doi:10.1111/imj.

13707

P O S I T I O N PA P E R

Considerations for pre-transfusion immunohaematology testing

in patients receiving the anti-CD38 monoclonal antibody
daratumumab for the treatment of multiple myeloma
Hang Quach,1,2 Simon Benson,3 Helen Haysom,3,4 Anne-Marie Wilkes,5 Nicole Zacher,3,6
Merrole Cole-Sinclair,2,5 Henry Miles Prince,1,7 Peter Mollee,8 Andrew Spencer,9,10 Phoebe Joy Ho,11
Simon J. Harrison,1,12 Cindy Lee,13 Bradley Augustson14 and James Daly3,15
1
Department of Medicine, The University of Melbourne, 2Department of Haematology, and 5Blood Transfusion Laboratory, St Vincent’s Hospital,
4
Department of Epidemiology and Preventive Medicine, and 9Australian Centre for Blood Diseases, Monash University, 7Department of Haematology,
Epworth Health, 10Department of Haematology, Alfred Hospital, and 12Department of Haematology, Peter MacCallum Cancer Centre, Melbourne,
Victoria, 3Australian and New Zealand Society of Blood Transfusion, and 11Department of Haematology, Royal Prince Alfred Hospital, Sydney, New
South Wales, 6Clinical Diagnostic Department, Capital Pathology, Canberra, Australian Capital Territory, 8Department of Haematology, Princess
Alexandra Hospital, and 15QML Pathology, Brisbane, Queensland, 13Department of Haematology, Royal Adelaide Hospital, Adelaide, South Austalia,
and 14Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia

Key words Abstract

transfusion, immunohaematology,
daratumumab, multiple myeloma. In recent years, the anti-CD38 monoclonal antibody daratumumab (Darzalex; Janssen-
Cilag Pty Ltd) has been shown to be highly efficacious in relapsed and refractory multiple
Correspondence myeloma, with the final results of treatment in newly diagnosed patients awaited. Despite
Hang Quach, Department of Haematology, awareness of the potential interference of daratumumab in pre-transfusion immunohae-
St Vincent’s Hospital, 41 Victoria Parade, Fitzroy, matology testing during phase I and II clinical studies, there was a degree of unprepared-
Vic. 3065, Australia. ness in the community upon the introduction of this drug into the clinics, particularly the
Email: [email protected] impact that it has on the operational processes in hospital transfusion laboratories and
timely issue of red blood cells (RBCs). Anti-CD38 interference in pre-transfusion immuno-
Received 30 November 2017; accepted haematology tests is a particular problem in patients being treated with daratumumab for
30 November 2017. multiple myeloma as many will require RBC transfusions during their disease treatment.
Panagglutination caused by anti-CD38 monoclonal antibody during the indirect antiglobu-
lin test may mask the presence of a clinically significant RBC alloantibody in the patient’s
plasma during the antibody screen and identification process, which may be overlooked,
particularly in urgent situations, subsequently resulting in a delayed or acute haemolytic
transfusion reaction. Here, we summarise daratumumab’s effects on pre-transfusion
immunohaematology testing and its impact on clinical practice and make practical recom-
mendations based on a consensus from medical and scientific transfusion experts and
myeloma specialists on behalf of the Australian and New Zealand Society of Blood Trans-
fusion and Myeloma Scientific Advisory Group to Myeloma Australia, respectively.

Introduction
In recent years, the anti-CD38 monoclonal antibody
(mAb) daratumumab (Darzalex; Janssen-Cilag Pty Ltd)
Funding: Janssen-Cilag provided funding for the authorship
has been shown to be highly efficacious in relapsed and
group to meet and discuss the guidelines. Janssen-Cilag refractory multiple myeloma (MM). In 2015, daratumu-
reviewed the guidelines for scientific accuracy, but the final mab was granted accelerated approval by the Food and
decision to publish was solely the authors. Drug Administration in the United States for the treat-
Conflict of interest: H. Quach has sat on scientific advisory ment of relapsed/refractory MM, with Australia’s Thera-
boards for Celgene, Janssen-Cilag and Amgen and has received
peutic Goods Administration (TGA) following suit in
research funding from Celgene and Amgen. H. M. Prince, A.
Spencer, P. J. Ho, S. J. Harrison and B. Augustson have sat on
2017. These decisions were based on results only from
scientific advisory boards for Janssen-Cilag Pty Ltd. H. Haysom, early phase I/II clinical studies, in which heavily pre-
S. Benson and M. Cole-Sinclair have no conflicts of interest. treated patients with MM were shown to have an overall

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 Daratumumab and the transfusion laboratory

survival improvement of approximately 11 months from compatibility, do not detect the effects of daratumumab.
single-agent daratumumab.1 As a result of this early There is some variability of expression of CD38 on RBC,
move into the clinics, there was an underappreciation of and the presence of daratumumab in the patient’s plasma
the impact of daratumumab’s interference with pre- typically causes weak panagglutination in IAT used for
transfusion immunohaematology testing and, therefore, pre-transfusion immunohaematology testing. In contrast,
on hospital/pathology transfusion laboratory operational daratumumab does not interfere with ABO or RhD
processes, timely issuing of blood, potential blood trans- typing.6,7
fusion reactions and, ultimately, patient safety. In the antibody screen and antibody identification
CD38 is an integral transmembrane glycoprotein that is panel, the plasma of patients treated with daratumumab
expressed on many cell types and highly expressed on exhibits weak (1+ or 2+, using 0–4 scoring) panaggluti-
plasma cells. It has diverse functions, including enzyme nation. This panagglutination occurs in all IAT tests, for
activity, intracellular calcium regulation and receptor- example, saline, low ionic-strength saline (LISS) and
mediated adhesion.2 It is also variably expressed on the polyethylene glycol (PEG), and all IAT methods, includ-
surface of red blood cells (RBCs). Anti-myeloma activity ing column agglutination technology (CAT) and tube
from daratumumab occurs though anti-CD38-mediated and solid phase.6 Positive IAT may persist for up to
immune mechanisms, including complement-dependent 6 months after discontinuation of daratumumab
cellular cytotoxicity (CDCC), antibody-dependent cellular therapy.7–9 The presence of panagglutination must be
cytotoxicity (ADCC), antibody-dependent cellular phago- investigated at each testing episode as the reactivity may
cytosis (ADCP) and immunoregulatory depletion of mask the presence of a clinically significant alloantibody
immune suppressive regulatory T cells.3–5 In addition, or the presence of autoimmune haemolytic anaemia.
direct tumouricidal activity occurs through pro-apoptotic Interestingly, while daratumumab in the patient’s
signalling pathways upon cross-linking of surface CD38. As plasma will cause agglutination in IAT with all reagent
an off-target side-effect, when bound to CD38 on RBC, RBC and donor RBCs, reactivity with the patient’s own
daratumumab interferes with the indirect antiglobulin tests RBC is not consistent, and the auto-control in the anti-
(IAT), a technique routinely used in pre-transfusion test- body identification panel is frequently negative, as is the
ing. Anti-CD38 interference in immunohaematology tests direct antiglobulin test (DAT). This suggests that the
is a particular problem in patients being treated for MM as patient’s RBCs with high levels of CD38 may be cleared
many will require blood transfusions as part of their sup- from the circulation and/or be subject to anti-CD38-
portive care during ongoing disease treatment. Panaggluti- mediated antigen downregulation,10 which may explain
nation caused by anti-CD38 may mask the presence of a why, to date, clinical manifestations of daratumumab-
clinically significant RBC antibody (Ab) in the patient’s related, immune-mediated haemolysis have not been
plasma, which may be overlooked, particularly in urgent reported in daratumumab-treated patients. That observa-
situations, and subsequently result in an acute or delayed tion notwithstanding, interference by daratumumab has a
haemolytic transfusion reaction. serious impact on the ability of transfusion laboratories to
Here, we summarise daratumumab’s impact on pre- perform timely pre-transfusion testing.11 The resolution of
transfusion immunohaematology testing, its impact on the interference requires time-consuming specialist inves-
clinical practice and provide practical recommendations tigations that inevitably lead to delays in the provision of
based on a consensus from medical and scientific trans- blood for transfusion, especially if it is not know that the
fusion experts and myeloma specialists on behalf of the patient is being or has been treated with daratumumab. In
Australian and New Zealand Society of Blood Transfu- addition, clinically significant RBC alloantibodies may be
sion (ANZSBT) and Myeloma Scientific Advisory Group masked and overlooked, potentially resulting in an acute
to Myeloma Australia (MSAG), respectively. or delayed haemolytic transfusion reaction. For urgent or
emergency transfusions, however, it should be possible to
determine the patient’s ABO and RhD blood group and
The nature of daratumumab’s
provide ABO-compatible blood, but provision of this with-
interference with pre-transfusion tests
out further investigation is not without risks.12,13
The binding of daratumumab to CD38 on human RBC is
detected using the IAT (or indirect Coomb’s test) carried
Overcoming the interference of anti-
out at 37 C, which is the primary antibody screening
CD38 therapy
method used to detect the presence of clinically significant
alloantibodies. Secondary testing methods that may be Several methods have been proposed to overcome anti-
used in antibody investigations, such as room temperature CD38 interference in immunohaematology testing and to
testing or immediate spin tests to check for ABO facilitate alloantibody screening, thus reducing the risk of

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Quach et al.

incompatible transfusions and the possibility of transfu-

sion reactions. These include testing the patient’s plasma Box 1 Antigens denatured or
against a panel of reagent RBC treated with dithiothreitol weakened by treatment with DTT or
(DTT) or trypsin. In addition, extended RBC phenotyping proteolytic enzymes15,16
or genotyping of the patient prior to the first dose of dara-
tumumab enables transfusion laboratories to provide RBC DTT Trypsin Papain/
with a phenotype that matches the patient’s RBC pheno- Bromelin
type, with the aim of preventing or at least minimising
Kell (K, k, Kpa, Kpb, Jsa, Cartwright Duffy
the risk of incompatibility, particularly when daratumu- Jsb, Ku) (Yta) MNSs, ‘N’
mab interference cannot be immediately resolved and/or Cartwright (Yta) Indian Indian
the RBC transfusion is urgent.6,14 Transfusion of Indian JMH JMH
phenotype- or genotype-matched RBC will also reduce JMH Ge2, Bpa
Scianna Ge3, Ge4 Ch/Rg
the risk of sensitisation and future alloantibody formation.
LW Dombrock Xga
DTT is a thiol-reducing agent that denatures RBC Lutheran Bpa EnaFS EnaTS
surface CD38 by disrupting the disulfide bonds in the mol- MER2 Ch/Rg Ge2, Ge4
ecule’s extracellular domain, therefore preventing anti- Ge3 Xga Fya, Fyb, Fy6
CD38 from binding to the RBC.6 The use of DTT treat- Dombrock MN Yta
Some Diego EnaTS
ment is a recognised immunohaematological method. The
Cromer Lutheran
test is robust and reproducible6 but not automated, and it Mer2
is primarily used by specialist or reference laboratories. Knops
Trypsin is a proteolytic enzyme not routinely used in
Australian laboratories and is less efficient than DTT treat-
ment at cleaving cell-surface CD38.7 Other more com- Cord blood cells do not bind anti-CD38 mAb. A sug-
monly used proteolytic enzymes, such as papain, gestion has been made that these cells could be used, but
bromelin or ficin, are used in immunohaematology test- manufacturers of reagent RBC are constrained by limited
ing as part of antibody identification protocols, to enhance supply. In a routine transfusion laboratory, other sources
weak antibody activity or aid in the resolution of multiple of suitable cord blood samples would not typically be
antibody specificities. These enzymes may also be used as available and would require registration as an in-house
part of the immunohaematology laboratory tool kit for in vitro diagnostic (IVD). In addition, cord cells have
daratumumab interference investigations, but no valida- altered expression of some antigens, and this method is
tion studies of the use of these enzymes in the resolution unlikely to be routinely offered by hospital or pathology
of daratumumab interference have been published. laboratories.14,17
It must be noted that DTT and trypsin (along with Obtaining an extended RBC phenotype for the
other proteolytic enzymes) also denature or weaken the patient prior to commencement of daratumumab ther-
reactivity of some RBC antigens (see Box 1), and this apy is important in the provision of phenotype-matched
should be taken into consideration when assessing RBC for future transfusions. Knowledge of the pheno-
results from tests where these agents are used. In partic- type means that donor RBCs negative for the common
ular, DTT is known to denature the Kell system antigens, clinically significant RBC antigens that the patient lacks
and therefore, when used to resolve daratumumab inter- can be selected for transfusion, thereby reducing the
ference, patients should be transfused with K-negative possibility of RBC antibody formation.14 Patient RBC
RBC unless they have been shown to be K-positive on phenotyping should be performed by the transfusion
previous testing.6 At present, reagent RBC pre-treated laboratory prior to the patient commencing daratumu-
with DTT or trypsin are not available from reagent man- mab and at least 3 months after any recent blood trans-
ufacturers. Australian laboratories may not have access fusion (which otherwise may lead to misleading
to sufficient quantities of reagent RBC to prepare and results). The patient sample could be sent for genotyp-
maintain DTT- or trypsin-treated antibody screening or ing where samples are unsuitable for phenotyping at
identification panels cells for regular routine use. any point pre- or post-commencement on daratumu-
An alternative and the optimal approach to managing mab, but typing prior to treatment is recommended.
the interference of the anti-CD38 antibody would be to The results are not received immediately, and this, in
neutralise the anti-CD38 antibody in the patient’s addition to antibody investigation confounded by the
plasma using soluble CD38 antigen or anti-CD38 idio- presence of daratumumab, might add to the delay in
type antibody. However, both are expensive and not provision of safe blood for transfusion. Ideally, this
currently routinely available. information should be sought prior to commencement

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 Daratumumab and the transfusion laboratory

of treatment. As a minimum, the patient should be cannot be excluded in the presence of daratumumab.
typed for Rh antigens, K, Jka, Jkb, Fya, Fyb and Ss.18 To Furthermore, phenotype- or genotype-matched RBC
manage workload and preserve reagents used, pheno- transfusions will minimise the potential for sensitisation
typing may be performed in regular, for example, and future alloantibody formation. A clinical decision
weekly batches. Genotyping is currently only offered in may be required on whether to limit or prioritise chosen
Australia by the Australian Red Cross Blood Service in phenotypes based on the urgency of the request and the
Brisbane. Rapid genotyping testing may be available, difficulty of providing matched units for transfusion.13
but routinely, a 1-week turnaround time should be Information relating to the immunohaematology test-
taken into consideration. ing should be maintained in the patient’s clinical and lab-
A practical approach for immunohaematology testing oratory files, and the patient should be provided with a
of RBCs in myeloma patients receiving treatment with ‘patient alert card’, which can inform healthcare providers
the anti-CD38 mAb, daratumumab, is detailed in the fol- that they are receiving anti-CD38 therapy. It is important
lowing section. The real-world constraints are discussed, to consider that patients may attend several hospitals and
recognising that investigations to resolve anti-CD38 be tested at several transfusion laboratories, and it is also
interference are time consuming and labour intensive important to remember that in the absence of a jurisdic-
and may not be available to all laboratories, especially tional or national alloantibody register, information about
regional or rural laboratories. the patient’s treatment with daratumumab and RBC phe-
notype and prior RBC alloantibody history may not be
accessible by the transfusion laboratory or hospital at
Pre-transfusion testing requirements
which the patient currently presents.

A: Prior to anti-CD38 therapy

Prior to treatment with daratumumab:
Clear and timely communication between the treating 1 Communications from treating professional and transfu-
clinician, patient and transfusion laboratory is absolutely sion laboratory to document that the patient is to start anti-
vital when anti-CD38 therapy is planned. Patients and CD38 mAb.
2 Provide a full transfusion, obstetric and drug history.
healthcare providers must be made aware of the poten-
3 Perform a blood group (ABO, RhD).
tial interference of anti-CD38 in pre-transfusion testing 4 Perform an antibody screen and DAT.
and of the potential sequelae if appropriate immunohae- 5 Perform an extended RBC phenotype (or genotype, where
matological testing is not performed. indicated).
The transfusion laboratory can be provided with a 6 Provide patient with an alert card (see Fig. 3).
request for phenotype if there has been no recent trans-
fusion or RBC genotyping if the patient has been
recently transfused or has a positive DAT, noting that
the patient will receive anti-CD38 therapy. The clinician
B: Following commencement of anti-CD38
should provide the transfusion laboratory with a full and
therapy
accurate transfusion, obstetric and drug history for the
patient, and this may also require review of both hospital It is extremely important for the transfusion laboratory to
and laboratory records. know that a potential transfusion recipient is receiving
Routine pre-transfusion testing includes a blood group anti-CD38 therapy. The treating clinician needs to under-
(ABO/RhD) and antibody screen and will establish pre- stand the impact on pre-transfusion testing and to con-
treatment baseline results. An RBC phenotype sider the timeframes for testing and provision of blood.
(or genotype) is most valuable and, as a minimum, Specimens from patients on anti-CD38 may need to be
should include: Rh (C, c, E, e), K, Jka, Jkb, Fya, Fyb and referred to a reference laboratory for the more complex
Ss antigens. Genotyping will be informative when phe- investigations necessary in these cases. The resource
notyping is not possible due to recent transfusion (i.e. in impacts on specialised reference services would be miti-
the last 3 months) or if the patient has a positive DAT or gated if the neutralising antibody was listed on the
if suitable phenotyping reagents are not available. The Australian Register of Therapeutic Goods (ARTG) and avail-
RBC phenotype and genotype can assist the laboratory able. This would also simplify and expedite pre-transfusion
not only by suggesting what RBC alloantibodies the testing and improve the relative safety of transfusion.
patient may potentially form but also by enabling trans- The ABO/RhD typing is unaffected by the presence of
fusion of phenotype- or genotype-matched RBC, which anti-CD38 and can be reported normally. The anti-CD38
will minimise the risk of RBC incompatibility in situa- panagglutination typically results in a universally weak
tions where underlying unexpected alloantibodies (1+ or 2+; using 0–4 scoring) positive antibody

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Quach et al.

screen.18,19 If one or more of the screening cells are which are destroyed by DTT and without routine typing
strongly reactive (3+ or 4+), this suggests the potential sera for donors or patients, will be missed. Clinicians need
presence of an antibody, possibly an alloantibody, other to pay careful attention for signs of acute or delayed hae-
than anti-CD38 (Fig. 1). molytic transfusion reactions in patients on daratumumab
To overcome anti-CD38 interference, the antibody after any transfusion; the genotype might provide a clue
screen can be repeated using DTT- or trypsin-treated where the phenotype is not available.
reagent screening RBC. If this is negative, it may be
assumed that no clinically significant RBC alloantibodies
are present, with the caveat that specificities directed Pre-transfusion testing following commencement of daratumumab:
against antigens denatured by the chosen enzyme cannot 1 Provide laboratory with a full transfusion, obstetric and
be excluded. In the case where DTT-treated cells are used, drug history.
the laboratory can select donor RBC that are ABO, RhD 2 Order a blood group (ABO/RhD) and DAT.
3 Perform antibody screen panel.
and K compatible, and these might be issued using the
4 If panagglutination is indicative of interference with anti-
standard institutional cross-match (XM) protocol for a CD38 mAb on the antibody screen (see Fig. 1), perform an
negative antibody screen, for example, electronic (com- antibody screen using DTT- or trypsin-treated screening cells.
puter) or immediate spin (IS) XM. In the absence of an (Other enzymes, e.g. papain, bromelain, ficin, may be used as
identified RBC alloantibody using DTT-treated screening an adjunct to help identify or exclude particular alloanti-
bodies to RBC (Note: Methods other than DTT or trypsin have been
cells, the decision to provide more extended phenotype-
used but might not be validated for the purpose of resolving daratu-
or genotype-matched RBC beyond RhD and K (including mumab interference. We suggest that if enzyme methods other than
Rh Cc, Ee, Jka, Jkb, Fya, Fyb and Ss) will be influenced by DTT or trypsin are used, then extended phenotype-/genotype-matched
the availability of suitable units, clinical urgency of trans- donor RBC should be given (Rh Cc, Ee, Jka, Jkb, Fya, Fyb and Ss).))
fusion, anticipated current and future transfusion require- 5 Perform an extended RBC phenotype (or genotype, where
indicated).
ments and local policy. If the patient is revealed to have
6 Issue donor RBC.
an unexpected genotype with potential antibody forma-
tion, this could be considered in planning.
Note that apart from DTT and trypsin, no validation
studies have been published for other enzymes or
methods for the purpose of resolving daratumumab C: Life-threatening bleeding and emergency
interference. Thus, if other enzymes or methods are transfusions
used, our consensus is that blood matched to the
For patients experiencing life-threatening bleeding or in
patient’s phenotype/genotype should be given, particu-
emergency situations where transfusion is required
larly if long-term transfusion support is anticipated.
within 2 h, there may not be time for the recommended
A positive antibody screen using DTT- or trypsin-
routine pre-transfusion testing. Previous antibody his-
treated reagent RBC suggests that the patient has an
tory, phenotype and genotype results are invaluable in
additional RBC alloantibody. The antibody specificity
this circumstance.
will need to be determined using a DTT- or trypsin-
There is a need to balance the clinical risks of transfu-
treated RBC. Antigen-negative blood may then be
sion versus those of not transfusing the patient, but
selected for XM. RBC that match the patient’s extended
under no circumstances should transfusion be delayed in
RBC phenotype/genotype should be selected for transfu-
the setting of a bleeding emergency.
sion, with the degree of matching determined by clinical
urgency and the practicable availability of the desired
phenotyped donor blood. A full IAT XM is required, but The greatest risk to the patient is transfusion of ABO-
incompatible blood. In emergency situations, the risk is
this will be incompatible unless DTT- or trypsin-treated
normally mitigated by transfusion of group O RhD-negative
donor cells are used for the XM. blood; however, it should be noted that RhD-negative
The flowchart (Fig. 2) represents the expert group’s blood is not necessarily the most appropriate in all cases,
recommendation for pre-transfusion testing in the pres- especially in patients that are Rh c-negative and or Rh e-
ence of anti-CD38. It is recognised that not all transfusion negative.
ABO and RhD typing are not affected by the presence of anti-
laboratories in Australia and New Zealand will either rou-
CD38 antibody in the patient’s plasma.
tinely use or have access to DTT- or trypsin-treated
reagent cells. The scope of testing will depend on institu-
tional policy, clinical urgency and availability of appropri- Transfusions should be in accordance with institutional
ately phenotyped (or genotyped) donor RBC. Antibodies critical bleeding or emergency transfusion policies. Fur-
developed by patients to antigens such as Dombrock, ther information on transfusion in emergency situations

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 Daratumumab and the transfusion laboratory

Figure 1 Typical red blood cell reactivity due to anti-CD38 in a patient’s plasma. (A) Indirect antiglobulin test (IAT) panel where all cells display reac-
tions consistent with anti-CD38 therapy; (B) IAT panel with some reactions consistent with anti-CD38 therapy; however, the pattern suggests that an
alloantibody is present; (C) Saline panel where there is no interference by anti-CD38 therapy in cells 1–3, while cells 4–11 are positive for alloantibody.

can be found in the ANZSBT’s ‘Guidelines for Transfusion interference of this drug in laboratory tests, particularly
and Immunohaematology Laboratory Practice’.20 pre-transfusion testing. The problem will increase if dar-
atumumab’s use expands to early-phase disease
treatment.
Clinical considerations
A crucial aspect in risk mitigation is education to
Daratumumab is the first anti-CD38 mAb that received increase awareness and a robust procedure to enable
clinic approval by the FDA in 2015 and subsequent TGA timely and routine communication with the blood trans-
approval in Australia in 2017. Its use in combination fusion laboratory. The patient and family members need
with current therapeutics, such as lenalidomide or borte- to be aware of daratumumab’s interference in pre-
zomib, increases the frequency of minimal residual dis- transfusion tests and the potential impact this may have
ease negative remissions in MM, which may translate to on any blood transfusions. A patient alert card (see Fig. 3)
improvement in survival outcome.21,22 Healthcare pro- is also useful for this purpose. All levels of medical care –
viders have not been adequately prepared for the critical from nursing staff to doctors and transfusion laboratory

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Quach et al.

Blood transfusion required

Is
YES
transfusion NO
urgent?

Life threatening bleeding / Emergency

Non-urgent (required > 2 h)
transfusion

Pretransfusion sample Perform Phenotyping or Genotyping (if time allows)

Issue blood using institutional protocols for emergency
Blood group (ABO/RhD), • Phenotype (if not transfused in preceding 3 months)
transfusion or Massive Transfusion Policy (MTP).a
antibody screen • Genotype (if recently transfused or DAT positive)
• Emergency O RhD-negative red cellsb
• Switch to ABO/RhD and Kell compatible red cells
where appropriate.
Take samples before transfusion for retrospective testing
and cross matching
Routine IAT
antibody NEGATIVE Proceed as per usual institutional protocol
screen

POSITIVE
PAN-AGGLUTINATION TYPICAL OF ANTI-CD38 (DARATUMUMAB) INTERFERENCE, E.G.
1+ TO 2+ REACTIONS WITH ALL CELLS; OWN CELLS (‘AUTO CONTROL’) MAY BE
NEGATIVE

Provide phenotype compatible blood, if

available or refer samples to reference
Does laboratory have laboratory for further evaluationd
capability for testing using NO Use of other routine laboratory tests (papain
or bromeline) to exclude the development of
DTT or trypsin treated red a new of existing alloantibody may assist in
cells?c the selection process for phenotype
compatible units

YES

Perform IAT antibody screen

NEGATIVE POSITIVE
using DTT or trypsin treated red cellsc

NEGATIVE POSITIVE
• Assume no clinically significant red cell alloantibody/ies • Suggests presence of red cell alloantibody/ies.
• Cannot exclude antibodies to antigens denatured by chosen • Identify antibody/s using DTT or trypsin treated ID antibody panel –
treatment method (see Box 1) may require investigation by a Reference Laboratory
• Transfuse ABO /RhD compatible blood and blood compatible for any • Cannot exclude alloantibodies against antigens denatured by chosen
significant antigens destroyed by the method used e.g. Kell treatment method (see Box 1)
compatible for DTT methods (see Box 1)
• Select blood that is compatible for antibody/s and antigens denatured
• Consider selecting blood matched to patient’s extended phenotype / by chosen treatment method, e.g. Kell compatible for DTT methods
genotype, particularly if long-term transfusion support anticipated (see Box 1)
• Abbreviated crossmatch (eXM or IS) and issue blood by usual • If alloantibody cannot be identified for any reason, consider selecting
protocol blood matched to patient’s extended phenotype/genotype,
particularly if long-term transfusion support anticipatedd
• If IAT crossmatch used – will be positive unless donor cells are DTT
or trypsin treated • Full IAT crossmatch – will be positive unless donor cells are DTT or
trypsin treated

Figure 2 Pre-transfusion testing recommendations. aRefer to ANZSBT Guidelines for Transfusion and Immunohaematology Laboratory Practice; bO-
negative blood is not without risk and may not be suitable in all circumstances, e.g. patient has anti-c or anti-e antibodies; cTests using DTT or trypsin
treated red cells are published methods for resolving anti-CD38 (daratumumab) interference; however, testing may not be available in all laboratories
and/or subject to regulatory restrictions; dExtended phenotype/genotype including as a minimum: Rh (C, c, D, E, e), K, Jka, Jkb, Fya, Fyb and Ss; ePapain
and bromeliad are not IAT methods for crossmatching purposes. DAT, direct antiglobulin test; DTT, dithiothreitol; IAT, indirect antiglobulin test.

216 Internal Medicine Journal 48 (2018) 210–220

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 Daratumumab and the transfusion laboratory

Figure 2 (Continued)

scientists – need to be educated to ensure effective com- baseline extended RBC phenotype (regardless of the
munication and adequate documentation in the patient immediate need for blood transfusion). The transfusions
record and the transfusion laboratory information sys- laboratory requires ongoing notification of daratumu-
tem (LIS). Every public and private haematology/oncol- mab treatment when RBC transfusion is requested for
ogy facility should have a procedure to automatically up to 6 months post-treatment cessation. Updating blood
notify the relevant transfusion laboratory when a patient transfusion requisition forms to include questions about
is about to commence daratumumab and provide the antiCD38 mAb might be considered, as well as suitable
appropriate specimens for testing. This will allow for alert notifications in electronic alert/chemotherapy

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Quach et al.

Name: _____________________________________

I am taking the following medication:

• <<insert anti-CD38 antibody>> product for the treatment of multiple myeloma

Dear Healthcare Provider,

Indirect antiglobulin test [IAT; Indirect Coomb’s test] may show positive results in
patients taking daratumumab, even in the absence of other clinically significant RBC
antibodies in the patient’s plasma. The determination of a patient’s ABO and RhD
blood type are not affected.

If an emergency transfusion is required, uncrossmatched, ABO/RhD compatible

RBC’s can be given as per local institutional policies. As dithiothreitol (DTT)
treatment also denatures Kell antigens, K-negative units must be provided unless the
patient is known to be K-positive.

For more information, please contact <<insert company name, telephone number
and email address>>

Additional information on interference with blood compatibility testing can be found in

the <<insert anti-CD38 antibody>> product information leaflet at <<insert website>>.

Before starting <<insert anti-CD38 antibody>>, my blood test results collected

on (date) ________________________________were:
Blood type: A B AB O Rh+ Rh-

Indirect Antiglobulin Test IAT (Coomb’s) antibody screen was:

Negative Positive for the following antibodies:

Other: _______________________________________

Contact details of institution where the blood tests were performed:

_____________________________________________________ Figure 3 Example of patient

alert card.

prescribing systems and alerts in the transfusion LIS to phenotype- or genotype-matched blood where available.
state that the patient is receiving daratumumab. The ensuing impact of increased demands on the ARCBS
In the transfusion laboratory, while both DTT and tryp- and the increasing need for relevant immunohaematol-
sin are widely recommended, these methods are not ogy expertise outside of large metropolitan laboratories
always practical when laboratories rely heavily on auto- will need to be considered. The establishment of a
mation. These methods are manual and laborious and national RBC alloantibody register has been under con-
incur additional costs. Although robust and reproducible,6 sideration and might reasonably include relevant docu-
in Australia, both DTT and trypsin used in these methods mentation for these circumstances.
have not been approved for use as in vitro diagnostics by With respect to the impact on patients, the risk per-
the TGA. There are no commercially available DTT or tryp- tains not only to possibility of missing a significant allo-
sin reagents listed on the ARTG, nor are DTT- or trypsin- antibody that may cause acute or delayed haematolytic
treated reagent RBC screening or extended panels avail- transfusion reactions but also to the delay in issuing of
able. Thus, both methods would be considered ‘in-house’ blood products. The potential for delay is present both
methods and may not meet Australian IVD device regula- when transfusion laboratories are unaware that patients
tions, despite being fully validated by laboratories before are receiving daratumumab and when, if aware, are
introduction. There is no current prospect of commercial required to undertake increased testing. Haemolytic
availability of ATRG-listed soluble CD38 or anti-idiotype transfusion reactions because of daratumumab interfer-
antibodies to neutralise the effect of daratumumab. ence with pre-transfusion testing were not reported in
In the face of these constraints, the default contin- the two pivotal phase III CASTOR23,24 and POLLUX25,26
gency for many laboratories will be to issue extended studies. The patients in these trials were in the relatively

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© 2018 Royal Australasian College of Physicians
 Daratumumab and the transfusion laboratory

early course of their disease (with a median of 1–2 prior daratumumab’s interference in serum protein electro-
lines of treatment) and were not commonly transfusion- phoresis and immunofixation assays, which are methods
dependent. Conversely, in the clinic, daratumumab is to quantitate and type monoclonal immunoglobulins
currently also FDA- and TGA-approved as monotherapy (M-proteins), respectively, in the serum or urine. In the
for heavily pretreated patients who have had at least absence of such a kit for pre-transfusion testing, other
three prior lines of therapy. It is, therefore, expected that ways to resolve the problem, to minimise workflow dis-
higher transfusion requirements will be seen in these ruption to transfusion laboratories and mitigate risks to
end-stage patients, and we cannot be certain of the patients must be considered.
notion that no haemolytic transfusion reactions have If a transfusion laboratory is not aware that a patient is
been observed in daratumumab-treated patients before. receiving daratumumab, protracted investigation and
Clinicians and laboratories should be aware of the poten- delays are likely to occur when unexpected panaggluti-
tial for acute and delayed haemolytic transfusion reac- nation is found in the routine antibody screen. A
tions and should investigate, document and report any national database (or register) of patients treated with
such reactions, or adverse events through their local daratumumab or any other mAb that interferes with
haemovigilance programme. pre-transfusion tests could provide an easily accessible
source of information for patients who may demonstrate
interference in immunohaematology testing. Such a
Future directions
database, if incorporated in an antibody register or data-
As the use of mAb is becoming increasingly prevalent for base, could also potentially alert the local laboratory ser-
therapy of cancers and other medical conditions, the vice when a patient is known to have RBC allo- or
concept of potential interference in critical laboratory autoantibodies. This might reduce delays in immunohae-
tests needs to be recognised and appropriate antibody matology testing and time to appropriate transfusion.
neutralising solutions developed, preferably prior to the Such databases have been recommended in other
widespread introduction of these agents into the com- jurisdictions.14
munity. The introduction of daratumumab into clinical At the hospital level, routine and automatic notifica-
use in MM has indeed created a predicament in the tion to the transfusion laboratory about a patient’s treat-
transfusion laboratory that is without precedent, but ment status could be mandated. Automated alerts,
should serve as a case in point to gain experience and through electronic medical record systems to the transfu-
prepare for similar scenarios in the future. Any mAb that sion laboratory, for every patient on treatment that may
targets common antigens present on RBC have the interfere with immunohaematology tests or require
potential to interfere with pre-transfusion testing. Cur- selection of specialised blood products could be imple-
rently, these include the other anti CD38 mAb, such as mented. Investment in the development of this infra-
isatuximab and MOR202,27,28 both of which are under- structure needs to happen now to prepare adequately
going clinical studies for the treatment of MM. While the for the surge of mAb in clinical use in the near future.
nature of interference of these monoclonal antibodies is For future targeted therapies, we emphasise the need to
anticipated to be similar to that of daratumumab, this explore fully any potential interference with critical labo-
may not become clear until the drugs are more widely ratory assays that may impact the other areas of clinical
used. It is unclear whether there is concurrent develop- practice prior to their introduction into the clinics.
ment of an antidote to neutralise any of their interfer-
ence in critical tests within the core laboratory. For
daratumumab, neutralisation methods (soluble anti-
Acknowledgements
CD38 mAb or anti-CD38 idiotype antibody) have been
used successfully and are a fast and uniform way to deal The authors thank Belinda Butcher, BSc (Hons), MBio-
with the interference.11 Such kits could attain IVD stat, PhD, CMPP, AStat (WriteSource Medical Pty Ltd.,
approval and reduce the need for labour-intensive test- Sydney, Australia) for providing medical writing support,
ing within the transfusion laboratory. Cost has been a which was funded by Janssen-Cilag Pty Ltd, Sydney,
barrier, and currently, the only commercial kit available Australia, in accordance with Good Publication Practice
(DIRA; Sebia, Evry Cedex, France) is in use to resolve (GPP3) guidelines (http://www.ismpp.org/gpp3).

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© 2018 Royal Australasian College of Physicians