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Vlachodimitropoulou E, Shehata N, Ryan G, Clarke G, Lieberman L. Management of pregnancies with anti-K alloantibodies and the predictive value of anti-K titration testing. Lancet Haematol 2024:S2352-3026(24)00239-4. [PMID: 39208835 DOI: 10.1016/s2352-3026(24)00239-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 07/15/2024] [Accepted: 07/18/2024] [Indexed: 09/04/2024]
Abstract
Anti-KEL1 antigen (also referred to as anti-Kell, or anti-K) alloimmunisation is the second most common cause of severe haemolytic disease of the fetus and newborn, after anti-rhesus D antigen, and can cause substantial fetal morbidity and mortality. Both fetal erythropoietic suppression and haemolysis contribute to anaemia. Typically, once a clinically significant alloantibody is identified during pregnancy, antibody titration is performed as a screening test to predict the risk of anaemia and the need for maternal-fetal medicine referral. The titre is a semiquantitative laboratory method based on the underlying principle that increased maternal antibody concentrations are associated with an increased risk of fetal anaemia. Because some studies report that anti-K alloantibodies can lead to severe anaemia even at a low antibody titration, guidelines are inconsistent with respect to the role of titration testing. Some experts recommend maternal-fetal medicine referral and middle cerebral artery Doppler ultrasound without titration testing or with the use of a very low cutoff titre. This Viewpoint evaluates management for pregnancies affected by anti-K alloantibodies and highlights literature regarding the predictive value of anti-K titration testing.
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Affiliation(s)
- Evangelia Vlachodimitropoulou
- Department of Fetal Medicine, Mount Sinai Hospital, Toronto, ON, Canada; Department of Obstetrics & Gynaecology, University of Toronto, Toronto, ON, Canada.
| | - Nadine Shehata
- Division of Hematology, Mount Sinai Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Division of Medical Oncology and Hematology, University Health Network, Toronto, ON, Canada
| | - Greg Ryan
- Department of Fetal Medicine, Mount Sinai Hospital, Toronto, ON, Canada; Department of Obstetrics & Gynaecology, University of Toronto, Toronto, ON, Canada
| | - Gwen Clarke
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Department of Clinical Pathology, University Health Network, Toronto, ON, Canada
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2
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Ning S, Morin PA, Elahie A, Li N, Liu Y, Barty R, Clarke G, Zeller M, Heddle NM. KEL1 negative red cell transfusions for females of current or future child-bearing potential: A clinical impact and feasibility study. Transfusion 2023; 63:59-68. [PMID: 36519693 DOI: 10.1111/trf.17201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 09/21/2022] [Accepted: 10/11/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Anti-K is an alloantibody stimulated in response to the KEL1 antigen and may cause hemolytic disease of the fetus and newborn (HDFN). Provision of KEL1 negative blood to females of child-bearing potential was not our practice. We assessed the impact of our policy and assessed feasibility of a KEL1 negative transfusion policy. STUDY DESIGN AND METHODS This is a cohort study spanning Jan 1, 2007-Jun 30, 2017 in Hamilton, Canada. Data were obtained via our institution's transfusion database. Chart reviews of females age ≤45 with anti-K were performed; data on RBC KEL1 phenotype were obtained from the blood supplier when needed to ascertain the cause of alloimmunization. Descriptive analysis of hospital KEL1 negative inventory demand and supply was performed. RESULTS From Jan 2007-Jun 2017, 8.6% of all RBC units transfused were provided to females age ≤45. There were 111 females with detectable anti-K. Median age at time of antibody detection was 34 years (interquartile range 27-40) and 28 of 111 (25.2%) patients may have been alloimmunized by transfusion. Of 49 pregnancies, seven had complications due to anti-K. We estimated that our existing RBC inventory (with 16% units known to be KEL1 negative in 2017) is sufficient to meet demand and support a KEL1 negative transfusion policy for females age ≤45. CONCLUSION Transfusion was responsible for alloimmunization in 25% of females with anti-K over 10 years. Analysis of supply and demand can be used to inform feasibility of a KEL1 negative transfusion policy.
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Affiliation(s)
- Shuoyan Ning
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Canadian Blood Services, Hamilton, Ontario, Canada
- Department of Pathology, Hamilton Regional Laboratory Medicine Program, McMaster University, Hamilton, Ontario, Canada
| | - Pierre-Aurele Morin
- Department of Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Allahna Elahie
- Department of Pathology, Hamilton Regional Laboratory Medicine Program, McMaster University, Hamilton, Ontario, Canada
| | - Na Li
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yang Liu
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Barty
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Gwen Clarke
- Canadian Blood Services, Centre for Innovation, Ottawa, Ontario, Canada
| | - Michelle Zeller
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Canadian Blood Services, Hamilton, Ontario, Canada
- Department of Pathology, Hamilton Regional Laboratory Medicine Program, McMaster University, Hamilton, Ontario, Canada
| | - Nancy M Heddle
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Canadian Blood Services, Centre for Innovation, Ottawa, Ontario, Canada
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3
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Petroff MG, Nguyen SL, Ahn SH. Fetal‐placental
antigens and the maternal immune system: Reproductive immunology comes of age. Immunol Rev 2022; 308:25-39. [PMID: 35643905 PMCID: PMC9328203 DOI: 10.1111/imr.13090] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/07/2022] [Accepted: 05/11/2022] [Indexed: 12/20/2022]
Abstract
Reproductive physiology and immunology as scientific disciplines each have rich, largely independent histories. The physicians and philosophers of ancient Greece made remarkable observations and inferences to explain regeneration as well as illness and immunity. The scientific enlightenment of the renaissance and the technological advances of the past century have led to the explosion of knowledge that we are experiencing today. Breakthroughs in transplantation, immunology, and reproduction eventually culminated with Medawar’s discovery of acquired immunological tolerance, which helped to explain the transplantation success and failure. Medawar’s musings also keenly pointed out that the fetus apparently breaks these newly discovered rules, and with this, the field of reproductive immunology was launched. As a result of having stemmed from transplantation immunology, scientist still analogizes the fetus to a successful allograft. Although we now know of the fundamental differences between the two, this analogy remains a useful tool to understand how the fetus thrives despite its immunological disparity with the mother. Here, we review the history of reproductive immunology, and how major and minor histocompatibility antigens, blood group antigens, and tissue‐specific “self” antigens from the fetus and transplanted organs parallel and differ.
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Affiliation(s)
- Margaret G. Petroff
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine Michigan State University East Lansing Michigan USA
- Departments of Microbiology and Molecular Genetics, College of Veterinary Medicine and College of Human Medicine Michigan State University East Lansing Michigan USA
- Cell and Molecular Biology Program, College of Natural Science Michigan State University East Lansing Michigan USA
| | - Sean L. Nguyen
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine Michigan State University East Lansing Michigan USA
- Cell and Molecular Biology Program, College of Natural Science Michigan State University East Lansing Michigan USA
| | - Soo Hyun Ahn
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine Michigan State University East Lansing Michigan USA
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4
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Luken JS, Folman CC, Lukens MV, Meekers JH, Ligthart PC, Schonewille H, Zwaginga JJ, Janssen MP, van der Schoot CE, van der Bom JG, de Haas M. Reduction of anti-K-mediated hemolytic disease of newborns after the introduction of a matched transfusion policy: A nation-wide policy change evaluation study in the Netherlands. Transfusion 2021; 61:713-721. [PMID: 33528025 PMCID: PMC7986406 DOI: 10.1111/trf.16276] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/27/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND During pregnancy, maternal red blood cell (RBC) antibodies can lead to life-threatening fetal hemolysis and anemia. Women can become immunized by a pregnancy or an unmatched transfusion. Our aim was to quantify the effect of a nationwide K-matched transfusion policy for women of childbearing age potential to prevent K-immunization in pregnancy. STUDY DESIGN AND METHODS In this nation-wide policy change evaluation study we determined the occurrence of RBC antibodies before and after introduction of a K-matched transfusion policy and evaluated the cause K alloimmunization 10 years after introduction of this measure. K-matched transfusion for females under 45 years of age is advised in the Dutch transfusion guideline since 2004. We used laboratory data from pregnancies with RBC antibodies identified in the period 1999-2018 obtained as part of a population-based screening program in the Netherlands. RESULTS Tests of 36 286 pregnancies produced a positive antibody screening result which concerned anti-K in 1550 pregnancies. The occurrence of anti-K decreased from 67.9 to 20.2 per 100 000 pregnancies. The relative risk reduction was 0.70 which largely exceeded the relative risk reduction of 0.27 for antibodies against RBC antigens for which no preventive matching is required. The number of pregnancies at risk for anti-K-mediated disease decreased from 9.7 to 4.2 per 100 000 pregnancies. CONCLUSIONS A K-matched transfusion policy is associated with a major decrease in a number of pregnant women with anti-K and pregnancies at risk for anti-K-mediated disease. A relatively simple measure is now shown to impact prevention of hemolytic disease in the fetus and newborn.
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Affiliation(s)
- Jessie S Luken
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Claudia C Folman
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Michaël V Lukens
- Department of Laboratory Medicine, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - Johan H Meekers
- Department of Laboratory Medicine, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - Peter C Ligthart
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Henk Schonewille
- Department of Experimental Immunohematology, Sanquin Research, Amsterdam, The Netherlands.,Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaap Jan Zwaginga
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands.,Center for Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands
| | - Mart P Janssen
- Transfusion Technology Assessment Department, Donor Medicine Research, Sanquin Research, Amsterdam, The Netherlands
| | - C Ellen van der Schoot
- Department of Experimental Immunohematology, Sanquin Research, Amsterdam, The Netherlands.,Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Johanna G van der Bom
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Masja de Haas
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands.,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands.,Center for Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands
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5
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Mallari RA, Chan A, Powers RJ, Pandipati S, Bensing KM, Biese D, Denomme GA. Fetal inheritance of GP*Mur causing severe HDFN in an unrecognized case of maternal alloimmunization. Transfusion 2020; 60:870-874. [PMID: 32056233 DOI: 10.1111/trf.15709] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND The clinical and laboratory features of hemolytic disease of the newborn can be challenging to diagnose during pregnancy in the apparent absence of a blood group antibody. Low-frequency antibodies go undetected due to the lack of appropriate antigen-positive reagent red blood cells (RBCs). CASE REPORT A pregnant woman of Southeast Asian descent was referred to a maternal-fetal medicine outpatient clinic due to a complicated obstetric history and a negative antibody screen. This initial visit at 29 weeks and 0 days' gestational age (GA) was unremarkable. A hydropic infant, born at 29 weeks and 5 days' GA, succumbed on the seventh day of life. Comprehensive laboratory testing was performed after birth. The hospital blood bank performed a maternal antibody identification. Direct antiglobulin test was performed on the cord blood. A reference laboratory confirmed an anti-Mia , performed paternal Mia phenotyping, and identified a hybrid glycophorin B-A-B GP*Mur allele. DISCUSSION Maternal alloimmunization to low-frequency antigens remains a challenge. Southeast Asians make up a significant percentage in some US locations. Worldwide reports on the frequency of maternal alloimmunization of the MNS system can be used to guide the use of specific reagent RBCs for testing. Such strategies rely on the identification of blood donor units for reagent manufacture and use in perinatal antibody screens. CONCLUSION The incidence of Mia and related antibodies is significant among Southeast Asians. In North America, prenatal antibody screening cells are not routinely chosen to match this population. The clinical and societal implications are discussed.
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Affiliation(s)
- Rose A Mallari
- Pathology & Laboratory Medicine, O'Connor Hospital/A Community Hospital of County of Santa Clara Heath System, San Jose, California
| | - Ada Chan
- Pathology & Laboratory Medicine, O'Connor Hospital/A Community Hospital of County of Santa Clara Heath System, San Jose, California
| | | | | | | | - Danielle Biese
- Immunohematology Reference Laboratory, Milwaukee, Wisconsin
| | - Gregory A Denomme
- Immunohematology Reference Laboratory, Milwaukee, Wisconsin.,Versiti Blood Research Institute, Wauwatosa, Wisconsin
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6
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Sun JB. The prenatal intervention of pregnancy complicated with anti-Kell isoimmunization: a review. J Matern Fetal Neonatal Med 2019; 34:2893-2899. [PMID: 31571493 DOI: 10.1080/14767058.2019.1671330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Since the first case of the hemolytic disease of the fetus and newborn (HDFN) caused by anti-K was reported in 1946, the fetal diagnosis of K-HDFN has made rapid progress from invasive immunological and biochemical tests to noninvasive Doppler ultrasound and molecular biology techniques. However, its treatment, especially prenatal intervention, has developed slowly compared with RhD-HDFN. This review attempts to clarify the current key points and explore the direction of the next phase by systematically reviewing the development of diagnosis and treatment of this disease, which involving multidisciplinary participation.
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Affiliation(s)
- Jun-Bo Sun
- Department of Blood Transfusion, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
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7
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Delaney M. Haemolytic disease of the fetus and newborn: advancements in precision and prevention. ACTA ACUST UNITED AC 2018. [DOI: 10.1111/voxs.12479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Meghan Delaney
- Pathology & Laboratory Medicine Division; Children's National Health System; Washington DC USA
- Department of Pediatrics & Pathology; George Washington University; Washington DC USA
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8
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Webb J, Delaney M. Red Blood Cell Alloimmunization in the Pregnant Patient. Transfus Med Rev 2018; 32:213-219. [PMID: 30097223 DOI: 10.1016/j.tmrv.2018.07.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/22/2018] [Accepted: 07/05/2018] [Indexed: 12/13/2022]
Abstract
Alloimmunization to red blood cell (RBC) antigens represents a challenge for physicians caring for women of child bearing potential. Exposure to non-self RBC antigens may occur during transfusion or pregnancy leading to the development of antibodies. If a subsequent fetus bears that antigen, maternal antibodies may attack the fetal red blood cells causing red cell destruction and clinically significant hemolytic disease of the fetus and newborn (HDFN). In the most severe cases, HDFN may result in intrauterine fetal demise due to high output cardiac failure, effusions and ascites, known as "hydrops fetalis". This article reviews strategies for management and prevention of RBC alloimmunization in women of child bearing potential.
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Affiliation(s)
- Jennifer Webb
- Children's National Health System, Washington, D.C., USA; The George Washington University, Departments of Pediatrics & Pathology, Washington, DC, USA.
| | - Meghan Delaney
- Children's National Health System, Washington, D.C., USA; The George Washington University, Departments of Pediatrics & Pathology, Washington, DC, USA
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9
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Abstract
The aim of pediatric transfusions should be based on the concept of avoiding unnecessary transfusions without jeopardizing the patient safety and providing correct blood components when there are well founded indications to transfuse. Despite considerable efforts from transfusion services to increase transfusion safety, transfusions are still associated with preventable and unpreventable adverse effects that may, in the worst case, have severe and fatal consequences. Transfusions to pediatric patients constitute a small proportion of all transfusions but have higher incidence of adverse events compared to adults. Pediatric transfusions consist of intrauterine transfusions, top-up transfusions to neonates and young children, exchange transfusions in the management of hemolytic disease of newborn (HDN), in addition to sickle cell crisis, chronic transfusion therapy in thalassemia patients, massive transfusion in trauma, HLA- and HPA-compatible platelets in immunized patients and neonates with fetal neonatal alloimmune thrombocytopenia (FNAIT). Packed red cells (PRCs) and platelet (PLT) concentrates are the most utilized blood components and will be reviewed here.
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10
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Zwiers C, Koelewijn JM, Vermij L, van Sambeeck J, Oepkes D, de Haas M, van der Schoot CE. ABO incompatibility and RhIG immunoprophylaxis protect against non-D alloimmunization by pregnancy. Transfusion 2018; 58:1611-1617. [PMID: 29624682 DOI: 10.1111/trf.14606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/19/2018] [Accepted: 02/21/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hemolytic disease of the fetus and newborn (HDFN) is caused by maternal antibodies against fetal red blood cell antigens, most often anti-D, -K, or -c. ABO incompatibility between mother and child and anti-D immunoprophylaxis (RhIG) are known to reduce the risk of D immunization and subsequent HDFN. However, no immunoprophylaxis has been developed to prevent non-D immunizations. STUDY DESIGN AND METHODS We evaluated whether ABO incompatibility has a preventive effect on formation of non-D alloantibodies, by performing a case-control study including pregnant women with newly detected non-D antibodies, identified within a nationwide data set, immunized during their first pregnancy and/or delivery. Subsequently, we assessed a possible protective effect of RhIG in a subgroup with non-Rh antibodies only. The proportions of previous ABO incompatibility and of RhIG administrations of these women were compared to the known rate of 19.4% ABO incompatibility and 9.9% RhIG administrations (D- women carrying a D+ child) in the general population of pregnant women. RESULTS A total of 11.9% of the 232 included immunized women had a possible ABO incompatibility in their first pregnancy (vs. expected 19.4%; 95% confidence interval [CI], 7.3-18.8; p = 0.036). Furthermore, 1.0% women with non-Rh antibodies were D-, delivered a D+ child, and had therefore received RhIG, whereas 9.9% was expected (95% CI, 0.18-5.50; p = 0.003). CONCLUSION We found that ABO incompatibility and RhIG reduce the risks not only for D, but also for non-Rh immunizations, suggesting that antibody-mediated immune suppression in this condition is not antigen specific.
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Affiliation(s)
- Carolien Zwiers
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Joke M Koelewijn
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam.,Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - Lisa Vermij
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Joost van Sambeeck
- Department of Transfusion Technology Assessment, Sanquin Research, Amsterdam.,Centre for Healthcare Operations Improvement & Research, University of Twente, Enschede, the Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Masja de Haas
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands.,Sanquin Diagnostic Services, Amsterdam, the Netherlands.,Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
| | - C Ellen van der Schoot
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam
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11
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Red blood cell alloimmunization: new findings at the bench and new recommendations for the bedside. Curr Opin Hematol 2017; 23:543-549. [PMID: 27454234 DOI: 10.1097/moh.0000000000000277] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW To summarize recent discoveries from clinical studies and animal models that contribute to understanding the alloimmune response to non-ABO blood group antigens. RECENT FINDINGS Several studies have confirmed high rates of alloimmunization among patients requiring chronic red blood cell (RBC) transfusion. Moreover, 'triggers' for alloantibody development in the transfusion setting have been identified, with a number of investigations linking recipient inflammation to a higher likelihood of alloimmunization. Additional associations between human leukocyte antigen expression and CD4 T-cell markers in 'responder' or 'nonresponder' humans have been revealed. Recent animal studies have described novel mechanistic properties by which the alloimmune response is governed, including the critical role played by dendritic cells in transfusion-associated alloimmunization. New light has also been shed on the properties of alloantibodies developed as a result of pregnancy, as well as mechanisms through which such alloimmunization may be prevented. SUMMARY Many of the clinical/biological factors that contribute to the RBC alloimmune response have been further elucidated. This knowledge will be applied to identify individuals most likely to mount an immune response to RBC antigens, such that appropriate resources and strategies for preventing alloimmunization (or mitigating its harmful effects) can be implemented.
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12
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Shehata N, Chassé M, Colas JA, Murphy M, Forster AJ, Malinowski AK, Ducharme R, Fergusson DA, Tinmouth A, Wilson K. Risks and trends of red blood cell transfusion in obstetric patients: a retrospective study of 45,213 deliveries using administrative data. Transfusion 2017. [PMID: 28643386 DOI: 10.1111/trf.14184] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transfusion data for obstetric patients are scarce. Identifying characteristics associated with red blood cell transfusion (RBCT) is of importance to better identify patients who would benefit from blood conservation strategies as the risk of alloimmunization from RBCT has the potential to affect the fetus and newborn. STUDY DESIGN AND METHODS We conducted a retrospective cohort study using hospital administrative data to identify trends and risk factors of RBCT in obstetric patients. Data were analyzed according to the mode of delivery. RESULTS A total of 45,213 deliveries were captured between January 1, 2007, and December 31, 2013. A higher proportion of patients undergoing cesarean sections (C/Ss) received an RBCT (2.3%) compared to other modes of delivery (0.7% for spontaneous vaginal delivery, 1.5% for instrumental delivery; p < 0.001). In addition, the risk of RBCT increased over the 7-year period for those patients undergoing C/S (relative risk [RR], 1.56; 95% confidence interval [CI], 1.14-2.15). An unavailable hemoglobin (Hb) level (RR, 12.94; 95% CI, 7.39-22.66) and Hb level of 70 to 80 g/L (RR, 7.78; 95% CI = 5.21-11.60) were strongly associated with RBCT among women undergoing C/S. Earlier gestational age at induction increased the risk of RBCT across all modes of delivery. CONCLUSIONS The higher frequency of RBCT for unknown and low Hb supports the need for predelivery patient blood management at the time of delivery. The additional risk factors associated with RBCT identified may be used to develop risk stratification tools by mode of delivery to assist in the identification of patients at the highest risk of requiring RBCT.
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Affiliation(s)
- Nadine Shehata
- Departments of Medicine and Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, Division of Hematology, Mount Sinai Hospital, Toronto, Ontario, Canada.,Canadian Blood Services, Toronto, Ontario, Canada
| | - Michaël Chassé
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Université de Montréal, Montréal, Québec, Canada.,Centre de Recherche du Centre Hospitalier Universitaire de Montréal, Montréal, Québec, Canada
| | - Jo Ann Colas
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Malia Murphy
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alan J Forster
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ann K Malinowski
- Department of Obstetrics and Gynecology, University of Toronto, Division of Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario
| | - Robin Ducharme
- Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kumanan Wilson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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13
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Abstract
In this issue of Blood, Liu et al investigated the mechanism of action in antibody-mediated immune suppression (AMIS) and the fate of antigen in a KEL mouse model system.1
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14
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Belsito A, Magnussen K, Napoli C. Emerging strategies of blood group genotyping for patients with hemoglobinopathies. Transfus Apher Sci 2016; 56:206-213. [PMID: 28040400 DOI: 10.1016/j.transci.2016.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 02/06/2023]
Abstract
Red cell alloimmunization is a serious problem in chronically transfused patients. A number of high-throughput DNA assays have been developed to extend or replace traditional serologic antigen typing. DNA-based typing methods may be easily automated and multiplexed, and provide reliable information on a patient. Molecular genotyping promises to become cheaper, being not dependent on serologic immunoglobulin reagents. Patients with hemoglobinopathies could benefit from receiving extended genomic typing. This could limit post transfusional complications depending on subtle antigenic differences between donors and patients. Patient/donor compatibility extended beyond the phenotype Rh/Kell may allows improved survival of transfused units of red blood cells (RBC) and lead to reduced need for blood transfusion and leading to less iron overload and reduced risk of alloimmunization. Here we discuss the advantages and limitations of current techniques, that detect only predefined genetic variants. In contrast, target enrichment next-generation sequencing (NGS) has been used to detect both known and de novo genetic polymorphisms, including single-nucleotide polymorphisms, indels (insertions/deletions), and structural variations. NGS approaches can be used to develop an extended blood group genotyping assay system.
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Affiliation(s)
- A Belsito
- Department of Internal Medicine and Specialistic Units Clinical Immunoematology Immunohematology U.O.C. Immunohematology, Transfusion Medicine and Organ Transplant Immunology (SIMT), Regional Reference Laboratory of Transplant Immunology (LIT), Department of Internal Medicine and Specialist Units, Azienda Universitaria Policlinico (AOU), Second University of Naples (SUN), Naples, Italy.
| | - K Magnussen
- Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - C Napoli
- Department of Internal Medicine and Specialistic Units Clinical Immunoematology Immunohematology U.O.C. Immunohematology, Transfusion Medicine and Organ Transplant Immunology (SIMT), Regional Reference Laboratory of Transplant Immunology (LIT), Department of Internal Medicine and Specialist Units, Azienda Universitaria Policlinico (AOU), Second University of Naples (SUN), Naples, Italy
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15
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Sonneveld ME, Koelewijn J, de Haas M, Admiraal J, Plomp R, Koeleman CAM, Hipgrave Ederveen AL, Ligthart P, Wuhrer M, van der Schoot CE, Vidarsson G. Antigen specificity determines anti-red blood cell IgG-Fc alloantibody glycosylation and thereby severity of haemolytic disease of the fetus and newborn. Br J Haematol 2016; 176:651-660. [PMID: 27891581 DOI: 10.1111/bjh.14438] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/02/2016] [Indexed: 01/08/2023]
Abstract
Haemolytic disease of the fetus and newborn (HDFN) is a severe disease in which fetal red blood cells (RBC) are destroyed by maternal anti-RBC IgG alloantibodies. HDFN is most often caused by anti-D but may also occur due to anti-K, -c- or -E. We recently found N-linked glycosylation of anti-D to be skewed towards low fucosylation, thereby increasing the affinity to IgG-Fc receptor IIIa and IIIb, which correlated with HDFN disease severity. Here, we analysed 230 pregnant women with anti-c, -E or -K alloantibodies from a prospective screening cohort and investigated the type of Fc-tail glycosylation of these antibodies in relation to the trigger of immunisation and pregnancy outcome. Anti-c, -E and -K show - independent of the event that had led to immunisation - a different kind of Fc-glycosylation compared to that of the total IgG fraction, but with less pronounced differences compared to anti-D. High Fc-galactosylation and sialylation of anti-c correlated with HDFN disease severity, while low anti-K Fc-fucosylation correlated with severe fetal anaemia. IgG-Fc glycosylation of anti-RBC antibodies is shaped depending on the antigen. These features influence their clinical potency and may therefore be used to predict severity and identify those needing treatment.
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Affiliation(s)
- Myrthe E Sonneveld
- Department of Experimental Immunohaematology, Sanquin Research, Amsterdam, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Joke Koelewijn
- Department of Immunohaematotology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - Masja de Haas
- Department of Immunohaematotology Diagnostics, Sanquin, Amsterdam, the Netherlands.,Centre for Clinical Transfusion Research, Sanquin Research and Dept of Immunohaematology and Blood Transfusion of Leiden University Medical Centre, Leiden, the Netherlands
| | - Jon Admiraal
- Department of Experimental Immunohaematology, Sanquin Research, Amsterdam, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Rosina Plomp
- Centre for Proteomics and Metabolomics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Carolien A M Koeleman
- Centre for Proteomics and Metabolomics, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Peter Ligthart
- Department of Immunohaematotology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - Manfred Wuhrer
- Centre for Proteomics and Metabolomics, Leiden University Medical Centre, Leiden, the Netherlands
| | - C Ellen van der Schoot
- Department of Experimental Immunohaematology, Sanquin Research, Amsterdam, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Gestur Vidarsson
- Department of Experimental Immunohaematology, Sanquin Research, Amsterdam, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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16
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Schonewille H, Honohan Á, van der Watering LM, Hudig F, te Boekhorst PA, Koopman-van Gemert AW, Brand A. Incidence of alloantibody formation after ABO-D or extended matched red blood cell transfusions: a randomized trial (MATCH study). Transfusion 2015; 56:311-20. [DOI: 10.1111/trf.13347] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/13/2015] [Accepted: 08/13/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Henk Schonewille
- Centre for Clinical Transfusion Research; Sanquin Research
- Jon J. Van Rood Centre for Clinical Transfusion Research; Sanquin-Leiden University Medical Centre; Leiden The Netherlands
| | - Áine Honohan
- Centre for Clinical Transfusion Research; Sanquin Research
- Jon J. Van Rood Centre for Clinical Transfusion Research; Sanquin-Leiden University Medical Centre; Leiden The Netherlands
| | - Leo M.G. van der Watering
- Centre for Clinical Transfusion Research; Sanquin Research
- Jon J. Van Rood Centre for Clinical Transfusion Research; Sanquin-Leiden University Medical Centre; Leiden The Netherlands
| | | | | | | | - Anneke Brand
- Jon J. Van Rood Centre for Clinical Transfusion Research; Sanquin-Leiden University Medical Centre; Leiden The Netherlands
- Department of Immuno-Hematology and Blood Transfusion; Leiden University Medical Centre; Leiden The Netherlands
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