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Bartolmäs T, Pruß A, Mayer B. Three different pathways of IgM-antibody-dependent hemolysis are mainly regulated by complement. Front Immunol 2023; 14:1114509. [PMID: 36817469 PMCID: PMC9933241 DOI: 10.3389/fimmu.2023.1114509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Antibodies to red blood cells (RBCs) may hemolyze erythrocytes via Fc-mediated phagocytosis or complement-dependent. Complement activation on RBCs can be detected by C3d-direct antiglobulin test (DAT), which is the only test in immune hematology that directly targets complement. However, a positive DAT with anti-C3d cannot distinguish between C3b-mediated extravascular hemolysis, C5b-C9-mediated intravascular hemolysis and C5b-C8-mediated eryptosis. Furthermore, DAT is not suitable to estimate the strength of hemolysis. Autoimmune hemolytic anemia (AIHA) is a rare disease that is caused by autoantibodies to red blood cells that is divided in warm AIHA and in cold agglutinin disease (CAD). The causative antibodies in CAD and sometimes in warm AIHA are from the IgM class. Depending on strength of complement activation they can induce extravascular hemolysis, intravascular hemolysis and eryptosis. We studied the three types of hemolysis by use of sera from patients with CAD under various conditions. We found that additionally to the routinely applied C3d-DAT, indirect tests for complement activity (free hemoglobin and Annexin V-binding to phosphatidylserine-exposing RBCs) should be used to determine the portion of extravascular, intravascular and eryptotic hemolysis. Eryptotic hemolysis may have a significant share in clinical relevant CAD or IgM warm AIHA, which should be considered for successful treatment.
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Affiliation(s)
| | - Axel Pruß
- Institute of Transfusion Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Ringel F, Kiesewetter H, Mayer B, Bartolmäs T, Sehouli J, Salama A. Silvernanoparticle-induced hemolysis confounded with direct antiglobulin test-negative autoimmune hemolytic anemias diagnosis. Transfusion 2022; 62:2648-2652. [PMID: 36325695 DOI: 10.1111/trf.17172] [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: 05/05/2022] [Revised: 08/12/2022] [Accepted: 08/20/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND We describe here the first patient with recurrent hemolysis related to disinfectant containing silver nanoparticles (AgNps). METHODS A 58-year-old chemist repeatedly experienced DAT-negative (Coombs-negative) hemolysis during the last 5 years. He was treated with a number of immunosuppressive drugs including 18 times rituximab. The attempt to treat him with cyclosporine A served only to increase the rate of hemolysis. Only by chance, we revealed that the patient regularly used a hand disinfectant containing AgNps. Serological testing was performed using standard techniques. Eryptosis was measured by binding annexin to exposed phosphatidylserine (PS) of the circulating red blood cells (RBCs). RESULTS Antiglobulin tests remained negative, and PS exposing RBCs were detected two times during the last hemolytic episodes. Hemolysis completely disappeared following discontinuation of AgNp containing products. CONCLUSION AgNps are increasingly being used in a large variety of products. Recently, it was reported that they induce in vitro prohemolytic and procoagulant effects via oxidative stress and eryptosis. The clinical findings imply the hemolysis was provoked by the patient's regular use of cleansing products containing AgNps. Our finding might help to explain the etiology of hemolytical disorders that may remain obscure in many cases.
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Affiliation(s)
- Frauke Ringel
- Klinik für Gynäkologie mit Zentrum für onkologische Chirurgie (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Medicover, Hämostaseologicum Mitte, Berlin, Germany
| | | | - Beate Mayer
- Institut for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thilo Bartolmäs
- Institut for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jalid Sehouli
- Klinik für Gynäkologie mit Zentrum für onkologische Chirurgie (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Abdulgabar Salama
- Klinik für Gynäkologie mit Zentrum für onkologische Chirurgie (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Medicover, Hämostaseologicum Mitte, Berlin, Germany
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Balola AHA, Mayer B, Bartolmäs T, Salama A. A fluorometric erythrophagocytosis assay using differentiated monocytic THP-1 cells to assess the clinical significance of antibodies to red blood cells. Vox Sang 2021; 116:1106-1116. [PMID: 33942922 DOI: 10.1111/vox.13105] [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: 10/11/2020] [Revised: 03/02/2021] [Accepted: 03/09/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES The significance of antibodies to red blood cells (RBCs) is variable and cannot be predicted solely by serological testing. A flow cytometry-based erythrophagocytosis assay was established using phorbol 12-myristate 13-acetate (PMA)-treated THP-1 cells and RBCs labelled with PKH26 to assess allo- and autoantibodies to RBCs. MATERIALS AND METHODS THP-1 cells were differentiated into macrophage-like cells by treatment with PMA. RBC samples coated with alloantibodies or autoantibodies were obtained from 16 patients with autoimmune haemolytic anaemia of warm type (wAIHA) as well as from five pregnant women with warm autoantibodies. RBCs from healthy blood donors were used as controls. RBCs were labelled with the red lipophilic fluorescent dye PKH26 and incubated with PMA-treated THP-1 cells. After removal of nonadherent RBCs by washing and haemolysis of adherent RBCs, erythrophagocytosis was quantified by flow cytometry. RESULTS We observed significant phagocytosis of RBCs coated with clinically relevant alloantibodies (i.e. anti-D and anti-K) or autoantibodies from patients with active wAIHA, but not of those coated with alloantibodies (anti-Ch) or autoantibodies from patients and pregnant women without haemolysis. CONCLUSION The flow cytometry-based erythrophagocytosis test described here is quantitative, highly reliable, and may be helpful for the assessment of the clinical significance of antibodies to RBCs.
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Affiliation(s)
- Abdelwahab Hassan Ahmed Balola
- Institute of Transfusion Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Beate Mayer
- Institute of Transfusion Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thilo Bartolmäs
- Institute of Transfusion Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Abdulgabar Salama
- Department of Gynecology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Eluate testing with monospecific antisera unmasks multiple immunoglobulin classes and identifies frequent IgA involvement in severe autoimmune hemolytic anemia. Transfus Apher Sci 2018; 57:384-387. [PMID: 29716828 DOI: 10.1016/j.transci.2018.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 03/18/2018] [Accepted: 04/17/2018] [Indexed: 11/23/2022]
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Bartolmäs T, Mayer B, Balola AH, Salama A. Eryptosis in autoimmune haemolytic anaemia. Eur J Haematol 2017; 100:36-44. [PMID: 28960523 DOI: 10.1111/ejh.12976] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Haemolysis and anaemia related to autoimmune haemolytic anaemia (AIHA) of warm type (wAIHA) and of cold type (cAIHA) are believed to be solely due to antibody and/or complement-mediated destruction and clearance of red blood cells (RBCs). There is evidence that RBCs of affected patients may also undergo eryptosis, the suicidal death of RBCs. METHOD RBCs from 24 patients with wAIHA, 7 patients with chronic cAIHA and one patient with AIHA of mixed type were analysed for exposed phosphatidylserine (PS) by treatment with phycoerythrin-labelled Annexin V, and cell-associated fluorescence was measured using a MACSQuant flow cytometer. RESULTS PS-exposing RBCs were detected in 7 of 13 patients with clinically significant wAIHA. Haemolysis was mostly related to IgM or IgA autoantibodies (aab) in those patients. In contrast, PS exposure in 11 patients with wAIHA in complete remission was comparable to that in healthy blood donors. All patients with chronic cAIHA and the patient with AIHA of mixed type showed haemolytic activity and high numbers of PS-exposing RBCs. Patients with decompensated AIHA appear to respond to treatment with erythropoietin, which is a known inhibitor of eryptosis. CONCLUSION Eryptosis may frequently occur in AIHA related to IgM or IgA aab. Inhibition of eryptosis with erythropoietin may represent a new therapeutic option in the treatment of AIHA.
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Affiliation(s)
- Thilo Bartolmäs
- Institut für Transfusionsmedizin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Beate Mayer
- Institut für Transfusionsmedizin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Abdelwahab H Balola
- Institut für Transfusionsmedizin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Abdulgabar Salama
- Institut für Transfusionsmedizin, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Bartolmäs T, Yürek S, Balola AHA, Mayer B, Salama A. Evidence Suggesting Complement Activation and Haemolysis at Core Temperature in Patients with Cold Autoimmune Haemolytic Anaemia. Transfus Med Hemother 2015; 42:328-32. [PMID: 26696802 PMCID: PMC4678319 DOI: 10.1159/000437200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/21/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It is unclear why haemolysis may somewhat persist in patients with cold autoimmune haemolytic anaemia (cAIHA) at 37 °C (core temperature). METHODS Seven patients with cAIHA were included in this study. Serological testing was performed using standard techniques. Bound autoantibodies (aab) on patients' RBCs were analysed by the direct antiglobulin test (DAT), dual antiglobulin test (DDAT) and flow cytometry (FC) using pre-warmed RBCs (37 °C). Temperature-dependent complement binding was determined by incubation of patients' serum samples with group O RBCs and fresh serum complement. RESULTS The DAT was strongly positive with anti-C3d in all cases, independent of season and outside temperature. Haemolysis usually improved during warm periods of time, but decompensated following febrile infections, and persisted throughout the year, though exposure to the cold was strictly avoided. In addition, trace amounts of IgM aab were infrequently detectable on patients' RBCs even at 37 °C, and complement activation was demonstrated following incubation of RBCs with the causative aab at 37 °C. CONCLUSIONS Binding of trace amounts of IgM aab at 37 °C may provide an explanation for the durable C3d-positive DAT and haemolysis in patients with cAIHA.
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Affiliation(s)
- Thilo Bartolmäs
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Salih Yürek
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Beate Mayer
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Abdulgabar Salama
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Yürek S, Mayer B, Almahallawi M, Pruss A, Salama A. Precautions surrounding blood transfusion in autoimmune haemolytic anaemias are overestimated. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:616-21. [PMID: 26192772 PMCID: PMC4624538 DOI: 10.2450/2015.0326-14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/03/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND It is very evident that many precautions are taken regarding transfusion of red blood cells in patients with autoimmune haemolytic anaemia. Frequently, considerable efforts are made to examine the indication and serological compatibility prior to transfusion in such patients. However, at times, this may unnecessarily jeopardize patients who urgently require a red blood cell transfusion. MATERIALS AND METHODS Thirty-six patients with warm-type autoimmune haemolytic anaemia were included in this study. All patients had reactive serum autoantibodies and required blood transfusion. Standard serological assays were employed for the detection and characterization of antibodies to red blood cells. RESULTS A positive direct antiglobulin test was observed in all 36 patients, in addition to detectable antibodies in both the eluate and serum. Significant alloantibodies were detected in the serum samples of three patients (anti-c, anti-JK(a), and anti-E). In 32 patients, red blood cell transfusion was administered with no significant haemolytic transfusion reactions due to auto- and/or allo-antibodies. Due to overestimation of positive cross-matches three patients received no transfusion or delayed transfusion and died, and one patient died due to unrecognised blood loss and anaemia which was attributed to an ineffective red blood cell transfusion. DISCUSSION Many of the reported recommendations regarding transfusion of red blood cells in autoimmune haemolytic anaemia are highly questionable, and positive serological cross-matches should not result in a delay or refusal of necessary blood transfusions.
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Affiliation(s)
- Salih Yürek
- Institute for Transfusion Medicine, Charité-University Medical School of Berlin, Berlin, Germany
| | - Beate Mayer
- Institute for Transfusion Medicine, Charité-University Medical School of Berlin, Berlin, Germany
| | - Mohammed Almahallawi
- Institute for Transfusion Medicine, Charité-University Medical School of Berlin, Berlin, Germany
| | - Axel Pruss
- Institute for Transfusion Medicine, Charité-University Medical School of Berlin, Berlin, Germany
| | - Abdulgabar Salama
- Institute for Transfusion Medicine, Charité-University Medical School of Berlin, Berlin, Germany
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Salama A. Clinically and/or Serologically Misleading Findings Surrounding Immune Haemolytic Anaemias. Transfus Med Hemother 2015; 42:311-5. [PMID: 26696799 PMCID: PMC4678313 DOI: 10.1159/000438960] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/26/2015] [Indexed: 11/19/2022] Open
Abstract
Autoimmune haemolytic anaemias (AIHAs) are well-characterized disorders. They can be differentiated from one another and from other non-immune haemolytic anaemias by clinical, laboratory and serological testing. However, several misleading clinical presentations and/or serological findings may result in misinterpretation, delay and/or misdiagnosis. Such failures are avoidable by adequate clinical and serological experience of the responsible physicians and serologists or, at least, by an optimised bidirectional communication. As long as this has not been achieved, unpleasant failures are to be expected. A true diagnosis of AIHA can neither be verified by clinical nor serological findings alone. Thus, a collective clinical and serological picture remains obligatory for fulfilling the criteria of optimal diagnosis and therapy. Ultimately, the majority of pioneer scientific and practical work in this field stems from scientists who were simultaneously involved in both the clinic and serology.
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Affiliation(s)
- Abdulgabar Salama
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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