Regional
From referral to resolution: building specialised immunohematology capacity in Iraq
Dhargam Aljebouri
Specialized Immunosciences Laboratory, Iraq
Yakoob Al-Mousawi
National Blood Transfusion Center and Blood Transfusion Services, Iraq
A patient requires transfusion, yet routine compatibility testing remains unresolved. Another sample may show discordant forward and reverse ABO grouping, pan-reactivity, or a positive direct antiglobulin test (DAT) that cannot be interpreted in isolation. In such situations, the transfusion service receives more than a blood sample; it receives a clinical and laboratory problem. Resolution requires a comprehensive review of the patient’s transfusion and pregnancy history, current medications, transplant history, and underlying disease, together with specimen verification, repeat testing and targeted laboratory investigation.
ABO/RhD typing, antibody screening and compatibility testing remain the foundation of pre-transfusion assessment.1 Complex cases may require additional investigations such as monospecific DAT, antibody identification, temperature-dependent serological testing, elution, adsorption or, when phenotyping is unreliable, molecular red-cell genotyping.2, 3 The objective is not to perform additional testing unnecessarily, but to select the investigations that address the clinical and laboratory question and translate the combined findings into a clear, clinically meaningful interpretation.
A central principle is to define the referral question before referral to a reference immunohematology. ABO discrepancies require a structured assessment of forward and reverse grouping rather than empirical repetition of testing.4 Positive DAT, pan-reactivity, unexplained incompatibility, and suspected alloantibodies, require targeted serologic investigation tailored to the underlying problem.2 Similarly, suspected hemolytic disease of the fetus and newborn (HDFN) requires pregnancy-focused antibody assessment.5 In pregnancy, clinically significant red-cell antibodies require coordinated laboratory evaluation because of their implications for both maternal transfusion support and fetal or neonatal risk.5
In ABO discrepancies, resolution begins by identifying whether the discordance involves forward or reverse grouping and then investigating the most likely underlying mechanism.4 Panreactivity presents a different challenge, as a broadly reactive autoantibody may mask a clinically significant alloantibody, particularly in patients with a history of transfusion or pregnancy. Adsorption studies can permit detection of for underlying alloantibodies, while eluation studies may help characterise antibodies bound to the patient’s red cells.2 When serologic phenotyping is unreliable, molecular genotyping can support antigen prediction and guide the selection of antigen-negative or matched red-cell units.3 Patient and specimen verification, history review, repeat sampling when required, and clear documentation are integral to the investigative process.1 Specialized immunohematology is therefore defined not by reliance on a single technique, but by the systematic and complementary use of available methods to answer a clearly defined clinical and laboratory question.
Building specialised capacity in the National Blood Transfusion Center in Baghdad
Between 2021 and the end of 2024, a structured immunohematology service was developed at the National Blood Transfusion Center in Baghdad, supported by institutional leadership and multidisciplinary collaboration. Capacity building focused on integrating referral triage, advanced serologic testing, standardized documentation, clinical interpretation, and professional education into a coordinated workflow. The immunohematology team, and reports to the Director of the National Blood Transfusion Center, Baghdad, Iraq and received referrals from hospitals across Iraq through paper-based request forms and managed complex ABO discrepancies, autoimmune and alloimmune serologic problems, HDFN, antibodies to high-prevalence antigens, and rare phenotypes, including Bombay, D--, Kidd-null and Duffy-null. These problems highlight the need for specialist expertise and appropriate reagents. When compatible blood is difficult to source, organised rare-donor resources become essential.6 However, a formal rare-donor programme and access to international rare-donor programmes is currently not available, representing an important area for future development.
The immunohematology team at the National Blood Transfusion Center, Baghdad, Iraq. From left to right: Sajjad Aldoori, Rawa Alattabi, Dhargam Aljebouri, Arwa Alkhamess and Bassam Alshaikhli.
Extending specialist practice into a regulated private-sector setting
After 2024, the service was extended into a privately operated Specialised Immunosceinces Laboratory in Baghdad. The Immunosceince Laboratory in Baghdad. The aim was not to duplicate the role of the governmental blood service, but to sustain specialist diagnostic practice within a private clinical laboratory operating in accordance with applicable Ministry of Health regulatory requirements.
This transition represented continuity rather than competition. History review, problem-oriented testing, advanced serologic investigation, cautious interpretation, and communication with clinicians remained central to complex referrals. The private-sector phase has included complex ABO discrepancies, autoimmune and alloimmune serologic problems, and rare red-cell phenotypes, including the Para-Bombay phenotype. In this setting, the cost of specialized immunohematology investigations is borne directly by patients, as these tests are not routinely covered by an health insurance. Recognition of such cases in this setting illustrates how specialized immunohematology expertise can be sustained across different healthcare settings while remaining complementary to the broader transfusion service.
Yakoob Al-Mousawi , the Director of the National Blood Transfusion Center, Baghdad, Iraq.
Quality improvement and professional development
Timely communication between the transfusion service, reference laboratory, and clinical team remains central to complex autoimmune haemolytic anaemia, compatibility, and pregnancy-related investigations, particularly when transfusion planning or HDFN risk is involved.2,5
Quality assurance in the reference laboratory is supported by daily internal quality control and participation in external proficiency testing through OneWorld Accuracy (1WA). External quality assessment provides an objective framework for identifying areas requiring improvement and strengthening laboratory performance.7
Professional development is being further supported through the upcoming ISBT Academy-supported activity (Advancing Immunohematology and Transfusion Safety in Iraq: A One-Day Case-Based Educational Workshop for Transfusion Professionals) to be hosted by the National Blood Transfusion Center in Baghdad on 14 November 2026. The programme will address immunohematology, platelet transfusion, haemovigilance, and transfusion safety through an interactive case-based format.
Immunohematology team at the Specialized Immunosceinces Laboratory, Baghdad, Iraq. From left to right: Maryam Alsgban, Dhargam Aljebouri and Abdulmohaimen Alaa.
Lessons learnt
Sustainable immunohematology capacity depends on trained personnel, robust quality systems, well-defined referral pathways, access to advanced serology and molecular methods, rare-donor resources, and sustained institutional support. No single laboratory can maintain every rare reagent, reference cell, molecular platform, or compatible rare blood unit. International rare-donor programmes exist because some transfusion challenges require cooperation beyond an individual institution or national system.8
The Iraqi experience also highlights the importance of continuity across governmental and regulated private settings. The key issue is not which sector provides specialized immunohematology, but whether complex referrals are managed according to consistent standards of specimen verification, investigation, interpretation, documentation, and communication.
The way forward
Further development should focus on strengthening referral pathways, expanding access to molecular immunohematology, supporting participation in external quality assessment programmes, improving the identification and documentation of rare donors, and sustaining professional education and regional collaboration.
A specialised immunohematology service receives more than a blood sample alone. It receives a clinical and laboratory problem that requires systematic resolution. Moving from referral to resolution requires history review, specimen verification, structured investigation, interpretation, effective communication, and institutional support. When these elements are integrated into a coordinated workflow, complex serology can be translated into safer patient management and more informed transfusion decisions.
References
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2. Johnson ST, Puca KE. Evaluating patients with autoimmune hemolytic anemia in the transfusion service and immunohematology reference laboratory: pretransfusion testing challenges and best transfusion-management strategies. Hematology Am Soc Hematol Educ Program. 2022; 2022: 96–104.
3. Akinbolaji TJ. When and why is red blood cell genotyping applicable in transfusion medicine: a systematic review of the literature. Immunohematology. 2024; 40: 58–64.
4. Meny GM. Recognizing and resolving ABO discrepancies. Immunohematology. 2017; 33: 76–81.
5. Regan F, Veale K, Robinson F, Brennand J, Massey E, Qureshi H, et al. Guideline for the investigation and management of red cell antibodies in pregnancy: A British Society for Haematology guideline. Transfus Med. 2025; 35: 3–23.
6. Paccapelo C. Managing a rare donor programme: the immunohaematology laboratory perspective. ISBT Sci Ser. 2018; 13: 11–15.
7. Buchta C, Coucke W, Mayr WR, Müller MM, Körmöczi GF. To win the battle, first know your enemy: error rates in immunohematology external quality assessment results. Transfus Med Hemother. 2020; 47: 80–87.
8. Nance S, Scharberg EA, Thornton N, Yahalom V, Sareneva I, Lomas-Francis C. International rare donor panels: a review. Vox Sang. 2016; 110: 209–218.
