Autologous Blood Transfusion in a Patient with Rare Anti-k Antibodies: A Case Report
Dr Svetlana Jovic Lackovic*
Polyclinic for Transfusion Medicine, University Clinical Centre Tuzla, Tuzla, Bosnia and Hercegovina
*Corresponding author
Dr Svetlana Jovic Lackovic, Polyclinic for Transfusion Medicine, University Clinical Centre Tuzla, Tuzla, Bosnia and Hercegovina
DOI: 10.55920/JCRMHS.2025.10.001453
Abstract
Background: Autologous transfusion involves the collection of whole blood from the patient before the scheduled surgery, its preservation, storage and distribution in case of need for transfusion treatment. In rare antigen phenotypes on erythrocytes, and especially in the presence of rare antierythrocyte antibodies in the patient's serum, it is the only way for the patient to undergo surgery and be transfused if necessary.
Case presentation: An elderly man comes to our institution with a referral for immunohematological tests of blood group and Rh-factor, where a positive screening of anti-erythrocyte antibodies is detected. Identification of antierythrocyte antibodies detects the presence of a very rare anti-k antibody (anti-cellano antibody). A less clinically significant anti-Lub-antibody was also detected, and it was concluded that these antibodies were produced as a result of blood transfusions during the war. After analyzing and considering the laboratory findings and the clinical condition of the patient, it was concluded that autologous blood collection and autologous transfusion is the only way for the patient to undergo hip replacement surgery. In addition to the prior preparation of the patient in order to achieve an adequate hematocrit for autologous blood collection (Hb≥0.35), which included oral iron and vitamin C, the patient was taken two doses of 450 ml of whole blood after which he underwent hip replacement surgery without complications.
Conclusion: In addition to regular phenotype testing for Rh antigens for all donors, erythrocyte phenotyping for Kell antigens should be introduced as soon as possible, because the appearance of rare antibodies from this group can cause enormous problems in finding adequate doses in transfusion therapy. The high antigenicity of these antigens continuously leads to more and more sensitized people after transfusion of blood products. Autologous blood transfusion should remain the choice for those patients with rare erythrocyte phenotypes and immune antibodies.
Keywords: Antierythrocyte Antibodies, Autologous Transfusion, Phenotype
Background
Pretransfusion testing plays a very important role in the process of finding an adequate dose of blood for a patient. Standard legally determined immunohematological tests for blood donors in Bosnia and Herzegovina include the determination of blood group in the ABO and Rh systems. Other blood group systems should not be neglected, including the Kell system, which contain 38 subgroups and is the third most immunogenically potent blood group system after the ABO and Rh systems (1). An aggravating circumstance is the presence of rare antierythrocyte antibodies in patients who need to perform an additional range of immunohematological tests to find a compatible dose of blood for transfusion (2).
In well-equipped immunohematology laboratories, it is very quickly possible to determine the specificity of immune antierythrocyte antibodies, the temperature optimum of agglutination and to find a phenotypically compatible dose of blood. However, rare phenotypes of blood groups and their corresponding immune antibodies always pose a challenge in smaller blood transfusion centers that have limited capacities for immunohematological testing and where the ability to transport adequate phenotyped doses of blood from other regional facilities is difficult (3). In these situations, autologous blood collection and autologous transfusion is the only way to provide doses of erythrocyte concentrate preoperatively.
Autologous transfusion involves the collection of whole blood from the patient 4-5 weeks before surgery, its preservation, storage and distribution in case of need for transfusion treatment (4,5) The autologous transfusion procedure is associated with reducing the risk of alloimmunization and infection with blood transmissive diseases (6). It is most often used in the operative fields of: cardiovascular surgery, thoracic surgery, orthopedics, traumatology and gynecology.
Case presentation
A 63-year-old man comes to our transfusion center with a referral for blood group and Rh factor, as a set of immunohematological laboratory tests as part of preoperative preparation for hip surgery. After taking a blood sample, its centrifugation, the blood group A RhD + was determined by the method on the plate and on ID-DIAMED cards (microgel technology). The screening of antierythrocyte antibodies in the indirect antiglobulin test (IAT) showed the presence of immune antibodies in the serum. Subsequent tests determined that the immune antibodies correspond to the specificity of anti-k (anti cellano – antibodies) with the KK phenotype on erythrocytes. The anti-k antibody is one of the rarest, clinically extremely important immune antibodies produced as a result of alloimmunization by blood transfusions or previous pregnancies. The presence of a rather rare and less clinically significant anti-Lub antibody from the Lutheran blood group system had also been demonstrated during the analysis.
After taking the anamnestic data, information was obtained that the patient had been suffering from chronic cardiovascular diseases, high blood pressure, hyperlipoproteinemia, chronic bronchitis and asthma for many years, which is why he consumed a lot of medication. The consumption of a large number of drugs had also led to chronic gastroduodenopathy, which, due to the reduced capacity of the gastric mucosa and small intestine, consequently led to chronic sideropenic anemia. It was also reported that the patient received one dose of erythrocyte concentrate due to wounds in the war 30 years ago. Due to severe coxarthrosis, an operation for the installation of an artificial prosthesis was planned and it was necessary to provide 3 doses of erythrocyte concentrate. After the completion and analysis of all laboratory findings and the clinical condition of the patient, it has been established that autologous blood collection and autologous transfusion was the only way for the patient to undergo surgery and receive his own autologous doses of the appropriate erythrocyte phenotype.
Table 1: Results of immunohematological tests
Since the collection of autologous blood requires an initial hemoglobin 110 g/L and a minimum hematocrit of 0.35, and since the patient had been suffering from chronic anemia for a long time with much lower hemoglobin and hematocrit values, he was first subjected to therapy with oral iron and vitamin C (Heferol caps., vit C tbl) for 30 days. After achieving an adequate value of hemoglobin and hematocrit, a single dose of autologous blood of 450 ml was taken. After 10 days, with the continuation of iron and vitamin C therapy, another dose of whole blood was taken. Due to the specificity of the case and the clinical condition of the patient, the initial requirement for the reservation of three doses of blood was reduced to two doses, which was ultimately sufficient for the safe performance of hip replacement surgery.
Discussion
Rare blood groups whose erythrocyte phenotyping is not legally regulated in most countries represent a huge problem in the functioning of patient blood management (7). A deficit in the technology of immunohematological testing and a lack of trained staff can significantly extend the time from the moment a blood sample arrival in the laboratory to finding an adequate dose of blood and transporting it to the patient. This is especially important for patients who urgently need blood transfusion (8).
Well-organized transfusion centers concentrated around a central blood transfusion institution generally represent a model organization in the countries of the European Union and in a large number of cases can provide assistance in finding a phenotypically compatible dose of blood. Unfortunately, small blood transfusion facilities have to rely on their own resources in these situations, so autologous transfusion remains the only option to provide compatible blood for patients with rare antierythrocyte antibodies preparing for surgery (9). In patients who are hospitalized for acute bleeding, plasma blood products (fresh frozen plasma and cryoprecipitate) remain the therapy of choice in normalizing the coagulation status of the patient, while in patients with chronic anemia, intravenous or oral iron medicines are the therapy of choice.
In cases when it is not possible to find a compatible dose of blood due to the presence of rare antierythrocyte antibodies and the inability to perform autologous blood transfusion, it is necessary to establish a connection with the International Blood Group Reference Laboratory in Bristol, so that all potential patients have an equal chance of transfusion treatment in the future (10).
Conclusion
Understanding the mechanisms of alloimmunisation with erythrocyte antigens could help develop strategies to prevent the formation of antierythrocyte antibodies and will help minimize immunohematological complications in transfused patients. Special emphasis should be placed on the expansion of the panel of standard immunohematological testing, and in addition to the phenotyping of erythrocytes of all blood donors to the Rh-antigens, also include the phenotyping of erythrocytes to antigens from the Kell system, because these antigens have proven to be extremely immunohematologically potent in alloimunisation of transfused patients.
Conflict of interest: The authors declare that there is no conflict of interest regarding the publication of the article.
Funding: None.
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