R2 R2 Phenotype Blood Requirements for Liver Transplantation Surgery in a Child with Multiple Rh Antibodies: Meeting Needs and Changing Indian Scenario : Global Journal of Transfusion Medicine

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R2 R2 Phenotype Blood Requirements for Liver Transplantation Surgery in a Child with Multiple Rh Antibodies

Meeting Needs and Changing Indian Scenario

Sachan, Deepti; Gundrajukuppam, Deepthi Krishna; Shanmugam, Naresh1; Rajalingam, Rajesh1; Rela, Mohamed1

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Global Journal of Transfusion Medicine 8(1):p 82-85, Jan–Jun 2023. | DOI: 10.4103/gjtm.gjtm_86_22
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Red cell alloimmunization often poses challenge for transfusion support during surgery. As transfusion needs are unpredictable in liver transplantation (LT) surgeries, transfusion services often need timely identification and arrangement of compatible units. We present a case of an 11-year-old child with multiple antibodies who required rare R2R2 phenotype blood units' arrangements and successfully underwent live donor LT.


An Eleven-year-old male child studying in 4th standard, weight 36 Kg, was admitted to our hospital for LT. He had underwent Kasai surgery at the age of 1 month for biliary atresia. The patient had a history of surgical re-exploration in 2014 and episodes of recurrent portal hypertension and variceal bleeds for which he received transfusion of multiple blood components. He was diagnosed as Waardenburg Syndrome due to the presence of skin hypopigmentation and white forelock of hair.

On admission, the patient had pancytopenia with hypersplenism with hemoglobin (Hb) 7.7 gm/dL, platelet count 97,000 cells/cmm, INR 1.29, total bilirubin 26.0 gm/dL and direct bilirubin 21 gm/dL, albumin 2.5 gm/dL, urea 35 mg/dL, and creatinine 0.72 mg/dL.

Immunohematology (IH) workup was done using column agglutination method. The patient's blood group was B positive. Antibody screening was performed using commercially available three-cell panel (Diacell I-II-III panel, BioRad, Switzerland) which showed positive agglutination in P1 (3+), P2 (0), and P3 (3+). Direct antiglobulin test (DAT) was negative. Antibody identification was performed in anti-human globulin phase (ID- Diapanel, Biorad, Switzerland). “Anti-C” Rh antibody was confirmed with possibility of additional weak antibodies [Figure 1]. The antibody identification (in AHG phase) was repeated after enzyme treatment. Antibodies which were weakly reactive at AHG phase were enhanced and were confirmed to be 'anti-e' as shown in Figure 2. Patient minor antigen phenotype was performed and was as following: R2R2 (C-c+E+e-), K-, k+, Fya +, Fyb-, S+, s+, Jka+, Jkb+, M+, N+, Lea-, Leb-. Presence of additional clinical red cell antibodies were ruled out.

Figure 1:
Patient antibody identification panel in AHG phase with Antegram. AHG: Anti human globulin
Figure 2:
Patient antibody identification panel in AHG phase after Enzyme treatment. AHG: Anti human globulin

The transplant team was informed regarding difficulty in arranging the compatible R2R2 units and possibility of delays in arrangements. Family members were screened for matched phenotype. Patient's sister had same phenotype, however, she was deferred due to under age. 140 leucodepleted packed red cells (LDPRC) units (33 B-positive, 107 O-Positive) were crossmatched and were found incompatible and we could not find R2R2 unit in inventory. We also approached various centers in South India for rare donor registry or availability of R2R2units; however, the donors were not available at the time of request. The request for R2R2 phenotype units were sent through social media (WhatsApp) and responses received across different states across country from blood centers who were doing Rh (DCcEe) phenotyping in blood donors.

Single shipment was planned from three blood Centres located in New Delhi due to higher requirement of blood units, logistics challenges and higher cost of air shipments. Logistics were arranged with Courier services with Data logger facilities. Eleven B positive R2R2 units were picked and air-shipped from three blood centers maintaining cold chain as shown in Figure 3. The shipment completed in 24 hours and on receipt of blood units, cold chain maintenance records and hemolysis were checked and the units were found suitable to use.

Figure 3:
Log chart showing cold chain monitoring over 24 h of air transportation of units from North India to Chennai, South India

Preoperative investigations were: Hb 8.3 gm/dL, platelet count 113,000 cells/cmm, INR1.3, fibrinogen 321 gm/dL, total bilirubin 31.0 gm/dL, and direct bilirubin 24.7 gm/dL. Intraoperatively, the patient received two units of LDPRC (R2R2 phenotype) and two units fresh frozen plasma (FFP). The patient further required three units LDPRC and three units FFP in immediate postoperative period. He developed high bilirubin levels due to graft dysfunction for which 2 cycles of plasmapheresis were performed. There was no evidence of hemolytic reaction or DAT positivity in the postoperative period. The bilirubin showed reducing trend and the patient was discharged on postoperative day-18 with Hb 8 gm/dL, platelet count 42,000 cells/cmm, and total bilirubin 4.56 gm/dL.


Transfusion medicine plays an important role in major surgeries by replacing important blood components and supporting surgical blood loss as well as perioperative hemostasis. In the same context, pretransplant IH workup plays an important role for timely detection of irregular auto or alloantibodies as well as timely arrangement for compatible blood units. In case of alloimmunization, it often comes as a challenge to provide timely transfusion support and hence often requires meticulous planning prior to surgery.

The multi-transfused patients often get alloimmunised and pose challenge for transfusion support major surgeries like liver transplantation. Recent data suggest that red blood cell (RBC) alloantibodies may affect LT outcomes.[1,2,3] Female patients are more likely to develop anti-RBC alloantibodies than male patients, because they can be alloimmunized during pregnancy. A study by Boyd et al. indicated that alloantibody history, independent of the patient's gender, is a predictor of worse outcomes after LT.[1]

The most frequently found antibodies in LT patients are directed against the RH antigens.[4,5] Rh antibodies are clinically significant and usually IgG in nature. The prevalence of “e” antigen in Indian population is 98%–99% and presence of anti-e alone or in combination will be difficult to manage with e negative units for any surgery in absence of donor registry. Need for national database for rare donors can help in managing such patients alloimmunized with multiple antibodies or with antibodies against high-frequency antigen as in our case. Arranging 10–12 R2R2 phenotype units for liver transplant was a herculean task and needed a wider approach and search for timely arrangements. It involved team work with transfusion medicine specialists, transplant surgeon, anesthesiologists, coordinators, voluntary organization, and logistic team.

In a previous published case-report, a multiparous female allo-immunised with multiple red cell antibodies (anti-C, anti-e and anti-K) had a long waiting period of 6 weeks and only 5 antigen matched units could be arranged for liver transplant surgery in 2016.[6]

However, in this case, with already phenotyped units were available in blood centres inventory, sufficient blood units were arranged in timely manner within 2 weeks in coordination with logistics team.

With Increasing facility of red cell phenotyping in major blood centres and ready availability of phenotype matched blood, highlights the changing scenario of Indian blood transfusion services.

However, phenotyping and individual registries are in their early phase in South India with limited donors of rare phenotype in registry. Hence, we were constrained to look into transfer of blood from other states which brought the challenges of blood transportation and need for third party for temperature monitored air shipment. Transfusion support to alloimmunised patients involves additional financial burden for additional reagents required for antibody identifications, phenotyping etc, transportation of samples to reference laboratories, transfer of antigen negative blood units and requires appropriate counseling of patient. The challenge of arranging rare phenotype units further depend on single/multiple antibodies, their specificity and antigenicity of population and need for inter-state or international transfer.

Finally, due to social networking, the transfusion medicine specialists are connected closely and respond actively to support other blood centers, and blood arrangements are being done on individualized basis and individual efforts. However, national rare blood donor registry should be established in coordination with blood centres as well as hospitals requiring rare phenotype units. Zone-wise registries will further help in quicker deliveries of blood units and minimize the cost of long transport hours.

Our blood center has started Rh and Kell phenotyping for all transplant recipients as well as O group blood donors and has completed more than 2000 donor screenings. This initiative will help in handling emergency needs for patients with Rh and Kell alloimmunization for our hospital as well as outside requests and is better prepared for handling emergency blood needs in alloimmunized patients.

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


Conflicts of interest

There are no conflicts of interest.


I would like to acknowledge Dr. Sangeeta Pathak (Max Superspeciality Hosptial, New Delhi), Dr. Kamini Khillan (Sir Gangaram Hospital, New Delhi), and Dr. Rasika Setia (BLK Memorial Hospital, New Delhi) for timely providing the units and coordinating for single day consignment from New Delhi to Chennai.

I would also like to thank Dr. Swati Kulkarni (NIH, Mumbai), Dr. Ankit Mathur (TTK Bangalore), Dr. Sanjay Gupta (Apollo Hospitals, Gujrat), Dr. Sanmukh Joshi, (Lok Samarpan Blood Bank, Surat), and Dr. Abhishekh Gowda (JIPMER, Puduchery) for their guidance and support for reserving additional units.

I also thank the Logistics team (Sequel logistics Pvt Ltd.), Liver transplant Coordinator Mr. Shiva Kumar (Transplant Coordinator, RIMC, Chennai) for coordination and shipment of Units.


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2. Shariatmadar S, Pyrsopoulos NT, Vincek V, Noto TA, Tzakis AG. Alloimmunization to red cell antigens in liver and multivisceral transplant patients Transplantation. 2007;84:527–31
3. Au WY, Liu CL, Lo CM, Fan ST, Lam MF, Lam CK. Red blood cell alloantibodies and liver transplantation in Chinese patients Transplantation. 2003;76:324–6
4. Ramsey G, Cornell FW, Hahn LF, Larson P, Issitt LB, Starzl TE. Red cell antibody problems in 1000 liver transplants Transfusion. 1989;29:396–400
5. Luzo AC, Pereira FB, de Oliveira RC, Azevedo PR, Cunha RD, Leonardi MI, et al Red blood cell antigen alloimmunization in liver transplant recipients Transplant Proc. 2010;42:494–5
6. Sachan D, Tiwari AK, Dara R, Jothimani D, Kaliamoorthy I, Reddy SM, et al Patient blood management in a patient with multiple red cell antibodies (anti-C, anti-e, and anti-K) undergoing liver transplant in South India: A team approach Asian J Transfus Sci. 2020;14:74–8

Alloimmunization; anti-e; liver transplant; patient blood management; R2R2 phenotype; rare donor registry; Rh antibodies

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