ABO DISCREPANCY EXERCISE INTRODUCTION: There are 4 basic types of ABO discrepancies. This is an exercise which will review the different types of ABO discrepancies, helpful hints to troubleshoot the problem, and finally, “case studies” to review involving discrepancies. Types of ABO discrepancies: 1. Discrepancy between the forward and reverse groupings due to weakly reacting or missing antibodies. = Newboms Elderly patients Patients with leukemias demonstrating hypogammaglobulinemia (CLL) Patients with immunodeficiency diseases Patients with bone marrow transplantations (Allogeneic mismatch) 2. Diserepancy between the forward and reverse groupings due to weakly reacting or missing antigens. Subgroups of A and/or subgroups of B may be present (Ax, Aci Aew Bu) * Leukemias may yield weakened A or B antigens = “Aquired B” phenomenon 3. Discrepancy between forward and reverse groupings caused by protein or plasma abnormalities and result in rouleaux formation, pseudoagglutination, etc. + Elevated levels of globulin from certain discasc states (multiple myeloma, Waldenstrom’s macroglobulinemia, advanced Hodgkin’s lymphomas) Blevated levels of fibrinogen. ‘Wharton’s jelly (Cord Blood testing) 4. Discrepancies between forward and reverse groupings due to miscellaneous problems, Polyagglutination Cold reactive antibodies (allo or auto) ‘Warm autoantibodies Unexpected ABO isoagglutinins (anti-A; in andA, or A:B individual) Unexpected alloantibodies (anti-M) “cis-AB” individuals +** Helpful hints to resolve discrepancies: "The most OBVIOUS and overlooked solution many times ts to REPEAT the testing the first time a discrepancy is encountered. Often anti-sera, cells or plasma may have been omitted in testing, the cell suspension ix too heavy or light, the Plasma/serum saniple may contain fibrin strands, or the specimen has been diluted or contaminated if drawn improperly. * Consider the age of the patient (newborn or elderly) if problem exists in the reverse syping.* Consider the diagnosis of the patient (“abnormal protein” disease states, BMT patient (“mismatch” transplant), leukemia, the immunosuppressed or immunodeficient patient, malignancy or obstruction of the stomach/intestine, These discrepanctes may be seen in the forward and/or reverse typings. + Uf the patient ts group “A” or “AB” (rarely group “B”), consider subgroups (Ax, Ax, Ack, Bu, etc), if unexpected isoagglutinins appear in the reverse typing or weak/absent forward typing is observed, * Always try washing the cell suspension 3-4 times to help rule out rouleaux, 6-8 times to help with cord specimens contaminated with Wharton's jelly. If rouleaux is suspected, the reverse type should be viewed under the microscope to check for the “stacked coin” phenomenon, along with performing the “saline replacement” technique for confirmation, = Consider the antibody screen status, Is it possible that a alloantibody, or cold/warm autoantibody is present? (example: an “A” patient forward types correctly, but reverse types as an “O”. The patient types as an Ay with lectin typing, which rules out anti-A}, A room temp panel is performed and reveals the presence of an anti- M. More than likely, the A; reverse cell is M+, which is causing the discrepancy). * Consider the drug history of the patient. Some medications, when taken in heavy doses, can cause the patient’s red blood cells to become coated with antibody which then promotes spontaneous agglutination. Examples would include alpha methyldopa (aldomet), IV penicillin and cephalosporins, The forward wping of the patient yields false positive results, the DAT will be positive, and the specimen may have to be sent to a consultation lab in order to remove the bound immunoglobulin by using a special elution technique, The blood type can then be verified. = CASE HISTORIES + An 80 year old male is scheduled for hip replacement. He has never been transfused before, and his doctor orders 2 units of packed rbc’s to be crossmatched, The results of his blood group typing are listed below: Reaction of patient’s cells with Reaction of patient's serum with Ants ‘Anti-B Anti-AB | Arcells Beells Patient 0 ae 4 0 0 What is the patient's probable blood type? What testing could be done to help resolve the"A 60 year old man in the OR for a colon resection types the following way: Reaction of paticnt’s cells with Reaction of patient’s serum with Anti-A Anti-B, Anti-AB | Ajcells Bells Patient ae 2 at 0 at ‘Where does the discrepancy exist? What is the possible explanation for the diserepancy? Any additional steps which could be performed to help resolve the discrepancy? Ifthe doctor needed blood before the discrepancy was resolved, what would your options be? «A pationt presents for the first time in the ER with a 6.5 hemoglobin and the doctor requests that 2 units be given ASAP. The specimen received types as follows: Reaction of t's cells with, Reaction of patient’s serum with ‘Anti-A. Ant-B Anti-A,B | Aycells B cells Patient, ae 2k at it at According to previous records, your patient typed as an “A” on four separate occasions You decide to repeat the testing using a fresh, “washed” x 2 patient cell suspension, and get the following results. Reaction of patient's cells with Reaction of patient's serum with Anti-A Anti-B Anti-A,B Ai cells Beells Patient ae 0 at 1+ ae In the meantime, 2 other pieces of information are revealed to help solve this puzzle: ‘The antibody screen results are negative The patient’s diagnosis is multiple myeloma Using these pieces of information, what is the probable blood type of the patient? ‘What testing could be performed to help confirm this? ‘Would the immediate spin crossmatch testing be affected as well? Why or why not?+ 432 year old female patient ( 11 month post bone marrow transplant) presents in the outpatient clinic with a hemoglobin of 7.2, Her doctor orders 2 units rhe’s to transfused today. A sample for type and ross arrives in the lab and types as follows. Hint: (patient’s original type was “A”, her donor was “O”) Reaction of patient’s cells with Reaction of patient’s serum with Anti-A Anti-B ‘Anti-AB Avcells Bells Patient it mf 0 1+ mf 0 2 What is the patient’s blood type? What is the explanation for the “mixed field” reactions? ‘What type of blood (A, B, AB, or ©) is appropriate for transfusion and why? = A 42 year old male presents in the ER with a gunshot wound to the chest. The ER doctor orders 6 units of blood to be type and crossmatched STAT. The blood sample types as follows. Reaction of patient’s cells with Reaction of patient’s serum with Antic AntiB AnticAB [Ar cells Bells Patient ae 0 at IF ae Where does the discrepancy exist? ‘What is the probable blood type of the patient? How would you resolve the discrepancy? (Any additional test?) If the doctor can’t wait for the diserepaney to be resolved, what type (A, B, AB or ) is appropriate for transfusion?+ A patient is transferred to our ICU department from a small, rural hospital with an admitting hemoglobin of 5.0. The doctor would like to transfuse 2 units ASAP, a sample is sent down and typed with the following results: Reaction of patient’s cells with Reaction of patient’s serum with ‘Anti-A Anti-B ‘Anti-A,B. Beells Patient 1+ 1e 1 a Based on these results, what would you think is the most probable blood type of this patient? After washing the cell suspension x 2 yields the same results, you begin to investigate previous history, diagnosis, etc. In the meantime the antibody screen yields the following results: 1=3+, TT=3+. You are able to contact the tech from the rural hospital lab and Jeam the following information ; The patient has a history of a “warm autoantibody” (two years ago). At that time they sent the specimen to the blood center consultation lab in order to obtain “compatible” blood for transfusion. The consultation tab determined the patient's blood type to be group “O”. They haven't seen the patient again until today, and didn’t do any testing since he was transferred out. Where does the discrepancy exist? What is causing the discrepancy? ‘What testing, if any can be performed by our lab? ional information (history) should be checked into before deciding how to proceed?