I had one antibody panel that I did that I suspected was an anti-E.  It came up 2+ in gel during antibody screen, but negative on cells 3 and 6.  What is your hospital's procedure for following up on testing?  Reason I ask is that it didn't come up as expected, and I got criticized by the supervisor, and it is bothering me.

 

As my co-workers and boss say, "antibodies don't read the textbook."

Yes..............all the time!

 

We recently had an antibody that we thought was an anti-D in an apparently D Positive patient.  We were not certain whether it was an auto-anti-D (although the auto control and the DAT were both negative) or an allo-anti-D in a Partial DIII or something similar.  We sent it to the International Blood Group Reference Laboratory for elucidation.  It was an anti-P1!!!!!!!!  Egg all over the face!!!!!!!!!!!

I have always trained my staff with these words, "Record what you see, not what you think it should be." In other words, proceed based on observations, not expectations.

I had one antibody panel that I did that I suspected was an anti-E.  It came up 2+ in gel during antibody screen, but negative on cells 3 and 6.  What is your hospital's procedure for following up on testing?  Reason I ask is that it didn't come up as expected, and I got criticized by the supervisor, and it is bothering me.

 

As my co-workers and boss say, "antibodies don't read the textbook."

Note:  Cell 3 had homozygous expression for anti-E and cell 6 was heterozygous for anti-E. 

 

Have you had negative reactions show up during a panel for something you suspected was anti-E?

Edited August 23, 201410 yr by Mosaics

Did you try the Ficin panel?

Did you try the Ficin panel?

 

Yep and cells 3 and 6 were 3+ positive.   

I had one antibody panel that I did that I suspected was an anti-E.  It came up 2+ in gel during antibody screen, but negative on cells 3 and 6.  What is your hospital's procedure for following up on testing?  Reason I ask is that it didn't come up as expected, and I got criticized by the supervisor, and it is bothering me.

 

As my co-workers and boss say, "antibodies don't read the textbook."

...but techs read the SOPs.   Maybe your SOP needs to be rewritten for cases like this?    

Edited August 24, 201410 yr by R1R2

Your cell 3 and  6 were 3+  in Ficin panel, negative in Untreated panel. Anti-E  was enhanced in Ficin.

You said you "suspected" Anti-E....was that based just on your Antibody Screen?  If so, that is what I like to call, "biased blood banking."  That may be why your supervisor was upset with you; because you based your panel on what you expected it to be (and I have seen people call negative reactions, positive, because they expected that cell to be positive; so biased blood banking can also be dangerous).

So what was your final conclusion?  While antibodies "don't read the book," it still seems a little odd that it would be Anti-E if only SCII was positive but both panel cells negative (unless perhaps you used a different methodology for the panel)?  I do see that you said it came up in Ficin.  Also, not sure if the outdate of your Screening Cells is different than the outdate of your Panel (i.e. perhaps panel cells were old.....but in general, would still expect them to react unless Antibody Screen was really weak).

Just some of my thoughts.

Brenda Hutson

The answer to the question is "way too often"! I agree with Brenda that, all things being equal, the panel should show parallel reactivity with the screening cells unless the antibody was teetering on the edge of detectability. Also, you mention that the E-positive ficin cells reacted. What I didn't see was the rest of them did not react. Please forgive me if a full ficin panel was performed - but be careful about just taking selected cells and testing them with a different methodology. The reactivity you see may not necessarily be due to the antibody you're suspecting - something else could be popping up that was not observable with the first method.

 

Phil

I am going under the assumption that you were using gel. I have seen that phenomenon many times,ie, cell 2 1-2+ with a negative panel. Ficin seems to make the E+ cells react, sometimes only the homozygous expression, the pt invariably types as E neg. I have also seen ficin destroy the cell 2 reactivity - I then go into the realm of HTLAs which are ficin sensitive.

There have been published articles about "enzyme only Anti-E" that is sometimes detectable very weakly in gel, but not in other methods. They are felt to be non-clinically significant. But of course we still honor them here by giving E negative units.

I once had an anti-E that was only detected by IAT,  but was not detectable using enzyme-treated red cells (confirmed by the International Blood Group Reference Laboratory). 

 

Now that was one Rh antibody that had REALLY not read the textbooks!!!!!!!!!!!!!!! :unsure: :unsure:

I am going under the assumption that you were using gel. I have seen that phenomenon many times,ie, cell 2 1-2+ with a negative panel. Ficin seems to make the E+ cells react, sometimes only the homozygous expression, the pt invariably types as E neg. I have also seen ficin destroy the cell 2 reactivity - I then go into the realm of HTLAs which are ficin sensitive.

David, do you have a thought as to why a R2R2 cell would react with a screen but not a panel under what I would think would be identical circumstances?

 

Phil

You said you "suspected" Anti-E....was that based just on your Antibody Screen?  If so, that is what I like to call, "biased blood banking."  That may be why your supervisor was upset with you; because you based your panel on what you expected it to be (and I have seen people call negative reactions, positive, because they expected that cell to be positive; so biased blood banking can also be dangerous).

So what was your final conclusion?  While antibodies "don't read the book," it still seems a little odd that it would be Anti-E if only SCII was positive but both panel cells negative (unless perhaps you used a different methodology for the panel)?  I do see that you said it came up in Ficin.  Also, not sure if the outdate of your Screening Cells is different than the outdate of your Panel (i.e. perhaps panel cells were old.....but in general, would still expect them to react unless Antibody Screen was really weak).

Just some of my thoughts.

Brenda Hutson

We used gel for antibody screen and panel.  Then, used cells 1 (negative for E), 3 (homozygous for E) and 6 (heterozygous for E).  All were in-dated.

The answer to the question is "way too often"! I agree with Brenda that, all things being equal, the panel should show parallel reactivity with the screening cells unless the antibody was teetering on the edge of detectability. Also, you mention that the E-positive ficin cells reacted. What I didn't see was the rest of them did not react. Please forgive me if a full ficin panel was performed - but be careful about just taking selected cells and testing them with a different methodology. The reactivity you see may not necessarily be due to the antibody you're suspecting - something else could be popping up that was not observable with the first method.

 

Phil

I was advised by my supervisor to run cells 1, 3 and 6.   I will keep in mind to do a full ficin panel.

I am going under the assumption that you were using gel. I have seen that phenomenon many times,ie, cell 2 1-2+ with a negative panel. Ficin seems to make the E+ cells react, sometimes only the homozygous expression, the pt invariably types as E neg. I have also seen ficin destroy the cell 2 reactivity - I then go into the realm of HTLAs which are ficin sensitive.

 

You assume correctly.  We use gel.  Very interesting that you have seen similar results. 

Your cell 3 and  6 were 3+  in Ficin panel, negative in Untreated panel. Anti-E  was enhanced in Ficin.

Yep.  I have had previous anti-E's that would react "as expected" in gel, but this is the first antibody where all cells were negative on the original panel.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

I am going under the assumption that you were using gel. I have seen that phenomenon many times,ie, cell 2 1-2+ with a negative panel. Ficin seems to make the E+ cells react, sometimes only the homozygous expression, the pt invariably types as E neg. I have also seen ficin destroy the cell 2 reactivity - I then go into the realm of HTLAs which are ficin sensitive.

 

 

David, do you have a thought as to why a R2R2 cell would react with a screen but not a panel under what I would think would be identical circumstances?

 

Phil

 

 

I've seen this sort of thing so often that it really makes me wonder.

 

I was out of town but just last week it happened with anti-Jk(a) that was interpreted as antibody of undetermined specificity. The patient was transfused IAT-compatible blood that was Jk(a)-positive. At least after that the antibody showed up in the panel.

I was advised by my supervisor to run cells 1, 3 and 6.   I will keep in mind to do a full ficin panel.

That is interesting that your supervisor would get upset with you for "thinking" it was Anti-E (perhaps biased), but then telling you to only run those 3 cells in Ficin.  You should always do parallel testing (I suggest, even running the same panel by each methodology) or that too is biased testing.  

Brenda

Regarding GEL and antibodies not hitting on all cells....

1 person referenced Jk^a.  The Kidd antibodies are something to definitely watch out for in GEL; I have even given lectures on this.  You may think you have ruled everything out; even using homozygous cells.  But then look back and see what your positive reactions all have in common.  If they are all homozygous for Jk^a or Jk^b (even if you have other homozygous cells that were negative), type the patient for that antigen (if they have not been transfused in past 3 months).  If they are negative.....if you have other potentiating media like PeG or Ficin, go after the Kidd.  If you do not, err on the safe side because I am telling you I have seen it enough times to know it is a very real phenomenon in GEL.....give the Jk^a or Jk^b negative!  If they have been recently transfused, try other potentiating media to pull it up more clearly or send out to a reference lab if that is what you do.  I was a reference lab supervisor at ARC at one point and we used to receive such specimens from Hospitals who only had GEL. 

But don't let this one get by you!  

Brenda

Could you perhaps post the antigrams, Mosaics?

I have seen lots of weak anti-E antibodies that did not react with single-dose cells.  If your cell 3 was somehow unusual (damaged or a strange E pos donor) then a weak anti-E might not react in any panel cells.  We had a panel a good while back that seemed to behave like this.  I wonder if Ortho has one homozygous donor with an unusual E antigen that not all antibodies recognize equally.

 

I request that Kidd antibodies in gel be ruled out with more than one double-dose cell because of the reactions described above.  I kind of think some of these antibodies would not even be detected in LISS so it isn't that gel is bad for them.  I think it is just pulling out really weak Kidd antibodies and they don't react consistently.  I have not tested this theory.

 

Although not really part of this case, I have been known to put the wrong antigrams back in the panel box (reversed them between 2 panels).  That really makes solving the antibody complicated!    It is now on my list of things to check when antibodies don't key out to anything.

 

David, do you have a thought as to why a R2R2 cell would react with a screen but not a panel under what I would think would be identical circumstances?

 

Phil

I have spoken with the Ortho technical folks about this. If I use another vendor's panel and make the cells 0.8% - invariably the neat panel is negative. Only sometimes will the R2R2 cells react when enzyme treated. I also have the Ortho B panel for instances like this. Even these R2R2 cells usually will not react but enzyme will make them all react ANd only the R2R2 cells, not the heterozygous expression. As I said above, the patient is invariabley E neg. When the R2s are reacting I have to call it anti-E. I think it must be one of those that develops without rbc stimulation but no one really knows. I know that doesn't answer your question. I really think that the screening cell 2 reactivity is a real phenomenon and is either a naturally occurring anti-E or when removed by enzyme, an HTLA like Chido/Rogers. I think I noticed that a lot of these seemed to occur in multips but I can't verify that now.

Another thing I've noticed is that the Ortho cells seem extremely sensitve. Something in their manufacturing process it must be - they also don't hemolyze. I keep panels for an extra 3 months and the Ortho cells are never hemolyzed. I find that interesting.

Edited September 4, 201410 yr by David Saikin

Despite both cells being R2R2, perhaps the screening cell donor still had a little more antigen on his/her cells than the panel cell donor. You wouldn't see the reverse situation because the screen would be negative and you wouldn't do a panel. Still, 2+ vs. nothing (the original post) is pretty impressive.