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Li Q, Xie J, Sun J, Fang K, Li T. Complex delayed blood transfusion reaction: A case report. Medicine (Baltimore) 2024; 103:e38467. [PMID: 38905393 PMCID: PMC11191959 DOI: 10.1097/md.0000000000038467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/15/2024] [Indexed: 06/23/2024] Open
Abstract
INTRODUCTION Inefficient blood transfusions present a significant challenge, leading to the wastage of crucial blood resources and increased medical expenses. This study aims to address this issue by providing a comprehensive analysis of a case involving an ineffective clinical transfusion and outlining the significance of identifying multiple alloantibodies in resolving transfusion challenges. CASE REPORT We present a detailed follow-up on a patient treatment journey, highlighting the critical role of identifying multiple alloantibodies through various methodologies in addressing the transfusion problem. Subsequently, a strategic intervention was implemented, leading to a successful patient outcome. CONCLUSION This study underscores the importance of conducting a thorough analysis of ineffective transfusions and implementing scientifically formulated transfusion plans based on rational explanations. Such an approach not only improves hemoglobin levels but also contributes to better patient outcomes, thereby reducing blood resource wastage and medical costs.
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Affiliation(s)
- Qiang Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Cell Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | | | - Jiali Sun
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Cell Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Kuo Fang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Cell Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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Evangelidis P, Evangelidis N, Vlachaki E, Gavriilaki E. What is the role of complement in bystander hemolysis? Old concept, new insights. Expert Rev Hematol 2024; 17:107-116. [PMID: 38708453 DOI: 10.1080/17474086.2024.2348662] [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: 01/07/2024] [Accepted: 04/24/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION Bystander hemolysis occurs when antigen-negative red blood cells (RBCs) are lysed by the complement system. Many clinical entities including passenger lymphocyte syndrome, hyperhemolysis following blood transfusion, and paroxysmal nocturnal hemoglobinuria are complicated by bystander hemolysis. AREAS COVERED The review provides data about the role of the complement system in the pathogenesis of bystander hemolysis. Moreover, future perspectives on the understanding and management of this syndrome are described. EXPERT OPINION Complement system can be activated via classical, alternative, and lectin pathways. Classical pathway activation is mediated by antigen-antibody (autoantibodies and alloantibodies against autologous RBCs, infectious agents) complexes. Alternative pathway initiation is triggered by heme, RBC microvesicles, and endothelial injury that is a result of intravascular hemolysis. Thus, C5b is formed, binds with C6-C9 compomers, and MAC (C5b-9) is formulated in bystander RBCs membranes, leading to cell lysis. Intravascular hemolysis, results in activation of the alternative pathway, establishing a vicious cycle between complement activation and bystander hemolysis. C5 inhibitors have been used effectively in patients with hyperhemolysis syndrome and other entities characterized by bystander hemolysis.
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Affiliation(s)
- Paschalis Evangelidis
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Evangelidis
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efthymia Vlachaki
- Adult Thalassemia Unit, 2nd Department of Internal Medicine, Aristotle University of Thessaloniki, Hippocration General Hospital, Thessaloniki, Greece
| | - Eleni Gavriilaki
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Floch A, Viret S, Malard L, Pakdaman S, Jouard A, Habibi A, Galacteros F, François A, Pirenne F. Eleven years of alloimmunization in 6496 patients with sickle cell disease in France who received transfusion. Blood Adv 2023; 7:7608-7620. [PMID: 37699002 PMCID: PMC10790094 DOI: 10.1182/bloodadvances.2022009328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 07/27/2023] [Accepted: 08/24/2023] [Indexed: 09/14/2023] Open
Abstract
ABSTRACT Red blood cell (RBC) transfusion is a major therapy for sickle cell disease (SCD). Patients are at risk of forming antibodies to RBC antigens, which can result in the impossibility to find compatible units and can cause hemolytic transfusion reactions. This retrospective study investigates the evolution of RBC consumption and the frequencies, specificities, and chronology of the appearance of antibodies in a population of patients consistently receiving RH (C, D, E, c, e) and K-matched RBC units (RBCus) from a predominantly European donor population. Over the 11-year period in the Paris area, 6496 patients received transfusion at least once for a total of 239 944 units. Antibodies were made by 1742 patients. The first antibodies of a patient were predictive of subsequent immunization. By the 17th RBCu transfused (by the 20th, excluding warm autoantibodies), 75% of the patients who would make antibodies had made their first. By the 16th, 90% who would make antibodies to a high frequency antigen had made their first antibody to these antigens. Females made their first antibodies slightly earlier than males. Patients who received multiple transfusions (>50 units) had a higher immunization prevalence than those who rarely received transfusion (<12 units) but fewer clinically significant antibodies. Patients with SCD and prophylactic RH-K matching not immunized by the 20th RBCu are likely to have a low alloimmunization risk (to antigens other than RH-K), that is, be low responders, especially relative to the most clinically significant antibodies. This number of 20 units is a point before which close monitoring of patients is most important but remains open to future adjustment.
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Affiliation(s)
- Aline Floch
- Etablissement Français du Sang Ile-de-France, Créteil, France
- INSERM U955, Equipe Transfusion et Maladies du Globule Rouge, Université Paris-Est Creteil, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Sophie Viret
- Etablissement Français du Sang Ile-de-France, Créteil, France
| | | | - Sadaf Pakdaman
- Etablissement Français du Sang Ile-de-France, Créteil, France
- INSERM U955, Equipe Transfusion et Maladies du Globule Rouge, Université Paris-Est Creteil, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Alicia Jouard
- Etablissement Français du Sang Ile-de-France, Créteil, France
- INSERM U955, Equipe Transfusion et Maladies du Globule Rouge, Université Paris-Est Creteil, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Anoosha Habibi
- Referral Center for Sickle Cell Disease, Henri Mondor Hospital, Créteil, France
| | - Frédéric Galacteros
- Referral Center for Sickle Cell Disease, Henri Mondor Hospital, Créteil, France
| | | | - France Pirenne
- Etablissement Français du Sang Ile-de-France, Créteil, France
- INSERM U955, Equipe Transfusion et Maladies du Globule Rouge, Université Paris-Est Creteil, Institut Mondor de Recherche Biomédicale, Créteil, France
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Guarente J, Tormey C. Transfusion Support of Patients with Myelodysplastic Syndromes. Clin Lab Med 2023; 43:669-683. [PMID: 37865510 DOI: 10.1016/j.cll.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Patients with MDS often suffer from anemia, and less often thrombocytopenia, and thus are a frequently transfused population. Red blood cell (RBC) transfusion may be used to improve functional capacity and quality of life in this population, while platelet transfusion is typically used to decrease bleeding risk. Despite the frequency of transfusion in patients with MDS, there are few well-defined guidelines for RBC and platelet transfusion support in this patient population. Transfusion is not without risk-patients with MDS who are frequently transfused may develop alloantibodies to RBC antigens, which can lead to hemolytic transfusion reactions and delays in obtaining compatible RBCs. Regular communication between clinicians and blood bank physicians is crucial to ensure that patients with MDS receive the most appropriate blood products.
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Affiliation(s)
- Juliana Guarente
- Department of Pathology and Genomic Medicine, Pathology Residency Program, Thomas Jefferson University Hospital, 111 South 11th Street Gibbon Building, Room 8220, Philadelphia, PA 19107, USA
| | - Christopher Tormey
- Department of Laboratory Medicine, Transfusion Medicine Fellowship, Yale University School of Medicine, Yale-New Haven Hospital, 55 Park Street, Floor 3, Room 329D, New Haven, CT 06511, USA
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Hairston HC, Ipe TS, Burdine L, Sexton K, Reif R, Jensen H, Kalkwarf KJ. Incidence of Red Cell Antibody Formation Following Massive Transfusion Protocol: Experience of a Single Institution. Am Surg 2023; 89:4715-4719. [PMID: 36169356 DOI: 10.1177/00031348221129500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Injured patients in hemorrhagic shock have a survival benefit with massive transfusion protocol (MTP). While there are many published studies on the transfusion management of massively bleeding patients, the risk of alloimmunization in patients that have received products during an MTP activation is relatively unknown. Therefore, we sought to determine the frequency of new antibody formation in MTP patients that received blood products from an uncrossmatched megapack. MATERIALS AND METHODS We conducted a retrospective data review of patients who underwent an MTP activation for trauma resuscitation between May 2014 and July 2020. Data were collected from patients who met the following criteria: MTP was activated, the patients received at least one unit of packed red blood cells, one unit of fresh frozen plasma, one unit of platelets, and had a repeat type and screen within 6 weeks of transfusion. These inclusion criteria resulted in 28 patients over the 6-year timeframe. RESULTS Overall, the risk of alloimmunization secondary to MTP is 3.6% in our trauma patient population. The newly developed antibodies post-MTP are considered clinically significant, meaning they can cause hemolysis if exposed to donor red blood cells containing those antigens. DISCUSSION Blood products should be given preferentially over crystalloids to acutely bleeding patients to prevent ischemic injury during an MTP activation despite the risk of alloimmunization. In our single-institution study, the alloimmunization rate in massive transfusions where patients receive uncrossmatched red blood cells is similar to those receiving crossmatched red blood cells.
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Affiliation(s)
| | - Tina S Ipe
- Department of Pathology and Laboratory Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lyle Burdine
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kevin Sexton
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rebecca Reif
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hanna Jensen
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kyle J Kalkwarf
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Inusa BP, Atoyebi W, Andemariam B, Hourani JN, Omert L. Global burden of transfusion in sickle cell disease. Transfus Apher Sci 2023; 62:103764. [PMID: 37541800 DOI: 10.1016/j.transci.2023.103764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/14/2023] [Accepted: 07/16/2023] [Indexed: 08/06/2023]
Abstract
Sickle cell disease (SCD) is the most common hereditary hemoglobinopathy. The underlying pathophysiology of the red blood cell (RBC) leads to pan-systemic complications which manifest at an early age. While curative and disease-modifying treatments exist for SCD, a key intervention in the management and treatment of SCD is RBC transfusion, which can alleviate or prevent many complications. SCD patients often require chronic RBC transfusion therapy which can result in complications, such as iron overload, alloimmunization and infection. In low- and middle-income countries (LMICs), SCD patients lack appropriate access to healthcare such as newborn screening, health education, prophylaxis for infection, and treatments to reduce both mortality and SCD-related adverse effects. Poor access to RBCs for transfusion, coupled with donated blood not meeting safety standards set by the World Health Organization, presents a significant barrier for patients requiring chronic transfusions in LMICs. Unmet needs associated with blood collection, blood component processing and recipient matching all pose a serious problem in many LMICs, although this varies depending on geographic location, political organizations and economy. This review aims to provide an overview of the global burden of SCD, focusing on the availability of current treatments and the burden of chronic RBC transfusions in patients with SCD.
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Affiliation(s)
- Baba Pd Inusa
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK.
| | | | - Biree Andemariam
- New England Sickle Cell Institute, University of Connecticut Health, Farmington, CT, USA
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Zheng Y, Gossett JM, Chen PL, Barton M, Ryan M, Yu J, Kang G, Hankins JS, Chou ST. Proinflammatory state promotes red blood cell alloimmunization in pediatric patients with sickle cell disease. Blood Adv 2023; 7:4799-4808. [PMID: 37023228 PMCID: PMC10469551 DOI: 10.1182/bloodadvances.2022008647] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 02/09/2023] [Accepted: 02/27/2023] [Indexed: 04/08/2023] Open
Abstract
We examined risk factors for red blood cell (RBC) alloimmunization in pediatric patients with sickle cell disease, focusing on the recipients' inflammatory state at the time of transfusion and anti-inflammatory role of hydroxyurea (HU). Among 471 participants, 55 (11.70%) participants were alloimmunized and formed 59 alloantibodies and 17 autoantibodies with an alloimmunization rate of 0.36 alloantibodies per 100 units. Analysis of 27 participants in whom alloantibodies were formed with specificities showed 23.8% (30/126) of units transfused during a proinflammatory event resulting in alloantibody formation compared with 2.8% (27/952) of units transfused at steady state. Therefore, transfusion during proinflammatory events increased the risk for alloimmunization (odds ratio [OR], 4.22; 95% confidence interval [CI], 1.64-10.85; P = .003). Further analysis of all the 471 participants showed that alloimmunization of patients who received episodic transfusion, mostly during proinflammatory events, was not reduced with HU therapy (OR, 6.52; 95% CI, 0.85-49.77; P = .071), HU therapy duration (OR, 1.13; 95% CI, 0.997-1.28; P = .056), or HU dose (OR, 1.06; 95% CI, 0.96-1.16; P = .242). The analysis also identified high transfusion burden (OR, 1.02; 95% CI, 1.003-1.04; P = .020) and hemoglobin S (HbSS) and HbSβ0-thalassemia genotypes (OR, 11.22, 95% CI, 1.51-83.38; P = .018) as additional risk factors for alloimmunization. In conclusion, the inflammatory state of transfusion recipients affects the risk of RBC alloimmunization, which is not modified by HU therapy. Judicious use of transfusion during proinflammatory events is critical for preventing alloimmunization.
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Affiliation(s)
- Yan Zheng
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jeffrey M. Gossett
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Pei-Lin Chen
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Martha Barton
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Missy Ryan
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jing Yu
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jane S. Hankins
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Stella T. Chou
- Departments of Pediatrics and Pathology, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
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Jacobs JW, Booth GS, Allen ES, Adkins BD. Commentary: Case report: Daratumumab treatment in pre-transplant alloimmunization and severe hemolytic anemia. Front Immunol 2023; 14:1133382. [PMID: 36776872 PMCID: PMC9912978 DOI: 10.3389/fimmu.2023.1133382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/18/2023] [Indexed: 02/14/2023] Open
Affiliation(s)
- Jeremy W Jacobs
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Garrett S Booth
- Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Elizabeth S Allen
- Department of Pathology, University of California San Diego, La Jolla, CA, United States
| | - Brian D Adkins
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, United States
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Wang Y, Rao Q, Li X. Adverse transfusion reactions and what we can do. Expert Rev Hematol 2022; 15:711-726. [PMID: 35950450 DOI: 10.1080/17474086.2022.2112564] [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: 11/04/2022]
Abstract
INTRODUCTION Transfusions of blood and blood components have inherent risks and the ensuing adverse reactions. It is very important to understand the adverse reactions of blood transfusion comprehensively for ensuring the safety of any future transfusions. AREAS COVERED According to the time of onset, adverse reactions of blood transfusion are divided into immediate and delayed transfusion reactions. In acute transfusion reactions, timely identification and immediate cessation of transfusion is critical. Vigilance is required to distinguish delayed responses or reactions that present non-specific signs and symptoms. In this review, we present the progress of mechanism, clinical characteristics and management of commonly encountered transfusion reactions. EXPERT OPINION The incidence of many transfusion-related adverse events is decreasing, but threats to transfusion safety are always emerging. It is particularly important for clinicians and blood transfusion staff to recognize the causes, symptoms and treatment methods of adverse blood transfusion reactions to improve the safety. In the future, at-risk patients will be better identified and can benefit from more closely matched blood components.
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Affiliation(s)
- Yajie Wang
- Department of Blood Transfusion, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Quan Rao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Xiaofei Li
- Department of Blood Transfusion, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Hendrickson JE. Management of hemolytic transfusion reactions. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:704-709. [PMID: 34889404 PMCID: PMC8791106 DOI: 10.1182/hematology.2021000308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Delayed hemolytic transfusion reactions (DHTRs) in patients with sickle cell disease are underappreciated and potentially fatal. Patients with DHTRs typically have symptoms of pain or dark urine days to weeks following a red blood cell (RBC) transfusion. In instances of DHTRs with hyperhemolysis, the patient's hemoglobin (Hgb) may be significantly lower than it was pretransfusion, and the Hgb A may drop by more than 50%. In most cases, at least 1 RBC alloantibody and sometimes multiple RBC alloantibodies can be identified during the DHTR, with those antibodies presumably having fallen below the level of detection at the time of the implicated transfusion. However, in up to one-third of cases, no new RBC alloantibodies can be identified posttransfusion. Complement is increasingly being appreciated to play a role in DHTRs and hyperhemolysis, not only due to classic pathway activation (with complement fixed antibody bound to RBCs) but also due to alternative pathway activation (resulting in part from plasma free heme). As such, anti-C5 inhibition has recently been reported to be effective at mitigating hemolysis in the setting of some severe DHTRs. Transfusion avoidance during DHTRs is recommended if possible, with long-term transfusion support advice being less clear; for example, a history of a severe DHTR may lead to questions regarding the safety of transfusions prior to curative therapies such as stem cell transplantation or gene therapy. A better understanding of antibody-positive and antibody-negative DHTRs, including patient- or disease-specific risk factors, is necessary to improve transfusion safety.
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Affiliation(s)
- 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
- Correspondence Jeanne E. Hendrickson, Yale University Department of Laboratory Medicine, 330 Cedar Street, Clinic Building 405, PO Box 208035, New Haven, CT 06520-0835; e-mail:
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Madany E, Lee J, Halprin C, Seo J, Baca N, Majlessipour F, Hendrickson JE, Pepkowitz SH, Hayes C, Klapper E, Gibb DR. Altered type 1 interferon responses in alloimmunized and nonalloimmunized patients with sickle cell disease. EJHAEM 2021; 2:700-710. [PMID: 35128535 PMCID: PMC8813163 DOI: 10.1002/jha2.270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Patients with sickle cell disease (SCD) have a high prevalence of RBC alloimmunization. However, underlying mechanisms are poorly understood. Given that proinflammatory type 1 interferons (IFNα/β) and interferon stimulated genes (ISGs) promote alloimmunization in mice, we hypothesized that IFNα/β may contribute to the increased frequency of alloimmunization in patients with SCD. To investigate this, expression of ISGs in blood leukocytes and peripheral blood mononuclear cells (PBMCs) of previously transfused SCD patients with or without alloimmunization and race-matched healthy controls were quantified, and IFNα/β gene scores were calculated. IFNα/β gene scores of SCD leukocytes and plasma cytokines were elevated, compared to controls (gene score, p < 0.01). Upon stimulation with IFNβ, isolated PBMCs from patients with SCD had elevated ISGs and IFNα/β gene scores (p < 0.05), compared to stimulated PBMCs from controls. However, IFNβ-stimulated and unstimulated ISG expression did not significantly differ between alloimmunized and non-alloimmunized patients. These findings indicate that patients with SCD express an IFNα/β gene signature, and larger studies are needed to fully determine its role in alloimmunization. Further, illustration of altered IFNα/β responses in SCD has potential implications for IFNα/β-mediated viral immunity, responses to IFNα/β-based therapies, and other sequelae of SCD.
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Affiliation(s)
- Emaan Madany
- Cedars-Sinai Medical Center, Department of Pathology and Laboratory Medicine, Los Angeles, California, United States
| | - June Lee
- Cedars-Sinai Medical Center, Department of Pathology and Laboratory Medicine, Los Angeles, California, United States
| | - Chelsea Halprin
- Cedars-Sinai Medical Center, Department of Pathology and Laboratory Medicine, Los Angeles, California, United States
| | - Jina Seo
- Cedars-Sinai Medical Center, Department of Pathology and Laboratory Medicine, Los Angeles, California, United States
| | - Nicole Baca
- Cedars-Sinai Medical Center, Department of Pediatrics, Los Angeles, California, United States
| | - Fataneh Majlessipour
- Cedars-Sinai Medical Center, Department of Pediatrics, Los Angeles, California, United States
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, United States.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Samuel H Pepkowitz
- Cedars-Sinai Medical Center, Department of Pathology and Laboratory Medicine, Los Angeles, California, United States
| | - Chelsea Hayes
- Cedars-Sinai Medical Center, Department of Pathology and Laboratory Medicine, Los Angeles, California, United States
| | - Ellen Klapper
- Cedars-Sinai Medical Center, Department of Pathology and Laboratory Medicine, Los Angeles, California, United States
| | - David R Gibb
- Cedars-Sinai Medical Center, Department of Pathology and Laboratory Medicine, Los Angeles, California, United States
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12
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Wu Y, Ji Y, Dai B, Guo F, Wu Y, He Z, Mo C, Wu S, Hu Y. A case of hyperhaemolysis syndrome in a pregnant Chinese woman with β-thalassemia during perinatal transfusion. Transfus Med 2020; 31:24-29. [PMID: 33331032 DOI: 10.1111/tme.12748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/01/2020] [Accepted: 12/06/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To report a case of hyperhaemolysis syndrome (HHS) that occurred during perinatal blood transfusion in a pregnant Chinese woman with β-thalassemia to deepen the understanding of HHS and the risk of transfusion therapy for patients with thalassemia. BACKGROUND Most HHS cases occur in people with sickle cell disease. So far, no cases of HHS have been reported in the Chinese population. Here, we report a pregnant Chinese women with β-thalassemia experiencing HHS. METHODS The patient received ABO- and RhD-matched red blood cell transfusion from six blood donors in four perinatal transfusions. Haemoglobinuria and lower haemoglobin levels compared to those before transfusion were observed after each transfusion, and the lactate dehydrogenase was consistently elevated. The blood samples were collected at different time points during the hospitalisation for direct antiglobulin test (DAT), antibody screening test and acid elution test. The antigens of six blood donors were identified, and the cross-matching tests were repeated using the blood sample of the patient with specific irregular antibodies after the last transfusion. RESULTS The DAT of the patient was negative for anti-IgG and positive (1+) for anti-C3d, and no red blood cell antibodies were detected in the eluent before, between and after transfusions. Before and between transfusions, blood samples were negative for red blood cell irregular antibodies, whereas IgM anti-P1 and IgG anti-Jka were detected in blood samples the next day after the last transfusion. In the six donors, two were negative for P1 and Jka , one was positive for P1 and negative for Jka , and three were negative for P1 and positive for Jka . The tentative cross-matching tests using the indirect antiglobulin method in saline showed that only agglutination occurred in the blood samples of the patient collected after last transfusion and the three Jka -positive blood donors. DISCUSSION The clinical manifestations and laboratory test results suggested that HHS occurred in this patient with β-thalassemia after each transfusion. Clinicians should be aware that HHS can occur with compatible blood transfusion.
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Affiliation(s)
- Yuanjun Wu
- Department of Blood Transfusion, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Yanli Ji
- Institute of Clinical Blood Transfusion, Guangzhou Blood Center, Guangzhou, China
| | - Bingmei Dai
- Department of obstetrics, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Faliang Guo
- Department of Critical Care Medicine, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Yong Wu
- Department of Blood Transfusion, Affiliated Tungwah Hospital of Sun yat-sen University, Dongguan, China
| | - Ziyi He
- Blood Transfusion Research Center, Dongguan City Blood Station, Dongguan, China
| | - Chunyan Mo
- Institute of Clinical Blood Transfusion, Guangzhou Blood Center, Guangzhou, China
| | - Shujie Wu
- Department of Blood Transfusion, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Yingming Hu
- Blood Transfusion Research Center, Dongguan City Blood Station, Dongguan, China
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Rutherford-Parker NJ, Campbell ST, Colby JM, Shajani-Yi Z. Voxelotor Treatment Interferes With Quantitative and Qualitative Hemoglobin Variant Analysis in Multiple Sickle Cell Disease Genotypes. Am J Clin Pathol 2020; 154:627-634. [PMID: 32561909 DOI: 10.1093/ajcp/aqaa067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Voxelotor was recently approved for use in the United States as a treatment for sickle cell disease (SCD) and has been shown to interfere with the quantitation of hemoglobin (Hb) S percentage. This study aimed to determine the effect of voxelotor on the quantitation of hemoglobin variant levels in patients with multiple SCD genotypes. METHODS In vitro experiments were performed to assess the impact of voxelotor treatment on hemoglobin variant testing. Whole blood samples were incubated with voxelotor and then analyzed by routinely used quantitative and qualitative clinical laboratory methods (high-performance liquid chromatography [HPLC], capillary zone electrophoresis [CZE], and acid and alkaline electrophoresis). RESULTS Voxelotor modified the α-globin chain of multiple hemoglobins, including HbA, HbS, HbC, HbD-Punjab, HbE, HbA2, and HbF. These voxelotor-hemoglobin complexes prevented accurate quantitation of multiple hemoglobin species, including HbS, by HPLC and CZE. CONCLUSIONS Technical limitations in quantifying HbS percentage may preclude the use of HPLC or CZE for monitoring patients treated with voxelotor. Furthermore, it is unclear whether HbS-voxelotor complexes are clinically equivalent to HbS. Consensus guidelines for reporting hemoglobin variant percentages for patients taking voxelotor are needed, as these values are necessary for determining the number of RBC units to exchange in acute situations.
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Affiliation(s)
- Nicola J Rutherford-Parker
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Sean T Campbell
- Department of Pathology, Montefiore Medical Center, Moses Division, The Bronx, NY
| | - Jennifer M Colby
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Zahra Shajani-Yi
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
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Kristiansson A, Gram M, Flygare J, Hansson SR, Åkerström B, Storry JR. The Role of α 1-Microglobulin (A1M) in Erythropoiesis and Erythrocyte Homeostasis-Therapeutic Opportunities in Hemolytic Conditions. Int J Mol Sci 2020; 21:ijms21197234. [PMID: 33008134 PMCID: PMC7582998 DOI: 10.3390/ijms21197234] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 02/06/2023] Open
Abstract
α1-microglobulin (A1M) is a small protein present in vertebrates including humans. It has several physiologically relevant properties, including binding of heme and radicals as well as enzymatic reduction, that are used in the protection of cells and tissue. Research has revealed that A1M can ameliorate heme and ROS-induced injuries in cell cultures, organs, explants and animal models. Recently, it was shown that A1M could reduce hemolysis in vitro, observed with several different types of insults and sources of RBCs. In addition, in a recently published study, it was observed that mice lacking A1M (A1M-KO) developed a macrocytic anemia phenotype. Altogether, this suggests that A1M may have a role in RBC development, stability and turnover. This opens up the possibility of utilizing A1M for therapeutic purposes in pathological conditions involving erythropoietic and hemolytic abnormalities. Here, we provide an overview of A1M and its potential therapeutic effect in the context of the following erythropoietic and hemolytic conditions: Diamond-Blackfan anemia (DBA), 5q-minus myelodysplastic syndrome (5q-MDS), blood transfusions (including storage), intraventricular hemorrhage (IVH), preeclampsia (PE) and atherosclerosis.
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Affiliation(s)
- Amanda Kristiansson
- Section for Infection Medicine, Department of Clinical Sciences, Lund University, 221 84 Lund, Sweden;
- Division of Hematology and Transfusion Medicine, Department of Laboratory Medicine, Lund University, 221 84 Lund, Sweden;
- Correspondence:
| | - Magnus Gram
- Department of Clinical Sciences Lund, Pediatrics, Lund University, 221 84 Lund, Sweden;
| | - Johan Flygare
- Department of Molecular Medicine and Gene Therapy, Lund Stem Cell Center, Lund University, 221 84 Lund, Sweden;
| | - Stefan R. Hansson
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences Lund, Lund University, 221 84 Lund, Sweden;
| | - Bo Åkerström
- Section for Infection Medicine, Department of Clinical Sciences, Lund University, 221 84 Lund, Sweden;
| | - Jill R. Storry
- Division of Hematology and Transfusion Medicine, Department of Laboratory Medicine, Lund University, 221 84 Lund, Sweden;
- Department of Clinical Immunology and Transfusion Medicine, Office of Medical Services, 221 85 Lund, Sweden
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15
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Vasanthamohan L, Choo S, Marshall T, Symons YT, Matsui D, Eastabrook G, Solh Z. Peripartum hyperhemolysis prophylaxis and management in sickle cell disease: A case report and narrative review. Transfusion 2020; 60:2448-2455. [PMID: 32851670 DOI: 10.1111/trf.16003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/26/2020] [Accepted: 06/29/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Sickle cell disease (SCD) is associated with hematologic complications including delayed hemolytic transfusion reactions (DHTRs) and pregnancy-related morbidity and mortality. Hyperhemolysis syndrome (HS) is the most severe form of DHTR in patients with SCD, in which both transfused and native red blood cells are destroyed. Further transfusions are avoided after a history of HS. Immunosuppressive agents can be used as prophylaxis against life-threatening hemolysis when transfusion is necessary. There is a paucity of evidence for the use of HS prophylaxis before transfusions, the continuation of hydroxyurea (HU) in lieu of chronic transfusion, and the use of erythropoiesis-stimulating agents (ESA) in pregnant SCD patients. CASE REPORT We present a case of a pregnant patient with SCD and a previous history of HS. HS prophylaxis was given before transfusion with corticosteroids, intravenous immunoglobulin, and rituximab. In addition, HU was continued during pregnancy to control SCD, along with the use of concomitant ESA to maintain adequate hemoglobin levels and avoid transfusion. We describe a multidisciplinary approach to pregnancy and delivery management including tailored anesthetic and obstetric planning. CONCLUSION This is the first published case of HS prophylaxis in a pregnant SCD patient, with good maternal and fetal outcomes after transfusion. HU and ESAs were able to control SCD and mitigate anemia in lieu of prophylactic transfusions during pregnancy. Further prospective studies are necessary to elucidate the ideal management of pregnant SCD patients with a history of HS or other contraindications to chronic transfusion.
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Affiliation(s)
- Lakshman Vasanthamohan
- Department of Medicine, Division of Hematology, Western University, London, Ontario, Canada
| | - Sheryl Choo
- Department of Obstetrics & Gynecology, Western University, London, Ontario, Canada
| | - Tonisha Marshall
- Department of Obstetrics & Gynecology, Western University, London, Ontario, Canada
| | | | - Doreen Matsui
- Department of Pediatrics, Division of Clinical Pharmacology, Western University, London, Ontario, Canada
| | - Genevieve Eastabrook
- Department of Obstetrics & Gynecology, Western University, London, Ontario, Canada
| | - Ziad Solh
- Department of Medicine, Division of Hematology, Western University, London, Ontario, Canada.,Department of Pathology & Laboratory Medicine, Division of Transfusion Medicine, Western University, London, Ontario, Canada
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16
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The cause and pathogenesis of hemolytic transfusion reactions in sickle-cell disease. Curr Opin Hematol 2020; 26:488-494. [PMID: 31589171 DOI: 10.1097/moh.0000000000000546] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The current review aims to summarize the epidemiology, cause, pathophysiology, and management of hemolytic transfusion reactions in sickle-cell disease (SCD). RECENT FINDINGS Patients undergoing occasional, isolated transfusions have been shown to have a higher risk of developing this condition. Despite the identification of well known risk factors, including alloimmunization, the pathophysiology of this syndrome remains unclear, as very severe forms with hyperhemolysis may develop in the absence of detectable antibodies, or with antibodies that are not considered to be clinically significant. Complement plays a crucial role in this reaction, particularly in cases of intravascular hemolysis. Complement triggers the reaction, but it also amplifies the inflammatory response and aggravates tissue damage. Free heme and hemoglobin are released and interact with complement, causing tissue damage. SUMMARY Hemolytic transfusion reactions are the most feared complications of blood transfusion in patients with SCD. This reaction is underdiagnosed because it mimics a vaso-occlusive crisis. Alloimmunization against red blood cell antigens is known to be a major trigger of this reaction, but abnormal complement activation and the underlying condition in patients with chronic hemolysis, may amplify the reaction. There is an urgent need to develop evidence-based approaches for preventing and treating this reaction.
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17
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Nickel RS, Flegel WA, Adams SD, Hendrickson JE, Liang H, Tisdale JF, Hsieh MM. The impact of pre-existing HLA and red blood cell antibodies on transfusion support and engraftment in sickle cell disease after nonmyeloablative hematopoietic stem cell transplantation from HLA-matched sibling donors: A prospective, single-center, observational study. EClinicalMedicine 2020; 24:100432. [PMID: 32637902 PMCID: PMC7327930 DOI: 10.1016/j.eclinm.2020.100432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) is curative for patients with sickle cell disease (SCD). Prior to HSCT, patients with SCD commonly receive RBC transfusions with some becoming RBC or HLA alloimmunized. This alloimmunization may impact post-HSCT transfusion requirements and donor engraftment. METHODS The study population included patients with SCD transplanted on a single-center nonmyeloablative, HLA-matched sibling HSCT trial at the National Heart, Lung, and Blood Institute (NHLBI) who had a pre-HSCT sample available for HLA class I antibody testing. We evaluated transfusion requirements and engraftment outcomes comparing patients with and without pre-existing HLA and RBC antibodies. FINDINGS Of 36 patients studied, 10 (28%) had HLA class I antibodies and 11 (31%) had a history of RBC alloantibodies. Up to day +45 post-HSCT, patients with HLA antibodies received more platelet transfusions (median 2.5 vs 1, p = 0.042) and those with RBC alloantibodies received more RBC units (median 7 vs 4, p = 0.0059) compared to respective non-alloimmunized patients. HLA alloimmunization was not associated with neutrophil engraftment, donor chimerism, or graft rejection. However, RBC alloimmunization correlated with a decreased donor T cell chimerism at 1 year (median 24% vs 55%, p = 0.035). INTERPRETATION Pre-existing HLA and RBC alloantibodies are clinically significant for patients undergoing HLA-matched nonmyeloablative HSCT. Testing for both HLA and RBC antibodies is important to help estimate transfusion needs peri‑HSCT. The association of lower donor T cell chimerism and pre-existing RBC alloantibodies needs further investigation. FUNDING NIH Clinical Center and NHLBI Intramural Research Program (Z99 CL999999, HL006007-11) and the Thrasher Research Fund.
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Affiliation(s)
- Robert Sheppard Nickel
- Children's National Hospital, Division of Hematology, 111 Michigan Ave NW, Washington, DC 20010, United States
- The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
- Corresponding author at: Children's National Hospital, Division of Hematology, 111 Michigan Ave NW, Washington, DC 20010, United States.
| | - Willy A. Flegel
- Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Sharon D. Adams
- Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Jeanne E. Hendrickson
- Departments of Laboratory Medicine and Pediatrics, Yale School of Medicine, New Haven, CT, United States
| | - Hua Liang
- The George Washington University, Department of Statistics, Washington, DC, United States
| | - John F. Tisdale
- Cellular and Molecular Therapeutics Branch, National Institutes of Health, Bethesda, MD, United States
| | - Matthew M. Hsieh
- Cellular and Molecular Therapeutics Branch, National Institutes of Health, Bethesda, MD, United States
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18
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Red blood cell alloimmunisation after platelet transfusion (excluding ABO blood group system). Transfus Clin Biol 2020; 27:185-190. [PMID: 32544526 DOI: 10.1016/j.tracli.2020.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/26/2020] [Accepted: 06/08/2020] [Indexed: 01/28/2023]
Abstract
Red blood cell alloimmunisation after transfusion of red blood cell concentrates carries a risk for every recipient. This risk is particularly high for patients with conditions such as sickle cell disease. However, red blood cell alloimmunisation can also occur after platelet concentrate transfusion. All blood group systems other than ABO are affected, and there are several mechanisms responsible for this alloimmunisation. The practical implications of this are a need to match red blood cell concentrates in all alloimmunised patients and, in pregnant women, recongnition of the risk of developing haemolytic disease of the foetus and newborn. Several measures can be taken to prevent alloimmunisation: in the case of the D antigen, for example, anti-RhD immunoglobulins can be infused before transfusing platelet concentrates from an RhD-positive donor in a RhD-negative recipient.
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19
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Abboud MR. Standard management of sickle cell disease complications. Hematol Oncol Stem Cell Ther 2020; 13:85-90. [DOI: 10.1016/j.hemonc.2019.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/11/2019] [Indexed: 01/10/2023] Open
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Two Consecutive Episodes of Severe Delayed Hemolytic Transfusion Reaction in a Sickle Cell Disease Patient. Case Rep Hematol 2020; 2020:2765012. [PMID: 32351743 PMCID: PMC7180413 DOI: 10.1155/2020/2765012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/05/2020] [Accepted: 03/26/2020] [Indexed: 11/23/2022] Open
Abstract
Patients with sickle cell disease (SCD) suffer from anemia and painful vaso-occlusive crisis (VOC) and sometimes need blood transfusions. Delayed hemolytic transfusion reaction (DHTR) is a rare life-threatening complication observed in SCD and mimics VOC. We describe a female SCD patient undergoing three surgical procedures during which DHTR developed following the first two. Prior to a planned tonsillectomy, she received transfusion and three days after surgery developed severe hemolysis as well as pain and respiratory symptoms. On suspicion of VOC, she received additional transfusions and became hemodynamically unstable, and her hemolytic anemia worsened. Gradually, she recovered and could be discharged after two weeks; DHTR was not suspected. Sixteen months later, an arthroplasty was performed due to avascular necrosis, and again she was transfused preoperatively. Similar to the initial surgery, she developed symptoms and signs of VOC after three days, but this time, DHTR was suspected and further transfusions were withheld. Although immunosuppressive medication did not alleviate the condition, she improved on combined treatment with darbepoietin, rituximab, and eculizumab. Six months later, a second arthroplasty was performed uneventfully after prophylaxis with rituximab and without transfusion. DHTR should be considered in the presence of severe, unexplained hemolysis following a recent transfusion, and additional transfusions in this setting should be given only on vital indication.
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21
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Delayed hemolytic transfusion reaction in sickle cell disease: A state of the art and the perspective in research. Transfus Clin Biol 2019. [DOI: 10.1016/j.tracli.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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