Providing Compatible Blood for a Patient with a Clinically Significant RBC Alloantibody - Example

Providing Compatible Blood for a Patient with a Clinically Significant RBC Alloantibody Name Institutional Affiliation Abstract The purpose of this report is to describe the processes for transfusing compatible blood for a patient with clinically significant RBC alloantibody. Pretransfusion testing is done to ensure that the patient receives the right donor RBC components that will survive without haemolytic or agglutination reactions in the post transfusion phase. The plasma components to be transfused to a patient with clinically significant RBC alloantibody may vary from other transfusion cases. Pretransfusion test requirements should be observed strictly and clerical errors avoided; for example, correctly labelling the sample for the correct patient, and ensuring that the recipient’s information matches that of the donor. Mandatory procedures that are conducted to ensure donor antigens match the patient’s plasma include phenotyping, antibody identification, selection of the appropriate blood for transfusion, crossmatch testing, and observance of post-transfusion reactions. The testing techniques that are used in the process, such as IAT for anti-body detection are described. The process of providing compatible blood for a patient with a clinically significant RBC alloantibody Introduction In transfusion therapy, red blood cell (RBC) alloantibody presents a common complication. Antigens not exclusively expressed on RBCs, can still influence transfusion therapy success. Pretransfusion testing is necessary to ensure both ABO compatibility and detection of pre-existing aberrant RBC antibodies in a crossmatch procedure. This report demonstrates the process of providing crossmatch compatible blood for a patient with clinically significant RBC alloantibody. The content discussed includes, the sampling and labelling requirements for transfusion testing, the antibody identification process, phenotyping requirements, selection of appropriate transfusion blood, the compatibility testing process, the testing techniques involved, and transfusion timeline considerations. a. Sample and labelling requirements for pretransfusion testing The pilot tubes for collecting the blood samples are marked in a way that they identify with their respective blood units, that is, from donor and patient (Milkins et al., 2010). Each tube containing the blood sample should be identified by a numeric/alpha numeric system at the time of the collection, to enable traceability back to the donor, and the recipient. A labelling system that ensures the final sample container is labelled after the mandatory tests have been completed should be in place. The label should attach firmly to the sample container, be clear, and readable. Accurate collection and labelling of sample from the outset is crucial to error-free serological testing and safe blood transfusion as errors in patient identification and sample labelling may lead to transfusions that are ABO- incompatible (Goodnough et al., 2011). Reagents used for ABO and D grouping must be appropriately marked, stored and used in accordance with the manufacturer’s directions (Chaffe et al., 2009). b. Process of antibody identification The process of antibody identification entails testing the plasma of the patient against single-donor unpooled suspension of reagent antibody-screening cells that, meet established standards (Goodnough et al., 2011). Antibody screening is necessary to detect the presence of atypical red cell antibodies of most clinical significance (Selleng et al., 2009). Reagent cells carry the blood group antigens required for exposing the most important clinically significant RBC alloantibodies (Powers et al., 2010). These are alloantibodies which, in the AHG phase of crossmatching, are reactive at 37 degree Celsius, in contrast to those that are reactive at room temperature (Seltsam et al., 2009). About four (4) drops of serum and one (1) drop of the reagent cells are incubated at 37 degree Celsius for 30 minutes. The mixture is spun, read for haemolysis and agglutination, washed about four times in normal saline and tested with anti-IgG using IAT (indirect antiglobulin technique). Macroscopic reading of the test result is done to check for agglutination, and if negative, a microscopic reading is done (Powers, et al., 2010; Selleng et al., 2009). Goodnough et al. (2009) recommends the use of more than one type of screening cells to enhance the opportunities of having all major RBC antigens in the homozygous form because, currently, use of one antibody screening tests cannot detect all clinically significant antibodies. If antibody-screening results to a positive test, further serological testing will be required which should use extensive dials of reagent RBCs for identification of clinically significant antibodies (Seltsam et al., 2009). Once the antibody specificity is known, donors are screened for the matching antigen and identification of antigen-lacking units. c. Phenotyping requirements Phenotyping determines the ABO group and the Rh type for both the donor’s and recipient’s blood. The ABO group is determined use of anti-A and anti-B reagents on red cells, followed by testing the serum with both A1 and B RBCs. Rhesus factor presence is determined using anti-Rh (anti-D). If the first test of the donor blood with anti-D is negative, then the blood is tested for weak D or Du. If either the Rh test is positive, the blood sample label indicates ‘Rh positive’. On the other hand, if the tests for both D and Du are negative, the sample label indicates ‘Rh negative’ (Berseus, et al., 2013). Determining whether the recipient’s RBC’s are Du, is not very important because Rh negative blood is not harmful if transfused. ABO grouping is a crucial serological test and the sensitivity and safety of testing systems must not be compromised (Berseus, et al., 2013). d. Selection of appropriate blood to be transfused Although the transfusion of ABO-incompatible blood is improbable today, it is important to ensure an accurate selection procedure that will give the crossmatch-or point where there is compatibility of donor’s and patient’s blood. Some laboratories are equipped with automated patient identification systems which help to reduce mistakes (ISBT, 2010). If a manual system is used, it is advised that a second sample for confirmation of the ABO group of a first-time patient be requested. Whatever crossmatching technique or procedure used, it should be able to detect ABO compatibility. To reduce errors, one person should carry put the crossmatching procedure from the start to finish, or an audit trail of relevant individuals should be involved during this phase (ISBT, 2010). In a patient with clinically significant RBC alloantibody, the red cells which have been phenotyped and found negative for the relevant antigen should be selected (Bashir, Nightingale & Cardigan, 2013). It is advisable to give K negative red cells to the patient because, sometimes it’s hard to exclude anti-K in the presence of other antibodies, and easy to select K-negative units. Also, antigen negative red cells should be selected when a clinically significant antibody has been initially identified but cannot be detected or exposed in the present sample (Bashir, Nightingale & Cardigan, 2013). If the patient has other Rh antibodies, he should additionally be matched for C, c E and e in order to prevent further Rh alloimmunisation, provided this does not distract the delivery of effective transfusion support (Bashir, Nightingale & Cardigan, 2013). e. The process of compatibility testing Compatibility testing is done after antibody detection testing and before transfusion of whole blood. Compatibility testing involves testing the patient’s serum/ plasma with antigens from the donor. For the patient with clinically significant alloantibodies, an AHG crossmatch (AHG-XM) is performed, beginning by an immediate-spin crossmatch (IS-XM) in which three drops of patient’s serum is mixed with one drop of donor RBCs suspended in a 5% saline solution in a test tube, immediately centrifuged and read for haemolysis and agglutination. The mixture is incubated at 37 degree Celsius for 30 minutes, then IAT by use of anti-IgG (Fontaine et al., 2010). f. Testing techniques involved IAT (indirect antiglobulin technique) is used to detect ABO and non-ABO antibody incompatibility between donor red cells and patient’s plasma (Summers et al., 2009). IAT can apply either automated or manual techniques. For cases of clinically significant alloantibodies, a low ionic strength solution (LISS) IAT is preferred as most suitable because of its speed, specificity, and sensitivity (ISBT, 2010). Strict 37 degree Celsius technique involves warming red cells and plasma before mixing and is used to eliminate cross reactions from cold auto-antibodies which interfere with routine antibody identification tests on the patient’s plasma (Lange et al., 2010). Neutralisation technique is used to neutralise antibodies to soluble antigens permitting removal of additional antibodies and dilution controls are included together with issuance of compatibility status of blood (Selleng et al., 2009). g. Transfusion timeline considerations Even if pretransfusion testing is performed, an instant number of deleterious reactions can still occur resulting from serological incompatibility (Sigler et al., 2009). Transfusion timeline considerations include knowing how to identify or expect reactions that could be stemming from the transfusion procedure. These include hives, fever, chills, rigors, pain, respiratory problems, nausea, vomiting, hypotension or hypertension. If RBC components have been recently transfused, one should consider the reaction could be caused by passive antibody infusion, or soluble allergens that may currently be reacting with the newly introduced blood (Heinrich, et al., 2012). Patient’s history can also help to identify if the reaction experienced results from the transfusion. IgA deficiency, and medications that the patient is receiving or has received in the time period leading up to the transfusion, such as premedication to prevent allergic reactions, antimicrobial medication, and ACE inhibitors are important consideratons (Heinrich, et al., 2012). Conclusion Processes involved in pretransfusion testing intended to provide compatible blood for a patient with clinically significant RBC alloantibody are explained. Pretransfusion testing assures ABO compatibility between patient’s and donor’s blood, and detects most clinically significant RBC alloantibodies that may react with donor’s RBC antigens. Pretransfusion testing is conducted to ensure that there is adequate amount of RBCs having the required red cell components that will prevail without haemolysis after transfusion has taken place. Also, the maintenance of satisfactory standards in pretransfusion testing requires a structured approach in the adoption of a quality management system. Clerical or technical errors, use of non-validated techniques and procedure non-compliance procedures may lead to missed incompatibilities, and immediate or delayed haemolytic reactions of the transfused RBCs. In clinically significant RBC alloantibody, the right blood selection procedure should be used to identify blood components to be added or avoided before transfusion of whole blood takes place. References: Bashir, S., Nightingale, M. J., Cardigan, R. (2013). Ensuring that blood transfusion sets administer an effective dose of functional blood components. Transfusion Medicine, 23(4), 226-230. Doi:10.1111/tme.12045. Berséus, O., Boman, K., Nessen, S., &. Westerberg, L. (2013). Risks of haemolysis due to anti- A and anti-B caused by the transfusion of blood or blood components containing ABO-incompatible plasma. Transfusion, 53, 114-123. Chaffe, B., Jones, J., Milkins, C., Taylor, C., Asher, D., Glencross, & Cohen, H. (2009). 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The value of automated gel column agglutination technology in the identification of true inherited blood types in massively transfused patients. Transfusion, 49(8), 1672-1677. Read More