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Hirschman L, Munchel A. Case of Hemolytic Disease of the Fetus and Newborn Treated Without Blood Products. J Pediatr Hematol Oncol 2024; 46:e118-e120. [PMID: 38032187 DOI: 10.1097/mph.0000000000002795] [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: 07/31/2023] [Accepted: 11/06/2023] [Indexed: 12/01/2023]
Abstract
Hemolytic disease of the fetus and newborn (HDFN) affects 3/100,000 to 80/100,000 patients yearly and can cause severe anemia and hyperbilirubinemia. Recombinant human erythropoietin has been used as an adjunct therapy in patients with HDFN and hypo-regenerative anemia in the setting of receiving intrauterine blood transfusions. This case describes a patient with HDFN, in which the family were Jehovah Witnesses, and blood transfusions were declined. The patient had symptomatic anemia with a hematocrit nadir of 18.6%. The patient was successfully treated with recombinant human erythropoietin, ferrous sulfate, and folic acid, avoiding the need for transfusion.
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Affiliation(s)
- Leah Hirschman
- University of Maryland Children's Hospital, Department of Pediatrics Baltimore, MD, 21201, Unites States
| | - Ashley Munchel
- Department of Pediatric, Hematology/Oncology, University of Maryland Children's Hospital, Baltimore, MD
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de Winter DP, Kaminski A, Tjoa ML, Oepkes D, Lopriore E. Hemolytic disease of the fetus and newborn: rapid review of postnatal care and outcomes. BMC Pregnancy Childbirth 2023; 23:738. [PMID: 37853331 PMCID: PMC10583489 DOI: 10.1186/s12884-023-06061-y] [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: 10/12/2022] [Accepted: 10/11/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Advances in postnatal care for hemolytic disease of the fetus and newborn (HDFN) have occurred over the past decades, but little is known regarding the frequency of postnatal treatment and the clinical outcomes of affected neonates. Most studies reporting on HDFN originate from high-income countries or relatively large centers, but important differences between centers and countries may exist due to differences in prevalence and available treatment options. We therefore aimed to evaluate the postnatal treatment landscape and clinical outcomes in neonates with Rhesus factor D (Rh(D))- and/or K-mediated HDFN and to provide recommendations for future research. METHODS We conducted a rapid literature review of case reports and series, observational retrospective and prospective cohort studies, and trials describing pregnancies or children affected by Rh(D)- or K-mediated HDFN published between 2005 and 2021. Information relevant to the treatment of HDFN and clinical outcomes was extracted. Medline, ClinicalTrials.gov and EMBASE were searched for relevant studies by two independent reviewers through title/abstract and full-text screening. Two independent reviewers extracted data and assessed methodological quality of included studies. RESULTS Forty-three studies reporting postnatal data were included. The median frequency of exchange transfusions was 6.0% [interquartile range (IQR): 0.0-20.0] in K-mediated HDFN and 26.5% [IQR: 18.0-42.9] in Rh(D)-mediated HDFN. The median use of simple red blood cell transfusions in K-mediated HDFN was 50.0% [IQR: 25.0-56.0] and 60.0% [IQR: 20.0-72.0] in Rh(D)-mediated HDFN. Large differences in transfusion rates were found between centers. Neonatal mortality amongst cases treated with intrauterine transfusion(s) was 1.2% [IQR: 0-4.4]. Guidelines and thresholds for exchange transfusions and simple RBC transfusions were reported in 50% of studies. CONCLUSION Most included studies were from middle- to high-income countries. No studies with a higher level of evidence from centers in low-income countries were available. We noted a shortage and inconsistency in the reporting of relevant data and provide recommendations for future reports. Although large variations between studies was found and information was often missing, analysis showed that the postnatal burden of HDFN, including need for neonatal interventions, remains high. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2021 CRD42021234940. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021234940 .
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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, Leiden, The Netherlands.
- Department of Immunohematology Diagnostic Services, Sanquin Diagnostic Services, Amsterdam, The Netherlands.
| | - Allysen Kaminski
- OPEN Health, Bethesda, MD, USA (Currently The George Washington University, Washington, DC, USA
| | | | - Dick Oepkes
- 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, Leiden, The Netherlands
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de Winter DP, Kaminski A, Tjoa ML, Oepkes D. Hemolytic disease of the fetus and newborn: systematic literature review of the antenatal landscape. BMC Pregnancy Childbirth 2023; 23:12. [PMID: 36611144 PMCID: PMC9824959 DOI: 10.1186/s12884-022-05329-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/21/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Prevention of pregnancy-related alloimmunization and the management of hemolytic disease of the fetus and newborn (HDFN) has significantly improved over the past decades. Considering improvements in HDFN care, the objectives of this systematic literature review were to assess the prenatal treatment landscape and outcomes of Rh(D)- and K-mediated HDFN in mothers and fetuses, to identify the burden of disease, to identify evidence gaps in the literature, and to provide recommendations for future research. METHODS We performed a systematic search on MEDLINE, EMBASE and clinicaltrials.gov. Observational studies, trials, modelling studies, systematic reviews of cohort studies, and case reports and series of women and/or their fetus with HDFN caused by Rhesus (Rh)D or Kell alloimmunization. Extracted data included prevalence; treatment patterns; clinical outcomes; treatment efficacy; and mortality. RESULTS We identified 2,541 articles. After excluding 2,482 articles and adding 1 article from screening systematic reviews, 60 articles were selected. Most abstracted data were from case reports and case series. Prevalence was 0.047% and 0.006% for Rh(D)- and K-mediated HDFN, respectively. Most commonly reported antenatal treatment was intrauterine transfusion (IUT; median frequency [interquartile range]: 13.0% [7.2-66.0]). Average gestational age at first IUT ranged between 25 and 27 weeks. weeks. This timing is early and carries risks, which were observed in outcomes associated with IUTs. The rate of hydrops fetalis among pregnancies with Rh(D)-mediated HDFN treated with IUT was 14.8% (range, 0-50%) and 39.2% in K-mediated HDFN. Overall mean ± SD fetal mortality rate that was found to be 19.8%±29.4% across 19 studies. Mean gestational age at birth ranged between 34 and 36 weeks. CONCLUSION These findings corroborate the rareness of HDFN and frequently needed intrauterine transfusion with inherent risks, and most births occur at a late preterm gestational age. We identified several evidence gaps providing opportunities for future studies.
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Affiliation(s)
- Derek P. de Winter
- grid.508552.fDepartment of Pediatrics, Division of Neonatology, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands ,grid.417732.40000 0001 2234 6887Department of Immunohematology Diagnostic Services, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Allysen Kaminski
- OPEN Health, Bethesda, MD USA ,grid.253615.60000 0004 1936 9510Present address: The George Washington University, Washington, DC, USA
| | - May Lee Tjoa
- grid.497530.c0000 0004 0389 4927Janssen Pharmaceuticals, Raritan, NJ USA
| | - Dick Oepkes
- grid.10419.3d0000000089452978Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, K-06-35, PO Box 9600, Leiden, 2300 RC The Netherlands
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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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Chang MR, Chon AH, Baskin J, Nael A, Chmait RH. Case 1: Cardiac Arrest in a 2-month-old Boy with a Prenatal Course Complicated by Alloimmunization. Pediatr Rev 2019; 40:243-246. [PMID: 31043443 DOI: 10.1542/pir.2018-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Andrew H Chon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology
| | - Jacquelyn Baskin
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA.,Children's Center for Cancer and Blood Disease
| | - Ali Nael
- Department of Pediatrics.,Department of Pathology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology
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Mattaloni SM, Arnoni C, Céspedes R, Nonaka C, Trucco Boggione C, Luján Brajovich ME, Trejo A, Zani N, Biondi CS, Castilho L, Cotorruelo CM. Clinical Significance of an Alloantibody against the Kell Blood Group Glycoprotein. Transfus Med Hemother 2016; 44:53-57. [PMID: 28275334 DOI: 10.1159/000448381] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 07/08/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Kell null (K0) individuals can produce anti-Ku, an antibody against many epitopes in the Kell glycoprotein, after transfusion and/or pregnancy. Since sensitized K0 patients are rare, little is known about anti-Ku clinical relevance and in particular about its association to hemolytic disease of the fetus and newborn. CASE REPORT This work describes a case of neonatal hyperbilirubinemia due to immune-mediated erythrocyte destruction by an alloantibody directed against the Kell glycoprotein. Serologic and molecular approaches identified an anti-Ku alloantibody in maternal serum. A homozygous IVS3 + 1g>a point mutation (KEL*02N.06 allele) was found to be responsible for the lack of Kell antigen expression in the mother's red blood cell and subsequent alloimmunization after a previous pregnancy. Even though in most cases Kell antibodies are clinically severe and may cause suppression of erythropoiesis, in our case the newborn had a moderate anemia and hyperbilirubinemia that was successfully treated with phototherapy without requiring exchange transfusion. Serological and molecular studies performed in the proband's family members allowed us to provide them with proper counseling regarding alloimmunization after transfusion and/or pregnancy. CONCLUSIONS This case enlarges the understanding of the clinical significance of alloantibodies against Kell blood group antigens.
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Affiliation(s)
- Stella Maris Mattaloni
- IDICER-CONICET, Rosario, Argentina; Laboratorio de Inmunohematología - Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario, Argentina
| | - Carine Arnoni
- Colsan-Associaçao Beneficente de Coleta de Sangue, Sao Paulo, Brazil
| | - Rosario Céspedes
- Hospital Zonal General de Agudos Dr. Carlos Bocalandro, Buenos Aires, Argentina
| | - Claudia Nonaka
- Hospital Nacional Profesor Alejandro Posadas, Buenos Aires, Argentina
| | - Carolina Trucco Boggione
- IDICER-CONICET, Rosario, Argentina; Laboratorio de Inmunohematología - Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario, Argentina
| | - Melina Eliana Luján Brajovich
- IDICER-CONICET, Rosario, Argentina; Laboratorio de Inmunohematología - Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario, Argentina
| | - Andrea Trejo
- Hospital Zonal General de Agudos Dr. Carlos Bocalandro, Buenos Aires, Argentina
| | - Néstor Zani
- Hospital Nacional Profesor Alejandro Posadas, Buenos Aires, Argentina
| | - Claudia Silvia Biondi
- Laboratorio de Inmunohematología - Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario, Argentina
| | | | - Carlos Miquel Cotorruelo
- IDICER-CONICET, Rosario, Argentina; Laboratorio de Inmunohematología - Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario, Argentina
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Morrison JF, Neufeld EJ, Grace RF. The use of erythropoietin-stimulating agents versus supportive care in newborns with hereditary spherocytosis: a single centre's experience. Eur J Haematol 2014; 93:161-4. [PMID: 24660843 DOI: 10.1111/ejh.12321] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2014] [Indexed: 01/19/2023]
Abstract
Hereditary Spherocytosis (HS) is a common haemolytic anaemia in which 75% of cases are autosomal dominant. As most newborns with HS have a family history of disease, haematologists often see these infants before their physiologic haemoglobin nadir, which is exaggerated in comparison with healthy infants. The objective of this study was to evaluate the frequency of implementation and cost of erythropoietin-stimulating agents (EPO) versus transfusion in infants with HS at a single paediatric programme. In the last decade, only 15% of infants with HS at our centre have been treated with EPO, which costs twice that of a single transfusion and EPO treated infants did not always avoid transfusion. Infrequent prescription of EPO therapy to infants with HS at our centre may be related to the incomplete data supporting its use.
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Hematological morbidity and management in neonates with hemolytic disease due to red cell alloimmunization. Early Hum Dev 2011; 87:583-8. [PMID: 21798676 DOI: 10.1016/j.earlhumdev.2011.07.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 07/05/2011] [Indexed: 11/21/2022]
Abstract
Treatment of severe anemia with intrauterine red cell transfusions in fetuses with red cell alloimmunization has led to a dramatic increase in perinatal survival. Due to this increased survival focus is nowadays shifting towards improving postnatal treatment options. Phototherapy, exchange transfusions and intravenous immunoglobulin are used to treat hyperbilirubinemia and prevent kernicterus. Postnatal treatment of anemia consists of top-up transfusions, supplements to support erythropoiesis such as folic acid and iron, and occasionally erythropoietin treatment. In addition to anemia, other hematological complications such as thrombocytopenia, coagulation disturbances, leucopenia and iron overload have been reported. This review focuses on the hematological morbidity in neonates with red cell alloimmunization and summarizes the current evidence on management options.
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Bleile MJ, Rijhsinghani A, Dwyre DM, Raife TJ. Successful use of maternal blood in the management of severe hemolytic disease of the fetus and newborn due to anti-Kpb. Transfus Apher Sci 2010; 43:281-283. [DOI: 10.1016/j.transci.2010.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Álvarez Domínguez E, Pérez Fernández J, Figueras Aloy J, Carbonell Estrany X. Tratamiento con eritropoyetina para la anemia tardía tras enfermedad hemolítica del recién nacido. An Pediatr (Barc) 2010; 73:334-9. [DOI: 10.1016/j.anpedi.2010.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 08/27/2010] [Accepted: 09/19/2010] [Indexed: 10/18/2022] Open
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Rath MEA, Smits-Wintjens VEHJ, Lindenburg ITM, Brand A, van Kamp IL, Oepkes D, Walther FJ, Lopriore E. Exchange transfusions and top-up transfusions in neonates with Kell haemolytic disease compared to Rh D haemolytic disease. Vox Sang 2010; 100:312-6. [DOI: 10.1111/j.1423-0410.2010.01408.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kang MG, Lim YA, Lee KM. [A hemolytic transfusion reaction due to Anti-Ku antibody in a patient with Knull phenotype: the first case in Korea]. Ann Lab Med 2009; 29:238-42. [PMID: 19571622 DOI: 10.3343/kjlm.2009.29.3.238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Knull phenotype completely lacks all Kell system antigens. Anti-Ku antibody is seen in immunized persons with Knull phenotype by transfusion or pregnancy. It can cause a fatal hemolytic transfusion reaction. A 66-yr-old male patient with liver cirrhosis visited emergency center due to acute bleeding. The patient was at hypovolemic shock status: his blood pressure was 80/50 mmHg, pulse rate was 110/min and hemoglobin level was 4.4 g/dL. Because of the presence of antibody against high incidence antigen, we could not find any compatible blood for the patient. Nevertheless, 4 units of packed RBCs had to be transfused. Moderate hemolytic transfusion reaction was developed after transfusion. At endoscopic examination, blood was spurting from gastric cardiac varix. Endoscopic histoacryl injection was tried, and bleeding was successfully controlled. After bleeding stopped, he was managed for anemia using steroid and other medical therapy instead of transfusion. His hemoglobin level was improved to 7.7 g/dL at the time of discharge. Later he has been proved to have a Knull phenotype, which is very rare, and anti-Ku antibody. This report is the first case of anti-Ku in a Knull phenotype person in Korea, who experienced a moderate hemolytic transfusion reaction.
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Affiliation(s)
- Min Gu Kang
- Department of Laboratory Medicine, Ajou University School of Medicine, Yeongtong-Gu, Suwon, Korea
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