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Ogura T, Shiraishi C. Efficacy of Prednisone Avoidance in Patients With Liver Transplant Using the U.S. Food and Drug Administration Adverse Event Reporting System. Cureus 2024; 16:e60193. [PMID: 38868240 PMCID: PMC11168242 DOI: 10.7759/cureus.60193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2024] [Indexed: 06/14/2024] Open
Abstract
Background Immunosuppressants are administered in various combinations to prevent immune-induced transplant rejection in patients with liver transplant, as each immunosuppressant acts on different cellular sites. However, the use of multiple immunosuppressants also increases the risk for adverse events. Therefore, it is desirable to reduce the types of immunosuppressants administered without increasing the incidence of transplant rejection. The effectiveness of prednisone avoidance has been suggested, although this was not based on statistical significance in many instances. To definitively establish the effectiveness of prednisone avoidance, a statistically significant difference from a prednisone-use group should be demonstrated. Additionally, the effectiveness of prednisone avoidance might vary depending on the combination of other immunosuppressants administered. It has therefore been considered necessary to investigate, for various immunosuppressant combinations, the administration patterns in which prednisone avoidance is effective. Objectives This study aimed to investigate the effectiveness of prednisone avoidance in patients with liver transplant and discuss the results based on statistically significant differences. Methods Data from the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) were obtained. In studying immunosuppressant combinations, it was essential to control for confounding. Thus, the immunosuppressant combinations, excluding prednisone, were kept the same in the two groups being compared (prednisone-use and prednisone-avoidance groups). The large sample from FAERS allowed for those various immunosuppressant combinations to be compared. Comparisons of transplant rejection in the prednisone-use and prednisone-avoidance groups used the reporting odds ratio (ROR) and the adjusted ROR (aROR), which controlled for differences in patient background. Results With the prednisone-use groups being set as the reference, ROR and aROR were calculated for the prednisone-avoidance groups. Various immunosuppressant combinations were evaluated, and in four patterns - (1) the combination of prednisone and tacrolimus, (2) the combination of prednisone, cyclosporine, and tacrolimus, (3) the combination of prednisone, tacrolimus, and basiliximab, and (4) the combination of prednisone and everolimus) - both the ROR and the aROR for transplant rejection in the prednisone-avoidance group were significantly <1.000. Conclusions This study identified effective immunosuppressant combinations for prednisone avoidance that were not associated with increased transplant rejection. The evidence supporting the effectiveness of prednisone avoidance is strengthened when combined with results from previous studies.
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Affiliation(s)
- Toru Ogura
- Clinical Research Support Center, Mie University Hospital, Tsu, JPN
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2
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Kehar M, Grunebaum E, Jimenez-Rivera C, Mozer-Glassberg Y, Jamal A, Ng VL, Avitzur Y. Conversion from tacrolimus to sirolimus as a treatment modality in de novo allergies and immune-mediated disorders in pediatric liver transplant recipients. Pediatr Transplant 2020; 24:e13737. [PMID: 32428390 DOI: 10.1111/petr.13737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 01/31/2020] [Accepted: 04/20/2020] [Indexed: 01/19/2023]
Abstract
De novo PTAID may develop in pediatric solid organ transplant recipients, have a diverse spectrum, and are occasionally treatment resistant. Previous reports showed resolution of immune cytopenias in solid organ transplant recipients following replacement of the calcineurin inhibitor tacrolimus with the mTOR inhibitor sirolimus. Herein we describe a retrospective review (2000-2017) of subjects who developed PTAID in whom immunosuppression was changed to sirolimus. Eight recipients (6 males) of either liver (n = 7) or multivisceral transplant (n = 1) suffered from severe, treatment-resistant PTAID and were switched from tacrolimus to sirolimus. The median age at transplant was 1 year (range 0.5-2.4 years). Six (75%) recipients developed de novo allergy and 2 immune-mediated diseases. The median age at presentation of PTAID was 2.7 (1.4-9) years at a median of 1.3 (0.25-8) years after transplantation. The median time from PTAID presentation to conversion to sirolimus was 1.8 (0.45-10) years. Complete resolution of symptoms was seen in 4 (50%) patients after a median of 12 (range 4-24) months including 2 patients with immune-mediated disease, 1 eczema, and 1 with eosinophilic colitis. One patient with multiple food allergies had a partial response and 3 (38%) had no response. None of the 8 recipients developed sirolimus-attributed adverse events or acute rejection during a median follow-up of 5 (0.6-8) years after the conversion. Immunosuppression conversion from tacrolimus to sirolimus can be an effective therapy in patients suffering severe or treatment-resistant PTAID, suggesting a potential role for tacrolimus in the pathogenesis of PTAID.
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Affiliation(s)
- Mohit Kehar
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Pediatrics, Queens University, Kingston, ON, Canada
| | - Eyal Grunebaum
- Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Carolina Jimenez-Rivera
- Division of Gastroenterology Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Yael Mozer-Glassberg
- Institute of Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center of Israel, Petah-Tikva, Israel
| | - Alisha Jamal
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Vicky Lee Ng
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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3
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Kanellopoulou T. Autoimmune hemolytic anemia in solid organ transplantation-The role of immunosuppression. Clin Transplant 2017. [PMID: 28621877 DOI: 10.1111/ctr.13031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hemolysis after solid organ transplantation can be caused by both immune and non-immune-mediated mechanisms, and the evaluation must take into account issues distinctive to the post-transplant period. Autoimmune hemolytic anemia usually occurs within the first year and has been attributed to immunosuppressive treatment, infections, or underlying post-transplant lymphoproliferative disorder. Review of the literature revealed 59 cases with autoimmune hemolytic anemia mostly in children after liver transplantation. Almost all of the patients at the time of diagnosis received immunosuppression with tacrolimus, and first-line treatment with steroids and/or intravenous immunoglobulin was ineffective for complete remission. Rituximab was used as second-line treatment especially in patients with underlying lymphoproliferative disorders whereas sirolimus showed encouraging results.
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Affiliation(s)
- Theoni Kanellopoulou
- Department of Clinical Hematology, Blood Bank and Hemostasis, Onassis Cardiac Surgery Centre, Kallithea, Greece
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4
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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5
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Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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6
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Park JA, Lee HH, Kwon HS, Baik CR, Song SA, Lee JN. Sirolimus for Refractory Autoimmune Hemolytic Anemia after Allogeneic Hematopoietic Stem Cell Transplantation: A Case Report and Literature Review of the Treatment of Post-Transplant Autoimmune Hemolytic Anemia. Transfus Med Rev 2016; 30:6-14. [DOI: 10.1016/j.tmrv.2015.09.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/18/2015] [Accepted: 09/18/2015] [Indexed: 12/18/2022]
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7
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Schoettler M, Elisofon SA, Kim HB, Blume ED, Rodig N, Boyer D, Neufeld EJ, Grace RF. Treatment and outcomes of immune cytopenias following solid organ transplant in children. Pediatr Blood Cancer 2015; 62:214-218. [PMID: 25308853 PMCID: PMC4394012 DOI: 10.1002/pbc.25215] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 07/10/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune cytopenias are a recognized life-threatening complication following pediatric solid organ transplants (SOT), but treatment responses and overall outcome are not well described. The aim of this study was to evaluate the demographic characteristics, response to treatments, and outcomes of a cohort of patients who developed immune cytopenias following SOT. PROCEDURE In this single center retrospective review, patients with immune cytopenias after SOT were identified by electronic medical record (EMR) search and transplant databases from 1995-2012. RESULTS Of 764 SOT patients, 19 (2.4%) developed immune cytopenias. Incidence varied widely by transplant type from 1.2% (renal) to 23.5% (multivisceral). Autoimmune hemolytic anemia (AIHA) was the most common immune cytopenia. Overall median time from transplant to immune cytopenia was 8 m and varied by transplant type from 3 m (liver) to 74 m (heart). Standard therapies for immune cytopenias were often used and ineffective. The most effective therapy for the immune cytopenia was changing immunosuppression from tacrolimus to another agent. Three of 19 patients died; none directly attributed to the immune cytopenia. CONCLUSIONS Immune cytopenias are not rare after SOT, and patients usually do not respond well to traditional first line therapies. Provided that the risk of organ rejection is otherwise manageable, temporary cessation of tacrolimus could be more widely explored in this challenging clinical context. Pediatr Blood Cancer 2015;62:214-218. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Michelle Schoettler
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
| | - Scott A Elisofon
- The Division of Gastroenterology, Boston Children's Hospital, Boston, MA
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | | | - Nancy Rodig
- Division of Nephrology, Boston Children's Hospital, Boston, MA
| | - Debra Boyer
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA
| | - Ellis J Neufeld
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
| | - Rachael F Grace
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
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8
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Acquazzino MA, Fischer RT, Langnas A, Coulter DW. Refractory autoimmune hemolytic anemia after intestinal transplant responding to conversion from a calcineurin to mTOR inhibitor. Pediatr Transplant 2013; 17:466-71. [PMID: 23730873 DOI: 10.1111/petr.12101] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2013] [Indexed: 11/28/2022]
Abstract
AIHA is a rare and serious complication of solid organ transplantation. Herein, we report four cases of warm or mixed AIHA in pediatric patients following combined liver, small bowel and pancreas transplant. The hemolysis was refractory to multiple treatment modalities including steroids, rituximab, IVIG, plasmapheresis, cytoxan, discontinuation of prophylactic penicillin, and a change in immunosuppression from tacrolimus to cyclosporine. All patients had resolution or marked improvement of hemolysis after discontinuation of maintenance of CNI and initiation of sirolimus immunosuppression. One patient developed nephrotic syndrome but responded to a change in immunosuppression to everolimus. Three of the four patients continue on immunosuppression with sirolimus or everolimus without further hemolysis, evidence of rejection or medication side effects. Based on our experience and review of similar cases in the literature, we have proposed a treatment algorithm for AIHA in the pediatric intestinal transplant patient population that recommends an early change in immunosuppressive regimen from CNIs to sirolimus therapy.
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Affiliation(s)
- Melissa A Acquazzino
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68198-2168, USA
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Miloh T, Arnon R, Roman E, Hurlet A, Kerkar N, Wistinghausen B. Autoimmune hemolytic anemia and idiopathic thrombocytopenic purpura in pediatric solid organ transplant recipients, report of five cases and review of the literature. Pediatr Transplant 2011; 15:870-8. [PMID: 22112003 DOI: 10.1111/j.1399-3046.2011.01596.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cytopenias are common among pediatric SOT; however, autoimmune cytopenias are infrequently reported. We report five cases of autoimmune cytopenias in pediatric LT patients: two with isolated IgG-mediated AIHA, two with ITP, and one with Evans syndrome (ITP and AIHA). All patients were maintained on tacrolimus as immunosuppression. Viral illness commonly preceded the autoimmune cytopenias. All patients responded well to medical therapy (steroids, intravenous immunoglobulin, and rituximab) and lowering tacrolimus serum level. Prognosis appears to be worse when more than one cell line (e.g., Evans syndrome) is affected, and/or there is no preceding viral illness. A critical literature review of autoimmune cytopenias in children following SOT is conducted. Autoimmune cytopenias are a rarely reported complication of pediatric SOT, but clinicians taking care of pediatric transplant recipients need to be aware of this complication.
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Affiliation(s)
- Tamir Miloh
- Department of Gastroenterology, Phoenix Children's Hospital, Phoenix, AZ 85016, USA.
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10
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Czubkowski P, Williams M, Bagia S, Kelly D, Gupte G. Immune-mediated hemolytic anemia in children after liver and small bowel transplantation. Liver Transpl 2011; 17:921-4. [PMID: 21472974 DOI: 10.1002/lt.22311] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Four children who underwent ABO-compatible combined liver and small bowel transplantation developed severe immune-mediated hemolytic anemia. The main management strategies were early and aggressive treatment with steroids, the introduction of rituximab (an anti-CD20 monoclonal antibody), and the use of plasma exchange together with compatible but minimal blood transfusions. Three of the 4 children developed thrombi in the major vessels. In small bowel transplant patients, the early recognition of hemolytic anemia and intensified management with anticoagulation are necessary for the prevention of this complication.
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Affiliation(s)
- Piotr Czubkowski
- Liver Unit, Birmingham Children's Hospital, National Health Service Foundation Trust, Birmingham, United Kingdom
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11
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Li M, Goldfinger D, Yuan S. Autoimmune hemolytic anemia in pediatric liver or combined liver and small bowel transplant patients: a case series and review of the literature. Transfusion 2011; 52:48-54. [DOI: 10.1111/j.1537-2995.2011.03254.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Daaboul DG, Yuki K, Wesley MC, DiNardo JA. Anesthetic and Cardiopulmonary Bypass Considerations for Cardiac Surgery in Unique Pediatric Patient Populations: Sickle Cell Disease and Cold Agglutinin Disease. World J Pediatr Congenit Heart Surg 2011; 2:364-70. [DOI: 10.1177/2150135111403329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Physiological disturbances induced by cardiopulmonary bypass (CPB) and hypothermia during cardiac surgery are particularly pronounced in certain unique patient populations, such as patients with sickle cell disease (SCD) and cold agglutinin disease. Red blood cells containing hemoglobin S (HbS) are at increased risk of sickling under conditions encountered during cardiac surgery, leading to SCD-related complications such as vaso-occlusive events. While a target level of HbS has not been determined for patients with SCD undergoing CPB, a safe practice includes increasing the Hb level to 10 g/dL and reducing the proportion of HbS to approximately 30%. This can be accomplished through simple or exchange transfusion prior to surgery or via the modification of the CPB circuit prime. There is no clear consensus on the formulation or the delivery temperature of the cardioplegia solution necessary to prevent sickling and microvascular occlusion. The presence of cold agglutinins is another entity requiring extra vigilance for the conduct of CPB, where hypothermia can lead to activation of cold agglutinins inducing massive hemagglutination, hemolysis, microvascular thrombosis, and possibly intracoronary thrombosis. Determination of thermal amplitude is important to provide a safe reference range of temperature during surgery. High-volume plasmapheresis may be warranted to reduce cold agglutinin titers. Both warm blood cardioplegia and cold crystalloid cardioplegia above the thermal amplitude have been utilized with success.
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Affiliation(s)
- Dima G. Daaboul
- Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Boston, MA, USA
- Department of Anaesthesia, Harvard, Medical School, Boston, MA, USA
| | - Koichi Yuki
- Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Boston, MA, USA
- Department of Anaesthesia, Harvard, Medical School, Boston, MA, USA
| | - Mark C. Wesley
- Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Boston, MA, USA
- Department of Anaesthesia, Harvard, Medical School, Boston, MA, USA
| | - James A. DiNardo
- Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Boston, MA, USA
- Department of Anaesthesia, Harvard, Medical School, Boston, MA, USA
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Abstract
Drug-induced immune hemolytic anemia (DIIHA) is rare; it can be mild or associated with acute severe hemolytic anemia (HA) and death. About 125 drugs have been implicated as the cause. The HA can be caused by drug-independent antibodies that are indistinguishable, in vitro and in vivo, from autoantibodies causing idiopathic warm type autoimmune hemolytic anemia (AIHA). More commonly, the antibodies are drug-dependent (i.e., will only react in vitro in the presence of the drug). The most common drugs to cause DIIHA are anti-microbials (e.g., cefotetan, ceftriaxone and piperacillin), which are associated with drug-dependent antibodies. The most common drug to cause AIHA is fludarabine. Finding out which drug is causing the problem and stopping that drug is the first approach to therapy. It is not easy to identify the drug interactions accurately in vitro; laboratories specializing in this area can be of great help.
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Affiliation(s)
- George Garratty
- American Red Cross Blood Services, Southern California Region, Pomona, CA 91768, United States.
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Haller W, Hind J, Height S, Mitry R, Dhawan A. Successful treatment of mixed-type autoimmune hemolytic anemia with rituximab in a child following liver transplantation. Pediatr Transplant 2010; 14:E20-5. [PMID: 19254271 DOI: 10.1111/j.1399-3046.2009.01128.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Development of a severe form of mixed-type AIHA after orthotopic liver transplantation is a rare, but a life-threatening event. We report a case of mixed-type AIHA that developed in a child after hepatocyte and living-related orthotopic liver transplantation for factor VII deficiency.
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Affiliation(s)
- Wolfram Haller
- Paediatric Liver Centre, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
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