Delayed Hemolytic Transfusion Reaction Due to Appearance of Multiple Antibodies Following Transfusion of Apparently Compatible Blood

Abstract

A delayed hemolytic transfusion reaction, appearing seven days after transfusions, characterized by jaundice, hemolysis and hemoglobinuria accompanied by the appearance of multiple antibodies in the patient's serum (anti‐hr″ (c) anti‐rh″ (E) and anti‐Jkb) is explained as an anamnestic phenomenon. The original sensitizing antigens and those which precipitated the recall mechanism may be traced to her 20‐year‐old son and to the single‐unit transfusion which she received five years previous to the last admission, and to the transfusions given with the operation from which she recovered. The important fact is that these latent antibodies failed to be detected by standard crossmatching tests (saline, high protein and Coombs) and by a pool of cells containing most of the antigens. The triple enzyme method was the only test which detected the anti‐rh″ (E) antibody. The direct Coombs test became positive at the height of the reaction and persisted for 48 hours. Blood tests after 31/2 and 41/2 months revealed that both the anti‐Jkb and anti‐rh″ (E) antibodies had vanished and only anti‐hr‘ (c) of low titer was still present.

Delayed Haemolytic Transfusion Reactions Simulating Auto-Immune Haemolytic Anemia

“…These findings support the suggestion of several authors [8,16] that patients should carry a card or bracelet recording the specificity of any irregular antibodies detected in their serum.…”

“…Nine months after the most severe transfusion reaction in the present series (Case 5), the anti-Fya had a titre of 1:4 and the other two antibodies (anti-Ce and anti-e) were barely detectable. In the case described by Joseph et al [8], the anti-Jkb and anti-E were no longer detectable six weeks after transfusion. In another case anti-E could no longer be detected even with EE cells, six months after transfusion.…”

“…Antibodies which had not been detectable before transfusion were then identified as anti-E [7, Case 1; 14, Case 3]; anti-c [13], anti-c and anti-Jka [15]; anti-c, anti-E and anti-Jkb [8]; and anti-k [7,Case 2].…”

Delayed Haemolytic Transfusion Reactions due to Anti-C

“…Delayed haemolytic transfusion reactions presenting with haemoglobinuria are of rare occurrence, and appear to be related to the rate of haemolysis or the specificity of the antibody rather than to the involvement of complement [9], In 10 reported cases of haemoglobinuria developing between 6 and 13 days after the transfusion of 2-10 U of blood, antibodies with the following speci ficities were present in the patient's serum: anti-U [8,14], anti-c [15], anti-c +-M [1], anti-Jka [13], anti-Jkb [4,7], anti-HI, -Jkb, -S, -Fya [3], anti-E, -K, -S, -Fya [10] and anti-C, -E, -Jkb [6]. A similar range of anti body specificities, but excluding anti-U, has been reported in cases of delayed haemolytic transfusion reactions presenting with jaun dice or anaemia [1, 2, 11 -13, 16].…”

Control of the antigen‐antibody ratio in antibody detection/compatibility tests

“…Although the literature contains many cases of antibody-mediated delayed hemolytic transfusion reaction (DHTR) in which subsequent retesting of pretransfusion specimens showed no antibody by "usual" or "standard" techniques, no information about what serum: cell ratio was employed is provided.4, 8-11, [14][15][16][17]20,21,[24][25][26][27]32 In order to minimize errors in in vitro tests for detection of clinically significant antigens and antibodies, it is important to I) standardize pretransfusion test methodology by adopting an optimum serum:cell ratio, 2) test the drop delivery volume of dropper pipettes used in antibody detection! compatibility tests as part of the quality control of equipment, 3) promote standardization of the concentration of commercial reagent red blood cells and the drop delivery volume of their vial droppers, and 4) save pretransfusion samples for 14 days after the patient's transfusion.…”