DHTR???

[lacs]

Has anyone seen a DHTR with negative results after transfusion?

That includes DAT, AB screen with untreated and treated cells, eluate, autocontrol...

Her clinical information screams DHTR but we could not find anything anywhere

[Malcolm Needs ☆]

Please would you give us some more details, including the patient's underlying condition, age, ethnic origin, etc?

Thanks.

[lacs]

Please would you give us some more details, including the patient's underlying condition, age, ethnic origin, etc?

Thanks.

Hi Malcom,

This is what I have on the patient

44 yo Hispanic lady. History of Gyn bleeding, iron deficiency, past transfusions and “transfusion reaction”.

Treated at the hospital last month for GI bleeding; Negative screen and DAT, transfused with 4(!) Units. Had appropriate response, normal labs, short episode of fever, but discharged.

Returned to the hospital ER last night (~9/2) with hematuria/flank pain, no fever. Hemoglobin at 8.5, indirect bili is >6 (icteric serum).

T&S still negative, DAT still negative.

more work done.

Thanks,

lacs

Cold Antibody screen- neg at RT and 18 degree C Post sample

Repeat DAT- IgG neg C3d neg at 5 mins Post sample

Gel antibody screen neg on Pre and Post samples

Pre sample- serum normal color 8-25-11

Post sample- serum icteric and hemolysed 8-31-11

[John Eggington]

Also; what is her ABO/D type (and any other red cell phenotypes you might have), what was her Hb at previous discharge, are there any 'haptoglobin' results, is there any thought of a single chronic condition/disease?

[Yanxia]

Hi Malcom,

This is what I have on the patient

44 yo Hispanic lady. History of Gyn bleeding, iron deficiency, past transfusions and “transfusion reaction”.

Treated at the hospital last month for GI bleeding; Negative screen and DAT, transfused with 4(!) Units. Had appropriate response, normal labs, short episode of fever, but discharged.

Returned to the hospital ER last night (~9/2) with hematuria/flank pain, no fever. Hemoglobin at 8.5, indirect bili is >6 (icteric serum).

T&S still negative, DAT still negative.

more work done.

Thanks,

lacs

Cold Antibody screen- neg at RT and 18 degree C Post sample

Repeat DAT- IgG neg C3d neg at 5 mins Post sample

Gel antibody screen neg on Pre and Post samples

Pre sample- serum normal color 8-25-11

Post sample- serum icteric and hemolysed 8-31-11

Have you redone the crossmatch with the transfused cells? Maybe the antibodies is against low incidence antigen not expressed on the screening cells?

[Malcolm Needs ☆]

Have you redone the crossmatch with the transfused cells? Maybe the antibodies is against low incidence antigen not expressed on the screening cells?

That was exactly what I was going to suggest shily, and the negative DAT could be because all of the transfused red cells expressing the corresponding low incidence antigen could have been removed from the circulation.

Thanks for the extra informations lacs.

The other thing is that, even if you found the red cells compatible with the pre-transfusion plasma prior to the actual transfusion, it could still be a case of an anamnestic response.

Edited September 11, 2011 by Malcolm Needs

[Eagle Eye]

crossmatch pre & post specimen with all 4 donors??? Run panel with post specimen eventhough your screen is negative. We had a classic case of anti-Kpa causing hemolytic reaction in a patient. the only way we detected this by doing crossmatch with psot specimen.

You may have an antibody to low frequency antigen...

[Yanxia]

And if the antibodies is consumption during the hemolysis, few days later it can be produced then to detect the plasma or serum against donor cells we can see the incompatible.

[lacs]

Also; what is her ABO/D type (and any other red cell phenotypes you might have), what was her Hb at previous discharge, are there any 'haptoglobin' results, is there any thought of a single chronic condition/disease?

She's OPOS R2R2 K-Fya-Jkb-S- and has a hx of anti-C and e (id'd somewhere else). From what we can tell, hx was not avail. until after she'd been transfused with random units. Doctor ruled out other conditions.

She came from a hospital so we did not have the Hh at prev. discharge or Haptoglobin result.

We did find an article dated 1985? about DHTR that could only be detected by Cr study. I don't have it to elaborate right now. I was just wondering if anyone else experienced the same/similar thing.

[lacs]

And if the antibodies is consumption during the hemolysis, few days later it can be produced then to detect the plasma or serum against donor cells we can see the incompatible.

We crossmatched the post transfusion samples with crossmatch units. Everything was NEGATIVE.

[lacs]

crossmatch pre & post specimen with all 4 donors??? Run panel with post specimen eventhough your screen is negative. We had a classic case of anti-Kpa causing hemolytic reaction in a patient. the only way we detected this by doing crossmatch with psot specimen.

You may have an antibody to low frequency antigen...

We ran the post sample with an untreated panel and ficin-treated panel; everything was negative. We also ran against a few low freq. antigen; result was negative.

[Malcolm Needs ☆]

Hi lacs,

I haven't actually experienced this myself, but many moons ago I was at a symposium where either George Garratty or Malcolm Beck (so long ago now, I can't remember which of them it was) spoke about just this kind of thing, where the patient in the US kept haemolysing after transfusion, but no antibodies could be detected, but when they gave e- blood, the haemolysing stopped.

A few years later, a colleague of mine, Bill Chaffe, came across exactly the same scenario in England.

[lacs]

Hi lacs,

I haven't actually experienced this myself, but many moons ago I was at a symposium where either George Garratty or Malcolm Beck (so long ago now, I can't remember which of them it was) spoke about just this kind of thing, where the patient in the US kept haemolysing after transfusion, but no antibodies could be detected, but when they gave e- blood, the haemolysing stopped.

A few years later, a colleague of mine, Bill Chaffe, came across exactly the same scenario in England.

Thank-you Malcolm. This was the first for us too. Fortunately, she's doing ok now. If transfusion is really necessary, she'll received R2R2 K- units next time......

lacs

[Malcolm Needs ☆]

Sounds like a good idea to me!