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Sun Q, Karafin MS, Garrett ME, Li Y, Ashley-Koch A, Telen MJ. A genome-wide association study of alloimmunization in the TOPMed OMG-SCD cohort identifies a locus on chromosome 12. Transfusion 2024. [PMID: 38966903 DOI: 10.1111/trf.17944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 06/10/2024] [Accepted: 06/20/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Red cell alloimmunization after exposure to donor red cells is a very common complication of transfusion for patients with sickle cell disease (SCD), resulting frequently in accelerated donor red blood cell destruction. Patients show substantial differences in their predisposition to alloimmunization, and genetic variability is one proposed component. Although several genetic association studies have been conducted for alloimmunization, the results have been inconsistent, and the genetic determinants of alloimmunization remain largely unknown. STUDY DESIGN AND METHODS We performed a genome-wide association study (GWAS) in 236 African American (AA) SCD patients from the Outcome Modifying Genes in Sickle Cell Disease (OMG-SCD) cohort, which is part of Trans-Omics for Precision Medicine (TOPMed), with whole-genome sequencing data available. We also performed sensitivity analyses adjusting for different sets of covariates and applied different sample grouping strategies based on the number of alloantibodies patients developed. RESULTS We identified one genome-wide significant locus on chr12 (p = 3.1e-9) with no evidence of genomic inflation (lambda = 1.003). Further leveraging QTL evidence from GTEx whole blood and/or Jackson Heart Study PBMC RNA-Seq data, we identified a number of potential genes, such as ARHGAP9, STAT6, and ATP23, that may be driving the association signal. We also discovered some suggestive loci using different analysis strategies. DISCUSSION We call for the community to collect additional alloantibody information within SCD cohorts to further the understanding of the genetic basis of alloimmunization in order to improve transfusion outcomes.
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Affiliation(s)
- Quan Sun
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Matthew S Karafin
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Melanie E Garrett
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Yun Li
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Allison Ashley-Koch
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Marilyn J Telen
- Division of Hematology, Department of Medicine, Duke Comprehensive Sickle Cell Center, Duke University Medical Center, Durham, North Carolina, USA
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2
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Kirkham JK, Estepp JH, Weiss MJ, Rashkin SR. Genetic Variation and Sickle Cell Disease Severity: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2337484. [PMID: 37851445 PMCID: PMC10585422 DOI: 10.1001/jamanetworkopen.2023.37484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/30/2023] [Indexed: 10/19/2023] Open
Abstract
Importance Sickle cell disease (SCD) is a monogenic disorder, yet clinical outcomes are influenced by additional genetic factors. Despite decades of research, the genetics of SCD remain poorly understood. Objective To assess all reported genetic modifiers of SCD, evaluate the design of associated studies, and provide guidelines for future analyses according to modern genetic study recommendations. Data Sources PubMed, Web of Science, and Scopus were searched through May 16, 2023, identifying 5290 publications. Study Selection At least 2 reviewers identified 571 original, peer-reviewed English-language publications reporting genetic modifiers of human SCD phenotypes, wherein the outcome was not treatment response, and the comparison was not between SCD subtypes or including healthy controls. Data Extraction and Synthesis Data relevant to all genetic modifiers of SCD were extracted, evaluated, and presented following STREGA and PRISMA guidelines. Weighted z score meta-analyses and pathway analyses were conducted. Main Outcomes and Measures Outcomes were aggregated into 25 categories, grouped as acute complications, chronic conditions, hematologic parameters or biomarkers, and general or mixed measures of SCD severity. Results The 571 included studies reported on 29 670 unique individuals (50% ≤ 18 years of age) from 43 countries. Of the 17 757 extracted results (4890 significant) in 1552 genes, 3675 results met the study criteria for meta-analysis: reported phenotype and genotype, association size and direction, variability measure, sample size, and statistical test. Only 173 results for 62 associations could be cross-study combined. The remaining associations could not be aggregated because they were only reported once or methods (eg, study design, reporting practice) and genotype or phenotype definitions were insufficiently harmonized. Gene variants regulating fetal hemoglobin and α-thalassemia (important markers for SCD severity) were frequently identified: 19 single-nucleotide variants in BCL11A, HBS1L-MYB, and HBG2 were significantly associated with fetal hemoglobin (absolute value of Z = 4.00 to 20.66; P = 8.63 × 10-95 to 6.19 × 10-5), and α-thalassemia deletions were significantly associated with increased hemoglobin level and reduced risk of albuminuria, abnormal transcranial Doppler velocity, and stroke (absolute value of Z = 3.43 to 5.16; P = 2.42 × 10-7 to 6.00 × 10-4). However, other associations remain unconfirmed. Pathway analyses of significant genes highlighted the importance of cellular adhesion, inflammation, oxidative and toxic stress, and blood vessel regulation in SCD (23 of the top 25 Gene Ontology pathways involve these processes) and suggested future research areas. Conclusions and Relevance The findings of this comprehensive systematic review and meta-analysis of all published genetic modifiers of SCD indicated that implementation of standardized phenotypes, statistical methods, and reporting practices should accelerate discovery and validation of genetic modifiers and development of clinically actionable genetic profiles.
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Affiliation(s)
- Justin K. Kirkham
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Jeremie H. Estepp
- Department of Hematology, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
- Now with Agios Pharmaceuticals, Cambridge, Massachusetts
| | - Mitch J. Weiss
- Department of Hematology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Sara R. Rashkin
- Department of Hematology, St Jude Children’s Research Hospital, Memphis, Tennessee
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3
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Patel SR, Maier CL, Zimring JC. Alloantigen Copy Number as a Critical Factor in RBC Alloimmunization. Transfus Med Rev 2023; 37:21-26. [PMID: 36725483 PMCID: PMC10023450 DOI: 10.1016/j.tmrv.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022]
Abstract
RBC alloimmunization remains a significant barrier to ongoing transfusion therapy leading to morbidity, and in extreme cases mortality, due to delayed or insufficient units of compatible RBCs. In addition, the monitoring and characterization of alloantibodies, often with multiple specificities in a single patient, consumes substantial health care resources. Extended phenotypic matching has mitigated, but not eliminated, RBC alloimmunization and is only logistically available for specialized populations. Thus, RBC alloimmunization remains a substantial problem. In recent decades it has become clear that mechanisms of RBC alloimmunization are distinct from other antigens and lack of mechanistic understanding likely contributes to the fact that there are no approved interventions to prevent RBC alloimmunization from transfusion. The combination of human studies and murine modeling have identified several key factors in RBC alloimmunization. In both humans and mice, immunogenicity is a function of alloantigen copy number on RBCs. Murine studies have further shown that copy number not only changes rates of immunization but the mechanisms of antibody formation. This review summarizes the current understanding of quantitative and qualitative effects of alloantigen copy number on RBC alloimmunization.
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Affiliation(s)
- Seema R Patel
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, GA, USA
| | - Cheryl L Maier
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - James C Zimring
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, VA, USA; Carter Immunology Center, University of Virginia, Charlottesville, VA, USA.
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4
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Stack G. Post-transfusion detection of RBC alloimmunization: Timing is everything. Transfusion 2021; 61:2219-2222. [PMID: 34289127 DOI: 10.1111/trf.16593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Gary Stack
- Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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5
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Rankin A, Darbari D, Campbell A, Webb J, Mo YD, Jacquot C, Delaney M, Luban NLC, Nickel RS. Screening for new red blood cell alloantibodies after transfusion in patients with sickle cell disease. Transfusion 2021; 61:2255-2264. [PMID: 34002408 DOI: 10.1111/trf.16444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with sickle cell disease (SCD) are frequent recipients of red blood cell (RBC) transfusions and are at risk for RBC alloimmunization. RBC alloimmunization is diagnosed by identifying RBC alloantibodies as part of pre-transfusion testing, but this testing fails to detect alloantibodies that have evanesced. It may be beneficial to screen for new RBC alloantibody development after transfusion before possible antibody evanescence. STUDY DESIGN AND METHODS Our institution started a new initiative for episodically transfused patients with SCD to obtain at least one antibody screen 2-6 months after transfusion as part of their clinical care. A database was created to prospectively track all transfused patients for 1 year and their post-transfusion antibody screen results. Patients received prophylactically CEK-matched RBC units. RESULTS During the study year, 138 patients with SCD received a total of 242 RBC transfusions. Patients with a history of an RBC alloantibody (n = 13, 9.4%) had previously received more RBC units than non alloimmunized patients (median 11 vs. 2 RBC units, p = .0002). A total of 337 post-transfusion antibody screens were obtained in 127 patients (92.0%) with 110 patients (79.7%) having at least one antibody screen 2-6 months post-transfusion. With this prospective testing, two new RBC alloantibodies (anti-C and -M) were identified in two patients. CONCLUSION It is feasible to test for new RBC alloantibody development in most episodically transfused patients with SCD as part of their routine care. The yield of this screening appears low with CEK matching, but it could still provide important information for individual patients.
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Affiliation(s)
- Alexander Rankin
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Pediatric Hematology-Oncology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Deepika Darbari
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Andrew Campbell
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Jennifer Webb
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Yunchuan Delores Mo
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Cyril Jacquot
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Meghan Delaney
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Naomi L C Luban
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Robert Sheppard Nickel
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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6
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Gerritsma JJ, Oomen I, Meinderts S, van der Schoot CE, Biemond BJ, van der Bom JG, Fijnvandraat K. Back to base pairs: What is the genetic risk for red bloodcell alloimmunization? Blood Rev 2021; 48:100794. [PMID: 33451870 DOI: 10.1016/j.blre.2020.100794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/17/2020] [Accepted: 12/24/2020] [Indexed: 01/05/2023]
Abstract
Red blood cell (RBC) alloimmunization is a serious complication of blood transfusions, challenging selection of compatible units for future transfusions. Genetic characteristics may be associated with the risk of RBC alloimmunization and may therefore serve to identify high-risk patients. The aim of this systematic review was to summarize the available evidence on genetic risk factors for RBC alloimmunization. Electronic databases were searched up to April 2020 for studies (Search terms included transfusion, alloimmunization and genetic). A total of 2581 alloimmunized cases and 26,558 controls were derived from 24 studies. The alleles that were most frequently studied and that demonstrated significant associations in a meta-analysis with alloimmunization to the Duffya antigen were HLA-DRB1*04 (Odds Ratio 7.80 (95%CI 4.57-13.33)), HLA-DRB1*15 (OR 3.76 (95%CI 2.14-6.59)), and HLA-DRB1*03 (OR 0.12 (95%CI 0.05-0.29)). Furthermore, significant associations with anti-K formation was found for the alleles HLA-DRB1*10 (OR 2.64 (95%CI 1.41-4.95)), HLA*DRB1*11 (OR 2.11, (95%CI 1.34-3.32)), and HLA-DRB1*13 (OR 1.71 (95%CI 1.26-2.33)). Overall, the available evidence was of moderate to low quality, hampering interpretation of reported results. There is an urgent need for high quality evidence on genetic risk factors for RBC alloimmunization.
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Affiliation(s)
- J J Gerritsma
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology, Amsterdam, the Netherlands; Sanquin Research and Landsteiner Laboratory, Immunopathology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - I Oomen
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology, Amsterdam, the Netherlands.
| | - S Meinderts
- Sanquin Research and Landsteiner Laboratory, Blood Cell Research, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C E van der Schoot
- Sanquin Research and Landsteiner Laboratory, Experimental Immunohematology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - B J Biemond
- Amsterdam UMC, University of Amsterdam, Department of Hematology, Amsterdam, the Netherlands.
| | - J G van der Bom
- Sanquin/LUMC, Center for Clinical Transfusion Research, Leiden, the Netherlands.
| | - K Fijnvandraat
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology, Amsterdam, the Netherlands; Leiden University Medical Center, Department of Clinical Epidemiology, Leiden, the Netherlands.
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7
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Hendrickson JE. Red blood cell alloimmunization and sickle cell disease: a narrative review on antibody induction. ANNALS OF BLOOD 2020; 5:33. [PMID: 33554044 PMCID: PMC7861514 DOI: 10.21037/aob-2020-scd-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The high prevalence of red blood cell (RBC) alloantibodies in people with sickle cell disease (SCD) cannot be debated. Why people with SCD are so likely to form RBC alloantibodies, however, remains poorly understood. Over the past decade, a better understanding of non-ABO blood group antigen variants has emerged; RH genetic diversity and the role this diversity plays in RBC alloimmunization is discussed elsewhere. Outside of antigen variants, the immune systems of people with SCD are known to be different than those of people without SCD. Some of these differences are due to effects of free heme, whereas others are impacted by hyposplenism. Descriptive studies of differences in white blood cell (WBC) subsets, platelet counts and function, and complement activation between people with SCD and race-matched controls exist. Studies comparing the immune systems of alloimmunized people with SCD to non-alloimmunized people with SCD to race-matched controls without SCD have uncovered differences in T-cell subsets, monocytes, Fcγ receptor polymorphisms, and responses to free heme. Studies in murine models have documented the role that recipient inflammation plays in RBC alloantibody formation, with human studies reporting a similar association. Murine studies have also reported the importance of type 1 interferon (IFNα/β), known to play a pivotal role in autoimmunity, in RBC alloantibody formation. The goal of this manuscript is to review existing data on factors influencing RBC alloantibody induction in people with SCD with a focus on inflammation and other immune system considerations, from the bench to the bedside.
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Affiliation(s)
- Jeanne E. Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
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9
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A locus on chromosome 5 shows African ancestry-limited association with alloimmunization in sickle cell disease. Blood Adv 2019; 2:3637-3647. [PMID: 30578281 DOI: 10.1182/bloodadvances.2018020594] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 11/08/2018] [Indexed: 12/11/2022] Open
Abstract
Red blood cell (RBC) transfusion remains a critical therapeutic intervention in sickle cell disease (SCD); however, the apparent propensity of some patients to regularly develop RBC alloantibodies after transfusion presents a significant challenge to finding compatible blood for so-called alloimmunization responders. Predisposing genetic loci have long been thought to contribute to the responder phenomenon, but to date, no definitive loci have been identified. We undertook a genome-wide association study of alloimmunization responder status in 267 SCD multiple transfusion recipients, using genetic estimates of ancestral admixture to bolster our findings. Analyses revealed single nucleotide polymorphisms (SNPs) on chromosomes 2 and 5 approaching genome-wide significance (minimum P = 2.0 × 10-8 and 8.4 × 10-8, respectively), with local ancestry analysis demonstrating similar levels of admixture in responders and nonresponders at implicated loci. Association at chromosome 5 was nominally replicated in an independent cohort of 130 SCD transfusion recipients, with meta-analysis surpassing genome-wide significance (rs75853687, P meta = 6.6 × 10-9), and this extended to individuals forming multiple (>3) alloantibodies (P meta = 9.4 × 10-5). The associated variant is rare outside of African populations, and orthogonal genome-wide haplotype analyses, contingent on local ancestry, revealed genome-wide significant sharing of a ∼60-kb haplotype of African ancestry at the chromosome 5 locus (Bayes Factor = 4.95). This locus overlaps a putative cis-acting enhancer predicted to regulate transcription of ADRA1B and the lncRNA LINC01847, both members of larger ontologies associated with immune regulation. Our findings provide potential insights to the pathophysiology underlying the development of alloantibodies and implicate non-RBC ancestry-limited loci in the susceptibility to alloimmunization.
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10
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Khaled MB, Ouederni M, Sahli N, Dhouib N, Abdelaziz AB, Rekaya S, Kouki R, Kaabi H, Slama H, Mellouli F, Bejaoui M. Predictors of autoimmune hemolytic anemia in beta-thalassemia patients with underlying red blood cells autoantibodies. Blood Cells Mol Dis 2019; 79:102342. [PMID: 31302454 DOI: 10.1016/j.bcmd.2019.102342] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 06/28/2019] [Indexed: 01/19/2023]
Abstract
In beta-thalassemia patients, erythrocyte autoantibodies can remain silent or lead to Autoimmune Hemolytic Anemia (AIHA).The aim of this study was to identify predictors of AIHA in beta-thalassemia patients with positive Direct Antiglobulin Test (DAT), in Tunisia. This longitudinal prognosis study was carried out on beta-thalassemia patients with a positive confirmed DAT. Predictors of AIHA were identified the Kaplan-Meier method. A Cox model analysis was used to identify independent predictors. Among 385 beta thalassemia patients, 87 developed positive DAT (22.6%). Autoimmune hemolytic anemia was occurred in 25 patients. Multivariate analysis showed that AIHA was independently associated with beta-thalassemia intermedia and similar family history of AIHA. Splenectomy in patients with positive DAT was independently associated with an increased risk of AIHA (HR = 6.175, CI: 2.049-18.612, p < 0.001). The risk of developing AIHA was higher during the first 72 transfusions. Autoimmune hemolytic anemia was significantly associated with polyspecific DAT (anti-complement and anti-IgG), blood group AB and prior alloimmunization. Whereas transfusion by phenotypic and leukoreduced blood was a protective factor. In summary, splenectomy after autoimmunization, prior alloimmunization, DAT specificity (IgG with complement), thalassemia intermedia, AB blood group and family history of AIHA were strongly associated with AIHA. Leukoreduced blood transfusion had a proven preventive role.
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Affiliation(s)
- Monia Ben Khaled
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia.
| | - Monia Ouederni
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | - Nessrine Sahli
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | - Nawel Dhouib
- Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | | | - Samia Rekaya
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | - Ridha Kouki
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | - Houda Kaabi
- National Center of Blood Transfusion, Tunis, Tunisia
| | - Hmida Slama
- National Center of Blood Transfusion, Tunis, Tunisia
| | - Fethi Mellouli
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | - Mohamed Bejaoui
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
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11
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El Kababi S, Benajiba M, El Khalfi B, Hachim J, Soukri A. Red blood cell alloimmunizations in beta-thalassemia patients in Casablanca/Morocco: Prevalence and risk factors. Transfus Clin Biol 2019; 26:240-248. [PMID: 31279519 DOI: 10.1016/j.tracli.2019.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 06/09/2019] [Indexed: 01/26/2023]
Abstract
Red blood cell alloimmunization is one of the major challenges to regular transfusions in β-thalassemic patients. In Morocco, rare studies have focused on this hemoglobinopathy. OBJECTIVE We aimed to study the prevalence and risk factors of red cell alloimmunization in β-thalassemic patients. PATIENTS AND METHODS Retrospective study during 9 years (2009-2018) was conducted on 160 β-thalassemic patients transfused regularly in pediatric department of children's hospital in Casablanca, Morocco. The main clinical, demographic and transfusional characteristics of alloimmunized and non-alloimmunized patients were compared. Red blood cells units transfused were leukodeplated and phenotypically matched for RH-KELL systems and for other systems after immunization. Screening and antibody identification were performed by gel-filtration method on BIO-RAD caseds using 3 and 11 red blood cells panels. To detect autoantibodies, autocontrol and direct antiglobulin tests were carried out using polyspecific coombs (IgG/C3d) gel cards. RESULTS The prevalence of alloimmunizations was 8.75% during the study period. Seventeen alloantibodies identified were directed mainly against antigens of KELL and RH systems: KEL 1 (35.29%), RH 3 (23.52%), RH1 (11.76%), Kpa (11.76%), RH2 (5.88%). Red blood cells autoantibodies had been detected in 6 of 14 (42.85%) of alloimmunized patients versus 12 of 146 (11.76%) of non-alloimmunized patients (P<0.01). Presence of autoantibodies, transfusional interval<3weeks and gender were associated with high rate of red cells alloimmunization. CONCLUSION This study proves the data of literature. The presence of red cell autoantibodies appears to be a major risk factors for alloimmunization in thalassemic children, and could advocate specific transfusion guidelines.
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Affiliation(s)
- S El Kababi
- Laboratory of Physiopathology, Genetics Molecular and Biotechnology (PGMB), Faculty of Sciences Ain Chock, Research Center Health and Biotechnology, University Hassan II of Casablanca, Km 8 Route El jadida, BP 5366, Mearif, 20100 Casablanca, Morocco
| | - M Benajiba
- National Blood Transfusion Center, Immuno-hematology, Bab-El-Irfane, rue m'fadel-Cherka, 10000 Rabat, Morocco
| | - B El Khalfi
- Laboratory of Physiopathology, Genetics Molecular and Biotechnology (PGMB), Faculty of Sciences Ain Chock, Research Center Health and Biotechnology, University Hassan II of Casablanca, Km 8 Route El jadida, BP 5366, Mearif, 20100 Casablanca, Morocco
| | - J Hachim
- Hematology-Oncology pediatric department, Children's Hospital Abderrahim Harouchi, Ibn Rochd University Hospital Center, Casablanca, Morocco; Faculty of Medicine and Pharmacy of Casablanca, Hassan 2 University, Tarik bnou ziad street, 20360 Casablanca, Morocco
| | - A Soukri
- Laboratory of Physiopathology, Genetics Molecular and Biotechnology (PGMB), Faculty of Sciences Ain Chock, Research Center Health and Biotechnology, University Hassan II of Casablanca, Km 8 Route El jadida, BP 5366, Mearif, 20100 Casablanca, Morocco.
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12
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Meinderts SM, Gerritsma JJ, Sins JWR, de Boer M, van Leeuwen K, Biemond BJ, Rijneveld AW, Kerkhoffs JLH, Habibi A, van Bruggen R, Kuijpers TW, van der Schoot E, Pirenne F, Fijnvandraat K, Tanck MW, van den Berg TK. Identification of genetic biomarkers for alloimmunization in sickle cell disease. Br J Haematol 2019; 186:887-899. [PMID: 31168801 DOI: 10.1111/bjh.15998] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/11/2022]
Abstract
Most sickle cell disease (SCD) patients rely on blood transfusion as their main treatment strategy. However, frequent blood transfusion poses the risk of alloimmunization. On average, 30% of SCD patients will alloimmunize while other patient groups form antibodies less frequently. Identification of genetic markers may help to predict which patients are at risk to form alloantibodies. The aim of this study was to evaluate whether genetic variations in the Toll-like receptor pathway or in genes previously associated with antibody-mediated conditions are associated with red blood cell (RBC) alloimmunization in a cohort of SCD patients. In this case-control study, cases had a documented history of alloimmunization while controls had received ≥20 RBC units without alloantibody formation. We used a customized single nucleotide polymorphism (SNP) panel to genotype 690 SNPs in 275 (130 controls, 145 cases) patients. Frequencies were compared using multiple logistic regression analysis. In our primary analysis, no SNPs were found to be significantly associated with alloimmunization after correction for multiple testing. However, in a secondary analysis with a less stringent threshold for significance we found 19 moderately associated SNPs. Among others, SNPs in TLR1/TANK and MALT1 were associated with a higher alloimmunization risk, while SNPs in STAM/IFNAR1 and STAT4 conferred a lower alloimmunization risk.
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Affiliation(s)
- Sanne M Meinderts
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Jorn J Gerritsma
- Department of Paediatric Haematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Department of Plasma Proteins, Sanquin Research and Landsteiner Laboratory, Academic Medical Centre, Univsersity of Amsterdam, Amsterdam, the Netherlands
| | - Joep W R Sins
- Department of Paediatric Haematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Department of Plasma Proteins, Sanquin Research and Landsteiner Laboratory, Academic Medical Centre, Univsersity of Amsterdam, Amsterdam, the Netherlands
| | - Martin de Boer
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Karin van Leeuwen
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Bart J Biemond
- Department of Haematology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Anita W Rijneveld
- Department of Haematology, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | | | - Anoosha Habibi
- Reference Centre for Sickle Cell Disease, Hôpital Henri Mondor, Créteil, France
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Taco W Kuijpers
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Department of Paediatric Haematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Ellen van der Schoot
- Department of Experimental Immunohaematology, Sanquin Research and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - France Pirenne
- Etablissement Français Du Sang Ile de France, INSERM U955, University of Paris Est-Créteil, Hôpital Henri Mondor, Créteil, France
| | - Karin Fijnvandraat
- Department of Paediatric Haematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Department of Plasma Proteins, Sanquin Research and Landsteiner Laboratory, Academic Medical Centre, Univsersity of Amsterdam, Amsterdam, the Netherlands
| | - Michael W Tanck
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Timo K van den Berg
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Department of Molecular Cell Biology, VU Medical Centre, Amsterdam, the Netherlands
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13
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Tormey CA, Hendrickson JE. Transfusion-related red blood cell alloantibodies: induction and consequences. Blood 2019; 133:1821-1830. [PMID: 30808636 PMCID: PMC6484385 DOI: 10.1182/blood-2018-08-833962] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/01/2018] [Indexed: 01/19/2023] Open
Abstract
Blood transfusion is the most common procedure completed during a given hospitalization in the United States. Although often life-saving, transfusions are not risk-free. One sequela that occurs in a subset of red blood cell (RBC) transfusion recipients is the development of alloantibodies. It is estimated that only 30% of induced RBC alloantibodies are detected, given alloantibody induction and evanescence patterns, missed opportunities for alloantibody detection, and record fragmentation. Alloantibodies may be clinically significant in future transfusion scenarios, potentially resulting in acute or delayed hemolytic transfusion reactions or in difficulty locating compatible RBC units for future transfusion. Alloantibodies can also be clinically significant in future pregnancies, potentially resulting in hemolytic disease of the fetus and newborn. A better understanding of factors that impact RBC alloantibody formation may allow general or targeted preventative strategies to be developed. Animal and human studies suggest that blood donor, blood product, and transfusion recipient variables potentially influence which transfusion recipients will become alloimmunized, with genetic as well as innate/adaptive immune factors also playing a role. At present, judicious transfusion of RBCs is the primary strategy invoked in alloimmunization prevention. Other mitigation strategies include matching RBC antigens of blood donors to those of transfusion recipients or providing immunomodulatory therapies prior to blood product exposure in select recipients with a history of life-threatening alloimmunization. Multidisciplinary collaborations between providers with expertise in transfusion medicine, hematology, oncology, transplantation, obstetrics, and immunology, among other areas, are needed to better understand RBC alloimmunization and refine preventative strategies.
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Affiliation(s)
- Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
- Pathology & Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, CT; and
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
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14
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How I safely transfuse patients with sickle-cell disease and manage delayed hemolytic transfusion reactions. Blood 2018; 131:2773-2781. [PMID: 29724898 DOI: 10.1182/blood-2018-02-785964] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/01/2018] [Indexed: 12/15/2022] Open
Abstract
Transfusions can be a life-saving treatment of patients with sickle-cell disease (SCD). However, availability of matched units can be limiting because of distinctive blood group polymorphisms in patients of African descent. Development of antibodies against the transfused red blood cells (RBCs), resulting in delayed hemolytic transfusion reactions (DHTRs), can be life-threatening and pose unique challenges for this population with regard to treatment strategies and transfusion management protocols. In cases where the transfused cells and the patient's own RBCs are destroyed, diagnosis of DHTR can be difficult because symptoms may mimic vaso-occlusive crisis, and frequently, antibodies are undetectable. Guidelines are needed for early diagnosis of DHTR because treatment may need to include temporarily withholding any new transfusions to avoid further hemolysis. Also needed are case-control studies to optimally tailor treatments based on the severity of DHTR and develop preventive transfusion strategies for patients at DHTR risk. Here, we will review gaps in knowledge and describe through case studies our recommended approach to prevent alloimmunization and to diagnose and treat symptomatic DHTRs for which complementary mechanistic studies to understand their pathogenesis are sorely needed.
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15
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Nonclassical FCGR2C haplotype is associated with protection from red blood cell alloimmunization in sickle cell disease. Blood 2017; 130:2121-2130. [PMID: 28899854 DOI: 10.1182/blood-2017-05-784876] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/06/2017] [Indexed: 01/21/2023] Open
Abstract
Red blood cell (RBC) transfusions are of vital importance in patients with sickle cell disease (SCD). However, a major complication of transfusion therapy is alloimmunization. The low-affinity Fcγ receptors, expressed on immune cells, are important regulators of antibody responses. Genetic variation in FCGR genes has been associated with various auto- and alloimmune diseases. The aim of this study was to evaluate the association between genetic variation of FCGR and RBC alloimmunization in SCD. In this case-control study, DNA samples from 2 cohorts of transfused SCD patients were combined (France and The Netherlands). Cases had a positive history of alloimmunization, having received ≥1 RBC unit. Controls had a negative history of alloimmunization, having received ≥20 RBC units. Single nucleotide polymorphisms and copy number variation of the FCGR2/3 gene cluster were studied in a FCGR-specific multiplex ligation-dependent probe amplification assay. Frequencies were compared using logistic regression. Two hundred seventy-two patients were included (130 controls, 142 cases). The nonclassical open reading frame in the FCGR2C gene (FCGR2C.nc-ORF) was strongly associated with a decreased alloimmunization risk (odds ratio [OR] 0.26, 95% confidence [CI] 0.11-0.64). This association persisted when only including controls with exposure to ≥100 units (OR 0.30, CI 0.11-0.85) and appeared even stronger when excluding cases with Rh or K antibodies only (OR 0.19, CI 0.06-0.59). In conclusion, SCD patients with the FCGR2Cnc-ORF polymorphism have over a 3-fold lower risk for RBC alloimmunization in comparison with patients without this mutation. This protective effect was strongest for exposure to antigens other than the immunogenic Rh or K antigens.
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16
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Alloimmunisation and nephropathy in sickle cell disease patients in Jeddah, Saudi Arabia. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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17
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Hendrickson JE. Red blood cell alloimmunisation: induction of immunity and potential mitigation strategies. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- J. E. Hendrickson
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven CT USA
- Department of Pediatrics; Yale University School of Medicine; New Haven CT USA
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18
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Natarajan P, Liu D, Patel SR, Santhanakrishnan M, Beitler D, Liu J, Gibb DR, Liepkalns JS, Madrid DJ, Eisenbarth SC, Stowell SR, Hendrickson JE. CD4 Depletion or CD40L Blockade Results in Antigen-Specific Tolerance in a Red Blood Cell Alloimmunization Model. Front Immunol 2017; 8:907. [PMID: 28824633 PMCID: PMC5545689 DOI: 10.3389/fimmu.2017.00907] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 07/17/2017] [Indexed: 02/01/2023] Open
Abstract
Approximately 3-10% of human red blood cell (RBC) transfusion recipients form alloantibodies to non-self, non-ABO blood group antigens expressed on donor RBCs, with these alloantibodies having the potential to be clinically significant in transfusion and pregnancy settings. However, the majority of transfused individuals never form detectable alloantibodies. Expanding upon observations that children initially transfused with RBCs at a young age are less likely to form alloantibodies throughout their lives, we hypothesized that "non-responders" may not only be ignorant of antigens on RBCs but instead tolerized. We investigated this question in a reductionist murine model, in which transgenic donors express the human glycophorin A (hGPA) antigen in an RBC-specific manner. Although wild-type mice treated with poly IC and transfused with hGPA RBCs generated robust anti-hGPA IgG alloantibodies that led to rapid clearance of incompatible RBCs, those transfused in the absence of an adjuvant failed to become alloimmunized. Animals depleted of CD4+ cells or treated with CD40L blockade prior to initial hGPA RBC exposure, in the presence of poly IC, failed to generate detectable anti-hGPA IgG alloantibodies. These non-responders to a primary transfusion remained unable to generate anti-hGPA IgG alloantibodies upon secondary hGPA exposure and did not prematurely clear transfused hGPA RBCs even after their CD4 cells had returned or their CD40L blockade had resolved. This observed tolerance was antigen (hGPA) specific, as robust IgG responses to transfused RBCs expressing a third-party antigen occurred in all studied groups. Experiments completed in an RBC alloimmunization model that allowed evaluation of antigen-specific CD4+ T-cells (HOD (hen egg lysozyme, ovalbumin, and human duffyb)) demonstrated that CD40L blockade prevented the expansion of ovalbumin 323-339 specific T-cells after HOD RBC transfusion and also prevented germinal center formation. Taken together, our data suggest that recipients may indeed become tolerized to antigens expressed on RBCs, with the recipient's immune status upon initial RBC exposure dictating future responses. Although questions surrounding mechanism(s) and sustainability of tolerance remain, these data lay the groundwork for future work investigating RBC immunity versus tolerance in reductionist models and in humans.
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Affiliation(s)
- Prabitha Natarajan
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Dong Liu
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Seema R. Patel
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Manjula Santhanakrishnan
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Daniel Beitler
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Jingchun Liu
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - David R. Gibb
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Justine S. Liepkalns
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - David J. Madrid
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, United States
| | - Stephanie C. Eisenbarth
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, United States
| | - Sean R. Stowell
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Jeanne E. Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, United States
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19
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Belsito A, Magnussen K, Napoli C. Emerging strategies of blood group genotyping for patients with hemoglobinopathies. Transfus Apher Sci 2016; 56:206-213. [PMID: 28040400 DOI: 10.1016/j.transci.2016.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 02/06/2023]
Abstract
Red cell alloimmunization is a serious problem in chronically transfused patients. A number of high-throughput DNA assays have been developed to extend or replace traditional serologic antigen typing. DNA-based typing methods may be easily automated and multiplexed, and provide reliable information on a patient. Molecular genotyping promises to become cheaper, being not dependent on serologic immunoglobulin reagents. Patients with hemoglobinopathies could benefit from receiving extended genomic typing. This could limit post transfusional complications depending on subtle antigenic differences between donors and patients. Patient/donor compatibility extended beyond the phenotype Rh/Kell may allows improved survival of transfused units of red blood cells (RBC) and lead to reduced need for blood transfusion and leading to less iron overload and reduced risk of alloimmunization. Here we discuss the advantages and limitations of current techniques, that detect only predefined genetic variants. In contrast, target enrichment next-generation sequencing (NGS) has been used to detect both known and de novo genetic polymorphisms, including single-nucleotide polymorphisms, indels (insertions/deletions), and structural variations. NGS approaches can be used to develop an extended blood group genotyping assay system.
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Affiliation(s)
- A Belsito
- Department of Internal Medicine and Specialistic Units Clinical Immunoematology Immunohematology U.O.C. Immunohematology, Transfusion Medicine and Organ Transplant Immunology (SIMT), Regional Reference Laboratory of Transplant Immunology (LIT), Department of Internal Medicine and Specialist Units, Azienda Universitaria Policlinico (AOU), Second University of Naples (SUN), Naples, Italy.
| | - K Magnussen
- Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - C Napoli
- Department of Internal Medicine and Specialistic Units Clinical Immunoematology Immunohematology U.O.C. Immunohematology, Transfusion Medicine and Organ Transplant Immunology (SIMT), Regional Reference Laboratory of Transplant Immunology (LIT), Department of Internal Medicine and Specialist Units, Azienda Universitaria Policlinico (AOU), Second University of Naples (SUN), Naples, Italy
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20
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Hendrickson JE, Tormey CA. Understanding red blood cell alloimmunization triggers. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:446-451. [PMID: 27913514 PMCID: PMC6142457 DOI: 10.1182/asheducation-2016.1.446] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Blood group alloimmunization is "triggered" when a person lacking a particular antigen is exposed to this antigen during transfusion or pregnancy. Although exposure to an antigen is necessary for alloimmunization to occur, it is not alone sufficient. Blood group antigens are diverse in structure, function, and immunogenicity. In addition to red blood cells (RBCs), a recipient of an RBC transfusion is exposed to donor plasma, white blood cells, and platelets; the potential contribution of these elements to RBC alloimmunization remains unclear. Much attention in recent years has been placed on recipient factors that influence RBC alloantibody responses. Danger signals, identified in murine and human studies alike as being risk factors for alloimmunization, may be quite diverse in nature. In addition to exogenous or condition-associated inflammation, autoimmunity is also a risk factor for alloantibody formation. Triggers for alloimmunization in pregnancy are not well-understood beyond the presence of a fetal/maternal bleed. Studies using animal models of pregnancy-induced RBC alloimmunization may provide insight in this regard. A better understanding of alloimmunization triggers and signatures of "responders" and "nonresponders" is needed for prevention strategies to be optimized. A common goal of such strategies is increased transfusion safety and improved pregnancy outcomes.
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Affiliation(s)
- Jeanne E. Hendrickson
- Department of Laboratory Medicine and
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Christopher A. Tormey
- Department of Laboratory Medicine and
- Pathology & Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, CT
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21
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Sippert EÂ, Visentainer JEL, Alves HV, Rodrigues C, Gilli SCO, Addas-Carvalho M, Saad STO, Costa FF, Castilho L. Red blood cell alloimmunization in patients with sickle cell disease: correlation with HLA and cytokine gene polymorphisms. Transfusion 2016; 57:379-389. [PMID: 27873324 DOI: 10.1111/trf.13920] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/29/2016] [Accepted: 09/30/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The reason for the difference in susceptibility to red blood cell (RBC) alloimmunization among patients with sickle cell disease (SCD) is not clearly understood and is probably the result of multiple factors. Our hypothesis is that genetic polymorphisms are associated with RBC alloimmunization. STUDY DESIGN AND METHODS We investigated the possible association of susceptibility to RBC alloimmunization with polymorphisms of HLA and cytokines genes in 161 SCD patients prior exposed to RBC transfusion. Cytokine gene polymorphisms were analyzed by polymerase chain reaction (PCR) and TaqMan assays. HLA Class I genotyping was performed using PCR-specific sequence of oligonucleotides. Polymorphism frequencies were compared using the Fisher's exact test. RESULTS Our results revealed increased percentage of the A allele and the GA genotype of the TNFA -308G/A cytokine among alloimmunized patients when compared to nonalloimmunized patients (A allele, 16.4% vs. 6.8%, p = 0.004; GA genotype, 32.8% vs. 11.7%, p = 0.0021). In addition, the IL1B -511T allele and the IL1B -511TT and CT genotype frequencies were overrepresented among alloimmunized patients (T allele, 53.0% vs. 37.5%, p = 0.0085; CT + TT genotypes, 81.82% vs. 60.87%, p = 0.0071). In relation to HLA Class I, we found a higher frequency of HLA-DRB1*15 among patients alloimmunized to Rh antigens when compared to nonalloimmunized patients (15.63% vs. 6.98%, p = 0.044). CONCLUSION Brazilian SCD patients with the TNFA, IL1B, and HLA-DRB1 gene polymorphisms were at increased risk of becoming alloimmunized by RBC transfusions. These findings may contribute to the development of future therapeutic strategies for patients with SCD with higher susceptibility of alloimmunization.
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Affiliation(s)
- Emilia Ângela Sippert
- Hematology and Hemotherapy Center, State University of Campinas, UNICAMP, Campinas, São Paulo, Brazil
| | | | - Hugo Vicentin Alves
- Basic Health Sciences Department, State University of Maringa, Maringá, Paraná, Brazil
| | - Camila Rodrigues
- Basic Health Sciences Department, State University of Maringa, Maringá, Paraná, Brazil
| | | | - Marcelo Addas-Carvalho
- Hematology and Hemotherapy Center, State University of Campinas, UNICAMP, Campinas, São Paulo, Brazil
| | | | - Fernando Ferreira Costa
- Hematology and Hemotherapy Center, State University of Campinas, UNICAMP, Campinas, São Paulo, Brazil
| | - Lilian Castilho
- Hematology and Hemotherapy Center, State University of Campinas, UNICAMP, Campinas, São Paulo, Brazil
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22
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Yazdanbakhsh K, Shaz BH, Hillyer CD. Immune Regulation of sickle Cell Alloimmunization. ACTA ACUST UNITED AC 2016; 12:248-253. [PMID: 28261322 DOI: 10.1111/voxs.12296] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Red blood cell (RBC) transfusion remains an important treatment for patients with sickle cell disease (SCD) and the majority of patients receive transfusions by adulthood. However, SCD patients are at a high risk of alloimmunization, which can cause life-threatening complications. The high rate of alloimmunization can in part be explained by chronic inflammatory condition in SCD characterized by significant immune and inflammatory activation. Heightened immune effector cell responses and/or impaired regulatory networks are likely to drive alloantibody production in alloimmunized SCD patients. In support of this, altered T cell immunoregulation, known to control antibody responses, have been reported in alloimmunized SCD patients. In addition, stronger follicular help T cell responses that help antibody production by B cells were described in alloimmunized as compared to non-alloimmunized SCD patients. Furthermore, several innate immune abnormalities have been identified in alloimmunized SCD patients, including a compromised anti-inflammatory response against extracellular cell free heme. The data support a model in which alloimmunized SCD patients are unable to switch off their proinflammatory state in response to the ongoing hemolytic state characteristic of SCD, placing this patient subset at a higher risk to develop a strong immune response against allogeneic determinants on transfused RBCs, thus increasing the risk of further alloimmunization. A detailed mechanistic understanding of innate immune abnormalities that can contribute to pathogenic T cell responses in alloimmunized SCD patients will lay the foundation for identification of biomarkers of alloimmunization with the goal that this information will ultimately help guide therapy in these patients.
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23
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Sins JW, Biemond BJ, van den Bersselaar SM, Heijboer H, Rijneveld AW, Cnossen MH, Kerkhoffs JLH, van Meurs AH, von Ronnen F, Zalpuri S, de Rijke YB, Ellen van der Schoot C, de Haas M, van der Bom JG, Fijnvandraat K. Early occurrence of red blood cell alloimmunization in patients with sickle cell disease. Am J Hematol 2016; 91:763-9. [PMID: 27102719 DOI: 10.1002/ajh.24397] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 04/18/2016] [Accepted: 04/19/2016] [Indexed: 12/14/2022]
Abstract
Red blood cell (RBC) alloimmunization is a major complication of transfusion therapy in sickle cell disease (SCD). Identification of high-risk patients is hampered by lack of studies that take the cumulative transfusion exposure into account. In this retrospective cohort study among previously non-transfused SCD patients in the Netherlands, we aimed to elucidate the association between the cumulative transfusion exposure, first alloimmunization and independent risk factors. A total of 245 patients received 11 952 RBC units. Alloimmunization occurred in 43 patients (18%), half of them formed their first alloantibody before the 8th unit. In patients with exposure to non-extended matched transfusions (ABO and RhD) the cumulative alloimmunization risk increased up to 35% after 60 transfused units. This was significantly higher compared to a general transfused population (HR 6.6, CI 4.2-10.6). Receiving the first transfusion after the age of 5 was an independent risk factor for alloimmunization (HR 2.3, CI 1.0-5.1). Incidental, episodic transfusions in comparison to chronic scheme transfusions (HR 2.3, CI 0.9-6.0), and exposure to non-extended matched units in comparison to extended matching (HR 2.0, CI 0.9-4.6) seemed to confer a higher alloimmunization risk. The majority of first alloantibodies are formed after minor transfusion exposure, substantiating suggestions of a responder phenotype in SCD and stressing the need for risk factor identification. In this study, older age at first transfusion, episodic transfusions and non-extended matched transfusions appeared to be risk factors for alloimmunization. Am. J. Hematol. 91:763-769, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joep W.R. Sins
- Department of Pediatric Hematology; Emma Children's Hospital, Academic Medical Center; Amsterdam The Netherlands
- Department of Hematology; Academic Medical Center; Amsterdam The Netherlands
| | - Bart J. Biemond
- Department of Hematology; Academic Medical Center; Amsterdam The Netherlands
| | - Sil M. van den Bersselaar
- Department of Pediatric Hematology; Emma Children's Hospital, Academic Medical Center; Amsterdam The Netherlands
- Department of Hematology; Academic Medical Center; Amsterdam The Netherlands
| | - H. Heijboer
- Department of Pediatric Hematology; Emma Children's Hospital, Academic Medical Center; Amsterdam The Netherlands
| | - Anita W. Rijneveld
- Department of Hematology; Erasmus MC, University Medical Center; Rotterdam The Netherlands
| | - Marjon H. Cnossen
- Department of Pediatric Hematology; Erasmus MC, University Medical Center-Sophia Children's Hospital; Rotterdam The Netherlands
| | | | | | - F.B. von Ronnen
- Department of Pediatric Hematology; Emma Children's Hospital, Academic Medical Center; Amsterdam The Netherlands
- Department of Hematology; Academic Medical Center; Amsterdam The Netherlands
| | - Saurabh Zalpuri
- Center for Clinical Transfusion; Sanquin Blood Supply Foundation; Leiden and Department of Clinical Epidemiology; Leiden University Medical Center; Leiden The Netherlands
| | - Yolanda B. de Rijke
- Department of Clinical Chemistry; Erasmus MC, University Medical Center Rotterdam; The Netherlands
| | - C. Ellen van der Schoot
- Department of Experimental Immunohematology; Sanquin Blood Supply Foundation; Amsterdam The Netherlands
| | - Masja de Haas
- Department of Experimental Immunohematology; Sanquin Blood Supply Foundation; Amsterdam The Netherlands
| | - Johanna G. van der Bom
- Center for Clinical Transfusion; Sanquin Blood Supply Foundation; Leiden and Department of Clinical Epidemiology; Leiden University Medical Center; Leiden The Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology; Emma Children's Hospital, Academic Medical Center; Amsterdam The Netherlands
- Unit of Clinical Transfusion Medicine; Sanquin Blood Supply Foundation; Amsterdam The Netherlands
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24
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Gibb DR, Calabro S, Liu D, Tormey CA, Spitalnik SL, Zimring JC, Hendrickson JE, Hod EA, Eisenbarth SC. The Nlrp3 Inflammasome Does Not Regulate Alloimmunization to Transfused Red Blood Cells in Mice. EBioMedicine 2016; 9:77-86. [PMID: 27345021 PMCID: PMC4972549 DOI: 10.1016/j.ebiom.2016.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/02/2016] [Accepted: 06/05/2016] [Indexed: 02/07/2023] Open
Abstract
Red blood cell (RBC) transfusions are essential for patients with hematological disorders and bone marrow failure syndromes. Despite ABO matching, RBC transfusions can lead to production of alloantibodies against “minor” blood group antigens. Non-ABO alloimmunization is a leading cause of transfusion-associated mortality in the U.S. Despite its clinical importance, little is known about the immunological factors that promote alloimmunization. Prior studies indicate that inflammatory conditions place patients at higher risk for alloimmunization. Additionally, co-exposure to pro-inflammatory pathogen associated molecular patterns (PAMPs) promotes alloimmunization in animal models, suggesting that RBC alloimmunization depends on innate immune cell activation. However, the specific innate immune stimuli and sensors that induce a T cell-dependent alloantibody response to transfused RBCs have not been identified. The NLRP3 inflammasome senses chemically diverse PAMPs and damage associated molecular patterns (DAMPs), including extracellular ATP and iron-containing heme. We hypothesized that activation of the NLRP3 inflammasome by endogenous DAMPs from RBCs promotes the alloimmune response to a sterile RBC transfusion. Using genetically modified mice lacking either NLRP3 or multiple downstream inflammasome response elements, we ruled out a role for the NLRP3 inflammasome or any Caspase-1 or -11 dependent inflammasome in regulating RBC alloantibody production to a model antigen. Transfusion of stored red blood cells (RBCs) induces proinflammatory cytokine production and alloimmunization to an RBC antigen in mice. Transfusion of stored RBCs, regardless of alloantigen expression, activates conventional dendritic cells in the spleen. NOD-like receptor (NLR) inflammasomes, including NLRP3, do not regulate inflammation and alloimmunization induced by stored RBCs.
Following a blood transfusion, the immune system may produce antibodies that have detrimental effects. To understand how the immune system recognizes factors in transfused blood, we examined the immune response of mice lacking important inflammatory molecules, called inflammasomes. The results demonstrate that inflammasomes do not affect the production of potentially harmful antibodies that recognize transfused red blood cells.
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Affiliation(s)
- David R Gibb
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Samuele Calabro
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Dong Liu
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Steven L Spitalnik
- Department of Pathology & Cell Biology, Columbia University Medical Center-New York Presbyterian Hospital, NY, New York 10032, USA
| | - James C Zimring
- Bloodworks NW Research Institute, Seattle, WA 98102, USA; Department of Laboratory Medicine, University of Washington School of Medicine, Seattle, WA 98102, USA; Department of Internal Medicine-Division of Hematology, University of Washington School of Medicine, Seattle, WA 98102, USA
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Eldad A Hod
- Department of Pathology & Cell Biology, Columbia University Medical Center-New York Presbyterian Hospital, NY, New York 10032, USA.
| | - Stephanie C Eisenbarth
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06520, USA.
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Hendrickson JE, Tormey CA. Red Blood Cell Antibodies in Hematology/Oncology Patients. Hematol Oncol Clin North Am 2016; 30:635-51. [DOI: 10.1016/j.hoc.2016.01.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Solh Z, Athale U, Arnold DM, Cook RJ, Foley R, Heddle NM. Transfusion-related alloimmunization in children: epidemiology and effects of chemotherapy. Vox Sang 2016; 111:299-307. [DOI: 10.1111/vox.12419] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/15/2016] [Accepted: 04/16/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Z. Solh
- Department of Pediatrics; Faculty of Health Sciences; McMaster University; Hamilton ON Canada
- Department of Pathology and Molecular Medicine; Faculty of Health Sciences; McMaster University; Hamilton ON Canada
- Centre for Innovation; Canadian Blood Services; Hamilton ON Canada
| | - U. Athale
- Department of Pediatrics; Faculty of Health Sciences; McMaster University; Hamilton ON Canada
| | - D. M. Arnold
- Department of Medicine; Faculty of Health Sciences; McMaster University; Hamilton ON Canada
| | - R. J. Cook
- Department of Statistics and Actuarial Science; University of Waterloo; Waterloo ON Canada
| | - R. Foley
- Department of Pathology and Molecular Medicine; Faculty of Health Sciences; McMaster University; Hamilton ON Canada
| | - N. M. Heddle
- Department of Medicine; Faculty of Health Sciences; McMaster University; Hamilton ON Canada
- Centre for Innovation; Canadian Blood Services; Hamilton ON Canada
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Tatari-Calderone Z, Gordish-Dressman H, Fasano R, Riggs M, Fortier C, Campbell AD, Charron D, Gordeuk VR, Luban NLC, Vukmanovic S, Tamouza R. Protective effect of HLA-DQB1 alleles against alloimmunization in patients with sickle cell disease. Hum Immunol 2016; 77:35-40. [PMID: 26476208 PMCID: PMC4747802 DOI: 10.1016/j.humimm.2015.10.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/06/2015] [Accepted: 10/10/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Alloimmunization or the development of alloantibodies to Red Blood Cell (RBC) antigens is considered one of the major complications after RBC transfusions in patients with sickle cell disease (SCD) and can lead to both acute and delayed hemolytic reactions. It has been suggested that polymorphisms in HLA genes, may play a role in alloimmunization. We conducted a retrospective study analyzing the influence of HLA-DRB1 and DQB1 genetic diversity on RBC-alloimmunization. STUDY DESIGN Two-hundred four multi-transfused SCD patients with and without RBC-alloimmunization were typed at low/medium resolution by PCR-SSO, using IMGT-HLA Database. HLA-DRB1 and DQB1 allele frequencies were analyzed using logistic regression models, and global p-value was calculated using multiple logistic regression. RESULTS While only trends towards associations between HLA-DR diversity and alloimmunization were observed, analysis of HLA-DQ showed that HLA-DQ2 (p=0.02), -DQ3 (p=0.02) and -DQ5 (p=0.01) alleles were significantly higher in non-alloimmunized patients, likely behaving as protective alleles. In addition, multiple logistic regression analysis showed both HLA-DQ2/6 (p=0.01) and HLA-DQ5/5 (p=0.03) combinations constitute additional predictor of protective status. CONCLUSION Our data suggest that particular HLA-DQ alleles influence the clinical course of RBC transfusion in patients with SCD, which could pave the way towards predictive strategies.
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Affiliation(s)
- Zohreh Tatari-Calderone
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, 111 Michigan Avenue, N.W., Washington, DC, United States; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Heather Gordish-Dressman
- Integrative Systems Biology, George Washington University School of Medicine and Health Sciences, Washington, DC, United States; Center for Genetic Medicine Research, Children's National Health System, Washington, DC, United States
| | - Ross Fasano
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, United States; Division of Hematology and Oncology, Children's National Health System, Washington, DC, United States; Division of Laboratory Medicine, Children's National Medical Center, Washington, DC, United States
| | - Michael Riggs
- Department of Biostatistics, Cato Research, Durham, NC, United States
| | - Catherine Fortier
- Laboratoire Jean Dausset and LabEx Transplantex, INSERM UMRS 1160, Monacord and ESH, Hôpital Saint-Louis, Paris, France
| | - Andrew D Campbell
- Division of Pediatric Hematology/Oncology, University of Michigan Health System, Ann Arbor, MI, United States
| | - Dominique Charron
- Laboratoire Jean Dausset and LabEx Transplantex, INSERM UMRS 1160, Monacord and ESH, Hôpital Saint-Louis, Paris, France
| | - Victor R Gordeuk
- Section of Hematology/Oncology, University of Illinois Comprehensive Sickle Cell Center, Chicago, IL, United States
| | - Naomi L C Luban
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, United States; Division of Hematology and Oncology, Children's National Health System, Washington, DC, United States; Division of Laboratory Medicine, Children's National Medical Center, Washington, DC, United States
| | - Stanislav Vukmanovic
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, 111 Michigan Avenue, N.W., Washington, DC, United States; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Ryad Tamouza
- Laboratoire Jean Dausset and LabEx Transplantex, INSERM UMRS 1160, Monacord and ESH, Hôpital Saint-Louis, Paris, France.
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Franklin AL, Said M, Cappiello CD, Gordish-Dressman H, Tatari-Calderone Z, Vukmanovic S, Rais-Bahrami K, Luban NLC, Devaney JM, Sandler AD. Are Immune Modulating Single Nucleotide Polymorphisms Associated with Necrotizing Enterocolitis? Sci Rep 2015; 5:18369. [PMID: 26670709 PMCID: PMC4680983 DOI: 10.1038/srep18369] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 11/16/2015] [Indexed: 01/01/2023] Open
Abstract
Necrotizing enterocolitis (NEC) is a devastating gastrointestinal emergency. The purpose of this study is to determine if functional single nucleotide polymorphisms (SNPs) in immune-modulating genes pre-dispose infants to NEC. After Institutional Review Board approval and parental consent, buccal swabs were collected for DNA extraction. TaqMan allelic discrimination assays and BglII endonuclease digestion were used to genotype specific inflammatory cytokines and TRIM21. Statistical analysis was completed using logistic regression. 184 neonates were analyzed in the study. Caucasian neonates with IL-6 (rs1800795) were over 6 times more likely to have NEC (p = 0.013; OR = 6.61, 95% CI 1.48–29.39), and over 7 times more likely to have Stage III disease (p = 0.011; OR = 7.13, (95% CI 1.56–32.52). Neonates with TGFβ-1 (rs2241712) had a decreased incidence of NEC-related perforation (p = 0.044; OR = 0.28, 95% CI: 0.08–0.97) and an increased incidence of mortality (p = 0.049; OR = 2.99, 95% CI: 1.01 – 8.86). TRIM21 (rs660) was associated with NEC-related intestinal perforation (p = 0.038; OR = 4.65, 95% CI 1.09–19.78). In premature Caucasian neonates, the functional SNP IL-6 (rs1800795) is associated with both the development and increased severity of NEC. TRIM21 (rs660) and TGFβ-1 (rs2241712) were associated with NEC- related perforation in all neonates in the cohort. These findings suggest a possible genetic role in the development of NEC.
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Affiliation(s)
- Ashanti L Franklin
- Division of General and Thoracic Surgery, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
| | - Mariam Said
- Division of Neonatology, Children's National Health System, Washington, DC, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC 20010
| | - Clint D Cappiello
- Division of General and Thoracic Surgery, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
| | - Heather Gordish-Dressman
- Children's Research Institute, Children's National Health System, Washington, DC, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC 20010
| | - Zohreh Tatari-Calderone
- Sheikh Zayed Institute, Children's National Health System, Washington, DC, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC 20010
| | - Stanislav Vukmanovic
- Sheikh Zayed Institute, Children's National Health System, Washington, DC, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC 20010
| | - Khodayar Rais-Bahrami
- Division of Neonatology, Children's National Health System, Washington, DC, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC 20010
| | - Naomi L C Luban
- Department Laboratory Medicine, Children's National Health System Washington, DC, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC 20010
| | - Joseph M Devaney
- Department of Genetic Medicine, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
| | - Anthony D Sandler
- Division of General and Thoracic Surgery, Children's National Health System, Washington, DC, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC 20010
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Nickel RS, Horan JT, Fasano RM, Meyer E, Josephson CD, Winkler AM, Yee ME, Kean LS, Hendrickson JE. Immunophenotypic parameters and RBC alloimmunization in children with sickle cell disease on chronic transfusion. Am J Hematol 2015; 90:1135-41. [PMID: 26361243 DOI: 10.1002/ajh.24188] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 09/03/2015] [Accepted: 09/09/2015] [Indexed: 12/16/2022]
Abstract
Alloimmunization against red blood cell (RBC) antigens is a cause of morbidity and mortality in transfused patients with sickle cell disease (SCD). To investigate distinguishing characteristics of patients who develop RBC alloantibodies after transfusion (responders) versus those who do not (non-responders), a cross-sectional study of 90 children with SCD on chronic RBC transfusion therapy at a single institution was conducted in which 18 immune parameters (including T and B cell subsets) were tested via flow cytometry, and medical records were reviewed. RBC alloimmunization was present in 26/90 (29%) patients, with anti-E, K, and C among the most commonly detected alloantibodies despite prophylactic matching for these antigens at the study institution. In addition, RBC autoantibodies had been detected in 18/26 (69%) of alloimmunized versus 7/64 (11%) of non-alloimmunized patients (P < 0.0001). Alloimmunized patients were significantly older (median 13.0 years vs. 10.7 years, P = 0.010) and had more RBC unit exposures (median 148 U vs. 82 U, P = 0.020) than non-alloimmunized patients. Sex, age at initiation of chronic transfusion, splenectomy, stroke, and transfusion outside of the study institution were not significantly associated with RBC alloimmunization. Alloimmunized patients had a significantly increased percentage of CD4+ T memory cells compared to non-alloimmunized patients (57% vs. 49%, P = 0.0047), with no other significant differences in immune cell subsets or laboratory values detected between these groups. Additional research of RBC alloimmunization is needed to optimize transfusion therapy and to develop strategies to prevent alloimmunization.
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Affiliation(s)
- Robert S. Nickel
- Division of Hematology; Children's National Health System; Washington District of Columbia
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine; Emory University; Atlanta Georgia
| | - John T. Horan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
| | - Ross M. Fasano
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine; Emory University; Atlanta Georgia
| | - Erin Meyer
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine; Emory University; Atlanta Georgia
| | - Cassandra D. Josephson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine; Emory University; Atlanta Georgia
| | - Anne M. Winkler
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine; Emory University; Atlanta Georgia
| | - Marianne E.M. Yee
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
| | - Leslie S. Kean
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Department of Pediatrics, University of Washington, and the Fred Hutchinson Cancer Research Center; Seattle Washington
| | - Jeanne E. Hendrickson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
- Department of Laboratory Medicine; Yale University; New Haven Connecticut
- Department of Pediatrics; Yale University; New Haven Connecticut
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Caamaño J, Musante E, Contreras M, Ulloa H, Reyes C, Inaipil V, Saavedra N, Guzmán N. Frequency and specificity of red blood cell alloimmunization in chilean transfused patients. Transfus Med Hemother 2014; 42:4-7. [PMID: 25960709 DOI: 10.1159/000370136] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 12/20/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Alloimmunization is an adverse effect of blood transfusions. In Chile, alloimmunization frequency is not established, and for this reason the aim of this study was to investigate the prevalence and specificity of red blood cell (RBC) alloantibodies in Chilean transfused subjects. METHODS Records from 4,716 multi-transfused patients were analyzed. In these patients, antibody screening was carried out prior to cross-matching with a commercially available two-cell panel by the microcolum gel test, and samples with a positive screen were analyzed for the specificity of the alloantibody with a 16-cell identification panel. RESULTS The incidence of RBC alloimmunization in transfused patients was 1.02% (48/4,716) with a higher prevalence in women (40/48). We detected 52 antibodies, the most frequent specificities identified were anti-E (30.8%), anti-K (26.9%), anti-D (7.7%), and anti-Fy(a) (5.8%). The highest incidence of alloantibodies was observed in cancer and gastroenterology patients. CONCLUSION The data demonstrated a low alloimmunization frequency in Chilean transfused patients, principally associated with antibodies anti-E, anti-K, anti-D, and anti-Fy(a).
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Affiliation(s)
- José Caamaño
- Banco de Sangre Hospital Dr. Hernán Henríquez Aravena, Temuco, Chile ; Facultad de Salud Universidad Santo Tomás, Temuco, Chile
| | - Evangelina Musante
- Banco de Sangre Hospital Dr. Hernán Henríquez Aravena, Temuco, Chile ; Facultad de Salud Universidad Santo Tomás, Temuco, Chile
| | | | - Hernán Ulloa
- Banco de Sangre Hospital Dr. Hernán Henríquez Aravena, Temuco, Chile
| | - Carolina Reyes
- Banco de Sangre Hospital Dr. Hernán Henríquez Aravena, Temuco, Chile
| | - Verónica Inaipil
- Banco de Sangre Hospital Dr. Hernán Henríquez Aravena, Temuco, Chile
| | - Nicolás Saavedra
- Centro de Biología Molecular y Farmacogenética, Núcleo Científico-Tecnológico en Biorecursos, Universidad de La Frontera, Temuco, Chile
| | - Neftalí Guzmán
- Escuela de Ciencias de la Salud, Universidad Católica de Temuco, Temuco, Chile ; Facultad de Ciencias de la Salud, Universidad San Sebastián, Concepción, Chile
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Telen MJ, Afenyi-Annan A, Garrett ME, Combs MR, Orringer EP, Ashley-Koch AE. Alloimmunization in sickle cell disease: changing antibody specificities and association with chronic pain and decreased survival. Transfusion 2014; 55:1378-87. [PMID: 25444611 DOI: 10.1111/trf.12940] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 09/14/2014] [Accepted: 09/30/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Alloimmunization remains a significant complication of transfusion and has been associated with multiple factors, including inflammation, an important pathophysiologic mechanism in sickle cell disease (SCD). We explored whether alloimmunization is associated with disease severity in SCD. STUDY DESIGN AND METHODS Adult SCD patients were enrolled in a study of outcome-modifying genes in SCD. Historical records of patients with SCD at two participating institutions were reviewed for data on antigen phenotype and alloimmunization. Differences in demographic, clinical, and laboratory findings; end-organ damage; and overall disease severity were then compared between alloimmunized and nonalloimmunized patients. RESULTS Of 319 patients, 87 (27%) were alloimmunized. Alloantibody specificities differed from those previously described, especially due to the significantly higher frequency of anti-S. Although alloimmunization was not associated with frequency of vasoocclusive episodes, a higher percentage of alloimmunized patients had chronic pain, as defined by daily use of short-acting narcotics (p = 0.006), long-acting narcotics (p = 0.013), or both (p = 0.03). Additionally, alloimmunized patients had poorer survival (hazard ratio, 1.92; p = 0.01) and were more likely to have avascular necrosis (p = 0.024), end-organ damage (p = 0.049), and red blood cell autoantibodies (p < 0.001), even after controlling for the effects of age, sex, and hemoglobin diagnosis. Alloimmunization was not associated with other SCD-related complications, such as acute chest syndrome or stroke. CONCLUSION Alloimmunization in SCD may be associated with chronic pain, risk of end-organ damage, and shorter survival. These novel findings suggest new directions for the investigation of immune response-mediated pathways common to alloimmunization and chronic pain.
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Affiliation(s)
- Marilyn J Telen
- Department of Medicine, Division of Hematology, Duke University Medical Center, Durham, North Carolina
| | - Araba Afenyi-Annan
- Department of Pathology & Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Melanie E Garrett
- Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina
| | - Martha R Combs
- Transfusion Service, Duke Hospital, Durham, North Carolina
| | - Eugene P Orringer
- Department of Medicine, Division of Hematology & Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Allison E Ashley-Koch
- Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina
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Tatari-Calderone Z, Luban NLC, Vukmanovic S. Genetics of transfusion recipient alloimmunization: can clues from susceptibility to autoimmunity pave the way? ACTA ACUST UNITED AC 2014; 41:436-45. [PMID: 25670931 DOI: 10.1159/000369145] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 10/01/2014] [Indexed: 01/08/2023]
Abstract
The search for genetic determinants of alloimmunization in sickle cell disease transfusion recipients was based on two premises: i) that polymorphisms responsible for stronger immune and/or inflammatory responses and hemoglobin β(S) mutation were co-selected by malaria; and ii) that stronger responder status contributes to development of lupus. We found a marker of alloimmunization in the gene encoding for Ro52 protein, also known as Sjögren syndrome antigen 1 (SSA1) and TRIM21. Surprisingly, the nature of the association was opposite of that with lupus; the same variant of a polymorphism (rs660) that was associated with lupus incidence was also associated with induction of tolerance to red blood cell antigens during early childhood. The dual function of Ro52 can explain this apparent contradiction. We propose that other lupus/autoimmunity susceptibility loci may reveal roles of additional molecules in various aspects of alloimmunization induced by transfusion as well as during pregnancy.
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Affiliation(s)
- Zohreh Tatari-Calderone
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, Washington, DC, USA ; Department of Pediatrics, George Washington University School of Medicine, Washington, DC, USA
| | - Naomi L C Luban
- Department of Pediatrics, George Washington University School of Medicine, Washington, DC, USA ; Division of Laboratory Medicine, Children's National Medical Center, Washington, DC, USA
| | - Stanislav Vukmanovic
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, Washington, DC, USA ; Department of Pediatrics, George Washington University School of Medicine, Washington, DC, USA
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Hanchard NA, Moulds JM, Belmont JW, Chen A. A Genome-Wide Screen for Large-Effect Alloimmunization Susceptibility Loci among Red Blood Cell Transfusion Recipients with Sickle Cell Disease. ACTA ACUST UNITED AC 2014; 41:453-61. [PMID: 25670933 DOI: 10.1159/000369079] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 10/01/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND A selective susceptibility of certain individuals to form multiple alloantibodies in response to red cell transfusion is well-recognized in clinical practice, and is a particular problem in persons with sickle cell disease (SCD). The reason for this differential susceptibility is unclear, but inter-individual genetic differences are likely to contribute. METHODS We conducted a pilot case-control genome-wide association study using 1,000,000 SNPs in 94 alloimmune responders (cases) and non-responders (controls) with SCD in order to identify loci of large effect size associated with alloimmunization. RESULTS No loci showed evidence of association at a genome-wide significance cut-off (p < 0.5 × 10(-8)). SNPs in the ARAP1/STARD10 region showed suggestive association (p < 1 × 10(-6)), but no association was observed at previously implicated loci TRIM21 or HLA. In analyses of the number of accumulated antibodies, a modest association was found with SNPs in the Toll-like receptor gene TLR10 (p < 1 × 10(-4)). CONCLUSIONS Alloimmunization in persons with SCD is unlikely to be mediated by loci of very large effect size; however, larger and more comprehensive studies are required to fully evaluate loci with more moderate effects. This study provides a working approach to such future studies in SCD.
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Affiliation(s)
- Neil A Hanchard
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA ; ARS/USDA/Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Joann M Moulds
- Scientific Support Services, LifeShare Blood Centers, Shreveport, LA, USA
| | - John W Belmont
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA ; ARS/USDA/Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Alice Chen
- Department of Pathology, Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX, USA
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Ryder AB, Zimring JC, Hendrickson JE. Factors Influencing RBC Alloimmunization: Lessons Learned from Murine Models. Transfus Med Hemother 2014; 41:406-19. [PMID: 25670928 PMCID: PMC4280453 DOI: 10.1159/000368995] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 10/01/2014] [Indexed: 01/25/2023] Open
Abstract
Red blood cell (RBC) alloimmunization may occur following transfusion or pregnancy/delivery. Although observational human studies have described the immunogenicity of RBC antigens and the clinical significance of RBC alloantibodies, studies of factors influencing RBC alloimmunization in humans are inherently limited by the large number of independent variables involved. This manuscript reviews data generated in murine models that utilize transgenic donor mice, which express RBC-specific model or authentic human blood group antigens. Transfusion of RBCs from such donors into nontransgenic but otherwise genetically identical recipient mice allows for the investigation of individual donor or recipient-specific variables that may impact RBC alloimmunization. Potential donor-related variables include methods of blood product collection, processing and storage, donor-specific characteristics, RBC antigen-specific factors, and others. Potential recipient-related variables include genetic factors (MHC/HLA type and polymorphisms of immunoregulatory genes), immune activation status, phenotype of regulatory immune cell subsets, immune cell functional characteristics, prior antigen exposures, and others. Although murine models are not perfect surrogates for human biology, these models generate phenomenological and mechanistic hypotheses of RBC alloimmunization and lay the groundwork for follow-up human studies. Long-term goals include improving transfusion safety and minimizing the morbidity/mortality associated with RBC alloimmunization.
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Affiliation(s)
- Alex B. Ryder
- Yale University School of Medicine, Department of Laboratory Medicine, New Haven, CT, USA
| | - James C. Zimring
- Puget Sound Blood Center Research Institute, Seattle, WA, USA
- University of Washington, Department of Laboratory Medicine, Seattle, WA, USA
| | - Jeanne E. Hendrickson
- Yale University School of Medicine, Department of Laboratory Medicine, New Haven, CT, USA
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Campbell-Lee SA, Kittles RA. Red blood cell alloimmunization in sickle cell disease: listen to your ancestors. Transfus Med Hemother 2014; 41:431-5. [PMID: 25670930 PMCID: PMC4280449 DOI: 10.1159/000369513] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 10/21/2014] [Indexed: 11/19/2022] Open
Abstract
Red blood cell (RBC) alloimmunization occurs in approximately 30% of transfused sickle cell disease patients compared to 2-5% of all transfusion recipients. Because RBC transfusion is an important part of therapy in sickle cell disease, the need for additional antigen matching once alloimmunization occurs is problematic and leads to therapeutic limitations. Thus, identification of risk factors would benefit this patient population. Genome-wide analyses, in particular, methods which take into account genetic ancestry such as admixture mapping, could identify molecular markers which could be used to identify immune responders to transfusion.
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36
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Affiliation(s)
- Daniel R Ambruso
- University of Colorado, Denver, Children's Hospital Colorado, Center for Cancer and Blood Disorders, Aurora, CO.
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37
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Genomics in premature infants: a non-invasive strategy to obtain high-quality DNA. Sci Rep 2014; 4:4286. [PMID: 24598548 PMCID: PMC3944721 DOI: 10.1038/srep04286] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 02/18/2014] [Indexed: 12/30/2022] Open
Abstract
We used a cost-effective, non-invasive method to obtain high-quality DNA from buccal epithelial-cells (BEC) of premature infants for genomic analysis. DNAs from BEC were obtained from premature infants with gestational age ≤ 36 weeks. Short terminal repeats (STRs) were performed simultaneously on DNA obtained from the buccal swabs and blood from the same patient. The STR profiles demonstrated that the samples originated from the same individual and exclude any contamination by external DNAs. Whole exome sequencing was performed on DNAs obtained from BEC on premature infants with and without necrotizing enterocolitis, and successfully provided a total number of reads and variants corroborating with those obtained from healthy blood donors. We provide a proof of concept that BEC is a reliable and preferable source of DNA for high-throughput sequencing in premature infants.
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38
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From Donor to Recipient: Current Questions Relating to Humoral Alloimmunization. Antibodies (Basel) 2014. [DOI: 10.3390/antib3010130] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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39
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Bao W, Zhong H, Manwani D, Vasovic L, Uehlinger J, Lee MT, Sheth S, Shi P, Yazdanbakhsh K. Regulatory B-cell compartment in transfused alloimmunized and non-alloimmunized patients with sickle cell disease. Am J Hematol 2013; 88:736-40. [PMID: 23720018 DOI: 10.1002/ajh.23488] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 05/15/2013] [Indexed: 01/01/2023]
Abstract
Transfusion therapy is a life-sustaining treatment for patients with sickle cell disease (SCD), but can cause serious complications including alloimmunization. We previously reported diminished regulatory T cells (Tregs) and skewed Th2 responses in alloimmunized SCD patients. We hypothesized that the B cell regulatory (Breg) compartment, which controls Treg and Th differentiation, may also be compromised in allosensitized SCD patients. Phenotypically, we did not find differences in the frequency or numbers of CD24(hi) CD38(hi) and CD24(hi) CD27(+) B cell subsets, both previously identified as human Bregs, between alloimmunized and non-alloimmunized SCD patients on regular transfusions. However, at the functional level, CD19+ B cells from alloimmunized SCD patients expressed lower levels of IL-10 following stimulation as compared with non-alloimmunized patients (P < 0.05), and had reduced ability in inhibiting autologous CD14+ monocyte TNF-α expression (P < 0.05). These findings suggest that Bregs from alloimmunized and non-alloimmunized SCD patients differ in their ability to produce IL-10 and dampen monocyte activation, all consistent with an altered immunoregulatory state in alloimmunized SCD patients.
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Affiliation(s)
- Weili Bao
- Laboratory of Complement Biology, New York Blood Center; New York; New York
| | - Hui Zhong
- Laboratory of Complement Biology, New York Blood Center; New York; New York
| | - Deepa Manwani
- Montefiore Medical Center, Albert Einstein College of Medicine; Bronx; New York
| | - Ljiljana Vasovic
- Montefiore Medical Center, Albert Einstein College of Medicine; Bronx; New York
| | - Joan Uehlinger
- Montefiore Medical Center, Albert Einstein College of Medicine; Bronx; New York
| | - Margaret T. Lee
- Pediatric Hematology; Columbia University Medical Center; New York; New York
| | - Sujit Sheth
- Division of Pediatric Hematology-Oncology, Weill Cornell Medical College; New York; New York
| | - Patricia Shi
- Clinical Services, New York Blood Center; New York; New York
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40
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Vichinsky E, Neumayr L, Trimble S, Giardina PJ, Cohen AR, Coates T, Boudreaux J, Neufeld EJ, Kenney K, Grant A, Thompson AA. Transfusion complications in thalassemia patients: a report from the Centers for Disease Control and Prevention (CME). Transfusion 2013; 54:972-81; quiz 971. [PMID: 23889533 DOI: 10.1111/trf.12348] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 05/06/2013] [Accepted: 06/01/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Transfusions are the primary therapy for thalassemia but have significant cumulative risks. In 2004, the Centers for Disease Control and Prevention (CDC) established a national blood safety monitoring program for thalassemia. This report summarizes the population and their previous nonimmune and immune transfusion complications. STUDY DESIGN AND METHODS The CDC Thalassemia Blood Safety Network is a consortium of centers longitudinally following patients. Enrollment occurred from 2004 through 2012. Demographics, transfusion history, infectious exposures, and transfusion and nontransfusion complications were summarized. Logistic regression analyses of factors associated with allo- and autoimmunization were employed. RESULTS The race/ethnicity of these 407 thalassemia patients was predominantly Asian or Caucasian. The mean ± SD age was 22.3 ± 13.2 years and patients had received a mean ± SD total number of 149 ± 103.4 units of red blood cells (RBCs). Multiorgan dysfunction was common despite chelation. Twenty-four percent of transfused patients had previous exposure to possible transfusion-associated pathogens including one case of babesia. As 27% were immigrants, the infection source cannot be unequivocally linked to transfusion. Transfusion reactions occurred in 48%, including allergic, febrile, and hemolytic; 19% were alloimmunized. Common antigens were E, Kell, and C. Years of transfusion was the strongest predictor of alloimmunization. Autoantibodies occurred in 6.5% and were associated with alloimmunization (p < 0.0001). Local institutional policies, not patient characteristics, were major determinants of blood preparation and transfusion practices. CONCLUSION Hemosiderosis, transfusion reactions, and infections continue to be major problems in thalassemia. New pathogens were noted. National guidelines for RBC phenotyping and preparation are needed to decrease transfusion-related morbidity.
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Affiliation(s)
- Elliott Vichinsky
- Children's Hospital Oakland, Oakland, California; Centers for Disease Control and Prevention, Atlanta, Georgia; Weill Medical College of Cornell University, New York, New York; Children's Hospital Philadelphia, Philadelphia, Pennsylvania; Children's Hospital Los Angeles, Los Angeles, California; Children's Healthcare of Atlanta at Scottish Rite, Atlanta, Georgia; Boston Children's Hospital, Boston, Massachusetts; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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41
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The association of CD81 polymorphisms with alloimmunization in sickle cell disease. Clin Dev Immunol 2013; 2013:937846. [PMID: 23762099 PMCID: PMC3674646 DOI: 10.1155/2013/937846] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 04/17/2013] [Accepted: 04/18/2013] [Indexed: 01/19/2023]
Abstract
The goal of the present work was to identify the candidate genetic markers predictive of alloimmunization in sickle cell disease (SCD). Red blood cell (RBC) transfusion is indicated for acute treatment, prevention, and abrogation of some complications of SCD. A well-known consequence of multiple RBC transfusions is alloimmunization. Given that a subset of SCD patients develop multiple RBC allo-/autoantibodies, while others do not in a similar multiple transfusional setting, we investigated a possible genetic basis for alloimmunization. Biomarker(s) which predicts (predict) susceptibility to alloimmunization could identify patients at risk before the onset of a transfusion program and thus may have important implications for clinical management. In addition, such markers could shed light on the mechanism(s) underlying alloimmunization. We genotyped 27 single nucleotide polymorphisms (SNPs) in the CD81, CHRNA10, and ARHG genes in two groups of SCD patients. One group (35) of patients developed alloantibodies, and another (40) had no alloantibodies despite having received multiple transfusions. Two SNPs in the CD81 gene, that encodes molecule involved in the signal modulation of B lymphocytes, show a strong association with alloimmunization. If confirmed in prospective studies with larger cohorts, the two SNPs identified in this retrospective study could serve as predictive biomarkers for alloimmunization.
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42
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Chou ST, Liem RI, Thompson AA. Challenges of alloimmunization in patients with haemoglobinopathies. Br J Haematol 2012; 159:394-404. [PMID: 23034087 DOI: 10.1111/bjh.12061] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Red blood cell (RBC) transfusions can be life-sustaining in chronic inherited anaemias, such as thalassaemia, and the indications for blood transfusions in patients with sickle cell disease continue to expand. Complications of transfusions, such as allosensitization, can create significant medical challenges in the management of patients with haemoglobinopathies. This review summarizes key findings from the medical literature related to alloimmunization in haemoglobinopathies and examines potential measures to mitigate these risks. Areas where future studies are needed are also addressed.
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Affiliation(s)
- Stella T Chou
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
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43
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Zimring JC, Stowell SR, Johnsen JM, Hendrickson JE. Effects of genetic, epigenetic, and environmental factors on alloimmunization to transfused antigens: Current paradigms and future considerations. Transfus Clin Biol 2012; 19:125-31. [PMID: 22682308 DOI: 10.1016/j.tracli.2012.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 03/24/2012] [Indexed: 01/03/2023]
Abstract
Transfused red blood cells, platelets, or coagulation factors have the capacity to induce alloantibodies, which once formed, can be a clinical barrier to future transfusion therapy and/or transplantation. Large observational studies over the last 50 years have characterized some of the general properties of transfusion induced alloimmunization, which appear to vary to a considerable extent from what is generally observed for human responses to other immunogens, such as microbial pathogens and vaccines. Transfused cells and factor only induce immune responses in the minority of recipients. There are data to suggest that differences in the unit may play a role. However, there are clearly differences in recipient biology, as once a recipient makes one antibody they are much more likely to make additional antibodies; indeed, recipients have been categorized as "responder" and "non-responder" by the field. Recent mechanistic studies have begun to define potential causes for such differences in alloimmunization from patient to patient, but much progress needs to be made to understand how, why, and in whom alloimmunization occurs. This review gives a general background on immunology in the context of transfusion, summarizes recent progress in the field, and discusses future directions for exploration. Particular attention is paid to the general concept that the human immune system is melded by the wide range of antigens encountered in our environment, and that the effects of such on the immune system may have a profound effect upon response to transfused cells.
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Affiliation(s)
- J C Zimring
- Puget Sound Blood Center Research Institute, 1551, Eastlake Avenue E, Seattle, WA 98102, USA.
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44
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Autoantigen TRIM21/Ro52 as a Possible Target for Treatment of Systemic Lupus Erythematosus. Int J Rheumatol 2012; 2012:718237. [PMID: 22701487 PMCID: PMC3373075 DOI: 10.1155/2012/718237] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 04/01/2012] [Accepted: 04/02/2012] [Indexed: 11/18/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic, systemic, and autoimmune disease, whose etiology is still unknown. Although there has been progress in the treatment of SLE through the use of glucocorticoid and immunosuppressive drugs, these drugs have limited efficacy and pose significant risks of toxicity. Moreover, prognosis of patients with SLE has remained difficult to assess. TRIM21/Ro52/SS-A1, a 52-kDa protein, is an autoantigen recognized by antibodies in sera of patients with SLE and Sjögren's syndrome (SS), another systemic autoimmune disease, and anti-TRIM21 antibodies have been used as a diagnostic marker for decades. TRIM21 belongs to the tripartite motif-containing (TRIM) super family, which has been found to play important roles in innate and acquired immunity. Recently, TRIM21 has been shown to be involved in both physiological immune responses and pathological autoimmune processes. For example, TRIM21 ubiquitylates proteins of the interferon-regulatory factor (IRF) family and regulates type I interferon and proinflammatory cytokines. In this paper, we summarize molecular features of TRIM21 revealed so far and discuss its potential as an attractive therapeutic target for SLE.
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45
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Red blood cell alloimmunization in sickle cell disease: pathophysiology, risk factors, and transfusion management. Blood 2012; 120:528-37. [PMID: 22563085 DOI: 10.1182/blood-2011-11-327361] [Citation(s) in RCA: 271] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Red blood cell transfusions have reduced morbidity and mortality for patients with sickle cell disease. Transfusions can lead to erythrocyte alloimmunization, however, with serious complications for the patient including life-threatening delayed hemolytic transfusion reactions and difficulty in finding compatible units, which can cause transfusion delays. In this review, we discuss the risk factors associated with alloimmunization with emphasis on possible mechanisms that can trigger delayed hemolytic transfusion reactions in sickle cell disease, and we describe the challenges in transfusion management of these patients, including opportunities and emerging approaches for minimizing this life-threatening complication.
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46
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Campbell-Lee SA. Red blood cell alloimmunization in sickle cell anemia: more questions than answers? Transfusion 2012; 52:214-6. [DOI: 10.1111/j.1537-2995.2011.03502.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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47
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Hendrickson JE, Hod EA, Perry JR, Ghosh S, Chappa P, Adisa O, Kean LS, Ofori-Acquah SF, Archer DR, Spitalnik SL, Zimring JC. Alloimmunization to transfused HOD red blood cells is not increased in mice with sickle cell disease. Transfusion 2011; 52:231-40. [PMID: 21790627 DOI: 10.1111/j.1537-2995.2011.03255.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Increased rates of red blood cell (RBC) alloimmunization in patients with sickle cell disease may be due to transfusion frequency, genetic predisposition, or immune dysregulation. To test the hypothesis that sickle cell pathophysiology influences RBC alloimmunization, we utilized two transgenic mouse models of sickle cell disease. STUDY DESIGN AND METHODS Transgenic sickle mice, which express human α and β(S) globin, were transfused with fresh or 14-day-stored RBCs containing the HOD (hen egg lysozyme, ovalbumin, and human Duffy(b) ) antigen; some recipients were inflamed with poly(I : C) before transfusion. Anti-HOD alloantibody responses were subsequently measured by enzyme-linked immunosorbent assay and flow crossmatch; a cohort of recipients had posttransfusion serum cytokines measured by bead array. RESULTS Both Berkeley and Townes homozygous (SS) and heterozygous (AS) mice had similar rates and magnitude of anti-HOD RBC alloimmunization after fresh HOD RBC transfusion compared with control animals; under no tested condition did homozygous SS recipients make higher levels of alloantibodies than control animals. Unexpectedly, homozygous SS recipients had blunted cytokine responses and lower levels of anti-HOD alloantibodies after transfusion of 14-day stored RBCs, compared with control animals. CONCLUSIONS In sum, homozygous β(S) expression and the ensuing disease state are not alone sufficient to enhance RBC alloimmunization to transfused HOD RBCs in two distinct humanized murine models of sickle cell disease under the conditions examined. These data suggest that other factors may contribute to the high rates of RBC alloimmunization observed in humans with sickle cell disease.
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Affiliation(s)
- Jeanne E Hendrickson
- Department of Pediatrics, Aflac Cancer Center and Blood Disorders Service, Children's Healthcare of Atlanta, Atlanta, GA 30322, USA.
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Fertrin KY, Costa FF. Genomic polymorphisms in sickle cell disease: implications for clinical diversity and treatment. Expert Rev Hematol 2011; 3:443-58. [PMID: 21083035 DOI: 10.1586/ehm.10.44] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Sickle cell disease (SCD) is one of the best characterized human monogenic disorders. The development of molecular biology allowed the identification of several genomic polymorphisms responsible for its clinical diversity. Research on the first genetic modulators of SCD, such as coinheritance of α-thalassemia and haplotypes in the β-globin gene cluster, have been followed by studies associating single nucleotide polymorphisms (SNPs) with variable risks for stroke, leg ulceration, pulmonary hypertension, priapism and osteonecrosis, with differences in the response to hydroxyurea, and with variability in the management of pain. Furthermore, multigenic analyses based on genome-wide association studies have shed light on the importance of the TGF-β superfamily and oxidative stress to the pathogenesis of complex traits in SCD, and may guide future therapeutic interventions on a genetically oriented basis.
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Affiliation(s)
- Kleber Yotsumoto Fertrin
- Hematology and Hemotherapy Center, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Distrito de Barão Geraldo, Campinas, SP 13083-878, Brazil
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Alloimmunization against RBC or PLT antigens is independent of TRIM21 expression in a murine model. Mol Immunol 2011; 48:909-13. [PMID: 21269695 DOI: 10.1016/j.molimm.2010.12.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 12/21/2010] [Accepted: 12/23/2010] [Indexed: 01/01/2023]
Abstract
Generation of alloantibodies to transfused RBCs can be a serious medical problem for patients who require chronic RBC transfusion therapy. Patients with sickle cell disease have a substantially increased rate of alloimmunization compared to other chronically transfused populations. A recent study has forwarded the hypothesis that a polymorphism in an immunoregulatory gene in close proximity to beta-globin (TRIM21 rs660) plays a role in the increased rates of RBC alloimmunization in sickle cell patients. In particular, it was hypothesized that rs660C/T decreases expression of TRIM21, resulting in loss of a negative feedback pathway in immune responses and increased RBC alloimmunization. To test the effects of TRIM21 expression on alloimmunization, we analyzed antibody responses to alloantigens on RBCs and platelets transfused into wild-type and TRIM21 KO mice. No significant increases were seen in the frequency or magnitude of humoral immunization to alloantigens on transfused RBCs or platelets in adult or juvenile TRIM21 KO recipients compared to wild-type controls. Moreover, recipient inflammation with poly (I:C) enhanced RBC alloimmunization to similar degrees in both TRIM21 KO and wild-type control recipients. Together, these data rule out the hypothesis that decreased TRIM21 expression enhances transfusion induced humoral alloimmunization, in the context of a reductionist murine model.
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50
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Zimring JC. Recent developments and future directions of alloimmunization to transfused blood products. Clin Lab Med 2010; 30:467-73. [PMID: 20513564 DOI: 10.1016/j.cll.2010.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Monitoring and managing alloimmunization are among the primary functions of the clinical transfusion medicine laboratory. However, despite hundreds of different blood group antigens that vary from person to person, only a minority of transfusion recipients become alloimmunized. Currently, there are no tests that predict which patients will become alloimmunized. Moreover, there are no therapeutic interventions to prevent alloimmunization (outside of RhD immune globulin) besides phenotypic matching. Understanding the biologic factors that regulate alloimmunization may allow the generation of clinical tests with predictive capabilities and provide a rational basis for developing therapeutic interventions. This article summarizes recent advances in understanding alloimmunization, with a focus of identifying future directions in laboratory testing and management of transfusion. In addition to analyzing humoral alloimmunization, potential extensions of transfusion medicine to sequelae of cellular immunization are explored.
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Affiliation(s)
- James C Zimring
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, 101 Woodruff Circle, Atlanta, GA 30322, USA.
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