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Brenda Hutson

Anti-f

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I debated which category to post this; but decided to do so here.

One of my Techs. left the panels and GEL cards last night on a patient she could not figure out. I always review panels the same way to prevent biased blood banking (rule-outs on all negative reactions first; then look at what is left; my first step is never to look at the positive cells and see what Antibody pattern they match).

Anyway, after ruling out on negative reactions from 2 Ortho Panels as well as the Surgiscreen, everytthing was clearly ruled out; except, anti-f. It is the perfect pattern for f.

When I first came here, no one knew what an anti-f was (and I don't even want to think about what they may have been calling them:eek:). I believe we have identified 3 in my 3+ years here; one on a pregnant woman (so we also performed Titers). That is the 3rd time in my career that an anti-f has been identified on a pregnant woman where I was working at the time.

And sadly, I have found this (mis identification of an anti-f) to be the same in other places I have worked; as well as some of our clients when I was a Reference Lab Supervisor.

Though not frequent, it is not infrequent either. Getting some staff to understand what an f is, can be difficult (especially Generalists who rotate through the dept; though one place that had not heard of it before I came, was a large well-known Medical Center where the BB staff only worked in the BB). But at least I "almost always" now see them cross it off when reviewing the work-ups and performing rule-outs; that is progress.

I have spelled out in the SOP, what antigen negative blood to provide the patient (in that if they don't understand the antbiody, it will not be intuitive to know what to transfuse).

There is 1 reactive cell which is f - (much weaker than all other cells) but that does not fit anything. May be a Low Incidence (true Low Incidence Malcolm :); not to be confused with Lua).

I wanted to post this because it concerns me just how many Techs. out there do not know what an f is, and therefore, are not ruling it out and/or identifying it (and are even calling it the next "closest" thing).:eek:

Brenda Hutson, CLS(ASCP)SBB :o

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Oops...forgot one thing I meant to say. I looked briefly on the Internet at f antibodies/antigens. I found a paragraph on a study that I was surprised to see in that it is erroneous! The statement made was:

"In routine antibody screening, anti-f cannot be detected because all reagent screening cells are usually R1R1 or R2R2".

Do many people out there actually use 2-cell screening cells? If yes, I guess the comment would have only been partially erroneous. Just wondering.

Brenda

I debated which category to post this; but decided to do so here.

One of my Techs. left the panels and GEL cards last night on a patient she could not figure out. I always review panels the same way to prevent biased blood banking (rule-outs on all negative reactions first; then look at what is left; my first step is never to look at the positive cells and see what Antibody pattern they match).

Anyway, after ruling out on negative reactions from 2 Ortho Panels as well as the Surgiscreen, everytthing was clearly ruled out; except, anti-f. It is the perfect pattern for f.

When I first came here, no one knew what an anti-f was (and I don't even want to think about what they may have been calling them:eek:). I believe we have identified 3 in my 3+ years here; one on a pregnant woman (so we also performed Titers). That is the 3rd time in my career that an anti-f has been identified on a pregnant woman where I was working at the time.

And sadly, I have found this (mis identification of an anti-f) to be the same in other places I have worked; as well as some of our clients when I was a Reference Lab Supervisor.

Though not frequent, it is not infrequent either. Getting some staff to understand what an f is, can be difficult (especially Generalists who rotate through the dept; though one place that had not heard of it before I came, was a large well-known Medical Center where the BB staff only worked in the BB). But at least I "almost always" now see them cross it off when reviewing the work-ups and performing rule-outs; that is progress.

I have spelled out in the SOP, what antigen negative blood to provide the patient (in that if they don't understand the antbiody, it will not be intuitive to know what to transfuse).

There is 1 reactive cell which is f - (much weaker than all other cells) but that does not fit anything. May be a Low Incidence (true Low Incidence Malcolm :); not to be confused with Lua).

I wanted to post this because it concerns me just how many Techs. out there do not know what an f is, and therefore, are not ruling it out and/or identifying it (and are even calling it the next "closest" thing).:eek:

Brenda Hutson, CLS(ASCP)SBB :o

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My training on f is still a "work in-progress" here in that the Tech. I asked to perform a complete Rh phenotype on the patient, stated that everything was positive (D+C+c+E+e+; = R1R2) so "it definitely was not an anti-f." I said, "NO, that is exactly what I expected to see; those are the people that make anti-f." So the other Techs. working in the area wanted a "visual;" so I wrote it all out (using Fisher-Race and Weiner). But I am thankful that they ask and want to learn.

Brenda

I agree entirely with your post Brenda.

The f- cell was (presumably) an R1R1 or R2R2, rather than an R1R2 that is really an Rzr?????????? Just a thought.

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Certainly, within the UK, an awful lot of laboratories do use two, rather than three screening cells, and these are R1R1 and R2R2.

The ce antigen is NOT required as a mandatory antigen on the screening cells by the BCSH Guidelines. This is probably because anti-f has caused neither clinically significant haemolytic transfusion reactions, nor clinically significant haemolytic disease of the foetus/newborn, but I do know that this worries quite a few people, and they tend to use a three cell screen, with the third call being rr.

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My training on f is still a "work in-progress" here in that the Tech. I asked to perform a complete Rh phenotype on the patient, stated that everything was positive (D+C+c+E+e+; = R1R2) so "it definitely was not an anti-f." I said, "NO, that is exactly what I expected to see; those are the people that make anti-f." So the other Techs. working in the area wanted a "visual;" so I wrote it all out (using Fisher-Race and Weiner). But I am thankful that they ask and want to learn.

Brenda

Sorry Brenda, I was asking about the cell that gave a weak reaction with the patient's plasma, rather than the patient's own probable Rh genotype.

I know, I know, I'm a pain!!!!!!!!!!!!!!!!!!!!!

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No, no; I just briefly glanced at your response and had actually gone back to Blood Bank Talk to elaborate, after talking with my staff about the antigen typing. So I did not actually read your response carefully. And now that I actually "read" your response, yes, I agree.

No problem....you are not a pain and I always appreciate the feedback!

Brenda

Sorry Brenda, I was asking about the cell that gave a weak reaction with the patient's plasma, rather than the patient's own probable Rh genotype.

I know, I know, I'm a pain!!!!!!!!!!!!!!!!!!!!!

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I have identified an anti-f once while performing antibody identification. I understand your frustration

in explaining the nature of this antibody to a generalist staff. Just a comment: this antibody is similar looking to an anti-c

in its pattern of reactivity so an inexperienced tech could easily mistake it for an anti-c which would not be the wost thing

since our transfusion recommendations were to issue blood that is either of the R1R1 or R2R2 phenotype.

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I have identified an anti-f once while performing antibody identification. I understand your frustration

in explaining the nature of this antibody to a generalist staff. Just a comment: this antibody is similar looking to an anti-c

in its pattern of reactivity so an inexperienced tech could easily mistake it for an anti-c which would not be the wost thing

since our transfusion recommendations were to issue blood that is either of the R1R1 or R2R2 phenotype.

I think I know what you mean, but I hope you wouldn't issue R2R2 blood to someone with anti-c!!!!! I think that it is just the way it read.

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I thought someone would say that; but the scary thing is, they do not always identify it as anti-c! I have seen (in Hospitals where I worked, before I taught them about anti-f, as well as clients when I was a reference lab supervisor) that when in doubt, just pick something! I have seen them misidentified as almost everything!

Brenda

I have identified an anti-f once while performing antibody identification. I understand your frustration

in explaining the nature of this antibody to a generalist staff. Just a comment: this antibody is similar looking to an anti-c

in its pattern of reactivity so an inexperienced tech could easily mistake it for an anti-c which would not be the wost thing

since our transfusion recommendations were to issue blood that is either of the R1R1 or R2R2 phenotype.

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I thought someone would say that; but the scary thing is, they do not always identify it as anti-c! I have seen (in Hospitals where I worked, before I taught them about anti-f, as well as clients when I was a reference lab supervisor) that when in doubt, just pick something! I have seen them misidentified as almost everything!

Brenda

That really is scary!

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We do a 2 cell screen. Switched back from a 3 cell screen a couple of years before I came here. I never thought about there being no f antigen on those screen cells. We even have an anti-f patient that was in sometime in the past year or so. I guess we found that back when we were doing 3 cell screens.

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Another thing that worries me is that Immucor just made a statement that they are going to remove the "f" pattern from their panels because so many of the cells are not antigen typed - the phenotype is "assumed" based on the entire RH typing of the test cell (hope I said that right!). Just think how many "anti-fs" will be missed when the pattern is no longer on the panel sheet! Maybe we can send this whole post off to Immucor and they will rethink their plan.

Why is it that "f" doesn't cause severe HDN or severe transfusion reactions when it has been missed, I wonder? So many of the rest of the Rh system antigens are major players with those problems - why not "f"?

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Why is it that "f" doesn't cause severe HDN or severe transfusion reactions when it has been missed, I wonder? So many of the rest of the Rh system antigens are major players with those problems - why not "f"?

Actually, if you think about it, there are a whole lot of antibodies within the Rh Blood Group System that do NOT cause severe HDN or severe transfusion reactions.

Anti-C does not cause severe HDN and only rarely causes a severe transfusion reaction.

Anti-E only causes severe HDN when the titre is really high, and rarely causes a severe transfusion reaction.

Anti-e usually only causes mild HDN and, like anti-E, rarely causes a severe transfusion reaction.

Anti-Ce only causes mild HDN and transfusion reactions (not surprisingly, as most cases of anti-C are, in reality, anti-Ce).

...and so on and so forth.

Mind you, I am NOT advocating that we drop the C, E and e antigens from the screen!!!!!!!!!!!!!!

:crazy::crazy::crazy::crazy::crazy:

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They can cause reactions; even if not severe. I realize we can deduce, the same as Immucor has been, which cells are f+ (according to genotype); however, given that I have found the majority of Techs. don't even know what anti-f is, I am concerned this will only make that worse. And as I said, unfortunately, an anti-f is not always mis-identified as anti-c (in that you can have cells that are f-c+). If the reactions don't fit a perfect pattern, many will just "pick the closest thing" on the panel. Scary, I know; but that is what I have found to be true in my 27 years.

Brenda

Another thing that worries me is that Immucor just made a statement that they are going to remove the "f" pattern from their panels because so many of the cells are not antigen typed - the phenotype is "assumed" based on the entire RH typing of the test cell (hope I said that right!). Just think how many "anti-fs" will be missed when the pattern is no longer on the panel sheet! Maybe we can send this whole post off to Immucor and they will rethink their plan.

Why is it that "f" doesn't cause severe HDN or severe transfusion reactions when it has been missed, I wonder? So many of the rest of the Rh system antigens are major players with those problems - why not "f"?

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Brenda,

I too have seen several Anti-f antibodies in recent years and they have always been on multiply transfused patients. There is only 1 cell on the panel that separates if from an Anti-c so I think in years passed it has been overlooked. I recently got a notice from Immucor that they are dropping f from their panels. UGH!!!!!!!!!!!

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Brenda, here is some more info on the f antigen that I found quite helpful.

The f antigen, an example of a compound antigen, is expressed on RBCs having c (RH4) and e (RH5) antigens in the same haplotype (in cis), for example, R1r (DCe/dce), R0R0 [Dee/Dee], etc. The antigen is not expressed when c and e occur on separate haplotypes (in trans), e.g., R1R2 (DCe/DcE).

However, RBCs of some people with the De- phenotype express f.

Anti-f is frequently a component of sera containing anti-c or anti-e. Anti-f is useful in distinguishing DCE/dce from DCe/DcE. Apparent anti-f in Blacks may be anti-hr's (see RH19). Anti-f frequently fade in vitro and in vivo.

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Well, it is true that some panels only have 1 cell that is c+f- (i.e. Ortho A); but if you look at Ortho B and probably some Immucor Panels, there can be several cells that are c+f-. That is when I become concerned that the inexperienced Tech. will not necessarily think that anti-c is "the closest thing."

And yes, I just noticed last week when looking at some Immucor Panels that they had removed f. I understand their point; that it is an assumption on their part. But it has always been that way and to remove it, in my mind, will become "out of sight; out of mind."

Brenda

Brenda,

I too have seen several Anti-f antibodies in recent years and they have always been on multiply transfused patients. There is only 1 cell on the panel that separates if from an Anti-c so I think in years passed it has been overlooked. I recently got a notice from Immucor that they are dropping f from their panels. UGH!!!!!!!!!!!

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I agree with your last comment Brenda - and that goes for the specificity of many other antibodies.

We also notice an awful lot of hospital laboratories (but by no means all) send us samples for antibody identification, rather than antibody confirmation, when the antibody is showing dosage (e.g. an anti-M or an anti-Fya). I think that this is another "out of sight, out of mind", because it is something you learn about at college/school/university, but see very rarely (well, comparatively rarely) and so it tends to be forgotten when the real thing comes along.

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Blood Group Antigen Facts Book says anti-C causes mild to severe transfusion reactions. Oh, wait, I see Malcom says it can be severe but only rarely. So how do we draw the lines so they are consistent in regard to all of our various sorts of risk? How do we even evaluate those risks? Historically we never allowed any serologic risk we could prevent but we know we accept some risk with not doing antiglobulin xms on every unit, and not using polyspecific AHG to catch the rare complement only antibody. And these risks are nothing compared to the effect and frequency with which patients are given the wrong drugs. But they don't have people as compulsive as blood bankers worrying about that, I guess.

Edited by Mabel Adams

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And from my years as a Reference Lab Supervisor, I could bring up horror stories much worse than any of these concerns. It actually made me create a list in my mind of Hospitals I would never want to be a patient at! I am shocked at the lack of knowledge of some of the Techs. who are working in Transfusion Services; even some who are the supervisors!!

Brenda

I agree with your last comment Brenda - and that goes for the specificity of many other antibodies.

We also notice an awful lot of hospital laboratories (but by no means all) send us samples for antibody identification, rather than antibody confirmation, when the antibody is showing dosage (e.g. an anti-M or an anti-Fya). I think that this is another "out of sight, out of mind", because it is something you learn about at college/school/university, but see very rarely (well, comparatively rarely) and so it tends to be forgotten when the real thing comes along.

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Blood Group Antigen Facts Book says anti-C causes mild to severe transfusion reactions.

Yes, and this is true Mabel, but, that notwithstanding, the severe transfusion reactions are very rare. I am NOT saying that they do not happen.

Edited by Malcolm Needs
I do SO wish that I could spell!!!!!!!!!

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Did you mean to say anti-C; or anti-c? You may very well have been discussing C; just clarifying since there was much discussion about f and the relationship to c.

Brenda

Blood Group Antigen Facts Book says anti-C causes mild to severe transfusion reactions. Oh, wait, I see Malcom says it can be severe but only rarely. So how do we draw the lines so they are consistent in regard to all of our various sorts of risk? How do we even evaluate those risks? Historically we never allowed any serologic risk we could prevent but we know we accept some risk with not doing antiglobulin xms on every unit, and not using polyspecific AHG to catch the rare complement only antibody. And these risks are nothing compared to the effect and frequency with which patients are given the wrong drugs. But they don't have people as compulsive as blood bankers worrying about that, I guess.

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And from my years as a Reference Lab Supervisor, I could bring up horror stories much worse than any of these concerns. It actually made me create a list in my mind of Hospitals I would never want to be a patient at! I am shocked at the lack of knowledge of some of the Techs. who are working in Transfusion Services; even some who are the supervisors!!

Brenda

Once again, I thoroughly agree!!!!!!!!!!!!

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