Hemolytic transfusion reaction due to anti-A

A cold scare: Formation of cold reactive anti-A1 coinciding with gross hemolysis

Anti-A₁ antibodies can be found as a usually clinically insignificant naturally occurring cold IgM antibody in A-subgroup patients. It is known from multiple prior case reports that warm-reactive anti-A₁ that reacts at 37 °C can be clinically significant, and it has been previously reported that it could form after alloimmunization with donor A₁ red blood cell (RBC) transfusion. In addition, the development of anti-A₁, often as an autoantibody, have been described in the setting of various malignancies, perhaps due to expressed subtle alterations of the ABO antigens provoking an immune response.

Here, we report a rare case of a cold-reactive anti-A₁ alloantibody (after multiple transfusions with group A₁ RBC units) in a 76 year old male patient (A₂) with history of myelodysplastic syndrome and metastatic carcinoma who presented with hemolytic anemia and dark urine. The patient had previously typed as blood type A without reverse typing reaction for anti-A₁; as a result, the patient had been transfused with group A₁ RBCs. Four days prior to discovery of the ABO discrepancy, the patient had a febrile transfusion reaction associated with his A₁ RBC transfusion. On admission, his immunohematology workup demonstrated an alloantibody to anti-A₁ that coincidentally appeared during a new onset of hemolytic anemia. Case reports of patients with hemolytic anemia with a newly developed anti-A₁ alloantibody are sparse in the literature, and this case is particularly interesting as the cold reactive anti-A₁ (without demonstrable wide thermal amplitude) appeared to form after alloimmunization and in the setting of an underlying malignancy.

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Anti-A₁ alloantibodies are usually clinically insignificant naturally occurring cold IgM antibodies that can occur in some A-subgroup patients.

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Anti-A₁ have been reported to be clinically significant if the antibody is reactive at 37 °C or body temperature on immunohematology testing.

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Rare case reports exist of anti-A₁ forming either after alloimmunization with exposure to A₁ antigen or forming in the context of a paraneoplastic process.

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This case is a report of an alloantibody to anti-A₁ forming in the context of both alloimmunization and in the context of an underlying metastatic carcinoma.

Risks of hemolysis due to anti-A and anti-B caused by the transfusion of blood or blood components containing ABO-incompatible plasma

BACKGROUND

The increasing use of fresh blood group O whole blood in acute trauma medicine makes it important to reevaluate the issue of hemolytic reactions related to the transfusion of ABO-incompatible plasma.

STUDY DESIGN AND METHODS

This review summarizes and evaluates published articles and case reports concerning hemolytic reactions in connection with the transfusion of group O whole blood or blood products to nongroup O recipients.

RESULTS

In 1945-1986, 15 nonmilitary publications reported hemolytic transfusion reactions with group O blood/blood products. All patients recovered except for two fatalities. Late in World War II and during the Korean and Vietnam wars and onward in Iraq and Afghanistan only "low anti-A, anti-B titer" group O whole blood has been used as universal blood. In spite of a large number of units transfused, there are no reports of hemolytic reactions. Twenty-five publications report hemolytic reactions after transfusion of group O platelets to nongroup O recipients. In all patients but one, the titer of the implicated A- or B-antibody was >100 (saline) or >400 (antiglobulin) and all cases with an infused volume of incompatible plasma <200 mL were related to anti-A or anti-B antiglobulin titers >1000.

CONCLUSION

In emergency lifesaving resuscitation, the risk of hemolytic transfusion reactions from transfusion of group O blood to nongroup O recipients constitutes risk that is outweighed by the benefits. A low titer of anti-A/B will minimize the risk for a hemolytic reaction, particularly if the screening is repeated after an immunization episode, e.g., blood transfusion, vaccination, or pregnancy.

ABO antibody titers are not predictive of hemolytic reactions due to plasma-incompatible platelet transfusions

BACKGROUND

The overall risk of hemolytic transfusion reactions (HTRs) from plasma (minor)-incompatible platelet (PLT) transfusions and the role of a critical anti-A or anti-B titer in predicting and preventing these reactions has not been clearly established.

STUDY DESIGN AND METHODS

We evaluated all apheresis PLT (AP) transfusions for 3 months. Using the gel titer method, we determined the anti-A and/or the anti-B immunoglobulin (Ig)G titer for all incompatible APs. Reported febrile transfusion reactions and HTRs were recorded; transfusions were not prospectively evaluated by the study team. A posttransfusion direct antiglobulin test (DAT) and eluate were performed after a reported febrile or hemolytic reaction for patients who received plasma-incompatible APs.

RESULTS

A total of 647 of 4288 AP transfusions (15.1%) were plasma incompatible. Group O APs (n = 278) had significantly higher anti-A and anti-B titers than group A or B APs (p < 0.0001). No group A or B APs had a titer of more than 128 (0/342). For group O APs, 73 had titers of 256 or greater (26.3%), and 27 had titers of 512 or greater (9.7%). No HTRs were reported to any plasma-incompatible AP transfusion during the study period. Two plasma-incompatible AP transfusions were associated with fever and chills and positive DATs, of which one had a positive eluate. The incidence of a DAT and eluate-positive febrile transfusion reaction in the plasma-incompatible AP population is 0.15% (95% confidence interval, 0.0%-0.86%).

CONCLUSION

A critical anti-A or -B titer is not sufficient to predict the risk of hemolysis in patients receiving plasma-incompatible APs, although underreporting of reactions to the blood bank may limit the generalizability of this study.

Transfusion of platelets containing ABO-incompatible plasma: a survey of 3156 North American laboratories

CONTEXT

Hemolytic transfusion reactions due to platelet transfusions containing ABO-incompatible plasma (ie, group O platelets into a non-group O patient) have been reported in the literature. However, limited data describe the extent to which transfusion services manage such platelet transfusions or the methods used to limit the risk of such reactions.

OBJECTIVE

To determine transfusion services' current practices regarding the use of platelets containing ABO-incompatible plasma.

DESIGN

In a College of American Pathologists' Transfusion Medicine Proficiency Testing Survey, supplemental questions asked participants whether a policy existed for the use of platelets containing ABO-incompatible plasma and, if a policy existed, what elements were part of the policy.

RESULTS

Of 3156 laboratories that transfused platelets, 3152 responded to the question of whether they had a policy. Of these respondents, 83% (n = 2623) had a policy. One or more elements were reported for transfusions in adults: only ABO-compatible plasma products (n = 1363); only ABO-compatible plasma and platelet products (n = 679); notification of medical director (n = 646); notification of ordering physician (n = 637); volume limit of ABO-incompatible plasma allowed (n = 255); volume-reduction of ABO-incompatible products (n = 168); screening for critical titer of anti-A or anti-B (n = 53). A total of 529 laboratories indicated that they did not have a policy.

CONCLUSIONS

A majority of laboratories have a policy, but most do not include a method to limit the risk of hemolysis if platelets containing ABO-incompatible plasma must be transfused. When such platelets are used, there does not appear to be consensus on a specific method to minimize the transfusion of anti-A or anti-B.

Transfusion of apheresis PLTs from IgA-deficient donors with anti-IgA is not associated with an increase in transfusion reactions

BACKGROUND

Passive transfer of antibodies through transfusion has been reported to cause adverse consequences. Approximately 1 in 700 individuals of Northern European ancestry lack IgA with up to 40 percent reported as having anti-IgA. Whether these antibodies when passively transfused were associated with reactions was examined.

STUDY DESIGN AND METHODS

Records were reviewed to identify IgA-deficient (<0.05 mg/dL detectable IgA) apheresis PLT donors with anti-IgA. Transfusion outcomes of products from these donors were compared to outcomes of control transfusions from donors who were not IgA-deficient.

RESULTS

Four IgA-deficient donors with anti-IgA donated a total of 25 apheresis PLT products transfused to 22 recipients. Of the transfused products, 1 (4.0%) was associated with fever that was classified as unrelated to transfusion. In the control group, 60 donors donated 78 apheresis PLT products transfused to 56 recipients. Among these, an allergic reaction was identified (1.3%). The reaction rates between both groups were not different whether the single event in the anti-IgA group was considered a reaction (chi-squared value 0.735, p = 0.3914) or considered unrelated to transfusion (chi-square value 0.324, p = 0.5694).

CONCLUSION

The transfusion of products containing anti-IgA does not appear to be associated with a greater frequency of reactions.

Transfusion of ABO-nonidentical platelets is not associated with adverse clinical outcomes in cardiovascular surgery patients

BACKGROUND

Current blood transfusion standards in Canada and the United States permit transfusion of ABO-nonidentical platelets when ABO-identical platelets are not available. This practice increases the availability of platelets, a component in chronic shortage in Ontario, Canada because of the 5-day shelf-life. The impact of transfusing ABO-nonidentical platelets on patient outcomes is unknown. STUDY DESIGN AND METHODS. A retrospective review of 1721 patients who had cardiovascular surgery between November 1989 and December 1999 and who had also received a platelet transfusion perioperatively was conducted. The impact of platelet and plasma incompatibility on clinical outcomes was analyzed.

RESULTS

The analysis included 1691 patients who were divided into two groups according to the compatibility of the first platelet transfusion received: ABO-identical platelet transfusion (n = 1008) and ABO-nonidentical platelet transfusion (n = 683). The only difference in baseline characteristics between the two groups was that there were more urgent cases in the ABO-identical platelet transfusion group (p = 0.04). There were no significant differences in mortality at 30 days (10% for both groups, p = NS) or in postoperative length of stay (median, 7.0 days for both groups, p = NS). No significant differences were found with respect to the use of blood components, indices of bleeding, incidence of infection, or platelet CCIs.

CONCLUSION

Transfusion of ABO-nonidentical platelets in patients undergoing cardiovascular surgery is not associated with an adverse impact on patient outcome.

An unusual sample of irregular anti-A1, probably causing an early delayed transfusion reaction

An unusual case of a 37 degrees C-active irregular anti-A1 is reported. Apparently consisting mainly of IgG, the antibody appeared in an A2B recipient only two days after massive transfusion of A1-cells in absence of previous transfusion. It was associated with severe hemolysis and renal failure which was reversed after exchange transfusion.

Cellular basis of immune response to antigens of ABO blood-group system. Capacity to provide help during response to T-cell-dependent ABO-system antigens is restricted to individuals of blood group O

It is postulated that the near-identity of the A and B antigens in man makes it impossible for individuals of groups A, A2, or B to provide T-cell help during a response to T-dependent non-self antigens by B2 lymphocytes. Thus, people of these groups are unable to produce immune IgG antibody. The presence of naturally occurring IgM antibody to non-self antigen from the age of 6 months is due to a separate system of T-cell-independent B1 cells which have arisen during evolution to protect the host against polysaccharide-encapsulated bacterial pathogens.

Haemolytic transfusion reaction due to ABO incompatible plasma in a platelet concentrate

A patients of blood type A1 developed brisk, but transient haemolysis after receiving a platelet transfusion derived from 4 group 0 donors. Anti-A was detected on his red cells and in his plasma. 2 of the platelet donor were found to have very high titers (1:10240) of anti-A and positive haemolysin tests. Thus, a haemolytic reaction can result from transfusion of incompatible plasma in a platelet concentrate.

The serological investigation of red cell incompatible transfusion reactions

The hospital blood bank plays a key role in the diagnosis of acute transfusion reactions involving red cell incompatibility. This paper discusses the interpretation of the serological tests performed by the laboratory. Because red cell incompatible transfusion reactions occur so infrequently it is difficult to accumulate practical experience in their laboratory presentation and this paper describes several of the pitfalls that may be encountered when laboratory findings deviate from classical descriptions. These include the absence of a positive direct antiglobulin test (Coombs) or an incompatible crossmatch, the absence of any apparent discrepancy between the pre- and post-transfusion specimens in cases of ABO incompatibility, the differentiation of auto-immune haemolytic anaemia from delayed transfusion reactions and the assessment of the clinical significance of any blood group antibodies that may be detected.