Department of Anaesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Korea
* Corresponding author. E-mail: Monday1031{at}yahoo.co.kr
Accepted for publication January 7, 2005.
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Abstract |
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Keywords: blood, transfusion
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Introduction |
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We report a case in which we transfused Rh+ A packed red blood cells (RBC), type Rh+ A fresh frozen plasma, and type Rh+ A platelet concentrates to a patient with type cis-AB blood during a redo cardiac operation without any adverse reactions, although the same patient had been transfused with Rh+ AB blood during the initial cardiac operation in infancy.
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Case report |
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One month before the current hospital admission the patient suffered sudden chest pain. Echocardiography and cardiac catheterization revealed serious right ventricular enlargement, mild to moderate tricuspid valve regurgitation, moderate pulmonary valve regurgitation and an enlarged right ventricular outflow tract. Serological testing revealed A2B weak and a weak non-autoreactive anti-B antibody, suggestive of the presence of a cis-AB blood group (Table 1).
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Owing to continuous bleeding in the paediatric intensive care unit, the patient was transfused with another five units of type Rh+ A RBCs, four units of type Rh+ A fresh frozen plasma and type Rh+ A platelets on postoperative day 1. On postoperative day 2, his haematocrit was 30%. A total of 10 units of type Rh+ A RBCs, seven units of type Rh+ A fresh frozen plasma and one unit of type Rh+ A platelets were transfused. Clinically, no adverse transfusion reactions were observed.
To assess potential haemolysis due to transfusion, direct and indirect antiglobulin tests were performed six times: before transfusion, immediately after transfusion of type Rh+ A RBCs, before transfusion of type Rh+ A fresh frozen plasma and after completing transfusion on postoperative days 1 and 2. All results from these tests were negative, suggesting the absence of transfusion-related haemolysis. The patient was transferred to the ward on postoperative day 1 and was discharged on postoperative day 8.
To confirm the patient's blood type, ABO genotyping was performed using the polymerase chain reactionrestriction fragment length polymorphism (PCRRFLP) method. The patient's allele was allele O: del-C-C-G-C-G and allele cis-AB: G-T-C-G-C-C, confirming the patient's ABO genotype as type O/cis-AB. Blood testing of the patient's parents and brothers could not be done for logistic reasons.
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Discussion |
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An alternative approach in such patients is to store the patient's own blood before the operation.1 The recommendation in our case would be that the patient be transfused with type A (or O) packed RBC, type AB fresh frozen plasma and type AB platelet concentrates. However, his parents wanted him to receive a directed transfusion from close friends whose type A RBCs and fresh frozen plasma were prepared for transfusion.
The total amount of blood transfused to this patient perioperatively was 70% of his blood volume. Despite such a large amount of blood, no clinical symptoms or signs of adverse transfusion reaction were observed. Interestingly, no haemolytic reaction between the anti-B antibody of the donated blood and the native B-antigen of the patient's RBC occurred. The amount of anti-B antibodies in the blood products administered might have been too low to result in a severe transfusion reaction. However, and probably more importantly, the patient in our case report had a weak B-antigen, indicated by the fact that his blood showed a mixed field agglutination reaction when mixed with anti-B antibodies. This might be the reason for the absence of a reaction between the transfused anti-B antibodies and the patient's weak B-antigen.
Interestingly, no clinically adverse reaction was observed when the patient was transfused with 520 ml of whole AB blood during his first operation at the age of 13 months. It is probable that AB blood was used in the first operation because diagnosis was based on an inadequate diagnostic technique or lack of knowledge of type cis-AB blood at that time. AB-antigen maturation may have been incomplete. It has been reported that AB-antigens are present in the embryo at 56 weeks and then continuously increase in number, go through more complex branching, and ultimately mature to the adult level 24 yr after birth. Moreover, ABO blood type antibodies begin to appear at the age of 36 months and reach adult level only at the age of 510 years. According to the transfusion test guidelines, blood cell typing results should prevail for infants who are 1 yr old because they may not have anti-A and anti-B in their serum.2 Therefore we can assume that the anti-titre of a 13-month-old infant, in the presence of cis-AB blood group antigens, is low enough for no clinically adverse reaction to occur even if type AB blood is transfused.
In conclusion, we report an exceptional case in which we successfully transfused type A blood corresponding to approximately 70% of the circulatory volume into a patient with type cis-AB blood without any adverse reaction.
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References |
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2 Han KS. Blood type In: Han KS, Park MH, Kim SI, eds. Transfusion Medicine, 2nd edn. Seoul: Korea Medical, 1999; 198324
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