The Effect of COVID Convalescent Plasma on Hospital Stay: A Retrospective Observational Study from a Tertiary Care Hospital in North India.

INTRODUCTION: COVID convalescent plasma (CCP) has been used as standard of care in patients all over the world. CCP is plasma collected from recently infected and currently recovered COVID-19 patients, which contains antiviral antibodies that can be used to treat patients with COVID-19. Several studies have shown a shorter hospital stay and lower mortality in patients treated with convalescent plasma in comparison with those not treated with it. OBJECTIVES: This study aims to determine the effect of COVID convalescent plasma (CCP) on the length of hospital stay in symptomatic patients and to determine outcome of the disease in patients who were administered CCP. METHODS: This was a retrospective observational study done at a tertiary health care centre from July 2020 to May 2021, including patients who received CCP during the course of their stay in the hospital. RESULTS: Among 257 participants, the patients with multiple comorbidities who were administered CCP had the longest average length of stay in the hospital which was 15 days, out of which, 92 (35.8%) patients were discharged while 9 (3.5%) patients died. Also, the maximum number of deaths was observed in those patients who had no associated comorbidity, being 11 (4.3%). It was observed that earlier administration of CCP in patients (< 5 days from symptom onset) was associated with a higher number of discharges as compared to deaths. CONCLUSION: Our study indicates that CCP may be efficient in treating COVID-19 patients if given in early course of the disease.

I-JAMM-(I): A survey providing an insight into the practices of isoagglutinin titration in ABO incompatible kidney and liver transplantation.

BACKGROUND AND OBJECTIVES: ABO-incompatible transplantations allow patients to receive timely transplants. Isoagglutinin titration to ascertain levels of incompatible antibodies in the recipient is important in determining patient selection and transplant survivability. To find out the prevalent trends in India, the largest, first of its kind survey was carried out among the transplant centers regarding their practices in isoagglutinin titration. METHODS: The survey was drafted by a working group of Transfusion and Transplant Immunology specialists from six different centers. Data was obtained via the use of an online questionnaire. RESULTS: Results were categorized into four categories, Hospital information, Titration methodology, Role of transfusion specialists and cut-off titers. Most centers had a well-established solid-organ transplant program with considerable number of ABO-incompatible transplantations. Most centers performed isoagglutinin titration in Transfusion Medicine department. Column Agglutination Technique (CAT) was the most common method, using EDTA blood samples and freshly-prepared in-house pooled cells. Most centers had a turn-around time of less than 12 h. While the policy for ascertaining baseline and threshold titers is well-defined in ABO-incompatible renal transplants, variations from center to center still exist for ABO-incompatible liver transplants. Most centers required a Transfusion Medicine consultation for the patients before such transplants. CONCLUSION: With increasing ABO-incompatible kidney and liver transplants across the country, the role of Transfusion medicine specialists has become vital in pre-conditioning regimes enabling the viability and success of such transplants. This was a unique survey that provided a snapshot of current trends and practices of isoagglutinin titration for ABO-incompatible transplants in India.

Immunohematological challenges in COVID infected patients.

BACKGROUND: Several autoimmune disorders have been reported to be related with COVID infection. In continuation to these autoimmune phenomenon, autoimmune hemolytic anaemia (AIHA) also has been noted in COVID infected patients. The aim of the study was to find out the prevalence of red cell alloimmunization, ABO discrepancy and positive direct antiglobulin test (DAT) results in COVID infected patients hospitalised in a tertiary care centre in North India. METHODOLOGY: This was a retrospective observational study done from July 2020 to June 2021. All symptomatic patients admitted to ICU tested positive for SARS CoV-2 whose blood samples were received in the immunohematology laboratory of department of Transfusion Medicine for determination of blood group and issue of packed red cells, and found to have positive antibody screen, blood group discrepancy and positive DAT results, were included in the study. RESULTS: A total of 10,568 tests were run, out of which 4437 were for determination of blood group, 5842 were for antibody screen and 289 were for direct antiglobulin test. Included in this study were 146 patients who either had blood group discrepancy, or had a positive antibody screen or had a positive DAT. Out of 115 positive antibody screen, 66 patients had only alloantibodies, 44 patients had only autoantibodies while only 5 patients had both auto as well as alloantibodies. Total number of positive DAT cases was 50 (50/289 = 17.3 %). There were 26 ABO discrepancies (26/4437 =0.58 %) found. CONCLUSION: Our results also indicate that there is rise in rate of alloimmunization and DAT positivity among COVID patients.

Patient outcome in antibody-positive systemic vasculitis treated with therapeutic plasma exchange.

BACKGROUND: Therapeutic plasma exchange (TPE) has been advocated as an adjunct to steroids and cytotoxic drugs in treating patients suffering from vasculitis and presenting with active disease, but we still have insufficient evidence on its effectiveness in improving the clinical response, especially in India. This study was planned to study the clinical outcome in severe vasculitic presentations treated with TPE as an adjunctive therapy. MATERIALS AND METHODS: A retrospective analysis of TPE procedures performed from July 2013 to July 2017 in the department of transfusion medicine at a large tertiary care hospital was done. All consecutive patients admitted with new diagnosis of systemic vasculitis presenting with active disease and severe presentations such as advanced renal failure or severe respiratory abnormalities or life-threatening vasculitis affecting the gastrointestinal tract, neurological and musculoskeletal system; who needed TPE for removal of preformed antibodies, were included in the study. RESULTS: There were a total of 31 patients in whom TPE was performed for severe systemic vasculitis; 26 adults and five pediatric. Six patients tested positive for perinuclear fluorescence, 13 for cytoplasmic fluorescence (cANCA), two for atypical antineutrophil cytoplasmic autoantibody, seven for anti-glomerular basement membrane antibodies, two for antinuclear antibodies (ANA), and one patient tested positive for ANA as well as cANCA before the augmentation of TPE. Out of 31, seven patients showed no clinical improvement and succumbed to the disease. At the end of desired number of procedures, 19 tested negative and five tested weak positive for their respective antibodies. CONCLUSION: Favorable clinical outcomes were observed with TPE in patients with antibody-positive systemic vasculitis.

A prospective observational study to evaluate effect of heat inactivation on ABO titers performed by column agglutination technology and conventional tube technique.

BACKGROUND AND AIMS: When determining ABO antibody titers, immunoglobulin G (IgG) antibodies can be masked by immunoglobulin M (IgM) antibodies. Hence, the measurement of actual concentration of IgG requires methods like heat inactivation (HI) of plasma. This study was aimed at determining the effects of HI on IgM and IgG titers performed by conventional tube technique (CTT) and column agglutination technique (CAT). MATERIALS AND METHODS: This was a prospective, observational study conducted from October 2019 to March 2020. All consecutive A, B, and O group donors who gave consent for participation were included. All samples were consecutively tested by CTT and CAT, before and after HI (pCTT, pCAT). RESULTS: A total of 300 donors were included. IgG titers were found to be more than IgM titers. For group O, IgG titer results were higher for both anti-A and anti-B compared to group A and B. For group A, B, and O, pretreatment results were higher than posttreatment IgG titer results. Median anti-A titers were similar to median anti-B titers across all categories. Median IgM and IgG titers were higher for group O individuals than nongroup O individuals. There was reduction in IgG and IgM titers after HI of plasma. One log reduction in median titers was observed when ABO titers were performed by CAT and CTT. CONCLUSION: There is one log difference between median antibody titers estimated using heat inactivated and nonheat inactivated plasma. The use of HI for ABO isoagglutinin titer estimation can be considered in low resource settings.

Single center experience of therapeutic plasma exchange in a resource-constrained setting: A study of trends in scope and complications.

BACKGROUND: Therapeutic apheresis procedures are becoming an increasingly integral part of modern medical practice, be it as a part of therapy or pre-conditioning regimes for solid organ transplants. In our center, we follow the American Society for Apheresis (ASFA) guidelines for categorizing these procedures. However, lack of a centralized registry for therapeutic apheresis in India, lack of consolidated data as well as a resource-constrained setting prevent it from being utilized to its full potential. STUDY DESIGN AND METHODS: This study was a retrospective analysis of therapeutic plasma exchange (TPE) procedures performed from January 2015 to October 2022 in the Department of Transfusion Medicine at a large tertiary care hospital in North India. All consecutive TPE procedures were included. Overall and specialty-wise scoring for all patients was performed. Mean scores were calculated. RESULTS: A total of 1434 procedures were performed during the study duration of 7 years. These procedures were performed for 284 different patients. Majority of the procedures were referred from nephrology (895 of 1434, 62.4%), followed by neurology, gastroenterology, and liver transplant teams, hematology, critical care, rheumatology, pediatrics, and internal medicine. Complete response, partial response, and no-response were observed in 1077 (75.1%), 201 (14%), and 156 (10.9%) procedures respectively. Only 14 procedures reported adverse effects. DISCUSSION: Increasing effectiveness of TPE in a number of procedures and a variety of indications has broadened its scope, while the small number of adverse events, when supervised by trained Transfusion Medicine physicians has made TPE a more viable and safer alternative to other treatment modalities.

Comparison of Two Different Serological Viral Marker Testing Assays for Screening of Apheresis Donors: Which Assay Provides Optimum Safety for Transfusion?

While whole blood testing has evolved over the years, viral marker testing for plateletpheresis donors is still performed by Rapid Diagnostic Tests (RDT). Aim of this study was to compare diagnostic accuracy of RDT and Chemiluminescence Immunoassay (CLIA) in serological testing for HBsAg, anti-HCV and anti-HIV antibodies. A prospective, analytical study was conducted in the department of Transfusion Medicine at a tertiary healthcare center in India between September 2016 and August 2018. Samples were simultaneously tested by CLIA, RDT and a confirmatory test. Sensitivity, specificity, negative and positive predictive values and mean time taken to report results were calculated. A total of 102 (1.48%) of the 6883 samples were found to be reactive by either or both the assays. A total of 74 (1.08%) samples were HBsAg reactive, 23 (0.33%) were reactive for anti-HCV antibodies and 5 (0.07%) were reactive for anti-HIV I and II antibodies. A combined sero-prevalence of 1.05% (72) was observed; 0.78% (54) for HBsAg, 0.26% (18) for anti-HCV antibodies and none for anti-HIV I and II antibodies. Four (3.85%) reactive samples were missed by RDT and therefore sensitivity of RDT was quite less as compared to CLIA. RDT and CLIA both were found to have a statistically significant shorter turnaround time than confirmatory tests. There is increasing need to develop a safe donor screening strategy for plateletpheresis. CLIA offers an excellent alterative to RDT for viral marker testing in terms of sensitivity.

An assessment of clinical and laboratory impact in a resource constraint setting: Does Rh and Kell phenotyping of donor units complement type and screen method of compatibility testing?

BACKGROUND AND AIM: Despite knowing benefits of extended phenotyping, a vast majority feel that phenotype matched units add to the cost of blood banking. The purpose of this study was to discuss advantages and disadvantages of performing Rh Kell phenotyping in Indian scenario. MATERIALS AND METHODS: This was a prospective, observational study conducted at a tertiary healthcare center between July 2014 and February 2020. All consecutive whole blood donors and all consecutive patients whose samples were sent for Rh-Kell phenotyping were included for calculating antigen, phenotype and gene frequencies. For rate of alloimmunization in patients transfused with phenotype matched units, all patients who were given Rh-Kell phenotype matched transfusions were included in the prophylactic antigen matched (PAM) category and those who were given random units were included in the non-PAM category. RESULTS: A total of 37,588 donors and 258 patients were included in the study for calculation of antigen, phenotype and gene frequencies. Percentage similarity of phenotypes between patient and donor populations was 33.8%. For rate of alloimmunization, results of a total of 31,991 patient samples revealed 0.94% prevalence of unexpected antibodies; highest against the Rh system. Three patients in the non-PAM category and one in the PAM category were alloimmunized during follow-up. Significant clinical and laboratory impact of phenotyping was observed in terms of reduced turnaround time and consumption of resources. CONCLUSION: Rh-Kell phenotyping of donors can prevent alloimmunization, reduce cost burden on the patient and the laboratory and help the laboratory personnel in smooth routine testing.

A rare case of clinically significant naturally occurring anti-Cw reported in a healthy male donor.

Anti-Cw antibody is an immunoglobulin against the red cell antigen Cw which is a low frequency red cell antigen that belongs to the Rh antigen system. It is a clinically significant antibody and may cause haemolysis on exposure to antigen positive red cells. Due to its low frequency, it is not included in routine antibody screening panels. A 32 years healthy male donor with no history of transfusion donated whole blood at the department of Transfusion Medicine & Blood Centre of our institute. As a part of routine pre-transfusion testing, the donor's samples were subjected to automated blood grouping and screening for unexpected red cell antibodies using 3 cells panel on solid-phase red-cell adherence (SPRCA) (Galileo Neo, Immucor, Norcross, USA). The antibody screening came out to be positive with a reaction in cell I of the antibody screening panel. Further the antibody was identified as anti Cw in using 16 cells panel, select cells and phenotyping. In the present case, the anti-Cw antibody was found to be reactive at 37 °C and AHG phase which could lead to haemolytic transfusion reaction. The fact that the male donor had no history of transfusion or transplant led us to the conclusion that it was a naturally occurring, but a clinically significant antibody. This case highlights the importance of performing an antibody screening for healthy donors as well and urges transfusion services to procure screening cells which incorporate Cw positive cells.

A prospective observational study to compare transfusion outcomes in ABO identical versus ABO non-identical single donor platelet concentrates: An experience from a tertiary healthcare center in India.

ABO incompatible single donor platelet concentrates (SDPC) have a concern about unsatisfactory increments as well as possibility of hemolytic transfusion reaction. But from Indian population no study has commented on the clinical and laboratory outcome of ABO mismatched platelet transfusion. The aim of study was to compare transfusion outcomes in ABO identical versus ABO non-identical single donor platelet concentrates. In this prospective observational study, 400 SDPC transfusions among different patients were included. In group A (n=200), ABO identical SDPC transfusions and in group B (n=200) ABO non-identical SDPC transfusions were added. Corrective count increment (CCI), absolute count increment (ACI), percent platelet recovery (PPR) were calculated and incidents of hemolytic transfusion reactions were noted. In group A mean±SD of ACI, CCI and PPR were as 30.78±12.51, 15.10±6.677, 39,948.9±20,099.392. In group B, mean±SD of ACI, CCI and PPR were - 25.4±15.65, 12.509±5.906, 33,559.2±22,150.304. And when CCI, ACI, PPR were compared with group A and group B, statistically significant differences were noted (P<0.05). There was statistically significant difference in CCI, ACI and PPR in oncology patients and other prophylactic recipients except patients with dengue and other infectious disease. But there was no hemolytic transfusion reaction noted in any group. Our study clearly establish the potential benefits of ABO-identical PLT transfusion. It also points out that in emergency conditions or when there is a paucity in inventory, ABO non-identical SDPC transfusion may be lifesaving and clinically significant.

Anti-D Alloimmunization After RhD Positive Red Cell Transfusion to Selected RhD Negative Patients.

Transfusion of RhD positive red cells to RhD negative individuals is not routine transfusion practice for the fear of alloimmunization. Aim of this study was to prospectively evaluate rate of alloimmunization after transfusion of RhD positive red cells in RhD negative individuals and to assess delay in transfusion due to decision making. This was a prospective, observational study conducted from 2014 to 2018. All patients were followed up for a period of three months, at 3, 14, 45 and 90 days with antibody screening. In addition, patients who were immunosuppressed and alloimmunized were followed up at 6 months and one year. During the period of the study, there were a total of 57 RhD negative patients (52 males and five females) who received a mean of 4.42 ± 2.85 transfusions. Alloimmunization was detected in 8 (14.03%) patients at a mean interval of 25.63 ± 16.04 days. Anti-D was detected in seven and one patient developed anti-E alloantibody. Mean number of red cell units transfused in alloimmunized was 1.7 ± 0.26 while it was 5.4 ± 1.82 in non-alloimmunized group. There was no delay in providing units to these patients. The TAT was found to be 68 min. Rate of alloimmunization after transfusion of RhD positive red cells to RhD negative individuals was found to be 12.3%. In life saving conditions, RhD negative patients can be transfused RhD positive red cells without delay in decision making.

Significance of Luminex-crossmatch assay and its mean fluorescence intensity - a retrospective observation in 380 renal transplant cases.

<b>Introduction:</b> Cell-based complement-dependent cytotoxicity crossmatch (CDC-XM) and solid phase assays were introduced for assessing HLA antibodies. However, the complexity of data from cell-based and solid phase assays have led to potential confusion about how to use the results for clinical decision making. </br></br> <b> Aim:</b> Aim of this study was to compare results of cell-based assay and solid phase assay, to evaluate the usefulness of L-XM for pretransplant detection of HLA class I and II donor-specific IgG antibodies, correlate the mean fluorescence intensity (MFI) values of class I and class II L-XM assay and with CDC-XM and L-PRA (panel reactive antibodies) results. </br></br> <b> Methods:</b> In this retrospective study, 380 prospective renal transplant recipients were tested for the presence of HLA antibodies by CDC-XM, IgG-L-XM, IgG-L-PRA & L-SAB screening with their corresponding donor. </br></br> <b>Results:</b> Fifty-one recipients (13.42%) had a positive CDC-XM. L-XM was positive in 125 recipients (32.89%); class I-L-XM was positive in 46 (36.80%) cases, and class II-L-XM was positive in 58 (46.4%) cases and 21 (16.8%) samples were positive for class I and class II. High background was present in 22 (5.87%) samples, the results of which were confirmed by retesting or by correlation with L-PRA and L-SAB assays. </br></br> <b>Conclusion:</b> The introduction of more sensitive approaches for the detection of anti-HLA-IgG-antibodies, such as L-XM and L-PRA assay, has allowed the identification of anti-HLA-antibodies in recipient serum which is not usually identified by CDC-XM alone. However, L-XM has some limitations; they can be overcome if we combine this assay with L-PRA.

A case report of multiple Rh alloantibodies in a pregnant female: Resolution by sequential adsorption.

Anti-G antibody mimics the reactivity pattern of coexistent anti-D and anti-C. Differentiating between the two is significant in antenatal females where the decision to administer RhD prophylaxis is based on the presence or absence of anti-D antibody. The aim of reporting this serological challenge is to emphasize the need for phenotyping red cells for sourcing appropriate in house red cell reagents and to help transfusion services sharpen problem-solving skills. A 26-year-old pregnant female with a complicated obstetric history and a positive indirect antiglobulin test presented to the hospital for antenatal assessment at 24 weeks. A positive antibody screen warranted identification of the implicating antibodies. Since identification was suggestive of multiple alloantibodies whose specificities could not be confirmed, step-wise sequential adsorption and elution was required. Anti-D, anti-C, and anti-E antibodies were identified in patient plasma with titers of 1024, 4, and 32, respectively. The absence of anti-G was also confirmed. Multiple alloantibodies can pose a challenge to transfusion services. However, with the help of select cells, phenotyping, adsorption elution studies, and phenotyped donor units; solving complex serological cases can be accomplished.

Outcome of desensitization in human leukocyte antigen and ABO incompatible living donor kidney transplantation: Single center experience of first 200 incompatible transplants.

BACKGROUND AND AIMS: Although desensitization is well established, concerns about graft outcome, patient survival and rejection still exist. The present study aims at comparing outcomes of renal transplant recipients across simultaneous ABO and human leukocyte antigen (HLA) incompatibility barriers to those with ABO or HLA incompatibility alone. MATERIALS AND METHODS: This was a retrospective study conducted from October 2015 to December 2018. All patients with a clinical diagnosis of chronic kidney disease, who were prospective HLA incompatible (HLAi) and/or ABO incompatible (ABOi) renal transplant recipients were included. A total of 400 cases including 36 ABOi transplants, 154 HLAi transplants, 10 simultaneously ABO and HLA incompatible transplants, and 200 ABO (ABOc) and HLA (HLAc) compatible kidney transplants from living donors were included. RESULTS: There were significantly more number of blood transfusions, previous transplants and pregnancies in HLAi transplant recipients relative to the ABOi or the control group. Mean number of therapeutic plasma exchange procedures per patient and mean plasma volume processed per procedure were slightly higher in the ABOi + HLAi category. The incidence of graft dysfunction due to suspected antibody-mediated rejection during first year was highest in the ABOi + HLAi group, followed by ABOc + HLAi and ABOi + HLAc, lowest in the ABOc + HLAc category. Mean time to first episode of graft dysfunction was significantly shorter with incompatible transplants. There were no kidney transplant recipient deaths in the study. CONCLUSION: Patient outcome and graft outcomes observed with incompatible transplants were not worse than those observed with compatible transplants.

Therapeutic apheresis in ABO-incompatible kidney and liver transplantation: A single-center experience of 50 patients.

ABO antigens play an important role in solid organ transplantation. Desensitization for ABO incompatibility offers patients awaiting transplant a larger donor pool. The aim of this study was to assess outcome of desensitization using the institutional preconditioning protocol in ABO-incompatible solid organ transplants. A retrospective analysis of ABO-incompatible solid organ transplants between October 2015 and June 2018, at a tertiary healthcare center was performed. The preconditioning regimen consisted of immunosuppression and therapeutic apheresis (TA). Pre- and post-TA titers were performed, until a target titer of 8 or below was achieved, at which transplant was performed. Follow-up data till 1 year was analyzed. A total of 50 ABO-incompatible solid organ transplantations, including 14 liver transplants and 36 renal transplants were analyzed. The median baseline anti-A and anti-B titers were 192 and 256, respectively. A total of 150 therapeutic plasma exchange (TPE) procedures were performed for renal transplant recipients; 19 TPE and eight immunoadsorption procedures (five preoperative and three intraoperative) were performed for liver transplant recipients. Five (10%) patients experienced minor adverse events. Biopsy revealed antibody-mediated rejection was observed in three cases in the immediate posttransplant phase and in three (6.67%) cases over 1 year. There was one death due to transplant-associated thrombotic microangiopathy. Graft survival for renal transplant was 100% and death-censored graft survival for liver transplant was 100%. Despite difficulties, ABO-incompatible transplants can be performed without antibody-mediated rejection with the use of an appropriate protocol.

Prospective audit of blood transfusion request forms and continuing medical education to optimise compliance of clinicians in a hospital setting.

OBJECTIVES: The aim of this study was to analyse blood requisition forms sent by clinicians in a tertiary care hospital to the transfusion service to ascertain their completeness and correctness. A secondary objective was to study the effect of continuing medical education (CME) in a hospital setting on clinician's behaviour regarding the importance of details that ought to be mentioned on blood requisition forms. BACKGROUND: Transfusion audits are useful tools in the evaluation and education of those requesting blood components. METHODS/MATERIALS: This was a prospective, observational study conducted in the department of Transfusion Medicine at a tertiary-level healthcare centre from June 2019 to December 2019. The study was divided into two phases: pre-CME (P1) and post-CME (P2). In both phases, an audit for assessing completeness and correctness of blood requisition forms, which were divided into four sections, was performed. A scoring system was devised to compare both phases. RESULTS: In the P1 phase, 45.77% of the blood requisition form entries were complete and correct; 23.45% of incomplete entries were generated by emergency and trauma. In the P2 phase, 76.75% of the blood requisition form entries were complete and correct; 35.09% of the incomplete entries were generated by obstetrics and gynaecology. Complete and correct entries increased from 45.7% (P1) to 76.75% (P2). Scores of P1 were found to be lower than scores of P2 for all four sections. Cumulative mean score for P1 (20687) was found to be significantly lower than the mean score for P2 (30870). CONCLUSION: Audit and CME regarding different aspects of transfusion medicine practices play a major role in the improvement of transfusion practices in hospitals.

Clinical outcome of living donor kidney transplantation across simultaneous ABO and HLA incompatibility: Single center experience of first ten cases.

BACKGROUND AND AIMS: Preconditioning using different protocols has been tested to prevent antibody mediated rejection (ABMR) individually for ABO and HLA incompatibility. However, simultaneous presence of both barriers is still less explored. The aim of this study was to report outcomes of institutional desensitization protocol in renal transplant recipients with simultaneous ABO and HLA incompatibility. MATERIALS AND METHODS: This was a retrospective study conducted from October 2015 to December 2018. All patients with a clinical diagnosis of dialysis dependent chronic kidney disease (CKD), who were prospective coexistent HLA and ABO incompatible renal transplant recipients were included in the study. Patients were followed up and graft function and patient survival was assessed at 1 y from the date of transplant. RESULTS: Median and mode baseline anti-A titers were 64, while median and mode baseline anti-B titers were 256. All recipients were discharged by tenth postoperative day. None of the patients had any bleeding complications. Post transplant infection rate was found to be 20 %. A total of 54 therapeutic plasma exchange (TPE) procedures were performed before transplant and 8 were performed after transplant. Graft survival and patient survival was 100 % at 3, 6, 9, and 12 months. Range and mean follow-up period was 15-42 months and 23 months respectively. Mean glomerular filtration rate (GFR) at 1 y using the CKD-EPI equation was 85.25 ± 13.76 mL/min. Biopsy proven ABMR was observed in one case only which was managed with TPE and immunosuppression. CONCLUSION: Simultaneous ABO and HLA incompatibility in renal transplant recipients can be managed successfully with adequate preconditioning and careful monitoring.

Applying Donath-Landsteiner test for the diagnosis of paroxysmal cold hemoglobinuria.

61-year old male patient was admitted to the hospital with clinical picture of hemolytic anemia with hemoglobinuria. Patient was suspected to have Infectious Mononucleosis (IM) with Auto Immune Hemolytic Anemia (AIHA). DAT was positive with anti-C3d specificity. Donath Landsteiner (DL) test was positive; confirming Paroxysmal Cold Hemoglobinuria (PCH). The final diagnosis was IM with PCH. Patient was managed conservatively and discharged after seven days. DL test specifically detects a biphasic autoantibody (IgG type) that binds to RBCs at cold temperatures, and fixes complement on the RBC membrane. However RBCs are only lysed upon warming to 37C when complement cascade proceeds to completion.