 and from pregnancy perhaps rather than transfusion to avoid the whole permanent deferral issue?)

regards

Denise

I've checked with someone who has worked in our Testing Department for many years, and we do discard any unit found to have an atypical alloantibody, even if it is probable that the stimulation came about by pregnancy.

[keisterkid]

I'm sorry keisterkid, you may not pass on the cost, but there is a cost.

There is the cost of the maintenance of the cell washer, there is the cost of the liquid consumables, such as the saline, there is the cost of the electricity to run the cell washer, there is the cost of the sterile bag into which the washed blood goes, there is the cost of the sterile docking tubing, there is the cost of the sterilising of all of these, there is the cost in terms of time of the person undertaking the washing, there is the cost of the labeling of the new bag, etc, etc.

The fact that there is no difference in pricing is not down to the fact that there is no cost, but the fact that your clients do not complain is down to the fact that you do not pass on the cost; but ask your finance people if there is a cost.

In no way am I saying that it is not a usable product (see my immediate previous post), but don't pretend that washing these units does not have a cost.

:mad::mad::mad::mad::mad:

Malcolm, why the hostility and pontification about cost? We charge the client the same as a packed cell, that is all, they don't complain. We are a nonprofit facility and care more about using the "gift" given to us and the community good will. As we are an expanding facility, I don't think we need lectures on cost. Everyone is happy...

[keisterkid]

I'm sorry keisterkid, you may not pass on the cost, but there is a cost.

There is the cost of the maintenance of the cell washer, there is the cost of the liquid consumables, such as the saline, there is the cost of the electricity to run the cell washer, there is the cost of the sterile bag into which the washed blood goes, there is the cost of the sterile docking tubing, there is the cost of the sterilising of all of these, there is the cost in terms of time of the person undertaking the washing, there is the cost of the labeling of the new bag, etc, etc.

The fact that there is no difference in pricing is not down to the fact that there is no cost, but the fact that your clients do not complain is down to the fact that you do not pass on the cost; but ask your finance people if there is a cost.

In no way am I saying that it is not a usable product (see my immediate previous post), but don't pretend that washing these units does not have a cost.

:mad::mad::mad::mad::mad:

Besides...who said anything about cost...I said the price we charge is the same. I didn't confuse the two, so don't assume that I did!!

[John C. Staley]

I'm very happy for those of you who have the luxury of throwing these units away. Before the additive solutions we would pack them as tight as we could just before issue and after the additives we didn't really give them much thought. Most of the time we were happy to have the units available.

I'm am curious as to why those of you who don't accept them/throw them away do this? What exactly is the motivation for wasting these units of blood? I can see throwing away the plasma but not the RBCs.

[Malcolm Needs ☆]

Keisterkid I am really sorry; I have reread my post and it does indeed sound hostile, which was unintentional.

What I meant was that I would not go to the expense of washing them in the first place (unless the antibody titre was really high, or the unit was destined for a recipient of small stature).

You are absolutely correct in saying that the gift should not be wasted, but as far as I am aware, apart from when plasma-rich components have been given to recipients of small stature, there are no credible cases of such a component causing a clinically-significant transfusion reaction, save one case of an anti-K in a donor that reacted with another K+ transfused unit. Therefore, why go to the expense of washing the red cells when, as John says, there is so little chance nowadays, with the packing of red cells and the resuspension in something like SAG-M, of a reaction.

As I said in an earlier post, I used to use these units myself, so I am not advocating throwing them away, but I am also not advocating washing them.

Once again, sincere apologies for the unintended tone of my earlier post, which was, I admit on re-reading, well over the top.

:redface::redface::redface::redface::redface:

[Malcolm Needs ☆]

I'm very happy for those of you who have the luxury of throwing these units away. Before the additive solutions we would pack them as tight as we could just before issue and after the additives we didn't really give them much thought. Most of the time we were happy to have the units available.

I'm am curious as to why those of you who don't accept them/throw them away do this? What exactly is the motivation for wasting these units of blood? I can see throwing away the plasma but not the RBCs.

I agree with you John, but in the UK it is the Law.

This Law was passed with the thought (and now the realisation) that vCJD could be passed on by a blood transfusion.

There is good reason why an individual who has themselves been transfused cannot be accepted as a blood donor (see slide 20 of the PowerPoint lecture "Donors and the Donation Process" in the References section).

Sadly, this Law was passed by politicians who, although advised by the great and the good of Transfusion Microbiology, still made o right horlicks of the whole thing.

So, under the Law in the UK, not only can we not use a person's blood for donation for other people if they themselves have been transfused, but, strictly speaking, without a medical deviation, we cannot use it for an autologous transfusion!

Normally, of course, this would not matter, BUT this extends to ALL patients, and so, if we have a (non-existent) patient with, for example, an anti-k+Vel, requiring blood from another (non-existent) donor who is also k-, Vel-, they would not be able, under the Law as it stands, to give blood for an autologous transfusion! Clever eh???????!!!!!!!!!!!!!!!!!!!!

We have to reject donors who have made an atypical alloantibody through stimulation by pregnancy, just in case they have had a transfusion without knowing it. Can you imagine the fuss if someone was to go down with vCJD having had blood from such a donor, even if there was no evidence that the transfusion caused the vCJD?

So, basically, although I agree with you, we have no choice.

:eek::eek:

[dherbert]

Ahhh thanks Malcolm, so it really is more about hhe CJD risk - makes sense In Australia we are fortunate enough (so far) to not have that worry.

Cheers

[rravkin@aol.com]

What is the frquency of occurance of PC's containing allo-Ab's in the donor pool? And of those that do contain allo-AB's of what type are they? I think we need to get more information about these units, about their ability to cause transfusion reactions, and see if they can be beneficial for a recient population before we go ahead and discard their use altogether.

[adiescast]

We use units that have allo-antibodies in them. Since they are pre-labeled with the antibody, it is sometimes nice to have them because you can match them with a patient with the same antibody. It is amazing the number of people who will give a 200 cc O platelet pheresis to an A patient without blinking, but will not give a red cell unit containing a tiny amount of plasma with an anti-K in it to anyone regardless of their K type.

This, of course, does not at all address the vCJD problem in the UK.

[dgibaud]

A nu mber of years back we transfused a unit w/anti-E into a lady we had not tested for E antigen. Our thoughts were the same as yours: there can't be enough antibody left in a red cell unit to do any harm. Turns out the lady had a nice mild reaction. Had a positive DAT for a few days and we couldn't ever really be sure there was any significant hemolysis. But...it DID cause some discomfort, and we realized that if something more unfortunate had happened we would be arguing from an indefensible position. We currently accept units with antibodies, but they all go to antigen-negative recipients. Better safe than sorry.

[dcharland]

Thank you all for your posts. What I have seen after transfusing these antibody units, is the passively aquired antibody showing up in the patient's next antibody screen. Now the patient's antibody screen is postive, requiring antibody identification, IgG crossmatches, unit antigen typing etc. etc. This is an additional cost to the patient which I struggle with ethically. How do explain this to the patient and the physician? Not to mention the additional workload for the blood bank?

[L106]

Thank you all for your posts. What I have seen after transfusing these antibody units, is the passively aquired antibody showing up in the patient's next antibody screen. Now the patient's antibody screen is postive, requiring antibody identification, IgG crossmatches, unit antigen typing etc. etc. This is an additional cost to the patient which I struggle with ethically. How do explain this to the patient and the physician? Not to mention the additional workload for the blood bank?

It is for this reason that we do not routinely accept donor units containing unexpected antibodies. Our concerns are not only the additional costs, but also the additional work for the BB staff and the delay that would result in providing appropriate donor blood to the patient.

One of the previous posts mentioned that they match up the donor antibody and patient (ie: giving a donor unit with Anti-E to a patient who already has Anti-E.) Now, that's a terrific idea!! (I'll give that some thought. For us, it would probably only work when we had advanced notice about the intended transfusion so we could specifically order the appropriate donor units from our supplier.)

[adiescast]

We haven't had any positive antibody screens result from this practice. The most we have seen is a mild positive DAT just as we have seen from giving out of type platelets. We don't even see that any more since we don't run DATs routinely on all patients.

I would not charge the patient for testing that resulted from giving them an antibody passively.

[Packer Banker]

It is amazing the number of people who will give a 200 cc O platelet pheresis to an A patient without blinking, but will not give a red cell unit containing a tiny amount of plasma with an anti-K in it to anyone regardless of their K type.

My thought exactly! However, I do see the value in antigen typing the patient to be safe. (Provided it's not an Anti-e!!) I was thinking the amount of antibody present couldn't be that much, but I guess I'm not sure if they titer it out at the blood center. In which case, yes, the possible subsequent antibody work-up could be a pain (I don't think you could charge for that?). Hopefully the Ab positive txn would be well documented, so you'd know exactly what you're working up- that would be a little faster. It would be interesting to see if, legally, you'd be required to transfuse Ag neg units after the detection of that antibody- even with a previously documented negative patient Ag type.