Faculty: Molly Harrison, MLS(ASCP)SBB Manager, Blood Bank Conemaugh Memorial Medical Center

Transcription

1 HTLA Antibodies: Identification and Management Strategies and Case Studies Program # Wednesday, April 17, :00 pm-3:30 pm (ET) ~ 6:00 pm-7:30 pm (GMT) This audioconference will focus on high titer low avidity(htla)-like antibodies. The "typical" serological characteristics of HTLA-like antibodies and the common antibodies that demonstrate HTLA-like activity will be discussed. Case studies will focus on the challenges faced when identifying HTLA-like antibodies and the different approaches to transfusion of patients with HTLA-like antibodies Objectives: Describe the common characteristics seen with antibodies previously known as HTLA antibodies. Discuss the antibodies that demonstrate HTLA-like characteristics. Discuss the clinical significance of HTLA-like antibodies. Director/Moderator: Michele Hayes, MT(ASCP)SBB Director, Immunohematology Reference Laboratory American Red Cross, Greater Alleghenies Blood Services Region Faculty: Molly Harrison, MLS(ASCP)SBB Manager, Blood Bank Conemaugh Memorial Medical Center

2 In accordance with AABB Policy on Disclosure of Faculty Relations, the faculty for this event have signed a conflict of interest form in which they have disclosed any significant financial interests or other relationships with industry relative to the topics that they will discuss at this program. Such disclosures allow you to better evaluate the objectivity of the information presented in the lectures. Director/Moderator: Michele Hayes, MT(ASCP)SBB Director, Immunohematology Reference Laboratory American Red Cross, Greater Alleghenies Blood Services Region Disclosures: No Disclosures Given Faculty: Molly Harrison, MLS(ASCP)SBB Manager, Blood Bank Conemaugh Memorial Medical Center Disclosures: Nothing to Disclose Name/Role in Content Planning Disclosure Nature of relationship Manufacturer/Provider Kristi Williams, planning committee member Colleen Aronson, planning committee member Nancy Dunbar, planning committee member Michele Hayes, planning committee member Nora Hirschler, board representative Drew Minardi, planning committee member Gail Moskowitz, planning committee member Jayanna Slayten, planning committee member Sharon Moffett, staff member Lauren Rohde, staff member Alyson Wagner, staff member none none none none none none yes none none none none Professional Professional GASCO Eastern District, Federal Credit Union- Chair of Supervisory Committee Board of Directors, Guide to Cord Blood Foundation

3 Accessing your Continuing Education Credits Online! 1. Log into the Live Learning Center from the website 2. Go to Professional Development 3. Click on red link that says AABB Live Learning Center on the left side of the page 4. Click on red link that says AABB Live Learning Center in the center of the page 5. Click the My Account link at the top of the page. 6. Log in using your address and password. 7. Click on the link that says My Transcripts 8. Go to the Select Conference drop down menu and select 2013 Audioconference Series 9. Choose the appropriate audioconference title.

4 HTLA Antibodies: Identification and Management Strategies and Case Studies Slide 1 HTLA Antibodies Objective Describe the typical serological characteristics of HTLA antibodies Discuss common antibodies associated with HTLA-like activity Identify the challenges faced when identifying HTLA-like antibodies and approaches to transfusion Slide 2 What are HTLA antibodies? Historically, antibodies that have be grouped together based on similar characteristics. More often, these antibodies are referred to as HTLA-like antibodies. The specificity of these antibodies can often be determined. Slide 3 1

5 HTLA- High Titer Low Avidity High Titer Reactivity continues to be observed at high dilutions Low Avidity Weak reactivity due to weak bonds Slide 4 Common Characteristics of HTLA-like Antibodies Weak, nebulous activity Diluted serum reacts Reactivity may be difficult to reproduce Antibodies to high frequency antigens (Issit & Anstee, 1998) Slide 5 Common Characteristics of HTLA-like Antibodies Some are neutralizable with pooled serum or plasma Do not adsorb well onto red cells (Issit & Anstee, 1998) Slide 6 2

6 Common Characteristics of HTLA-like Antibodies Not usually considered to be clinically significant Transfusion reactions are not seen when least incompatible blood is transfused Post transfusion, a positive DAT may be observed; however, there is no evidence that red cell clearance is accelerated (Issit & Anstee, 1998) Slide 7 Why are HTLA-like antibodies important? Mask underlying clinically significant antibodies Some clinically significant antibodies have HTLA-like characteristics (Issit & Anstee, 1998) Slide 8 HTLA-like Antibodies Usually have HTLA-like charachteristics: Cs a Knops system Chido/Rodgers JMH Sometimes have HTLA-like charachteristics Gy a, Hy, Jo a (Issit & Anstee, 1998) Slide 9 3

7 HTLA-like Antibodies Some of these antibodies can have HTLA-like characteristics Ge2, Ge3 Lu b Yt a Fy3 Co a Di b In b Vel (Issit & Anstee, 1998) Slide 10 Challenges with Antibody Identification and HTLA-like Antibodies Weak reactivity Not reproducible Mask clinically significant antibodies May be a clinically significant antibody has HTLA-like characteristics Reacts with the majority of red cells (Issitt & Antee, 1998) Slide 11 Rh MNS P Lewis Kell Duffy Kidd IS 37C W W W W Weak reactions, no apparent specificity, most of the cells react.what are the possibilities? Multiple antibodies High Frequency antibody HTLA-like antibody 12 4

8 What Tools Can Be Used Perform Antibody Identification? Patient history Red Cell Phenotype Test with other enhancement media Titration Studies Enzymes/Chemicals Neutralization Studies (Harmening, 2005) Slide 13 Patient History Has the patient been transfused or pregnant? High frequency negative individuals are more prevalent in certain populations Red Cell Phenotype Determine what antibodies the patient can make Testing a phenotypically similar reagent red cell can give additonal information Slide 14 Test with Other Enhancement Media HTLA-like antibodies often react have the same reactivity strength regardless of what enhancement media is used or not used. Rh MNS P Lewis Kell Duffy Kidd PEG W+ W+ W W+ W+ W W+ W+ W W+ W+ W

9 Titration Studies Rh MNS P Lewis Kell Duffy Kidd PEG :2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1: W+ W+ M+ M+ M+ M Perform titration with a phenotypically similar red cell -Weak reactivity will be observed at high dilutions 16 Enzymes/Chemicals Can be used to enhance or destroy antigens Reactivity patterns with different enzymes or chemicals can help distinguish specificity Ficin Destroys M, N, S, s, Fy a, Fy b, Ch, Rg, Ge2, Indian, JMH, Yt a Dithiothreitol (DTT) Destroys Indian, JMH,Yt a, Kell, LW, Scianna, Knops, Cromer, Lutheran, Dombrock (Reid & Lomas-Francis, 2004) Slide 17 Neutralization Studies Pooled serum or plasma can neutralize reactivity of some HTLA-like antibodies. Untreated AB Dilution Neutalize Control Rh MNS P Lewis Kell Duffy Kidd W+ 0 W W+ 0 W

10 Transfusion of Patients with HTLA-like Antibodies Depends on: -Clinical condition of patient. How quickly does the patient need transfused? -Can the antibody specificity be determined? Does the patient need antigen negative blood? Slide 19 Transfusion of Patients with HTLA-like Antibodies Options: -Antigen negative blood if indicated (based on antibody specificity) -Phenotypically similar, crossmatch compatible, and/or least incompatible units -Monocyte Monolayer Assay Testing - Slide 20 Case Study #1 Female, 56 years old Hemoglobin=7.4 g/dl Scheduled for outpatient transfusion of one unit when available No previous transfusion history, three pregnancies Slide 21 7

11 A, Rh positive Positive Antibody Screen Case Study #1 Rh MNS P Lewis Kell Duffy Kidd IS 37C W M W W AC Case Study #1 The patient s red cell phentoype was found to be: Positive for: E, c, e, M, N, S, s, P 1, Fy a, Fy b, Jk b Negative for: C, K, Jk a Was a phenotypically similar cell tested? Rh MNS P Lewis Kell Duffy Kidd IS 37C M The doctor s office was closed for the evening and the patient could not be reached for additional information on ethnic background. 23 Case Study #1 Rh MNS P Lewis Kell Duffy Kidd PEG :2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024 W+ W+ M+ M+ M

12 Different Enhancement Media Case Study #1 Rh MNS P Lewis Kell Duffy Kidd PEG W+ W+ W M+ M W+ W+ W W+ W+ W AC Ficin and DTT red cells Case Study #1 Rh MNS P Lewis Kell Duffy Kidd Ficin DTTtreated Cells W+ 0 W M+ 0 M W+ 0 W W+ 0 W+ -Antibody is to an antigen destroyed by ficin, but not by DTT -Titers to a dilution of 32 -Reacts similar with PEG,, or without enhancement media 26 Case Study #1 Neutralization Studies Rh MNS P Lewis Kell Duffy Kidd Dilution AB Control Neutralized W+ 0 W M+ 0 M W+ 0 W W+ 0 W+ -Neutralized by AB Serum -Ruled out clinically significant alloantibodies -Antibody to Chido or Rodgers antigen 27 9

13 Case Study #1 Which unit should be transfused? IS 37C Unit A C-, K-, Jk(a-) Unit B, C-, K-, Jk(a-) M+ Unit C Unit D 0 0 M+ Unit E 0 0 M+ 28 Case Study #2 Female, 27 years old Hemoglobin=11.5 g/dl Routine Prenatal Antibody Screen Two previous pregnancies, all previous antibody screens were negative No transfusion history Slide 29 O, Rh negative Positive Antibody Screen Case Study #2 Rh MNS P Lewis Kell Duffy Kidd IS 37C AC

14 Different Enhancement Media Case Study #2 Rh MNS P Lewis Kell Duffy Kidd PEG AC 0 31 Second antibody panel Case Study #2 Rh MNS P Lewis Kell Duffy Kidd IS 37C W Js(a-) Kp(a-) o + 0 U Ch Case Study #2 Rh MNS P Lewis Kell Duffy Kidd PEG :2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1: M+ M Sent to a Reference Lab for further investigation 33 11

15 Case Study #2 Reactivity was observed with both ficintreated and DTT-treated red cells. Molecular Red Cell Phenotyping was performed, and the patient was determined to be Lu(b-) by molecular methods The Reference Lab determined the patient had anti-lu b Slide 34 Case Study #2 How should the patient be transfused? Is there a risk of HDN? Slide 35 Case Study #3 Male, 72 years old Hemoglobin=10.5 g/dl Broken hip, scheduled for surgery in the morning Transfused 6 years ago following open heart surgery. Antibody screen was negative at that time. Slide 36 12

16 AB, Rh positive Positive Antibody Screen Case Study #3 Rh MNS P Lewis Kell Duffy Kidd IS 37C W M W W M+ AC Case Study #3 Rh MNS P Lewis Kell Duffy Kidd Ficin DTT W M W W M Case #3 The patient s red cells were phenotyped Positive: C, e, K, k, M, N, S, s, Fy a, Jk a, Jk b, Le b, P 1 Negative: E, c, Fy b, Le a Reactivity was observed to a dilution of 64 with a phenotypically similar cell. Slide 39 13

17 Case Study #3 Phenotypically similar red cells Rh MNS P Lewis Kell Duffy Kidd IS 37C W W M+ Unit AUnit B, E-, c-, Fy(b-) Unit B, E-, c-, Fy(b-) Unit B, E-, c-, Fy(b-) 0 0 W+ 0 0 W+ 0 0 M+ In addition, similar reactivity was observed when testing was performed, PEG, or without enhancement media 40 Case Study #3 Rh MNS P Lewis Kell Duffy Kidd IS 37C Yt(a-) Yt(a-) JMH- 0 0 M+ The patient s red cells phenotyped Yt(a-) What units should be crossmatched for surgery? Should MMA testing be performed? 41 Case Study #4 Male, 56 years old Hemoglobin=12.5 g/dl MVA, trauma,actively bleeding Transfused two units of O, Rh positive units on the way to the hospital Want 4 units ASAP Slide 42 14

18 O, Rh positive Positive Antibody Screen Case Study #4 Rh MNS P Lewis Kell Duffy Kidd IS 37C W W M W AC Second antibody panel Case Study #4 Rh MNS P Lewis Kell Duffy Kidd IS 37C W o Case Study #4 IS 37C Unit A Unit B 0 0 M+ Unit C Unit D 0 0 M+ Unit E 0 0 M+ Unit F

19 Case Study #4 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024 W+ W+ M+ M+ M Similar reactivity with PEG testing -Resources are not available for further investigation at the hospital. -What should be done? -How should the patient be transfused? 46 HTLA-like Antibodies Not usually considered to be clinically significant Some are neutralizable with pooled serum or plasma Do not adsorb well onto red cells. Mask underlying clinically significant antibodies Some clinically significant antibodies have HTLA-like characteristics (Issit & Anstee, 1998) Slide 47 Important Investigation Tools Patient history Red Cell Phenotype Test with other enhancement media Titration Studies Enzymes/Chemicals Neutralization Studies Slide 48 16

20 Transfusion of Patient s with HTLA-like antibodies Antigen negative Phenotypically similar Crossmatch compatible Crossmatch least incompatible MMA testing Clinical situation of the patient Slide 49 Works Cited Harmening, D. (2005). Modern Blood Banking & Transfusion Practices (5 th Ed.), Philadelphia, PA: F.A. Davis Company. Issitt, P.D., & Anstee, D. J. (1998). Applied Blood Group Serology (4 th Ed.), Durham, NC: Montgomery Scientific Publications. Reid, M., & Lomas-Francis, C. (2004). The Blood Group Antigen FactsBook (2 nd Ed.), Amsterdam, Netherlands: Academic Press. Roback, J. (Ed.), et al. (2011). Technical Manual (17 th Ed.), Bethesda, MD: AABB. Slide 50 Any Questions? Molly A. Harrison mharriso@conemaugh.org Slide 51 17

21 Upcoming Cellular Therapies Audioconference: Protocols for Supporting HPC Transplant Patients Prior to, During, and After HPC Transplants* April 24, :00 pm to 3:30 pm (ET); 6:00 pm to 7:30 pm (GMT) Program # Hematopoietic stem cell or progenitor cell transplants (HPC) are used as treatments for many hematological diseases and some non-hematological diseases including autoimmune disorders, solid tumors, and several inherited metabolic and immunodeficiency diseases. Due to the critical timing of transfusion support before, during and after HPC transplants, hospitals must develop safe and effective transfusion protocols to support these transplant patients. The purpose of this audioconference lecture is to review these protocols and special blood product requirements, criteria for selection of donor and recipients with emphasis on ABO/Rh(D) and red blood cell antigens, and immunological consequences following transplant including hemolytic reactions. The program will also be given to address any long-term transfusion needs following HPC transplants. *Cellular Therapy Program Objectives: Review special blood product requirements needed for compatible and safe blood transfusion to HPC transplant patients. Review criteria for selection of HPC donors with consideration of donor and recipient ABO/Rh(D) and selection of blood products for peritransplant transfusion support. Discuss transfusion complications following transplant including adverse hemolotyic reactions. Intended Audience: Physicians, Scientists, Technologists, Nurses, Managers/Supervisors Event Level: Intermediate to Advanced Director/Moderator: Deborah Sesok-Pizzini, MD, MBA Medical Director, Blood Bank University of Pennsylvania Faculty: Thomas Klumpp, MD, FACP Nicole Aqui, MD

22 AABB would like to thank the members of the AABB Distance Learning Program Unit for their assistance in developing these programs: 2013 Distance Learning Program Unit CHAIR Kristi Williams, MT(ASCP)SBB, CQA, CQIA(ASQ) Manager, Biomedical Headquarters IRL Operational Support, American Red Cross Washington, IL Colleen Aronson, MT(ASCP)SBB Quality Programs Coordinator, Northshore University Healthsystem Evanston, IL Meghan Delaney, DO, MPH Assistant Medical Director, Puget Sound Blood Center Seattle, WA Nancy Dunbar, MD Assistant Professor, Dartmouth-Hitchcock Medical Center Hanover, NH Michele Hayes, MT(ASCP)SBB Director of Immunohematology Reference Laboratory, American Red Cross Johnstown, PA Nora Hirschler, MD CEO, Blood Centers of the Pacific San Francisco, CA Drew Minardi, Director of Education for School of Medical Laboratory Science, Atlantic Health Saddle Brook, NJ Sharon Moffett, CAE Director of Education and Professional Development, AABB Bethesda, MD Gail Moskowitz, MD Independent Consultant New York, NY Lauren Rohde Programs Manager, AABB Bethesda, MD Jayanna Slayten, MS, MT(ASCP)SBB Reference Laboratory Supervisor, Indiana Blood Center Indianapolis, IL Alyson Wagner Cellular Therapy Program Manager, AABB Bethesda, MD