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Berentsen S, Vos JMI, Malecka A, Tjønnfjord GE, D'Sa S. The impact of individual clinical features in cold agglutinin disease: hemolytic versus non-hemolytic symptoms. Expert Rev Hematol 2024; 17:479-492. [PMID: 38938203 DOI: 10.1080/17474086.2024.2372333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/21/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION During the last decades, the pathogenesis of cold agglutinin disease (CAD) has been well elucidated and shown to be complex. Several documented or investigational therapies have been made available. This development has resulted in major therapeutic advances, but also in challenges in choice of therapy. AREAS COVERED In this review, we address each step in pathogenesis: bone marrow clonal lymphoproliferation, composition and effects of monoclonal cold agglutinin, non-complement mediated erythrocyte agglutination, complement-dependent hemolysis, and other effects of complement activation. We also discuss the heterogeneous clinical features and their relation to specific steps in pathogenesis, in particular with respect to the impact of complement involvement. CAD can be classified into three clinical phenotypes with consequences for established treatments as well as development of new therapies. Some promising future treatment approaches - beyond chemoimmunotherapy and complement inhibition - are reviewed. EXPERT OPINION The patient's individual clinical profile regarding complement involvement and hemolytic versus non-hemolytic features is important for the choice of treatment. Further development of treatment approaches is encouraged, and some candidate drugs are promising irrespective of clinical phenotype. Patients with CAD requiring therapy should be considered for inclusion in clinical trials.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
| | | | - Agnieszka Malecka
- Department of Haematology, Oslo University Hospital, Oslo, Norway
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Shirley D'Sa
- UCLH Centre for Waldenstrom macroglobulinaemia and Related Conditions, University College London Hospitals NHS Foundation Trust, London, UK
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Jalink M, Yan MTS, Cohn CS, Eichbaum QG, Fung MK, Lu W, Murphy MF, Pagano MB, Stanworth SJ, Shih AW. Systematic review for the serological testing for cold agglutinins: The BEST collaborative study. Transfusion 2024; 64:1331-1349. [PMID: 38642020 DOI: 10.1111/trf.17842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/16/2024] [Accepted: 04/08/2024] [Indexed: 04/22/2024]
Affiliation(s)
- Marit Jalink
- Center for Clinical Transfusion Research, Sanquin Research, Amsterdam, The Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthew T S Yan
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Medical Affairs and Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Quentin G Eichbaum
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark K Fung
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Wen Lu
- Department of Laboratory Medicine and Pathology, Center for Regenerative Biotherapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael F Murphy
- NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, and the University of Oxford, Oxford, UK
| | - Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Washington, USA
| | - Simon J Stanworth
- NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, and the University of Oxford, Oxford, UK
| | - Andrew W Shih
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
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Shen W, Zhang E, Kasinath N, Kazior M. Cold Agglutinins Causing Intracoronary Hemagglutination During Premature Ventricular Contraction Ablation Requiring Thrombectomy and Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2023; 37:2305-2309. [PMID: 37635040 DOI: 10.1053/j.jvca.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Wesley Shen
- Virginia Commonwealth University School of Medicine, Richmond, VA.
| | - Elizabeth Zhang
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Nagesha Kasinath
- Department of Anesthesiology, Hunter Holmes McGuire VA Medical Center, Richmond, VA
| | - Michael Kazior
- Department of Anesthesiology, Hunter Holmes McGuire VA Medical Center, Richmond, VA; Department of Anesthesiology, Virginia Commonwealth University Health, Richmond, VA
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Schmidt HM, DeVallance ER, Lewis SE, Wood KC, Annarapu GK, Carreño M, Hahn SA, Seman M, Maxwell BA, Hileman EA, Xu JZ, Velayutham M, Geldenhuys WJ, Vitturi DA, Shiva S, Kelley EE, Straub AC. Release of hepatic xanthine oxidase (XO) to the circulation is protective in intravascular hemolytic crisis. Redox Biol 2023; 62:102636. [PMID: 36906950 PMCID: PMC10025133 DOI: 10.1016/j.redox.2023.102636] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/09/2023] [Accepted: 02/11/2023] [Indexed: 02/15/2023] Open
Abstract
Xanthine oxidase (XO) catalyzes the catabolism of hypoxanthine to xanthine and xanthine to uric acid, generating oxidants as a byproduct. Importantly, XO activity is elevated in numerous hemolytic conditions including sickle cell disease (SCD); however, the role of XO in this context has not been elucidated. Whereas long-standing dogma suggests elevated levels of XO in the vascular compartment contribute to vascular pathology via increased oxidant production, herein, we demonstrate, for the first time, that XO has an unexpected protective role during hemolysis. Using an established hemolysis model, we found that intravascular hemin challenge (40 μmol/kg) resulted in a significant increase in hemolysis and an immense (20-fold) elevation in plasma XO activity in Townes sickle cell phenotype (SS) sickle mice compared to controls. Repeating the hemin challenge model in hepatocyte-specific XO knockout mice transplanted with SS bone marrow confirmed the liver as the source of enhanced circulating XO as these mice demonstrated 100% lethality compared to 40% survival in controls. In addition, studies in murine hepatocytes (AML12) revealed hemin mediates upregulation and release of XO to the medium in a toll like receptor 4 (TLR4)-dependent manner. Furthermore, we demonstrate that XO degrades oxyhemoglobin and releases free hemin and iron in a hydrogen peroxide-dependent manner. Additional biochemical studies revealed purified XO binds free hemin to diminish the potential for deleterious hemin-related redox reactions as well as prevents platelet aggregation. In the aggregate, data herein reveals that intravascular hemin challenge induces XO release by hepatocytes through hemin-TLR4 signaling, resulting in an immense elevation of circulating XO. This increased XO activity in the vascular compartment mediates protection from intravascular hemin crisis by binding and potentially degrading hemin at the apical surface of the endothelium where XO is known to be bound and sequestered by endothelial glycosaminoglycans (GAGs).
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Affiliation(s)
- Heidi M Schmidt
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Evan R DeVallance
- Center for Inhalation Toxicology, West Virginia University School of Medicine, Morgantown, WV, USA; Department of Physiology and Pharmacology, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Sara E Lewis
- Department of Physiology and Pharmacology, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Katherine C Wood
- Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gowtham K Annarapu
- Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mara Carreño
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott A Hahn
- Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Madison Seman
- Department of Physiology and Pharmacology, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Brooke A Maxwell
- Department of Physiology and Pharmacology, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Emily A Hileman
- Department of Physiology and Pharmacology, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Julia Z Xu
- Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA; Division of Hematology /Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Werner J Geldenhuys
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV, USA; Department of Neuroscience, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Dario A Vitturi
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA; Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sruti Shiva
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA; Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Eric E Kelley
- Department of Physiology and Pharmacology, Health Sciences Center, West Virginia University, Morgantown, WV, USA.
| | - Adam C Straub
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA; Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.
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Gelbenegger G, Berentsen S, Jilma B. Monoclonal antibodies for treatment of cold agglutinin disease. Expert Opin Biol Ther 2023; 23:395-406. [PMID: 37128907 DOI: 10.1080/14712598.2023.2209265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Cold agglutinin disease (CAD) is a difficult-to-treat autoimmune hemolytic anemia and B cell lymphoproliferative disorder associated with fatigue, acrocyanosis and a risk of thromboembolic events. Cold-induced binding of autoantibodies agglutinates red blood cells and triggers the classical complement pathway, leading to predominantly extravascular hemolysis. AREAS COVERED This review summarizes clinical and experimental antibody-based treatments for CAD and analyzes the risks and benefits of B cell and complement directed therapies, and discusses potential future treatments for CAD. EXPERT OPINION Conventional treatment of CAD includes a B cell targeted treatment approach with rituximab, yielding only limited treatment success. Addition of a cytotoxic agent (e.g. bendamustine) increases efficacy but this is accompanied by an increased risk of neutropenia and infection. Novel complement-directed therapies have emerged and were shown to have a good efficacy against hemolysis and safety profile but are expensive and unable to address circulatory symptoms. Complement inhibition with sutimlimab may be used as a bridging strategy until B cell directed therapy with rituximab takes effect or continued indefinitely if needed. Future antibody-based treatment approaches for CAD involve the further development of complement-directed antibodies, combination of rituximab and bortezomib, and daratumumab. Non-antibody based prospective treatments may include the use of Bruton tyrosine kinase inhibitors.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Berentsen S, Barcellini W, D'Sa S, Jilma B. Sutimlimab for treatment of cold agglutinin disease: why, how and for whom? Immunotherapy 2022; 14:1191-1204. [PMID: 35946351 DOI: 10.2217/imt-2022-0085] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Therapies for cold agglutinin disease have been directed at the pathogenic B-cell clone. Sutimlimab, a monoclonal antibody that targets C1s, is the first complement inhibitor to be extensively studied in cold agglutinin disease. Sutimlimab selectively blocks the classical activation pathway and leaves the alternative and lectin pathways intact. Trials have documented high response rates with rapid improvement in hemolysis, hemoglobin levels and fatigue scores and low toxicity. Sutimlimab was recently approved in the USA. This drug appears to be particularly useful in severely anemic patients who require a rapid response, in acute exacerbations that do not resolve spontaneously and in patients in whom chemoimmunotherapy is contraindicated or has failed. The choice of therapy in cold agglutinin disease should be individualized.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
| | - Wilma Barcellini
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shirley D'Sa
- University College London Hospitals Centre for Waldenström and Associated Conditions, University College London Hospitals National Health Service Foundation Trust, London, UK
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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7
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Patriquin CJ, Pavenski K. O, wind, if winter comes … will symptoms be far behind?: Exploring the seasonality (or lack thereof) and management of cold agglutinin disease. Transfusion 2021; 62:2-10. [PMID: 34893982 DOI: 10.1111/trf.16765] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 12/04/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Christopher J Patriquin
- Division of Medical Oncology & Hematology, University Health Network, Toronto General Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Katerina Pavenski
- Departments of Medicine & Laboratory Medicine, St. Michael's Hospital, Toronto, Canada.,Departments of Medicine & Laboratory Medicine, University of Toronto, Toronto, Canada
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MESH Headings
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/pathology
- Anemia, Hemolytic, Autoimmune/physiopathology
- Anemia, Hemolytic, Autoimmune/therapy
- Blood Transfusion
- Complement Inactivating Agents/therapeutic use
- Glucocorticoids/therapeutic use
- Hemoglobinuria, Paroxysmal/diagnosis
- Hemoglobinuria, Paroxysmal/pathology
- Hemoglobinuria, Paroxysmal/physiopathology
- Hemoglobinuria, Paroxysmal/therapy
- Humans
- Immunologic Factors/therapeutic use
- Rituximab/therapeutic use
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Affiliation(s)
- Sigbjørn Berentsen
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
| | - Wilma Barcellini
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
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9
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Koenigbauer UF. Laboratory Detection of Blood Groups and Provision of Red Cells. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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10
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Bizjak M, Košnik M, Terhorst-Molawi D, Dinevski D, Maurer M. Cold Agglutinins and Cryoglobulins Associate With Clinical and Laboratory Parameters of Cold Urticaria. Front Immunol 2021; 12:665491. [PMID: 33995398 PMCID: PMC8117240 DOI: 10.3389/fimmu.2021.665491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/19/2021] [Indexed: 11/15/2022] Open
Abstract
Mast cell-activating signals in cold urticaria are not yet well defined and are likely to be heterogeneous. Cold agglutinins and cryoglobulins have been described as factors possibly associated with cold urticaria, but their relevance has not been explained. We performed a single-center prospective cohort study of 35 cold urticaria patients. Cold agglutinin and cryoglobulin test results, demographics, detailed history data, cold stimulation test results, complete blood count values, C-reactive protein, total immunoglobulin E levels, and basal serum tryptase levels were analyzed. Forty six percent (n = 16) of 35 tested patients had a positive cold agglutinin test and 27% (n = 9) of 33 tested patients had a positive cryoglobulin test. Cold agglutinin positive patients, when compared to cold agglutinin negative ones, were mainly female (P = 0.030). No gender-association was found for cryoglobulins. A positive cold agglutinin test, but not a positive cryoglobulin test, was associated with a higher rate of reactions triggered by cold ambient air (P = 0.009) or immersion in cold water (P = 0.041), and aggravated by increased summer humidity (P = 0.007). Additionally, patients with a positive cold agglutinin test had a higher frequency of angioedema triggered by ingestion of cold foods or drinks (P = 0.043), and lower disease control based on Urticaria Control Test (P = 0.023). Cold agglutinin levels correlated with erythrocyte counts (r = −0.372, P = 0.028) and monocyte counts (r = −0.425, P = 0.011). Cryoglobulin concentrations correlated with basal serum tryptase levels (r = 0.733, P = 0.025) and cold urticaria duration (r = 0.683, P = 0.042). Results of our study suggest that cold agglutinins and cryoglobulins, in a subpopulation of cold urticaria patients, are linked to the course and possibly the pathogenesis of their disease.
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Affiliation(s)
- Mojca Bizjak
- Urticaria Center of Reference and Excellence (UCARE), University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Mitja Košnik
- Urticaria Center of Reference and Excellence (UCARE), University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Dorothea Terhorst-Molawi
- Urticaria Center of Reference and Excellence (UCARE), Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dejan Dinevski
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Marcus Maurer
- Urticaria Center of Reference and Excellence (UCARE), University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
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New Insights in Autoimmune Hemolytic Anemia: From Pathogenesis to Therapy Stage 1. J Clin Med 2020; 9:jcm9123859. [PMID: 33261023 PMCID: PMC7759854 DOI: 10.3390/jcm9123859] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 12/15/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a highly heterogeneous disease due to increased destruction of autologous erythrocytes by autoantibodies with or without complement involvement. Other pathogenic mechanisms include hyper-activation of cellular immune effectors, cytokine dysregulation, and ineffective marrow compensation. AIHAs may be primary or associated with lymphoproliferative and autoimmune diseases, infections, immunodeficiencies, solid tumors, transplants, and drugs. The direct antiglobulin test is the cornerstone of diagnosis, allowing the distinction into warm forms (wAIHA), cold agglutinin disease (CAD), and other more rare forms. The immunologic mechanisms responsible for erythrocyte destruction in the various AIHAs are different and therefore therapy is quite dissimilar. In wAIHA, steroids represent first line therapy, followed by rituximab and splenectomy. Conventional immunosuppressive drugs (azathioprine, cyclophosphamide, cyclosporine) are now considered the third line. In CAD, steroids are useful only at high/unacceptable doses and splenectomy is uneffective. Rituximab is advised in first line therapy, followed by rituximab plus bendamustine and bortezomib. Several new drugs are under development including B-cell directed therapies (ibrutinib, venetoclax, parsaclisib) and inhibitors of complement (sutimlimab, pegcetacoplan), spleen tyrosine kinases (fostamatinib), or neonatal Fc receptor. Here, a comprehensive review of the main clinical characteristics, diagnosis, and pathogenic mechanisms of AIHA are provided, along with classic and new therapeutic approaches.
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Chung E, Park S, Lee J. Incidentally discovered cold hemagglutinin disease with massive blood clots in the cardioplegia line and coronary artery, during coronary artery bypass graft. J Cardiothorac Surg 2020; 15:79. [PMID: 32393295 PMCID: PMC7216728 DOI: 10.1186/s13019-020-01130-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cold hemagglutinin disease (CHAD) is a rare autoimmune disease, in which patients manifest symptoms when the body temperature decreases. It causes critical problems with blood clotting and hemolysis during hypothermia in cardiac surgery. Although various methods are recommended, the CHAD discovered incidentally during cardiac surgery is still a clinical challenge. CASE PRESENTATION A 76-year-old male visited our hospital for chest pain. Angiography revealed unstable angina, left-main and three-vessel disease. We performed coronary artery bypass graft (CABG) with cardiopulmonary bypass after heparin injection. Shortly after aorta cross-clamping (ACC) and infusion of cold blood cardioplegia, we found massive blood clots in the cardioplegia line. Upon suspicion of CHAD, we raised the temperature and infused warm blood cardioplegia in a retrograde manner. After performing cardiac arrest, we opened the coronary artery and found blood clots in the coronary artery. We eliminated the clots and washed with warm crystalloid cardioplegia simultaneously in an antegrade and retrograde manner. During the ACC, warm cardioplegia was infused every 15 min, via retrograde and antegrade techniques simultaneously. After distal anastomosis of the saphenous venous graft (SVG) to the coronary artery, we performed a direct SVG warm cardioplegia infusion. Finally, before the proximal SVG anastomosis to the aorta, we used warm cardioplegia to eliminate the remaining microemboli. The cold reactive protein test showed a positive result. The patient was discharged without any complications. CONCLUSION In this rare case, we incidentally discovered CHAD associated with massive blood clots in the cardioplegia line and the coronary artery, during CABG. However, we performed CABG without any complications using a reasonable and appropriate cardioplegia infusion technique, including direct SVG warm cardioplegia infusion.
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Affiliation(s)
- Euysuk Chung
- Department of Cardiothoracic Surgery, School of Medicine, Inje University, Sanggye Paik Hospital, 1342, Dongil-ro, Nowon-gu, Seoul, South Korea.
| | - Sungjoon Park
- Department of Cardiothoracic Surgery, School of Medicine, Inje University, Sanggye Paik Hospital, 1342, Dongil-ro, Nowon-gu, Seoul, South Korea
| | - Jaehoon Lee
- Department of Cardiothoracic Surgery, School of Medicine, Inje University, Sanggye Paik Hospital, 1342, Dongil-ro, Nowon-gu, Seoul, South Korea
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13
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Berentsen S. New Insights in the Pathogenesis and Therapy of Cold Agglutinin-Mediated Autoimmune Hemolytic Anemia. Front Immunol 2020; 11:590. [PMID: 32318071 PMCID: PMC7154122 DOI: 10.3389/fimmu.2020.00590] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/13/2020] [Indexed: 12/12/2022] Open
Abstract
Autoimmune hemolytic anemias mediated by cold agglutinins can be divided into cold agglutinin disease (CAD), which is a well-defined clinicopathologic entity and a clonal lymphoproliferative disorder, and secondary cold agglutinin syndrome (CAS), in which a similar picture of cold-hemolytic anemia occurs secondary to another distinct clinical disease. Thus, the pathogenesis in CAD is quite different from that of polyclonal autoimmune diseases such as warm-antibody AIHA. In both CAD and CAS, hemolysis is mediated by the classical complement pathway and therefore can result in generation of anaphylotoxins, such as complement split product 3a (C3a) and, to some extent, C5a. On the other hand, infection and inflammation can act as triggers and drivers of hemolysis, exemplified by exacerbation of CAD in situations with acute phase reaction and the role of specific infections (particularly Mycoplasma pneumoniae and Epstein-Barr virus) as causes of CAS. In this review, the putative mechanisms behind these phenomena will be explained along with other recent achievements in the understanding of pathogenesis in these disorders. Therapeutic approaches have been directed against the clonal lymphoproliferation in CAD or the underlying disease in CAS. Currently, novel targeted treatments, in particular complement-directed therapies, are also being rapidly developed and will be reviewed.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
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14
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Duffy C, Bain C, Cairo SA, Hogan C, Geldard P, Larobina M, Lin E, Tutungi E, Miles LF. Cold Agglutinin Disease and Hemolytic Crisis After Hypothermic Circulatory Arrest in a Patient With Beta-Thalassemia Minor. J Cardiothorac Vasc Anesth 2020; 34:3086-3092. [PMID: 32245720 DOI: 10.1053/j.jvca.2020.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Christopher Duffy
- Melbourne Cardiac Anaesthesia, Ivanhoe, Melbourne, Victoria, Australia
| | - Christopher Bain
- Melbourne Cardiac Anaesthesia, Ivanhoe, Melbourne, Victoria, Australia
| | - Sesto A Cairo
- Melbourne Cardiac Anaesthesia, Ivanhoe, Melbourne, Victoria, Australia
| | - Christopher Hogan
- Department of Pathology, Austin Health, Heidelberg, Melbourne, Victoria, Australia
| | - Paul Geldard
- Melbourne Cardiac Anaesthesia, Ivanhoe, Melbourne, Victoria, Australia
| | - Marco Larobina
- Victorian Cardiovascular Services, Richmond, Melbourne, Victoria, Australia
| | - Enjarn Lin
- Melbourne Cardiac Anaesthesia, Ivanhoe, Melbourne, Victoria, Australia
| | - Elli Tutungi
- Melbourne Cardiac Anaesthesia, Ivanhoe, Melbourne, Victoria, Australia
| | - Lachlan F Miles
- Melbourne Cardiac Anaesthesia, Ivanhoe, Melbourne, Victoria, Australia; Centre for Integrated Critical Care, The University of Melbourne, Parkville, Melbourne, Victoria, Australia.
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Berentsen S, Hill A, Hill QA, Tvedt THA, Michel M. Novel insights into the treatment of complement-mediated hemolytic anemias. Ther Adv Hematol 2019; 10:2040620719873321. [PMID: 31523413 PMCID: PMC6734604 DOI: 10.1177/2040620719873321] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/08/2019] [Indexed: 12/20/2022] Open
Abstract
Complement-mediated hemolytic anemias can either be caused by deficiencies in regulatory complement components or by autoimmune pathogenesis that triggers inappropriate complement activation. In paroxysmal nocturnal hemoglobinuria (PNH) hemolysis is entirely complement-driven. Hemolysis is also thought to be complement-dependent in cold agglutinin disease (CAD) and in paroxysmal cold hemoglobinuria (PCH), whereas warm antibody autoimmune hemolytic anemia (wAIHA) is a partially complement-mediated disorder, depending on the subtype of wAIHA and the extent of complement activation. The pathophysiology, clinical presentation, and current therapies for these diseases are reviewed in this article. Novel, complement-directed therapies are being rapidly developed. Therapeutic terminal complement inhibition using eculizumab has revolutionized the therapy and prognosis in PNH but has proved less efficacious in CAD. Upstream complement modulation is currently being investigated and appears to be a highly promising therapy, and two such agents have entered phase II and III trials. Of these, the anti-C1s monoclonal antibody sutimlimab has shown favorable activity in CAD, while the anti-C3 cyclic peptide pegcetacoplan appears to be promising in PNH as well as CAD, and may also have a therapeutic potential in wAIHA.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, P.O. Box 2170, Haugesund, 5504, Norway
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | - Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | - Marc Michel
- Department of Medicine, Henri Mondor Hospital, Université Paris-Est, Assistance Publique Hôpitaux de Paris Creteil, Creteil, France
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Berentsen S, Röth A, Randen U, Jilma B, Tjønnfjord GE. Cold agglutinin disease: current challenges and future prospects. J Blood Med 2019; 10:93-103. [PMID: 31114413 PMCID: PMC6497508 DOI: 10.2147/jbm.s177621] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/01/2019] [Indexed: 12/19/2022] Open
Abstract
Cold agglutinin disease (CAD) is a complement-dependent, classical pathway-mediated immune hemolytic disease, accounting for 15–25% of autoimmune hemolytic anemia, and at the same time, a distinct clonal B-cell lymphoproliferative disorder of the bone marrow. The disease burden is often high, but not all patients require pharmacological treatment. Several therapies directed at the pathogenic B-cells are now available. Rituximab plus bendamustine or rituximab monotherapy should be considered first-line treatment, depending on individual patient characteristics. Novel treatment options that target the classical complement pathway are under development and appear very promising, and the C1s inhibitor sutimlimab is currently being investigated in two clinical Phase II and III trials. These achievements have raised new challenges and further prospects, which are discussed. Patients with CAD requiring therapy should be considered for clinical trials.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
| | - Alexander Röth
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulla Randen
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,KG Jebsen's Center for B-cell Malignancies, University of Oslo, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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17
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The impact of xanthine oxidase (XO) on hemolytic diseases. Redox Biol 2018; 21:101072. [PMID: 30580157 PMCID: PMC6305892 DOI: 10.1016/j.redox.2018.101072] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 01/13/2023] Open
Abstract
Hemolytic diseases are associated with elevated levels of circulating free heme that can mediate endothelial dysfunction directly via redox reactions with biomolecules or indirectly by upregulating enzymatic sources of reactive species. A key enzymatic source of these reactive species is the purine catabolizing enzyme, xanthine oxidase (XO) as the oxidation of hypoxanthine to xanthine and subsequent oxidation of xanthine to uric acid generates superoxide (O2•-) and hydrogen peroxide (H2O2). While XO has been studied for over 120 years, much remains unknown regarding specific mechanistic roles for this enzyme in pathologic processes. This gap in knowledge stems from several interrelated issues including: 1) lethality of global XO deletion and the absence of tissue-specific XO knockout models have coalesced to relegate proof-of-principle experimentation to pharmacology; 2) XO is mobile and thus when upregulated locally can be secreted into the circulation and impact distal vascular beds by high-affinity association to the glycocalyx on the endothelium; and 3) endothelial-bound XO is significantly resistant (> 50%) to inhibition by allopurinol, the principle compound used for XO inhibition in the clinic as well as the laboratory. While it is known that circulating XO is elevated in hemolytic diseases including sickle cell, malaria and sepsis, little is understood regarding its role in these pathologies. As such, the aim of this review is to define our current understanding regarding the effect of hemolysis (free heme) on circulating XO levels as well as the subsequent impact of XO-derived oxidants in hemolytic disease processes.
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18
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Bras J, Uminski K, Ponnampalam A. Cold agglutinin disease complicating management of aortic dissection. Transfus Apher Sci 2018; 57:236-238. [PMID: 29885944 DOI: 10.1016/j.transci.2018.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 02/25/2018] [Accepted: 02/26/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cold agglutinin disease is characterized by acrocyanosis, hemolytic anemia, and occasionally, frank hemoglobinuria. Although cold agglutinins are commonly detected, they are rarely clinically significant due to subphysiologic temperatures at which agglutination occurs. Cardiovascular surgical procedures requiring hypothermia present a unique challenge for these patients, requiring modification of the conduct of cardiopulmonary bypass and cardioplegia. CASE REPORT Herein we report a case of a patient with a prior history of symptomatic cold agglutinin disease and type A aortic dissection, presenting with dilation of his known diseased ascending aorta, requiring semi-urgent repair. The patient underwent plasma exchange on two successive days preceding surgery to reduce the cold agglutinin titre. A modified Bentall procedure and replacement of ascending aorta and hemiarch under deep hypothermic circulatory arrest was performed without complication. CONCLUSIONS This case demonstrates the efficacy of employing plasma exchange in preparation for cardiac surgery with deep hypothermic circulatory arrest in a patient with clinically significant cold agglutinin disease. Plasma exchange alone may be sufficient in preparing patients with cold agglutinin disease for procedures requiring significant hypothermia when the delayed onset of action of alternative therapies is not acceptable. Choice of replacement fluid is critical in ensuring maintenance of coagulation proteins perioperatively and minimizing complement activation.
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Affiliation(s)
- James Bras
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Kelsey Uminski
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada.
| | - Arjuna Ponnampalam
- Department of Internal Medicine, Section of Hematology & Medical Oncology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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Berentsen S. Complement Activation and Inhibition in Autoimmune Hemolytic Anemia: Focus on Cold Agglutinin Disease. Semin Hematol 2018; 55:141-149. [PMID: 30032751 DOI: 10.1053/j.seminhematol.2018.04.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/03/2018] [Indexed: 12/25/2022]
Abstract
The classical complement pathway and, to some extent, the terminal pathway, are involved in the immune pathogenesis of autoimmune hemolytic anemia (AIHA). In primary cold agglutinin disease (CAD), secondary cold agglutinin syndrome and paroxysmal cold hemoglobinuria, the hemolytic process is entirely complement dependent. Complement activation also plays an important pathogenetic role in some warm-antibody AIHAs, especially when immunoglobulin M is involved. This review describes the complement-mediated hemolysis in AIHA with a major focus on CAD, in which activation of the classical pathway is essential and particularly relevant for complement-directed therapy. Several complement inhibitors are candidate therapeutic agents in CAD and other AIHAs, and some of these drugs seem very promising. The relevant in vitro findings, early clinical data and future perspectives are reviewed.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna HF, Haugesund, Norway.
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20
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation; Haugesund Hospital; Haugesund Norway
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Heath M, Walker J, Barbeito A, Williams A, Welsby I, Maxwell C, Daneshmand M, Haney J, Hoffman M. Differentiating between cold agglutinins and rouleaux: a case series of seven patients. Perfusion 2017; 33:164-169. [PMID: 28823225 DOI: 10.1177/0267659117727593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We present a case series of seven patients with suspected cold agglutinin antibodies, discovered after initiation of bypass. Laboratory analysis of blood samples intraoperatively determined the cause of the aggregation to be rouleaux formation in three of the patients and cold agglutinins in the other four.
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Affiliation(s)
- Michele Heath
- 1 Durham VA Medical Center, Durham, North Carolina, 508 Fulton Street, Durham, NC, 27705, USA
| | - Julie Walker
- 1 Durham VA Medical Center, Durham, North Carolina, 508 Fulton Street, Durham, NC, 27705, USA
| | - Atilio Barbeito
- 1 Durham VA Medical Center, Durham, North Carolina, 508 Fulton Street, Durham, NC, 27705, USA.,2 Duke University Hospital, Durham, North Carolina, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Adam Williams
- 2 Duke University Hospital, Durham, North Carolina, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Ian Welsby
- 1 Durham VA Medical Center, Durham, North Carolina, 508 Fulton Street, Durham, NC, 27705, USA.,2 Duke University Hospital, Durham, North Carolina, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Cory Maxwell
- 1 Durham VA Medical Center, Durham, North Carolina, 508 Fulton Street, Durham, NC, 27705, USA.,2 Duke University Hospital, Durham, North Carolina, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Mani Daneshmand
- 1 Durham VA Medical Center, Durham, North Carolina, 508 Fulton Street, Durham, NC, 27705, USA.,2 Duke University Hospital, Durham, North Carolina, 2301 Erwin Road, Durham, NC, 27710, USA
| | - John Haney
- 1 Durham VA Medical Center, Durham, North Carolina, 508 Fulton Street, Durham, NC, 27705, USA.,2 Duke University Hospital, Durham, North Carolina, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Maureane Hoffman
- 1 Durham VA Medical Center, Durham, North Carolina, 508 Fulton Street, Durham, NC, 27705, USA
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22
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Hill QA, Stamps R, Massey E, Grainger JD, Provan D, Hill A. The diagnosis and management of primary autoimmune haemolytic anaemia. Br J Haematol 2016; 176:395-411. [PMID: 28005293 DOI: 10.1111/bjh.14478] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - John D Grainger
- Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Drew Provan
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
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23
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Yalamuri S, Maxwell C. Preoperative Cold Agglutinin Testing: Consider an Algorithm. J Cardiothorac Vasc Anesth 2016; 31:e10-e11. [PMID: 27919725 DOI: 10.1053/j.jvca.2016.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Suraj Yalamuri
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Cory Maxwell
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
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24
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Laboratory Detection of Blood Groups and Provision of Red Cells. Transfus Med 2016. [DOI: 10.1002/9781119236504.ch10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Yalamuri S, Heath M, McCartney S, Cushman T, Maxwell C. Cardiopulmonary Bypass Management Complicated by a Stenotic Coronary Sinus and Cold Agglutinins. J Cardiothorac Vasc Anesth 2016; 31:233-235. [PMID: 27498258 DOI: 10.1053/j.jvca.2016.03.130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Suraj Yalamuri
- Duke University Medical Center, Department of Anesthesiology, Durham, NC.
| | | | - Sharon McCartney
- Duke University Medical Center, Department of Anesthesiology, Durham, NC
| | - Tera Cushman
- Duke University Medical Center, Department of Anesthesiology, Durham, NC
| | - Cory Maxwell
- Duke University Medical Center, Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Veteran Affairs Anesthesiology, Durham, NC
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26
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Patel PA, Ghadimi K, Coetzee E, Myburgh A, Swanevelder J, Gutsche JT, Augoustides JGT. Incidental Cold Agglutinins in Cardiac Surgery: Intraoperative Surprises and Team-Based Problem-Solving Strategies During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2016; 31:1109-1118. [PMID: 27624931 DOI: 10.1053/j.jvca.2016.06.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kamrouz Ghadimi
- Divisions of Cardiothoracic Anesthesiology and Critical Care, Anesthesiology and Critical Care, Duke University Medical Center, Durham, NC
| | - Ettienne Coetzee
- Cardiothoracic Anesthesia, Department of Anesthesia and Perioperative Medicine, School of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adriaan Myburgh
- Cardiothoracic Anesthesia, Department of Anesthesia and Perioperative Medicine, School of Medicine, University of Cape Town, Cape Town, South Africa
| | - Justiaan Swanevelder
- Cardiothoracic Anesthesia, Department of Anesthesia and Perioperative Medicine, School of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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27
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Sapatnekar S, Figueroa PI. Cold Antibodies in Cardiovascular Surgery: Is Preoperative Screening Necessary? Am J Clin Pathol 2016; 145:789-95. [PMID: 27298398 DOI: 10.1093/ajcp/aqw054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Cold antibodies (CAs) are rarely significant for transfusion, but they can cause complications under the hypothermic conditions of cardiovascular surgery. The purpose of this study was to determine the incidence of such complications. METHODS Patients with CAs who underwent cardiovascular surgery were identified, and their records were reviewed for intraoperative complications attributable to CAs. RESULTS Over 14.5 years, of the 47,373 patients who underwent cardiovascular surgery, 99 had CAs before or within 30 days after surgery. Ninety-seven patients had hypothermic surgery, and intraoperative agglutination was noted in four; two of these cases were never reported to the transfusion service. CONCLUSIONS The incidence of intraoperative complications among our patients with CAs was only 4%; therefore, the use of special testing protocols for the preoperative identification of CAs is neither necessary nor justified. Patient risk is best managed by preoperative clinical evaluation for potentially pathogenic CAs and intraoperative vigilance for agglutination.
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Affiliation(s)
- Suneeti Sapatnekar
- From the Section of Transfusion Medicine, Department of Laboratory Medicine, Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH.
| | - Priscilla I Figueroa
- From the Section of Transfusion Medicine, Department of Laboratory Medicine, Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH
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28
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Berentsen S, Randen U, Tjønnfjord GE. Cold agglutinin-mediated autoimmune hemolytic anemia. Hematol Oncol Clin North Am 2015; 29:455-71. [PMID: 26043385 DOI: 10.1016/j.hoc.2015.01.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cold antibody types account for about 25% of autoimmune hemolytic anemias. Primary chronic cold agglutinin disease (CAD) is characterized by a clonal lymphoproliferative disorder. Secondary cold agglutinin syndrome (CAS) complicates specific infections and malignancies. Hemolysis in CAD and CAS is mediated by the classical complement pathway and is predominantly extravascular. Not all patients require treatment. Successful CAD therapy targets the pathogenic B-cell clone. Complement modulation seems promising in both CAD and CAS. Further development and documentation are necessary before clinical use. We review options for possible complement-directed therapy.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Medicine, Haugesund Hospital, Karmsundgata 120, Haugesund NO-5504, Norway.
| | - Ulla Randen
- Department of Pathology, Oslo University Hospital, Ullernchausseen 70, NO-0310 Oslo, Norway
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Sognsvannsveien 20, NO-0372 Oslo, Norway
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29
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Mukherji J, Hood RR, Edelstein SB. Overcoming Challenges in the Management of Critical Events During Cardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth 2014; 18:190-207. [DOI: 10.1177/1089253214526646] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Critical events during cardiopulmonary bypass (CPB) can challenge the most experienced perfusionists, anesthesiologists, and surgeons and can potentially lead to devastating outcomes. Much of the challenge of troubleshooting these events requires a key understanding of these situations and a well-defined strategy for early recognition and treatment. Adverse situations may be anticipated prior to going on CPB. Atherosclerosis is pervasive, and a high plaque burden may have implications in surgical technique modification and planning of CPB. Hematologic abnormalities such as cold agglutinins, antithrombin III deficiency, and hemoglobin S have been discussed with emphasis on managing complications arising from their altered pathophysiology. Jehovah’s witness patients require appropriate techniques for cell salvage to minimize blood loss. During initiation of CPB, devastating situations leading to acute hypoperfusion and multiorgan failure may be encountered in patients undergoing surgery for aortic dissection. Massive air emboli during CPB, though rare, necessitate an urgent diagnosis to detect the source and prompt management to contain catastrophic outcomes. Gaseous microemboli remain ubiquitous and continue to be a major concern for neurocognitive impairment despite our best efforts to improve techniques and refine the CPB circuit. During maintenance of CPB, adverse events reflect inability to provide optimal perfusion and can be ascribed to CPB machine malfunction or physiological aberrations. We also discuss critical events that can occur during perfusion and the need to monitor for organ perfusion in altered physiologic states emanating from hemodilution, hypothermia, and acid–base alterations.
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Affiliation(s)
| | - Ryan R. Hood
- Loyola University Medical Center, Maywood, IL, USA
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