Cancer Translational Medicine

: 2020  |  Volume : 6  |  Issue : 1  |  Page : 21--23

Best-match blood transfusion in pediatric patients with mixed autoantibodies

Debasish Mishra1, Dibyajyoti Sahoo1, Smita Mahapatra2, Ashutosh Panigrahi3,  
1 Department of Transfusion Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Transfusion Medicine, SCB Medical College, Cuttack, Odisha, India
3 Department of Clinical Hematology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Correspondence Address:
Dr. Debasish Mishra
Department of Transfusion Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha


Finding matched blood in autoimmune hemolytic anemic (AIHA) patients is extremely difficult due to autoantibodies. Generally, these antibodies directed against antigens of high prevalence. It is essential for transfusion purposes to provide blood without alloantibodies. We report three cases of mixed AIHA in children. Mixed AIHA may present with blood group discrepancy, as well as incompatibility may possess difficult situation for transfusion laboratory to provide blood units to patients. The patient must be transfused cautiously with least-incompatible, ABO and Rh/ Kell phenotype-matched packed red blood cells slowly under strict supervision and steroid cover.

How to cite this article:
Mishra D, Sahoo D, Mahapatra S, Panigrahi A. Best-match blood transfusion in pediatric patients with mixed autoantibodies.Cancer Transl Med 2020;6:21-23

How to cite this URL:
Mishra D, Sahoo D, Mahapatra S, Panigrahi A. Best-match blood transfusion in pediatric patients with mixed autoantibodies. Cancer Transl Med [serial online] 2020 [cited 2020 Aug 13 ];6:21-23
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Full Text


Autoimmune hemolytic anemic (AIHA) patient shows two critical characteristics: decreased red blood cell (RBC) survival and presence of autoantibodies. Positive direct anti-globulin test (DAT) is usually seen in patients of autoantibodies.[1]

Based on the temperature at which autoantibodies bind specifically to RBCs, AIHA is divided into warm, cold, or mixed. Warm antibody AIHA is found in 80%–90% of adult cases and peak prevalence between 60-70 years. Age of presentation in children occurs predominantly between 2–12 years of age. IgG antibodies, which bind RBCs at 37°C, cause hemolysis in warm AIHA.[2],[3],[4] Similarly, cold autoantibodies are mediated by IgM antibodies, which react with red cells maximally at 4°C. Unusual patients with mixed AIHA exhibit the presence of both cold- and warm-reactive autoantibodies.[5],[6]

Most of the times, AIHA patients require urgent blood transfusion as live-saving management. Here, we share our experience of transfusing the least-incompatible blood to pediatric patients with mixed autoantibodies.

 Case Report

Three cases of pediatric patients were admitted to the hematology department with symptoms and signs of anemia and clinical features [Table 1]. Laboratory features of three cases are shown in [Table 2]. All three cases neither received a blood transfusion nor transplanted in the past. Blood transfusion request was sent to the department of transfusion medicine and blood bank along with the blood samples for ABO, Rh D typing, and cross-match.{Table 1}{Table 2}

Immunohematological workup

In all cases, autoagglutination was found on the EDTA blood, and there was blood group discrepancy. Therefore, fresh blood sample was collected under strict warm condition. Red cell, plasma, and serum were separated at 3000 rpm for 3 min and were kept at 37°C. The red cell was washed with warm saline 5–6 times. The forward grouping was done on 5% red cell suspension along with 6% bovine albumin as control which showed no agglutination. The reverse grouping was done at 37°C with incubation for 1 h and results were interpreted without centrifugation. Blood group was confirmed as A Rh D positive in case 1 and case 2 and O Rh D positive in case 3.

Auto control means testing patient's own serum and 5% red cell suspension in three different temperatures (4°C, room temperature, 37°C) in Test tube method. There were 3+ strength of agglutination in all temperatures. Polyspecific direct agglutination test (IgG + C3d, Tulip Diagnostics, Goa, India) was done in standard test tube method. Then, monospecific DAT was done using IgG, C3d antisera separately. Both polyspecic and monospecic DAT became 3+ strength of reaction with IgG and C3d specificity. Antibody screening and identification (Ortho Clinical Diagnostics, USA) showed panagglutination (2+) at immediate spin, 37°C, and Coombs phase. Cold agglutinin titers at 4°C were 16, 32, and 32 for case 1, 2, and 3, respectively. The above finding suggests the presence of both warm and cold antibodies, i.e., mixed AIHA. Rh-extended antigen phenotypes were done by Conventional test tube technique (CTT) method using antisera (Ortho Clinical Diagnostics, USA). The results were c+C-E-e+, c+C-E+e-, c-C+E-e+ in case 1, case 2 and case 3 respectively.

Two units of A Rh D-positive and one unit of O Rh D-positive Rh phenotype-matched, leukoreduced, least-incompatible packed RBC (PRBC) using column agglutination test (Ortho BioVue, USA) was transfused slowly under close observation in case 1, case 2, and case 3, respectively. Both patients were started corticosteroid therapy and discharged in clinically stable condition.


The diagnosis, prognosis, and management of AIHA continue to be challenging in current practice. AIHA can be subdivided into warm, cold, and mixed based on the reactivity of autoantibody with the red cell at temperature. Warm antibodies are generally IgG antibodies, most commonly affect children, do not activate complement, and do not causein vitro RBC agglutination. However, cold antibodies are IgM antibodies, activate complement, and causein vitro RBC agglutination. Mixed AIHA is usually diagnosed when monospecific DAT positive for IgG and C3d, and cold antibody shows high thermal amplitude (>30°C), without showing characteristic features of cold antibody syndrome.[7],[8],[9]

Before diagnosing mixed AIHA, warm AIHA with cold, insignificant antibodies and cold agglutination syndrome must be ruled out. In Cold agglutinin syndrome (CAS), titer of cold autoantibodies when tested at 4°C are generally above 1000. But cold autoantibodies present in mixed AIHA have titre less than 64.[7] All of our cases presented with high thermal amplitude and low titer.

Monospecific DAT and Indirect antiglobulin test (IAT) and autocontrol at 4°C and 37°C help for differentiation cold, warm autoantibodies. As autoantibodies were formed against high prevalence antigens, hence finding antigen-negative units is extremely difficult. Adsorption studies were required to find out alloantibodies because autoantibody can mask underlying alloantibodies. History of pregnancy, transfusion and transplant are three major risk factor of alloantibody formation. There was less chance of alloantibody formation as no such history in our cases. Best match, leukoreduced and extended Rh phenotype matched PRBCS were transfused in all three cases.

Corticosteroid therapy and avoiding exposure to cold are the primary treatments of mixed AIHA; underlying disease should also be treated in secondary AIHA.[10]


We reported these three cases of mixed AIHA in children. These patients might be presented with blood group discrepancy as well as incompatibility during pre-transfusion testing which complicates the transfusion support. The patient must be transfused cautiously with least-incompatible, ABO and Rh/Kell phenotype-matched, leukoreduced PRBCs slowly under strict supervision and steroid cover. CAT testing method should be implemented for cross-matching, as it is more sensitive, less time-consuming, so also minimum subjective variation.

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Conflicts of interest

There are no conflicts of interest.


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