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Christensen RD, Bahr TM, Ohls RK, Ilstrup SJ, Moise KJ, Lopriore E, Meznarich JA. Erythrokinetic mechanism(s) causing the "late anemia" of hemolytic disease of the fetus and newborn. J Perinatol 2024; 44:916-919. [PMID: 38216678 DOI: 10.1038/s41372-024-01872-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/19/2023] [Accepted: 01/04/2024] [Indexed: 01/14/2024]
Abstract
A transfusion-requiring "late anemia" can complicate the management of neonates convalescing from hemolytic disease of the fetus and newborn (HDFN). This anemia can occur in any neonate after HDFN but is particularly prominent in those who received intrauterine transfusions and/or double-volume exchange transfusions. Various reports describe this condition as occurring based on ongoing hemolysis, either due to passive transfer of alloantibody through breast milk or persistence of antibody not removed by exchange transfusion. However, other reports describe this condition as the result of inadequate erythrocyte production. Both hypotheses might have merit, because perhaps; (1) some cases are primarily due to continued hemolysis, (2) others are primarily hypoproductive, and (3) yet others result from a mixture of these two mechanisms. We propose prospective collaborative studies that will resolve this issue by serially quantifying end-tidal carbon monoxide. Doing this will better inform the assessment and treatment of neonates recovering from HDFN.
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Affiliation(s)
- Robert D Christensen
- Women and Newborns Research, Intermountain Health, Murray, UT, USA.
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
| | - Timothy M Bahr
- Women and Newborns Research, Intermountain Health, Murray, UT, USA
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Robin K Ohls
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Sarah J Ilstrup
- Transfusion Medicine, Department of Pathology, Intermountain Health, Murray, UT, USA
| | - Kenneth J Moise
- Comprehensive Fetal Care Center at Dell Children's Medical Center and Department of Women's Health, Dell Medical School, Austin, TX, USA
| | - Enrico Lopriore
- Division of Neonatology, Leiden University Medical Centre, Leiden, Netherlands
| | - Jessica A Meznarich
- Division of Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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2
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Ahmed M, Jackson DE. The role of measuring peak systolic velocity of the middle cerebral artery blood flow and anti-K1 titre during pregnancy to detect foetuses with severe anaemia, foetal hydrops, and the requirement of intrauterine transfusion: A systematic review and meta-analysis. Hematol Transfus Cell Ther 2024:S2531-1379(24)00035-X. [PMID: 38429195 DOI: 10.1016/j.htct.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 09/04/2023] [Accepted: 02/02/2024] [Indexed: 03/03/2024] Open
Abstract
The clinical manifestation of foetal anaemia caused by maternal Kell alloantibodies differs from that caused by non-Kell alloantibodies. Severe anaemia develops in the foetus in the early weeks of gestation; therefore, proper management and early intervention are important. A systematic review and meta-analysis was performed to determine whether the anti-K1 titre can determine the sequelae of Kell alloimmunised pregnancies. Prospective and retrospective cohort studies were used to conduct a systematic review following a comprehensive literature search, in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Studies were screened based on a defined set of inclusion and exclusion criteria. A total of 5143 potential articles were identified. Ten studies were used in the meta-analysis of pregnancy outcomes for a specific anti-K1 titre cut-off. The meta-analysis identified statistical significance for intrauterine transfusion (ARD: 0.351; 95 % CI: 0.593-0.109; p-value = 0.004), hydrops (ARD: 0.808; 95 % CI: 1.145-0.472; p-value <0.001), intrauterine foetal death (ARD: 0.938; 95 % CI:1.344 to -0.533; p-value <0.001) and intrauterine transfusion for Doppler middle cerebral artery >1.5 MoM (ARD: 0.381; 95 % CI:1.079 to -0.317; p-value = 0.285). It was concluded that there is no correlation between anti-K1 titre and Kell sensitised pregnancy outcomes, but monitoring the anti-K1 titre is important to manage the pregnancy and it helps clinicians determine the need for intrauterine transfusions. Doppler middle cerebral artery peak systolic velocity is strongly correlated with foetal anaemia and is an efficient routine method for determining the need for intrauterine transfusions in pregnancies affected by anti-K1.
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Affiliation(s)
- Mufleha Ahmed
- Thrombosis and Vascular Diseases Laboratory, School of Health and Biomedical Sciences-STEM College, RMIT University, Bundoora, Victoria, Australia
| | - Denise E Jackson
- Thrombosis and Vascular Diseases Laboratory, School of Health and Biomedical Sciences-STEM College, RMIT University, Bundoora, Victoria, Australia.
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3
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Carpenter MC, Souter SC, Zipkin RJ, Ackerman ME. Current Insights Into K-associated Fetal Anemia and Potential Treatment Strategies for Sensitized Pregnancies. Transfus Med Rev 2024; 38:150779. [PMID: 37926651 PMCID: PMC10856777 DOI: 10.1016/j.tmrv.2023.150779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023]
Abstract
K-associated anemic disease of the fetus and newborn (K-ADFN) is a rare but life-threatening disease in which maternal alloantibodies cross the placenta and can mediate an immune attack on fetal red blood cells expressing the K antigen. A considerably more common disease, D-associated hemolytic disease of the fetus and newborn (D-HDFN), can be prophylactically treated using polyclonal α-D antibody preparations. Currently, no such prophylactic treatment exists for K-associated fetal anemia, and disease is usually treated with intrauterine blood transfusions. Here we review current understanding of the biology of K-associated fetal anemia, how the maternal immune system is sensitized to fetal red blood cells, and what is understood about potential mechanisms of prophylactic HDFN interventions. Given the apparent challenges associated with preventing alloimmunization, we highlight novel strategies for treating sensitized mothers to prevent fetal anemia that may hold promise not only for K-mediated disease, but also for other pathogenic alloantibody responses.
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Affiliation(s)
| | | | | | - Margaret E Ackerman
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA; Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
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Christensen RD, Bahr TM, Ilstrup SJ, Dizon-Townson DS. Alloimmune hemolytic disease of the fetus and newborn: genetics, structure, and function of the commonly involved erythrocyte antigens. J Perinatol 2023; 43:1459-1467. [PMID: 37848604 DOI: 10.1038/s41372-023-01785-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/13/2023] [Accepted: 09/19/2023] [Indexed: 10/19/2023]
Abstract
Hemolytic disease of the fetus and newborn (HDFN) can occur when a pregnant woman has antibody directed against an erythrocyte surface antigen expressed by her fetus. This alloimmune disorder is restricted to situations where transplacental transfer of maternal antibody to the fetus occurs, and binds to fetal erythrocytes, and significantly shortens the red cell lifespan. The pathogenesis of HDFN involves maternal sensitization to erythrocyte "non-self" antigens (those she does not express). Exposure of a woman to a non-self-erythrocyte antigen principally occurs through either a blood transfusion or a pregnancy where paternally derived erythrocyte antigens, expressed by her fetus, enter her circulation, and are immunologically recognized as foreign. This review focuses on the genetics, structure, and function of the erythrocyte antigens that are most frequently involved in the pathogenesis of alloimmune HDFN. By providing this information we aim to convey useful insights to clinicians caring for patients with this condition.
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Affiliation(s)
- Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA.
- Obstetric and Neonatal Operations, Intermountain Health, Salt Lake City, UT, USA.
| | - Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
- Obstetric and Neonatal Operations, Intermountain Health, Salt Lake City, UT, USA
| | - Sarah J Ilstrup
- Intermountain Health Transfusion Services and Department of Pathology, Intermountain Medical Center, Murray, UT, USA
| | - Donna S Dizon-Townson
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, and Intermountain Health, Salt Lake City, UT, USA
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5
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Abels E, Adkins BD, Allen ES, Booth GS, DiGuardo MA, Ding JJ, Guarente J, Klein M, Stephens LD, Tormey CA, Woo JS, Jacobs JW. Updates in the care of the alloimmunized pregnant patient: A transfusion medicine and clinical laboratory perspective. Am J Clin Pathol 2023; 160:441-443. [PMID: 37471256 DOI: 10.1093/ajcp/aqad083] [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] [Indexed: 07/22/2023] Open
Affiliation(s)
- Elizabeth Abels
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US
| | - Brian D Adkins
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, US
| | - Elizabeth S Allen
- Department of Pathology, University of California San Diego, La Jolla, CA, US
| | - Garrett S Booth
- Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, TN, US
| | | | - Jia Jennifer Ding
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, US
| | - Juliana Guarente
- Department of Pathology and Genomic Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, US
| | - Monica Klein
- Department of Laboratory Medicine, Mayo Clinic, Rochester, MN, US
| | - Laura D Stephens
- Department of Pathology, University of California San Diego, La Jolla, CA, US
| | | | - Jennifer S Woo
- Department of Pathology, City of Hope National Medical Center, Irvine, CA, US
| | - Jeremy W Jacobs
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US
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6
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Kim HJ, Seo SW, Chung Y, Kim H, Hwang SH, Oh HB, Ko DH. Clinical significances and distribution of unexpected antibodies found in infants. Transfus Apher Sci 2023; 62:103765. [PMID: 37532599 DOI: 10.1016/j.transci.2023.103765] [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: 06/12/2023] [Revised: 07/05/2023] [Accepted: 07/19/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION The unexpected antibody test is an essential for ensuring the safety of blood transfusions. In infants, different pre-transfusion tests and transfusion strategies are needed due to their immature antigen/antibody system. This study aims to analyze the pattern of unexpected antibodies and their clinical significance in infants. METHODS A retrospective analysis was conducted on the results of unexpected antibody identification tests performed on infants under one year of age at Asan Medical Center from 1999 to 2022. Patients' unexpected antibody identification test results and clinical information were investigated. The results of unexpected antibody identification and phenotype of each patient's mother were collected. RESULTS 45 cases of antibody results were studied. 25 cases were found in infants under 4 months of age, and 18 cases (76%) were associated with hemolytic disease of the fetus and newborn (HDFN). The most common unexpected antibody in infants was anti-M (17 cases). There was one case of severe HDFN caused by anti-M. In 10 cases, anti-E and anti-c were found together, and 9 of these cases were associated with HDFN. There were four cases with a history of previous transfusion. CONCLUSIONS Non-ABO antibodies found in infants showed a different pattern compared to adults. Interpreting unexpected antibody tests in infants, it is important to consider the clinical status of the infant and the test results of the mother, due to possibility of HDFN. To our knowledge, this is the first study to reveal the distribution and clinical significances of unexpected antibodies found in infants in Korea.
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Affiliation(s)
- Han Joo Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Suk Won Seo
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yousun Chung
- Department of Laboratory Medicine, Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Hyungsuk Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sang-Hyun Hwang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Heung-Bum Oh
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dae-Hyun Ko
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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7
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Morales Painamil RA, de Aledo-Castillo JMG, Teresa-Palacio M, Argudo-Ramírez A, López-Galera RM, Paredes-Fuentes AJ, Aldecoa-Bilbao V, Alsina-Casanova M. Foetal Haemoglobin as a Marker of Bone Marrow Suppression Secondary to Anti-Kell Alloimmunisation. Int J Neonatal Screen 2023; 9:ijns9020024. [PMID: 37218889 DOI: 10.3390/ijns9020024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/24/2023] Open
Abstract
Anti-Kell alloimmunisation is a potentially severe minor blood group type incompatibility, not only as a cause of haemolytic disease of the foetus and newborn, but also due to the destruction of red blood cells (RBC) and mature form in the bone marrow with the subsequent hyporegenerative anaemia. In severe cases and when the foetus shows signs of anaemia, an intrauterine transfusion (IUT) may be necessary. When repeated, this treatment can suppress erythropoiesis and worsen the anaemia. We report the case of a newborn who required four IUTs plus an additional RBC transfusion at one month of life due to late onset anaemia. The identification of an adult haemoglobin profile with a complete absence of foetal haemoglobin in the patient's newborn screening samples at 2 and 10 days of life warned us of a possible late anaemia. The newborn was successfully treated with transfusion, oral supplements and subcutaneous erythropoietin. A blood sample taken at 4 months of life showed the expected haemoglobin profile for that age with a foetal haemoglobin of 17.7%. This case illustrates the importance of a close follow-up of these patients, as well as the usefulness of the haemoglobin profile screening as a tool for anaemia assessment.
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Affiliation(s)
| | | | - Marta Teresa-Palacio
- Department of Neonatology, BCNatal, Seu Maternitat, Hospital Clínic de Barcelona, 08028 Barcelona, Spain
| | - Ana Argudo-Ramírez
- Inborn Errors of Metabolism-IBC Section, Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Rosa M López-Galera
- Inborn Errors of Metabolism-IBC Section, Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Abraham J Paredes-Fuentes
- Inborn Errors of Metabolism-IBC Section, Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Victoria Aldecoa-Bilbao
- Department of Neonatology, BCNatal, Seu Maternitat, Hospital Clínic de Barcelona, 08028 Barcelona, Spain
| | - Miguel Alsina-Casanova
- Department of Neonatology, BCNatal, Seu Maternitat, Hospital Clínic de Barcelona, 08028 Barcelona, Spain
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8
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He Y, Gao W, Li Y, Xu C, Wang Q. A single-center, retrospective analysis of 17 cases of hemolytic disease of the fetus and newborn caused by anti-M antibodies. Transfusion 2023; 63:494-506. [PMID: 36727659 DOI: 10.1111/trf.17249] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 12/27/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We aimed to summarize the laboratory findings and clinical features of hemolytic disease of the fetus and newborn (HDFN). METHODS We retrospectively analyzed the data for 17 infants with anti-M-induced HDFN (anti-M-HDFN) diagnosed between June 2013 and May 2019. Their maternal history, neonatal diagnosis on admission, and laboratory test results were compared with those of 15 infants with HDFN involving the ABO blood group system, 15 infants with HDFN involving the Rh system, and 15 premature infants. RESULTS In the anti-M-HDFN group, 94.12% (16/17), 35.29% (6/17), and 17.65% (3/17) had free antibodies in plasma, a positive direct antiglobulin test, and a positive elution test, respectively. In 12 infants, free antibody reactions were stronger at 4°C than at 37°C, and the antibody titer at 4°C ranged from 1 to 512. All 17 infants with anti-M-HDFN developed anemia: 14 were treated with blood transfusion and 1 with neonatal exchange transfusion. Sixteen infants improved, and one died. Anti-M-HDFN had a higher rate of maternal stillbirth, lower gestational age, lower birthweight, and higher incidence of respiratory distress than other HDFN types. CONCLUSION Anti-M may cause HDFN. It may present with varying degrees of anemia, low regenerative anemia, and low bilirubin levels. In addition, infants with anti-M-HDFN may have a negative elution test and direct antiglobulin test. These tests are helpful in examining antibody responses at a low temperature of 4°C.
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Affiliation(s)
- Yanjing He
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Wa Gao
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yang Li
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Chang Xu
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Qiushi Wang
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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9
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Tran A, Yan MTS, Branch DR, Blacquiere M, Pineault N, Pasha R, Clarke G. Severe fetal anemia caused by anti-Jr a : Burst forming unit-erythroid colony formation inhibition assay suggesting possible erythroid suppression mechanism. Transfusion 2023; 63:877-882. [PMID: 36727643 DOI: 10.1111/trf.17265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Jr blood group system includes a single, high-prevalence antigen, Jra , encoded by the ABCG2 gene. The impact of anti-Jra in pregnancy is variable, ranging from no clinical effect to severe anemia including some fetal deaths. Case reports have postulated that anti-Jra mediated fetal anemia is poorly hemolytic, suggesting other mechanisms of anemia may be involved. STUDY DESIGN AND METHODS We describe the case of severe anti-Jra mediated fetal anemia. At Canadian Blood Services laboratories, maternal anti-Jra was tested for phagocytic activity via a monocyte monolayer assay (MMA) and erythroid suppression via inhibition of burst forming unit-erythroid (BFU-E) colony formation assays. The New York Blood Center sequenced exons 4 and 7 of the ABCG2 gene. RESULTS AND DISCUSSION Sequencing of exons 4 and 7 of the ABCG2 gene revealed maternal compound heterozygosity for two nonsense mutations at exon 7 (c.706 C > T and c.784G > T). Fetal sequencing revealed the c.706C > T polymorphism. The MMA showed a borderline phagocytic index (around the cutoff of five for both donor segments tested [5 ± 1 and 7 ± 3]). The BFU-E colony formation inhibition assay suggested a dose-dependent inhibition of BFU-E colony formation with inhibition percentages of 4%, 11%, and 43% at maternal serum concentrations of 2%, 5%, and 10%, respectively. Our findings support the hypothesis that anti-Jra may impair erythropoiesis leading to clinically significant fetal/neonatal anemia. A referral to maternal fetal medicine is recommended if anti-Jra is detected in pregnancy, regardless of the titer.
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Affiliation(s)
- Ann Tran
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - 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
| | - Donald R Branch
- Medical Affairs and Innovation, Canadian Blood Services, Ottawa, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Megan Blacquiere
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicolas Pineault
- Medical Affairs and Innovation, Canadian Blood Services, Ottawa, Ontario, Canada.,Department of Biochemistry, Microbiology & Immunology, University of Ottawa, Ottawa, Ontario, Canada
| | - Roya Pasha
- Medical Affairs and Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Gwen Clarke
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Medical Affairs and Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
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De Winter DP, Hulzebos C, Van 't Oever RM, De Haas M, Verweij EJ, Lopriore E. History and current standard of postnatal management in hemolytic disease of the fetus and newborn. Eur J Pediatr 2023; 182:489-500. [PMID: 36469119 DOI: 10.1007/s00431-022-04724-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 12/07/2022]
Abstract
UNLABELLED Since the discovery of the Rh blood group system in 1940, a greater understanding of hemolytic disease of the fetus and newborn (HDFN) was gained. In the years thereafter, researchers and clinicians came to the current understanding that fetal and neonatal red blood cells (RBC) are hemolyzed by maternal alloantibodies directed against RBC antigens potentially leading to severe disease. Preventative measures, such as Rhesus(D) immunoprophylaxis (RhIG), have greatly decreased the prevalence of Rh(D)-mediated HDFN, although a gap between high-income countries and middle- to low-income countries was created largely due to a lack in availability and high costs of RhIG. Other important developments in the past decades have improved the identification, monitoring, and care of pregnancies, fetuses, and neonates with HDFN. Prenatally, fetal anemia may occur and intrauterine transfusions may be needed. Postnatally, pediatricians should be aware of the (antenatally determined) risk of hemolysis in RBC alloimmunization and should provide treatment for hyperbilirubinemia in the early phase and monitor for anemia in the late phase of the disease. Through this review, we aim to provide an overview of important historic events and to provide hands-on guidelines for the delivery and postnatal management of neonates with HDFN. Secondarily, we aim to describe recent scientific findings and evidence gaps. CONCLUSION Multiple developments have improved the identification, monitoring, and care of pregnancies and neonates with HDFN throughout the centuries. Pediatricians should be aware of the (antenatally determined) risk of hemolysis in RBC alloimmunization and should provide treatment for hyperbilirubinemia in the early phase and monitor for late anemia in the late phase of the disease. Future studies should be set in an international setting and ultimately aim to eradicate HDFN on a global scale. WHAT IS KNOWN • Developments have led to a greater understanding of the pathophysiology, an improved serological identification and monitoring of at-risk cases and the current pre- and postnatal treatment. WHAT IS NEW • This review provides the pediatrician with hands-on guidelines for the delivery and postnatal management of neonates with HDFN. • Future studies should be set in an international setting with the ultimate aim of eradicating HDFN.
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Affiliation(s)
- Derek P De Winter
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Albinusdreef 2, 2333, Leiden, The Netherlands. .,Department of Immunohematology Diagnostic Services, Sanquin Diagnostic Services, Amsterdam, The Netherlands.
| | - Christian Hulzebos
- Department of Pediatrics, Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Renske M Van 't Oever
- Department of Immunohematology Diagnostic Services, Sanquin Diagnostic Services, Amsterdam, The Netherlands.,Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Masja De Haas
- Department of Immunohematology Diagnostic Services, Sanquin Diagnostic Services, Amsterdam, The Netherlands.,Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ejt Joanne Verweij
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Albinusdreef 2, 2333, Leiden, The Netherlands
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11
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van 't Oever RM, Zwiers C, de Winter D, de Haas M, Oepkes D, Lopriore E, Verweij EJJ. Identification and management of fetal anemia due to hemolytic disease. Expert Rev Hematol 2022; 15:987-998. [PMID: 36264850 DOI: 10.1080/17474086.2022.2138853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Hemolytic disease of the fetus and newborn (HDFN) is a condition caused by maternal alloantibodies against fetal red blood cells (RBCs) that can cause severe morbidity and mortality in the fetus and newborn. Adequate screening programs allow for timely prevention and intervention resulting in significant reduction of the disease over the last decades. Nevertheless, HDFN still occurs and with current treatment having reached an optimum, focus shifts toward noninvasive therapy options. AREAS COVERED This review focusses on the timely identification of high risk cases and antenatal management. Furthermore, we elaborate on future perspectives including improvement of screening, identification of high risk cases and promising treatment options. EXPERT OPINION In high-income countries mortality and morbidity rates due to HDFN have drastically been reduced over the last decades, yet worldwide anti-D mediated HDFN still accounts for 160,000 perinatal deaths and 100,000 patients with disabilities every year. Much of these deaths and disabilities could have been avoided with proper identification and prophylaxis. By implementing sustainable prevention, screening, and disease treatment measures in all countries this will systemically reduce unnecessary perinatal deaths. There is a common responsibility to engage in this cause.
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Affiliation(s)
- Renske M van 't Oever
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Immunohematology Diagnostics, Sanquin,Amsterdam, The Netherlands
| | - Carolien Zwiers
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Derek de Winter
- Department of Immunohematology Diagnostics, Sanquin,Amsterdam, The Netherlands.,Willem-Alexander Children's Hospital, department of Pediatrics, division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Masja de Haas
- Department of Immunohematology Diagnostics, Sanquin,Amsterdam, The Netherlands.,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Willem-Alexander Children's Hospital, department of Pediatrics, division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - E J Joanne Verweij
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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12
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Petroff MG, Nguyen SL, Ahn SH. Fetal‐placental
antigens and the maternal immune system: Reproductive immunology comes of age. Immunol Rev 2022; 308:25-39. [PMID: 35643905 PMCID: PMC9328203 DOI: 10.1111/imr.13090] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/07/2022] [Accepted: 05/11/2022] [Indexed: 12/20/2022]
Abstract
Reproductive physiology and immunology as scientific disciplines each have rich, largely independent histories. The physicians and philosophers of ancient Greece made remarkable observations and inferences to explain regeneration as well as illness and immunity. The scientific enlightenment of the renaissance and the technological advances of the past century have led to the explosion of knowledge that we are experiencing today. Breakthroughs in transplantation, immunology, and reproduction eventually culminated with Medawar’s discovery of acquired immunological tolerance, which helped to explain the transplantation success and failure. Medawar’s musings also keenly pointed out that the fetus apparently breaks these newly discovered rules, and with this, the field of reproductive immunology was launched. As a result of having stemmed from transplantation immunology, scientist still analogizes the fetus to a successful allograft. Although we now know of the fundamental differences between the two, this analogy remains a useful tool to understand how the fetus thrives despite its immunological disparity with the mother. Here, we review the history of reproductive immunology, and how major and minor histocompatibility antigens, blood group antigens, and tissue‐specific “self” antigens from the fetus and transplanted organs parallel and differ.
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Affiliation(s)
- Margaret G. Petroff
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine Michigan State University East Lansing Michigan USA
- Departments of Microbiology and Molecular Genetics, College of Veterinary Medicine and College of Human Medicine Michigan State University East Lansing Michigan USA
- Cell and Molecular Biology Program, College of Natural Science Michigan State University East Lansing Michigan USA
| | - Sean L. Nguyen
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine Michigan State University East Lansing Michigan USA
- Cell and Molecular Biology Program, College of Natural Science Michigan State University East Lansing Michigan USA
| | - Soo Hyun Ahn
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine Michigan State University East Lansing Michigan USA
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13
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Wu Y, Wu Y, Yang Y, Chen B, Li J, Guo G, Xiong F. Case Report: First Case of Cefotaxime-Sulbactam-Induced Acute Intravascular Hemolysis in a Newborn With ABO Blood Type Incompatibility by the Mechanism of Non-Immunologic Protein Adsorption. Front Immunol 2022; 12:698541. [PMID: 35003054 PMCID: PMC8727536 DOI: 10.3389/fimmu.2021.698541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023] Open
Abstract
Background ABO blood type incompatibility hemolytic disease of newborn (ABO-HDN) and drug-induced immune hemolytic anemia (DIIHA) due to non-immunologic protein adsorption (NIPA) mainly cause extravascular hemolysis. All the reported severe DIIHA were caused by drug-induced antibodies, and rare report of acute intravascular hemolysis was caused by the NIPA mechanism or ABO-HDN. Case presentation We report the first case of acute intravascular hemolysis induced by cefotaxime sodium - sulbactam sodium (CTX - SBT) in a case of ABO-HDN which resulted in death at 55 h after birth. The mother’s blood type was O and RhD-positive, and the newborn’s blood type was B and RhD-positive. No irregular red blood cell (RBC) antibodies or drug-dependent antibodies related to CTX or SBT was detected in the mother’s plasma and the plasma or the RBC acid eluent of the newborn. Before the newborn received CTX - SBT treatment, the result of direct antiglobulin test (DAT) was negative while anti-B was positive (2 +) in both plasma and acid eluent. After the newborn received CTX - SBT treatment, the results of DAT for anti-IgG and anti-C3d were both positive, while anti-B was not detected in plasma, but stronger anti-B (3 +) was detected in acid eluent. In vitro experiments confirmed that NIPA of SBT promoted the specific binding of maternal-derived IgG anti-B to B antigen on RBCs of the newborn, thereby inducing acute intravascular hemolysis. Conclusion The NIPA effect of SBT promoted the specific binding of mother-derived IgG anti-B in newborn’s plasma to the newborn’s RBC B antigens and formed an immune complex, and then activated complement, which led to acute intravascular hemolysis. Drugs such as SBT with NIPA effect should not be used for newborns with HDN.
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Affiliation(s)
- Yuanjun Wu
- Department of Blood Transfusion, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Yong Wu
- Department of Blood Transfusion, Dongguan Tungwah Hospital, Dongguan, China
| | - Yong Yang
- Department of Neonatology, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Baochan Chen
- Department of Blood Transfusion, Dongguan Tungwah Hospital, Dongguan, China
| | - Jianqun Li
- Department of Blood Transfusion, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Ganping Guo
- Department of Blood Transfusion, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Fu Xiong
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China.,Key Laboratory of Single Cell Technology and Application in Guangdong, Guangzhou, China
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14
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Vlachodimitropoulou E, Garbowski M, Anne Solomon S, Abbasi N, Seaward G, Windrim R, Keunen J, Kelly E, Van Mieghem T, Shehata N, Ryan G. Outcome predictors for maternal red blood cell alloimmunisation with anti-K and anti-D managed with intrauterine blood transfusion. Br J Haematol 2021; 196:1096-1104. [PMID: 34862601 DOI: 10.1111/bjh.17956] [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: 08/15/2021] [Revised: 10/29/2021] [Accepted: 10/30/2021] [Indexed: 11/29/2022]
Abstract
Red blood cell (RBC) alloimmunisation with anti-D and anti-K comprise the majority of cases of fetal haemolytic disease requiring intrauterine red cell transfusion (IUT). Few studies have investigated which haematological parameters can predict adverse fetal or neonatal outcomes. The aim of the present study was to identify predictors of adverse outcome, including preterm birth, intrauterine fetal demise (IUFD), neonatal death (NND) and/or neonatal transfusion. We reviewed the records of all pregnancies alloimmunised with anti-K and anti-D, requiring IUT over 27 years at a quaternary fetal centre. We reviewed data for 128 pregnancies in 116 women undergoing 425 IUTs. The median gestational age (GA) at first IUT was significantly earlier for anti-K than for anti-D (24·3 vs. 28·7 weeks, P = 0·004). Women with anti-K required more IUTs than women with anti-D (3·84 vs. 3·12 mean IUTs, P = 0·036) and the fetal haemoglobin (Hb) at first IUT was significantly lower (51.0 vs. 70.5 g/l, P = 0·001). The mean estimated daily decrease in Hb did not differ between the two groups. A greater number of IUTs and a slower daily decrease in Hb (g/l/day) between first and second IUTs were predictive of a longer period in utero. Earlier GA at first IUT and a shorter interval from the first IUT until delivery predicted IUFD/NND. Earlier GA and lower Hb at first IUT significantly predicted need for phototherapy and/or blood product use in the neonate. In the anti-K group, a greater number of IUTs was required in women with a higher titre. Furthermore, the higher the titre, the earlier the GA at which an IUT was required in both groups. The rate of fall in fetal Hb between IUTs decreased, as the number of transfusions increased. Our present study identified pregnancies at considerable risk of an unfavourable outcome with anti-D and anti-K RBC alloimmunisation. Identifying such patients can guide pregnancy management, facilitates patient counselling, and can optimise resource use. Prospective studies can also incorporate these characteristics, in addition to laboratory markers, to further identify and improve the outcomes of these pregnancies.
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Affiliation(s)
- Evangelia Vlachodimitropoulou
- Fetal Medicine Unit, Ontario Fetal Center, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Maciej Garbowski
- Department of Haematology, University College London Hospital, London, UK
| | - Shelley Anne Solomon
- Fetal Medicine Unit, Ontario Fetal Center, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Nimrah Abbasi
- Fetal Medicine Unit, Ontario Fetal Center, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Gareth Seaward
- Fetal Medicine Unit, Ontario Fetal Center, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Rory Windrim
- Fetal Medicine Unit, Ontario Fetal Center, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Johannes Keunen
- Fetal Medicine Unit, Ontario Fetal Center, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Edmond Kelly
- Fetal Medicine Unit, Ontario Fetal Center, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Tim Van Mieghem
- Fetal Medicine Unit, Ontario Fetal Center, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Nadine Shehata
- Fetal Medicine Unit, Ontario Fetal Center, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Ontario Fetal Center, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
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15
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Felimban RI, Sumeda SM. Distribution of Kell antigens K, k, Kp a, and Kp b among blood donors in Jeddah city of Western Saudi Arabia. Asian J Transfus Sci 2021; 15:75-81. [PMID: 34349461 PMCID: PMC8294449 DOI: 10.4103/ajts.ajts_109_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/17/2021] [Accepted: 03/07/2021] [Indexed: 11/27/2022] Open
Abstract
CONTEXT: Kell blood group system is considered as the third clinically significant blood group in blood transfusion due to the highly immunogenetic of their antigens. No data are available regarding the frequencies of the Kell blood group antigens in Jeddah city. Knowledge of the antigen and phenotype frequencies is crucial to assess the risk of alloimmunization and to guide the probability of finding antigen-negative donor blood, which can be useful when blood transfusion is required for a patient who has multiple red cell alloantibodies. AIMS: The aim of this study was to determine the distribution of Kell blood group: K, k, Kpa, and Kpb antigens and phenotypes among blood donors in Jeddah city, western Saudi Arabia, to improve the transfusion services in the area. SUBJECTS AND METHODS: Seven hundred and fifty-eight blood samples from blood donors were used in the study. The samples were collected from different national blood bank centers in Jeddah city hospitals. Kell antigens were typed through gel card method using commercial antisera. STATISTICAL ANALYSIS USED: The gathered data were analyzed using the SPSS program. Frequency and crosstab tests were completed to achieve the objectives of the current study. RESULTS: The most frequent Kell phenotype in this study was Kp(a−b+), followed by K−k+, K+k+, and then Kp(a+b+), and the less frequent was K+k−. K−k− and Kp(a+b−) phenotypes were not observed in studied donors. CONCLUSIONS: This study is the first report to determine the frequency of Kell antigens and phenotypes among blood donors in Jeddah city. These results appear to be useful in providing better care for patients by implementing tests that should become a routine in blood banks. The Kell system is very important in transfusion medicine practice.
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Affiliation(s)
- Raed I Felimban
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia.,Center of Innovation in Personalized Medicine (CIPM), King Abdulaziz University, Jeddah, Saudi Arabia
| | - Samaha M Sumeda
- Department of Blood Bank, King Abdullah Medical Complex, Jeddah, Saudi Arabia
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16
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Li S, He Z, Mo C, Ji Y, Luo Y, Fang Q, Gao Y. Hyporegenerative anemia in anti-M-associated hemolytic disease of the fetus. Transfusion 2021; 61:1908-1915. [PMID: 33938570 DOI: 10.1111/trf.16350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 12/21/2020] [Accepted: 01/28/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND The anti-M antibody can lead to hemolytic disease of the fetus and newborn (HDFN) and adverse fetal outcomes, especially in the Asian population. However, fetal erythropoiesis resulting from M alloimmunization needs further investigation. STUDY DESIGN AND METHODS We analyzed erythropoiesis in eight fetuses with M alloimmunization and compared them with the fetuses affected by anti-D. They were matched as pairs according to the gestational age of diagnosis and the hematocrit before treatment. Paired t-tests or paired Wilcoxon rank-sum tests were conducted to compare the difference in the cord blood indexes. Pearson correlation analysis was used to evaluate the correlativity between hematocrit and the reticulocyte percentage in the two groups. RESULTS The fetuses in the MN group had lower reticulocyte count and percentage than those in the RhD group (p < .05). All of the fetal reticulocyte production indexes (RPIs) in the MN group were less than 2, indicating an inadequate hemopoietic response to anemia, while the majority of the RPIs in the RhD group (85.7%) were significantly higher (p = .003), with 6 cases greater than 2.5. Hematocrit was negatively correlated with reticulocyte percentage (y = 54.7-171.7x, r2 = 0.825, p = .005) in the RhD group, while no significant correlation was found in the MN group. No difference in the number of IUT, interval, or the fetal outcome was found between the two groups. CONCLUSION Fetal reticulocytopenia provided direct evidence of an inadequate hemopoietic response in HDFN due to anti-M, leading to hyporegenerative anemia. Once the IgG component of anti-M is detected, close monitoring should be considered.
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Affiliation(s)
- Si Li
- Department of Obstetrics, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Fetal Medicine Center, Department of Obstetrics, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhiming He
- Fetal Medicine Center, Department of Obstetrics, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chunyan Mo
- Guangzhou Blood Center, Insititute of Clinical Blood Transfusion, Guangzhou, China
| | - Yanli Ji
- Guangzhou Blood Center, Insititute of Clinical Blood Transfusion, Guangzhou, China
| | - Yanmin Luo
- Fetal Medicine Center, Department of Obstetrics, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qun Fang
- Fetal Medicine Center, Department of Obstetrics, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yu Gao
- Department of Obstetrics, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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17
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Guttenberg P, Heigl F, Hettich R, Brand G, Taenzel S, Zenk S, Felberbaum R, Zahn E, Puhl AG. Therapeutische Apherese als erfolgreiches Behandlungskonzept einer Alloimmunisierung in der Schwangerschaft am Beispiel von maternalen Anti-Kell- und Anti-Duffy-Antikörpern. Geburtshilfe Frauenheilkd 2021. [DOI: 10.1055/a-1277-4079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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18
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Alshehri AA, Jackson DE. Non-Invasive Prenatal Fetal Blood Group Genotype and Its Application in the Management of Hemolytic Disease of Fetus and Newborn: Systematic Review and Meta-Analysis. Transfus Med Rev 2021; 35:85-94. [PMID: 33781630 DOI: 10.1016/j.tmrv.2021.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/03/2021] [Accepted: 02/12/2021] [Indexed: 11/17/2022]
Abstract
Hemolytic disease of fetus and newborn (HDFN) imposes great healthcare burden being associated with maternal alloimmunization against parental-inherited fetal red blood cell antigens causing fetal anemia or death. Noninvasive prenatal analysis (NIPT) provides safe fetal RHD genotyping for early identification of risk pregnancies and proper management guidance. We aimed to conduct systematic review and meta-analysis on NIPT's beneficial application, in conjunction with quantitative maternal alloantibody analysis, for early diagnosis of pregnancies at risk. Search for relevant articles was done in; PubMed/Medline, Scopus, and Ovid (January 2006April 2020), including only English-written articles reporting reference tests and accuracy data. Nineteen eligible studies were critically appraised. NIPT was estimated highly sensitive/specific for fetal RHD genotyping beyond 11-week gestation. Amplifications from ≥2 exons are optimum to increase accuracy. NIPT permits cost-effectiveness, precious resources sparing, and low emotional stress. Knowledge of parental ethnicity is important for correct NIPT result interpretations and quantitative screening. Cut-off titer ≥8-up-to-32 is relevant for anti-D alloantibodies, while, lower titer is for anti-K. Alloimmunization is influenced by maternal RHD status, gravida status, and history of adverse obstetrics. In conclusion, NIPT allows evidence-based provision of routine anti-D immunoprophylaxis and estimates potential fetal risks for guiding further interventions. Future large-scale studies investigating NIPT's non-RHD genotyping within different ethnic groups and in presence of clinically significant alloantibodies are needed.
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Affiliation(s)
- Abdulrahman Ali Alshehri
- Thrombosis and Vascular Diseases Laboratory, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Denise E Jackson
- Thrombosis and Vascular Diseases Laboratory, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia.
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19
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D'Mello RJ, Hsu CD, Chaiworapongsa P, Chaiworapongsa T. Update on the Use of Intravenous Immunoglobulin in Pregnancy. Neoreviews 2021; 22:e7-e24. [PMID: 33386311 DOI: 10.1542/neo.22-1-e7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intravenous immunoglobulin (IVIG) was first administered to humans in the 1980s. The mechanism of action of IVIG is still a subject of debate but the pharmacokinetics have been well characterized, albeit outside of pregnancy. IVIG has been used in pregnancy to treat several nonobstetrical and obstetrical-related conditions. However, current evidence suggests that IVIG use during pregnancy can be recommended for 1) in utero diagnosis of neonatal alloimmune thrombocytopenia; 2) gestational alloimmune liver disease; 3) hemolytic disease of the fetus and newborn for early-onset severe intrauterine disease; 4) antiphospholipid syndrome (APS) when refractory to or contraindicated to standard treatment, or in catastrophic antiphospholipid syndrome; and 5) immune thrombocytopenia when standard treatment is ineffective or rapid increase of platelet counts is needed. All recommendations are based on case series and cohort studies without randomized trials usually because of the rare prevalence of the conditions, the high incidence of adverse outcomes if left untreated, and ethical concerns. In contrast, IVIG therapy cannot be recommended for recurrent pregnancy loss, and the use of IVIG in subgroups of those with recurrent pregnancy loss requires further investigations. For non-obstetrical-related conditions, we recommend using IVIG as indicated for nonpregnant patients. In conclusion, the use of IVIG during pregnancy is an effective treatment in some obstetrical-related conditions with rare serious maternal side effects. However, the precise mechanisms of action and the long-term immunologic effects on the fetus and neonate are poorly understood and merit further investigations.
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Affiliation(s)
- Rahul J D'Mello
- Department of Obstetrics and Gynecology, Detroit Medical Center, Detroit, MI
| | - Chaur-Dong Hsu
- Department of Obstetrics and Gynecology and.,Department of Physiology, Wayne State University School of Medicine, Detroit, MI
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20
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Ohto H, Denomme GA, Ito S, Ishida A, Nollet KE, Yasuda H. Three non-classical mechanisms for anemic disease of the fetus and newborn, based on maternal anti-Kell, anti-Ge3, anti-M, and anti-Jr a cases. Transfus Apher Sci 2020; 59:102949. [PMID: 32994126 DOI: 10.1016/j.transci.2020.102949] [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] [Indexed: 01/21/2023]
Abstract
Maternal alloantibody-mediated hemolytic disease of the fetus and newborn (HDFN) ranges from no or mild symptoms to severe hydrops and intrauterine fetal demise. Hemolytic anti-D-mediated HDFN proceeds via a long-known mechanism, to which three other pathways to fetal/neonatal anemia may be added: (0) Fetal erythrocyte destruction can proceed by extravascular phagocytosis. (1) An apoptotic pathway has been described for anti-Kell, and anti-Ge3. (2) Erythropoietic suppression may arise from altered or deformed erythroblast architecture in anti-M-mediated disease. (3) Clonal escape from erythropoietic suppression is hypothesized to arise from maternal anti-Jra immune pressure, albeit this requires further elucidation. Alloantibody-mediated anemic disease of the fetus and newborn (ADFN) is a designation we favor for cases when hemolysis or hyperbilirubinemia are not the dominant features, such as those provoked by anti-Kell, anti-Ge3, anti-M, and anti-Jra.
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Affiliation(s)
- Hitoshi Ohto
- Fukushima Medical University, Fukushima, 960-1295, Japan.
| | - Gregory A Denomme
- Blood Research Institute / Diagnostic Laboratories, Versiti, Milwaukee, WI, USA
| | - Shoichi Ito
- Japanese Red Cross Tohoku Block Blood Center, Sendai, Japan
| | - Atsushi Ishida
- Department of Pediatrics, Gifu Prefectural Tajimi Hospital, Gifu, Japan
| | - Kenneth E Nollet
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan
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21
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Lieberman L, Callum J, Cohen R, Cserti-Gazdewich C, Ladhani NNN, Buckstein J, Pendergrast J, Lin Y. Impact of red blood cell alloimmunization on fetal and neonatal outcomes: A single center cohort study. Transfusion 2020; 60:2537-2546. [PMID: 32893897 DOI: 10.1111/trf.16061] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/03/2020] [Accepted: 07/08/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Alloimmunization can impact both the fetus and neonate. STUDY OBJECTIVES (a) calculate the incidence of clinically significant RBC isoimmunization during pregnancy, (b) review maternal management and neonatal outcomes, (c) assess the value of prenatal and postnatal serological testing in predicting neonatal outcomes. STUDY DESIGN AND METHODS A retrospective audit of consecutive alloimmunized pregnancies was conducted. Data collected included demographics, clinical outcomes, and laboratory results. Outcomes included: incidence of alloimmunization; outcomes for neonates with and without the cognate antigen; and sensitivity and specificity of antibody titration testing in predicting hemolytic disease of the fetus and newborn (HDFN). RESULTS Over 6 years, 128 pregnant women (0.4%) were alloimmunized with 162 alloantibodies; anti-E was the most common alloantibody (51/162; 31%). Intrauterine transfusions (IUTs) were employed in 2 (3%) of 71 mothers of cognate antigen positive (CoAg+) neonates. Of 74 CoAg+ neonates, 58% required observation alone, 23% intensive phototherapy, 9% top up transfusion, and 3% exchange transfusion; no fetal or neonatal deaths occurred. HDFN was diagnosed in 28% (21/74) of neonates; anti-D was the most common cause. The sensitivity and specificity of the critical gel titer >32 in predicting HDFN were 76% and 75%, respectively (negative predictive value 95%; positive predictive value 36%). The sensitivity and specificity of a positive direct antiglobulin test (DAT) in predicting HDFN were 90% and 58%, respectively (NPV 97%; PPV 29%). CONCLUSION Morbidity and mortality related to HDFN was low; most alloimmunized pregnancies needed minimal intervention. Titers of >32 by gel warrant additional monitoring during pregnancy.
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Affiliation(s)
- Lani Lieberman
- Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, Ontario, Canada
| | - Robert Cohen
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Christine Cserti-Gazdewich
- Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, Ontario, Canada
| | - Noor Niyar N Ladhani
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jonah Buckstein
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jacob Pendergrast
- Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, Ontario, Canada
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22
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Castleman JS, Moise KJ, Kilby MD. Medical therapy to attenuate fetal anaemia in severe maternal red cell alloimmunisation. Br J Haematol 2020; 192:425-432. [PMID: 32794242 DOI: 10.1111/bjh.17041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/22/2020] [Indexed: 12/01/2022]
Abstract
Haemolytic disease of the fetus and newborn (HDFN) remains an important cause of fetal mortality with potential neonatal and longer-term morbidity. HDFN is caused by maternal red cell alloimmunisation, with IgG antibodies crossing the placenta to destroy fetal erythroid cells expressing the involved antigen. Intrauterine fetal blood transfusion is the therapy of choice for severe fetal anaemia. Despite a strong evidence base and technical advances, invasive fetal therapy carries risk of miscarriage and preterm birth. Procedure-related risks are increased when invasive, in utero transfusion is instituted prior to 22 weeks to treat severe early-onset fetal anaemia. This review focuses upon this cohort of HDFN and discusses intravenous immunoglobin (IVIg) and novel monoclonal antibody (M281, nipocalimab) treatments which, if started at the end of the first trimester, may attenuate the transplacental passage and fetal effects of IgG antibodies. Such therapy has the ability to improve fetal survival in this severe presentation of HDFN when early in utero transfusion may be required and may have wider implications for the perinatal management in general.
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Affiliation(s)
- James S Castleman
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Kenneth J Moise
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Mark D Kilby
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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23
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Rahimi-Levene N, Chezar J, Yahalom V. Red blood cell alloimmunization prevalence and hemolytic disease of the fetus and newborn in Israel: A retrospective study. Transfusion 2020; 60:2684-2690. [PMID: 32770778 DOI: 10.1111/trf.15987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/16/2020] [Accepted: 06/20/2020] [Indexed: 11/28/2022]
Abstract
Hemolytic disease of the fetus and newborn (HDFN) is a severe form of anemia caused by maternal antibodies against fetal red blood cells (RBC) that can cause intrauterine and perinatal morbidity and mortality. The prevalence and specificities of alloantibodies among Israeli pregnant women and clinical outcomes for their fetuses and newborns are unknown. STUDY DESIGN AND METHODS A retrospective study of women who gave birth between January 1, 2011, and December 31, 2011, was performed. Data were obtained for obstetric admissions from 16 of 27 hospitals, which included results of maternal ABO, D, antibody screens, antibody identification, and requirements for intrauterine or newborn exchange transfusions. RESULTS Data on 90 948 women representing 70% of all births during 2011 were analyzed. Antibody screen was positive in 5245 (5.8%) women. Alloantibodies, excluding anti-D titer (<16) were identified in 900 (1.0%) women. Of 191 D- women, 75 (39.3%) had anti-D titer of 16 or greater. Other common clinically significant antibodies were anti-E (204, 23%), anti-K (145, 16%), and anti-c (97, 10.8%) alone or in antibody combinations. Multiple alloantibodies were observed in 132 of 900 (15%) of women. Severe HDFN developed in 6.8% (9/132) of these pregnancies. Seventeen fetuses and newborns (0.02% of births) including one set of twins required RBC transfusions. Two fetuses whose mothers had multiple alloantibodies received intrauterine transfusions; one of them was hydropic and died. CONCLUSION The prevalence of RBC alloantibodies was 1.0% among Israeli pregnant women. Transfusion was required in 0.02% of the fetuses and newborns. Severe HDFN developed in 6.8% of pregnancies with multiple maternal alloantibodies.
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Affiliation(s)
- Naomi Rahimi-Levene
- Blood Bank, Shamir Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Judith Chezar
- Blood Bank, Galilee Medical Center, Nahariya, Israel
| | - Vered Yahalom
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Blood Services and Apheresis Institute, Rabin Medical Center, Petach Tikva, Israel.,National Blood Group Reference Laboratory, Magen David Adom, National Blood Services, Ramat Gan, Israel
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Suppression of compensatory erythropoiesis in hemolytic disease of the fetus and newborn due to intrauterine transfusions. Am J Obstet Gynecol 2020; 223:119.e1-119.e10. [PMID: 31978433 DOI: 10.1016/j.ajog.2020.01.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/28/2019] [Accepted: 01/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infants with severe hemolytic disease of the fetus and newborn often require 1 or multiple intrauterine transfusions to treat fetal anemia. Intrauterine transfusions may have an inhibiting effect on fetal and neonatal erythropoiesis. OBJECTIVE To quantify the effect of 1 or multiple intrauterine transfusions on the fetal erythropoiesis by assessing the fetal reticulocyte counts in a population with severe hemolytic disease of the fetus and newborn. STUDY DESIGN This was an observational cohort study in infants admitted to the Leiden University Medical Center who received 1 or multiple intrauterine transfusions for hemolytic disease of the fetus and newborn caused by (Rh)D or Kell antibodies and were born between January 2005 and December 2018. RESULTS A total of 235 patients were included, of whom 189 were patients with D-mediated hemolytic disease of the fetus and newborn and 46 with Kell-mediated hemolytic disease of the fetus and newborn. Absolute fetal reticulocyte count in D-mediated hemolytic disease of the fetus and newborn declined exponentially over the course of consecutive intrauterine transfusions, with a 62% decline after 1 intrauterine transfusion (95% confidence interval, 56-67). A similar exponential decline was observed in Kell-mediated hemolytic disease of the fetus and newborn, with 32% (95% confidence interval, 19-45) decline after 1 intrauterine transfusion. This decline was not associated with the varying gestational age at the time of the first intrauterine transfusion or the total number of intrauterine transfusions. The number of red blood cell transfusions for postnatal anemia was greater for infants with D and Kell-mediated hemolytic disease of the fetus and newborn with >2 intrauterine transfusions (median of 3 [interquartile range, 2-3] vs 2 [interquartile range, 1-3], P=.035, in D-mediated disease and median of 2 [interquartile range, 1-2] vs 1 [interquartile range, 1-1], P<.001, in Kell-mediated disease). Infants born after >2 intrauterine transfusions less often required exchange transfusion in D-mediated hemolytic disease of the fetus and newborn (19/89 [21%] vs 31/100 [31%], P=.039), compared with infants with 1-2 intrauterine transfusions. CONCLUSION Treatment with intrauterine transfusions causes an exponential decrease in fetal reticulocyte counts in both D- and Kell-mediated hemolytic disease of the fetus and newborn. Suppression of the compensatory erythropoiesis leads to prolonged postnatal anemia and an increased requirement of red blood cell transfusions after birth.
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25
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Tang J, Ye Z, Liu Y, Zhou M, Huang L, Mo Q, Su X, Qin C. Autophagy-deficiency in bone marrow mononuclear cells from patients with myasthenia gravis: a possible mechanism of pathogenesis. Int J Neurosci 2020; 131:239-253. [PMID: 32122204 DOI: 10.1080/00207454.2020.1738429] [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] [Indexed: 12/20/2022]
Abstract
Myasthenia gravis (MG) is a chronic autoimmune disorder resulting from autoantibodies against neuromuscular junction components. Research shows that this disease might be a primary bone marrow (BM) stem cell disorder. Autophagy protects the dynamics and homeostasis of the host cells by removing damaged mitochondria, protein aggregates and other intercellular materials. Dysfunctional autophagy is associated with autoimmune diseases. However, the autophagy activity and mechanisms in BM stem cell from MG patients remain largely uncharacterized. We evaluated the autophagy activity in bone marrow mononuclear cells (BM-MNCs) and the effects of autophagy on cell survival from patients with MG and healthy controls. Our results revealed that autophagy was significantly decreased in patients with MG before immunomodulation treatment compared with that in age-/sex-matched controls, and was lower in generalized MG (GMG) patients than in ocular MG (OMG) patients. Immunomodulatory treatment partially increased autophagy activity of BM-MNCs in MG patients and improved the symptoms. Furthermore, defective BM-MNCs differentiation, proliferation and apoptosis were observed due to dysfunctional autophagy. These findings suggest for the first time that BM-MNCs autophagy is impaired in patients with MG before immunomodulation therapy, and that autophagy is indispensable for the survival of BM-MNCs, implicating autophagy might be a potential pathogenic mechanism of MG and a novel therapeutic strategy for MG treatment.
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Affiliation(s)
- Jingqun Tang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Ziming Ye
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Yi Liu
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Mengxiao Zhou
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Liqiang Huang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Qin Mo
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Xiaotao Su
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Chao Qin
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
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26
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Castleman JS, Kilby MD. Red cell alloimmunization: A 2020 update. Prenat Diagn 2020; 40:1099-1108. [PMID: 32108353 DOI: 10.1002/pd.5674] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/17/2020] [Accepted: 02/21/2020] [Indexed: 12/27/2022]
Abstract
Management of maternal red cell alloimmunization has been revolutionized over the last 60 years. Advances in the prevention, screening, diagnosis, and treatment of alloimmune-induced fetal anemia make this condition an exemplar for contemporary practice in fetal therapy. Since survival is now an expectation, attention has turned to optimization of long-term outcomes following an alloimmunized pregnancy. In this review, the current management of red cell alloimmunization is described. Current research and future directions are discussed with particular emphasis on later life outcomes after alloimmune fetal anemia.
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Affiliation(s)
- James S Castleman
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Mark D Kilby
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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27
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Moosavi M, Ma Y, Baez J, Jeffreys R, Ward DC, Ziman A, McGonigle AM. Resolving Blocked Antigen Phenomenon in Hemolytic Disease of the Fetus and Newborn Due to Anti-K. Transfus Med Rev 2020; 34:124-127. [PMID: 32209273 DOI: 10.1016/j.tmrv.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 11/19/2022]
Abstract
High-titer antibodies are a cause of false-negative reactions in red blood cell antigen phenotyping, an event referred to as blocked antigen phenomenon (BAP). In hemolytic disease of the fetus and newborn, BAP complicates laboratory workups as fetal phenotype is helpful in confirming the responsible antibody. Acid elution techniques, techniques using ethylenediaminetetraacetic glycine acid, as well as those using chloroquine diphosphate have been used to resolve BAP; however, ethylenediaminetetraacetic glycine acid destroys K-antigen expression and chloroquine diphosphate is not always effective. We report a case of severe hemolytic disease of the fetus and newborn from anti-K where a modified gentle heat elution resolved BAP. Although infrequently considered with isolated reports in the literature, heat elution is simple, is effective, and involves readily available materials in most blood banks.
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Affiliation(s)
- Mitchell Moosavi
- From the Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Yao Ma
- From the Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Janet Baez
- From the Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Rebecca Jeffreys
- From the Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dawn C Ward
- From the Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alyssa Ziman
- From the Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Andrea M McGonigle
- From the Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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28
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Virk M, Papakonstantino K, Cai W, Oh D, Andrews J. Blood Donation During Pregnancy Due to Anti-Ku Hemolytic Disease of the Fetus and Newborn. Lab Med 2020; 50:421-425. [PMID: 31089725 DOI: 10.1093/labmed/lmz020] [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: 11/12/2022] Open
Abstract
BACKGROUND Management of pregnancy in patients with Kell-null phenotype can be challenging. The immune systems of these patients form an antibody that is universally reactive against the Kell Blood Group System and can cause hemolytic disease of the fetus and newborn. METHODS A 29-year-old woman, pregnant for the first time, developed anti-D and anti-Ku. The mother had to have labor induced when her fetus showed signs of severe anemia, but no compatible blood was available for transfusion. The induction was delayed so that a unit of blood could be collected from the mother. RESULTS Due to delayed cord clamping at delivery, the newborn did not have anemia and did not require a transfusion. The remaining blood was frozen for future needs. CONCLUSION Blood donation by a pregnant woman for potential transfusion to a newborn with anemia is safe for the mother and fetus, and is possibly the only option in hemolytic disease of the newborn due to a rare antibody.
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Affiliation(s)
- Mrigender Virk
- Department of Pathology, Stanford University, California
| | | | - Wei Cai
- Department of Pathology, Stanford University, California
| | - David Oh
- Stanford Blood Center, Stanford University
| | - Jennifer Andrews
- Department of Pathology, Stanford University, California.,Department of Pediatrics, Stanford University, California
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29
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Sun JB. The prenatal intervention of pregnancy complicated with anti-Kell isoimmunization: a review. J Matern Fetal Neonatal Med 2019; 34:2893-2899. [PMID: 31571493 DOI: 10.1080/14767058.2019.1671330] [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] [Indexed: 10/25/2022]
Abstract
Since the first case of the hemolytic disease of the fetus and newborn (HDFN) caused by anti-K was reported in 1946, the fetal diagnosis of K-HDFN has made rapid progress from invasive immunological and biochemical tests to noninvasive Doppler ultrasound and molecular biology techniques. However, its treatment, especially prenatal intervention, has developed slowly compared with RhD-HDFN. This review attempts to clarify the current key points and explore the direction of the next phase by systematically reviewing the development of diagnosis and treatment of this disease, which involving multidisciplinary participation.
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Affiliation(s)
- Jun-Bo Sun
- Department of Blood Transfusion, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
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30
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Katsuragi S, Ohto H, Yoshida A, Otake A, Tsuneyama H, Ogasawara K, Isa K, Ikeda T. Anemic Disease of the Newborn With Little Increase in Hemolysis and Erythropoiesis Due to Maternal Anti-Jr a: A Case Study and Review of the Literature. Transfus Med Rev 2019; 33:183-188. [PMID: 31227265 DOI: 10.1016/j.tmrv.2019.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/28/2019] [Accepted: 03/28/2019] [Indexed: 10/26/2022]
Abstract
The severity of the hemolytic disease of the fetus and newborn (HDFN) due to Jra mismatch ranges from no symptoms to severe anemia that requires intrauterine and exchange transfusions. We encountered a newborn, born to a healthy mother having anti-Jra at 38 weeks of pregnancy, who had moderate anemia, a positive direct antiglobulin test (DAT) result, no increased erythropoiesis, and no jaundice at birth. Flow cytometry revealed that the Jra antigen of red cells in the infant was nearly negative at birth, biphasic at 5 weeks, and lowly expressed at 7 months of life. We searched online for previous case reports on HDFN due to Jra incompatibility. Among 63 reported cases, excluding 25 cases, 38 were included with the present case for analysis. Of 39 newborns, 10 developed clear anemia (hemoglobin <10.0 g/dL), and 1 died, 5 developed hydrops fetalis, 4 needed intrauterine transfusion and/or exchange transfusion, and 3 received red cell transfusion after birth; overlaps were included. Among 29 neonates with no anemia, 8 needed interventions including phototherapy and γ-globulin infusion, and the remaining 21 received conservative supports only. The maternal anti-Jra titer, ranging between 4 and 2048, did not correlate with the severity of anemia, levels of bilirubin, or any interventions required. The DAT of red cells was positive in 29 of 36 fetuses/newborns tested, whereas it was often negative among anemic neonates (4 of 9) (P < .05). Hematopoiesis did not increase effectively, as indicated by reticulocyte ratios between 1.7% and 22.3%, even with the increase in reticulocytes in anemic neonates compared with nonanemic neonates (P < .05). Total bilirubin levels ranged broadly between 0.2 and 14.3 mg/dL but were generally low. The maternal anti-Jra titer and IgG3 subclass did not correlate with the morbidity of the newborns. Being identical/compatible between mothers and their infants may possibly enhance infants' morbidity, as a weak tendency was observed (P = .053). Maternal anti-Jra may suppress erythropoiesis in fetuses via a mechanism different from the established HDFN, such as anti-D, as evidenced by the lower reticulocyte count and small increase in bilirubin in neonates. As the anti-Jra titer, IgG subclass, and DAT were not correlated with the severity, the mechanism of anti-Jra-induced HDFN remains to be elucidated.
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Affiliation(s)
- Shinji Katsuragi
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Tokyo, Japan
| | - Hitoshi Ohto
- Department of Advanced Cancer Immunotherapy, Fukushima Medical University, Fukushima, Japan.
| | - Atsushi Yoshida
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Tokyo, Japan
| | - Akiko Otake
- Department of Clinical Laboratory, Sakakibara Heart Institute, Tokyo, Japan
| | - Hatsue Tsuneyama
- Kanto-Koshinetsu Block Blood Center, Japanese Red Cross Society, Tokyo, Japan
| | | | - Kazumi Isa
- Japanese Red Cross Central Blood Institute, Tokyo, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, School of Medicine Mie University, Mie, Japan
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31
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Li S, Mo C, Huang L, Shi X, Luo G, Ji Y, Fang Q. Hemolytic disease of the fetus and newborn due to alloanti-M: three Chinese case reports and a review of the literature. Transfusion 2018; 59:385-395. [PMID: 30520533 DOI: 10.1111/trf.15054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/04/2018] [Accepted: 09/17/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Alloanti-M was once regarded as not clinically significant, with a few exceptions in extremely rare cases. However, an increasing number of cases of severe hemolytic disease of the fetus and newborn (HDFN), resulting in fetal hydrops and recurrent abortion caused by alloanti-M, have been reported mainly in the Asian population. STUDY DESIGN AND METHODS Three pregnant Chinese women with a history of abnormal pregnancy with hydrops fetalis were encountered. During this pregnancy, a series of clinical examinations and an alloantibody identification against RBCs and platelets were conducted. Intrauterine transfusion and postnatal transfusion were then performed in the fetuses. In addition, the HDFN cases caused by alloanti-M reported in different ethnic groups as well as their clinical and serologic features are also summarized. RESULTS Three pregnant women were identified with an M-N+ phenotype and IgM mixed with IgG alloanti-M in serum. Their fetuses were found by ultrasound examination and cord blood testing to have severe anemia. Additionally, an M+N+ phenotype and IgG alloanti-M were detected in the cord blood of the three fetuses with titers ranging from 1:1 to 1:128. Moreover, low reticulocyte counts and negative direct antiglobulin tests were also shown in two of the fetuses. After receiving intrauterine transfusions and postnatal transfusions several times, these three fetuses eventually survived and then healthfully developed in the follow-up tracking. CONCLUSION Alloanti-M immunization can cause severe HDFN with hyporegenerative anemia, often seen in the Asian population, and suppression of erythropoiesis might account for it.
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Affiliation(s)
- Si Li
- Fetal Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510000, China
| | - Chunyan Mo
- Guangzhou Blood Center, Insititute of Clinical Blood Transfusion, Guangzhou, 510095, China
| | - Linhuan Huang
- Fetal Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510000, China
| | - Xiaomei Shi
- Guangdong Women's and Children's Hospital, Guangzhou, 510010, China
| | - Guangping Luo
- Guangzhou Blood Center, Insititute of Clinical Blood Transfusion, Guangzhou, 510095, China
| | - Yanli Ji
- Guangzhou Blood Center, Insititute of Clinical Blood Transfusion, Guangzhou, 510095, China
| | - Qun Fang
- Fetal Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510000, China
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Patel SR, Gibb DR, Girard-Pierce K, Zhou X, Rodrigues LC, Arthur CM, Bennett AL, Jajosky RP, Fuller M, Maier CL, Zerra PE, Chonat S, Smith NH, Tormey CA, Hendrickson JE, Stowell SR. Marginal Zone B Cells Induce Alloantibody Formation Following RBC Transfusion. Front Immunol 2018; 9:2516. [PMID: 30505302 PMCID: PMC6250814 DOI: 10.3389/fimmu.2018.02516] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 10/12/2018] [Indexed: 12/12/2022] Open
Abstract
Red blood cell (RBC) alloimmunization represents a significant immunological challenge for some patients. While a variety of immune constituents likely contribute to the initiation and orchestration of alloantibodies to RBC antigens, identification of key immune factors that initiate alloantibody formation may aid in the development of a therapeutic modality to minimize or prevent this process. To define the immune factors that may be important in driving alloimmunization to an RBC antigen, we determined the specific immune compartment and distinct cells that may initially engage transfused RBCs and facilitate subsequent alloimmunization. Our findings demonstrate that the splenic compartment is essential for formation of anti-KEL antibodies following KEL RBC transfusion. Within the spleen, transfused KEL RBCs are found within the marginal sinus, where they appear to specifically co-localize with marginal zone (MZ) B cells. Consistent with this, removal of MZ B cells completely prevented alloantibody formation following KEL RBC transfusion. While MZ B cells can mediate a variety of key downstream immune pathways, depletion of follicular B cells or CD4 T cells failed to similarly impact the anti-KEL antibody response, suggesting that MZ B cells may play a key role in the development of anti-KEL IgM and IgG following KEL RBC transfusion. These findings highlight a key contributor to KEL RBC-induced antibody formation, wherein MZ B cells facilitate antibody formation following RBC transfusion.
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Affiliation(s)
- Seema R Patel
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - David R Gibb
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Kathryn Girard-Pierce
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Xiaoxi Zhou
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Lilian Cataldi Rodrigues
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Connie M Arthur
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Ashley L Bennett
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Ryan P Jajosky
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Megan Fuller
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Cheryl L Maier
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Patricia E Zerra
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, GA, United States
| | - Nicole H Smith
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Sean R Stowell
- Department of Laboratory Medicine and Pathology, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
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Mayer B, Hinkson L, Hillebrand W, Henrich W, Salama A. Efficacy of Antenatal Intravenous Immunoglobulin Treatment in Pregnancies at High Risk due to Alloimmunization to Red Blood Cells. Transfus Med Hemother 2018; 45:429-436. [PMID: 30574060 DOI: 10.1159/000490154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/15/2018] [Indexed: 01/14/2023] Open
Abstract
Background Alloimmunization to red blood cells (RBCs) may result in fetal anemia prior to 20 weeks gestation. The question as to whether early commencement of antenatal treatment with high-dose intravenous immunoglobulins (IVIG) may prevent or at least delay the development of fetal anemia in the presence of alloantibodies to RBCs is highly relevant. Patients and Results Here we describe a patient with high-titer anti-K and two other severely affected pregnant women with a history of recurrent pregnancy loss due to high-titer anti-D or anti-D plus anti-C. Early commencement of treatment with IVIG (1 g/kg/week) resulted in prevention of intrauterine transfusion (IUT) in the former two cases, and in a significant delay of development of fetal anemia in the remaining case (26 weeks gestation). Conclusion Based on our findings and of previously published cases, early initiation of treatment of severely alloimmunized women with IVIG (1 g/kg/week) could potentially improve the outcome of fetuses at risk.
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Affiliation(s)
- Beate Mayer
- Institute of Transfusion Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Larry Hinkson
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Wiebke Hillebrand
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Abdulgabar Salama
- Department of Gynecology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
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Abstract
The diagnosis and management of fetal anemia has been at the forefront of advances in the fields of fetal physiology, immunology, fetal imaging, and fetal therapy among others. Alloimmunization and parvovirus infection are the leading cause of fetal anemia in the United States. The middle cerebral artery peak systolic velocity (MCA-PSV) diagnoses fetal anemia. Its discovery is considered one of the most important achievements in fetal medicine. Accumulation of experience in recent years as well as refinement of surgical techniques have led to safer invasive procedures. It is expected that long term follow-up of affected pregnancies, continues to reflect all these improvements in care. It is also expected that treatment of other less common causes of fetal anemia becomes more frequently reported and that the management principles of fetal anemia are successfully applied to other fetal pathologies.
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Affiliation(s)
- Pedro S Argoti
- Department of Obstetrics and Gynecology, Health Sciences Center, University of Tennessee, Memphis, TN, USA -
| | - Giancarlo Mari
- Department of Obstetrics and Gynecology, Health Sciences Center, University of Tennessee, Memphis, TN, USA
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35
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Phung TV, Houfflin-Debarge V, Ramdane N, Ghesquière L, Delsalle A, Coulon C, Subtil D, Vaast P, Garabedian C. Maternal red blood cell alloimmunization requiring intrauterine transfusion: a comparative study on management and outcome depending on the type of antibody. Transfusion 2018; 58:1199-1205. [DOI: 10.1111/trf.14542] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 01/11/2018] [Accepted: 01/13/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Thanh-Vy Phung
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
| | - Véronique Houfflin-Debarge
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
- Perinatal Environment and Growth; EA 4489, University of Lille North of France; Lille France
| | - Nassima Ramdane
- Department of Biostatistics; EA 2694, UDSL, CHU Lille; Lille France
| | - Louise Ghesquière
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
- Perinatal Environment and Growth; EA 4489, University of Lille North of France; Lille France
| | - Anne Delsalle
- Etablissement français du Sang, Nord Pas de Calais; France
| | - Capucine Coulon
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
| | - Damien Subtil
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
- Perinatal Environment and Growth; EA 4489, University of Lille North of France; Lille France
| | - Pascal Vaast
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
| | - Charles Garabedian
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
- Perinatal Environment and Growth; EA 4489, University of Lille North of France; Lille France
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36
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Deleers M, Guizani M, Jani J, Hulot M, El Kenz H. A case of severe foetal anaemia due to anti-Kell that could not be detected by the weekly assessment of middle cerebral artery peak systolic velocity. Transfus Apher Sci 2018; 57:111-113. [PMID: 29449170 DOI: 10.1016/j.transci.2018.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/09/2018] [Accepted: 01/15/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Marie Deleers
- Department of Transfusion, CHU-Brugmann, LHUB-ULB, Brussels, Belgium.
| | - Meriem Guizani
- Department of Obstetrics and Gynaecology, CHU-Brugmann, Brussels, Belgium
| | - Jacques Jani
- Department of Obstetrics and Gynaecology, CHU-Brugmann, Brussels, Belgium
| | - Martine Hulot
- Department of Transfusion, CHU Saint-Pierre, LHUB-ULB, Brussels, Belgium
| | - Hanane El Kenz
- Department of Transfusion, CHU-Brugmann, LHUB-ULB, Brussels, Belgium
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Sonneveld ME, Koeleman CAM, Plomp HR, Wuhrer M, van der Schoot CE, Vidarsson G. Fc-Glycosylation in Human IgG1 and IgG3 Is Similar for Both Total and Anti-Red-Blood Cell Anti-K Antibodies. Front Immunol 2018; 9:129. [PMID: 29445378 PMCID: PMC5797742 DOI: 10.3389/fimmu.2018.00129] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/16/2018] [Indexed: 11/17/2022] Open
Abstract
After albumin, immunoglobulin G (IgG) are the most abundant proteins in human serum, with IgG1 and IgG3 being the most abundant subclasses directed against protein antigens. The quality of the IgG-Fc-glycosylation has important functional consequences, which have been found to be skewed toward low fucosylation in some antigen-specific immune responses. This increases the affinity to IgG1-Fc-receptor (FcγR)IIIa/b and thereby directly affects downstream effector functions and disease severity. To date, antigen-specific IgG-glycosylation have not been analyzed for IgG3. Here, we analyzed 30 pregnant women with anti-K alloantibodies from a prospective screening cohort and compared the type of Fc-tail glycosylation of total serum- and antigen-specific IgG1 and IgG3 using mass spectrometry. Total serum IgG1 and IgG3 Fc-glycoprofiles were highly similar. Fc glycosylation of antigen-specific IgG varied greatly between individuals, but correlated significantly with each other for IgG1 and IgG3, except for bisection. However, although the magnitude of changes in fucosylation and galactosylation were similar for both subclasses, this was not the case for sialylation levels, which were significantly higher for both total and anti-K IgG3. We found that the combination of relative IgG1 and IgG3 Fc-glycosylation levels did not improve the prediction of anti-K mediated disease over IgG1 alone. In conclusion, Fc-glycosylation profiles of serum- and antigen-specific IgG1 and IgG3 are highly similar.
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Affiliation(s)
- Myrthe E Sonneveld
- Department of Experimental Immunohematology, Sanquin Research, Amsterdam, Netherlands.,Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Carolien A M Koeleman
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, Netherlands
| | - H Rosina Plomp
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, Netherlands
| | - Manfred Wuhrer
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, Netherlands
| | - C Ellen van der Schoot
- Department of Experimental Immunohematology, Sanquin Research, Amsterdam, Netherlands.,Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Gestur Vidarsson
- Department of Experimental Immunohematology, Sanquin Research, Amsterdam, Netherlands.,Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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38
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Gormley M, Ona K, Kapidzic M, Garrido-Gomez T, Zdravkovic T, Fisher SJ. Preeclampsia: novel insights from global RNA profiling of trophoblast subpopulations. Am J Obstet Gynecol 2017; 217:200.e1-200.e17. [PMID: 28347715 DOI: 10.1016/j.ajog.2017.03.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/15/2017] [Accepted: 03/17/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The maternal signs of preeclampsia, which include the new onset of high blood pressure, can occur because of faulty placentation. We theorized that transcriptomic analyses of trophoblast subpopulations in situ would lend new insights into the role of these cells in preeclampsia pathogenesis. OBJECTIVE Our goal was to enrich syncytiotrophoblasts, invasive cytotrophoblasts, or endovascular cytotrophoblasts from the placentas of severe preeclampsia cases. Total RNA was subjected to global transcriptional profiling to identify RNAs that were misexpressed compared with controls. STUDY DESIGN This was a cross-sectional analysis of placentas from women who had been diagnosed with severe preeclampsia. Gestational age-matched controls were placentas from women who had a preterm birth with no signs of infection. Laser microdissection enabled enrichment of syncytiotrophoblasts, invasive cytotrophoblasts, or endovascular cytotrophoblasts. After RNA isolation, a microarray approach was used for global transcriptional profiling. Immunolocalization identified changes in messenger RNA expression that carried over to the protein level. Differential expression of non-protein-coding RNAs was confirmed by in situ hybridization. A 2-way analysis of variance of non-coding RNA expression identified particular classes that distinguished trophoblasts in cases vs controls. Cajal body foci were visualized by coilin immunolocalization. RESULTS Comparison of the trophoblast subtype data within each group (severe preeclampsia or noninfected preterm birth) identified many highly differentially expressed genes. They included molecules that are known to be expressed by each subpopulation, which is evidence that the method worked. Genes that were expressed differentially between the 2 groups, in a cell-type-specific manner, encoded a combination of molecules that previous studies associated with severe preeclampsia and those that were not known to be dysregulated in this pregnancy complication. Gene ontology analysis of the syncytiotrophoblast data highlighted the dysregulation of immune functions, morphogenesis, transport, and responses to vascular endothelial growth factor and progesterone. The invasive cytotrophoblast data provided evidence of alterations in cellular movement, which is consistent with the shallow invasion often associated with severe preeclampsia. Other dysregulated pathways included immune, lipid, oxygen, and transforming growth factor-beta responses. The data for endovascular cytotrophoblasts showed disordered metabolism, signaling, and vascular development. Additionally, the transcriptional data revealed the differential expression in severe preeclampsia of 2 classes of non-coding RNAs: long non-coding RNAs and small nucleolar RNAs. The long non-coding RNA, urothelial cancer associated 1, was the most highly up-regulated in this class. In situ hybridization confirmed severe preeclampsia-associated expression in syncytiotrophoblasts. The small nucleolar RNAs, which chemically modify RNA structure, also correlated with severe preeclampsia. Thus, we enumerated Cajal body foci, sites of small nucleolar RNA activity, in primary cytotrophoblasts that were isolated from control and severe preeclampsia placentas. In severe preeclampsia, cytotrophoblasts had approximately double the number of these foci as the control samples. CONCLUSION A laser microdissection approach enabled the identification of novel messenger RNAs and non-coding RNAs that were misexpressed by various trophoblast subpopulations in severe preeclampsia. The results suggested new avenues of investigation, in particular, the roles of PRG2, Kell blood group determinants, and urothelial cancer associated 1 in syncytiotrophoblast diseases. Additionally, many of the newly identified dysregulated molecules might have clinical utility as biomarkers of severe preeclampsia.
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Affiliation(s)
- Matthew Gormley
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences; The Eli & Edythe Broad Center for Regeneration Medicine and Stem Cell Research; and the Department of Anatomy, University of California San Francisco, San Francisco, CA
| | - Katherine Ona
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences; The Eli & Edythe Broad Center for Regeneration Medicine and Stem Cell Research; and the Department of Anatomy, University of California San Francisco, San Francisco, CA
| | - Mirhan Kapidzic
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences; The Eli & Edythe Broad Center for Regeneration Medicine and Stem Cell Research; and the Department of Anatomy, University of California San Francisco, San Francisco, CA
| | - Tamara Garrido-Gomez
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences; The Eli & Edythe Broad Center for Regeneration Medicine and Stem Cell Research; and the Department of Anatomy, University of California San Francisco, San Francisco, CA
| | - Tamara Zdravkovic
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences; The Eli & Edythe Broad Center for Regeneration Medicine and Stem Cell Research; and the Department of Anatomy, University of California San Francisco, San Francisco, CA
| | - Susan J Fisher
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences; The Eli & Edythe Broad Center for Regeneration Medicine and Stem Cell Research; and the Department of Anatomy, University of California San Francisco, San Francisco, CA.
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39
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Schorge JO, Russo AL, Greene MF, Woythaler MA, Oliva E. Case 21-2017. A 28-Year-Old Pregnant Woman with Endocervical Carcinoma. N Engl J Med 2017; 377:174-182. [PMID: 28700849 DOI: 10.1056/nejmcpc1703511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- John O Schorge
- From the Departments of Obstetrics and Gynecology (J.O.S., M.F.G.), Radiation Oncology (A.L.R.), Pediatrics (M.A.W.), and Pathology (E.O.), Massachusetts General Hospital, and the Departments of Obstetrics, Gynecology, and Reproductive Biology (J.O.S., M.F.G.), Radiation Oncology (A.L.R.), Pediatrics (M.A.W.), and Pathology (E.O.), Harvard Medical School - both in Boston
| | - Andrea L Russo
- From the Departments of Obstetrics and Gynecology (J.O.S., M.F.G.), Radiation Oncology (A.L.R.), Pediatrics (M.A.W.), and Pathology (E.O.), Massachusetts General Hospital, and the Departments of Obstetrics, Gynecology, and Reproductive Biology (J.O.S., M.F.G.), Radiation Oncology (A.L.R.), Pediatrics (M.A.W.), and Pathology (E.O.), Harvard Medical School - both in Boston
| | - Michael F Greene
- From the Departments of Obstetrics and Gynecology (J.O.S., M.F.G.), Radiation Oncology (A.L.R.), Pediatrics (M.A.W.), and Pathology (E.O.), Massachusetts General Hospital, and the Departments of Obstetrics, Gynecology, and Reproductive Biology (J.O.S., M.F.G.), Radiation Oncology (A.L.R.), Pediatrics (M.A.W.), and Pathology (E.O.), Harvard Medical School - both in Boston
| | - Melissa A Woythaler
- From the Departments of Obstetrics and Gynecology (J.O.S., M.F.G.), Radiation Oncology (A.L.R.), Pediatrics (M.A.W.), and Pathology (E.O.), Massachusetts General Hospital, and the Departments of Obstetrics, Gynecology, and Reproductive Biology (J.O.S., M.F.G.), Radiation Oncology (A.L.R.), Pediatrics (M.A.W.), and Pathology (E.O.), Harvard Medical School - both in Boston
| | - Esther Oliva
- From the Departments of Obstetrics and Gynecology (J.O.S., M.F.G.), Radiation Oncology (A.L.R.), Pediatrics (M.A.W.), and Pathology (E.O.), Massachusetts General Hospital, and the Departments of Obstetrics, Gynecology, and Reproductive Biology (J.O.S., M.F.G.), Radiation Oncology (A.L.R.), Pediatrics (M.A.W.), and Pathology (E.O.), Harvard Medical School - both in Boston
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40
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Gniadek TJ, McGonigle AM, Shirey RS, Brunker PA, Streiff M, Philosophe B, Bloch EM, Ness PM, King KE. A rare, potentially life-threatening presentation of passenger lymphocyte syndrome. Transfusion 2017; 57:1262-1266. [DOI: 10.1111/trf.14055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 12/23/2016] [Accepted: 01/06/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Thomas J. Gniadek
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Andrea M. McGonigle
- Department of Pathology and Laboratory Medicine; Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, David Geffen School of Medicine at the University of California-Los Angeles; Los Angeles California
| | - R. Sue Shirey
- Department of Pathology, Division of Transfusion Medicine; Johns Hopkins Hospital; Baltimore Maryland
| | - Patricia A. Brunker
- Department of Pathology, Division of Transfusion Medicine; Johns Hopkins Hospital; Baltimore Maryland
- American Red Cross; Greater Chesapeake & Potomac Region; Baltimore Maryland
| | - Michael Streiff
- Department of Medicine, Division of Hematology; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Benjamin Philosophe
- Department of Surgery, Division of Transplantation; Johns Hopkins Hospital; Baltimore Maryland
| | - Evan M. Bloch
- Department of Pathology, Division of Transfusion Medicine; Johns Hopkins Hospital; Baltimore Maryland
| | - Paul M. Ness
- Department of Pathology, Division of Transfusion Medicine; Johns Hopkins Hospital; Baltimore Maryland
| | - Karen E. King
- Department of Pathology, Division of Transfusion Medicine; Johns Hopkins Hospital; Baltimore Maryland
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41
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Anti-K1 (Kell) Antibody Expressed in Maternal Breastmilk: A Case Report of a Neonate with Multiple Intrauterine Transfusions and Postnatal Exposure to Kell Antibody in Maternal Breastmilk. Case Rep Pediatr 2017; 2017:6927813. [PMID: 28357148 PMCID: PMC5357519 DOI: 10.1155/2017/6927813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/23/2017] [Indexed: 11/28/2022] Open
Abstract
Hemolytic disease of the fetus and newborn is a common consideration in newborn medicine, especially among the jaundiced. Maternal breastmilk provides numerous benefits to the infant, including nutrition and immunologic factors. Here, we present an infant who received three intrauterine transfusions for anemia secondary to anti-K1 (Kell), anti-C, and anti-e antibodies and whose maternal breastmilk tested positive for anti-Kell antibodies. The infant required another transfusion at 4 weeks of life for anemia. We review the pathophysiology of anti-Kell antibodies, the immunology of breast milk, and the intersection of these two topics.
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42
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Arthur CM, Patel SR, Smith NH, Bennett A, Kamili NA, Mener A, Gerner-Smidt C, Sullivan HC, Hale JS, Wieland A, Youngblood B, Zimring JC, Hendrickson JE, Stowell SR. Antigen Density Dictates Immune Responsiveness following Red Blood Cell Transfusion. THE JOURNAL OF IMMUNOLOGY 2017; 198:2671-2680. [PMID: 28250159 DOI: 10.4049/jimmunol.1601736] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/15/2017] [Indexed: 01/01/2023]
Abstract
Although RBC transfusion can result in the development of anti-RBC alloantibodies that increase the probability of life-threatening hemolytic transfusion reactions, not all patients generate anti-RBC alloantibodies. However, the factors that regulate immune responsiveness to RBC transfusion remain incompletely understood. One variable that may influence alloantibody formation is RBC alloantigen density. RBC alloantigens exist at different densities on the RBC surface and likewise exhibit distinct propensities to induce RBC alloantibody formation. However, although distinct alloantigens reside on the RBC surface at different levels, most alloantigens also represent completely different structures, making it difficult to separate the potential impact of differences in Ag density from other alloantigen features that may also influence RBC alloimmunization. To address this, we generated RBCs that stably express the same Ag at different levels. Although exposure to RBCs with higher Ag levels induces a robust Ab response, RBCs bearing low Ag levels fail to induce RBC alloantibodies. However, exposure to low Ag-density RBCs is not without consequence, because recipients subsequently develop Ag-specific tolerance. Low Ag-density RBC-induced tolerance protects higher Ag-density RBCs from immune-mediated clearance, is Ag specific, and occurs through the induction of B cell unresponsiveness. These results demonstrate that Ag density can potently impact immune outcomes following RBC transfusion and suggest that RBCs with altered Ag levels may provide a unique tool to induce Ag-specific tolerance.
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Affiliation(s)
- Connie M Arthur
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | - Seema R Patel
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | - Nicole H Smith
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | - Ashley Bennett
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | - Nourine A Kamili
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | - Amanda Mener
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | - Christian Gerner-Smidt
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | - Harold C Sullivan
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | - J Scott Hale
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA 30322.,Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA 30322
| | - Andreas Wieland
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA 30322.,Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA 30322
| | - Benjamin Youngblood
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA 30322.,Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA 30322
| | - James C Zimring
- Bloodworks Northwest Research Institute, Seattle, WA 98102.,Division of Hematology, Department of Laboratory and Internal Medicine, University of Washington, Seattle, WA 98195; and
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine and Pediatrics, Yale University School of Medicine, New Haven, CT 06520
| | - Sean R Stowell
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322;
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43
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Sonneveld ME, Koelewijn J, de Haas M, Admiraal J, Plomp R, Koeleman CAM, Hipgrave Ederveen AL, Ligthart P, Wuhrer M, van der Schoot CE, Vidarsson G. Antigen specificity determines anti-red blood cell IgG-Fc alloantibody glycosylation and thereby severity of haemolytic disease of the fetus and newborn. Br J Haematol 2016; 176:651-660. [PMID: 27891581 DOI: 10.1111/bjh.14438] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/02/2016] [Indexed: 01/08/2023]
Abstract
Haemolytic disease of the fetus and newborn (HDFN) is a severe disease in which fetal red blood cells (RBC) are destroyed by maternal anti-RBC IgG alloantibodies. HDFN is most often caused by anti-D but may also occur due to anti-K, -c- or -E. We recently found N-linked glycosylation of anti-D to be skewed towards low fucosylation, thereby increasing the affinity to IgG-Fc receptor IIIa and IIIb, which correlated with HDFN disease severity. Here, we analysed 230 pregnant women with anti-c, -E or -K alloantibodies from a prospective screening cohort and investigated the type of Fc-tail glycosylation of these antibodies in relation to the trigger of immunisation and pregnancy outcome. Anti-c, -E and -K show - independent of the event that had led to immunisation - a different kind of Fc-glycosylation compared to that of the total IgG fraction, but with less pronounced differences compared to anti-D. High Fc-galactosylation and sialylation of anti-c correlated with HDFN disease severity, while low anti-K Fc-fucosylation correlated with severe fetal anaemia. IgG-Fc glycosylation of anti-RBC antibodies is shaped depending on the antigen. These features influence their clinical potency and may therefore be used to predict severity and identify those needing treatment.
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Affiliation(s)
- Myrthe E Sonneveld
- Department of Experimental Immunohaematology, Sanquin Research, Amsterdam, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Joke Koelewijn
- Department of Immunohaematotology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - Masja de Haas
- Department of Immunohaematotology Diagnostics, Sanquin, Amsterdam, the Netherlands.,Centre for Clinical Transfusion Research, Sanquin Research and Dept of Immunohaematology and Blood Transfusion of Leiden University Medical Centre, Leiden, the Netherlands
| | - Jon Admiraal
- Department of Experimental Immunohaematology, Sanquin Research, Amsterdam, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Rosina Plomp
- Centre for Proteomics and Metabolomics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Carolien A M Koeleman
- Centre for Proteomics and Metabolomics, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Peter Ligthart
- Department of Immunohaematotology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - Manfred Wuhrer
- Centre for Proteomics and Metabolomics, Leiden University Medical Centre, Leiden, the Netherlands
| | - C Ellen van der Schoot
- Department of Experimental Immunohaematology, Sanquin Research, Amsterdam, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Gestur Vidarsson
- Department of Experimental Immunohaematology, Sanquin Research, Amsterdam, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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44
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Cro' F, Lapucci C, Vicari E, Salsi G, Rizzo N, Farina A. An innovative test for non-invasive Kell genotyping on circulating fetal DNA by means of the allelic discrimination of K1 and K2 antigens. Am J Reprod Immunol 2016; 76:499-503. [PMID: 27730708 DOI: 10.1111/aji.12593] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/20/2016] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The aim of this study was to present a new method for fetal Kell genotyping by means of the allelic discrimination of K1 and K2 in real-time polymerase chain reaction (PCR). METHODS Real-time quantitative polymerase chain reaction incorporating an allele-specific primer was developed for detecting the K allele of KEL. RESULTS By means of this method, the K1/K2 genotype was able to be determined in all blood samples analyzed. Results using cell-free fetal DNA (cffDNA) from two Kell-negative pregnant women confirmed the Kell-positive genotype of fetuses. The real-time PCR analysis also allowed the determination of the fetal fraction using the quantification of Kell-positive DNA. CONCLUSION An efficient and reliable strategy for Kell genotyping is herein presented. The method was optimized on cffDNA to create a non-invasive prenatal test which could be routinely used for the prevention of hemolytic disease of the fetus and the newborn (HDFN).
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Affiliation(s)
| | | | | | - Ginevra Salsi
- Division of Prenatal Medicine, Department of Medicine and Surgery (DIMEC), University of Bologna, Bologna, Italy
| | - Nicola Rizzo
- Division of Prenatal Medicine, Department of Medicine and Surgery (DIMEC), University of Bologna, Bologna, Italy
| | - Antonio Farina
- Division of Prenatal Medicine, Department of Medicine and Surgery (DIMEC), University of Bologna, Bologna, Italy
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45
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Hemolytic Disease of the Fetus and Newborn: Modern Practice and Future Investigations. Transfus Med Rev 2016; 30:159-64. [DOI: 10.1016/j.tmrv.2016.05.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 05/23/2016] [Indexed: 11/20/2022]
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46
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White J, Qureshi H, Massey E, Needs M, Byrne G, Daniels G, Allard S. Guideline for blood grouping and red cell antibody testing in pregnancy. Transfus Med 2016; 26:246-63. [DOI: 10.1111/tme.12299] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/26/2016] [Accepted: 03/01/2016] [Indexed: 10/22/2022]
Affiliation(s)
- J White
- UK National External Quality Assessment Scheme for Blood Transfusion Laboratory Practice; Watford
| | - H Qureshi
- Department of Haematology; University Hospitals of Leicester
| | - E Massey
- NHS Blood and Transplant & University Hospitals Bristol NHS Foundation Trust
| | - M Needs
- Institute of Biomedical Scientists and NHS Blood and Transplant
| | - G Byrne
- Department of Haematology; University Hospitals of Leicester
| | - G Daniels
- International Blood Group Reference Laboratory; NHS Blood and Transplant
| | - S Allard
- Barts Health NHS Trust and NHS Blood and Transplant
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47
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Santhanakrishnan M, Tormey CA, Natarajan P, Liu J, Hendrickson JE. Clinically significant anti-KEL RBC alloantibodies are transferred by breast milk in a murine model. Vox Sang 2016; 111:79-87. [PMID: 26950259 DOI: 10.1111/vox.12387] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 01/14/2016] [Accepted: 01/15/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Fetuses affected by maternal RBC alloantibodies may have prolonged anaemia after birth, leading one to question whether maternal alloantibody transfer may occur outside the placenta. In response to a recent publication describing breast milk transfer of clinically significant amounts of maternal antiplatelet IgA antibodies from mother to nursing infant, we hypothesized that maternal RBC alloantibodies may also be capable of being transferred in breast milk. MATERIALS AND METHODS The presence and clinical significance of breast milk alloantibody transfer were tested through a series of pregnancy, fostering and transfusion experiments, using a murine model in which transgenic RBCs express the human KEL glycoprotein. RESULTS Maternal anti-KEL immunoglobulins, induced through transfusion or pregnancy, were detected in the aqueous phase of breast milk. Further, efficient transfer of maternal anti-KEL IgG and IgA to nursing pups was observed in fostering experiments. The breast milk-acquired alloantibodies were clinically significant in wild-type pups in a transfusion setting, binding to 'incompatible' KEL RBCs and leading to premature clearance from the circulation. Although breast milk-acquired alloantibodies also bound to the RBCs of transgenic KEL-positive fostered pups, no anaemia resulted. CONCLUSIONS Taking these murine data in combination with recently published human data of maternal antiplatelet IgA antibodies in breast milk leading to sequelae in some infants, it is theoretically possible that maternal anti-RBC IgA alloantibodies may also be transferred in human breast milk and may lead to sequelae in some infants under some circumstances.
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Affiliation(s)
- M Santhanakrishnan
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - C A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| | - P Natarajan
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - J Liu
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - J E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
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Fujita S, Kashiwagi H, Tomimatsu T, Ito S, Mimura K, Kanagawa T, Endo M, Miyoshi T, Okamura Y, Tani Y, Tomiyama Y, Kimura T. Expression levels of ABCG2 on cord red blood cells and study of fetal anemia associated with anti-Jra. Transfusion 2016; 56:1171-81. [DOI: 10.1111/trf.13515] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 12/22/2015] [Accepted: 12/30/2015] [Indexed: 01/01/2023]
Affiliation(s)
| | | | | | - Shoichi Ito
- Tohoku Block Blood Center, Japanese Red Cross; Miyagi
| | | | | | | | - Tomomitsu Miyoshi
- Department of Integrative Physiology, Graduate School of Medicine; Osaka University; Osaka
| | - Yasushi Okamura
- Department of Integrative Physiology, Graduate School of Medicine; Osaka University; Osaka
| | - Yoshihiko Tani
- Kinki Block Blood Center, Japanese Red Cross; Osaka Japan
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49
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Affiliation(s)
- Janet Brennand
- Fetal and Maternal Medicine The Queen Mother's Hospital Yorkhill, Glasgow G3 8SJ United Kingdom
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50
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Abstract
AbstractHemolytic disease of the fetus and newborn (HDFN) affects 3/100 000 to 80/100 000 patients per year. It is due to maternal blood group antibodies that cause fetal red cell destruction and in some cases, marrow suppression. This process leads to fetal anemia, and in severe cases can progress to edema, ascites, heart failure, and death. Infants affected with HDFN can have hyperbilirubinemia in the acute phase and hyporegenerative anemia for weeks to months after birth. The diagnosis and management of pregnant women with HDFN is based on laboratory and radiographic monitoring. Fetuses with marked anemia may require intervention with intrauterine transfusion. HDFN due to RhD can be prevented by RhIg administration. Prevention for other causal blood group specificities is less studied.
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