Case Study: Jackie Ensley, MLS(ASCP) CM SBB CM Immunohematology - PowerPoint PPT Presentation

Case Study: Jackie Ensley, MLS(ASCP) CM SBB CM Immunohematology Reference Laboratory Manager Kentucky Blood Center 1

Objectives 1. To discuss a case study which required more complex antibody detection and identification 2. To review different methods of antibody detection 3. To discuss the transfusion recommendations and blood group involved with the case study 2

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HOSPITAL RESULTS • April 2017 patient reported to hospital with no defined antibody pattern:  1+ reactions in gel  No reactions in tube at AHG Needs 2 units 4

PATIENT HISTORY • Female, 45 years old, Caucasian • Last Transfusion in 2014 • History: B Positive -No blood bank history at any of the larger surrounding hospitals -Previously had non-specific gel reactivity - Hgb 6.2 -Patient diagnosis includes anemia and cellulitis left leg 5

Reference Lab testing ABO/Rh performed Anti-A Anti-B Anti-D A1 Cell B Cell ABO/Rh 0 4+ 4+ 4+ 0 B Positive DAT Performed Poly/tube Anti-IgG/ tube Anti-C3/ tube 0√ 0√ 0√ 6

Reference Lab testing Phenotyping Rh System Kell Duffy Kidd Lewis P MNS D C c E e K Fy a Fy b Jk a Jk b Le a Le b P 1 M N S s + + + + + 0 + 0 + 0 + 0 + 0 + + 0 Be sure to rule out anti-f, -K, -Fyb, -Jkb, -Leb, -M, -s Most likely R1R2 7

Reference Lab Testing – Plasma Rh System Kell Duffy Kidd Lewis P MNS Lutheran AHG-PeG IS Cell D C c E e V Cw K k Kp a Kp b Js a Js b Fy a Fy b Jk a Jk b Le a Le b Lu a Lu b P 1 M N S s I 0 1+ + + 0 0 + 0 0 + + 0 + 0 + + 0 + 0 0 + + 0 + + + 0 + II 0 0  + 0 + + 0 0 0 0 + 0 + 0 + + + + + + 0 + + + + 0 0 + AC 0 0  8

Reference Lab Testing – Plasma Rh System Kell Duffy Kidd Lewis P MNS AHG- PeG IS Cell C c E e K k Kp a Kp b Js a Js b Fy a Fy b Jk a Jk b Le a Le b P 1 M N D S s 1 0 0 + 0 + 0 + 0 + 0 + 0 0 + 0 0 + + 0 + 0 0 0 0  2 + + 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 0 + + 0 + 0 0  3 0 0 + + 0 + 0 0 + 0 + 0 + 0 + + 0 0 0 + 0 + 0 0  4 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + + 0 0 + 0 0  5 + + 0 0 + + + 0 + 0 + + 0 0 + 0 + + 0 + 0 + 0 0  6 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 0 + 0 + 0 + 0 0 0  Auto + + + + + 0 + 0 + 0 + 0 + 0 + + 0 0 0  9

Reference Lab Testing – Plasma Rh System Kell Duffy Kidd Lewis P MNS Lutheran GEL Cell C c E e K k Kp a Kp b Js a Js b Fy a Fy b Jk a Jk b Le a Le b P 1 Lu a Lu b D M N S s 1 + + 0 0 + 0 + 0 + 0 + + + + 0 + 0 + + + + + 0 + 1+ 2 + + 0 0 + 0 + 0 + 0 + + + 0 + 0 + + + 0 + 0 0 + 2+ 3 + 0 + + 0 0 + 0 + 0 + 0 0 + 0 0 + + + 0 + + + + 3+ 4 + 0 + 0 + 0 + 0 + 0 + 0 + + 0 0 0 + 0 + + + 0 + 1+ 5 0 + + 0 + 0 + 0 + 0 + + + + + + 0 + + + + + 0 + 1+ 6 0 0 + + + + + 0 + 0 + + 0 0 + 0 + 0 + 0 + + 0 + 3+ 7 0 0 + 0 + + + 0 + 0 + 0 + + + + 0 0 + 0 0 + 0 + 3+ 8 0 0 + 0 + 0 + 0 + 0 + 0 + 0 + 0 + + + 0 + + 0 + 2+ 9 0 0 + 0 + 0 + 0 + 0 + + 0 + + 0 + 0 0 + 0 + 0 + 0 10 0 0 + 0 + 0 + 0 + 0 + 0 + + 0 0 0 + + 0 + 0 0 + 2+ 11 + 0 + 0 + + + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 1+ Auto + + + + + 0 + 0 + 0 + 0 + 0 + + 0 0 10

Reference Lab Testing – Plasma Rh System Kell Duffy Kidd Lewis P MNS AHG- PeG GEL Cell C c E e K k Kp a Kp b Js a Js b Fy a Fy b Jk a Jk b Le a Le b P 1 M N D S s 1 0 0 + 0 + 0 + 0 + 0 + 0 0 + 0 0 + + 0 + 0 0 0  3+ 2 + + 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 0 + + 0 + 0  3+ 3 0 0 + + 0 + 0 0 + 0 + 0 + 0 + + 0 0 0 + 0 + 0  3+ 4 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + + 0 0 + 0  1+ 5 + + 0 0 + + + 0 + 0 + + 0 0 + 0 + + 0 + 0 + 0  2+ 6 0 0 + 0 + 0 + 0 + 0 + + 0 + 0 0 + 0 + 0 + 0 0  3+ Auto + + + + + 0 + 0 + 0 + 0 + 0 + + 0 0  Additional cells are tested in the gel and range from 1+ to 3+ as well 11

Serologic Problem Solving So where do we go at this point? • Let’s look at what we know:  Phase of reactivity: AHG  Strength/pattern of reactivity: almost all reactive, different strengths, weak in tube reacts best in gel  Patient history: previous history of non-specific gel reactivity  DAT/autocontrol: negative  Other info: B+ 12

Serologic Problem Solving So where do we go at this point? • Test phenotypically similar cell - negative for f, Fyb, Jkb, Leb, M, s Positive • Alloadsorption attempted Unsuccessful • Test with ficin treated cells Negative • Test with 0.2M DTT treated cells Positive 13

Testing Results Ficin / papain - Sensitive DTT 0.2M - Resistant Almost all cells reactive Different reaction strengths Does not adsorb out Reacts best in gel, not very well in tube Gerbich antibody Chido/Rodgers antibody 14

Pooled Plasma Inhibition 15

Pooled Plasma Inhibition Control Original plasma plasma Pooled plasma reactivity reactivity reactivity (6% albumin) 1+ 1+ 0 1+ 1+ 0 16

Great! 17

Gotcha! 18

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Anti-Ch IgG IAT >90% Class Optimal Occurrence DTT FICIN RESISTANT SENSITIVE 20

Chido/Rodgers Fun Fact: Named after the first antibody producers, Chido and Rodgers. 21 From Human Blood Groups by Geoff Daniels

Chido/Rodgers - “HTLA” • Reacts with majority of panel cells • Frequently described as “reactive weakly by the antiglobulin test.” – Reactions are very weak and will break apart very readily due to the weak attraction between the antigens and antibodies (low avidity). – Repeated reactions may be irreproducible and not give the same strength or reactivity • However, reactions of at least 1-2+ have also been seen using gel technique. 22

Chido/Rodgers - “HTLA” • These antibodies are not clinically significant • Weak reactivity with high titers >64 are characteristic, but titers below 64 have also been seen. **A high titer does not give us a specificity, but can help the lab determine if they are on the right track with identification** 23

Chido/Rodgers - “HTLA” • Usually negative DAT, but each patient is different with unique history, diagnosis and treatment plans • Reaction pattern suggests an antibody to a high-frequency antigen, and all or most cells are reactive at IgG. • Reactions do not seem to fit a specific antibody or combination of antibodies pattern 24

Chido/Rodgers - “HTLA” • 1-2 phenotypically similar cells are run and are reactive • Theoretically should not adsorb out of the plasma because of the low-avidity of the antibody 25

Transfusions • Antibody is not clinically significant • Give compatible RBCs if able to but due to high prevalence of antigen may not be able to find crossmatch compatible • May rarely see anaphylactic reactions with plasma products + platelets 26

Resources • Reid, Marion and Christine Lomas-Francis (2012). The Blood Group Antigen FactsBook , Elsevier. • Daniels, G. (2013) Human Blood Groups , 3rd edition, Wiley- Blackwell, Oxford, UK. Email me at jensley@kybloodcenter.org 27