ORIGINAL RESEARCH
The evanescence and persistence of RBC alloantibodies
in blood donors
Ronald G. Hauser,1,2 Denise Esserman,3 Matthew S. Karafin ,4,5 Sylvia Tan,6 Raisa Balbuena-Merle ,1,2
Bryan R. Spencer,1,7 Nareg H. Roubinian ,8,9 Yanyun Wu ,1,10 Darrell J. Triulzi,11 Steve Kleinman,12
Jerome L. Gottschall,4,5 Jeanne E. Hendrickson ,1,13 Christopher A. Tormey ,1,2
(for the NHLBI Recipient Epidemiology and Donor Evaluation Study-III (REDS-III))
BACKGROUND: Blood donors represent a healthy
population, whose red blood cell (RBC) alloantibody
persistence or evanescence kinetics may differ from
those of immunocompromised patients. A better
understanding of the biologic factors impacting antibody
persistence is warranted, as the presence of
alloantibodies may impact donor health and the fate of
the donated blood product.
METHODS: Donor/donation data collected from four US
blood centers from 2012 to 2016 as part of the Recipient
Epidemiology and Donor Evaluation Study-III (REDS-III)
were analyzed. Clinically significant antibodies from
blood donors with more than one donation who
underwent at least one follow-up antibody screen after
the initial antibody identification were included. Of
632,378 blood donors, 481 (128 males and 353 females)
fit inclusion criteria.
RESULTS: Antibody screens detected
562 alloantibodies, with 368 of 562 (65%) of antibodies
being persistently detected and with 194 of 562 (35%)
becoming evanescent. Factors associated with antibody
persistence included antibody specificity, detection at the
first donation, reported history of transfusion, and
detection of multiple antibodies concurrently. Anti-D, C,
and Fya were most likely to persist, while anti-M, Jka,
and S were most frequently evanescent.
CONCLUSIONS: These data provide insight into
variables impacting the duration of antibody detection,
and they may also influence blood donor center policies
regarding donor recruitment/acceptance.
R
ed blood cell (RBC) alloantibodies are clinically sig-
nificant in the transfusion setting, with substantial
blood bank resources dedicated to completing RBC
antibody screens and to identifying RBC antibodies
ABBREVIATIONS: REDS-III = Recipient Epidemiology and Donor
Evaluation Study-III.
From the 1Yale University, Department of Laboratory Medicine, the
3
Department of Biostatistics, Yale School of Public Health, the
13
Department of Pediatrics, Yale University, New Haven,
2
Department of Pathology & Laboratory Medicine Service, Veterans
Affairs Connecticut Healthcare System, West Haven, Connecticut;
the 4Versiti, the 5Department of Pathology & Laboratory Medicine,
Medical College of Wisconsin, Milwaukee, Wisconsin; the 6RTI
International, Rockville, Maryland; the 7American Red Cross
Scientific Affairs, Dedham, Massachusetts; the 8Department of
Laboratory Medicine, University of California, the 9Blood Systems
Research Institute, San Francisco, California; the 10Bloodworks
Northwest, Seattle, Washington; the 11University of Pittsburgh and
Vitalant, Pittsburgh, Pennsylvania; and the 12Department of
Pathology and Laboratory Medicine, University of British Columbia,
Vancouver, British Columbia, Canada.
Address reprint requests to: Christopher A. Tormey, MD,
333 Cedar Street, PO Box 208035, New Haven, CT 06520; e-mail:
christopher.tormey@yale.edu.
Funding/Support: The authors were supported by research
contracts from the National Heart, Lung, and Blood Institute
(NHLBI Contracts HHSN2682011000002I, HHSN2682011000003I,
HHSN2682011000004I, HHSN2682011000005I, and
HHSN268201100006I) for the Recipient Epidemiology and Donor Eval-
uation Study-III (REDS-III). The funding source designated an
investigator-led steering committee, which independently oversaw the
design and conduct of the study; collection, management, analysis,
and interpretation of the data; preparation, review, and approval of the
manuscript; and decision to submit the manuscript for publication.
Received for publication November 17, 2019; revision received
January 30, 2020, and accepted January 30, 2020.
doi:10.1111/trf.15718
© 2020 AABB
TRANSFUSION 2020;9999;1–9
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HAUSER ET AL.

in patients.1 Though most antibodies do not lead to adverse

transfusion outcomes, some may substantially delay the provi-
sion of compatible RBC units, thereby impacting patient care.
On occasion, acute and delayed hemolytic transfusion reac-
tions occur despite antibody screening and crossmatch
policies,2,3 due in part to previously formed RBC alloantibodies
falling below the level of detection by transfusion services.2,4
This property, referred to as alloantibody evanescence, has
been primarily studied in transfused patients, including
patients with general disorders as well as those with chronic
transfusion needs such as sickle cell disease.2,4–8 In such
groups, antibody disappearance rates have ranged from 30% to
80%, with testing over longer time periods being associated
with a higher likelihood of the antibody falling below the level
of detectability.9
Although alloantibody evanescence rates have been
established among patient populations, the rates of antibody
evanescence in healthy allogeneic blood donors are not well
established. Evanescence in patients may demonstrate differ-
ent kinetics than in blood donors through modifications of
their immune system, due in part to aging and/or to underlying
disease or concomitant therapies. Medications given to
patients may also impact antibody detection and durability.
Moreover, the alloimmunization event (e.g., transfusion as
compared to pregnancy) may influence an antibodyʼs
evanescence.10
For these reasons, we studied antibody evanescence
among blood donors in the REDS-III blood donor database.
This database, established in 2012 and consisting of data from
four geographically diverse blood centers across the United
States, provides an opportunity to investigate RBC antibody
evanescence (and epidemiologic associations) in blood
donors. Since AABB Standards require that serum or plasma
from blood donors be tested for unexpected antibodies to RBC
antigens,11 essentially all US blood donors (including those in
this database) undergo RBC antibody screening with each
donation. In addition, this REDS-III donation database allows
the unique opportunity to investigate exposure history, includ-
ing reported past transfusions or pregnancies. Using this
database, we have now established the rates and properties of
non-ABO alloantibody persistence and evanescence in a study
population healthy enough to donate blood and have identi-
fied associations between clinical or biologic factors and anti-
body fates.
STUDY DESIGN AND METHODS
Study population
The data from this observational study comes from the REDS-
III blood donor/donation database, a data set collected from
four geographically diverse US blood centers located in Califor-
nia, Connecticut, Pennsylvania, and Wisconsin.12 In total, the
entire data set contains donor information on 632,378 blood
Fig. 1. Determination of study population.
donors, who donated 2,045,204 units from 2012 to 2016
(Fig. 1).12
Eligible blood donors had common, established clinically
significant RBC alloantibody(ies) (“antibody”) identified:
anti-D, -C, -c, -E, -e, -Jsa, -K, -k, -Jka, -Fya, -M (IgG), -S, and -s.
Other antibodies, including many that were clinically signifi-
cant, were also identified; those with few occurrences (≤1% of
all antibodies) were grouped into an “other” antibody category,
which included anti-Wra, -Cw, -Cob, -Lua, -Kpa, -Jkb, -V, -U,
-Yka, -Kna, -Kpb, -LW, -Ge2, -Bg. High-titer, low-avidity and
low-incidence antibodies were also grouped into “other,” with
no further data availability to subspecify these alloantibodies.
As in previous studies, warm autoantibodies, cold autoanti-
bodies, cold reactive immunoglobulin M class alloantibodies,
and nonspecific antibodies were excluded.12,13 Methodologies
for antibody screening and determination of antibody specific-
ity varied by blood center. For example, blood centers used
solid phase (two centers), gel card (one center), and enhanced
tube (one center) antibody screening platforms.12
The present studyʼs focus on antibody evanescence
necessitated that eligible blood donors have two or more
qualifying donations. Each qualifying donation involved a
successful blood donation and antibody screen. The detec-
tion of a clinically significant alloantibody had to occur
before the last donation, to determine if the antibody eva-
nesced or persisted over time.
Of note, each participating study site had slightly differ-
ent approaches for future donations from donors with a
positive antibody screen, including the following practices:
one site notifying donors only of their antibody status; one
site permanently deferring donors only for subsequent
plasma/platelet donations (and not for whole blood, RBC,
or granulocyte collections); one site performing no

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 RBC ANTIBODY EVANESCENCE IN BLOOD DONORS

permanent deferrals or selection of products that can/-
cannot be donated but determining eligibility subsequently
on a case-by-case basis; and one site deferring donors for
1 year after their first positive RBC antibody result. No sites
had a permanent RBC donor deferral policy after one posi-
tive antibody screen, and no sites had a deferral policy that
was based on the antibody specificity detected in the donor.
Overall, the majority of participating sites allowed for subse-
quent donations of at least whole blood products for donors
with a positive antibody screen.

TABLE 1. Description of the donor population

analyzed
Age* 54.2 (14.9) Study design
Sex, n (%)
We designed the study as a survival analysis with the primary
Female 353 (73)
Male 128 (27) outcome as the time to antibody evanescence. Covariates
Race, n (%) included donor characteristics (i.e., age, sex, race, ethnicity,
White 389 (81)
parity, transfusion history) and the alloantibodyʼs specificity. A
Other/unknown 83 (17)
Black 7 (1) covariate to denote if the antibody was detected at the first
Asian 2 (0) donation was added. Another covariate denoted if the first
Ethnicity, n (%)
detection of the antibody coincided with the first detection of
Non-Hispanic 476 (99)
Hispanic 5 (1) one or more other antibodies.
Self-reported history of pregnancy for females, n (%) After an alloantibody was reported, we tracked its persis-
Yes 284 (80)
tence or evanescence in subsequent donations. Donations with
No 69 (20)
Self-reported history of transfusion, n (%) a positive antibody screen before the determination of an anti-
Yes 158 (33) bodyʼs specificity were excluded. If a blood center reported a
No 267 (56)
positive antibody screen after a donation with a confirmed
Unknown 56 (12)
Antibody detected at first donation, n (%) antibody specificity but did not report the specificity at the sub-
Yes 365 (65) sequent donation, the antibody specificity identified previously
No 197 (35)
was assumed to remain present. Antibody evanescence
Multiple antibodies detected concurrently, n (%)
Yes 170 (30) occurred when a subsequent donation had 1) a negative screen
No 392 (70) for all antibodies originally identified or 2) a positive screen
Antibody specificity, n (%)
without the original antibody specificity reported when other
Anti-E 138 (25)
Anti-K 110 (20) specificities were reported. The antibody was administratively
Anti-D 88 (16) censored, a term used in survival analysis to indicate that the
Anti-M 62 (11)
antibody persisted throughout all available donations, if on the
Anti-C 40 (7)
Anti-Fya 32 (6) donorʼs last donation 1) the antibody continued to be reported
a
Anti-Jk 22 (4) or 2) a positive antibody screen was reported without a speci-
Anti-c 18 (3)
ficity reported, under the conditions described above.
Anti-S 15 (3)
Anti-Cw 3 (1) The donorʼs age, sex, race, and ethnicity were recorded.
b
Anti-Fy 3 (1) For each donation, the donorʼs transfusion history, number of
Anti-HTLA 3 (1)
pregnancies, and antibody specificity were recorded. If the
Anti-LOW 3 (1)
Anti-Wra 3 (1) information did not exist for a donation, the information was
Anti-Cob 2 (<1) inferred from the donorʼs response across other available
Anti-G 2 (<1)
donations.
Anti-Jkb 2 (<1)
Anti-k 2 (<1)
Anti-Kpa 2 (<1)
Anti-Lua 2 (<1)
Anti-V 2 (<1)
Anti-Bg 1 (<1)
Anti-e 1 (<1) TABLE 2. Donors by the number of persistent/
Anti-Ge2 1 (<1) evanescent antibodies
Anti-Kna 1 (<1) Donors with a persistent antibody 301
Anti-Kpb 1 (<1) 1 persistent antibody 247
Anti-LW 1 (<1) 2 persistent antibodies 47
Anti-U 1 (<1) ≥3 persistent antibodies 7
Anti-Yka 1 (<1) Donors with an evanescent antibody 181
Continuous variables are shown as mean (standard deviation). 1 evanescent antibody 169
Categorical variables are displayed as counts. Number of unique 2 evanescent antibodies 11
donors = 481. Number of unique donor antibodies = 562. ≥3 evanescent antibodies 1
* Since age could change between donations, a donorʼs age * 1 donor had one persistent and one evanescent antibody.
was calculated as the average age across donations. Number of unique donors = *481.

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 HAUSER ET AL.

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TABLE 3. Antibody specificity by persistence or evanescence in female or male blood donors
Persistent* Evanescent* Total Total Persistent Persistent Evanescent Evanescent
Total (%) (%) female male female† (%) male† (%) female† (%) male† (%)
Antibody Anti-E 138 85 (61.6) 53 (38.4) 102 36 63 (61.8) 22 (61.1) 39 (38.2) 14 (38.9)
specificity Anti-K 110 83 (75.5) 27 (24.5) 73 37 55 (75.3) 28 (75.7) 18 (24.7) 9 (24.3)
Anti-D 88 72 (81.8) 16 (18.2) 70 18 57 (81.4) 15 (83.3) 13 (18.6) 3 (16.7)
Anti-M 62 12 (19.4) 50 (80.6) 36 26 9 (25.0) 3 (11.5) 27 (75.0) 23 (88.5)
Anti-C 40 33 (82.5) 7 (17.5) 31 9 27 (87.1) 6 (66.7) 4 (12.9) 3 (33.3)
Anti-Fya 32 26 (81.3) 6 (18.8) 23 9 19 (82.6) 7 (77.8) 4 (17.4) 2 (22.2)
Anti-Jka 22 12 (54.5) 10 (45.4) 20 2 12 (60.0) 0 (0) 8 (40.0) 2 (100)
Anti-c 18 12 (66.7) 6 (33.3) 15 3 10 (66.7) 2 (66.7) 5 (33.3) 1 (33.3)
Anti-S 15 9 (60.0) 6 (40.0) 12 3 7 (58.3) 2 (66.7) 5 (41.7) 1 (33.3)
Other 37 24 (64.9) 13 (35.1) 24 13 16 (66.7) 8 (61.5) 8 (33.3) 5 (38.5)
Total 562 368 (65.5) 194 (34.5) 406 156 275 (67.7) 93 (59.6) 131 (32.3) 63 (40.4)
History of Yes 192 147 (76.6) 45 (23.4) 144 48 110 (76.4) 37 (77.1) 34 (23.6) 11 (22.9)
transfusion No 305 180 (59.0) 125 (41.0) 213 92 133 (62.4) 47 (51.1) 80 (37.6) 45 (48.9)
Unknown 65 41 (63.1) 24 (36.9) 49 16 32 (65.3) 9 (56.3) 17 (34.7) 7 (43.8)
Total 562 368 (65.5) 194 (34.5) 406 156 275 (67.7) 93 (59.6) 131 (32.3) 63 (40.4)
History of Yes 367 248 (67.6) 119 (32.4) 367 0 248 (67.6) N/A 119 (32.4) N/A
pregnancy No 39 27 (69.2) 12 (30.8) 39 0 27 (69.2) N/A 12 (30.8) N/A
Male 156 93 (59.6) 63 (40.4) 0 156 N/A 93 (59.6) N/A 63 (40.4)
Total 562 368 (65.5) 194 (34.5) 406 156 275 (67.7) 93 (59.6) 131 (32.3) 63 (40.4)
Numbers represent antibody counts, while values in parentheses represent percentages of a given total for respective specificities.
* % reflects percentage of the total column for a given specificity.
† % reflects percentage of either total female or total male antibodies detected, respectively, for a given specificity.
N/A = not applicable.
 RBC ANTIBODY EVANESCENCE IN BLOOD DONORS

Statistical analysis
We performed a survival analysis using Cox proportional haz-
ard regression with a robust variance estimator to account for
donors with multiple antibodies,14 adjusting for antibody spec-
ificity, race (white/other), detection at first donation, detection
of multiple antibodies concurrently, transfusion history, sex,
sex*pregnancy history (this interaction term was included to
avoid missing data issues, and to decipher between a male and
female with no pregnancy), and age. Ethnicity was excluded
from this model due to only six records indicating Hispanic
ethnicity. Hazard ratios and 95% confidence intervals are pres-
ented. To reduce the effect of passive (transient) anti-Ds in the
data set from women of childbearing age, we removed all
women ≤45 years of age with anti-Ds. The Kaplan–Meier prod-
uct limit estimator was plotted to visually present the
unadjusted rate at which antibodies became undetectable for
significant variables; statistical significance was set at 0.05. R
software (version 3.6.1) was used for statistical analyses.
antibody specificity identified, donated two or more times, and
had a repeat antibody screen allowing for assessment of anti-
body persistence or evanescence (Fig. 1). Among these total
subjects, there were 128 males and 400 females, representing
10.9% (528/4,861) of all donors with a positive antibody screen.
Table S1, available as supporting information in the online ver-
sion of this paper summarizes the key population and demo-
graphic data for the entire cohort of blood donors.
Before any analysis, females ≤45 years of age with anti-Ds
(n = 53) were excluded due to the possible confounder of RhIg
administration. Table 1 summarizes the analyzed study popu-
lation with the exclusion of these donors. In total, 481 unique
donors (including 128 males and 353 females) were studied;
the larger proportion of alloimmunized females compared to
males is consistent with prior alloimmunization studies of this
cohort12 and is likely attributable to pregnancy. The mean age
was 54.2 years, and most subjects (81%) were white.

Antibody specificity and evanescence

RESULTS
A total of 562 antibodies were detected in 481 unique
Demographics donors, yielding a rate of 1.17 antibodies per donor. The
Of the nearly 4900 blood donors with a positive antibody number of donors with a persistent antibody (n = 301) out-
screen extracted from the REDS-III database,12 528 had an numbered the number of donors with an evanescent

TABLE 4. Cox proportional hazard regression of antibody persistence

Variable Unadjusted HR (95% CI) p value Adjusted HR (95% CI) p value
Antibody <0.001 <0.001
Anti-c 0.70 (0.32-1.53) 1.08 (0.45-2.61)
Anti-C 0.40 (0.18-0.91) 0.76 (0.30-1.89)
Anti-D 0.98 (0.67-1.44) 0.49 (0.28-0.86)
Anti-Fya 0.41 (0.18-0.91) 0.66 (0.29-1.52)
Anti-Jka 1.36 (0.73-2.52) 1.34 (0.67-2.67)
Anti-K 0.56 (0.36-0.89) 0.72 (0.44-1.20)
Anti-M 3.79 (2.58-5.58) 3.07 (1.95-4.82)
Anti-S 1.44 (0.65-3.19) 2.11 (1.01-4.38)
Other 0.87 (0.43-1.75) 1.52 (0.78-2.95)
Anti-E 1 (Reference) 1 (Reference)
Detected at first donation <0.001 <0.001
Yes 0.27 (0.20-0.36) 0.34 (0.24-0.48)
No 1 (Reference) 1 (Reference)
History of transfusion <0.001 0.007
No 2.32 (1.60-3.36) 1.83 (1.18-2.84)
Unknown 1.97 (1.18-3.29) 1.36 (0.76-2.43)
Yes 1 (Reference) 1 (Reference)
Multiple antibodies detected concurrently <0.001 0.04
Yes 0.31 (0.19-0.51) 0.55 (0.32-0.96)
No 1 (Reference)
Pregnancy history*sexa 0.29 0.41
Female no pregnancy 1.02 (0.65-1.60) 1.11 (0.71-1.72)
Female 1 pregnancy 1.19 (0.80-1.76) 1.03 (0.71-1.51)
Female 2 pregnancies 1.12 (0.78-1.60) 0.97 (0.81-1.15)
Female 3 pregnancies 1.05 (0.74-1.50) 0.90 (0.76-1.08)
Male 1 (Reference) 1 (Reference)
Age 0.98 (0.97-0.99) <0.001 1.01 (0.99-1.02) 0.31
Race 0.52 0.54
White 0.90 (0.62-1.31) 1.15 (0.73-1.80)
Other/unknown 1 (Reference) 1 (Reference)
Hazard ratios <1 indicate the antibody is more likely to remain detectable (e.g., persistence).
* Some females had up to six pregnancies.

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HAUSER ET AL.
antibody (n = 181); one donor had a persistent antibody
and an evanescent antibody (Table 2).
Of the 562 detected antibodies, the specificities included
anti-E (25%, n = 138), K (20%, n = 110), D (16%, n = 88), M (11%,
n = 62), C (7%, n = 40), Fya (6%, n = 32), Jka (4%, n = 22), c (3%,
n = 18), S (3%, n = 15), and others (<1% each) (Table 1). The
characteristics of the persistent and evanescent antibodies by
specificity are shown in Table 3. Of the 562 antibodies identified,
194 became undetectable over time, yielding an overall evanes-
cence rate of 35% (194/562). The duration of detectability for
evanescent antibodies ranged from 47 to 1333 days, with a mean
detectability of 318 days and a median detectability of 190 days.
There was substantial variability noted in persistence and
evanescence rates among antibodies by specificity. For anti-
body specificities detected in at least five donors, the highest
evanescence rates occurred with: anti-M (81%, 50/62), anti-Jka
(45%, 10/22), anti-S (40%, 6/15), and anti-E (38%, 53/138). In
contrast, the lowest evanescence rates occurred with anti-D
(18%, 16/88), anti-C (18%, 7/40), anti-Fya (19%, 6/32), anti-K
(25%, 27/110), and anti-c (33%, 6/18).
Transfusion and pregnancy history
A strength of the REDS-III database is the inclusion of self-
reported data on transfusion and lifelong history of pregnancy
(Table 3). Of the 562 unique donor antibodies, donors reported
Fig. 2. Kaplan-Maier curves of detection of the alloantibody at the first donation (A), detection of multiple alloantibodies detected
concurrently (B), history of transfusion (C), and antibody specificity (D). [Color figure can be viewed at wileyonlinelibrary.com]
6 TRANSFUSION
a history of transfusion in 33% (158/562) of cases. Of the
406 unique donor antibodies from females, 90% (367/406)
occurred in donors who reported a past pregnancy. A self-
reported history of transfusion emerged as a statistically signifi-
cant variable for antibody persistence (p = 0.007).
Univariate and multivariate analysis of factors
associated with antibody persistence
By univariate analysis, antibody specificity (p < 0.001), anti-
body detection at the first donation in the database (p < 0.001),
self-reported history of transfusion (p < 0001), the detection of
multiple antibodies concurrently (p < 0.001), and increasing
age (p < 0.001) were associated with antibody persistence. By
multivariate analysis, all these factors except age remained
associated with antibody persistence (Table 4).
Figure 2 graphically demonstrates the associations
between the statistically significant variables by multivariate
analysis and alloantibody persistence. Our analysis showed
antibodies detected at a first study donation had a higher rate
of persistence than those acquired over the course of the study
(Fig. 2A, p < 0.001). An antibody that formed along with
another antibody (multiple antibodies detected concurrently)
tended to persist at a higher rate (Fig. 2B, p = 0.04). Patients
who reported having previously received a blood transfusion
had antibody persistence at a higher rate than patients without

a reported blood transfusion (Fig. 2C, p = 0.007). Evanescence
curves by antibody specificity are shown in Fig. 2D, p < 0.001;
of the antibodies with more than 22 occurrences, antibodies
with anti-M specificity had the highest rate of evanescence,
and this evanescence occurred more rapidly than for anti-
bodies of other specificities.
DISCUSSION
While the phenomena of RBC alloantibody persistence and
evanescence have long been appreciated in the field of transfu-
sion medicine, most data regarding duration of antibody
detectability have been derived from patient populations.2,8
Further, few large studies have investigated the prevalence of
RBC alloantibodies in healthy blood donors.12,15–17 In this
study, we describe alloantibody evanescence rates in a study
population healthy enough to donate blood. This unique data
set allowed us to observe the properties of antibodies in people
without known immune compromise, as well as providing
access to several other variables that could be evaluated rela-
tive to antibody persistence. To our knowledge, this is the first
manuscript to investigate evanescence rates in blood donors.
Among the most common specificities identified, we
found that anti-D was the most persistent, while anti-M was
the most evanescent. The persistence of anti-D agrees with
previous studies in patient populations.2 Anti-M evanesced
at a higher rate in blood donors than reported in previous
studies in transfusion recipients.2 It is known that some
anti-Ms are “naturally occurring,” and this may be the
explanation for why anti-Ms evanesced at a higher rate than
other antibody specificities.
Evanescence rates of other antibody specificities generally
agreed between past studies in patients and the present study in
blood donors, with both populations showing highly variable
evanescence rates among other common, clinically significant
antibody specificities. We believe that this is an important obser-
vation as we speculate that this implies the baseline immune sta-
tus of individuals does not substantially impact the duration of
detectability on an antibody specificity-by-specificity basis.
Thus, other nonhost factors, perhaps antigen-specific variables
(e.g., immunogenicity, density, and degree of “foreignness” rela-
tive to the host), may be playing more important deterministic
roles in the duration of alloantibody responses to a particular
antigen.
Our analysis showed that antibodies detected at a first
study donation had a higher rate of persistence than those
acquired during the study. This is consistent with prior obser-
vations in patients, wherein “preexisting” alloantibodies identi-
fied at a first screening test were associated with more durable
immune responses than “hospital-acquired” antibodies.2
Although this could reflect a biologic influence of age of sub-
jects at time of alloimmunization with a higher likelihood of a
durable immune response when individuals are younger, the
relatively short time frame over which the REDS-III study was
RBC ANTIBODY EVANESCENCE IN BLOOD DONORS
performed limits age-associated influence. It is thus more likely
that antibodies detected at a first screening test, whether in
people healthy enough to donate blood or in hospitalized
patients, are being selected precisely because of their persistent
nature—in other words, since they had already persisted from
the time of initial induction to the time of testing for inclusion
in the study analysis, they were likely to continue to persist over
the duration of the study period.
This observation has potential practical implications for
donor centers. For example, if a donor center has a policy to
exclude donors (or their donated products) based on a positive
antibody screen, donors demonstrating an antibody at their
first donation are more likely to be continued to be excluded at
future donations because of the probable future persistence of
those antibodies. Alternatively, centers that permanently
exclude donors based on a history of alloimmunization alone
may reconsider this practice, allowing for reentry of upwards of
one-third of donors whose antibodies become undetected
over time.
Our study also found that multiply alloimmunized
patients (i.e., those with >1 antibody) demonstrate persistence
rates greater than patients with a single alloantibody. The phe-
nomenon of concurrent alloimmunization and its impact on
antibody duration of detection has been studied, albeit on a
limited basis, in hospitalized groups. Notably, previous studies
of hospital-based patients have not shown a significant differ-
ence in evanescence rates for multiple antibodies detected
concurrently versus those occurring singly18,19—therefore, it is
intriguing that in healthy donors, making more than one allo-
antibody is associated with a more durable response among all
immunized antigens. Murine animal model studies have
shown that recipients “primed” to one antigen (e.g., KEL) dem-
onstrate enhanced responsiveness to other, unrelated antigens
(e.g., HOD).20 It is possible that in immune-competent hosts,
such as blood donors, a priming phenomenon does occur and
can lead to more durably detected alloantibodies than those
seen in patients. It remains to be determined whether a defini-
tive biologic explanation for this observation can ultimately
be made.
Study limitations must always be considered. Errors in
data entry, or differences in data entry between blood donor
sites, are always possible in database studies. For example,
some donor sites identified all specific antibodies responsible
for each antibody screen–positive donation, whereas other
donor sites identified specific antibodies only in the first posi-
tive antibody screen and assumed future positive screens were
due to the previously identified antibodies. Although each site
used subtly different serologic methods of antibody detection,
these methods remained consistent across the study duration.
Another consideration is that some blood donors may not have
recalled prior transfusions. In fact, a prior REDS study
highlighted the median length of time between transfusion and
blood donation to be 22 years.21
Next, each blood donor had differences in donation fre-
quency and number. However, a subanalysis of time from
TRANSFUSION 7
HAUSER ET AL.
antibody detection to next donation showed no major differ-
ences across study variables. Finally, females ≤45 years old
with anti-Ds were excluded, due to presumed RhIg administra-
tion leading to transiently detected anti-Ds. Since titer data
were not available, it was impossible for us to distinguish pas-
sive from immune-stimulated anti-D. It is conceivable, how-
ever, that some of the excluded donors had authentic
transfusion- or pregnancy-associated anti-Ds. As a result, our
ability to draw conclusions about anti-D persistence rates in
previously pregnant female blood donors is somewhat limited.
Given the highly persistent nature of anti-D,2 however, we
assume that transiently detected D alloimmunization events in
women of childbearing age likely reflected passive immuniza-
tion. Finally, it is worth noting that our study reflects the gen-
eral demographics of the US donor population and therefore
does not provide significant insight into the persistence/eva-
nescence characteristics of non-Caucasian blood donors.
In summary, this study of 481 repeat blood donors in the
REDS-III donor database found antibody evanescence patterns
to be highly associated with the specificity of the antibody (anti-
D being most persistent and anti-M being most evanescent),
the detection at first donation (with such antibodies being
highly persistent), and a reported history of past transfusion
(with such antibodies also being highly persistent). Donors with
multiple RBC alloantibodies detected concurrently were also
quite likely to have persistently detected antibodies. These data
provide insight into variables impacting the duration of anti-
body detection; they may also influence blood donor center
policies regarding donor recruitment/acceptance.
ACKNOWLEDGMENTS
The authors thank Denis Colomb Jr for his contributions to manu-
script preparation and the REDS-III Publications Committee for
their helpful input. RGH, JEH, and CAT designed the study, orga-
nized the data, wrote, and edited the manuscript. ST organized the
initial data set. RGH and DE completed statistical analysis on the
data. All authors analyzed the data and contributed to the final ver-
sion of the manuscript.
CONFLICT OF INTEREST
The authors have disclosed no conflicts of interest.
APPENDIX
The NHLBI Recipient Epidemiology Donor Evaluation
Study- III (REDS-III), domestic component, is the respon-
sibility of the following persons:
Hubs: A.E. Mast and J.L. Gottschall, BloodCenter of
Wisconsin (BCW), Milwaukee, WI.
D.J. Triulzi and J.E. Kiss, University of Pittsburgh and
The Institute for Transfusion Medicine, now Vitalant,
Pittsburgh, PA.
8 TRANSFUSION
E.L. Murphy and E. St. Lezin, University of California,
San Francisco (UCSF), San Francisco, CA.
E.L. Snyder, Yale University School of Medicine, New
Haven, CT and R. G Cable, American Red Cross Blood Ser-
vices, Farmington, CT.
Data coordinating center: D.J. Brambilla and
M.T. Sullivan, RTI International, Rockville, MD.
Publication Committee Chairman: R.Y. Dodd, Ameri-
can Red Cross, Holland Laboratory, Rockville, MD.
Steering Committee Chairman: S.H. Kleinman, Uni-
versity of British Columbia, Victoria, BC, Canada.
National Heart, Lung, and Blood Institute, National
Institutes of Health: S.A. Glynn and K. Malkin.
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SUPPORTING INFORMATION
Additional Supporting Information may be found in the
online version of this article.
Table S1. Description of the entire donor population, before
removing females ≤45 years of age with anti-D antibodies
Continuous variables are shown as mean (standard devia-
tion). Categorical variables are displayed as counts. Number
of unique donors = 528. Number of unique donor
antibodies = 615.
TRANSFUSION 9