NYU Langone Health Baltimore, New York, United States
Background/Case Studies: Communication and coordination of care for patients, especially those with more complex transfusion needs, is essential to provide optimal patient care. We describe a case describing joint decision-making regarding transfusion support for a patient with previously identified RBC antibodies undergoing simultaneous care at two different institutions.
Study
Design/Methods: The patient is a 16-year-old female with sickle cell disease on hydroxyurea, L-glutamine and crizanlizumab undergoing evaluation for gene therapy versus bone marrow transplant. Both transfusion services reviewed the patient’s testing and transfusion history and collaborated to provide appropriate transfusion support.
Results/Findings: Prior type and screen testing showed anti-C and anti-D-like reactivity in plasma and a strong warm autoantibody in the eluate. Subsequent antibody screens were negative. Human erythrocyte antigen (HEA) testing identified the following phenotype: D+ C- E+ c+ e+(partial). The patient received D-C-E-K- negative RBCs. Upon transfer of care, RhD and RhCE genotyping was performed, confirming the Rh genotype as RHD/RHD. Therefore, while the patient is not at risk of making an allo-anti-D, they are at risk of making an allo-anti-C and/or allo-anti-e.
A multidisciplinary meeting amongst transfusion medicine and hematologist-oncologist providers at both institutions was held to discuss transfusion support options for this patient. We evaluated the risk of continuing with the current rr RBC transfusion strategy, versus protecting against development of allo-anti-e, by transfusing R2R2 and/or r”r” RBCs. Due to the rarity of the r”r” donor pool, it was determined to be an impractical long term transfusion option. Since the patient’s little-e (variant) was historically challenged with the transfusion of > 80 units of rr RBCs over a span of 15 years without the formation of an anti-e, the consensus was to continue the rr RBC transfusion protocol.
In preparation for transplant, the patient went on to have three red cell exchanges with units phenotyped in alignment with the predetermined plan. All procedures were uneventful, and the antibody screen remains negative.
Conclusions: This case highlights the importance of transfusion service investigation into patients’ transfusion history, particularly those who will require extensive transfusion support or where there is significant risk. Our joint decision-making allowed for consensus about this patient’s transfusion strategy, as well as awareness of therapy plans between institutions.
