1
|
Xhaard A, Floch A, Ruggiu M, Robin M, Sicre de Fontbrune F, Michonneau D, Kaphan E, Prata PHDL, Socié G, Traineau R, Peffault de Latour R, Leprêtre AC. Donor/recipient Rh-mismatched allogeneic hematopoietic stem cell transplantation: transfusion strategy and allo-immunization to red blood cell antigens. Bone Marrow Transplant 2024:10.1038/s41409-024-02316-0. [PMID: 38796632 DOI: 10.1038/s41409-024-02316-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/28/2024]
Abstract
In the case of donor/recipient rhesus (Rh)-incompatibility after allogeneic hematopoietic stem cell transplantation (alloHSCT), the transfusion policy in France is to transfuse red blood cells (RBC) in the donor's Rh phenotype from the day of transplantation, leading to a risk of allo-immunization, either of donor or recipient origin. In this single-center retrospective study, the incidence of donor/recipient Rh incompatibility was 7.1% over an 8-year period including 1012 alloHSCT. Six of 58 evaluable patients (10.3%) developed alloantibodies to RBC antigens within one year of alloHSCT. None of these allo-immunizations were directed against the donor-mismatched Rh antigens and none could have been prevented by the transfusion of recipient and donor Rh-compatible RBC units. None of these allo-immunizations led to immune-mediated hemolytic anemia. We observed a statistically significant higher incidence of chronic GVHD among patients with anti-RBC allo-immunization. In the context of donor/recipient Rh incompatibility, the transfusion of packed RBC units in the donor's Rh phenotype from the day of alloHSCT is feasible and not associated with a high risk of allo-immunization. The generalization of this strategy could be discussed even when donor and recipient Rh phenotypes could be respected, to allow the preservation of units of infrequent phenotypes for other indications.
Collapse
Affiliation(s)
- Aliénor Xhaard
- Service Hématologie Greffe, Hôpital Saint-Louis, Université Paris Cité, Paris, France.
| | - Aline Floch
- Université Paris Est Créteil, INSERM U955 Equipe Transfusion et Maladies du Globule Rouge, IMRB, Créteil, France
- Laboratoire de Biologie Médicale de Référence en Immunohématologie Moléculaire, Etablissement Français du Sang Ile-de-France, Créteil, France
| | - Mathilde Ruggiu
- Service Hématologie Greffe, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - Marie Robin
- Service Hématologie Greffe, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | | | - David Michonneau
- Service Hématologie Greffe, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - Eleonore Kaphan
- Service Hématologie Greffe, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | | | - Gérard Socié
- Service Hématologie Greffe, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - Richard Traineau
- Etablissement Français du Sang Ile-de-France Site Saint-Louis, Paris, France
| | | | | |
Collapse
|
2
|
Matteocci A, Pierelli L. Immuno-Hematologic Complexity of ABO-Incompatible Allogeneic HSC Transplantation. Cells 2024; 13:814. [PMID: 38786038 PMCID: PMC11119197 DOI: 10.3390/cells13100814] [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: 02/06/2024] [Revised: 04/23/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024] Open
Abstract
ABO incompatibility is not considered a contraindication for hematopoietic stem cell transplantation (HSCT). Approximately 30% of transplants from related donors and up to 50% of transplants from unrelated donors are ABO incompatible. Immuno-hematologic investigations allow to estimate donor/recipient ABO mismatch and anti-A/B isohemagglutinin (IHA) titration in the pre-HSCT phase. Immediate hemolysis or delayed complications (passenger lymphocyte syndrome and pure red cell aplasia) can occur post HSCT. Some preventive measures take into consideration either decision-making algorithms based on the recipient's IHA titration or clinical protocols for the removal/reduction of IHAs through plasma exchange or immunoadsorption procedures. Product manipulation through red blood cell (RBC) and/or plasma depletion can also be taken into account. Currently, the best approach in the management of ABO-incompatible transplant is not defined in expert consensus documents or with solid evidence. In addition, the methods for IHA titration are not standardized. A transfusion strategy must consider both the donor's and recipient's blood group systems until the RBC engraftment catches on and ABO conversion (forward and reverse typing) is confirmed on two consecutive and independent samples. Therefore, ABO incompatibility in HSCT represents a demanding immuno-hematologic challenge and requires all necessary preventive measures, including the appropriate selection of ABO blood components for transfusion.
Collapse
Affiliation(s)
- Antonella Matteocci
- Transfusion Medicine and Stem Cells Unit, San Camillo Forlanini Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy;
| | - Luca Pierelli
- Transfusion Medicine and Stem Cells Unit, San Camillo Forlanini Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy;
- Department of Experimental Medicine, Sapienza University, 00185 Rome, Italy
| |
Collapse
|
3
|
Spadea M, Saglio F, Ceolin V, Barone M, Zucchetti G, Quarello P, Fagioli F. Immune-mediated cytopenias (IMCs) after HSCT for pediatric non-malignant disorders: epidemiology, risk factors, pathogenesis, and treatment. Eur J Pediatr 2023; 182:2471-2483. [PMID: 36967419 PMCID: PMC10257634 DOI: 10.1007/s00431-023-04912-6] [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] [Received: 12/21/2022] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 06/11/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) represents a curative option for pediatric patients affected by malignant and non-malignant disorders. Several complications may arise during the post-transplantation period, including immune-mediated disorders. Immune-mediated cytopenias (IMCs) account for up to 22% of pediatric HSCT complications, representing an important cause of morbidity and mortality post-HSCT. So far, their pathogenesis is not well-understood, and their management may be very challenging. Further, most patients are refractory to first-line treatment which is based on high-dose intravenous steroids, immunoglobulin, and the monoclonal anti-CD20 antibody - rituximab. No clear consensus has been reached for second- and third-line therapeutic options. CONCLUSION We reviewed the epidemiology, risk factors, pathogenesis, and treatment of IMCs, aiming to offer a deeper understanding of these complications as a guide to improving the management of these fragile patients and a cue for the design of tailored clinical trials. WHAT IS KNOWN • IMCs arising in the post-HSCT setting represent a rare but potentially life-threatening complication. Younger patients affected by non-malignant disorders are at the greatest risk of IMCs arising after HSCT. Corticosteroids, intravenous immunoglobulin, and rituximab represent the undiscussed first-line therapeutic approach. WHAT IS NEW • This review highlitghts how children present unique risk factors for post HSCT IMCs, which are the result of the complex relationship between the immaturity of their infantile immune system and all the perturbing agents and factors which characterize the post-HSCT setting. Future efforts are warranted to establish the best option for refractory patients, for whom a standard and validated approach is not currently available. Among new agents, ibrutinib or bortezomib and fostamatinib or low-dose IL-2 could represent a good therapeutic option for patients with graft-versus-host disease and hemolytic anemia or graft-versus-host disease and thrombocytopenia, respectively.
Collapse
Affiliation(s)
- Manuela Spadea
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- University of Torino, Turin, Italy
| | - Francesco Saglio
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Valeria Ceolin
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- Erasmus University MC-Sophia Childrens Hospital, Rotterdam, Netherlands
| | - Marta Barone
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Giulia Zucchetti
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Paola Quarello
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy.
- University of Torino, Turin, Italy.
| | - Franca Fagioli
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- University of Torino, Turin, Italy
| |
Collapse
|
4
|
Jekarl DW, Kim JK, Han JH, Lee H, Yoo J, Lim J, Kim Y. Transfusion support in hematopoietic stem cell transplantation. Blood Res 2023; 58:S1-S7. [PMID: 36843378 PMCID: PMC10133853 DOI: 10.5045/br.2023.2023004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/16/2023] [Accepted: 01/20/2023] [Indexed: 02/28/2023] Open
Abstract
Transfusion support for hematopoietic stem cell transplantation (HSCT) is an essential part of supportive care, and compatible blood should be transfused into recipients. As leukocyte antigen (HLA) matching is considered first and as the blood group does not impede HSCT, major, minor, bidirectional, and RhD incompatibilities occur that might hinder transfusion and cause adverse events. Leukocyte reduction in blood products is frequently used, and irradiation should be performed for blood products, except for plasma. To mitigate incompatibility and adverse events, local transfusion guidelines, hospital transfusion committees, and patient management should be considered.
Collapse
Affiliation(s)
- Dong Wook Jekarl
- Departments of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, Seoul, Korea
| | - Jae Kwon Kim
- Departments of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, Seoul, Korea
| | - Jay Ho Han
- Departments of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, Seoul, Korea
| | - Howon Lee
- Departments of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, Seoul, Korea
| | - Jaeeun Yoo
- Departments of Laboratory Medicine, Incheon St. Mary’s Hospital, College of Medicine, Incheon, Korea
| | - Jihyang Lim
- Departments of Laboratory Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yonggoo Kim
- Departments of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, Seoul, Korea
| |
Collapse
|
5
|
Post-Hematopoietic Stem Cell Transplantation Immune-Mediated Anemia: A Literature Review and Novel Therapeutics. Blood Adv 2021; 6:2707-2721. [PMID: 34972204 PMCID: PMC9043947 DOI: 10.1182/bloodadvances.2021006279] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/23/2021] [Indexed: 01/19/2023] Open
Abstract
Anemia after allogeneic hematopoietic stem cell transplantation (HSCT) can be immune or non–immune mediated. Auto- or alloimmunity resulting from blood group incompatibility remains an important cause in post-HSCT immune-mediated anemia. ABO incompatibility is commonly encountered in HSCT and may lead to serious clinical complications, including acute hemolysis, pure red cell aplasia, and passenger lymphocyte syndrome. It remains controversial whether ABO incompatibility may affect HSCT outcomes, such as relapse, nonrelapse mortality, graft-versus-host disease, and survival. Non-ABO incompatibility is less frequently encountered but can have similar complications to ABO incompatibility, causing adverse clinical outcomes. It is crucial to identify the driving etiology of post-HSCT anemia in order to prevent and treat this condition. This requires a comprehensive understanding of the mechanism of anemia in blood group–incompatible HSCT and the temporal association between HSCT and anemia. In this review, we summarize the literature on post-HSCT immune-mediated anemia with a focus on ABO and non-ABO blood group incompatibility, describe the underlying mechanism of anemia, and outline preventive and treatment approaches.
Collapse
|
6
|
Frequency, reactivity and evolution of human leukocyte antigen and human platelet antigen antibodies in the setting of hematopoietic cell transplantation. Transfus Apher Sci 2021; 61:103301. [PMID: 34774441 DOI: 10.1016/j.transci.2021.103301] [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: 07/22/2021] [Revised: 10/18/2021] [Accepted: 10/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Antibodies (Ab) against HLA and HPA antigens play an important role in HCT. In this prospective study we evaluated prevalence and kinetics of HLA- and HPA-Ab after HCT, including a possible donor-recipient transfer and their clinical relevance in respect to platelet transfusion refractoriness (PTR). MATERIALS AND METHODS Patients were consecutively recruited. Ab were determined by microbead assay technique and a mean fluorescence intensity cut-off of 1,000. RESULTS At baseline, 21 donors (42 %) and 27 patients (54 %) had HLA-Ab with a mean panel reactivity (cPRA) of 34.9 ± 29.4 % and 46.1 ± 36.5 %, respectively. We observed a significant higher number of HLA-Ab specificities in female donors and patients and a predominance of HLA-class I Ab. At day 0 we detected an increase of HLA-Ab (from 526 to 673) and cPRA (55.2 ± 31.9 %). Thirty-six patients (72 %) developed new HLA-Ab, mainly 3 weeks after HCT. In 7 patients an HLA-Ab with the same specificity as detected in the corresponding donor emerged, suggesting a possible transfer from the donor to the recipient. Overall, MFI showed a high variation. Type and number of transfusions were not associated with number and intensity of HLA-Ab (ρ: -0.05 - 0.02). Number of HLA-Ab, cPRA and intensity were not associated with PTR, which occurred in 9 patients (18 %) and none had bleeding WHO > 2. CONCLUSIONS Although a considerable number of patients have and develop HLA-Ab before and early after HCT, we found no association with PTR and bleeding and management should be individualized.
Collapse
|
7
|
Kompotiatis P, Manohar S, Alkhateeb HB, Hogan WJ, Nath KA, Leung N. Hemoglobinuria in the Early Poststem-Cell-Transplant Period: Risk Factors and Association with Outcomes. KIDNEY360 2021; 2:1569-1575. [PMID: 35372983 PMCID: PMC8785790 DOI: 10.34067/kid.0002262021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/06/2021] [Indexed: 02/04/2023]
Abstract
Background Information on risk factors of hemoglobinuria after hematopoietic stem-cell transplant (HSCT) and its association with AKI, mortality, and engraftment is limited. Methods We conducted a retrospective cohort study on all consecutive adults that underwent HSCT from January 6, 1999, to November 6, 2017. The study included 6039 patients that underwent bone marrow transplantation (BMT), umbilical cord blood, and peripheral blood stem-cell transplantation (PBSCT). Results Early post-HSCT, AKI occurred in 393 (7%) patients, and 52 (0.9%) patients had post-HSCT hemoglobinuria. Post-HSCT hemoglobinuria was associated with graft type (BMT+Cord), underlying disease (lymphoma, acute leukemia), and fludarabine-based conditioning regimen. Post-HSCT hemoglobinuria was associated with early (48-72 hours) post-HSCT AKI. Graft type (BMT+Cord) was associated with AKI among patients with hemoglobinuria. AKI in patients with hemoglobinuria was associated with delayed platelet engraftment and delayed WBC engraftment but not 100-day mortality. Conclusion Close monitoring is recommended in this patient group to facilitate a good engraftment outcome.
Collapse
Affiliation(s)
| | - Sandhya Manohar
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | | | | | - Karl A. Nath
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota,Division of Hematology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
8
|
Immune cytopenia after allogeneic haematopoietic stem-cell transplantation: challenges, approaches, and future directions. LANCET HAEMATOLOGY 2021; 8:e229-e239. [PMID: 33636143 DOI: 10.1016/s2352-3026(20)30404-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/24/2020] [Accepted: 11/30/2020] [Indexed: 12/20/2022]
Abstract
Immune-mediated cytopenia after allogeneic haematopoietic stem-cell transplantation is rare. The pathophysiology of immune-mediated anaemia, thrombocytopenia, and neutropenia, which occur alone or in combination with other cytopenias, is unclear and most probably a consequence of immune dysregulation. Risk factors for this complication have been identified in retrospective studies but these should be interpreted with caution and should not be generalised to this heterogeneous patient population. Diagnosis is challenging, requires awareness of such complications, and has to be differentiated from a multitude of other, and sometimes overlapping, possible complications. The clinical course of immune-mediated cytopenia is highly variable. Treatment requires an interdisciplinary approach and ranges from observation to symptomatic measures and directed therapies. Intensive immunosuppression is associated with an increased risk of infections and relapse, and current treatments are based on approaches in patients who have not undergone transplantation. Plasma cell-directed therapies, immunomodulation, and receptor-stimulating agents can be used to treat immune-mediated cytopenia.
Collapse
|
9
|
Adkins BD, Andrews J, Sharma D, Hughes C, Kassim AA, Eichbaum Q. Low rates of anti-recipient isohemagglutinins in ABO incompatible hematopoietic stem cell transplants. Transfus Apher Sci 2020; 60:102965. [PMID: 33127310 DOI: 10.1016/j.transci.2020.102965] [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: 08/07/2020] [Revised: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Isohemagglutinins occur naturally and form in an 'opposite' (antigen-negative) pattern to a patient's ABO blood type. Patients undergoing minor and bidirectional ABO incompatible hematopoietic stem cell transplantation (HSCT) may demonstrate detectable antibodies against their native blood type. In this study, we sought to characterize the rates of such antibody formation and evaluate the clinical significance of our findings. MATERIALS AND METHODS An internal database of HSCT patients at an academic medical center was queried for ABO incompatible transplant patients from 2009-2019. Serum typing results, clinical histories, and laboratory data were compiled and reviewed. RESULTS A total of 182 minor and bidirectional ABO incompatible HSCT patients were identified. Anti-recipient isohemagglutinins were found in 9% (16/182) of the HSCT patients. The rate was higher in patients with minor incompatibility (12%: 15/127) versus bidirectional ABO incompatibility (2%: 1/55) (p = 0.04). No anti-recipient isohemagglutinins were identified in umbilical cord HSCT patients (0%: 0/7). Serologic agglutination reactions of recipient isohemagglutinins were overall mostly weak (13/16 weak + to 1+). There was a trend towards a higher rate of acute graft-versus-host-disease in patients with anti-recipient isohemagglutinins compared to those without (75% vs. 53%; p = 0.12), though not statistically significant. Rates of alloimmunization to minor red cell antigens were similar between the two groups. Few patients showed laboratory evidence of hemolysis at 12 months follow up. DISCUSSION AND CONCLUSIONS Anti-recipient isohemagglutinins occur at low rates in ABO incompatible HSCT and are significantly more common in minor ABO incompatible transplant compared to bidirectional transplants. Larger cohort studies are needed to better understand the relationship between anti-recipient isohemagglutinins and HSCT outcomes.
Collapse
Affiliation(s)
- Brian D Adkins
- Vanderbilt University Medical Center, Department of Pathology, Microbiology and Immunology, Division of Transfusion Medicine, USA; University of Virginia Health System, Department of Pathology, Charlottesville, VA, USA.
| | - Jennifer Andrews
- Vanderbilt University Medical Center, Department of Pathology, Microbiology and Immunology, Division of Transfusion Medicine, USA; Vanderbilt University Medical Center, Department of Pediatrics, Division of Hematology/Oncology, USA
| | - Deva Sharma
- Vanderbilt University Medical Center, Department of Pathology, Microbiology and Immunology, Division of Transfusion Medicine, USA; Vanderbilt University Medical Center, Department of Medicine, Division of Hematology/Oncology, USA
| | - Caitlin Hughes
- Vanderbilt University Medical Center, Department of Pathology, Microbiology and Immunology, Division of Transfusion Medicine, USA
| | - Adetola A Kassim
- Vanderbilt University Medical Center, Department of Medicine, Division of Hematology/Oncology, USA
| | - Quentin Eichbaum
- Vanderbilt University Medical Center, Department of Pathology, Microbiology and Immunology, Division of Transfusion Medicine, USA; Veterans Administration Hospital, Tennessee Valley Health Care System, TN, USA
| |
Collapse
|
10
|
Even-Or E, Naser Eddin A, Shadur B, Dinur Schejter Y, Najajreh M, Zelig O, Zaidman I, Stepensky P. Successful treatment with daratumumab for post-HSCT refractory hemolytic anemia. Pediatr Blood Cancer 2020; 67:e28010. [PMID: 31544339 DOI: 10.1002/pbc.28010] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/20/2019] [Accepted: 09/08/2019] [Indexed: 12/24/2022]
Abstract
Autoimmune cytopenias (AIC) following allogeneic hematopoietic stem cell transplantation (HSCT) may cause significant morbidity and mortality and are often challenging to treat. We present a case of a pediatric patient with primary myelofibrosis of infancy caused by VPS45 protein deficiency, who developed severe refractory hemolytic anemia and immune-mediated thrombocytopenia 3.5 months following HSCT. After the failure of several treatments, he received daratumumab, an anti-CD38 specific antibody, and demonstrated fast and sustained response. The only side effect was delayed recovery of humoral immunity. Daratumumab, by targeting antibody-producing plasma cells, may be a valid treatment option for refractory post-HSCT AIC.
Collapse
Affiliation(s)
- Ehud Even-Or
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Adeeb Naser Eddin
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Bella Shadur
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Immunology Division, The Garvan Institute of Medical Research, Sydney, New South Wales, Australia.,Graduate Research School, University of New South Wales, Sydney, New South Wales, Australia
| | - Yael Dinur Schejter
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Mohammad Najajreh
- The Huda Al Masri Pediatric Cancer Department, Beit Jala Hospital, Beit Jala, Palestine
| | - Orly Zelig
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Irina Zaidman
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Polina Stepensky
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| |
Collapse
|
11
|
Stussi G, Buser A, Holbro A. Red Blood Cells: Exchange, Transfuse, or Deplete. Transfus Med Hemother 2019; 46:407-416. [PMID: 31933570 DOI: 10.1159/000504144] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022] Open
Abstract
Erythrocytapheresis, red blood cell (RBC) depletion, and RBC exchange transfusions are apheresis techniques used to rapidly lower the circulating RBC mass or to exchange the patient erythrocyte mass with donor RBC. Automated RBC exchange is performed using an apheresis device, while manual RBC exchange is based on sequential phlebotomies and isovolemic replacement. Compared to simple RBC transfusions, RBC exchange offers several advantages, e.g., a lower risk for iron accumulation and efficient control of pathological erythrocyte populations. Disadvantages are the higher costs of the procedure, the increased use of donor RBC, and the requirement of apheresis devices and trained hospital staff. The most frequent indication for RBC exchange is sickle cell disease (SCD). RBC exchange transfusions are standard treatment in SCD patients with a history of or a risk for acute stroke and are clinical options for other acute complications of SCD. The most common indication for RBC depletion is the removal of donor RBC from the bone marrow grafts in major ABO-incompatible allogeneic hematopoietic stem cell transplantation to avoid immediate hemolysis. Rare indications for RBC exchange are severe infections with intraerythrocytic pathogens such as malaria or babesiosis and severe erythrocytosis or hereditary hemochromatosis where the aim is to rapidly decrease RBC populations or the iron content. However, only few high-quality studies are available looking at the efficacy of RBC exchange in the different disease entities, and treatment is often based on low levels of evidence and should therefore be decided in close collaboration with a transfusion medicine specialist.
Collapse
Affiliation(s)
- Georg Stussi
- Division of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Andreas Buser
- Regional Transfusion Service, Swiss Red Cross, Basel, Switzerland.,Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Andreas Holbro
- Regional Transfusion Service, Swiss Red Cross, Basel, Switzerland.,Division of Hematology, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
12
|
Gray PE, McCarthy H, Siggs OM, Saleem MA, O' Brien T, Frith K, Ziegler JB, Kitching AR, Fogo AB, Hudson BG, Pedchenko V. Molecular Analysis of Goodpasture's Disease Following Hematopoietic Stem Cell Transplant in a Pediatric Patient, Recalls the Conformeropathy of Wild-Type Anti-GBM Disease. Front Immunol 2019; 10:2659. [PMID: 31798588 PMCID: PMC6868084 DOI: 10.3389/fimmu.2019.02659] [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: 07/24/2019] [Accepted: 10/28/2019] [Indexed: 11/28/2022] Open
Abstract
Background: Goodpasture's disease (GP) is mediated by autoantibodies that bind the glomerular and alveolar basement membrane, causing rapidly progressive glomerulonephritis with or without pulmonary hemorrhage. The autoantibodies bind neoepitopes formed upon disruption of the quaternary structure of α345NC1 hexamer, a critical structural domain of α345 collagen IV scaffolds. Hexamer disruption leads to a conformational changes that transitions α3 and α5NC1 subunits into immunogens, however, the trigger remains unknown. This contrasts with another anti-GBM disease, Alports' post-transplant nephritis (APTN), where the pathogenic alloantibody binds directly to native NC1 hexamer. The current report includes the first study of antigenic specificity and allo-incompatability in anti-GBM disease occurring after allogeneic haematopoietic stem cell transplant (HSCT). Results: The anti-GBM antibodies were found to be directed predominantly against the EA epitope of the α3 NC1 monomer of collagen IV and developed rapidly in patient serum reaching peak level within 5 weeks. Autoantibody binding to native α345NC1 hexamer was minimal; however, binding was greatly increased upon dissociation of the native hexamer. There were no polymorphic genetic differences between donor and recipient collagen IV genes which would be predicted to cause a significant NC1 conformational change or to provide a target for antibody binding. Both patient and donor possessed the Goodpasture's susceptibility HLA-allele DRB1*1501. Conclusions: The current report includes the first in-depth study of allo-incompatability and antigenic specificity in anti-GBM disease occurring after allogeneic haematopoietic stem cell transplant (HSCT). No polymorphic genetic differences were identified between donor and recipient collagen IV genes which would be predicted to provide a target for antibody binding. Furthermore, autoantibody binding to native α345NC1 hexamer was minimal, increasing greatly upon dissociation of the native hexamer, resembling wild-type GP diseases and marking this as the first example of a post-HSCT conformeropathy.
Collapse
Affiliation(s)
- Paul E Gray
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, NSW, Australia.,Faculty of Medicine, School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Hugh McCarthy
- Department of Nephrology, Sydney Children's Hospital, Sydney, NSW, Australia
| | - Owen M Siggs
- Immunology Division, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | - Moin A Saleem
- Faculty of Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Tracy O' Brien
- Faculty of Medicine, School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia.,Kid's Cancer Centre, Sydney Children's Hospital, Sydney, NSW, Australia
| | - Katie Frith
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, NSW, Australia
| | - John B Ziegler
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, NSW, Australia.,Faculty of Medicine, School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - A Richard Kitching
- Faculty of Medicine, Nursing & Health Sciences, Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia
| | - Agnes B Fogo
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States.,Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, United States.,Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Billy G Hudson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, United States.,Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Vadim Pedchenko
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| |
Collapse
|
13
|
Immune-Mediated Cytopenias After Hematopoietic Cell Transplantation: Pathophysiology, Clinical Manifestations, Diagnosis, and Treatment Strategies. Curr Oncol Rep 2019; 21:87. [PMID: 31414187 DOI: 10.1007/s11912-019-0838-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Discuss the pathophysiology, clinical presentation, diagnosis, and treatment of immune-mediated cytopenias (IMC) after hematopoietic cell transplantation (HCT). RECENT FINDINGS Key risk factors for post-HCT IMC include younger age, non-malignant disease, and umbilical cord blood stem cell source. While anemia predominates, any or all three hematopoietic cell lines can be affected. In rare cases, IMC can cause graft failure or death. IMC is hypothesized to result from immune dysregulation upon reconstitution of donor hematopoietic cells (i.e., dysfunctional regulatory T cells). Aside from blood product transfusions, IMC treatment includes immune-suppressive or ablative agents. First-line therapies, including corticosteroids and intravenous immunoglobulin, are often inadequate, prompting use of additional agents aimed at antibody production/T cell dysfunction or direct antibody removal via plasmapheresis. IMC occurs in up to 20% of high-risk HCT populations. Morbidity and mortality from IMC post-HCT have been reduced by improved recognition and aggressive early interventions.
Collapse
|
14
|
Zhang ZM, Lai YR, Li QC, Luo L, Liu RR, Shi LL, Liu LJ. [Clinical analysis of autoimmune hemolytic anemia after allogeneic hematopoietic stem cell transplantation in thalassemia major]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 39:908-911. [PMID: 30486586 PMCID: PMC7342357 DOI: 10.3760/cma.j.issn.0253-2727.2018.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
目的 探讨重型地中海贫血(地贫)患者异基因造血干细胞移植(allo-HSCT)后并发自身免疫性溶血性贫血(AIHA)诊断、治疗及转归,以提高地贫患者造血干细胞移植疗效。 方法 回顾性分析2007年7月至2017年12月共计291例行allo-HSCT重型地贫患者的临床资料。 结果 重型地贫allo-HSCT后AIHA发生率为1.72%(5/291);AIHA中位发生时间为移植后7(5~12)个月,5例移植后AIHA患者直接和间接Coombs试验均阳性,患者主要表现为头晕、乏力、面色苍白、皮肤巩膜黄染、酱油色尿。228例HLA相合同胞供者移植患者有1例(0.43%)移植后发生AIHA,而63例非亲缘供者移植患者有4例(6.36%)移植后发生AIHA。非亲缘供者移植患者AIHA发生率高于HLA相合同胞供者移植患者。1例患者单用泼尼松治疗死亡,4例患者采用甲泼尼龙联合利妥昔单抗治疗有效,目前生存良好,其中2例Coombs试验转阴。 结论 该组重型地贫患者allo-HSCT后AIHA发生率为1.72%,Coombs试验有助于诊断移植后AIHA,非亲缘供者移植病例移植后AIHA发生率高于HLA相合同胞供者移植组,利妥昔单抗联合糖皮质激素是治疗重型地贫allo-HSCT后AIHA的有效方法。
Collapse
Affiliation(s)
- Z M Zhang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medial University, Nanning 530021, China
| | | | | | | | | | | | | |
Collapse
|
15
|
Hess J, Su L, Nizzi F, Beebe K, Magee K, Salzberg D, Stahlecker J, Miller HK, Adams RH, Ngwube A. Successful treatment of severe refractory autoimmune hemolytic anemia after hematopoietic stem cell transplant with abatacept. Transfusion 2018; 58:2122-2127. [DOI: 10.1111/trf.14907] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/21/2018] [Accepted: 06/01/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Jennifer Hess
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Leon Su
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Frank Nizzi
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Kristen Beebe
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
| | - Kyrie Magee
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
| | - Dana Salzberg
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Jennifer Stahlecker
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Holly K. Miller
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Roberta H. Adams
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
| |
Collapse
|
16
|
Isobe M, Konuma T, Abe-Wada Y, Hirata K, Ogami K, Kato S, Oiwa-Monna M, Tanoue S, Nagamura-Inoue T, Takahashi S, Tojo A. Alloimmune hemolysis due to major RhE incompatibility after unrelated cord blood transplantation. Leuk Lymphoma 2017; 59:1000-1003. [PMID: 28727478 DOI: 10.1080/10428194.2017.1352095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Masamichi Isobe
- a Department of Hematology/Oncology , The Institute of Medical Science, The University of Tokyo , Tokyo , Japan
| | - Takaaki Konuma
- a Department of Hematology/Oncology , The Institute of Medical Science, The University of Tokyo , Tokyo , Japan
| | - Yuka Abe-Wada
- b Department of Cell Processing and Transfusion , The Institute of Medical Science, The University of Tokyo , Tokyo , Japan
| | - Kyoko Hirata
- b Department of Cell Processing and Transfusion , The Institute of Medical Science, The University of Tokyo , Tokyo , Japan
| | - Kazuo Ogami
- b Department of Cell Processing and Transfusion , The Institute of Medical Science, The University of Tokyo , Tokyo , Japan
| | - Seiko Kato
- a Department of Hematology/Oncology , The Institute of Medical Science, The University of Tokyo , Tokyo , Japan
| | - Maki Oiwa-Monna
- a Department of Hematology/Oncology , The Institute of Medical Science, The University of Tokyo , Tokyo , Japan
| | - Susumu Tanoue
- a Department of Hematology/Oncology , The Institute of Medical Science, The University of Tokyo , Tokyo , Japan
| | - Tokiko Nagamura-Inoue
- b Department of Cell Processing and Transfusion , The Institute of Medical Science, The University of Tokyo , Tokyo , Japan
| | - Satoshi Takahashi
- a Department of Hematology/Oncology , The Institute of Medical Science, The University of Tokyo , Tokyo , Japan
| | - Arinobu Tojo
- a Department of Hematology/Oncology , The Institute of Medical Science, The University of Tokyo , Tokyo , Japan
| |
Collapse
|
17
|
Chang TY, Jaing TH, Wen YC, Huang IA, Chen SH, Tsay PK. Risk factor analysis of autoimmune hemolytic anemia after allogeneic hematopoietic stem cell transplantation in children. Medicine (Baltimore) 2016; 95:e5396. [PMID: 27861376 PMCID: PMC5120933 DOI: 10.1097/md.0000000000005396] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a clinically relevant complication after allogeneic hematopoietic stem cell transplantation (HSCT). Currently, there is no established consensus regarding the optimal therapeutic approach. Whether AIHA contributes to increased mortality is still somewhat controversial.We investigated the incidence, risk factors, and outcome of post-transplant AIHA in 265 consecutive pediatric patients undergoing allo-HSCT over a 17-year period. Onset of AIHA was calculated from the first documented detection of AIHA by either clinical symptoms or positive direct agglutinin test. Resolution of AIHA was defined as normalization of hemoglobin and biochemical markers of hemolysis with sustained transfusion independence.We identified 15 cases of AIHA after allo-HSCT (incidence rate, 6%). Ten (67%) of these patients had a positive direct antiglobulin test. Data were obtained for 9 boys and 6 girls after a median follow-up of 53 months (range 4-102). The median age was 5.1 years (range 0.5-15.4) at the time of HSCT and the median time to emergence was 149 days (range 42-273). No significant risk factor for post-transplant AIHA has emerged from our data to date. In the majority (14 of 15; 93%) of AIHA patients, multiple agents for treatment were required, with 12 of 15 (80%) patients achieving complete resolution of AIHA. No splenectomy was performed in any of our patients.For various reasons, post-transplantation AIHA poses an extraordinary challenge to transplant physicians. Despite the advancements in diagnostic tools, therapeutic challenges remain due to the myriad interacting pathways in AIHA.
Collapse
MESH Headings
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/epidemiology
- Anemia, Hemolytic, Autoimmune/etiology
- Anemia, Hemolytic, Autoimmune/therapy
- Child, Preschool
- Coombs Test/methods
- Disease Management
- Female
- Hematopoietic Stem Cell Transplantation/adverse effects
- Humans
- Incidence
- Longitudinal Studies
- Male
- Outcome and Process Assessment, Health Care
- Risk Factors
- Taiwan/epidemiology
Collapse
Affiliation(s)
| | | | - Yu-Chuan Wen
- Department of Nursing, Chang Gung Children's Hospital
| | - I-Anne Huang
- Divisions of Hematology/Oncology
- Division of Pediatric General Medicine, Department of Pediatrics
| | | | - Pei-Kwei Tsay
- Department of Public Health and Center of Biostatistics, College of Medicine, Chang Gung University, Linkou, Taoyuan, Taiwan
| |
Collapse
|
18
|
|