Autologous donation by a patient whose red cells show a positive direct antiglobulin test

A transfusion medicine physician in Buenos Aires reports a 75 year-old female (2 pregnancies, no transfusions) who typed as group A, Rh positive (phenotype CDe/cde), for whom two units of autologous whole blood were ordered by her surgeon in advance of hip arthroplasty. On routine immunohematology workup she has a positive direct antiglobulin test (DAT 4+), with anti-IgG AHG showing 4+ reactivity, but non-reactive with anti-C3 reagents. Her serum reacts 2+ positive in an antibody screen, but there is no apparent specificity to the serum antibody. She does not appear to have alloantibodies in her serum based on a negative absorbed serum reactivity after 4 auto-absorptions. Interestingly, her hematocrit, serum bilirrubin, serum LDH and serum haptoglobin are all within normal limits. She had pneumonia during July of 2004 for which she had received antibiotics; testing for antibodies for mycoplasma pneumonia IgG and IgM were negative. She has a positive ANA test and her platelets are slightly low (140,000/microL). Her surgeon was notifed and the surgery was posponed until the patient could be seen by a rheumatologist.

The inquiring physician asks the following questions:

• what is the chance of a reaction (including hemolysis) upon returning her DAT-positive autologous red cells
• how well do antibody-coated red cells such as hers hold up under storage
• would others store the patient's autologous blood for future use during surgery, in case she needs transfusion?

Editor's note: The following published case report and e-Network Forum discussion may be germane to the current discussion:

• Baussaud V et al. Hemolysis after Autologous Transfusion. Ann Intern Med. 1996 May 15;124(10):931-2.
• A case of unexplained hemoglobinuria after transfusion of frozen-deglycerolized autologous red cells

ADDENDA Jan. 3, 2005

The following comments have been received.

1. A transfusion medicine physician in Palo Alto wonders what the Buenos Aires colleague has done to work up the patient for the possibility that her autoimmune findings are drug-induced, possibly as a result of the antibiotic used to treat her antecedent pneumonia. Was an eluate done, and if so, what did it show? Was each drug that she took in July of 2004 considered as a possible cause for her current immunohematologic findings, and if so, was she worked up accordingly?
   
   
2. A colleague in Ohio reports that they had a similiar situation when a male patient was scheduled for orthopedic surgery. During the patient's pre-admission testing he was discovered to have a warm autoantibody with no underlying alloantibodies. Prior to the aforementioned pre-admission testing, the patient had donated two autologous whole blood units. It was noted that the autologous units developed gross hemolysis to the point that both had to be discarded.

ADDENDA Jan. 4, 2005

3. The colleague from Bueno Aires replies to the colleague from Palo Alto that he doubts (but cannot prove one way or the other) that the reaction is drug (antibiotic) induced because the antibiotics were administered in June and the patient's DAT was positive in September (3 months later). With the exception of drugs that induce autoantibodies (like aldomet), to his knowledge a positive DAT induced by drugs would not have remained positive for so many months. Secondly, an eluate was obtained using a rapid glycine-acid method which showed the same reactivity as the serum (an autoantibody with no relative specificity), and a potent reaction (4+ in Gel and in a 37ºC LISS/AHG (anti-IgG) tube method). The eluate was not tested in the presence of antibiotics.
   
   To the colleague from Ohio he would like to know if the patient had C3 and/or IgG attached to the DAT positive autologous red cells. The Argentinean suspects that the Ohio patient had at least C3 attached to his red cells because of the gross hemolysis of the autologous blood that developed with storage. The patient in Argentina has only IgG coating the autologous red cells.

ADDENDA Sept. 14, 2005

4. A physician at a medical center in California wonders what others in the community do in the case of an autologous blood donation that is discovered to be both direct (DAT) and indirect antiglobulin test (IAT) positive. He reports that a male patient recently donated a unit of autologous blood which was discovered to have warm autoantibodies (detected in an IAT) and a positive DAT. The patient (who was making his autologous donation in advance of an elective surgery) was asymptomatic without any evidence (clinical or laboratory) of hemolysis, and without any history of transplantation or recent transfusion. The inquiring physician wants to know how others would answer the following questions:
   1. Are DAT positive units such as the one described above safe to give back to the patient, or would allogeneic, non-DAT positive units be a better choice?
   2. Should the hospital transfusion service laboratory perform an antiglobulin crossmatch (which would be expected to be positive due to the autoantibody and positive DAT), and perform a full work-up for warm auto antibodies?
   3. Would it be acceptable to merely perform an Immediate Spin crossmatch for the autologous unit described above?
   4. Assuming that the patient donated multiple autologous units, and assuming he receives one unit autologous unit during surgery and a second autologous unit is requested to be transfused on post-operative day 4. Would a new pretransfusion sample need to be collected for testing before issuing the autologous unit for transfusion on post-operative day 4, and if so, how extensive of a workup would others do before transfusion of any additional autologous units?
   5. In the event that you used a DAT positive autologous unit for a patient with a positive antibody screen, would you have a waiver signed by the physician when releasing the unit.

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Ira A. Shulman, MD
CBBS e-Network Forum Senior Editor & Moderator

W. Tait Stevens, MD
CBBS e-Network Forum Editor & Moderator

Elizabeth M. St. Lezin, MD
CBBS e-Network Forum Associate Editor & Moderator