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Association Bulletin #16-02
Date: January 15, 2016
UPDATED APRIL 2024
To: AABB Members
From: Donna M. Regan, MT(ASCP)SBB—President
Miriam A. Markowitz—Chief Executive Officer
Re: Mitigating the Anti-CD38 Interference with Serologic Testing
Summary
A class of therapeutic agents originally approved for multiple myeloma, monoclonal antibodies to
CD38, can result in interference with blood bank serologic tests and thereby cause delays in
issuing Red Blood Cell (RBC) units to patients receiving these agents. To minimize these delays,
hospitals should set up procedures to inform the transfusion service when patients start receiving
these agents. Considerations for the transfusion service, both before and after initiation of anti-
CD38 therapy, are detailed below.
The AABB Clinical Transfusion Medicine Committee and Transfusion Medicine Subsection
Coordinating Committee has developed this bulletin to provide background information and
guidance to members regarding anti-CD38 interference with serologic testing.
Association Bulletins, which are approved for distribution by the AABB Board of Directors, may
include announcements of standards or requirements for accreditation, recommendations on
emerging trends or best practices, and/or pertinent information. This bulletin contains
information and recommendations. No new standards are proposed.
Background
Anti-CD38 monoclonal antibodies are a treatment for multiple myeloma
CD38 is an integral membrane protein that is highly expressed on myeloma cells that has been
shown to be an effective target antigen for monoclonal antibody therapies. There are currently
two anti-CD38 monoclonal antibodies approved by the Food and Drug Administration,
daratumumab and isatuximab. However, there are other anti-CD38 monoclonal antibodies
under development and in trials. In addition, new off label uses for anti-CD38 monoclonal
antibodies are coming into clinical practice.
Of note, anti-CD38 may cause a small decrease in hemoglobin in vivo (~1 g/dL), but severe
hemolysis has not been observed among treated patients.
3,6
2
Anti-CD38 monoclonal antibodies interfere with blood bank serologic tests
In addition to immune cells, CD38 is weakly expressed on red cells. Anti-CD38 binds to CD38
on reagent RBCs, causing panreactivity in vitro.
2,3
Plasma samples from anti-CD38-treated
patients consistently cause positive reactions in indirect antiglobulin tests (IATs), antibody
detection (screening) tests, antibody identification panels, and anti-human globulin (AHG)
crossmatches. Agglutination due to anti-CD38 may occur in all media (eg, saline, low ionic
strength saline, polyethylene glycol), and with all IAT methods (eg, gel, tube, solid phase).
Agglutination reactions caused by anti-CD38 are usually weak (1+), but stronger reactions (up
to 4+) may be seen in solid-phase testing. However, anti-CD38 does NOT interfere with
ABO/RhD typing or with immediate-spin crossmatches.
Other notes on anti-CD38 serologic interference:
• Dithiothreitol (DTT)-treated cells eliminate the interference.
2,7
• Cord blood cells lack CD38 antigen and could be used to eliminate interference if
available and especially considered in patients with anti-K or other suspected
antibody to antigen denatured by DTT-treatment.
9
• Adsorptions using either untreated or ZZAP-treated cells fail to eliminate the
interference.
• Anti-CD38 may result in a positive IgG direct antiglobulin test (DAT) and
autocontrols tested in antibody identification panel.
• Some rare dominant Lu(a–b–) cells are not reactive in the presence of anti-CD38,
potentially giving the false impression that the patient has a Lutheran-related antibody.
4,5
• Positive IATs can be observed for up to six months after anti-CD38 is discontinued.
1,3
Anti-CD38 interference can cause delays in issuing RBCs
If the transfusion service is unaware that a patient has received anti-CD38, the following
scenario may occur when the patient’s sample is tested:
Test
Negative (no
interference)
Positive
(reactive
with all
cells)
Negative or
positive
ABO/RhD
typing
X
N/A
N/A
Antibody
detection
(“screen”)
N/A
X
N/A
Antibody
identification
N/A
X
N/A
DAT
N/A
X
IS
crossmatch
N/A
X
N/A
3
AHG
crossmatch*
N/A
X
N/A
*AHG crossmatch compatible with DTT-treated cells
This leads to delays in issuing RBCs to the patient. In some cases, the anti-CD38 interference
could mask the presence of a clinically significant alloantibody.
Recommendations
To avoid problems with transfusion, hospitals should set up procedures to inform the transfusion
service whenever any patient is scheduled to begin taking anti-CD38.
BEFORE a patient begins taking anti-CD38:
• A baseline type and screen should be performed.
• In addition, a baseline phenotype or genotype may be considered. Genotyping can be
performed after the patient receives anti-CD38.
o Given low rate of alloimmunization in cohorts of multiple myeloma patients
receiving anti-CD38 therapeutic monoclonal antibodies, some studies suggest a
more targeted approach for extended antigen phenotyping/genotyping.
10,11,12
AFTER a patient begins taking anti-CD38:
• ABO/RhD typing can be performed normally.
• For antibody detection (screening) and identification, dithiothreitol (DTT)-treated cells
can be used to eliminate the interference.
2,7
o Because DTT treatment destroys Kell antigens, K-negative units should be
provided unless the patient is known to be K-positive.
o Antibodies against other DTT-sensitive blood group antigens (anti-k, anti-Yt
a
,
anti-Do
a
/Do
b
, etc) will not be detectable when the antibody screen with DTT-
treated cells is performed; such antibodies are encountered infrequently,
however.
Crossmatch
• For patients with a negative antibody screen using DTT-treated cells, an electronic or
immediate-spin crossmatch with ABO/RhD-compatible, K-matched units may be
performed.
• For patients with known alloantibodies, phenotypically or genotypically matched RBC
units may be provided.
6,8
o As some typing antisera require the use of AHG, phenotyping should be
performed before the patient receives anti-CD38.
o AHG crossmatches with phenotypically or genotypically matched units will
still be incompatible.
• Alternatively, an AHG crossmatch may be performed using DTT-treated donor cells
(K-matched units).
Other notes on issuing blood for transfusion
• Some clinically significant antibodies may be missed with the use of uncrossmatched
phenotypically or genotypically matched units, although this will occur infrequently.
• If an emergency transfusion is required, uncrossmatched ABO/RhD-compatible
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RBCs may be given per local blood bank practices.
Future/alternative approaches to mitigating the anti-CD38 interference
It is possible to neutralize anti-CD38 in plasma and eliminate the interference using either
recombinant soluble human CD38 or daratumumab idiotype antibody.
2,3
Neither reagent is
widely available at this time, and additional validation would be needed. In principle, soluble
CD38 could be used to neutralize any anti-CD38, while different idiotype antibodies would be
needed to neutralize different CD38 therapeutic antibodies. Antigen-typed cord cells have
been used for the antibody screen as an alternative to DTT-treated cells.
9
There is a report that
a manual polybrene method with standard PEG-IAT can also eliminate daratumumab
interference, but may still not provide adequate sensitivity in the Kell system.
13
Some groups
have reported using 0.01M or 0.04M rather than 0.2M DTT-treated reagent red cells to remove
daratumuamb interference while preserving Kell blood group antigenicity.
14,15
Additional
validation of these lower DTT concentrations would be needed.
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References
1. Darzalex package insert. Horsham, PA: Janssen Biotech, 2015. [Available at:
http://www.darzalex.com/shared/product/darzalex/darzalex-prescribing-information.pdf
(accessed January 7, 2016).]
2. Chapuy CI, Nicholson RT, Aguad MD, et al. Resolving the daratumumab interference with
blood compatibility testing. Transfusion 2015;55(6pt2):1545-54.
3. Oostendorp M, Lammerts van Bueren JJ, Doshi P, et al. When blood transfusion medicine
becomes complicated due to interference by monoclonal antibody therapy. Transfusion
2015;55(6pt2):1555-62.
4. Velliquette RW, Shakarian G, Jhang J, et al. Daratumumab-derived anti-CD38 can be easily
Mistaken for clinically significant antibodies to Lutheran antigens or to Knops antigens
(abstract). Transfusion 2015;55(3S):26A.
5. Aye T, Arndt PA, Leger RM, et al. Myeloma patients receiving daratumumab (anti-CD38)
can appear to have an antibody with Lutheran-related specificity (abstract). Transfusion
2015;55(3S):28A.
6. Chari A, Satta T, Tayal A, et al. (2015, December) Outcomes and management of red blood
cell transfusions in multiple myeloma patients treated with daratumumab (oral and poster
abstract presented Monday, December 7, 2015, 6:00 PM-8:00 PM at 57
th
Annual American
Society of Hematology meeting). Blood 2015;26(Suppl):Abstract 3571.
7. Chapuy CI, Aguad MD, Nicholson RT, et al. International validation of a dithiothreitol
(DTT)-based method to resolve the daratumumab interference with blood compatibility
testing (oral and poster abstract presented Monday, December 7, 2015, 6:00 PM-8:00 PM at
57th Annual American Society of Hematology meeting). Blood 2015;126(Suppl):Abstract
3567.
8. Hannon JL, Caruk B, Clarke G. Serological findings related to treatment with a human
monoclonal antibody (daratumumab) in patients with advanced plasma cell myeloma
(abstract). Transfusion 2014;54(2S):162A.
9. Schmidt AE, Kirkley S, Patel N, et al. An alternative method to dithiothreitol treatment for
antibody screening in patients receiving daratumumab (abstract). Transfusion
2015;55(3S):2292-3.
10. Tauscher C, Moldenhauer S, Bryant S, DiGuardo M, Jacob E. Antibody incidence and RBC
transfusions in patients on daratumumab. Transfusion. 2021; 61(12): 3468–72.
11. Bullock T, Foster A, Clinkard B. Alloimmunisation rate of patients on Daratumumab: A
retrospective cohort study of patients in England. Transfus Med. 2021;31(6):474-480.
12. Lee ES, Hendrickson JE, Tormey CA. RBC alloimmunization and daratumumab: Are efforts
to eliminate interferences and prevent new antibodies necessary? Transfusion.
2021;61(12):3283-3285.
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13. Yeh TJ, Yeh CJ, Liu YC, Hsiao HH. Manual polybrene method for pretransfusion test could
overcome the interference of daratumumab therapy in myeloma. Transfusion.
2019;59(8):2751-2752.
14. Hosokawa M, Kashiwagi H, Nakayama K, et al. Distinct effects of daratumumab on indirect
and direct antiglobulin tests: a new method employing 0.01 mol/L dithiothreitol for negating
the daratumumab interference with preserving K antigenicity(Osaka method). Transfusion
2018;58:3003-13.
15. Izaguirre EC, del Mar Luis-Hidalgo M, González LL, Castaño CA. New method for
overcoming the interference produced by anti-CD38 monoclonal antibodies in compatibility
testing. Blood Transfusion. 2020;18(4):290.
