Hemolysis following platelet transfusions from

ABO-incompatible donors
L. M. REICH,A N D K. MAYER
R. N. PIERCE,

Two hemolytic transfusion reactions related to isoagglutinins present in group 0 platelet

concentrates are reported. The first, a severe reaction in a group A 10-kg patient, resulted
from transfusion of 200 ml of plasma containing a hemolytic anti-A, titer 16, and an IgG
anti-A, titer of 32.W. In the second case, a group 6 adult received between 50 and 70 ml of 0
plasma with a titer (16.000) of anti-6. This was followed by hemolysis of approximately 40
percent of the patient's red cell volume. TRANSFUSION 1985;25:60-62.

TRANSFUSION
OF PLATELETS to thrombocytopenic
patients carries with it t h e general hazards of blood
transfusion (for example, hepatitis). as well as its own
particular risks. Given the limited supply of platelets, it
has become common practice t o transfuse ABO-
incompatible platelets when group-specific platelets
are not available. A relatively small volume of plasma
(commonly 50-70 ml per unit') and few red cells (less
than 0.1 ml) may be present in most platelet transfu-
sions. Transfusions which are not group-specific
generally are considered safe and are accepted as
clinically effective. Transfusions of incompatible plate-
lets are not, however, without risks related to passively
transfused antibodies. Two hemolytic reactions, one
fatal, are reported below.
Case Reports
Case one
A Z%-year-old girl weighing 10 kg was admitted to
Memorial-Sloan Kettering Cancer Center (MSKCC) in July
1982, with a 10-month history of acute nonlymphoblastic
leukemia. A short-lived remission was only attained after
two previous attempts. using multiple chemotherapeutic
agents, failed. Because of the very poor response to
chemotherapy and the hopelessness of the situation, a bone
marrow transplant was attempted from her mixed lympho-
cyte culture (MLC)-compatible but only haploidentical
father. She was prepared by total body irradiation and
cyclophosphamide cytoreduction. Following transplanta-
tion, her course was very stormy and her condition was
critical. She clinically appeared septic although her previ-
ously positive blood cultures (Escherichiucoli) had become
negative. Bleeding profusely, with a platelet count of 23,000
per pl, and known to be resistant to random and HLA-
matched singledonor platelet transfusion, she was transfused
From the Blood Bank, Walter Reed Army Medical Center,
Washington, D.C.. and Blood Bank, Memorial Sloan-Kettering
Cancer Center, New York, New York.
The opinions or assertions contained herein arc the private views
of the authors, and arc not to be construed as official or as reflecting
the view of the Department of the Army or Department of Defense.
Submitted for publication November 29. 1982; revision received
June IS. 1984, and accepted June 19, 1984.
with "single donor" platelets obtained by cytapheresis from
her mother who was group 0,Rh positive. The patient was
group A. Rh positive.
The apheresis platelets were suspended in 200 ml of the
mother's plasma. Because of the small size of the recipient,
the platelet transfusion was divided and each half was given
12 hours apart. Following the first transfusion of platelets
(about 100 ml). there was no reaction distinguishable from
her sepsis. Following transfusion of the remainder of the
platelets and plasma, her blood pressure dropped. a seizure
ensued, she developed abdominal distention. and there was
generalized oozing from venipuncture sites. She developed
intense jaundice. Her laboratory studies showed a classic
picture of disseminated intravascular coagulation. (pro-
thrombin time 22.5 sec. activated partial thromboplastin
time I 12.3 sec. fibrin split products 80 pg/ml. fibrinogen. 93
mg/ dl) accompanied by a precipitous drop in hemoglobin
(from I I .5 to 5.7 g/dl) and rise in bilirubin (from 0.4 to 17.4
mg/dl). The plasma was the color of port wine. The patient
was continued on intensive support therapy for multisystem
failure, including exchange transfusions. In spite of all
efforts. she died 5 days later.
Cose two
A 58-year-old group B. Rh-positive woman was admitted
to the coronary care unit of Walter Reed Army Medical
Center (WRAMC) with a IOday history of episodic chest
pain on exertion. General physical examination and routine
laboratory studies on admission were normal. and the
clinical diagnosis was unstable angina. Cardiac catheteri-
zation on August 16 revealed severe narrowing (estimated
95% occlusion) of the right coronary artery, and a
percutaneous coronary angioplasty to correct this lesion was
performed. Within minutes following the completion of the
angioplasty. the patient became hypotensive, bradycardic,
and had electrocardiographical changes. The patient under-
went emergency coronary artery bypass to correct acute
dissection involving the right coronary artery complicated by
ventricular fibrillation.
She was transfused 2 units of red cells, 2 units of whole
blood, and 2 units fresh-frozen plasma (all group B). A
single-vessel bypass was performed. She also received
randomdonor platelets, 5 group B units and I group 0 unit
were pooled, followed by another unit of group B red cells.
Serial hemoglobin determinations showed a steady de-
crease from 14.3 g per dl on the first postoperative day to 8.2
g per dl 7 days later. Concurrently, total serum bilirubin
concentration increased from 3.2 mg per dl to a peak of 7.0
mg per dl on the 5th day and fell to 2.2 mg per dl on the 7th

60
TRANSFUSION
1985-Vol. 25, No. I HEMOLYSIS FOLLOWING PLATELET TRANSFUSIONS
postoperative day. A rise in serum lactic dehydrogenase
roughly paralleled the bilirubin, with a peak of 770 u per 1
(normal 60-200 u/l) 5 days postoperatively. Serum hapto-
globin on the 6th postoperative day was less than 35 mg per
dl. and it was 95 mg per dl 10 days postoperatively (normal
60-270 mg/dl). Plasma samples showed no visible hemo-
globin. The prothrombin time. partial thromboplastin time,
thrombin time, and serum creatinine remained normal
throughout the hospital course. She was discharged on the
10th postoperative day.
Methods and Materials
Reagent red cells and antisera were those used routinely in
the WRAMC and MSKCC Blood Banks (in this case,
Biological Corporation of America, West Chester, PA;
Gamma Biologicals, Houston, TX; Ortho Diagnostics,
Raritan. NJ). and standard methods (AAEB Technicul
Munuul') were followed.
Case one
The donor was group 0. Rh positive. When originally
screened for anti-A at a dilution of I to 50 (at room
t e m p e r a t u r e M 5 minutes, the red cell suspension at 4-6%).
she was thought to have been negative. When the test was
repeated after the transfusion reaction, it was found to have
been weakly positive. After incubation both at room
temperature and at 37OC for 30 minutes, there was
agglutination of A cells at a dilution of 1 to 512 and
hemolysis at a dilution of 1 to 4. When tested with broad
spectrum antiglobulin serum, the serum reacted at a titer of
32,000 when tested against A cells. The recipient's red cells
developed a strongly positive direct antiglobulin test which,
on heat elution, was shown to be due to anti-A.
Case rwo
The recipient was group B. Rh positive. Preoperatively.
the antibody screen and direct antiglobulin test were
negative. Following surgery and transfusion, the direct
antiglobulin test was positive (2+) with IgG-specific anti-
globulin reagent, and a digitonin eluate showed anti-B
coating the red cells. The red cells reacted 4+ when tested
with anti-B serum, and there was a mixed-field pattern when
tested with anti-A. When tested with anti-D. the cells reacted
4+, and the D control resulted in a mixed-field pattern. The
patient's serum was incompatible with reagent B red cells and
with B donor red cells, showing I+ reactions at 37OC. and at
the antiglobulin phase of the testing, irregular antibodies
were not detected when tested against panels of group 0
reagent cells. Segments from all the units of red cells
transfused and the patient's pretransfusion specimen were
regrouped; all were confirmed to be group B. Five days
postoperatively. anti-B was still detectable in the serum and
on the circulating red cells; but on the 10th postoperative
day, no anti-B was detectable. (Testing with anti-C3D
reagent was weakly positive.)
All samples, including those drawn 21 days postopera-
tively. had negative antibody screening tests. Anti-A titers
obtained 5. 10. and 21 days postoperatively showed no
significant change ( 128-256).
Since I of the 6 units of platelet concentrate transfused was
from a group 0 donor, a sample of that donor's plasma was
tested for anti-A and anti-B. (The donor sample was tested at
Gulf Coast Regional Blood Center, Houston, TX.) The
61
reaction following immediate spin was positive for anti-A at
37OC a titer of 64.and in the antiglobulin phase, a titer of 256.
Anti-B titers were as follows: 5 12 on immediate spin, 2048 at
37OC. and 16,384 with the indirect antiglobulin test. Efforts
to locate the donor for procurement of additional samples
were unsuccessful; donor records indicated that she was a
first-time blood donor.
Discussion
Platelet transfusion containing ABO-incompatible
plasma was associated with hemolysis in both patients.
Although case o n e was septic at time of transfusion.
the temporal relationship of hemolytic transfusion
reaction a n d hemolysis strongly suggest a causal
relationship. The 10-kg infant had a n estimated blood
volume of 800 ml (300 ml red cells) and received
4 X 10" platelets suspended in over 200 ml of plasma,
albeit the transfusion was divided and given as two
subdivided units 12 hoursapart. With anti-A detectable
by the antiglobulin technique a t a titer of 32,000, it
would not be surprising that this volume of plasma
could have a marked effect o n the recipient's red cells.
T h e second case is remarkable in that the implicated
antibody was passively acquired from the plasma of a
single unit of transfused platelets, in this case 50 t o 70
ml of g r o u p 0 plasma which had a n anti-B titer of over
16.000 in the antiglobulin phase. When the mixed-field
reaction with anti-A serum was first noted, considera-
tion was given t o the possibility of erroneous transfu-
sion of group A red cells; however, regrouping of donor
segments a n d a n extensive clerical check gave n o
evidence f o r such a n occurrence. Unchanged anti-A
titers effectively rule this out. It is unclear to what
extent the persistence and severity of the patient's
hypotension postoperatively can be ascribed t o the
infusion of incompatible plasma. She tolerated the
hemolysis of an estimated 40 percent of her red cell
mass, a n d otherwise made a rapid postoperative
recovery.
Because platelets a r e often in short supply, it is
c o m m o n practice t o transfuse ABO-incompatible
platelets. Incompatible plasma has caused acute and
delayed hemolytic transfusion reactions.2 Much of the
information about such reactions has come from the
use of "universal donor" 0 blood. Early methods for
detection of "dangerous universal donors" were based
o n the saline titer of i~oagglutinins.~.'It has been
pointed out that screening plasma on the basis of the
saline agglutinin titer alone may miss certain "danger-
ous universal donors,'' a n d screening tests based o n
immune titer5 a n d titers of hemolysins6.' have been
proposed. Because the plasma volume in platelet
concentrates is generally small, transfusion of ABO-
incompatible platelets must be a n uncommon cause of
62 PIERCE, REICH, AND MAYER
hemolytic transfusion reactions.8 In our second case,
the relatively small amount of plasma transfused in
platelet concentrates seems to have been significant, as
residual group 0 plasma in red cells has been known to
cause hemolysis.' The hazard increases as greater
volumes are transfused. Zoes et a1.I' reported a case of
a nonfatal hemolytic transfusion reaction occurring in
a group AimB patient who received 10 units of group 0
platelets, presumably in several hundred milliliters of
group 0 plasma. In another case reported by McLeod
et al.." a group A I patient developed hemolysis after
receiving single-donor group 0 platelets and group 0
random platelet concentrates. Retrospectively, two of
the platelet donors were found to have high titers of
anti-A.
A case involving singledonor platelets from a group
0 donor with a high titer anti-A was reported.12 In this
instance, an adult patient developed a hemolytic
transfusion reaction following the infusion of platelets
in 199 ml of plasma; the high titer of anti-A was related
to immunization of the donor with Pneumovax
(Merck. Sharp & Dohme, Rahway, NJ). a mixture of
purified pneumococcal polysaccharides, 1 month
before.
Though transfusion of ABO incompatible platelets
infrequently results in overt hemolytic reactions, there
are several recognized ways to minimize this risk: first,
as with all blood products, the quantity of platelet
transfusions should be limited to what is necessary and
effective. Second, when possible, the plasma transfused
should be compatible with the recipient's red cells. If
minor incompatibility cannot be avoided, care should
be taken that the amount of plasma transfused is
minimal. Memorial Sloan-Kettering Cancer Center
policy requires that whenever platelets from donors
having ABO antibodies to the recipient's red cells are
used, the donor's serum must contain an agglutinating
anti-A and/or anti-B titer of no greater than 50, nor
should equal volumes of fresh donor serum and
recipient (or type A, or B) red cells hemolyze after 15
minutes incubation at 3 7 O C.This excludes about 70
percent of group 0 platelets from transfusion to group
A or AB recipients, but in view of the cited experience,
it is anticipated that this policy will improve safety.
Adoption of such policies is intended to reduce the risk
of transfusing platelets from donors with minor
incompatibility.
TRANSFUSION
Vol. 25, No. 1-1985
Acknowledgments
The authors thank Ms. Koki Thapar. Dr. Janet Levick (case one),
and Ms. Maxine Schultz and Mr. Pablo Fortes for serological
evaluation of the donor sample in the second case, and Captain
Robert Sullivan for his help and encouragement (case two).
References
I . Widmann FK. ed. Technical manual. 8th ed. Washington:
American Association of Blood Banks, 1981:48.
2. Mollison PL. Blood transfusion in clinical medicine. 6th ed.
Oxford: Blackwell, 1979;548-56.
3. Tisdall LH. Garland DM. Szanto PB. Hand AM, Bonnett JC.
The effects of the transfusion of group 0 blood of high iso-
agglutinin titer into recipients of other blood groups. Am J Clin
Pathol 1946;16: 193-206.
4. Kendrick DB. Blood Program in World War 11. Washington:
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6. Ervin DM. Young LE. Dangerous universal donors. 1.
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9. lnwood MJ. Zuliani B. Anti-A hemolytic transfusion with
packed 0 cells. Ann Intern Med 1978;89:5154.
10. Zoes C, Dube VE. Miller HJ, Vye MV. Anti-A1 in the plasma
of platelet concentrates causing a hemolytic reaction. Tranrfu-
sion 1977;17:29-32.
1 1 . McLeod BC. Sassetti RJ. Weens JH, Vaithianathan T.
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12. Siber GR. Ambrosino DM. Gorgone BC. Blood-groupA-like
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Richard N. Pierce, MD, MAJ. MC, USA. Associate Medical
Director. Blood Bank, Walter Reed Army Medical Center,
Washington, D.C. 20012.
Lilian M. Reich. MD. Associate Director, Blood Bank, Memorial
Sloan-Kettenng Cancer Center.
Klaus Mayer. MD, Director. Blood Bank. Memorial Sloan-
Kettering Cancer Center, 1275York Avenue, New York. NY 10021.
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