Technical Specialist II Johns Hopkins Hospital Baltimore, Maryland, United States
Background/Case Studies: Background/Case Study: A 37-year-old female presented for a deceased donor liver transplant. The patient’s RHCE genotype was RHCE*ceMO/ceMO with a predicted Rh phenotype of C-, E-, partial c+, partial e+w, hrB-, hrS-, CEVF(Rh61)-. She had a history of anti-e, anti-C and anti-K and, given her RHCE*ceMO variant, was at risk to make other Rh antibodies, including antibodies to high frequency antigens. Per hospital guidelines, deceased donor liver transplant procedures require a container with 6 red blood cells (RBC) and 6 plasma units (FFP), but many patients require additional units. Obtaining RHCE genotype matched RBC units was unsuccessful due to lack of donors. The patient was precluded from autologous donation due to pre-operative anemia. A new anti-E was identified on the day of transplant, further complicating transfusion management.
Study
Design/Methods: Study
Design/Methods: RHCE genotyping and antibody history was obtained from an outside hospital. The patient’s ABORh was tested by automated microplate method using commercial reagents. The patient’s antibody detection and identification (ID) tests were performed by automated solid phase red cell adherence (SPRCA) and automated gel column agglutination technology (CAT). Compatibility testing was performed by manual gel CAT.
Results/Findings: Results/Findings: The patient’s ABORh was A positive. The antibody detection test was positive, demonstrating anti-C and anti-K on the ID panel (SPRCA). Historical anti-e was not detected. Volunteer donor RBC that were C, e and K antigen negative were all crossmatch incompatible. Additional ID panels performed by automated gel CAT identified an anti-E, which was undetected in prior samples. Anti-E had been initially ruled out on the SPRCA ID panel using one cell with double dose E expression. RBC units that were C, E and K antigen negative were crossmatch compatible with the patient’s plasma and supplied for transplant. Conclusions:
Conclusion: This patient tolerated transfusion of 6 non-genotype matched, C, E and K antigen negative (presumed e antigen positive) RBC units perioperatively without complication. The decision to give E-e+ RBC for surgery was based on serologic and genotype results. The anti-e was never demonstrable in her plasma at our facility, and the predicted e+w phenotype indicated that the historical anti-e may have been autoantibody. The risk of giving E+ units with demonstrable anti-E outweighed the risk of giving e+ units. At 10-month follow-up, her antibody detection test was negative, which may be due to immunosuppression. For patients who require RBC of rare phenotype, it may be necessary to provide antigen positive units for life saving procedures. These decisions should be made cautiously with consideration of the patient’s antibody history and risks of transfusion.
Importance of research: This case describes a transfusion management strategy for a patient with an uncommon RHCE variant who had anti-E and anti-e. The patient was undergoing a liver transplant which would potentially require numerous red blood cell units for transfusion, and genotype matched units were unavailable in sufficient quantity. Successful management with partial phenotype matched units highlights the need to adapt transfusion strategies for difficult to match patients undergoing non-elective procedures.
