Hemolytic tranfusion reaction

[velliott]

We just had a hemolytic transfusion reaction with a negative DAT and eluate. The antibody involved is Fya. The patient also has an anti D and anti big C but did receive an rr unit. Will the DAT become positive over the course of several days or has the unit already been competely hemolyzed and the DAT will never be positive? Another point the unit was transfused during dialysis and would this also be one of the reasons the DAT is negative? Also another question do you only, immediately, report a hemolytic reaction if there is a dealth? Is this currently on the list of "nevers" that Medicare will not reimburse for ?

Thanks:cries:

[Malcolm Needs ☆]

We just had a hemolytic transfusion reaction with a negative DAT and eluate. The antibody involved is Fya. The patient also has an anti D and anti big C but did receive an rr unit. Will the DAT become positive over the course of several days or has the unit already been competely hemolyzed and the DAT will never be positive? Another point the unit was transfused during dialysis and would this also be one of the reasons the DAT is negative? Also another question do you only, immediately, report a hemolytic reaction if there is a dealth? Is this currently on the list of "nevers" that Medicare will not reimburse for ?

Thanks:cries:

What were the actual symptoms that led you to think that it was a haemolytic transfusion reaction caused by anti-Fya in the first place, if the DAT is negative?

If you perform Duffy typing of the patient's red cells now (post-transfusion) you should be able to see if there is a mixed-field reaction with anti-Fya. I would be surprised if a complete unit has been destroyed, unless the symptoms were very serious.

The answer to my first quesion is very important in this particular case.

:confused::confused:

[velliott]

At the end of the tranfusion the patients temperature increased 1.8 degrees F. The patient has multiple issues one in which is HIT. The physician thought the patient was septic because they had been having febrile episodes during their hospilitization. The patients pre and post HGB were the same and the physician wanted another unit. We collected a new sample that was grossly icteric.....and the saga started. It appears that the only "immediate" symptom was the temperature.

[velliott]

Also let me add....this was an error. The original antibody screen that was reported as negative is actually positive. The pre sample was D, C and Fya and maybe E. The other scary scenerio is that the pre sample was still an indate specimen and an additional unit could have been added to it. The tech thought the sample looked hemolyzed and asked for another specimen to be drawn. So we could have given another incompatible unit.

[Yanxia]

You say the plasma was icteric, I think the hemolysis can destroy the infused cells in such a short time was intravascular hemolysis, the plasma is hemolyzed not icteric. What about the Fya antigen on the infused cells?

It just my guess that the post HGB result, does it drawn during the dialysis, does it consider the dilution during dialysis?

[velliott]

The plasma is the classic brown / green plasma....the unit was Fya positive.

[Malcolm Needs ☆]

Sorry to be such a pain asking all these questions velliot, but what colour was the plasma on the specimen used to cross-match in the first place (the pre-transfusion sample)?

[Yanxia]

Velliot also can detect the Fya antigen after transfusion specimen, if there is negtive, the transfused cells destroyed because immune hemolysis caused by anti- Fya and maybe other antibodies we don't know at this stage .

If the result is mix-field, and as you mentioned before the post transfusion DAT is neg, I don't think it is immune hemolysis.

[velliott]

The pre-transfusion specimen was a little hemolyzed due to difficulty in sticking the patient. Physician ordered another unit because the patient was hypotensive and had fevers which he considered to be from sepsis even though there were no positive cultures (blood or urine). HGB pre and post were both the same. Interestingly enough the patients HGB on pre transfusion was 9.6, their reason for transfusion was Cardio Vascular Disease.

[Malcolm Needs ☆]

Velliot also can detect the Fya antigen after transfusion specimen, if there is negtive, the transfused cells destroyed because immune hemolysis caused by anti- Fya and maybe other antibodies we don't know at this stage .

If the result is mix-field, and as you mentioned before the post transfusion DAT is neg, I don't think it is immune hemolysis.

Whilst there was an obvious error made, I mus agree with shily that this does not sound like a "full blown" haemolytic transfusion reaction, but much more like a febrile non-haemolytic transfusion reaction, possibly exacerbated by a mild anti-Fya/Fy(a) reaction, leading to the brownish plasma.

:confused::confused:

[velliott]

I've been "googling" reasons for a negative DAT and suspected hemolytic reactions and found the following postings.

"If the post sample is collected 3-6 hours after the hemolytic event bilirubin may be present in the plasma (brown / green color) causing a bright yellow discoloration. The DAT can be paradoxically negative if the incompatible red cells have been rapidly destroyed. The DAT on the patients post transfusion sample may be negative even though a hemolytic transfusion reaction has occured - if at the time of testing most or all transfused donor red cells have been removed from circulation." Our post sample was collected almost 24 hours after the completion of transfusion. A febrile reaction would not have reported by nursing because the temperature was less than 2 degrees.

[Eagle Eye]

Do you have pre and post bilirubin, LDH levels? Did you do Haptoglobin? How about Urine specimen?

All these will help in detemining in the classification of reaction? If specimen was drawn after 24 hrs, you may be correct in saying unit was hemolyzed rapidly?

Chemistry will help us in this case?

Do you use tube or Gel? do you do DAT by Tube or Gel? Eventhough your DAT was negative, can you try to do elution? When you try to eluate an antibody you may be able to pick up antibody eventhough your DAT is negative. We have seen this in real life.

If you are using Gel, gel will be able to pick up antibody which you might not be able to pick up with tube.

[Malcolm Needs ☆]

Do you have pre and post bilirubin, LDH levels? Did you do Haptoglobin? How about Urine specimen?

All these will help in detemining in the classification of reaction? If specimen was drawn after 24 hrs, you may be correct in saying unit was hemolyzed rapidly?

Chemistry will help us in this case?

Do you use tube or Gel? do you do DAT by Tube or Gel? Eventhough your DAT was negative, can you try to do elution? When you try to eluate an antibody you may be able to pick up antibody eventhough your DAT is negative. We have seen this in real life.

If you are using Gel, gel will be able to pick up antibody which you might not be able to pick up with tube.

Totally agree, but I still think there would me more severe symptoms if an entire unit had been cleared from this patient's circulation in 24 hours.

:confused::confused:

[Dar]

I agree. Look at pre & post chems. Also, look at RBC morphology on the pre & post diffs. This patient might have something else going on.... Negative DAT may be because Duffy's are fickle. They don't always react beautifully. Then again, I've always heard that any antibody can cause a hemolytic reaction, given the right conditions. We are basically a group of gamblers, going for the odds.

[kkskuruppu]

I am interestingly following your discussion. If post transfusion sample shows a negative DAT and a mixed field reaction with anti Fya, indicating Free Fya cells in the circulation, there should be some other reason for gross icterus of plasma (otherthan the possible anti Fya mediated extra vascular haemolysis). The 1.8 degree Temperature rise at the end of transfusion should also have some other reason than possible anti Fya mediated immune haemolysis. Could be Febrile non haemolytic one or due to underlying condition/s.