rravkin@aol.com

Malcom and Goodchild, as we all know there is already general risks of transfusion. Anti A1 does not have a great association with adverse effects of transfusion but there are rare cases as have been mentioned. This possibility is staring us right in the face from the work-up presented. So why not avoid by suggesting O rbc's or B rbc's? You know that there are more than enough times that we cannot avoid a conflict but this is not one of them at the moment. So, again I would ask, what is the benefit to our patient if they do acquire an Anti A1 that was completely avoidable?

Thank you Malcom and Galvania for providing these texts. I look forward to reading them. But, I would also like to ask you if there is anything written in these texts that states that there is a conclusive benefit for our 87 year old oncology patient, who appears to type as an A variant B, Rh Positive, and who tests negative for the A1 antigen, in acquiring an Anti A1 in addition to other considerable clinical variables? Or is there any conclusive evidence of a definitive benefit in acquiring an Anti A1 for any other patient population?

Dear Galvania, I searched "Anti A1 Clinical Relevance" and found two articles. The first is on the site, Blood Bank Guy, posted 2012 and completed agrees with your and Malcom's statement that Anti A1 is clinically insignificant in the majority of cases. It also states that information on the production of Anti A1 antibodies is "sparse;" and it gives disclaimer at the bottom of the post entered by Monica Lasarre in 2012. The second site I saw was from PubMed.gov, US National Library of Medicine, National Institutes of Health, an Abstract from 2009 by Daskova NG, Ragimos AA, and Asoskova TK where they state that " The risk of the development of post transfusion reactions or complications is particularly great when Anti A1 antibodies are active at 37C and belong to the IgG class. They go on to suggest donors of O RBC's or BRBC's for recipients that are type A2B, which our 87yr old oncology patient appears to be; given the reactions presented. As these two findings are the only one's that came up in my search it appears that information on Anti A1 and it's clinical relevance is limited and conflicting. As such, I would still respectfully disagree with giving this patient A or AB rbc's because of the unnecessary additional, and potential, complications that may arise post transfusion and/or additional unnecessary complications with the Blood Bank work-up and compatibility testing. The article from the National Institute of Health suggested B rbc's as well as O rbc's. The B rbc suggestion seems better then O rbc's because the majority of B rbc donor would have residual Anti A1 for which the patient has been shown to not have the A1 antigen, and the patient (recipient) is also shown to not have Anti B; however this type may be limited in their inventory. Do you or Malcom know of any other current articles addressing the clinical significance of Anti A1? Thank you for any reply, Ronald

Galvania, Thank you for your post but I was not trying to compare reaction strength; I was more focused on antibody prevention. That is the comparison; both the neonate and our patient here are part of immune suppressed populations. With respect to the neonate we know that the suppression is really a lack of development of the immune system and that in three to four months the immune will be competent and capable of producing antibodies when sensitized. Our patient is also immune suppressed for two reasons, elderly and under treatment for cancer. The difference from the neonate is that we do not know when, if ever, our patient will become immune competent. Furthermore the immune competency in general may not be fully understood at all about our patient but given the age and treatment of our patient the better blood product is that which will not add any additional risk in antibody production. I practice and believe that part of our work in supplying compatible blood products is not only to identify an antibody but also to reduce the risk of producing an antibody as well; this reduction in risk of antibody production can circumvent complications in compatibility testing as well as any in-vivo complications, either acute or delayed. I firmly believe that this is the logic of the pathologist in switching to type O red cells in this case. These types of issues maybe resolved if and when molecular testing becomes more affordable; but I am sure this testing will lead to other discussions as well. And if you do not mind, Cliff, Malcom, Galvania and everyone, I would like to ask you to take a moment of silence in condolence for the passing of Glen Frye, one of the founding members of the Eagles, and know that his passing along with the passing of David Bowie last week are just happy an sad reminders that none of us are getting any younger and that we should take a moment to sit back and appreciate our lives and our privileges, especially this site and our ability to communicate and exchange ideas.

Hi Anna, I have been giving this situation much thought and I think that we are speaking about practical and theoretical issues. Lets look at another immune compromised population, the neonate. If we have a neonate with an Rh typing of Negative or undetermined we would, in practice give Rh Negative red cells. However, we know that the immune competence of the neonate is well documented and that the neonate can not generate an immune response and therefore can not produce an Anti D if we were to give Rh Positive red cells; and for sake of argument, not considering any maternal influences. However, we know that normally the neonate immune system has the capability to produce antibodies after three to four months of life; at, or greater than, the three month RBC circulating life cycle; therefore the neonate, theoretically, if give Rh Positive red cells would most likely not develop an Anti D. With respect to this case, which as I said, is also, most probably, immune compromised for two reasons, we do not know when this patient may become immune competent, unlike the Neonate, and therefore, more practical to give type O red cells. I hope this lends some clarification. Also, my name is Ronald but Roland is a good derivative.

Chris, I am not understanding why you are not ordering Irradiated products, upon need, from your blood product supplier?

With respect to the Acid Elution; according to procedure instructions in the package insert the cells are washed once with saline and four time with working wash solution but saline can be substituted for the working wash solution if none specific bonding is suspected; this would be a total of five washes in saline. Long ago when we had a very large blood bank lesure for documenting all testing and transactions, the blood bank supervisor explained that washing the cells excessively; six times or more could cause a loss of the antigen and therefore it would not be detected. We currently wash cord cells a maximum of four times prior to testing to remove Worten's Jelly and other unbound stuff.

Hi Malcolm, I agree with you that there is probably an unlikely possibility that this patient will develop and Anti A1 and any other antibody to the more antigenic antigen systems at present and perhaps in the future as well given the great probability of a state of immune compromise. (I would also like to ask you if you know of any studies that address when an immune compromised patient would regain immune competence; I know there are probably many variables to be considered.) I also agree that the probability of being sensitized to another antigen system is probably greater, and this risk is a general possibility any time any patient is transfused. But I would still agree with the pathologist in transfusing O Pos PC's because we know that there is already the general risk of sensitization to the A1 antigen and even though an Anti A1 may not be as harmful as other antibodies, why add an additional 25% percent of risk. I also think that perhaps this pathologist may not be as expert as you and is therefore covering their bases. But, Malcolm, I also wanted to wish you and your family the happiest of New Years and my best wishes, Ronald PS I can see molecular testing used more regularly on the horizon with all of it's benefits and liabilities.

Hi Malcolm, Thank for your good wishes. For this case, I think I understand what you are saying as far as the patient not demonstrating the A1 antibody at this time but this patient is most likely immune compromised for two reaesons; elderly, and under cancer treatment; so perhaps this is why there is no antibody. But then, there is the question of potential to produce this Anti A1. Does this patient have that potential to produce an Anti A1 at a later time? And then with respect to the issue of inventory management, type O Pos is far more readily available (at least in the Northeast Section of the US) then AB; as a matter of fact in our current inventory, we have over twenty times more O Pos PC's then AB PC's. So the O cells are readily available. As far as the Oh example, the Bombay phenotype, if I'm not mistaken; with respect to the described recipient phenotype, this donor would be ideal if the Oh type was not so rare. I would agree with the pathologist in this case and give O PC's, at least until there is some resolve with the cancer and/or treatment and then repeat the Type and Screen later when the patient is more immune competent, and go from there. But then I do not recall why this patient was in need of blood in the first place; is the need theropeutic or is the patient actively bleeding. The reason for the need could also impact the chioce of ABO type.

Hi Malcolm. Happy Holidays to you and family. The results given appear to suggest an A variant; with no Anti A1. Usually group A donor packed red blood cells are actually A1. Despite probable immune compromise of this patient would transfusion with group A packed red blood cells not be contraindicated? Would O packed cells not be the better choice here?

SSmith, I am sorry for your lose. Did you find out why the antibody screen was positive? This information is very important with regard to your current pregnancy.

Mabel, When you say "..weakly reactive.." are you refering to a ranking of 2+ or less?

Thank you so much Terri and Congrulations again.

Ditto

Terri, congratulations! Can I ask if you studied through a program or on your own. And if a program, which one?

Malcolm, I follow what you are explaining up to the last sentence. We always use a random Cord blood specimen as a positive control for the Kleihauer stain because this stain is specific for Fetal Hgb and it is a rare occasion when this positive control comes up negative; and if it does it is usually do to human error.

From what I understand, Albumin used in prep of cytospins allows the cells to migrate slower such that their morphology is not altered upon impact with the slide. ( Without the albumin making a cytospin on low viscosity body fluid is like throwing eggs at a brick wall; the eggs being the cells.) As far as the volume of Albumin used; I usually use one drop albumin to one to two drops of specimen depending on the white count; if using one drop of albumin to several drops of specimen it defeats the purpose; I had come across a good explanation of the use of albumin in the prep of cytospins through CAP continuing education. Also, when working with a bloody body fluid it is best to use the most minimal dilution to make your cytospin where the WBC's can be readily distinguished from RBC's and accurately counted. I hope this helps.

Hi Terry, I was just curious, is a thawed unit of FFP still good for five days using this microwave?

Mosaics, did you request a second specimen for confirmation? Did you check patient history to see when and where the Bone Marrow transplant was done?

Hi Brenda, this is an interesting situation; have you tried calling the mentioned "small hospital" and speaking to a blood bank rep directly?

Hi Evilwarning, that is a hell of a name; pun intended. I used Mary Turgeon hematology text when I studied for the HASCP. I would suggest seeing if a current text is in print. Also, a poster on this site had suggested McKenzie's Clinical Lab Hematology, 2nd edition, 2010, which they used to sit for their SHASCP. I hope this helps.

Hi John, I would agree that given the patient's age the A1 antigen may very well be weaken however if we are seeing Anti-A reaction at 2+ shouldn't we expect some reactivity with Anti-A1 lectin if the patient indeed has an A1 antigen? I am not sure which test if either is more sensitive, or if sensitivity is even an issue.

JPCroke, very interesting post here; can you further explain the specifics of the "monolayer methods, specialized testing?" Also, in the example you give with the Anti-E, are you not first antigen typing these units, or are you just performing the extended crossmatch (Coombs Crossmatch) and assuming with compatibility the units are negative for Anti-E?

How about a sub-section of the Education section on the site, "Everything You Wanted to Ask About Blood Bank.. but where afraid to.." Here, in this section novel and experienced blood bankers can readily exchange questions and ideas in a broad context. A section like this may attract even more users to the site and provoke more current users to post questions and/or answers. Let me know what you think... Ronald

On Meditch we use the code E2684 to indicate 5day Thawed Plasma. But actually I think we use this code to indicate the thawing of the plasma and we enter the expiration date 5 days later.