Non-immune Hemolysis: Diagnostic Considerations

Coombs-Negative Hemolytic Anemia in an Elderly COVID-19 Patient

COVID-19 infections are known to cause multi-organ complications. Hematological complications like autoimmune hemolytic anemia with a positive direct antiglobulin test (DAT), are commonly encountered. However, Coombs-negative hemolytic anemia is extremely rare. We report an interesting case of an elderly female with moderate-severe acute respiratory distress syndrome in the setting of COVID-19 pneumonia-causing Coombs-negative hemolytic anemia. This patient initially presented with sudden onset abdominal pain and vomiting, found to have an incarcerated inguinal hernia with small bowel obstruction (SBO) on imaging. Additionally, labs revealed positive COVID-19 antigen test and normocytic anemia. The hospital course was complicated by worsening hemolytic anemia and thrombocytopenia requiring blood products. Extensive workup for hemolysis in this patient with no prior hematological abnormalities, was negative for DAT and other conditions associated with or causative of hemolysis. At discharge, hemolytic parameters improved and on follow-up, hemoglobin returned to baseline, and repeat hemolytic parameters were normal. This case emphasizes the importance of considering SARS-CoV-2 along with other viral infections as one of the differentials for Coombs-negative hemolytic anemia.

Exploring the intersection: Peptic ulcers and hemolysis-Unraveling the complex relationship

This paper investigates the intriguing relationship between peptic ulcers and hemolysis, 2 seemingly distinct medical conditions, aiming to unravel their potential interconnections and clinical implications. While traditionally studied in isolation, recent evidence has surfaced suggesting possible links and shared mechanisms between these conditions. This paper explores the underlying pathophysiological associations, shared risk factors, diagnostic challenges, management strategies, and implications for clinical practice and health policy. The interplay between peptic ulcers and hemolysis stems from shared inflammatory pathways, notably attributed to Helicobacter pylori infection in peptic ulcers, which might trigger systemic inflammatory responses contributing to hemolysis. Common risk factors including genetic predispositions, autoimmune disorders, and medication use (such as nonsteroidal anti-inflammatory drugs) are implicated in the development of both peptic ulcers and hemolytic conditions, suggesting a potential convergence of these disorders in affected individuals. Diagnostic considerations pose challenges, as overlapping symptoms and laboratory findings may complicate accurate differentiation between peptic ulcers and hemolysis. Recognizing the potential interplay between peptic ulcers and hemolysis holds significant implications for clinical practice and health policy. Streamlining diagnostic algorithms, fostering interdisciplinary collaborations, and developing tailored guidelines are pivotal in optimizing patient care. Continued research efforts, collaborative clinical approaches, and informed health policies are essential in advancing our understanding and enhancing patient care for individuals navigating the intersection of peptic ulcers and hemolysis.

A retrospective analysis of the hemolysis occurrence during extracorporeal membrane oxygenation in a single center

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO)-associated hemolysis still represents a serious complication. The present study aimed to investigate those predictive factors, such as flow rates, the use of anticoagulants, and circuit connected dialysis, that might play a pivotal role in hemolysis in adult patients.

METHODS

This is a retrospective single-center case series of 35 consecutive adult patients undergoing veno-venous ECMO support at our center between April 2014 and February 2020. Daily plasma-free hemoglobin (pfHb) and haptoglobin (Hpt) levels were chosen as hemolysis markers and they were analyzed along with patients' characteristics, daily laboratory findings, and corresponding ECMO system variables, as well as continuous renal replacement therapy (CRRT) when administered, looking for factors influencing their trends over time.

RESULTS

Among the many settings related to the ECMO support, the presence of CRRT connected to the ECMO circuit has been found associated with both higher daily pfHb levels and lower Hpt levels. After correction for potential confounders, hemolysis was ascribable to circuit-related variables, in particular the membrane oxygenation dead space was associated with an Hpt reduction (B = -215.307, p = 0.004). Moreover, a reduction of ECMO blood flow by 1 L/min has been associated with a daily Hpt consumption of 93.371 mg/dL (p = 0.001).

CONCLUSIONS

Technical-induced hemolysis during ECMO should be monitored not only when suspected but also during quotidian management and check-ups. While considering the clinical complexity of patients on ECMO support, clinicians should not only be aware of and anticipate possible circuitry malfunctions or inadequate flow settings, but they should also take into account the effects of an ECMO circuit-connected CRRT, as an equally important key factor triggering hemolysis.

Towards an Innovative Sensor in Smart Capsule for Aerial Drones for Blood and Blood Component Delivery

Aerial drone technology is currently being investigated worldwide for the delivery of blood components. Although it has been demonstrated to be safe, the delivered medical substances still need to be analyzed at the end of the flight mission to assess the level of haemolysis and pH prior to the use in a patient. This process can last up to 30 min and prevent the time saved using drone delivery. Our study aims to integrating an innovative sensor for the haemolysis and pH detection into the Smart Capsule, an already demonstrated technology capable of managing transfusion transport through drones. In the proposed scenario, the haemolysis is evaluated optically by a minilysis device using LED-photodetector combination. The preliminary validation has been demonstrated for both the thermal stability of the Smart Capsule and the haemolysis detection of the minilysis device prototype. Firstly, the onboard temperature test has shown that the delivery system is capable of maintaining proper temperature, even though the samples have been manipulated to reach a higher temperature before inserting into the Smart Capsule. Then, in the laboratory haemolysis test, the trend of linear regression between the outputs from the spectrophotometer and the minilysis prototype confirmed the concept design of the minilysis device.

Non-immune Hemolysis in Gaucher Disease and Review of the Literature

Gaucher disease (GD) is an autosomal recessive disease characterized by the buildup of glucocerebrosides in macrophages, resulting in the formation of "Gaucher cells." These cells predominantly infiltrate the liver, spleen, and bone marrow leading to hepatosplenomegaly, cytopenia, and bone pain. Anemia in GD is typically considered to result from non-hemolytic processes. Although rare, a higher rate of hemolytic anemia of the autoimmune type has been reported in GD than in the general population. The literature on non-immune hemolytic anemia in GD is scarce. We review the literature on hemolytic anemia in GD and report on a case of non-immune hemolytic anemia secondary to GD. We believe this is the first description of a patient with confirmed GD and symptomatic non-immune hemolytic anemia that responded to GD-specific treatment.

Plasma hemoglobin: A method comparison of six assays for hemoglobin and hemolysis index measurement

INTRODUCTION

Plasma hemoglobin (Hb) is measured for assessment of in vivo and in vitro hemolysis. The objective of the present investigation was to conduct a method comparison of five quantitative and one semi-quantitative Hb and H-index (hemolysis index) assays to evaluate their performance measuring plasma Hb in clinical specimens.

METHODS

One hundred and fourteen clinical specimens previously tested for plasma Hb using a laboratory-developed spectrophotometric assay were also tested for Hb using a HemoCue Plasma/Low Hb assay (azide methemoglobin), a laboratory-modified Pointe Scientific Hb assay (cyanmethemoglobin), tested for H-index measurements using a Roche cobas c501, an Abbott Architect c8000, and a semi-quantitative (binned) H-index measurement on a Beckman AU5800. The reference result was defined as the median Hb score (median of all Hb or H-index results).

RESULTS

The laboratory-developed spectrophotometric Hb assay and Roche H-index methods mostly closely matched the median Hb score across all data, as well as for lower range median Hb score results ≤2.0 g/L. Two-way frequency table analysis using an Hb (or H-index) cutoff of 0.5 g/L (or 0.5 H-index units) was then performed to compare methods to the median Hb score cutoff. The Beckman method had the highest accuracy at this cutoff, the Roche and Abbott methods had the highest positive predictive value (PPV), and the Beckman, HemoCue, and Pointe methods had the highest negative predictive value (NPV).

CONCLUSIONS

Plasma Hb and H-index results vary by method. Laboratories should evaluate the performance characteristics of their respective assays when considering adoption of spectrophotometric or chemical methods for plasma Hb assessment.

Differences in the Hemolytic Behavior of Two Isomers in Ophiopogon japonicus In Vitro and In Vivo and Their Risk Warnings

Ophiopogonin D (OPD) and Ophiopogonin D′ (OPD′) are two bioactive ingredients in Ophiopogon japonicus. Previously published studies have often focused on the therapeutic effects related to OPD's antioxidant capacity but underestimated the cytotoxicity-related side effects of OPD′, which may result in unpredictable risks. In this study, we reported another side effect of OPD′, hemolysis, and what was unexpected was that this side effect also appeared with OPD. Although hemolysis effects for saponins are familiar to researchers, the hemolytic behavior of OPD or OPD′ and the interactions between these two isomers are unique. Therefore, we investigated the effects of OPD and OPD′ alone or in combination on the hemolytic behavior in vitro and in vivo and adopted chemical compatibility and proteomics methods to explain the potential mechanism. Meanwhile, to explain the drug-drug interactions (DDIs), molecular modeling was applied to explore the possible common targets. In this study, we reported that OPD′ caused hemolysis both in vitro and in vivo, while OPD only caused hemolysis in vivo. We clarified the differences and DDIs in the hemolytic behavior of the two isomers. An analysis of the underlying mechanism governing this phenomenon showed that hemolysis caused by OPD or OPD′ was related to the destruction of the redox balance of erythrocytes. In vivo, in addition to the redox imbalance, the proteomics data demonstrated that lipid metabolic disorders and mitochondrial energy metabolism are extensively involved by hemolysis. We provided a comprehensive description of the hemolysis of two isomers in Ophiopogon japonicus, and risk warnings related to hemolysis were presented. Our research also provided a positive reference for the development and further research of such bioactive components.

Genotoxicity and Hemocompatibility of a Novel Calcium Aluminate-Based Cement

Objective:

The aim of this in vitro study was to evaluate the genotoxicity and hemocompatibility of a novel calcium aluminate-based cement, EndoBinder (EB) (Binderware, São Carlos, SP, Brazil) and compare it with Angelus White Mineral Trioxide Aggregate (MTA) (AWMTA) (Angelus, Soluções Odontológicas, Londrina, PR, Brazil).

Methods:

For evaluation of genotoxicity, a comet assay was performed with Chinese hamster ovary (CHO) cells that had been grown for 24 h in Dulbecco’s Modified Eagle Medium incubated with each of the cements for 24 h at 37°C. DNA percentage in head and Olive tail moment were analyzed. For assessment of hemocompatibility, erythrocyte lysis quantification, and concentration of plasma fibrinogen were determined in human blood samples placed in contact with each of the materials. One way analysis of variance (ANOVA) followed by post hoc Tukey test and Student t-test were used for data analysis of genotoxicity and hemocompatibility, respectively.

Results:

Results showed that the genotoxic effects of EB and AWMTA were comparable to that of the negative control, with no statistically significant differences between AWMTA and negative control (P>0.05). Compared to AWMTA, EB showed greater hemolytic potential when placed in direct contact with erythrocytes (P<0.05). Fibrinogen values were low for both materials, with protein concentration being greater in samples exposed to EB than to AWMTA.

Conclusion:

Both materials presented a higher hemolytic behaviour compared to what is established by international standards. Fibrinogen formation was low for both materials, and DNA damage induction was not observed in a comet assay.

Hemolysis during and after 21 days of head-down-tilt bed rest

Hemoconcentration is observed in bed rest studies, descent from altitude, and exposure to microgravity. Hemoconcentration triggers erythrocyte losses to subsequently normalize erythrocyte concentration. The mechanisms of erythrocyte loss may involve enhanced hemolysis, but has never been measured directly in bed rest studies. Steady‐state hemolysis was evaluated by measuring two heme degradation products, endogenous carbon monoxide concentration [CO] and urobilinogen in feces, in 10 healthy men, before, during, and after two campaigns of 21 days of 6° head‐down‐tilt (HDT) bed rest. The subjects were hemoconcentrated at 10 and 21 days of bed rest: mean concentrations of hemoglobin (15.0 ± 0.2 g/L and 14.6 ± 0.1 g/L, respectively) and erythrocytes (5.18 ± 0.06E6/μL and 5.02 ± 0.06E6/μL, respectively) were increased compared to baseline (all Ps < 0.05). In contrast, mean hemoglobin mass (743 ± 19 g) and number of erythrocytes (2.56 ± 0.07E13) were decreased at 21 days of bed rest (both Ps < 0.05). Indicators of hemolysis mean [CO] (1660 ± 49 ppb and 1624 ± 48 ppb, respectively) and fecal urobilinogen concentration (180 ± 23 mg/day and 199 ± 22 mg/day, respectively) were unchanged at 10 and 21 days of bed rest compared to baseline (both Ps > 0.05). A significant decrease in [CO] (−505 ppb) was measured at day 28 after bed rest. HDT bed rest caused hemoconcentration in parallel with lower hemoglobin mass. Circulating indicators of hemolysis remained unchanged throughout bed rest supporting that enhanced hemolysis did not contribute significantly to erythrocyte loss during the hemoconcentration of bed rest. At day 28 after bed rest, decreased hemolysis accompanied the recovery of erythrocytes, a novel finding.

Evaluation of Anemia

Anemia is a common problem in primary care. Classification based on mean cell volume narrows the differential diagnosis and directs testing. A marked macrocytosis is characteristic of vitamin B12 and folate deficiencies, certain medications, and primary bone marrow disorders. The three most common causes of microcytic anemia are iron deficiency, thalassemia trait, and anemia of inflammation. Additional laboratory testing is required for diagnosis. Determination of the rate of development of anemia and examination of a blood smear may provide diagnostic clues to guide more specialized testing. Diagnosis of iron, vitamin B12, or folate deficiency mandates determination of the underlying cause.