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Mikame M, Tsuno NH, Miura Y, Kitazaki H, Uchimura D, Miyagi T, Miyazaki T, Onodera T, Ohashi W, Kameda T, Ohkawa R, Kino S, Muroi K. Anti-A and anti-B titers, age, gender, biochemical parameters, and body mass index in Japanese blood donors. Immunohematology 2023; 39:155-165. [PMID: 38179781 DOI: 10.2478/immunohematology-2023-023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
It has been reported that anti-A and anti-B (ABO antibody) titers decrease with age, but little is known about the association between ABO antibody titers and physiologic/biochemical parameters such as body mass index (BMI), gamma-glutamyl transpeptidase (GGT), and total cholesterol (T-Cho). We investigated the present situation of ABO antibody titers among healthy blood donors in Japan and the physiologic/biochemical factors that may be associated with changes in ABO antibody titers. Plasma from 7450 Japanese blood donors was tested for ABO antibody titers using ABO reverse typing reagents by an automated microplate system; donor samples were classified into low, middle, and high titers according to the agglutination results obtained with diluted plasma samples. Multivariate regression analysis was performed to analyze the association between ABO antibody titers and age, gender, biochemical parameters (alanine transaminase [ALT], GGT, globulin, T-Cho, and glycosylated albumin [GA]), and BMI according to the ABO blood groups. A significant correlation between ABO antibody titers and age/gender, except for gender in anti-A of blood group B donors, was observed. BMI showed significant but negative correlations with anti-A and anti-B (β = -0.085 and -0.062, respectively; p < 0.01) in blood group O donors. In addition, significant but negative correlations between GGT and T-Cho with anti-B of blood group A donors (β = -0.055 and -0.047, respectively; p < 0.05) were observed. Although differences existed among the ABO blood groups, ABO antibody titers seem to be associated with physiologic and biochemical parameters of healthy individuals.
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Affiliation(s)
- M Mikame
- Development Researcher, Japanese Red Cross Kanto-Koshinetsu Block Blood Center, and Central Blood Institute, Clinical Bioanalysis and Molecular Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 2-1-67, Tatsumi, Koto-ku, Tokyo, 135-8521, Japan
| | - N H Tsuno
- Deputy General Manager, Japanese Red Cross Kanto-Koshinetsu Block Blood Center, and Central Blood Institute, Tokyo, Japan
| | - Y Miura
- Clinical Laboratory Staff, Japanese Red Cross Hokkaido Block Blood Center, Hokkaido, Japan
| | - H Kitazaki
- Clinical Laboratory Staff, Japanese Red Cross Hokkaido Block Blood Center, Hokkaido, Japan
| | - D Uchimura
- Clinical Laboratory Staff, Japanese Red Cross Hokkaido Block Blood Center, Hokkaido, Japan
| | - T Miyagi
- Section Head, Japanese Red Cross Kanto-Koshinetsu Block Blood Center, and Central Blood Institute, Tokyo, Japan
| | - T Miyazaki
- Section Head, Japanese Red Cross Central Blood Institute, Tokyo, Japan
| | - T Onodera
- Head of Department, Japanese Red Cross Kanto-Koshinetsu Block Blood Center, Tokyo, Japan
| | - W Ohashi
- Head of Department, Japanese Red Cross Hokkaido Block Blood Center, Hokkaido, Japan
| | - T Kameda
- Senior Lecturer, Department of Clinical Laboratory Science, Teikyo University, and Clinical Bioanalysis and Molecular Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - R Ohkawa
- Professor, Clinical Bioanalysis and Molecular Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - S Kino
- General Manager, Japanese Red Cross Hokkaido Block Blood Center, Hokkaido, Japan
| | - K Muroi
- General Manager, Japanese Red Cross Kanto-Koshinetsu Block Blood Center, Tokyo, Japan
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Mikame M, Tsuno NH, Miura Y, Kitazaki H, Uchimura D, Miyazaki T, Miyagi T, Onodera T, Ohashi W, Kameda T, Ohkawa R, Kino S, Muroi K. Decreased rate of blood donors with high ABO antibody titers in Japan and the underlying factors: Comparisons between 2010 and 2021. Transfus Apher Sci 2023; 62:103812. [PMID: 37734993 DOI: 10.1016/j.transci.2023.103812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/21/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND AND OBJECTIVES Previously (2007), it was reported that ABO antibody titers in Japanese blood donors had decreased significantly compared to 20 years before. Here we evaluated whether further decrease of antibody titers had occurred in recent years, and the potential factors associated with changes in antibody titers. MATERIALS AND METHODS Serum/plasma from random blood donors in 2010 and 2021 (2010: 3369, 2021: 5796 donors) was classified into low, middle, and high ABO antibody titers according to the reactivity of diluted serum/plasma (2.5-fold and 20-fold) by an automated microplate system. The rates of low/high titer in the two periods were compared. Logistic regression and age-gender-BMI subgroup analyses were conducted to identify the factors that contributed to changes in antibody titers. RESULTS Compared to 2010, the rate of donors with high ABO antibody titers was decreased in 2021 for both anti-A and anti-B (anti-A, 2010: 23.8%, 2021: 19.3%; anti-B, 2010: 23.8%, 2021: 16.4%). In logistic regression analysis, age was found to significantly affect both anti-A and anti-B antibody titers (anti-A, adjusted odds ratio 0.36, 95% CI 0.31-0.41; anti-B, 0.42, 0.37-0.47), and BMI (0.82, 0.73-0.92) and other time-related factors (0.79, 0.71-0.88) significantly affect anti-B antibody titers. Subgroup analysis revealed decreased rate of high anti-B titers in the higher age group in 2021. CONCLUSION The rate of high ABO antibody titers, especially high anti-B titers, was significantly decreased in 2021, and our results suggested an association with aging and obesity of blood donors as well as other time-related factors.
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Affiliation(s)
- Masamichi Mikame
- Japanese Red Cross Kanto-Koshinetsu Block Blood Center, 2-1-67, Tatsumi, Koto-ku, Tokyo, Japan; Japanese Red Cross Central Blood Institute, 2-1-67, Tatsumi, Koto-ku, Tokyo, Japan; Clinical Bioanalysis and Molecular Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
| | - Nelson Hirokazu Tsuno
- Japanese Red Cross Kanto-Koshinetsu Block Blood Center, 2-1-67, Tatsumi, Koto-ku, Tokyo, Japan; Japanese Red Cross Central Blood Institute, 2-1-67, Tatsumi, Koto-ku, Tokyo, Japan
| | - Yoshino Miura
- Japanese Red Cross Hokkaido Block Blood Center, 1-1-20, Niju-Yonken-Nijo, Nishi-ku, Sapporo-shi, Hokkaido, Japan
| | - Hideaki Kitazaki
- Japanese Red Cross Hokkaido Block Blood Center, 1-1-20, Niju-Yonken-Nijo, Nishi-ku, Sapporo-shi, Hokkaido, Japan
| | - Daisuke Uchimura
- Japanese Red Cross Hokkaido Block Blood Center, 1-1-20, Niju-Yonken-Nijo, Nishi-ku, Sapporo-shi, Hokkaido, Japan
| | - Toru Miyazaki
- Japanese Red Cross Central Blood Institute, 2-1-67, Tatsumi, Koto-ku, Tokyo, Japan
| | - Toru Miyagi
- Japanese Red Cross Kanto-Koshinetsu Block Blood Center, 2-1-67, Tatsumi, Koto-ku, Tokyo, Japan; Japanese Red Cross Central Blood Institute, 2-1-67, Tatsumi, Koto-ku, Tokyo, Japan
| | - Takayuki Onodera
- Japanese Red Cross Kanto-Koshinetsu Block Blood Center, 2-1-67, Tatsumi, Koto-ku, Tokyo, Japan
| | - Wataru Ohashi
- Japanese Red Cross Hokkaido Block Blood Center, 1-1-20, Niju-Yonken-Nijo, Nishi-ku, Sapporo-shi, Hokkaido, Japan
| | - Takahiro Kameda
- Clinical Bioanalysis and Molecular Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan; Department of Clinical Laboratory Science, Teikyo University, 2-11-1, Kaga, Itabashi-ku, Tokyo, Japan
| | - Ryunosuke Ohkawa
- Clinical Bioanalysis and Molecular Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Shuichi Kino
- Japanese Red Cross Hokkaido Block Blood Center, 1-1-20, Niju-Yonken-Nijo, Nishi-ku, Sapporo-shi, Hokkaido, Japan
| | - Kazuo Muroi
- Japanese Red Cross Kanto-Koshinetsu Block Blood Center, 2-1-67, Tatsumi, Koto-ku, Tokyo, Japan
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Aguilar G, Ortiz N, Gonzales D, Loyola S, Paredes JA. High titers of anti-A1 and anti-B antibodies among Peruvian group O platelet donors. Transfus Apher Sci 2021; 61:103341. [PMID: 34916156 DOI: 10.1016/j.transci.2021.103341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/22/2021] [Accepted: 12/08/2021] [Indexed: 11/15/2022]
Abstract
Critical antibody titers have been described as factors associated with hemolysis in ABO plasma-incompatible platelet (PLT) transfusions. This study was carried out to describe the frequency of high-titers anti-A and antiB IgM and IgG antibodies in group O apheresis platelet donors, and to explore differences according to the donor characteristics. A cross-sectional study was carried out at the Blood Bank of a National Hospital in Peru from January to March 2019. IgM and IgG antibodies against A1 and B antigens were quantified in 339 platelet donors using the direct hemagglutination technique and the solid-phase adherence technique, respectively. For analysis purposes, two cut-off points; ≥128 and ≥64, were used to define a critical titer for IgM due to a lack of consensus. An IgG titer of ≥256 was also defined as critical. Of the donors, 22.1 % had critical IgM titers when the cut-off point was defined as ≥128. However, when the IgM cut-off was ≥64, the frequency of platelet donors with critical titers increased to 54.0 %. The frequency of donors with critical IgG titers was 23.5 %. Higher IgG titers were associated with female donors while higher IgM titers were negative associated with age. One in two or three platelet donors, depending on the cutoff point used to define a critical IgM titer, had at least one critical titer of anti-A or anti-B antibodies. Early identification of platelet donors with critical antibody titers could prevent passive transfusion of ABO antibodies to non-isogroup recipients.
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Affiliation(s)
- Gissel Aguilar
- Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Nathalie Ortiz
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Donna Gonzales
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Steev Loyola
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru; Doctorado en Medicina Tropical, Facultad de Medicina, Universidad de Cartagena, Cartagena de Indias, Colombia; Grupo de Investigación UNIMOL, Facultad de Medicina, Universidad de Cartagena, Cartagena de Indias, Colombia
| | - José A Paredes
- Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Peru; Servicio de Hemoterapia y Banco de Sangre, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru.
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ABO antibody titer performance characteristics and correlates between two automated platforms. Transfus Apher Sci 2021; 60:103262. [PMID: 34483036 DOI: 10.1016/j.transci.2021.103262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND AABB standards require a policy for assessing transfusing ABO-incompatible plasma. After a fatal hemolytic event with incompatible plasma, our institution instituted platelet donor population titer method for ABO antibodies on the PK7300, with high-titer being defined as having isohemagglutinin titers greater than 256. We recently switched titering platforms to the Neo Iris and we seek to determine the equivalent isohemagglutinin high-titer cutoff on the Neo Iris as compared to the PK7300. METHODS We measured the titers on 299 apheresis platelet donors and compared its performance characteristics at various cutoffs to the PK7300 reference standard. Discrepant results were manually diluted and retested on the Neo Galileo. Furthermore, since the Neo Iris is able to determine isotype and antigen specific titers, we also characterized these features in our donor population. RESULTS IgM titer of 128 on the Neo Iris has better accuracy compared to the titer of 64 (94 % vs 93.6 %). Eleven of sixteen discordant results were in agreement with Neo Iris. Blood group O had the highest IgG antibody titers for both anti-A and anti-B (p = 8.4E-17 and 4.3E-09, respectively). Additionally, group O donors exhibited lower anti-A2 than anti-A1 IgG titers. DISCUSSION The Neo Iris titer cut-off of 128 had the best overall accuracy and correlation with a 256 cut-off on our laboratory developed test on the PK7300 platform. Additionally, we found that group O donors had the highest titer antibodies, with typically higher IgG titers than IgM, and generally multiple dilution levels greater than other blood types.
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Cardigan R, New HV, Estcourt L, Zhiburt E, Dubey R, Bengtsson J, Jöud M, Castillo C, Cid J, Lozano M, Gounder D, Flanagan P, Morley S, Clarke G, Devine D, Hindawi S, AlOtaibi A, Bub CB, Kutner JM, Ikeda T, Goto N, Okazaki H, Fontaine MJ, Pasion J, Song L, Latham T, Kerkhoffs JL, de Haas M, Zwaginga JJ, Gathof BS, Ommer K, Pirenne F, Raba M, Francois A, Daly J, Powley T, Dunbar N. International Forum on Policies and Practice for Transfusion of ABO and RhD Non-Identical Platelets: Responses. Vox Sang 2021; 117:e1-e20. [PMID: 34258774 DOI: 10.1111/vox.13130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 11/30/2022]
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Pediatric Hemovigilance and Adverse Transfusion Reactions. Clin Lab Med 2020; 41:51-67. [PMID: 33494885 DOI: 10.1016/j.cll.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Some types of transfusion reactions occur more frequently in the pediatric than the adult population. Allergic reactions are the most common, followed by nonhemolytic transfusion reactions; male children seem most susceptible to such reactions. Platelets are often implicated and pulmonary reactions are understudied in children. Clinical sequelae in neonates, such as bronchopulmonary dysplasia/chronic lung disease and intraventricular hemorrhage, have received increasing attention in relation to transfusion. There is a need to better understand the pathophysiology of transfusion reactions in neonatal and pediatric populations so preventive strategies can be undertaken. There is also a need for robust hemovigilance systems.
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Jacob RP, Wang D, Hodghead K, Pham TD. Identifying correlations between donor demographics and isohemagglutinin titers as a potential method to screen for low-titer group O whole blood. Transfus Apher Sci 2020; 60:102970. [PMID: 33223473 DOI: 10.1016/j.transci.2020.102970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/17/2020] [Accepted: 10/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND With more hospitals using low-titer group O whole blood in trauma resuscitation, having an efficient screening method for low-titer donors is critical. Our blood center uses an automated screen for high-titer isohemagglutinins in our platelet donations while collecting detailed donor demographic information. Using this data, we can identify key demographics often associated with titer status, thereby helping develop a donor-triaging method for titering. STUDY DESIGN AND METHODS Titer results were read with an automated microplate system as either high or low, based on agglutination, with a cutoff equivalent to 1:256 (both anti-A and anti-B). Donor demographic data analyzed included date of donation, blood group, age, gender, and ethnicity. RESULTS 57,508 donations were collected from 2073 unique donors between 2014 and 2018. We found the following demographics to be correlated with titer status: gender, ABO blood group, age, and ethnicity. Variability in titer status was identified in 215 individuals. This represented around 10 % of the total unique donors and was split equally amongst gender. We also found that donors between the ages of 41-60 ha d the highest likelihood of having variability in titer status, peaking at 13 %, and this proportion declined past age 60. CONCLUSION Titer status is associated with the following donor demographics: gender, ABO type, age, and ethnicity. We also discovered that variability in titer status is correlated with age. In blood centers that do not have automated and routine titer screening procedure, these findings could be used as a method to efficiently identify low-titer donors a-priori.
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Affiliation(s)
- Reuben P Jacob
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, 94305, United States
| | - Duan Wang
- Stanford Blood Center, Stanford Medicine, Stanford, CA 94305, United States
| | - Kathryn Hodghead
- Stanford Blood Center, Stanford Medicine, Stanford, CA 94305, United States
| | - Tho D Pham
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, 94305, United States; Stanford Blood Center, Stanford Medicine, Stanford, CA 94305, United States.
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Adkins BD, Arnold Egloff SA, Fahey-Ahrndt K, Kjell AL, Cohn CS, Young PP. An exploration of the advantages of automated titration testing: low inter-instrument variability and equivalent accuracy for ABO and non-ABO antibody titres relative to tube testing. Vox Sang 2020; 115:314-322. [PMID: 32052467 DOI: 10.1111/vox.12893] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 01/17/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Obtaining IgM and IgG titres is important in numerous clinical situations, including solid-organ transplant, obstetrics, and for testing of out-of-group plasma-containing components. Tube method is the most prevalent testing modality, though it is both labour-intensive and known for intra- and inter-laboratory variability. The utility of automated gel testing as a method to improve both inter- and intra-laboratory reproducibility is unknown. MATERIALS AND METHODS Two academic centres participated in a study evaluating automated gel titreing. Group O plasma samples were used to measure titres of antibodies against ABO (IgM) with buffered gel cards and 4 minor and minor red-blood-cell antigens (IgG) anti-IgG gel cards. Multiple ORTHO VISION automated analyzers were used to assess inter-instrument variation. A subset of ABO (IgM) samples were compared between laboratories to evaluate inter-laboratory variability. Multiple samples were titred by tube and by automated gel technology to determine similarity of results. RESULTS Testing demonstrated no significant difference between analysers or between sites when performing automated titrations (P ≥ 0·99). Non-ABO IgG titres were evaluated and demonstrated little inter-instrument variability. The IgM anti-A and -B titres obtained by automated gel testing were neither consistently higher nor lower than tube titres. Greater than 90% of titre values were within one dilution. CONCLUSION Based on this study, our data suggest that titreing by automated gel testing is both highly reproducible (IgM and IgG) and does not differ significantly from manual tube testing results of direct agglutination (IgM).
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Affiliation(s)
- Brian D Adkins
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Shanna A Arnold Egloff
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN.,Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN
| | - Kayla Fahey-Ahrndt
- Blood Bank Laboratory, M-Health, Fairview Hospital, Minneapolis, Minnesota
| | - Andrea L Kjell
- Blood Bank Laboratory, M-Health, Fairview Hospital, Minneapolis, Minnesota
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Pampee P Young
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN.,American Red Cross, Biomedical Services, Washington, D.C
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Balbuena-Merle R, West FB, Tormey CA, Hendrickson JE. Fatal acute hemolytic transfusion reaction due to anti-B from a platelet apheresis unit stored in platelet additive solution. Transfusion 2019; 59:1911-1915. [PMID: 30865314 DOI: 10.1111/trf.15240] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemolytic transfusion reactions from out-of-group plasma in platelet (PLT) transfusions are uncommon, with most involving passive transfer of anti-A. Only rare reactions have ever been reported due to anti-B. STUDY DESIGN AND METHODS An apheresis PLT product was donated by a blood group O male, processed using PLT additive solution, and pathogen reduced. Postreaction recipient testing included an antibody screen using gel technology, a direct antiglobulin test (DAT) using immunoglobulin G and C3, and an eluate against group O and B cells. Postreaction donor testing included measuring anti-B titers in saline, with and without anti-human globulin. RESULTS A 60-year-old blood group B patient with relapsed acute myeloid leukemia developed confusion, fever, and hypotension within hours after a blood group O PLT transfusion. The posttransfusion reaction evaluation was remarkable for a positive DAT 3+ for C3; the eluate showed anti-B. Rapid extravascular hemolysis occurred, with a 50% decline in hemoglobin, a high lactate dehydrogenase, and a high bilirubin. She was resuscitated with fluids, blood products, pressors, and oxygen and died of asystole 60 hours later. The donor's anti-B titers were 128 by tube testing at immediate spin and 512 at the anti-human globulin phase. Notably, a group B patient at a different hospital received a split of the same apheresis unit, with no reaction. CONCLUSION To our knowledge, this is the first fatality reported from passively transfused anti-B. The fact that one transfusion recipient died whereas another did not have any reported reaction highlights the potential importance of recipient variables in isohemagglutinin-mediated hemolysis.
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Affiliation(s)
- Raisa Balbuena-Merle
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut.,Pathology & Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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