1
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Milosavić M, Lilić M, Andrić Z. Impact of human leucocyte antigen class II polymorphism on anti-red blood cell antibody development: Correlations and indications. Vox Sang 2024; 119:720-727. [PMID: 38596887 DOI: 10.1111/vox.13632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/16/2024] [Accepted: 03/24/2024] [Indexed: 04/11/2024]
Abstract
BACKROUND AND OBJECTIVES Blood transfusion therapy is vital for many patient groups. They can cause many complications, and the development of anti-red blood cell (RBC) antibodies is of significant importance. Molecules of class II human leucocyte antigens (HLA) are one of the several factors that influence antibody development in patients. MATERIALS AND METHODS In this study, we investigated 108 patients who developed antibodies against different erythrocyte antigens and 115 patients on multiple transfusion therapies who did not develop anti-RBC antibodies. The HLA loci HLA-DRB1 and HLA-DQB1 were typed using commercial molecular assays routinely used in HLA laboratories. RESULTS An increased frequency of the HLA-DRB1*04 allele group was observed in patients who developed antibodies. Additionally, HLA-DRB1*09 was also significant for anti-E development and in patients with multi-specific alloimmunization. It was found that the HLA-DRB1*07 allele group is associated with antibodies to antigents of the Rh and MNS systems but also lacks an association with anti-K development. The HLA-DRB1*11 and -DRB1*01 allele groups displayed a protective mechanism for anti-E development, similar to that of HLA-DQB1*02 for anti-K. CONCLUSION There is an association between various HLA class II alleles and anti-RBC development.
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Affiliation(s)
- Milanka Milosavić
- Laboratory for Molecular Immunohematology, Institute for Transfusion Medicine of Republika Srpska, Banja Luka, Bosnia and Herzegovina
| | - Marko Lilić
- Department of Biology, University of Osijek, Osijek, Croatia
| | - Zorana Andrić
- Tissue Typing Department, Blood Transfusion Institute of Serbia, Belgrade, Serbia
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2
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Li Q, Xie J, Sun J, Fang K, Li T. Complex delayed blood transfusion reaction: A case report. Medicine (Baltimore) 2024; 103:e38467. [PMID: 38905393 PMCID: PMC11191959 DOI: 10.1097/md.0000000000038467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/15/2024] [Indexed: 06/23/2024] Open
Abstract
INTRODUCTION Inefficient blood transfusions present a significant challenge, leading to the wastage of crucial blood resources and increased medical expenses. This study aims to address this issue by providing a comprehensive analysis of a case involving an ineffective clinical transfusion and outlining the significance of identifying multiple alloantibodies in resolving transfusion challenges. CASE REPORT We present a detailed follow-up on a patient treatment journey, highlighting the critical role of identifying multiple alloantibodies through various methodologies in addressing the transfusion problem. Subsequently, a strategic intervention was implemented, leading to a successful patient outcome. CONCLUSION This study underscores the importance of conducting a thorough analysis of ineffective transfusions and implementing scientifically formulated transfusion plans based on rational explanations. Such an approach not only improves hemoglobin levels but also contributes to better patient outcomes, thereby reducing blood resource wastage and medical costs.
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Affiliation(s)
- Qiang Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Cell Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | | | - Jiali Sun
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Cell Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Kuo Fang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Cell Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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3
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Chang DY, Wankier Z, Arthur CM, Stowell SR. The ongoing challenge of RBC alloimmunization in the management of patients with sickle cell disease. Presse Med 2023; 52:104211. [PMID: 37981194 DOI: 10.1016/j.lpm.2023.104211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023] Open
Abstract
RBC transfusion remains a cornerstone in the treatment of sickle cell disease (SCD). However, as with many interventions, transfusion of RBCs is not without risk. Allogeneic RBC exposure can result in the development of alloantibodies, which can make it difficult to find compatible RBCs for future transfusion and increases the likelihood of life-threatening complications. The development of RBC alloantibodies occurs when a patient's immune system produces alloantibodies against foreign alloantigens present on RBCs. Despite its longstanding recognition, RBC alloimmunization has increasingly become a challenge when caring for patients with SCD. The growing prominence of alloimmunization can be attributed to several factors, including expanded indications for transfusions, increased lifespan of patients with SCD, and inadequate approaches to prevent alloimmunization. Recognizing these challenges, recent observational studies and preclinical models have begun to elucidate the immune pathways that underpin RBC alloimmunization. These emerging data hold promise in paving the way for innovative prevention strategies, with the goal of increasing the safety and efficacy of RBC transfusion in patients with SCD who are most vulnerable to alloimmunization.
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Affiliation(s)
- Daniel Y Chang
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Zakary Wankier
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Connie M Arthur
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Sean R Stowell
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
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4
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Zheng Y, Gossett JM, Chen PL, Barton M, Ryan M, Yu J, Kang G, Hankins JS, Chou ST. Proinflammatory state promotes red blood cell alloimmunization in pediatric patients with sickle cell disease. Blood Adv 2023; 7:4799-4808. [PMID: 37023228 PMCID: PMC10469551 DOI: 10.1182/bloodadvances.2022008647] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 02/09/2023] [Accepted: 02/27/2023] [Indexed: 04/08/2023] Open
Abstract
We examined risk factors for red blood cell (RBC) alloimmunization in pediatric patients with sickle cell disease, focusing on the recipients' inflammatory state at the time of transfusion and anti-inflammatory role of hydroxyurea (HU). Among 471 participants, 55 (11.70%) participants were alloimmunized and formed 59 alloantibodies and 17 autoantibodies with an alloimmunization rate of 0.36 alloantibodies per 100 units. Analysis of 27 participants in whom alloantibodies were formed with specificities showed 23.8% (30/126) of units transfused during a proinflammatory event resulting in alloantibody formation compared with 2.8% (27/952) of units transfused at steady state. Therefore, transfusion during proinflammatory events increased the risk for alloimmunization (odds ratio [OR], 4.22; 95% confidence interval [CI], 1.64-10.85; P = .003). Further analysis of all the 471 participants showed that alloimmunization of patients who received episodic transfusion, mostly during proinflammatory events, was not reduced with HU therapy (OR, 6.52; 95% CI, 0.85-49.77; P = .071), HU therapy duration (OR, 1.13; 95% CI, 0.997-1.28; P = .056), or HU dose (OR, 1.06; 95% CI, 0.96-1.16; P = .242). The analysis also identified high transfusion burden (OR, 1.02; 95% CI, 1.003-1.04; P = .020) and hemoglobin S (HbSS) and HbSβ0-thalassemia genotypes (OR, 11.22, 95% CI, 1.51-83.38; P = .018) as additional risk factors for alloimmunization. In conclusion, the inflammatory state of transfusion recipients affects the risk of RBC alloimmunization, which is not modified by HU therapy. Judicious use of transfusion during proinflammatory events is critical for preventing alloimmunization.
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Affiliation(s)
- Yan Zheng
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jeffrey M. Gossett
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Pei-Lin Chen
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Martha Barton
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Missy Ryan
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jing Yu
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jane S. Hankins
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Stella T. Chou
- Departments of Pediatrics and Pathology, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
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5
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Giger U. Crossmatch: Alloimmunization versus unspecific agglutination reactions? Vet Med (Auckl) 2023; 37:8-9. [PMID: 36598027 PMCID: PMC9889666 DOI: 10.1111/jvim.16626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 11/07/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Urs Giger
- DACVIM (Small Animal Internal Medicine), DECVIM‐CA (Internal Medicine), DECVCP (Clinical Pathology)ZürichSwitzerland
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6
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Titze TL, Hamnvik LHD, Hauglum IM, Carlsen AET, Tjeldhorn L, Nguyen NT, Akkök ÇA. Management of Wrong Blood Transfusion to an RhD Negative Woman in Labor. Int J Womens Health 2023; 15:1-6. [PMID: 36628052 PMCID: PMC9826603 DOI: 10.2147/ijwh.s390661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/06/2022] [Indexed: 01/12/2023] Open
Abstract
Blood transfusion is life-saving in massive hemorrhage. Before pre-transfusion tests with ABO and RhD typing results are available, O RhD negative packed red blood cell (PRBC) units are used without cross-matching in emergency. RhD negative girls and women of child-bearing age should always receive RhD negative blood transfusions to prevent RhD-alloimmunization because anti-D-related hemolytic disease of fetus and newborn (HDFN) can result in mild to severe anemia, and in a worst-case scenario death of an RhD positive fetus and/or newborn. However, "wrong blood to wrong patient" happens unintentionally. Here we report an emergency blood transfusion with one unit of RhD positive PRBCs to an RhD negative young woman when estimated blood loss was 2500 mL during delivery and surgical removal of retained placenta. Realizing the mistake, management with high dose anti-D immunoglobulin (Ig) was initiated to remove the RhD positive red blood cells (RBCs) from the patient's circulation. Such mitigation is recommended only for girls and women of child-bearing age. Follow-up was performed by flow cytometry until RhD positive RBCs were no longer detected. Ten months after the delivery, antibody screening was negative. However, we still do not know whether we managed to prevent RhD-alloimmunization.
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Affiliation(s)
- Thomas Larsen Titze
- Department of Laboratory Medicine, Vestre Viken Health Trust, Drammen, Norway
| | | | - Inga Marie Hauglum
- Department of Laboratory Medicine, Vestre Viken Health Trust, Drammen, Norway
| | | | - Lena Tjeldhorn
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | - Nhan Trung Nguyen
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | - Çiğdem Akalın Akkök
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway,Correspondence: Çiğdem Akalın Akkök, Department of Immunology and Transfusion Medicine, Oslo University Hospital, Ullevaal, Kirkeveien 166, Oslo, N-0407, Norway, Tel +47 92 03 47 47, Fax + 47 22 11 88 50, Email
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7
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Herter L, Weingart C, Merten N, Bock N, Merle R, Kohn B. Alloimmunization in dogs after transfusion: A serial cross-match study. J Vet Intern Med 2022; 36:1660-1668. [PMID: 36161382 PMCID: PMC9511065 DOI: 10.1111/jvim.16521] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 08/02/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Cross-matching is performed to determine the serological compatibility of donor and recipient blood. Current guidelines recommend that cross-matching should be performed in dogs when an initial transfusion was performed more than 4 days ago or when the transfusion history is unknown. HYPOTHESIS Determination at what time point alloantibodies are detected in dogs after transfusion. The hypothesis was that dogs would form alloantibodies within 4 days after a transfusion. ANIMALS Twenty-one anemic dogs were transfused and monitored for at least 4 subsequent days. Exclusion criteria were persistent red blood cell (RBC) agglutination and a previous transfusion. METHODS Prospective observational study. Cross-matching was performed before the initial DEA 1-compatible transfusion and on days 1, 2, 3, and 4 and if possible, between day 5 and 28, using the tube method without enhancement (major cross-match, recipient controls); recipients were monitored for transfusion reactions. RESULTS In 12/21 dogs a positive cross-match (microscopic degree of agglutination [AD] 1+ to 2+) was observed within 4 days after the transfusion. In a nonlinear regression model, no significant association was detected between type of anemia (P = .41), RBC storage time (P = .44), immunosuppressive treatment (P = .75) nor transfusion volume (P = .70) and the occurrence of positive cross-matches within 4 days after transfusion. Another 4 dogs developed a positive cross-match (microscopic AD 1+ to 2+) after 6 to 13 days. CONCLUSIONS AND CLINICAL IMPORTANCE Because production of alloantibodies was detected as early as 1 day after transfusion, cross-matching should be performed before every subsequent transfusion.
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Affiliation(s)
- Lisa Herter
- Clinic for Small Animals, Faculty of Veterinary MedicineFreie Universität BerlinBerlinGermany
| | - Christiane Weingart
- Clinic for Small Animals, Faculty of Veterinary MedicineFreie Universität BerlinBerlinGermany
| | - Nina Merten
- Clinic for Small Animals, Faculty of Veterinary MedicineFreie Universität BerlinBerlinGermany
| | - Nicole Bock
- Clinic for Small Animals, Faculty of Veterinary MedicineFreie Universität BerlinBerlinGermany
| | - Roswitha Merle
- Institute for Veterinary Epidemiology and Biostatistics, Department of Veterinary MedicineFreie Universität BerlinBerlinGermany
| | - Barbara Kohn
- Clinic for Small Animals, Faculty of Veterinary MedicineFreie Universität BerlinBerlinGermany
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8
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Covington ML, Cone-Sullivan JK, Andrzejewski C, Lu W, Thomasson RR, O'Brien K, Brunker PAR, Stowell SR. Unmasking delayed hemolytic transfusion reactions in patients with sickle-cell disease: Challenges and opportunities for improvement. Transfusion 2022; 62:1662-1670. [PMID: 35778994 DOI: 10.1111/trf.16967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/30/2022] [Accepted: 05/17/2022] [Indexed: 12/25/2022]
Affiliation(s)
- Mischa L Covington
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jensyn K Cone-Sullivan
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Chester Andrzejewski
- Transfusion Medicine Service, Baystate Medical Center, Baystate Health, Springfield, Massachusetts, USA
| | - Wen Lu
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Reggie R Thomasson
- Department of Pathology and Laboratory Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kerry O'Brien
- Department of Pathology, Beth Israel Deaconess, Harvard Medical School, Boston, Massachusetts, USA
| | - Patricia A R Brunker
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sean R Stowell
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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9
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Safic Stanic H, Dogic V, Bingulac-Popovic J, Kruhonja Galic Z, Stojic Vidovic M, Puljic K, Jukic I. RhD alloimmunization by DEL variant missed in donor testing. Transfusion 2022; 62:1084-1088. [PMID: 35318689 DOI: 10.1111/trf.16862] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/13/2022] [Accepted: 03/01/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Exposure to normal or variably expressed RhD antigens in an antigen-negative individual can elicit an immune response and lead to the formation of clinically significant anti-D alloantibodies. We present the case of anti-D alloimmunization by DEL variant missed in routine blood donor screening. MATERIAL AND METHODS Blood donors were typed for D antigen using the direct serologic micromethod. Nonreactive samples were confirmed in the indirect antiglobulin method with an IgM/IgG anti-D monoclonal reagent. Genomic DNA was extracted using a commercial QIAamp DNA Blood Mini kit on the QIAcube device (Qiaqen, Germany). RHD genotyping was performed using the PCR-SSP genotyping kits- Ready Gene D weak, Ready Gene D weak screen, Ready Gene CDE, and Ready Gene D AddOn (Inno-Train, Germany). Unidentified alleles were sent for DNA genome sequencing. RESULTS After identifying DEL positive blood units in RhD negative blood donor pool, a look-back study was performed to determine if their previous donations caused alloimmunization in recipients. Out of 40 D negative recipients, one developed anti-D alloantibody after 45 days. The patient did not receive other RhD positive blood products. Blood donor typed D negative in direct and indirect agglutination method. RHD screening was positive, but RHD genotyping and DNA sequencing showed no mutation indicating the normal genotype. CONCLUSION Currently used methods in RHD genotyping are insufficient to identify many variant alleles, especially intronic variations. We suggest additional gene investigation including yet unexplored regions of regulation and intron regions to justify our serological finding.
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Affiliation(s)
- Hana Safic Stanic
- Department of Immunohematology, Croatian Institute of Transfusion Medicine, Zagreb, Croatia
| | - Vesna Dogic
- Department of Molecular Diagnostics, Croatian Institute of Transfusion Medicine, Zagreb, Croatia
| | - Jasna Bingulac-Popovic
- Department of Molecular Diagnostics, Croatian Institute of Transfusion Medicine, Zagreb, Croatia
| | - Zrinka Kruhonja Galic
- Department of Immunohematology, Croatian Institute of Transfusion Medicine, Zagreb, Croatia
| | - Miljana Stojic Vidovic
- Department for Blood donor testing, Croatian Institute of Transfusion Medicine, Zagreb, Croatia
| | - Kresimir Puljic
- Department for woman's psychotic disorders, University Psychiatric Hospital "Vrapče", Zagreb, Croatia
| | - Irena Jukic
- Medical Department, Croatian Institute of Transfusion Medicine, Zagreb, Croatia.,Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
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10
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Rankin A, Webb J, Nickel RS. Preventing antibody positive delayed hemolytic transfusion reactions in sickle cell disease: Lessons learned from a case. Transfus Med 2022; 32:433-436. [PMID: 35318744 DOI: 10.1111/tme.12862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/02/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Red blood cell (RBC) transfusions are important in the management of patients with sickle cell disease (SCD). However, a potentially catastrophic complication of transfusion in this population is the delayed hemolytic transfusion reaction (DHTR). The pathophysiology of all DHTRs is not understood, but some are known to be caused by an anamnestic resurgence of RBC alloantibodies. CASE PRESENTATION A child with SCD transfused for acute chest syndrome re-presented a week after hospital discharge with severe anaemia, hemolysis, and a newly detected anti-E. This patient had been previously transfused years ago at an outside institution and the anti-E had not been previously documented. DISCUSSION The presented case of an antibody positive DHTR illustrates several concepts critical to the prevention of this complication. RBC alloantibodies must be detected and this information must be shared. Prophylactic C/c, E/e, K antigen matching is helpful for patients with SCD, but systems must be in place to identify these patients. Patients transfused at multiple different hospitals are especially at risk for this complication and efforts are needed to prevent them from suffering a DHTR.
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Affiliation(s)
- Alexander Rankin
- Children's National Hospital, Washington, District of Columbia, USA.,Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jennifer Webb
- Children's National Hospital, Washington, District of Columbia, USA.,The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Robert Sheppard Nickel
- Children's National Hospital, Washington, District of Columbia, USA.,The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
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11
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Hendrickson JE. Management of hemolytic transfusion reactions. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:704-709. [PMID: 34889404 PMCID: PMC8791106 DOI: 10.1182/hematology.2021000308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Delayed hemolytic transfusion reactions (DHTRs) in patients with sickle cell disease are underappreciated and potentially fatal. Patients with DHTRs typically have symptoms of pain or dark urine days to weeks following a red blood cell (RBC) transfusion. In instances of DHTRs with hyperhemolysis, the patient's hemoglobin (Hgb) may be significantly lower than it was pretransfusion, and the Hgb A may drop by more than 50%. In most cases, at least 1 RBC alloantibody and sometimes multiple RBC alloantibodies can be identified during the DHTR, with those antibodies presumably having fallen below the level of detection at the time of the implicated transfusion. However, in up to one-third of cases, no new RBC alloantibodies can be identified posttransfusion. Complement is increasingly being appreciated to play a role in DHTRs and hyperhemolysis, not only due to classic pathway activation (with complement fixed antibody bound to RBCs) but also due to alternative pathway activation (resulting in part from plasma free heme). As such, anti-C5 inhibition has recently been reported to be effective at mitigating hemolysis in the setting of some severe DHTRs. Transfusion avoidance during DHTRs is recommended if possible, with long-term transfusion support advice being less clear; for example, a history of a severe DHTR may lead to questions regarding the safety of transfusions prior to curative therapies such as stem cell transplantation or gene therapy. A better understanding of antibody-positive and antibody-negative DHTRs, including patient- or disease-specific risk factors, is necessary to improve transfusion safety.
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Affiliation(s)
- Jeanne E. Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
- Correspondence Jeanne E. Hendrickson, Yale University Department of Laboratory Medicine, 330 Cedar Street, Clinic Building 405, PO Box 208035, New Haven, CT 06520-0835; e-mail:
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12
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Juskewitch JE, Tauscher CD, Moldenhauer SK, Schieber JE, Jacob EK, DiGuardo MA. To Give or Not to Give: RhD Immunoglobulin for an RHD * 39 Pregnant Woman with Sickle Cell Disease. Transfus Med Hemother 2021; 48:244-249. [PMID: 34539319 DOI: 10.1159/000512644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/27/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Patients with sickle cell disease (SCD) have repeated episodes of red blood cell (RBC) sickling and microvascular occlusion that manifest as pain crises, acute chest syndrome, and chronic hemolysis. These clinical sequelae usually increase during pregnancy. Given the racial distribution of SCD, patients with SCD are also more likely to have rarer RBC antigen genotypes than RBC donor populations. We present the management and clinical outcome of a 21-year-old pregnant woman with SCD and an RHD*39 (RhD[S103P], G-negative) variant. Case Presentation Ms. S is B positive with a reported history of anti-D, anti-C, and anti-E alloantibodies (anti-G testing unknown). Genetic testing revealed both an RHD*39 and homozygous partial RHCE*ceVS.02 genotype. Absorption/elution testing confirmed the presence of anti-G, anti-C, and anti-E alloantibodies but could not definitively determine the presence/absence of an anti-D alloantibody. Ms. S desired to undergo elective pregnancy termination and the need for postprocedural RhD immunoglobulin (RhIG) was posed. Given that only the G antigen site is changed in an RHD*39 genotype and the potential risk of RhIG triggering a hyperhemolytic episode in an SCD patient, RhIG was not administered. There were no procedural complications. Follow-up testing at 10 weeks showed no increase in RBC alloantibody strength. Discussion/Conclusion Ms. S represents a rare RHD*39 and partial RHCE*ceVS.02 genotype which did not further alloimmunize in the absence of RhIG administration. Her case also highlights the importance of routine anti-G alloantibody testing in women of childbearing age with apparent anti-D and anti-C alloantibodies.
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Affiliation(s)
| | - Craig D Tauscher
- Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Eapen K Jacob
- Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota, USA
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13
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Zerra PE, Patel SR, Jajosky RP, Arthur CM, McCoy JW, Allen JWL, Chonat S, Fasano RM, Roback JD, Josephson CD, Hendrickson JE, Stowell SR. Marginal zone B cells mediate a CD4 T-cell-dependent extrafollicular antibody response following RBC transfusion in mice. Blood 2021; 138:706-721. [PMID: 33876205 PMCID: PMC8394907 DOI: 10.1182/blood.2020009376] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/30/2021] [Indexed: 01/07/2023] Open
Abstract
Red blood cell (RBC) transfusions can result in alloimmunization toward RBC alloantigens that can increase the probability of complications following subsequent transfusion. An improved understanding of the immune mechanisms that underlie RBC alloimmunization is critical if future strategies capable of preventing or even reducing this process are to be realized. Using the HOD (hen egg lysozyme [HEL] and ovalbumin [OVA] fused with the human RBC antigen Duffy) model system, we aimed to identify initiating immune factors that may govern early anti-HOD alloantibody formation. Our findings demonstrate that HOD RBCs continuously localize to the marginal sinus following transfusion, where they colocalize with marginal zone (MZ) B cells. Depletion of MZ B cells inhibited immunoglobulin M (IgM) and IgG anti-HOD antibody formation, whereas CD4 T-cell depletion only prevented IgG anti-HOD antibody development. HOD-specific CD4 T cells displayed similar proliferation and activation following transfusion of HOD RBCs into wild-type or MZ B-cell-deficient recipients, suggesting that IgG formation is not dependent on MZ B-cell-mediated CD4 T-cell activation. Moreover, depletion of follicular B cells failed to substantially impact the anti-HOD antibody response, and no increase in antigen-specific germinal center B cells was detected following HOD RBC transfusion, suggesting that antibody formation is not dependent on the splenic follicle. Despite this, anti-HOD antibodies persisted for several months following HOD RBC transfusion. Overall, these data suggest that MZ B cells can initiate and then contribute to RBC alloantibody formation, highlighting a unique immune pathway that can be engaged following RBC transfusion.
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Affiliation(s)
- Patricia E Zerra
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, and
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA and
| | - Seema R Patel
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA and
| | - Ryan Philip Jajosky
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, and
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and
| | - Connie M Arthur
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, and
| | - James W McCoy
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, and
| | - Jerry William Lynn Allen
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA and
| | - Ross M Fasano
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, and
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA and
| | - John D Roback
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, and
| | - Cassandra D Josephson
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, and
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA and
| | | | - Sean R Stowell
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and
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14
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Oud JA, Evers D, de Haas M, de Vooght KMK, van de Kerkhof D, Som N, Péquériaux NCV, Hudig F, Albersen A, van der Bom JG, Zwaginga JJ. The effect of extended c, E and K matching in females under 45 years of age on the incidence of transfusion-induced red blood cell alloimmunisation. Br J Haematol 2021; 195:604-611. [PMID: 34346067 PMCID: PMC9290146 DOI: 10.1111/bjh.17697] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
Maternal alloantibodies directed against fetal red blood cell (RBC) antigens may cause potentially life‐threatening haemolytic disease of the fetus and newborn (HDFN). Dutch transfusion guidelines therefore prescribe preventive cEK matching for all (pre‐)fertile females. To quantify the impact of cEK matching, we compared overall and antigen‐specific cumulative RBC alloimmunisation incidences in females and males aged <45 years. Among a multicentre cohort comprised of patients who received their first and subsequent RBC unit between 2005 and 2019, first‐formed RBC alloantibodies were detected in 47 of 2998 (1·6%) females and 49 of 2507 (2·0%) males. Comparing females and males, overall alloimmunisation incidences were comparable (3·1% [95% confidence interval (CI) 2·1–4·4] versus 3·5% (95% CI 2·4–4·9, P = 0·853) after 10 units transfused). However, cEK alloimmunisation incidences were significantly lower among females (0·6% (95% CI 0·3–1.5) versus 2·2% (95% CI 1·5–3·4, P = 0·001) after 10 units transfused). Yet, despite cEK‐matching guidelines being in effect, 6·5%, 3·6% and 0·2% of all RBC units remained mismatched for c, E or K antigens respectively. Most of these mismatches were almost always due to emergency settings. Even though cEK alloimmunisation was not prevented completely, implementation of cEK matching resulted in an alloantigen‐exposure risk reduction of up to 98%.
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Affiliation(s)
- Josine A Oud
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Haematology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Dorothea Evers
- Department of Haematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Masja de Haas
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Haematology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Immunohaematology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - Karen M K de Vooght
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daan van de Kerkhof
- Department of Clinical Chemistry and Haematology, Catharina Hospital, Eindhoven, the Netherlands
| | - Nel Som
- Department of Clinical Chemistry, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Nathalie C V Péquériaux
- Department of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | | | - Arjan Albersen
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, 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
| | - Jaap Jan Zwaginga
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Haematology, Leiden University Medical Center, Leiden, the Netherlands
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15
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Stack G. Post-transfusion detection of RBC alloimmunization: Timing is everything. Transfusion 2021; 61:2219-2222. [PMID: 34289127 DOI: 10.1111/trf.16593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Gary Stack
- Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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16
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Rankin A, Darbari D, Campbell A, Webb J, Mo YD, Jacquot C, Delaney M, Luban NLC, Nickel RS. Screening for new red blood cell alloantibodies after transfusion in patients with sickle cell disease. Transfusion 2021; 61:2255-2264. [PMID: 34002408 DOI: 10.1111/trf.16444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with sickle cell disease (SCD) are frequent recipients of red blood cell (RBC) transfusions and are at risk for RBC alloimmunization. RBC alloimmunization is diagnosed by identifying RBC alloantibodies as part of pre-transfusion testing, but this testing fails to detect alloantibodies that have evanesced. It may be beneficial to screen for new RBC alloantibody development after transfusion before possible antibody evanescence. STUDY DESIGN AND METHODS Our institution started a new initiative for episodically transfused patients with SCD to obtain at least one antibody screen 2-6 months after transfusion as part of their clinical care. A database was created to prospectively track all transfused patients for 1 year and their post-transfusion antibody screen results. Patients received prophylactically CEK-matched RBC units. RESULTS During the study year, 138 patients with SCD received a total of 242 RBC transfusions. Patients with a history of an RBC alloantibody (n = 13, 9.4%) had previously received more RBC units than non alloimmunized patients (median 11 vs. 2 RBC units, p = .0002). A total of 337 post-transfusion antibody screens were obtained in 127 patients (92.0%) with 110 patients (79.7%) having at least one antibody screen 2-6 months post-transfusion. With this prospective testing, two new RBC alloantibodies (anti-C and -M) were identified in two patients. CONCLUSION It is feasible to test for new RBC alloantibody development in most episodically transfused patients with SCD as part of their routine care. The yield of this screening appears low with CEK matching, but it could still provide important information for individual patients.
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Affiliation(s)
- Alexander Rankin
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Pediatric Hematology-Oncology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Deepika Darbari
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Andrew Campbell
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Jennifer Webb
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Yunchuan Delores Mo
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Cyril Jacquot
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Meghan Delaney
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Naomi L C Luban
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Robert Sheppard Nickel
- Divisions of Hematology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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17
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Red-cell alloimmunization profile in multi transfused patients: Findings and insights of a blood transfusion service. Transfus Clin Biol 2021; 28:258-263. [PMID: 33901640 DOI: 10.1016/j.tracli.2021.04.006] [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: 12/01/2020] [Revised: 04/07/2021] [Accepted: 04/16/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Blood transfusion is a key intervention for decreasing morbidity and mortality in many cases and, besides its importance, potentially fatal consequences of incompatible transfusion are a great risk to patients. This study evaluated the incidence and specificity of erythrocyte alloantibodies in multi-transfused patients enrolled at an important Regional Blood Center. MATERIALS/METHODS This was a single-center retrospective cohort study that eveluated patients enrolled at a Regional Blood Center in a period of four years. A total of 29,128 patient samples were screened, out of which 79 (0.27%) were multiple-transfused patients with alloantibodies identified. RESULTS The most common alloantibody found was anti-E (22.55%) followed by anti-D (14.71%), anti-C (5.88%), anti-c (5.88%), anti-e (1.96%) and anti-Cw (0.98%). We also identified combinations of alloantibodies (25.32%), 5.88% of which showed an IgG autoantibody isolated or combined with alloantibodies. The most frequent reason for the need of blood transfusion included cases of surgery, emergency and urgency (36.71%). CONCLUSIONS A low rate of development of alloantibodies in multi-transfused patients was found, which could be a consequence of the implementation of red blood cell phenotyping for patients who may receive frequent transfusions, as in the case of some hematological neoplasms and hemoglobinopathies. However, the most common alloantibodies identified were against the Rh and/or Kell systems, with high clinical significance since both can cause delayed hemolytic transfusion reactions. Thus, the implementation of reliable antibody screening tests and the transfusion of phenotyped units for selected patients in all transfusion services represent important measures to increase transfusion safety.
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18
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Gupta GK, Balbuena-Merle R, Hendrickson JE, Tormey CA. Immunohematologic aspects of alloimmunization and alloantibody detection: A focus on pregnancy and hemolytic disease of the fetus and newborn. Transfus Apher Sci 2020; 59:102946. [PMID: 32962917 DOI: 10.1016/j.transci.2020.102946] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Alloimmunization to non-ABO, red blood cell (RBC) antigens remains one of the most clinically-relevant complexities faced by blood banking practitioners. In the setting of transfusion therapy, these antibodies raise risks for incompatibilities, while for pregnant patients they can mediate deadly forms of hemolytic disease of the fetus and newborn. As such, a thorough understanding of pathways that lead to alloimmunization, as well as the tools used by blood banks to detect alloantibodies, is critical to transfusion practice. In this review, in which alloimmunization in the setting of pregnancy will be emphasized, we will review: 1) the clinical impacts of RBC alloantibodies in the peri-partum period; 2) the current pathophysiologic mechanisms thought to influence non-ABO antigen alloimmunization; 3) the strengths and weaknesses of laboratory tools used in aiding alloimmunization detection; and 4) future directions of the transfusion community related to alloimmunization impacting pregnancy.
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Affiliation(s)
- Gaurav K Gupta
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Raisa Balbuena-Merle
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States; Pathology & Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, CT, United States
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States; Department of Pediatrics, Yale University School of Medicine, New Haven, CT, United States
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States.
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19
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El Fetouh RMA, Elmoniem GMA, Allam RM, Sobeih ME, Kamel MM, Radwan SM. Frequency and specificity of Red blood cell alloantibodies in multitransfused Egyptian patients with hematological and nonhematological malignancies. Transfus Apher Sci 2020; 59:102909. [PMID: 32888823 DOI: 10.1016/j.transci.2020.102909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 07/15/2020] [Accepted: 08/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Repeated blood transfusions can result in the production of alloantibodies against one or more red blood cell (RBC) antigens, which can complicate future transfusions. AIM This study aims to determine the frequency and specificities of RBC alloantibodies in multitransfused adult cancer patients admitted at the National Cancer Institute, Cairo University. METHODS This cohort study enrolled 2000 multitransfused cancer patients diagnosed with different types of malignancies; they were screened for RBC alloantibodies using Serascan Diana 3 and Identisera Diana 11-cell identification panels (Diagnostic Grifols, Spain). RESULTS Of the 2000 patients tested, 25 had autoantibodies and were excluded from the study. Of the remaining 1975 patients, 181 patients had a total of 267 different alloantibodies (9.16%), with some having more than 1 antibody detected. Our study showed that more female patients (63%) than male patients (37%) had acquired RBC alloantibodies, and a higher prevalence of alloantibodies in patients with nonhematological malignancies (14%) compared with those with hematological malignancies (6.5%). The highest percentage of alloantibodies belongs to the Rh blood group system, followed by the Kell system, then Duffy, MNS, Kidd, and Lewis. Patients who received combined chemotherapy and immunotherapy exhibited a lesser antibody response compared to other patients. CONCLUSION The prevalence of alloimmunization in our study is comparable to previous reports on oncology patients. Repeated blood transfusions, which can lead to alloimmunization, often complicate future transfusions. Therefore, we recommend extending phenotype matching for patients who are presumed to depend on blood transfusions in the long term.
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Affiliation(s)
- Randa M Abo El Fetouh
- Clinical Pathology Department, National Cancer Institute-Cairo University, Cairo, Egypt
| | - Gamal M Abd Elmoniem
- Clinical Pathology Department, National Cancer Institute-Cairo University, Cairo, Egypt
| | - Rasha Mahmoud Allam
- Biostatistics and Cancer Epidemiology Department, National Cancer Institute-Cairo University, Cairo, Egypt
| | - Mohamed Emam Sobeih
- Medical Oncology Department, National Cancer Institute-Cairo University, Cairo, Egypt
| | - Mahmoud M Kamel
- Clinical Pathology Department, National Cancer Institute-Cairo University, Cairo, Egypt.
| | - Samah M Radwan
- Clinical Pathology Department, National Cancer Institute-Cairo University, Cairo, Egypt
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20
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Gehrie EA, Savani BN, Booth GS. Risk factors for hemolytic transfusion reactions resulting from ABO and minor red cell antigen incompatibility: From mislabeled samples to stem cell transplant and sickle cell disease. Blood Rev 2020; 45:100719. [PMID: 32561028 DOI: 10.1016/j.blre.2020.100719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/08/2020] [Accepted: 06/04/2020] [Indexed: 10/24/2022]
Abstract
Advances in laboratory testing, pathogen reduction and donor qualification have dramatically reduced the risk of acquiring an infection from a blood transfusion. Despite this progress, the most feared complication of transfusion - a hemolytic reaction due to incompatibility between donor and recipient - remains, with essentially no recent progress in the prevention or recognition of this rare but frequently lethal complication. Herein, the role that compatibility testing and transfusion practice play in the occurrence of acute hemolysis are described, with a special emphasis on clinical scenarios confer an increased risk of a severe hemolytic reaction in response to red blood cell or platelet transfusion. In addition, the signs and symptoms of a severe hemolytic reaction are summarized, along with the initial approach to clinical management.
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Affiliation(s)
- Eric A Gehrie
- Department of Pathology, Division of Transfusion Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Bipin N Savani
- The Department of Oncology, Vanderbilt University Medical Center, Nashville, TN, USA; Tennessee Valley Veterans Affairs Hospital, Nashville, TN, USA.
| | - Garrett S Booth
- The Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
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21
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Hauser RG, Hendrickson JE, Tormey CA. TRIX with treats: the considerable safety benefits of a transfusion medicine registry. Transfusion 2020; 59:2489-2492. [PMID: 31374148 DOI: 10.1111/trf.15449] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 06/25/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Ronald G Hauser
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT.,Pathology & Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, CT
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT.,Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT.,Pathology & Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, CT
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22
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Hauser RG, Esserman D, Karafin MS, Tan S, Balbuena-Merle R, Spencer BR, Roubinian NH, Wu Y, Triulzi DJ, Kleinman S, Gottschall JL, Hendrickson JE, Tormey CA. The evanescence and persistence of RBC alloantibodies in blood donors. Transfusion 2020; 60:831-839. [PMID: 32061102 DOI: 10.1111/trf.15718] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Blood donors represent a healthy population, whose red blood cell (RBC) alloantibody persistence or evanescence kinetics may differ from those of immunocompromised patients. A better understanding of the biologic factors impacting antibody persistence is warranted, as the presence of alloantibodies may impact donor health and the fate of the donated blood product. METHODS Donor/donation data collected from four US blood centers from 2012 to 2016 as part of the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) were analyzed. Clinically significant antibodies from blood donors with more than one donation who underwent at least one follow-up antibody screen after the initial antibody identification were included. Of 632,378 blood donors, 481 (128 males and 353 females) fit inclusion criteria. RESULTS Antibody screens detected 562 alloantibodies, with 368 of 562 (65%) of antibodies being persistently detected and with 194 of 562 (35%) becoming evanescent. Factors associated with antibody persistence included antibody specificity, detection at the first donation, reported history of transfusion, and detection of multiple antibodies concurrently. Anti-D, C, and Fya were most likely to persist, while anti-M, Jka , and S were most frequently evanescent. CONCLUSIONS These data provide insight into variables impacting the duration of antibody detection, and they may also influence blood donor center policies regarding donor recruitment/acceptance.
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Affiliation(s)
- Ronald G Hauser
- Yale University, Department of Laboratory Medicine, New Haven, Connecticut.,Department of Pathology & Laboratory Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Matthew S Karafin
- Versiti, Milwaukee, Wisconsin.,Department of Pathology & Laboratory Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Raisa Balbuena-Merle
- Yale University, Department of Laboratory Medicine, New Haven, Connecticut.,Department of Pathology & Laboratory Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Bryan R Spencer
- Yale University, Department of Laboratory Medicine, New Haven, Connecticut.,American Red Cross Scientific Affairs, Dedham, Massachusetts
| | - Nareg H Roubinian
- Department of Laboratory Medicine, University of California, San Francisco, California.,Blood Systems Research Institute, San Francisco, California
| | - Yanyun Wu
- Yale University, Department of Laboratory Medicine, New Haven, Connecticut.,Bloodworks Northwest, Seattle, Washington
| | | | - Steve Kleinman
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jerome L Gottschall
- Versiti, Milwaukee, Wisconsin.,Department of Pathology & Laboratory Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jeanne E Hendrickson
- Yale University, Department of Laboratory Medicine, New Haven, Connecticut.,Department of Pediatrics, Yale University, New Haven, Connecticut
| | - Christopher A Tormey
- Yale University, Department of Laboratory Medicine, New Haven, Connecticut.,Department of Pathology & Laboratory Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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23
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Thein SL, Pirenne F, Fasano RM, Habibi A, Bartolucci P, Chonat S, Hendrickson JE, Stowell SR. Hemolytic transfusion reactions in sickle cell disease: underappreciated and potentially fatal. Haematologica 2020; 105:539-544. [PMID: 32029505 PMCID: PMC7049330 DOI: 10.3324/haematol.2019.224709] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/18/2019] [Indexed: 12/20/2022] Open
Affiliation(s)
- Swee Lay Thein
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MA, USA
| | - France Pirenne
- Etablissement Français du Sang, INSERM U955, Université Paris Est Créteil, Créteil, France.,Laboratoire d'Excellence GR-Ex, Paris, France
| | - Ross M Fasano
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, Atlanta, GA, USA.,Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Anoosha Habibi
- Laboratoire d'Excellence GR-Ex, Paris, France.,Sickle Cell Referral Center, Department of Internal Medicine, Henri-Mondor University Hospital- UPEC, AP-HP, Créteil, France
| | - Pablo Bartolucci
- Sickle Cell Referral Center, Department of Internal Medicine, Henri-Mondor University Hospital- UPEC, AP-HP, Créteil, France
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeanne E Hendrickson
- Departments of Laboratory Medicine and Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Sean R Stowell
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, Atlanta, GA, USA
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24
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25
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Delayed haemolytic and serologic transfusion reactions: pathophysiology, treatment and prevention. Curr Opin Hematol 2019; 25:459-467. [PMID: 30124474 DOI: 10.1097/moh.0000000000000462] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to summarize the basic epidemiology, pathophysiology and management of delayed serologic and delayed haemolytic transfusion reactions (DHTRs), as well as recent developments in our understanding of these adverse events. RECENT FINDINGS Several studies have identified risk factors for DHTRs, including high alloantibody evanescence rates among both general patient groups and those with sickle cell disease (SCD). Antibody detection is also hampered by the phenomenon of transfusion record fragmentation. There have also been enhancements in understanding of what may contribute to the more severe, hyperhaemolytic nature of DHTRs in SCD, including data regarding 'suicidal red blood cell death' and immune dysregulation amongst transfusion recipients with SCD. With growing recognition and study of hyperhaemolytic DHTRs, there have been improvements in management strategies for this entity, including a multitude of reports on using novel immunosuppressive agents for preventing or treating such reactions. SUMMARY Delayed serologic and haemolytic reactions remain important and highly relevant transfusion-associated adverse events. Future directions include further unravelling the basic mechanisms, which underlie DHTRs and developing evidence-based approaches for treating these reactions. Implementing practical preventive strategies is also a priority.
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26
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Pena JJ, Bottiger BA, Miltiades AN. Perioperative Management of Bleeding and Transfusion for Lung Transplantation. Semin Cardiothorac Vasc Anesth 2019; 24:74-83. [DOI: 10.1177/1089253219869030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Perioperative allogeneic blood product transfusion is common in lung transplantation and has various implications on the short- and long-term outcomes of lung recipients. This review summarizes the effect of transfusion on outcomes including primary graft dysfunction, chronic lung allograft dysfunction, and all-cause mortality. We outline known risk factors for increased transfusion requirement in lung transplantation and present current evidence regarding the effect of hemostatic agents including antifibrinolytics, recombinant factor VII, and prothrombin complex concentrates. Finally, we highlight the roles of point-of-care coagulation testing and goal-directed transfusion strategies in reducing transfusion requirements in lung transplantation.
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27
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Guidetti M, Goy-Thollot I, Boisvineau C, Giger U. Alloimmunization of a dog erythrocyte antigen 1- dog transfused with weakly dog erythrocyte antigen 1+ blood. J Vet Intern Med 2019; 33:2037-2045. [PMID: 31361062 PMCID: PMC6766507 DOI: 10.1111/jvim.15565] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/02/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Acute hemolytic transfusion reactions because of dog erythrocyte antigen (DEA) 1 sensitization after mismatched transfusions are serious complications. Dog erythrocyte antigen 1 expression varies from negative to weakly to strongly positive. OBJECTIVES To assess alloimmunization after transfusion of weakly DEA 1+ blood to a DEA 1- dog. ANIMALS One DEA 1- recipient and 1 weakly DEA 1+ donor, and 106 control dogs. METHODS Long-term follow-up study. Matched for DEA 3, 4, 5, and 7, Dal, and Kai 1 and 2, weakly DEA 1+ donor packed red blood cells (RBCs) were transfused 3 times (0.45 mL/kg at Day 0, 16, and 37) to a DEA 1- recipient. Alloantibodies against RBCs from donor and 106 controls were determined in recipient's plasma samples using a commercial antiglobulin-enhanced immunochromatographic strip and gel tube crossmatches. Alloantibody titers were determined. RESULTS The DEA 1- recipient was sensitized after 16 days to ≥1657 days after transfusion to weakly DEA 1+ and otherwise matched RBCs. Strong to moderate crossmatch incompatibilities were observed between recipient's plasma and all 61 DEA 1+ crossmatched controls. Moderate to weak incompatibilities were also observed to DEA 1- controls. Anti-DEA 1 and other alloantibodies were detected over the 4.5 year observation period. CONCLUSIONS AND CLINICAL IMPORTANCE Blood from a weakly DEA 1+ donor induces a strong and durable alloimmunization in a DEA 1- recipient dog. Additional alloantibodies developed against yet to be defined RBC antigens. Those results support the recommendation of typing dogs against DEA 1, considering weakly DEA 1+ as immunogenic, and crossmatching all previously transfused dogs.
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Affiliation(s)
| | | | | | - Urs Giger
- University of Pennsylvania - Section of Medical Genetics, Philadelphia, Pennsylvania
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Boateng LA, Ngoma AM, Bates I, Schonewille H. Red Blood Cell Alloimmunization in Transfused Patients With Sickle Cell Disease in Sub-Saharan Africa; a Systematic Review and Meta-Analysis. Transfus Med Rev 2019; 33:162-169. [PMID: 31345590 DOI: 10.1016/j.tmrv.2019.06.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/23/2019] [Accepted: 06/04/2019] [Indexed: 02/07/2023]
Abstract
Sickle cell disease (SCD) is the most common monogenic disorder in sub-Saharan Africa (SSA). Blood transfusion to increase the oxygen carrying capacity of blood is vital in the management of many patients with SCD. However, red blood cell (RBC) alloimmunization is a major challenge to transfusions in these patients. Commonly in SSA, pretransfusion tests only involve ABO D grouping and compatibility without RBC antibody testing. Data on the frequency of RBC alloimmunization in patients with SCD in SSA are limited. We performed a systematic review and meta-analysis on available data on alloimmunization in transfused patients with SCD to determine the published prevalence of RBC alloimmunization in SCD patients in SSA. Six databases were systematically searched to identify relevant studies, without year or language restrictions. In all, 249 articles were identified and 15 met our selection criteria. The overall proportion of alloimmunization was 7.4 (95% confidence interval: 5.1-10.0) per 100 transfused patients. Antibodies against E, D, C, and K antigens accounted for almost half of antibody specificities, and antibodies to low- and high-frequency antigens were also common and represented almost 30% (20% to low-frequency antigens and 9% to high-frequency antigens) of specificities. Heterogeneity between studies was moderate, and meta-analysis found region of Africa as the major contributor to the heterogeneity. We also observed inconsistencies across studies in reporting of factors that may influence alloimmunization. This review provides an overview of the extent of the alloimmunization problem in SSA and provides a baseline against which to compare the effect of any interventions to reduce the alloimmunization risk.
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Affiliation(s)
- Lilian Antwi Boateng
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK; Medical Laboratory Technology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Alain Mayindu Ngoma
- Douglas Hospital Research Centre, McGill University, Montreal, Quebec, Canada
| | - Imelda Bates
- Medical Laboratory Technology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Henk Schonewille
- Department of Experimental Immunohematology, Sanquin, Amsterdam, Netherlands
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29
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Gammeren AJ, Bos AG, Som N, Veldhoven C, Vossen RCRM, Folman CC. A national Transfusion Register of Irregular Antibodies and Cross (X)‐match Problems: TRIX, a 10‐year analysis. Transfusion 2019; 59:2559-2566. [DOI: 10.1111/trf.15351] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/13/2019] [Accepted: 04/28/2019] [Indexed: 12/19/2022]
Affiliation(s)
| | | | - Nel Som
- Amsterdam University Medical, VUmc Amsterdam the Netherlands
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30
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Perez‐Alvarez I, Hayes C, Hailemariam T, Shin E, Hutchinson T, Klapper E. RHDgenotyping of serologic RhD‐negative blood donors in a hospital‐based blood donor center. Transfusion 2019; 59:2422-2428. [DOI: 10.1111/trf.15325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 03/10/2019] [Accepted: 03/20/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ingrid Perez‐Alvarez
- Department of Pathology, Division of Transfusion MedicineUniversity of California Irvine Medical Center Irvine California
| | - Chelsea Hayes
- Department of Pathology, Division of Transfusion MedicineCedars‐Sinai Medical Center Los Angeles California
| | | | | | | | - Ellen Klapper
- Department of Pathology, Division of Transfusion MedicineCedars‐Sinai Medical Center Los Angeles California
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31
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Tormey CA, Hendrickson JE. Transfusion-related red blood cell alloantibodies: induction and consequences. Blood 2019; 133:1821-1830. [PMID: 30808636 PMCID: PMC6484385 DOI: 10.1182/blood-2018-08-833962] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/01/2018] [Indexed: 01/19/2023] Open
Abstract
Blood transfusion is the most common procedure completed during a given hospitalization in the United States. Although often life-saving, transfusions are not risk-free. One sequela that occurs in a subset of red blood cell (RBC) transfusion recipients is the development of alloantibodies. It is estimated that only 30% of induced RBC alloantibodies are detected, given alloantibody induction and evanescence patterns, missed opportunities for alloantibody detection, and record fragmentation. Alloantibodies may be clinically significant in future transfusion scenarios, potentially resulting in acute or delayed hemolytic transfusion reactions or in difficulty locating compatible RBC units for future transfusion. Alloantibodies can also be clinically significant in future pregnancies, potentially resulting in hemolytic disease of the fetus and newborn. A better understanding of factors that impact RBC alloantibody formation may allow general or targeted preventative strategies to be developed. Animal and human studies suggest that blood donor, blood product, and transfusion recipient variables potentially influence which transfusion recipients will become alloimmunized, with genetic as well as innate/adaptive immune factors also playing a role. At present, judicious transfusion of RBCs is the primary strategy invoked in alloimmunization prevention. Other mitigation strategies include matching RBC antigens of blood donors to those of transfusion recipients or providing immunomodulatory therapies prior to blood product exposure in select recipients with a history of life-threatening alloimmunization. Multidisciplinary collaborations between providers with expertise in transfusion medicine, hematology, oncology, transplantation, obstetrics, and immunology, among other areas, are needed to better understand RBC alloimmunization and refine preventative strategies.
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Affiliation(s)
- Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
- Pathology & Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, CT; and
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
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32
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Balbuena-Merle R, Hendrickson JE. Red blood cell alloimmunization and delayed hemolytic transfusion reactions in patients with sickle cell disease. Transfus Clin Biol 2019; 26:112-115. [PMID: 30857806 DOI: 10.1016/j.tracli.2019.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Red blood cell (RBC) alloimmunization is more common in patients with sickle cell disease (SCD) than in any other studied patient population. The high prevalence of RBC alloimmunization is multi-factorial, likely involving the chronic hemolysis and inflammatory status of SCD itself, the transfusion burden of patients, and the RH genetic diversity of patients and blood donors, among other reasons. Antibody evanescence, or the decrease of RBC alloantibodies below levels detectable by blood bank testing, occurs frequently with fewer than 30% of alloantibodies estimated to be detected by current screening practices. Evanescence increases the likelihood that a patient with SCD will have a delayed hemolytic transfusion reaction upon future RBC exposure, with previously undetected alloantibodies coming roaring back in an anamnestic manner after exposure to the cognate RBC antigen. A subset of patients having delayed hemolytic transfusion reactions go on to experience hyperhemolysis; some but not all cases of hyperhemolysis are associated with previously evanescent RBC alloantibodies. There is an increasing appreciation of the association between RBC alloantibodies and RBC autoantibodies, as well as involvement of the alternative complement pathway in some instances of hyperhemolysis. A case report in this manuscript describes a highly alloimmunized patient with SCD who experiences a delayed hemolytic transfusion reaction with bystander hemolysis due to a previously evanescent, complement binding anti-M RBC alloantibody. Additional studies, including those involving multiple centers and countries, are needed to further understand RBC alloimmunization in patients with SCD and to develop strategies to prevent or mitigate potentially life-threatening hemolytic transfusion reactions.
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Affiliation(s)
- R Balbuena-Merle
- Department of Laboratory Medicine, 330 Cedar Street, CB 405, New Haven, CT 06520-8035, United States
| | - J E Hendrickson
- Department of Laboratory Medicine, 330 Cedar Street, CB 405, New Haven, CT 06520-8035, United States.
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33
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Cserti-Gazdewich C. Shifting ground and gaps in transfusion support of patients with hematological malignancies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:553-560. [PMID: 30504357 PMCID: PMC6246005 DOI: 10.1182/asheducation-2018.1.553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The transfusion support of hematological malignancies considers 2 dimensions: the quantity of what we order (in terms of triggers, doses, targets, and intervals), and the special qualities thereof (with respect to depths of matching and appropriate product modifications). Meanwhile, transfusion-related enhancements in the quantity and quality of life may not be dose dependent but rather tempered by unintended patient harms and system strains from overexposure. Evidence and guidelines concur in endorsing clinically noninferior conservative red blood cell (RBC) transfusion care strategies (eg, triggering at hemoglobin <7-8 g/dL and in single-unit doses for stable, nonbleeding inpatients). However, the unique subpopulation of patients with hematological malignancies who are increasingly managed on an outpatient basis, and striving at least as much for quality of life as quantity of life, is left on the edges of these recommendations, with more questions than answers. If a sufficiently specific future wave of evidence can satisfy the concerns (and contest the assumptions) of the remaining proponents of liberalism, and if conservatism is broadly adopted, savings may be potentially immense. These savings can then be reinvested to address other gaps and inconsistencies in RBC transfusion care, such as the best achievable degrees of prophylactic antigen matching that can minimize alloimmunization-related service delays and reactions.
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Affiliation(s)
- Christine Cserti-Gazdewich
- Laboratory Medicine and Pathobiology (Transfusion Medicine) and Medicine (Clinical Hematology), University Health Network/University of Toronto, Toronto, ON, Canada
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34
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Karafin MS, Tan S, Tormey CA, Spencer BR, Hauser RG, Norris PJ, Roubinian NH, Wu Y, Triulzi DJ, Kleinman S, Gottschall JL, Hendrickson JE. Prevalence and risk factors for RBC alloantibodies in blood donors in the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III). Transfusion 2018; 59:217-225. [PMID: 30427537 DOI: 10.1111/trf.15004] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/31/2018] [Accepted: 09/04/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Little information exists on red blood cell (RBC) alloimmunization in healthy US blood donors, despite the potential significance for donors themselves, blood recipients, and the blood center. STUDY DESIGN AND METHODS Donor/donation data were sourced from the Recipient Epidemiology and Donor Evaluation Study-III, which contains information from four US blood centers during 2012 through 2016. Multivariable logistic regression was used to assess prevalence of positive antibody screen by donor demographics, blood type, parity, and transfusion history. RESULTS More than 2 million units were collected from 632,378 donors, with 0.51% of donations antibody screen positive and 0.77% of donors having at least one positive antibody screen. The most common antibody specificities were D (26.4%), E (23.8%), and K (21.6%). Regression analysis indicated that increasing age, female sex, D-negative status, and history of transfusion and pregnancy were positively associated with a positive antibody screen. Prior transfusion history was most strongly associated with a positive antibody screen, with donors reporting a prior transfusion having a higher adjusted odds ratio (3.9) of having a positive antibody screen compared to donors reporting prior pregnancy (adjusted odds ratio, 2.0). Though transfusion was a more potent immune stimulus for RBC alloantibody formation than pregnancy, the sheer number of previously pregnant donors contributed to pregnancy being a risk factor for the majority of clinically significant RBC alloantibodies detected in females. CONCLUSION These findings on prevalence of and risk factors for RBC antibodies may have implications for future medical care of donors and for operations at blood centers.
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Affiliation(s)
- Matthew S Karafin
- Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University, New Haven, Connecticut.,VA CT, West Haven, Connecticut
| | - Bryan R Spencer
- Department of Laboratory Medicine, Yale University, New Haven, Connecticut.,American Red Cross, Dedham, Massachusetts
| | - Ronald G Hauser
- Department of Laboratory Medicine, Yale University, New Haven, Connecticut.,VA CT, West Haven, Connecticut
| | - Philip J Norris
- University of California, San Francisco, California.,Blood Systems Research Institute, San Francisco, California
| | - Nareg H Roubinian
- University of California, San Francisco, California.,Blood Systems Research Institute, San Francisco, California
| | - Yanyun Wu
- Department of Laboratory Medicine, Yale University, New Haven, Connecticut.,Bloodworks Northwest, Seattle, Washington
| | - Darrell J Triulzi
- University of Pittsburgh and Institute of Transfusion Medicine, Pittsburgh, Pennsylvania
| | - Steve Kleinman
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Jerome L Gottschall
- Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University, New Haven, Connecticut.,Department of Pediatrics, Yale University, New Haven, Connecticut
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35
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Pessoni LL, Ferreira MA, Silva JCRD, Alcântara KCD. Red blood cell alloimmunization among hospitalized patients: transfusion reactions and low alloantibody identification rate. Hematol Transfus Cell Ther 2018; 40:326-331. [PMID: 30370410 PMCID: PMC6200715 DOI: 10.1016/j.htct.2018.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/05/2018] [Indexed: 11/20/2022] Open
Abstract
Background Unexpected red blood cell alloantibodies can cause hemolytic transfusion reactions. In this study, the prevalence of alloimmunization, the rate of identification of alloantibodies and the rate of blood transfusion reactions among transfused patients were identified in a clinical emergency hospital in Brazil. Methods Transfusions and clinical records of patients who had a positive indirect antiglobulin test between January and December 2013 were analyzed. Results Of 1169 patients who received blood transfusions, 28 had positive indirect antiglobulin tests, with one patient having two positive tests at different times, resulting in 29 positive tests during the period of this study. Alloantibodies were identified in 58.6% (17/29) of the cases. In 27.5% (8/29), identification was inconclusive and it was not possible to confirm alloimmunization. The rate of red blood cell alloimmunization was 1.71% (21/1169). Of 21 cases of alloimmunization, four (19%) were unidentified due to an unusual agglutination profile. All identified alloantibodies were clinically significant (10/17 anti-Rh, 5/17 anti-Kell and 2/17 anti-MNS). In two patients who had positive indirect antiglobulin tests, one had an unidentified alloantibody, and the other had an inconclusive test and developed a hemolytic transfusion reaction. Conclusion The prevalence of clinically important red blood cell alloantibodies and hemolytic transfusion reactions among patients with unidentified alloantibodies suggests that specific laboratory techniques should be performed to identify alloantibodies in cases of pan-reactivity or autoantibodies to improve transfusion safety.
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Affiliation(s)
- Lívia Lara Pessoni
- Hospital das Clinicas da Universidade Federal de Goiás (HC/UFG), Goiânia, GO, Brazil
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36
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Howe JG, Stack G. Relationship of epitope glycosylation and other properties of blood group proteins to the immunogenicity of blood group antigens. Transfusion 2018; 58:1739-1751. [PMID: 29770450 DOI: 10.1111/trf.14609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND The intrinsic properties of polypeptide blood group antigens that determine their relative immunogenicities are unknown. Because size, composition, charge, dose, and epitope glycosylation affect the immunogenicity of other polypeptides, we examined whether similar properties were related to the immunogenicity of blood group antigens. STUDY DESIGN AND METHODS Amino acid (AA) sequences of antithetical blood group antigens were searched for N- and O-glycosylation sites. Regression analysis was carried out to determine whether blood group protein properties, including total and ectodomain size, red blood cell (RBC) antigen site density, number of mismatched AAs between an antigen and its closest homolog, and differences in mass, charge, and hydrophobicity of the mismatched AAs, were related to immunogenicity. RESULTS The immunogenicities of non-RhD polypeptide antigens were directly related to the total and ectodomain sizes of their carrier proteins. A negative power relationship existed between RBC antigen site density and immunogenicity, such that the most immunogenic antigens had the lowest site density. The strong immunogenicity of RhD was related to the number of AA mismatches between RhD and RhCE, to their cumulative hydrophobicity and electrostatic mismatch scores, and the cumulative AA mass difference. No N- or O-glycosylation differences were predicted for antithetical or homologous antigens, other than a previously known N-glycosylation difference between K and k. CONCLUSION Epitope glycosylation appeared not to be a determinant of immunogenicity for blood group antigens, except possibly for K. The immunogenicity of blood group antigens was positively related to total and ectodomain sizes of blood group proteins and negatively related to antigen site density. Such findings should be considered hypothesis generating for future, more definitive studies.
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Affiliation(s)
- John G Howe
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Gary Stack
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut.,Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, Connecticut
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37
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Karafin MS, Westlake M, Hauser RG, Tormey CA, Norris PJ, Roubinian NH, Wu Y, Triulzi DJ, Kleinman S, Hendrickson JE. Risk factors for red blood cell alloimmunization in the Recipient Epidemiology and Donor Evaluation Study (REDS-III) database. Br J Haematol 2018; 181:672-681. [PMID: 29675950 DOI: 10.1111/bjh.15182] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 01/29/2018] [Indexed: 12/22/2022]
Abstract
Despite the significance of red blood cell (RBC) alloimmunization, the lack of standardized registries in the US has prevented the completion of large studies. Data from 3·5 years of the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) recipient database, containing information from 12 hospitals, were studied. A RBC alloantibody responder had an antibody identified at any point during the study, and a non-responder had a negative antibody screen at least 15 days post-RBC transfusion. Demographics, blood type, ICD9/10 codes, and other potential correlates were evaluated. Of 319 177 (2·07%) screened patients, 6597 had a total of 8892 clinically significant RBC alloantibodies identified, with 75% being in the Rh or Kell families. Alloimmunization was more common in females (2·38%) than males (1·68%), and in RhD negative (2·82%) than RhD positive (1·94%) patients. Age, sex, RhD status and race were associated with being a responder, and certain diagnoses (including sickle cell disease or trait, systemic lupus erythematosus, rheumatoid arthritis and myelodysplastic syndrome) were more common among responders than non-responders. Data collected in this multi-centre recipient database provide the largest RBC alloimmunized patient cohort studied in the US, with previously known demographic and disease associations of responder status confirmed, and new associations identified.
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Affiliation(s)
| | | | - Ronald G Hauser
- Department of Laboratory Medicine, Yale University, New Haven, CT, USA.,VA CT, West Haven, CT, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University, New Haven, CT, USA.,VA CT, West Haven, CT, USA
| | - Philip J Norris
- University of California, San Francisco, CA, USA.,Blood Systems Research Institute, San Francisco, CA, USA
| | - Nareg H Roubinian
- University of California, San Francisco, CA, USA.,Blood Systems Research Institute, San Francisco, CA, USA
| | - Yanyun Wu
- Department of Laboratory Medicine, Yale University, New Haven, CT, USA.,Bloodworks Northwest, Seattle, WA, USA
| | - Darrell J Triulzi
- University of Pittsburgh and Institute of Transfusion Medicine, Pittsburgh, PA, USA
| | - Steve Kleinman
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University, New Haven, CT, USA.,Department of Pediatrics, Yale University, New Haven, CT, USA
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38
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Molecular immunohaematology round table discussions at the AABB Annual Meeting, Orlando 2016. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018. [PMID: 29517973 DOI: 10.2450/2018.0260-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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39
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Nadarajan VS. The prevalence, immunogenicity, and evanescence of alloantibodies to MUT and Mur antigens of GP.Mur red blood cells in a Southeast Asian patient cohort. Transfusion 2018; 58:1189-1198. [PMID: 29441590 DOI: 10.1111/trf.14538] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/12/2018] [Accepted: 01/12/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antibodies to Mia , MUT, and Mur are among the most frequently identified alloantibodies in Southeast Asia. Understanding the characteristics of these antibodies in terms of induction and evanescence would aid in optimizing methods for their detection. STUDY DESIGN AND METHODS Antibody testing results between the years 2013 and 2015 with relevant patient demographic data and red blood cell (RBC) transfusion history were retrieved. Cumulative alloimmunization incidence and evanescence to MUT and Mur were estimated by Kaplan-Meier analysis in relation to the number of RBC units transfused and time. RESULTS Of 70,543 selected patients, 6186 nonalloimmunized subjects with available antibody testing results posttransfusion were identified. Cumulative alloimmunization incidence for MUT increased from 0.12% (95% confidence interval [CI], 0.03-0.21) to 0.63% (95% CI, 0.25-1.01), while for Mur it increased from 0.04% (95% CI, 0-0.09) to 0.42% (95% CI, 0.05-0.79) when a patient was transfused 2 RBC units as compared to 12. Both antibodies had high evanescence rates and at 1 year, anti-MUT and -Mur will be detected in only 45% (95% CI, 35%-57%) and 27% (95% CI, 17%-43%), respectively, of previously positive patients. MUT and Mur immunogenicity was estimated to be 1.7 and 1.2 times higher than E when their rate of evanescence was taken into account. CONCLUSION Antibodies to MUT and Mur develop following multiple RBC exposures. Immunogenicity of MUT/Mur and evanescence rates of the corresponding antibodies is higher compared to anti-E. Appropriate selection of antibody screening cells is needed in view of the high prevalence, immunogenicity, and evanescence of the antibodies.
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Affiliation(s)
- Veera Sekaran Nadarajan
- Department of Pathology, Faculty of Medicine, University Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia
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40
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Le Niger C, André C, Bourcier V, Augey L, Bazin A, Berger E, Betbeze V, Damais-Cepitelli A, Daurat G, De Meyer E, Ducroz S, Gouezec H, Huchet C, Lassale B, Leo-Kodeli S, Lovi V, Puntous M, Pujol S, Renom P, Rieux C. [Is the research of posttransfusional alloantibodies still relevant?]. Transfus Clin Biol 2017; 25:8-13. [PMID: 29273503 DOI: 10.1016/j.tracli.2017.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/26/2017] [Indexed: 10/18/2022]
Abstract
The decision of November 6th, 2006 defining the principles of best practices recommends that posttransfusional red cell alloantibodies research is performed after one to three months after. In the University hospital of Brest, the haemovigilance unit takes charge of sending the medical prescription within the required time and centralizing the results. We wished to estimate if the realization of this research still remains relevant. METHODS A prospective analysis was performed in 2015. We evaluated the realization rate, the red cell alloantibodies rate and the recipient adverse reactions with the diagnostic category: alloimmunization (delayed serological transfusion reaction, DSTR). RESULTS In 2015, 2162 prescriptions were sent to the 3271 transfused patients. One thousand and eighteen red cell alloantibodies research were done, i.e. a return rate of 61%. Among them, 12 alloantibodies appeared (0.9%) within an average of 56 days. Thirty-three other alloantibodies appeared and were discovered most frequently before a new transfusion. In 10 cases, a posttransfusional research was done that was negative. A survey was conducted among GHCOH members to describe the practices in these health institutions. Twelve questionnaires were analysed. Ten institutions performed a posttransfusional alloantibodies research by issuing a prescription at the patient's exit with a return rate between 0.14 and 16%; 1 institution has a centralized organization with a return rate of 68.3%; 1566 red cell alloantibodies research were performed and among them, 24 alloantibodies appeared (1.53%). CONCLUSION These results indicate that to be effective, the management of this biological test must be centralized. Despite this, the red cell alloantibodies rate remains very low (0.9 and 1.53%) and raises the question of the relevance of this systematic testing after transfusion, which is in any case mandatory before a new transfusion of red blood cells.
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Affiliation(s)
- C Le Niger
- Unité d'hémovigilance, hôpital Morvan, CHRU de Brest, 5, avenue Foch, 29609 Brest cedex, France.
| | - C André
- Unité d'hémovigilance, hôpital Morvan, CHRU de Brest, 5, avenue Foch, 29609 Brest cedex, France
| | - V Bourcier
- Unité d'hémovigilance, CHU de Besançon, 25030 Besançon, France
| | - L Augey
- Unité d'hémovigilance, CHU de Lyon, 69495 Lyon, France
| | - A Bazin
- Unité d'hémovigilance, CHU de Caen, 14033 Caen, France
| | - E Berger
- Unité d'hémovigilance, CHU de Dijon, 21079 Dijon, France
| | - V Betbeze
- Unité d'hémovigilance, Hôtel-Dieu, CHU de Nantes, 40093 Nantes, France
| | - A Damais-Cepitelli
- Unité d'hémovigilance, groupe hospitalier Le Havre, 76600 Le Havre, France
| | - G Daurat
- Unité d'hémovigilance, CHU de Nîmes, 30029 Nîmes, France
| | - E De Meyer
- Unité de sécurité transfusionnelle et d'hémovigilance, CHU Henri-Mondor, 94010 Créteil cedex, France
| | - S Ducroz
- Unité de sécurité transfusionnelle et d'hémovigilance, centre hospitalier Montluçon, 03113 Montluçon, France
| | - H Gouezec
- Unité de sécurité transfusionnelle et d'hémovigilance, CHU de Rennes, 35033 Rennes, France
| | - C Huchet
- Unité de sécurité transfusionnelle, centre hospitalier Bretagne-Atlantique, 56017 Vannes cedex, France
| | - B Lassale
- Unité d'hémovigilance, AP-hôpitaux de Marseille, 13274 Marseille, France
| | - S Leo-Kodeli
- Unité de sécurité transfusionnelle et d'hémovigilance, CHR d'Orléans, 45067 Orléans, France
| | - V Lovi
- Unité de sécurité transfusionnelle et d'hémovigilance, centre hospitalier Roubaix, 59100 Roubaix, France
| | - M Puntous
- Unité de sécurité transfusionnelle et d'hémovigilance, CHU de Bordeaux, 33076 Bordeaux, France
| | - S Pujol
- Unité de sécurité transfusionnelle et d'hémovigilance, CHU de Bordeaux, 33076 Bordeaux, France
| | - P Renom
- Unité de sécurité transfusionnelle, CHU de Lille, 59037 Lille, France
| | - C Rieux
- Unité de sécurité transfusionnelle et d'hémovigilance, CHU Henri-Mondor, 94010 Créteil cedex, France
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41
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Zheng Y, Pollak J, Henderson K, Hendrickson JE, Tormey CA. A novel association between high red blood cell alloimmunization rates and hereditary hemorrhagic telangiectasia. Transfusion 2017; 58:775-780. [DOI: 10.1111/trf.14451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/28/2017] [Accepted: 11/01/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Yan Zheng
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven Connecticut
| | - Jeffrey Pollak
- Department of Radiology and Biomedical Imaging; Yale University School of Medicine; New Haven Connecticut
| | - Katharine Henderson
- Department of Radiology and Biomedical Imaging; Yale University School of Medicine; New Haven Connecticut
| | - Jeanne E. Hendrickson
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven Connecticut
- Department of Pediatrics; Yale University School of Medicine; New Haven Connecticut
| | - Christopher A. Tormey
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven Connecticut
- Pathology & Laboratory Medicine Service; VA Connecticut Healthcare System; West Haven Connecticut
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42
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Hendrickson JE. Red blood cell alloimmunisation: induction of immunity and potential mitigation strategies. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- J. E. Hendrickson
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven CT USA
- Department of Pediatrics; Yale University School of Medicine; New Haven CT USA
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Shmookler A, Hamad D, Scrape S, Chen J. Acute Hemolytic Transfusion Reaction Caused by a Red Cell Antibody That Was Missed by Pretransfusion Testing Using Tube Method. Lab Med 2017; 48:258-261. [PMID: 28934518 DOI: 10.1093/labmed/lmx037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pretransfusion testing is very important to prevent transfusion of incompatible red cells, which might result in a hemolytic transfusion reaction. This includes the detection of antibodies in recipients' serum and compatibility testing between donor cells and recipient serum. The most commonly used methods include gel and tube techniques. We present a case in which an anti-E alloantibody was detected by gel method but not by tube testing. As a result, red cells that were retrospectively phenotyped as positive for E antigen were inadvertently selected and transfused after crossmatch using the same tube method. After transfusion, the patient developed signs of hemolytic transfusion reaction. This case highlights the potential risk of transfusion of incompatible red cells when alloantibody detection is solely relied on tube testing.
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Affiliation(s)
- Aaron Shmookler
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Diane Hamad
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Scott Scrape
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Noiret L, Slater A, Higgins JM. Determinants of red blood cell alloantibody detection duration: analysis of multiply alloimmunized patients supports peritransfusion factors. Transfusion 2017. [DOI: 10.1111/trf.14157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Lorette Noiret
- Center for Systems Biology, Harvard Medical School; Boston Massachusetts
- Department of Pathology; Harvard Medical School; Boston Massachusetts
- Department of Systems Biology; Harvard Medical School; Boston Massachusetts
| | - Amy Slater
- Department of Pathology; Harvard Medical School; Boston Massachusetts
- Blood Transfusion Service, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - John M. Higgins
- Center for Systems Biology, Harvard Medical School; Boston Massachusetts
- Department of Pathology; Harvard Medical School; Boston Massachusetts
- Department of Systems Biology; Harvard Medical School; Boston Massachusetts
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45
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Sloan SR. The importance of antibody screens after transfusions. Transfusion 2016; 56:2653-2654. [DOI: 10.1111/trf.13818] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 08/05/2016] [Indexed: 11/29/2022]
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