Need someone experienced with anti-hrS

[Mabel Adams]

We have an elderly A+ female patient that is recorded as Native Hawaiian that was given 2 units almost 4 weeks ago and now came in needing 3 more. She was given 5 units in Dec and 3 in 2005. Previous screens neg. This screen was very weak in gel in 1 cell so PEG screen was done last night to see if it was just "gel junk." Ended up pulling up a pretty clearcut anti-f in PEG. Although recently transfused, the patient appears to be R1R2 although the e typing was only 1+. There were no f pos cells on the 2 cell screen run in gel so today we decided to test a panel in gel to see if the anti-f reacted. Not only did it react as a nice 3+ but 8 of 17 cells tested from w+ to 1+ in gel. One f neg, e neg cell rected 3+ in gel; it is Lua+ but we have no other Lua+, f neg cells to test to prove it at this point.

Every one of the 8 f neg cells that reacted is e+. There are 3 e+ cells that did not react... 2 of them RzR1 (thus e heterozygous) and one R1R1. All other non-rective cells are e neg.

We gave her 3 units last night that were xm compatible in PEG with a 30 min incubation and she took them fine (so far). Two of them were R1R2 and one was c neg so assume R1R1.

Is this consistent with an anti-hrS-like (Rh19) antibody? Would the patient's e type be weak? Why isn't it reacting with the one R1R1 cell? Could that panel cell be something other than a normal R1R1? It does not show the signs in P1, Fya or S typings that suggest a black donor. What more do I need to do for the ID? What blood should we transfuse next time (assuming she doesn't have 4 new antibodies)? Is this antibody unheard of in non-blacks? Is there any research on polynesions? She is apparently a chronic anemia so I expect we will see her again.

[Malcolm Needs ☆]

Anti-hrS is a bit of problem, to say the least! It's reactions mimic anti-ce (anti-f) very closely; in fact, so closely that there are occasions that, serologically, it can be almost impossible to tell the two apart. Your weak reaction with reagent anti-e and the patient's own cells suggests that she has an e variant, but does not prove it.

Personally, I think that this is definitely one for a Reference Laboratory and molecular work. The reason I say that is because anti-hrS can also mimic anti-hrB, and you really need to detect the mutations in the RHCE gene as a guide to which of the three specificities with which you are dealing.

The good news is that this lady is D positive. This means that you can safely transfuse her with R2R2 compatible blood. The RHcE haplotype is negative for ce (f), hrS and hrB!

The bad news is that, if it is anti-hrS, the specificity could broaden to anti-Hr, and if it is anti-hrB, it could broaden to anti-HrB - but either would be very rare, so don't worry too much.

I must admit to not knowing about the frequency of e variants in the Polynesian population.

[Mabel Adams]

I made a mistake. It looks like I have 2 (not 1) R1R1 cells that did not react (plus the 2 RzR1 that didn't). Would you be willing to rule out anti-hrS in these circumstances? I still have 8 R1R1 cells that did react with no explanation for them if it is not anti-hrS.

[Pony]

Don't give up the ship just yet. Working at a national ref lab, I've seen more than my fair share of -hrB and -hrS. Did you look at the rest of the phenotype on the 2 R1R1 cells? Any chance the donor could have been black or mixed descent? That would be my kind of bad luck to have 2 such cells in an inventory that carry weak expressions of e. Plus, more of the antibodies I have worked with that are directed at variants, do not react with a predictable strength because we really don't know the availability of the epitopes the antibody is binding with. There is too much variability with single dose cells to be comfortable with using them for exclusion. As long as R2R2 cells are working for transfusion, I agree with Malcolm. Getting the molecular work done could tell you exactly where you stand and add to our body of knowledge.

[Malcolm Needs ☆]

I don't know if you agree with me Pony, but I have found with both anti-hrB and anti-hrS, that the antibody tends to react much stronger with C+, e+ red cells, than with C-, e+ red cells. Indeed, so much so that the antibody sometimes appears to be a mixture of anti-C+e (or anti-Ce+e), with the apparent anti-C (or anti-Ce) seemingly reacting more stongly than the apparent anti-e. Unfortunately, this does not hold true in every case - so this is not "diagnostic" of the specificity.

In this case, though, with the R1R1 cells being negative, I think this may really be an anti-ce (anti-f).

:idea::idea:

[Mabel Adams]

Neither of the R1R1 panel cells that did not react are Fya-b-, S-s- or strong P1 pos so I have no evidence they are from black donors. Any idea how significant it is that the patient is apparently not black? Are e variants unheard of in other populations? Can we justify the cost of getting molecular testing done when we can safely give R2R2 units for now at least? My reference lab is pretty convinced this is just an anti-f with some extraneous non-specific reactivity although they suggest we give R2R2 units until the additional antibody specificity becomes more clear.

[Pony]

I don't know if you agree with me Pony, but I have found with both anti-hrB and anti-hrS, that the antibody tends to react much stronger with C+, e+ red cells, than with C-, e+ red cells. Indeed, so much so that the antibody sometimes appears to be a mixture of anti-C+e (or anti-Ce+e), with the apparent anti-C (or anti-Ce) seemingly reacting more stongly than the apparent anti-e. Unfortunately, this does not hold true in every case - so this is not "diagnostic" of the specificity.

In this case, though, with the R1R1 cells being negative, I think this may really be an anti-ce (anti-f).

:idea::idea:

Malcolm,

On hrB, I agree with what you see with C+e+, Immunohematology. 1995;11(3):74-7. I found Ro patients had a nasty habit of looking like -f or -e and then turned out to be hrS. But this is a different population. I was working exclusively with Black patients. though the ones we found of mixed descent were the biggest pain to work with. The Polynesian group will probably have mixed descent folks as well and that will add a new kink to what we know. Or thought we did anyway.

[Mabel Adams]

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Let's see if I can post the workup. I may not have mentioned above that we also suspect an antibody to a low freq, possibly Lu a. The tech switched to PEG when the original gel screen showed one really weak reaction which he thought was junk (and maybe was because it didn't come up on a repeat screen). We tried gel the next day after she was transfused just to see how the apparent anti-f reacted in gel and then found the additional reactions to R1R1 cells.

I really appreciate your help.

[Pony]

[ATTACH]628[/ATTACH]

Let's see if I can post the workup. I may not have mentioned above that we also suspect an antibody to a low freq, possibly Lu a. The tech switched to PEG when the original gel screen showed one really weak reaction which he thought was junk (and maybe was because it didn't come up on a repeat screen). We tried gel the next day after she was transfused just to see how the apparent anti-f reacted in gel and then found the additional reactions to R1R1 cells.

I really appreciate your help.

In looking at your results, there are things I'd rule out before going the hrS route. I'd be more likely to call this an anti-f that may or may not have an auto component to it. I agree the Lua is there. I'm not sure how confident I'd be about -Jka not being there based on your 2 rule out cells. I've been doing quite a bit with -Jka lately and it varies as much on testing platform as it does on dose. That gives me chills.

An eluate and triple absorption with R1R1, R2R2, and rr cells needs to be done to see what you can separate.[ make sure one of the abs cells is Jk(a+b-)] If the eluate just reacts with everything, there's the auto specificity with he bulk of it on the patient's cells. Any chance you could separate retics? I'd really hate to commit on this one without a true phenotype.

Lots of luck

[Rh-fan]

I agree that this not sounds ase a real anti hrs, it goes more to f.

I do not have a lot of experiance with polynaisian people (beside the Jka-b-) but I can immagine that there is a other kind of e variantion there in which patiants can make anti f and a form of anti e.

I think (just als Malcolm and Pony) that it is a good thing to do a genotyping. In hrs and hrb neg people there is a big change of also having a variation of RhD. At this moment there is no anti D but after the genotyping you know if you need e neg D neg blood in the future.

I also like the absorption/elution test pony suggested.

Peter

[John Eggington]

How about something more boring;

1) Rh/JK typing results not valid because of recent transfusion

2) Patient is R2R2, not R1R2

3) Antibodies detecetd (anti-f +/- anti-e +/- anti-C) are weak alloantibodies

4) Auto/DAT results are 'inconclusive' because only the residual cells fron 4 weeks ago have antibody coating them

5) Delayed-type 'transfusion reaction' is occuring (but not clinically significant)

[Malcolm Needs ☆]

Thanks for sending me your results Mabel.

Having seen them, I have little doubt that it is an anti-f (anti-ce), with anti-Lua.

Sorry Egg, but I don't buy that one - the reactions are "not the right strength" for me.

[John Eggington]

Just trying to pose a 'simpler' hypothesis. Would be good to know what was the matter with the patient.

[Malcolm Needs ☆]

Just trying to pose a 'simpler' hypothesis. Would be good to know what was the matter with the patient.

Not putting down your thoughts John; just posing a sort of question.

[Mabel Adams]

Patient has a history of CABG and redo, diabetes, possibly GI bleed and "chronic anemia" with a usual Hgb of 8-9. Ulcers on legs due to circulatory insufficiency. No record of cause of anemia other than something about iron deficiency. She came in with a hgb this time of about 6 but after 3 units was close to 12. She weighs about 125 lbs (52? kg). There were two pre-transfusion hgbs that were both 6ish. They discharged her before doing anything more. The last hgb was probably drawn soon after transfusion was finished so my guess is it will "settle out" lower once her volume adjusts. Not enough sample left for adsorption even if we had the ability to do triple alloadsorptions. The only thing that bugs me about anti-f and Lua with a weak warm auto mimicking anti-e is that I expect her DAT to be positive. Still the purported weak auto reacts only with homozygous e cells which the auto-plus-transfused cells are not, so maybe that explains it. I have thought of asking for a new specimen in a few weeks to see if anything has changed. Otherwise, we will just wait to see if she comes back. Probably can't justify the cost of molecular testing at this point much as I would like more information for my education. We will give her e neg units until the antibodies become more clear.

[John Eggington]

Not putting down your thoughts John; just posing a sort of question.

Never thought I was being put down, Malcom, just my 'idle musings'! Trying to interpret 'weak stuff' is always a bit of 'hit and miss' job!

[John Eggington]

Mabel, do you have the Rh phenotypes of the units given 4 weeks ago?

[Malcolm Needs ☆]

We will give her e neg units until the antibodies become more clear.

I can understand your reluctance to go to molecular testing.

I think that is the correct thing to do at this stage Mabel.

Great thread by the way!

[Mabel Adams]

No Rh phenotypes from prior units. I suppose I could check with the Red Cross to see if they might have some history on the donors. They probably wouldn't have been in regular inventory if they were known to be anything very special.

[John Eggington]

My thoughts are; if the unts given 4 weeks ago were 'random' Rh phenotypes, then all will (almost certainly) have been e positive (and have a good chance of being f positive, and slightly less so of being C positive). The circulating residue would give phenotyping results that are difficult to interpret, promote an (allo) immune response, and give ambiguous auto/DAT results (patricularly if the technique of auto and DAT vary a little). So I'm till clutching at straws for my 'boring' answer!

[Mabel Adams]

I also wonder if this patient is "reticking" very well due to her chronic anemia. That would make the 2 units 4 weeks prior have more impact on her antigen type. Also, an Rh antibody might not remove the transfused cells from circulation all that fast compared to say, a Kidd antibody. Since this time we gave her 3 units that were compatible in PEG, f neg but e positive, if she is making a real anti-e it should be there "with bells on" in a few weeks. If so, she will have destroyed all the transfused cells and probably be back for more.

[Yanxia]

I think the antibodies apart from anti-f , is antibodies some antigen the Native Hawaiian have , sorry I can't research it out.

And the blood she received , the donor's race is also important to result this problem. Such as Mur and Diego in China we will detect it, but they are not in your panels, I know in your country it is not major clinical antibody, but in nowadays race differ is not so linked with regional differ, if the donor is an Asia or Black , what kin dof antibody will stimulate ?

[Mabel Adams]

Yanxia, the donors in the northwest US are still predominantly caucasion. Diego is sometimes listed as an extended antigen type on our panels in the column at the right. I believe they require it on South American screen cells because the antibody is more common there, just as I have heard Asian screen cells usually include such antigens as Mur. You are right that we may need to all be able to detect these antibodies better in the future as more traveling and immigration occurs. I read recently that some Chinese come to the US to have their babies because of the US policy to grant citizenship to anyone born here. I hope the mother brings her records if she has anti-Mur because we might never find the antibody in this country.

[Yanxia]

Mabel,you are right.

If the patient is not native , we do screening and full crossmatch not computer crossmatch, maybe the risk of have hemolytic transfusion reaction is rare.

As your case, you give her PEG compatible units. I am curious why you don't use gel but Peg do the crossmatch, I feel the antibody react better in gel.

Edited May 1, 2012 by shily

[Mabel Adams]

When we get a really weak, atypical reaction in a gel screen as this was, the techs sometimes just do a PEG screen to see if it is anything "real". We have some trouble with the gel screening cells picking up false positives so, since PEG is about as sensitive as gel, it is our backup method. In this case, the tech found the PEG screen to be postive as well, so did a PEG panel and PEG crossmatches before issuing PEG crossmatch compatible blood. Only after the day shift came in the next morning did we wonder how the antibody might react in gel and did all of the gel testing that I posted besides the original gel screen. We were very surprised to pick up what looked like another antibody because usually PEG and gel match pretty well. If it is an weak auto with a mimicking anti-e specificity that would fit since gel is really good at picking up warm autos. I think he continued with PEG also because the reactions seemed much stronger in PEG than the one gel screen cell that he found possibly positive (it only had a couple of dots above the cell button). It wasn't positive for e, f or Lua so not sure what we actually were picking up in the gel screen. In fact, on repeat, it was negative. Maybe her guardian angel just needed us to find the anti-f which is not possible with a 2 cell screen made of R1R1 and R2R2 cells. Our PEG screen in a 3 cell screen with an rr cell on it.