Introduction
Patients with sickle cell disease (SCD) often receive blood transfusions to overcome the sickle cell crisis.[1 2
Materials and Methods
Grouping antisera for forward grouping were of commercial source (Tulip, India), while RBCs used for reverse grouping were in-house preparation. The other reagent RBCs used in antibody screening and identification tests were of commercial origin (Immucor, USA). The low ionic strength solution (LISS) was prepared in-house.
Standard serological methods were used in the tube for grouping, crossmatching as well as antibody screening tests (ASTs), and antibody identification tests. The patient was found to have multiple alloantibodies including anti-M (agglutinating in saline phase, optimally at 4°C) and anti-c and anti-E (reacting at 37°C in IAT phase). The crossmatching protocol was molded accordingly to test first at 4°C to select the nonagglutinating red cells, presumably the M antigen-negative units to further crossmatch by IAT at 37°C. Any unit found compatible by the tube method were confirmed by the gel-IgG-card method, being more sensitive than the tube method in the detection of antibody.
Further conservative approach was mooted through the use of recycled antibodies saved from the test supernatant (TS). The TS was harvested as described earlier.[2
Results
The case
A 32-year-old female patient, with SCD and liver failure, was admitted for correction of anemia before surgical treatment. Her blood specimen was referred to our blood center with a request to provide blood for transfusion. She was grouped as A, Rh. D+ by forward grouping but reverse serum showed reactivity with both A and B cells. AST on her serum was positive and the antibody identification test with an 11-cell panel on an anti-IgG gel card was inconclusive as it reacted with almost all the cells in the panel. The tube test results, however, revealed the presence of multiple antibodies in her serum. One of the antibodies reacted in the saline phase, with broad thermal amplitude (optimum strength at 4°C) with anti-M specificity. Other two specificities reacting in the LISS-IAT phase were identified as anti-c and anti-E. With this situation, it was Herculean task to find the blood units that lack all three antigens. Keeping this view in mind, we adopted a unique strategy to maneuver the crossmatch test.
A total of 641 blood units of group A and O red cells were included in the crossmatch test. Initially, the RBCs of 138 units were tested with the patient's serum by saline tube method at 4°C, of which 124 units showed direct agglutination, and 14 units did not agglutinate so were followed up for testing at 37°C by LISS-IAT-tube method that gave 2 units compatible. The TS was saved from the tests performed in the tube for further crossmatching.
The red cells from 503 blood units were tested using the TS by saline tube method at 4°C, of which 428 units showed direct agglutination and 75 units did not agglutinate and were followed up for testing at 37°C by LISS-IAT-tube method to get 8 units compatible, of which 2 units showing confirmed compatibility by the gel-IgG-card method.
The 10 units found compatible by the tube method were tested with the original serum using the gel-IgG-card method and 4 of these with clear compatibility were issued for transfusion purposes. The crossmatch strategy is depicted in Figure 1 .
Figure 1: Flowchart showing crossmatch approach for a patient having multiple alloantibodies
Discussion
Blood transfusion therapy in SCD is aimed to refurbish the oxygen-carrying capacity of the RBCs in circulation by the introduction of RBCs with normal hemoglobin Hb-A to help minimizing the complications of vaso-occlusion created by HbS.[3 4 5 6
However, transfusion may be associated with the risk of iron overload, alloimmunization for foreign blood group antigens, and hemolytic transfusion reaction (HTR) due to alloantibody developed through previous transfusions.[1 7 8
Some of the patients are considered good immune responders and produce multiple alloantibodies that pose difficulty to find compatible blood. Sometimes, a patient with alloantibodies and having a recent history of incompatible blood transfusion may show a positive DAT that may misguide in diagnosis as autoimmune hemolytic anemia by virtue of the pan-agglutinating property of the antibodies present. While a patient with autoantibody in autoimmune hemolytic anemia may tolerate the guise of the “least” incompatible blood,[9 8
The patient with multiple antibodies may require a large number of units to be screened to find the compatible blood units and therefore need a greater amount of blood specimens for crossmatch purposes. Repeated phlebotomy may contribute to iatrogenic blood loss to the patient who is already under stress with lower hematocrit values due to an underline condition. The crossmatch test strategy described here would certainly help in the efficient management of the patient's blood specimen. Besides, the most steps are taken use the tube method so it becomes more cost-effective as compared to the gel-card technology.
Conclusion
We consumed a total of 7 ml of the patient's serum and 26 ml of TS saved out of it in this entire exercise. Had we not used the TS, we would have consumed over 33 ml serum to screen the blood units numbering this magnitude. Besides, if we would have used the gel-card method for testing, it would have incurred enormous material costs as well. As such, the unique strategy adopted using elimination rounds of a large number of incompatible units by tube method and then, a few units found compatible by tube method were confirmed using the sensitive gel-card method, we have saved a lot of resources to make it cost-effective in finding the compatible units for transfusion to the patient having multiple antibodies.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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