Anti-A1 –

? Clinical
significance
Jo Cameron
ACT Pathology
The Canberra Hospital
Case 1 – Excerpt from Patient Notes
21/1/11. Patient had a mild transfusion reaction
yesterday- clinicians thought most likely due to
hypocalcaemia, but workup done. Both pre-and post-tx
sample had a positive DCT with an anti-A1 eluted- grade
0.5 - 1 reactions against three A1 cells and negative
against 3 A2 cells. The same units are IAT crossmatch
compatible though so is not detectable in plasma.
Patient has not had intragam, so there is a possibility
that he is group A2 and has developed an anti-A1. Can't
perform a subtype to confirm whether patient is A2 due to
regular transfusions, but to be sure please perform IAT
crossmatch (A2 if available).
14/02/2011. xx
Anti-A1 not detected in plasma.
DCT positive (0.5), elution non reactive, no Anti-A1
3/6/11 xx
Full IAT XM on 2x A2 units irradiated and sent to Calvary
by the wonderful TCH staff.
Units are 3105955 and 3096056. IAT XM non-reactive.
Issued as per standard procedure.
4.8.11 xxx
After much discussion we are thinking that it is ok to
computer crossmatch (A2 units not required) this man as
we do believe that the anti-A1 was passive from his
platelet transfusions. Please review reverse group
carefully each presentation just in case.
(xx 8/8)
Hooray!!
xxx 22/08/2011
Sorry people - we have discussed this again and decided
for these types of cases we should IAT xm all units.
Should be ok to use A1 though, provided they dont react
in the crossmatch

This patient had been transfused with 2 bags of O Pooled

platelets prior to the first date on these notes.
 Case 2 – Excerpt from Patient Notes
22/03/2011 xx
Gritty reaction in A1 cells of reverse group.
Patient has been transfused with 2 doses of IvIg.
Anti-A1 was eluted from red cells (2 reaction).
27/03/2011 xx
Discrepancy again in A1 cells due to the IvIg infusions.
No blood transfusions so DCT and elution not performed.
11/04/2011 xxx
Patient typed against Anti-A1. A1 Neg.
Reverse group grade 2 against A1 cells, negative against
A2 cells. Saline 3 cell screen negative.
It has now been around a month since intragam
administered- ? lingering antibody or a true
allo-antibody. Two A2 units have been IAT crossmatched
just in case.
27/6/11 xxx
grade 3 reaction again against A1 cells. 0.5 reaction against A2
cells in tube today as well. The IAT crossmatch showed a
weak reaction against one of the A2 cells. The A1 cell showed a
grade 3 reaction in IAT.? Maybe due to some Atni-A from the
intragam- as units were crossmatch incompatible two O units
selected for crossmatch.
PLEASE NOTE: The reactions against A1 cells are much stronger
than those against A2 cells, and patient appears to be A2 group.
Please treat the Anti-A1 as a real active allo-antibody, not just one
passively acquired (ie he needs an IAT crossmatch ).
29.6.11 xx
slight mixed field with anti-A, patient has been transfused O cells.
09.07.11 xx
xm 2 O Pos units. slight mixed field in group.
13/7/11 xx
mixed field today against anti-A due to group O tx. Anti-A1 strong
today (grade 2) in IAT, no reactions against A2 cells today.
Case 3 – Excerpt from Patient notes
21/1/10 xxx
Weak reactions against A1 cells on autovue (0.5), duplicated in tube (1) after ten minutes
incubation at room temperature. Patient's red cells tested against anti-A1 = negative, with no
agglutination against a2 cells and a negatvie ab screen using room temp saline. Two units
requested, a2 units found to be issued after IAT crossmatch.

19/03/2010. xx
Same results as above.3 units issued after IAT crossmatch.

23/03/2010 xx
1 A2 and 2 ORh(D) pos crossmatched compatible.

25/03/2010 xx
2 O Rh(D)Pos units crossmatched. All clear.

14/05/2010 xxx
Level 2 group on the autoVue gives 0.5 against A1 cells, in tube cant see it at all. IAT xm gives
grade 2 reactions against A1 cells and 0 against O cells. have issued O.

17/5/10 xxx
still 0.5 against A1 cells in reverse group. Now also good mixed field in forward group due to
transfused O cells. Group O issued again today as no A2 cells available.
22.5.10 xx
Reaction against A1 cells. Xmatched 2 A2 units both clear.
26/5/10 xx
weak reaction against A1 cells, with mixed field in A forward well due to recent O
transfusions.
02/06/10 xx
2 O pos units full cross match: all clear.

5/6/10 xxx
grouping reactions as before, 1 A2 and 1 O unit found and xm'ed

07/06/2010 xx
grade 0.5 against a1 cells with mix field in anti a forward cell. two units O pos
crossmatched.
7/6/10 xx
Positive DCT today. Elution only generated weak results but showed specificity against
A1 cells only (eluate not reactive against a2 cells). This specificity a bit strange
as patient should not have any A1 cells in her circulation for the antibody to bind
to?? She has been having regular intragam infusions so not sure if this antibody is
of her own making or due to the intragam- so to be safe please crossmatch group
O cells only.
Case 4 – Excerpt from Patient notes
1/11/2010xxx
DCT positive (2), IgG Specificity (2)
Anti-A1 detected in eluate. This is deemed to be passive from IvIg
dose - do not need to IAT xmatch - can give A unit
3/11/2010xxx
- after speaking to (Haematologist) this woman is potentially showing
signs of active haemolysis so it has been decided to give this
patient O to be on the safeside......
will need elution next presentation.
10/11/2010. xxx
elution still shows anti-A. Group O units isued as per
above.
The History!
• Once upon a time at a meeting between clinical
haematologists and lab staff it was decided it was ok to
computer xmatch patients with anti-A1 if it was thought
to be passively acquired through IvIg infusion (ie found in
eluate only post IvIg infusion)
• Why? - Nobody remembers!!!
• It was suggested we apply this same ruling to passively
acquired anti-A1 from pooled platelet transfusions
• Cases above demonstrate that doesn’t work
The rules!
ANZSBT Guidelines
Antibody Screening
2.1.2.1 Pretransfusion testing must include an antibody screen capable of detecting potentially
clinically
significant red cell antibodies. Clinically significant antibodies are generally those, which are
reactive in the indirect antiglobulin test [IAT] performed at 37°C.
However, anti-A, -B and -
A,B must always be regarded as clinically significant.

Crossmatching
2.1.4.1 The laboratory must have procedures in place to exclude incompatibility between the recipient
and donor using suitable crossmatching techniques such as immediate-spin, IAT or computer
crossmatching. The
crossmatching procedures must be able to detect ABO
incompatibility.

For patients with antibodies of no or doubtful clinical significance such as anti-A1, -P1, -Lea, -
Leb, -Lea+b, auto-anti-I, -HI or other cold agglutinins reactive by IAT, select IAT crossmatch
compatible red cells. The red cells need not be antigen negative.
The Science (and the logic!)
• Cases presented above all demonstrate some
“clinical significance”

• ? Tx reaction
• ? Haemolysis
The Future………
ANZSBT Guidelines
Antibody Screening
2.1.2.1 Pretransfusion testing must include an antibody screen capable of detecting potentially
clinically
significant red cell antibodies. Clinically significant antibodies are generally those, which are
reactive in the indirect antiglobulin test [IAT] performed at 37°C.
However, anti-A, -B and -
A,B must always be regarded as clinically significant.

Crossmatching
2.1.4.1 The laboratory must have procedures in place to exclude incompatibility between the recipient
and donor using suitable crossmatching techniques such as immediate-spin, IAT or computer
crossmatching. The
crossmatching procedures must be able to detect ABO
incompatibility.

For patients with antibodies of no or doubtful clinical significance such as anti-A1, -P1, -Lea, -
Leb, -Lea+b, auto-anti-I, -HI or other cold agglutinins reactive by IAT, select IAT crossmatch
compatible red cells. The red cells need not be antigen negative.