68 y/o african american female presents to ED with severe abdominal pain and heavy vaginal bleeding. Imaging is performed and there's a significant concern for malignancy. Patient has a history of multiple pregnancies, three live births, unclear transfusion history. Labs: 5 g/dL hgb. elevated coags, negative antibody screen in gel.

 

Patient is transfused 4 RBCs during the first and second days of admission.

Day three the patient is transfused 2 FFP for a procedure.

Day ten the patient is tested for type and screen again for the upcoming OR case and the screen is 1+ positive in gel, three cell. The three cell is rr K+k+Fy(a+b-)Jk(a+b-)Le(a-b+)M+N+S-s+. The gel antibody panel was negative with a 1+ positive autocontrol. The DAT was 1+ positive by polyspecific and IgG. An acid elution was performed and found to be negative.

On day eleven the sample is tested for antibody screen in tubes with PEG and found to be negative. The antibody is reported as undetermined specificity, requiring IAT XMs. The patient is transfused 2 RBCs operatively.

On day twelve another RBC is transfused.

On day thirteen another RBC is transfused.

On day fifteen the patient is tested for type and screen again due to expiration and the screen is 2+ positive in gel, three cell, same lot as before. The gel antibody panel shows an obvious pattern with Jk(a). The autocontrol is still positive. The DAT is 1+ positive with poly, IgG and complement. The acid elution shows an obvious pattern with Jk(a). Segments from the transfused units are phenotyped for Jk(a) and 6 of 8 were antigen positive.

 

If you encountered a scenario like this in real-time, how would you have approached it, from a reviewers standpoint? e.g. would you have performed any additional testing with the day ten sample or would that have been appropriate per your facility's policies? would you have performed any repeat testing with the day ten or day fifteen samples?

The only additional thing I would have performed is an enzyme pretreated panel in gel. I have started doing that routinely on screen positive/panel neg or inconclusive results. I also have found an anti-Jka (on a heavily transfused oncology referral) only with the pretreated cells. My screening cell (#3 also) was so minimally positive that I would have called it negative if it wasn't an onco pt.

In fact, if you use the enzyme-pretreated panel on Coombs cards (an enzyme Coombs) with 15mins incubation at 37°C this usually gives good reactions with anti-Jk antibodies.  Also, I would have done a full phenotype on the pre-transfusion sample

On day 10 we also had performed enzym treated cells in anti IgG cards. When only one or a few reactions are found and they are all Jka or Jkb pos, we do that to look for anti Jk antibodies. The most sensitive methode to look for anti Jk antibodies. And also feno- or genotype the patient tot see what can be made.

I think all the posts above is wonderful.

What about the patient's manifestation except the pos DAT. We don't often use enzyme ,because some patient has anti-enzyme antibodies that confuse us. Maybe my opinion is somehow improper, but I want to say it out: If the undetected weak antibodies does no harm to the receipient, why would we do extra test , my meaning is gel often cause false pos just because its sensitivity , if we confirm every case by enzyme and try to avoid anti-enzyme to do other test, we need to prove it is worthful.

The pattern showed a Jka pattern so I would also enzyme treat panel & then perform IAT with patient's serum. - Helps.

 

A lot of work - but I might have been empted to phenotype for common antigens of patient's original sample (admittedly @ day 10, they may have deteriorated somewhat) when a problem emerged and also transfused units. ??????

But isn't hindsight a wonderful thing!

 

Cheers

Eoin

 

"Serving others is the rent we pay for our place on earth"

Eoin I do admit that it's easy for me to question the decisions that were made now that I have all of the information but this is why I wanted to check with my BBT colleagues as sort of a "peer review."

 

The reasons I was concerned:

 

Procedure for handling situtations like this wasn't followed.

Pos screen & neg (or autocontrol pos only) panel -> repeat screen with different cells of same lot. Repeat pos -> Look at the antigen expression on the positive cell(s). Perform alternate methodology/enhancement technique.

We recently updated our procedure after doing an in-depth retrospective review of our antibody studies and acute/delayed transfusion reactions.

 

Antibody study review process wasn't followed

We save all of our gel cards for a couple of days specifically for the purpose of being able to review problems/questionable circumstances and antibodies of undetermined specificity. This wasn't done. That same week we had another anti-Jk(a) reported as antibody of undetermined specificity because of a negative panel. During review another hospital was contacted who informed us of the patient's history of anti-Jk(a) and transfusion reaction. When the gel cards were reviewed weak reactions could be seen that matched anti-Jk(a).

 

And some other variables I won't address.

I am not sure we would have done anything more when the eluate turned out negative.  We don't keep any enzyme.  There are often stray positive reactions in gel (Bg etc.) and PEG will usually pick up Kidd antibodies quite well.  Of course, if your procedure wasn't followed then that is a problem.

 

Did the patient have a symptomatic reaction or just decreased H & H?

I agree with both David and Anna for their respective suggestions of an enzyme pretreated panel in gel and extended phenotype on the pre-transfusion sample.

You have done an elution on the patient's post-transfusion red cells, and the resulting

eluate tested for antibody specificity.

Note  that in this case, even though the antibody elutes from the patient's red cells, it is NOT an autoantibody as it actually eluted from the donor's red cells now in the patient's circulation.

Edited September 7, 201410 yr by Abdulhameed Al-Attas

Great case scenerio.  Thanks for sharing this with us.  I have had a weak Anti-Jka before and since it appears that you had a newly forming antibody, I might have repeated it with 4 drops of plasma and extended the incubation period for 30-45 min.  We have a policy that if the C3 becomes positive that we do the panel manually with polyspecific AHG and that is how we found our weak Anti-Jka.  I plan to share this with my senior CLS students.

Increasing the incubation time in gel to 30-40 minutes has also brought out weak anti-Jka reactions for me. Yes, I have validated the test at those times.

I agree with Mabel. We do not keep enzymes so that would not have been an option for us. The only failure I see (if you can even call it that) is the ambiguous transfusion history.

I am also curious as to if the patient was symptomatic. Was this called a DHTR?

I am not sure we would have done anything more when the eluate turned out negative.  We don't keep any enzyme.  There are often stray positive reactions in gel (Bg etc.) and PEG will usually pick up Kidd antibodies quite well.  Of course, if your procedure wasn't followed then that is a problem.

 

Did the patient have a symptomatic reaction or just decreased H & H?

 

My response on how we would have handled the situation is the same as Mabel's response.

 

Donna

Thanks everyone for reading and responding.

 

It was classified as a serological reaction. The patient did appear symptomatic, the h&h went down and the bili/creatinine went up however this was also during the patient's post-op course.

 

I didn't highlight all of this information in the original description of the case because I wanted to see how much the perception would change:

 

Our antibody screen is performed on the Ortho ProVue analyzer and all weak/? reactions are classified as 1+.

We only have the one analyzer however so we do antibody identification panels by manual method.

My main concern is the classification of weak gel reactions as negative because they're simply "junk."

 

How are junk reactions handled at your institution? Are gel cards for undetermined/inconclusive antibodies saved for subsequent review?

I have a question , will you call this patient has anti-Jka or not or suspicious has?

I am always looking for a Kidd antibody when I have a possible delayed transfusion reaction.  Since we don't have enzymes available, I use my Polyspecific AHG reagent with the elution [by tube] and it ususally comes up positive rather than using the IgG AHG reagent.  Just a thought.

Edited September 27, 201410 yr by profbaud

I have a question , will you call this patient has anti-Jka or not or suspicious has?

 

We called it anti-Jka.

So would we.