Neonatal jaundice due to ABO incompatibility in Sri Lankan

A prospective study was carried out on 101 neonates with jaundice due to ABO incompatibility. The direct Coomb's test was weakly positive in 4 cases. The indirect Coomb's test using the eluate was positive in 8 cases. In the maternal blood either IgG anti-A or anti-B haemolysin was present in high titre in every case. Phototherapy was given when the indirect serum bilirubin level exceeded 9 mg/dl. Exchange transfusion was done-in 39 cases, 9 babies requiring multiple exchanges. There were 2 deaths.

Heteroduplex generator in analysis of Rh blood group alleles

We describe the use of heteroduplex analysis to enhance the resolution of different rhesus-derived (Rh) isotypes. Heteroduplex analysis of different domains of the Rh D and Rh CE loci can be performed to diagnose a variety of blood group incompatibilities. One application of this technique is the ability to test for fetal-maternal blood group incompatibilities during pregnancy. Several new serotype-specific sequence variations were discovered in the mapping of the Rh locus, and used in the construction of artificial heteroduplex generators (HGs). HGs facilitate the resolution of the Rh isotypes by electrophoretic methods.

A reassessment of ABO incompatibility in pediatric liver transplantation

The present study examined 144 pediatric liver transplants to determine the impact of ABO matching on liver allograft outcome. Pediatric transplants were divided into 3 groups: ABO identical (ABO-Id; n = 108), ABO-compatible nonidentical (ABO-Comp; n = 22), and ABO incompatible (ABO-Inc; n = 14). A higher proportion of United Network for Organ Sharing status 4 recipients in the ABO-Comp group (50% vs. 22% and 36% for ABO-Id and ABO-Inc, P < 0.05) and less time spent on the waiting list for ABO-Inc recipients (46 +/- 12 vs. 87 +/- 11 and 61 +/- 20 days for ABO-Id and ABO-Comp, P < 0.01) were noted. OKT3 induction therapy was greater in ABO-Inc grafts (57% vs. 19% and 14% for ABO-Id and ABO-Comp, P < 0.05), as was incidence of acute cellular rejection (79% vs. 59% and 41% for ABO-Id and ABO-Comp, P = 0.08). One- and 3-year patient survival rates were 87% and 83% in the ABO-Id group, 95% and 88% in the ABO-Comp group, and 79% and 79% in the ABO-Inc group (P = NS). One- and 3-year graft survival rates were 83% and 78% in the ABO-Id group, 87% and 80% in the ABO-Comp group, and 71% and 71% in the ABO-Inc group (P = NS). ABO-Inc transplantations can be performed successfully in pediatric recipients and warrant a reassessment of the utilization of ABO-Inc livers.

[Diagnosis and therapy of fetal alloimmune thrombocytopenia]

In fetal alloimmune thrombocytopenia, maternal IgG antibodies directed against platelets pass into the fetal circulation and lead to the destruction of fetal platelets. Fetal thrombocytopenia is usually first noted postnatally, but the maternal alloantibodies may lead to severe fetal haemorrhage in utero in the second or, more commonly, third trimester. Platelet-specific antibodies appear to play the major role in the pathogenesis of fetal alloimmune thrombocytopenia. Antenatal serological diagnosis is complicated by the fact that no platelet-specific alloantibodies are detectable in untreated maternal serum in about 20% of cases. Even when antibodies are detected, repeated estimation of the titre in the mother gives no indication of the severity of the fetal thrombocytopenia. Therefore, when the diagnosis of fetal alloimmune thrombocytopenia is suspected, it should be confirmed and subsequently monitored by cordocentesis. The intrauterine transfusion of compatible platelets and the administration of high dose IgG infusions to the mother and/or fetus are currently being used as approaches to treatment. Despite advances in the antenatal diagnosis and therapy of fetal alloimmune thrombocytopenia, the clinical effects on the fetus remain unpredictable.

[The blood bank as a consultation service]

This is a 6-month prospective clinical trial which evaluates the importance that blood bank may have as a consultation service for in-patient care. From January 31-July 31 1994, the blood bank physicians gave 108 consults which helped the consulting physician in an adequate diagnostic and therapeutic management of transfusion-related problems. The main reasons for consultation were coagulopathies, suspicion of refractoriness to platelet concentrates, and presence of antibodies against red cell antigens. The main underlying disorders were hematological, surgical, hepatic, renal and rheumatic diseases. We conclude that our blood bank as a consultation service was helpful in improving the transfusional management of our patients.

[Septicemia in children treated with exchange transfusions because of hemolytic disease of the newborn]

Clinical signs and laboratory test results were analyzed in 70 neonates (42 boys and 28 girls) hospitalized because of neonatal haemolytic disease who were treated with exchange transfusion and later developed septicaemia. Serological Rh-D incompatibility was diagnosed in 11 children, ABO incompatibility in 59. Signs of infection appeared between days 1 and 7 after transfusion. Pneumonic signs and diarrhoea dominated clinically in 45 newborns, skin abscesses were observed in 10, osteomyelitis in 4. Septic shock occurred in 7. Gram-negative bacteria predominated (52.85%). A significant diagnostic value of the following was found (chi2): granulocytic band forms (expressed as percentages > or = 0.10, a neutrophil index > 0.2 and toxic granulations in neutrophils. These results were obtained in the early, asymptomatic stage of infection, i.e. before the exchange transfusion was performed. The importance of the presence of risk factors, not exchange transfusion per se, is stressed.

The gel test: investigation into the aetiology and the significance of a positive auto-control

BACKGROUND

Shortly after the gel test was introduced into routine immunohaematology, an increased percentage of patients were reported to show a positive auto-control in the indirect antiglobulin test (IAT) of uncertain significance as the direct antiglobulin test (DAT) in the tube technique was negative.

MATERIALS AND METHODS

In our study 13,280 randomized patient blood samples were screened and additional investigations carried out including an analysis of patient histories in the 97 blood samples that were auto-control positive in the gel test.

RESULTS

In 87.4%, a re-testing with polyspecific antiglobulin serum (83.2% with anti-IgG) showed positive results in contrast to only 52.9% re-tested by the tube test. Neither nonspecificity nor cold agglutinins were significant. None of the patients examined showed any signs of haemolysis except for one with pernicious anaemia. We concluded that the increased number of positive auto-controls and DATs is due to the greater sensitivity of the gel test and thus the detection of minute quantities of specific cell-bound IgG molecules, i.e. warm auto-antibodies or drug-induced antibodies.

CONCLUSION

Prior to transfusion, a positive result should be confirmed by a tube DAT. If this test is negative and there is no history of a previous transfusion or of haemolysis, the transfusion should not be delayed by carrying out further time-consuming investigations.

Analysis of functional abnormalities uncovered during preoperative evaluation of donor candidates for living-related liver transplantation

Functional abnormalities of the liver uncovered during preoperative routine evaluation were analyzed in 109 donor candidates for 100 cases of living-related liver transplantation (LRLT) performed during the period from June, 1990 to May, 1994 at the Second Department of Surgery, Kyoto University Hospital. High serum transaminase (GOT, GPT) levels were noted in 10 (9.2%) cases among 109 candidates, high alkaline phosphatase in 4 (3.7%), hyperbilirubinemia in 3 (2.8%), anemia in 3 and high choline esterase in 3 cases. Positive hepatitis C antibody (HCV) was also noted in 1 case. Fatty liver was detected in 10 (9.2%) cases, cholecystitis in 2 cases, 1 case each of cyst and calcification in the liver by diagnostic imaging (ultra sonograph and/or computed tomography). These abnormalities of the liver necessitated replacing the initial candidate with the other parent in 9 cases, including 1 case without any functional abnormality whose graft liver was too large to fit the recipient abdominal cavity. There were 14 cases of ABO blood type incompatible combination. Switching the initial candidate due to these abnormalities mentioned above resulted in incompatible combinations in 4 of these 14 cases. Although the advantages of the LRLT are the superior viability of the donor graft and the genetic histocompatibility between recipient and donor, to optimize the advantage of LRLT, all donor candidates should be strongly advised to make every effort preoperatively to improve their physical condition in preparation for the LRLT protocol, since many of these abnormalities are typically reversible.

Intact survival with transfusion-associated graft-versus-host disease proved by human leukocyte antigen typing of lymphocytes in skin biopsy specimens

A transient transfusion-associated graft-versus-host disease occurred in a premature infant of 30 weeks of gestation. We demonstrated donor lymphocytes in a skin biopsy specimen with a two-step immunoperoxidase technique using monoclonal antibodies against human leukocyte antigen determinants specific for the donor. The girl survived and is immunocompetent.

Prevalence and lack of clinical significance of blood group incompatibility in mothers with blood type A or B

PURPOSE

To examine the prevalence and clinical significance of blood group incompatibility in infants whose mothers have blood type A or B.

METHODS

We prospectively analyzed cord blood samples from 4996 consecutive love-born infants for blood type, hematocrit, and results of direct antiglobulin (Coombs) test (DAT) and indirect Coombs test (ICT).

OUTCOME MEASURES

Erythrocyte sensitization was determined by positive DAT or ICT results. Significant hyperbilirubinemia (> or = 224 mumol/L (12.8 mg/dl) and mean cord hematocrits were compared between mother-infant pairs with ABO incompatibility and positive DAT or ICT results and those with negative Coombs test results.

RESULTS

Of all births, 6.9% (343/4996) were of infants who had ABO incompatibility and had been born to mothers with blood type B or A; 44 (13%) of 343 infants had a positive antiglobulin test result, of whom 43 had a positive ICT result only. Type A or B mothers were 5.5 times less likely to have sensitization than type O mothers; A-B, B-A, A-AB, and B-AB mother-infant pairs with a positive antiglobulin test result had mean cord hematocrits and rates of significant hyperbilirubinemia similar to those of corresponding pairs whose antiglobulin tests both showed negative results. Infants with a positive DAT result had lower mean cord hematocrits than infants with negative results on both antiglobulin tests or on a positive ICT result only. Significant hyperbilirubinemia was more frequent in infants with a positive DAT result than in infants with negative results on both antiglobulin tests or a positive ICT result only.

CONCLUSION

Sensitization is much rare when the mother has blood type A or B than when she has blood type O, as demonstrated by the antiglobulin test. The incidence of significant hyperbilirubinemia and lower cord hematocrit is not increased by sensitization when the mother has type A or B.

[Acute intravasal hemolysis in Clostridium perfringens sepsis. Differential diagnosis of hemolytic episodes]

A 19-year-old man with acute lymphoblastic leukaemia developed fever, general deterioration and somnolence 3 days after a cycle of cytostatic treatment. He had anaemia (haemoglobin 6.6 g/dl), leukopenia (100/microliters) and thrombocytopenia (7,000/microliters). As an acute septicaemia was suspected he received broad spectrum antibiotic therapy, together with two units of red cell and platelet concentrates. However, his condition worsened rapidly over the next 5 hours (meningism, seizures, fever to 41.1 degrees C, dyspnoea). Another blood count revealed severe haemolysis. Computed tomography of the skull demonstrated multilocular intraparenchymal gas formation. Although the antibiotic treatment was extended the patient died several hours later. Retrospective examination for suspected transfusion mismatch provided no evidence for erythrocyte incompatibility. But there was liberation of T-antigen as sign of a bacterial cause of erythrocyte damage. An anaerobic blood culture grew Clostridium perfringens. This case demonstrates that acute intravascular haemolysis in septicaemia should be considered in the differential diagnosis of transfusion mismatch.

Immunofluorescence techniques in the investigation of a transfusion fatality due to ABO incompatibility

A 5-year-old girl died some minutes after starting to receive a transfusion of blood, without having previously typed her blood group or that of the donor, who were both supposedly of group 0. Blood groups were investigated in pharynx tissues taken 10 days after her death using the immunofluorescence technique and counter-staining with p-phenylenediamine. It was discovered that the girl was of blood group B and that the transfusion was of blood group A, hence a transfusion error as cause of death is proposed. A field of great medicolegal interest is opened by using immunofluorescent techniques in forensic pathology as an efficient complementary test when doing an autopsy on a person who died during a blood transfusion.

[RH and ABO incompatibility in newborns treated in a pediatric hospital]

A clinical analysis is presented of 85 cases of serological incompatibility in newborns hospitalized in neonatal diseases department within 7 years. In 35 newborns Rh incompatibility was diagnosed including 24 with the presence of anti-D antibodies, and in eight newborns antibodies were found against other Rh antigens. In 53 newborns AB0 incompatibility was diagnosed, and the overwhelming majority of mothers had 0 blood group and almost 70% of the newborns has A blood group. In all newborns pathological jaundice occurred. Among newborns with Rh incompatibility prematurity, birth weight below 2500 g, perinatal complications and low Apgar score were more frequently found. Almost 80% of the newborns with Rh incompatibility and over 60% of the newborns with AB0 incompatibility showed signs of infection, and bacterial sepsis was most frequently diagnosed.

Common reactions to transfusions

A blood transfusion is a special kind of transplantation, with the transfer of living tissue from one person to another. Reactions can occur with as little as 10 to 15 ml of incompatible blood. The onset of a reaction may be misleading or delayed, and its detection requires astute assessment. Responsibility for recognition of a transfusion reaction lies with the transfusionist, who is often a nurse. The following types of response can occur: hemolytic reactions, transfusion-induced graft-versus-host disease, hemoglobinuria, purpura, fever, circulatory overload, thrombophlebitis, urticaria, hyperkalemia, asymptomatic hemoglobinuria, pulmonary edema, and allergic and anaphylactic reactions. Critical care nurses need to be aware of the dangers of blood and blood product transfusions and to be prepared to react quickly.

Delayed haemolytic transfusion reactions in patients with sickle cell disease

We describe two cases which illustrate the difficult diagnostic and therapeutic problems posed by delayed haemolytic transfusion reactions in patients with sickle-cell disease. The cases emphasize the need for meticulous phenotypic and serological assessment of sickle-cell patients prior to transfusion therapy.

[Manual polybrene test versus saline test as a means of detecting alloantibodies against red cells in the pretransfusion examination]

Two tests for detecting red cell alloantibodies in pre-transfusion studies were compared. Saline test is a well-known and recognized method, although it has a disadvantage: the 30 minutes incubation time at 37 degrees C can become a problem in emergencies. In such cases a method as quick as polybrene manual test (PMT), as recommended by the American Association of Blood Banks (AABB) Manual, seems the method of choice. So, in spite of the good results attained by us with the saline test, both methods were subjected to comparison. The results achieved with the saline test were better than with the PMT since this last failed to detected one anti-D, two anti-E and two anti-K antibodies, plus a warm antibody of undetermined specificity. All the antibodies not detected by PMT have clinical significance, so we decided not to use PMT in routine pre-transfusion testing.

[Immunization against blood group antigens by allogeneic bone transplantation]

33 bone allotransplants (cryopreserved) of AB0- and Rh-incompatible (donor-recipient) patients were performed to evaluate the question which AB0 Rh-incompatibility leads to immunization of the bone transplant recipient. Several different antibodies were tested pre- and postoperatively in the recipient. Regarding the Rh-system no immunization was demonstrable; however, a significant increase of antibody leads was found regarding the AB0-system. Thus, in bone bank techniques AB0 compatibility is important for allogeneic bone transplantation in young women. Otherwise, there is a risk for the development of MHN in case of pregnancy. Blood group-typing is not necessary in other patient groups. Although no Rh-antibodies were demonstrable, a similar mechanism can be postulated for the Rh-system. We, thus, conclude that in allogeneic bone tx in young women the Rh-system has to be taken into consideration.