Exeley Inc.

Mougey, Ruth

BOOK REVIEW: Transfusion Reactions

Mallory, Delores

McGinniss, Mary

Letter From the Editors: To Contributors to the 2002 issues There is no doubt that the journal depe

Fogg Leach, Miriam

AuBuchon, James P.

Development of anti-Bw6 reactivity in patients receiving r-GCSF: a preliminary report

Friedman, Mark T.

Carioti, Alan P.

Letter to the Editors: A hemolytic transfusion reaction due to anti-K undetected by a LISS antibody screen

IN MEMORIUM: Fred Stratton, BSc, MD (1913 &ndash; 2001)

Storry, Jill R.

A review: modification of the red blood cell membrane and its application in blood group serology

Żupańska, Barbara

Lenkiewicz, B.

Moderate hemolytic disease of the newborn due to anti-Hr0 in a mother with the D&ndash;&ndash;/D&ndash;&ndash; phenotype

Combs, Martha R.

Bennett, Donald H.

Telen, Marilyn J.

I M M U N O H E M A T O L O G Y ,  V O L U M E  1 6 ,  N U M B E R  3 ,  2 0 0 0120
Many transfusion services are reluctant to accept red blood cell
(RBC) units containing antibodies. We evaluated the impact of
accepting routine shipments of our region’s inventory of alloanti-
body-positive RBC units over a 4-month period.  All patients’ samples
received up to 30 days after transfusion of such units were evaluated
for the presence of passively acquired antibody, and labor and
reagent costs were determined. During the study period, we
received 259 alloantibody-containing RBC units, and 253 of these
were transfused to 187 patients. Follow-up samples were received on
99 of these187 patients, and 10 of these patients had detectable pas-
sive antibody in posttransfusion antibody screening tests. Two
patients had anti-C and -D and eight patients had anti-D. Due to our
negotiation of a small discount for antibody-containing units and the
use of 20 units based on labeled phenotype rather than antigen typ-
ing in our laboratory, we experienced a net savings of $3814 over the
4-month period.  This savings was achieved despite some additional
costs incurred,  including costs of data entry and additional testing on
patients’ samples.  We concluded that large-scale use of RBC units
from donors with alloantibodies is safe and likely to have a minimal
impact on a busy transfusion service’s workload and costs.
Furthermore, nationwide use of such units would help alleviate pro-
jected blood shortages. Immunohematology 2000;16:120–123.
Key Words: red blood cells (RBCs), passively acquired
alloantibodies, cost-saving, antigen phenotyping 
Reports have estimated that as many as 24,000 red
blood cell (RBC) units from donors with unexpected
alloantibodies are discarded annually in the United
States. However, almost half of these units can be
expected not to have detectable antibody in the final
RBC product.1 A major cause of this wastage is the reluc-
tance of many transfusion services to accept RBC units
containing alloantibodies. This unwillingness has sever-
al potential causes, including concerns that the detec-
tion of passive antibody in posttransfusion samples will
lead to additional testing, such as antibody identification
panels, phenotyping of RBC units, and antiglobulin-
phase crossmatches, if passively acquired antibody were
found in a posttransfusion sample. Another concern is
the possibility of minor incompatibility and consequent
hemolysis if the patient’s RBCs are positive for an anti-
gen against which a passively acquired antibody is direct-
ed. As a result, some institutions will only transfuse anti-
body-positive units if they are washed free of the
antibody-containing plasma, or if the patient’s RBC’s are
known to lack the antigen to which the antibody is
directed. These limitations result in the performance of
additional pretransfusion testing and handling by the
blood center or transfusion service. Thus, it is often dif-
ficult for blood centers to find transfusion services will-
ing to use products containing alloantibodies, and many
antibody-positive units expire before being used.
Because we are a large transfusion service that issues
more than 40,000 RBC units per year, we hypothesized
that our ability to use antibody-positive units could con-
tribute substantially to the efficient use of blood prod-
ucts in our region. We further reasoned that, due to the
low plasma volumes in these packed RBC units, detec-
tion of passively acquired antibody and minor incom-
patibility would be rare. Finally, we felt that any addi-
tional testing involved could be incorporated easily into
our already large testing volume. Therefore,we set up an
agreement with our sole blood supplier, the Carolinas
Region American Red Cross, to receive all of their other-
wise acceptable RBC units containing alloantibodies. We
then evaluated the impact of accepting these units over
a 4-month period.
Methods
During the study period, antibody-positive units were
shipped weekly at a discounted price $14 less per unit
than our standard price. Antibody-positive units were
handled as routine inventory, except that we recorded
the identities of the recipients of all antibody-containing
units for the purposes of this study. For 30 days follow-
ing receipt of these units, we recorded and analyzed the
results of all posttransfusion type and screen samples
from patients who had received antibody-positive units,
in order to identify the frequency of detectable passive-
ly acquired antibody. Direct antiglobulin tests were not
routinely performed on these posttransfusion samples,
consistent with our routine procedures. No blood sam-
ples were requested or drawn specifically for this study.
Posttransfusion samples were only received when the
physicians providing care to the patients felt that further
transfusion might be needed. In addition, labor and sup-
ply costs incurred due to the use of antibody-containing
Large-scale use of red blood cell
units containing alloantibodies
M.R. COMBS, D.H. BENNETT,AND M.J.TELEN
Use of RBC units containing alloantibodies
I M M U N O H E M A T O L O G Y ,  V O L U M E  1 6 ,  N U M B E R  3 ,  2 0 0 0 121
units and subsequent additional testing necessitated by
presence of passively acquired antibody were deter-
mined.
Results 
Transfusion of antibody-positive RBC units.
We received 259 RBC units containing a total of 312
alloantibodies; of these, 233 (90%) contained potentially
clinically significant antibodies. As shown in Table 1,
more than half of these antibodies were anti-D or anti-K.
These proportions are consistent with a survey of 1000
antibody-positive units from our region performed dur-
ing a 1-year period (Rebecca Bullock, Carolinas Regions
Red Cross, personal communication). Of the 259 anti-
body-positive units received,253 were transfused to 187
patients. Of the six units not transfused, two were mis-
handled by the patient care unit and four units expired
without being dispensed from the transfusion service.
The four expired units included three group A, D–  with
anti-D and one group B, D–  with anti-D.
Posttransfusion testing and detection of passively
acquired antibodies
Posttransfusion samples were received from 99 (53%)
of the 187 patients who had received antibody-positive
units. Ten patients (10% of those for whom posttransfu-
sion samples were received) had detectable passively
acquired antibody in posttransfusion samples. Of these
10 patients, six had each received one antibody-positive
unit, three had each received two antibody-positive
units, and one patient had received four antibody-posi-
tive units. Thirteen posttransfusion samples received
from these 10 patients had positive antibody screens
using polyethylene glycol (PEG), which is our standard
antibody detection method (Table 2). Two patients had
passively acquired anti-C and -D and eight patients had
passively acquired anti-D. All 10 patients were D–. No
hemolytic transfusion reactions were reported in any
patients receiving antibody-positive units during this
period. In addition,no autocontrols were positive in the
posttransfusion samples for which antibody panels were
performed. During the 4-month study period, 34 trans-
fusion reactions were reported to the Transfusion
Service. Four of these were in patients that had received
antibody-positive units,but none were in patients (listed
in Table 2) who had passively acquired antibody detect-
ed at any time. The four reported transfusion reactions
in the 187 patients who had received antibody-positive
units were evaluated as being febrile (two patients),aller-
gic (one patient), and a reaction consisting of transient
hypotension with no apparent cause (one patient).
Additional testing resulting from detection of passive-
ly acquired antibody included 10 antibody identification
panels, two antigen typing tests, and 30 antiglobulin-
phase crossmatches. The number of additional antibody
identification panels was relatively limited due to our
longstanding policy of not performing panels on sam-
ples with previously identified antibodies as long as
there is no indication in the three-cell antibody screen or
crossmatch that a new antibody is present.
Costs incurred and overall financial impact
To determine the financial impact of accepting anti-
body-positive RBC units, we calculated labor as well as
supply costs (Table 3). The 259 units were received at a
discount of $14 per unit, for a total savings of $3626.
Table 1. Specificities of antibodies contained in RBC units received
Antibody Specificity Number (%)
D 101 (39)
K 67 (26)
C 38 (15)
E 37 (14)
Fya 16 (6)
c 13 (5)
Lea 13 (5)
M 10 (4)
Leb 6 (2)
S 5 (2)
Jka 4 (2)
Kpa 1 (<1)
Jsa 1 (<1)
Table 2. Posttransfusion samples containing passively acquired 
alloantibodies
Patient Date (number of Posttransfusion Presence of passively
RBCs received) sample dates acquired antibody
1 1/15/98 (1) 1/18/98 Positive
2 1/28/98 (1) 2/12/98 Positive
2/17/98 Positive
3/9/98 Negative
3 2/2/98 (1) 2/8/98 Positive
2/20/98 Positive
4 2/17/98 (1) 2/18/98 Positive
2/25/98 Negative
3/5/98 Negative
5 2/24/98 (1) 2/28/98 Positive
6 3/11/98 (2) 3/25/98 Positive
3/29/98 Positive
7 3/12/98 (1) 3/16/98 Positive
4/1/98 Negative
8 3/24–26/98 (3) 3/27/98 Positive
4/4/98 Negative
4/7/98 Negative
4/8/98 (1) 4/11/98 Negative
9 4/16–17/98 (2) 4/20/98 Positive
10 4/19/98 (1) 5/16/98 Positive
M.R. COMBS ET AL.
Additional savings of $488 were due to the use of 20
units for patients with known alloantibodies; the labeled
antigen-negative phenotype for these units obviated the
need to perform antigen typing in our laboratory. By
accepting antibody-positive units with determined RBC
phenotypes, we were able to use these 20 units for 16
patients with anti-K, -E, -C, -c, -Jka, and -Fya. We calculated
the savings achieved based on the frequency of the anti-
gen and the number of units and controls necessary to
find the required antigen-negative units. We based our
calculations on a cost of $9.81 for antigen typing tests
using the indirect antiglobulin test and $6.45 for direct
agglutination tests. We were also able to use six units
containing anti-D for four patients with anti-D. Even
though this did not provide savings in terms of pheno-
typing—as with phenotyped units for patients alloim-
munized against other antigens—we were able to use
these units without concern for additional testing due to
detection of passively acquired antibody.
Additional costs incurred by the use of antibody-posi-
tive units included $73 for data entry. This cost was
based on one additional minute of technologist time per
unit at an average rate of technologist pay of $16.28 per
hour. Labor and supply costs for the additional antibody
identification panels, antigen typings, and antiglobulin
crossmatches for those patients with detectable passive-
ly acquired antibody was $227 (10 antibody panels at a
total cost of $114.50, two antigen typings at a total cost
of $25.80, and 30 antiglobulin crossmatches at a total
cost of $86.40.)
Discussion
Over the 4-month evaluation period,we had a net sav-
ings of $3814 through the use of 253 antibody-positive
RBC units. Without a discounted price for these units,
however, our net savings only would have been $188.
Moreover,our net savings may actually be less due to the
expiration of four of the antibody-positive RBC units pro-
vided by the Red Cross. The antibody-positive units had
a 1.5 percent attrition rate (4/259), slightly higher than
our overall attrition rate for all products of 1 percent. It
is difficult to determine if the presence of alloantibody
was a factor in red cell wastage. Because all of the
expired units contained anti-D and were non-group O,
they were more difficult to assign to patients and may
not have been selected for D+ recipients by technolo-
gists who were fearful of minor incompatibility.
However, our net savings also may be underestimated,
because additional testing related to the detection of
passive antibody was charged to the patient. The bud-
getary impact of costs passed on to the patient is diffi-
cult to determine, as collected revenues may differ sub-
stantially from charges billed. Furthermore, in a
managed care or capitated environment, the hospital
and transfusion service may not receive compensation
for such additional costs. Primary savings may be real-
ized through the negotiation of a discounted price for
the antibody-positive units as well as through the use of
labeled phenotype information on antibody-positive
units to select RBCs for alloimmunized patients.
We concluded that the large-scale use of RBC units
containing alloantibody is a safe practice that had mini-
mal impact on the workload of our busy transfusion ser-
vice. First, the receipt of posttransfusion samples con-
taining passively acquired antibody occurred in less than
6 percent of the patients transfused with units contain-
ing alloantibody, as only 10 percent of those patients
with posttransfusion samples had detectable antibody.
Second, as indicated previously, more than half of the
antibodies found in these units were anti-D or anti-K.
When these antibodies are detectable in a posttransfu-
sion sample, they are easily identified,and units that lack
the antigen can be found easily. Because most units con-
taining anti-D will be transfused to D–recipients and the
frequency of the K antigen is only 9 percent, these anti-
body specificities rarely would be involved in minor
incompatibility. Antibodies of other specificities (such as
anti-C, -E, and -Fya) would more likely result in minor
incompatibility based on antigen frequencies; however,
the generally low titer of these antibodies and the small
plasma volume remaining in RBC units made significant
reactions due to passively acquired antibody unlikely.
Furthermore, there is not  a convincing report of non-
ABO antibodies passively acquired from RBC units caus-
ing significant hemolysis of a recipient’s antigen-positive
RBCs; but  interdonor incompatibility leading to limited
hemolysis has been reported.2–5 Because antibody
screens are performed on all samples and antiglobulin
crossmatches are performed if antibody is present, there
I M M U N O H E M A T O L O G Y ,  V O L U M E  1 6 ,  N U M B E R  3 ,  2 0 0 0122
Table 3. Financial impact of accepting 259 antibody-positive RBC units
Savings
Discount from supplier $3626.00
Antigen typings not required $488.00
Total $4114.00
Costs
Data Entry $73.00
Antibody identification $114.50
Antigen typing $25.80
Antiglobulin crossmatches $86.40
Total $299.70
Net Savings $ 3814.30
Use of RBC units containing alloantibodies
I M M U N O H E M A T O L O G Y ,  V O L U M E  1 6 ,  N U M B E R  3 ,  2 0 0 0 123
Current Issues in Platelet Transfusion Therapy and
Platelet Alloimmunity. Thomas S.Kickler,MD,and Jay H.
Herman, MD, eds. Bethesda, MD:American Association
of Blood Banks (AABB) Press, 1999. 306 pp. Domestic:
member $99, nonmember $119. International: member
$139, nonmember $159. ISBN: 1-56 395-105-3. To order:
e-mail: sales@aabb.org or fax: (301) 951-7150.
It is hard to believe that,not so long ago,controversies
regarding platelet transfusion therapy centered around
issues such as the relative merits of platelet transfusions
in patients undergoing splenectomy for idiopathic
thrombocytopenic purpura or the practice of empiric
platelet therapy in trauma patients receiving massive red
cell transfusions. The areas of discussion have changed
such that we currently debate the very content of
platelet products (e.g., platelet dosage and leukoreduc-
tion) but the issues are no less contentious. So this text-
book on current issues in platelet transfusion therapy is
a welcome addition to sources of information to guide
clinical therapy and laboratory practice. The authors are
an esteemed roster of experts in platelet transfusion
who have done a very good job of providing the reader
with an up-to-date bibliography in this rapidly evolving
field.
Because the book focuses on ”current issues,”contro-
versies on any given topic often require some depth of
discussion along with summaries of the authors’ opin-
ions. This is done particularly well in the chapter cri-
tiquing the clinical trials to prevent alloimmunization to
platelets. The published data are summarized in an
approachable,helpful manner that show the reader how
the thought processes have evolved along with the data.
Through clear exposition and,in one chapter,useful case
examples, the reader quickly progresses through the
wide variety of issues that now confront anyone
attempting to decide what type of platelet component
to transfuse to which patient on what indication. In
other areas,however,additional pages devoted to further
exploration of topics might have provided not only a
good introduction but a thorough review of key fields.
For example, lack of discussion of the problem of
hypotension associated with kinin activation by bedside
leukoreduction filters in patients taking angiotensin-con-
verting enzyme inhibitors is an important omission of an
admittedly rare phenomenon. The text’s brief discussion
of platelet transfusion indications do not explore some
areas of controversy thoroughly, such as platelet transfu-
sion in cardiac surgery, nor provide the reader insight
into how clinical practices have come to be so varied.
is a theoretical risk of interdonor incompatibility only if
administration of an antigen-positive unit follows admin-
istration of an antibody-positive unit before the next
sample is obtained.
Most important, the routine use of antibody-positive
units should help reduce the number that are discarded
rather than transfused. Given the prediction that our
blood supply may fail to meet our needs in the coming
years as demand continues to outpace donations, a strat-
egy for using antibody-positive RBC units should be use-
ful in maximizing use of this limited resource.
References
1. Nobiletti J, Badon S, Cable R, et al. Unexpected red
cell antibodies are not detected in 46% of additive
red cells from antibody positive donors.Transfusion
1998;38 (Suppl):87S.
2. Zettner A, Bove JR. Hemolytic transfusion reaction
due to interdonor incompatibility. Transfusion
1963;3:48–51.
3. Morse EE. Interdonor incompatibility as a cause of
reaction during granulocyte transfusion. Vox Sang
1978;35:215–8.
4. Franciosi RA,Awer E, Santana M. Interdonor incom-
patibility resulting in anuria. Transfusion 1967;
7:297–8.
5. Abbott D,Hussain S. Intravascular coagulation due to
inter-donor incompatibility. Can Med Assoc J
1970;103:752–3.
Martha R. Combs, BS, MT(ASCP)SBB, Transfusion
Service, Duke University Medical Center, Durham, NC;
Donald H. Bennett, BS, MT(ASCP), Transfusion
Service, Duke University Medical Center, Durham, NC;
and Marilyn J.Telen, MD (corresponding author),
Professor of Medicine, Duke University Medical
Center, DUMC 2615, Durham, NC 27710.
B O O K  R E V I E W


Large-scale use of red blood cell units containing alloantibodies

Letters From the Editors: Ortho-Clinical Diagnostics Sponsorship

Grossman, Brenda J.

BOOK REVIEW: Blood Transfusion Therapy: A Physician&#39;s Handbook

Not a member yet

BOOK REVIEW: Transfusion Reactions

Letter From the Editors: To Contributors to the 2002 issues There is no doubt that the journal depe

Development of anti-Bw6 reactivity in patients receiving r-GCSF: a preliminary report

Letter to the Editors: A hemolytic transfusion reaction due to anti-K undetected by a LISS antibody screen

IN MEMORIUM: Fred Stratton, BSc, MD (1913 – 2001)

A review: modification of the red blood cell membrane and its application in blood group serology

Moderate hemolytic disease of the newborn due to anti-Hr0 in a mother with the D––/D–– phenotype

Large-scale use of red blood cell units containing alloantibodies

Letters From the Editors: Ortho-Clinical Diagnostics Sponsorship

BOOK REVIEW: Blood Transfusion Therapy: A Physician's Handbook

4,746

6,096