What do you do if you suspect 2 or more antibodies?

[ahalim]

I appreciate Malcolm's efforts for help. I can understand that double antibodies are real headache but that doesn't mean to underestimate others efforts. i have just finished a presentation in our hospital topic was "Rh Typing : Simple Test Or Controversy" I was sure that almost all attendees (physicians and nurses) heard this for the first time and it took me about 1 month preparing the talk, but i felt that i was speaking Chinese!! Disappointed as, I think, Malcolm is!!

[BB enthusiast]

Hello guys,

Have u ever encountered a patient with auto antibody seen only in his elution? his phenotype is e positive, no antibody in his serum but anti-e was eluted. please shed light. I'll appreciate all the lectures and information related to this. thanks.

[BB enthusiast]

Hello guys,

Have u ever encountered a patient with auto antibody seen only in his elution? his phenotype is e positive, no antibody in his serum but anti-e was eluted. please shed light. I'll appreciate all the lectures and information related to this. thanks.

[rravkin@aol.com]

Hello guys,

Have u ever encountered a patient with auto antibody seen only in his elution? his phenotype is e positive, no antibody in his serum but anti-e was eluted. please shed light. I'll appreciate all the lectures and information related to this. thanks.

BB enthusiast,

Has the patient been transfused within the last three months??

[Malcolm Needs ☆]

Hello guys,

Have u ever encountered a patient with auto antibody seen only in his elution? his phenotype is e positive, no antibody in his serum but anti-e was eluted. please shed light. I'll appreciate all the lectures and information related to this. thanks.

This is the kind of scenario you see when the auto-antibody is comparatively weak; in other words, almost all of the auto-antibody is adsorbed onto the red cell surface, with very little in the plasma. This does not mean that the antibody is clinically insignificant, as the patient's reticulo-endothelial system will still remove autologous red cells.

I don't know if you have tried using enzyme-treated red cells in the panel, but, if not, you will probably find that these do give positive results.

Although the patient is e+, and the antibody appears to be an auto-anti-e, the chances are that this specificity is a mimicking auto-anti-e, and that the actual specificity is actually an auto-anti-Rh17. However, the only way to prove this is to use really rare red cell samples, such as Rhnull and -D-/-D-; and it is just not worth wasting such rare cells on proving the specificity.

It is quite acceptable to transfuse such a patient with e+ red cells (as these will last as long in the circulation as the patient's own red cells), but, if the patient is E-, you should not transfuse R2R2/r"r"/ryry/RzRz (or any combination of these haplotypes), as, if he produces an anti-E, and his auto-antibody becomes more virulent, you will then have real problems!

:):):)

[BB enthusiast]

BB enthusiast,

Has the patient been transfused within the last three months??

Yes, patient is multiply transfused

[rravkin@aol.com]

Yes, patient is multiply transfused

BB enthusiast,

Can you give a full and specific history including diagnosis, transfused products, age, gender, and previous type and antibody history if any?

[BB enthusiast]

BB enthusiast,

Can you give a full and specific history including diagnosis, transfused products, age, gender, and previous type and antibody history if any?

Patient is Male, 20 years old in oncology, transfused only with Oneg rbc as his blood type is Oneg and had the C antibody and confusingly e+ in his elution.

[rravkin@aol.com]

This is the kind of scenario you see when the auto-antibody is comparatively weak; in other words, almost all of the auto-antibody is adsorbed onto the red cell surface, with very little in the plasma. This does not mean that the antibody is clinically insignificant, as the patient's reticulo-endothelial system will still remove autologous red cells.

I don't know if you have tried using enzyme-treated red cells in the panel, but, if not, you will probably find that these do give positive results.

Although the patient is e+, and the antibody appears to be an auto-anti-e, the chances are that this specificity is a mimicking auto-anti-e, and that the actual specificity is actually an auto-anti-Rh17. However, the only way to prove this is to use really rare red cell samples, such as Rhnull and -D-/-D-; and it is just not worth wasting such rare cells on proving the specificity.

It is quite acceptable to transfuse such a patient with e+ red cells (as these will last as long in the circulation as the patient's own red cells), but, if the patient is E-, you should not transfuse R2R2/r"r"/ryry/RzRz (or any combination of these haplotypes), as, if he produces an anti-E, and his auto-antibody becomes more virulent, you will then have real problems!

:):):)

Malcolm,

Given the fact that this patient has been transfused within the last three months how can we call this new antibody an Autoantibody?:)

[BB enthusiast]

Malcolm,

Given the fact that this patient has been transfused within the last three months how can we call this new antibody an Autoantibody?:)

e+ phenotyping was recorded long before first transfusion. if this is not considered an autoantibody, what could be the other possibilities?

[LisaM]

Trisram,

I think that what Malcolm and others were trying to explain is that after the first panel is complete and you can not rule out two antibodies you must then continue with selected panel cells of panels in your blood bank other then the panel just used. These selected panel cells are cells that you select that are negative for the corresponding antigen of one of your two suspected antibodies and positive for the other; and vise versa. Here's an example, your ABSC is positive, your subsequent panel concludes with two antibodies that you cannot rule out; lets say Anti-E and Anti-Fya.

Your next step would be to review the histograms of other panels that are in your blood bank (even outdated panels) and look for cells that are positive for Ag-E and negative for Ag-Fya; and look for other cells that are positive for Ag-Fya and negative for Ag-E. Now, here's a question for you; how many positve cells do we need in order to rule in an antibody? It is this number of positive cells you want to accumulate for each of your suspected antibodies individually; ie a cell that is positive for Ag-E and negative for AG-Fya, and vise versa. Please let me know your answer.

Where I work, we have to use either two homozygous cells or three heterozygous cells to rule out an antibody, but as far as ruling in, I don't think we have a set number of panel cells that we've established for that. If we can't rule it out, then we would transfuse antigen-negative blood to the patient, and if things got really messy and we couldn't rule anything out, we'd send the patient's sample to the Red Cross reference lab for specialized testing that we don't do where I work---like what happened to me last night: I had a patient that had a positive DAT, Autocontrol and every cell on the panel was positive, but two were stronger than the rest. It looked like a perfect "E" hiding under a warm autoantibody, but again, we don't have the means to absorb out the warm auto where I am, so I couldn't rule out anything--send out time!

[adiescast]

e+ phenotyping was recorded long before first transfusion. if this is not considered an autoantibody, what could be the other possibilities?

If your patient typing is definitely pre-transfusion, then it is most likely an auto antibody. Most of these (correct me if I am wrong, Malcolm) are actually mimicking the anti-e and not actually directed against the e antigen. I have seen several of these go on to more non-specific (panagglutinating) autoantibody reactivity as the process continues, particularly when the autoantibody was induced by the patient's disease state. As Malcolm stated already, you can give e positive blood in these cases and you definitely want to give E negative if the patient is E negative lest you have an even bigger problem on your hands for later transfusions!

[Malcolm Needs ☆]

Most of these (correct me if I am wrong, Malcolm) are actually mimicking the anti-e and not actually directed against the e antigen. /QUOTE]

Absolutely correct.

:D:D:D:D

[Brenda K Hutson]

To me, that would depend on how many negative reactions you have as well as, how urgent the need for blood is.

If you only have 1 to 2 negative reactions (or maybe no negative reactions but varying strengths lead you to believe it might be multiples), you might want to come in from the back door (so to speak). That is, perform a complete phenotype on the patient (if not transfused in past 3 months and if you carry the antisera of the major blood groups). Once you have the phenotype, run a phenotypically similar cell. That can tell you 2 things:

1. If the phenotypically matched cell is negative, you are dealing with multiple antibodies; if positive, most likely a High

Incidence.

2. It tells you what the patient "can" make; you can then rule out some antibodies that perhaps you have not yet ruled

out on the panel, based on the patient's phenotype.

3. Even if the patient was transfused in past 3 months, if you are just spending too much time because you have few

(if any) negative reactions, you "may" still be able to get some assistance from a complete phenotype. In that case,

you have to consider how many units the patient received in the past 3 months, and how long ago. If minimal, look

for mixed field reactions and strength of reactivity. You should not "result" a phentoype under these

circumstances, but it may be helpful in getting a good "idea" of what the patient is positive and negative for; then

you can select cells accordingly and hope for the best.

Brenda Hutson, CLS(ASCP)SBB

[jayinsat]

Isn't the proper term for this a "warm autoantibody with anti-e specificity"?

[Malcolm Needs ☆]

Isn't the proper term for this a "warm autoantibody with anti-e specificity"?

I would argue that the proper term for this is a "warm auto-antibody with anti-e-like specificity."

:o:o:o:o

[Brenda K Hutson]

By the way; I had only taken a moment to read the question of the initial thread when I responded. Now that I stopped and read all of the responses, I see we kind of moved on. So, my response is only in reference to the initial question. Sorry; next time I will read everything before responding.

Brenda