Hemolytic transfusion reaction due to inter-donor kell incompatibility: report of two cases and review of the literature.
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Blood Group Incompatibility↗
Biomedical subjects
I A Shulman
Publications and source records attributed to I A Shulman.
When should antibody screening tests be done for recently transfused patients?
The American Association of Blood Banks (AABB) requires that blood samples used for pretransfusion testing of recently transfused (or pregnant) patients must be obtained within 3 days of scheduled transfusions. This requirement, which became effective in July 1988, amended Standard G2.000 of the AABB, which previously required that pretransfusion testing must be done on blood samples obtained within 2 days of scheduled transfusions. The present study was designed to estimate the risk associated with adopting the amended version of Standard G2.000. Sixty patients who developed significant unexpected alloantibodies after transfusion were studied retrospectively. Thirteen of the 60 patients were found to have newly detectable antibodies within 83 hours of a sample reported to be negative for the new antibody. Had the amended version of Standard G2.000 been in effect, the detection of some of these antibodies might have been delayed up to 24 hours. It was estimated that the implementation of the new AABB requirement at the authors' institution could potentially place about 1 in 3000 transfused patients at risk for an acute or delayed hemolytic transfusion reaction.
Blood Group Incompatibility↗
The impact of screening a heterogeneous donor population for alanine aminotransferase and hepatitis B core antibody. Experience at a large southern California hospital.
To reduce the transmission of non-A, non-B (NANB) hepatitis, the American Association of Blood Banks (AABB) has recommended that donors be screened for elevated levels of alanine aminotransferase (ALT) and for the presence of antibody to hepatitis B core antigen (anti-HBc). In this survey of 5,336 donors, the authors report the impact of using both of these surrogate tests on a heterogeneous donor population that was composed of white, black, Hispanic, and Asian donors. Hispanic and male donors had relatively high ALT levels, and black and Asian donors had a higher prevalence of anti-HBc than their respective counterparts. The overall impact of using both surrogate tests resulted in a discard rate of 12.1% with a disproportionately high percentage of Hispanic and male donors excluded because of ALT testing and black and Asian donors because of anti-HBc testing. It appears that surrogate testing has a much greater impact on blood collection facilities that rely considerably on Hispanic, Asian, black, or male donors than those that largely draw white or female donors.
Black or African American↗
The risk of bacterial growth in units of blood that have warmed to more than 10 degrees C.
Most transfusion services discard unopened units of blood that have been returned to the blood bank more than 30 minutes after the issuance or have attained a temperature of more than 10 degrees C. The objective of this study was to learn the prevalence of bacterial growth, if any, in the units of blood that were exposed twice, for six hours each time, to room temperature during their refrigerated storage. All of the 396 units cultured were negative except one red cell unit that grew a Bacillus species, probably B. subtilis. Further studies suggested that the growth of B. subtilis was due to laboratory contamination. The authors concluded that more work is needed to study the bacterial growth and the effect on red cell enzymes in the units of blood that are exposed to room temperature for varying periods or are returned to the blood bank after 30 minutes of issuance. If no adverse effect is noted, the policy of not reissuing such units may need revision so that more units could be salvaged.
Bacteria↗
Can storage of thawed cryoprecipitate be extended to more than six hours?
Fresh-frozen plasma (FFP) and cryoprecipitate both contain Factors I and VIII, however thawed FFP may be stored at 1-6 degrees C for 24 hours, but thawed cryoprecipitate may only be stored at 1-6 degrees C for six hours when used for Factor VIII content. To determine whether it would be safe and effective to extend the storage period of thawed cryoprecipitate from 6 to 24 hours, Factor VIII (and fibrinogen) levels were measured in 25 units of cryoprecipitates immediately on thawing and at 6 hours and 24 hours thereafter. The Factor VIII activity level decreased to 86% of the original activity level within 6 hours, but the drop between 6 and 24 hours was relatively small. Eighty percent of the original activity was still present at 24 hours after thawing. The fibrinogen level decreased to 87% of the original level within 6 hours but remained stable between 6 and 24 hours. Additional testing showed that fibrinogen levels remained stable between 6 and 74 hours. These data suggested that the storage of thawed cryoprecipitate might be extended to 24 hours when this blood product is used for Factor VIII content and to 74 hours when it is used for fibrinogen content. Furthermore, the lack of prohibition on the use of cryoprecipitate that has been thawed for more than six hours and stored at 4 degrees C for its fibrinogen content seems reasonable.
Blood Preservation↗
Immune hemolytic anemia associated with biclonal cold autoagglutinins.
A 65-year-old man with bladder outlet obstruction due to prostatic hypertrophy was incidentally discovered to have cold-antibody autoimmune hemolytic anemia (cold-aggluthinin syndrome; CAS) due to autoanti-I (titer 1,024 at 4 degrees C and 64 at 30 degrees C), and a biclonal gammopathy. Immunofixation electrophoresis of serum and a red blood cell eluate revealed the patient's autoantibody to be biclonal IgM kappa and IgA kappa. No underlying cause could be determined to explain the development of either the biclonal gammopathy or the CAS. To our knowledge, this is the first reported case of CAS associated with a biclonal gammopathy and biclonal cold autoagglutinins of the IgM kappa, IgA kappa type.
Aged↗
Autoanti-Ge associated with severe autoimmune hemolytic anemia.
Severe autoimmune hemolytic anemia due to anti-Ge is described. The patient's red cells had a positive direct antiglobulin test, and they typed as Ge+ using saline reactive reagents. Anti-Ge was eluted from her RBCs, and her serum had an IgG and IgM anti-Ge2,3.
Adult↗
The risk of an overt hemolytic transfusion reaction following the use of an immediate spin crossmatch.
The major crossmatch must include an anti-human globulin test, unless the transfusion recipient has no apparent significant unexpected antibodies, in which case the use of only an immediate spin crossmatch method is considered acceptable. However, a minority of laboratories utilize only an immediate spin crossmatch as their routine major crossmatch, possibly because contemporary antibody screening tests occasionally miss detecting some unexpected antibodies, and these missed antibodies are more often detected by the anti-human globulin crossmatch than by the immediate spin crossmatch. In the present study, 20 hospitals were surveyed to determine how often an acute hemolytic transfusion reaction would occur when only an immediate spin crossmatch was used as the major crossmatch method. During the study period, 1.3 million immediate spin crossmatches were performed, and five patients experienced acute overt hemolytic transfusion reactions that were believed to be caused by antibodies that were missed by both the antibody screening test and immediate spin crossmatch (one hemolytic event per 250,000 immediate spin crossmatches). The implicated antibodies were anti-Jka, anti-Wra, anti-C, anti-c, and anti-Kpa. These survey data demonstrate that the routine crossmatching of blood using an immediate spin crossmatch may rarely result in an acute hemolytic transfusion reaction if the antibody screening cells used during pretransfusion compatibility testing fail to detect some clinically significant red blood cell antibodies.
Blood Group Incompatibility↗
Compatibility of ADSOL-stored red cells with intravenous solutions.
Five percent dextrose in water (D5W) and lactated Ringer's (RL) are two intravenous solutions that are incompatible with citrate phosphate dextrose (CPD) anticoagulated RBCs. Hemolysis, agglutination, and clotting can occur when RBCs are mixed with, infused together with, or transfused in the same line following administration of these fluids. Although minimal plasma remains in units of RBCs containing adenine-saline-dextrose solution (ADSOL; Fenwal Laboratories, Deerfield, IL), clots are seen immediately after contact is made with RL. Clumping and hemolysis are seen when ADSOL-stored RBCs or saline-washed RBCs are mixed with D5W. This study reinforces the unsafe practice of mixing RBCs with certain intravenous solutions.
Adenine↗
The sensitivity and specificity of the immediate-spin crossmatch.
The immediate-spin (IS) crossmatch is used to detect ABO incompatibility between donor red cells (RBCs) and the serum of the intended recipient. However, this test may be positive in the absence of ABO incompatibility (false positive) or it may be negative when ABO incompatibility exists (false negative). During a 25-month study, the rates of both false-positive and false-negative IS crossmatch results were evaluated, and the sensitivity and specificity of the IS crossmatch were determined. During the study period, 53,656 IS crossmatches were performed for patients without significant RBC antibodies. Fifty-five patients had positive IS crossmatches, and no false-negative reactions were found. In tests of 55 patients with positive IS crossmatches, 77 false-positive and 5 true-positive reactions were noted. The causes of the false-positive reactions were rouleaux (36 patients), cold-reactive antibodies (8 patients), a combination of rouleaux and cold-reactive antibodies (2 patients), fibrin clot (1 patient), and undetermined (3 patients). The sensitivity and specificity of the IS crossmatch were 100 and 99.86 percent, respectively. Laboratory personnel should be aware that the IS crossmatch may have false-positive or false-negative results, and they should develop written protocols to distinguish quickly between true-positive and false-positive reactions.
ABO Blood-Group System↗
A review of donor alanine aminotransferase testing. Implications for the blood donor and practitioner.
To reduce the incidence of post-transfusion non-A, non-B hepatitis, the American Association of Blood Banks has required that serum alanine aminotransferase activity be used to screen blood donors. Consequently, approximately 2% to 3% of all blood donations will be discarded owing to an elevated alanine aminotransferase level. In addition, approximately 0.7% of blood donors will be notified of an abnormal alanine aminotransferase result. While some of these donors may have viral hepatitis, factors such as the donor's age, gender, body weight, ethnic background, alcohol intake, diet, and exercise must also be considered when interpreting an elevated alanine aminotransferase level. Donors with significant or persistently elevated alanine aminotransferase levels should have their conditions evaluated so that treatable diseases can be recognized and/or treated.
Alanine Transaminase↗
Adverse reactions to blood transfusion.
The transfusion of whole blood and blood components is usually a temporarily effective means of correcting red cell, white cell, platelet, and coagulation factor deficits. Unfortunately, blood and blood components are occasionally unavoidably unsafe, which results in a spectrum of adverse reactions following transfusion. These reactions may be immunologically or nonimmunologically mediated, and may vary in severity from mild to fatal. Physicians should weigh the potential risks versus the potential benefits of each blood transfusion. Only when the benefits clearly outweigh the risks should a blood transfusion be administered. Transfusionists must carefully monitor each blood transfusion for signs and symptoms of transfusion reactions in order to minimize their adverse effects.
Humans↗
Blood transfusion in medically treatable chronic anemia. Pernicious anemia as a model for transfusion overuse.
Transfusion practice in patients with treatable, readily recognizable, chronic anemia was reviewed because such patients only infrequently need to be transfused. Pernicious anemia with hemoglobin concentration below 100 g/L was chosen as the model for this assessment. Sixty-two (51%) of 122 patients received blood transfusion, although most patients had chronic, low-grade symptoms despite their low hemoglobin levels and could have been satisfactorily managed without transfusion. Only 34 of the 122 had findings suggesting an urgent need to raise the blood cell count, but their transfusion rate (44%) was no different from that in patients without such findings. These observations in pernicious anemia indicate that transfusion of patients with medically reversible anemia is a common problem. They further suggest that current transfusion usage overemphasizes laboratory results (ie, hemoglobin levels) at the expense of clinical assessment of severity of symptoms. Improvement of current practice is needed, particularly in view of valid concerns about the serious side effects of transfusion, shortages of available blood resources, and health care costs.
Adolescent↗
Safety in transfusion practice. Is it safe to eliminate the major crossmatch for selected patients?
If a patient has no clinically significant unexpected antibodies, a major crossmatch is not required prior to blood transfusion so long as a test method that demonstrates ABO incompatibility is done. In this study, the safety of using a noncrossmatch method for detecting ABO incompatibility was compared with the use of an immediate spin crossmatch (ISCX). This noncrossmatch method consisted of the duplicate ABO testing of blood recipients, the repeated ABO testing of donor blood, and a clerical check to assure that only ABO matched or compatible blood was selected for transfusion. During the one-year study, 7124 patient samples were tested in duplicate for ABO, 26,942 U of red blood cells received from blood collection facilities were retested for ABO, and 23,962 U of blood selected for transfusion based on the noncrossmatch method were tested by an ISCX. ABO test results were concordant for 7115 of 7124 patient samples and discordant for nine. Seven of the nine discordant patient test results were resolved prior to transfusion, and two were inadvertently overlooked. ABO test results were concordant for 26,922 of 26,942 donor units and discordant for 20. Seventeen of the 20 discordant donor test results were resolved prior to transfusion and three were inadvertently overlooked. Two ABO incompatibilities were missed by the noncrossmatch method but were detected by the ISCX. Unless clerical errors can be totally eliminated, it may be safer to retain the ISCX.
ABO Blood-Group System↗
Detection of minor red blood cell populations using an immunocytochemical stain.
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Female↗
Use of a table-top analyzer for predonation screening for alanine aminotransferase--a cost-effective approach?
To reduce the transmission of non-A-non-B hepatitis, the American Association of Blood Banks has required that all blood donations with alanine aminotransferase (ALT) levels above a certain cut-off level to be discarded. This discard rate resulting from high ALT levels was 5.3% at the authors' donor center, which was more than double the expected rate of 2.3%. If blood donors could be tested for their ALT levels before blood donation, unnecessary discarding of blood and related expenses could be eliminated. Therefore, the authors evaluated a table-top ALT analyzer for screening donors before blood donation. The method was precise and linear and correlated well with the SMAC-II analyzer. Based on a cost-savings analysis, the authors found it to be financially beneficial to perform predonation ALT testing. Because the cost of labor and reagents may vary from institution to institution, however, other facilities should perform their own cost-savings analyses before implementing predonation ALT testing.
Alanine Transaminase↗
Additional limitations of the immediate spin crossmatch to detect ABO incompatibility.
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ABO Blood-Group System↗
The impact of alanine aminotransferase testing on Hispanic blood donations.
The American Association of Blood Banks, Arlington, Va, has required that all blood donors must be tested for serum alanine aminotransferase (ALT), and that donations from donors with ALT levels above a certain cutoff value must be discarded. To assess the impact of this requirement on different ethnic/racial groups, the ALT levels of 1781 blood donors were compared. Hispanic blood donors had significantly higher ALT levels than did black and non-Hispanic white blood donors. No significant difference in ALT was seen between black and non-Hispanic white blood donors. We conclude that there are statistically significant differences in the ALT levels between Hispanic and non-Hispanic blood donors, and that a disproportionate number of Hispanic blood donations (11% to 13%) will be discarded as a result of testing blood donors for ALT.
Alanine Transaminase↗