Pilot study of HLA alloimmunization after transfusion with pre-storage leucodepleted blood products in aplastic anaemia

We have performed a pilot study to examine the incidence of alloimmunization using pre-storage leucocyte-depleted blood products (PLDP) in 16 previously transfused aplastic anaemia (AA) patients with no detectable HLA antibodies. A further eight AA patients with HLA antibodies received HLA-matched PLDP. Leucodepleted apheresed platelets were obtained using either Cobe spectra or Haemonetics system with an integral pall filter. Pall BPF4 filters were used for red cell preparation. Patients' sera were tested for HLA antibodies using lymphocytotoxicity (LCT). Patients who were HLA antibody negative by LCT at study entry were further tested with enzyme-linked immunoassay (ELISA). Out of 16 patients, two (12%) formed anti-HLA antibodies with a median follow-up of 9 months (range 1-15), but did not display platelet refractoriness to random donor platelets. Two patients were inadvertently transfused with non-leucodepleted blood products when later referred back to their local hospital. Both subsequently demonstrated HLA antibodies by LCT and became platelet refractory. These results contrast with a 50% incidence of HLA alloimmunization in a control group of AA patients transfused prior to this study with non-PLDP. HLA antibodies could no longer be detected by LCT in follow-up of three out of eight patients with HLA antibodies at study entry. Only one patient experienced non-haemolytic febrile transfusion reactions (NHFTR). We conclude that PLDP reduce the risk of alloimmunization even in previously transfused AA patients, PLDP are associated with a low incidence of NHFTR, and all new AA patients should receive PLDP from diagnosis.

Pure red cell aplasia after major ABO-incompatible bone marrow transplantation: two case reports of treatment with recombinant human erythropoietin

A 34-year-old man with acute myelocytic leukemia (AML: MO) and a 32-year-old woman with AML: M2 developed pure red cell aplasia (PRCA) after receiving a major ABO incompatible bone marrow transplant (BMT). The first patient responded to recombinant human erythropoietin (rhEPO) therapy, while the second did not. The second patient also received methylprednisolone (m-PSL) but developed reticulocytosis and hemolysis after the administration of m-PSL. Plasmapheresis was then performed and the patient promptly recovered from hemolysis and PRCA. We conclude that close attention must be paid when treating PRCA following major ABO-incompatible BMT with rhEPO and m-PSL, as there is always the potential for massive hemolysis.

Successful management of hemolysis in ABO-nonidentical orthotopic liver transplantation by steroid therapy: a case report

Hemolysis due to donor-derived B lymphocytes has been reported in patients who have undergone ABO-nonidentical orthotopic liver transplantation (OLT). Yet, until now, little was known about the management of this transplantation-induced hemolysis. In this report we describe our experience with hemolysis in a patient after OLT. In addition, based on theoretical assumption, we hypothesize that corticosteroids can be helpful in the management of ABO-nonidentical OLT-induced hemolysis.

Mixed erythrocyte chimerism: implications for tolerance of the donor immune system to recipient non-ABO system red cell antigens

We report a case of a minor degree of ABO incompatibility in a BMT recipient, demonstrating mixed RBC chimerism, who, late in the post-transplant period, developed a warm autoimmune hemolytic anemia and subsequently developed antibodies with donor-anti-recipient specificities for non-ABO system RBC antigens. While this implies a lack of tolerance of the donor immune system for recipient non-ABO system RBC antigens, other factors may be operating and should be evaluated before such a conclusion is reached. Underscored is the importance of obtaining pretransplant RBC antigen phenotypes on both the recipient and donor.

Transfusion requirements after bone marrow transplantation from HLA-identical siblings: effects of donor-recipient ABO incompatibility

Transfusion requirements of 477 patients with hematologic malignancies undergoing BMT from HLA-identical siblings were studied. The median (range) number of red cells transfused in the first, second and third months were 4 (0-32), 1 (0-39), and 0 (0-22) respectively, and the number of random donor platelet concentrates 32.5 (0-196), 0 (0-220) and 0 (0-135). On multivariate analysis, diagnosis other than acute leukemia, conditioning regimen other than cyclophosphamide-TBI, cyclosporine-methotrexate GVHD prophylaxis, and occurrence of acute GVHD increased platelet requirements significantly in the first month. Diagnosis other than acute leukemia, donor-recipient ABO incompatibility, conditioning regimen other than cyclophosphamide-TBI, and age over 18 years increased red cell requirements significantly in the first month. Platelet requirements in the second month and red cell requirements in the second and third months were increased significantly by the occurrence of acute GVHD, a diagnosis other than acute leukemia, and a conditioning regimen other than cyclophosphamide-TBI. Platelet requirements in the third month were influenced only by acute GVHD. We conclude that ABO incompatibility does not influence platelet requirements after allogeneic BMT. It affects red cell requirements in the first month along with the diagnosis, conditioning regimen, and age. However, other factors outweigh the influence of ABO-incompatibility on red cell requirements beyond the first month.

Hemolytic transfusion reaction due to Rh antibodies detectable only by manual polybrene and polyethylene glycol technique

The authors report two cases of severe hemolytic transfusion reaction (HTR) attributable to Rh antibodies, which were not detectable by the saline indirect antiglobulin test (SIAT), low ionic strength saline solution technique (LISS), or two-stage enzyme (Enz) indirect antiglobulin test (IAT), but were readily detectable by the manual polybrene technique (MPT), MPT-IAT, and polyethylene glycol (PEG) IAT. With rare exceptions, Rh antibodies can usually be easily detected by the SIAT or Enz-IAT, and seldom cause intravascular HTR. The two cases in this report illustrate the value of the MPT and PEG-IAT in the detection of clinically significant Rh antibodies that would not otherwise be detectable by conventional methods.

Canine transfusion reactions and their management

There is a wide range of mechanisms by which transfusion reactions may occur. These reactions typically are categorized as immune- or nonimmune-mediated and also as to whether they are acute or delayed in nature. The type and severity of clinical signs vary according to the specific reaction present. Many reactions can be prevented with the use of standard and appropriate transfusion medicine procedures. These methods include careful collection and storage of blood products, adequate screening and blood typing of donor dogs, crossmatching donor and recipient blood, use of component therapy, correct administration of blood products, and the use of pretransfusion prophylaxis when appropriate. Because many reactions are dose dependent, careful monitoring of transfusions cannot be overemphasized. Rapid recognition of a transfusion reaction and immediate discontinuation of the transfusion, along with appropriate supportive therapy, is essential for the successful treatment of transfusion reactions. A summary of transfusion reactions including clinical signs, diagnosis, and basic treatment protocols is given in Table 4. When used appropriately, transfusion of blood products can be a highly beneficial, low-risk form of therapy.

[Septicemia in children treated with exchange transfusions because of hemolytic disease of the newborn]

Clinical signs and laboratory test results were analyzed in 70 neonates (42 boys and 28 girls) hospitalized because of neonatal haemolytic disease who were treated with exchange transfusion and later developed septicaemia. Serological Rh-D incompatibility was diagnosed in 11 children, ABO incompatibility in 59. Signs of infection appeared between days 1 and 7 after transfusion. Pneumonic signs and diarrhoea dominated clinically in 45 newborns, skin abscesses were observed in 10, osteomyelitis in 4. Septic shock occurred in 7. Gram-negative bacteria predominated (52.85%). A significant diagnostic value of the following was found (chi2): granulocytic band forms (expressed as percentages > or = 0.10, a neutrophil index > 0.2 and toxic granulations in neutrophils. These results were obtained in the early, asymptomatic stage of infection, i.e. before the exchange transfusion was performed. The importance of the presence of risk factors, not exchange transfusion per se, is stressed.

Hemolytic transfusion reactions in a dog with an alloantibody to a common antigen

Alloantibodies to high-frequency red cell antigens, defined as inherited traits occurring in 92% to 99% or more of the general population, are recognized as a cause of hemolytic transfusion reactions in humans. Here we describe a dog (dog erythrocyte antigen [DEA] 1.2- and DEA 4-positive) sensitized by prior blood transfusion, for which a compatible blood donor could not be found; transfusion of DEA 1.1-negative blood resulted in hemolytic transfusion reactions. Patient serum from days 1 (before first transfusion) and 16 was available for further testing; using 4 dogs with different blood types as potential donors, the major crossmatches were compatible using serum from day 1. However the crossmatches were all incompatible with serum from day 16, indicating that the patient was sensitized to an antigen after the first transfusion. The presence of an alloantibody against DEA 1.1 was not ruled out in this patient, but the incompatibility reactions of patient serum with red cells from donors negative for DEA 1.1 indicated that an alloantibody against a red cell antigen other than DEA 1.1 or any other known DEA for which typing reagents were available (DEA 3, 5, and 7) was present. Subsequently, red cells from 1 of the patient's siblings (DEA 1.2-, 4-, and 7-positive) were found not to agglutinate when incubated with patient's serum from day 16, ruling out the presence of an anti-DEA 7 antibody, and suggesting that an alloantibody against a common red cell antigen missing in the patient and sibling was responsible for the blood incompatibility reactions.(ABSTRACT TRUNCATED AT 250 WORDS)

An acute hemolytic transfusion reaction caused by dog erythrocyte antigen 1.1 incompatibility in a previously sensitized dog

An acute hemolytic transfusion reaction resulting from dog erythrocyte antigen (DEA) 1.1 incompatibility developed in a dog previously sensitized to DEA 1.1 by a transfusion 3 years earlier. The dog developed fever, pigmenturia, and lethargy, and its PCV did not rise as expected. The donor blood was type DEA 1.1 positive, whereas the recipient's blood was type DEA 1.1, DEA 1.2, and DEA 7 negative. A major crossmatch was later found to be strongly incompatible. Studies of the recipient's plasma revealed a specific anti-DEA 1.1 alloantibody of the IgG class with high hemolysin and agglutinin activity. Such acute hemolytic transfusion reactions can be avoided by crossmatching previously transfused dogs and by using dogs that are type DEA 1.1 negative (and preferably also type DEA 1.2 and DEA 7 negative) as blood donors.

The differentiation of delayed hemolytic and delayed serologic transfusion reactions: incidence and predictors of hemolysis

BACKGROUND

After differentiation of the entities of clinically detectable delayed hemolytic (DHTR) and delayed serologic transfusion reactions (DSTR), previous investigators calculated a DHTR:DSTR incidence ratio of 18:72 from a retrospective review of patients with serologic evidence of DHTR or DSTR. There are no published data on factors that may influence the occurrence of DHTR versus DSTR in a given patient.

STUDY DESIGN AND METHODS

Retrospective review was conducted of 292 patients at the Mayo Clinic who, between 1980 and 1992, received a clinical diagnosis of DHTR or DSTR concurrently with a serologic diagnosis. Red cell alloantibody specificity, the activity of the patient's reticuloendothelial system, and concurrent immunosuppression were evaluated as potential predictors of the occurrence of DHTR versus DSTR in different patients.

RESULTS

The incidence of DHTR or DSTR was 1 in 1899 allogeneic red cell units transfused, with a DHTR:DSTR ratio of 36:64. Alloantibody specificity was the only variable that affected the occurrence of DHTR versus DSTR at the clinical level, with the anti-Jka and anti-Fya specificities, as well as multiple coexisting specificities, significantly associated with detectable hemolysis (p < 0.05).

CONCLUSION

Clinically detectable DHTRs are found to occur more commonly than previously believed when the clinical and serologic diagnoses are made concurrently and appropriate work-ups for hemolysis are ordered. The association of certain alloantibody specificities with detectable DHTRs may have implications for clinical transfusion practice.

[Haemolytic transfusion reaction of surgical patients due to incompatibility of Rh blood groups]

Haemolytic transfusion reactions occurred in 4 patients under plastic surgery due to incompatibility of Rh blood groups. The reaction in one of the patient occurred not only abrupt but severe and finally died of renal failure. Other three patients with delayed haemolytic reactions survived after treatment. Since more than 99.5% Chinese population is Rh positive, cross-matching on Rh blood groups is not a routine. The reactions develop usually different from typical ABO blood group haemolytic reactions and are not easy to make an early diagnose. If the surgical patients show profound anemia and haemorrhage following transfusion which could not be explained by bleeding and coagulation abnormalities, haemolytic transfusion reactions due to incompatibility of Rh blood groups might be considered.

Red cell alloantibodies in patients with haemoglobinopathies

The present study was carried out to determine the evidence of alloimmunization against red blood cells in 364 patients transfused in our center over a period of 4 years (1990-1993). Among these patients, 127 were thalassemic and 182 had sickle cell disease (SCD). In 55 control patients, who received blood matched for the ABO, Rhesus and Kell antigen systems from the outset of transfusion, no immunization was detected. However, in the study group, who initially received blood matched only for ABH and Rh D antigens, the frequency of alloimmunization was 7.76% (24/309). Only one antibody was detected in 15 patients (62.5%) and two or more in 9 patients (37.5%). Alloimmunization concerned the Rhesus system in 58.82% of cases and the Kell system in 26.47%, while the frequency of immunization was significantly lower in patients of less than 5 years as compared to those in the age range 5-10 years (p < 0.001).

High-affinity cytotoxic T lymphocytes after non-HLA-sharing blood transfusion--the other side of the coin

Previously, we have shown that pretransplantation blood transfusion modulates the T cell repertoire to a great extent. Patients receiving a BT from a donor sharing one HLA haplotype with the patient (HLA-sharing BT) develop CTL nonresponsiveness against cells of the BT donor and show a selective decrease in the usage of T cell receptor V beta families. The present study has focused on the analysis of the T cell repertoire in patients receiving an HLA mismatched (non-HLA-sharing) BT. CTL precursor frequencies were measured against single class I-mismatched antigens in split-well analysis. In addition, blocking studies of CTL-target cell interaction were performed with anti-CD8 monoclonal antibodies. The results demonstrate that non-HLA-sharing BT immunizes and induces the generation of CD8 independent, high-affinity CTL against immunogenic class I-mismatched antigens. Such HLA class I antigens might become nonacceptable mismatches in subsequent organ transplantation.

Pure red cell aplasia following ABO-incompatible bone marrow transplantation: response to erythropoietin

Allogeneic bone marrow transplants with major ABO incompatibility may be associated with delayed erythroid engraftment. A case of a male patient with erythroleukemia (blood group O) who received a bone marrow transplant from an HLA-identical sibling (blood group AB) is reported. The bone marrow transplantation was followed by normal myeloid and megakaryocytic engraftment, but pure red cell aplasia was present for more than 230 days after bone marrow transplant. Despite documentation of an elevated endogenous erythropoietin level (360 mU/mL; normal value, < 19 mU/mL) during the period of absent erythropoiesis, erythroid engraftment was observed soon after the initiation of human recombinant erythropoietin at a dose of 50 U per kg daily. This experience suggests that high-dose erythropoietin may stimulate sufficient production of erythroid precursors to overcome circulating inhibitors resulting in the correction of pure red cell aplasia.