Biological significance of the York, Cost, McCoy and Knops alloantibodies

Blood Transfusion and Immunohaematology Tome XXV. - - N ° 2. - - 1982

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Biological Significance of the York, Cost, McCoy and Knops Alloantibodies by L. MOLTHAN Miller Memorial Blood Center BETHLEHEM, Pa, U.S.A.

INTRODUCTION is a p r o b l e m relative to the red blood cell antigens, York, T HERE Cost, McCoy, and Knops, and the alloantibodies which define them. The p r o b l e m is, are the antibodies biologically significant ? Do they cause erythroblastosis fetalis a n d / o r hemolytic transfusion reactions, either intravascular or extravascular ? One m e t h o d used to judge biological significance of a p a r t i c u l a r group of antibodies is to search the literature for d o c u m e n t e d cases of erythroblastosis fetalis a n d / o r hemolytic transfusion reactions. If the particular g r o u p of antibodies is not biologically significant, the literature search should p r o d u c e cases of d o c u m e n t e d successful transfusions of incompatible blood, and cases of antigen positive infants with no evidence of erythroblastosis fetalis b o r n to m o t h e r s with antibodies. I n the case of the alloantibodies directed against Yk", CsL the McCoy antigens and Kn", a literature search has been carried out. There are six references [5, 7, 8, 10, 11, 14] w h i c h m e n t i o n incompatible transfusions, two references [12, 13] which r e p o r t on 5~Cr studies, and two reports [1, 2] w h i c h describe neonatal cases.

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The l i t e r a t u r e s e a r c h a n d i n t e r p r e t a t i o n of t h e p u b l i s h e d d a t a is one a s p e c t of this p a p e r . The o t h e r a s p e c t is an a n a l y s i s of t h e clinical d a t a p r o v i d e d b y t h e 304 p a t i e n t r e f e r r a l s , t h o s e cases w h o s e b l o o d s a m p l e s have b e e n s t u d i e d b y t h e a u t h o r since 1965. The a n a l y s i s s h o u l d p r o v i d e evidence a b o u t i m m u n i z a t i o n s due to p r e g n a n c i e s , e r y t h r o b l a s t o s i s fetalis a n d h e m o l y t i c t r a n s f u s i o n r e a c t i o n s . F u r t h e r , t h e analysis should provide information about transfusion practices, f o r it is in the h o s p i t a l s w h e r e d e c i s i o n s a r e m a d e b y p h y s i c i a n s r e l a t i v e to t h e u s e of c o m p a t i b l e or i n c o m p a t i b l e t r a n s f u s i o n s .

CASE MATERIAL T h e r e w e r e 304 p a t i e n t s w h o s e b l o o d s a m p l e s w e r e r e f e r r e d to t h e a u t h o r since 1965: l l l p a t i e n t s w h o m a d e anti-Yk% 20 w i t h a n t i - e s ~, five w i t h a n t i - Y k ' + e s % 72 w h o m a d e anti-McC% 38 w i t h o t h e r McCoy specificities, 30 w i t h anti-Kn", a n d 28 w h o m a d e antiMcCoy + K n o p s . I n f o r m a t i o n on 127 p a t i e n t s w h o w e r e t r a n s f u s e d s u b s e q u e n t to a n t i b o d y d e t e c t i o n has b e e n o b t a i n e d . Eighty-six r e c e i v e d autologous a n d / o r c o m p a t i b l e h o m o l o g o u s d o n o r u n i t s exclusively, however, 41 p a t i e n t s r e c e i v e d i n c o m p a t i b l e d o n o r units. Case h i s t o r i e s on 15 of t h e l a t t e r a r e p r e s e n t e d . The d a t a f o r t h e a n a l y s i s of t r a n s f u s i o n p r a c t i c e s w e r e o b t a i n e d f r o m t h e 147 p a t i e n t r e f e r r a l s r e c e i v e d in 1979, 1980, a n d 1981. The d i f f e r e n t i a l a g g l u t i n a t i o n s t u d i e s w e r e d i r e c t t e s t s u s i n g p o t e n t r e a g e n t a n t i s e r a s e l e c t e d to d e t e c t d o n o r s ' r e d cell m a r k e r s . The " i n v i t r o " s t u d i e s of a r t i f i c i a l m i x t u r e s u p o n w h i c h i n t e r p r e t a t i o n s w e r e b a s e d a r e d e s c r i b e d in a r e c e n t r e p o r t [10]. CASE I . - H.G. was a Caucasian man with a diagnosis of anemia secondary to myelofibrosis. He was transfused initially in June 1977, at which time his serum contained no unexpected antibody. On 9/9/77, unexpected alloantibodies were detected. Anti-Kpa and anti-Yk~ were demonstrated. During September and October, 1977, transfusions with donor units incompatible with the anti-Yk~ resulted in only slight rises in hematocrit values and the rises were not maintained. The patient was placed on steroid therapy in October. This, combined with transfusions of blood obtained from compatible family members, resulted in the maintenance of hemoglobin values at 14 gm/dl until June 1978. The patient's steroid dosage was reduced sharply on 6/2/78, and he was admitted to hospital eight days later with a hemoglobin value of 2.5 gm/dl. On 6/10/78, the patient received a unit of blood which was Group O, K p ( a - - ) , but incompatible. After 15 minutes into the transfusion, he complained of nausea and vomiting and had a fever. At 30

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minutes, he c o m p l a i n e d of low back pain and had to void. He was seen by a physician at 60 minutes, and w h e n h e m o g l o b i n u r i a was noted, the a l m o s t c o m p l e t e d ' tr a n s f u s io n was discontinued. S u b s e q u e n t to this event, the p a t i e n t received c o m p a t i b l e transfusions and experienced no adverse reactions. T h ree post-transfusion red cell samples, all taken within 12 hours of the reaction, showed positive direct antiglobulin tests w i t h polyspecific r eag en t ( + 1 ) and w e a k e r tests w i t h anti-Ca reagent. An eluate p r e p a r e d f r o m a s a m p l e o b t a i n e d 36 h o u r s post-transfusion, was non-reactive. The p l a s m a h e m o g l o b i n was 14 m g m / d l pre-transfusion, 99 m g m / d l i m m e d i a t e l y post-transfusion, 53 m g m / d l at 12 hours and 23 m g m / d l at 24 hours post-transfusion~ The patient's r e d b lo o d cells w e r e Group O, DCe/dce, kk, K p ( a - - b + ) , J s ( b + ) , F y ( a + b + ) , Jk ( a + b + ) , MSNS, PI, L e ( a - - b + ) , L u ( a - - b + ) , Vel positive. Following the r e a c t i o n of 6/10/78, his s e r u m was again studied at t h ree r eferen c e l a b o r a t o r i e s and only anti-Kp a and anti-Yk ~ were identified. S e r u m samples d a t e d 6/9/78 and 7/6/78 w e r e r e f e r r e d to the a u t h o r in N o v e m b e r 1978. Anti-Kp ~, anti-Bg a, and anti-Yk ~ w e r e identified in each sample. Multiple c o m p a t i b l e Y k ( a - - ) panel cells ruled out the presence of anti-E, anti-C w, anti-K, and anti-s. CASE 2 . - A.Y., a Caucasian w o m a n with c a r c i n o m a of the ovary diagnosed in 1958, was t r a n s f u s e d w i t h 42 units of c o m p a t i b l e blood and 21 units of blood i n c o m p a t i b l e on the basis of Yk ~ during four hospitalizations in 1969. This t r e a t m e n t was to replace blood lost t h r o u g h massive exsanguinating gastric h e m o r r h a g e s . Following the i n c o m p a t i b l e transfusions, the direct antiglobulin tests b e c a m e positive, h er s e r u m was icteric, and the anti-Yk a increased in strength. On two occasions, w h e n bleeding had ceased and i n c o m p a t i b l e units were given, there was little sustained i m p r o v e m e n t in h e m o g l o b i n and h e m a t o c r i t levels. No effort was m a d e to a d e q u a t e l y study the efficacy of the i n c o m p a t i b l e transfusions. CASE 3. - - V.G. was a 49 year old Caucasian w o m a n with breast carcinoma. During the course of the study, she received c h e m o t h e r a p y but had no surgery n o r evidence of h e m o r r h a g e . On day one, h er h e m a t o c r i t level was 24.1%. A w e a k alloantibody, later identified as anti-Yk ~, was detected. On day one, she received two " c o m p a t i b l e " packed red cell units (PRC) and e x p e r ie n c e d chills and fever. The h e m a t o c r i t was 26_2% on day two and she received two m o r e " c o m p a t i b l e " PRC units. By day 3, the antibody was s t r o n g e r and she received two i n c o m p a t i b l e PRC units. On day six, the h e m a t o c r i t was 30.3%, on day ten 29.3% and on day 18 it was 27.9% despite a m a r k e d reticulocyte response which peaked at 21%. S am p l es t a k e n on day 18 w e r e sent to two reference laboratories w h e r e the antibody was identified as anti-Yk ". Differential agglutination studies showed a m i n i m a l presence of donors' cells. The expected h e m a t o c r i t value following the t r an sf u si o n of six PRC units is 40.0%. The m a x i m a l value a t t a i n e d in this patient was 30.3% on day six and twelve days later it was 27.9% despite the m a r k e d reticulocyte response. CAS~ 4 . - S.W. was a 66 y e a r old Caucasian w o m a n with c o r o n a r y a r t e r y disease and hypertension, a d m i t t e d to hospital for elective coronary by-pass s u r g er y on day one. S u r g e r y was p e r f o r m e d on day two and the pat i en t was t r a n s f u s e d w i t h six PRC units on that date and two PRC

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units on day four. H e r h e m a t o c r i t level on ad m i ssi o n was 47.7%. It stabilized at 33% on days five and six. A p r e s c r i p t i o n for additional transfusions was received on day eight to t r e a t u n ex p l ai n ed anemia. The b l o o d loss since day six h a d b e e n 50 m l of PRC, and the h e m a t o c r i t on day eight was 28.5%. An anti:Yk ~ was identified in the day eight sample. With no f u r t h e r b lo o d loss a f te r day seven, the h e m a t o c r i t c o n t i n u e d to drop and was 26.4% on day ten. Two compatible, Y k ( a - - ) , PRC units w e r e t r a n s f u s e d on day 11, and the h e m a t o c r i t was 33.5% on day 13 and 36.2% on day 18. Reticulocytes w e r e 3.0% on those dates. Calculations show an o t h e r w i s e u n e x p l a i n e d loss of 403 m l of PRC b e t w e e n day four and day 13, and this is a t t r i b u t e d to e x t r a v a s c u l a r hemolysis due to Yk ~ incompatibility. The patient's day one s e r u m c o n t a i n e d anti-Yk ~. I t h ad n o t been detected by the L I S S m e t h o d o l o g y w h i c h was the hospital's r o u t i n e technic for detection of u n e x p e c t e d antibodies and c o m p a t i b i l i t y testing. On day eight, w h e n additional transfusions w e r e prescribed, the anti-Yk ~ was detected by the L I S S m e t h o d at the hospital. These samples and subseq u e n t samples w e r e sent to the r e f e r e n c e laboratory. All showed antiYk " by r o u t i n e technic, b u t the a n t i b o d y in the pre-transfusion s a m p l e was non-reactive by m u l t i p l e L I S S technics. The antibody was w e a k initially and was p r o g r e s s i v e ly s t r o n g e r on days 8, 10 and 15. The direct antiglobulin test was negative on day one, positive on days 8, 10 and 15. Differential agglutination studies showed p r o g r essi v e loss of the initially t r a n s f u s e d donors' r e d ceils. This p a t i e n t h ad E H T R due to a LISS m i s s e d anti-Yk ~. CASE 5. - - H.W., was a 56 y e a r old Caucasian w o m a n w i t h pancytopenia, splenomegaly, and cirrhosis of the liver. H e r s e r u m co n t ai n ed anti-Yk ~ and anti-Bg a. In J a n u a r y 1980, she was a d m i t t e d to hospital for t r e a t m e n t of anemia. The initial h e m o g l o b i n value was 8.0 g m / d l . She received two PRC units i n c o m p a t i b l e on the basis of YkL one on day one, the second on day three. H e r h e m o g l o b i n value on day four was 8.5 g m / d l and the next level d e t e r m i n e d on day 42 was 8.1 g m / d l . The units w e r e c o m p a t i b l e on testing at the hospital b u t s h o w n to be Y k ( a + ) , B g ( a - - ) and incompatible on testing at the r e f e r e n c e iaboratory. The direct antiglobulin test initially negative, was positive post-transfusion. Differential agglutination studies s h o w e d p o o r d o n o r cells survival. B et ween M a r c h and S e p t e m b e r 1980, she received eight c o m p a t i b l e transfusions, the donors being h e r tw o Y k ( a - - ) B g ( a - - ) sons. A p p r o p r i a t e rises in h e m o g l o b i n values w e r e achieved and the direct antiglobulin tests w e r e negative. CASE 6. - - J. LaP. was a 50 y e a r old Caucasian m a l e a d m i t t e d to hospital for t r e a t m e n t of intestinal obstruction. His colon a d e n o c a r c i n o m a was initially diagnosed and r e s e c t e d tw o years earlier at w h i ch t i m e he r e c e i v e d 11 transfusions w i t h o u t serologic or clinical p r o b l em s. Two m o n t h s p r i o r to admission no u n e x p e c t e d antibody was d e t e c t e d and he r e c e i v e d one transfusion. The pre-operative s a m p l e of day one r e v e a l e d an unexpected alloantibody s u b s e q u e n t l y identified by four r e f e r e n c e laboratories as anti-Yk% C o m p a t i b l e d o n o r units w e r e p r o v i d e d f o r surgery b u t w e r e not given. C h e m o t h e r a p y was given during the s u b s e q u e n t course during wh ic h t h e r e was no evidence of h e m o r r h a g e . The h e m a t o c r i t

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value on day t w o was 37.1% and the level decreased gradually to 27% by day 14. On day 16, the p a t i e n t received two i n c o m p a t i b l e PRC units and a n o t h e r on day 18. H e m a t o c r i t values w e r e 32.4% on day 19 and 31.0% on day 24. On day 25, he received one c o m p a t i b l e and one incompatible unit. H e m a t o c r i t s w e r e 32.9% and 33.5% on days 27 and 31. The p a t i e n t was discharged f r o m hospital the next day and expired within a week. Direct antiglobulin tests w e r e negative on samples of days 1, 16, 18, 24 and 25. N o r m a l d o n o r cell survival was o b s e r v e d in the only s a m p l e so tested, t h a t of day 25, seven days after the initial three i n c o m p a t i b l e transfusions. Antibody s t r e n g t h did not a p p e a r to change during the p e r i o d of study. CASE 7 . - M.J.T., a 73 y e a r old Caucasian woman, was a d m i t t e d to hospital for diagnosis and t r e a t m e n t of l o w e r intestinal bleeding. She had received f o u r transfusions one y e a r p r i o r and no u n e x p e c t e d antib o d y was detected at t h a t time. On day one, the h e m a t o c r i t was 25.8%, the reticulocyte count Was 6.7% and no u n e x p e c t e d antibody was detected using LISS technic. She received two c o m p a t i b l e (LISS technic) PRC units on day one and again on day six. A right h e m i c o l e c t o m y was p e r f o r m e d on day seven and surgical blood loss was 150 ml. Unexpected alloantibody was d e t e c t e d (LISS technic) for the first t i m e on day eight and all of the blood samples w e r e f o r w a r d e d to the r ef er en ce laboratory. H e m a t o c r i t values stabilized at 28-29% following the initial transfusions and at 32.7-33.1% following the day six units and the surgery. The day 11 h e m a t o c r i t was 32.7% and the p a t i e n t was discharged on day 14. She was seen as an o u t p a t i e n t on four occasions over the next seven weeks. H e r h e m a t o c r i t was 28% on these visits and there was evidence of co n t i n u ed gastro-intestinal bleeding. On r e a d m i s s i o n to hospital a diagnosis of h e m o r r h a g i c duodenitis was established, non-surgical treatm e n t i n i t i at ed and a h e m a t o c r i t value of 28% obtained. At the r e f e r e n c e l a b o r a t o r y anti-Yk ~ was detected by r o u t i n e technic in the day one, six and eight samples b u t this antibody was not detected using t h r ee different L I S S solutions in the first two samples. It showed a m a r k e d increase in s t r e n g t h over the t i m e span. The four d o n o r units w e r e Y k ( a + ) . The direct antiglobulin test was negative on days one, six and eight, b u t positive on days 10, ! l , 14 and 43. Eluates f r o m the l a t t e r t wo samples c o n ta in e d anti-Yk ~. The DAT b e c a m e negative on day 52. Differential agglutination studies showed a p p a r e n t l y n o r m a l donor cell survival t h r o u g h day 43. Despite the d e v e l o p m e n t of positive direct antiglobulin tests with eluates containing anti-Yk a, this case is j u d g e d as a successful t r an sf u si o n experience. I t is a n o t h e r e x a m p le of a LISS m i s s e d anti-Yk ~. CASE 8. - - D.H. was a 60 year old Caucasian w o m a n w i t h leiomyob l a s t o m a of the stomach. She received 17 transfusions in 1975. In 1978 she was a d m i t t e d to hospital f o r t r e a t m e n t of t u m o r recurrence. No u n e x p e c t e d a n t i b o d y was found and a f u r t h e r gastric resection and t r a n s f u s i o n of f o u r PRC units w e r e p e r f o r m e d on day four. Unexplained a n e m i a was evident on day 16. The blood sample h ad a positive DAT and anti-Yk~+Cs a w e r e fotmd in the s e r u m and eluate. The p at i en t received i n c o m p a t i b l e units on days 21 and 25, h ad continued a n e m i a and h y p e r b i l i r u b i n e m i a and developed oliguria and anuria. This case is r e p o r t e d in detail i n d e p e n d e n t l y [10].

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CASE 9. -E.P. was a 78 year old Caucasian w o m a n w i t h adenocarcin o m a of the kidney. She h a d received t h r e e transfusions 13 days p r i o r to admission. The s e r u m on day one c o n tai n ed anti-E, anti-Le a and anti-Cs ~. The initial h e m a t o c r i t was 31.3%, on day six it was 28.2% an d on day nine 29.6%. The day seven sample showed only 5% of donors' cells to be p res en t on differential agglutination. On day 12 she received one compatible and one i n c o m p a t i b l e PRC unit and a t t a i n e d h e m a t o c r i t s of 32.4% and 32.9% on days 19 and 20. This r e s p o n s e is a p p r o p r i a t e for a single PRC transfusion. The d o n o r units w e r e lacking Rh-E and Le a. Microcytes and b u r r cells w e r e seen in the day 19 sample.

The patient was r e a d m i t t e d to hospital th r e e m o n t h s later. A decompression l a m i n e c t o m y was p e r f o r m e d on day one. She received two incompatible R1R1 L e ( a - - ) units during surgery and h e m a t o c r i t s l at er that day were 39.2% and 38.4%. There was no post-operative bleeding. H e m a t o c r i t s w e r e 35.7% on day six and 31.8% on day 18. Microcytes and b u r r cells were o b s e r v e d in the day six sample. The p at i en t 's anti-Cs a increased in strength over the period of study. The patient showed evidence of ongoing e x t r a v a s c u l a r h e m o l y t i c transfusion reaction w h e n a d m i t t e d initially, an i n a p p r o p r i a t e response to the two units t r a n s f u s e d during that admission, and s h o r t e n e d d o n o r cell survival of the units t r a n s f u s e d during the second admission. All together these data have been a d j u d g e d as E H T R s due to anti-Cs ~. CASE 10. M.L. was a Negro w o m a n w h o h ad R h e u m a t o i d Arthritis. A total hip r e p l a c e m e n t was p e r f o r m e d in October, 1972. The surgical blood loss was 1400 ml. Post-operatively, h er h e m o g l o b i n value was 3 gm/dl. She was t r a n s f u s e d w i t h t h r e e units of i n c o m p a t i b l e b l o o d which raised the h e m o g l o b i n to 7 g m / d l . Over the next 48 hours, the hemoglobin gradually d r o p p e d to 3 g m / d l . Th er e was no evidence of intravascular hemolysis n o r bleeding. The h a p t o g l o b i n levels w e r e decreased, there was an increase in b il ir u b i n levels, the direct antiglobulin test became positive, and the p a t i e n t developed left u p p e r q u a d r a n t tenderness and splenomegaly. On 11/1/72, she received a c o m p a t i b l e transfusion (donor M. Helgeson, M c C ( a - - ) K n ( a - - ) ) and on 11/9 a n o t h e r compatible t r an s f u s i o n (donor T. Vincequerra, M c C ( a - - ) K n ( a - - ) ) . She also received iron t h e r a p y and h a d a m a r k e d reticulocyte response. On 11/15/72, her h e m o g l o b i n value was 9.5 g m / d l . -

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A blood sample dated 11/3/72 was tested by the author. The p at i en t 's red blood cells w e r e Group O, DCe/dce, kk, M c C ( a - - ) K n ( a + ) . The direct antiglobulin test was weakly positive, and the s e r u m showed the p r e s e n c e of only anti-McC a. CASE 1 1 . - This case was r e p o r t e d previously [8]. C.K., a 42 year old Caucasian man, was a d m i t t e d to hospital in 1975 for t r e a t m e n t of intractable low back pain. In 1960, he h a d h a d an a o r t o f e m o r a l by-pass p e r f o r m e d to t r e a t an aortic aneurysm, and he was t r a n s f u s e d w i t h o u t incident. He had an e x p lo r a t o r y l a p a r o t o m y p e r f o r m e d on an e m e r g e n c y basis on day one. A false a n e u r y s m of the a b d o m i n a l a o r t a was found at the anastomosis of the previous graft to the aorta. The p r e s c r i p t i o n for donor blood was received in the l a b o r a t o r y w h e n the p a t i e n t was in the operating room. The patient's s e r u m c o n t ai n ed anti-McC ~. Th r ee least incompatible donor units w e r e t r a n s f u s e d during the surgical procedure and two m o r e were t r a n s f u s e d on day 2. He received a c o m p a t i b l e

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unit, d o n at ed by a b r o t h e r on day seven, and a n o t h e r c o m p a t i b l e unit on day nine. The p a t i e n t died on day 11. The patient's r e d blood cells w e r e Group O, R1R~_, kk, MSs, P1 Le(a--b+), Fy(a+b+), Jk(a+b+), McC(a--), Kn(a+). The day one blo o d s a m p l e was n o r m a l in a p p e a r a n c e and h ad a negative direct antiglobulin test. Samples of days two, six, seven and nine showed progressive positivity of the DAT, and icterus w i t h progressive increase in intensity. H e m o g l o b i n levels r e m a i n e d b e t w e e n 5 and 6 g m / d l , postoperatively. Differential agglutination studies w e r e p e r f o r m e d . The only do n o r m a r k e r was N. F o u r of the i n c o m p a t i b l e donors were MN, the fifth was MM. The c o m p a t i b l e b r o t h e r is MM and the other c o m p a t i b l e do n o r is NN. Studies using r a b b i t anti-N showed agglutination of 20% of the red cells in the day two sample, 40% in the day six sample, and 20% in the day nine sample. The anti-McC ~ increased in strength over the p e r i o d of study. The p at i en t ' s m e d i c a l r e c o r d for this a d m i ssi o n have been missing since his death. A copy of the death s u m m a r y was m a d e available in 1980. This s u m m a r y lists as diagnoses: false a n e u r y s m of the ab d o m i n al aorta, hemolysis and h e m o l y t i c anemia, renal failure, pneumonia, and Clostridial septicemia. It lists u n d e r complications "°transfusion reaction w h i ch led to m as s i v e hemolysis, acute renal failure secondary to transfusion reaction, septicemia, pneumonia, h e m o l y t i c a n e m i a secondary to t r a n s f u s i o n reaction, t h r o m b o c y t o p e n i a secondary to t r an sf u si o n r e a c t i o n " . It is n o t k n o w n w h e t h e r a p o s t - m o r t e m e x a m i n a t i o n was p e r f o r m e d . Based on the diagnosis of the attending physician, this p at i en t h ad E H T R due to anti-McC a and this c o n t r i b u t e d to his death. CAs~ 12. - - H.M. is a N e g r o man, b o r n in 1953, w h o has Sickle Cell Disease. During the p e r i o d of study in 1979, there was no evidence of infection n o r h e m o r r h a g e . He was a d m i t t e d to hospital for treatm e n t of anemia. His s e r u m c o n t a i n e d anti-E and anti-McC d. On day one his h e m a t o c r i t level was 23.3% and he received two c o m p a t i b l e PRC units. On days two and f o u r the h e m a t o c r i t levels were 29.9% and on day 14 it was 27%. On days 16 and 17 he received four E negative PRC units w h ic h w e r e i n c o m p a t i b l e on the basis of McC d. The h e m a t o c r i t level was 33% on day 18, 31.4% on day 23, 28.9% on day 34 and 27.7% on day 35. The direct antiglobulin test, negative p r i o r to the i n c o m p a t i b l e transfusions, was m o d e r a t e l y positive w h e n tested subsequently. Differential agglutination studies on red cell samples showed decreasing survival of donors' cell. The anti-McC a increased in strength o v e r the period of study. The expected h e m a t o c r i t value following the four transfusions of days 16 and 17 is 40%. The achieved value was 33% and this fell to baseline, 27.7% in 18 days. The p at i en t was r e a d m i t t e d to hospital in 1980 for t r e a t m e n t of an abscess of the buttock. His baseline h e m a t o c r i t value was 25.6%. His s e r u m again co n t a in e d anti-E and anti-McC d. He received two E negative M c C ( d + ) PRC units on day one. The units w e r e c o m p a t i b l e on cross m a t c h at the hospital b u t w e r e i n c o m p a t i b l e on testing at the reference laboratory. His h e m a t o c r i t levels on days two t h r o u g h five w e r e 31.531.6%. However, by day 11 the h e m a t o c r i t h a d fallen to 27.6%. On t h a t day and again on day 12, he received one unit of E negative, M c C ( d - - ) blood. The h e m a t o c r i t on day 16 was 32.9% and on day 22 it was 33.7%. The direct antiglobulin test, initially negative, b e c a m e positive following

134

M O L T H A N L.

the incompatible units. Differential a g g l u t i n a t i o n studies showed good survival of the McC(d+) u n i t s in the day five sample, poor survival i n the day 12 sample, and good survival of the M c e ( d - - ) u n i t s in the day 23 sample. The anti-McCa increased in strength over the period of study. Following the i n c o m p a t i b l e u n i t s of day one, the expected h e m a t o c r i t level increase was achieved a n d m a i n t a i n e d for five days, then fell over the next five days. The compatible u n i t s of day 11 and 12 resulted in achieving and m a i n t a i n i n g the expected response over the ensuing 11 days of observation. This p a t i e n t experienced E H T R in 1979 a n d again in 1980 due to anti-McC a. Controls, n o r m a l survival of compatible units, existed on both occasions. CASE 1 3 . - L.B., a 63 year old Caucasian woman, h a d had chronic mechanical hemolytic anemia secondary to a b n o r m a l i t i e s of two artificial cardiac valves for several years. She usually m a i n t a i n e d a h e m o g l o b i n level of 10 gm/dl, a n d u n d e r u s u a l circumstances her s e r u m contained free hemoglobin, reduced haptoglobin a n d increased bilirubin. The p a t i e n t was a d m i t t e d to hospital i n October 1979 with a h e m o g l o b i n level of 5.5 gm/dl, h e m a t o c r i t 14.9%. She received two PRC u n i t s on day one and two PRC u n i t s on day two. The expected h e m a t o c r i t value for the immediate post-transfusion period is 27%, the expected value after a d j u s t m e n t of blood volume is 33.5%. On day four, 36 hours after the final transfusions, the patient's h e m a t o c r i t was 29.3% a n d the next value determined, seven days later, was 28.7%. A week later, the hematocrit was 28% a n d 30 days post-transfusion, it was 25.7%. The patient's s e r u m pre-transfusion c o n t a i n e d anti-K, anti-C, a n d anti-~ McC a. All four donor u n i t s were lacking K a n d C, one was M c C ( d - - ) and three were M c e ( d + ) . They were c o m p a t i b l e on cross-match at the hospital b u t the three M c C ( d + ) donors were i n c o m p a t i b l e w h e n tested at the reference laboratory. Two of the i n c o m p a t i b l e u n i t s h a d S as a marker. Thirty-six days post-transfusion, only 2-3% of S positive cells were present, a n d 50 days post-transfusion, n o n e were present. Using McC a as a m a r k e r , there were no M c e ( d + ) cells detected at 36 and 50 days post-transfusion. The p a t i e n t ' s direct a n t i g l o b u l i n test was weakly positive p r e - t r a n s f u s i o n a n d was decidedly stronger o n 10/26, 36 hours post-transfusion. The anti-McCa increased in strength d u r i n g the period of study. This is an u n i n t e r p r e t a b l e case. Evidence of E H T R such as hyperbilirubinemia, reduced h a p t o g l o b i n levels, a n d a n e m i a were m a s k e d by their presence due to u n d e r l y i n g disease. The case is presented for this very reason since such a situation occurs quite c o m m o n l y in medicine. CASE 14. - - I.W., a 47 year old Negro male was a d m i t t e d to hospital for elective cardiac surgery. Three m o n t h s prior, anti-McCa had been identified in his serum. A 51Cr red cell survival study using 20 ml. incompatible PRC was p e r f o r m e d a n d the T50 survival was r e p o r t e d to be 5.3 days. The study was done over a 48 hour period. Cardiac by-pass surgery, a m i t r a l c o m m i s s u r o t o m y , was p e r f o r m e d on day one. Operative blood loss was estimated at 450 ml. and no t r a n s f u s i o n s were given d u r i n g the operative procedure. Because of a post-operative , bleeding p r o b l e m >,, he received two t r a n s f u s i o n s on day one, two

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135

t r a n s f u s i o n s on day two a n d one on day three. All donor units were incompatible. The patient's h e m a t o c r i t values were 44% pre-operatively, 26% and 23% post-operatively on day one; 35%, 37% a n d 31% on day two; 28% on day three; 30% on day four; 27% on day five; 29% on days six a n d n i n e a n d 32% on day 38. No serologic n o r chemistry studies were p e r f o r m e d post-transfusion. The day 38 sample had a negative direct a n t i g l o b u l i n test a n d a negative typing for McC~. Anti-McC" was the only alloantibody identified a n d its strength had increased significantly. This case is judged u n i n t e r p r e t a b l e despite the prolonged unexplained a n e m i a because of the lack of supportive data. CASK 15. - - D.B. was a 59 year old Caucasian w o m a n with c a r c i n o m a of the ovary, m e t a s t a t i c in the abdomen. She was a d m i t t e d to hospital for t r e a t m e n t of small bowel obstruction. Surgery, lysis of adhesions and small bowel resections, was p e r f o r m e d on day three with estimated blood loss of 200 ml. At no time during the hospital course was there evidence of h e m o r r h a g e or sepsis and no chemotherapy was given. The patient's h e m a t o c r i t on day one was 22%, the total b i l i r u b i n 1 mg/dl, a n d the direct a n t i g l o b u l i n test was negative. She received three t r a n s f u s i o n s on day one, one on day three during surgery, and three on day four. H e m a t o c r i t s were 32% on day five, 28% on day seven, 26% on day n i n e and 23% on day 11. Bilirubin was 10.3 m g / d l on day eight a n d 8.1 m g / d l on day 11. The DAT became positive and persisted. She s u b s e q u e n t l y received 10 more t r a n s f u s i o n s over the next 64 days a n d each set of t r a n s f u s i o n s was characterized by shortened d o n o r cell survival and h y p e r b i l i r u b i n e m i a . On admission, the patient's s e r u m contained anti-K, anti-E, anti-Fyb a n d anti-Kn~. All 17 t r a n s f u s i o n s were lacking Rh-E, Kell a n d Fy b b u t were i n c o m p a t i b l e o n the basis of K n a. The anti-Kn~ increased in strength during the period of study.

RESULTS A n a l y s i s of p a t i e n t r e f e r r a l s

Pregnancy i m m u n i z a t i o n s and h e m o l y t i c disease of the n e w b o r n T h e m a j o r i t y of t h e p a t i e n t s h a d h i s t o r i e s of h a v i n g r e c e i v e d t r a n s f u s i o n s p r i o r to a n t i b o d y d e t e c t i o n . T h e r e w e r e 11 w o m e n who denied having been transfused and whose only known exposures to f o r e i g n h u m a n r e d b l o o d cells w e r e p r e g n a n c i e s . T e n of t h e w o m e n h a d a n t i b o d i e s of McCoy a n d / o r K n o p s s p e c i f i c i t i e s a n d o n e h a d a n t i - Y k a. T h e s e w o m e n , a n d six o t h e r s w h o h a d p r i o r t r a n s f u s i o n s as a p r o b a b l e c a u s e of i m m u n i z a t i o n , d e l i v e r e d 41 i n f a n t s . I n n o n e of t h e s e i n f a n t s w a s t h e r e c l i n i c a l e v i d e n c e n o r a h i s t o r y of e r y t h r o b l a s t o s i s . S e v e r a l case h i s t o r i e s m e n t i o n e d i n f a n t m o r b i d i t y a n d t w o w o m e n h a d h a d s t i l l b i r t h s , b u t d o c u m e n t a t i o n n e e d e d to e s t a b l i s h c a u s e a n d effect w a s n o t a v a i l a b l e .

136

M O L T H A N L.

Transfusions received by patients with antibodies I n f o r m a t i o n is a v a i l a b l e o n 127 p a t i e n t s w h o w e r e t r a n s f u s e d f o l l o w i n g a n t i b o d y d e t e c t i o n a n d / o r i d e n t i f i c a t i o n . E i g h t y - s i x rec e i v e d c o m p a t i b l e t r a n s f u s i o n s exclusively, 17 r e c e i v e d i n c o m p a t i b l e t r a n s f u s i o n s only, a n d 24 p a t i e n t s r e c e i v e d a m i x t u r e of c o m p a t i b l e a n d i n c o m p a t i b l e d o n o r r e d cells u n i t s . T h e d a t a r e l a t i v e to a n t i b o d y s p e c i f i c i t y is p r e s e n t e d i n T a b l e I. S i n c e 38 of t h e 41 p a t i e n t s who received incompatible transfusions were not under direct o b s e r v a t i o n s b y t h e a u t h o r , t h e d e t e r m i n a t i o n of t h e i n d i c a t i o n s for t h e t r a n s f u s i o n s is d i f f i c u l t . T h e i n d i c a t i o n c o u l d n o t b e d e t e r m i n e d i n t e n cases, w a s a n e m e r g e n c y i n 13 cases a n d a p p e a r e d to h a v e b e e n e l e c t i v e i n 18 cases. F o r six p a t i e n t s w h o r e c e i v e d i n c o m p a t i b l e t r a n s f u s i o n s , t h e i n t e n t h a d b e e n to p r o v i d e c o m p a t i b l e b l o o d . There were deficiencies in the serologic technics used in the hospitals w h i c h led to t h e i n c o m p a t i b l e t r a n s f u s i o n s . O p t i m a l t e c h n i c f o r d e t e c t i n g t h e s e a n t i b o d i e s is 60 m i n u t e i n c u b a t i o n s a t 37°C f o l l o w e d b y t h e i n d i r e c t a n t i g l o b u l i n t e c h n i c . T h e a b b r e v i a t e d 37°C i n c u b a t i o n s w h i c h a r e p a r t of e m e r g e n c y c o m p a t i b i l i t y t e s t i n g a n d L I S S p r o t o c o l s s o m e t i m e s fail to d e t e c t t h e s e a n t i b o d i e s . TABLE I Transfusions received after antibody detection in 127 patients, 1965-1981. ANTIBODY SPECIFICITY

anti-Yka anti-Csa anti-Yka + Csa anti-McCoys anti-Kna anti-McCoy + Knop s

# PATIENTS TRANSFUSED 54

TRANSFUSIONS TRANSFUSIONS TRANSFUSIONS INCOMPATIBLE BOTH COMPATIBLE COMPATIBLE AND INCOMPATIBLE ONLY ONLY

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40

15

9

42

29

16

8

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Six patients, three with anti-Yka, two with anti-McC d, and one with antiMcCoy + Knops received incompatible units inadvertently, due to deficient technic. T a b l e I I lists t h e t r a n s f u s i o n i n f o r m a t i o n a n d t h e i n t e r p r e t a t i o n s of t h e o u t c o m e s o n 21 p a t i e n t s w h o r e c e i v e d i n c o m p a t i b l e b l o o d . T h e list is c o m p r i s e d of t h e 15 p a t i e n t s w h o s e case h i s t o r i e s a r e presented; three patients who were transfused when in extremis a n d w h o d i e d w i t h i n h o u r s ; a n d t h e t h r e e cases of WELLS et al. [14];

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p a t i e n t s , no p o s t - t r a n s f u s i o n d a t a w e r e p r o v i d e d a n d following the incompatible transfusions are not known. a n d l a b o r a t o r y f i n d i n g s of t h e p a t i e n t s w i t h case s u m m a r i z e d in T a b l e I I I . DISCUSSION

One of the c r i t e r i a u s e d to j u d g e b i o l o g i c a l s i g n i f i c a n c e of aiMa n t i b o d i e s is the f i n d i n g of d o c u m e n t e d cases of h e m o l y t i c t r a n s f u s i o n reactions a n d / o r e r y t h r o b l a s t o s i s fetalis in t h e l i t e r a t u r e . If t h e l i t e r a t u r e s e a r c h w e r e to r e v e a l no d o c u m e n t e d cases of t h e s e diseases d u e to a p a r t i c u l a r g r o u p of a l l o a n t i b o d i e s , one m i g h t conclude t h a t t h o s e a n t i b o d i e s h a d no b i o l o g i c a l significance. This could be an e r r o n e o u s c o n c l u s i o n u n l e s s the l i t e r a t u r e s e a r c h p r o v i d e d d o c u m e n t e d cases of s u c c e s s f u l t r a n s f u s i o n s of i n c o m p a t i b l e b l o o d a n d / o r successful pregnancy results with antigen positive infants delivered of m o t h e r s w h o h a d t h e a n t i b o d i e s . The l i t e r a t u r e s e a r c h r e v e a l e d no cases of e r y t h r o b l a s t o s i s fetalis due to anti-YkL anti-Cs", anti-McCoy, n o r a n t i - K n ". The t w o references to s u c c e s s f u l p r e g n a n c y r e s u l t s d e s c r i b e a K n ( a + ) i n f a n t b o r n to a w o m a n w i t h a n t i - K n ~ [1] a n d a M c e ( a + ) i n f a n t d e l i v e r e d of a w o m a n w i t h anti-McC" [2]. The l i t e r a t u r e s e a r c h r e l a t i v e to d o c u m e n t e d cases of h e m o l y t i c transfusion reactions was frustrating. The o r i g i n a l m a n u s c r i p t s d e s c r i b i n g the n e w a n t i g e n s Cost [3], Y o r k [7], K n o p s [5], a n d McCoy [8], w e r e w r i t t e n to d o c u m e n t t h e n e w specificities, to d e t a i l their serologic c h a r a c t e r i s t i c s , a n d to p r o v i d e p o p u l a t i o n a n d f a m i l y data. Little a t t e n t i o n w a s p a i d to the b i o l o g i c a l s i g n i f i c a n c e of t h e new a n t i b o d i e s . The m a n u s c r i p t on Cost c o n t a i n s no m e n t i o n of t r a n s f u s i o n s f o l l o w i n g a n t i b o d y d e t e c t i o n in t h e t h r e e p a t i e n t s rep o r t e d to have anti-Cs ~. The m a n u s c r i p t on K n o p s r e p o r t e d t h e use of K n ( a - - ) t r a n s f u s i o n s in one p a t i e n t w i t h a n t i - K n ~ a n d t h e i n a d v e r t e n t t r a n s f u s i o n of t w o u n i t s of K n ( a + ) b l o o d in a s e c o n d p a t i e n t w i t h t h a t a n t i b o d y . T h e r e w a s no clinical d a t a in t h e m a n u s c r i p t r e l a t i v e to this p a t i e n t a n d t h u s no c o n c l u s i o n c a n b e r e a c h e d c o n c e r n i n g t h e success of t h e a n t i g e n p o s i t i v e t r a n s f u s i o n s . The a r t i c l e on Y o r k m e n t i o n s a p a t i e n t w h o r e c e i v e d 44 c o m p a t i b l e and 20 i n c o m p a t i b l e t r a n s f u s i o n s in 1969. The p a p e r d e s c r i b e s t h e d e v l o p m e n t of p o s i t i v e d i r e c t a n t i g l o b u l i n r e a c t i o n s a n d m a d e t h e o b s e r v a t i o n t h a t i n t r a v a s c u l a r h e m o l y s i s d i d n o t occur. The t h r e e cases p u b l i s h e d b y WELLS, et al. [14], w e r e i n t e r p r e t e d by the a u t h o r s as p r o v i d i n g e v i d e n c e t h a t the a n t i b o d i e s w e r e n o t clinically significant.

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Oca., anti-McC a, h a d a 51Cr study of M c C ( a ÷ ) red cells with survival of 97% at one h o u r and a T½ calculated to be 15 days based on a four day study. He then received eight compatible and three incompatible units during m a j o r surgery. Mil., anti-McCL h a d a sJCr study of M c C ( a + ) red cells with survival of 99% at one h o u r and a T½ calculated to be 22 days based on a 13 day study. He received nine compatible and one incompatible units during m a j o r surgery. If the incompatible units were t r a n s f u s e d initially, evidence of shortened cells survival would not exist. The sequence of the transfusions was not mentioned. Both patients developed positive direct antiglobulin reactions. The third patient, Kit., with anti-KnL had ~lCr survivals of incompatible red cells of 87% and 89% at one hour. He received 42 incompatible and five compatible transfusions and had positive direct antiglobulin reactions t h r o u g h o u t . It is quite possible that he h a d a continual extravascular hemolytic transfusion reaction. It is m y opinion that the data provided on these three cases can only be considered as u n i n t e r p r e t a b l e relative to judging the efficacy of the transfusions. The m a n u s c r i p t w h i c h r e p o r t e d the McC '~ antigen [8] describes the experience of C. Keller. This patient is again p r e s e n t e d in the case history section of this p a p e r since new clinical data b e c a m e available in 1980. I n reviewing the differential agglutination studies p e r f o r m e d in 1975, the s e r u m used to detect McC~ as a d o n o r cell m a r k e r was s h o w n later to be anti-McC~+Kn ~ and the patient's own ceils were K n ( a + ) . I n retrospect, the i n t e r p r e t a t i o n of the results using N as a d o n o r cell m a r k e r are confused by the fact that one of the compatible donors is NN. Sophistication in p e r f o r m i n g and interpreting differential agglutination studies in post-transfusion samples was limited in 1975. The m a n u s c r i p t also mentions five other patients with anti-McC" w h o received incompatible transfusions with no evidence of intravascular hemolysis. The s t a t e m e n t refers to Oca., Mil., Keller, M.L. and I.W. The latter two cases are described herein. TILLEY et al. [13] in 1977 r e p o r t e d on a 51Cr study of Y k ( a + ) red cells in a patient with anti-Yk ". There was 89% cell survival of the tagged ceils at 23 hours, a value i n t e r p r e t e d as n o r m a l u n d e r the study conditions. SHORE et al. [12] in 1978 describe a ~ICr study in a patient with anti-Cs" and a similar study in a patient with anti-Yk ~. They stated "essentially n o r m a l survival was observed (T½ 21.5 d a y s ) " in the Cs" case and "survival of tagged cells was n o r m a l (T½ 20 d a y s ) " in the Yk ~ case. These studies d o c u m e n t only the success of test doses of tagged incompatible red cells since full units of incompatible blood were not given.

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GRIFFITH ]'4] in 1978 r e p o r t e d on one p a t i e n t with anti-Kn a w h o was t r a n s f u s e d exclusively w i t h K n ( a - - ) blood. RYDEN [11] in a Letter to the E d i t o r r e p o r t s the successful experience of a p a t i e n t w i t h anti-Yk ~ w h o received one c o m p a t i b l e and f o u r i n c o m p a t i b l e units during a surgical p r o c e d u r e . The d a t a needed to d o c u m e n t this result are not included in the report. MOLTHAN et al. [10] describe a p a t i e n t w h o experienced multiple e x t r a v a s c u l a r h e m o l y t i c t r a n s f u s i o n reactions due to anti-Yk~+Cs ~, I t is u n f o r t u n a t e t h a t the w o r k s h o p b o o k l e t High-Titer LowAvidity Antibodies, Recognition and Resolution [15], did not address the p r o b l e m of the biological significance of York, Cost, McCoy and Knops. The r e f e r e n c e l a b o r a t o r y s y s t e m in the United States and Canada m a k e s it difficult f o r these l a b o r a t o r i e s to obtain follow-up information on p a t i e n t s w h o s e b l o o d s a m p l e s have b e e n received and studied. Hence, data concerning t r a n s f u s i o n s a d m i n i s t e r e d a f t e r a n t i b o d y detection h a v e b e e n o b t a i n e d on only 127 patients. Eight-six patients received c o m p a t i b l e t r a n s f u s i o n s exclusively and 41 patients received i n c o m p a t i b l e blood. T h e r e w e r e no r e p o r t s of t r a n s f u s i o n reactions in the p a t i e n t s w h o received c o m p a t i b l e transfusions. Since anti-Yk a, - - C s ~, - - M c C o y , a n d anti-Kn a are coating antibodies of i m m u n o globulin class IgG, they m i g h t be expected to cause h e m o l y t i c transfusion reactions of the e x t r a v a s c u l a r type (EHTR).

The m a n i f e s t a t i o n s of E H T R clinically are unexplained a n e m i a with or w i t h o u t u n e x p l a i n e d jaundice. Chilis, fever, aches, n a u s e a and v o m i t i n g m a y also occur. More rarely DIC, renal shutdown, a n d h e m o g l o b i n u r i a have b e e n r e p o r t e d . Unexplained a n e m i a is defined as either a decrease in h e m o g l o b i n levels following the a t t a i n m e n t of expected levels following t r a n s f u s i o n a n d / o r the failure to attain expected levels following transfusion. The collaborative l a b o r a t o r y findings in E H T R such as anemia, reticulocytosis, b u r r cells, spherocytes, h y p e r b i l i r u b i n e m i a , h y p o h a p t o g l o b i n e m i a , increased urobilinogen and h e m o s i d e r i n in the urine are all signs of increased d e s t r u c t i o n of red blood cells regardless of etiology. The i m m u n o h e m a t o l o g i c findings of i n c o m p a t i b i l i t y of donors' red cel]s, positive direct antiglobulin tests, the finding of the specific a n t i b o d y in eluates and the d e m o n s t r a t i o n b y differential agglutination of loss of d o n o r s ' red cells, give p r o o f t h a t the increased red cell d e s t r u c t i o n is due to the p a t i e n t ' s specific a n t i b o d y destroying the donors' red cells. Antibody r e s p o n s e is also u s e d as a criterion of i n c o m p a t i b i l i t y of d o n o r blood. I t is evident in the case r e p o r t s t h a t the data used to d o c u m e n t h e m o l y t i c t r a n s f u s i o n reactions w e r e available in varying degrees.

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All the data which exist have been included. I n the 10 cases diagnosed as HTR, all experienced anemia as a result of the incompatible transfusions. Eight developed positive direct antiglobulin tests due to the incompatibilities, the o t h e r two were not tested. Four ddveloped hyperbilirubinemia, four were not so tested and two had pre-existing h y p e r b i l i r u b i n e m i a w h i c h h i n d e r e d interpretation of the data post-transfusion. Poor d o n o r cell survival observed on differential agglutination studies [10] was present in seven cases, but not studied in three cases. I n c r e a s e in strength of the a n t i b o d y was observed in the eight cases so studied. Reticulocytosis was observed in the three patients so tested. The patient who experienced intravascular hemolysis h a d h e m o g l o b i n e m i a and hemoglobinuria. It is hypothesized that since he h a d anti-Bg ~ he could also have had HLA antibodies. These c o m b i n e d with the anti-Yk ~ m i g h t have triggered the c o m p l e m e n t cascade p r o d u c i n g intravascular hemolysis. A similar case who had anti-Bg~ and a York-like antibody and intravascular hemolysis has been r e p o r t e d [9]. Two patients with extravascular hemolysis had renal failure. The diagnosis of hemolytic transfusion reaction was m a d e on the basis of clinical and l a b o r a t o r y data which d o c u m e n t e d increased d e s t r u c t i o n of d o n o r s ' red cells due to incompatibility. Adequate m o n i t o r i n g of patients who have received incompatible transfusions, w h e t h e r u n d e r e m e r g e n c y or elective conditions, is very difficult. Definitive l a b o r a t o r y tests are expensive and m a y not be ordered for that and o t h e r reasons. There is often a sense of guilt felt on the p a r t of the t r a n s f u s i o n service personnel for their inability to provide compatible blood. F u r t h e r complicating this area, are the medical-legal considerations relative to missed incompatibilities secondary to deficient technic, the intentional use of incompatible transfusions in elective clinical situations, and o t h e r legal matters such as m a l p r a c t i c e in the diagnosis or t r e a t m e n t of patients which led to the need for transfusions. I n early 1979, the fact that there was c o n t r o v e r s y concerning the biological significance of these antibodies in the t r a n s f u s i o n situation was b r o u g h t to m y attention. For this reason, a great effort was made to obtain p e r t i n e n t clinical data on all patients whose blood samples were studied at the reference laboratory. Data on 113 of the 147 referrals since 1978 were obtained. Forty-two were not transfused b u t 10 of these h a d compatible d o n o r units available to cover potential needs during surgery or delivery. Nine patients have a u t o d o n a t e d for frozen blood p r o g r a m s . Of the 71 patients who were transfused after antibody detection, 55 or 77.5% received compatible units exclusively, autologous in three cases, h o m o l o g o u s

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in 52. During the period f r o m 1966 t h r o u g h 1978, 31 or 55.4% of the 56 t r a n s f u s e d patients received compatible units exclusively. Of the 16 patients who received incompatible transfusions since 1978, five were on the basis of deficient " c r o s s - m a t c h " technic and three were t r a n s f u s e d as emergencies w h e n the patients were in extremis. Case history 3 describes a n o t h e r patient electively transfused with incompatible units. The remaining seven cases are ones on w h o m no clinical data have been obtainable. The decision w h e t h e r to t r a n s f u s e compatible or incompatible d o n o r blood into patients with these or with any unexpected antibodies is the responsibility of the hospital physicians: the patient's attending physician and the physician director of the transfusion service. The attending physician has the ultimate authority, responsibility and liability in t h i s regard. He or she m u s t rely heavily on the expertise of the t r a n s f u s i o n service physician and b o t h should consult with the hospital's blood b a n k technologists and with the professionals of their regional blood center and reference laboratory. E v e r y o n e should have access to the c u r r e n t literature. The t r a n s f u s i o n practices which have taken place since 1978 suggest that the hospital personnel either consider that the antibodies u n d e r discussion are potentially significant or they consider that patients should receive compatible blood, whenever time permits, regardless of the specificities of their alloantibodies. This is excellent practice w h a t e v e r the motive. It is particularly so in the case of York, Cost, McCoy and Knops antibodies since almost one-half of these sera have contained additional alloantibodies, some of w h i c h were not identified initially. The use of compatible d o n o r blood avoids the potential for hemolytic t r a n s f u s i o n reactions due to b o t h the recognized and the unrecognized antibodies. Of the 71 patients with these antibodies who were t r a n s f u s e d since 1978, the intent was to transfuse compatible blood in at least 62 cases and compatible units were available for 10 o t h e r patients who were not transfused. The regional blood centers involved c o o p e r a t e d fully in carrying out the intent to transfuse compatible blood. R e p o r t of 5JCr studies have been collected on 15 patients. The results have been expressed in different ways and details of the technics used are available in varying degrees. According to MOLLISON [6], n o r m a l survivals are 96% at 24 hours, 94% at 48 hours, 92% at 72 hours, 85% at seven days, and 50% at 30 days. The result expressed as T½ is i n t e r p r e t e d to m e a n T50 and the n o r m a l T50 is 30 days. Unpublished slCr studies r e p o r t e d herein include a T50 of seven days in a patient with anti-Yk ~. The patient received compatible

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t r a n s f u s i o n s d u r i n g s u b s e q u e n t c a r d i a c surgery. The p a t i e n t w i t h a TS0 of 5.3 days f o r M c C ( a + ) ceils is d e s c r i b e d in the case h i s t o r y s e c t i o n 14. A p a t i e n t w i t h anti-McC d h a d a T50 of 21 days b u t was n o t s u b s e q u e n t l y t r a n s f u s e d . A p a t i e n t w h o s e T50 was 22 h o u r s w i t h K n ( a + ) ceils r e c e i v e d a u t o l o g o u s b l o o d d u r i n g l a t e r c a r d i a c surgery. F u r t h e r r e p o r t s i n c l u d e a 97% s u r v i v a l at one h o u r in a p a t i e n t w i t h anti-McC"+Kn~ who was later transfused with compatible blood d o n a t e d b y relatives; a 74% s u r v i v a l at 48 h o u r s in a n o t h e r p a t i e n t w i t h a n t i - M c C ~ + K n a w h o w a s t h e n t r a n s f u s e d w i t h s e v e r a l incomp a t i b l e units. Clinical d a t a on t h e l a t t e r case have n o t b e e n p r o v i d e d . A case w i t h anti-McC ~ s h o w e d 91% s u r v i v a l at one h o u r a n d 82% at 48 h o u r s b u t t h e r e a r e no o t h e r d a t a on this p a t i e n t ; a n o t h e r w i t h anti-McC ~ s h o w e d s u r v i v a l s of 94% at 24 h o u r s , 69% at 48 h o u r s a n d 66% at 96 h o u r s ; he h a s n - f r e c e i v e d t r a n s f u s i o n s since t h e study. The final p a t i e n t , w h o h a s anti-McC d, s h o w e d 82% s u r v i v a l at 24 h o u r s . Clinical d a t a on this case has n o t b e e n p r o v i d e d . I t is u n f o r t u n a t e t h a t in t h o s e cases w h e r e i n c o m p a t i b l e t r a n s f u sions w e r e given f o l l o w i n g 51Cr studies, t h a t e i t h e r t h e efficacy of the transfusions was not documented a n d / o r the documentation has b e e n w i t h h e l d f r o m me. I t is only t h r o u g h s t u d i e s to d o c u m e n t efficacy of i n c o m p a t i b l e t r a n s f u s i o n s f o l l o w i n g 51Cr s t u d i e s t h a t t h e value of t h e s e t e s t s can be d e t e r m i n e d . This is t r u e also f o r t e s t s such as IgG s u b c l a s s i n g a n d m a c r o p h a g e assays. ~lCr s t u d i e s a r e n o t g e n e r a l l y a v a i l a b l e in h o s p i t a l s a n d t h e o t h e r t e s t s a r e d o n e in only a few r e f e r e n c e l a b o r a t o r i e s . None have p e r t i n e n c e in emergency cases. The p r o b l e m p r e s e n t e d w a s w h e t h e r a l l o a n t i b o d i e s d i r e c t e d a g a i n s t t h e r e d b l o o d cell a n t i g e n s , YkL Cs a, McCL McC d, a n d Kn ~ a r e biologically significant. The e x p e r i m e n t a l m e t h o d s u s e d w e r e a l i t e r a t u r e s e a r c h a n d an a n a l y s i s of d a t a on 304 p a t i e n t r e f e r r a l s . The liter a t u r e s e a r c h r e v e a l e d no cases of e r y t h r o b l a s t o s i s fetalis a n d two r e f e r e n c e s to t h e s u c c e s s f u l p r e g n a n c y o u t c o m e s of a n t i g e n p o s i t i v e infants. The a n a l y s i s of the p a t i e n t r e f e r r a l s s h o w e d 11 p r e g n a n c y i m m u n i z a t i o n s a n d no h i s t o r y of e r y t h r o b l a s t o s i s fetalis in 41 i n f a n t s d e l i v e r e d of m o t h e r s h a v i n g t h e s e a n t i b o d i e s . The p o t e n t i a l does exist, h o w e v e r , for m i l d cases of e r y t h r o b l a s t o s i s fetalis since t h e a n t i b o d i e s a r e IgG a n d t h e a n t i g e n s a r e well d e v e l o p e d on c o r d cells. T h e l i t e r a t u r e s e a r c h p r o v i d e d one d o c u m e n t e d case of h e m o l y t i c t r a n s f u s i o n r e a c t i o n a n d one u n d o c u m e n t e d c a s e of s u c c e s s f u l t r a n s fusions of i n c o m p a t i b l e b l o o d . The a n a l y s i s of the p a t i e n t r e f e r r a l s p r o d u c e d t w o cases of p r o b a b l e s u c c e s s f u l t r a n s f u s i o n s of incomp a t i b l e b l o o d , nine cases of e x t r a v a s c u l a r h e m o l y t i c t r a n s f u s i o n r e a c t i o n s a n d one case of i n t r a v a s c u l a r h e m o l y t i c t r a n s f u s i o n r e a c t i o n .

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I a m concluding, therefore, t h a t alloantibodies directed against Yk a, Cs", the McCoy antigens, and Kn ~ are biologically significant in the t r a n s f u s i o n situation. As w i t h any alloantibody, c o m p a t i b l e d o n o r b l o o d should be p r o v i d e d for all elective transfusions, and the intentional use of i n c o m p a t i b l e b l o o d m u s t b e r e s e r v e d for lifet h r e a t e n i n g exsanguinations a n d t r u e e m e r g e n c y surgeries. Recipients should have the benefit of n o r m a l d o n o r cell survival w h e n e v e r possible. ABSTRACT The biological significance of alloantibodies directed against the red b l o o d cell antigens York, Cost, McCoy, and K n o p s has b e e n investigated by m e a n s of a l i t e r a t u r e search and an analysis of 304 p a t i e n t r e f e r r a l s received since 1965. N e i t h e r m e t h o d detected d o c u m e n t e d cases of e r y t h r o b l a s t o s i s fetalis due to these antibodies. The analysis of the p a t i e n t r e f e r r a l s identified 11 w o m e n i m m u n i z e d b y pregnancy. The l i t e r a t u r e search p r o v i d e d one d o c u m e n t e d case of h e m o l y t i c t r a n s f u s i o n r e a c t i o n a n d one p r o b a b l e case of successful t r a n s f u s i o n of i n c o m p a t i b l e blood. The analysis of the p a t i e n t r e f e r r a l s revealed two cases of p r o b a b l e successful t r a n s f u s i o n s of i n c o m p a t i b l e blood, nine p a t i e n t s w i t h d o c u m e n t e d evidences of e x t r a v a s c u l a r h e m o l y t i c t r a n s f u s i o n reactions, and one patient w i t h d o c u m e n t e d evidence of i n t r a v a s c u l a r h e m o l y t i c t r a n s f u s i o n reaction. The conclusion r e a c h e d is t h a t alloantibodies directed against the York, Cost, McCoy, and K n o p s antigens are biologically significant w i t h r e s p e c t to red b l o o d cell t r a n s f u s i o n s in some patients. Transfusion p r a c t i c e s show t h a t m o s t patients have received c o m p a t i b l e transfusions, a n indication t h a t the physicians in the hospitals a d h e r e to the p h i l o s o p h y of c o m p a t i b l e transfusions, w h e n e v e r possible. RESUME I m p o r t a n c e biologique des alloanticorps York, Cost, McCoy et Knops. L ' i m p o r t a n c e biologique des alloanticorps dirig6s contre les antig6nes 6 r y t h r o c y t a i r e s York, Cost, McCoy et K n o p s est pr6sent6e la suite d'une r e c h e r c h e de la litt6rature et d ' u n e analyse de 304 cas de p a t i e n t s re~us en c o n s u l t a t i o n depuis 1965. Ces 6tudes n ' o n t pas r6v616 de cas d o c u m e n t 6 s d ' 6 r y t h r o b l a s t o s e f6tale a t t r i b u a b l e s h ces anticorps. L'analyse des cas re~us en consultation a p e r m i s d'identifier onze f e m m e s i m m u n i s 6 e s p a r grossesse. L'dtude de la litt6rature

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p r 6 s e n t e u n cas de r 6 a c t i o n t r a n s f u s i o n n e l l e h 6 m o l y t i q u e e n p l u s d ' u n cas d e r 6 u s s i t e t r a n s f u s i o n n e l l e p r o b a b l e e n p r 6 s e n c e d e s a n g i n c o m patible. L'analyse des cas re~us en consultation donne deux cas de r6ussite transfusionnelle probable face au sang incompatible, neuf patients dormant preuve documentable de r6action transfusionnelle h 4 m o l y t i q u e e x t r a v a s c u l a i r e , et u n p a t i e n t d o n n a n t p r e u v e d o c u m e n table de rdaction transfusionnelle h6molytique intravasculaire. I1 f a u t c o n c l u r e q u e les a n t i c o r p s d i r i g 6 s c o n t r e les a n t i g 6 n e s York, Cost, M c C o y , e t K n o p s o n t u n e i m p o r t a n c e b i o l o g i q u e signific a t i v e p a r r a p p o r t h la t r a n s f u s i o n d ' h 6 m a t i e s e h e z c e r t a i n s p a t i e n t s . Les p r o t o c o l e s d e t r a n s f u s i o n d 6 m o n t r e n t q u e la p l u p a r t d e s p a t i e n t s o n t re~u d e s t r a n s f u s i o n s d e s a n g c o m p a t i b l e et c e c i i n d i q u e q u e les m 6 d e c i n s d e s h 6 p i t a u x a d h 6 r e n t ~ la p h i l o s o p h i e d e t r a n s f u s i o n c o m p a t i b l e l o r s q u e celle-ci e s t d a n s le d o m a i n e d u p o s s i b l e . Request r e p r i n t s f r o m : Lyndall MOLTHAN, Miller M e m o r i a l Blood Center 2100 W e s t g a t e Drive P.O. Box 2867 BETHLEHEM. Pa. 18001. U.S.A.

REFERENCES [1] ESKA P., ROSCHE E., GRINDON A. - - Uneventful delivery of p a t i e n t with a n t i b o d y in K n o p s group. L e t t e r to the editor, Transfusion, 16, 190-191, 1976. [2] FERGUSON S. - - Studies on the Knops-McCoy b l o o d group system. Canad. J. Med. Tech. (in press), 1981. [3] GILES C.M., HuTrI M.C., WILSON T.E., LEWIS H.B.M., GROVE. G.E.B. - - Three examples of a n e w antibody, anti-Cs ~. Vox Sang., 10, 405415, 1965. [4] GRIFFITH E.M. - - Massive t r a n s f u s i o n during m a j o r s u r g e r y in a child w i t h anti-Knops a a n d one kidney. Transfusion, 18, 562-565, 1978. [4] HELGESON M., SWANSON J., POLESKY H.E. - - Knops-Helgeson (Kn~), a high-frequency e r y t h r o c y t e antigen. Transfusion, 10, 137-138, 1970. [6] MOLLISON P.L. - - Blood T r a n s f u s i o n in Clinical Medicine, 6th ed. Blackwell, p. 27, 1979. [7] MOLTHANL., GILES C.M. - - A n e w antigen, Yk ~ (York) and its relationship to Cs ~ (Cost). Vox Sang., 29, 145-153, 1975. [8] MOLTHAN L., MOULDS J.J. - - A new antigen McC ~ (McCoy) a n d its relationship to K n a (Knops). Transfusion, 18, 566-568, 1978. .[9] MOLTHAN L. - - T r a n s f u s i o n r e a c t i o n p r e s u m a b l e due to anti-Bg a. Letter to the editor. Transfusion, 19, 103, 1979.

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[10] MOLTHAN L., GROSS B.M., WICK R. - - E x t r a v a s c u l a r h em o l y t i c transfusion reactions due to anti-Yka+Cs ~. Blood Transfusion and I m m u n o haematoIogy, 24, 263-271, 1981. [11] RYDEN S.E. - - Successful t r a n s f u s i o n of a p at i en t with anti-Yk a. L e t t e r to the editor. Transfusion, 21, 130, 1981. [12] SHORE G.M., STEANE E.A. - - Survival of i n c o m p a t i b l e red cells in a p a t i e n t w i t h anti-Cs ~ and t h r e e o t h e r patients w i t h antibodies to high f r e q u e n c y r e d cell antigens. (Abstract). Transfusion, 18, 387, 1978. [13] TILLEY C.A., CROOKSTON M.C., HADDADS,A., SHUMAK K.H. - - Red blood cell survival studies in patients w i t h anti-Ch ~, anti-Yk ~, anti-Ge and anti-Vel. Transfusion, 17, 169-172, 1977. [14] WELLS R.F., KORN G., HAFLEIG~I B., GRUMET F.C. - - Characterization of t h r ee n ew a p p a r e n t l y r e l a t e d high f r e q u e n c y antigens. Transfusion, 16, 427-433, 1976. [15] A m e r i c a n Association of Blood Banks W o r k s h o p b o o k l e t : High-titer low-avidity antibodies, r e c o g n it io n and resolution, 1979.