Development and temporal exploratory evaluation of a multi-criteria decision analysis framework for Rh antigen-matched red blood cell donor prioritization

Rh antigen matching is an established strategy for reducing red blood cell (RBC) alloimmunization after transfusion. However, routine pretransfusion testing primarily determines whether a donor unit is acceptable on the basis of ABO/RhD compatibility, antibody-screening results, and crossmatch compatibility. For recipients with a negative pretransfusion antibody screen, selection of the optimal unit among multiple acceptable RBC candidates remains largely dependent on empirical judgment and inventory availability.

An MCDA framework was constructed using RhD-positive RBC transfusion data, incorporating RhC, c, E, and e antigen matching characteristics together with inventory-related considerations. Expert preferences were quantified using the analytic hierarchy process (AHP), and donor antigen-profile options were ranked using the technique for order preference by similarity to ideal solution (TOPSIS). The expert panel included seven professionals with backgrounds in transfusion medicine or clinical laboratory practice. The AHP-derived weights assigned to Rh antigen criteria were 0.5528 for c, 0.2687 for E, 0.1202 for e, and 0.0583 for C. At the unit level, high match was defined as Rank 1, or Rank 2 with an Rh antigen matching score of at least 9 and an integrated priority score within 10% of the highest-ranked option. Units not meeting these criteria were considered low match. For patients receiving multiple RBC units, high-match status required all transfused units to meet the unit-level high-match criteria; otherwise, the patient was classified as low match. Patients were categorized according to the concordance between the actual transfused donor RBC unit and the MCDA-derived donor-unit priority ranking, and the association between matching status and newly detected irregular antibody positivity within 6 months was assessed.

The MCDA framework generated structured donor priority rankings across different recipient Rh phenotypes. The ranking order remained consistent under alternative weight perturbation scenarios, supporting the stability of the proposed prioritization approach. The temporal exploratory cohort included 313 patients, with 156 classified into the high-match group and 157 into the low-match group. The incidence of newly detected irregular antibodies within 6 months was 3.2% (5/156) in the high-match group and 11.5% (18/157) in the low-match group, representing an absolute difference of 8.3 percentage points. Firth-corrected logistic regression analysis showed that high-match status was associated with a lower likelihood of newly detected irregular antibodies compared with low-match status [odds ratio [OR], 0.29; 95% confidence interval [CI], 0.10-0.82]. Sensitivity analyses yielded consistent results.

We developed an MCDA-based Rh antigen-matched RBC donor prioritization framework that enables structured and interpretable ranking among multiple clinically acceptable transfusion options. In this temporal exploratory evaluation, greater concordance between actual transfusion practice and MCDA-based ranking was associated with a lower incidence of newly detected irregular antibodies. The proposed framework is intended to complement, rather than replace, conventional immunohematologic testing. It may provide additional decision support when multiple compatible RBC units are available. Further multicenter prospective studies are warranted to determine its feasibility, clinical utility, and impact on transfusion practice.