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.) 

 

 

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.

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...

 

It would do her less harm than her bleeding to death.

5 minutes ago, Malcolm Needs said:

It would do her less harm than her bleeding to death.

Yes, that is what I tell them. 

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.

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

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.

We have an Anti-Jk3 and an Anti-AnWj.  Both are just so much fun.

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.

We had a patient with anti-Lub.  We gave phenotypically similar units positive for Lub.   

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?

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.

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.

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.

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

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.

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-Lu^b is interesting and rare enough to be exciting, but it is, nevertheless, clinically benign.

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, 20169 yr by heathervaught

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

We have a pregnant patient with an anti-U (also anti-N and anti-Leb)!

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?

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.

Isn't there something special that I'm trying to pull out of my brain in regard to N-,U-negative patients?

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!