Lynsi Rahorst, MT(ASCP) IRL Staff Technologist II. Everything But the Kitchen Sink!

Transcription

1 Lynsi Rahorst, MT(ASCP) IRL Staff Technologist II Everything But the Kitchen Sink!

2 49 year old African American male with sickle cell anemia Requests for units Hospital A 6/03/ E-, Jk(b-) units 6/08/ E-, C-, Jk(b-) units 6/19/ E-, C-, Jk(b-) units 2

3 Request for units Hospital B 5/14/ E-, C-, Jk(b-), S- units Antibody Registry 3

4 Request for units Hospital B 7/06/ E-, C-, Jk(b-), S- units Both 1+ incompatible in gel!! 4

5 7/6/2010: IRL Sample submitted to IRL Diagnosis: Renal Failure Hgb: 7.0, orders to transfuse if <6.5 Recently transfused: 5/14/10 5

6 7/6/2010: IRL Blood Type: O pos DAT: Polyspecific Anti-IgG Anti-C3b,- C3d Saline DAT +w +w 0 0 6

7 7/6/2010: IRL Patient Phenotype: What more can he make? Recently Transfused- Microhematocrit Cell Separation 7

8 Patient Phenotype Patient Cells E c C e K Fy a Fy b Jk a Jk b S s Unseparated Retics Patient Phenotype: R o, K-, Fy(a-b-), Jk(a+b-), S-s+ 8

9 Eluate Testing D C C w Rh MNSs Kell Duffy Kidd Results E c e M N S s K k Fy 1 R1R1w R1R R2R Ror r r r r rr rr rr rr R1R Retics + a Fy b Jk a Jk b PEG IAT 9

10 Eluate Testing D C C w Rh MNSs Kell Duffy Kidd Results E c e M N S s K k Fy 1 R1R1w R1R R2R Ror r r r r rr rr rr rr R1R Retics + Conclusion: Warm autoantibody in the eluate a Fy b Jk a Jk b PEG IAT 10

11 Plasma Testing: Ficin Panel Rh MNSs Kell Duffy Kidd Results D C C E c e M N S s K k Fy Fy Jk Jk 30 I A w a b a b 37C T 1 R1R1w * 2 R1R * 3 R2R * 4 Ror * 5 r r * 6 r r * 7 rr * 8 rr s * 9 rr * 10 rr s * 11 R1R w * * Agglutinated after washing 11

12 Plasma Testing: Cold Screen D C C w Rh MNSs Kell Duffy Kidd Results E c e M N S s K k K p a I R1R II R2R III rr Auto 0 4+ Conclusion: Cold autoantibody at 4C K p b J s a J s b F y a F y b J k a J k b 30 RT 30 4C 12

13 Plasma Testing: LISS Panel Rh MNSs Kell Duffy Kidd Results D C Cw E c e M N S s K k Fya Fyb Jka Jkb 5' LISS LISS IAT RT 37C w w w +w w +w w w w w 1+ Previously Identified : anti-c, anti-e, anti-s, anti-jk b 13

14 Plasma Testing: LISS Panel Rh MNSs Kell Duffy Kidd Results D C Cw E c e M N S s K k Fya Fyb Jka Jkb 5' RT LISS 37C LISS IAT w w w w Auto 0 +w +w 0 Patient Phenotype: R o, K-, Fy(a-b-), Jk(a+b-), S-s+ 14

15 7/6/2010: IRL Conclusions: DAT IgG positive Warm autoantibody in the eluate Plasma contains anti-c, -E, -S, -Jk b Cold autoantibody at 4C **Recommend transfusing C-, E-, S-, Jk(b-) units 15

16 Request for units - Hospital B 08/10/ E-,C-,Jk(b-), S- units 10/12/ E-,C-,Jk(b-), S- units 10/26/ E-,C-,Jk(b-), S- units 01/13/ E-,C-,Jk(b-), S- units 06/03/ E-,C-,Jk(b-), S- units 11/30/ E-,C-,Jk(b-), S- units 16

17 02/04/2012: IRL Sample submitted to IRL Diagnosis: RLE Cellulitis, Renal Patient Recently transfused: 11/30/11 DAT: Polyspecific Anti-IgG Anti-C3b,- C3d Saline DAT

18 Eluate Testing D C C w Rh MNSs Kell Duffy Kidd Results E c e M N S s K k Fya Fyb Jka Jkb PEG IAT 1 R1R1w R1R R2R Ror r r r r rr rr rr rr R1R

19 Explaining a Negative Eluate: 1.Drug-Induced Hemolytic Anemia 2.Anti-A/Anti-B 3.Antibody to a low incidence antigen 4.Antibody not at detectable levels 19

20 D C C w Plasma Testing: LISS Panel Rh MNSs Kell Duffy Kidd Results E c e M N S s K k Fya Fyb Jka Jkb 5 RT Auto LISS 37 LISS IAT Reactive with all C-, E-, S-, Jk(b-) cells Cold reactivity gone New reactivity at IAT stronger warm autoantibody??? 20

21 Plasma Testing: LISS Panel Rh MNSs Kell Duffy Kidd Results D C Cw E c e M N S s K k Fya Fyb Jka Jkb 5 RT Auto Unit #1 Unit #2 Unit #3 Unit # LISS 37 LISS IAT Negative reactions!!!! 21

22 Plasma Testing: LISS Panel Rh MNSs Kell Duffy Kidd Results D C Cw E c e M N S s K k Fya Fyb Jka Jkb 5 RT Auto 0 0 +w Unit #1 Unit #2 Unit #3 Unit # Patient Phenotype: R o, K-, Fy(a-b-), Jk(a+b-), S-s+ LISS LISS IAT

23 02/04/2012: IRL Conclusions: DAT IgG positive Eluate nonreactive New anti-fy 3 in the plasma **Recommend transfusing C-, E-, S-, Jk(b-), Fy(a-b-) units 23

24 Proposed seven transmembrane spanning topology of DARC. (A) Molecular modeling predicts that DARC has topologic features similar to other members of the chemokine receptor family. Hadley T J, Peiper S C Blood 1997;89: by American Society of Hematology

25 Duffy System More Than You Want to Know about Duffy: 6 antigens: Fy a Fy b Fy 3 negative on Fy(a-b-) RBCs Fy 4 reported in 1973, existence doubted Fy 5 - negative on Fy(a-b-) RBCs from blacks, negative on Rh null RBCs Fy 6 only defined by murine monoclonal antibodies 25

26 Fy(a-b-) Phenotype Resistant to Plasmodium Vivax Most common Duffy phenotype in blacks (68% of African Americans) Most blacks have FyFy genotype Fy structurally same as Fy b GATA-1 site mutation Anti-Fy b, anti-fy 3 rare Rarely, Fy(a-b-) is the result of a partially deleted Duffy gene Makers of anti-fy b, anti-fy 3 26

27 Anti-Fy 3 Anti-Fy 3 is rare: Patient has to be Fy(a-b-) No GATA-1 mutation Clinical significance of anti-fy 3 : Mild to moderate transfusion reaction Mild (rare) HDN 27

28 02/19/2012: IRL Sample submitted to IRL Diagnosis: ESRD, post cardiac arrest, GI bleed DAT: Polyspecific Anti-IgG Anti-C3b,- C3d Saline DAT

29 Eluate Testing Rh MNSs Kell Duffy Kidd Results D C Cw E c e M N S s K k Fya Fyb Jka Jkb PEG IAT Conclusion: Anti-Fy 3 in eluate 29

30 Conclusions: 02/19/2012: IRL DAT IgG positive Anti-Fy 3 in eluate LISS testing detected no new alloantibodies in plasma 30

31 But wait, that s not how it s supposed to happen!!! 1. Anti-Fy 3 detected in plasma before it was detected in eluate 2. Anti-Fy3 detected in the eluate, but patient hadn t been recently transfused with Fy+ blood 3. Anti-Fy 3 in patient with the GATA-1 mutation 31

32 Lessons Learned: Patient phenotype helps in complicated cases involving multiple antibodies Warm autos have to react with the patient s cells! Antibodies don t always follow the rules 32

33 33

34 34