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Loriamini M, Cserti-Gazdewich C, Branch DR. Autoimmune Hemolytic Anemias: Classifications, Pathophysiology, Diagnoses and Management. Int J Mol Sci 2024; 25:4296. [PMID: 38673882 PMCID: PMC11049952 DOI: 10.3390/ijms25084296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Autoimmune hemolytic anemias (AIHAs) are conditions involving the production of antibodies against one's own red blood cells (RBCs). These can be primary with unknown cause or secondary (by association with diseases or infections). There are several different categories of AIHAs recognized according to their features in the direct antiglobulin test (DAT). (1) Warm-antibody AIHA (wAIHA) exhibits a pan-reactive IgG autoantibody recognizing a portion of band 3 (wherein the DAT may be positive with IgG, C3d or both). Treatment involves glucocorticoids and steroid-sparing agents and may consider IVIG or monoclonal antibodies to CD20, CD38 or C1q. (2) Cold-antibody AIHA due to IgMs range from cold agglutinin syndrome (CAS) to cold agglutin disease (CAD). These are typically specific to the Ii blood group system, with the former (CAS) being polyclonal and the latter (CAD) being a more severe and monoclonal entity. The DAT in either case is positive only with C3d. Foundationally, the patient is kept warm, though treatment for significant complement-related outcomes may, therefore, capitalize on monoclonal options against C1q or C5. (3) Mixed AIHA, also called combined cold and warm AIHA, has a DAT positive for both IgG and C3d, with treatment approaches inclusive of those appropriate for wAIHA and cold AIHA. (4) Paroxysmal cold hemoglobinuria (PCH), also termed Donath-Landsteiner test-positive AIHA, has a DAT positive only for C3d, driven upstream by a biphasic cold-reactive IgG antibody recruiting complement. Although usually self-remitting, management may consider monoclonal antibodies to C1q or C5. (5) Direct antiglobulin test-negative AIHA (DAT-neg AIHA), due to IgG antibody below detection thresholds in the DAT, or by non-detected IgM or IgA antibodies, is managed as wAIHA. (6) Drug-induced immune hemolytic anemia (DIIHA) appears as wAIHA with DAT IgG and/or C3d. Some cases may resolve after ceasing the instigating drug. (7) Passenger lymphocyte syndrome, found after transplantation, is caused by B-cells transferred from an antigen-negative donor whose antibodies react with a recipient who produces antigen-positive RBCs. This comprehensive review will discuss in detail each of these AIHAs and provide information on diagnosis, pathophysiology and treatment modalities.
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Affiliation(s)
- Melika Loriamini
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Centre for Innovation, Canadian Blood Services, Keenan Research Centre, Room 420, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Christine Cserti-Gazdewich
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Laboratory Medicine Program, Blood Transfusion Laboratory, University Health Network, Toronto, ON M5G 2C4, Canada
- Blood Disorders Program, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Donald R. Branch
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Centre for Innovation, Canadian Blood Services, Keenan Research Centre, Room 420, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Medicine, University of Toronto, Toronto, ON M5B 1W8, Canada
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Kuter DJ, Piatek C, Röth A, Siddiqui A, Numerof RP, Dummer W. Fostamatinib for warm antibody autoimmune hemolytic anemia: Phase 3, randomized, double-blind, placebo-controlled, global study (FORWARD). Am J Hematol 2024; 99:79-87. [PMID: 37929318 DOI: 10.1002/ajh.27144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/18/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023]
Abstract
Warm antibody autoimmune hemolytic anemia (wAIHA) is characterized by hemolysis and symptomatic anemia with no approved treatment options. Fostamatinib is an oral spleen tyrosine kinase inhibitor approved in the US and Europe for treatment of adults with chronic immune thrombocytopenia. In this phase 3 study, patients with an insufficient response to ≥1 prior wAIHA treatment were randomized to fostamatinib or placebo. The primary endpoint was the proportion of patients to achieve a durable hemoglobin (Hgb) response (Hgb ≥10 g/dL and increase from baseline of ≥2 g/dL on 3 consecutive visits) during the 24-week treatment period. Ninety patients were randomized, 45 to each arm. Of the fostamatinib-treated patients, 35.6% achieved a durable Hgb response versus 26.7% on placebo (p = .398). A post hoc analysis revealed a large placebo response in Eastern European patients. Significantly more patients on fostamatinib from North America, Australia and Western Europe exhibited a durable Hgb response compared to placebo (36% vs. 10.7%, p = .030). After censoring for Hgb values impacted by steroid rescue received during screening and excluding 2 placebo patients found to likely not have wAIHA, a reanalysis demonstrated a difference in durable Hgb response between fostamatinib and placebo (15/45 [33.3%] vs. 6/43 [14.0%], p = .0395). At least 1 AE was reported in 42 (93.3%) and 40 (88.9%) patients receiving fostamatinib and placebo, respectively. The most common AEs in the fostamatinib group were diarrhea (26.7%), hypertension (24.4%), and fatigue (15.6%). In this study, fostamatinib demonstrated a clinically meaningful benefit for patients in Western regions, and no new safety signals were identified.
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Affiliation(s)
- David J Kuter
- Department of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Caroline Piatek
- Division of Hematology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California, USA
| | - Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Asif Siddiqui
- Department of Development, Rigel Pharmaceuticals, Inc., South San Francisco, California, USA
| | - Robert P Numerof
- Department of Development, Rigel Pharmaceuticals, Inc., South San Francisco, California, USA
| | - Wolfgang Dummer
- Department of Development, Rigel Pharmaceuticals, Inc., South San Francisco, California, USA
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Osyodlo GV, Husieva SA, Svicharova SV, Savichan KV. Autoimmune Hemolytic Anemia Associated with COVID-19 Infection in a Patient with High Cardio-metabolic Risk. Mil Med 2023:usad446. [PMID: 38015753 DOI: 10.1093/milmed/usad446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/19/2023] [Accepted: 11/01/2023] [Indexed: 11/30/2023] Open
Abstract
The article analyses data on the occurrence of hematological abnormalities in severe acute respiratory syndrome 2 infection. Among these hematological abnormalities, the majority of patients develop a hypercoagulable state associated with thromboembolic complications and poor prognosis. Approximately one-third of patients with severe acute respiratory syndrome 2 infection are diagnosed with mild to severe thrombocytopenia. Another hematological autoimmune disease observed in patients with coronavirus disease 2019 is autoimmune hemolytic anemia. A clinical case with the development of autoimmune hemolytic anemia in the setting of coronavirus infection was described. The diagnosis was based on the presence of anemia, reticulocytosis, a significant decrease in haptoglobin levels, and a positive antiglobulin test (Coombs test). Given the comorbidity, the risks of adverse effects of severe coronavirus disease were high, despite this, it was possible to achieve clinical and hematological remission of autoimmune hemolytic anemia by prescribing pathogenetic therapy with anti-CD-20 monoclonal antibody (rituximab), recombinant erythropoietin and glucocorticoid hormones. This clinical case demonstrates the possibility of successful treatment of patients with severe hemolytic anemia. Special attention should be paid to the discrepancy between the severity of the condition and objective data. This case demonstrates the need for a more in-depth approach to each patient with anemia associated with coronavirus disease infection, namely, in the presence of anemic syndrome, it is imperative to include a full range of laboratory tests.
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Affiliation(s)
- Galyna V Osyodlo
- Military Therapy Department, Ukrainian Military Medical Academy, Kyiv 01010, Ukraine
| | - Svitlana A Husieva
- Military Therapy Department, Ukrainian Military Medical Academy, Kyiv 01010, Ukraine
| | - Svitlana V Svicharova
- Military Therapy Department, Ukrainian Military Medical Academy, Kyiv 01010, Ukraine
| | - Kyrylo V Savichan
- Military Therapy Department, Ukrainian Military Medical Academy, Kyiv 01010, Ukraine
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Pande A, Kumar A, Krishnani H, Acharya S, Shukla S. Recent Advances in the Management of Microangiopathic Hemolytic Anemias (MAHA): A Narrative Review. Cureus 2023; 15:e47196. [PMID: 38021690 PMCID: PMC10653637 DOI: 10.7759/cureus.47196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Red blood cells (RBCs) start to break down early in hemolytic anemia, which can be chronic or life-threatening. It should be considered while determining if normocytic or macrocytic anemia is present. Hemolysis in the reticuloendothelial system may happen intravascularly, extravascularly, or both. It accounts for a broad spectrum of laboratory and clinical situations, both physiological and pathological. Whenever the frequency of RBC breakdown is rapid enough to lower hemoglobin levels below the normal range, hemolytic anemia occurs. Microangiopathic hemolytic anemia (MAHA) is a term used to describe non-immune hemolysis induced by intravascular RBC fragmentation caused by substances in the tiny blood arteries that generate schistocytes in the peripheral circulation. Microvasculature abnormalities, such as small arterioles and capillaries, are usually involved. Furthermore, MAHA can also be brought on by intravascular devices like a prosthetic heart valve or assistive technologies. Poor deformity results in entrapment, phagocytosis, antibody-mediated elimination through phagocytosis or direct complement activation, fragmentation brought about by microthrombi or acute mechanical stress, oxidation, or spontaneous cellular death. Hemolysis may cause acute anemia, jaundice, hematuria, dyspnea, tiredness, tachycardia, and possibly hypotension. This article aims to synthesize existing research, identify therapeutic strategies, and provide insights into current and emerging approaches for managing this complex hematological disorder.
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Affiliation(s)
- Arundhati Pande
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Abhishek Kumar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Harshil Krishnani
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sourya Acharya
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Samarth Shukla
- Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Liu J, Dong S, Ru Y. Ultrastructural analysis of nucleated erythrocyte in patients with autoimmune hemolytic anemia (AIHA). Ultrastruct Pathol 2023:1-7. [PMID: 37158191 DOI: 10.1080/01913123.2023.2211358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is a group of diseases characterized by immune-mediated lysis of mature red blood cells (RBCs). It is mainly classified into primary and secondary types based on etiology and mechanisms underlying autoantibody production. AIHA is diagnosed using morphological observation of bone marrow smears under a light microscope and monospecific direct antiglobulin test to detect hemolysis. Here, we retrospectively studied ultrastructural abnormalities of nucleated erythroid cells in bone marrows from 10 patients with AIHA using transmission electron microscopy. Our results revealed severe damage and injury to nucleated erythroid cells, including morphological irregularity, pyknosis, karyolysis, expansion of perinuclear cisternae and cytoplasmic lysis. These results indicate that aberrant immunity attacks not only mature RBCs but also nucleated erythroid cells, and ineffective hematopoiesis is partly involved in the pathogenesis of AIHA.
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Affiliation(s)
- Jing Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Shuxu Dong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yongxin Ru
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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Harsini S, Rezaei N. Autoimmune diseases. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Muacevic A, Adler JR, Kananeh S, Hassan A, Jumaah O. Lymphoplasmacytic Lymphoma/Waldenstrom Macroglobulinemia Masquerading as IgM Warm Antibody Autoimmune Hemolytic Anemia in Association With Mycoplasma pneumoniae Infection: A Case Report. Cureus 2022; 14:e31693. [PMID: 36561576 PMCID: PMC9765329 DOI: 10.7759/cureus.31693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 11/21/2022] Open
Abstract
Warm antibody autoimmune hemolytic anemia (AIHA) is mostly of IgG subtype. IgM subtype is extremely rare and has not been reported in association with lymphoplasmacytic lymphoma (LPL)/Waldenström macroglobulinemia (WM). We are reporting the case of a 75-year-old female patient who presented with severe hemolytic anemia and Mycoplasma pneumoniae pneumonia (MPP). Cold agglutinin and serum protein electrophoresis (SPEP) were negative but immunofixation was positive for IgM. Ultimately, hemolytic anemia was labeled warm antibody AIHA in association with MPP. She presented again one year later with more severe hemolytic anemia. Persistently elevated IgM was seen in immunofixation and triggered bone marrow biopsy that confirmed LPL/WM. This case highlights the clinical pearl that warm antibody AIHA in association with MPP is a rare entity and more intensive investigation to rule out other etiologies is mandated. Also, this case is rare as it is of IgM subtype warm AIHA and observed in the context of LPL/WM.
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Hafez W, Ziade MA, Arya A, Saleh H, Abdelrahman A. The significance of antiglobulin (Coombs) test reactivity in patients with COVID-19. Immunobiology 2022; 227:152240. [PMID: 35839729 PMCID: PMC9258419 DOI: 10.1016/j.imbio.2022.152240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 06/17/2022] [Accepted: 07/02/2022] [Indexed: 12/15/2022]
Abstract
Previous case reports have described patients with COVID-19-associated autoimmune hemolytic anemia (AIHA), and cold agglutinin disease (CAD) which is characterized by a positive direct antiglobulin (DAT) or "Coombs" test, yet the mechanism is not well understood. To investigate the significance of Coombs test reactivity among COVID-19 patients, we conducted a retrospective study on hospitalized COVID-19 patients treated at NMC Royal Hospital between 15 April and 30 May 2020. There were 27 (20%) patients in the Coombs-positive group and 108 (80%) in the Coombs-negative group. The cold agglutinin titer was examined in 22 patients due to symptoms suggestive of cold agglutinin disease, and all tested negative. We demonstrated a significant association with reactive Coombs test results in univariate analysis through clinical findings such as ICU admission rate, the severity of COVID-19, and several laboratory findings such as CRP, D-dimer, and hemoglobin levels lactate dehydrogenase, and RDW-CV. However, only hemoglobin levels and disease severity had a statistically significant association in multivariate analysis. A possible explanation of COVID-19-associated positive Coombs is cytokine storm-induced hyperinflammation, complement system activation, alterations of RBCs, binding of SARS-CoV-2 proteins to hemoglobin or its metabolites, and autoantibody production. Coombs-positive patients were tested for hemolysis using indirect bilirubin, consumed haptoglobin, and/or peripheral smear that ruled out any evidence of hemolysis. Understanding this etiology sheds new light on RBC involvement as a pathophysiological target for SARS-CoV-2 by interfering with their function; consequently, therapies capable of restoring RBC function, such as erythrocytapheresis, could be repurposed for the treatment of worsening severe and critical COVID-19.
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Affiliation(s)
- Wael Hafez
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates; Medical Research Division, Department of Internal Medicine, The National Research Center, Cairo, Egypt.
| | - Mohamad Azzam Ziade
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Arun Arya
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Husam Saleh
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Ahmed Abdelrahman
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates; Internal Medicine Department, Zagazig School of Medicine, Zagazig, Egypt
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Red cell autoantibodies with well-defined Rh specificity in patients with warm autoimmune hemolytic anemia: a report of 3 cases. Med J Armed Forces India 2022; 78:368-370. [DOI: 10.1016/j.mjafi.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022] Open
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Das SS, Mukherjee S. Influence of immunohematological markers on severity of in vivo hemolysis in human warm autoimmune haemolytic anemia. Transfus Apher Sci 2022; 61:103492. [PMID: 35773127 DOI: 10.1016/j.transci.2022.103492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022]
Abstract
Autoantibody production in autoimmune haemolytic anemia (AIHA) is the result of the loss of self-immunological tolerance of the host. Here we investigated the various immunohematological markers that may influence the severity of in vivo hemolysis in warm AIHA (WAIHA). Complete direct antiglobulin test (DAT) evaluation and immunohematological characterization were performed in 247 patients of WAIHA following departmental protocols. Clinical and laboratory details of patients were obtained from patient file. The median age of WAIHA patients was 47 years with a female preponderance. Lymphoproliferative diseases were the major underlying causes of secondary WAIHA. The mean haemoglobin (Hb) and reticulocyte count (Retic) were 6.43 gm/dL and 7.58% respectively. Single autoantibody bound to red cells was investigated in 151 patients. The main IgG subclass was IgG1. Multiple autoantibodies like IgG+ C, IgG+IgA and IgG+IgA+C were found in 87 (35.2%) patients. Free autoantibodies were observed in 112 patients with a median indirect antiglobulin test (IAT) reactivity of 2+. Derangement of haematological and biochemical values was statistically significant with increase in DAT reactivity, presence of multiple autoantibodies on red cells, coating of red cells by IgG3 or multiple IgG subclass, higher DAT dilution and increasing IAT reactivity. We conclude that several important but simple immunohematological parameters may influence the degree of in vivo hemolysis in WAIHA. Since a set of common haematological and biochemical test determines the severity of in vivo hemolysis therefore a comprehensive clinical and immunohematological evaluation is advisable for a correct diagnostic and therapeutic workup of WAIHA.
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Affiliation(s)
- Sudipta Sekhar Das
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata 700054, India.
| | - Sourav Mukherjee
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata 700054, India
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Yui JC, Brodsky RA. Updates in the Management of Warm Autoimmune Hemolytic Anemia. Hematol Oncol Clin North Am 2022; 36:325-339. [DOI: 10.1016/j.hoc.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Suzuki T, Okamoto T, Kawai F, Okuyama S, Fukuda K. Hemolytic Anemia after Acute Hepatitis B Virus Infection: A Case Report and Systematic Review. Intern Med 2022; 61:481-488. [PMID: 34433718 PMCID: PMC8907784 DOI: 10.2169/internalmedicine.7690-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Hemolytic anemia and pure red cell aplasia are rare hematological complications of hepatitis B virus infection. We herein report a 24-year-old man who was diagnosed with hemolytic anemia and possible transient pure red cell anemia eight weeks after a severe episode of acute hepatitis B virus infection. Rapid recovery was observed with conservative management. Hemoglobin returned to baseline within three months. As the clinical features of hemolytic anemia associated with hepatitis B virus have not yet been elucidated, we conducted a systematic review and present an analysis of the 20 reported cases, including our present case.
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Affiliation(s)
- Takahiro Suzuki
- Department of Gastroenterology, St. Luke's International Hospital, Japan
| | - Takeshi Okamoto
- Department of Gastroenterology, St. Luke's International Hospital, Japan
| | - Fujimi Kawai
- St. Luke's International University Library, Japan
| | - Shuhei Okuyama
- Department of Gastroenterology, St. Luke's International Hospital, Japan
| | - Katsuyuki Fukuda
- Department of Gastroenterology, St. Luke's International Hospital, Japan
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Das SS, Chakrapani A, Bhattacharya S, Biswas RN, Safi M. Immunohematological and Clinical Characterization of Complement and Non-Complement Associated Warm Autoimmune Haemolytic Anemia and Risk Factors Predicting their Occurrences. Indian J Hematol Blood Transfus 2021; 37:623-631. [PMID: 34744345 DOI: 10.1007/s12288-021-01402-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/10/2021] [Indexed: 12/17/2022] Open
Abstract
Antigen - antibody complexes on heavily coated red cells in Warm autoimmune haemolytic anemia (WAIHA) often activates the complement pathway and red cells bound C3 complement component are encountered in complement associated WAIHA (CWAIHA). Patients belonging to CWAIHA and non-complement associated WAIHA (NCWAIHA) may demographically, clinically and immunohematologically behave differently therefore we planned to study the clinical and immunohematological characteristics of CWAIHA and NCWAIHA with emphasis to various potential factors associated with CWAIHA. The prospective study included 229 patients of WAIHA. Complete DAT evaluation was performed in all these patients. Details of patients and their hematological and biochemical parameters were obtained from patient file and Hospital Information System. In vivo hemolysis was documented as per the criteria established by previous workers. Statistical analysis was done using SPSS statistical package. Of the total 229 patients of WAIHA, 83 (36.2%) belonged to the complement associated WAIHA group. A total of 146 (63.8%) patients were females of which 43 (29.4%) had CWAIHA. The median age of WAIHA patients was 37 years. A total of 46 (56.1%) patients above age 40 years suffered from CWAIHA. Where secondary WAIHA was found in 121 (52.8%) patients; more than half (61.4%) with CWAIHA had underlying aetiology. Over 95% of patients in both categories presented with weakness and pallor. Strong DAT (> 2 +) was observed in 86.7% of CWAIHA patients. Factors like gender, age, aetiology and DAT IgG dilution were independent risk factors for CWAIHA. DAT remained positive even at the end of 10 months of successful treatment. We conclude that detailed characterization of WAIHA with particular emphasis to complement and non-complement associated WAIHA is essential to evaluate the disease characters, immunological behaviours, prognosis and therapeutic management. Moreover an understanding of the risk factors of CWAIHA will help physicians / hematologists and immunohematologists to manage WAIHA more prudently and solicitously.
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Affiliation(s)
- Sudipta Sekhar Das
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Anupam Chakrapani
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Soumya Bhattacharya
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Rathindra Nath Biswas
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Mahammad Safi
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
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Ma C, Feng Y, Yang L, Wang S, Sun X, Tai S, Guan X, Wang D, Yu Y. In vitro Immunomodulatory Effects of Human Umbilical Cord-Derived Mesenchymal Stem Cells on Peripheral Blood Cells from Warm Autoimmune Hemolytic Anemia Patients. Acta Haematol 2021; 145:63-71. [PMID: 34284381 DOI: 10.1159/000506759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 02/24/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Autoimmune hemolytic anemia is a potentially lethal disease characterized by autoimmune hemolysis. Although human umbilical cord-derived mesenchymal stem cells (hUC-MSCs) have been reported as a promising therapy, there is limited evidence regarding warm autoimmune hemolytic anemia (wAIHA) patients. This study aimed to investigate the potential therapeutic effects of hUC-MSCs via immune regulation in wAIHA patients. METHODS Peripheral blood mononuclear cells (PBMCs) from 10 wAIHA patients and 8 healthy controls were isolated from peripheral blood and cultured for 3 days with or without the presence of hUC-MSCs; PBMCs were co-cultured with hUC-MSCs using Transwell assays. The supernatant cytokine levels were measured after culture through AimPlex Multiple Immunoassays for Flow, including IL-2, IL-4, IL-10, IFN-γ, TNF-α, and IL-17A. The percentages of regulatory T cells, regulatory B cells, and Th1/Th2 in PBMCs were also assessed before and after culturing. RESULTS In the wAIHA group, hUC-MSCs could upregulate the Treg and Breg proportions after culturing for 3 days, and the Treg and Breg percentages increased after co-culturing with hUC-MSCs in the wAIHA group compared with PBMC cultured alone for 3 days (8.29 ± 8.59 vs. 6.82 ± 1.32, 3.82 ± 1.87 vs. 1.75 ± 1.20, respectively). Compared with the PBMC wAIHA group, the levels of TNF-α (2.13 ± 2.07 vs. 16.20 ± 21.13 pg/mL, p = 0.019) and IL-10 (10.51 ± 18.42 vs. 37.78 ± 44.20 pg/mL, p = 0.012) were significantly elevated in the PBMC + hUC-MSCs wAIHA group. CONCLUSION The hUC-MSCs contributed to the increasing proportion of regulatory cell populations in PBMCs of wAIHA patients, thereby potentially regulating autoimmune response; thus, hUC-MSCs may be a promising approach for wAIHA treatment.
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Affiliation(s)
- Chunya Ma
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yannan Feng
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lu Yang
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Shufang Wang
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaolin Sun
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Shengfei Tai
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaozhen Guan
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Deqing Wang
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yang Yu
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
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15
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Tranekær S, Hansen DL, Frederiksen H. Epidemiology of Secondary Warm Autoimmune Haemolytic Anaemia-A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10061244. [PMID: 33802848 PMCID: PMC8002719 DOI: 10.3390/jcm10061244] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/09/2021] [Accepted: 03/14/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Warm autoimmune haemolytic anaemia (wAIHA) is a haemolytic disorder, most commonly seen among adults and is classified as either primary or secondary to an underlying disease. We describe the age and sex distribution and the proportion of secondary wAIHA. Method: We retrieved 2635 published articles, screened abstracts and titles, and identified 27 articles eligible for full-text review. From these studies, we extracted data regarding number of patients, sex distribution, age at diagnosis, number of patients with secondary wAIHA, and whether the patients were diagnosed through local or referral centres. All data were weighted according to the number of included patients in each study. Results: 27 studies including a total of 4311 patients with wAIHA, of which 66% were females, were included. The median age at diagnosis was 68.7 years, however, wAIHA affected all ages. The mean proportion of secondary wAIHA was 49%, most frequently secondary to systemic lupus erythematosus. The proportions of secondary wAIHA reported from primary vs. referral centres were 35% vs. 59%, respectively. Conclusion: This review consolidates previously reported gender distribution. The higher proportion of secondary wAIHA in referral centres suggests that the most severely affected patients are disproportionally more frequent in such facilities.
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Affiliation(s)
- Stinne Tranekær
- Haematological Research Unit, Department of Clinical Research, University of Southern, 5230 Odense M, Denmark; (S.T.); (D.L.H.)
- Department of Haematology, Odense University Hospital, 5000 Odense C, Denmark
| | - Dennis Lund Hansen
- Haematological Research Unit, Department of Clinical Research, University of Southern, 5230 Odense M, Denmark; (S.T.); (D.L.H.)
- Department of Haematology, Odense University Hospital, 5000 Odense C, Denmark
| | - Henrik Frederiksen
- Haematological Research Unit, Department of Clinical Research, University of Southern, 5230 Odense M, Denmark; (S.T.); (D.L.H.)
- Department of Haematology, Odense University Hospital, 5000 Odense C, Denmark
- Correspondence:
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16
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Kasinathan G, Sathar J. Mixed-type autoimmune hemolytic anaemia presenting as multiple thromboses: A case report. Ann Med Surg (Lond) 2020; 60:323-326. [PMID: 33204423 PMCID: PMC7653202 DOI: 10.1016/j.amsu.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/01/2020] [Accepted: 11/01/2020] [Indexed: 11/13/2022] Open
Abstract
Autoimmune hemolytic anaemia (AIHA) is a heterogenous disorder characterised by the presence of IgG or IgM pathological autoantibodies that target antigens of erythrocytes resulting in active hemolysis. Case presentation: A 40-year-old gentleman presented to a medical centre with chest pain and right sided hemiparesis for a week. He was pale and jaundiced. The power of the right upper and lower limbs was 3/5. His spleen was palpable. His complete blood count revealed macrocytic anaemia of 7.6 g/dL. The brain Magnetic Resonance Imaging (MRI) showed left fronto-parietal infarction. The right cardiac and left carotid angiogram revealed thromboses involving the right coronary and left internal carotid artery respectively. At the cardiology department, he was transfused with two units of red blood cells without his anemia being investigated and a stent was deployed to the left internal carotid artery. He was referred to the hematology department in which his peripheral blood smear revealed hemolysis and his direct antiglobulin test was positive. He responded to a course of steroids and direct oral anticoagulation and is in complete remission for the past 18 months. Conclusion: It is always imperative to investigate the cause of anaemia and consider hemolysis in a patient presenting with multiple unexplained thromboses.
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Affiliation(s)
- Ganesh Kasinathan
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
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17
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Michalak SS, Olewicz-Gawlik A, Rupa-Matysek J, Wolny-Rokicka E, Nowakowska E, Gil L. Autoimmune hemolytic anemia: current knowledge and perspectives. IMMUNITY & AGEING 2020; 17:38. [PMID: 33292368 PMCID: PMC7677104 DOI: 10.1186/s12979-020-00208-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 11/10/2020] [Indexed: 02/07/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is an acquired, heterogeneous group of diseases which includes warm AIHA, cold agglutinin disease (CAD), mixed AIHA, paroxysmal cold hemoglobinuria and atypical AIHA. Currently CAD is defined as a chronic, clonal lymphoproliferative disorder, while the presence of cold agglutinins underlying other diseases is known as cold agglutinin syndrome. AIHA is mediated by autoantibodies directed against red blood cells (RBCs) causing premature erythrocyte destruction. The pathogenesis of AIHA is complex and still not fully understood. Recent studies indicate the involvement of T and B cell dysregulation, reduced CD4+ and CD25+ Tregs, increased clonal expansions of CD8 + T cells, imbalance of Th17/Tregs and Tfh/Tfr, and impaired lymphocyte apoptosis. Changes in some RBC membrane structures, under the influence of mechanical stimuli or oxidative stress, may promote autohemolysis. The clinical presentation and treatment of AIHA are influenced by many factors, including the type of AIHA, degree of hemolysis, underlying diseases, presence of concomitant comorbidities, bone marrow compensatory abilities and the presence of fibrosis and dyserthropoiesis. The main treatment for AIHA is based on the inhibition of autoantibody production by mono- or combination therapy using GKS and/or rituximab and, rarely, immunosuppressive drugs or immunomodulators. Reduction of erythrocyte destruction via splenectomy is currently the third line of treatment for warm AIHA. Supportive treatment including vitamin supplementation, recombinant erythropoietin, thrombosis prophylaxis and the prevention and treatment of infections is essential. New groups of drugs that inhibit immune responses at various levels are being developed intensively, including inhibition of antibody-mediated RBCs phagocytosis, inhibition of B cell and plasma cell frequency and activity, inhibition of IgG recycling, immunomodulation of T lymphocytes function, and complement cascade inhibition. Recent studies have brought about changes in classification and progress in understanding the pathogenesis and treatment of AIHA, although there are still many issues to be resolved, particularly concerning the impact of age-associated changes to immunity.
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Affiliation(s)
- Sylwia Sulimiera Michalak
- Department of Pharmacology and Toxicology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland.
| | - Anna Olewicz-Gawlik
- Department of Anatomy and Histology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland.,Department of Infectious Diseases, Hepatology and Acquired Immune Deficiencies, Poznan University of Medical Sciences, Poznan, Poland.,Department of Immunology, Poznan University of Medical Sciences, Poznan, Poland
| | - Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Edyta Wolny-Rokicka
- Department of Radiotherapy, Multidisciplinary Hospital, Gorzów Wielkopolski, Poland
| | - Elżbieta Nowakowska
- Department of Pharmacology and Toxicology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
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18
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Ito T, Kometani K, Minato N, Hamazaki Y. Bone Marrow Endothelial Cells Take Up Blood-Borne Immune Complexes via Fcγ Receptor IIb2 in an Erythropoietin-Dependent Manner. THE JOURNAL OF IMMUNOLOGY 2020; 205:2008-2015. [PMID: 32907997 DOI: 10.4049/jimmunol.1901101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 08/10/2020] [Indexed: 11/19/2022]
Abstract
Immune complexes (ICs) in blood are efficiently removed mainly by liver reticuloendothelial systems consisting of sinusoidal endothelial cells and Kupffer cells expressing FcγR. The bone marrow (BM) also has sinusoidal vasculatures, and sinusoidal BM endothelial cells (BMECs) bear unique function, including hematopoietic niches and traffic regulation of hematopoietic cells. In this study, we found that sinusoidal BMECs express FcγRIIb2, which is markedly increased in anemic conditions or by the administration of erythropoietin (Epo) in healthy mice. BMECs expressed Epo receptor (EpoR), and the Epo-induced increase in FcγRIIb2 expression was abolished in Epor-/- ::HG1-Epor transgenic mice, which lack EpoR in BMECs except for BM erythroblasts, suggesting the effect was directly mediated via EpoR on BMECs. Further, although BMECs hardly captured i.v.-injected soluble ICs in healthy mice, Epo administration induced a remarkable increase in the uptake of ICs in a FcγRIIb-dependent manner. Enhancement of the IC incorporation capacity by Epo was also observed in cultured BMECs in vitro, suggesting the direct effect of Epo on BMECs. Moreover, we found that i.v.-injected ICs in Epo-treated mice were more rapidly removed from the circulation than in PBS-treated mice. These results reveal a novel function of BMECs to efficiently remove circulating blood-borne ICs in an FcγRIIb2-mediated manner.
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Affiliation(s)
- Takeshi Ito
- Center for iPS Cell Research and Application, Laboratory of Immunobiology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan; and
| | - Kohei Kometani
- Center for iPS Cell Research and Application, Laboratory of Immunobiology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan; and
| | - Nagahiro Minato
- Medical Innovation Center, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Yoko Hamazaki
- Center for iPS Cell Research and Application, Laboratory of Immunobiology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan; and
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19
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Ray GK, Mishra D, Jena RK, Mahapatra S, Palai S, Parida AA. Clinical Profile and Severity of Hemolysis in Adult Patients of Primary Autoimmune Hemolytic Anemia and Their Response to Steroid: A Prospective Cohort Study from Single Institution. Indian J Hematol Blood Transfus 2020; 37:119-125. [PMID: 33707844 DOI: 10.1007/s12288-020-01326-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/29/2020] [Indexed: 11/29/2022] Open
Abstract
Autoimmune hemolytic anaemia (AIHA) has traditionally been classified based on the temperature sensitivity of the autoagglutinins as warm (WAIHA), cold (CAIHA) and mixed type. Autoagglutinin may be of IgG or IgM type. The present prospective study was conducted to evaluate the profile of clinical picture, severity of haemolysis, treatment response of steroid. This study on patients of adult primary AIHA was conducted by taking complete history followed by detail physical examination. Laboratory investigations were performed to establish haemolytic anaemia and to assess severity of haemolysis. Immunehematological work up including blood grouping, direct antiglobulin test (DAT), IAT, antibody screening, adsorption elution was performed to diagnose type of AIHA. All cases were followed up to assess the response to prednisolone. All the data were collected and analysed by SPSS 19. Out of 62 primary AIHA cases, female were affected more than male (41:21). WAIHA is most common type (42, 67.8%) followed by mixed (20.9%) and cold AIHA (11.3%). Severity of haemolysis showed significant correlation with the DAT strength and not with type of AIHA. (P < 0.05) On oral prednisolone, 22 cases attended complete remission, while relapse, drug dependency and partial remission was achieved in 13, 9, 3 cases respectively. Severity of haemolysis in AIHA is directly related with DAT strength. WAIHA is most common type and can be managed with oral prednisolone (cr 45.2%), without red cell transfusion in most of cases. Mixed type AIHA cases were presented mostly with severe haemolysis, with minimum therapeutic response to prednisolone and maximum relapse/drug dependency.
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Affiliation(s)
- Gopal Krushna Ray
- Department of Transfusion Medicine, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
| | - Debasish Mishra
- Department of Transfusion Medicine, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
| | - Rabindra Kumar Jena
- Department of Clinical Hematology, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
| | - Smita Mahapatra
- Department of Transfusion Medicine, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
| | - Sabita Palai
- Department of Transfusion Medicine, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
| | - Ansuman Abhishek Parida
- Department of Pharmacology, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
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20
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Defining autoimmune hemolytic anemia: a systematic review of the terminology used for diagnosis and treatment. Blood Adv 2020; 3:1897-1906. [PMID: 31235526 DOI: 10.1182/bloodadvances.2019000036] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/21/2019] [Indexed: 12/11/2022] Open
Abstract
The terminology applied to autoimmune hemolytic anemia (AIHA) seems inconsistent. We aimed to evaluate the consistency of definitions used for diagnosis and treatment. In this systematic review of literature from January 2006 to December 2015, we assessed heterogeneity in the definition of AIHA and its subtypes, refractory disease, disease phase, severity, criteria for treatment response, and response durability. A Medline search for anemia, hemolytic, autoimmune was supplemented with keyword searches. Main exclusions were conference abstracts, animal and non-English studies, and studies with <10 cases. Of 1371 articles retrieved, 1209 were excluded based on titles and abstracts. Two authors independently reviewed 10% and 16% of abstracts and full papers, respectively. After full-paper review, 84 studies were included. AIHA was most frequently (32 [52%] of 61) defined as hemolytic anemia with positive direct antiglobulin test (DAT) and exclusion of alternatives, but 10 of 32 also recognized DAT-negative AIHA. A lower threshold for diagnosis of DAT-negative AIHA was observed in literature on chronic lymphocytic leukemia. Definitions of anemia, hemolysis, and exclusion criteria showed substantial variation. Definitions of primary/secondary cold agglutinin disease/syndrome were not consistent. Forty-three studies provided criteria for treatment response, and other than studies from 1 center, these were almost entirely unique. Other criteria were rarely defined. Only 7, 0, 3, 2, 2, and 3 studies offered definitions of warm AIHA, paroxysmal cold hemoglobinuria, mixed AIHA, AIHA severity, disease phase, and refractory AIHA, respectively. Marked heterogeneity in the time period sampled indicates the need to standardize AIHA terminology.
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21
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Delaney M, Apelseth TO, Bonet Bub C, Cohn CS, Dunbar NM, Mauro Kutner J, Murphy M, Perelman I, Selleng K, Staves J, Wendel S, Ziman A. Red-blood-cell alloimmunization and prophylactic antigen matching for transfusion in patients with warm autoantibodies. Vox Sang 2020; 115:515-524. [PMID: 32249930 DOI: 10.1111/vox.12914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 01/26/2020] [Accepted: 03/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Warm autoantibodies (WAA) are antibodies that react with an antigen on a patient's own red-blood-cells and can complicate compatibility testing whether or not they cause clinical haemolysis. The goal of this study was to understand the overall prevalence of WAA, the risk of RBC alloimmunization and determine whether RBC selection practices have an impact on alloimmunization. MATERIALS AND METHODS Records of patients (>1 year of age) with an indirect antibody detection test (IAT) and serologic evidence of WAA over a 10-year-period were included. Eight centres from 5 countries collectively reviewed 1 122 245 patients who had an IAT. RESULTS Of patients having IAT, 1214 had WAA (0·17%). Transfusion information for 1002 of the patients was available; 631 were transfused after identification of the WAA (63%); of the transfused patients, 390 received prophylactic antigen-matched (PAM) RBCs and 241 did not. Of the 372 patients with WAA who were transfused and had serologic testing 30+ days following transfusion (30-2765 days), 56 developed new RBC alloimmunization (15·1%). Patients who were transfused using a PAM strategy were not protected from new RBC alloimmunization [14·6% (31 of 212 patients) having PAM transfusion approach compared with those not receiving PAM approach (15·6%, 25 of 160 patients, P = 0·8837)]. CONCLUSIONS The prevalence of WAA in patients having an IAT is low (<1%). A significant portion of patients with WAA form new RBC alloimmunization (15·1%); however, the use of PAM approach for RBC selection was not found to be protective against new alloimmunization.
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Affiliation(s)
- Meghan Delaney
- Bloodworks NW, Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Torunn Oveland Apelseth
- Department of Immunology and Transfusion Medicine, Department of Clinical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | | | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | | | | | - Michael Murphy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Kathleen Selleng
- Institute for Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Julie Staves
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Alyssa Ziman
- Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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22
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Diagnosis and treatment of autoimmune hemolytic anemia in adults: Recommendations from the First International Consensus Meeting. Blood Rev 2019; 41:100648. [PMID: 31839434 DOI: 10.1016/j.blre.2019.100648] [Citation(s) in RCA: 236] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Abstract
Autoimmune hemolytic anemias (AIHAs) are rare and heterogeneous disorders characterized by the destruction of red blood cells through warm or cold antibodies. There is currently no licensed treatment for AIHA. Due to the paucity of clinical trials, recommendations on diagnosis and therapy have often been based on expert opinions and some national guidelines. Here we report the recommendations of the First International Consensus Group, who met with the aim to review currently available data and to provide standardized diagnostic criteria and therapeutic approaches as well as an overview of novel therapies. Exact diagnostic workup is important because symptoms, course of disease, and therapeutic management relate to the type of antibody involved. Monospecific direct antiglobulin test is considered mandatory in the diagnostic workup, and any causes of secondary AIHA have to be diagnosed. Corticosteroids remain first-line therapy for warm-AIHA, while the addition of rituximab should be considered early in severe cases and if no prompt response to steroids is achieved. Rituximab with or without bendamustine should be used in the first line for patients with cold agglutinin disease requiring therapy. We identified a need to establish an international AIHA network. Future recommendations should be based on prospective clinical trials whenever possible.
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23
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Hantaweepant C, Pairattanakorn P, Karaketklang K, Owattanapanich W, Chinthammitr Y. Efficacy and safety of second-line treatment in Thai patients with primary warm-type autoimmune hemolytic anemia. ACTA ACUST UNITED AC 2019; 24:720-726. [PMID: 31581907 DOI: 10.1080/16078454.2019.1671060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives:: To investigate the efficacy and safety of second-line treatment in Thai patients with primary warm-type autoimmune hemolytic anemia (AIHA) that failed corticosteroid treatment. Methods:: This descriptive retrospective study included patients aged >14 years who were diagnosed with and treated for primary warm-type AIHA at the Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, during January 2007 to December 2016. All 54 included patients failed first-line corticosteroid treatment after which second-line treatment was prescribed. Baseline clinical characteristics, laboratory results at diagnosis and at start of second-line treatment, type of second-line treatment, treatment outcome, and complications of treatment including death were collected. Results:: Included patients had a mean age at onset of 55.8 years (14.5-87.4) and 83.3% of patients were female. Most patients (63%) were refractory to steroids, and the rest of them relapsed while on steroids. The second-line medications were azathioprine (61.1%), cyclophosphamide (31.5%), chlorambucil (1.9%), danazol (3.7%), and rituximab (1.9%), with respective response rates of 78.8%, 58.8%, 1/1 patient, 2/2 patients, and 0/1 patient. Strong positive direct Coombs' test (3+-4+) was the only predictive factor of treatment response (p = 0.008). Males had better relapse-free survival than females (not reached vs. 20.6 months) (p = 0.023). Approximately 40% of the patients who responded to second-line treatment relapsed at a median of 7.4 months. Conclusion:: Immunosuppressive drugs are the most common second-line treatment for primary warm-type AIHA in Thailand; however, relapse was common. Additional therapies are needed to reduce the relapse rate and prolong remission.
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Affiliation(s)
- Chattree Hantaweepant
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University , Bangkok , Thailand
| | - Prat Pairattanakorn
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University , Bangkok , Thailand
| | - Khemajira Karaketklang
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University , Bangkok , Thailand
| | - Weerapat Owattanapanich
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University , Bangkok , Thailand
| | - Yingyong Chinthammitr
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University , Bangkok , Thailand
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24
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Lecouffe-Desprets M, Graveleau J, Artifoni M, Connault J, Agard C, Pottier P, Hamidou M, Néel A. [Hemolytic disorders and venous thrombosis: An update]. Rev Med Interne 2019; 40:232-237. [PMID: 30773236 DOI: 10.1016/j.revmed.2018.10.387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 10/04/2018] [Accepted: 10/18/2018] [Indexed: 01/05/2023]
Abstract
Many factors can contribute to the risk of venous thrombosis observed in hemolytic diseases. Some mechanisms are related to hemolysis by itself, while others seem more specific to each disease. Despite recent advances in the quantification of this risk and in understanding its physiopathology, the association of hemolysis with venous thrombosis is often unknown. The purpose of this general review is to clarify the main pro-thrombotic mechanisms during hemolysis and to synthesize the clinical data currently available. We will focus on the main types of hemolytic pathologies encountered in current practice, namely paroxysmal nocturnal hemoglobinuria, hemoglobinopathies, auto-immune hemolytic anemia and thrombotic microangiopathies.
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Affiliation(s)
- M Lecouffe-Desprets
- Service de médecine interne, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes, France
| | - J Graveleau
- Service de médecine interne, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes, France
| | - M Artifoni
- Service de médecine interne, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes, France
| | - J Connault
- Service de médecine interne, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes, France
| | - C Agard
- Service de médecine interne, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes, France
| | - P Pottier
- Service de médecine interne, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes, France
| | - M Hamidou
- Service de médecine interne, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes, France
| | - A Néel
- Service de médecine interne, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes, France.
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25
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Recommendations on RBC Transfusion Support in Children With Hematologic and Oncologic Diagnoses From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S149-S156. [PMID: 30161070 PMCID: PMC6126910 DOI: 10.1097/pcc.0000000000001610] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the recommendations and supporting evidence for RBC transfusions in critically ill children with hematologic and oncologic disease from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations and research priorities for RBC transfusions in critically ill children. The hematologic/oncologic subgroup included seven experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS The hematologic/oncologic subgroup developed 14 recommendations (seven clinical, seven research); all achieved greater than 80% agreement. In patients with sickle cell disease, Transfusion and Anemia Expertise Initiative recommends: 1) RBC transfusion to achieve a target hemoglobin concentration of 10 g/dL rather than hemoglobin of less than 30% prior to surgical procedures requiring general anesthesia and 2) exchange transfusion over simple (nonexchange) transfusion if the child's condition is deteriorating (based on clinical judgment), otherwise a simple, nonexchange RBC transfusion is recommended. There is insufficient evidence to make recommendations on transfusion thresholds for patients with sickle cell disease prior to minor procedures, with acute stroke or with pulmonary hypertension. For patients with oncologic disease or undergoing hematopoietic stem cell transplant, a hemoglobin concentration of 7-8 g/dL is recommended. Due to lack of evidence, research is needed to clarify the appropriate transfusion thresholds in these patients. CONCLUSIONS Transfusion and Anemia Expertise Initiative developed specific pediatric recommendations regarding RBC transfusion management in critically ill children with sickle cell disease, oncologic disease, and hematopoietic stem cell transplant and recommendations to help guide future research priorities.
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26
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Rock N, Ansari M, Villard J, Ferrari-Lacraz S, Waldvogel S, McLin VA. Factors associated with immune hemolytic anemia after pediatric liver transplantation. Pediatr Transplant 2018; 22:e13230. [PMID: 29885007 DOI: 10.1111/petr.13230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2018] [Indexed: 01/27/2023]
Abstract
Immune-mediated hemolytic anemia following SOT is a rare disorder, the risk factors for which are unknown. Our purpose was to analyze a seemingly increased incidence in our center with the aim to identify predisposing factors. This recipients single-center retrospective study reviewed the medical records of 96 pediatric LT between 2000 and 2013. IHA was defined as acute anemia with a positive direct antiglobulin test. Seven cases of immune-mediated hemolytic anemia were identified (incidence 8.5%). Three cases presented during the first 3 months following LT (early IHA), and 4 presented later (late IHA). All patients with late IHA required rituximab. Using univariate analysis, the following factors were associated with IHA onset: BA (P = .04), younger age (P = .04), and the use of IGL-1 preservation solution (P = .05). Late IHA was associated with viral infections occurring beyond 3 months following LT, younger age, and BA (P = .01). Overall, CMV infection was associated with the development of both early and late IHA: CMV-negative recipients who received an organ from a CMV-positive donor were more likely to develop IHA (P = .035), and de novo CMV infection during the first year post-LT was associated with late IHA (P = .03). IHA is a rare complication following pediatric LT, occurring more frequently in younger patients and patients with an initial diagnosis of BA. CMV-negative recipients and patients who experience a de novo CMV infection in the first year following LT seem particularly vulnerable. IGL-1 preservation solution may be associated with an increased likelihood of developing IHA, a novel finding which warrants further investigation.
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Affiliation(s)
- Nathalie Rock
- Swiss Center for Liver Disease in Children, University Hospitals Geneva, Geneva, Switzerland
| | - Marc Ansari
- Pediatric Hematology and Oncology Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Jean Villard
- Transplant Immunology Unit, Division of Immunology and Allergy, University Hospitals Geneva, Geneva, Switzerland
| | - Sylvie Ferrari-Lacraz
- Transplant Immunology Unit, Division of Immunology and Allergy, University Hospitals Geneva, Geneva, Switzerland
| | - Sophie Waldvogel
- Immunology and Hematology Laboratory, University Hospitals Geneva, Geneva, Switzerland
| | - Valérie Anne McLin
- Swiss Center for Liver Disease in Children, University Hospitals Geneva, Geneva, Switzerland
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Ajmi H, Mabrouk S, Hassayoun S, Regaieg H, Tfifha M, Jalel C, Skouri H, Zouari N, Abroug S. Success of anti-CD20 monoclonal antibody treatment for severe autoimmune hemolytic anemia caused by warm-reactive immunoglobulin A, immunoglobulin G, and immunoglobulin M autoantibodies in a child: a case report. J Med Case Rep 2017; 11:321. [PMID: 29132419 PMCID: PMC5684746 DOI: 10.1186/s13256-017-1449-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 09/12/2017] [Indexed: 11/17/2022] Open
Abstract
Background Autoimmune hemolytic anemia is rare in children. First-line therapies for this disease consist of corticosteroids and intravenously administered immunoglobulin that are effective in most patients. However, a small proportion of cases (5 to 10%) is refractory to these therapies and may represent a medical emergency, especially when hemolysis is due to warm immunoglobulin M. Recently, reports of the use of rituximab in adult autoimmune diseases have shown promising results. In children, there are few studies on the use of rituximab in the treatment for autoimmune hemolytic anemia, especially on its long-term efficacy and adverse effects. Case presentation Here, we report the case of a 10-year-old Tunisian girl with refractory acute autoimmune hemolytic anemia caused by warm-reactive immunoglobulin A, immunoglobulin G, immunoglobulin M, and C3d autoantibodies. First-line treatments using corticosteroids and intravenously administered immunoglobulin were ineffective in controlling her severe disease. On the other hand, she was successfully treated with rituximab. In fact, her hemolytic anemia improved rapidly and no adverse effects were observed. Conclusions The case that we report in this paper shows that rituximab could be an alternative therapeutic option in severe acute autoimmune hemolytic anemia with profound hemolysis refractory to conventional treatment. Moreover, it may preclude the use of plasmapheresis in such an urgent situation with a sustained remission.
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Affiliation(s)
- Houda Ajmi
- Pediatrics Department, Sahloul Teaching Hospital, 4054, Sousse, Tunisia.
| | - Sameh Mabrouk
- Pediatrics Department, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Saida Hassayoun
- Pediatrics Department, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Haifa Regaieg
- Hematology Department, Farhat Hached Teaching Hospital, 4031, Sousse, Tunisia
| | - Minyar Tfifha
- Pediatrics Department, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Chemli Jalel
- Pediatrics Department, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Hadef Skouri
- Hematology Laboratory, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Noura Zouari
- Pediatrics Department, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Saoussan Abroug
- Pediatrics Department, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
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Williams MF, Doss EP, Montgomery M. Possible Trimethoprim-Sulfamethoxazole-Induced Hemolytic Anemia: A Case Report. J Pharm Pract 2017; 30:653-657. [PMID: 29121838 DOI: 10.1177/0897190016683303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To report a case of hemolytic anemia in a patient who received trimethoprim/sulfamethoxazole (TMP-SMX) for a urinary tract infection (UTI). SUMMARY A 47-year-old woman recently diagnosed with uncomplicated UTI received 3 doses of TMP-SMX. She developed yellowing of the skin and eyes, lethargy, mild abdominal pain, and dry mucous membranes. Laboratory testing demonstrated significant anemia with red blood cells (RBCs) of 1.99, hemoglobin (Hgb) of 6.3 g/dL, and hematocrit (Hct) of 18.1%. TMP-SMX was immediately discontinued. The patient was given methylprednisolone 60 mg intravenously (IV) followed by oral steroids and infused with 3 units of packed RBCs over the course of a 10-day inpatient admission. On discharge, the patient continued oral steroids. Outpatient follow-up indicated Hgb of 11.0 g/dL and Hct of 32.7%, 41 days after hospital discharge. Utilizing the Naranjo adverse drug reaction probability scale, there is a probable association between the patient's hemolytic anemia and TMP-SMX. CONCLUSION We report a case of hemolytic anemia resulting from the use of TMP-SMX. Although this is a rare adverse effect, clinicians should be aware of the signs and symptoms of hemolytic anemia, and so appropriate treatment can be administered should it occur.
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Affiliation(s)
- Montgomery F Williams
- 1 Department of Pharmacy Practice, Belmont University College of Pharmacy, Nashville, TN, USA
| | - Emily P Doss
- 2 Department of Pharmacy, University of Louisville Hospital, Louisville, KY, USA
| | - Maggie Montgomery
- 3 Department of Pharmacy, St Luke's Cornwall Hospital, Newburgh, NY, USA
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29
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Nedelcu E, Desai M, Green J, Bensing KM, Turner A, Head D, Young PP. Acute autoimmune hemolytic anemia due to anti-Enaautoantibody successfully treated with rituximab. Transfusion 2017; 58:176-180. [DOI: 10.1111/trf.14363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 08/15/2017] [Accepted: 08/21/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Elena Nedelcu
- University of California San Francisco, Department of Laboratory Medicine; San Francisco California
| | - Megan Desai
- Vanderbilt University Medical Center, Department of Pathology, Microbiology and Immunology; Nashville Tennessee
| | - Jennifer Green
- Vanderbilt University Medical Center, Department of Medicine, Division of Hematology; Nashville Tennessee
| | - Kathleen M. Bensing
- Immunohematology Reference Laboratory; BloodCenter of Wisconsin; Milwaukee Wisconsin
| | - Austin Turner
- Vanderbilt University Medical Center, Department of Pathology, Microbiology and Immunology; Nashville Tennessee
| | - David Head
- Vanderbilt University Medical Center, Department of Pathology, Microbiology and Immunology; Nashville Tennessee
| | - Pampee P. Young
- Vanderbilt University Medical Center, Department of Pathology, Microbiology and Immunology; Nashville Tennessee
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30
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Robertson JJ, Brem E, Koyfman A. The Acute Hemolytic Anemias: The Importance of Emergency Diagnosis and Management. J Emerg Med 2017; 53:202-211. [DOI: 10.1016/j.jemermed.2017.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 01/30/2017] [Accepted: 02/25/2017] [Indexed: 01/07/2023]
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Sys J, Provan D, Schauwvlieghe A, Vanderschueren S, Dierickx D. The role of splenectomy in autoimmune hematological disorders: Outdated or still worth considering? Blood Rev 2017; 31:159-172. [DOI: 10.1016/j.blre.2017.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 12/12/2016] [Accepted: 01/03/2017] [Indexed: 01/26/2023]
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Autoimmune cytopenias associated with inflammatory bowel diseases: Insights from a multicenter retrospective cohort. Dig Liver Dis 2017; 49:397-404. [PMID: 28063954 DOI: 10.1016/j.dld.2016.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Autoimmune cytopenias (AIC) including autoimmune hemolytic anemia (AIHA) and immunologic thrombocytopenia (ITP) are rare immunologic disorders, scarcely reported in inflammatory bowel diseases (IBD). We conducted a multicentric retrospective study, including a case-control analysis, that aimed to describe the characteristics and outcomes of patients affected by AIC and IBD. METHOD Forty cases were recruited from 4 IBD centers and 2 AIC tertiary centers. Controls were recruited from the MICISTA registry. RESULTS From the MICISTA registry, incidences were estimated at 4.1/100,000 patient-years and 12.5/100,000 patient-years after IBD diagnosis for AIHA and ITP, respectively. All AIHA patients (n=14) had colonic involvement (13/14 with UC), whereas CD (52%) and UC (48%) diagnoses were evenly distributed among ITP patients. Compared to control IBD patients, cases were characterized by a higher frequency of extra-intestinal manifestations (37.5% vs 17%, p<0.001) and by the presence of IBD severity's hallmark. AIHA and IBD ran mainly in parallel, and 12 out of 14 AIHA were warm AIHA. In isolated cases, rituximab and infliximab were efficient to treat IBD and AIC, respectively. IBD surgery may induce AIC remission in some cases. CONCLUSION Although low, incidence of AIC appears higher in IBD patients compared to the general population. The association seems to be mainly non-fortuitous, especially for colitis-associated AIHA.
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33
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How I treat autoimmune hemolytic anemia. Blood 2017; 129:2971-2979. [PMID: 28360039 DOI: 10.1182/blood-2016-11-693689] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 03/21/2017] [Indexed: 12/17/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is an uncommon entity that presents diagnostic, prognostic, and therapeutic dilemmas despite being a well-recognized entity for over 150 years. This is because of significant differences in the rates of hemolysis and associated diseases and because there is considerable clinical heterogeneity. In addition, there is a lack of clinical trials required to refine and update standardized and evidence-based therapeutic approaches. To aid the clinician in AIHA management, we present four vignettes that represent and highlight distinct clinical presentations with separate diagnostic and therapeutic pathways that we use in our clinical practice setting. We also review the parameters present in diagnostic testing that allow for prognostic insight and present algorithms for both diagnosis and treatment of the AIHA patient in diverse situations. This is done in the hope that this review may offer guidance in regard to personalized therapy recommendations. A section is included for the diagnosis of suspected AIHA with negative test results, a relatively infrequent but challenging situation, in order to assist in the overall evaluation spectrum for these patients.
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Sudulagunta SR, Kumbhat M, Sodalagunta MB, Settikere Nataraju A, Bangalore Raja SK, Thejaswi KC, Deepak R, Mohammed AH, Sunny SP, Visweswar A, Suvarna M, Nanjappa R. Warm Autoimmune Hemolytic Anemia: Clinical Profile and Management. J Hematol 2017; 6:12-20. [PMID: 32300386 PMCID: PMC7155818 DOI: 10.14740/jh303w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2017] [Indexed: 12/20/2022] Open
Abstract
Background Autoimmune hemolytic anemia (AIHA) is a rare autoimmune disease in which autoantibodies target red blood cells leading to marked decrease in their lifespan. The classification of AIHA is based on the immunochemical properties of the RBC autoantibody. Warm antibody AIHA (wAIHA) accounts for 75-80% of all adult AIHA cases. The treatment of wAIHA is mainly corticosteroids. Our retrospective study aimed to study the clinical profile and management of wAIHA. Methods Data of 75 patients admitted with wAIHA or presented to outpatient department (previous medical records) with wAIHA between January 2003 and January 2016 were analyzed. Results In our study, females constituted 12 and 26 patients of primary and secondary wAIHA, while males constituted 17 and 20 patients of primary and secondary wAIHA, respectively. Mean hemoglobin level at AIHA onset was found to be 7.1 ± 1.7 g/dL in primary wAIHA group and 6.3 ± 1.2 g/dL in secondary wAIHA group, which is statistically significant. Splenectomy was used as mode of treatment in one (3.4%) patient of primary wAIHA group and 15 (32.60%) patients of secondary wAIHA group, which is statistically significant. Mean age of wAIHA onset was 69.7 ± 21.5 years in wAIHA group secondary to lymphoma and 54.3 ± 25.7 years in other wAIHA group, which is statistically significant. Conclusion The most common causes of secondary wAIHA are B-cell lymphoma, systemic lupus erythematosus, rheumatoid arthritis, chronic lymphocytic leukemia (CLL), common variable immune deficiency, renal cell carcinoma and secondary to drug usage (alpha methyldopa and carbamazepine), respectively. Reducing the cumulative dose of corticosteroids with second line treatment whenever possible and therefore reducing the risk of sepsis, specifically in older patients with comorbidities will reduce morbidity and mortality.
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Affiliation(s)
| | - Monica Kumbhat
- Department of Pathology, Sri Ramachandra Medical College, Chennai, India
| | | | | | | | | | - Raj Deepak
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | | | - Sony P Sunny
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | - Amulya Visweswar
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | - Mikita Suvarna
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | - Rashmi Nanjappa
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
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Ntanishyan KI, Sabirov KR, Shcherbakova OV, Vybornykh DE, Shupletsova IA, Tsvetaeva NV. [Autoimmune hemolytic anemia associated with mesenteric teratoma]. TERAPEVT ARKH 2017; 89:78-81. [PMID: 28252632 DOI: 10.17116/terarkh201789178-81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The paper describes a case of autoimmune hemolytic anemia (AIHA) in a 27-year-old woman whose examination revealed mesenteric teratoma. AIHA was characterized by a hypertensive crisis and a temporary response to corticosteroid therapy that was complicated by the development of somatogenic psychosis and discontinued. A relapse of hemolysis developed 6 months later. The patient underwent laparoscopic splenectomy and removal of mesenteric root teratoma. Immediately after surgery, a hematological response was obtained as relief of hemolysis and restoration of a normal hemoglobin level. There is a sustained remission of AIHA for the next 16 months.
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Affiliation(s)
- K I Ntanishyan
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - K R Sabirov
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - O V Shcherbakova
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - D E Vybornykh
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - I A Shupletsova
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - N V Tsvetaeva
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
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Hill QA, Stamps R, Massey E, Grainger JD, Provan D, Hill A. The diagnosis and management of primary autoimmune haemolytic anaemia. Br J Haematol 2016; 176:395-411. [PMID: 28005293 DOI: 10.1111/bjh.14478] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - John D Grainger
- Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Drew Provan
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
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Ziman A, Cohn C, Carey PM, Dunbar NM, Fung MK, Greinacher A, Stanworth S, Heddle NM, Delaney M. Warm-reactive (immunoglobulin G) autoantibodies and laboratory testing best practices: review of the literature and survey of current practice. Transfusion 2016; 57:463-477. [DOI: 10.1111/trf.13903] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/01/2016] [Accepted: 09/10/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Alyssa Ziman
- Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine; University of California Los Angeles; Los Angeles California
| | - Claudia Cohn
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Patricia M. Carey
- Hoxworth Blood Center and Department of Pathology and Laboratory Medicine; University of Cincinnati; Ohio
| | - Nancy M. Dunbar
- Departments of Pathology and Medicine; Dartmouth-Hitchcock Medical Center; Lebanon New Hampshire
| | - Mark K. Fung
- Department of Pathology and Laboratory Medicine; University of Vermont Medical Center; Burlington Vermont
| | - Andreas Greinacher
- Department of Immunology and Transfusion Medicine; Ernst-Moritz-Arndt-University; Greifswald Germany
| | - Simon Stanworth
- National Health Service (NHS) Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, United Kingdom; the Radcliffe Department of Medicine, University of Oxford; Oxford United Kingdom
| | - Nancy M. Heddle
- Faculty of Health Sciences, Department of Medicine; , Canadian Blood Services, McMaster University, and Centre for Innovation; Hamilton Ontario Canada
| | - Meghan Delaney
- Bloodworks NW; Seattle Washington
- Department of Laboratory Medicine; University of Washington; Seattle Washington
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38
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Velo-García A, Castro SG, Isenberg DA. The diagnosis and management of the haematologic manifestations of lupus. J Autoimmun 2016; 74:139-160. [DOI: 10.1016/j.jaut.2016.07.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/21/2022]
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Gómez-Rubio J, Bárcena-Atalaya A, Dominguez-Hidalgo L. Enfermedad por crioglobulinas secundaria a infección por Epstein-Barr: una complicación infrecuente de una enfermedad frecuente. Semergen 2016; 42:423-4. [DOI: 10.1016/j.semerg.2015.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 06/23/2015] [Indexed: 10/23/2022]
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40
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Wouters D, Zeerleder S. Complement inhibitors to treat IgM-mediated autoimmune hemolysis. Haematologica 2016; 100:1388-95. [PMID: 26521297 DOI: 10.3324/haematol.2015.128538] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Complement activation in autoimmune hemolytic anemia may exacerbate extravascular hemolysis and may occasionally result in intravascular hemolysis. IgM autoantibodies as characteristically found in cold autoantibody autoimmune hemolytic anemia, in cold agglutinin disease but also in a considerable percentage of patients with warm autoantibodies are very likely to activate complement in vivo. Therapy of IgM-mediated autoimmune hemolytic anemia mainly aims to decrease autoantibody production. However, most of these treatments require time to become effective and will not stop immediate ongoing complement-mediated hemolysis nor prevent hemolysis of transfused red blood cells. Therefore pharmacological inhibition of the complement system might be a suitable approach to halt or at least attenuate ongoing hemolysis and improve the recovery of red blood cell transfusion in autoimmune hemolytic anemia. In recent years, several complement inhibitors have become available in the clinic, some of them with proven efficacy in autoimmune hemolytic anemia. In the present review, we give a short introduction on the pathogenesis of autoimmune hemolytic anemia, followed by an overview on the complement system with a special focus on its regulation. Finally, we will discuss complement inhibitors with regard to their potential efficacy to halt or attenuate hemolysis in complement-mediated autoimmune hemolytic anemia.
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Affiliation(s)
- Diana Wouters
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, University of Amsterdam, the Netherlands
| | - Sacha Zeerleder
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, University of Amsterdam, the Netherlands Department of Hematology, Academic Medical Center, University of Amsterdam, the Netherlands
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41
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A monocentric retrospective study comparing pulse cyclophosphamide therapy versus low dose rituximab in the treatment of refractory autoimmune hemolytic anemia in adults. Int J Hematol 2016; 104:462-7. [PMID: 27376943 DOI: 10.1007/s12185-016-2056-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 06/24/2016] [Accepted: 06/26/2016] [Indexed: 10/21/2022]
Abstract
This retrospective study aims at confirming the efficacy and safety of low dose rituximab and pulse cyclophosphamide in the treatment of refractory AIHA in adults and making comparison of the two. Forty-nine adult patients with refractory AIHA have been enrolled. Results showed low dose rituximab combined with steroid therapy (group B) got more CR (78.9 %, 15/19) compared to that in intermittent intravenous cyclophosphamide combined with steroid therapy (group A) (42.1 %, 8/19) (P = 0.04) at 6 months after treatment. The hemoglobin level in group B was higher than group A at the time point of 1 month (P = 0.02) after treatments. The RFS in group A was 87.9 % at 6 months and 82.7 % at 12 months, which were no significant difference with group B (91.1 % at 6 months and 86.0 % at 12 months) (P = 0.81). Both the two therapies were well tolerated with pulmonary infections as the most common side effects. In conclusion, low dose rituximab combined with steroid therapy presents to be a better choice in the treatment of refractory AIHA in adults comparing with pulse cyclophosphamide therapy.
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42
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Zulfiqar AA, Pennaforte JL, Andres E. Autoimmune Hemolytic Anemia in Individuals Aged 75 and Older: A Study of 10 Individuals. J Am Geriatr Soc 2016; 64:1372-4. [DOI: 10.1111/jgs.14167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Abrar-Ahmad Zulfiqar
- Department of Internal Medicine and Geriatrics; University Hospital of Reims; Reims France
| | | | - Emmanuel Andres
- Department of Internal Medicine; University Hospital of Strasbourg; Strasbourg France
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43
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Losos M, Hamad D, Joshi S, Scrape S, Chen J. Warm Autoimmune Hemolytic Anemia and Direct Antiglobulin Testing With a False-Negative Result in a 53-Year-Old Man: The DAT Will Set You Free. Lab Med 2016; 47:227-32. [PMID: 27287943 DOI: 10.1093/labmed/lmw018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Warm autoimmune hemolytic anemia (WAIHA), the most common of the relatively uncommon autoimmune-mediated hemolytic anemias (AIHAs), is mediated by polyclonal immunoglobulin (Ig)G autoantibodies in most cases. Herein, we present a case of WAIHA involving a direct antiglobulin test (DAT) with an initially negative result. Using a modified DAT protocol, repeat testing of the same specimen material from a previously healthy 53-year-old man yielded positive results. This case demonstrates that investigation of an apparently negative DAT result plays a critical role in the differential diagnosis of patients with rapidly progressing hemolytic anemia and the reversal of that decline.
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Affiliation(s)
- Michael Losos
- Department of Pathology, The Ohio State University Wexner Medical Center
| | - Diane Hamad
- Department of Pathology, The Ohio State University Wexner Medical Center
| | - Sarita Joshi
- Department of Hematology, Nationwide Children's Hospital, Columbus, Ohio
| | - Scott Scrape
- Department of Pathology, The Ohio State University Wexner Medical Center
| | - Jian Chen
- Department of Pathology, The Ohio State University Wexner Medical Center,
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Abstract
Hemolytic anemia can be caused by various hereditary or acquired diseases. Classification is usually based on corpuscular or extracorpuscular defects. Beside the anemia, laboratory testing indicates increased lactate dehydrogenase, unconjugated bilirubin and reticulocytes as well as reduced or absent plasma haptoglobin. Knowledge of further diagnostic procedures (e.g., Coombs test, schistocytes, hemoglobin electrophoresis or flow cytometric analysis) leads in many cases to an underlying disease with differentiated therapeutic options. Autoimmune hemolytic anemia (AIHA) is often associated with diseases as HIV, connective tissue disease, lymphomas or malignant tumors and the hemolytic process is preexisting in many cases. Thrombotic microvascular diseases (e.g., thrombotic thrombocytopenic purpura or hemolytic-uremic syndrome) are further important causes of hemolytic anemia which need immediate diagnosis and treatment.
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Affiliation(s)
- A Tuchscherer
- Klinik I für Innere Medizin, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland,
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45
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Thedsawad A, Taka O, Wanachiwanawin W. Significances of red cell bound immunoglobulin G as detected by flow cytometry in patients with Coombs-negative immune hemolysis. Transfus Med 2016; 26:130-7. [PMID: 26914629 DOI: 10.1111/tme.12282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 01/07/2016] [Accepted: 01/16/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES This study was to investigate the use of flow cytometry for detection and quantitation of red blood cells (RBC) bound IgG in immune hemolysis of patients with autoimmune hemolytic anaemia (AIHA) and systematic lupus erythematosus (SLE). BACKGROUND Two to ten percent of patients with warm-autoimmune hemolytic anaemia (WAIHA) exhibit a negative direct Coombs test. Flow cytometry has been applied to detect RBC bound IgG with high accuracy, reproducibility and sensitivity. METHODS In this study 45 and 75 patients with AIHA and SLE, respectively were evaluated for RBC bound IgG by direct Coombs test and flow cytometry. RESULTS Seventy-one percent (32/45) and 31% (23/75) of patients with AIHA and SLE respectively, had laboratory evidence of hemolysis. A positive flow cytometry, as defined by mean fluorescent intensity (MFI) values >0·21 and IgG molecules >28, was found in 4 of 32 (12·5%) and 4 of 23 (17·4%) patients with AIHA and SLE who had hemolysis with a negative direct Coombs test. There were very strong and strong correlations between the strength of direct Coombs test with MFI values and IgG molecules in patients with AIHA and SLE, respectively. CONCLUSION Flow cytometry can be applied in the diagnosis of Coombs-negative hemolytic anaemia in patients with AIHA and SLE.
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Affiliation(s)
- A Thedsawad
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - O Taka
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - W Wanachiwanawin
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Laribi K, Bolle D, Ghnaya H, Sandu A, Besançon A, Denizon N, Truong C, Pineau-Vincent F, de Materre AB. Rituximab is an effective and safe treatment of relapse in elderly patients with resistant warm AIHA. Ann Hematol 2016; 95:765-9. [PMID: 26858026 DOI: 10.1007/s00277-016-2605-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 01/27/2016] [Indexed: 11/25/2022]
Abstract
We evaluated the efficacy and safety of rituximab for the treatment of 23 elderly patients (median age 78 years) with warm autoimmune haemolytic anaemia (AIHA). The median follow-up was 31 months. Patients had received one to five previous treatments. Rituximab was administered by intravenous infusion at a dose of 375 mg/m(2) once weekly for 4 weeks. The OR rate was 86.9 % (CR = 39.1 %, PR = 47.8 %). Median OS was 87 months. The median OS of patients who reached CR could not be calculated, and that of patients with PR was 67 months. At last follow-up, eight of the 20 responding patients, including one patient in CR and seven in PR, had relapsed after a median of 6 months. Failure to achieve CR was a risk factor for relapse (p = 0.028). We did not identify any pretreatment characteristics predictive of response to rituximab. In conclusion, rituximab is an effective treatment for elderly patients with refractory warm AIHA.
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Affiliation(s)
- Kamel Laribi
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France.
| | - Delphine Bolle
- Pharmacy Department, Centre hospitalier, Le Mans, France
| | - Habib Ghnaya
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
| | - Andrea Sandu
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
| | - Anne Besançon
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
| | - Nathalie Denizon
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
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Yang D, Zhang S, Hu Y, Chen J, Bao B, Yuwen L, Weng L, Cheng Y, Wang L. AIE-active conjugated polymer nanoparticles with red-emission for in vitro and in vivo imaging. RSC Adv 2016. [DOI: 10.1039/c6ra18678e] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Novel AIE-active conjugated polymer nanoparticles with bright fluorescence emission and excellent photostability have been prepared for imaging in cells and zebrafish.
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Affiliation(s)
- Dongliang Yang
- Key Laboratory for Organic Electronics & Information Displays (KLOEID)
- Institute of Advanced Materials (IAM)
- Nanjing University of Posts & Telecommunications
- Nanjing 210046
- China
| | - Shuwei Zhang
- Key Lab of Mesoscopic Chemistry of MOE
- School of Chemistry and Chemical Engineering
- Nanjing University
- Nanjing 210093
- China
| | - Yanling Hu
- Key Laboratory for Organic Electronics & Information Displays (KLOEID)
- Institute of Advanced Materials (IAM)
- Nanjing University of Posts & Telecommunications
- Nanjing 210046
- China
| | - Jia Chen
- Key Laboratory for Organic Electronics & Information Displays (KLOEID)
- Institute of Advanced Materials (IAM)
- Nanjing University of Posts & Telecommunications
- Nanjing 210046
- China
| | - Biqing Bao
- Key Laboratory for Organic Electronics & Information Displays (KLOEID)
- Institute of Advanced Materials (IAM)
- Nanjing University of Posts & Telecommunications
- Nanjing 210046
- China
| | - Lihui Yuwen
- Key Laboratory for Organic Electronics & Information Displays (KLOEID)
- Institute of Advanced Materials (IAM)
- Nanjing University of Posts & Telecommunications
- Nanjing 210046
- China
| | - Lixing Weng
- College of Geography and Biological Information
- Nanjing University of Posts and Telecommunications
- Nanjing 210046
- China
| | - Yixiang Cheng
- Key Lab of Mesoscopic Chemistry of MOE
- School of Chemistry and Chemical Engineering
- Nanjing University
- Nanjing 210093
- China
| | - Lianhui Wang
- Key Laboratory for Organic Electronics & Information Displays (KLOEID)
- Institute of Advanced Materials (IAM)
- Nanjing University of Posts & Telecommunications
- Nanjing 210046
- China
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González-Naranjo LA, Betancur OM, Alarcón GS, Ugarte-Gil MF, Jaramillo-Arroyave D, Wojdyla D, Pons-Estel GJ, Rondón-Herrera F, Vásquez-Duque GM, Quintana-López G, Da Silva NA, Tavares Brenol JC, Reyes-Llerena G, Pascual-Ramos V, Amigo MC, Massardo L, Alfaro-Lozano J, Segami MI, Esteva-Spinetti MH, Iglesias-Gamarra A, Pons-Estel BA. Features associated with hematologic abnormalities and their impact in patients with systemic lupus erythematosus: Data from a multiethnic Latin American cohort. Semin Arthritis Rheum 2015; 45:675-83. [PMID: 26698222 DOI: 10.1016/j.semarthrit.2015.11.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/03/2015] [Accepted: 11/06/2015] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To examine hematological manifestations' correlates and their impact on damage accrual and mortality in SLE patients from the multiethnic, Latin American, GLADEL cohort. METHODS In patients with recent SLE diagnosis (≤2 years), the association between follow-up hematological manifestations (per ACR criteria) and socio-demographic and clinical variables was examined by univariable and multivariable logistic regressions; their impact on damage accrual and mortality was examined by Poisson and Cox proportional-hazards regression analyses, respectively. RESULTS Of 1437 patients, 948 (66.0%) developed ≥1 hematological manifestation [5.5% hemolytic anemia (AHA), 16.3% thrombocytopenia, and 56.4% lymphopenia] over 4.3 (3.3) follow-up years. Younger age, Mestizo ethnicity, hematologic disorder (at/or before SLE diagnosis), and first damage recorded were associated with hematological manifestations while antimalarials were negatively associated. AHA (at/or before SLE diagnosis), anti-Sm, and anti-RNP antibodies were associated with subsequent AHA occurrence while musculoskeletal involvement was negatively associated. Thrombocytopenia (at/or before SLE diagnosis), AHA, anti-phospholipid antibodies (aPLs), anti-SSA/Ro, anti-SSB/La antibodies, and first damage recorded were associated with later thrombocytopenia occurrence. Lymphopenia (at/or before SLE diagnosis), younger age at diagnosis, Mestizo ethnicity, having medical insurance, and first damage recorded were associated with subsequent lymphopenia occurrence while antimalarials and azathioprine treatment were negatively associated. AHA was associated with damage accrual and mortality after adjusting for variables known to affect these outcomes. CONCLUSIONS Mestizo ethnicity and early hematological manifestations are risk factors for their subsequent occurrence while antimalarials have a protective effect. The associations between AHA and aPLs and thrombocytopenia were corroborated. AHA contributes independently to damage accrual and diminished survival.
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Affiliation(s)
- Luis A González-Naranjo
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Calle 70 No. 52-21, Medellin, Antioquia 229, Colombia.
| | | | - Graciela S Alarcón
- Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Manuel F Ugarte-Gil
- Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru; Universidad Científica del Sur, Lima, Peru
| | - Daniel Jaramillo-Arroyave
- Rheumatology Unit, Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Daniel Wojdyla
- Escuela de Estadística, Universidad Nacional de Rosario, Rosario, Argentina
| | - Guillermo J Pons-Estel
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, Spain
| | - Federico Rondón-Herrera
- Rheumatology Unit, Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Gloria M Vásquez-Duque
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Calle 70 No. 52-21, Medellin, Antioquia 229, Colombia
| | - Gerardo Quintana-López
- Rheumatology Unit, Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Nilzio A Da Silva
- Rheumatology Unit, Faculdade de Medicina da Universidade Federal de Goias, Goiania, Brazil
| | - João C Tavares Brenol
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil; Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Gil Reyes-Llerena
- Servicio Nacional de Reumatología, Centro de Investigaciones Médico Quirúrgicas (CIMEQ), La Habana, Cuba
| | - Virginia Pascual-Ramos
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - Mary C Amigo
- Reumatología, Centro Médico ABC, Ciudad de México, Mexico
| | - Loreto Massardo
- Department of Clinical Immunology and Rheumatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - José Alfaro-Lozano
- Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - María I Segami
- Hospital Nacional "Edgardo Rebagliatti Martins", Essalud, Lima, Peru
| | - María H Esteva-Spinetti
- Servicio de Reumatología, Departamento de Medicina, Hospital Central de San Cristóbal, San Cristóbal, Venezuela
| | - Antonio Iglesias-Gamarra
- Rheumatology Unit, Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
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Dey A. Elderly female with Autoimmune hemolytic anemia. J Midlife Health 2015; 6:132-3. [PMID: 26538992 PMCID: PMC4604674 DOI: 10.4103/0976-7800.165596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare disease with an estimated prevalence of around 17/100,000. It is often difficult to diagnose and treat AIHA, especially in elderly. A 60-year-old female was admitted with the complaints of low grade fever, on-off for 6 months, progressive fatigue and dyspnea on exertion. She was transfused with three units of blood within these 6 months. Examination revealed pallor, edema, hemic murmur, and palpable liver. Hb was 2.9 gm%, T Bil 5.2 mg/dl, ESR 160 mm, and reticulocyte count 44.05%. Direct Coombs test was positive, anti-nuclear antibody (ANA) and Anti ds DNA were positive. A diagnosis of systemic lupus erythematosus (SLE) with AIHA was considered and patient was transfused with two units of packed red cells and put on steroid (prednisolone) at 1 mg/kg body weight daily. After 3 weeks, her Hb had increased to 10.4 gm% with gross clinical improvement.
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Affiliation(s)
- Anupam Dey
- Department of Medicine, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
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50
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Anémie hémolytique auto-immune de l’enfant. Transfus Clin Biol 2015; 22:291-8. [DOI: 10.1016/j.tracli.2015.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 10/06/2015] [Indexed: 11/22/2022]
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