Asian Journal of Transfusion Science
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ORIGINAL ARTICLE Table of Contents   
Year : 2013  |  Volume : 7  |  Issue : 1  |  Page : 16-20
Frequencies and specificities of red cell alloantibodies in the Southern Thai population


1 Department of Pathology, Blood Bank and Transfusion Medicine Unit, Faculty of Medicine, Prince of Songkla University, Songkla, South Australia
2 Department of Medical Sciences, Bureau of Laboratory Quality Standards, Ministry of Public Health, Nonthaburi, South Australia
3 SA Pathology Transfusion Service, Flinders Medical Centre, Bedford Park, South Australia

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Date of Web Publication2-Feb-2013
 

   Abstract 

Context: Detailed reports of red cell alloantibody frequencies and specificities in the Thai population are limited. The aims of this study were to determine the specificity and compare the frequency of alloantibodies detected using column agglutination technology (CAT) and conventional tube techniques in blood donors and previously transfused patients. Settings and Design: We retrospectively reviewed antibody screening and identification records for two time periods: January-December 2006 during which conventional tube techniques were used and January 2008-December 2009 when CAT was used. Results: The overall prevalence of alloantibodies in both patients and donors when using conventional tube techniques was 0.7%, for patients only was 0.9% and donors 0.6%. The most frequent antibodies detected in both groups were anti-Lea, anti-Mia, anti-Leb, anti-P1 and anti-E. When using CAT, alloantibodies were found in 0.8% of patients and 0.13% of donors with the five most common alloantibodies found in patients were anti-Mia, anti-E, anti-Lea, anti-c and anti-Leb respectively. Similarly the common alloantibody specificities in donors were anti-Lea, anti-Mia, anti-Leb, anti-M and anti-D. Conclusions: One of the most commonly identified alloantibodies in the Thai population studied was anti-Mia suggesting that Mia positive red cells should routinely be included in antibody screening and identification in this population. For antibody screening and identification, CAT method detected immune and warm alloantibody (ies) more frequently than that associated with conventional tube techniques.

Keywords: Alloantibody frequency in thais, antibody identification, antibody screen, column agglutination technology, conventional tube method

How to cite this article:
Promwong C, Siammai S, Hassarin S, Buakaew J, Yeela T, Soisangwan P, Roxby D. Frequencies and specificities of red cell alloantibodies in the Southern Thai population. Asian J Transfus Sci 2013;7:16-20

How to cite this URL:
Promwong C, Siammai S, Hassarin S, Buakaew J, Yeela T, Soisangwan P, Roxby D. Frequencies and specificities of red cell alloantibodies in the Southern Thai population. Asian J Transfus Sci [serial online] 2013 [cited 2019 Dec 6];7:16-20. Available from: http://www.ajts.org/text.asp?2013/7/1/16/106718



   Introduction Top


Sensitization to red cell antigens may result from previous transfusions, pregnancy, transplantation or injection of immunogenic material. Blood group antibodies may also be naturally occurring. The frequency of alloantibodies varies depending on population demographics and the sensitivity of detection techniques used.

The southern Thai population have different ethnic origins compared to other regions of Thailand. The majority of the southern population is local Thais living in the upper South. Thai people living in lower southern Thailand near the border with Malaysia often may have Malay ancestry.

The aims of this study were to determine the specificity and compare the frequency of alloantibodies detected using column agglutination technology (CAT) and conventional tube techniques using normal saline suspended red cells in blood donors and previously transfused patients.


   Settings and Design Top


Antibody screening and identification

All patient's blood group, antibody screen, antibody identification and cross-match records from the Blood Bank and Transfusion Medicine Unit, Songklanagarind University Hospital for the 1 year period of 1 st January- 31 st December 2006 and the 2 year period of 1 st January 2008-31 st December 2009 were reviewed. Similarly blood donor laboratory records from 1 st January-31 st December 2006 and during 1 st January 2008-31 st December 2009 were reviewed.

Prior to 2007 conventional tube techniques using red cells suspended in normal saline were routinely used for antibody screening using two group O screening cells. Antigen coverage included D, C, E, c, e, Fy a , Fy b , Jk a , Jk b , Le a , Le b , Mi a , M, N, K, k, S, s, P1, Lu a , Lu b and Di a . Antibody identification was performed using a panel of eleven group O cells. Antibody screening and antibody identification panel cells were provided by the Thai National Blood Centre (NBC) of Thai Red Cross.

The indirect antiglobulin tube technique was used for antibody screening. Antibody identification techniques included a room temperature incubation phase, a 37 o C phase and indirect antiglobulin phase using polyspecific anti-human globulin (containing anti-IgM, anti-IgG and anti-C3d which was manufactured by the Thai NBC).

Column agglutination technology was introduced into routine laboratory techniques for ABO and RhD grouping, antibody screening and antibody identification in 2008. All blood grouping and antibody screening was performed using an automated platform (AutoVue Innova TM , Ortho Clinical Diagnostics, USA). ABO and RhD groups were tested using BioVue ABO-Rh/Reverse Grouping cassettes (Ortho BioVue® System, Ortho Clinical Diagnostics, USA). Standard reverse grouping cells were A 1 and B cells (0.8% Affirmagen® , Ortho-Clinical Diagnostics, USA).

Antibody screening was performed using BioVue Poly cassettes (Ortho BioVue® System). Three group O screening cells were used in the antibody screen. 2 screening cells were obtained from Ortho Clinical Diagnostic (0.8% Selectogen® , Ortho-Clinical Diagnostics, USA). Antigens covered included: D, C, E, c, e, Fy a , Fy b , Jk a , Jk b , Le a , Le b , M, K, k, S, s, N, P 1 , Lu b , Kp b , and Js b . In addition a third group O screening cell which was Mi a and Di a positive, was provided by the Thai NBC. 0.8% cell suspensions of this screening cell were made in low ionic strength salt solution (LISS) supplied by Ortho Clinical Diagnostics (Ortho® 0.8% red cell diluent).

Antibodies were further identified by manual CAT techniques using either DiaMed ID LISS-Coombs micro typing cards (DiaMed, Switzerland) or BioVue Poly cassettes (Ortho BioVue® System, Ortho Clinical Diagnostics, USA) using a panel of eleven group O red cells provided by the Thai NBC. The CAT indirect antiglobulin technique was employed and performed at 37 o C according to the manufacturer's instructions. Selective red cell antigen typing for the corresponding blood group alloantibody(ies) was performed following antibody(ies) identification.


   Results Top


During 2006 when conventional tube techniques were used for antibody screening and antibody identification 220 out of 18,627 (1.2%) patients were identified with positive antibody screens [Table 1]. Red cell alloantibodies were found in 0.9% (168/18,627 cases), antibodies of unclear specificity in 0.3% (51/18,627 cases) and autoantibodies in 16/18,627 (0.09%) cases [Table 1]. Twelve red cell alloantibody specificities were identified [Table 2]. In transfused patients, the five most frequent red cell antibody specificities identified by tube techniques were anti-Le a (31.4%), anti-Mi a (21.1%), anti-Le b (20.1%), anti-P 1 (11.3%) and anti-E (9.3%) respectively [Table 2]. Single alloantibodies were found in 135 (80.4%) patients, two in 31 (18.5%) and three or more were found in 2 (1.2%) alloimmunized patients (data not tabulated).
Table 1: Frequency of antibodies detected in patients and donors by tube technique during Jan-Dec 2006 and CAT during Jan 2008-Dec 2009

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Table 2: Red cell alloantibody specificities detected by tube techniques in patients and blood donors during Jan-Dec 2006

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Similarly blood donor data using conventional tube techniques were reviewed for the same period. There were 20,786 blood donors tested and 0.9% (183/20,786) had a positive antibody screen [Table 1]. Antibodies were identified in 116/20,786 (0.6%) blood donors [Table 1]. Anti-Le a (57.2%), anti-Le b (29.0%), anti-Mi a (7.0%), anti-E (3.5%) and anti-P 1 (2.8%) were the five most common antibodies identified [Table 2]. 0.3% (67/20,786) of donors had an alloantibody of unclear specificity. Single alloantibodies were found in 87/116 donors (75%) and two antibodies in 29/116 donors (25%) (data not tabulated).

There were 27 patients (0.15%) who had immune alloantibody(ies) within the Rh, Duffy, Kidd, S and Diego systems and only 5 donors had an immune alloantibody in Rh system.

In both patient and donor populations, alloantibodies were found in 0.9% of subjects and overall the most frequent alloantibodies identified were anti-Le a (42.1%), anti-Le b (23.8%), anti-Mi a (15.2%), anti-P 1 (7.7%) and anti-E (6.9%) respectively [Table 1] and [Table 2].

For data from January 2008-December 2009 when CAT techniques were used for antibody screening, there was a total of 96,384 blood donors and patients tested. 566/96,384 (0.6%) donors and patients had a positive antibody screen and 422/566 had a specific antibody identified [Table 1].

Of the 47,155 patients tested, 468 (1%) had a positive antibody screen. Alloantibodies were identified in 0.8 % of patients (357/47,155), 0.2% of patients had autoantibody (103/47,155) and 0.17% of patients had an antibody of unclear specificity (78/47,155) [Table 1]. Sixteen red cell alloantibody specificities were identified. The five most frequent red cell alloantibodies were anti-Mi a (32.9%), anti-E (17.1%), anti-Le a (13.8%), anti-c (8.1%) and anti-Le b (7.6%) respectively [Table 3]. Single alloantibodies were found in 76.8% patients, two alloantibodies were found in 17.9% and three or more in 5.3% of alloimmunized patients. Some patients had combinations of alloantibody(ies) and autoantibody or alloantibody(ies) and antibody of unclear specificity (data not tabulated).
Table 3: Red cell alloantibody specificities detected by CAT in patients and blood donors during Jan 2008-Dec 2009

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There were 49,229 blood donors tested during Jan 2008-Dec 2009. 98 of the 49,229 donors (0.2%) had a positive antibody screen [Table 1]. Antibodies were identified in 65/49,229 (0.13%) donors and included anti-Le a (39.2%), anti-Mi a (29.7%), anti-Le b (18.9%), anti-M (6.8%) and anti-D (4.1%). Antibodies of unclear specificity were found in 33/49,229 (0.07%). A single alloantibody was found in 56 donors and two alloantibodies in 9 donors (data not tabulated). In both patients and donors, 0.44% of subjects had alloantibodies and the most frequent alloantibodies detected were anti-Mi a (32.4%), anti-Le a (17.2%), anti-E (15.1%), anti-Le b (9.1%), anti-c (7.0%) and anti-D (3.9%) respectively [Table 3].

There were 131 patients (0.28%) who had immune alloantibody(ies) within the Rh, Duffy, Kidd, S and Diego systems and only 4 donors had an immune alloantibody in Rh system.


   Discussion Top


In the Southern Thai population when CAT was used for antibody detection and identification, the frequency of alloantibodies detected was 0.44%. Anti-Mi a , anti-Le a , anti-E, anti-Le b , anti-c and anti-D respectively were most frequently detected. While in the transfused patient population studied, the frequency of alloantibodies was 0.8% [0.28% were immune alloantibody(ies)]. In this group of subjects, the most frequent alloantibodies were anti-Mi a , anti-E, anti-Le a , anti-c, anti-Le b and anti-D respectively.

When conventional tube techniques were used, the overall frequency of alloantibodies in patients and donors was 0.7% with the most frequent alloantibodies being anti-Le a , anti-Le b , anti-Mi a , anti-P 1 and anti-E respectively. 0.9% of transfused patients had alloantibodies and 0.15% of patients had immune alloantibody(ies). In this group, in order of frequency, the most common antibody specificities were anti-Le a , anti-Mi a , anti-Le b , anti-P 1 and anti-E respectively.

The alloantibody specificities detected by conventional tube technique were consistent with previous reports in Central Thai patients. In Central Thais, the frequency of detected alloantibodies was 4.91% and the most frequent alloantibodies were anti-Le a (35.4%), anti-Le b (28.36%), anti-P 1 (21.83%), anti-Mi a (6.4%) and anti-E (3.88%). [1] Another study reported the frequency of alloantibodies ranging between 2.2 to 3.9%. [2] Again anti-Le a (26.3%), anti-Le b (19.4%), anti-Mi a (16.4%), anti-P 1 (6.7%) and anti-E (5.3%) were the most common alloantibodies.

The frequencies of alloantibodies detected and the rank of antibody frequency in these studies were different from other studies. Possible explanations include different techniques, temperatures, and cells used for antibody screening and identification. Incubation at cooler temperatures would detect more cold reactive antibodies with fewer warm reactive alloantibodies. To our knowledge this would be the first report of alloantibody(ies) frequency in Thais using CAT for antibody screening and identification.

Following introduction of CAT for antibody screening and identification into our laboratory the incidence of anti-Mi a , anti-E, anti-c, Kidd and Duffy antibodies were more frequent than that associated with conventional tube techniques. Immune alloantibody(ies) were detected nearly twice as frequently when CAT was used compare to that of conventional tube techniques (0.28% v/s 0.15%). The reasons may include the increased sensitivity of CAT, or the improved quality of the antibody screen or panel cells. Anti-Le a , anti-Le b and anti-P 1 were less common in CAT compared to tube techniques again this was likely due to incubation at 37°C only for CAT.

Anti-Mi a is a very common antibody in Thais, Chinese and Taiwanese while there are no reports in Caucasians. [3],[4],[5] The Miltenberger antigen (Mi a ) is commonly found in up to 15% of Chinese and South East Asian populations whereas it is far less common in other populations (<0.01%). [6] Antibodies to variant MNS antigens (Mi a ) are common and behave like other MNS blood group antibodies. Most of these antibodies detected with Mi positive cells are IgM and tend to react best at cold temperatures. However, there are some that are IgG, active at 37 o C reactive and clinically relevant. The frequency of anti-Mi a in Central Thais was previously reported as 9.72%. [7] In this study we found that anti-Mi a was very common. The frequency of anti-Mi a varied depending on the detection technique used. For tube techniques anti-Mi a comprised 15.2% of alloantibodies detected, whereas when using CAT and screening cells that were Mi a positive, anti-Mi a was the most frequent antibody detected (32.4%). Again this difference may be due to different techniques and antigenic make-up of screening cells used. Anti-Mi a is clinically significant with reports of haemolytic transfusion reaction. [8],[9] and haemolytic disease of the newborn. [3] Therefore in Asian Mongoloid populations it is extremely important that Mi a positive antibody screening cells and a number of those cells used for antibody identification are Mi a positive. Anti-c and anti-E were also frequent immune alloantibodies detected in Southern Thais. Both of these antibodies are clinically significant and have been associated with haemolytic transfusion reactions and mild to moderate haemolytic disease of the newborn (HDN). [10],[11],[12] Anti-D (3.9%) was not frequent in the Thai population due to the low frequency of RhD negative (<1.0%) within the Thais population. [13] Although anti-D is rare in Thais, it often causes problems in clinical transfusion and severe haemolytic disease of the newborn because it is not well recognized by many clinicians.

There are differences in antibody specificities between Caucasian and Asian Mongoloid. Anti-K is a very clinically significant alloantibody in both clinical transfusion and haemolytic disease of the new born. [12] and is found frequently in Caucasians but is very rare in Thai populations. In our study anti-K was not detected. Bejrachandra et al. [1] found anti-K in only 1 out of 100,308 Central Thais tested. This may be due to the fact that most Thais are homogeneous kk [14] thus the rate of alloimmunization is very low.

Although there are increasing intermarriages between Thai women and Caucasian men there are no reports of HDN due to anti-K in the Thai population at this point in time. However, prenatal antibody screening is not included in the standard antenatal testing in most pregnancies throughout Thailand, the majority of pregnant women are only tested for ABO and RhD.

Anti-Jk a and anti-Di a were frequent in multiply transfused patients such as thalassemic patients in our study (unpublished observation). Di a antigen is one of the antigens with low incidence among Caucasians but it is a relatively higher incidence among Asian-Mongoloid population. [15] Anti-Di a has been reported of causing haemolytic transfusion reaction and haemolytic disease of the newborn. [16],[17],[18]

In this study antibodies were detected against antigens within the Rh, Kidd, Duffy, MNS and Diego systems. These are clinically significant alloantibodies (anti-D, -C, -c, -E, -e, -Fy a , -Fy b , -Jk a , -Jk b , -M (active 37 o C), S, -s, -U and -Di a ) and patients must receive antigen negative blood for transfusion [19] and pregnant women screened for these antibodies due to the risk of HDN.


   Conclusion Top


The overall frequency of alloantibodies in Southern Thais was 0.44% identified by CAT while the incidence in patients was 0.8%. The most frequent alloantibodies were anti-Mi a , anti-Le a , anti-E, anti-Le b and anti-c. Anti-D and anti-Jk a were also identified but less frequently while anti-K was not detected at all. Anti-Mi a was very frequently identified in Southern Thais while anti-Di a was not as common. However, Mi a and Di a antigens should be incorporated in antibody screening cell panels for Asian-Mongoloid population.


   Acknowledgement Top


We are thankful to all staff of the Blood Bank and Transfusion Medicine Unit, Songklanagarind University Hospital for performing laboratory work.

 
   References Top

1.Bejrachandra S, Chandanayingyong D. Unexpected red cells antibodies in donors and patients at Siriraj Hospital. Southeast Asian J Trop Med Public Health 1979;10:204-6.  Back to cited text no. 1
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2.Archavarungson N. Incidence of red cell alloantibodies. Vajira Medical Journal 2002;46:51-7.  Back to cited text no. 2
    
3.Broadberry RE, Lin M. The incidence and significance of anti-Mia in Taiwan. Transfusion 1994;34:349-52.  Back to cited text no. 3
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4.Lin CK, Mak KH, Cheng G, Lao TT, Tang MH, Yuen CM, et al. Serologic characteristics and clinical significance of Miltenberger antibodies among Chinese patients in Hong Kong. Vox Sang 1998;74:59-60.  Back to cited text no. 4
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5.Lee CK, Ma ES, Tang M, Lam CC, Lin CK, Chan LC. Prevalence and specificity of clinically significant red cell alloantibodies in Chinese women during pregnancy-a review of cases from 1997 to 2001. Transfus Med 2003;13:227-31.  Back to cited text no. 5
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6.Reid ME, Lomas-Francis C. The Blood Group Antigen Facts Book. 2 nd ed, London: Academic Press; 2004.  Back to cited text no. 6
    
7.Chandanayingyong D. Bejrachandra S. Studies on the Miltenberger complex frequency in Thailand and family studies. Vox Sang 1975;28:152-5.  Back to cited text no. 7
    
8.Lin M, Broadberry RE. An intravascular haemolytic transfusion reaction due to anti-Mia in Taiwan (letter). Vox Sang 1994; 67:320.  Back to cited text no. 8
    
9.Chiewsilp P, Wiratkasem Y, Sae-huan C. Delayed haemolytic transfusion reaction due to anti- Mia. Thai J of Hematol Transfus Med 1996;6:289-90.  Back to cited text no. 9
    
10.Heddle NW, Wentworth P, Anderson DR, Emmerson D, Kelton JG, Blajchman MA. Three examples of Rh haemolytic disease of the newborn with a negative direct antiglobulin test. Transfus Med 1995;5:113-6.  Back to cited text no. 10
    
11.Cheepsattayakorn R, Fongsatitkul L, Chotinaruemol S, Mahawongtong M. Anti-E as a cause of haemolytic disease of the newborn. J Med Assoc Thai 1997;80 Suppl 1:S1-4.  Back to cited text no. 11
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12.Robert I. Prenatal and childhood transfusion. In: Murphy MF, Pamphilon DH, editors. Practical Transfusion Medicine. 2 nd ed, Oxford UK: Blackwell publishing; 2005. p. 97-118.  Back to cited text no. 12
    
13.Chandanayingyong D, Bejrachandra S, Metaseta P, Pongsataporn S. Further study of Rh, Kell, Duffy, P, MN, Lewis and Gerbich blood groups of Thais. Southeast Asian J Trop Med Public Health 1979;10:209-11.  Back to cited text no. 13
    
14.Nathalang O, Kuvanont S, Punyaprasiddhi P, Tassaniyanonda C, Sriphaisal T. A preliminary study of the distribution of blood group systems in Thai blood donors determined by the gel test. Southeast Asian J Trop Med Public Health 2001;32:204-7.  Back to cited text no. 14
    
15.Klein HG, Anstee DJ. Haemolytic Transfusion Reactions. In: Mollison's Blood Transfusion in Clinical Medicine. 11 th ed. Oxford UK: Blackwell publishing; 2005. p. 209-52.  Back to cited text no. 15
    
16.Hickley ME, Huestis DW. Case report. An immediate hemolytic transfusion reaction apparently caused by anti-Dia. Rev Fr Transfus Immunohematol 1979;22:581-5.  Back to cited text no. 16
    
17.Monestier M, Rigal D, Meyer F, Juron-Dupraz F, Baboin-Jaubert M, Marseglia GL. Hemolytic disease of newborn infants caused by anti-Diego antibodies. Arch Fr Pediatr 1984;41:641-3.  Back to cited text no. 17
    
18.Chung MA, Park FH, Lee CH, Namgung R, Kim HO, Park MS, et al. A case of hemolytic disease in the newborn due to anti-Dia antibody. Korean J Lab Med 2002;27:373-6.  Back to cited text no. 18
    
19.Chapman JF, Elliott C, Knowles SM, Milkins CE, Poole GD; Working Party of the British Committee for Standards in Haematology Blood Transfusion Task Force. Guidelines for compatibility procedures in blood transfusion laboratories. Transfus Med 2004;14:59-73.  Back to cited text no. 19
    

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Correspondence Address:
Charuporn Promwong
Blood Bank and Transfusion Medicine, Sanpasitthiprasong Hospital, Ubon Ratchathani, Thailand

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-6247.106718

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    Tables

  [Table 1], [Table 2], [Table 3]

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    Abstract
   Introduction
   Settings and Design
   Results
   Discussion
   Acknowledgement
   Conclusion
    References
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