Transfusion Medicine, 2006, 16, 375–379
CASE REPORT
Repeat ABO-incompatible platelet transfusions leading to
haemolytic transfusion reaction
D. T. Sadani,* S. J. Urbaniak,† M. Bruce‡ & J. E. Tighe§ *National Blood Service, Leeds, †Academic Transfusion
Medicine Unit, Scottish National Blood Transfusion Service, Aberdeen, ‡Scottish National Blood Transfusion Service, Edinburgh, and §Department of
Haematology, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
Received 27 November 2005; accepted for publication 21 May 2006
SUMMARY. A 65-year-old woman, blood group A
RhD positive, who had completed her first course of
induction chemotherapy for acute myeloid leukaemia
was transfused with apheresis platelets over a number
of days.
On three occasions she received group O RhD
positive units, which had been screened and found not
to contain high-titre anti-A,B isoagglutinins. Follow-
ing the third unit, she developed a haemolytic trans-
fusion reaction and died soon thereafter. This has led
to change in policy of the supplying centre in testing for
Platelet transfusions play an important role in
managing patients with thrombocytopenia, especially
in those who have secondary marrow failure, e.g. post-
chemotherapy. However, the demand for platelet
transfusions is increasing and because of the limited
shelf-life of platelets, most transfusion centres find it
difficult to provide ABO-compatible platelets at all
times (Murphy, 1988).
ABO-incompatible platelet transfusions have been
shown to have varied outcomes in cases of a major
mismatch, i.e. group A or B platelets to O recipients.
In some cases reduction in the platelet increment is
seen (Duguesnoy et al., 1979; Heal et al., 1987),
whereas in others minor or little differences in post-
transfusion increments are seen (Lin et al., 2002).
Minor ABO-incompatible platelet transfusions, how-
ever, i.e. group O platelets to group A or B patients,
have infrequently been reported to cause a severe
haemolytic transfusion reaction due to the presence
Correspondence: DT Sadani, MBBS, MD, DTM, CTM, MRCPath,
National Blood Service - Leeds, Bridle Path, Leeds, LS15 7TW,
United Kingdom.
Tel.: 144113 2148648; fax: 144113 2148696;
e-mail: deepak.sadani@nbs.nhs.uk
# 2006 Blackwell Publishing Ltd
doi: 10.1111/j.1365-3148.2006.00684.
high-titre anti-A,B isoagglutinins. Blood group O
apheresis platelets and fresh-frozen plasma units are
now labelled as high titre with a cut-off of 1/50 as
compared to the previous cut-off of 1/100 for anti-A,B
isoagglutinins. A universal approach to testing dona-
tions for high-titre anti-A,B isoagglutinins, better
compliance of guidelines and monitoring of patients
is necessary.
Key words: apheresis platelets, isoagglutinin, trans-
fusion reaction.
of high-titre anti-A or anti-B in the donor plasma
(Lozano & Cid, 2003). The two major factors
determining the likelihood of the transfusion reac-
tions in these circumstances are the amount of plasma
in minor incompatible platelet transfusions and the
titre of anti-A,B isoagglutinins (Larsson et al., 2000).
There is variation in local, national and interna-
tional policies on a number of issues related to this
problem (Reesink, 2005). Firstly, the cut-off of
labelling high-titre anti-A,B isoagglutinins in Ôuniver-
sal group O donorsÕ is not agreed upon. Secondly, the
best method to measure these titres is also debated
and the different blood services in the UK have their
own policies for measuring these titres. Thirdly,
a policy on limiting multiple incompatible trans-
fusions and testing for evidence of haemolysis in
patients receiving such incompatible transfusions does
not exist in all centres transfusing platelets.
A case of acute myeloid leukaemia is discussed, in
which the patient received platelet transfusion support
during induction chemotherapy. She developed a
severe haemolytic reaction following transfusion of
one apheresis unit of platelets, which was minor ABO
group incompatible.
375
376 D. T. Sadani et al.
CASE REPORT
A 65-year-old woman presented with complaints of
progressive tiredness, generalized aches, headaches
and weakness developing over a period of 6 months.
A routine full blood count revealed pancytopenia,
with red cell anisopoikilocytosis, including tear
drops, macrocytes, contracted burr red cells and a
population of myeloblasts. A bone marrow aspirate
confirmed a diagnosis of acute myeloblastic leukae-
mia without maturation. Her blood was grouped as A
RhD positive and she was transfused red cells. She
was entered in to the Medical Research CouncilÕs
AML-14 trial.
She tolerated her first cycle of induction chemother-
apy well apart from an episode of diarrhoea during
the neutropenic phase. She was treated with broad-
spectrum antibiotics, including gentamicin as well as
granulocyte colony-stimulating factor. She required
regular prophylactic units of platelets for severe
thrombocytopenia.
In the 11 days following her chemotherapy, she
received a total of five apheresis packs of platelets,
three of which were minor ABO group incompatible.
Following the fifth unit of platelets, she was once again
noted to be anaemic. Clinically, no transfusion
reactions had been reported. A sample was sent to
the local blood transfusion services with a request for
three units of packed red cells. Serological investiga-
tion of this post-transfusion sample documented the
presence of anti-A in reverse grouping. A direct
antiglobulin test (Alba Bioscience, Edinburgh, UK)
was positive: IgG111 C31 and her cells were auto-
reactive with her own plasma. IgG-reacting anti-A
isoagglutinin was eluted from her red cells.
Overnight, the patient developed haemoglobinuria
and jaundice. The next day a repeat comparison of
blood samples before and after the last platelet
transfusion revealed gross haemolysis and a haemo-
globin of 39 g L21. Urine examination confirmed
haemoglobinuria (Table 1). The differential diagnosis
Table 1. Pre- and post-transfusion laboratory results in the recipient of the minor ABO-incompatible platelet transfusions
reflecting changes associated with an acute haemolytic transfusion reaction
Haemoglobin (NR: 120–160 g L21)
Haematocrit (NR: 0
37–0
47)
Bilirubin (NR: 1–22 mmol L21)
Lactate dehydrogenase (NR: 10–250 U L21)
Urea (NR: 3
4–7
0 mmol L21)
Creatinine (NR: 60–110 mmol L21)
NR, normal range.
considered at this stage included neutropenic sepsis,
drug-induced haemolysis, microangiopathic haemo-
lytic anaemia and autoimmune haemolytic anaemia.
With a possibility of the latter diagnosis, she was
started on steroids. However, she proceeded to develop
acute renal failure requiring haemodialysis. The pos-
sibilities considered at this stage included gentamicin
toxicity, although the gentamicin levels had consis-
tently been in the therapeutic range, and an acute
haemolytic transfusion reaction, although the three
units of O RhD positive platelets that had been trans-
fused in this period had all met the requirements of
having low-titre anti-A.
The implicated platelet apheresis unit had been
tested for the presence of anti-A,B isoagglutinins
using an automated blood group analyser (Olympus
PK7200; Olympus Life and Material Science Europa
GMbH, Hamburg, Germany). This detects the pre-
sence or absence of high-titre anti-A,B isoagglutinins
by direct agglutination test using a single dilution of 1/
100 with A1 and B cells (Alba Bioscience, Edinburgh,
UK). The unit was cleared for issue with no Ôhigh-titre
anti-A,B isoagglutininsÕ label. Subsequent repeat
individual investigations done on the retained sample
from the implicated platelet pheresis unit included
testing in serial doubling dilutions with A1 cells. This
revealed a consistent recognizable reaction of grade 2
(¼single plus) at dilution of 1/128, which is considered
equivalent to 1/100 dilution on the automated blood
group analyser (MacLennan, 2002) (Table 2). As the
repeat testing showed borderline results for cut-off in
labelling the unit as being high titre, more tests were
done.
To further delineate the IgM component of the anti-
A, direct agglutination and indirect antiglobulin tests
using dithiothreitol (DTT) were performed. DTT
abolishes both agglutinating and complement-binding
activities of the IgM isoagglutinins. Direct agglutina-
tion results on DTT-treated plasma suggested that the
directly agglutinating IgG 1 IgM combined were of
high concentration showing an end-point of 1/160;
Pre-transfusion Post-transfusion (2 days later)
77 39
0
24 0
12
21 68
124 2157
4
7 22
3
43 131
# 2006 Blackwell Publishing Ltd, Transfusion Medicine, 16, 375–379
 Repeat ABO-incompatible platelet transfusions 377

Table 2. Serial dilution of plasma from the implicated platelet unit tested against A1 red cells indicating the presence of anti-A
in a reproducible titre of 1/128 at both room temperature and 37 °C

Dilution factor, 1 in:

1 2 4 8 16 32 64 128 256 512 1024

Concentrated A1 red cells (5%)

15 min RT spin 5 5 5 5 5 5 4 2 2 1 0
30 min 37° spin 5 5 5 5 5 4 2 1 0 0 0
Alba Bioscience A1 red cells (2–3%)
15 min RT spin 5 5 5 5 5 4 3 2 1 0 0
30 min 37° spin 5 5 5 5 5 5 3 2 1 1 0

the IgG component alone was of low concentration
(1/20 ¼ reliable end-point) (Table 3). In indirect anti-
globulin tests the last dilution at which both gave a
single plus (grade 2) reaction was 1/640. However, as the
DTT-treated sample gave such a reaction at 1/1280,
this was considered as the end-point. IgG 1 IgM were
thus present at a titre of 1/640 in the indirect anti-
globulin test, whereas IgG alone was at 1/1280,
indicating potentially significant amounts of antibody
in the implicated unit.
The empty platelet pack had been discarded by then
and was not available for culture. Cultures taken from
the patient herself before and after the episode
remained negative for aerobic and anaerobic organ-
isms. She remained severely pancytopenic and died of
a suspected fatal central nervous system bleed on day
54 post-diagnosis of leukaemia and 18 days after the
last ABO-incompatible unit of platelets had been
transfused.
DISCUSSION
For transfusion of red cells, ABO compatibility is
of prime importance as a mismatch will result in
potentially lethal complications. However, in contrast,
Table 3. Anti-A concentration from the implicated platelet
unit showing an IgG direct agglutination titre of 1/160
without and 1/20 on DTT treatment (IgG); with an IgM
indirect titre of 1/640 and a DTT-treated titre of 1/1280
Dilution factor, 1 in:
10 20 40 80 160 320 640 1280 2560 5120
Direct agglutination
Untreated 5 5 4 2 2 1 0 0 0
DTT treated NT 2 1 0 0 0 0 0 0
Indirect antiglobulin
Untreated 5 5 4 4 3 2 2 1 0
DTT treated NT 5 5 4 4 2 2 2 1
NT, not tested.
# 2006 Blackwell Publishing Ltd, Transfusion Medicine, 16, 375–379
ABO-incompatible platelet transfusions are consid-
ered less critical, although platelets bear ABO blood
group antigens and the plasma contained in platelet
concentrates results in passive transfer of anti-A or
anti-B isoagglutinins (Heal et al., 1989). Mair &
Benson (1998) have estimated the risk of clinically
significant acute haemolysis as 1 per 46 176 platelet
transfusions or 1 per 9000 minor ABO-mismatched
platelet transfusions. Moreover, there is acceptance
that the rate of under-recognition and/or under-
reporting of this complication is probably very
significant (Lozano & Cid, 2003). There are a number
of single case reports (Zoes et al., 1977; McLeod et al.,
1982; Conway & Scott, 1984; Pierce et al., 1985;
Ferguson, 1988; Reis & Coovadia, 1989; Murphy et al.,
1990; McManigal & Sims, 1999; Valbonesi et al., 2000;
Larsson et al., 2000) in the literature. In all these case
reports, the minimum titres reported were 1/128 in
saline at room temperature and 1/256 by Anti-Human
Globulin method. Mollison et al. (1993) quote two
studies done in the 1940s where plasma infusions
identified titres above 1/512 present in about 40% and
1/640 present in 23% of normal group O donors
causing haemoglobinaemia. Thus, levels above which
donors were recognized as being Ôdangerous universal
donorsÕ were designated as being Ôabove 1/128 in
serum or plasma of group O donors when tested with
A1 and B red cell samplesÕ as was set out in the third
edition of the Guidelines for the Blood Transfusion
Services in the United Kingdom (1994). There was no
stipulation of the method and the amendment in 1999
recognized the lack of consensus on this issue. Hence,
the guideline was changed to a requirement that each
donation testing laboratory should have in place
a testing and issuing policy which would avoid the
0 transfusion of blood from high-titre anti-A and/or
0
anti-B donors to non-group O recipients, without
giving guidance on the testing procedure itself
0
(MacLennan, 2002).
0
Similarly, although the ÔGuidelines for administra-
tion of blood products: transfusion of infants and
378 D. T. Sadani et al.
neonatesÕ (British Committee for Standards in Hae-
matology, Blood Transfusion Task Force, 1994)
recognized the hazard of transfusing large volumes
of incompatible plasma in these subjects, it also failed
to provide guidance as to the methodology of
determining units which are of low risk of causing
haemolysis due to anti-A or -B. These guidelines
updated recently only mention that incompatible
plasma and platelets should lack high-titre anti-A/
anti-B (British Committee for Standards in Haematol-
ogy, Blood Transfusion Task Force, 2004). Blood
collection and processing centres in the UK have
replaced manual detection by automating the blood
grouper to identify donations with haemolysins above
1/100 as this has been widely regarded as equivalent to
the manual 1/128 titre. Josephson et al. (2004), after
observing two cases of acute haemolysis following
infusion of O single-donor platelets to group A
patients, did a prospective study to find the incidence
and do a rough cost-benefit analysis. This study
suggested a cut-off titre of 1/64 for IgM and
1/256 for IgG isoagglutinins in platelet concentrates.
The above case highlights the limitations of testing
plasma with a single dilution cut-off of 1/100. The
Scottish National Blood Transfusion Service had at
the time of the reaction used this cut-off in direct
agglutination tests to define Ôhigh titre anti-A,BÕ. This
level has been subsequently brought down to 1/50 and
all units above this level are labelled as high titre. The
unit had been screened using a single-dilution method
as positive or negative reaction and had been found to
be Ôlow titreÕ. The difficulty in consistently detecting
haemagglutination at the limit of its detection (as in
this unit) is well recognized. To compare this with
serial dilution, titration is further fraught with prob-
lems as a sample which gave a potency result of
1/128 in a doubling dilution series would probably give
a negative result when directly diluted to 1/128, as has
happened in this particular unit.
Other than testing for anti-A titres, further steps to
reduce the incidence of acute haemolytic transfusion
reactions could involve the reduction of the volume of
incompatible plasma. Substituting this plasma with
platelet additive solution is one viable option. Reduc-
ing the amount of plasma by substituting it with AB
plasma increases donor exposure, and washing the
platelets and resuspension in saline leads to a 35% to
55% loss of platelets and may increase platelet
requirement. Limiting the issue of platelets to type
specific rather than type compatible will put further
pressure on a stressed inventory management system
associated with the limited 5-day storage period.
Patients who are being given ABO-type-incompatible
platelets need to be monitored on a regular basis by
determination of the DAT. This can be done by
looking for any evidence of haemolysis in the recipient
and a limit defined as to the number of incompatible
units, which could be issued over a period of time.
Also, better compliance with guidance regarding ABO
compatibility of platelet transfusions (British Com-
mittee for Standards in Haematology, 2003) should
help minimize the risk of severe haemolysis as has
occurred in this instance.
This was the first documented case of haemolysis
resulting from a minor mismatched platelet trans-
fusion in the Aberdeen Centre out of an annual issue
rate of around 1500 units of platelets, of which
approximately 10% are ABO incompatible. An
international forum (Reesink, 2005) highlights aware-
ness but uncovers differences in measures taken to
prevent this rare occurrence across various countries.
It is imperative that consensus is reached for universal
testing of all blood products containing high-titre anti-
A,B plasma. This can be achieved by designating
a single cut-off value of 1/128 and providing suitable
standards for validation. The Standing Advisory
Committee on Immunohaematology for the UK
Blood Transfusion Services is in the process of
developing such standards (S. MacLennan, pers.
comm., National Blood Service, Leeds). In addition,
a conscious move away from using non-identical ABO
group plasma/platelets should be considered and more
recruitment of group A donors initiated.
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