ABO Typing Discrepancies

Jayme Heimonen MT(ASCP)SBB

Blood Bank Technical Specialist
Borgess Medical Center
Kalamazoo, MI

ASCLS-Michigan 2016

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 ABO Typing Discrepancies
• Expected reactions are missing

Anti-A Anti-B Anti-D Co A1 Cells B Cells

4+ 0 4+ 0 0 0

Anti-A Anti-B Anti-D Co A1 Cells B Cells

0 0 4+ 0 0 3+

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 ABO Typing Discrepancies
• Unexpected reactions are present.

Anti-A Anti-B Anti-D Co A1 Cells B Cells

4+ 0 4+ 0 2+ 4+

Anti-A Anti-B Anti-D Co A1 Cells B Cells

4+ 2+ 4+ 2+ 0 4+

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 ABO Typing Discrepancies
• Reactions are weaker than expected.

Anti-A Anti-B Anti-D Co A1 Cells B Cells

1+ 0 4+ 0 0 4+

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 ABO Typing Discrepancies
First Steps;
• Always repeat the testing in all tubes or
microtubes, following your SOPs and the
manufacturers product insert.
• Repeat using washed cells (at least 3 times).
• Observe tube testing reactions microscopically
if possible.
• Obtain the patient’s history including age,
transfusion history and diagnosis.
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 ABO Typing Discrepancies
Next steps:
• Evaluate the reactions in the forward and
reverse typing to determine which type is
most convincing.
• Remember: Forward type tests the antigens
on the cells. Reverse type test the antibody in
the plasma.
• Determine what ABO group to crossmatch for
the patient.
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 ABO Typing Discrepancies
What can lead to forward type discrepancies?
• Transfusions with other ABO types
• Weak Subgroups
• Mixed cell population (HSCT)
• Certain disease states
• Rouleaux

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 ABO Typing Discrepancies
Example with Transfusions
***Expected reaction is missing
Anti-A Anti-B Anti-D Co A1 Cells B Cells
4+ 0*** 4+ 0 0 0

AB patient massively transfused with Group: A

red blood cells.

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 ABO Typing Discrepancies
Group: AB patient massively transfused with
Group: A red blood cells.
• Phone call to other hospital where
transfusions were administered. Have they
typed a pre-transfusion specimen?
• Observe reactions microscopically(tube
testing)-may see weak reactions with patient’s
cells and anti-B.
• Transfuse with Group: AB, A, B or O cells
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 ABO Typing Discrepancies
Weak subgroups
***Expected reaction is missing
Anti-A Anti-B Anti-D Co A1 Cells B Cells
0*** 0 4+ 0 0 3+
Weak subgroup of A such as Am
• Adsorption/elution.
• Secretor testing.
• Transfusion with Group: O red blood cells.

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 ABO Typing Discrepancies
Mixed cell population
***Expected reaction is weaker
Anti-A Anti-B Anti-D Co A1 Cells B Cells
1+*** 0 4+ 0 0 3+

Group: O patient who received a Group: A

HSCT in last 30 days.

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 ABO Typing Discrepancies
Group: O patient who received a Group: A HSCT in last
30 days.
• Call the Blood Bank of the transplant hospital for
their transfusion guidelines.
• Transfuse Group: O red blood cells until there is
evidence marrow has engrafted.
• Transfuse Group: A plasma product to be compatible
with newly produced red blood cells.
• Transfuse irradiated blood products.

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 ABO Typing Discrepancies
Disease states such as acute myeloid leukemia
and other cancers with chemotherapy.
***Expected reaction is weak
Anti-A Anti-B Anti-D Co A1 Cells B Cells
0 1+*** 4+ 0 3+ 0
• Previous typing history.
• Enhance agglutination.
• Adsorption/elution.

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 ABO Typing Discrepancies
Disease states such as warm autoimmune
hemolytic anemia
***unexpected reaction
Anti-A Anti-B Anti-D Co A1 Cells B Cells
4+ 2+*** 4+ 2+*** 0 4+
• Spontaneous agglutination-cells coated with high
concentration of warm autoantibodies.
• Perform direct antiglobulin test.
• Always give Group: O blood until discrepancy is
resolved.

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 ABO Typing Discrepancies
Disease states such as Cold Hemagglutinin
disease
Anti-A Anti-B Anti-D Co A1 Cells B Cells
4+ 3+ 4+ 3+ 0 4+
• Incubate type at 37oC.
• Wash cells in 37oC saline.
• Prewarm reagents and serum/plasma.

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 ABO Typing Discrepancies
Rouleaux
Anti-A Anti-B Anti-D Co A1 Cells B Cells
4+ 2+ 2+ 2+ 2+ 4+
Microscopically observe cells as a stacked coin
retractile appearance:
Anti-A Anti-B Anti-D Co A1 Cells B Cells
4+ R R R R 4+
• Saline replacement.

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 ABO Typing Discrepancies
What can lead to reverse type discrepancies?
• Weak or missing antibodies.
• Extra antibodies.
• Transfusion.
• Bone Marrow recipient.
• Rouleaux.

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 ABO Typing Discrepancies
Weak or missing antibodies
***Expected reaction missing
Anti-A Anti-B Anti-D Co A1 Cells B Cells
4+ 0 4+ 0 0 0***
Elderly patient with low anti-B titer
• Incubate all tubes including autocontrol at room
temperature for 30 min or 4oC.
• Increase serum/plasma to cell ratio.
• Increase incubation time.
• Transfuse with Group: A red blood cells.
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 ABO Typing Discrepancies
Weak or missing antibodies
***Expected reaction missing
Anti-A Anti-B Anti-D Co A1 Cells B Cells
0 4+ 4+ 0 0*** 0
Increased antibody concentration where
antibody exhibits prozoning.
• Perform isohemagglutinin titer.

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 ABO Typing Discrepancies
Atypical antibodies
***Unexpected reaction present
Anti-A Anti-B Anti-D Co A1 Cells B Cells
4+ 0 4+ 0 2+*** 0
Weak subgroup of A with anti-A1 present.
• Type patient’s cells with A1 lectin.
• Test patient’s serum/plasma with cells lacking A1
antigen (such as A2 cells).
• Perform antibody identification for anti-A1.
• Transfuse Group: A cells lacking A1 antigen or Group:
O cells.

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ABO Typing Discrepancies

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 ABO Typing Discrepancies
Atypical antibodies
***Unexpected reaction present
Anti-A Anti-B Anti-D Co A1 Cells B Cells
4+ 0 4+ 0 2+*** 0
Patient with alloantibody (anti-M, Anti-N, anti-
P1, anti-Lea or anti-Leb).
• Perform antibody identification procedures.
• Test patient with A1 cell lacking antigen.

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ABO Typing Discrepancies

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ABO Typing Discrepancies

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ABO Typing Discrepancies

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ABO Typing Discrepancies

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ABO Typing Discrepancies

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 ABO Typing Discrepancies
Transfusion
***Unexpected reaction
Anti-A Anti-B Anti-D Co A1 Cells B Cells
4+ 4+ 4+ 0 0 3+***
Group AB patient transfused with Group O
cryoprecipitate.

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 ABO Typing Discrepancies
Hematopoietic stem cell recipient

Anti-A Anti-B Anti-D Co A1 Cells B Cells

0 1+ 4+ 0 0 1+
Group: A recipient transplanted with Group: B
donor at day 56
• Contact the transplant hospital and get their
guidelines for transfusion of packed red cells and
plasma products.

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