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Adverse Occurrence type:
Alerting signals, symptoms, evidence of occurrence:
Patient received a total of 6 units of RBCs during hospitalization. He was discharged on Hospital Day 6, but returned a few hours later complaining of fever. His Hb at readmission was 7.2 g/dL. Repeat serologic workup now showed panreactivity (2+ at anti-human globulin) with a positive direct antiglobulin test (DAT; 1+ for immunoglobulin Gand C3d). An eluate was also pan-reactive. Although these results were consistent with a warm autoantibody, the timing was suspect for a delayed hemolytic transfusion reaction. The following morning his Hb had decreased to 5.4 g/dL. The patient now had symptomatic anemia and was transfused with 3 units of least incompatible RBCs. Shortly thereafter, he developed acute dyspnea and hypoxia requiring intubation.
Demonstration of imputability or root cause:
A veteran blood bank technologist phenotyped his pretransfusion sample and noted that he was negative for Jka and Jkb. She believed that he had an amnestic anti-Jk3 based on his ethnicity and clinical history. According to his family, he had received 1 unit of RBCs 5 years earlier. A donor known to be Jk(a-b-) had just given 2 units of RBCs at the local donor center. The patient’s plasma was fully cross-match compatible with these units. The plasma fHb normalized after the third total plasma exchange (TPE).This case illustrates the potential benefit of utilizing TPE in patients with critically high levels of plasma fHb due to massive hemolysis secondary to acute and delayed hemolytic transfusion reactions.
Suggest new keywords:
Delayed hemolytic transfusion reaction, alloimmunization, red blood cell transfusion, anti-Jk3
Cain, M.D., Roberts, C. and Dissanayake, R.B. Therapeutic plasma exchange for massive anti-JK3–mediated hemolysis. Transfusion 53:1861-1863.
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Expert comments for publication:
Kidd antibodies, anti-Jka, -Jkb, and -Jk3, have been responsible for severe and fatal immediate and delayed reactions.