J Clin Pathol 1993;46:585-588 585

Leaders

New technology in hospital blood banking

J Clin Pathol: first published as 10.1136/jcp.46.7.585 on 1 July 1993. Downloaded from http://jcp.bmj.com/ on August 1, 2020 by guest. Protected by copyright.
J K M Duguid, I M Bromilow

Introduction to perform an anti-IgG based indirect

Scientists and doctors interested in transfu- antiglobulin test (IAT) but may offer cost and
sion medicine have long recognised that it is time savings in certain laboratories.6
difficult to establish uniform serological test- Biotest Ltd have recently introduced a
ing which allows for consistently accurate similar microplate solid phase technique and
antibody identification and which can be BioProducts laboratories (BPL Elstree) are
adapted to suit clinical expediency. also developing a solid phase enzyme linked
The basis of traditional serological tech- immunosorbent assay (ELISA) based system
niques depends on the detection of agglutina- designed for automated reading, but this sys-
tion in a liquid phase. Commonly used tem is not currently commercially available.
serological techniques are affected by many
variables including serum:cell ratio, ionic
strength incubation time, and pH. These may Column technology
be difficult to control and standardise. To Recently, interest has been generated in the
minimise these problems various new tech- use of column technology for serological test-
niques have been developed. Most of these, ing. The original technique was based on the
however, still depend on interpretation of a principle of gel filtration for separation of red
liquid phase agglutination reaction and, par- blood cells from human blood.7 It was found
ticularly when the reaction is weak, reliable that the principle of gel centrifugation could
results are only obtained when the reaction is be modified for use as a serological tool using
examined within a short space of time by an Sephadex G100 superfine or Sephadex G200
experienced person. The introduction of Superfine. Originally described by Lapierre et
microplates, initially for ABO grouping and al,8 the aim of this technology is to standard-
Rh typing,' has led to the use of automated ise red blood cell agglutination reactions, and
readers,2' but due to lack of an objective end- by trapping the agglutinates, to permit simple
point automated readers still have difficulty and reliable reading.
distinguishing weak agglutination reactions The column consists of special microtubes
from negative reactions.4 containing a dextran gel matrix. Red blood
The introduction of solid phase tests and cells and serum or red blood cells alone are
column technology has helped to overcome dispensed into the microtubes, incubated if
these problems. necessary, and then centrifuged under strictly
controlled parameters. The gel within the
microtubes acts as a sieve, unagglutinated red
Solid phase tests blood cells form a pellet at the bottom of the
These depend on the immobilisation of one microtube, and agglutinated red blood cells
of the reactants so that during testing the are trapped in the gel. The gel may be neutral
immobilised component captures additional or contain specific reagents such as AHG or
reactants from the liquid phase and binds specific antibodies (anti-A, -B, anti-D, anti-
them to the solid phase.5 These techniques Kell, etc). Reactions are easily visible and
have been successfully developed for a range may be graded (fig 1). When performing the
of serological testing, including red cell antiglobulin tests no washing of the red blood
grouping, antiglobulin testing, and antibody cells is required because during centrifuga-
detection.4 They are used routinely in many tion, the cells are separated from their sus-
Mersey & North Wales laboratories but are still associated with some pension medium and serum as they pass into
Regional Transfusion technical problems, particularly when used the microtube. Red cells sensitised by IgG or
Centre for antibody detection using antihuman glob- complement components react with the AHG
West Derby Street,
Liverpool L7 8TW ulin (AHG). The commercially available contained in the gel and the resulting aggluti-
J K M Duguid Capture-R solid phase system (Immucor Ltd; nates are retained within the matrix. The
I M Bromilow Georgia USA, distributed in the United serum fraction does not, therefore, make con-
Correspondence
Dr J K M Duguid
to: Kingdom by Solent Diagnostics, Hants) has tact with the AHG impregnated gel, so that
Accepted for publication
been shown to be sensitive for antibody neutralisation of the AHG reagent is avoided.
7 January 1993 detection in routine use. It can only be used This technique also obviates the need to use
586 Duguid, Bromilow

Aluminium sheet of conventional tube tests without any loss of

specificity.8-' A comparison with an auto-

Gel
t mated polybrene technique, a two-stage
papain technique microtitre plate IAT, and a
spin tube low ionic strength IAT for routine
antenatal antibody screening and identifica-

J Clin Pathol: first published as 10.1136/jcp.46.7.585 on 1 July 1993. Downloaded from http://jcp.bmj.com/ on August 1, 2020 by guest. Protected by copyright.
tion, showed an increased antibody detection
Ea rate (148 antibodies v 95 antibodies in 3900
0 --1 1 2 1 3 1 4 1 5
Lo samples) and a decrease in the number of
non-specific enzyme only antibodies and false
positive screens. Antibody titres showed an
Neg. Positive. reactions 1- 5 'Mixed' increased reaction strength and so titre scores
field were higher than tube IAT titres, suggesting
0- 1I reaction
an increased sensitivity for the gel system.'0
Use in a routine hospital blood bank
7cm laboratory for red cell phenotyping (ABO,
Rh, Kell M and N), direct antiglobulin test-
Figure I Reading and grading of haemagglutination in ID gel test.
ing (DAT), antibody screening and indirect
antiglobulin test compatibility testing showed
that care must be taken to ensure that no
greater than a 1% suspension of red blood
pre-sensitised control cells to check negative cells is used and that problems may be
reactions. encountered in patients who are DAT posi-
Neutral cards can be used as part of anti- tive." It has also been shown, however, that
body screening for a two stage enzyme the serological assessment of drug induced
treated cell technique (fig 2). immune haemolytic anaemias is considerably
Reactions using gel techniques are stable improved by using the gel system.'2
for at least 48 hours and have the added facil- One study has cast doubts on the sensitiv-
ity of being able to be photocopied, thereby ity of the antiglobulin "gel-test" for antibody
providing a permanent record for future ref- detection,'3 because of an apparent inability
erence. This system is currently marketed in of the gel system to detect a few specially
this country as the ID-Microtyping System selected weak "difficult" antibodies with het-
(DiaMed-GB Ltd, Dalkeith, Midlothian, erozygous cells. The clinical importance of
Scotland). these antibodies is unknown as they were
Another system is also available based on principally used for assessment of AHG
column technology-the Ortho Biovue reagents and techniques. This type of testing
System (Ortho Diagnostic Systems Ltd., was recognised as being a stringent sensitivity
High Wycombe, Bucks). This column con- test'4 and was being compared with a "well-
tains a density gradient comprising a combi- performed" spin tube IAT. The relevance of
nation of a macromolecular density barrier this type of testing to routine work in a busy
and glass microspheres. The system is cur- hospital or transfusion centre serology labora-
rently available as microtubes with columns tory is uncertain. Available reports indicate
containing AHG or neutral density gradients. that routine use in a busy district general hos-
Again, this system offers the ability to pital showed a decrease in false positive anti-
perform a "no wash" antiglobulin test. body detection, with an associated increased
Preliminary reports suggest that this system is antibody identification rate (Thomas BE,
easy to use and produces stable results which Yates S. IMLS 20th Triennial Conference,
can also be photocopied. September 1992, abstract 123).
PRACTICAL APPLICATIONS OF GEL ADVANTAGES OF MICROTUBE SYSTEMS
TECHNOLOGY (Table 1)
Implementation of the DiaMed-ID gel system Both commercially available column systems
indicates that its sensitivity is superior to that using microtubes embedded in plastic cards

3 62 Table 1 Advantages and disadvantages of use ofgel

techniques for routine serology
1. Neutral gel. Advantages Disadvantages
2. Enzyme treated red cell suspension. Easy to use Commercial control
3. Serum. Standardisation of technique Cost
Stability of reactions Loss of
"traditional"
Results can be photocopied skills
Small sample volumes used
1
Tubes can be sealed easily,
therefore useful for "high risk"
samples
Labour saving
Decreased false positive reaction
Figure 2 Use of "neutral" ID gel test for two-stage enzyme treated ceU technique.
New technology in hospital blood banking 587

Table 2 Comparative costs of ABO and D grouping plus antibody screening by various freedom of choice of reagents, particularly
techniques (150 sampleslday) AHG, and there may be cost implications
associated with this. All techniques are per-
e P171.1777 sssssssssssss formed using a low ionic strength suspension
medium. Problems known to occur with the
2

J Clin Pathol: first published as 10.1136/jcp.46.7.585 on 1 July 1993. Downloaded from http://jcp.bmj.com/ on August 1, 2020 by guest. Protected by copyright.
use of this type of medium for certain anti-
-
a
C
bodies may therefore remain. There have also
been grave anxieties expressed at the possibil-
ity that certain laboratory skills will be lost, in
particular the ability to perform a reliable spin
4 tube IAT. It has to be recognised that this is
not necessarily detrimental. Certain labora-
5
tory skills considered essential in the past
6 have been lost because of the implementation
of new technology: this has led to improved
patient care.
I I III I I I Il.
I
0 0-5 1-o 15 20 25
Cost (f/sample) Costing
1. All conventional tube tests. Hospital transfusion laboratories are not con-
2. All microtitre plate tests. sidered high spenders (excluding the cost of
3. All DiaMed ID gel tests. blood and products). The cost of these com-
4. Microtitre plate ABO/D + tube ICT + enzyme screen. mercially available systems may therefore
5. Microtitre plate ABO/D + Capture-R ICT (no enzyme test). appear prohibitive.
6. Microtitre plate ABO/D + DiaMed ID ICT + enzyme screen. Perceived savings generated by decreased
false positive and non-specific antibody
detection or by the ability to alter staffing will
obviously vary among individual laboratories.
are technically easy to use. The "no-wash" An analysis of comparative costing of ABO
IAT means that reliable testing can be per- and D grouping and antibody screening using
formed by a wide variety of staff. Most false tubes, microplates, a gel technique, a solid
negative IAT results, when using conven- phase technique and a continuous flow
tional tube techniques, are known to be analyser has been performed.'5 Costs depend
caused by inefficient cell washing or from on the volume of samples handled, and for
trauma to weak red blood cell agglutinates laboratories processing more than 25 sam-
produced by over-vigorous agitation following ples/day gel cards for ABO and D grouping
excessive centrifugation. These problems are incurred significantly more expense. A
eliminated when using microtube columns, combination of microplate grouping and gel
allowing for the use of a broader skill-mix of antibody screening, however, was shown to
staff in individual laboratories and also facili- cost less than conventional tube techniques
tating the use of multidisciplinary on-call (table 2).
staff. Both these aspects of staffing are also
helped by the stability and robustness of the
reactions which means that results can be Conclusion
checked by experienced transfusion staff. It is unlikely that for serologists there will ever
Both systems require only small amounts be a single system that encompasses cost
of red blood cells and serum for testing effectiveness, ease of use, and accuracy.
(10-40 pl), making them ideal for neonatal Transfusion laboratory practice will always be
and paediatric use. The ability to photocopy problematic due to the combination of rou-
results and thus keep a permanent record is tine and emergency work, together with
also an advantage. sometimes unreasonable clinical and financial
Microtubes can be sealed once cells and pressures. The introduction of gel technol-
serum have been dispensed thus eliminating ogy, however, provides a refreshingly new
aerosol formation during processing and approach which may, by its sheer simplicity
making the system particularly useful for han- of use and standardisation of technique, facil-
dling "high risk" samples. itate the working practices of transfusion lab-
Currently 5% of United Kingdom partici- oratories and thus enhance the quality of the
pants in the NEQAS serology scheme use service provided to both patients and clini-
DiaMed-ID gel technology. As yet NEQAS cians.
organisers do not routinely analyse results
from these laboratories as a separate group,
but there is an international quality assurance 1 Wegmann TG, Smithies I. A simple haemagglutination
scheme available to all users of gel technology system requiring small amounts of red cells and anti-
organised by DiaMed. Results from this bodies. Transfusion 1966;6:67-73.
2 Bowley AR, Gordon I, Ross DW. Computer controlled
scheme are analysed and circulated regularly automated reading of blood groups using microplates.
to all participants. Med Lab Sci 1984;41:19-28.
3 Sevems ML, Shoeppner SL, Cozart MJ, et al. Automated
determination of ABO/Rh in microplates. Vox Sang
DISADVANTAGES OF MICROTUBE SYSTEMS 1 984;47:293-303.
4 Scott ML. The principles and applications of solid-phase
(Table 1) blood group serology. Transfusion Med 199 1;1:60-72.
The use of column techniques means loss of 5 Plapp FV. New techniques for compatibility testing. Arch
588 Duguid, Bromilow

Pathol Lab Med 1989;113:262-9. ig and identification. Transfusion Med 1991;1: 159-61.
6 Sangster JM, Wiggens CS. Experience with "Capture-R" 11 de Figueiredo M, Lima M, Morais S, Porto G, Justica B.
solid phase antibody screening. Proceedings of the The gel test: some problems and solutions. Transfusion
Microplate Coordinating Group. London: British Blood Med 1992;2:115-8.
Transfusion Society, 1991:7-8. 12 Salama A, Berghofer H, Mueller-Eckhardt C. Detection
7 Kanura T, Kurashina S, Nakao M. A gel filtration tech- of cell-drug (hapten)-antibody complexes by the gel
nique for separation of erythrocytes from human blood. test. Transfusion 1992;32:554-6.
J7 Lab Clin Med 1974;83:840-4. 13 Phillips PK, Whitton CM, Lavin F. The use of the

J Clin Pathol: first published as 10.1136/jcp.46.7.585 on 1 July 1993. Downloaded from http://jcp.bmj.com/ on August 1, 2020 by guest. Protected by copyright.
8 Lapierre Y, Rigal D, Adam J, et al. The gel test: a new way antiglobulin 'gel-test' for antibody detection. Transfusion
to detect antigen-antibody reactions. Transfusion 1990; Med 1992;2:111-3.
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