COMPATIBILITY TESTING

( PRETRANSFUSION TESTING)

Mrs. Pichi Arcilie E. Malintad , RMT

 Pre-Transfusion Testing
final step to determine that blood given to the patient
is safe and wont cause adverse reactions
consists of a series of tests performed on the blood of
the prospective recipient of a blood transfusion and on
the blood of the proposed donor

Purpose of Compatibilty Testing :

1. to minimize the risk of blood transfusion to a patient
by selecting blood and blood components that will
have acceptable survival when transfused and will
not cause destruction of the recipients red cells.
2. to prevent a transfusion reaction whether it is
hemolytic reaction or a less severe one
 Pre-Transfusion Testing

General steps in Pre-transfusion Testing:

( Compatibility Testing Protocol )
1. Identification of the patient & donor &
collection of appropriate samples for testing
2. Testing of the donor sample
3. Testing of the patient sample & review of the
past blood bank records
4. Selection of appropriate donor units
5. Crossmatching
6. Re-identification of the patient prior to
infusion of blood
 Pre-Transfusion Testing
FLOWCHART:
PATIENT

1. Positive identification of patient

* Blood request form : two independent identifiers
( Name & unique hospital # & the date of sample
collection) , age, date of birth & Name
attending physician

2. Collection of blood for testing

a. 5- 10 ml ; not hemolyzed
b. serum is preferable
c. should not be contaminated with intravenous
infusion
d. Should not be collected in tubes that contain clot
activators or silicone coating
 Pre-Transfusion Testing
c. Patient sample should be stored for 7 days after
transfusion ( tube stoppered, refrigerated at 1-6 C,
labelled with adequate volume)

3. Testing & review of past blood bank records

a. assigned unique ID ( for verification of result of
previous & current testing)
b. Review of records
ABO & Rh typing
Unusual serologic reactions
Identify of unexpected antibodies
Accurate medical history ( medications,
transfusions & pregnancy )
 Pre-Transfusion Testing
c. Testing
1. Do advance testing, 3 days before the
scheduled transfusion ( day of collection is day 0). If the
patient has the following history:
has been transfused within the preceding 3 months
with blood or component containing RBCs, or
has been pregnant with in the preceding 3 months
or
the history is uncertain or unavailable
2. ABO Grouping ( most critical serologic test)
3. Rh typing ( Du typing not done on recipients)
4. Antibody Screen :
Objective: detect al many possible clinically significant Abs
( clinically significant antibodies refers to Abs reactive at 37 C &/ or
in the AHG test & are known to cause transfusion reaction or
unacceptably short survival of red cells)
 Pre-Transfusion Testing
DONOR
,
1. Positive Identification of the donor
2. Collection of samples for testing:
a. Must be taken at the time as full donor unit( can
be clotted or anticoagulated blood)
b. Label with unique code ( donor info card, pilot
samples for processing & collection bag ) before
phlebotomy & verified again after filling
c. Ideal samples: from segmented tubing thru which
the donor was bleed. The tubing are attached to the
collection bag & have the same numbers imprinted
 Pre-Transfusion Testing

on them and are positive means of sampling a

given
unit of blood. Store the segment with the cut end
down in the test tube to decrease contamination.
* Donor cells can be obtained from the segments in 2 ways:
1. use a lancet to make a tiny hole in the segment thru which
which a drop of blood can be expressed easily

2. cut the end of the segment next to the cell pack & use an
applicator stick to remove the cells or express a drop by
squeezing the tubing.

d. Store donor sample for 7 days after transfusion ( tube

stoppered, refrigerated at 1-6 C, labelled with
adequate volume.)
 Pre-Transfusion Testing
3. Testing of donor sample:
a. Done at the facility where the donor unit was
collected & results clearly indicated on all product labels
on the unit.
b. Done on sample of blood taken at the time of
collection of unit of blood from the donor.
c. Tests done:
1. ABO Grouping
2. Rh typing & test for weak D (Du)
3. serologic tests intended to prevent
disease transmission
4. Screening tests for unexpected Abs to
red cells Ags ( done for donors revealing
history of previous transfusion or pregnancy)
 Pre-Transfusion Testing
5. Confirmation by Transfusion facility of the
following:
a. ABO Grouping
b. Rh typing on all Rh(-) blood received from
other collecting facilities. ( Tests for Du not required to
be repeated)
c. Transfusion facility not required to repeat any
other testing procedure

Sample for confirmation taken from the attached segment on

the donor unit.
 Pre-Transfusion Testing
PATIENT DONOR

4. SELECTION OF APPROPRIATE DONOR UNITS

a. Preferably patients own ABO & Rh type selected
for transfusion
b. If above(a) is not possible ; selected units for
transfusion must lack any Ag against which the
patient has a significant Ab.
e.g. Group O packed red cells, Rh(-)
Packed red cells must be used rather whole blood
( whole blood contains plasma antibodies that are
 Pre-Transfusion Testing
Decision to give Rh(+) bld to Rh(-) bld. Only given
to males & females beyond child-bearing age as long as
no anti-D demonstrated in the serum.
c. Patients serum with positive unexpected
antibodies , select blood either by:
c. 1. phenotyping red cells with commercial anti-
serum, or
c.2. crossmatch with patients serum.
Phenotyping the compatible units with
commercial antisera to verify if they are Ag negative (
in vitro reactions)
 Pre-Transfusion Testing
d. Select donor units where the red cells are of
appropriate age for the patients needs & will not expire
prior to use

Choice of Alternative Blood Groups when ABO

Identical are not Available
Patients Bld. Group Component ABO Group
1st choice 2nd choice 3rd choice 4thchoice
AB AB A B O
A A O
B B O
O O
* given as packed cells
Component ABO group of recipient Alternate
group
compatible
None (only ABO group
1. Whole blood O,A,B,AB
specific blood)
None use only 0 group
2. Red cell
Concentrate O O
A O
B O
AB A,B or O
O A,B, or AB
3. Plasma
A AB
B AB
AB Note use only AB
4. Platelet
Concentrate Compatible with red
All ABO group
cells are preferred
 Pre-Transfusion Testing

e. Visual examination of the Donor units prior to

compatibility testing
1. unusual appearance ( color change, turbidity,
clot)
2. correct labeling ( incomplete, improper labeling)
3. hermetic seal integrity (leakage)

5. Crossmatching

6. Re-Identification of Patient prior to infusion of

Blood
 Crossmatching
is the final step to determine the compatibility of
recipient serum/plasma with donor RBCs
the terms compatibility test and crossmatch are
sometimes used interchangeably
a crossmatch is only a part of compatibilty test

Elements of Pretransfusion Testing:

1. Review of patients past blood bank history &
records
2. ABO & Rh grouping of the patient & donor
3. Antibody screening of the recipient serum(plasma)
with screening cells
4. Crossmatch of the recipient serum with donor rbcs
 Crossmatching
Two main functions of the crossmatch test :

1. It is final check of ABO compatibility between donor

& patient

2. It may detect the presence of an antibody in the

patients serum that will react with Ags on the
donor red cells but was not detected in the
antibody screening because the corresponding Ag was
lacking from the screening cells.
 Crossmatching
Serologic crossmatch testing procedures have been
divided into two parts :`

1. Major Crossmatch : PS versus DC

procedure used to determine the

compatibility between red cells of the donor
and serum of the recipient

detects Abs in the serum of the recipient which

may damage or destroy the red cells of the donor

more critical for ensuring safe transfusion

 Crossmatching

2. Minor Crossmatch : PC versus DS

a procedure used to determine compatibility

between serum of the donor and red cells of
the recipient

detect Abs in donors serum that can possibly

react with the patients cells.

has been completely eliminated in most blood

banks because donor samples are screened
beforehand for the more common Abs.
 Crossmatching
Methods for Major Crossmatch Tests :

1. Immediate Spin Crossmatch: ( Saline Phase)

detects most ABO incompatibility and may be

performed if the antibody screen in non-reactive and
there is no history of unexpected antibody
is performed by making a 2% - 5% suspension of
donor and mixing with a patients serum/plasma.
After a brief centrifugation, the cell button is
gently dislodged and inspected for the presence or
absence of agglutination or hemolysis
Interpretation:
absence of agglutination or hemolysis is nonreactive test
and the unit is considered acceptable for transfusion
( compatible)
 Crossmatching

simplest & most frequently used method to

demonstrate ABO compatibility
Drawback:
does not detect all ABO incompatibilites
false reactions may be seen in the presence of:
a) other immediate spin-reactive antibodies(e.g.,
autoanti-I),
b) in patients with hyperimmune ABO antibodies
c) when the procedure is not performed correctly(
delay in centrifigation or reading)
d) when rouleaux is observed
 Crossmatching
adding ethylenediaminetetraacetic to the test
system has been reported to eliminate some of the
false-positive reactions thus improving the
sensitivity of the immediate spin cross match

Abbreviated Crossmatch:
an immediate spin, saline, major cross match used
to coupled with type and screen is used to
determine ABO compatibility in patient with
no demonstrable clinically significant antibodies &
(-) history of antibody formation
 Crossmatching
2. Incubation at 370C ( High Protein Phase)

patients who have clinically significant antibodies

either by current testing or by history must have a
crossmatch performed that includes a 370 C
incubation phase & the antiglobulin test

enhancement medium such as albumin or LISS is

added and tube is incubated for 15-60 mins. at 370
C

after incubation, the tube is centrifuged and

examined macroscopically for agglutination or
hemolysis ( confirm microscopically)
 Crossmatching
3. Indirect Antiglobilin Test Crossmatch

the antiglobulin crossmatch procedure begins in

the same manner as the iS crossmatch, continues
to a 37 C incubation, finishes with an antiglobuilin
test

tube is washed is washed 3x with saline & after

the final decanting of saline, AHG reagent is added

tube is gently mixed, centrifuged & examined for

agglutination or hemolysis. ( confirm
microscopically)
 Crossmatching
One tube-Donor-unit Crossmatch :
Procedure :
1. Into an appropriate labeled 10 x 75 mm test tube,
add 2-3 drops of recipient serum to achieve an
approximate 2:1 ratio of serum to RBC ( Droppers
used to dispense RBCs and serum should be of
equivalent size . )

2. Dispense 1 drop of a washed 2-5 % suspension of

donor RBCs

3. Centrifuge at time and speed that have been

previously shown to give clear-out differentiation
between positive & negative results ( 15 sec in a
Serofuge)
 Crossmatching
4. Observe supernatant for hemolysis that must
be considered indicative of an antigen-antibody
reaction. Resuspend cell button by gentle
manipulation of the tube. Grade all positive
results.
Record observations. ( Stop here for immediate
spin crossmatch)

5. Add 2 drops of LISS ( or enhancement medium

such as 22% albumin) to the tube ( the
enhancement medium may be omitted , if desired;
incubating tubes for at least 30 minutes at 37 C)
Mix and incubate for time indicated in enhancement
media manufacturers instructions at 37 C)
 Crossmatching
6. Centrifuge as above, observe supernatant fro
hemolysis, gently resuspend cell button, and
record results.
7. Wash 3-4x using an automated instrument or
manual washing technique. Decant saline
completely from the last wash and blot dry to
achieve dry button
8. Add 2-3 drops of AHG serum to tube: ( Follow
manufacturers directions for use of reagent)
Centrifuge, gently resuspend cell button, and
record reaction results.
 Crossmatching
9. Add 1 drop IgG-sensitized RBCs to each negative
reaction test. Centrifuge and examine. Test must
be positive or results or procedure are invalid and
test must be repeated.
 Crossmatching
Antibodies Detected at Various Phases

Phase Antibodies Detected

Immediate spin IgM abs ( anti-A. anti-B, anti-Le a, anti-Leb,

anti-M,anti-N)
detects ABO incompatibility often due to
incorrect typing
370C IgG abs-high titered Rh abs ( anti-
D,C,c,E,e, occ. Anti-kell)
High Protein albumin enhances Rh
antibodies
AHG IgG abs (antiFya,anti-Fyb, anti-kell & Rh abs)
Most immune antibodies. It is the only
method to detect anti-Fy,anti Jk & most
anti-K abs
 Crossmatching
Cases to demonstrate the types of Reactivity
detected in Crossmatching Patients:
Case 1: examination at room temperature
Patient : Gp. O Rh(+) serum: anti-A , anti-B RBCs: no Ags
plus
Donor: Gp. A Rh(+) serum: anti-B RBCs: A Ags

major side minor side

Patient anti-A No A & B Ags
anti-B
plus plus
Donor A antigen anti-B
Incompatible Compatible
 Crossmatching
Case 2 : examination at 37 C

Patient: Group A Rh(-) with Serum: anti-B, anti- rbcs: A Ags

anti-D D
plus
Donor: Gp A Rh (+) serum: anti-B rbcs: A & D Ags
major side minor side
Patient anti-B A antigen
anti-D
plus plus
donor A antigen
D antigen anti-B
Incompatible Compatible
 Crossmatching

Case 3: examination after addition of AHG:

Patient: Gp A, Rh(+), serum anti-B rbcs: A &
Kell(+) Kell Ag
plus
donor: Gp A , Rh(+), serum: anti-B, anti- rbcs: A Ag
with anti-kell kell
major side minor side
patient anti-B A antigen
Kell antigen
plus plus
anti-B
A Ag__ anti-kell_
Compatible Compatible
 Labeling and Release of Blood
1. A blood transfusion form indicating the recipient;s name,
identification number and ABO/D types must be
completed for each donor unit or component.
a. One copy of form for patient's chart.
b. One copy must remain attached to donor unit.
2. The form must also include the following:
a. Donor identification number.
b. Donor ABO/D types.
c. Interpretation of compatibility testing.
d. Identification of the person performing the test.
e. The current status of serologic testing when blood must
be issued before compatibility problems are resolved.
 3. Prior to issuing a unit of blood, blood bank personnel must:
a. Securely attach to the unit of a blood a compatibility
label with all the information mentioned above.
b. Check the expiration date of the blood to avoid issuing
an outdated component.
c. Inspect the unit for abnormal appearance.
d. Indicate on an appropriate form the:
1) Name of the individual issuing the blood.
2) Date and time of issue.
3) Name of person to whom blood was issued or
destination.
e. Final identification of the recipient prior to transfusion
tests with the transfusionist, who must identify
the patient and donor unit and certify that identifying
 Crossmatching
Exceptional Protocols:
A. Massive Transfusion:
When the total blood volume of an individual has been
replaced with donor blood within 24 hours
Frequently during these instances, an abbreviated
crossmatch may be performed at the discretion of the of
the director of the transfusion service

B. Emergency (Urgent) Crossmatch:

has 3 phases but shortened incubation time
IS cross match can be done & blood be issued if this phase is
(-) & let the physician sign a waiver
Pre-transfusion testing should be completed up to AHG
phase
 Crossmatching
EMERGENCY TRANSFUSION PROTOCOL:

Emergency classified based on urgency & need of

blood:

1. Extreme emergency( a matter of life & death when

no blood sustitute is available:)
a. transfuse Gp. O, Rh(D) (-) blood of low titer may
be release without typing or crossmatching

2. If a 15-30 minute period is available:

a. Establish the patients ABO & Rh type & release
uncrossmatched but type specific blood,( or X-match up
 Crossmatching
b. While the patient is receiving blood the
crossmatch Iis completed the usual way
3. If 30-45 minute period is available:
a. Blood is cross matched, but the procedure is
shortened by reducing the incubation periods
b. Blood may be released after 10 min of
incubation during the AHG phase if compatible, but
the lab should continue the cross match then usual
technique
4. Mass casualties:
a. in emergencies that allow only a minimal amount
of time for typing and crossmatching, anti-A serum may
 Crossmatching

used to group patients into those who react with anti- A

( groups A & AB) and those who do not react ( groups O
& B).

b. the slide test should be used for Rh typing. Rh-

specific blood of group A is administered to patients of
groups A & AB and group O to patients of group O and B.
 Crossmatching
The Electronic Computer Crossmatch:

recognized by the AABB standards as an acceptable

crossmatch procedure
compares recent ABO serologic results and
interpretations on file for both the donor and the
patient being matched and determines compatibility
based on comparison.
this non-serologic crossmatch may be performed
when only the detection of ABO incompatibilty is
required, provided the following criteria are met:
 Computer Crossmatch
1. The computer must be validated on-site to prevent
the release of ABO incompatible components
2. The recipients ABO group has been determined at
least twice, with complete testing of both serum
and cells. One determination must be made on a
current sample . The second determination may
be made on the same sample, on a second current
sample, or by comparison with previous records.
3. The computer must contain the :
a. Identification number ( identifier) and the name
of the component
b. the ABO and Rh types of the unit
c the ABO confirmation tests performed on the unit
 d. The recipient ABO group and Rh type

4. There must be a method to verify the correct entry

of date prior to release of blood or component.

5. The system contains logic to alert the users to

discrepancies between information on the donor
unit label and the interpretation of blood group
confirmatory test, and the ABO incompatibilities
between recipient and donor unit
 Advantages of the Computer Crossmatch :

1. decreased workload
2. reduced volume of patients blood samples
3. reduced exposure of personnel to blood specimens
4. elimination of false reactions associated with the IS
cross match
 Gel Technology
Newer Routine Non-test tube Method for
Compatibility Testing:
Innovative technique, invented buy Dr. Yves Lapierre
of France
To minimize problems associated with conventional
techniques
Now used worldwide
utilizes a small plastic card that contains six
microtubes, each filled with a gel for a specific test
3 kinds of gel available:
a) specific gel( ABO, Rh type & other phenotyping)
b) buffered gel for reverse typing
C) antiglobulin gel ( DAT/IAT)
 Principle of Gel Technology

the Sephadex gel matrix acts as a sieve

is a variation of liquid agglutination & uses dextran

acrylamide gel & principle 0f size exclusion
chromatography to separate agglutinated from
unagglutinated RBCs.

Under centrfugal force, agglutinated RBCs are

trapped by the gel, whereas unagglutinated RBCs
form a pellet at the bottom of the microtube
 Uses of Gel Technology

The ID system may be used for any

immunohaematological test that has
haemagglutination as its end point.
ABO & Rh typing
Typing for other blood group systems
Antibody screening/identification
Compatibility testing including Crossmatching
 The gel technology has several functions:

1. it serves as a reaction medium that separates

agglutinated from unagglutinated RBCs

2. it entraps RBCs & facilitates a stabilized serologic

reaction that can be interpreted many hours after the
test is performed

3. it entraps unbound IgG so that washing before AHG

is unnecessary
 The sensitivity of the gel test is greater than
that of standard tube test:

1. both the gel & the diluent used have low ionic
strength characteristics

2. there is no washing before the AHG test so antibody

dissociation or washing away is diminished

3. there is no resuspension of RBCs so weak Ag & Ab

bonds are not broken
 Problems with Conventional Tests:

labor intensive
skilled reading is required
Instability of completed test
Poor wash phase; false weak/negative
Inappropriate handling of completed test; results to
downgrade/negative
addition of sensitized control cells to check negative
results
 Advantages of Gel Technology

Standardizaton of lab technique

simple and rapid
stable reactions ( 48 hrs.)
No wash antiglobulin testing
Training facilitated
small sample volume
Enhanced laboratory safety
long shelf life
decreased waste
automation
A diagram of gel test reaction patterns and grading scheme. Reactions are graded
from 0 to 4+. (A) 4+ reaction is indicated by a solid band of red cells on the top of
the gel; (B) 3+ reaction displays agglutinated red cells in the upper half of the gel
column; (C) 2+ reaction is characterized by red cell agglutinates through the length
of the column; (D) 1+ reaction is indicated by red cell agglutinates mainly in the
lower half of the gel column with some unagglutinated red cells pelleted at the
bottom; and (E) Negative reactions display a pellet at the bottom and no
agglutinates in the matrix of the gel column. A mixed field reaction may be
observed
PROBLEMS IN CROSSMATCHING

Pichi Arcilie E. Malintad, RMT

 Resolving incompatibilities in the Major
Crossmatching:

The primary objective of the Major Crossmatch:

to detect the presence of an Abs in the recipients serum,
including anti-A and anti-B, that could destroy the transfused
red cells
a positive result in the major crossmatch requires explaination,
and the patient should not receive a transfusion until the cause
of incompatibility has fully determined
when the crossmatch is positive, the results of the autocontrol
and the antibody screening test should be reviewed to identify
the patterns that may help determine the cause of the problem.
 3 Components used principally in the investigation
of crossmatch:
1. Major Crossmatch
2. Autocontrol
3. Antibody Screening Test

The principal types of problems that can produce

agglutination/incompatibilty in the major crossmatch
are the following:
1. Incorrect ABO grouping of patient & donor
2. An alloantibody in the PS reacting with the corresponding
Ag on the donors erythrocytes
3. An autoantibody in the PS reacting with the corresponding Ag
 on the donors erythrocytes
4. Prior coating of the donors erythrocytes, which
produces a (+) DAT
5. Abnormalities in the patients serum
6. Contaminants in the test system
 Crossmatch will not:
1. prevent immunization/sensitization
2. detect error in Rh typing
3. detect antibody unless specific for red cells antigen
4. detect errors in labeling, numbering and other clerical
errors.
Antibody Screening using the patients serum:
Advantages or Uses in Such Cases:
1. Compatible crossmatch but the patient serum has the Ab
with no screening done may offer potential danger.
2. antibody present in circulation may drop to levels below
detectable concentration and accidental re-stimulation by
incompatible donors result to delayed reaction
3. Dosage effect Ab react strongly with cells carrying double
dose of corresponding antigen.
 4. Poor condition of the stored cells in pilot tubes
resulting into weak Ab going undetected in the
crossmatch.

Design of a crossmatch:
A. Provide conditions suitable for optimum reactivity
of all clinically significant Abs
a.1 temperature of reactivity
a.2 medium of reaction
B. Specimen used:
b.1 patients serum- not more than 48 hours old
b.2 not inactivated
b.3 not plasma
 Defining the Problem

1. At what stage of the crossmatch was the

incompatibility observed ?
2. Is the autologous control (-) or (+)? Or does the
patient serum reacts with his own cells and those
of the donor under the same conditions?
3. What is the appropriate % of incompatible
crossmatch?
 4. Are all incompatible donors reacting in the same
manner?
5. Is hemolyis or mixed field agglutination present?
6. What is the patients diagnosis?

Resolving Problems in Crossmatch:

A) Categories of Crossmatch difficulties:
a.1 Patient problem ( in vivo)
a.2 Laboratory problem ( in vitro)
Patient Problem :
presence of specific antibodies ( warm/cold)
resolve: look for another blood that could be
compatible
2. Laboratory Problem ( in vitro)
technical error
presence of non-specific agglutinins
rouleaux formation

B) Considerations in attempting to resolve the

Crossmatch:
1. Grading System
4+ - massive agglutination
3+ - many large clumps
2+ - many small clumps
1+ - just visible macroscopically
Mi - visible microscopically
H - hemolysis
2. Centrifugation :
standardized
minimum time

3. Complete the Crossmatch

Incompatibility in the Room temperature phase:
- little indication of thermal optimum reactivity of
Ab encountered which could be a
a. High titered cold agglutinin
b. Low titered warm agglutinin
gross agglutination/hemolysis would suggest
ABO incompatibilty
 same reaction in the 1st phase continued incubation
at a higher temperature, the reaction is :
enhanced - warm agglutinin
diminished - cold agglutinin
proceed to AHG phase : non-specific reactions such
as rouleaux will not be found
4. Setting-up Controls:
Autocontrol - patients serum + own cells
(+) Autocontrol, Incompatible crossmatch:
: due to laboratory problem
a. rouleaux formation
b. presence of autoantibodies/non-specific
agglutinins
5. Crossmatch more donors:
detect % of incompatible donors
establish the cause of specific Ab
 Causes of Positive in the Major Crossmatch:

1. Incorrect ABO grouping of the patient or donor:

ABO grouping should be repeated especially if
strong incompatibility is noted in reading taken after
IS. Samples that bears undisputable identity with the
original patient sample and the donor bag should be
used for testing.
2. An alloantibody in the patients serum reacting with
the corresponding antigen on donor red cells.
The auto-control tube will be negative unless the
patient has recently received incompatible cells in the
transfusion.
 if the antibody screening test is positive, panel
studies should allow identification of antibody
specificity, which then permits selection of units
lacking the offending antigens for compatibility
testing.
a. If red cells of all donors tested are incompatible with
the patients serum and the antibody screening test
is positive, suspect either an antibody directed
against an antigen of high incidence or multiple
antibodies in the patients serum.
Consults a reference lab if you are unable to
identify the specificity. (if the patient has ABO-
compatible siblings, they may lack the antigen/s to
which the patient has been sensitized and may be
b. If the antibody screening test is negative and only one donor
is incompatible, an antibody in the patients serum may be
directed against an antigen of relatively low incidence that is
present on the donors red cells. Panel studies on the patients
serum are usually non-informative, and identification of an
antibody is academic of other compatible units are easily
located.

c. If the antibody test is negative, the patients serum may

contain either naturally occurring antibodies (anti-A1) or
passively acquired agglutinins. Passive acquisition of anti-A,
anti-A,B may occur after transfusion of non-ABO specific blood
produces (platelets) or by organ (liver) or bone marrow
transplantation. Checking the serum grouping result to confirm
the presence of an unexpected reaction with A1 cells and or
checking the patients transfusion and transplant histories is
helpful in the investigation of the cases.
 3. An autoantibody in the patients serum reacting
with the corresponding antigen on donor red cells.
The autocontrol tube will be (+). The antibody screening
test and tests of the PS and DCs will show (+) results. Most
of the antibodies have specificity for antigens of relatively
high incidence.
Panel and adsorption studies are important to assess
whethe rthe underlying alloantibodies are also present
Techniques for the management of patients with
autoantibodies include autoadsorption of the patients
serum to remove the autoantibody activity
Compatibility testing could be performed using the
autoadsorpbed serum
4. Prior coating of the donor red cells with protein,
resulting in a (+) AHG test:
If one isolated (+) result is obtained, a DAT should be
performed on the donors red cells
Donor cells that demonstrate a (+) DAT will be
incompatible with all recipients tested in then AHG phase,
because the cells already coated with immunoglobulins
and/or complement

5. Abonormalities in the patients serum:

a. Imbalance by the normal ratio of albumin and gamma
globulins( A/G ratio) as in diseases such as myeloma and
macrglobulinemia, may cause the red cells to stick together
on their flat sides, giving the appearance of stacks of coins
when viewed microscopically --- roulleaux formation.
b. The presence of high molecular-weight dextrans or other
plasma expanders may cause false (+) results in compatibilty
testing and other tests. In scenarios in which the plasma
expanders interfere, all tests, including the autocontrol are
generally affected equally.
Saline replacement may be useful to resolve the problem.

c. An antibody against additives in the albumin reagents

may cause false positive results in the compatibility tests.
This occurs when the patient has antibodies to the
stabilizing substances such as caprylate, added to the
albumin reagents.
Thus, caprylate free albumin should be used in the testing