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da Silva Araújo A, Silva Pinto AC, de Castro Lobo CL, Figueiredo MS, Menosi Gualandro SF, Olalla Saad ST, Cançado RD. Sickle Cell Disease in Brazil: Current Management. Hemoglobin 2024; 48:218-230. [PMID: 38663998 DOI: 10.1080/03630269.2024.2344790] [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: 07/21/2023] [Revised: 04/11/2024] [Accepted: 04/14/2024] [Indexed: 10/24/2024]
Abstract
Sickle cell disease (SCD) comprises inherited red blood cell disorders due to a mutation in the β-globin gene (c20A > T, pGlu6Val) and is characterized by the presence of abnormal hemoglobin, hemoglobin S, hemolysis, and vaso-occlusion. This mutation, either in a homozygous configuration or in compound states with other β-globin mutations, leads to polymerization of hemoglobin S in deoxygenated conditions, causing modifications in red blood cell shape, particularly sickling. Vaso-occlusive crisis (VOC) is the hallmark of the disease, but other severe complications may arise from repeated bouts of VOCs. SCD is considered a global health problem, and its incidence has increased in some areas of the world, particularly the Americas and Africa. Management of the disease varies according to the region of the world, mainly due to local resources and socioeconomic status. This review aimed to describe more recent data on SCD regarding available treatment options, especially in Brazil. New treatment options are expected to be available to all patients, particularly crizanlizumab, which is already approved in the country.
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Affiliation(s)
- Aderson da Silva Araújo
- Department of Hematology, Fundação de Hematologia e Hemoterapia de Pernambuco, Recife, Brazil
| | - Ana Cristina Silva Pinto
- Department of Medical Imaging, Hematology and Oncology, Hemocentro de Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP, Ribeirão Preto, Brazil
| | - Clarisse Lopes de Castro Lobo
- Department of Clinical Research, Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, RJ, Brazil
| | - Maria Stella Figueiredo
- Department of Clinical and Experimental Oncology, Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | | | | | - Rodolfo Delfini Cançado
- Department of Hematology and Oncology, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
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Chang TC, Yu J, Wang Z, Hankins JS, Weiss MJ, Wu G, Westhoff CM, Chou ST, Zheng Y. Machine learning to optimize automated RH genotyping using whole-exome sequencing data. Blood Adv 2024; 8:2651-2659. [PMID: 38522094 PMCID: PMC11157206 DOI: 10.1182/bloodadvances.2023011660] [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: 09/13/2023] [Revised: 02/05/2024] [Accepted: 02/25/2024] [Indexed: 03/26/2024] Open
Abstract
ABSTRACT Rh phenotype matching reduces but does not eliminate alloimmunization in patients with sickle cell disease (SCD) due to RH genetic diversity that is not distinguishable by serological typing. RH genotype matching can potentially mitigate Rh alloimmunization but comprehensive and accessible genotyping methods are needed. We developed RHtyper as an automated algorithm to predict RH genotypes using whole-genome sequencing (WGS) data with high accuracy. Here, we adapted RHtyper for whole-exome sequencing (WES) data, which are more affordable but challenged by uneven sequencing coverage and exacerbated sequencing read misalignment, resulting in uncertain predictions for (1) RHD zygosity and hybrid alleles, (2) RHCE∗C vs. RHCE∗c alleles, (3) RHD c.1136C>T zygosity, and (4) RHCE c.48G>C zygosity. We optimized RHtyper to accurately predict RHD and RHCE genotypes using WES data by leveraging machine learning models and improved the concordance of WES with WGS predictions from 90.8% to 97.2% for RHD and 96.3% to 98.2% for RHCE among 396 patients in the Sickle Cell Clinical Research and Intervention Program. In a second validation cohort of 3030 cancer survivors (15.2% Black or African Americans) from the St. Jude Lifetime Cohort Study, the optimized RHtyper reached concordance rates between WES and WGS predications to 96.3% for RHD and 94.6% for RHCE. Machine learning improved the accuracy of RH predication using WES data. RHtyper has the potential, once implemented, to provide a precision medicine-based approach to facilitate RH genotype-matched transfusion and improve transfusion safety for patients with SCD. This study used data from clinical trials registered at ClinicalTrials.gov as #NCT02098863 and NCT00760656.
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Affiliation(s)
- Ti-Cheng Chang
- Center for Applied Bioinformatics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jing Yu
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Zhaoming Wang
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jane S. Hankins
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Mitchell J. Weiss
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Gang Wu
- Center for Applied Bioinformatics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Connie M. Westhoff
- Laboratory of Immunohematology and Genomics, New York Blood Center Enterprises, New York, NY
| | - Stella T. Chou
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Yan Zheng
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
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Kearney L, Bosnick R, Phillips H, Ghio A, Cullen D, Sweat L, Zheng Y. Optimization of single-needle red cell exchange in patients with sickle cell disease. J Clin Apher 2024; 39:e22118. [PMID: 38682445 DOI: 10.1002/jca.22118] [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: 02/12/2024] [Revised: 03/25/2024] [Accepted: 04/14/2024] [Indexed: 05/01/2024]
Abstract
The hypercoagulable state associated with sickle cell disease (SCD) can be challenging for apheresis procedures. Among 62 single-needle red cell exchanges (SN-RCEs) performed over a 15-month period, 4 patients experienced 6 hemolytic events with a discolored plasma layer, elevated plasma/RBC interface in the centrifuge, and accompanying alarms of "Cells were detected in plasma line from centrifuge" or "AIM system detected RBC at top of connector." The hemolysis originated from the apheresis instrument because samples from the apheresis belt but not the patients' peripheral blood were positive for hemolysis. Further analysis showed the alarms occurred more often in SN-RCEs (20.4%) than double-needle RCEs (2.7%), and the hemolysis was probably secondary to clumping. To optimize SN-RCE, we increased the anticoagulant dosage by changing Inlet/AC ratio from 13 to 8 and lowered the inlet rate to the level comparable to double-needle RCE. The adjustments were well-tolerated with no more hemolysis.
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Affiliation(s)
- Lilora Kearney
- Department of Nursing, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Regina Bosnick
- Department of Nursing, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Haley Phillips
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Amanda Ghio
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Dierdre Cullen
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Lori Sweat
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Yan Zheng
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Sam AE, Weber Z, Peña A, Henderson C, King JM, Carr NR. A pilot study to evaluate clinical factors associated with iron and ferritin elevations during pediatric extracorporeal membrane oxygenation. Perfusion 2024; 39:585-592. [PMID: 36725017 DOI: 10.1177/02676591231154750] [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] [Indexed: 02/03/2023]
Abstract
Introduction: Elevations in serum ferritin and serum iron occur during pediatric extracorporeal membrane oxygenation (ECMO). Previous reports attribute the elevation to frequent red blood cell transfusions and/or hemolysis. Chronic transfusion can cause iron deposition in tissues leading to multisystem organ dysfunction. This study aims identify clinical factors associated with elevated ferritin and iron in pediatric ECMO patients, along with post-decannulation magnetic resonance imaging (MRI) assessment of iron deposition in liver and brain.Methods: Prospective, pilot study, using descriptive statistics to investigate potential associations between patient characteristics, serum ferritin and iron levels, and post-decannulation hepatic and basal ganglia iron deposition.Results: In this study, nine patients (100%) had elevated serum ferritin levels during ECMO. High ferritin levels were more common with veno-arterial than with veno-venous cannulation (p = 0.026) and were also associated with high plasma free hemoglobin levels (p < 0.001). Five patients presented with elevated serum iron levels. High serum iron levels were associated with higher daily (p = 0.016) and cumulative transfusion volumes (p = 0.013) as well ECMO duration beyond 7 days. MRI scans were performed on three patients with no evidence of abnormal iron deposition detected in the liver or brain.Conclusions: This pilot study shows that during pediatric ECMO, elevations in serum ferritin and serum iron occur and those elevations may be related to the cannulation modality, ECMO duration, amount of hemolysis, and volume of red blood cell transfusions. Further investigation is warranted to fully understand the implications of elevated serum iron and ferritin in pediatric ECMO.
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Affiliation(s)
- Ashley E Sam
- Brooke Army Medical Center, Fort Sam Houston, Texas, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Zachary Weber
- Brooke Army Medical Center, Fort Sam Houston, Texas, USA
- National Capital Consortium, Bethesda, MD, USA
| | - Alejandra Peña
- University Medical Center, Lubbock, TX, USA
- University of Texas Health Science Center San Antonio Joe and Teresa Lozano Long School of Medicine, San Antonio, TX, USA
| | - Cody Henderson
- Children's Hospital of San Antonio, San Antonio, TX, USA
| | | | - Nicholas R Carr
- Brooke Army Medical Center, Fort Sam Houston, Texas, USA
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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Adkins BD, Jacobs JW, Booth GS, Savani BN, Stephens LD. Transfusion Support in Hematopoietic Stem Cell Transplantation: A Contemporary Narrative Review. Clin Hematol Int 2024; 6:128-140. [PMID: 38817704 PMCID: PMC11086996 DOI: 10.46989/001c.94135] [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: 12/01/2023] [Accepted: 02/05/2024] [Indexed: 06/01/2024] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a cornerstone of modern medical practice, and can only be performed safely and effectively with appropriate transfusion medicine support. Patients undergoing HSCT often develop therapy-related cytopenia, necessitating differing blood product requirements in the pre-, peri-, and post-transplant periods. Moreover, ensuring optimal management for patients alloimmunized to human leukocyte antigens (HLA) and/or red blood cell (RBC) antigens, as well as for patients receiving ABO-incompatible transplants, requires close collaboration with transfusion medicine and blood bank professionals. Finally, as updated transfusion guidelines and novel blood product modifications emerge, the options available to the transplant practitioner continue to expand. Herein, we detail contemporary blood transfusion and transfusion medicine practices for patients undergoing HSCT.
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Affiliation(s)
- Brian D. Adkins
- PathologyThe University of Texas Southwestern Medical Center
| | | | - Garrett S. Booth
- Pathology, Microbiology, and ImmunologyVanderbilt University Medical Center
| | - Bipin N. Savani
- Internal Medicine, Division of Hematology/ OncologyVanderbilt University Medical Center
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Cigna M, Leiva-Torres GA, Baillargeon N, Yanez JC, Robitaille N. Management of a patient with sickle cell disease and multiple red blood cell alloantibodies in preparation for a hematopoietic stem cell transplantation. Transfusion 2024; 64:554-559. [PMID: 38205646 DOI: 10.1111/trf.17715] [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: 09/11/2023] [Revised: 11/29/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Hematopoietic stem cell transplant (HSCT) is currently the only widely available curative option for patients with sickle cell disease (SCD). Alloimmunization in this population is frequent and can complicate transfusion management during the HSCT period. The case of a pediatric patient with severe SCD clinical phenotype, multiple alloantibodies (9), and hyperhemolysis syndrome who underwent haploidentical HSCT is described. STUDY DESIGN AND METHODS The patient was known for an anti-e, despite RHCE*01.01 allele, which predicts a C- c+ E- weak e+ phenotype. Donors matching the patient's extended phenotype were targeted for RHCE genotyping. RESULTS Donors homozygotes or heterozygotes for RHCE*01.01 were selected for compatibility analyses and ranked based on strength of reactions. Discordance between zygosity and strength of reactions was observed, as the most compatible donors were heterozygotes for RHCE*01.01. In total, the patient received seven RBC units from two different donors during HSCT process without transfusion reaction or development of new alloantibodies. Six months post-HSCT, his hemoglobin level is stable at around 120 g/L and his chimerism is 100%. DISCUSSION This case highlights the complexity of transfusion management during HSCT of alloimmunized patients with SCD. Collecting sufficient compatible units requires early involvement of transfusion medicine teams and close communication with the local blood provider. Genotyping of donors self-identifying as Black is useful for identifying compatible blood for those patients but has some limitations. HSCT for heavily alloimmunized patients is feasible and safe with early involvement of transfusion medicine specialists. Further research on the clinical impact of genotypic matching is needed.
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Affiliation(s)
- Maude Cigna
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Canada
| | | | | | | | - Nancy Robitaille
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Canada
- Transfusion Medicine, Hema-Quebec, Montreal, Canada
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Wei WH, Cho G, Smith M, Morley S. Dissecting the complexity of pediatric blood transfusions and risk of adverse reactions in Aotearoa New Zealand. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2023; 21:428-436. [PMID: 36580030 PMCID: PMC10497383 DOI: 10.2450/2022.0178-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 12/06/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Children have different clinical and physiological drivers for transfusion from adult recipients. However, adverse transfusion reactions (ATRs) in pediatric patients are usually reported using the same criteria as for adults. Broad assessments of pediatric ATRs neglect substantial variation in different developmental stages. MATERIALS AND METHODS This retrospective study included 342,950 patients, ~2.43 million transfusions, and 5,540 ATR reports collated from New Zealand hospitals between 2005 and 2021. Using 16 years as the upper age limit, 138,856 pediatric transfusions and 402 pediatric ATR reports were identified and dissected at three levels: pediatric as a whole, pediatric developmental stage (i.e., neonate, infant, preschool, and school), and chronological age to identify patients at high risk of ATRs. Multivariate logistic regression analysis was followed to quantify risk factors. RESULTS Pediatric recipients had a higher ATR risk than adults (p=6.9-07) but the high risk was associated mainly with children older than 2 years. Neonates and infants accounted for 75.0% of pediatric recipients but had much lower ATR rates than adults. Pediatric transfusion recipients showed a clear male bias prior to age 11 years and then a female bias. However, gender difference in experiencing ATRs was significant only after age 13 years (p=2.3-04). Analyses focusing on the high-risk group revealed allergic reactions being the cause of the elevated risk and identified the main risk factors of number of transfusions (p=4.5-10) and multiple types of components transfused (p=2.0-13). DISCUSSION The identified ATR risk factors signal linkage with the biological drivers for transfusion. Low ATR rates in infancy could also be attributed to use of neonatal components, low transfusions per patient, and less developed immunity. The relative increase in female recipients from age 11 may be associated with increased red blood cell demand following puberty.
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Affiliation(s)
- Wen-Hua Wei
- New Zealand Blood Service, Auckland, New Zealand
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Gavin Cho
- New Zealand Blood Service, Auckland, New Zealand
| | | | - Sarah Morley
- New Zealand Blood Service, Auckland, New Zealand
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Han H, Hensch L, Tubman VN. Indications for transfusion in the management of sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:696-703. [PMID: 34889416 PMCID: PMC8791131 DOI: 10.1182/hematology.2021000307] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The transfusion of red blood cells (RBCs) is a crucial treatment for sickle cell disease (SCD). While often beneficial, the frequent use of transfusions is associated with numerous complications. Transfusions should be offered with specific guidelines in mind. Here we present updates to the indications for transfusion of RBCs in SCD. We review recent publications and include expert perspectives from hematology and transfusion medicine. For some clinical indications, such as ischemic stroke, the role of transfusion has been well studied and can be applied almost universally. For many other clinical scenarios, the use of transfusion therapy has less conclusive data and therefore must be tailored to individual needs. We highlight the roles of RBC transfusions in preventing or mitigating neurological disease, in reducing perioperative complications, in managing acute chest syndrome, and in optimizing pregnancy outcomes in SCD. We further highlight various transfusion techniques and when each might be considered. Potential complications of transfusion are also briefly discussed.
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Affiliation(s)
- Hyojeong Han
- Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Lisa Hensch
- Division of Transfusion Medicine and Coagulation, Texas Children's Hospital, Houston, TX
- Department of Pathology and Immunology and Anesthesiology, Baylor College of Medicine, Houston, TX
| | - Venée N Tubman
- Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
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