Volume 43, October 2003

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Blackwell Science, LtdOxford, UKTRFTransfusion0041-11322003 American Association of Blood BanksOctober 20034310Original Article

ACUTE HEMOLYSIS CAUSED BY CHIMERIC RBCPRUSS ET AL.

From the Institute for Transfusion Medicine, Clinic for

Anesthesiology, and Clinic for Rheumatology and Clinical

Immunology, University Hospital Charité, Humboldt University,

Berlin, Germany.

Address reprint requests to:

Axel Pruss, MD, Institute for

Transfusion Medicine, University Hospital Charité, Campus

Charité Mitte, Schumannstr. 20/21, D-10117 Berlin, Germany;

e-mail: axel.pruss@charite.de.

Received for publication March 3, 2003; revision received

April 14, 2003, and accepted May 23, 2003.

TRANSFUSION

2003;43:1449-1451.

T R A N S F U S I O N C O M P L I C A T I O N S

Acute intravascular hemolysis after transfusion ofa chimeric RBC unit

Axel Pruss, Guido A. Heymann, Anette Hell, Ulrich J. Kalus, Dietmar Krausch, Thomas Dörner,

Holger H. Kiesewetter, and Abdulgabar Salama

BACKGROUND:

Natural blood cell chimerism rarely occurs in humans. The case of a patient who developed transfusion reaction due to the transfusion of chimeric RBCs is reported.

CASE REPORT:

A 61-year-old male patient with blood group O received two units of packed and O-grouped RBCs after elective kidney surgery. Immediately after blood transfusion, the patient developed a hemolytic transfusion attack. The serologic re-examination revealed only a mixed-field pattern of agglutination of RBCs in one of the two transfused units. The donor of this unit was an apparently healthy 24-year-old male with a twin sister. Both of them showed an identical mixture of roughly 95 percent group O and 5 percent group B RBCs by gel agglutination technology and flow cytometry. The results were also confirmed by ABO blood group genotyping.

CONCLUSIONS:

This is the first report of a hemolytic transfusion reaction related to the transfusion of chimeric RBCs.

uman blood group chimerism is a rare phe-nomenon that can occur during the fetaldevelopment of dizygotic twins, triplets, andtetragametic (dispermic) chimeras and, in

isolated cases, in unrelated individuals (unestablishedtype).

1,2

Because the proportions of the different cell pop-ulations associated with chimerism are highly variable,some cases may escape detection.

3

Chimerism-associatedhemolysis is a well-known syndrome associated with BMTand, less commonly, with solid organ transplantation.

4-7

Immune hemolysis due to the transfusion of chimericRBCs has never been described before.

CASE REPORT

A 61-year-old male Caucasian underwent surgery forresection of a multilocular renal cell carcinoma of the rightkidney. After surgery, the patient was transferred to theintensive care unit because of severe hypertension. Threedays after surgery, his Hb level declined from 12.4 to 10.6 gper dL, and two units of packed and O-grouped RBCs wereadministered. The patient’s blood group was O ccD.Ee,K-, and antibody screening test including autocontrol wasnegative.

Approximately 30 minutes after transfusion, thepatient developed chills, tachypnea, tachycardia, andhemoglobinuria. His free plasma Hb level increased fromless than 2 to 25.2 mg per dL, and lactate dehydrogenaseincreased from 225 to 435 units per L. The hemolysis sub-sided within a few hours, and the patient did not requirefurther blood transfusions.

MATERIALS AND METHODS

Serologic tests

ABO grouping, Rh typing, antibody screening, cross-matches, and DAT and IAT were performed by conven-tional test tube and/or gel cards (DiaMed, Cressiers/Morat, Switzerland). Elution was performed with anRBC acid-elution system (R-E-S, Immucor, Roedermark,Germany).

H

PRUSS ET AL.

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Detection of chimerism by flow cytometry analysis

The flow cytometry analysis was performed on RBCs usinga flow cytometer (FACScan, Becton-Dickinson, San Jose,CA).

8

For B and D antigen detection, we used MoAbs(anti-B-clon BS72IgG1, anti

D

-clon BS221, Biotest, Dreie-ich, Germany) and fluorescein-conjugated goat anti-mouse F(ab

¢

)

2

fragments (Jackson Immunoresearch, WestGrove, PA) as the secondary antibody.

Blood group genotyping

The presence of twin chimeras was also confirmed byABO blood group genotyping of the twins and the daugh-ter of donor’s sister. We used previously describedprimers

9

and the PCR sequence-specific primer (SSP)technique. The polymorphic positions 261 and 297 inexon 6 and positions 796, 802, and 1059 in exon 7 of theABO-transferase gene were tested.

RESULTS

The serologic analysis of patients and donors revealed thatthe DAT of the patient became positive and that the RBCsof one of the two transfused units showed a mixed-fieldpattern of agglutination (see Table 1). The donor of thisunit was an apparently healthy 24-year-old male with atwin sister. In the serologic and flow cytometric tests, thedonor and his sister showed an identical mixture ofroughly 95 percent group O and 5 percent group B RBCs(Figs. 1 and 2). Similar results were also seen with D anti-gens (Fig. 2). In addition, only anti-A isoagglutinins weredetected in their serum samples. The results of bloodgroup genotyping reflected strong amplification of groupO alleles and weak amplification of group B alleles in bothcases (Fig. 3). Unfortunately, blood samples of the parentsof the twins were not available for testing. However, theblood group of the mother was documented as B and ofthe father as O.

DISCUSSION

The first report of blood cell chimerism in twins

10

waspublished 50 years ago, and more than 100 cases havesince been described in the literature.

1,3,11

However, mostof the reported cases have dealt with serologic and/or

TABLE 1. Results of serologic re-examination

*

Test Patient

Transfused RBC units

1 2ABO O O O (B)

mix fieldRh (D) D

+

D

+

D- (D

+

)mix field

anti-A

+

+

+

+

NT NTanti-B (isoagglutinins)

+

+

+

+

(anti-B-titer: 4)NT NT

Antibody screening – NT NTDAT C3d

+

+

, IgG

+

NT NTEluate – NT NTCrossmatch (

+

)

* Agglutination score:

+

+

+

+

=

very strong,

+

+

+

=

strong,

+

+

=

moderate,

+

=

weak, (

+

)

=

very weak, –

=

negative. NT

=

not tested.

Fig. 1.

Group O and B mixed-field pattern of the donor.

Fig. 2.

ABO and D populations of the chimeric donor (FACS).

ACUTE HEMOLYSIS CAUSED BY CHIMERIC RBC

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genetic markers.

12-15

In the present study, we describe apatient who developed an acute hemolytic transfusionreaction after the transfusion of a chimeric blood unitcontaining group O and only a small amount of group BRBCs. The minor population of B cells could be quanti-tated by gel agglutination test, flow cytometry, andblood group genotyping. The transfused chimeric unithad a total volume of 281 mL. Thus, the transfusedincompatible RBC volume amounted to only about15 mL of RBCs. Although the affected patient had detect-able anti-B hemolysin (titer 4), the reason why evensmall amounts of ABO-mismatched RBCs can causemassive reactions in some patients remains largelyobscure.

It is worth mentioning that a discrepancy betweenRBC and serum grouping results was already apparentwhen donor’s blood was tested before the transfusion,but this discrepancy was inaccurately interpreted, andthe donor was incorrectly typed as group O. Similarly,the weak serologic incompatibility was completely over-looked before blood transfusion. Thus, accurate pro-cessing of donors is absolutely essential for maintainingtransfusion safety, and any abnormality should beclarified before the donated blood is released fortransfusion.

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Fig. 3.

Results of ABO genotyping.