Systematic Approach to a Case of Multiple Alloantibodies in a Liver Transplantation Recipient

Transfusion therapy in an alloimmunized liver transplantation (LT) recipient still remains a major challenge due to the unpredictable blood unit requirements and difficulty in finding compatible antigen-negative units. We present the case report of a 30-year-old male patient with multiple red blood cell alloantibodies admitted for LT. Immunohematological tests by column agglutination method (gel) were employed for testing for antibodies. The antibodies were confirmed to be anti-E, anti-S, and anti-Fyb, and over a period of 10 days, nearly ninety units were crossmatched and phenotyped matched units were reserved for surgery. During the intraoperative phase, the patient could be supported with all three antigen-negative blood units. However, in the postoperative period, transfusions were switched over to two antigen-negative compatible units (E-Fyb−) under close monitoring. Direct antiglobulin test remained negative with no evidence of hemolysis throughout the perioperative period. This case delineates the approach to a case with multiple red blood cell antibodies and accentuates the role of well-equipped immunohematology laboratory for timely detection of alloantibodies and transfusion support for patients. An effective strategy for such patients needs to be devised well ahead to prevent the possible risk of any hemolytic reactions during the perioperative course. This case also re-emphasizes on the need of adequate inventory, advance assays like monocyte monolayer assay, and the active national rare donor registry to aid in the management of patients with single/multiple antibodies.