Exchange Transfusion for Neonatal Hyperbilirubinemia in Johannesburg, South Africa, from 2006 to 2011

Hematological abnormality and associated factors in newborns with hyperbilirubinemia before and after phototherapy at University of Gondar Comprehensive Specialized Hospital

This study aimed to assess the magnitude of hematological toxicity and associated factors in newborns with hyperbilirubinemia. A cross-sectional study was conducted from April to December 2023. A total of 247 newborns were included. The data were collected using questionnaires and a data extraction sheet. Four 4 ml of blood was collected. A Sysmex KX-21 analyzer was used for blood analysis, and a Mindray BS-240 analyzer was used for bilirubin measurement. The data were entered into Epi-data and analyzed by SPSS. The logistic regression was used. The P value was set at 0.05. Before phototherapy, the hematological toxicities, such as anemia, leucopenia, and thrombocytopenia, were 45.7%, 22.2%, and 6.1%, respectively, whereas after phototherapy, anemia and thrombocytopenia, significantly increased, but the leucopenia, significantly decreased. The risk of developing anemia increased, 3.5, 2.7, and 2.1-fold among newborns with bilirubin > 18 mg/dl, with Rh blood group incompatibility, and treated with intensive phototherapy, respectively. Both low birth weight and intensive phototherapy increased the incidence of thrombocytopenia by 2 and 3.4-fold, respectively. Hematological toxicity was found to be a severe public health issue in newborns. Thus, strict follow-up and early detection of toxicity by considering aggravation factors are necessary.

Exchange blood transfusion for hyperbilirubinaemia: Neonatal characteristics and short-term outcomes

Background. Factors that have been associated with severe hyperbilirubinaemia requiring exchange blood transfusion (EBT) are early discharge, late preterm birth and haemolytic disease. Early discharge is a common practice in neonatal care, so it is important to identify and audit neonates who received EBT, in order to identify modifiable factors.  Objectives. To describe the characteristics and outcomes of infants requiring EBT.  Methods. We reviewed records of infants admitted with severe jaundice requiring EBT from January 2009 to December 2013. Descriptive analysis of characteristics, clinical presentation, laboratory findings and outcome at discharge was performed.  Results. A total of 150 neonates received EBT (30 per year), and 101 were reviewed. Of these, 34 (33.7%) were inpatients and 67 (66.3%) were new admissions (2.34/1 000 new admissions). The majority of neonates requiring EBT were born vaginally (86.1%), were late preterm births (20.8%) and were exclusively breastfed (82.2%). The median postnatal age at presentation was 5 days. Clinical signs suggestive of acute bilirubin encephalopathy were present in 24.8% of cases. Among mother-infant pairs with known blood groups, 9.3% and 70.4% had rhesus (Rh) and ABO incompatibility, respectively. A Coombs test was positive in 62.5% of those with Rh incompatibility compared with 31.7% of those with ABO incompatibility. A total of 6 patients (5.9%) died, all within 7 days of EBT, but none during EBT.  Conclusion. The majority of neonates requiring EBT presented post discharge after birth and had been born vaginally at term, suggesting early discharge after delivery. More than two-thirds of cases were related to ABO incompatibility. Screening for jaundice before discharge must be prioritised, especially for infants born to mothers who are Rh negative or ABO blood group O. 

Efficacy of Red Blood Cell Exchange as Adjunctive Treatment for Hypoxemia and Survival Rate of Patients With Severe Coronavirus-2 Disease: An Open-Labeled Phase 2 Randomized Clinical Trial

Background

Severe acute respiratory syndrome (SARS) coronavirus-2 may infect red blood cells (RBCs) and impact oxygenation. We aimed to evaluate the efficacy of RBC exchange as an adjunctive treatment for hypoxemia and the survival rate of patients with severe coronavirus disease 2019 (COVID-19).

Methods

In a randomized clinical trial, we divided sixty patients with severe COVID-19 into two groups. The intervention group received the standard treatment of severe COVID-19 with RBC exchange three to four times in 2 days. The control group only received the standard treatment. Our primary outcomes were improving hypoxemia in 7 days, recovery or discharge, and death in 28 days. We conducted Chi-square test, independent samples t-test, and Fisher’s exact test to analyze the results. The ethical committee of Aja University of Medical Sciences approved the study (IR.AJAUMS.REC.1399.054), and the Iranian clinical trial registration organization registered it (IRCT20160316027081N2).

Results

Twenty-nine men and thirty-one women with a mean age of 67.5 years entered the study. The frequency of hypertension and diabetes mellitus was 86.7 and 68.3%, respectively. The most common symptoms of severe COVID-19 were dyspnea (91.6%), cough (75%), and fever (66.6%). Our results showed that hypoxemia improved in 21 of the 30 patients (70%) in the intervention group and 10 of the 30 patients (33.3%) in the control group (P < 0.004). The recovery and discharge rates were 19 of 30 patients (63.3%) in the intervention group and 2 of 30 patients (6.7%) in the control group (P < 0.001).

Conclusion

The RBC exchange improved the oxygenation and survival rate in patients with severe COVID-19.

High levels of unbound bilirubin are associated with acute bilirubin encephalopathy in post-exchange transfusion neonates

BACKGROUND

Although it is known that unbound bilirubin can enter the brain, there is little evidence of its association with the development of acute bilirubin encephalopathy. Here, we investigated this potential relationship in neonates who had undergone exchange transfusion.

METHODS

Data from 46 newborns who underwent exchange transfusion between 2016 and 1-1 to 2018-12-31 at the First People's Hospital of Changde City in China were analyzed. The unbound bilirubin level was taken as the independent variable and the development of the acute bilirubin encephalopathy as the dependent variable. The covariates were age, birth weight, sex, red blood cell count, blood glucose, hemolytic disease, and whether the infant had received phototherapy.

RESULTS

The mean age and gestational age of the neonates were 146.5 ± 86.9 h and 38.6 ± 1.3 weeks [38.7(34.6-41.1) weeks] old, respectively; 52.17% were male. Binary logistic regression analysis after adjustment for covariates showed a positive association between the levels of unbound bilirubin and the development of acute bilirubin encephalopathy (odds ratio = 1.41, 95% confidence intervals 1.05-1.91, P = < 0.05).

CONCLUSION

There is a significant association between unbound bilirubin levels and the development of acute bilirubin encephalopathy in neonates. Further investigations are required to explore the mechanisms.

Pattern of serum bilirubin changes following double volume exchange blood transfusion in neonates at a tertiary health facility in Nigeria

Introduction

exchange blood transfusion (EBT) is a form of massive transfusion useful in rapidly reducing serum bilirubin levels, but serum bilirubin levels frequently rebound within hours of completing the procedure, due to equilibration of extravascular bilirubin as well as on-going hemolysis. The study was carried out to determine the pattern of reduction in serum bilirubin levels following EBT among neonates with severe hyperbilirubinemia, as well as the factors contributing to this pattern, so as to establish evidence-based expectations following EBT.

Methods

a retrospective descriptive study covering a two-year period in a Nigerian tertiary hospital. Details of the EBT procedures, including serial serum bilirubin levels, were obtained from the hospital records of all newborn babies who had double volume EBT done for severe hyperbilirubinaemia during the study period. Data was analyzed using the statistical software SPSS version 21.0.

Results

the mean total serum bilirubin (TSB) before EBT in the 36 babies was 17.9 ± 6.3 mg/dl. The mean percentage decrease in TSB immediately following EBT was 44.3 ± 10.2%. Six hours after EBT, TSB levels had increased from the immediate post-EBT values by an average of 57.5 ± 32.2%. Twenty-four hours after the procedure, TSB values in most (87.1%) cases were still higher than the immediate post-EBT values, but lower than the pre-EBT values. Post-EBT anemia was recorded among 33.3% of the babies.

Conclusion

EBT is effective in rapidly reducing serum bilirubin levels and preventing acute bilirubin encephalopathy in neonates with severe hyperbilirubinemia, despite the rebound increase that occurs in TSB values after the procedure.

The Spectrum of Hemolytic Disease of the Newborn: Evaluating the Etiology of Unconjugated Hyperbilirubinemia Among Neonates Pertinent to Immunohematological Workup

Background and objective The exact burden of hemolytic disease of the newborn (HDN) attributed to neonatal unconjugated hyperbilirubinemia (NUH) in developing nations is still unclear. Still, anti-D is reported to be the most common cause of HDN in India. ABO incompatibility has emerged as a leading cause of exchange transfusion (ET) in many countries. But many centers in our country rely on direct antiglobulin test (DAT) as a screening tool to evaluate immunological causes, whereas advanced immunohematological workup like antibody screening, identification, and elution tests are also required. Early identification of implicated antibodies resulting in HDN can aid in the proper selection of blood units when ET is indicated, and hence also in managing the subsequent pregnancy. This study focused on determining the causes of neonatal hyperbilirubinemia (NH), especially with respect to immunohematological evaluation. This cross-sectional study was conducted on 240 neonates requiring neonatal intensive care unit (NICU) support for NUH at a tertiary care hospital. Materials and methods Demographic data, along with detailed history pertaining to the cause of hyperbilirubinemia, was collected. Clinical and laboratory evaluation and complete immunohematological work including DAT, heat elution, antibody screening, antibody identification, and Rh Kell phenotyping were performed from neonate blood samples. Data were analyzed using SPSS Statistics version 19 (IBM Corp., Armonk, NY). Results Pathological jaundice was more common (62.1%) than physiological jaundice (37.9%). The various pathological causes identified were HDN (42.6%), sepsis (12%), cephalohematoma (5.4%), and idiopathic (1.7%). Among HDN cases, ABO incompatibility (39.2%) was the most prevalent cause, followed by Rh HDN and G6PD deficiency (1.7% each). DAT was positive in only 14 cases out of 94 ABO-incompatible cases. Elution revealed antibodies in four DAT-negative neonates with ABO incompatibility and more specificity to the OA setting. DAT was positive with 100% sensitivity in Rh HDN cases (n=4). Elution demonstrated the presence of anti-D (n=2), anti-D + anti-C (n=1) and anti-E (n=1), confirming Rh HDN. DAT strength was found to be significantly associated with hemoglobin (Hb) level (p=0.048). The majority of cases were treated with phototherapy only (94.1%), and 10 cases received both ET and phototherapy. Four neonates' condition improved without any intervention. Conclusion This study highlighted the shift in the trend from Rh HDN to ABO incompatibility as the cause of hemolytic jaundice in NICU neonates. Elution tests can aid in the diagnosis of DAT-negative ABO-incompatible hemolytic anemia. Early diagnosis, along with timely intervention and appropriate measures, can prevent neonatal morbidity and mortality. Negative DAT does not rule out HDN. Sensitive techniques like elution must be used in the presence of clinical suspicion.

Exchange Transfusion for Hyperbilirubinemia among Term and Near Term in NICU of a Tertiary Care Hospital of Bangladesh: Findings from a Prospective Study

Background

Exchange transfusion in newborns is recommended as emergency management of hyperbilirubinemia to prevent bilirubin encephalopathy and kernicterus.

Aim

This study aimed to determine the frequency and document common side effects of exchange transfusion and outcomes of newborns requiring exchange transfusion.

Materials and methods

This prospective study was done in the Neonatal Intensive Care Unit (NICU) of Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh, from January 2016 to December 2019. Information was obtained regarding maternal details, newborn demographics, and clinical status. Blood grouping and Rh typing were done for both mothers and newborns. In all newborns, pre-exchange complete blood count, peripheral blood film, Coombs test, reticulocyte count, serum bilirubin and post-exchange serum bilirubin, hemoglobin, random blood sugar, serum electrolyte, and calcium were done. G6PD level was done wherever suspected. Frequency, maternal and neonatal factors, indications, and outcomes were analyzed.

Results

Among 839 admitted cases of unconjugated hyperbilirubinemia, 41 patients (4.9%) required exchange transfusion. Most of the babies were inborn (90.2%). Ninety-five percent of mothers received regular antenatal care; among them, 76.3% had bad obstetric history. Only 36.6% of mothers received anti-D in previous pregnancy. None had sonographic findings of hydrops. The commonest indication was Rh incompatibility (80.5%). Coombs test was positive in 58.5% of cases. Mean pre-exchange TSB was 9.44 ± 6.4, and post-exchange TSB was 4.41 ± 2.59. The commonest adverse events noted were hyperglycemia (51.2%), sepsis (19.5%), anemia requiring top-up transfusion (17.1%), and hypocalcemia (14.6%). There were no catheter-related complications. Bilirubin encephalopathy was present in 4.9% of cases. There was one mortality but not due to the procedure.

Conclusion

Exchange transfusion was required among 4.9% of the admitted newborns with unconjugated hyperbilirubinemia. The common adverse effects were hyperglycemia and sepsis. The commonest indication was Rh incompatibility (80.5%). Overall outcome after exchange transfusion was favorable.

How to cite this article

Dey SK, Jahan S, Jahan I, et al. Exchange Transfusion for Hyperbilirubinemia among Term and Near Term in NICU of a Tertiary Care Hospital of Bangladesh: Findings from a Prospective Study. Euroasian J Hepato-Gastroenterol 2021;11(1):21–26.

Use of serum bilirubin/albumin ratio for early prediction of bilirubin induced neurological dysfunction

Background

Kernicterus or bilirubin encephalopathy is a preventable cause of handicap, still occurs in our country. The aim of the current study was to assess the role of bilirubin/albumin ratio in improving the morbidity of the cases with unconjugated hyperbilirubinemia and to estimate of the cutoff value for B/A ratio for prevention and early management of bilirubin-induced neurological dysfunction.

Results

The mean gestational age was 37.1 ± 2.11 weeks; the mean age of onset of jaundice was 2.36 ± 1.04 days; the mean level of total bilirubin was 26.14 ± 7.36 mg/dl. At chosen cutoff value of bilirubin albumin ratio (B/A) 6.68, sensitivity was 82% while specificity was 64% and accuracy was 95%.

Conclusion

Bilirubin encephalopathy still occurs in significant number in our country though it is a preventable cause of handicapping. TSB is a sensitive but not a specific indicator of ABE, B/A ratio is more specific indicator of the neurologic outcome and should be utilized in the decision of early intervention.