Immunohematology Workshop on Rh D Variants.

1. Immunohematology
Workshop
27th of March
2019
Presented by : - Dr. G.D.A. Samaranayaka
Prepared by :- Dr. Susudu Jayanetti, Dr. Dineesha Subasinghe

2. Case 1

3. History
• 28 years old lady
• P4C1
• Managed for Pregnancy Induced Hypertension
• Blood requested due to postpartum hemorrhage
• No history of recent anti D prophylaxis
• History of red cell transfusion >3 months)

4. Investigations done at the local
hospital
• Full blood count
• Hemoglobin - 10.4 g/dl
• Platelet count - 201x109/l
• WBC - 8.96x1011/l
• Blood Bank investigations
• Blood group - B Rh D positive
• Direct Antiglobulin Test - Negative
Anti A Anti AB Anti B Anti D A1 Cell B cell O cell
0 +4 +4 +4 +4 0 0

5. Investigations done at the local
hospital
• Antibody Screening (LISS)
S1 +2
S2 +2
S3 0
Auto 0

6. Investigations done at IHRL
• Blood group: B Rh D positive
• Direct Antiglobulin Test: Negative
Anti A Anti AB Anti B Anti D A1 Cell B cell O cell
0 +4 +4 +4 +4 0 0

7. Investigations done at IHRL
• Antibody Screening (LISS)
• Probable antibodies; Anti D, Anti Fya, Anti Jka
37oC IAT
Poly AHG CC cells
S1 +1 +2 -
S2 +1 +2 -
S3 0 0 +2
Auto 0 0 +2
+ cont(weak antiD + R1r) 0 +3 -
- cont(inert AB + R1r) 0 0 +2

8. Investigations done at IHRL
• Antibody identification (LISS)
• Interpretation: Anti D detected
• Possibility of technical errors were excluded

9. Investigations done at IHRL
• Phenotyping
• Interpretation
• Most probable phenotype - R1r, Kell negative
• (D+C+E-c+e+, K-k+)
Rh phenotype Kell
D C E c e K
Patient +4 +4 0 +4 +4 0
+ cont +4 +4 +4 +4 +4 +4
- cont 0 0 0 0 0 0
phenotype R1r Kell Neg

10. Investigations done at IHRL
• Cross match (LISS):
• Group B Rh D negative rr kell negative, 37 oC IAT cross match compatible
blood unit was selected and issued
• Antibody titer: 32
• Paternal Testing
• Blood group :A Rh D positive
• Probable Rh phenotype :R1R1 Kell negative
• Baby’s investigations
• Blood group :B Rh D positive
• Direct Antiglobulin Test :Positive with IgG specificity
• Probable Rh phenotype :R1r Kell negative
• Elution Study :Anti D eluted

11. Variant D Confirmation
• Monoclonal partial D typing kit
• Molecular Rh D typing
Molecular Biology of partial D and weak D: Implications for Blood Bank Practice WILLY A.
FLEGEL, FRANZ F. WAGNER; Clin. Lab. 2002;48:53-59

12. Case 2

13. History
• A 78 years old male
• Admitted to Teaching Hospital Jaffna with right side
femoral neck fracture
• awaiting surgery (proximal femoral nail)
• History of transfusion in June 2017 following a snake bite.

14. Blood bank investigations
• Blood group - B Rh D Positive
• Direct Antiglobulin Test was negative
Anti A Anti AB Anti B Anti D A1 Cell B cell O cell
0 +4 +4 +4 +4 0 0

15. Blood bank investigations
• Antibody screening - positive
• NISS IAT cross match 1 pack and strict 37 IAT cross match 6
packs were positive.
S1 +2
S2 +2
S3 +2
Auto 0

16. Investigations done at IHRL
• Blood group
• Direct Antiglobulin Test
Anti A Anti AB Anti B Anti D A1 Cells B cells O Cells
0 4+ 4+ 4+ 4+ 0 0
Poly Anti IgG Anti C3d
Test 0 - -
CC Cells 2+

17. Investigations done at IHRL
• Antibody Screening
RT 370C LISS IAT Pre Warm
S1 0 2+ 3+ 4+
S2 0 2+ 3+ 4+
S3 0 2+ 3+ 4+
Auto 0 0 0 0

18. Investigations done at IHRL
• Antibody Identification - Pan-reactive panel
• Phenotyping
Rh Kell Kidd Duffy MNSs Lewis
D C E c e K k Jka Jkb Fya Fyb M N S s Lea Leb
Patient +4 0 0 0 0 0 +4 +3 +3 +3 0 +4 0 0 +3 +3 0
+ Control +4 +4 +4 +4 +4 +4 +4 +4 +4 +4 +4 +4 +4 +4 +4 +4 +4
- Control 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Phenotype D+C-E-c-e- K-k+ Jk(a+b+) Fy(a+b-) M+N-S-s+ Le(a+b-)

19. Management
• Detected antibody - Anti Hr0/Anti Rh17
• Family screening was suggested
• Patient was the last child in the family
• older siblings and parents had passed away.
• Rh phenotyping done on the four children - compatible
phenotype was not found.
• Pre deposit autologous donation was suggested.
• Patient’s HGB was 9.7g/dl
• started on Hematanics and Erythropoietin
• conservative (non interventional) surgical management

20. Anti-Rh17 (anti-Hr0)
• Monospecific IgG alloantibody
• Reacts with a common determinant on the RhCE protein.
• Incidence is rare - produced after immune stimulus
• Designated as D- - and was first described by Race and Sanger in
1950.
• Detected best with antiglobulin testing - react with both normal and
enzyme-treated red blood cells.
• Implicated in transfusion reactions & mild to severe HDFN
• Compatible blood products - Rh deletion phenotype and lack RhCE
antigens.
• Extremely difficult to find Hr0 negative blood
• Autologous donation.

21. Immunohematology
Workshop
27th of March 2019