Requests that an alloimmunized patient be transfused, even if 'antigen negative' RBCs are unavailable

A transfusion service supervisor at a hospital in Maryland reports that they have an alloimmunized female patient who has a history of anti-D, anti-C, and anti-hrB. This patient was transfused with group O Rh negative, Rh5 negative, C negative red cells a few weeks ago. The patient now presents with anti-E in addition to her other alloantibodies. Her hematocrit is dropping and the hospital is hoping to get phenotype appropriate "antigen negative" donor RBC as soon as possible. The transfusion service supervisor asks for input from colleagues as to what others would do, if it gets to the point where the patient's physician requests that the patient be transfused, even if 'antigen negative' RBCs are unavailable.

The following comments have been received in response:

ADDENDA August 7, 2009

1. The following information is provided by Sandra Nance [director of the American Rare Donor Program (ARDP)], Dr Geralyn Meny [Medical Director of ARDP], and Cynthia Flickinger [Manager of ARDP] (attributions used with permission). The ARDP is a partnership of AABB and American Red Cross (see previous e-Network Forum discussion) which processes requests for rare products (frequency less than 1:1000). The ARDP is a program designed to ensure that patients who need rare blood get the blood they need. Through an extraordinary collaboration of over 80 AABB and American Red Cross facilities, most needs are able to be met. The case described above from Maryland of an alloimmunized female patient who has a history of anti-D, anti-C, -E and -hrB highlights a rare but extremely challenging request. If the hospital with the patient is not an ARDP member, they should contact their blood supplier who may be. And if not, the blood supplier normally contacts an ARDP member facility. It is required that the antibody identification is performed or reviewed by an ARDP member IRL. The ARDP IRL makes the request for products. In situations involving the need for rare products, the recommendation is to immediately obtain samples or units from potential sibling donors and the patient for molecular testing for RH and CE, and to provide clinical information for Medical Director interactions. Every effort is made by the ARDP to procure compatible blood units for such rare needs as the patient referenced above, through the use of the molecular test results of the patient and the recruitment of molecularly matched donors. An assessment should be made by the clinician regarding the patient’s potential as an autologous donor. In cases where blood is not immediately available in the USA, it is important to ascertain the clinical situation of the patient to provide appropriate transfusion recommendations. In extreme situations, it may be necessary to transfuse serologically incompatible blood while compatible blood is being obtained. For this circumstance, a monocyte monolayer assay may be of benefit in the selection of which antibody(ies) to transfuse over. If the blood is not available in the USA, a determination must be made regarding importing international units. There may also be a remote possibility of obtaining a blood substitute (hemoglobin based oxygen carrier) via compassionate use. In all these scenarios, it is vital that the communication channels be open. A suggestion is to immediately set up an email group between the hospital blood bank and blood bank Medical Director, Blood Center IRL Supervisor, Blood Center physician and the Manager of the ARDP. This is especially valuable if there are differences in time zones or if international units are required. The ARDP is housed in Philadelphia where the National Reference Laboratory for Blood Group Serology and the National Reference Laboratory for Molecular Testing are also located. A process flow, established by the International Society of Blood Transfusion Working Party for Rare Donors shows the process followed when blood is not immediately available locally, nationally and internationally. Questions can be directed to ardp@usa.redcross.org.

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