Obvious and unexpected problems in a massive transfusion of a patient with Anti-Lu^b antibodies

The clinical relevance of several antibodies against high-frequency antigens is unclear, so the question of whether immunized patients should be transfused with antigen-negative RBCs is often not easy to answer. If antigen-negative RBCs are available for transfusion, the Rhesus- and Kell-antigens are often not taken into account, which can lead to further immunization. We report the case of a patient with Anti-Lub who had a high transfusion requirement due to a complex cardiac surgery situation.

A 58-year-old woman after myocardial infarction and dissection of the right coronary artery needed coronary bypass grafting complicated by a re-thoracotomy due to a pericardial hematoma. A total of 9 RBCs were transfused ahead of admission to our hospital as part of the surgical procedures. The transfusion was complicated by an anti-Lub antibody and Lub- RBCs were selected. Due to the scarcity of these RBCs, some of them were incompatible regarding the Rhesus and Kell blood group system. Subsequently, the patient was transferred to our hospital to evaluate further treatment options. Serological studies including antibody screening test in the indirect antiglobulin test (IAT) and papain test, as well as direct antiglobulin test (DAT) were performed using the standard gel technique.

The patient"s blood group was 0 RhD-pos, CcD.ee, K-, Lu(a+b-). Anti-Lub reactive 1+ to 2+ in the IAT was confirmed. As further RBC transfusions were required instantly because of urgent cardiosurgical interventions and because anti-Lub was considered only a mild to moderate trigger of hemolytic transfusion reactions, the patient received a total of 20 predominantly Rh and K compatible RBCs over the next 10 weeks, without Anti-Lub being taken into account further. Five and 9 weeks after the initial transfusion with Lu(b-) RBCs, anti-E, anti-K and anti-M antibodies were newly detected. The Lu(b+) RBCs were tolerated well without clear signs of hemolysis and with a reasonable increase in hemoglobin.

The hemolytic potential of anti-Lub is limited. The patient tolerated Lu(b+) transfusions very well. On the contrary, the Lu(b-) transfusion led to further immunizations with relevant antibodies, resulting in a difficult treatment situation. It should be considered whether Rh- and K-compatible transfusion should be preferred to Lu(b-) transfusion if an increased need for transfusion is foreseeable. In addition, an assessment of the clinical relevance with a phagocytosis test may be helpful.

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