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Missing Plasma Protocol


Lingkwyz
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Hi guys,

I haven't been exposed as a blood banker for quite some time, so please bear with me. Recently, our institution had a case of transfusion reaction (lower back pain) with one unit of PRBCs. The testing details are as follows:

History: Non-specific reaction (Multiple encounters)

Pre Transfusion Sample

Solid Phase : 2 of 3 cels 2+ (Positive

Gel Card (Regular) : Negative

Gel Card (Enzyme) : Negative

Dx: Non-Specific Reaction, all siginificant antibodies excluded

Transfusion Reaction Investigation Sample

Solid Phase : 2 of 3 cels 2+ (suggestive with Anti-Jka)

Gel Card (Regular) : Positive (2+) Minimum grade (Clear-cut Anti-Jka)

Gel Card (Enzyme) : Positive (4+)  (Clear-cut Anti-Jka)

DAT (Gel Card) : Positive

Elution Testing: Anti-Jka Detected

Dx: Anti-Jka

 

Analyzing the encounter, me and a colleague, through curiosity re-ran the Pre Transfusion Sample:

Pre Transfusion Sample: (Curiosity Run)

Solid Phase : 2 of 3 cels 2+ (suggestive with Anti-Jka)

Gel Card (Regular) : Positive ; Wp Minimum grade (suggestive with Anti-Jka)

Gel Card (Enzyme) : Positive ; 1+ Minimum grade (suggestive with Anti-Jka)

 

Taking all details, I could presume that the Gel Card  results (both regular and enzyme, which I believe was ran at the same time) of the 1st Pre Transfusion Sample was the jinx. So confidence to the testing method lies to the daily QC of the Gel Card which was ran first thing of the day. Now, I'm asking, if Solid-phase technology could incorporate a positive control and negative control to each strip of testing, why aren't there any on the Gel Card Method? Next, if the Solid-phase technology could also incorporate a "system trap" to ensure the addition of patient's sample to the testing, through it's Capture LISS, why cant the Gel Card  do so? I believe that seeing an all-negative resulted panel would be enough for some people for exclusion. Lastly, if reagents aren't available for the Gel card method to ensure the addition of plasma, should our institution enforce a backup procedure that could ensure the reviewer that none of the essential components of the testing (e.g. Patient's plasma) is not missed?

Hoping for the masters..

 

Thanks !

 

lingkywz

 

 

Edited by Lingkwyz
added Capture LISS
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I'm not entirely sure what you are asking...

But why was antibody identification not done in solid-phase?

Kidd antibodies are known to love the solid-phase environment, gel not so much. We have had numerous examples of Kidds that react in Capture and not in gel during our validation testing and since.

It is always a best practice to be performing your identification in the same method as your screening. And that would extend to crossmatches as well.

Edited by Rapundaa
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Hi Rapundaa!

 

Thanks for the input and my bad. See, the antibody screening and the ID was done in Solid Phase. The initial identification had only 2 cells positive (2+), suggestive of anti-Jka but was eventually ruled out because of the nonreactivity of the other Jka pos cells. So, as it seems, the MTOD proceeded to another method which is the Gel Card Method which got all results negative.

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I would say, particularly with antibodies within the Kidd Blood Group System, which are notorious for becoming labile both in vitro and in vivo, but causing severe delayed haemolytic transfusion reactions due to anamnestic responses, that, if there is a strong index of suspicion, the specificity should be honoured, whether it can be proved or not.  The only time that I would not do this is if the patient is proved to be, for example, Jk(a+), and the antibody looks like anti-Jka, or Jk(b+), and the antibody looks like an anti-Jkb.  I think it is better to give Jk(a-) or Jk(b-) blood unnecessarily than to find out afterwards, when the patient has a reaction.

This, however, is a personal view, rather than a hard and fast "rule".

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10 minutes ago, Malcolm Needs said:

I would say, particularly with antibodies within the Kidd Blood Group System, which are notorious for becoming labile both in vitro and in vivo, but causing severe delayed haemolytic transfusion reactions due to anamnestic responses, that, if there is a strong index of suspicion, the specificity should be honoured, whether it can be proved or not.  The only time that I would not do this is if the patient is proved to be, for example, Jk(a+), and the antibody looks like anti-Jka, or Jk(b+), and the antibody looks like an anti-Jkb.  I think it is better to give Jk(a-) or Jk(b-) blood unnecessarily than to find out afterwards, when the patient has a reaction.

This, however, is a personal view, rather than a hard and fast "rule".

Hi Malcolm Needs!

 

I do agree that prophylactically we must give antigen negative units to suspected antibodies, proven or not. But to this situation, the results gave negative reactions to two Jka positive cells in Solid Phase panel and no reaction to Gel Card both regular and enzyme. Also, this patient have had multiple testings in our lab, all of which were interpreted as  "Non-specific" reactions.

I also had to point out that as a person seeing the result, what would be my indicator for the validity of the Pre Transfusion Gel Card results (which were all negative) which was also taken into consideration, thus the "Non-specific" reaction interpretation.

Thanks for the enlightenments guys and hope to learn more from you guys..

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42 minutes ago, Malcolm Needs said:

Yes, I can see from where you are coming.  It can be so difficult on occasions (which is why I have always maintained that we should be paid our worth)!!!!!!!!!!!!!

I could not agree more Malcolm.. True that!!!

 

As I see, and I hope everyone agrees, working on a "routine" blood bank must have its own system "traps". Cruising through a day of "regular" patient samples sometimes gets you to overlook really tricky ones. In our institution, I would say that we are benefiting on the "Non-specific Reaction" dump. Anything unequivocally an antibody would fall to that dump. Sadly, the situation above fell into that.

 

As per the fee, nah! I always tell my self that I will be here for the science. Sadly again, my wallet don't feel the same! :)

 

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We have a couple of policies that might have helped (although if the tech was convinced that the reactivity in solid phase was a false positive, he might still have missed this--our expectations are powerful).  We require (well, there are some exceptions) that 2 double dose (homozygous donor) Jka positive cells not react in gel before we can rule it out.  I have seen too many anti-Jka antibodies that react with one cell but not another in gel.  We pretty much never rule it out with just "positive" cells.  I know I look particularly hard at whether something "sort of" fits a Kidd antibody because of their tendency to be weak to undetectable.  If all of the positive reactions are on Kidd double-dose cells, I will be doing some extra work to rule it out.  Antigen type the patient, as Malcolm says.

We train and it is in our procedure that the gel card must be "QCd" after running which includes looking for proper centrifugation of the card and whether the cell and plasma volumes are correct.  I can't promise that no one ever gets lazy and skips this but then they are not following the procedure.  

Some other options would be that gel cards run to follow up on questionable solid phase results have to be incubated for 30 minutes instead of 15 (we have validated up to 40 minutes which is about the maximum allowed I believe in MTS gel).  This will sometimes bring out a weak antibody or make it react with more cells.  It does not change the non-specifics much usually.

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14 hours ago, Mabel Adams said:

We have a couple of policies that might have helped (although if the tech was convinced that the reactivity in solid phase was a false positive, he might still have missed this--our expectations are powerful).  We require (well, there are some exceptions) that 2 double dose (homozygous donor) Jka positive cells not react in gel before we can rule it out.  I have seen too many anti-Jka antibodies that react with one cell but not another in gel.  We pretty much never rule it out with just "positive" cells.  I know I look particularly hard at whether something "sort of" fits a Kidd antibody because of their tendency to be weak to undetectable.  If all of the positive reactions are on Kidd double-dose cells, I will be doing some extra work to rule it out.  Antigen type the patient, as Malcolm says.

We train and it is in our procedure that the gel card must be "QCd" after running which includes looking for proper centrifugation of the card and whether the cell and plasma volumes are correct.  I can't promise that no one ever gets lazy and skips this but then they are not following the procedure.  

Some other options would be that gel cards run to follow up on questionable solid phase results have to be incubated for 30 minutes instead of 15 (we have validated up to 40 minutes which is about the maximum allowed I believe in MTS gel).  This will sometimes bring out a weak antibody or make it react with more cells.  It does not change the non-specifics much usually.

Hi Mabel!

Clearly in this case, the Anti-Jka was missed. Enhancement techniques (e.g increase in incubation time, increase in plasma-cell ratio) isn't a popular idea from where I'm at. Sadly, was on the patient's expense.

I would rather educate myself and ask from you guys on how you would have handled the case. Although this was not my case, but then again, information is everything. 

"QC" as you've pointed out might be the visual inspection of gel card materials as you do your test. But, my challenge is that, as a reviewer, how sure are you that none of the components of testing, especially the patient's sample is not omitted? I would rather ask for a proactive approach so situations like these gets controlled/prevented.

Next, I would agree on your input regarding being skeptical on "treacherous" antibodies. For me, (for all its worth actually-hehe) caution must be taken in dumping a positive reaction into the "Nonspecific Reaction" ditch.

Thanks for the input Mabel.

 

-Paolo

 

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I also think that one must understand the vagaries of the different test systems.  Ortho's gel, for example, has a notoriety of not being the best for detecting the Kidd abs (though I have not encountered this it seems it is fairly well documented, just ask an Immucor rep).  Also, you mention that some Jka cells reacted and some did not - you did not mention whether the ones that did not react expressed Jka as homozygous or heterozygous, ditto for the ones that did react.  You answered my question about the panel (in solid phase vs gel).  I think that is all I have to say except I really dislike the Kidds.

Edited by David Saikin
hit enter too soon
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On ‎7‎/‎9‎/‎2016 at 7:49 PM, Mabel Adams said:

We have a couple of policies that might have helped (although if the tech was convinced that the reactivity in solid phase was a false positive, he might still have missed this--our expectations are powerful).  We require (well, there are some exceptions) that 2 double dose (homozygous donor) Jka positive cells not react in gel before we can rule it out.  I have seen too many anti-Jka antibodies that react with one cell but not another in gel.  We pretty much never rule it out with just "positive" cells.  I know I look particularly hard at whether something "sort of" fits a Kidd antibody because of their tendency to be weak to undetectable.  If all of the positive reactions are on Kidd double-dose cells, I will be doing some extra work to rule it out.  Antigen type the patient, as Malcolm says.

We basically do this exact same thing.

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21 hours ago, David Saikin said:

I also think that one must understand the vagaries of the different test systems.  Ortho's gel, for example, has a notoriety of not being the best for detecting the Kidd abs (though I have not encountered this it seems it is fairly well documented, just ask an Immucor rep).  Also, you mention that some Jka cells reacted and some did not - you did not mention whether the ones that did not react expressed Jka as homozygous or heterozygous, ditto for the ones that did react.  You answered my question about the panel (in solid phase vs gel).  I think that is all I have to say except I really dislike the Kidds.

I think, in a routine lab as we are in, these antibodies are a hit-or-miss.. Not having  PEG, DTT, ZZAP, adsorption techniques etc. keeps us in the dark on situations like these. I kinda suggested these to our greater management but they are totally apathetic about it.

Yup, I did miss to inform that the screening cells of the solid phase in the pre-transfusion testing  pointed out a pattern of Anti-Jka. But on the Ready-ID panel got one cell positive which was homozygous to Jka. Nevertheless, there were approximately more than 3 more Jka pos cells which were negative. Also, on the gel card testing of the same sample, all results were negative to screening and panel 11 which i would say are filled with Jka pos homozygous cells.

Thanks David.

 

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