Unexpected antibody against the high-prevalence P antigen before cardiac surgery

P is a high-prevalence antigen present in 99.9 percent of the population and is fully developed at birth. P– individuals form naturally occurring antibodies against P, which are often of immunoglobulin (Ig)M and/or IgG type, very potent in complement activation, and able to cause serious intravascular hemolytic transfusion reactions. Some people with anti-P have the rare P₁^k phenotype, which lacks P in the presence of P1 and P^k. Blood transfusion in patients with anti-P is challenging, as is described here. A male patient without a history of blood transfusion was admitted for a planned cardiac surgery. The preoperative ABO blood group could not be determined because of unexpected reactions in the reverse grouping, and all red blood cells (RBCs) in the antibody detection test were positive, except for the autocontrol. Further analysis of the patient’s sample confirmed the presence of the P₁^k phenotype, and anti-P was identified. If transfusion was needed, P– blood would be required, and the only P– RBCs available were at the national Sanquin Bank of Frozen Blood. These units are limited, expensive, and only available for 48 hours after thawing. In the case of massive blood loss, first ABO and Rh-compatible units should be transfused, followed by P– units after the bleeding stops. In our case, the surgery was conducted without transfusion. This case illustrates the importance of preoperative ABO blood group testing and antibody screening in cases where blood loss can be expected. In recent years, more focus has been put on patient blood management. A good collaboration between the local laboratory, surgery department, and dedicated blood transfusion laboratory is critical to prevent unnecessary incompatible blood transfusions with potentially serious outcomes.