Delayed haemolytic transfusion reaction caused by anti-M antibody in a patient receiving interleukin-2 and interferon for metastatic renal cell cancer

Anti-M–Induced Delayed Hemolytic Transfusion Reaction

Background

Anti-M is most often assumed to be naturally occurring and can be comprised of a mixture of predominantly immunoglobulin(Ig)M with a lesser IgG component. Anti-M-antibodies usually do not react at 37°C and therefore are considered to be of little clinical significance.

Methods

A 28-year-old man presented with hemorrhagic shock from numerous injuries sustained in a motor vehicle collision. The patient received several units of red blood cells (RBCs). The antibody screen, the direct antiglobulin test (DAT), and the RBC genotype were sent for laboratory evaluation.

Results

A total of 12 days after the first antibody screening result was negative (7 days after transfusion), the lowest hemoglobin value was 5.5 g per dL, and we observed a positive antibody screening result and DAT with immunoglobulin (Ig)G anti-M identified. After transfusion of 4 units of M antigen–negative RBC, the post-transfusion hemoglobin level increased to 8.9 g per dL.

Conclusion

Obtaining M antigen–negative compatible RBCs is necessary in patients demonstrating IgG anti-M in plasma.

Cold reacting anti-M causing delayed hemolytic disease of the newborn

BACKGROUND

Hemolytic disease of the fetus and newborn (HDFN) is due to passively transferred maternal antibodies directed against fetal red blood cell (RBC) antigens and can lead to severe morbidity and mortality. Anti-M is usually a naturally occurring antibody of low clinical significance, although occasionally severe cases of HDFN are seen.

CASE REPORTS

Two M+ sisters are presented, each developing hemolysis during the first 2 weeks of life due to maternal anti-M, resulting in severe anemia and requiring blood transfusion. RBC agglutination was observed in peripheral blood samples of both infants at room temperature with dissociation at 37°C. Maternal anti-M detected by column indirect agglutination technique, was of low titer (1:16) and demonstrated low thermal amplitude, reacting in saline at 4°C but was not detectable in saline at 37°C.

CONCLUSIONS

Anti-M of low thermal amplitude may cause hemolytic disease of the newborn with laboratory features resembling cold agglutinin disease.

Anti-m antibody in solid tumors-two case reports

Anti-M antibodies are usually of IgM, appear as cold agglutinins and are clinically insignificant. We are reporting two cases of anti-M in cases of solid tumors where the anti-M caused discrepancy in blood grouping, reacted in coombs phase of crossmatching. Anti-M in first case showed dosage effect. These antibodies can be clinical significant when detected in coombs phase, making M antigen negative coombs compatible unit transfusion imperative.

Clinical significance of antibody specificities to M, N and Lewis blood group system

Context:

The clinically significant antibodies are those active at 37°C and/or by the indirect antiglobulin test. Most of the published literature refers to antibodies of Lewis blood group system to be insignificant, whereas antibodies to M and N blood groups are associated with variable clinical significance.

Aims:

The aim of this study is to find the frequency and clinical significance of antibodies to M, N and Lewis blood group systems.

Settings and Design:

The study was carried out retrospectively from January 2009 to December 2012.

Materials and Methods:

Antibody screening was performed by solid phase red cell adherence (SPRCA) technique using four cell screening panel on a fully automated platform GALILEO (Immucor Inc. USA). In case of a positive antibody screen, antibody identification was performed using SPRCA (GALILEO, Immucor Inc. USA).

Results:

A total of 49,077 red cell antibody screens were performed and a total of 427 identifications of red cell antibodies were carried out. A total of 304 specific antibodies were detected: 8.22% of antibodies were of anti-M specificity and 2.96% were of anti-N specificity. Majority (84%) of anti-M and 77.78% of anti-N were of Immunoglobulin G (IgG) class reacting at 37°C. 1.31% of the antibodies were directed against Lewis system antigens of which 0.65% were anti-Lea and 0.65% were anti-Leb. Half of the Lewis system antibodies, i.e., 1 each of anti-Lea and anti-Leb were of IgG class.

Conclusion:

Our study highlights the importance of detecting the thermal amplitude of antibodies with variable clinical significance especially if both IgG and IgM types of antibodies are associated with it so as to establish their clinical significance.

Mouse models of IgG- and IgM-mediated hemolysis

Well-characterized mouse models of allo-immune antibody-mediated hemolysis would provide a valuable approach for gaining greater insight into the pathophysiology of hemolytic transfusion reactions. To this end, mouse red blood cells (mRBCs) from human glycophorin A transgenic (hGPA-Tg) donor mice were transfused into non-Tg recipients that had been passively immunized with IgG or IgM hGPA-specific monoclonal antibodies (mAbs). In this novel murine "blood group system," mRBCs from hGPA-Tg mice are "antigen positive" and mRBCs from non-Tg mice are "antigen negative." Passive immunization of non-Tg mice with the IgG1 10F7 and IgG3 NaM10-2H12 anti-hGPA mAbs each induced rapid clearance of incompatible transfused hGPA-Tg-mRBCs in a dose-response manner. Using various knockout mice as transfusion recipients, both the complement system and activating Fcgamma receptors were found to be important in the clearance of incompatible mRBCs by each of these IgG mAbs. In addition, the IgM E4 anti-hGPA mAb induced complement-dependent intravascular hemolysis of transfused incompatible hGPA-Tg-mRBCs accompanied by gross hemoglobinuria. These initial studies validate the relevance of these new mouse models for addressing important questions in the field of transfusion medicine.

Alteration of amino acid residues at the L-chain N-terminus and in complementarity-determining region 3 increases affinity of a recombinant F(ab) for the human N blood group antigen

BACKGROUND

To examine the fine specificity of glycopeptide-specific antibodies, this study focused on the human MN blood group system. F(ab) phage display methods were previously used to construct an F(ab) family in which the H-chain Fd fragment was held constant whereas the L chains were "shuffled." This yielded two related F(ab), N92 and NNA7, with low and high affinity for N, respectively. Although their L-chain sequences are very similar, sharing 92 percent amino acid identity, there are intriguing differences at the N-terminus and in complementarity-determining region 3 (CDR3) at positions 89, 91, 92, and 96.

STUDY DESIGN AND METHODS

Site-directed mutagenesis, ELISA, and hemagglutination were used to examine the contributions of these variations to antibody affinity.

RESULTS

Studies with the N92-S91G and NNA7-G91S mutants demonstrated that the Gly at position 91 was critically important for ensuring high affinity. Indeed, the affinity of N92-S91G was almost as high as N92TM, in which all four CDR3 residues were changed to match NNA7. N-terminal L-chain differences were surprisingly important in determining affinity. For example, when the N-terminus of N92 was changed to match that of NNA7, affinity increased approximately 30-fold.

CONCLUSION

Specific residues at the L-chain N-terminus and in CDR3 significantly affected F(ab) affinity for N. Future structural studies of these F(ab), alone and complexed with this glycopeptide antigen, will provide further insights into these phenomena.