Weak alloantibody anti Jka missed on routine crossmatching: a case report illustrating the importance of “Type & Screen”

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Weak alloantibody anti Jka missed on routine crossmatching: a case report illustrating the importance of “Type & Screen”

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Weak alloantibody anti Jka missed on routine crossmatching: a case report illustrating the importance of “Type & Screen”

  1. 1. Weak alloantibody anti Jka missed on routine crossmatching: a case report illustrating the importance of “Type & Screen”
  2. 2. Case Report Weak alloantibody anti Jka missed on routine crossmatching: a case report illustrating the importance of “Type & Screen” Rajnath Makroo a, *, Aakanksha Bhatia b , Rosamma c a Director & Senior Consultant, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India b Registrar, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India c Chief Technical Officer, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India a r t i c l e i n f o Article history: Received 7 January 2014 Accepted 17 February 2014 Available online xxx Keywords: Clinically significant Hemolytic transfusion reactions Dosage effect Group and screen policy a b s t r a c t THE KIDD system of blood groups was discovered in 1951 by Allen, Diamond and Niedziela. The Kidd antibodies are clinically significant antibodies and a number of hemolytic transfusions reactions resulting from them have been reported. Kidd antibodies are at times difficult to detect. They exhibit distinct dosage effect. We present here one such case of alloantibody anti Jka , that could have easily been missed, if the “Group and Screen policy” routinely practiced at our hospital was not in place. Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Provision of safe blood for transfusion is the prime re- sponsibility of every transfusion facility. This does not only imply thorough testing for infectious markers, but also pro- tection from hemolytic transfusion reactions resulting from alloimmunization. Ever increasing efforts at improving blood safety have led to incorporation of regular screening protocols for detection of irregular immune antibodies at various transfusion centers across the globe. The ultimate goal is to identify the exact specificity of the antibody and provide the corresponding antigen negative blood to the patients. In most transfusion centers across India, detailed sero- logical workup for such irregular antibodies is performed either in cases where a blood group discrepancy is detected or in cases of an incompatible/positive crossmatch. Since such a practice is less time consuming and cost effective, it appears to be the most practical approach, especially in the Indian setting. However, there is a definite chance of missing certain antibodies, some of which may be clinically significant. This usually happens when the units that are cross matched lack the particular antigen/s against which the patient has devel- oped antibodies. Also at times the titer of the irregular anti- body may be fairly low for causing a positive crossmatch. Besides this there are several antigens and their * Corresponding author. E-mail address: makroo@apollohospitals.com (R. Makroo). Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3 Please cite this article in press as: Makroo R, et al., Weak alloantibody anti Jka missed on routine crossmatching: a case report illustrating the importance of “Type & Screen”, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.02.004 http://dx.doi.org/10.1016/j.apme.2014.02.004 0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
  3. 3. corresponding antibodies that display a “Dosage Effect” resulting in misleading crossmatch findings. Examples of such antibodies are anti-Jka , anti-Jkb , anti-Fya , anti-Fyb , anti-C, anti-E, and anti-c.1,2 THE KIDD system of blood groups was discovered in 1951 by Allen, Diamond and Niedziela.3 The Kidd antibodies are clinically significant antibodies, usually IgG in nature and a number of hemolytic transfusion reactions (HTRs), espe- cially delayed HTRs resulting from them have been re- ported.4 Kidd antibodies are at times difficult to detect. They may directly agglutinate antigen positive cells; however the reactions are generally weak. They exhibit distinct dosage effect. The anti Jka reacts more strongly with Jk (aþbÀ) cells than with Jk (aþbþ), while some anti Jka can only be detected using Jk (aþbÀ) screening cells and thus all screening and identification cell panels must contain at least one such cell.5 We present here one such case of alloantibody anti Jka , that could have easily been missed, had we not had been following the “Group and Screen policy” routinely at our hospital. 2. Case report A 17-year-old girl with epilepsy was admitted to our hospital. CT showed a subdural hematoma, which required evacuation. As a routine protocol her “Group and Screen” sample was received at the department of Transfusion Medicine. Her blood group was B Positive, and antibody screening performed using the Solid Phase Red Cell Adherence technology (Capture, Immucor Inc. Norcross, GA) was negative. Two units of crossmatch compatible packed red cells were issued for the patient. Two weeks later another request for two units of packed red cells was received for this patient. As it had been over 72 hours since the previous transfusion episode, as per the transfusion policy followed at our center, antibody screening was repeated. To our dismay this time the antibody screen performed using a four cell panel of Capture (Immucor Inc. Norcross, GA.) was positive in one of the cells. The results are shown in Table 1. In the meanwhile, at the crossmatching counter two random B positive units had already been cross matched for the patient, both of which were compatible. Resisting the tendency to issue crossmatch compatible blood looking at the low hemoglobin levels of the patient and rising pressure from the clinical side, we went ahead with antibody identification. Appropriate samples were requested to be sent to the blood bank for testing. The serological investigations performed were as follows: Direct Coomb’s Test e Positive (1þ). Auto control e Positive (most likely due to positive DAT). Antibody identification was run on the automated analyzer Galileo (Immucor Inc. Norcross, GA). The results obtained are shown in Table 2. The reaction pattern clearly points towards an anti Jka . Since the reaction strengths were only weak to 1þ, we concluded that this patient had a weak alloantibody anti Jka . Extended antigen typing of the patient could not be performed since she was recently transfused. Table1eAntibodyscreeningcharte4cellpanel(ImmucorInc.Norcross,GA). Rh-HrKellDuffyKiddLewisPMNSsLuth-erenXg DCcEeFVCw KKpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1MNSsLua Lub Xga 1þþ00þ00þþþ0þ0þþþþþþ0þþþ0þ0þ01þ 2þ0þþ00000þþþ0þþ00þ0þ0þþ000þþ0 300þ0þþ000þ0þ0þþ0þ00þþþ0þþ0þ01þ 400þ0þþ000þ0þ0þ0þ0þ0þþ0þ0þ0þþ0 a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e32 Please cite this article in press as: Makroo R, et al., Weak alloantibody anti Jka missed on routine crossmatching: a case report illustrating the importance of “Type & Screen”, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.02.004
  4. 4. Further, this case clearly exemplifies the dosage effect shown by this antibody. In the cells where the Jka antigen is present in a homozygous state (double dose), the reaction strength is higher, while in the cells where the antigen is present in heterozygous state (single dose), the reaction is weak. With these results in hand, we went back to the units that had been cross matched for the patient and typed them for the Kidd antigens. The results of the antigen typing are shown in Table 3. The first unit was typed as Jka ÀJkb þ and was thus compatible. It was the second unit that was Jka þ Jkb þ but still compatible that raised a question on issuing blood merely based on crossmatch compatibilities. In the second unit the Jka antigen was in heterozygous state and hence the results of crossmatch were misleading. 3. Conclusion The initial negative antibody screen in this case suggests either absence of alloantibodies or the presence of very weak existing alloantibodies before transfusion. The detection of anti-Jka in post transfusion sample indicates immunization due to transfused units. Had we relied on crossmatch alone we could have transfused antigen positive blood to this alloimmunized young lady, thereby adding fuel to the fire. This case clearly illustrates the need of the “Type and Screen” policy being incorporated in routine trans- fusion practice. Conflicts of interest All authors have none to declare. r e f e r e n c e s 1. Makroo RN. Practice of Safe Blood Transfusion: Compendium of Transfusion Medicine. 2nd ed. New Delhi, India: KongPosh Publications Pvt. Ltd.; 2009. 2. Reid ME, Lomas-Francis C. The Blood Group Antigen Facts Book. 2nd ed. New York: Elsevier Academic Press; 2004. 3. Allen F, Diamond L, Niedziela B. A new blood group antigen. Nature. 1951;167:482. 4. Pineda AA, Vamvakes EC, Gorden LD, Winters JL, Moore SB. Trends in the incidence of delayed haemolytic and delayed serologic transfusion reactions. Transfusion. 1999;39:1097e1103. 5. Daniels G. Human Blood Groups. 2nd ed. Blackwell Science Ltd; 2002. Table2eAntibodyIdentificationchart-14cellpanel(ImmucorInc.Norcross,GA). Rh-hrKellDuffyKiddLewisPMNSsLuth-erenXg DCcEefVCwKkKpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1MNSsLua Lub Xga 1þþ0þþ0000þ0þ0þþþþ00þþ0þ0þ0þ01þ 2þþ00þ00þ0þ0þ0þþ00þ0þþ0þ0þ0þþ0 3þ0þþ0000þþ0þ0þþþ0þ0þþþ00þ0þþ0 4þ0þ0þþþ00þ0þ0þ0þþ00þþþþ000þ01þ 50þþ0þþ000þ0þþ00þþþ0þ0þþþþ0þ0w 600þþþþ000þ0þ0þþ00þ0þþþþ0þ0þþ0 700þ0þþ000þ0þ0þ0þþþ00þþþ0þ0þþw 800þ0þþ00þþ0þ0þ0þþþ0þ00þ0þþþ0w 900þ0þþ000þ0þ0þþ00þþ0þþþ0þ0þ00 1000þ0þþ000þ0þ0þ00þ0þ0þþþ0þ0þþ1þ 1100þ0þþ000þ0þ0þþ0þþþ000þþþ0þþw 1200þ0þþ000þþþ0þþWþ00þ0þþþ00þ01þ 1300þ0þþ000þ0þ0þ0þþ00þþþ00þþþ01þ 14þþ00þ00þþ00þ0þþþþþþ00þ0þþ0þ0w Table 3 e Kidd antigen typing of the cross matched donor units. X match Donors Result Kidd typing Patient Donor 1 Compatible Jka ÀJkb þ Donor 2 Compatible Jka D Jkb D Donor 2 red cells are indicated in bold since they were compatible inspite of being positive for Jka antigen. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3 3 Please cite this article in press as: Makroo R, et al., Weak alloantibody anti Jka missed on routine crossmatching: a case report illustrating the importance of “Type & Screen”, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.02.004
  5. 5. Apollohospitals:http://www.apollohospitals.com/ Twitter:https://twitter.com/HospitalsApollo Youtube:http://www.youtube.com/apollohospitalsindia Facebook:http://www.facebook.com/TheApolloHospitals Slideshare:http://www.slideshare.net/Apollo_Hospitals Linkedin:http://www.linkedin.com/company/apollo-hospitals Blog:Blog:http://www.letstalkhealth.in/

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