1
|
Jajosky RP, Zerra PE, Chonat S, Stowell SR, Arthur CM. Harnessing the potential of red blood cells in immunotherapy. Hum Immunol 2024; 85:111084. [PMID: 39255557 DOI: 10.1016/j.humimm.2024.111084] [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: 05/17/2024] [Revised: 07/30/2024] [Accepted: 08/01/2024] [Indexed: 09/12/2024]
Abstract
Red blood cell (RBC) transfusion represents one of the earliest and most widespread forms of cellular therapy. While the primary purpose of RBC transfusions is to enhance the oxygen-carrying capacity of the recipient, RBCs also possess unique properties that make them attractive vehicles for inducing antigen-specific immune tolerance. Preclinical studies have demonstrated that RBC transfusion alone, in the absence of inflammatory stimuli, often fails to elicit detectable alloantibody formation against model RBC antigens. Several studies also suggest that RBC transfusion without inflammation may not only fail to generate a detectable alloantibody response but can also induce a state of antigen-specific non-responsiveness, a phenomenon potentially influenced by the density of the corresponding RBC alloantigen. The unique properties of RBCs, including their inability to divide and their stable surface antigen expression, make them attractive platforms for displaying exogenous antigens with the goal of leveraging their ability to induce antigen-specific non-responsiveness. This could facilitate antigen presentation to the host's immune system without triggering innate immune activation, potentially enabling the induction of antigen-specific tolerance for therapeutic applications in autoimmune disorders, preventing immune responses against protein therapeutics, or reducing alloreactivity in the setting of transfusion and transplantation.
Collapse
Affiliation(s)
- Ryan P Jajosky
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Patricia E Zerra
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Satheesh Chonat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Sean R Stowell
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Connie M Arthur
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| |
Collapse
|
2
|
Sun Q, Karafin MS, Garrett ME, Li Y, Ashley-Koch A, Telen MJ. A genome-wide association study of alloimmunization in the TOPMed OMG-SCD cohort identifies a locus on chromosome 12. Transfusion 2024. [PMID: 38966903 DOI: 10.1111/trf.17944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 06/10/2024] [Accepted: 06/20/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Red cell alloimmunization after exposure to donor red cells is a very common complication of transfusion for patients with sickle cell disease (SCD), resulting frequently in accelerated donor red blood cell destruction. Patients show substantial differences in their predisposition to alloimmunization, and genetic variability is one proposed component. Although several genetic association studies have been conducted for alloimmunization, the results have been inconsistent, and the genetic determinants of alloimmunization remain largely unknown. STUDY DESIGN AND METHODS We performed a genome-wide association study (GWAS) in 236 African American (AA) SCD patients from the Outcome Modifying Genes in Sickle Cell Disease (OMG-SCD) cohort, which is part of Trans-Omics for Precision Medicine (TOPMed), with whole-genome sequencing data available. We also performed sensitivity analyses adjusting for different sets of covariates and applied different sample grouping strategies based on the number of alloantibodies patients developed. RESULTS We identified one genome-wide significant locus on chr12 (p = 3.1e-9) with no evidence of genomic inflation (lambda = 1.003). Further leveraging QTL evidence from GTEx whole blood and/or Jackson Heart Study PBMC RNA-Seq data, we identified a number of potential genes, such as ARHGAP9, STAT6, and ATP23, that may be driving the association signal. We also discovered some suggestive loci using different analysis strategies. DISCUSSION We call for the community to collect additional alloantibody information within SCD cohorts to further the understanding of the genetic basis of alloimmunization in order to improve transfusion outcomes.
Collapse
Affiliation(s)
- Quan Sun
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Matthew S Karafin
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Melanie E Garrett
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Yun Li
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Allison Ashley-Koch
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Marilyn J Telen
- Division of Hematology, Department of Medicine, Duke Comprehensive Sickle Cell Center, Duke University Medical Center, Durham, North Carolina, USA
| |
Collapse
|
3
|
Chang DY, Wankier Z, Arthur CM, Stowell SR. The ongoing challenge of RBC alloimmunization in the management of patients with sickle cell disease. Presse Med 2023; 52:104211. [PMID: 37981194 DOI: 10.1016/j.lpm.2023.104211] [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] [Indexed: 11/21/2023] Open
Abstract
RBC transfusion remains a cornerstone in the treatment of sickle cell disease (SCD). However, as with many interventions, transfusion of RBCs is not without risk. Allogeneic RBC exposure can result in the development of alloantibodies, which can make it difficult to find compatible RBCs for future transfusion and increases the likelihood of life-threatening complications. The development of RBC alloantibodies occurs when a patient's immune system produces alloantibodies against foreign alloantigens present on RBCs. Despite its longstanding recognition, RBC alloimmunization has increasingly become a challenge when caring for patients with SCD. The growing prominence of alloimmunization can be attributed to several factors, including expanded indications for transfusions, increased lifespan of patients with SCD, and inadequate approaches to prevent alloimmunization. Recognizing these challenges, recent observational studies and preclinical models have begun to elucidate the immune pathways that underpin RBC alloimmunization. These emerging data hold promise in paving the way for innovative prevention strategies, with the goal of increasing the safety and efficacy of RBC transfusion in patients with SCD who are most vulnerable to alloimmunization.
Collapse
Affiliation(s)
- Daniel Y Chang
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Zakary Wankier
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Connie M Arthur
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Sean R Stowell
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| |
Collapse
|
4
|
Arthur CM, Stowell SR. The Development and Consequences of Red Blood Cell Alloimmunization. ANNUAL REVIEW OF PATHOLOGY 2023; 18:537-564. [PMID: 36351365 PMCID: PMC10414795 DOI: 10.1146/annurev-pathol-042320-110411] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
While red blood cell (RBC) transfusion is the most common medical intervention in hospitalized patients, as with any therapeutic, it is not without risk. Allogeneic RBC exposure can result in recipient alloimmunization, which can limit the availability of compatible RBCs for future transfusions and increase the risk of transfusion complications. Despite these challenges and the discovery of RBC alloantigens more than a century ago, relatively little has historically been known regarding the immune factors that regulate RBC alloantibody formation. Through recent epidemiological approaches, in vitro-based translational studies, and newly developed preclinical models, the processes that govern RBC alloimmunization have emerged as more complex and intriguing than previously appreciated. Although common alloimmunization mechanisms exist, distinct immune pathways can be engaged, depending on the target alloantigen involved. Despite this complexity, key themes are beginning to emerge that may provide promising approaches to not only actively prevent but also possibly alleviate the most severe complications of RBC alloimmunization.
Collapse
Affiliation(s)
- Connie M Arthur
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, ,
| | - Sean R Stowell
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, ,
| |
Collapse
|
5
|
Genotyping and the Future of Transfusion in Sickle Cell Disease. Hematol Oncol Clin North Am 2022; 36:1271-1284. [DOI: 10.1016/j.hoc.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
6
|
van de Weem RHG, Wemelsfelder ML, Luken JS, de Haas M, Niessen RWLM, van der Schoot CE, Hoogeveen H, Janssen MP. Preventing alloimmunization using a new model for matching extensively typed red blood cells. Vox Sang 2021; 117:580-586. [PMID: 34725840 DOI: 10.1111/vox.13217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 10/06/2021] [Accepted: 10/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Alloimmunization is a well-known adverse event associated with red blood cell (RBC) transfusions, caused by phenotype incompatibilities between donor and patient RBCs that may lead to haemolytic transfusion reactions on subsequent transfusions. Alloimmunization can be prevented by transfusing fully matched RBC units. Advances in RBC genotyping render the extensive typing of both donors and patients affordable in the foreseeable future. However, the exponential increase in the variety of extensively typed RBCs asks for a software-driven selection to determine the 'best product for a given patient'. MATERIALS AND METHODS We propose the MINimize Relative Alloimmunization Risks (MINRAR) model for matching extensively typed RBC units to extensively typed patients to minimize the risk of alloimmunization. The key idea behind this model is to use antigen immunogenicity to represent the clinical implication of a mismatch. Using simulations of non-elective transfusions in Caucasian donor and patient populations, the effect on the alloimmunization rate of the MINRAR model is compared with that of a baseline model that matches antigens A, B and RhD only. RESULTS Our simulations show that with the MINRAR model, even for small inventories, the expected number of alloimmunizations can be reduced by 78.3% compared with a policy of only matching on antigens A, B and RhD. Furthermore, a reduction of 93.7% can be achieved when blood is issued from larger inventories. CONCLUSION Despite an exponential increase in phenotype variety, matching of extensively typed RBCs can be effectively implemented using our MINRAR model, effectuating a substantial reduction in alloimmunization risk without introducing additional outdating or shortages.
Collapse
Affiliation(s)
- Ronald H G van de Weem
- Transfusion Technology Assessment Group, Donor Medicine Research Department, Sanquin Research, Amsterdam, The Netherlands
| | - Merel L Wemelsfelder
- Transfusion Technology Assessment Group, Donor Medicine Research Department, Sanquin Research, Amsterdam, The Netherlands
| | | | | | | | - C Ellen van der Schoot
- Department of Experimental Immunohematology, Sanquin Research, Amsterdam, The Netherlands
| | | | - Mart P Janssen
- Transfusion Technology Assessment Group, Donor Medicine Research Department, Sanquin Research, Amsterdam, The Netherlands
| |
Collapse
|
7
|
Madany E, Lee J, Halprin C, Seo J, Baca N, Majlessipour F, Hendrickson JE, Pepkowitz SH, Hayes C, Klapper E, Gibb DR. Altered type 1 interferon responses in alloimmunized and nonalloimmunized patients with sickle cell disease. EJHAEM 2021; 2:700-710. [PMID: 35128535 PMCID: PMC8813163 DOI: 10.1002/jha2.270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 01/05/2023]
Abstract
Patients with sickle cell disease (SCD) have a high prevalence of RBC alloimmunization. However, underlying mechanisms are poorly understood. Given that proinflammatory type 1 interferons (IFNα/β) and interferon stimulated genes (ISGs) promote alloimmunization in mice, we hypothesized that IFNα/β may contribute to the increased frequency of alloimmunization in patients with SCD. To investigate this, expression of ISGs in blood leukocytes and peripheral blood mononuclear cells (PBMCs) of previously transfused SCD patients with or without alloimmunization and race-matched healthy controls were quantified, and IFNα/β gene scores were calculated. IFNα/β gene scores of SCD leukocytes and plasma cytokines were elevated, compared to controls (gene score, p < 0.01). Upon stimulation with IFNβ, isolated PBMCs from patients with SCD had elevated ISGs and IFNα/β gene scores (p < 0.05), compared to stimulated PBMCs from controls. However, IFNβ-stimulated and unstimulated ISG expression did not significantly differ between alloimmunized and non-alloimmunized patients. These findings indicate that patients with SCD express an IFNα/β gene signature, and larger studies are needed to fully determine its role in alloimmunization. Further, illustration of altered IFNα/β responses in SCD has potential implications for IFNα/β-mediated viral immunity, responses to IFNα/β-based therapies, and other sequelae of SCD.
Collapse
Affiliation(s)
- Emaan Madany
- Cedars‐Sinai Medical CenterDepartment of Pathology and Laboratory MedicineLos AngelesCaliforniaUnited States
| | - June Lee
- Cedars‐Sinai Medical CenterDepartment of Pathology and Laboratory MedicineLos AngelesCaliforniaUnited States
| | - Chelsea Halprin
- Cedars‐Sinai Medical CenterDepartment of Pathology and Laboratory MedicineLos AngelesCaliforniaUnited States
| | - Jina Seo
- Cedars‐Sinai Medical CenterDepartment of Pathology and Laboratory MedicineLos AngelesCaliforniaUnited States
| | - Nicole Baca
- Cedars‐Sinai Medical CenterDepartment of PediatricsLos AngelesCaliforniaUnited States
| | - Fataneh Majlessipour
- Cedars‐Sinai Medical CenterDepartment of PediatricsLos AngelesCaliforniaUnited States
| | - Jeanne E. Hendrickson
- Department of Laboratory MedicineYale University School of MedicineNew HavenConnecticutUnited States
- Department of PediatricsYale University School of MedicineNew HavenConnecticutUnited States
| | - Samuel H. Pepkowitz
- Cedars‐Sinai Medical CenterDepartment of Pathology and Laboratory MedicineLos AngelesCaliforniaUnited States
| | - Chelsea Hayes
- Cedars‐Sinai Medical CenterDepartment of Pathology and Laboratory MedicineLos AngelesCaliforniaUnited States
| | - Ellen Klapper
- Cedars‐Sinai Medical CenterDepartment of Pathology and Laboratory MedicineLos AngelesCaliforniaUnited States
| | - David R. Gibb
- Cedars‐Sinai Medical CenterDepartment of Pathology and Laboratory MedicineLos AngelesCaliforniaUnited States
| |
Collapse
|
8
|
Linder GE, Chou ST. Red cell transfusion and alloimmunization in sickle cell disease. Haematologica 2021; 106:1805-1815. [PMID: 33792218 PMCID: PMC8252926 DOI: 10.3324/haematol.2020.270546] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Indexed: 01/23/2023] Open
Abstract
Red cell transfusion remains a critical component of care for acute and chronic complications of sickle cell disease. Randomized clinical trials demonstrated the benefits of transfusion therapy for prevention of primary and secondary strokes and postoperative acute chest syndrome. Transfusion for splenic sequestration, acute chest syndrome, and acute stroke are guided by expert consensus recommendations. Despite overall improvements in blood inventory safety, adverse effects of transfusion are prevalent among patients with sickle cell disease and include alloimmunization, acute and delayed hemolytic transfusion reactions, and iron overload. Judicious use of red cell transfusions, optimization of red cell antigen matching, and the use of erythrocytapheresis and iron chelation can minimize adverse effects. Early recognition and management of hemolytic transfusion reactions can avert poor clinical outcomes. In this review, we discuss transfusion methods, indications, and complications in sickle cell disease with an emphasis on alloimmunization.
Collapse
Affiliation(s)
- Grace E Linder
- Department of Pathology and Lab Medicine, Children's Hospital of Philadelphia
| | - Stella T Chou
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.
| |
Collapse
|
9
|
Gerritsma JJ, Oomen I, Meinderts S, van der Schoot CE, Biemond BJ, van der Bom JG, Fijnvandraat K. Back to base pairs: What is the genetic risk for red bloodcell alloimmunization? Blood Rev 2021; 48:100794. [PMID: 33451870 DOI: 10.1016/j.blre.2020.100794] [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: 07/24/2020] [Revised: 11/17/2020] [Accepted: 12/24/2020] [Indexed: 01/05/2023]
Abstract
Red blood cell (RBC) alloimmunization is a serious complication of blood transfusions, challenging selection of compatible units for future transfusions. Genetic characteristics may be associated with the risk of RBC alloimmunization and may therefore serve to identify high-risk patients. The aim of this systematic review was to summarize the available evidence on genetic risk factors for RBC alloimmunization. Electronic databases were searched up to April 2020 for studies (Search terms included transfusion, alloimmunization and genetic). A total of 2581 alloimmunized cases and 26,558 controls were derived from 24 studies. The alleles that were most frequently studied and that demonstrated significant associations in a meta-analysis with alloimmunization to the Duffya antigen were HLA-DRB1*04 (Odds Ratio 7.80 (95%CI 4.57-13.33)), HLA-DRB1*15 (OR 3.76 (95%CI 2.14-6.59)), and HLA-DRB1*03 (OR 0.12 (95%CI 0.05-0.29)). Furthermore, significant associations with anti-K formation was found for the alleles HLA-DRB1*10 (OR 2.64 (95%CI 1.41-4.95)), HLA*DRB1*11 (OR 2.11, (95%CI 1.34-3.32)), and HLA-DRB1*13 (OR 1.71 (95%CI 1.26-2.33)). Overall, the available evidence was of moderate to low quality, hampering interpretation of reported results. There is an urgent need for high quality evidence on genetic risk factors for RBC alloimmunization.
Collapse
Affiliation(s)
- J J Gerritsma
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology, Amsterdam, the Netherlands; Sanquin Research and Landsteiner Laboratory, Immunopathology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - I Oomen
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology, Amsterdam, the Netherlands.
| | - S Meinderts
- Sanquin Research and Landsteiner Laboratory, Blood Cell Research, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C E van der Schoot
- Sanquin Research and Landsteiner Laboratory, Experimental Immunohematology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - B J Biemond
- Amsterdam UMC, University of Amsterdam, Department of Hematology, Amsterdam, the Netherlands.
| | - J G van der Bom
- Sanquin/LUMC, Center for Clinical Transfusion Research, Leiden, the Netherlands.
| | - K Fijnvandraat
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology, Amsterdam, the Netherlands; Leiden University Medical Center, Department of Clinical Epidemiology, Leiden, the Netherlands.
| | | |
Collapse
|
10
|
Hendrickson JE. Red blood cell alloimmunization and sickle cell disease: a narrative review on antibody induction. ANNALS OF BLOOD 2020; 5:33. [PMID: 33554044 PMCID: PMC7861514 DOI: 10.21037/aob-2020-scd-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The high prevalence of red blood cell (RBC) alloantibodies in people with sickle cell disease (SCD) cannot be debated. Why people with SCD are so likely to form RBC alloantibodies, however, remains poorly understood. Over the past decade, a better understanding of non-ABO blood group antigen variants has emerged; RH genetic diversity and the role this diversity plays in RBC alloimmunization is discussed elsewhere. Outside of antigen variants, the immune systems of people with SCD are known to be different than those of people without SCD. Some of these differences are due to effects of free heme, whereas others are impacted by hyposplenism. Descriptive studies of differences in white blood cell (WBC) subsets, platelet counts and function, and complement activation between people with SCD and race-matched controls exist. Studies comparing the immune systems of alloimmunized people with SCD to non-alloimmunized people with SCD to race-matched controls without SCD have uncovered differences in T-cell subsets, monocytes, Fcγ receptor polymorphisms, and responses to free heme. Studies in murine models have documented the role that recipient inflammation plays in RBC alloantibody formation, with human studies reporting a similar association. Murine studies have also reported the importance of type 1 interferon (IFNα/β), known to play a pivotal role in autoimmunity, in RBC alloantibody formation. The goal of this manuscript is to review existing data on factors influencing RBC alloantibody induction in people with SCD with a focus on inflammation and other immune system considerations, from the bench to the bedside.
Collapse
Affiliation(s)
- Jeanne 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
| |
Collapse
|
11
|
Hendrickson JE. Toll-like receptor SNPs and sickle cell disease: a PRRfect storm for RBC alloimmunization. Br J Haematol 2019; 186:803-804. [PMID: 31155710 DOI: 10.1111/bjh.16001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jeanne E Hendrickson
- Departments of Laboratory Medicine and Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|