(BQ) Part 2 book Immunohematology and transfusion medicine - A case study approach presents the following contents: Playing with enzymes, differential alloadsorption, the case of low platelets, cruising for a bruising, do the math,...
Chapter 14 Playing with Enzymes Clinical History A 70-year-old female of African American decent, with history of hypertension, type diabetes mellitus, anemia, and congestive heart failure, is admitted to the hospital because of symptomatic anemia (hemoglobin, Hgb level 7.2 g/dL) The patient has a history of red blood cell (RBC) transfusions and is known to have alloantibodies (anti-C, -K, and -Fya) The patient was last transfused two units of RBCs weeks ago Two RBC units are now requested, and a type and crossmatch sample (ethylenediaminetetraacetic acid, EDTA anticoagulant) is submitted to the blood bank ABO/Rh/Antibody Screen ABO/Rh (gel method) Patient RBCs (forward typing) Anti-A Anti-B Anti-D 0 4+ Antibody screen (gel method) SC1 2+ SC2 2+ Reaction scale = 0 (no reaction) to 4+ (strong reaction) RBC red blood cell Patient plasma (reverse typing) A1 cells B cells 4+ 4+ &URVVPDWFKHG5%&¶V *URXS2 &.)\D DQWLJHQ1HJDWLYH $+* && 'RQRU8QLW 17 'RQRU8QLW 17 © Springer International Publishing Switzerland 2016 M T Friedman et al., Immunohematology and Transfusion Medicine, DOI 10.1007/978-3-319-22342-1_14 67 5 5 5 5 5 5 5 U 5 U UU UU 5 U UU 5 U ' & ( F H 5KKU I & Z N 3RO\VSHFLILF : 5HDFWLRQVFDOH QRUHDFWLRQ WR VWURQJUHDFWLRQ 3DWLHQW &HOO 5KKU &HOO *HODQG(Q]\PH3DQHO 6HOHFWHG&HOOV S D E S HOO -V D )\ D E )\ 'XII\ ,J* : '$73URILOH -V E -N D E -N LGG /H D /H /HZLV E 016 V 6 : /X E &G : 6 /X D /XWKHUDQ 3 : *HO 17 )LFLQ 7HVW5HVXOWV &HOO 68 14 Playing with Enzymes UU UU UU 5 5 & ' ( F H 5KKU I &Z N SE -VD -VE )\D )\E 'XII\ -ND -NE LGG /HD /HE /HZLV $QWLJHQ3KHQRW\SH5HVXOWV 3ULRU+LVWRU\ SD HOO 016 V '& ( FH. )\D )\E -ND-NE6 V013/HD /HE 5HDFWLRQVFDOH QRUHDFWLRQ WR VWURQJUHDFWLRQ /DVW:DVK6& /DVW:DVK6& UU 5 U U U 5 5 UU 5 5 5:5 5KKU &HOO $FLG(OXDWH3DQHO 6 : : 6 /XD /XE /XWKHUDQ 3 &HOO 17 17 17 17 17 17 17 17 17 && ,$77XEH $+* 7HVW5HVXOWV 17 17 17 17 )LFLQ ABO/Rh/Antibody Screen 69 WR VWURQJUHDFWLRQ 17 17 17 17 17 && 7HVW5HVXOWV 5 5 ( LGG /DVW:DVK6& 5 5 & 'XII\ &G 5:5 ' HOO '$73URILOH ,J* /DVW:DVK6& 5KKU &HOO 5KKU $FLG(OXDWH3DQHO 3RO\VSHFLILF ABO/Rh/Antibody Screen 111 112 22 The Case of Low Platelets Questions What antibodies did you identify in the patient’s sample? What are the possible sources of the antibodies, and how does the patient’s history and laboratory values lead you to the most likely source? In consideration of the platelet count, is platelet transfusion indicated for this patient? Why or why not? Inlight of the patient’s Rh(D) type and the antibody present in the panel, would you transfuse this patient with Rh-positive or Rh-negative blood? Answers What antibodies did you identify in the patient’s sample? Anti-D is apparently present However, given that the patient is Rh positive, it is not certain from the panel whether the antibody is an auto- or an alloantibody The latter would occur in the case of a partial-D type Adsorption with D-positive and D-negative cells could possibly differentiate the two as an autoanti-D (which has broad reactivity) and could be removed by adsorption with both D-positive and D-negative cells while an alloanti-D would be removed only by adsorption with D-positive cells Finally, an autoanti-LW (LW is a blood group antigen that is closely associated with the Rh(D) antigen) should also be considered and may be distinguished through testing with dithiothreitol (DTT)-treated cells; DTT destroys LW antigen but not Rh(D) antigen What are the possible sources of the antibodies, and how does the patient’s history and laboratory values lead you to the most likely source? In light of the above discussion, alloanti-D may have been acquired through prior transfusion or pregnancy exposure to the Rh(D) antigen if the patient is a partial-D type However, in this case, because of the patient’s thrombocytopenia, the patient was suspected to have idiopathic thrombocytopenic purpura (ITP) and history was promptly obtained that in fact the patient had received IV Rh immunoglobulin (RhIg) several weeks ago for treatment of the ITP Thus, based upon this history, it is apparent that the anti-D was passively acquired, and further work up to differentiate an autoanti-D or an autoanti-LW was unnecessary IV RhIg is specifically indicated for treatment of ITP in patients who are Rh positive, who have a functioning spleen, and who are not significantly anemic (since the treatment causes further anemia through IgG coating of Rh-positive RBCs and removal via the spleen, essentially an iatrogenic hemolytic anemia) For more information on IV RhIg in the treatment of thrombocytopenia, refer to Chap #6, question Is platelet transfusion indicated for this patient? Why or why not? Since the patient has ITP, platelet transfusion is generally contraindicated unless there is life-threatening bleeding Recommended Reading 113 In light of the patient’s Rh(D) type and the antibody present in the panel, would you transfuse this patient with Rh-positive or Rh-negative blood? Since the goal of RBC transfusion is to treat the patient’s anemia (i.e., increase the Hgb level), Rh-negative blood might be paradoxically given to this Rh-positive patient in the presence of the passively acquired anti-D (which could shorten the survival of transfused Rh-positive blood) Recommended Reading Klein HG, Anstee DJ The transfusion of platelets, leucocytes, haematopoietic progenitor cells and plasma components In: Klein HG, Anstee DJ, editors Mollison’s blood transfusion in clinical medicine 12th ed West Sussex: Wiley; 2014 p. 625 Chapter 23 The Perils of Transfusing the Sickle Cell Patient Clinical History A 44-year-old female with sickle cell disease presents to the emergency department with acute pain crisis (pain in shoulders and upper back) The patient’s hemoglobin (Hgb) level is 7.2 g/dL, which is around her usual baseline Hgb The patient received RBC units in the outpatient department of another hospital days prior to admission (her Hgb level was 7.6 g/dL prior to transfusion at that time), and as per that hospital’s blood bank, the patient has an antibody history of warm autoantibody, anti-Fya, and anti-Jkb Overnight in the emergency department, the patient’s blood pressure dropped to 90/56 mmHg, and the Hgb level dropped to 5.4 g/dL with total bilirubin (T-Bili) level 15.3 mg/dL and the lactate dehydrogenase (LDH) level 10,000 U/L The patient is admitted to the the medical intensive care unit (MICU), and a type and screen sample (ethylenediaminetetraacetic acid, EDTA anticoagulant) is submitted to the blood bank along with a request for two units of RBCs ABO/Rh/Antibody Screen ABO/Rh (gel method) Patient RBCs (forward typing) Patient plasma (reverse typing) Anti-A Anti-B Anti-D A1 cells B cells 0 4+ 4+ 4+ Antibody screen (Gel method) SC1 1+ SC2 1+ Reaction scale = 0 (no reaction) to 4+ (strong reaction) RBC red blood cell, SC screen cell © Springer International Publishing Switzerland 2016 M T Friedman et al., Immunohematology and Transfusion Medicine, DOI 10.1007/978-3-319-22342-1_23 115 5:5 5 5 5 U U U UU UU UU UU UU 5 5 ' & ( F H 5KKU I &Z N 5HDFWLRQVFDOH QRUHDFWLRQ WR VWURQJUHDFWLRQ 3DWLHQW &HOO 5KKU &HOO *HO3DQHO SD SE HOO -VD -VE )\D )\E 'XII\ -ND -NE LGG /HD /HE /HZLV 016 V : 6 : 6 /XD /XE /XWKHUDQ 3 : : : : : : : : : *HO &HOO 7HVW 5HVXOWV 116 23 The Perils of Transfusing the Sickle Cell Patient 5U U U UU UU UU UU UU 55 F H I &Z N SD SE -VE -VD )\D )\E -ND -NE /HD /HE /HZLV 016 V : 6 6 : 6 /XD /XE /XWKHUDQ 31 &HOO : : : : : W+ : : : : : $+* 5HDFWLRQVFDOH QRUHDFWLRQ WR VWURQJUHDFWLRQ 17 17 17 17 17 17 17 17 17 17 17 CC 7HVW5HVXOWV ,$77XEH 55 ( LGG /DVW:DVK6& 55 & 'XII\ &G 5:5 ' HOO ,J* : /DVW:DVK6& 5KKU &HOO 5KKU $FLG(OXDWH3DQHO 3RO\VSHFLILF : '$73URILOH ABO/Rh/Antibody Screen 117 5:5 5 5 5 5 5 U U U UU UU UU UU UU 5 5 ' & ( F H I &Z N SD 5HDFWLRQVFDOH QRUHDFWLRQ WR VWURQJUHDFWLRQ 3DWLHQW &HOO 5KKU &HOO 5KKU 7XEHDQG(Q]\PH3DQHO SE HOO -VD -VE )\D )\E 'XII\ -ND -NE LGG /HD /HE /HZLV 016 V : 6 6 : /XD /XE /XWKHUDQ 3 &HOO : : : 17 17 17 && ,$77XEH $+* 7HVW5HVXOWV 17 17 17 17 17 17 : 17 17 17 )LFLQ 118 23 The Perils of Transfusing the Sickle Cell Patient 5 U 5 U ' & ( F H I &Z N SD 5HDFWLRQVFDOH QRUHDFWLRQ ... International Publishing Switzerland 20 16 M T Friedman et al., Immunohematology and Transfusion Medicine, DOI 10.1007/97 8-3 -3 1 9 -2 234 2- 1 _15 73 74 15 The Platelet Transfusion shaking chills, and. .. West KA, et al Low incidence of anti-D alloimmunization following D+ platelet transfusion The Anti-D alloimmunization after D-incompatible platelet transfusions (ADAPT) study Br J Haematol 20 15;168(4):598–603... to antigen-negative RBCs for previously identified alloantibodies (anti-C, -K, and -Fya), the patient also needs RBCs that are negative for S antigen and Fy3 antigen (RBCs lacking Fy3 antigen also