Case Study:

Jackie Ensley, MLS(ASCP)CMSBBCM

Immunohematology Reference Laboratory Manager

Kentucky Blood Center

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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

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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

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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

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ABO/Rh performed

DAT Performed

Anti-A Anti-B Anti-D A1 Cell B Cell ABO/Rh

0 4+ 4+ 4+ 0 B Positive

Poly/tube Anti-IgG/ tube Anti-C3/ tube

0√ 0√ 0√

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Reference Lab testing

Reference Lab testing

Phenotyping

Be sure to rule out anti-f, -K, -Fyb, -Jkb, -Leb, -M, -s

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Rh System Kell Duffy Kidd Lewis P MNS

D C c E e K Fya Fyb Jka Jkb Lea Leb P1 M N S s

+ + + + + 0 + 0 + 0 + 0 + 0 + + 0

Most likely R1R2

Reference Lab Testing – Plasma

Rh System Kell Duffy Kidd Lewis P MNS Lutheran

IS

AH

G-P

eG

Cell

D C c E e V Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub

I

+ + 0 0 + 0 0 + + 0 + 0 + + 0 + 0 0 + + 0 + + + 0 + 0 1+ II

+ 0 + + 0 0 0 0 + 0 + 0 + + + + + + 0 + + + + 0 0 + 0 0 AC

0 0

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Reference Lab Testing – Plasma

Rh System Kell Duffy Kidd Lewis P MNS

IS

AH

G-

Pe

G

Cell D C c E e K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N 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

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Reference Lab Testing – Plasma

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Rh System Kell Duffy Kidd Lewis P MNS Lutheran

GEL

Cell D C c E e K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub

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

Reference Lab Testing – Plasma

Rh System Kell Duffy Kidd Lewis P MNS

AH

G-

Pe

G

GEL

Cell D C c E e K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N 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

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Additional cells are tested in the gel and range from 1+ to 3+ as well

• 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+

Serologic Problem Solving

So where do we go at this point?

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• 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

Serologic Problem Solving

So where do we go at this point?

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Gerbich antibody

Chido/Rodgers antibody

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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

Pooled Plasma Inhibition

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Pooled Plasma Inhibition

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Original plasma reactivity

Control plasma

reactivity (6% albumin)

Pooled plasma reactivity

1+ 1+ 0

1+ 1+ 0

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Great!

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Gotcha!

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Anti-Ch

IgG Class

IAT Optimal

>90% Occurrence

FICIN SENSITIVE

DTT RESISTANT

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.

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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**

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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

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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

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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

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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

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