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Chang DY, Wankier Z, Arthur CM, Stowell SR. The ongoing challenge of RBC alloimmunization in the management of patients with sickle cell disease. Presse Med 2023; 52:104211. [PMID: 37981194 DOI: 10.1016/j.lpm.2023.104211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023] Open
Abstract
RBC transfusion remains a cornerstone in the treatment of sickle cell disease (SCD). However, as with many interventions, transfusion of RBCs is not without risk. Allogeneic RBC exposure can result in the development of alloantibodies, which can make it difficult to find compatible RBCs for future transfusion and increases the likelihood of life-threatening complications. The development of RBC alloantibodies occurs when a patient's immune system produces alloantibodies against foreign alloantigens present on RBCs. Despite its longstanding recognition, RBC alloimmunization has increasingly become a challenge when caring for patients with SCD. The growing prominence of alloimmunization can be attributed to several factors, including expanded indications for transfusions, increased lifespan of patients with SCD, and inadequate approaches to prevent alloimmunization. Recognizing these challenges, recent observational studies and preclinical models have begun to elucidate the immune pathways that underpin RBC alloimmunization. These emerging data hold promise in paving the way for innovative prevention strategies, with the goal of increasing the safety and efficacy of RBC transfusion in patients with SCD who are most vulnerable to alloimmunization.
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Affiliation(s)
- Daniel Y Chang
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Zakary Wankier
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Connie M Arthur
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Sean R Stowell
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
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2
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Sotolongo G, Poisson JL. Increased red blood cell alloimmunization rates in transfused aplastic anemia and myelofibrosis patients. Transfusion 2023; 63:1803-1808. [PMID: 37644882 DOI: 10.1111/trf.17529] [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: 09/01/2022] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Red blood cell (RBC) alloimmunization (AI) is a well-known complication of RBC transfusions, which results in the formation of alloantibodies to non-self antigens on donor RBCs, putting patients at risk of transfusion-related complications. The rate of AI with RBC transfusions in the general hospitalized population is estimated to be 2%-3%. However, some patients who are deemed "transfusion-dependent" require regular transfusions of blood products due to persistently low cell counts, putting them at even greater risk of RBC AI and increased morbidity. However, few studies currently exist investigating RBC AI in some transfusion-dependent patient populations, e.g., aplastic anemia (AA) and myelofibrosis (MF). STUDY DESIGN AND METHODS We conducted a 5-year retrospective review to investigate the prevalence of RBC AI, alloantibody incidence, and the number of RBC transfusions in AA and MF patients, who received RBC transfusions within our hospital system. RESULTS During the study period, 64 AA and 93 MF patients received 1301 and 2766 RBC transfusions, respectively. Compared to the RBC AI rate in the generalized hospitalized patient population (1%-2%), patients with AA and MF had an increased rate of RBC AI incidence rate at 14.1% and 12.9%, respectively. Furthermore, patients with primary MF demonstrated an isolated increased RBC AI incidence rate of 13.3%. The most common alloantibodies produced were anti-E and anti-K. DISCUSSION Within our institution, patients with AA and MF had increased incidence rates of RBC AI compared to the general hospitalized patient population and may benefit from an antigen-matched protocol to minimize AI-related complications.
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Affiliation(s)
- G Sotolongo
- Department of Pathology, Duke University Hospital, Durham, North Carolina, USA
| | - J L Poisson
- Department of Pathology, Duke University Hospital, Durham, North Carolina, USA
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3
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Arthur CM, Stowell SR. The Development and Consequences of Red Blood Cell Alloimmunization. ANNUAL REVIEW OF PATHOLOGY 2023; 18:537-564. [PMID: 36351365 PMCID: PMC10414795 DOI: 10.1146/annurev-pathol-042320-110411] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
While red blood cell (RBC) transfusion is the most common medical intervention in hospitalized patients, as with any therapeutic, it is not without risk. Allogeneic RBC exposure can result in recipient alloimmunization, which can limit the availability of compatible RBCs for future transfusions and increase the risk of transfusion complications. Despite these challenges and the discovery of RBC alloantigens more than a century ago, relatively little has historically been known regarding the immune factors that regulate RBC alloantibody formation. Through recent epidemiological approaches, in vitro-based translational studies, and newly developed preclinical models, the processes that govern RBC alloimmunization have emerged as more complex and intriguing than previously appreciated. Although common alloimmunization mechanisms exist, distinct immune pathways can be engaged, depending on the target alloantigen involved. Despite this complexity, key themes are beginning to emerge that may provide promising approaches to not only actively prevent but also possibly alleviate the most severe complications of RBC alloimmunization.
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Affiliation(s)
- Connie M Arthur
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, ,
| | - Sean R Stowell
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, ,
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4
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Garraud O, Chiaroni J. An overview of red blood cell and platelet alloimmunisation in transfusion. Transfus Clin Biol 2022; 29:297-306. [PMID: 35970488 DOI: 10.1016/j.tracli.2022.08.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Post-transfusion alloimmunisation is the main complication of all those observed after one or more transfusion episodes. Alloimmunisation is observed after the transfusion of red blood cell concentrates but also of platelet concentrates. Besides alloimmunisation due to antigens carried almost exclusively by red blood cells such as those of the Rhesus-Kell system, alloimmunisation often raises against HLA antigens; the main responsibility for that, apart from platelet transfusions, lies with residual leukocytes in the products transfused, hence the central importance of effective leukoreduction right from the blood product preparation stage. Alloimmunization is not restricted to transfusion, but it is also observed during pregnancies, carrying out microtransfusions of blood from the fetus immunizing the mother through the placenta (in a retrograde way). Preexisting maternal-fetal immunization can complicate a transfusion program and intensify the creation of alloantibodies in several blood and tissue group systems. The occurrence of autoantibodies, created by several pathogenic reasons, can also interfere with the propensity of certain recipients of blood components to produce alloantibodies. The genetic condition of individuals is in fact strongly linked to the ability or not to recognize antigenic variants foreign to their own biological program and mount an alloimmune response. Some hemoglobin diseases, in carriers of which transfusions can be iterative and lifelong, are complicated by frequent alloimmunizations and amplification of the complications of these alloimmunizations, imposing even stricter transfusion rules. This review details the mechanisms favoring the occurrence of alloimmunization and the immunological principles for the production of molecular and cellular tools for alloimmunization. It concludes with the main preventive measures available to limit the occurrence of these frequent complications of varying severity but sometimes severe.
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Affiliation(s)
- Olivier Garraud
- Sainbiose-Inserm_U1059, Faculty of Medicine, University of Saint-Etienne, Saint-Etienne, France.
| | - Jacques Chiaroni
- Etablissement Français du Sang Provence-Alpes-Côte d'Azur-Corse, 13005 Marseille, France; Biologie des Groupes Sanguins, EFS, CNRS, ADES, Aix Marseille University, 13005 Marseille, France
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5
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A clinical effect of disease-modifying treatment on alloimmunisation in transfused patients with myelodysplastic syndromes: data from a population-based study. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2022; 20:18-26. [PMID: 33370223 PMCID: PMC8796846 DOI: 10.2450/2020.0168-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/09/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Alloimmunisation against blood products is an adverse event, causing time-consuming compatibility testing. Current literature has not yet identified the influence of treatment on the risk of alloimmunisation in patients with myelodysplastic syndromes (MDS). MATERIALS AND METHODS An observational, population-based study, using the HemoBase registry, was performed including all transfused patients who were diagnosed with MDS between 2005 and 2017 in Friesland, a province in the Netherlands. Information about transfusion dates, types, and treatment regimens was collected from the health records. Blood products were matched for ABO and Rhesus D. The effect of disease-modifying treatment was estimated with incidence rates and a Cox time-dependent analysis. RESULTS 233 patients were included in this study, with a median follow-up of 13.0 months. Alloimmunisation occurred in 21 patients (9.0%) and predominantly occurred early in follow-up. Three (5%) and 18 (11%) alloimmunisation events occurred in patients with and without disease-modifying treatment, respectively. The hazard ratio for alloimmunisation without treatment compared to during treatment was 2.7 (95% CI: 0.35-20.0), with incidence rates of 7.18 and 2.41 per 100 patient-years, respectively. DISCUSSION In a non-selected real-world population of MDS patients receiving blood transfusions, the percentage of patients with alloimmunisation was below 10%. The results of this study support the hypothesis that disease-modifying treatment affects the ability of the immune system to mount an antibody response to non-self blood group antigens.
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van de Weem RHG, Wemelsfelder ML, Luken JS, de Haas M, Niessen RWLM, van der Schoot CE, Hoogeveen H, Janssen MP. Preventing alloimmunization using a new model for matching extensively typed red blood cells. Vox Sang 2021; 117:580-586. [PMID: 34725840 DOI: 10.1111/vox.13217] [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: 05/31/2021] [Revised: 10/06/2021] [Accepted: 10/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Alloimmunization is a well-known adverse event associated with red blood cell (RBC) transfusions, caused by phenotype incompatibilities between donor and patient RBCs that may lead to haemolytic transfusion reactions on subsequent transfusions. Alloimmunization can be prevented by transfusing fully matched RBC units. Advances in RBC genotyping render the extensive typing of both donors and patients affordable in the foreseeable future. However, the exponential increase in the variety of extensively typed RBCs asks for a software-driven selection to determine the 'best product for a given patient'. MATERIALS AND METHODS We propose the MINimize Relative Alloimmunization Risks (MINRAR) model for matching extensively typed RBC units to extensively typed patients to minimize the risk of alloimmunization. The key idea behind this model is to use antigen immunogenicity to represent the clinical implication of a mismatch. Using simulations of non-elective transfusions in Caucasian donor and patient populations, the effect on the alloimmunization rate of the MINRAR model is compared with that of a baseline model that matches antigens A, B and RhD only. RESULTS Our simulations show that with the MINRAR model, even for small inventories, the expected number of alloimmunizations can be reduced by 78.3% compared with a policy of only matching on antigens A, B and RhD. Furthermore, a reduction of 93.7% can be achieved when blood is issued from larger inventories. CONCLUSION Despite an exponential increase in phenotype variety, matching of extensively typed RBCs can be effectively implemented using our MINRAR model, effectuating a substantial reduction in alloimmunization risk without introducing additional outdating or shortages.
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Affiliation(s)
- Ronald H G van de Weem
- Transfusion Technology Assessment Group, Donor Medicine Research Department, Sanquin Research, Amsterdam, The Netherlands
| | - Merel L Wemelsfelder
- Transfusion Technology Assessment Group, Donor Medicine Research Department, Sanquin Research, Amsterdam, The Netherlands
| | | | | | | | - C Ellen van der Schoot
- Department of Experimental Immunohematology, Sanquin Research, Amsterdam, The Netherlands
| | | | - Mart P Janssen
- Transfusion Technology Assessment Group, Donor Medicine Research Department, Sanquin Research, Amsterdam, The Netherlands
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7
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Oud JA, Evers D, de Haas M, de Vooght KMK, van de Kerkhof D, Som N, Péquériaux NCV, Hudig F, Albersen A, van der Bom JG, Zwaginga JJ. The effect of extended c, E and K matching in females under 45 years of age on the incidence of transfusion-induced red blood cell alloimmunisation. Br J Haematol 2021; 195:604-611. [PMID: 34346067 PMCID: PMC9290146 DOI: 10.1111/bjh.17697] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
Maternal alloantibodies directed against fetal red blood cell (RBC) antigens may cause potentially life‐threatening haemolytic disease of the fetus and newborn (HDFN). Dutch transfusion guidelines therefore prescribe preventive cEK matching for all (pre‐)fertile females. To quantify the impact of cEK matching, we compared overall and antigen‐specific cumulative RBC alloimmunisation incidences in females and males aged <45 years. Among a multicentre cohort comprised of patients who received their first and subsequent RBC unit between 2005 and 2019, first‐formed RBC alloantibodies were detected in 47 of 2998 (1·6%) females and 49 of 2507 (2·0%) males. Comparing females and males, overall alloimmunisation incidences were comparable (3·1% [95% confidence interval (CI) 2·1–4·4] versus 3·5% (95% CI 2·4–4·9, P = 0·853) after 10 units transfused). However, cEK alloimmunisation incidences were significantly lower among females (0·6% (95% CI 0·3–1.5) versus 2·2% (95% CI 1·5–3·4, P = 0·001) after 10 units transfused). Yet, despite cEK‐matching guidelines being in effect, 6·5%, 3·6% and 0·2% of all RBC units remained mismatched for c, E or K antigens respectively. Most of these mismatches were almost always due to emergency settings. Even though cEK alloimmunisation was not prevented completely, implementation of cEK matching resulted in an alloantigen‐exposure risk reduction of up to 98%.
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Affiliation(s)
- Josine A Oud
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Haematology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Dorothea Evers
- Department of Haematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Masja de Haas
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Haematology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Immunohaematology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - Karen M K de Vooght
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daan van de Kerkhof
- Department of Clinical Chemistry and Haematology, Catharina Hospital, Eindhoven, the Netherlands
| | - Nel Som
- Department of Clinical Chemistry, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Nathalie C V Péquériaux
- Department of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | | | - Arjan Albersen
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Johanna G van der Bom
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jaap Jan Zwaginga
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Haematology, Leiden University Medical Center, Leiden, the Netherlands
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8
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Zidan M, Nafea DA, Okasha HAS, Abouelnour AF, Eshmawey HA. Evaluation of pulmonary complications in patients undergoing allogenic stem cell transplantation. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2020. [PMCID: PMC7527666 DOI: 10.1186/s43168-020-00032-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Mature blood cells can be differentiated from hematopoietic stem cells; thus, the latter can play a crucial role in maintaining defense against different microorganisms. Thus, hematopoietic stem cell transplantation is one of the most important lines of immunotherapy. Major systemic complications may occur post transplantation and could be fatal. Pulmonary complications include infectious and non-infectious complications. The aim of this study was to detect the pulmonary complications in allogeneic stem cell transplantation patients. Results We studied 20 patients after transplantation of allogeneic stem cells with regular follow-up in outpatient clinic of hematology department of Alexandria Main University Hospital. All the studied patients were subjected to history taking, plain x-ray chest PA view, CT chest, complete blood count, serum creatinine, liver enzymes, and serum cytomegalovirus (CMV) detection by antibodies IgG and IgM. Regarding sputum sampling, 7 patients’ samples (35%) were obtained either spontaneously or by induction via hypertonic saline 3%. One patient (5%) had miniBAL done, while bronchoalveolar lavage using fiber optic bronchoscopy was done for 2 patients (10%). Samples could not be obtained from the remaining patients. Samples were analyzed for culture for bacteria, Pneumocystis jiroveci using immunofluorescence test, CMV PCR, fungal culture, and smear for acid fast bacilli (AFB). Among the examined patients, 2 patients (20%) had pulmonary bacterial infection including streptococcus and multidrug-resistant strain of Klebsiella, 3 patients (30%) had pulmonary candida infection, and one patient (10%) had positive result of pulmonary CMV of low count which was considered insignificant. None of our patients had positive results for pulmonary tuberculosis nor Pneumocystis jiroveci. Six patients (30%) had CMV in serum; 3 patients (15.8%) had manifested CMV reactivation. One patient (5%) of our patients had pulmonary graft versus host disease GVHD. One patient (5%) had died during our study course within 12 days post-transplantation due to ARDS followed by multiple organ failure. Conclusion The prevalence of pulmonary infectious complications after allogenic stem cell transplantation was 50% of all studied patients, while 5% of the studied patients presented with non-infectious pulmonary complications.
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9
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El Fetouh RMA, Elmoniem GMA, Allam RM, Sobeih ME, Kamel MM, Radwan SM. Frequency and specificity of Red blood cell alloantibodies in multitransfused Egyptian patients with hematological and nonhematological malignancies. Transfus Apher Sci 2020; 59:102909. [PMID: 32888823 DOI: 10.1016/j.transci.2020.102909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 07/15/2020] [Accepted: 08/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Repeated blood transfusions can result in the production of alloantibodies against one or more red blood cell (RBC) antigens, which can complicate future transfusions. AIM This study aims to determine the frequency and specificities of RBC alloantibodies in multitransfused adult cancer patients admitted at the National Cancer Institute, Cairo University. METHODS This cohort study enrolled 2000 multitransfused cancer patients diagnosed with different types of malignancies; they were screened for RBC alloantibodies using Serascan Diana 3 and Identisera Diana 11-cell identification panels (Diagnostic Grifols, Spain). RESULTS Of the 2000 patients tested, 25 had autoantibodies and were excluded from the study. Of the remaining 1975 patients, 181 patients had a total of 267 different alloantibodies (9.16%), with some having more than 1 antibody detected. Our study showed that more female patients (63%) than male patients (37%) had acquired RBC alloantibodies, and a higher prevalence of alloantibodies in patients with nonhematological malignancies (14%) compared with those with hematological malignancies (6.5%). The highest percentage of alloantibodies belongs to the Rh blood group system, followed by the Kell system, then Duffy, MNS, Kidd, and Lewis. Patients who received combined chemotherapy and immunotherapy exhibited a lesser antibody response compared to other patients. CONCLUSION The prevalence of alloimmunization in our study is comparable to previous reports on oncology patients. Repeated blood transfusions, which can lead to alloimmunization, often complicate future transfusions. Therefore, we recommend extending phenotype matching for patients who are presumed to depend on blood transfusions in the long term.
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Affiliation(s)
- Randa M Abo El Fetouh
- Clinical Pathology Department, National Cancer Institute-Cairo University, Cairo, Egypt
| | - Gamal M Abd Elmoniem
- Clinical Pathology Department, National Cancer Institute-Cairo University, Cairo, Egypt
| | - Rasha Mahmoud Allam
- Biostatistics and Cancer Epidemiology Department, National Cancer Institute-Cairo University, Cairo, Egypt
| | - Mohamed Emam Sobeih
- Medical Oncology Department, National Cancer Institute-Cairo University, Cairo, Egypt
| | - Mahmoud M Kamel
- Clinical Pathology Department, National Cancer Institute-Cairo University, Cairo, Egypt.
| | - Samah M Radwan
- Clinical Pathology Department, National Cancer Institute-Cairo University, Cairo, Egypt
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10
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Lemay AS, Faughnan M, Krok E, Pavenski K. A curious case of delayed hemolytic transfusion reaction with evanescent antibodies in a patient with hereditary hemorrhagic telangiectasia. Transfusion 2019; 59:3570-3574. [PMID: 31710384 DOI: 10.1111/trf.15582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 09/04/2019] [Accepted: 09/13/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Delayed hemolytic reactions are potential complications of incompatible transfusions and are usually associated with the identification of a new antibody on serologic studies, following a second immunization event. However, in rare cases, the antibody investigation remains negative even if the clinical presentation would lead one to suspect otherwise. CASE REPORT A 44-year-old woman with hereditary hemorrhagic telangiectasia presented to the emergency department with hematuria and low back pain after she had received three units of RBCs 2 weeks earlier. Hematology and biochemistry results were consistent with delayed hemolytic transfusion reaction, but surprisingly, serologic antibody investigations were negative. It was only when her plasma was tested with enzyme (ficin)-treated panel cells that anti-e was finally detected, with a 3+ reaction with all homozygous e+ cells. No reaction was seen with heterozygous e+ cells. Four months later, an anti-K was also detected on standard panels, while the anti-e remained detectable only with ficin-treated panel cells. Three years later, both antibodies had vanished and remained undetectable. The weakness of anti-e reaction, combined with the quick evanescence of both antibodies led to the suspicion of a potential underlying immunodeficiency disorder, which was confirmed by low immunoglobulin levels on two occasions. CONCLUSION To our knowledge, this is the first case of immunodeficiency disorder diagnosed after the identification of evanescent antibody reactions. This case also outlines the importance of a good clinical history that should lead to further investigations when a hemolytic transfusion reaction is suspected.
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Affiliation(s)
- Anne-Sophie Lemay
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, CIUSSS MCQ, Trois-Rivières, Quebec, Canada
| | - Marie Faughnan
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Elizabeth Krok
- Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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11
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Balbuena-Merle R, Hendrickson JE. Red blood cell alloimmunization and delayed hemolytic transfusion reactions in patients with sickle cell disease. Transfus Clin Biol 2019; 26:112-115. [PMID: 30857806 DOI: 10.1016/j.tracli.2019.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Red blood cell (RBC) alloimmunization is more common in patients with sickle cell disease (SCD) than in any other studied patient population. The high prevalence of RBC alloimmunization is multi-factorial, likely involving the chronic hemolysis and inflammatory status of SCD itself, the transfusion burden of patients, and the RH genetic diversity of patients and blood donors, among other reasons. Antibody evanescence, or the decrease of RBC alloantibodies below levels detectable by blood bank testing, occurs frequently with fewer than 30% of alloantibodies estimated to be detected by current screening practices. Evanescence increases the likelihood that a patient with SCD will have a delayed hemolytic transfusion reaction upon future RBC exposure, with previously undetected alloantibodies coming roaring back in an anamnestic manner after exposure to the cognate RBC antigen. A subset of patients having delayed hemolytic transfusion reactions go on to experience hyperhemolysis; some but not all cases of hyperhemolysis are associated with previously evanescent RBC alloantibodies. There is an increasing appreciation of the association between RBC alloantibodies and RBC autoantibodies, as well as involvement of the alternative complement pathway in some instances of hyperhemolysis. A case report in this manuscript describes a highly alloimmunized patient with SCD who experiences a delayed hemolytic transfusion reaction with bystander hemolysis due to a previously evanescent, complement binding anti-M RBC alloantibody. Additional studies, including those involving multiple centers and countries, are needed to further understand RBC alloimmunization in patients with SCD and to develop strategies to prevent or mitigate potentially life-threatening hemolytic transfusion reactions.
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Affiliation(s)
- R Balbuena-Merle
- Department of Laboratory Medicine, 330 Cedar Street, CB 405, New Haven, CT 06520-8035, United States
| | - J E Hendrickson
- Department of Laboratory Medicine, 330 Cedar Street, CB 405, New Haven, CT 06520-8035, United States.
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12
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Ghosh S, Lalani R, Patel V, Bardoliwala D, Maiti K, Banerjee S, Bhowmick S, Misra A. Combinatorial nanocarriers against drug resistance in hematological cancers: Opportunities and emerging strategies. J Control Release 2019; 296:114-139. [DOI: 10.1016/j.jconrel.2019.01.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/10/2019] [Accepted: 01/11/2019] [Indexed: 12/16/2022]
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13
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Akkök ÇA, Seghatchian J. Immunohematologic issues in ABO-incompatible allogeneic hematopoietic stem cell transplantation. Transfus Apher Sci 2018; 57:812-815. [DOI: 10.1016/j.transci.2018.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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14
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Karafin MS, Westlake M, Hauser RG, Tormey CA, Norris PJ, Roubinian NH, Wu Y, Triulzi DJ, Kleinman S, Hendrickson JE. Risk factors for red blood cell alloimmunization in the Recipient Epidemiology and Donor Evaluation Study (REDS-III) database. Br J Haematol 2018; 181:672-681. [PMID: 29675950 DOI: 10.1111/bjh.15182] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 01/29/2018] [Indexed: 12/22/2022]
Abstract
Despite the significance of red blood cell (RBC) alloimmunization, the lack of standardized registries in the US has prevented the completion of large studies. Data from 3·5 years of the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) recipient database, containing information from 12 hospitals, were studied. A RBC alloantibody responder had an antibody identified at any point during the study, and a non-responder had a negative antibody screen at least 15 days post-RBC transfusion. Demographics, blood type, ICD9/10 codes, and other potential correlates were evaluated. Of 319 177 (2·07%) screened patients, 6597 had a total of 8892 clinically significant RBC alloantibodies identified, with 75% being in the Rh or Kell families. Alloimmunization was more common in females (2·38%) than males (1·68%), and in RhD negative (2·82%) than RhD positive (1·94%) patients. Age, sex, RhD status and race were associated with being a responder, and certain diagnoses (including sickle cell disease or trait, systemic lupus erythematosus, rheumatoid arthritis and myelodysplastic syndrome) were more common among responders than non-responders. Data collected in this multi-centre recipient database provide the largest RBC alloimmunized patient cohort studied in the US, with previously known demographic and disease associations of responder status confirmed, and new associations identified.
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Affiliation(s)
| | | | - Ronald G Hauser
- Department of Laboratory Medicine, Yale University, New Haven, CT, USA.,VA CT, West Haven, CT, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University, New Haven, CT, USA.,VA CT, West Haven, CT, USA
| | - Philip J Norris
- University of California, San Francisco, CA, USA.,Blood Systems Research Institute, San Francisco, CA, USA
| | - Nareg H Roubinian
- University of California, San Francisco, CA, USA.,Blood Systems Research Institute, San Francisco, CA, USA
| | - Yanyun Wu
- Department of Laboratory Medicine, Yale University, New Haven, CT, USA.,Bloodworks Northwest, Seattle, WA, USA
| | - Darrell J Triulzi
- University of Pittsburgh and Institute of Transfusion Medicine, Pittsburgh, PA, USA
| | - Steve Kleinman
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University, New Haven, CT, USA.,Department of Pediatrics, Yale University, New Haven, CT, USA
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15
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Singhal D, Kutyna MM, Chhetri R, Wee LYA, Hague S, Nath L, Nath SV, Sinha R, Wickham N, Lewis ID, Ross DM, Bardy PG, To LB, Reynolds J, Wood EM, Roxby DJ, Hiwase DK. Red cell alloimmunization is associated with development of autoantibodies and increased red cell transfusion requirements in myelodysplastic syndrome. Haematologica 2017; 102:2021-2029. [PMID: 28983058 PMCID: PMC5709101 DOI: 10.3324/haematol.2017.175752] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/27/2017] [Indexed: 11/09/2022] Open
Abstract
Up to 90% of patients with a myelodysplastic syndrome require red blood cell transfusion; nevertheless, comprehensive data on red cell alloimmunization in such patients are limited. This study evaluates the incidence and clinical impact of red cell alloimmunization in a large cohort of patients with myelodysplastic syndrome registered in the statewide South Australian-MDS registry. The median age of the 817 patients studied was 73 years, and 66% were male. The cumulative incidence of alloimmunization was 11%. Disease-modifying therapy was associated with a lower risk of alloimmunization while alloimmunization was significantly higher in patients with a revised International Prognostic Scoring System classification of Very Low, Low or Intermediate risk compared to those with a High or Very High risk (P=0.03). Alloantibodies were most commonly directed against antigens in the Rh (54%) and Kell (24%) systems. Multiple alloantibodies were present in 49% of alloimmunized patients. Although 73% of alloimmunized patients developed alloantibodies during the period in which they received their first 20 red cell units, the total number of units transfused was significantly higher in alloimmunized patients than in non-alloimmunized patients (90±100 versus 30±52; P<0.0001). In individual patients, red cell transfusion intensity increased significantly following alloimmunization (2.8±1.3 versus 4.1±2.0; P<0.0001). A significantly higher proportion of alloimmunized patients than non-alloimmunized patients had detectable autoantibodies (65% versus 18%; P<0.0001) and the majority of autoantibodies were detected within a short period of alloimmunization. In conclusion, this study characterizes alloimmunization in a large cohort of patients with myelodysplastic syndrome and demonstrates a signficant increase in red cell transfusion requirements following alloimmunization, most probably due to development of additional alloantibodies and autoantibodies, resulting in subclinical/clinical hemolysis. Strategies to mitigate alloimmunization risk are critical for optimizing red cell transfusion support.
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Affiliation(s)
- Deepak Singhal
- Cancer Centre, Royal Adelaide Hospital, Adelaide, Australia.,Haematology Department, SA Pathology, Adelaide, Australia.,School of Medicine, University of Adelaide, Australia
| | | | | | - Li Yan A Wee
- Haematology Department, SA Pathology, Adelaide, Australia
| | - Sophia Hague
- Transfusion Medicine, SA Pathology, Adelaide, Australia
| | - Lakshmi Nath
- Haematology, Clinpath Laboratories, Adelaide, Australia
| | - Shriram V Nath
- Haematology, Clinpath Laboratories, Adelaide, Australia.,Adelaide Haematology Centre, Ashford Specialist Centre, Adelaide, Australia
| | - Romi Sinha
- Blood, Organ and Tissue Programs, Public Health & Clinical Systems, Department of Health, Adelaide, Australia
| | - Nicholas Wickham
- Adelaide Cancer Centre, Ashford Specialist Centre, Adelaide, Australia
| | - Ian D Lewis
- Cancer Centre, Royal Adelaide Hospital, Adelaide, Australia.,Haematology Department, SA Pathology, Adelaide, Australia.,School of Medicine, University of Adelaide, Australia
| | - David M Ross
- Cancer Centre, Royal Adelaide Hospital, Adelaide, Australia.,Haematology Department, SA Pathology, Adelaide, Australia.,School of Medicine, University of Adelaide, Australia.,Haematology & Genetic Pathology, Flinders University, Bedford Park, Australia.,Cancer Research, Cancer Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Peter G Bardy
- Cancer Centre, Royal Adelaide Hospital, Adelaide, Australia.,Haematology Department, SA Pathology, Adelaide, Australia.,School of Medicine, University of Adelaide, Australia
| | - Luen Bik To
- Cancer Centre, Royal Adelaide Hospital, Adelaide, Australia.,Haematology Department, SA Pathology, Adelaide, Australia.,School of Medicine, University of Adelaide, Australia
| | - John Reynolds
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Erica M Wood
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - David J Roxby
- Transfusion Medicine, SA Pathology, Adelaide, Australia.,Haematology & Genetic Pathology, Flinders University, Bedford Park, Australia
| | - Devendra K Hiwase
- Cancer Centre, Royal Adelaide Hospital, Adelaide, Australia .,Haematology Department, SA Pathology, Adelaide, Australia.,School of Medicine, University of Adelaide, Australia.,Cancer Research, Cancer Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
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16
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Hendrickson JE. Red blood cell alloimmunisation: induction of immunity and potential mitigation strategies. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- J. E. Hendrickson
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven CT USA
- Department of Pediatrics; Yale University School of Medicine; New Haven CT USA
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17
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Evers D, van der Bom JG, Tijmensen J, de Haas M, Middelburg RA, de Vooght KMK, van de Kerkhof D, Visser O, Péquériaux NCV, Hudig F, Zwaginga JJ. Absence of the spleen and the occurrence of primary red cell alloimmunization in humans. Haematologica 2017; 102:e289-e292. [PMID: 28411255 DOI: 10.3324/haematol.2016.162685] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Dorothea Evers
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Sanquin, Amsterdam, the Netherlands
| | - Johanna G van der Bom
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Deptartment of Clinical Epidemiology, Leiden University Medical Center, Sanquin, Amsterdam, the Netherlands
| | - Janneke Tijmensen
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Sanquin, Amsterdam, the Netherlands
| | - Masja de Haas
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Sanquin, Amsterdam, the Netherlands.,Department of Immunohematology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - Rutger A Middelburg
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Deptartment of Clinical Epidemiology, Leiden University Medical Center, Sanquin, Amsterdam, the Netherlands
| | - Karen M K de Vooght
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Eindhoven, the Netherlands
| | - Daan van de Kerkhof
- Department of Clinical Chemistry and Hematology, Catharina Hospital, Eindhoven, the Netherlands
| | - Otto Visser
- Department of Hematology, VU Medical Center, Amsterdam, the Netherlands
| | - Nathalie C V Péquériaux
- Department of Clinical Chemistry and Hematology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | | | - Jaap Jan Zwaginga
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands .,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Sanquin, Amsterdam, the Netherlands
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