ElinF Posted February 15, 2016 Share Posted February 15, 2016 So, interesting patient last month. We had a patient with a history of anti-e. (not good) Worked her up and every cell on the panel was positive (even the e neg antigen cell). Her auto control and DAT were negative. Come to find out after sending her to our reference lab for a full work up, which then sent her to the American Red cross that she has developed anti-Kpb. She was Kpb antigen negative. She would need blood negative for K, Kpb, e and C (could not rule out big C). After a long search she is not compatible with any of the blood (rare donor databases I am assuming) in the US. If we wanted to start a global search the physician would have to get in contact with the director the ARC directly. It was crazy! We are a small hospital who never sees this kind of crazy stuff, but I guess it was our turn. (The patient is responding to iron treatments and has been doing ok with out blood transfusions thus far.) amym1586 1 Link to comment Share on other sites More sharing options...
David Saikin Posted February 15, 2016 Share Posted February 15, 2016 Let's hope you only get one of these turns. I have a pt with anti-Kpb also. Best of luck to both of us. Link to comment Share on other sites More sharing options...
ElinF Posted February 15, 2016 Author Share Posted February 15, 2016 48 minutes ago, David Saikin said: Let's hope you only get one of these turns. I have a pt with anti-Kpb also. Best of luck to both of us. So, what would happen if she were to get into a trauma situation. what are the chances giving her blood would actually hurt her in an acute situation? That is what everyone is asking me... Link to comment Share on other sites More sharing options...
Malcolm Needs ☆ Posted February 15, 2016 Share Posted February 15, 2016 It would do her less harm than her bleeding to death. Auntie-D, jayinsat, tricore and 5 others 8 Link to comment Share on other sites More sharing options...
ElinF Posted February 15, 2016 Author Share Posted February 15, 2016 5 minutes ago, Malcolm Needs said: It would do her less harm than her bleeding to death. Yes, that is what I tell them. jayinsat 1 Link to comment Share on other sites More sharing options...
David Saikin Posted February 16, 2016 Share Posted February 16, 2016 15 hours ago, Malcolm Needs said: It would do her less harm than her bleeding to death. Absolutely - you can deal with any sequellae afterwards. DPruden 1 Link to comment Share on other sites More sharing options...
SMILLER Posted February 16, 2016 Share Posted February 16, 2016 Except that, if I am not mistaken, the primary sequelae in this case would be death from a severe HTR. So not much from a clinical standpoint to deal with there. I suppose if they were bleeding out for some reason, they would be OK for the time being, and later die from a DHTR. I am not sure if there would be any way around this, even if only a few units were transfused. This case would be a huge problem even for a large teaching hospital. We have to hope that someday we will have real, practical blood substitutes that carry oxygen. Scott jayinsat and jsherrie 2 Link to comment Share on other sites More sharing options...
jalomahe Posted February 16, 2016 Share Posted February 16, 2016 Interesting! We also currently have a patient with a high incidence, ours is anti-Lub. Scheduled for elective surgery that's low risk for bleeding. Just enough time for the patient to do autologous donation (only 1 unit though) which was our and our blood center's recommendation. Still has us on pins and needles that nothing goes wrong. Link to comment Share on other sites More sharing options...
tbostock Posted February 16, 2016 Share Posted February 16, 2016 We have an Anti-Jk3 and an Anti-AnWj. Both are just so much fun. Malcolm Needs and Lifeandplasma 2 Link to comment Share on other sites More sharing options...
catchmenow51 Posted February 16, 2016 Share Posted February 16, 2016 You could also find out if the patient has siblings and test them for compatibility and then have them do directed donations for the patient. Lifeandplasma, Maureen and Malcolm Needs 3 Link to comment Share on other sites More sharing options...
Okie Posted February 16, 2016 Share Posted February 16, 2016 We had a patient with anti-Lub. We gave phenotypically similar units positive for Lub. Lifeandplasma and Malcolm Needs 2 Link to comment Share on other sites More sharing options...
goodchild Posted February 16, 2016 Share Posted February 16, 2016 What to do in trauma situations for patients with these kind of antibodies is always a topic of discussion but that's a fairly obvious choice. Much less discussed (and more likely) is how to handle the patient with MDS or a GI bleed who are both hemodynamically stable but need blood transfusion? Link to comment Share on other sites More sharing options...
Auntie-D Posted February 16, 2016 Share Posted February 16, 2016 1 hour ago, SMILLER said: Except that, if I am not mistaken, the primary sequelae in this case would be death from a severe HTR. So not much from a clinical standpoint to deal with there. I suppose if they were bleeding out for some reason, they would be OK for the time being, and later die from a DHTR. I am not sure if there would be any way around this, even if only a few units were transfused. This case would be a huge problem even for a large teaching hospital. We have to hope that someday we will have real, practical blood substitutes that carry oxygen. Scott They're not going to die from that though - a DHTR may occur, but there have been cases where Kpb+ units have been transfused without any shortening of the red cell lifespan. They may have unpleasant clinical manifistations that the clinicians can deal with at some point but this is a better option than exanguination. Stick them on iron, B12, folate and erythropoetin and they will produce their own red cells pretty sharpish - hopefully quicker than the transfused cells are destroyed with a DHTR. As long as the clinicians are aware that it is going to happen, they can deal with it. AMcCord, heathervaught, David Saikin and 2 others 5 Link to comment Share on other sites More sharing options...
David Saikin Posted February 16, 2016 Share Posted February 16, 2016 2 hours ago, SMILLER said: Except that, if I am not mistaken, the primary sequelae in this case would be death from a severe HTR. So not much from a clinical standpoint to deal with there. I suppose if they were bleeding out for some reason, they would be OK for the time being, and later die from a DHTR. I am not sure if there would be any way around this, even if only a few units were transfused. This case would be a huge problem even for a large teaching hospital. We have to hope that someday we will have real, practical blood substitutes that carry oxygen. Scott Have you not had to transfuse anyone with ag+ red cells? As long as they are ABO compatible the patient is not going to die (from the transfusions anyway). Granted, the rbcs are not going to survive very long, BUT they are not going to be destroyed in a catastrophic hemolytic reaction. I had a pt who had anti-E,-K,-Fyb - the docs knew they could go to the OR with 3u (they had ordered 10). When I went back to work, she was back in the OR for the 3rd time and we weren't screening for anything. She eventually developed a positive DAT with the Duffy. She survived. Malcolm Needs and amym1586 2 Link to comment Share on other sites More sharing options...
AMcCord Posted February 16, 2016 Share Posted February 16, 2016 If they can get her hemoglobin up and if she's physically able, you could consider having her donate autologous units for frozen storage. That gives at least 10 years of availability. Catchmenow's suggestion of checking siblings is a good one - if someone matches they also could donate for frozen storage providing a little long term security. Yes, it would take time to get the blood if you needed it, but it would be there. Link to comment Share on other sites More sharing options...
SMILLER Posted February 16, 2016 Share Posted February 16, 2016 David. Point well taken. We have, indeed, transfused gobs of RBCs to patients who turned out later to have anti-E or anti-K or whathaveyou. The thing is, once the immediate acute situation has passed (and probably most of the incompatible blood has bled out anyway), these patients will be getting properly Ag screened units. But how does one deal with a patient for whom you are never going to have compatible blood for? Scott Link to comment Share on other sites More sharing options...
Malcolm Needs ☆ Posted February 16, 2016 Share Posted February 16, 2016 36 minutes ago, SMILLER said: But how does one deal with a patient for whom you are never going to have compatible blood for? Scott I would not for one minute deny that such patients do exist, but they are just SO rare. Most of the time, you can get away with using IVIgG and blood that is positive for the cognate antigens, but we would still trawl the world's frozen blood banks to see if we could get antigen negative blood. pstruik, SMILLER, David Saikin and 1 other 4 Link to comment Share on other sites More sharing options...
Malcolm Needs ☆ Posted February 16, 2016 Share Posted February 16, 2016 2 hours ago, jalomahe said: Interesting! We also currently have a patient with a high incidence, ours is anti-Lub. Scheduled for elective surgery that's low risk for bleeding. Just enough time for the patient to do autologous donation (only 1 unit though) which was our and our blood center's recommendation. Still has us on pins and needles that nothing goes wrong. Anti-Lub is interesting and rare enough to be exciting, but it is, nevertheless, clinically benign. tricore, StevenB, Auntie-D and 1 other 4 Link to comment Share on other sites More sharing options...
heathervaught Posted February 17, 2016 Share Posted February 17, 2016 (edited) You all are officilally scaring me. I am starting a new job next month as the director of the transfusion services at THREE large academic medical centers (two adult hospitals and one pediatric). I am almost positive that one of these patients will show up in my first weeks. I wanted to share that because I feel compelled to compliment you all on your willingness to share your own knowledge in these forums. I have been studying them for weeks trying to glean tidbits of valuable information that I might be able to use in the upcoming weeks, months, and even years. BloodBank Talk has some of the best and brightest minds in the industry openly sharing a wealth of information, and I appreciate each and every one of you who contribute to the conversations! Edited February 17, 2016 by heathervaught Dr. Pepper, AMcCord, Auntie-D and 3 others 6 Link to comment Share on other sites More sharing options...
Auntie-D Posted February 17, 2016 Share Posted February 17, 2016 Heather - don't panic! You will have bright minds in your own centres - it's just a case of identifying them. I don't envy your job - your biggest challenge will be stamping out ingrained habits that are terrible practice. Every lab has that one tech who just does it their own way despite the SOPs. They're easy enough to identify as they are the one that noone wants to take over from, and if they have to they will start again rather than taking over and continuing David Saikin, Ensis01 and AMcCord 3 Link to comment Share on other sites More sharing options...
mollyredone Posted February 17, 2016 Share Posted February 17, 2016 We have a pregnant patient with an anti-U (also anti-N and anti-Leb)! Link to comment Share on other sites More sharing options...
Malcolm Needs ☆ Posted February 17, 2016 Share Posted February 17, 2016 21 minutes ago, mollyredone said: We have a pregnant patient with an anti-U (also anti-N and anti-Leb)! What titre is the anti-U, and how pregnant is the lady? Link to comment Share on other sites More sharing options...
mollyredone Posted February 17, 2016 Share Posted February 17, 2016 This is her second pregnancy that we have worked on and throughout the first the titer was too weak for titration, so we are keeping our fingers crossed this time as well. They did suggest that at some time she should consider autologous donations for future needs. Link to comment Share on other sites More sharing options...
goodchild Posted February 17, 2016 Share Posted February 17, 2016 Isn't there something special that I'm trying to pull out of my brain in regard to N-,U-negative patients? Link to comment Share on other sites More sharing options...
Malcolm Needs ☆ Posted February 17, 2016 Share Posted February 17, 2016 11 minutes ago, mollyredone said: This is her second pregnancy that we have worked on and throughout the first the titer was too weak for titration, so we are keeping our fingers crossed this time as well. They did suggest that at some time she should consider autologous donations for future needs. Thanks for that. Anti-U is a bit of an enigma. The first two described were responsible for a fatal HTR and an IUD, but the vast majority, at least as far as HDFN are concerned, But also many as far as HTR are concerned, appear to be clinically benign - and nobody seems to know why (with any certainty). My pathologist and I thought that it might be that they are of the "wrong" IgG sub-class, but we haven't been able to prove this yet! Both true U Negative individuals, and U variant individuals can produce an anti-U, but the latter tend to produce an anti-U that is low titre; I just wonder if your lady is a U variant, rather than a true U Negative (all individuals of both types are S-s-, but many examples of anti-U do not react with U variant red cells). The U antigen and anti-U can be a right pain!!!!!!!!!!! I think your idea of autologous donation is extremely sound! Auntie-D, mollyredone, AMcCord and 1 other 4 Link to comment Share on other sites More sharing options...
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