Finding the Phenotype of a Recently Transfused Warm Autoantibody - PowerPoint PPT Presentation

Finding the Phenotype of a Recently Transfused Warm Autoantibody Patient Kathy Evans MS, MT(ASCP)BB Blood Bank Master Tech at UKHC Good Samaritan Hospital August 18, 2017 gkev@uky.edu

• Indiana Blood Center IRL, Indianapolis, IN • UK HealthCare Good Samaritan Hospital, Lexington, KY Background

• Identify the key differences between a typical patient and a patient that presents with a warm autoantibody in the Blood Bank. • Describe the additional testing required to complete a warm autoantibody. • Discuss the practical use for molecular testing for recently transfused patients with a warm autoantibody. Objectives

Case Patient: Atypical, Andy BLOOD TYPE Anti-A Anti-B Anti-A,B Anti-D Ctrl A1 C B C Interp 4+ 0 4+ 4+ 0 0 4+ A positive IAT SCREEN Cell Antigens Gel D C E c e K k Fya Fyb Jka Jkb M N S s I + + 0 0 + 0 + + + 0 + + + 0 + 0 II + 0 + + 0 0 + + 0 + 0 0 + 0 + 3+ III 0 0 0 + + + + 0 + + + + 0 + 0 0 INTERPRETATION: IAT Positive IAT PANEL Cell Antigens Testing D C E c e K k Fya Fyb Jka Jkb M N S s Gel 1 + + 0 0 + 0 + 0 + + 0 + + 0 + 0 2 + + 0 0 + 0 + + + + 0 0 + 0 + 0 3 + 0 + + 0 0 + + + + + + 0 0 + 4+ 4 + 0 0 + + 0 + 0 0 + 0 + + 0 + 0 5 0 + 0 + + 0 + 0 + + 0 + + 0 + 0 6 0 0 + + + 0 + 0 0 + 0 + + 0 + 3+ 7 0 0 0 + + + + 0 + 0 + + 0 + + 0 8 0 0 0 + + 0 + + 0 + + + + 0 + 0 9 0 0 0 + + 0 + + 0 + + + + 0 + 0 10 0 0 0 + + 0 + + 0 0 + 0 + + 0 0 AC 0 INTERPRETATION: Anti-E Single Alloantibody

• Panel with Autocontrol • Direct Antiglobulin Test • Elution • IgG removal • Cell separation* • Extended red cell phenotype • Auto-adsorption or Allo-adsorption* • Auto-checks Additional testing

Case Patient: Transfused, Teddy BLOOD TYPE Anti-A Anti-B Anti-A,B Anti-D Ctrl A1 C B C Interp 4+mf 0 4+mf 4+ 0 0 4+ A positive IAT SCREEN Cell Antigens Gel D C E c e K k Fya Fyb Jka Jkb M N S s I + + 0 0 + 0 + + + 0 + + + 0 + 4+ II + 0 + + 0 0 + + 0 + 0 0 + 0 + 4+ III 0 0 0 + + + + 0 + + + + 0 + 0 4+ INTERPRETATION: IAT Positive DAT SCREEN Rh Phenotype Poly IgG IgG IgG Ctrl C3 C3 Interp C E c e Ctrl ctrl 2+mf 1+mf 4+ 4+ 0 3+mf 3+mf 0 0 0 positive Looks like a Warm Autoantibody

Case Patient: Transfused, Teddy IAT PANEL Cell Antigens Testing D C E c e K k Fya Fyb Jka Jkb M N S s Gel PEG LISS 1 + + 0 0 + 0 + 0 + + 0 + + 0 + 4+ 4+ 3+ 2 + + 0 0 + 0 + + + + 0 0 + 0 + 4+ 4+ 3+ 3 + 0 + + 0 0 + + + + + + 0 0 + 4+ 4+ 3+ 4 + 0 0 + + 0 + 0 0 + 0 + + 0 + 4+ 4+ 3+ 5 0 + 0 + + 0 + 0 + + 0 + + 0 + 4+ 4+ 3+ 6 0 0 + + + 0 + 0 0 + 0 + + 0 + 4+ 4+ 3+ 7 0 0 0 + + + + 0 + 0 + + 0 + + 4+ 4+ 3+ 8 0 0 0 + + 0 + + 0 + + + + 0 + 4+ 4+ 3+ 9 0 0 0 + + 0 + + 0 + + + + 0 + 4+ 4+ 3+ 10 0 0 0 + + 0 + + 0 0 + 0 + + 0 4+ 4+ 3+ AC 4+ 4+ 3+ Looks like a Warm Autoantibody

Case Patient: Transfused, Teddy IgG IgG Acid wash IgG IgG IgG Eluate Patient’s Red Cells ELUTION Cell Antigens Testing D C E c e K k Fya Fyb Jka Jkb M N S s ELU LW Elution 0 SC I + + 0 0 + 0 + + + 0 + 0 + + 0 4+ 0 SC2 + 0 + + 0 + + 0 + + 0 0 + 0 + 4+ 0 4+ SC3 0 0 0 + + 0 + + 0 + + + 0 0 +

• When your red cells are coated with IgG • EGA (EDTA glycine acid) • CDP (Choloroquin diphosphate) IgG Y Ls Ls Ls Ls IgG Ls Ls Patient coated red cells Patient treated red cells IgG removed IgG Coated Red Cells

• Why is “recently transfused” important to know? • Cell Separation Techniques: Retic harvest Hypotonic cell wash Recently transfused

6mm Rh Phenotype Rh Phenotype C E c e Ctrl C E c e Ctrl 2+mf 1+mf 4+ 4+ 0 0 0 4+ 4+ 0 Impact of Cell Separation on Phenotype testing:

Case Patient: Transfused, Teddy BLOOD TYPE Anti-A Anti-B Anti-A,B Anti-D Ctrl A1 C B C Interp 4+ 0 4+ 4+ 0 0 4+ A positive DAT SCREEN Poly IgG IgG IgG Ctrl C3 C3 Interp ctrl 3+ 3+ 0 0 0 positive IgG REMOVAL 0 Patient 0 Control Donor Rh Phenotype C E c e Ctrl 0 0 4+ 4+ 0 Extended Phenotype K k Fya Fyb Jka Jkb S s M N Lea Leb 0 NA 0 0 0 3+ 0 4+ NA NA NA NA Extended phenotype testing

• ZZAP treated patient cells • Patient’s plasma • Depending on strength of reactions, could be up to 4 serial adsorptions (45 minutes each) A C B Patient Patient Bound and unbound IgG Auto-Adsorption Alloantibody if present

• ZZAP treated known cells (R1R1, R2R2, rr) • Patient’s plasma • Depending on strength of reactions, could be up to 4 serial adsorptions each (45 minutes each) C B A R1R1 Patient R2R2 rr Auto-IgG and Allo-IgG Allo-Adsorption

Case Patient: Transfused, Teddy ALLO-ADSORPTION PANEL (x4) Cell Antigens Testing D C E c e K k Fya Fyb Jka Jkb M N S s R1 R2 rr LISS LISS LISS 0 0 0 1 + + 0 0 + 0 + 0 + + 0 + + 0 + 0 0 0 2 + + 0 0 + 0 + + + + 0 0 + 0 + 0 0 0 3 + 0 + + 0 0 + + + + + + 0 0 + 0 0 0 4 + 0 0 + + 0 + 0 0 + 0 + + 0 + 0 0 0 5 0 + 0 + + 0 + 0 + + 0 + + 0 + 0 0 0 6 0 0 + + + 0 + 0 0 + 0 + + 0 + 7 0 0 0 + + + + 0 + 0 + + 0 + + 3+ 3+ 3+ 0 0 0 8 0 0 0 + + 0 + + 0 + + + + 0 + 0 0 0 9 0 0 0 + + 0 + + 0 + + + + 0 + 10 0 0 0 + + 0 + + 0 0 + 0 + + 0 3+ 3+ 3+ 0 0 0 PT* INTERPRETATION: Warm Autoantibody Transfused WAA Allo-adsorption

Case Patient: Transfused, Teddy Treated cells IgG IgG AUTO CHECKS (after cell separation) Auto-Checks DAT IgG PEG-AHG LISS-AHG Gel Eluate 0 3+ 3+ 4+ 3+

• Quantity Not a Sufficient Quantity of patient red cells • Quality -Ability to provide red cell separation based on when the last transfusion occurred -The patient is not producing retics -IgG coating red cells too heavy to be removed Transfused WAA Common Issues

• Can provide extended antigen typing otherwise difficult to conclude with serological testing • Not effected by recent transfusions • Future alloantibodies generally limited to absent antigens • Provide information about “self - antibodies” • Serologic typing discrepancy or ambiguity Advantages to Molecular

• Anemias (sickle cell, thalassemia), autoantibodies, anti- CD38, complex multiple unidentified or high frequency antigen alloantibodies, antibodies with no or little typing sera available such as Do, Js, Kp, V Patient Population

• The key differences between a typical patient and a patient that presents with a warm autoantibody in the Blood Bank are; panreactivity seen in the antibody screen and panel, a positive autocontrol, and a positive DAT. • Additional testing required to complete a warm autoantibody include; direct antiglobulin testing, elution, IgG removal, extended phenyotyping, cell separation, and adsorptions. • Antigen typing by Molecular method on recently transfused patients with a warm autoantibody can provide conclusive extended antigen typing dependent of transfusion status and bound IgG on the patient’s red cells. This will aid in future transfusions for these patients. Conclusions:

• Technical Manual AABB Bethesda Maryland • The Blood Group Antigen Facts Book Marion E Reid & Christine Lomas-Francis • Modern Blood Banking and Transfusion Practices Denise M Harmening • Beadchip Molecular Immunohematology JoAnne M Moulds References