Hemolytic Anemia Research Articles

Measurement of serum hepcidin-25 by latex agglutination in healthy volunteers and patients with hematologic disorders.

Iron is an essential trace metal, vital for various physiologic processes, but excess levels can harm health. Maintaining iron homeostasis is critical, with hepcidin playing a key role. The isoform hepcidin-25 exerts the most significant influence on iron metabolism, making its serum levels a valuable diagnostic tool. However, mass-spectrometry and other conventional measurement methods can be difficult to perform, and some immunoassays lack reliability. In this study, we employed a recently developed latex agglutination method integrated with a readily available automated analyzer to quantify serum hepcidin-25 levels in both volunteers recruited from personnel of our hospital (n = 93) and patients with various hematological disorders (n = 112). Our findings unveiled a robust positive correlation between serum hepcidin-25 and ferritin, as well as C-reactive protein levels, in both volunteers and patients. Among the patients with hematological disorders, there was a noteworthy negative correlation between hepcidin-25 levels and hemoglobin concentrations, as well as reticulocyte counts. Interestingly, the hepcidin-25/ferritin ratio was remarkably low in patients with hemolytic anemia and myelodysplastic syndromes with ring sideroblasts. Our findings suggest that quantifying serum hepcidin-25 and the hepcidin-25/ferritin ratio using this method may be valuable for screening of hematopoietic diseases and other iron metabolism disorders.

Regional Prevalence of Hemoglobin C Across Saudi Arabia: An Epidemiological Survey

IntroductionHbC is a common structural hemoglobinopathy especially in West Africa. Prevalence and regional distribution of HbC in Saudi Arabia are widely undocumented. Patients with homozygous HbC disease may have mild hemolytic anemia whereas combination with hemoglobin S (HbS) leads to a clinically severe phenotype.AimThe current epidemiological study, considered the largest from Saudi Arabia, aimed to evaluate the regional prevalence of the HbC variant among the couples participating in the premarital screening program from 2011 to 2018.MethodsData from the PMSGC program were obtained for premarital screening and genetic counseling. The collected data were then entered into the SEHA platform, a centralized electronic repository for the 13 designated regions in Saudi Arabia. Hemoglobin electrophoresis samples are analyzed using either HPLC, capillary electrophoresis, or a combination of both methods to confirm the presence of abnormal hemoglobin bands.ResultsThis study included 1,871,184 individuals from 2011 to 2018. Of those, 49.8% were males and 50.2% were females. 112,618 (6.0%) had an abnormal test. Total number of Hb C cases were 778 (0.04%). HbC trait (HbAC) was detected in 764 participants while homozygous HbC (HbCC) and combined heterozygous (HbSC) were found in 9 and 5 cases, respectively. The regions near the Red Sea have higher rates than the central and eastern regions.ConclusionHbC is a rare variant in Saudi Arabia with varying regional frequencies. HbC variant is more common in Mecca and Madina regions. The geographic area of HbC distribution differs from the areas with high prevalence of HbS, which explains why HbSC disease cases are overwhelmingly rare.

The Role of Glucose-6-phosphate Dehydrogenase in the Wine Yeast Hanseniaspora uvarum.

Hanseniaspora uvarum is the predominant yeast species in the majority of wine fermentations, which has only recently become amenable to directed genetic manipulation. The genetics and metabolism of H. uvarum have been poorly studied as compared to other yeasts of biotechnological importance. This work describes the construction and characterization of homozygous deletion mutants in the HuZWF1 gene, encoding glucose-6-phosphate dehydrogenase (G6PDH), which provides the entrance into the oxidative part of the pentose phosphate pathway (PPP) and serves as a major source of NADPH for anabolic reactions and oxidative stress response. Huzwf1 deletion mutants grow more slowly on glucose medium than wild-type and are hypersensitive both to hydrogen peroxide and potassium bisulfite, indicating that G6PDH activity is required to cope with these stresses. The mutant also requires methionine for growth. Enzyme activity can be restored by the expression of heterologous G6PDH genes from other yeasts and humans under the control of a strong endogenous promoter. These findings provide the basis for a better adaptation of H. uvarum to conditions used in wine fermentations, as well as its use for other biotechnological purposes and as an expression organism for studying G6PDH functions in patients with hemolytic anemia.

Characterization of Novel RHD Allele Variants and Their Implications for Routine Blood Group Diagnostics.

The Rh system, including the highly immunogenic D antigen, is one of the clinically most important blood group systems in transfusion medicine. Numerous alleles of the RHD gene are associated with variant RhD phenotypes. In case of Rh incompatibility, some of them can induce hemolytic transfusion reactions and hemolytic disease of the fetus and newborn. Thus, accurate blood group diagnostics are critical for safe transfusion therapy. We characterized phenotypes of four individuals revealing weakened D expression during routine pre-transfusion testing. Standard gel card matrix techniques with monoclonal and polyclonal anti-D antibodies were used for serological typing, complemented using D epitope and antigen density analysis. Genotyping employing PCR with sequence-specific primers, genomic and allele-specific Sanger sequencing and in silico protein analysis were performed. Four novel RHD alleles associated with weak D or partial D phenotypes were identified. One of the mutations is predicted to disrupt the terminal stop codon and result in an elongated translation of the mutant D protein that phenotypically exhibits a loss of D epitopes. Furthermore, a hybrid gene formed with the homologue RHCE gene is described. The presented data enhances the understanding of the Rh system and may contribute to continued advances in blood group diagnostics.

A Case of Idiopathic Autoimmune Hemolytic Anemia: Every Anemia – First Type It and Then Treat It

Autoimmune hemolytic anemia (AIHA) is a medical disorder where the immune system erroneously targets and destroysred blood cells (RBCs), causing a reduction in their longevity. This results in an inadequate supply of RBCs to carry oxygen,leading to symptoms like fatigue, weakness and jaundice. AIHA is categorized into warm and cold types based on theoptimal temperature for antibody activity. A comprehensive grasp of the immunological mechanisms involved is essentialfor accurate diagnosis and effective management of this autoimmune condition. AIHA is a frequently missed diagnosis aspatient are not fully investigated, and treated with vitamin B12, folic acid and iron in outpatient department.

Hematologic complications in vascular malformations: A case study of 2 patients

Vascular malformations are congenital vascular anomalies resulting from a disruption in the vasculogenesis process. (1) They are congenital changes that enlarge as the child develops and do not undergo spontaneous involution. They can be classified based on the type of vessels involved (capillary, arterial, venous, lymphatic, mixed) and the nature of the vascular flow (low-flow and high-flow). The clinical presentation of vascular malformations is highly diverse, and despite being congenital, they can remain asymptomatic for a long time, complicating the diagnostic process. (1,3)
 
 The presence of malformations carries the risk of health-threatening complications. One such complication is Kasabach-Merritt syndrome, characterized by thrombocytopenia, microangiopathic hemolytic anemia, and consumptive coagulopathy in the presence of a rapidly enlarging vascular tumor. (4,5) Another threat is a coagulopathy limited to the vascular anomaly (LIC). It is characterized by elevated D-dimers and fibrin degradation products, low levels of fibrinogen, FV, FVIII, FXIII, and antithrombin, and sometimes mild to moderate thrombocytopenia. (6,7) Early implementation of anticoagulant therapy allows for the avoidance of health-threatening conditions and the development of disseminated intravascular coagulation syndrome (DIC). (8)

Evaluation of hepatic toxicity in autoimmune hemolytic anemia (AIHA) and Evans syndrome patients: a single-center Egyptian study

IntroductionBenign auto-immune illnesses include Evans syndrome (ES) and auto-immune hemolytic anemia (AIHA). Despite being benign in nature, the patients’ livers are burdened by the disease’s chronicity and the accompanying problems beyond the course of treatment. An additional burden stems from HCV infection, of which a significant proportion of Egyptians are positive. The purpose of this study was to identify the hepatotoxicity risks and the variables that influence the prognosis and survival of patients with AIHA/ES. There are 126 AIHA patients in this observational study, which is retrospective. From June 2009 to March 2021, patients visited the Haematology Unit of the Oncology Centre in Egypt. One hundred and sixteen patients have available data.ResultsThere was no significant difference between primary and secondary AIHA groups as regards baseline hemoglobin (Hb), bilirubin, LDH, or reticulocyte count. Thirty-four patients (29.31%) had HCV-positive tests and 1 patient (0.9%) had HBV. There was no difference between HCV-positive and negative cases as regards mean Hb concentration, mean platelet, or immune markers (P > 0.05). AIHA patients with HCV-positive showed a significantly higher relapse rate (56%) than HCV-negative patients (32%) (P = 0.034). HCV positivity and low platelet counts at diagnosis were poor predictors for overall survival (OS) (P 0.022 and 0.04, respectively). Median OS was significantly better in patients with no viral hepatitis infection (1101 days, 95% CI 592–2068) than in patients with positive HCV infection (521, 95% CI 326–1325) (P = 0.019).ConclusionsAzathioprine is the least hepatotoxic in AIHA patients under treatment. Viral hepatitis represents a superadded damage to the liver besides AIHA concerning clinical characteristics and outcomes.

Nontargeted Plasma Proteomic Analysis of Renal Disease and Pulmonary Hypertension in Patients with Sickle Cell Disease.

Sickle cell disease (SCD) is characterized by red blood cell sickling, vaso-occlusion, hemolytic anemia, damage to multiple organ systems, and, as a result, shortened life expectancy. Sickle cell disease nephropathy (SCDN) and pulmonary hypertension (pHTN) are common and frequently co-occurring complications of SCD; both are associated with markedly accelerated mortality. To identify candidate circulating biomarkers of SCDN and pHTN, we used mass spectrometry to quantify the relative abundance of >1000 proteins in plasma samples from 189 adults with SCD from the Outcome Modifying Genes in SCD (OMG-SCD) cohort (ProteomeXchange identifier PXD048716). Forty-four proteins were differentially abundant in SCDN, most significantly cystatin-C and collagen α-1(XVIII) chain (COIA1), and 55 proteins were dysregulated in patients with SCDN and pHTN, most significantly insulin-like growth factor-binding protein 6 (IBP6). Network analysis identified a module of 133 coregulated proteins significantly associated with SCDN, that was enriched for extracellular matrix proteins, insulin-like growth factor binding proteins, cell adhesion proteins, EGF-like calcium binding proteins, and several cadherin family members. Collectively, these data provide a comprehensive understanding of plasma protein changes in SCDN and pHTN which validate numerous studies of chronic kidney disease and suggest shared profiles of protein disruption in kidney dysfunction and pHTN among SCD patients.

Expert consensus on clonal screening and monitoring of complement inhibitor therapy in paroxysmal nocturnal hemoglobinuria (2024)

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal disease with abnormal hematopoietic stem cells that causes intravascular hemolytic anemia, thrombosis, and peripheral blood cytopenia. It has a chronic progressive course and can be fatal in severe cases if not treated aggressively. Complement inhibitors are the first-line recommended treatment for hemolysis-related symptoms of PNH. With the rapid development of new complement inhibitors, it is critical to quickly screen and confirm the diagnosis, identify patients with complement inhibitor indications, and monitor breakthrough hemolysis and extravascular hemolysis during complement inhibitor therapy. Drawing on the most recent guidelines, works of literature, and meta-reviews from around the world, as well as combining with experience from the experts, this consensus focused on PNH screening principles, the significance of PNH cloning detection, and post-treatment monitoring of terminal complement inhibitors, which may contribute to a better understanding of diagnosis and treatment monitoring in the era of complement inhibitors.

Les cytopénies auto-immunes de l’enfant : Quand penser au déficit immunitaire primitif ?

Autoimmune cytopenias are defined by autoantibodies' immune destruction of one or more blood elements. Most often it is autoimmune hemolytic anemia or immune thrombocytopenia or both that define Evans syndrome. It may be secondary to infection or to underlying pathology such as systemic autoimmune disease or primary immunodeficiency, especially when it becomes chronic over several years. Primary Immunodeficiencies or inborn errors of immunity (IEI) are no longer defined solely by infections: autoimmunity is part of the clinical features of several of these diseases. It is dominated by autoimmune cytopenias, in particular, immune thrombocytopenia (ITP) and autoimmune hemolytic anaemia (AIHA). The challenges for the clinician are the situations where autoimmune cytopenias are chronic, recurrent and/or refractory to the various long-term therapeutic options. Most of these therapies are similar in action and generally consist of non-mediated immune suppression or modulation. In these situations, primary Immunodeficiencies must be diagnosed as soon as possible to allow the initiation of a targeted treatment and to avoid several ineffective therapeutic lines.

Mitapivat improves ineffective erythropoiesis and iron overload in adult patients with pyruvate kinase deficiency

AbstractPyruvate kinase (PK) deficiency is a rare, hereditary disease characterized by chronic hemolytic anemia. Iron overload is a common complication regardless of age, genotype, or transfusion history. Mitapivat, an oral, allosteric PK activator, improves anemia and hemolysis in adult patients with PK deficiency. Mitapivat’s impact on iron overload and ineffective erythropoiesis was evaluated in adults with PK deficiency who were not regularly transfused in the phase 3 ACTIVATE trial and long-term extension (LTE) (#NCT03548220/#NCT03853798). Patients in the LTE received mitapivat throughout ACTIVATE/LTE (baseline to week 96; mitapivat-to-mitapivat [M/M] arm) or switched from placebo (baseline to week 24) to mitapivat (week 24 to week 96; placebo-to-mitapivat [P/M] arm). Changes from baseline in markers of iron overload and erythropoiesis were assessed to week 96. Improvements in hepcidin (mean, 4770.0 ng/L; 95% confidence interval [CI], −1532.3 to 11 072.3), erythroferrone (mean, −9834.9 ng/L; 95% CI, −14 328.4 to −5341.3), soluble transferrin receptor (mean, −56.0 nmol/L; 95% CI, −84.8 to −27.2), and erythropoietin (mean, −32.85 IU/L; 95% CI, −54.65 to −11.06) were observed in the M/M arm (n = 40) from baseline to week 24, sustained to week 96. No improvements were observed in the P/M arm (n = 40) to week 24; however, upon transitioning to mitapivat, improvements similar to those observed in the M/M arm were seen. Mean changes from baseline in liver iron concentration by magnetic resonance imaging at week 96 in the M/M arm and the P/M arm were −2.0 mg Fe/g dry weight (dw; 95% CI, −4.8 to −0.8) and −1.8 mg Fe/g dw (95% CI, −4.4 to 0.80), respectively. Mitapivat is the first disease-modifying pharmacotherapy shown to have beneficial effects on iron overload and ineffective erythropoiesis in patients with PK deficiency. This trial was registered at www.ClinicalTrials.gov as #NCT03548220 (ACTIVATE) and #NCT03853798 (LTE).

Genetics of Gallstone Disease and Their Clinical Significance: A Narrative Review.

Gallstone (GS) disease is common and arises from a combination of genetic and environmental factors. Although genetic abnormalities specifically leading to cholesterol GSs are rare, there are clinically significant gene variants associated with cholesterol GSs. In contrast, most bilirubin GSs can be attributed to genetic defects. The pathogenesis of cholesterol and bilirubin GSs differs greatly. Cholesterol GSs are notably influenced by genetic variants within the ABC protein superfamily, including ABCG8, ABCG5, ABCB4, and ABCB11, as well as genes from the apolipoprotein family such as ApoB100 and ApoE (especially the E3/E3 and E3/E4 variants), and members of the MUC family. Conversely, bilirubin GSs are associated with genetic variants in highly expressed hepatic genes, notably UGT1A1, ABCC2 (MRP2), ABCC3 (MRP3), CFTR, and MUC, alongside genetic defects linked to hemolytic anemias and conditions impacting erythropoiesis. While genetic cases constitute a small portion of GS disease, recognizing genetic predisposition is essential for proper diagnosis, treatment, and genetic counseling.

Hemolytic Disease in Newborn Due to Jka Antibody: A Unique Clinical Presentation

Hemolytic disease in newborn results from alloimmune-mediated destruction of fetal or neonatal red blood cells caused by maternal alloantibodies. While ABO and Rh (D) incompatibilities are common causes, other minor antigenic mismatches such as Kidd are relatively infrequent. Here, we report a case of a female infant displaying conjugated hyperbilirubinemia and hepato-splenomegaly. Lab tests revealed both mother’s and baby’s blood groups as A positive, along with elevated reticulocyte count and a positive direct antiglobulin test. An abdominal ultrasound unveiled inspissated bile syndrome, likely due to calcium bilirubin sludge, leading to the conjugated hyperbilirubinemia. Further assessment revealed the infant and the father had a JKa-positive RBC phenotype, while the mother had a JKa-negative phenotype. This case highlights the significance of blood group antigen beyond the Rh system as a potential cause of hemolytic disease in newborn.

Characteristics of anti-melanoma differentiation associated gene 5 antibody-positive dermatomyositis with thrombotic microangiopathy.

Anti-melanoma differentiation associated gene 5 antibody (anti-MDA5 Ab)-positive dermatomyositis (DM) is a representative of rapidly progressive interstitial pneumonia. However, its association with thrombotic microangiopathy (TMA), characterized by thrombocytopenia, haemolytic anaemia, and organ dysfunction, has not been defined. This study aimed to elucidate the characteristics of anti-MDA5 Ab-positive DM accompanied by TMA. We reviewed our hospital records from November 2009 to September 2022. We included patients in accordance with the 2017 European League Against Rheumatism/American College of Rheumatology classification criteria and the criteria of Bohan and Peter. TMA was diagnosed according to the criteria for transplantation-associated TMA proposed by the International Working Group. This study enrolled a total of 26 anti-MDA5 Ab-positive DM patients, four of whom developed TMA. The patients with TMA had an increased urine protein/creatinine ratio. In addition, these four of them showed significantly elevated levels of ferritin and anti-MDA5 Ab titers and were considered to have high disease activity; yet, all of them survived. Our study indicated that anti-MDA5 Ab-positive DM patients with hyperferritinemia, a high anti-MDA5 Ab titer, and an increased urine protein/creatinine ratio should be carefully managed, bearing in mind a complication of TMA.

HELLP Syndrome and Differential Diagnosis with Other Thrombotic Microangiopathies in Pregnancy.

Thrombotic microangiopathies (TMAs) comprise a distinct group of diseases with different manifestations that can occur in both pediatric and adult patients. They can be hereditary or acquired, with subtle onset or a rapidly progressive course, and they are particularly known for their morbidity and mortality. Pregnancy is a high-risk time for the development of several types of thrombotic microangiopathies. The three major syndromes are hemolysis, elevated liver function tests, and low platelets (HELLP); hemolytic uremic syndrome (HUS); and thrombotic thrombocytopenic purpura (TTP). Because of their rarity, clinical information and therapeutic results related to these conditions are often obtained from case reports, small series, registries, and reviews. The collection of individual observations, the evolution of diagnostic laboratories that have identified autoimmune and/or genetic abnormalities using von Willebrand factor post-secretion processing or genetic-functional alterations in the regulation of alternative complement pathways in some of these TMAs, and, most importantly, the introduction of advanced treatments, have enabled the preservation of affected organs and improved survival rates. Although TMAs may show different etiopathogenesis routes, they all show the presence of pathological lesions, which are characterized by endothelial damage and the formation of thrombi rich in platelets at the microvascular level, as a common denominator, and thrombotic damage to microcirculation pathways induces "mechanical" (microangiopathic) hemolytic anemia, the consumption of platelets, and ischemic organ damage. In this review, we highlight the current knowledge about the diagnosis and management of these complications during pregnancy.

Plasma Exchanges: Observational Study at the Mohammed V Rabat Military Training Hospital Blood Transfusion Center from January 2016 to December 2019

Since their initial indications as the ultimate treatment for certain serious pathologies, plasma exchanges (PE) have been utilized as frontline therapies up to lifesaving interventions. In this observational study conducted at the Mohammed V Military Training Hospital Blood Transfusion Center from January 2016 to December 2019, we aimed to elucidate the practical modalities and therapeutic indications of plasma exchanges. Our findings revealed that among the patients treated, the majority suffered from neurological pathologies (37%), followed by autoimmune pathologies such as thrombotic thrombocytopenic purpura and thrombotic microangiopathy (25%), and finally haematological and nephrological pathologies, each representing 19%. These results align with existing literature, emphasizing the prevalence of neurological indications for plasma exchanges.
 Moreover, the study showcased the effectiveness of plasma exchanges in various neurological conditions, with notable sessions for myasthenia, multiple sclerosis, neuromyelitis, polyradiculoneuritis, and meningoencephalitis. For nephrological pathologies, the sessions were primarily conducted for patients with ANCA+ intra-alveolar haemorrhage and Wegener's disease. Additionally, plasma exchanges demonstrated significant clinical improvements in patients with haematological pathologies, such as Waldenstrom's disease and hemolytic anaemia, and autoimmune diseases like thrombotic thrombocytopenic purpura and thrombotic microangiopathy.
 Ultimately, this study underscores the importance of collaboration between the transfusion centre and clinical and biological services for optimal patient management. The insights gained contribute to the broader understanding of plasma exchange applications in various pathologies, emphasizing its role as a crucial therapeutic intervention.

Emergence of additional anti-C with amplification of anti-D titer post-Rh-Kell phenotype-matched intrauterine transfusions in severe hemolytic disease of fetus

Abstract Transplacental ultrasound-guided intrauterine transfusion (IUT) acts as a lifesaving therapy to prevent fetal anemia or even to reverse fetal hydrops. IUTs are generally initiated after 22–24 weeks of gestation and repeated every 2–4-week period of gestation. Although Rh-Kell phenotype-matched, fresh irradiated leukoreduced donor-packed red cells help to increase fetal hemoglobin level, this invasive procedure can increase fetal complications by fetomaternal hemorrhage. Women receiving IUTs are noted to be high allo-responders to red cell antigens, which can cause enhanced antibody titer or the formation of additional antibodies which might complicate future pregnancies. Hereby, we are reporting the case of a multiparous woman who underwent three sessions of IUTs between 24 weeks and 31+-week period of gestation and developed an additional anti-C antibody which was incidentally detected during compatibility testing at 34 weeks, along with raised anti-D immunoglobulin G titer of 1024 from initial titer of 128.

Risk of Ceftriaxone (Antibiotic) in the Tigris River Water, Iraq

There are several causes of hemolytic diseases, such as viral or bacterial contamination, enlarged spleen, and typhoid fever, which can be transmitted through contaminated water. Polluted wastewater samples were collected for the period of June-2022 to (May-2023) from five stations in Baghdad City such as Al- Gureat, Al-Ahdamyah, Bab Al-Muhadum, Bab Al-Sharqy and Al-Jadryah stations on the Tigris Riverbanks for the studying of Ceftriaxone antibiotic risk. The concentrations of ceftriaxone have been detected using high-performance liquid chromatography (HPLC). The results reveal that concentrations of ceftriaxone in the water fluctuated via sampling stations and seasons; so the highest concentration was 8 × 10-5 ppm in site 2 at Ahdamyah station, while the lowest concentrations was 1 × 10-7 ppm in site 5 sites at Al-Jadryah station during wet season 2023. The results of the statistical analysis showed that there were no significant differences between the study stations, except for the control station. The detection of ceftriaxone in raw surface water confirms that sewage from health institutions reaches the river without any effective treatment.

Hybrid glycophorin GP (A-B) and anti-Ena antibody in a multiparous woman

Abstract The MNS system is a large, complex group of antigens, with 50 antigens at present. The major antigens of the system are carried on glycophorins A and B, which are important red cell sialoglycoproteins. Altered expression of MNS antigens is possible in cases where there is a formation of hybrid glycophorins. Some of these patients may make clinically significant antibodies which can be associated with hemolytic transfusion reactions (HTR) or hemolytic disease of the fetus and the newborn. This is a report of one such case with both these phenomena, in a multiparous woman. Incompatible cross-matches at the referral center caused the samples to be sent to this immunohematological laboratory where the serological profile was detailed. On sending the samples to a third blood group reference laboratory, gene sequencing was done and the antibody was identified. At this immunohematological laboratory, the phenotype was determined as M-N+. The patient’s sera showed panreactivity with all panel cells (3-cell and 11-cell). At blood group reference laboratory, the findings were as follows- GYP (A-B) hybrid gene consistent with hemi/homozygosity for GYP*JL was confirmed and the panreactive antibody was identified as anti - Ena. Rare, atypical phenotypes in the MNS system can result from mutations affecting the sialoglycoproteins the antigens are carried on. The subset of antigens expressed in individual phenotypes varies and these patients can develop antibodies against the antigens they lack. When they present with immunohematological challenges such as panreactivity and incompatibility, a combination of serology, molecular technologies, and family studies help solve the problem. Alternatives to transfusion are also useful options in managing such cases.

Rare combination of alloantibodies causing hemolytic disease of the newborn – Challenge for identification

Abstract Hemolytic disease of the newborn (HDN) refers to the destruction of the fetal and newborn red cells by maternal red cell antibodies specific for paternally inherited antigens on fetal red cells or erythroid precursors.[1] ABO-incompatibility is the most common cause of HDN. Rh-negative mothers can be alloimmunized with Rh-positive fetus. Prophylactic Rh immunoglobulin use has greatly reduced the HDN due to Rh incompatibility. Alloimmunization can also occur due to other clinically significant minor blood group antigens such as E, c, C, k, KP(a), Js(a), Js(b), Jk(a), Jk(b), Fy(a), Fy(b), S, s, and U. Multiple alloantibodies in mothers’ blood can pose a difficult challenge for identification and finding compatible blood for exchange transfusion. We report a case of HDN due to multiple antibodies and a rare combination of anti-c and anti-Jkb, challenges associated with the identification, confirmation, and finding of compatible blood units.