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Jalink M, Yan MTS, Cohn CS, Eichbaum QG, Fung MK, Lu W, Murphy MF, Pagano MB, Stanworth SJ, Shih AW. Systematic review for the serological testing for cold agglutinins: The BEST collaborative study. Transfusion 2024; 64:1331-1349. [PMID: 38642020 DOI: 10.1111/trf.17842] [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] [Received: 01/11/2024] [Revised: 03/16/2024] [Accepted: 04/08/2024] [Indexed: 04/22/2024]
Affiliation(s)
- Marit Jalink
- Center for Clinical Transfusion Research, Sanquin Research, Amsterdam, The Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - 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
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Quentin G Eichbaum
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark K Fung
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Wen Lu
- Department of Laboratory Medicine and Pathology, Center for Regenerative Biotherapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael F Murphy
- NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, and the University of Oxford, Oxford, UK
| | - Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Washington, USA
| | - Simon J Stanworth
- NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, and the University of Oxford, Oxford, UK
| | - Andrew W Shih
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
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2
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A Curious Case of Hemolytic Anemia with Pseudoreticulopenia. Case Rep Hematol 2022; 2022:6423143. [PMID: 35495180 PMCID: PMC9050323 DOI: 10.1155/2022/6423143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 11/18/2022] Open
Abstract
Herein, we present a unique case of a Coombs-negative, steroid-refractory autoimmune hemolytic anemia (AIHA) complicated by pseudoreticulopenia, describe its clinical presentation, histopathologic findings, and management, and review the salient literature. Coombs-negative, steroid-refractory AIHAs represent fewer than 1% of all AIHAs. Diagnosis of the disease is difficult and often delayed due to the pursuit of alternate diagnoses following a negative Coombs test. However, when suspicion remains high for an autoimmune process, the super-Coombs test may be utilized for the diagnosis of AIHA that the traditional Coombs test fails to detect. A majority of cases respond to rituximab as the indicated second-line therapy, but delays in diagnosis and subsequent treatment may increase morbidity. Reticulopenia may be associated with AIHAs secondary to bone marrow dysfunction, but this patient had a normal function marrow confirmed on biopsy. Indeed, reticulopenia in this case was a diagnostic conundrum that further obscured the diagnosis and delayed treatment. Ultimately, reticulopenia was determined to be pseudoreticulopenia secondary to an alteration in the maturation of the erythroid lineage due to an independent, newly diagnosed pernicious anemia. The interaction of these multiple coexisting disease processes is not previously described in the literature. Increased physician awareness of steroid-refractory, Coombs-negative AIHA, and the development of pseudoreticulopenia as a laboratory finding in pernicious anemia may help to improve patient outcomes.
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3
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Kamesaki T. Diagnostic algorithm for classification and characterization of direct antiglobulin test-negative autoimmune hemolytic anemia with 1-year clinical follow-up. Transfusion 2021; 62:205-216. [PMID: 34668206 DOI: 10.1111/trf.16709] [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: 01/14/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Approximately 5%-10% of autoimmune hemolytic anemia (AIHA) cases are negative for direct antiglobulin test (DAT). We previously reported a classification system for untreated patients with DAT-negative AIHA by quantifying levels of red blood cell (RBC)-bound IgG. This study investigated the clinical utility of a novel diagnostic algorithm with a comprehensive classification system and characterized each subgroup in DAT-negative AIHA. STUDY DESIGN AND METHODS We assessed 637 patients with undiagnosed hemolytic anemia using our diagnostic algorithm and classification system, which was based on RBC-bound IgG levels and results of column method-DAT before and after washing RBCs. RESULTS Patients were diagnosed with DAT-negative AIHA with 97% sensitivity and 84% specificity when the laboratory tests were performed before treatment and classified into the following six categories: tube DAT-negative, low-affinity IgG, double DAT-negative, IgA- or IgM-positive, low-affinity IgM, and s/o non-AIHA. The first three types were major conditions and accounted for 76% of DAT-negative AIHA cases. Based on multivariate analyses of idiopathic DAT-negative AIHA (n = 71), platelet count and albumin concentration were significant factors for survival at 1-year follow-up. The low-affinity IgG group showed the highest platelet count and albumin levels, better response to steroids, and higher 1-year survival rate than those in other groups. DISCUSSION Our classification included DAT-negative, IgA-driven, and warm-IgM AIHA categories, which were atypical forms of AIHA with the severe onset and increased risk of relapse. When treating a patient with DAT-negative hemolysis, atypical AIHA should be considered and tested in reference laboratories, especially before treatment.
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Affiliation(s)
- Toyomi Kamesaki
- Division of Support in Community Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan
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Merrill SA, Brodsky RA, Lanzkron SM, Naik R. A case-control analysis of hyperhemolysis syndrome in adults and laboratory correlates of complement involvement. Transfusion 2019; 59:3129-3139. [PMID: 31292968 DOI: 10.1111/trf.15445] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/10/2019] [Accepted: 06/18/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hyperhemolysis syndrome (HS) is a poorly understood, severe hemolytic anemia provoked by transfusion. Both host and donor RBCs are destroyed in HS; thus, transfusion paradoxically worsens anemia. Risk factors and mechanism of HS are unknown. STUDY DESIGN AND METHODS A retrospective case-control analysis was performed on adults with HS. Patients with HS were matched 1:1 with matched, transfused controls, and HS risk factors were analyzed with multivariable logistic regression. HS samples were analyzed for complement deposition by flow cytometry, and an in vitro model of bystander hemolysis was developed. RESULTS Forty-one patients with 54 episodes of HS were identified in a 26-year period from 1992 to 2018. Of the HS episodes, only 18.5% were associated with a new alloantibody, and such patients were more tolerant of additional transfusion in the acute episode (p = 0.005). Thirteen percent of episodes were fatal, and HS recurred in 52.6%. Alloimmunization (odds ratio [OR], 17.3), non-B blood type (OR, 9.8), D antigen (OR, 9.1), and infection (OR, 5.5) were associated with HS on multivariable analysis. Hyperbilirubinemia was predictive of fatal HS (OR, 33.6). Increased complement was observed on RBCs during HS episodes, and the in vitro model of bystander hemolysis recapitulated complement decoration of sickled RBCs. CONCLUSIONS HS is associated with significant morbidity, mortality, and recurrence. Risk factors such as known alloimmunization, blood group, and infection predispose to HS. Bystander complement activation may drive HS. These factors may help physicians refine risk-benefit assessments for transfusion and guide further therapeutic development.
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Affiliation(s)
- Samuel A Merrill
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sophie M Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rakhi Naik
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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5
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Lucidi CA, Gerlach JA, Forney S, Jutkowitz LA, Scott MA. Analytic characterization of flow cytometric assays for detection of immunoglobulin G on canine erythroid cells, including detection of dog erythrocyte antigen 1 on erythroid precursors. Am J Vet Res 2018; 79:1123-1132. [PMID: 30372157 DOI: 10.2460/ajvr.79.11.1123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To develop and characterize flow cytometric assays for detecting IgG bound to canine erythrocytes and bone marrow erythroid precursors. SAMPLE Blood samples from 20 healthy and 61 sick dogs with (n = 33) or without (28) immune-mediated hemolytic anemia (IMHA) and bone marrow samples from 14 healthy dogs. PROCEDURES A flow cytometric assay for measurement of IgG on RBCs was developed, and appropriate positive control cells were generated. Analytic and diagnostic performance were characterized. The RBC IgG assay was then combined with density-gradient fractionation of aspirated bone marrow cells and a 2-color process to yield an assay for detecting IgG on nucleated RBCs (nRBCs). Cell sorting and cytologic examination confirmed target cell populations, and anti-dog erythrocyte antigen 1 (DEA1) blood-typing serum was used to generate IgG-positive nRBCs. RESULTS Within- and between-run coefficients of variation for the RBC IgG assay were 0.1% to 13.9%, and > 90% of spiked IgG-positive RBCs were detected. Diagnostic sensitivity and specificity of the assay for detection of IMHA were 88% and 93%, respectively. Cytologic findings for sorted bone marrow fractions rich in early-, mid-, and late-stage nRBCs from 3 healthy dogs indicated 89% to 98% nRBC purity. After IgG coating with anti-DEA1 blood-typing serum, IgG was detected on nRBCs from DEA1-positive, but not DEA1-negative, healthy dogs. CONCLUSIONS AND CLINICAL RELEVANCE The developed RBC IgG assay had favorable analytic and diagnostic performance for detection of IMHA in dogs and was successfully adapted to detect IgG on canine nRBCs of various maturation stages. The findings supported the presence of DEA1 on canine nRBCs.
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6
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Ladogana S, Maruzzi M, Samperi P, Perrotta S, Del Vecchio GC, Notarangelo LD, Farruggia P, Verzegnassi F, Masera N, Saracco P, Fasoli S, Miano M, Girelli G, Barcellini W, Zanella A, Russo G. Diagnosis and management of newly diagnosed childhood autoimmune haemolytic anaemia. Recommendations from the Red Cell Study Group of the Paediatric Haemato-Oncology Italian Association. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 15:259-267. [PMID: 28151390 PMCID: PMC5448833 DOI: 10.2450/2016.0072-16] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 11/09/2016] [Indexed: 01/20/2023]
Abstract
Autoimmune haemolytic anaemia is an uncommon disorder to which paediatric haematology centres take a variety of diagnostic and therapeutic approaches. The Red Cell Working Group of the Italian Association of Paediatric Onco-haematology (Associazione Italiana di Ematologia ed Oncologia Pediatrica, AIEOP) developed this document in order to collate expert opinions on the management of newly diagnosed childhood autoimmune haemolytic anaemia.The diagnostic process includes the direct and indirect antiglobulin tests; recommendations are given regarding further diagnostic tests, specifically in the cases that the direct and indirect antiglobulin tests are negative. Clear-cut definitions of clinical response are stated. Specific recommendations for treatment include: dosage of steroid therapy and tapering modality for warm autoimmune haemolytic anaemia; the choice of rituximab as first-line therapy for the rare primary transfusion-dependent cold autoimmune haemolytic anaemia; the indications for supportive therapy; the need for switching to second-line therapy. Each statement is provided with a score expressing the level of appropriateness and the agreement among participants.
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Affiliation(s)
- Saverio Ladogana
- Paediatric Onco-haematology Unit, “Casa Sollievo della Sofferenza” Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Matteo Maruzzi
- Paediatric Onco-haematology Unit, “Casa Sollievo della Sofferenza” Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Piera Samperi
- Paediatric Onco-haematology Unit, Azienda Policlinico “Vittorio Emanuele”, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Silverio Perrotta
- Department of Women, Children and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | | | - Lucia D. Notarangelo
- Paediatric Onco-haematology Unit, Children’s Hospital, Spedali Civili, Brescia, Italy
| | - Piero Farruggia
- Paediatric Onco-haematology Unit, Civico Hospital, Palermo, Italy
| | | | - Nicoletta Masera
- Paediatric Department, University of Milano-Bicocca, “San Gerardo” Hospital, Monza, Italy
| | - Paola Saracco
- Paediatric and Adolescent Science Department, University of Turin, Turin, Italy
| | - Silvia Fasoli
- Paediatric Unit, “Carlo Poma” Hospital, Mantua, Italy
| | - Maurizio Miano
- Clinical and Experimental Haematology Unit, “G. Gaslini” Children’s Hospital, Genoa, Italy
| | - Gabriella Girelli
- Immunohaematology and Transfusion Medicine Unit, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Wilma Barcellini
- Onco-haematology, Physiopathology of Anaemia Unit, IRCCS Ca’ Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Onco-haematology, Physiopathology of Anaemia Unit, IRCCS Ca’ Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Russo
- Paediatric Onco-haematology Unit, Azienda Policlinico “Vittorio Emanuele”, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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Ziman A, Cohn C, Carey PM, Dunbar NM, Fung MK, Greinacher A, Stanworth S, Heddle NM, Delaney M. Warm-reactive (immunoglobulin G) autoantibodies and laboratory testing best practices: review of the literature and survey of current practice. Transfusion 2016; 57:463-477. [DOI: 10.1111/trf.13903] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/01/2016] [Accepted: 09/10/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Alyssa Ziman
- Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine; University of California Los Angeles; Los Angeles California
| | - Claudia Cohn
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Patricia M. Carey
- Hoxworth Blood Center and Department of Pathology and Laboratory Medicine; University of Cincinnati; Ohio
| | - Nancy M. Dunbar
- Departments of Pathology and Medicine; Dartmouth-Hitchcock Medical Center; Lebanon New Hampshire
| | - Mark K. Fung
- Department of Pathology and Laboratory Medicine; University of Vermont Medical Center; Burlington Vermont
| | - Andreas Greinacher
- Department of Immunology and Transfusion Medicine; Ernst-Moritz-Arndt-University; Greifswald Germany
| | - Simon Stanworth
- National Health Service (NHS) Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, United Kingdom; the Radcliffe Department of Medicine, University of Oxford; Oxford United Kingdom
| | - Nancy M. Heddle
- Faculty of Health Sciences, Department of Medicine; , Canadian Blood Services, McMaster University, and Centre for Innovation; Hamilton Ontario Canada
| | - Meghan Delaney
- Bloodworks NW; Seattle Washington
- Department of Laboratory Medicine; University of Washington; Seattle Washington
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8
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Thedsawad A, Taka O, Wanachiwanawin W. Significances of red cell bound immunoglobulin G as detected by flow cytometry in patients with Coombs-negative immune hemolysis. Transfus Med 2016; 26:130-7. [PMID: 26914629 DOI: 10.1111/tme.12282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 01/07/2016] [Accepted: 01/16/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES This study was to investigate the use of flow cytometry for detection and quantitation of red blood cells (RBC) bound IgG in immune hemolysis of patients with autoimmune hemolytic anaemia (AIHA) and systematic lupus erythematosus (SLE). BACKGROUND Two to ten percent of patients with warm-autoimmune hemolytic anaemia (WAIHA) exhibit a negative direct Coombs test. Flow cytometry has been applied to detect RBC bound IgG with high accuracy, reproducibility and sensitivity. METHODS In this study 45 and 75 patients with AIHA and SLE, respectively were evaluated for RBC bound IgG by direct Coombs test and flow cytometry. RESULTS Seventy-one percent (32/45) and 31% (23/75) of patients with AIHA and SLE respectively, had laboratory evidence of hemolysis. A positive flow cytometry, as defined by mean fluorescent intensity (MFI) values >0·21 and IgG molecules >28, was found in 4 of 32 (12·5%) and 4 of 23 (17·4%) patients with AIHA and SLE who had hemolysis with a negative direct Coombs test. There were very strong and strong correlations between the strength of direct Coombs test with MFI values and IgG molecules in patients with AIHA and SLE, respectively. CONCLUSION Flow cytometry can be applied in the diagnosis of Coombs-negative hemolytic anaemia in patients with AIHA and SLE.
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Affiliation(s)
- A Thedsawad
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - O Taka
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - W Wanachiwanawin
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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9
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Lyse or not to lyse: Clinical significance of red blood cell autoantibodies. Blood Rev 2015; 29:369-76. [DOI: 10.1016/j.blre.2015.05.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/03/2015] [Accepted: 05/04/2015] [Indexed: 01/08/2023]
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10
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11
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Anémie hémolytique auto-immune de l’enfant. Transfus Clin Biol 2015; 22:291-8. [DOI: 10.1016/j.tracli.2015.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 10/06/2015] [Indexed: 11/22/2022]
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12
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Meulenbroek EM, de Haas M, Brouwer C, Folman C, Zeerleder SS, Wouters D. Complement deposition in autoimmune hemolytic anemia is a footprint for difficult-to-detect IgM autoantibodies. Haematologica 2015; 100:1407-14. [PMID: 26354757 DOI: 10.3324/haematol.2015.128991] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 08/03/2015] [Indexed: 11/09/2022] Open
Abstract
In autoimmune hemolytic anemia autoantibodies against erythrocytes lead to increased clearance of the erythrocytes, which in turn results in a potentially fatal hemolytic anemia. Depending on whether IgG or IgM antibodies are involved, response to therapy is different. Proper identification of the isotype of the anti-erythrocyte autoantibodies is, therefore, crucial. However, detection of IgM autoantibodies can be challenging. We, therefore, set out to improve the detection of anti-erythrocyte IgM. Direct detection using a flow cytometry-based approach did not yield satisfactory improvements. Next, we analyzed whether the presence of complement C3 on a patient's erythrocytes could be used for indirect detection of anti-erythrocyte IgM. To this end, we fractionated patients' sera by size exclusion chromatography and tested which fractions yielded complement deposition on erythrocytes. Strikingly, we found that all patients with C3 on their erythrocytes according to standard diagnostic tests had an IgM anti-erythrocyte component that could activate complement, even if no such autoantibody had been detected with any other test. This also included all tested patients with only IgG and C3 on their erythrocytes, who would previously have been classified as having an IgG-only mediated autoimmune hemolytic anemia. Depleting patients' sera of either IgG or IgM and testing the remaining complement activation confirmed this result. In conclusion, complement activation in autoimmune hemolytic anemia is mostly IgM-mediated and the presence of covalent C3 on patients' erythrocytes can be taken as a footprint of the presence of anti-erythrocyte IgM. Based on this finding, we propose a diagnostic workflow that will aid in choosing the optimal treatment strategy.
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Affiliation(s)
- Elisabeth M Meulenbroek
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Masja de Haas
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Conny Brouwer
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Claudia Folman
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Sacha S Zeerleder
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Department of Hematology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Diana Wouters
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Lai M, De Stefano V, Landolfi R. Haemoglobin levels in autoimmune haemolytic anaemias at diagnosis: relationship with immunoproteins on red blood cells. Immunol Res 2015; 60:127-31. [PMID: 24619312 DOI: 10.1007/s12026-014-8497-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Previous investigations of the relationship between characteristics of immunoproteins on red blood cells (RBCs) and the occurrence of autoimmune haemolysis yielded divergent results. Here, we studied these characteristics in autoimmune haemolytic anaemias (AIHAs) to determine their relationship with the degree of anaemia at diagnosis. We studied at diagnosis 52 cases of warm AIHA with positive direct antiglobulin test. Immunohaematological testing and determination of immunoglobulin class, complement, and immunoglobulin G (IgG) were performed using gel technology (GCT). Median haemoglobin (Hb) levels significantly differed between cases with IgG1 only or negative for IgG subclasses (7.4 g/dl), those with IgG3 or IgG1 + IgG3 (6.5 g/dl), and those with multiple immunoglobulins (5 g/dl). Logistic regression indicated that IgG3 detection was the only variable significantly related to the occurrence of RBC transfusion in AIHA (odds ratio 4.05, 95 % CI 1.1-14.7). In our study, the type of immunoprotein(s) on the RBC surface was associated with different Hb levels at AIHA diagnosis. IgG3 and multiple immunoglobulins were associated with lower Hb levels; IgG3 was also associated with a higher percentage of patient transfusions in the first week after diagnosis. Thus, qualitative differences in these immunoproteins may lead to deeper and more prolonged anaemia levels, influencing the need for RBC transfusion.
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Affiliation(s)
- Marco Lai
- Transfusion Centre, Institute of Hematology, Catholic University, Rome, Italy,
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14
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Male-predominant plasma transfusion strategy for preventing transfusion-related acute lung injury: a systematic review. Crit Care Med 2015; 43:205-25. [PMID: 25514705 DOI: 10.1097/ccm.0000000000000675] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To assess 1) the effectiveness of male-predominant plasma transfusion strategy for preventing transfusion-related acute lung injury and related mortality; and 2) whether this effect varies across different patient subgroups. DESIGN Systematic Review and meta-analysis: Data were identified by querying MEDLINE and EMBASE (including proceedings of major conferences on blood transfusions), searching the Internet for hemovigilance reports, reviewing reference lists of eligible articles and contacting experts in the field. Eligible were all studies reporting transfusion-related acute lung injury incidence, all-cause mortality (primary outcomes), hospital length of stay, time to extubation, PaO2/FIO2-ratio or blood pressure changes (secondary outcomes) in recipients of plasma transfusions containing relatively more plasma from individuals at low risk of carrying leukocyte-antibodies ("male plasma") than those receiving comparator plasma ("control plasma"). No limits were placed on study design, population or language. The only exclusion criteria were non-human subjects and lack of control group. Prespecified study quality indicators (including risk of bias assessment) and potential effect modifiers were tested using Cochran's Q Test. Final analyses using random-effects models and I2 to assess heterogeneity were performed in the subset of studies judged to provide the best evidence and separately for significantly different subgroups using STATA 12.1 (StataCorp, College Station, TX). SETTING As per primary studies. PATIENTS/SUBJECTS As per primary studies. INTERVENTIONS As per primary studies (generally: exposure to plasma containing relatively more male plasma than comparator plasma). MEASUREMENTS AND MAIN RESULTS From a total of 850 retrieved records, we identified 45 eligible studies. For transfusion-related acute lung injury incidence, final analysis was restricted to 13 cohort studies and one randomized controlled trial in which transfusion-related acute lung injury cases only involved plasma transfusions. Risk of transfusion-related acute lung injury and mortality in plasma recipients exposed to men when compared with control plasma were 0.27 (95% CI, 0.20-0.38; p < 0.001; I = 0%; n = 14; 286 events) and 0.89 (95% CI, 0.80-1.00; p = 0.04; I = 79%; n = 7; 5, 710 events), respectively. No other significant interactions were found. Secondary outcomes showed similar results but were less reported and the studies were more heterogeneous. Sensitivity analyses did not alter the results. There was no evidence of publication bias. DISCUSSION More than 800 million people in 17 countries are subject to male-predominant plasma transfusion policy and at least three more countries are planning or considering adoption of this strategy. On the basis of most observational data, judged to be of high quality, male-predominant plasma transfusion strategy reduces plasma-related transfusion-related acute lung injury incidence and possibly mortality. There was no evidence that the effect differs across patient subgroups, but power to detect such differences was low.
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Bloch EM, Sakac D, Branch HA, Cserti-Gazdewich C, Pendergrast J, Pavenski K, Branch DR. Western immunoblotting as a new tool for investigating direct antiglobulin test-negative autoimmune hemolytic anemias. Transfusion 2015; 55:1529-37. [DOI: 10.1111/trf.13082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 02/08/2015] [Accepted: 02/10/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Evgenia M. Bloch
- Department of Laboratory Medicine and Pathobiology; University of Toronto
- Centre for Innovation; Canadian Blood Services
| | | | | | - Christine Cserti-Gazdewich
- Department of Laboratory Medicine and Pathobiology; University of Toronto
- Centre for Innovation; Canadian Blood Services
- Department of Medicine; University of Toronto
- Toronto General Hospital, University Health Network
| | - Jacob Pendergrast
- Department of Laboratory Medicine and Pathobiology; University of Toronto
- Department of Medicine; University of Toronto
- Toronto General Hospital, University Health Network
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology; University of Toronto
- St. Michael's Hospital; Toronto Ontario Canada
| | - Donald R. Branch
- Department of Laboratory Medicine and Pathobiology; University of Toronto
- Centre for Innovation; Canadian Blood Services
- Department of Medicine; University of Toronto
- Toronto General Hospital, University Health Network
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Alzate MA, Manrique LG, Bolaños NI, Duarte M, Coral-Alvarado P, González JM. Simultaneous detection of IgG, IgM, IgA complexes and C3d attached to erythrocytes by flow cytometry. Int J Lab Hematol 2014; 37:382-9. [PMID: 25269888 DOI: 10.1111/ijlh.12297] [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] [Received: 05/24/2014] [Accepted: 09/02/2014] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Immune complexes attached to erythrocyte membrane are involved in autoimmune hemolytic anemia (AIHA) pathogenesis. Currently, direct antiglobulin test (DAT) is used for AIHA diagnosis; however, its performance can be variable. The aim of this study was to design a flow cytometry protocol for simultaneous detection of IgG, IgM, IgA immune complexes and C3d attached to erythrocytes in AIHA patients . METHODS A procedure was standardized for assessing independent or simultaneous IgG, IgM, IgA immune complexes and C3d, which were detected using secondary antibodies. The protocol developed was applied to blood samples of patients with AIHA, donors at risk of developing the disease, and healthy controls. RESULTS Twenty-four blood samples were assessed: nine patients with AIHA, five donors at risk of developing the disease, and 10 healthy controls. In the AIHA group, all were positive for C3d, seven for IgG, four for IgA, and one for IgM. Two AIHA patients that were negative for DAT-IgG and C3d were positive for C3d by flow cytometry. CONCLUSION Flow cytometry is a consistent method for identifying the presence of IgG, IgM, IgA immune complexes and C3d attached to erythrocytes and can be helpful for understanding the mechanisms involved in AIHA pathogenesis.
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Affiliation(s)
- M A Alzate
- Grupo de Ciencias Básicas Médicas, School of Medicine, Universidad de los Andes, Bogotá, DC, Colombia
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Michel M. Diagnostic d’une anémie hémolytique en réanimation. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0710-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lai M, Leone G, Landolfi R. Autoimmune hemolytic anemia with gel-based immunohematology tests. Am J Clin Pathol 2013; 139:457-63. [PMID: 23525616 DOI: 10.1309/ajcptu9aeqzxvzd4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
We used gel centrifugation tests (GCTs) to analyze the relationship between the diagnosis and immunohematology tests used for autoimmune hemolytic anemia (AIHA). The study included 588 samples positive for the direct antiglobulin test (DAT). Of these, 52 were from patients diagnosed with AIHA. Immunoglobulin (Ig) class, IgG1, IgG3, and complement were measured. DAT strength had the strongest correlation with AIHA diagnosis (odds ratio [OR], 23), followed by anti-IgG titer 300 (OR, 8.4), anti-IgG titer 1,000 (OR, 10.5), and C3d agglutination strength (OR, 1.7). Decision tree analysis revealed that DAT strength and anti-IgG titer higher than 100 were the best predictors of AIHA. Multidimensional scanning analysis found a high grade of similarity among DAT strength, anti-IgG titer, and IgG strength in the AIHA samples. This observation was not detected in DAT-positive samples from patients without AIHA. DAT strength remained the best diagnostic indicator for AIHA and had the strongest association with AIHA compared with other commercially available immunohematology tests. The other tests, despite good correlation with AIHA diagnosis, did not add useful information.
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Affiliation(s)
- Marco Lai
- Immunohematology Laboratory, Transfusion Centre, Catholic University of Sacred Heart, Rome, Italy
| | - Giuseppe Leone
- Institute of Hematology Medicine, Catholic University of Sacred Heart, Rome, Italy
| | - Raffaele Landolfi
- Internal Medicine Department, Catholic University of Sacred Heart, Rome, Italy
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FAYEK MH, SAAD A, EISSA DG, TAWFIK LM, KAMAL G. Role of gel test and flow cytometry in diagnosis of Coombs’ negative autoimmune haemolytic anaemia. Int J Lab Hematol 2012; 34:311-9. [DOI: 10.1111/j.1751-553x.2011.01397.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rigal D, Meyer F. [Autoimmune haemolytic anemia: diagnosis strategy and new treatments]. Transfus Clin Biol 2011; 18:277-85. [PMID: 21474357 DOI: 10.1016/j.tracli.2011.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Accepted: 03/01/2011] [Indexed: 12/25/2022]
Abstract
The pattern of autoimmune hemolytic anemia has changed significantly these last 15 years. With regard to the diagnosis strategy, the use of gel filtration technique to perform the direct antiglobulin test (DAT) has decreased the number of autoimmune haemolytic anemias with negative tests results. In recent years, autoimmune haemolytic anemia increased in patients receiving purine nucleoside analogues, blood transfusions, solid organ transplantation or hematopoietic stem cells transplantation. These difficult autoimmune haemolytic anemia cases need to use new kinds of treatments. With regard to the treatment, very little progress was made this latter 50 years. The discovery of the efficacy of anti-CD20 antibody in this disease represents a breakthrough. Nowdays, the second-line treatment includes rituximab or splenectomy. Sometimes, the anti-CD20 treatment could be proposed in first-line but some clinical trials are needed.
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Affiliation(s)
- D Rigal
- Laboratoire d'immunohématologie et service d'hémovigilance, établissement français du sang, 1-3, rue du Vercors, 69007 Lyon, France.
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Loustau V, Guillaud C, Garcon L, Godeau B, Michel M. [Hemolytic anemia in adults: Main causes and diagnostic procedure]. Presse Med 2011; 40:470-85. [PMID: 21295436 DOI: 10.1016/j.lpm.2010.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 11/03/2010] [Accepted: 11/04/2010] [Indexed: 10/18/2022] Open
Abstract
Hemolytic anemia (HA) is not an exceptional situation in adults. While establishing the hemolytic mechanism of an anemia is usually rather easy, finding the etiology may be quite difficult as both some hereditary (corpuscular) and acquired causes of HA may occur during adulthood. The diagnosis of HA therefore requires a multiple step procedure taking into account both patient's and family history, a careful analysis of the blood smear and a direct antiglobulin test. Based on these first data, the diagnosis procedure may then require more specific tests whose indications are discussed in this review.
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Affiliation(s)
- Valentine Loustau
- CHU Henri-Mondor, centre de référence pour les cytopénies auto-immunes de l'adulte, service de médecine interne, 94010 Créteil cedex, France
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Castro C, Gourley M. Diagnostic testing and interpretation of tests for autoimmunity. J Allergy Clin Immunol 2010; 125:S238-47. [PMID: 20061009 DOI: 10.1016/j.jaci.2009.09.041] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Accepted: 09/15/2009] [Indexed: 01/11/2023]
Abstract
Laboratory testing is of great value when evaluating a patient with a suspected autoimmune disease. The results can confirm a diagnosis, estimate disease severity, aid in assessing prognosis and are useful for following disease activity. Components of the laboratory examination include a complete blood count with differential, a comprehensive metabolic panel, measurement of inflammatory markers and autoantibodies, and flow cytometry. This chapter discusses these components and includes a discussion about organ-specific immunologic diseases for which immunologic laboratory testing is used. Comprehensive laboratory evaluation of a suspected autoimmune illness in conjunction with a thorough clinical evaluation provides a better understanding of a patient's immunologic disease.
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Affiliation(s)
- Christine Castro
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892, USA.
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