Clinically significant allo-anti-I in an I-negative patient with massive hemorrhage

A 37-year-old white man who had never been transfused was admitted as an emergency patient with a ruptured spleen and a falling hematocrit (19% on admission). All crossmatches were incompatible. His serum contained anti-I, and his red cells (RBCs) were I-negative and strongly i-positive. Only 4 units of crossmatch-compatible I-negative frozen RBCs were available immediately. Because of the likelihood that more than 4 units would be required, chromium survival studies were performed using I-positive cells. Samples obtained at 15 and 30 minutes after injection revealed less than 1 percent survival of the donor RBCs. He received the 4 units of I-negative RBCs during the operation in addition to reinfusion of RBCs harvested from 1800 ml of blood aspirated from the abdominal cavity. The postoperative hematocrit remained greater than 30 percent and the bilirubin less than 1.5 mg per dl. Before recommending frozen storage of autologous RBCs, 51Cr labeled I-positive RBCs from the patient's daughter (obligate li heterozygote) were infused. Survival was 100 percent at 15 and 30 minutes, 90 percent at 3 hours, 85 percent at 26 hours; the remaining RBCs disappeared at a normal rate (T 1/2 27 days) over the succeeding 2 weeks. A repeat 51Cr-labeled RBC study with the original I-positive donor confirmed greater than 92 percent destruction in 90 minutes. The clinical significance of this allo-anti-l (apparently primarily against RBCs from homozygous I-positive donors) is in marked contrast to reported findings with auto-anti-l antibodies.