Asian Journal of Transfusion Science
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   Table of Contents - Current issue
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January-June 2020
Volume 14 | Issue 1
Page Nos. 1-101

Online since Friday, July 24, 2020

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EDITORIAL  

Convalescent plasma: Would it prove to be magic potion/boon in the current scenario of COVID pandemic? Highly accessed article p. 1
Sangeeta Pathak
DOI:10.4103/0973-6247.290652  
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REVIEW ARTICLE Top

Red blood cell alloimmunization in Iran: A Comprehensive review of the literature Highly accessed article p. 4
Maryam Sadat Hosseini, Leila Jafari, Reza Shiri Heris, Ahmad Gharehbaghian
DOI:10.4103/ajts.AJTS_137_17  
Background: Alloimmunization is an immune response against foreign antigens which introduced into the body through transfusion, pregnancy, or transplantation. This phenomenon is a big challenge in patients, which require regular transfusions. In the current study, we tried to have a comprehensive review on the status of alloimmunization in Iran. For this purpose, we searched for papers investigating alloimmunization in transfusion-dependent patients and also in patients with no regular transfusions who are candidate for surgery or who need blood. Methods: We searched PubMed, Google Scholar, SID, and MAGIRAN databases using the following keywords: “blood transfusion,” “alloimmunization,” “alloantibodies,” “irregular antibodies,” “red cell antibodies,” and “Iran.” No limitation for the date of publication and language of the papers was defined. All the identified records were then screened for the relevance and duplication. Results: A total of 22 papers were included in this study. All of the studies were conducted from 1999 to 2016 and providing alloimmunization data from different cities all over of Iran. In general, the results showed that the most prevalent alloantibodies are anti-Kell (anti-K antigen) and anti-Rh system, mainly anti-E, anti-D, anti-C, and anti-c. Conclusion: Anti-Kell and anti-Rh antibodies are the most prevalent antibodies responsible for alloimmunization in Iranian population.
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ORIGINAL ARTICLES Top

Lewis blood group phenotype vis-a-vis biochemical and physiological parameters of coronary artery disease: A study in North Indian population p. 9
Ramasubramaniam Natarajan, Hari Krishan Dhawan, Saugata Choudhury, Rajesh Vijayvergiya, Neelam Marwaha
DOI:10.4103/ajts.AJTS_15_19  
Background: Many studies have proposed the lack of Lewis antigen as a marker for coronary artery disease (CAD); on the contrary, some of the studies found no association in this regard. This study aims to assess the association of the expression of Lewis antigen as an independent risk factor for CAD separately in males and females. Materials and Methods: In this cross-sectional observational study, patients with angiographically proven CAD were taken as test group, and angiographically, negative patients were included as a control group. The individuals were examined for established CAD risk factor and Lewis antigen expression on red cell. Red cell Lewis phenotyping was done using microcolumn gel agglutination technology. Statistical tests were applied to see the association between lack of Lewis antigen expression and CAD. Results: Of these 232 patients included in the study, 161 patients had more than 50% luminal stenosis in a major epicardial artery on coronary angiography (Test Group), and 71 were normal on angiography (Control Group). When males and females were considered together, there was an increased frequency of Lewis-negative phenotype among the angiography-positive group (26.7%) as compared to angiography normal control group (16.9 %), though was not statistically significant (P = 0.19). When males and females were segregated in multivariate analysis, Le (a-b-) females had a higher incidence of CAD (P = 0.03) with the odds ratio of 4.97, though an association was not found significant in males (P = 0.71). Conclusion: The association between Lewis phenotypes and CAD was not significant in males and in among the overall study population, but this association was statistically significant in females. Further studies based on a larger sample size may substantiate as well as delineate the possible hypotheses.
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Immunoadsorption in ABO-incompatible kidney transplantation in adult and pediatric patients with follow-up on graft and patient survival: First series from India p. 13
Aseem Kumar Tiwari, Geet Aggarwal, Dinesh Arora, Gunjan Bhardwaj, Manish Jain, Shyam Bihari Bansal, Sidharth K Sethi
DOI:10.4103/ajts.AJTS_82_19  
Background: There are no published reports on desensitization protocol for ABO-incompatible kidney transplants using Immuno-Adsorption (IA) plasmapheresis from India. IA offers certain advantages including processing of larger plasma volumes, quicker reduction of isoagglutinin titers and no requirement of replacement fluids. Aims and Objectives: Authors' center evaluated success of desensitization protocol, and graft/patient outcomes when IA procedures were performed for desensitization in adult and pediatric ABO-incompatible kidney transplant patients. Methods: Patients undergoing ABO-incompatible kidney transplant with use of IA were evaluated at tertiary care center in north India. Patient records for 2-years were collated from hospital information system (HIS) and procedure forms. Results: Sixteen IA procedures were performed in five patients who underwent successful ABO-incompatible kidney transplant. Initial isoagglutinin IgG titer ranged from 32-512. Mean number of IA procedures performed to achieve the desired pre-transplant IgG titer ≤8 was 3.2. New IA column was used for each patient (and re-used for the same patient, if needed, after sterilization with Low temperature steam of formaldehyde). Mean plasma volume processed during each IA procedure was 4.5 times. No adverse events were observed during any IA procedure. All patients achieved successful desensitization. All patients continue to do well clinically with mean follow-up period of 8.8 months. Although IA was expensive, it offered advantages like specificity, larger plasma volume processing with desired reduction in titer, no 'replacement fluid' requirements and no adverse events in present case series. Conclusion: IA plasmapheresis was universally successful in decreasing the ABO-isoagglutinin titers to desired level in all prospective ABO incompatible kidney transplant patients.
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Prophylactic administration of oral calcium carbonate during plateletpheresis: A bicentric prospective study p. 19
Prashant Kumar Pandey, Aseem Tiwari, Nitin Agarwal, Ravi C Dara
DOI:10.4103/ajts.AJTS_114_17  
Background: Administration of anticoagulant citrate and dextrose (ACD-A) chelates ionized calcium in blood and causes hypocalcemia in plateletpheresis donors. The aim of the study was to observe the effects of oral calcium (Ca) supplementation during plateletpheresis on various parameters related to calcium metabolism. Materials and Methods: This study was performed between January 2014 and December 2014 on 200 plateletpheresis donors.They were divided into two groups. In group A donors (n=100), no prophylactic oral calcium supplementation was given. In group B (n=100) donors, 2000 mg of calcium was given one hour before the start of the procedure, 500 mg was given at the start of the procedure and 500 mg calcium was given just before the end of procedure. Biochemical parameters like serum total calcium (T Ca), serum total magnesium (T Mg) and ionized calcium level (iCa) were measured before and after the procedure. Relative risk of citrate toxicity was measured between the two groups. Results: There was a significant fall in total calcium (pre 9.02 mg/dl, post 8.23 mg/dl,), ionized calcium level (pre 1.14 mmol/L, post 0.91 mmol/L) and total magnesium (pre 1.92 mg/dl, post 1.79 mg/dl) amongst the donors who did not receive prophylactic calcium supplementation. Despite calcium intake, in prophylactic calcium intake group, we did observe a significant drop in total magnesium (pre 2.04 mg/dl, post 1.94 mg/dl) and ionized calcium level (pre 1.25 mmol/L, post 1.12 mmol/L, p<0.01). We did observe a drop in total calcium level, however, this observation was not statistically significant. The risk (RR=5.44) of citrate toxicity was higher among group A donors. Conclusion: Prophylactic oral calcium carbonate supplementation would help in to reduce the risk of citrate toxicity. Therefore, we suggest for prophylactic oral administration of 3000 mg elemental calcium carbonate in three divided doses to make PP procedures uneventful.
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Comparative assessment of single-donor plateletpheresis by Haemonetics® MCS® plus and Trima Accel® p. 23
Sukanya Baruah, Meenu Bajpai
DOI:10.4103/ajts.AJTS_138_17  
Background: Single-donor platelets (SDPs) prepared by sophisticated automated equipment offer several advantages over random-donor platelets and are being increasingly used to support thrombocytopenic patients. Different apheresis machines working on the principle of centrifugation are being used worldwide to collect platelets. This retrospective study was done to compare plateletpheresis on two automated cell seperators – Haemonetics® MCS® Plus and Trima Accel®. Materials and Methods: Data for 100 single-donor plateletpheresis procedures, fifty on each machine, were retrospectively collected and analyzed. Donor characteristics were analyzed by Student's t-test and no significant difference was found between the two groups. The parameters compared between the two machines were yield, collection efficiency, blood volume processed, procedure time, acid-citrate-dextrose (ACD) used, leukodepletion achieved, quality control of the products, and adverse donor reactions. Results: Platelet yield (3.054 ± 0.14 vs. 3.120 ± 0.25), quality control of the platelets, leukodepletion achieved, and donor safety were comparable in both the machines. The blood volume processed (2230.74 ± 227.01 vs. 2452.90 ± 318.61), ACD used during procedure (265.48 ± 43.21 vs. 298.10 ± 53.32), procedural time (55.92 ± 13.00 vs. 68.86 ± 12.64), and the postprocedural decrease in donor count in Trima Accel® (183.10 ± 23.99 vs. 161.44 ± 63.47) were significantly less than those in Haemonetics® MCS® Plus. The median collection efficiency of Trima Accel® was found to be greater than Haemonetics® MCS® Plus (0.000649 vs. 0.000608, P = 0.020). Conclusion: Both Trima Accel® and Haemonetics® MCS® Plus can collect SDPs safely and efficiently. Trima Accel® has higher collection efficiency and reduced incidence of citrate-related adverse effects. It also has better potential to optimize productivity due to decreased procedural time.
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Vasovagal reaction among whole blood donors in Hospital Pulau Pinang. A statistical-epidemiological study p. 28
Ilyas Hasan, Anizah Arshad, Norhaza Abdul Rahim, Peng Yen Soo
DOI:10.4103/ajts.AJTS_111_17  
Context: Whole blood donation is generally considered a safe procedure; however, a small percentage of donors could develop vasovagal reactions (VVRs) during or after completion of blood donation. Aims: This study was undertaken to establish the prevalence of VVR among whole blood donors in Hospital Pulau Pinang and to investigate factors that lead to its occurrence. Settings and Design: A cross-sectional study was conducted involving 27,890 whole blood donations in 2016. Subjects and Methods: For each donation, donor's demographic and blood donation-related information was extracted from the blood bank database. Statistical Analysis Used: Qualitative data including age group, sex, race, frequency, and location of donation were analyzed using Chi-square tests, while blood pressure was analyzed using t-test. Results: Overall, 425 cases of VVRs were reported, resulting in a VVR rate of 1.5% (one event in every 65 donations). We found a statistically significant association (P < 0.05) between the occurrence of VVRs with the young age group, female gender, Indian race, first-time donor, lower predonation blood pressure, and donation performed in a mobile donation campaign. The most common vasovagal symptoms are lightheadedness (88%), followed by nausea (5.4%), muscle twitching (3.5%), vomiting (1.4%), loss of consciousness <30 s (1.4%), and paresthesia (0.2%). Conclusions: The prevalence of VVRs among whole blood donors in Hospital Pulau Pinang appeared to be low. Our study reaffirms that blood donation is a relatively safe process, and the incidence of VVR can be further reduced by ensuring strict screening procedure before blood donation.
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History of indigenous policies as trace of erythrocyte antigen Dia in the current population of the American continent relationship between indigenous policies and blood phenotypes p. 33
Sebastiana Azzaro, Gustavo H Marin, Rosana Clapsos, Lupe Marin, Silvia Margineda, Facundo Cillero
DOI:10.4103/ajts.AJTS_38_18  
Objective: The study aim to establish a debate on the different policies implemented at indigenous population in the American continent and their relationship with the presence of DiegoA antigen (AgDia) in blood phenotype of inhabitants of Buenos Aires,Argentina. Methods: It is a descriptive study with qualitative/quantitative approach. A comprehensive search of medical/social databases, using MeSH words. Limits were applied to include studies published after 1950 written in Portuguese, English and Spanish. Results: Dia antigen in the population of several American countries is relatively high, hence, it should be considered in screening panels perform to blood donors. Noteworthy, the exception of this panorama is Buenos Aires State, where the prevalence of this antigen is low. This data was correlated with indigenous policies carried out by former governments. The results showed in population living in regions where Dia is high policy performed by the colonizers towards the indigenous peoples was domination+integration+miscegenation. In Buenos Aires, however, that policy was annihilation of the natives which could explain the low presence of the antigen in the current population. Conclusion: The presence of Ag-Dia in the population of Buenos Aires is low compared to other Latin- American regions. The presence of Ag-Dia in Buenos Aires population is low compared to other regions of Latin-America. The reason could be explained by the distinctive indigenous policy performed in this area. It might be possible then to predict the prevalence Dia in the current population, taking into account the history of indigenous policy in colonization of American continent.
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Rationalizing blood transfusion in elective breast cancer surgery: Analyzing justification and economy p. 39
Vikas K Agarwal, Sudipta Sekhar Das
DOI:10.4103/ajts.AJTS_107_17  
Background: Transfusion of allogeneic blood in breast cancer surgery is variable, and differences of transfusion incidence have been observed in the literature. Most hospital guidelines including ours dictate group and reserve policy of blood before breast surgery. Here, we aimed to audit the blood utilization in patients undergoing elective breast surgery in our hospital and thereby optimize the blood ordering schedule, economic burden, and loss of clinical resources. Materials and Methods: The study included 478 breast cancer surgeries over a period of 6 years. Patient and disease details were obtained from patient file and hospital information system. Blood samples sent to blood bank were subjected to compatibility test and reserved. All transfusions were documented, and statistical analysis was done. Results: Of the total 478 patients, most underwent wide local excision of the breast and modified radical mastectomy. A total of 16 patients received 71 units of blood and blood components in all categories of surgeries. Only 103 were younger women (≤40 years), with a mean age of 31 years. Nontransfused patients were significantly more than transfused ones (P < 0.05). Frequency of blood transfusion was more in young patients (4.9%). Seven (22.6%) of the total 31 Stage IV patients received blood transfusions. Frequency of blood transfusion was more in patients undergoing surgery after chemotherapy (8.8%). A significant loss of time and loss of revenue was observed. Conclusion: We conclude that routine compatibility test is not justified for all patients undergoing breast surgery. A more targeted approach is needed to reduce blood demand and associated cost to patient and blood transfusion services.
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Prevalence and predictors of adverse reactions in plateletpheresis donors with the perspective of donor safety in a tertiary care hospital of Northern India p. 44
Archana Solanki, Rahul Katharia, Ashutosh Singh, Abhishek Chauhan, Tulika Chandra, Atul Sonker, Prashant Agarwal
DOI:10.4103/ajts.AJTS_28_20  
Background: Plateletpheresis procedures are generally safe and associated with low adverse reactions. Although donor reactions and injuries are self-limited events, they may discourage donors from future platelet donations. Aim: The purpose of this study was to determine the prevalence and predictors of adverse donor reactions in plateletpheresis donors, which could serve as targets for interventions to reduce reactions. Materials and Methods: The study included 106 platelet donors over a period of 2 years. The demographic, biometric, and clinical parameters were noted. The data were analyzed for predictors of adverse donor reactions. Statistical Analysis Used: The data were analyzed using independent sample t-test to correlate donor variables such as gender. To correlate other variables such as age, weight, and whole blood processed, Chi-square test was used. Results: A total of 106 plateletpheresis donations were performed and 13.2% of vasovagal reactions were observed. The significant predictive factors for reactions were young female donors with low body weight in which more than 2.5 L volume of whole blood was processed and more than 250 ml of acid, citrate, and dextrose-A was infused and with single venous access procedures. Conclusions: The results of this study are encouraging and helpful in identifying donors at risk for developing adverse reactions during plateletpheresis so that proper and close observation during and after donation as well as timely intervention can prevent most of the unpleasant events of plateletpheresis donors.
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Comparison of the accuracy of capillary hemoglobin estimation and venous hemoglobin estimation by two models of HemoCue against automated cell counter hemoglobin measurement p. 49
Ashish Jain, Nilotpal Chowdhury
DOI:10.4103/ajts.AJTS_93_17  
Background: HemoCue point of care devices has been extensively used in screening for anemia in blood banking. HemoCue can estimate hemoglobin (Hb) both from venous as well as capillary blood. However, the suitability of HemoCue Hb estimation in donor selection is unclear. Aims: The aims of this study were to evaluate variance of difference in Hb measurement in capillary HemoCue estimation as compared to venous HemoCue estimation from automated cell counter and to assess accuracy of two different HemoCue models (201 and 301) against automated cell counter Hb measurements in both capillary as well as venous blood. Materials and Methods: HemoCue 201 and 301 were evaluated by a comparison of methods study against Sysmex XP-100 three-part analyzer at a blood bank of a tertiary care hospital in Uttarakhand, India, in 2017. Assessment for anemia of 115 donors was done initially by capillary Hb by a convenience sampling to 2 instruments from 2 different models of HemoCue (total of 4 instruments). Venous blood collected was analyzed by Sysmex XP-100 and all HemoCue analyzers. Results: For capillary method, bias ranged from −0.97 to −0.37 g/dL, upper limit of agreement (LOA) ranged from 0.72 to −1.06 g/dL, and lower LOA ranged from −2.65 to −1.79 g/dL. For venous method, bias ranged from −0.03 to −0.24 g/dL, the upper LOA ranged from 0.81 to −1.07 g/dL, and lower LOA ranged from −1.04 to −0.57 g/dL. Thus, capillary HemoCue estimation exhibited greater bias as well as wider LOA. Variance of the differences from automated counter was significantly lower for venous HemoCue comparison compared to capillary HemoCue estimation (P < 0.001 for each instrument). Conclusion: Errors in capillary sampling of blood show the extent to which preanalytical errors can influence results in point-of-care devices. We suggest augmentation of any blood bank-based Hb screening process based just on capillary sampling to be augmented by a properly selected venous sampling to reduce deferral for a false-positive screen of anemia.
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CASE SERIES Top

Case series investigation on the Lewis system antibodies encountered during a routine screening in a tertiary care hospital-based blood center p. 54
AM Gayathri, Debasish Gupta
DOI:10.4103/ajts.AJTS_60_19  
Background: Anti-Lewis antibodies, usually do not react at 37°C, hence are clinically insignificant. However, on rare occasions, these antibodies have been reported as the cause for hemolytic transfusion reaction (HTR). Aim: We report our experience on the 6 cases of anti-Lewis antibodies that reacted at room temperature (RT) and at 37°C. Materials and Methods: Standard serological methods were employed in detection and identification of antibodies. Demographic and clinical details were obtained from the records on the subjects under study. Results: These were found among the patients and the blood donors of varied age groups and gender (21 to 65 years). Also, they were found among the patients with varied clinical diagnosis. The 2 patients in second trimester had anti-Le a or anti-Le b and other 2 male patients had anti-Le ab or anti-Le b with wide thermal amplitude were found during the course of pre- transfusion compatibility tests including antibody screening and cross-matching. Two male donors typed Le (a−b−) had anti-Le ab with wide thermal amplitude. Lewis antigen negative RBC units were provided for transfusion in the situation. Conclusion: Although antibodies to Lewis blood group antigens often react at lower temperatures and therefore remain clinically insignificant, some of them, on rare circumstances, may react at higher temperature of 37°C and may produce hemolytic episode or at least yield reduce survival of incompatible red cells in transfusion recipients. On safer side, the antigen-negative unit may be used in transfusion. The donors' registry with detailed phenotype profile may go a long way to provide blood for transfusion in emergency situations.
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CASE REPORTS Top

Applying Donath–Landsteiner test for the diagnosis of paroxysmal cold hemoglobinuria p. 57
Aseem Kumar Tiwari, Geet Aggarwal, Subhasis Mitra, Dinesh Arora, Gunjan Bhardwaj, Ankita Ratan, Divya Setya
DOI:10.4103/ajts.AJTS_132_17  
61-year old male patient was admitted to the hospital with clinical picture of hemolytic anemia with hemoglobinuria. Patient was suspected to have Infectious Mononucleosis (IM) with Auto Immune Hemolytic Anemia (AIHA). DAT was positive with anti-C3d specificity. Donath Landsteiner (DL) test was positive; confirming Paroxysmal Cold Hemoglobinuria (PCH). The final diagnosis was IM with PCH. Patient was managed conservatively and discharged after seven days. DL test specifically detects a biphasic autoantibody (IgG type) that binds to RBCs at cold temperatures, and fixes complement on the RBC membrane. However RBCs are only lysed upon warming to 37C when complement cascade proceeds to completion.
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A rare case of naturally occurring allo anti-Jk(a) missed in manual screening test on tube method p. 60
Ashish N Kanani, Snehal B Senjaliya, Manisha M Rajapara, Anurag K Gupta, Sanmukh R Joshi
DOI:10.4103/ajts.AJTS_104_19  
Background: Antibodies to the Kidd blood group are mainly red blood cell (RBC) immune, but a few reports on naturally occurring antibodies have been documented. Aim: The aim of this study is to study the anti-Jk(a) for its unusual reactivity with different serological methods. Materials and Methods: Donor's plasma was tested with RBCs from in house donors and commercial panels by manual and automated devices. Results: A 36-year-old male blood donor with naturally occurring anti-Jk(a) is detected by solid-phase assays and the gel card technique but not by the tube method. The IgG antibody with the titer of >32 was not a complement-fixing hemolysin, showed a reduced reactivity with enzyme-treated RBCs, and was detectable through 8 months' follow-up period. The donor was typed as (Jk(a−). Conclusion: An unusual naturally occurring anti-Jk(a) detected by solid-phase red-cell adherence but not reacting by tube technique reflected on the sensitivity of the methods used.
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Passenger lymphocyte syndrome in a bidirectional ABO-mismatched renal transplant p. 63
PA Prethika, Shamee Shastry, Ganesh Mohan, Ravindra Attur Prabhu, Shankar Prasad Nagaraju, Dharshan Rangaswamy
DOI:10.4103/ajts.AJTS_98_19  
Passenger lymphocyte syndrome (PLS), a subtype of graft-versus-host disease, is due to the production of antibodies by the donor “passenger” B lymphocytes against recipient's red cells. It is a rare disorder encountered mostly in ABO blood group-mismatched solid organ transplantation. The present case report illustrates the clinical presentation and the mode of management of PLS in a bidirectional ABO-incompatible renal transplantation. A 43-year-old male diagnosed with chronic kidney disease Stage 5-D (diabetic nephropathy) Type-2 hypertension with ischemic heart disease underwent ABO bidirectional-mismatched renal transplantation. The blood group of the patient was B Rh D positive and that of the donor (patient's wife) was A Rh D positive. In the pretransplantation phase, immunoglobulin G anti-A titer was 64 by column agglutination method, which was subsequently brought down to 4 by therapeutic plasma exchange and immunosuppression. Good graft function was established in the posttransplantation phase, but a significant drop in the hemoglobin (Hb) was noted. A fall in Hb, peripheral smear findings suggestive of hemolysis, and direct antiglobulin test positivity along with raised lactate dehydrogenase suggested the diagnosis of PLS; the patient was managed successfully for the same by transfusion of O blood group packed red blood cell transfusion and immunosuppression. PLS is a rare but important cause of immune-mediated hemolytic anemia in ABO-mismatched transplants.
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Immuno-hematological consequence of intravenous drug abuse? p. 67
Aikaj Jindal, Anil Luther, Aseem K Tiwari, Amit Mahajan, Subhasis Mitra
DOI:10.4103/ajts.AJTS_88_19  
Intravenous (IV) drug abuse has been well established to be the source of transfer of infections, such as HIV, hepatitis C virus, and hepatitis B virus. However, often overlooked fact is that IV drug abusers have a potential for developing alloimmunization due to universal practice of flushing/washing out the syringe by own blood to rinse out the drug in the syringe. We present here a case of a 28-year-old man who presented with a rather unique predicament of having developed four different alloantibodies after exposure to allogenic blood through IV drug abuse. This case was detected promptly due to routine usage of type and screen policy for all the patients receiving transfusion. Such screening for atypical antibodies must be instituted to preemptively identify these antibodies and arrange compatible blood, which could have been difficult otherwise, at short notice during routine crossmatch. This is the first of its kind case ever reported from India and has no precedence.
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Red blood cell exchange in sickle cell disease patient with multiple alloantibodies p. 70
Geet Aggarwal, Aseem Kumar Tiwari, Pratibha Dhiman, Dinesh Arora, Swati Mehta Pabbi, Divya Setya
DOI:10.4103/ajts.AJTS_36_18  
There are several reports in medical literature about Red Cell Exchange (RCE) being routinely performed pre-operatively in sickle cell disease patients to provide immediate decrease in HbS concentration and prevent post-operative complications. We would like to present one such case of SCD who also had multiple allo-antibodies and had to undergo hemi-arthroplasty for avascular necrosis of head femur. Grouping and antibody screening was performed using column agglutination technique. 3-cell and 11- cell panel were used for antibody screening and identification, respectively. Automated RBC exchange was performed on apheresis machine Com.Tec using the standard PL1 kit (Fresenius Kabi, Germany). Multiple (anti-c, E) allo-antibodies were identified and successful pre-operative RCE was done with corresponding antigen-negative AHG compatible RBC units. Single RCE procedure reduced HbS concentration from 65% to 25%. The patient underwent uneventful hemi-arthroplasty and was discharged on post-operative day-7. Patient is on regular follow-up and continues to do well two months after the day of surgery. This is possibly the first case report from India, which illustrates successful automated RCE in a SCD patient with alloimmunization.
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Patient blood management in a patient with multiple red cell antibodies (anti-C, anti-e, and anti-K) undergoing liver transplant in South India: A team approach p. 74
Deepti Sachan, Aseem K Tiwari, Ravi Dara, Dinesh Jothimani, Ilankumaran Kaliamoorthy, Srinivas Mettu Reddy, Mohamed Rela
DOI:10.4103/ajts.AJTS_54_18  
End-stage liver disease (ESLD) patients undergoing liver transplant (LT) surgery are often multiply alloimmunized and pose significant challenges to the transfusion services in terms of red cell cross-match incompatibility, unpredictable blood requirements, and often lead to significant delays in availing compatible red cell units. We report a case of a 64-year-old female from Bahrain, a known case of hepatitis C-related ESLD referred for LT surgery. She had a history of multiple uneventful transfusions in the preceding year. Her blood group was A-positive, direct antiglobulin test, and cold antibodies were negative. Indirect antiglobulin test was positive, and antibody identification confirmed the presence of anti-C, anti-e, and anti-K. Her red cell phenotype was R2R2and Kell negative (C-c+E+e-K-). The patient was started on erythropoietin. Requests for R2R2and Kell negative units were sent to various blood banks across the country. After >800 A/O group units phenotyping and a waiting period of 6 weeks, two compatible R2R2phenotypes and Kell negative could be arranged in-house and three units were received from Gurgaon, North India. Intraoperative management included blood preservation techniques including cell salvage, antifibrinolytic drug, and monitoring using thromboelastography. The estimated blood loss was 350 ml with pre- and postoperative Hb 10.4 gm% and 9.2 gm%, respectively. She received intraoperatively two units of single-donor platelet and four units of fresh frozen plasma and postoperatively one unit of leukocyte-depleted-packed red cells and doing well at 12-month follow-up. This case highlights the importance of advance immunohematology for timely detection of alloimmunization and providing antigen-negative compatible units, proper communication between the transfusion specialists, and the clinical team for proper patient blood management as well as the need for central rare donor registry program to avoid delays in providing compatible blood in such inevitable cases.
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Implication of a positive virtual crossmatch with negative flow crossmatch: A mind-boggler p. 79
Mohit Chowdhry, Soma Agrawal, Yogita Thakur, Sandeep Guleria, Vandana Sharma
DOI:10.4103/ajts.AJTS_159_18  
There are occasions when tests performed before considering a patient for transplant are ambiguous and require further workup. One such condition is the presence of a positive virtual crossmatch (VXm) (anti-human leukocyte antigen [HLA-A]*26: 01 antibody in this case) with a negative complement-dependent cytotoxicity, Luminex, and flow crossmatch. To ascertain the nature of the antibody, the beads used in single-antigen bead assay (SAB) were treated by acid to denature the antigens and retested with the control and test sample. The mean fluorescence intensities (MFIs) from the patient sera with acid-treated beads increased considerably as compared to the regularly untreated SAB indicating additional antigen epitopes become available by the denaturation process. The MFIs of the antibodies from that of the control sera were reduced to half on testing with the acid-treated SAB assay, indicating that HLA antigen HLA-A*26 was susceptible to acid treatment. Therefore, results of VXm should be interpreted with caution.
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Hemolytic disease of the fetus and newborn due to multiple alloantibodies in pregnancy p. 83
Vidushi Gupta, Meena Sidhu, Saadat Nazir Shah
DOI:10.4103/ajts.AJTS_40_19  
Immune hemolytic disease of the fetus and newborn is a condition in which there is the premature destruction of fetal or neonatal red cells due to maternal alloantibody against red cell antigen inherited from father. We report the case of Hemolytic disease of fetus and newborn (HDFN) due to anti-E and anti-Fya antibody. Blood grouping was done using the conventional tube technique. Rh and Kell phenotyping of the patient and her husband performed by column agglutination and Duffy phenotyping were done by the conventional tube technique. Direct antiglobulin test was performed by column agglutination technique. Antibody screening and identification were done. Anti-E and Anti-Fya were identified with titer of Anti-E: 1:64 and Anti-Fya: 1:256. The patient's neonate developed jaundice. Phototherapy was given. Bilirubin stabilized and discharged on the 12th day.
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Unexpected high platelet counts in a potential platelet donor: A clue to essential thrombocythemia p. 87
Anisha Navkudkar, Priti Desai, Sunil Rajadhyaksha
DOI:10.4103/ajts.AJTS_114_19  
Essential thrombocythemia (ET) (primary thrombocythemia) is a nonreactive, chronic myeloproliferative clonal disorder in which sustained megakaryocyte proliferation leads to an increase in the number of circulating platelets. It is silent disorder and is diagnosed as high platelet counts with or without associated symptoms or as an accidental finding. We, hereby, report a case of ET as an incidental finding during screening of a potential platelet donor. Donors with high platelet count should be investigated properly to rule out ET. The role of transfusion medicine specialist is not only to recruit donors but also to identify such donors during screening and counsel them for detailed investigation and proper management.
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Posttransfusion purpura sans purpura: A novel presentation p. 90
Ravindra Prasad Thokala, Ashwin Anandan, Krishnamoorthy Radhakrishnan, Vinod Kumar Panicker, Niranj Rathan
DOI:10.4103/ajts.AJTS_66_19  
Posttransfusion purpura (PTP) is a rare condition that develops 5–10 days after transfusion of platelet containing blood component. Temporal relationship to blood transfusion, thrombocytopenia, and purpuric rashes with or without bleeding manifestation, supported by the serological presence of antiplatelet antibodies, are characteristic of PTP. We, herein, report a case of posttransfusion thrombocytopenia without purpuric rashes or bleeding symptoms, which is a rare presentation. A 44-year-old multiparous female, being treated for menorrhagia, who was transfused with three packed red blood cell units developed significant thrombocytopenia on day 8 after transfusion of the first unit. Her coagulation profile was normal. No purpuric rashes or bleeding manifestation was seen. Serum revealed the presence of antiplatelet antibodies on performing platelet antibody screen. Her platelet count improved from day 9 and reached above 50,000/μ l on day 10. She was managed conservatively with frequent monitoring for bleeding manifestations and blood counts.
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Bernard–Soulier syndrome (BSS) with uncontrollable menorrhagia p. 93
Debasmita Bhadra, Somajita Chakraborty
DOI:10.4103/ajts.AJTS_61_18  
Menorrhagia is a common problem in women of reproductive age group and 5% of women between 30 and 49 years of age group consult their general practitioner for this problem. Menorrhagia occurring in adolescent age group and perimenopausal age group is chiefly due to anovulatory cycles. In perimenopausal age group, local pathology like leiomyomas can also contribute to menorrhagia. Recently, bleeding disorders like von Willebrand Disease, single coagulation factor deficiencies particularly factor XI, VIII, Factor V and platelet function disorders have been found to be prevalent in patients presenting with menorrhagia. Bernerd soulier syndrome is extremely rare haemostatic disorder due deficiency in GP IB/IX/V receptor complex present on platelet membrane which is necessary for platelet aggregation. As a result of the defect patients have prolonged bleeding time, which might vary in symptoms ranging from spontaneous self- limiting epistaxis to life threatening haemorrhage. Here we report a case of 31-year-old woman known case of Bernard soulier syndrome with severe menorrhagia treated with mirena insertion and course of complication and its management.
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ILLUSTRATION Top

Importance of documentation of the preanalytical variable on test requisition for sterility reporting of autoclave p. 96
Suchet Sachdev, Divjot Singh Lamba, Manisha Biswal, Ratti Ram Sharma, Neelam Marwaha
DOI:10.4103/ajts.AJTS_43_19  
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Validation of lateral flow assay for blood grouping on hemolyzed sample p. 98
Deepika Chenna, Shamee Shastry, Vijayram Reddy Kanukula, B Poornima Baliga
DOI:10.4103/ajts.AJTS_28_17  
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LETTER TO THE EDITOR Top

Naturally occurring non-ABO alloantibodies in voluntary blood donors p. 99
Saurabh Lahare, Maitry D Gajjar, Nidhi Bhatnagar, Tarak Patel, Mamta Shah, Minal Wasnik
DOI:10.4103/ajts.AJTS_80_19  
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2006 - Asian Journal of Transfusion Science | Published by Wolters Kluwer - Medknow
Online since 10th November, 2006