Multiple Irregular Antibodies in Alloimmunized Patients: immunohematologic techniques for their detection and typing
DOI:
https://doi.org/10.56294/saludcyt20262655Keywords:
Alloimmunization, Irregular erythrocyte antibodies, Blood group antigens, Coombs test, Column agglutination, Solid-phase adherenceAbstract
Introduction: alloimmunization is a frequent complication in chronically transfused patients, resulting from repeated exposure to erythrocyte antigens that differ from the recipient’s own. This immune response leads to the development of irregular alloantibodies that compromise transfusion compatibility and increase the risk of hemolytic reactions, particularly when multiple alloantibodies coexist.
Methods: a systematic review was performed following the PRISMA guidelines, based on a search of regional and international scientific databases. Studies published between 2020 and 2025 that addressed alloimmunization, the presence of multiple irregular erythrocyte alloantibodies, and the immunohematologic techniques used for their detection were included.
Results: the most frequently identified alloantibodies primarily belonged to the Rh and Kell blood group systems, with recurrent simultaneous combinations among them. For their detection, the manual tube test, column agglutination (CAT), and solid-phase red cell adherence (SPRCA) techniques were evaluated. SPRCA demonstrated higher sensitivity for detecting weak or coexisting alloantibodies, whereas CAT provided standardized interpretation and broad clinical applicability.
Conclusions: the detection of multiple irregular alloantibodies requires a strategic combination of immunohematologic methodologies. Although SPRCA offers superior analytical sensitivity in complex samples, CAT remains a reliable and widely accessible alternative in routine clinical laboratory practice, supporting safer transfusion decision-making.
References
1. Angarita Merchan M, Urbano Cáceres EX, Cantor-Becerra ML. Anticuerpos irregulares en donantes de sangre. Revista Cubana de Hematología, Inmunología y Hemoterapia. 2021;37(4). Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0864-02892021000400008&lang=pt
2. Subramaniyan R. Serological characteristics of Lewis antibodies and their clinical significance – A case series. Hematol Transfus Cell Ther. 2023;45(2):159–64. Available from: https://doi.org/10.1016/j.htct.2021.07.007 DOI: https://doi.org/10.1016/j.htct.2021.07.007
3. Kahar MA. Determination of C,c,E and e Antigens Section Prevalence in Rh D Negative Individuals: Is it Good Exercise with Utilities in Clinical Blood Transfusion Practices? JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. 2022;16(11):EC16–9. Available from: https://doi.org/10.7860/JCDR/2022/58527.17131 DOI: https://doi.org/10.7860/JCDR/2022/58527.17131
4. Orhan M, Adigül M, Altindiş M, Köroğlu M. Major and minor subgroup profile of blood in patients receiving multiple transfusions and donors. Asian J Transfus Sci. 2022;16(2):219. Available from: https://doi.org/10.4103/ajts.ajts_17_21 DOI: https://doi.org/10.4103/ajts.ajts_17_21
5. Shah SD, Bhatnagar NM, Shah MC, Thakkar GH, Ahuja U, Patel A, et al. Rh and Kell phenotyping in voluntary blood donors: A study from a tertiary care blood center of western India. Asian J Transfus Sci. 2024 Jan;18(1):67–72. Available from: https://doi.org/10.4103/ajts.ajts_214_23 DOI: https://doi.org/10.4103/ajts.ajts_214_23
6. Wang CP, Malicki D, Thornburg CD, Martinez S, Yu JC. A Case Report of Red Blood Cell Alloimmunization and Delayed Hemolytic Transfusion Reaction in a Patient with an Uncommon Phenotype in Sickle Cell Disease: Review of Diagnosis and Management. Case Rep Hematol. 2024(1):9980747. Available from: https://doi.org/10.1155/2024/9980747 DOI: https://doi.org/10.1155/2024/9980747
7. Little JT, Blackall DP. Evaluation of solid-phase panreactivity with negative direct antiglobulin testing. Immunohematology. 2023;39(4):151–4. Available from: https://doi.org/10.2478/immunohematology-2023-022 DOI: https://doi.org/10.2478/immunohematology-2023-022
8. Johnson ST, Puca KE. Evaluating patients with autoimmune hemolytic anemia in the transfusion service and immunohematology reference laboratory: pretransfusion testing challenges and best transfusion-management strategies. Hematology Am Soc Hematol Educ Program. 2022(1):96–104. Available from: https://doi.org/10.1182/hematology.2022000406 DOI: https://doi.org/10.1182/hematology.2022000406
9. Oud JA, Evers D, M de H, K de VKM, D van de K, Som N, et al. The effect of extended c, E and K matching in females under 45 years of age on the incidence of transfusion-induced red blood cell alloimmunisation. Br J Haematol . 2021;195(4):604–11. Available from: https://doi.org/10.1111/bjh.17697 DOI: https://doi.org/10.1111/bjh.17697
10. Ohto H, Denomme GA, Ito S, Ishida A, Nollet KE, Yasuda H. Three non-classical mechanisms for anemic disease of the fetus and newborn, based on maternal anti-Kell, anti-Ge3, anti-M, and anti-Jra cases. Transfusion and Apheresis Science. 2020;59(5):102949. Available from: https://doi.org/10.1016/j.transci.2020.102949 DOI: https://doi.org/10.1016/j.transci.2020.102949
11. Kokoris SI, Kalantzis D, Moschandreou D, Papaioannou K, Grouzi E. Panagglutination on the indirect antiglobulin test... this is the challenge! Asian J Transfus Sci. 2022;16(2):257–62. Available from: https://doi.org/10.4103/ajts.ajts_133_20 DOI: https://doi.org/10.4103/ajts.ajts_133_20
12. Soumee B, Devi AMS, Sitalakshmi S. Prevalence of ABO, Rh (D, C, c, E, and e), and Kell (K) antigens in blood donors: A single-center study from South India. Asian J Transfus Sci. 2024;18(2):219–24. Available from: https://doi.org/10.4103/ajts.ajts_159_21 DOI: https://doi.org/10.4103/ajts.ajts_159_21
13. Jenbere G, Urgessa F, Tibebu M. Assessment of Minor Blood Group System Antigens and Their Phenotype among Voluntary Blood Donors in Ethiopian Blood and Tissue Bank Service, Addis Ababa, Ethiopia. Ethiop J Health Sci. 2023;33(5):813–20. Available from: https://doi.org/10.4314/ejhs.v33i5.11 DOI: https://doi.org/10.4314/ejhs.v33i5.11
14. Meyer BM. The utility of an acid elution when a direct antiglobulin test is positive due to complement alone. Immunohematology. American National Red Cross, 2025;41(2): 54-60. https://doi.org/10.2478/immunohematology-2025-009 DOI: https://doi.org/10.2478/immunohematology-2025-009
15. Natukunda B, Wagubi R, Taremwa I, Okongo B, Mbalibulha Y, Teramura G, et al. The utility of “home-made” reagent red blood cells for antibody screening during pre-transfusion compatibility testing in Uganda. Afr Health Sci. 2021;21(2):782–7. Available from: https://doi.org/10.4314/ahs.v21i2.38 DOI: https://doi.org/10.4314/ahs.v21i2.38
16. Soni-Trinidad C, Vázquez-García RE, Soni-Gallardo J, Rodríguez-Infante LI, Velasco-Cárdenas DF, Sosa-González CK. Embarazo con betatalasemia menor y aloanticuerpo irregular de baja frecuencia. Reporte de caso. Ginecol Obstet Mex. 2022: 90(1):90–5. Available from: https://doi.org/10.24245/gom.v90i1.5521 DOI: https://doi.org/10.24245/gom.v90i1.5521
17. Aboderin FI, Oduola T, Davison GM, Oguntibeju OO. Investigation of haematological, inflammatory parameters and the incidence of alloimmunization in multi-transfused sickle cell diseased patients. Hematol Transfus Cell Ther. 2025;47(3):103937. Available from: https://doi.org/10.1016/j.htct.2025.103937 DOI: https://doi.org/10.1016/j.htct.2025.103937
18. Faisal IB, Abbas MS, Thabit ZA, Aljebouri DM, Almusawi YA. The prevalence of erythrocyte alloimmunization in clinical practice: A hospital-based study. Iraqi Journal of Hematology. 2024; 13(2):213–22. Available from: https://doi.org/10.4103/ijh.ijh_51_24 DOI: https://doi.org/10.4103/ijh.ijh_51_24
19. Sachan D, Tiwari A, Dara R, Jothimani D, Kaliamoorthy I, Reddy S, et al. Patient blood management in a patient with multiple red cell antibodies (anti-C, anti-e, and anti-K) undergoing liver transplant in South India: A team approach. Asian J Transfus Sci. 2020;14(1):74. Available from: https://doi.org/110.4103/ajts.AJTS_54_18 DOI: https://doi.org/10.4103/ajts.AJTS_54_18
20. Conrath S, Vantilcke V, Parisot M, Maire F, Selles P, Elenga N. Increased Prevalence of Alloimmunization in Sickle Cell Disease? Should We Restore Blood Donation in French Guiana? Front Med (Lausanne). 2021; 8:681549. Available from: https://doi.org/10.3389/fmed.2021.681549 DOI: https://doi.org/10.3389/fmed.2021.681549
21. Yadav BK, Chaudhary RK, Elhence P, Phadke SR, Mandal K, Saxena D, et al. Red cell alloimmunization and associated risk factors in multiply transfused thalassemia patients: A prospective cohort study conducted at a tertiary care center in Northern India. Asian J Transfus Sci. 2023;17(2):145–50. Available from: https://doi.org/10.4103/ajts.ajts_2_23 DOI: https://doi.org/10.4103/ajts.ajts_2_23
22. Contelli HS, de Oliveira MC, Ido AAS, Francalanci EM, Terra PO da C, Filho ER, et al. Assessment of erythrocyte alloimmunization among patients treated at a Brazilian university hospital. Hematol Transfus Cell Ther. 2024;46: S128–35. Available from: https://doi.org/10.1016/j.htct.2024.04.128 DOI: https://doi.org/10.1016/j.htct.2024.04.128
23. Wang YJ, Yang YQ, Li ZF, Li W, Hu HB, Zhao D. Erythrocyte Alloimmunization and Autoimmunization in the Pediatric Population: A Multicenter, Cross-Sectional Study in Central China. TRANSFUSION MEDICINE AND HEMOTHERAPY. 2024;51(6):402–13. Available from: https://doi.org/10.1155/2024/9980747 DOI: https://doi.org/10.1159/000538448
24. Calderón Morán WA, Guerrero Quiroz EI. IIdentificación de anticuerpos irregulares y su prevalencia en pacientes transfundidos en el centro zonal de fraccionamiento de la provincia de El Oro, 2022-2023. AlfaPublicaciones. 2024;6(4):41–58. Available from: https://doi.org/10.33262/ap.v6i4.545 DOI: https://doi.org/10.33262/ap.v6i4.545
25. Agrawal S, Chowdhry M, Gajullupalli S, Muthukumaravel. Autoantibodies mimicking alloantibodies: A case series unveiling the dilemmas of transfusion. Asian J Transfus Sci. 2022; 17(1):58. Available from: https://doi.org/10.4103/ajts.ajts_161_20 DOI: https://doi.org/10.4103/ajts.ajts_161_20
26. Sanders DR. Comparison of solid-phase red cell adherence and microcolumn agglutination technology using untreated and enzyme-treated red blood cells. Immunohematology. 2023 Dec 1;39(4):166–71. Available from: https://doi.org/10.2478/immunohematology-2023-024 DOI: https://doi.org/10.2478/immunohematology-2023-024
27. Devi KM, Nepram L, Hajong R, Bhattacharyya D. Prevalence and Specificity of Red Blood Cell Alloantibodies in Patients in a Tertiary Care Center in Meghalaya, India. Cureus. 2025;17(6): e86347. Available from: https://doi.org/10.7759/cureus.86347 DOI: https://doi.org/10.7759/cureus.86347
28. Pereira Bueno ML, Mitestainer MB, Da Silva JAR, Benites BD, Roversi FM. Red-cell alloimmunization profile in multi transfused patients: Findings and insights of a blood transfusion service. Transfusion Clinique et Biologique. 2021;28(3):258–63. Available from: https://doi.org/10.1016/j.tracli.2021.04.006 DOI: https://doi.org/10.1016/j.tracli.2021.04.006
29. Dinić, R., Bujandrić, N., Grujić, J. Prevalence and Specificity of Red Blood Cell Alloimmunization: Insights from Transfusion-Dependent Populations in Serbia. Thalassemia Reports 2025, Vol 15, Page 5. 2025;15(2):5. Available from: https://doi.org/10.3390/thalassrep15020005 DOI: https://doi.org/10.3390/thalassrep15020005
30. Blomme S, De Maertelaere E, Verhoye E. A comparison of three column agglutination tests for red blood cell alloantibody identification. BMC Res Notes. 2020;13(1):1–6. Available from: https://doi.org/10.1186/s13104-020-04974-x DOI: https://doi.org/10.1186/s13104-020-04974-x
31. Cupaiolo R, Mahadeb B, Barreau I, El Kenz H. Solid-phase red cell adherence versus gel column agglutination: Is there any difference for the detection of alloantibodies associated with the JK system? Transfusion (Paris). 2025;65(3):615–23. Available from: https://doi.org/10.1111/trf.18125 DOI: https://doi.org/10.1111/trf.18125
32. Felimban R, Sumeda S. Distribution of Kell antigens K, k, Kpa, and Kpbamong blood donors in Jeddah city of Western Saudi Arabia. Asian J Transfus Sci. 2021;15(1):75–81. Available from: https://doi.org/10.4103/ajts.AJTS_109_19. DOI: https://doi.org/10.4103/ajts.AJTS_109_19
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