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Zakieh A, Mercure-Corriveau N, Lanzkron S, Feng X, Vozniak S, Crowe EP, Rai H, Lawrence C, Bekkouri D, Goel R, Tobian AAR, Bloch EM. Chronic automated red cell exchange therapy for sickle cell disease. Transfusion 2024; 64:1509-1519. [PMID: 39003570 PMCID: PMC11316647 DOI: 10.1111/trf.17924] [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: 02/07/2024] [Revised: 05/01/2024] [Accepted: 06/02/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND The data to support chronic automated red cell exchange (RCE) in sickle cell disease (SCD) outside of stroke prevention, is limited, especially in adults. STUDY DESIGN AND METHODS A retrospective analysis was conducted of patients with SCD who were referred for chronic RCE at our institution over a 10-year period. Data that were evaluated included patient demographics, referral indications, and procedural details (e.g., vascular access, adverse events, etc.). In a subanalysis, the number of annual acute care encounters during 3 years of chronic RCE was compared with that in the year preceding the first RCE. RESULTS A total of 164 patients were referred for chronic RCE: median age was 28 years (interquartile range [IQR] = 22-36) at referral and 60% were female. Seventy (42.6%) were naïve to chronic transfusion (simple or RCE) prior to referral. The leading indications for referral were refractory pain (73/164, 44.5%) and iron overload (57/164, 34.7%). A total of 5090 procedures occurred during the study period (median = 19, IQR = 5-45). Of the 138 patients who had central vascular access, 8 (6%) and 16 (12%) had ≥1 central-line-related thrombosis and/or infection, respectively. Of those who were not RBC alloimmunized at initiation of RCE, 12/105 (11.4%) developed new antibodies during chronic RCE. In those 30 patients who were adherent to therapy for 3 years, there was no significant difference in acute care encounters following initiation of RCE. CONCLUSION Prospective clinical trials are needed to determine which patients are most likely to benefit from chronic RCE and refine selection accordingly.
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Affiliation(s)
- Abdulhafiz Zakieh
- Department of Pediatrics, Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Nicolas Mercure-Corriveau
- Department of Pathology, Division of Transfusion Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sophie Lanzkron
- Department of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xinyi Feng
- Department of Pathology, Division of Transfusion Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sonja Vozniak
- Department of Pathology, Division of Transfusion Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth P Crowe
- Department of Pathology, Division of Transfusion Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Herleen Rai
- Department of Pathology, Division of Transfusion Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Courtney Lawrence
- Department of Pediatrics, Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Denise Bekkouri
- Department of Pediatrics, Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ruchika Goel
- Department of Pathology, Division of Transfusion Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Vitalant, Scottsdale, Arizona, USA
| | - Aaron A R Tobian
- Department of Pathology, Division of Transfusion Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Evan M Bloch
- Department of Pathology, Division of Transfusion Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Leiva-Torres GA, Cigna M, Constanzo-Yanez J, St-Louis M, Perreault J, Lavoie J, Laflamme G, Lewin A, Pastore Y, Robitaille N. Transfusing children with sickle cell disease using blood group genotyping when the pool of Black donors is limited. Transfusion 2024; 64:716-726. [PMID: 38497419 DOI: 10.1111/trf.17778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 01/19/2024] [Accepted: 02/26/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Red blood cell transfusion is an effective treatment for patients with sickle cell disease (SCD). Alloimmunization can occur after a single transfusion, limiting further usage of blood transfusion. It is recommended to match for the ABO, D, C, E, and K antigens to reduce risks of alloimmunization. However, availability of compatible blood units can be challenging for blood providers with a limited number of Black donors. STUDY DESIGN AND METHODS A prospective cohort of 205 pediatric patients with SCD was genotyped for the RH and FY genes. Transfusion and alloimmunization history were collected. Our capacity to find RhCE-matched donors was evaluated using a database of genotyped donors. RESULTS Nearly 9.8% of patients carried a partial D variant and 5.9% were D-. Only 45.9% of RHCE alleles were normal, with the majority of variants affecting the RH5 (e) antigen. We found an alloimmunization prevalence of 20.7% and a Rh alloimmunization prevalence of 7.1%. Since Black donors represented only 1.40% of all blood donors in our province, D- Caucasian donors were mostly used to provide phenotype matched products. Compatible blood for patients with rare Rh variants was found only in Black donors. A donor with compatible RhCE could be identified for all patients. CONCLUSION Although Rh-compatible donors were identified, blood units might not be available when needed and/or the extended phenotype or ABO group might not match the patient. A greater effort has to be made for the recruitment of Black donors to accommodate patients with SCD.
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Affiliation(s)
| | - Maude Cigna
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Canada
| | | | | | | | - Josée Lavoie
- Hema-Quebec, Medical Affairs and Innovation, Quebec, Canada
| | | | - Antoine Lewin
- Hema-Quebec, Medical Affairs and Innovation, Quebec, Canada
- Faculty of Medicine and Health Science, Sherbrooke University, Sherbrooke, Canada
| | - Yves Pastore
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Canada
| | - Nancy Robitaille
- Hema-Quebec, Transfusion Medicine, Montreal, Canada
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Canada
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Ito S, Pandya A, Hauser RG, Krishnamurti L, Stites E, Tormey C, Krumholz HM, Hendrickson JE, Goshua G. Decreasing alloimmunization-specific mortality in sickle cell disease in the United States: Cost-effectiveness of a shared transfusion resource. Am J Hematol 2024; 99:570-576. [PMID: 38279581 DOI: 10.1002/ajh.27211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/28/2024]
Abstract
Red blood cell alloimmunization and consequent delayed hemolytic transfusion reaction (DHTR) incidence and mortality in patients with sickle cell disease (SCD) are high. A shared transfusion resource has decreased both in other countries, while in the United States cost concerns persist. We conducted a Markov cohort simulation of a birth cohort of alloimmunized patients with SCD to estimate lifetime DHTR incidence, DHTR-specific mortality, quality-adjusted life expectancy (QALE), and costs with the implementation of a shared transfusion resource to identify antibody history versus without (i.e., status quo). We conducted our analysis using a lifetime analytic time horizon and from a United States health system perspective. Implementation of shared transfusion resource projects to decrease cumulative DHTR-specific mortality by 26% for alloimmunized patients with SCD in the United States, relative to the status quo. For an average patient population of 32 000, this intervention would generate a discounted increment of 4000 QALYs at an incremental discounted cost of $0.3 billion, resulting in an incremental cost-effectiveness ratio of $75 600/QALY [95% credible interval $70 200-81 400/QALY]. The results are most sensitive to the baseline lifetime medical expenditure of patients with SCD. Alloantibody data exchange is cost-effective in 100% of 10 000 Monte Carlo simulations. The resource would theoretically need a minimum patient population of 1819 patients or cost no more than $5.29 million annually to be cost-effective. By reducing DHTR-specific mortality, a shared transfusion resource in the United States projects to be a life-saving and cost-effective intervention for patients with SCD in the United States.
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Affiliation(s)
- Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ronald G Hauser
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Pathology and Laboratory Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Lakshmanan Krishnamurti
- Section of Pediatric Hematology, Oncology and Bone Marrow Transplant, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Edward Stites
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Chris Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine and Pathology, Emory University, Atlanta, Georgia, USA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
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4
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Mercure-Corriveau N, Crowe EP, Vozniak S, Feng X, Rai H, Van Denakker T, Zakieh A, Grabowski MK, Lanzkron S, Tobian AAR, Bloch EM. Euvolemic automated transfusion to treat severe anemia in sickle cell disease patients at risk of circulatory overload. Transfusion 2024; 64:124-131. [PMID: 38069526 PMCID: PMC10841671 DOI: 10.1111/trf.17613] [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: 10/13/2023] [Revised: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Red blood cell (RBC) transfusion remains a major treatment for sickle cell disease (SCD). Patients with SCD have a high prevalence of renal impairment and cardiorespiratory disease, conferring risk of transfusion-associated circulatory overload (TACO). STUDY DESIGN AND METHODS We describe an approach, titled euvolemic automated transfusion (EAT), to transfuse SCD patients with severe anemia who are at risk of TACO. In EAT, plasmapheresis is performed using donor RBCs, rather than albumin or plasma, as replacement fluid. Euvolemia is maintained. A retrospective analysis was conducted of patients with SCD who underwent EAT at our institution over a 10-year period, to evaluate the efficacy and safety of EAT. RESULTS Eleven SCD patients underwent 109 EAT procedures (1-59 procedures per patient). The median age was 42 years (IQR = [30-49]) and 82% (n = 9) were female. Most (82%; n = 9) patients had severe chronic kidney disease and 55% (n = 6) had heart failure. One (9%) patient had a history of life-threatening TACO. Mean pre- and post-procedure Hct values were 19.8% (SD ± 1.6%) and 29.1% (SD ± 1.4%), respectively. The average Hct increment was 3.2% per RBC unit. Only two EAT-related complications were recorded during the 109 procedures: central line-associated infection and citrate toxicity (muscle cramping). EAT used an average of two RBC units less than that projected for standard automated RBC exchange. CONCLUSION Our findings suggest that EAT is safe and effective to treat patients with SCD and severe anemia, who are at risk for TACO. EAT requires fewer RBC units compared to automated RBC exchange.
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Affiliation(s)
- Nicolas Mercure-Corriveau
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth P Crowe
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sonja Vozniak
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xinyi Feng
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Herleen Rai
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tayler Van Denakker
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Abdulhafiz Zakieh
- Division of Hematology-Oncology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - M Kate Grabowski
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sophie Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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5
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Choi J, Markantonis JE, De Simone N, Nero A, Kim J, Sarode R. Hemoglobin S target of <50% as compared to 30% in chronic red cell exchange for secondary stroke prevention in sickle cell disease. J Clin Apher 2023; 38:677-684. [PMID: 37525930 DOI: 10.1002/jca.22078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 07/03/2023] [Accepted: 07/13/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Sickle cell disease (SCD) patients with a history of stroke are encouraged to receive chronic red blood cell exchange (RBCx) for stroke prevention. The American Society of Hematology guideline published in 2020 recommends an HbS target of <30%. However, this approach necessitates more frequent RBCx and more RBC units. UT Southwestern has devised a chronic exchange protocol that elevates the HbS target to <50% in patients with a low risk of stroke. STUDY DESIGN This retrospective chart review study reviewed the medical records of patients receiving chronic RBCx with a target of HbS <50% over the past 10-year period to assess the safety of maintaining higher HbS targets in SCD patients with a low risk of cerebrovascular accidents (CVA). RESULTS Among 49 SCD patients in the chronic RBCx program for secondary stroke prevention, 33 patients were maintained on an HbS target of <50% (average measured: 35.4%) for the duration of RBCx program enrollment (median 93.0 months, 95% CI, 83-99). Stroke or transient ischemic attack (TIA) clearly attributable to changing target HbS had not been identified among the 33 study subjects. Seven patients experienced conversion between the HbS targets of <50% and <30% HbS target. Significant reductions were observed in the frequency of RBCx and usage of blood volume in four of them. CONCLUSION The findings suggest that liberalizing the HbS target could confer clinical flexibility without increasing the risk of CVA in a selective population. Further studies to fully evaluate the potential benefits of this approach are indicated.
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Affiliation(s)
- Jihee Choi
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Nicole De Simone
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Alecia Nero
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jaehyup Kim
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ravi Sarode
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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6
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Buban KR, Lawrence CE, Zhu XJ, Tobian AAR, Gehrie EA, Vozniak S, Shrestha R, Lokhandwala PM, Bloch EM. Algorithm‐based selection of automated red blood cell exchange procedure goals reduces blood utilization in chronically transfused adults with sickle cell disease. J Clin Apher 2022; 37:468-475. [DOI: 10.1002/jca.22004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 05/11/2022] [Accepted: 06/22/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Kristen R. Buban
- Division of Transfusion Medicine, Department of Pathology Johns Hopkins University Baltimore Maryland USA
| | - Courtney E. Lawrence
- Division of Transfusion Medicine, Department of Pathology Johns Hopkins University Baltimore Maryland USA
| | - Xianming Joshua Zhu
- Division of Transfusion Medicine, Department of Pathology Johns Hopkins University Baltimore Maryland USA
| | - Aaron A. R. Tobian
- Division of Transfusion Medicine, Department of Pathology Johns Hopkins University Baltimore Maryland USA
| | | | - Sonja Vozniak
- Division of Transfusion Medicine, Department of Pathology Johns Hopkins University Baltimore Maryland USA
| | - Ruchee Shrestha
- Division of Transfusion Medicine, Department of Pathology Johns Hopkins University Baltimore Maryland USA
| | | | - Evan M. Bloch
- Division of Transfusion Medicine, Department of Pathology Johns Hopkins University Baltimore Maryland USA
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7
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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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8
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Jalali Far MA, Oodi A, Amirizadeh N, Mohammadipour M, Keikhaei Dehdezi B. The Rh blood group system and its role in alloimmunization rate among sickle cell disease and sickle thalassemia patients in Iran. Mol Genet Genomic Med 2021; 9:e1614. [PMID: 33547762 PMCID: PMC8104156 DOI: 10.1002/mgg3.1614] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/03/2021] [Accepted: 01/18/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The alloimmunization following blood transfusion can be life-threatening. The Rh alloantibodies are one of the most common causes contributing to alloimmunization. This study aimed to evaluate the rate and causes of alloimmunization and to determine the Rh phenotypes and genotypes among sickle cell disease (SCD) and sickle thalassemia (Sβ). MATERIALS AND METHODS Our study included 104 SCD and Sβ patients referring to Baghaei 2 Hospital of Ahvaz in 2019 using a non-random simple sampling method. The blood samples were collected for Rh phenotypes, alloantibody screening and identification, and molecular tests. The SSP-PCR and RFLP methods with the Pst 1 enzyme were used. RESULTS The alloimmunization rate was 9.6% and 13.2% based on immunohematological tests and medical records, respectively. The main alloantibodies (90%) were anti-Rh, and 40% of the patients had multiple alloantibodies. A significant correlation was found between gender and alloimmunization. The phenotypes of DCce (37.5%), DCcEe (24%), Dce (20.2%), and dce (5.8%) and genotypes of R1r (25%), R1R2 (20.2%), R1R1 (18.3%), and R1R0 (10.6%) were the most prevalent. The R1R2 was a frequent genotype in Sβ. CONCLUSION R0r' and R1R0 genotypes were limited to our population in Iran. Due to the differences in RH genotypes between our population and others, the blood transfusion from other ethnicities increased our total alloimmunization rate.
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Affiliation(s)
- Mohammad Ali Jalali Far
- Blood Transfusion Research CenterHigh Institute for Research and Education in Transfusion MedicineTehranIran
| | - Arezoo Oodi
- Blood Transfusion Research CenterHigh Institute for Research and Education in Transfusion MedicineTehranIran
| | - Naser Amirizadeh
- Blood Transfusion Research CenterHigh Institute for Research and Education in Transfusion MedicineTehranIran
| | - Mahshid Mohammadipour
- Blood Transfusion Research CenterHigh Institute for Research and Education in Transfusion MedicineTehranIran
| | - Bijan Keikhaei Dehdezi
- Thalassemia & Hemoglobinopathy Research Center, Research Institute of HealthAhvaz Jundishapur University of Medical SciencesAhvazIran
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9
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Pal M, Bao W, Wang R, Liu Y, An X, Mitchell WB, Lobo CA, Minniti C, Shi PA, Manwani D, Yazdanbakhsh K, Zhong H. Hemolysis inhibits humoral B-cell responses and modulates alloimmunization risk in patients with sickle cell disease. Blood 2021; 137:269-280. [PMID: 33152749 PMCID: PMC7820872 DOI: 10.1182/blood.2020008511] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/12/2020] [Indexed: 12/24/2022] Open
Abstract
Red blood cell alloimmunization remains a barrier for safe and effective transfusions in sickle cell disease (SCD), but the associated risk factors remain largely unknown. Intravascular hemolysis, a hallmark of SCD, results in the release of heme with potent immunomodulatory activity, although its effect on SCD humoral response, specifically alloimmunization, remains unclear. Here, we found that cell-free heme suppresses human B-cell plasmablast and plasma cell differentiation by inhibiting the DOCK8/STAT3 signaling pathway, which is critical for B-cell activation, as well as by upregulating heme oxygenase 1 (HO-1) through its enzymatic byproducts, carbon monoxide and biliverdin. Whereas nonalloimmunized SCD B cells were inhibited by exogenous heme, B cells from the alloimmunized group were nonresponsive to heme inhibition and readily differentiated into plasma cells. Consistent with a differential B-cell response to hemolysis, we found elevated B-cell basal levels of DOCK8 and higher HO-1-mediated inhibition of activated B cells in nonalloimmunized compared with alloimmunized SCD patients. To overcome the alloimmunized B-cell heme insensitivity, we screened several heme-binding molecules and identified quinine as a potent inhibitor of B-cell activity, reversing the resistance to heme suppression in alloimmunized patients. B-cell inhibition by quinine occurred only in the presence of heme and through HO-1 induction. Altogether, these data suggest that hemolysis can dampen the humoral B-cell response and that B-cell heme responsiveness maybe a determinant of alloimmunization risk in SCD. By restoring B-cell heme sensitivity, quinine may have therapeutic potential to prevent and inhibit alloimmunization in SCD patients.
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Affiliation(s)
| | | | | | | | - Xiuli An
- Laboratory of Membrane Biology, New York Blood Center, New York, NY
| | - William B Mitchell
- Department of Pediatrics, Montefiore Health Center, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY
| | - Cheryl A Lobo
- Laboratory of Blood-Borne Parasites, New York Blood Center, New York, NY
| | - Caterina Minniti
- Department of Medicine, Division of Hematology, Montefiore Health Center, Albert Einstein College of Medicine, Bronx, NY; and
| | - Patricia A Shi
- Sickle Cell Clinical Research Program, New York Blood Center, New York, NY
| | - Deepa Manwani
- Department of Pediatrics, Montefiore Health Center, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY
| | | | - Hui Zhong
- Laboratory of Immune Regulation, and
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10
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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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11
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Castleman JS, Kilby MD. Red cell alloimmunization: A 2020 update. Prenat Diagn 2020; 40:1099-1108. [PMID: 32108353 DOI: 10.1002/pd.5674] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/17/2020] [Accepted: 02/21/2020] [Indexed: 12/27/2022]
Abstract
Management of maternal red cell alloimmunization has been revolutionized over the last 60 years. Advances in the prevention, screening, diagnosis, and treatment of alloimmune-induced fetal anemia make this condition an exemplar for contemporary practice in fetal therapy. Since survival is now an expectation, attention has turned to optimization of long-term outcomes following an alloimmunized pregnancy. In this review, the current management of red cell alloimmunization is described. Current research and future directions are discussed with particular emphasis on later life outcomes after alloimmune fetal anemia.
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Affiliation(s)
- James S Castleman
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Mark D Kilby
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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12
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Van Buren NL, Gorlin JB, Corby SM, Cassidy S, FritchLilla S, Nelson SC, Westhoff CM. How do I incorporate red cell genotyping to improve chronic transfusion therapy? Transfusion 2019; 60:16-25. [DOI: 10.1111/trf.15599] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 09/20/2019] [Accepted: 10/26/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Nancy L. Van Buren
- Innovative Blood Resources St. Paul Minnesota
- Transfusion Services, Children's Minnesota Minneapolis Minnesota
| | - Jed B. Gorlin
- Innovative Blood Resources St. Paul Minnesota
- Transfusion Services, Children's Minnesota Minneapolis Minnesota
| | | | - Sandra Cassidy
- Transfusion Services, Children's Minnesota Minneapolis Minnesota
| | | | - Stephen C. Nelson
- Cancer and Blood Disorders, Children's Minnesota Minneapolis Minnesota
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13
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Hauser RG, Kwon RJ, Ryder A, Cheng C, Charifa A, Tormey C. Transfusion Medicine Equations Made Internet Accessible. Transfus Med Rev 2019; 34:5-9. [PMID: 31785949 DOI: 10.1016/j.tmrv.2019.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 09/06/2019] [Accepted: 10/02/2019] [Indexed: 11/25/2022]
Abstract
Multiple mathematical equations inform the practice of transfusion medicine. These equations apply to a wide range of topics: dosage of blood products, calculation of fluid volumes, and even specific treatment decisions (e.g. corrected count increment for determination of platelet refractoriness). The calculation of these equations can be complicated, prone to error, and time-consuming. A trusted source is needed to accurately perform these calculations 24 hours a day without error and without monetary cost. We sought to build internet-enabled calculators relevant to the practice of transfusion medicine. We partnered with MDCalc, an online host of medical calculators with 1 million monthly users in 196 countries, to design and host the calculators. The calculators guide users in the application of transfusion medicine equations by providing indications for use, inputs for the equations variables, error-checking, warnings for bad inputs, and interpretive guidance of the result. The following calculators were built: blood volume, corrected count increment (CCI), plasma dosage, cryoprecipitated antihemophilic factor dosage, approximate number of units for compatibility testing, maternal-fetal hemorrhage Rh(D) immune globulin dosage, intrauterine RBC transfusion dosage, neonatal polycythemia partial exchange, theoretical removal of a substance by plasmapheresis, sickle cell RBC exchange volume, peripheral blood stem cell collection, and a calculator relevant to donor lymphocyte infusion. Clinicians can now utilize this reputable and highly visible online source to access these common transfusion medicine equations at any time with an internet-enabled device (https://www.mdcalc.com/search?filter=transfusion+medicine).
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Affiliation(s)
- Ronald George Hauser
- Veterans Affairs Connecticut Healthcare, West Haven, CT; Yale University School of Medicine, Department of Laboratory Medicine, New Haven, CT.
| | | | - Alex Ryder
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN; University of Tennessee Health Science Center, Department of Pediatrics and Department of Pathology, Memphis, TN 38103
| | - Caleb Cheng
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Ahmad Charifa
- Yale University School of Medicine, Department of Laboratory Medicine, New Haven, CT
| | - Christopher Tormey
- Veterans Affairs Connecticut Healthcare, West Haven, CT; Yale University School of Medicine, Department of Laboratory Medicine, New Haven, CT
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14
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Affiliation(s)
- Sandhya R Panch
- From the Department of Transfusion Medicine, Warren G. Magnuson Clinical Center, National Institutes of Health Clinical Center, Bethesda, MD
| | - Celina Montemayor-Garcia
- From the Department of Transfusion Medicine, Warren G. Magnuson Clinical Center, National Institutes of Health Clinical Center, Bethesda, MD
| | - Harvey G Klein
- From the Department of Transfusion Medicine, Warren G. Magnuson Clinical Center, National Institutes of Health Clinical Center, Bethesda, MD
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15
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Poole GD. Is extended red cell antigen matching of blood donors and recipients a practical reality? Transfus Med 2019; 28:458-459. [PMID: 30549382 DOI: 10.1111/tme.12571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/26/2018] [Indexed: 11/30/2022]
Affiliation(s)
- G D Poole
- British Blood Transfusion Society, Enterprise House, Lloyd Street North, Manchester Science Park, Manchester, UK
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16
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Yoshida T, Prudent M, D’Alessandro A. Red blood cell storage lesion: causes and potential clinical consequences. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2019; 17:27-52. [PMID: 30653459 PMCID: PMC6343598 DOI: 10.2450/2019.0217-18] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 12/06/2018] [Indexed: 11/21/2022]
Abstract
Red blood cells (RBCs) are a specialised organ that enabled the evolution of multicellular organisms by supplying a sufficient quantity of oxygen to cells that cannot obtain oxygen directly from ambient air via diffusion, thereby fueling oxidative phosphorylation for highly efficient energy production. RBCs have evolved to optimally serve this purpose by packing high concentrations of haemoglobin in their cytosol and shedding nuclei and other organelles. During their circulatory lifetimes in humans of approximately 120 days, RBCs are poised to transport oxygen by metabolic/redox enzymes until they accumulate damage and are promptly removed by the reticuloendothelial system. These elaborate evolutionary adaptions, however, are no longer effective when RBCs are removed from the circulation and stored hypothermically in blood banks, where they develop storage-induced damages ("storage lesions") that accumulate over the shelf life of stored RBCs. This review attempts to provide a comprehensive view of the literature on the subject of RBC storage lesions and their purported clinical consequences by incorporating the recent exponential growth in available data obtained from "omics" technologies in addition to that published in more traditional literature. To summarise this vast amount of information, the subject is organised in figures with four panels: i) root causes; ii) RBC storage lesions; iii) physiological effects; and iv) reported outcomes. The driving forces for the development of the storage lesions can be roughly classified into two root causes: i) metabolite accumulation/depletion, the target of various interventions (additive solutions) developed since the inception of blood banking; and ii) oxidative damages, which have been reported for decades but not addressed systemically until recently. Downstream physiological consequences of these storage lesions, derived mainly by in vitro studies, are described, and further potential links to clinical consequences are discussed. Interventions to postpone the onset and mitigate the extent of the storage lesion development are briefly reviewed. In addition, we briefly discuss the results from recent randomised controlled trials on the age of stored blood and clinical outcomes of transfusion.
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Affiliation(s)
| | - Michel Prudent
- Laboratoire de Recherche sur les Produits Sanguins, Transfusion Interrégionale CRS, Epalinges, Switzerland
- Faculté de Biologie et de Médicine, Université de Lausanne, Lausanne, Switzerland
| | - Angelo D’Alessandro
- Department of Biochemistry and Molecular Genetics University of Colorado, Denver, CO, United States of America
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17
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van Sambeeck JHJ, de Wit PD, Luken J, Veldhuisen B, van den Hurk K, van Dongen A, Koopman MMW, van Kraaij MGJ, van der Schoot CE, Schonewille H, de Kort WLAM, Janssen MP. A Conceptual Framework for Optimizing Blood Matching Strategies: Balancing Patient Complications Against Total Costs Incurred. Front Med (Lausanne) 2018; 5:199. [PMID: 30090809 PMCID: PMC6069448 DOI: 10.3389/fmed.2018.00199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 06/18/2018] [Indexed: 01/06/2023] Open
Abstract
Alloimmunization is currently the most frequent adverse blood transfusion event. Whilst completely matched donor blood would nullify the alloimmunization risk, this is practically infeasible. Current matching strategies therefore aim at matching a limited number of blood groups only, and have evolved over time by systematically including matching strategies for those blood groups for which (serious) alloimmunization complications most frequently occurred. An optimal matching strategy for controlling the risk of alloimmunization however, would balance alloimmunization complications and costs within the entire blood supply chain, whilst fulfilling all practical requirements and limitations. In this article the outline of an integrated blood management model is described and various potential challenges and prospects foreseen with the development of such a model are discussed.
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Affiliation(s)
- Joost H J van Sambeeck
- Department of Transfusion Technology Assessment, Sanquin Research, Amsterdam, Netherlands.,Center for Healthcare Operations Improvement and Research, University of Twente, Enschede, Netherlands
| | - Puck D de Wit
- Department of Donor Studies, Sanquin Research, Amsterdam, Netherlands
| | - Jessie Luken
- Sanquin Diagnostic Services, Amsterdam, Netherlands
| | - Barbera Veldhuisen
- Sanquin Diagnostic Services, Amsterdam, Netherlands.,Sanquin Research and Landsteiner Laboratory, Department of Experimental Immunohematology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | | | - Anne van Dongen
- Department of Donor Studies, Sanquin Research, Amsterdam, Netherlands
| | - Maria M W Koopman
- Department of Transfusion Medicine, Sanquin Blood Bank, Amsterdam, Netherlands
| | - Marian G J van Kraaij
- Department of Transfusion Medicine, Sanquin Blood Bank, Amsterdam, Netherlands.,Department of Donor Affairs, Sanquin Blood Bank, Amsterdam, Netherlands.,Department of Clinical Transfusion Research, Sanquin Research, Amsterdam, Netherlands
| | - C Ellen van der Schoot
- Sanquin Research and Landsteiner Laboratory, Department of Experimental Immunohematology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Henk Schonewille
- Sanquin Research and Landsteiner Laboratory, Department of Experimental Immunohematology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Wim L A M de Kort
- Department of Donor Studies, Sanquin Research, Amsterdam, Netherlands.,Department of Social Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Mart P Janssen
- Department of Transfusion Technology Assessment, Sanquin Research, Amsterdam, Netherlands
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18
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Webb J, Delaney M. Red Blood Cell Alloimmunization in the Pregnant Patient. Transfus Med Rev 2018; 32:213-219. [PMID: 30097223 DOI: 10.1016/j.tmrv.2018.07.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/22/2018] [Accepted: 07/05/2018] [Indexed: 12/13/2022]
Abstract
Alloimmunization to red blood cell (RBC) antigens represents a challenge for physicians caring for women of child bearing potential. Exposure to non-self RBC antigens may occur during transfusion or pregnancy leading to the development of antibodies. If a subsequent fetus bears that antigen, maternal antibodies may attack the fetal red blood cells causing red cell destruction and clinically significant hemolytic disease of the fetus and newborn (HDFN). In the most severe cases, HDFN may result in intrauterine fetal demise due to high output cardiac failure, effusions and ascites, known as "hydrops fetalis". This article reviews strategies for management and prevention of RBC alloimmunization in women of child bearing potential.
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Affiliation(s)
- Jennifer Webb
- Children's National Health System, Washington, D.C., USA; The George Washington University, Departments of Pediatrics & Pathology, Washington, DC, USA.
| | - Meghan Delaney
- Children's National Health System, Washington, D.C., USA; The George Washington University, Departments of Pediatrics & Pathology, Washington, DC, USA
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