When you think you should transfuse don't!

A 48-year-old female presented to the emergency department with severe fatigue. Admission laboratory test results were hemoglobin 6.6 g/dL, platelet count 287,000/µL, and white blood cell count 25,200/µL. Lactate dehydrogenase was elevated at 898 U/L, haptoglobin was markedly decreased (< 31 mg/dL), indirect bilirubin was elevated (5.3 mg/dL), and the absolute reticulocyte count was low at 0.0050/µL. A sample was sent to the immunohematology reference laboratory. The direct antiglobulin test immunoglobulin G was negative; C3 was 1+. All cells were reactive at immediate spin phase, indirect antiglobulin testing (IAT) with polyethylene glycol, with low ionic strength saline, neat, prewarm, and in the solid phase. All cells were nonreactive at IAT-ficin. Additional testing included a cold antibody titer that was 1:4096 and thermal amplitude studies demonstrating reactivity of 2+ at 37°C. These results were consistent with a clinically significant anti-Pr and cold agglutinin disease (CAD). Although rituximab is effective in autoimmune hemolytic anemia, this may take weeks. The patient was treated with pegcetacoplan, a pegylated peptide that targets C3 inhibiting hemolysis. The patient was discharged on day 29 with a hemoglobin of 8 g/dL. This is a report of one of the first patients successfully treated with pegcetacoplan for CAD.

Comparison of RhD Typing Results by Serology and Molecular Methods.

OBJECTIVE: Molecular testing determines D antigen status when abnormal serologic results are observed. Molecular testing is routinely batched, resulting in longer turnaround time for abnormal D status resolution. During the interim, obstetric patients with questionable/uninterpretable and weak D typing results by serology, per the immunohematology reference laboratory (IRL) policy, will receive RhD negative blood. This study aimed to determine whether serology results achieved a concordance. METHODS: Six hospitals provided samples to the IRL (first IRL) for RhD status by DNA. De-identified samples were sent for serology RhD (second IRL). A concordance of ≥80% was acceptable. RESULTS: Forty-nine samples were evaluated. Results were concordant (65.3% [32/49]) and discordant (34.7% [17/49]). This is significantly lower than clinically acceptable 80% (z = 2.57, P < .05). The turnaround-time was 3.0 hours for serology and 4.4 days for molecular evaluation. CONCLUSION: Due to a low concordance, serology could not be used in place of molecular testing.

A Hemolytic Transfusion Reaction Caused by an Unexpected Leb Antibody.

A Black male patient aged 21 years with a history of sickle cell disease and HIV was admitted to the hospital with vaso-occlusive crisis. A transfusion reaction was called after the patient developed a fever (39.5°C), tachycardia, chills, and hematuria after receiving 300 mL of red blood cells. A posttransfusion specimen was submitted to the Immunohematology Reference Laboratory for investigation. Antibody identification revealed an anti-Leb as the probable cause of the immediate acute hemolytic transfusion reaction. Lewis antibodies are considered clinically insignificant. This case shows the importance of considering cold antibodies, including Lewis antibodies, as a possible cause of an acute hemolytic transfusion reaction.

A Rare Cohort of Two Rhnull Individuals.

OBJECTIVE: A 77 year old female was admitted with a subdural hematoma requiring 1 unit of apheresis platelets. She was a study subject in the 1960s and was found to be Rhnull, along with another individual who previously served as a directed donor for her. METHODS: Serologic testing performed by the immunohematology reference laboratory (IRL) confirmed that the patient was Rhnull and expressed anti-Rh29 antibodies. While searching for red blood cells (RBCs) for possible transfusion, it was discovered that the individual from the original study had recently donated an autologous unit. RESULTS: The IRL discovered that the donor's antigen typing was r'r'. Testing had been performed using a molecular human erythrocyte antigen BeadChip (HBC). Due to the discrepancy between current and historical testing results, a donor segment was thawed and by tube testing confirmed to be Rhnull. A limitation of HBC is that many null phenotypes will be missed. CONCLUSION: This case demonstrated that Rhnull evaluation of the donor required both serological and molecular methods.

An international effort and use of social media to save a young girl.

BACKGROUND AND OBJECTIVES: A 2-year-old female with neuroblastoma needed In(b-), E- red blood cells (RBCs). No units were available at the blood centre (BC) nor in the rare donor programme member's inventories. BC's Immunohematology Reference Laboratory (IRL) and its marketing department concentrated on recruiting and testing those donors more likely to be antigen negative based on ethnicity. MATERIALS AND METHODS: The BC's communication plan utilized social and traditional media to assist in the search for In(b-) blood. Media strategies directed donors in the United States (US) and Canada to go to their nearest BC for collection, tagging and testing of units. Two segments from each donation were shipped overnight to the BC's IRL (associated with the patient) for testing. Diluted anti-Inb sera was tested by microtechniques to conserve resources. Additionally, the American Rare Donor Program (ARDP) facilitated the international searches and acted as a liaison to the Food and Drug Administration (FDA). RESULTS: More than 25 000 people responded to the appeal. Seventy-seven BCs submitted segments from 4197 units. Two donors were In(b-) but E+ and thus not compatible with the patient but were submitted to ARDP for future needs. The prevalence of In(b-) units identified in the search was 0·048%. In total, five known In(b-) donors, two from the US and three from international sources, provided units for this patient. CONCLUSION: Social media sparked a viral response to the rare blood need. While a match was not found among the units tested, domestic and international searches were able to meet the patient's blood needs.

Rare blood donor needed.

BACKGROUND: Here, we describe a 14-year-old male with leukocyte adhesion deficiency type 2 who was transferred to a university hospital with anemia (hemoglobin 6 g/dL) and multiple singular abscesses refractory to antimicrobials. CASE REPORT: As leukocyte adhesion deficiency type 2 is associated with Bombay phenotype, the patient's red blood cells (RBCs) were tested with commercial anti-H lectin Ulex europaeus. An allogeneic adsorption with phenotype-matched cells was performed. RBCs negative for H antigen (Oh ) were tested with patient's plasma. The American Rare Donor Program was contacted to find granulocyte donors. The patient was Bombay phenotype (Oh ). All major clinically significant alloantibodies were excluded testing Oh cells and allogeneic adsorbed plasma. Two Bombay RBC units and five doses of granulocytes were requested from the blood center. Two frozen Bombay RBC units were obtained through another blood center. The American Rare Donor Program found one eligible granulocyte donor who lived 4 hours by car from the collection center. Because of this concern and other major logistic challenges, the blood center considered other options. These methods included gravity sedimentation and a cell separation system to isolate the RBCs from granulocytes. Unfortunately, neither one could be implemented. Auspiciously, the patient's condition improved and granulocytes were no longer needed. CONCLUSION: To avoid the challenge of finding compatible granulocyte donors for patients with rare blood types and clinically significant antibodies, our blood center considered validating and implementing gravity separation to remove the incompatible RBCs from granulocyte collections.