The IgE-dependent pathway in allergic transfusion reactions: involvement of donor blood allergens other than plasma proteins

Pilot study on the use of basophil activation tests and skin tests for the prevention of allergic transfusion reactions

Background and objectives

Management of severe allergic transfusion reactions (ATR) is challenging. In this study, we investigate the usefulness of skin tests and basophil activation tests (BAT) in chronically transfused patients for the prevention of future ATR.

Materials and methods

BAT and skin tests were carried with the supernatant of red blood cell (RBC) units for a sickle-cell disease patient under chronic exchange transfusion who has presented a severe ATR, in order to prevent potential future ATR. If the results for both BAT and skin tests were negative, the RBC units could be transfused to the patient. If either one of the results was positive, the tested RBC unit was discarded for the patient.

Results

192 RBC units were tested with both tests. The level of results concordance between the two tests was 95%. Out of the 169 negative units with both tests, 118 units were transfused to the patient for which he presented no ATR.

Conclusion

In our study, combining both BAT and skin tests was associated with a good negative predictive value since we were able to safely transfuse our patient. Further studies are still necessary to confirm this result but this pilot study indicates that skin tests and BAT might help prevent ATR. When BAT is not available, skin tests may also be useful in preventing ATR.

Transfusion reactions associated with COVID-19 convalescent plasma in outpatient clinical trials

BACKGROUND

COVID-19 convalescent plasma (CCP) is an important therapeutic option for outpatients at high risk of hospitalization from SARS-CoV-2 infection. We assessed the safety of outpatient CCP transfusions administered during clinical trials.

STUDY DESIGN AND METHODS

We analyzed data pertaining to transfusion-related reactions from two randomized controlled trials in the U.S. that evaluated the efficacy of CCP versus control plasma in various ambulatory settings. Multivariable logistic regression was used to assess whether CCP was associated with transfusion reactions, after adjusting for potential confounders.

RESULTS

The combined study reported 79/1351 (5.9%) adverse events during the transfusion visit, with the majority 62/1351 (4.6%) characterized by mild, allergic-type findings of urticaria, and/or pruritus consistent with minor allergic transfusion reactions; the other reported events were attributed to the patients' underlying disease, COVID-19, or vasovagal in nature. We found no difference in the likelihood of allergic transfusion reactions between those receiving CCP versus control plasma (adjusted odds ratio [AOR], 0.75; 95% CI, 0.43-1.31). Risk of urticaria and/or pruritus increased with a pre-existing diagnosis of asthma (AOR, 2.33; 95% CI, 1.16-4.67). We did not observe any CCP-attributed antibody disease enhancement in participants with COVID-19 or increased risk of infection. There were no life-threatening severe transfusion reactions and no patients required hospitalization related to transfusion-associated complications.

DISCUSSION

Outpatient plasma administration was safely performed for nearly 1400 participants. CCP is a safe therapeutic option for outpatients at risk of hospitalization from COVID-19.

Basophil activation test for allergic and febrile non-haemolytic transfusion reactions among paediatric patients with haematological or oncological disease

BACKGROUND AND OBJECTIVES

Allergic transfusion reactions (ATRs) and febrile non-haemolytic transfusion reactions (FNHTRs) are common, although their mechanisms remain unclear. Immunoglobulin E (IgE)-mediated type I hypersensitivity may be involved in the pathogenesis of ATR. A basophil activation test (BAT) may help elucidate this process.

MATERIALS AND METHODS

The BAT was based on peripheral blood samples from paediatric patients with a haematological or oncological disease and on samples of residual blood products transfused in each case. Dasatinib was used to evaluate whether basophil activation was mediated by an IgE-dependent pathway.

RESULTS

Twenty-seven patients with and 19 patients without ATR/FNHTR were included in this study, respectively. The median BAT values associated with ATR- (n = 41) and FNHTR-causing (n = 5) blood products were 22.1% (range = 6.1%-77.0%) and 27.8% (range = 15.2%-47.8%), respectively, which were higher than the median value of 8.5% (range = 1.1%-40.9%) observed in blood products without a transfusion reaction. Dasatinib suppressed basophil activity. BAT values were comparable in patients with ATR regardless of severity. Meanwhile, BAT values analysed with blood products non-causal for ATR/FNHTR were higher in patients with ATR/FNHTR than in those without.

CONCLUSION

The IgE-mediated type I hypersensitivity may be involved in the pathogenesis of ATR and FNHTR. BAT analyses may help elucidate the underlying mechanisms and identify patients at risk.

Perceptions About Blood Transfusion Therapy Among the General Public and Healthcare Professionals in the Qassim Region of Saudi Arabia

Purpose

Blood transfusion is a conventional therapeutic procedure; however, the perceptions of general public and healthcare professionals (HCPs), especially physicians and nurses, remain unclear, although the insights of HSPs may affect the treatment decision. This study aimed to assess the awareness of HCPs and the public about blood transfusion risks and consent in Qassim region of Saudi Arabia, to uncover the factors that may influence such perceptions.

Patients and Methods

This study used two different closed questionnaires that were distributed electronically between February and March 2018 among the population and HCPs in Qassim region.

Results

A total of 400 general public participants and 135 HCPs completed the survey. Among the surveyed participants, 70% believed that blood transfusion therapy was safe. The perceived risk of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) was the highest among all complications (74%). Furthermore, 88.2% of respondents were willing to accept a blood transfusion as a therapeutic measure, primarily from a first-degree relative, although the remaining 11.8% rejected the idea of a transfusion due to fear of medical error. From the HCP survey, 80% were previously involved in a blood transfusion therapy consent process. HCPs typically reported explaining the benefits, risks, and alternatives described in the consent form (74.1%, 67.4%, and 53.3%, respectively).

Conclusion

Our results indicated that despite the current high level of acceptance and knowledge regarding blood transfusions, additional educational efforts remain necessary to increase public awareness of blood transfusion therapy.

Immunoglobulin (Ig)G antibodies against IgE identified by basophil activation test as the putative causative agent of a serious allergic transfusion reaction: potential utility of the test as a new safety measure for allergic transfusion reactions

BACKGROUND

In most cases of allergic transfusion reactions (ATRs), the causative agents have not been identified and the mechanisms are largely unknown, with a few exceptions. The basophil activation test (BAT) was recently introduced in the field of transfusion to investigate the causal relationships between ATRs and transfusion, as well as the mechanisms behind them.

STUDY DESIGN AND METHODS

The BAT was used to screen the residual supernatants (SNs) of 43 blood components associated with serious ATRs for those that can activate basophils of many healthy volunteers. The SNs were then fractionated by centrifugal ultrafiltration and protein G column chromatography and each separated fraction was reexamined by the BAT.

RESULTS

Of the 43 such blood components, one activated basophils from 19 of 21 healthy volunteers. In the blood component, the IgG antibody against IgE was identified as a putative causative agent.

CONCLUSION

Blood donors who possessed the IgG antibody against IgE may be dangerous to transfusion recipients. The BAT would be useful in identifying such high-risk blood donors, when it is used to screen the blood components associated with serious ATRs for residual SNs that can activate the basophils of many healthy volunteers.

Amotosalen-inactivated plasma is as equally well tolerated as quarantine plasma in patients undergoing large volume therapeutic plasma exchange

A retrospective - single center - survey compared tolerance of individual donor therapeutic plasma in a series of 88 patients principally presenting with thrombotic microangiopathy; all patients underwent therapeutic plasma exchange (TPE) performed with more than 90% of either of two types of plasma preparations. One plasma type used in TPE was prepared with pathogen reduction by amotosalen addition and UVA illumination, and the other one was non-manipulated (quarantine plasma). Both types of plasma were single donor. Occurrences of adverse reactions were equally low in either arm (amotosalen: 9 in 4689 bags of ∼200mL [0.019] versus quarantine: 2 in 828 bags [0.024]), confirming the safe use of amotosalen inactivated therapeutic plasma for TPE.

Clinical utility of a passive immune basophil activation test for the analysis of allergic transfusion reactions

BACKGROUND

In previous studies, we demonstrated that the basophil activation test, which is performed using patient blood and the supernatants from transfused blood components, was able to elucidate not only the causative relationship between allergic transfusion reactions and the transfusion but also the mechanisms behind allergic transfusion reactions. However, for a large number of allergic transfusion reactions, patients are in a state of myelosuppression, and the basophil activation test cannot be performed for these patients because there are insufficient numbers of peripheral blood basophils.

STUDY DESIGN AND METHODS

To overcome this obstacle, we developed a passive immune basophil activation test, in which patient plasma and residually transfused blood are used as the patient's sources of immunoglobulin E and allergen, respectively, whereas healthy volunteer basophils serve as the responder cell source. The passive immune basophil activation test was performed for two patients who had severe allergic transfusion reactions, using supernatants of the residual platelet concentrates and the patients' own immunoglobulin E.

RESULTS

There were no differences in either surface immunoglobulin E or activation in response to allergens between untreated basophils and so-called quasi-basophils, in which immunoglobulin E was replaced by a third party's immunoglobulin E. In these patients, the supernatants of the residual platelet concentrates exclusively activated basophils in response to quasi-basophils onto which the patients' immunoglobulin E, but not a third party's immunoglobulin E, was bound.

CONCLUSION

The passive immune basophil activation test may help clarify the causal relationship between allergic transfusion reactions and transfused blood, even when patients experience myelosuppression.

Clinical utility of the basophil activation test for analysis of allergic transfusion reactions: a pilot study

BACKGROUND AND OBJECTIVES

In previous studies, we demonstrated that the basophil-activating effects of supernatants found in residual-transfused platelet concentrates (PC-SNs) on whole blood basophils in cases of allergic transfusion reactions (ATRs) could be assessed by the basophil activation test (BAT) in terms of allergen/IgE dependency. However, in these studies, the basophils were derived from third-party healthy volunteers. In this study, we performed BAT using patients' own blood basophils to analyse ATRs.

MATERIALS AND METHODS

The BAT was performed in two cases of severe ATRs using residual PC-SNs and the patients' own basophils in the presence and absence of dasatinib, an inhibitor of IgE-mediated basophil activation.

RESULTS

In both cases, PC-SNs exhibited basophil-activating activity against the patients' basophils, but not against basophils from third-party healthy volunteers. In addition, basophil activation was inhibited in the presence of dasatinib, indicating that the basophils were activated in an allergen/IgE-dependent manner. Of note, the basophils in Case 2, but not in Case 1, were activated by PC-SNs from some unrelated non-haemolytic transfusion reaction cases.

CONCLUSION

This pilot study indicates that the BAT may be useful in clarifying the causal relationship between ATRs and transfused blood as well as in elucidating the mechanisms behind ATRs considering the allergen/IgE-dependent pathway.

Mitochondrial damage-associated molecular patterns as potential proinflammatory mediators in post-platelet transfusion adverse effects

BACKGROUND

Platelet concentrates (PCs) are the most common blood components eliciting nonhemolytic transfusion reactions (NHTRs), such as allergic transfusion reactions and febrile reactions. However, the precise mechanisms of NHTRs in PC transfusion remain largely unknown. Previous studies reported that mitochondria-derived damage-associated molecular patterns (DAMPs) could be important mediators of innate cell inflammation. Platelets (PLTs) represent a major reservoir of mitochondria in the blood circulation. The aim of this study was to determine the possible involvement of mitochondrial DAMPs in NHTRs.

STUDY DESIGN AND METHODS

The amount of mitochondrial DAMPs was determined as an index of total copy numbers of mitochondrial DNA (mtDNA), including mtDNA itself and free mitochondria, using quantitative real-time polymerase chain reaction. To examine whether neutrophils, monocytes, and basophils were activated by mitochondrial DAMPs in vitro, an in vitro whole blood cell culture assay was performed.

RESULTS

In blood components associated with NHTRs, the mean total mtDNA concentration was highest in PCs followed in order by fresh-frozen plasma and red blood cells. The amount of mtDNA in NHTR PCs was higher than that in control PCs without NHTRs. The mitochondrial DAMPs present in NHTR PCs was high enough to activate neutrophils, monocytes, and basophils, when costimulated with N-formyl-l-methionyl-l-leucyl-l-phenylalanine or HLA antibodies.

CONCLUSION

PLT-derived mitochondrial DAMPs are candidate risk factors for the onset of NHTRs.