Saline–indirect antiglobulin test

J.R. Hamilton

A saline–indirect antiglobulin test (IAT) is performed without Reagents/Supplies

addition of enhancement media to increase the binding of
antibody to the red blood cell antigen during the 37°C incubation. Reagents Supplies
Although infrequently used as a primary means for antibody • Antibody detection or • Test tubes (10 × 75 or 12 ×
detection or identification, this test is useful because of the identification RBCs 75 mm)
variety of possible applications in antibody identification studies. • 0.9 percent saline or PBS, • Pipettes
It is critical to the test sensitivity to allow enough incubation time pH 6.5–7.5
• Calibrated serofuge and/or
(30–60 minutes) for maximum antibody binding to occur. The • Antihuman globulin cell washer
saline test can also be subject to a direct agglutination reading (polyspecific or anti-IgG)
• Calibrated timer
after immediate spin, room temperature, or incubation at 37°C
S E R O LO G I C M E T H O D R E V I E W

• IgG-coated reagent RBCs

before conversion to the IAT. This step allows further flexibility
in assessing the reactivity of directly agglutinating allo- or RBCs = red blood cells; PBS = phosphate-buffered saline.
autoantibodies in tests performed at 37°C or lower temperatures.
Immunohematology 2019;35:156–158. Procedural Steps

Key Words: saline, IAT, antibody identification • Add two drops plasma or serum to properly labeled tube.
• Add one drop 2–5 percent reagent/donor RBC suspension.
• Centrifuge, and perform immediate spin reading (if desired).
Principle • Incubate 30–60 minutes at 37°C.
• Centrifuge, and perform 37°C reading (if desired).
The saline–indirect antiglobulin test (IAT) or saline– • Wash three to four times in isotonic saline/PBS.
• Add one to two drops antiglobulin reagent (per manufacturer’s
indirect Coombs test refers to a test incubated at 37°C without instructions).
enhancement media before washing and the addition of • Centrifuge, and perform IAT reading.
antihuman globulin (AHG) reagent. Saline-IAT tests rely Procedural steps captured from Fung.4
solely on the binding kinetics between plasma antibodies and RBC = red blood cell; PBS = phosphate-buffered saline;
IAT = indirect antiglobulin test.
antigens expressed on red blood cells (RBCs) suspended in
isotonic saline. In this environment, the Na+ in the saline may
partially neutralize the oppositely charged RBC membrane,
blocking the attraction of the antibody to its antigen.1 It is of low-ionic-strength solution (LISS) or polyethylene glycol
important to allow sufficient incubation time at 37°C for (PEG), which is often prepared as a low-ionic-strength reagent.
maximum binding of antibody to the RBCs, since no test Any increased volume of plasma in these tests can raise the
modification is used to decrease this ionic shielding. When overall ionic strength of the final test environment and reduce
more antibody can be attached to RBCs, the likelihood of visible the sensitivity of the test when the manufacturer’s specified
agglutination by cross-linking of the sensitized RBCs after incubation time is used.2 Wright3 determined that a volume
addition of AHG increases. Assessment of direct agglutination of four drops (160–200 μL) of serum to one drop (40–60 μL)
after immediate spin, room temperature, or 37°C incubation of a 5 percent RBC suspension resulted in a serum:cell ratio
of saline tests, and before washing for the IAT, can also be designed for maximum antibody sensitization. The volume
informative in antibody identification studies. of patient plasma/serum required might be considered a
A saline-IAT can be made more sensitive by adding potential limitation in a saline-IAT designed for maximum
more plasma/serum to increase the serum:cell ratio, since the antibody binding, since an increased amount of patient sample
increased plasma/serum provides more antibody for binding is required. Even so, saline-IAT remains a useful test in a
to the antigen sites. This modification for increased sensitivity laboratory’s antibody identification repertoire.
cannot be used in tests potentiated by commercial preparations

156 I M M U N O H E M ATO LO GY, Vo l u m e 3 5, N u m b e r 4, 2 019

 Saline-IAT

Indications Procedure

Saline testing is a method used in antibody detection Place two drops of patient or donor plasma into a properly
and identification studies. The saline-IAT is rarely used labeled tube, followed by one drop of the 2–5 percent RBC
as a primary RBC antibody detection method. Rather, the suspension to be tested. The sensitivity of the test may be
usefulness of saline testing lies in the flexibility of the tests that increased if four drops of patient or donor plasma are used.
can be performed. If an immediate spin reading is desired, centrifuge at the
Applications of saline tests include: calibrated time for a low-protein test and gently resuspend
• Confirmation of cold-reacting allo- or autoantibodies in while examining the tube for RBC agglutination. Incubate
saline immediate spin or room temperature tests that the tube at 37°C for 30–60 minutes. Incubation at the upper
are causing weak IAT-phase reactions without apparent end of this range may increase the sensitivity of the test.
specificity in other test methods. Centrifuge as for a low-protein test. If serum is being tested,
• Performance of antibody titration studies, since dilution the tube can be examined for hemolysis before beginning
of plasma in saline or 6 percent albumin does not resuspension of the RBCs. Gently resuspend the RBC button
adversely affect saline-IATs. Specific antibody titration while examining the tube for RBC agglutination; this is the
procedures should be used. saline-37°C reading. Wash the RBCs three to four times with
• Avoidance of warm or cold autoantibody reactivity, large quantities of isotonic saline. Add one to two drops of
allowing clinically significant alloantibodies to common AHG reagent, as specified by the AHG manufacturer’s insert.
RBC antigens to be detected without adsorption Two drops of AHG reagent generally produces a more sensitive
studies when adequate incubation time is used. No test. Centrifuge at the calibrated time for an AHG reading.
reading for direct agglutination after 37°C incubation Gently resuspend the RBC button while examining the tube
would be performed when using this test to avoid cold for RBC agglutination. Add IgG-coated reagent RBCs to all
autoantibody reactivity. negative tests. Centrifuge, and read for agglutination. A test
• Assessment of saline-IAT reactivity of antibodies such that does not show agglutination or shows agglutination that
as anti-M, anti-Lea, anti-Leb, and anti-P1 for which is weaker than expected per the manufacturer’s instructions
reactivity may be enhanced by the pH or sensitivity of indicates inadequate washing has occurred. This test is invalid
other test methods. Results of this testing have been and must be repeated.
used to evaluate the need for antigen-negative units for
transfusion. Quality Control
• Detection of complement-binding antibodies when
serum and polyspecific AHG reagent are used in testing. When this method is being used to assess samples for
This step may allow detection of the JK system and unexpected antibodies, a weakly reactive antibody (<2+)
other complement-dependent antibodies that are not should give the expected reactions with the antibody-detection
clearly demonstrable in other methods. cells in saline-IATs on each day of use.
• Recognition of reagent-dependent antibodies when Quality control of other components of the test system
saline 37°C or saline-IAT is nonreactive when compared should be performed according to laboratory protocols.
with a moderate or strongly reactive potentiated test.
• Enhancement of antibodies in Knops or Chido/Rodgers Limitations
blood group systems. Known for their frequent high-
titer, low-avidity reactivity pattern, these antibodies No single test method will detect all clinically significant
may show stronger reactivity than seen in other tube alloantibodies. Antibodies reactive in a potentiated IAT
methods. This finding may be due to the increased test may not be reactive by saline-IAT method. Insufficient
incubation time which allows for their recognition and incubation time is expected to decrease the sensitivity of the
identification.5 test. Improper centrifugation may result in false results.

I M M U N O H E M ATO LO GY, Vo l u m e 3 5, N u m b e r 4, 2 019 157

J.R. Hamilton

References 4. Fung MK, Ed. Method 3-2: Saline indirect antiglobulin test. In:
Technical manual. 19th ed. Bethesda, MD: AABB, 2017.
1. Moore BPL. Antibody uptake: the first stage of the 5. Rolih S. A review: antibodies with high-titer, low-avidity
hemagglutination reaction. In: Bell CA, Ed. Seminar on characteristics. Immunohematology 1990;6:59–67.
antigen-antibody reactions revisited. Washington, DC: AABB,
1982:47–66.
2. Issitt PD, Anstee DJ. Applied blood group serology. 4th ed. Janis R. Hamilton, MS, MT(ASCP)SBB, Manager, Immunohema-
Durham, NC: Montgomery Scientific Publications, 1998. tology Reference Laboratory, American Red Cross, Southeastern
3. Wright J. Variations on a theme by Coombs. Can J Med Tech Michigan Region, 1415 Trumbull Avenue, Detroit, MI 48216,
1967;29:191–206. Jan.Hamilton@redcross.org.

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