Aspirin-Dipyridamole Prophylaxis of Sickle Cell Disease Pain Crises

We have previously reported that long term daily administration of aspirin-dipyridamole significantly improved laboratory findings indicative of disease activity in patients with sickle-cell disease. The laboratory index most influenced by platelet inhibitory drug therapy was the plasma concentration of high molecular weight fibrin(ogen) complexes (HMWFC), a moiety which reflects the rate of fibrin formation in vivo. Although improvement of laboratory findings with therapy was accompanied by apparent clinical improvement, the limited clinical data then available did not reach statistical significance.

This report describes extension of the trial of prophylactic platelet inhibitory drug therapy. Three patients were studied during a two year period on daily aspirin-dipyridamole therapy and during a two year control period. Plasma fibrinogen concentration was correlated with patient clinical status and the clinical findings suggested that the treatment was of modest prophylactic efficacy.

In 1976, we reported a characteristic pattern of blood coagulation abnormalities accompanying painful musculoskeletal sickle-cell disease (SSD) crises (1,2). With the onset of crisis, there was an increase in plasma high molecular weight fibrin(ogen) complexes (HMWFC) and a transient fall in platelets and in plasma Factor XIII. Subsequently, plasma fibrinogen concentration rose (peak at 1 week after onset of symptoms), platelets rose (peak at 2 weeks) and plasma Factor XIII increased (peak at 3 weeks). Subsidence of crisis was associated with a fall in HMWFC and a subsequent increase in fibrinogen first derivative, which reflects the rate of fibrinogenolysis. Plasma HMWFC concentration reflects the rate of fibrin formation in vivo (3) and plasma Factor XIII concentration decreases with intravascular fibrin deposition (4). Thus these laboratory findings support the hypothesis that in the early stages of SSD crisis, fibrin deposition and/or thrombosis significantly enhance the role of sickled erythrocytes in producing vascular occlusion and/or organ infarction.

We also reported that, over extended periods of observation, hemostatic findings and patient clinical status were generally correlated. Except for persistent depression of plasma Factor XIII concentration, laboratory findings during asymptomatic periods were essentially normal. Emphasis was placed on the value of hemostatic measurements as objective documentation of clinical status, and both laboratory and preliminary clinical observations were reported in three patients during a control period and during daily aspirin-dipyridamole therapy. Aspirin-dipyridamole therapy significantly improved laboratory measures of disease activity, particularly mean plasma HMWFC concentration, but insufficient data was obtained to determine whether the treatment was of clinical value.

We have now observed each of the three patients at weekly intervals for a minimum of 104 weeks on daily aspirin-dipyridamole, followed by a minimum of 104 weeks off the antiplatelet prophylactic regimen. This report compares clinical and laboratory findings during platelet inhibitory drug administration and following its discontinuation. Plasma fibrinogen measurements correlated with patient clinical status and the clinical findings suggest that the treatment was of modest prophylactic benefit.

THE NATURE AND CONTROL OF REACTIONS IN BIOLUMINESCENCE : WITH SPECIAL REFERENCE TO THE MECHANISM OF REVERSIBLE AND IRREVERSIBLE INHIBITIONS BY HYDROGEN AND HYDROXYL IONS, TEMPERATURE, PRESSURE, ALCOHOL, URETHANE, AND SULFANILAMIDE IN BACTERIA

On the basis of available data with regard to the chemical and physical properties of the "substrate" luciferin (LH₂) and enzyme, luciferase (A), and of kinetic data derived both from the reaction in extracts of Cypridina, and from the luminescence of intact bacteria, the fundamental reactions involved in the phenomenon of bioluminescence have been schematized. These reactions provide a satisfactory basis for interpreting the known characteristics of the system, as well as the theoretical chemistry with regard to the control of its over-all velocity in relation to various factors. These factors, here studied experimentally wholly with bacteria, Photobacterium phosphoreum in particular, include pH, temperature, pressure, and the drugs sulfanilamide, urethane, and alcohol, separately and in relation to each other. Under steady state conditions of bacterial luminescence, with excess of oxidizable substrate and with oxygen not limiting, the data indicate that the chief effects of these agents center around the pace setting reactions, which may be designated by the equation: A + LH₂ → ALH₂ following which light emission is assumed proportional to the amount of the excited molecule, AL*. The relation between pH and luminescence intensity varies with (a), the buffer mixture and concentration, (b), the temperature, and (c), the hydrostatic pressure. At an optimum temperature for luminescence of about 22° C. in P. phosphoreum, the effects of increasing or decreasing the hydrogen ion concentration are largely reversible over the range between pH 3.6 and pH 8.8. The relation between luminescence intensity and pH, under the experimental conditions employed, is given by the following equation, in which I₁ represents the maximum intensity, occurring about pH 6.5; I₂ the intensity at any other given pH; K₅ the equilibrium constant between hydrogen ions and the AL_-; and K₆ the corresponding constant with respect to hydroxyl ions: See PDF for Equation The value of K₅, as indicated by the data, amounts to 4.84 x 10⁴, while that of K₆ amounts to 4.8 x 10⁵. Beyond the range between approximately pH 3.8 and 8.8, destructive effects of the hydrogen and hydroxyl ions, respectively, were increasingly apparent. By raising the temperature above the optimum, the destructive effects were apparent at all pH, and the intensity of the luminescence diminished logarithmically with time. With respect to pH, the rate of destruction of the light-emitting system at temperatures above the optimum was slowest between pH 6.5 and 7.0, and increased rapidly with more acid or more alkaline reactions of the medium. The reversible effects of slightly acid pH vary with the temperature in the manner of an inhibitor (Type I) that acts independently of the normal, reversible denaturation equilibrium (K₁) of the enzyme. The per cent inhibition caused by a given acid pH in relation to the luminescence intensity at optimum pH, is much greater at low temperatures, and decreases as the temperature is raised towards the optimum temperature. The observed maximum intensity of luminescence is thus shifted to slightly higher temperatures by increase in (H⁺). The apparent activation energy of luminescence is increased by a decrease in pH. The value of ΔH‡ at pH 5.05 was calculated to be 40,900 calories, in comparison with 20,700 at a pH of 6.92. The difference of 20,200 is taken to represent an estimate of the heat of ionization of ALH in the activation process, and compares roughtly with the 14,000 calories estimated for the same process, by analyzing the data from the point of view of hydrogen ions as an inhibitor. The decreasing temperature coefficient for luminescence in proceeding from low temperatures towards the optimum is accounted for in part by the greater degree of ionization of ALH. At the optimum temperature and acid reactions, pressures up to about 500 atmospheres retard the velocity of the luminescent oxidation. At the same temperature, with decrease in hydrogen ion concentration, the pressure effect is much less, indicating a considerable volume increase in the process of ionization and activation. In the extremely alkaline range, beyond pH 9, luminescence is greatly reduced, as compared with the intensity at neutrality, and under these conditions pressure causes a pronounced increase in intensity, presumably by acting upon the reversible denaturation equilibrium of the protein enzyme, A. Sulfanilamide, in neutral solutions, acts on luminescence in a manner very much resembling that of hydrogen ions at acidities between pH 4.0 and pH 6.5. Like the hydrogen ion equilibrium, the sulfanilamide equilibrium involves a ratio of approximately one inhibitor molecule to one enzyme molecule. The heat of reaction amounts to about 11,600 calories or more in a reversible combination that evidently evolves heat. Like the action of H ions, sulfanilamide causes a slight shifting of maximum luminescence intensity in the direction of higher temperatures, and an increase in the energy of activation. The effect of sulfanilamide on the growth of broth cultures of eight species of luminous bacteria indicates that there is no regular relationship among the different organisms between the concentration of the drug that prevents growth, and that which prevents luminescence in the cells which develop in the presence of sulfanilamide. p-Aminobenzoic acid (PAB) antagonizes the sulfanilamide inhibition of growth in luminous bacteria, and the cultures that develop are luminous. When (PAB) is added to cells from fully developed cultures, it has no effect on luminescence, or causes a slight inhibition, depending on the concentration. With luminescence partly inhibited by sulfanilamide, the addition of PAB has no effect, or has an inhibitory effect which adds to that caused by sulfanilamide. Two different, though possibly related, enzyme systems thus appear to limit growth and luminescence, respectively. The possible mechanism through which both the inhibitions and the antagonism take place is discussed. The irreversible destruction of the luminescent system at temperatures above that of the maximum luminescence, in a medium of favorable pH to which no inhibitors have been added, proceeds logarithmically with time at both normal and increased hydrostatic pressures. Pressure retards the rate of the destruction, and the analysis of the data indicates that a volume increase of roughly 71 cc. per gm. molecule at 32° C. takes place in going from the normal to the activated state in this reaction. At normal pressure, the rate of destruction has a temperature coefficient of approximately 90,000 calories, or about 20,000 calories more than the heat of reaction in the reversible denaturation equilibrium. The data indicate that the equilibrium and the rate process are two distinct reactions. The equation for luminescence intensity, taking into account both the reversible and irreversible phases of the reaction is given below. In the equation b is a proportionality constant; k' the rate constant of the luminescent reaction; A₀ the total luciferase; A_0i the total initial luciferase at time t equals 0; k_n the rate constant for the destruction of the native, active form of the enzyme; k_d the rate constant for the destruction of the reversibly denatured, inactive form; t the time; and the other symbols are as indicated above: See PDF for Equation For reasons cited in the text, k_n evidently equals k_d. Urethane and alcohol, respectively, act in a manner (Type II) that promotes the breaking of the type of bonds broken in both the reversible and irreversible reactions and so promotes the irreversible denaturation. This result is in contrast to the effects of sulfanilamide, which at appropriate concentrations may give rise to the same initial inhibition as that caused by urethane, but remains constant with time. The inhibition caused by urethane and alcohol, respectively, increases as the temperature is raised. As a result, the apparent optimum is shifted to lower temperatures, and the activation energy for the over-all process of luminescence diminishes. An analysis for the approximate heat of reaction in the equilibrium between these drugs and the enzyme, indicates 65,000 calories for urethane, and 37,000 for alcohol. A similar analysis with respect to the effect of hydroxyl ions as the inhibitor gives 60,300 calories. The effects of alcohol and urethane are sensitive to hydrostatic pressure. Moderate inhibitions at optimum temperature and pH, caused by relatively small concentrations of either drug, are completely abolished by pressures of 3,000 to 4,000 pounds per square inch. At optimum temperature and pH, increasing concentrations of alcohol caused the apparent optimum pressure for luminescence to shift markedly in the direction of higher pressures. Analysis of the data with respect to concentration of alcohol at different pressures indicated that the ratio of alcohol to enzyme molecules amounted to approximately 4, at 7,000 pounds, but only about 2.8 at normal pressures. This phenomenon was taken to indicate that more than one equilibrium is established between the alcohol and the protein. A similar interpretation was suggested in connection with the fact that analysis of the relation between concentration of urethane and amount of inhibition at different temperatures also indicated a ratio of urethane to enzyme molecules that increased with temperature in the equilibria involved. Analysis of the data with respect to pressure and the inhibition caused by a given concentration of alcohol at different temperatures indicated that the volume change involved in the combination of alcohol with the enzyme must be very small, while the actual effect of pressure is apparently mediated through the reversible denaturation of the protein enzyme, which is promoted by alcohol, urethane, and drugs of similar type.

Prevalence of HLA sensitization in female apheresis donors

BACKGROUND

Transfusion-related acute lung injury (TRALI) is a serious complication of plasma-containing blood components. Studies have implicated HLA antibodies along with biologically active lipids in stored blood in the pathogenesis of TRALI. It has been proposed that the exclusion of HLA-untested, multiparous donors of plasma-rich components, including plasma and single-donor apheresis platelets, would substantially reduce the risk of TRALI.

STUDY DESIGN AND METHODS

To investigate the feasibility of such an exclusion, 332 female plateletpheresis donors with a record of over 9000 donations, none of which were associated with TRALI, were studied.

RESULTS

Seventeen percent of female donors demonstrated HLA sensitization. Parity and HLA sensitization were significantly correlated (p<0.0001), with sensitized donors having an average of 2.9 (+/- 0.6 95% CI) prior pregnancies and unsensitized donors having an average of 1.8 (+/- 0.2 95% CI) prior pregnancies. The percentage of HLA-sensitized women with 0, 1 to 2, and > or = 3 pregnancies was 7.8, 14.6, and 26.3, respectively.

CONCLUSION

These findings confirm the hypothesis that multiparous women (> or = 3 pregnancies) represent an increased potential risk for TRALI. However, the exclusion of multiparous plateletpheresis donors would eliminate one-third of our female donor pool. Screening such donors for HLA sensitization may represent the optimal approach for identifying donors at risk for causing TRALI, but this still would result in the deferral of 8 percent of female plateletpheresis donors. At present, prospective screening to identify donors at risk for causing TRALI is not justified.

Fatal outcome in a patient with autoimmune hemolytic anemia associated with an IgM bithermic anti-ITP

BACKGROUND

Several cold autoantibodies (usually IgG) with IT specificity have been reported previously, as have autoantibodies with joint I and P blood group specificities (IP1, ITP1, iP1, IP). A fatal outcome associated with an IgM cold autoantibody of ITP specificity is reported.

CASE REPORT

A 54-year-old man suffered from progressively severe cold autoimmune hemolytic anemia for 9 months. Hemoglobin concentration ranged from 6 to 7 g per dL (60-70 g/L) and reticulocytes from 3 to 5 percent (0.030-0.050). The direct antiglobulin test was weakly positive for IgM and strongly positive for C3d. The serum contained a cold agglutinin that reacted strongest with cord i red cells (RBCs) > adult I RBCs > adult i RBCs, which is consistent with IT specificity. The Donath-Landsteiner test was positive; the reaction was neutralized by globoside. The serum reacted weakly or was negative with RBCs from five group p blood donors, which suggests anti-ITP specificity. Dithiothreitol treatment of the serum abolished the cold agglutinin reactivity, which suggests that the anti-IT was IgM. The patient received > 40 RBC transfusions and failed to respond to oral steroids, oral cytoxan, high-dose pulse intravenous steroids, and plasma exchange at room temperature and at 35 degrees C. He died of sepsis following an unsuccessful trial of chlorambucil. Autopsy revealed unsuspected disseminated non-Hodgkin's lymphoma.

CONCLUSION

Serologic studies are consistent with our patient's having a single IgM cold autoantibody with IT and P specificities (anti-ITP) and requiring both specificities on the same RBC to permit maximal antibody expression.

Low retention of white cell fragments by polyester fiber white cell-reduction platelet filters

BACKGROUND

There is intense interest in the potential of current white cell (WBC)-reduction filters to prevent the alloimmunization of patients by the residual donor WBCs in filtered blood components transfused to them. Little attention has been paid to the capacity of current synthetic fiber filters to remove WBC membrane fragments bearing detectable leukocyte antigens.

STUDY DESIGN AND METHODS

Fluorescein isothiocyanate-conjugated monoclonal antibody to a universal WBC membrane antigen (CD45) and high-speed centrifugation coupled with ficoll-hypaque differential sedimentation were used to quantitate low-density WBC fragments in single-donor platelet components before and after filtration to determine if a polyester fiber filter retained WBC fragments.

RESULTS

Prefiltration measurements in 25 single-donor platelet components indicated that WBC fragments increased with length of storage up to 5 days at room temperature (p < 0.0001). When fragments in eight components were measured before and after filtration, absolute values for differences were insignificant (p = 0.15).

CONCLUSION

WBC fragments were poorly retained by these polyester fiber WBC-reduction filters. The antigenicity of WBC fragments could contribute to the WBC alloimmunization of some recipients of WBC-reduced blood components.

A latex particle assay for platelet-associated IgG

A modified, sensitive, solid-phase assay for platelet-associated IgG is reported. Direct comparisons were made between a 125I monoclonal radioimmunoassay (RIA) and the polyclonal antibody latex particle assay. In 209 simultaneous comparisons with the RIA, the sensitivity of the latex test was 91 percent, specificity was 100 percent, and overall efficiency was 97 percent. Commencing with platelet-rich plasma, the direct latex particle test for platelet-bound IgG requires 45 minutes; 90 minutes are required to crossmatch one patient with 12 donors. The advantages of the latex assay are absence of radioactivity, stability of reagents, economy, speed, specificity, and sensitivity.

Severe immune-mediated hemolytic anemia secondary to treatment with cefotetan

Severe acute hemolytic anemia developed in a woman following treatment with multiple antibiotics for possible postpartum uterine infection. On admission, the hemoglobin was 5 g per dL (50 g/L), the reticulocytes were 35 percent (0.350), the direct antiglobulin test was strongly positive for IgG and C3d (mixed fields), and the indirect antiglobulin test was negative. Serologic studies revealed antibody to cefotetan that reacted by both the immune complex and the drug adsorption mechanisms. Before the diagnosis of cefotetan-related immune hemolysis was made, all medications had been discontinued, and the patient received 4 units of red cells and a short course of adrenocorticosteroids. Recovery was prompt and complete.

Refractory immune hemolytic anemia with a high thermal amplitude, low affinity IgG anti-Pra cold autoantibody

A 54 y.o. woman presented with acute Coombs-negative hemolytic anemia at an outside hospital where she received 25 RBC transfusions and did not respond to prednisone or splenectomy. On transfer to our hospital, routine DAT and IAT were weakly positive, occasionally negative. When a modified "cold" antiglobulin test was employed, the result was strongly positive for IgG, weakly positive for C3d. Cold agglutinin titer was 32, and the Donath-Landsteiner test was negative. The autoantibody exhibited Pra specificity. The patient failed IV-IgG, high dose IV pulse steroids and cyclophosphamide, and continued to require daily transfusions. She responded 21 days after receiving daily plasma exchange (x3), with pulse cyclophosphamide on the third day, followed by escalating daily oral cyclophosphamide.

Experience of a combined apheresis, blood collection, and blood transfusion unit in a large tertiary care medical center

The Barnes Hospital Apheresis Blood Collection and Blood Transfusion Unit is part of Barns Hospital Blood Bank. Because of its size and complexity, we report our experience which may be useful to administrators and physicians involved in the planning or management of similar services. From 1985 through 1988 we collected platelets from 1,976 different donors, the majority of which (87%) were community donors. Sixty-nine percent of 1,976 donors donated in 1988 an average of 4.9 times. Of 6,568 apheresis products collected. 1.1% were discarded because of positive screening tests and 0.7% were discarded because of outdating or presence of fibrin clot. In 1988 a total of nine cell separators were used. All donor apheresis were done with seven blood separators, and on average a separator produced an apheresis product every 4.5 worked hours. All therapeutic apheresis (338) were done on two separators. Most of them (88%) were performed during work hours. In 1988 donor and therapeutic apheresis were done by 17 1/2 full-time employees (FTEs) during work hours. Considering the Workload Unit Value per procedure given by the College of American Pathologists (CAP) and that each FTE worked 1,864 hours per year, the worked hour productivity for donor and therapeutic apheresis was 78.2%. Blood collections, therapeutic bleeds, and outpatient transfusions (1,127, 114 and 1,745 respectively) were accomplished by two FTEs, for a worked hour productivity of 35.5%. Because 95.1% of total worked units was produced by efficient donor and therapeutic apheresis activities, overall efficiency remained high at 73.8%.

Life-threatening, antiglobulin test-negative, acute autoimmune hemolytic anemia due to a non-complement-activating IgG1 kappa cold antibody with Pra specificity

A 21-year-old man with fulminant cold autoantibody hemolytic anemia (CAHA) was hospitalized with hemoglobinemia, hemoglobinuria, hemoglobin concentration of 3.3 gm per dL, a negative direct antiglobulin test (DAT) with polyspecific and anti-C3d reagents, a negative Donath-Landsteiner test, and a cold agglutinin titer of 80. He failed to respond to corticosteroids, multiple plasma exchanges, and cyclophosphamide; he required 54 transfusions in 10 days to maintain a hemoglobin concentration of 6.0 to 10.0 g per dL. He improved dramatically after a splenectomy was performed. The wide-thermal-amplitude cold agglutinin proved to be an IgG1 kappa antibody with Pra specificity. The patient's serum exhibited normal complement activation. When the DAT was carried out at 0 to 4 degrees C, the result was strongly positive for IgG; the indirect antiglobulin test at 0 to 4 degrees C was positive with the patient's serum diluted 1 in 640. Within 6 months, he was in complete remission and receiving no therapy. As compared with eight patients with CAHA that was exclusively IgG-mediated, this patient is remarkable for his requirement for many transfusions and for DATs that were consistently negative for C3d.

Inhibition of an anti-Pr1d cold agglutinin by citrate present in commercial red cell preservative solutions

A patient with known cold autoimmune hemolyticanemia was admitted for surgery. Routine cold agglutinin evaluations, using commercial red cells (RBCs) in modified Alsever's preservative solution, revealed a cold agglutinin titer of 4 to 16. However, using RBCs washed four times with saline, a high-titer (greater than 2000 at 4 degrees C) cold autoagglutinin was demonstrated. The cold agglutinin was shown to be an IgM kappa paraprotein with anti-Pr1d specificity. The addition of Alsever's solution to washed RBCs inhibited the cold agglutinin. Each major component of Alsever's solution (neomycin, chloramphenicol, inosine, dextrose, and citrate) was tested individually; only citrate inhibited the patient's cold agglutinin. Various compounds structurally related to citrate were tested and found to cause various degrees of inhibition. The strongest inhibition correlated with the presence of either three carboxyl groups on molecules devoid of double-bonded carbon atoms or two carboxyl groups in cis configuration. A panel of 54 cold agglutinins, including 7 with anti-Pr specificity, was analyzed. None was significantly inhibited by Alsever's solution, although one with anti-Pr2 specificity was weakly inhibited. In summary, these studies describe an anti-Pr1d cold autoagglutinin that was inhibited by citrate in RBC preservative solutions. The failure to detect such a cold agglutinin can result from not washing RBCs free of citrate before testing.

Invalidation of antiglobulin tests by a high thermal amplitude cryoglobulin

A multiply transfused patient was referred for evaluation of a transfusion reaction. The direct and indirect antiglobulin tests (DAT, IAT) for alloantibody were negative. However, IgG-coated control cells failed to agglutinate in the negative reactions, casting doubt on their validity. At 4 degrees C, the patient's serum exhibited a large cryoprecipitate (2.9 mg/mL), made up predominantly of an IgG kappa paraprotein and having trace amounts of IgM and C3. Clear serum separated at 37 degrees C became cloudy within 10 minutes at room temperature (RT); within 4 hours, approximately 60 percent of the total precipitable cryoprotein had precipitated. Red cells (RBCs) incubated in fresh serum that had cooled to RT or RBCs obtained from RT or refrigerated samples contained cryoprecipitate that sedimented with the RBCs during washing with RT saline. On resuspension, enough IgG cryoglobulin redissolved to neutralize completely the commercial anti-IgG reagents. If the patient's samples were maintained at 37 degrees C, cryoprecipitate did not form, and RBCs washed four times at 37 degrees C gave valid DAT and IAT reactions. The removal of all cryoprecipitate from the patient's serum by centrifugation after overnight incubation at 4 degrees C also made possible valid antibody screening and compatibility tests.

Risks of viral transmission by blood products: current status of preventive measures

Patients are likely to ask their physicians about the safety of blood transfusions in the present era of AIDS fear. The authors address these concerns and discuss the risks of acquiring viral disease from a transfusion.

Severe paravalvular mechanical hemolysis with a normal blood smear

A 74-year-old white female presented with clinical and laboratory evidence of severe hemolysis caused by paravalular leakage around a prosthetic mitral valve. The unique aspect of ther case is the absence of red blood cell fragments in the peripheral smear. Red blood cell transfusions, which averaged three to four units per week, were no longer required after operative repair of the primary suture line. All evidence for hemolysis disappeared; hematologic values returned to normal and remained so during the subsequent six months.

Effectiveness of two synthetic fiber filters for removing white cells from AS-1 red cells

Two commercially available synthetic fiber filters were studied for their effectiveness at removing white cells (WBCs) from AS-1-preserved red cells (RBCs) stored less than or equal to 14 days. In all, 65 filtrations were performed. An automated microprocessor-controlled hydraulic system designed for use with cellulose acetate fiber filters was employed to prepare filtered RBCs before release for transfusion. Studies were also carried out on polyester fiber filters, which are designed to be used in-line during transfusion. Residual WBCs were below the accurate counting range of Coulter counters and of conventional manual chamber counts. An isosmotic ammonium chloride RBC lysis method, plus a modified chamber counting technique, permitted a 270-fold increase over the number of WBCs counted by the conventional manual method. For the polyester fiber-filtered products, residual WBCs per unit were not affected by speed of filtration, prior length of storage, or mechanical tapping during filtration. The effectiveness of WBC removal (mean 99.7%), total residual WBCs (means, 4.8 and 5.5 x 10(6], and RBC recovery (mean, 93%) was the same for both filters. The majority of residual WBCs were lymphocytes. WBC removal and RBC recovery were strikingly superior to results reported with nonfiltration methods.

Preliminary trial of minidose heparin prophylaxis for painful sickle cell crises

Four patients with well-documented severe recurrent painful sickle cell crises received 12-month courses of self-administered minidose heparin (5000-7500 units every 12 hours). Patients were evaluated weekly or bi-weekly for symptoms and signs of sickle crises. The observations were compared with identical observations during 12 months off heparin (control). Prior to starting heparin, baseline laboratory values were established, including hematocrits, platelet counts, and plasma coagulation factors. Bone density was evaluated by radiologic measurement of metacarpal cortical width and by forearm transmission osteodensitometry. Laboratory values were repeated at each visit; bone density was reevaluated every 6 months. At each visit clinical status for the preceding 1-2 weeks was classified as: no pain (I), minor pain controllable by non-prescription medications (II), pain requiring office or emergency room admissions for parenteral narcotics (III), hospitalized for about 3 days for pain crisis (IV). One patient completed a single 2-year cycle; one patient completed 2 cycles (followed 4 years), and 2 patients have undertaken 3 cycles (followed greater than or equal to 6 years). No treatment-related complications occurred requiring discontinuation of heparin. Thrombocytopenia was not observed. There was no evidence of progressive osteopenia. All patients improved while receiving heparin; 1 moderately, 3 markedly. Cumulative data (8.7 patient years on heparin, 12 control years) revealed a 73% reduction in days of hospitalization per year and 74% reduction in hours spent in emergency rooms per year during heparin administration. Pretreatment pain patterns recurred when heparin was discontinued.

Effect of ABO mismatching on a radioimmunoassay for platelet compatibility. Successful adsorption of ABO alloantibodies with synthetic A and B substance

IgG and IgM anti-A and/or -B agglutinin titers were determined on 17 serum samples (5 group 0, 7 group A, 5 group B) to range from 8 to 1024. The presence of hemolysins was also evaluated. Single adsorptions with solid-state synthetic A and B substances greatly reduced or eliminated anti-A and -B titers but did not adsorb known platelet antibodies. Unadsorbed and adsorbed serum samples were crossmatched with ABO-compatible and -incompatible platelets by a radioimmunoassay employing 125I-labeled monoclonal antibodies specific for human gamma, mu, and C3d antigens. IgG and IgM crossmatch incompatibility was directly related to ABO alloantibody titers greater than or equal to 64. The use of adsorbed serum in the crossmatch eliminated or greatly reduced incompatible results that were due to ABO alloagglutinins alone, thus allowing the reliable detection of platelet and/or HLA antibodies.

Multiple plasma exchanges successfully maintain a young adult patient with Crigler-Najjar syndrome type I

Plasmapheresis has been shown to reduce total and free bilirubin levels in acute exacerbations of Crigler-Najjar syndrome, type I (CNS-TI), but its effectiveness in long-term management has not been reported. An 18-year-old (yo) male with CNS-TI, who required prolonged daily high-intensity phototherapy to prevent cerebral nervous system symptoms, developed increasingly frequent bouts of confusion, nausea, and vomiting associated with free bilirubin concentrations (fbcs) greater than 10-15 nmol/L. Pending consideration of orthotopic liver transplantation, plasma exchange (approximately 3 liters per procedure) was begun in 12/84 using the IBM/COBE 2997 with 5% albumin as replacement fluid. Frequency of treatments was guided by twice weekly fbcs, with plasma exchange for fbc greater than 10-15 nmol/L. Pre-exchange and postexchange fbcs ranged from 27.5 to 11 nmol/L and 9.2 to 2 nmol/L, respectively. Seventy-two exchanges were performed over a 28 month period. Irreversible CNS damage did not occur, and the patient underwent successful liver transplantation in April of 1987, with complete correction of his metabolic disorder. He remains well 18 months following transplantation.

Blood component use in orthotopic liver transplantation

Blood component use during orthotopic liver transplantation (OLT) was evaluated after an initial 23-month experience with 37 consecutive transplant procedures. Blood component support of OLTs in 24 adult and 13 pediatric patients was reviewed. Adult procedures required intraoperatively a mean of 24.5 units of red cells (RBCs), 38.7 units of fresh-frozen plasma (FFP), 26.1 random-donor platelets (RDP), and 12.2 units of cryoprecipitate (Cryo); pediatric procedures required 4.8 units of RBCs, 5.8 of FFP, 3.9 of RDP, and 1.2 of Cryo. RBC salvage constituted 17 percent of the RBCs transfused intraoperatively. Intraoperative support in adult and pediatric OLT patients accounted for the majority of the total components required for the entire hospital stay. OLT blood component use constituted 1.3, 7.0, 3.6, and 8.1 percent of hospital-wide use of RBC, FFP, RDP, and Cryo, respectively, during the period of the study.

First example of familial posttransfusion purpura in two PlA1-negative sisters

Posttransfusion purpura (PTP) (platelet count 5000/microliter) was diagnosed in a female patient (never transfused, gravida IV, para IV) 1 week after transfusion for hysterectomy in 1978. She did not respond to pooled random-donor platelets but recovered following a single plasma exchange. Her platelets were PlA1 negative, and her plasma contained potent anti-PlA1. In 1986, her sister (never transfused, gravida III, para III) developed PTP (platelet counts 5-15,000/microliter) following surgery-associated transfusion. She did not respond to pooled random-donor platelets. Platelet-associated IgG was markedly elevated (5365) molecules/platelet; normal, less than 660); her plasma contained a potent platelet antibody with anti-PlA1 specificity. Her platelets were subsequently shown to be PlA1 negative. The platelet count did not rise above 30,000 per microliter, despite 3 days of high-dose methylprednisolone sodium succinate and 2 weeks of prednisone (80 mg/day). Later, her platelet count increased and remained normal after steroids were discontinued. The two sisters proved to be HLA-identical, and each possessed one haplotype carrying the DR3 marker, which has been implicated as a risk factor in neonatal alloimmune thrombocytopenia associated with anti-PlA1.

Anti-Jka, -C, and -E in a single patient, initially demonstrable only by the manual hexadimethrine bromide (Polybrene) test, with incompatibilities confirmed by 51Cr-labeled red cell studies

Published reports have confirmed the superior sensitivity of the manual hexadimethrine bromide (Polybrene) test (MPT) for demonstrating many alloantibodies in vitro; however, the clinical significance of alloantibodies demonstrable exclusively by MPT has not been shown conclusively. A patient with macroglobulinemia experienced chills, fever, hemoglobinemia, and hemoglobinuria following the transfusion of 1 unit of red cells (RBCs) shown to be compatible by the low-ionic-strength antiglobulin (LIS-AG) method. Serologic investigation was negative. Intravascular hemolysis occurred with a second "compatible" unit. Serologic studies were again negative by LIS-AG and ficin-AG methods, but revealed anti-Jka by MPT. Both donors were Jk(a+b-), and 51Cr studies of the second donor's RBCs revealed a t1/2 of less than 30 minutes, with marked intravascular hemolysis. A LIS-AG-compatible Jk(a-) unit was transfused uneventfully, but with no rise in hematocrit. MPT next revealed anti-C; subsequent 51Cr studies with the Jk(a-), Cc donor's RBCs showed a 51Cr t1/2 of 100 minutes with slight intravascular lysis. Four transfusions of Jk(a-), C- blood were uneventful, but 5 days later the patient's hemoglobin declined. The following day, anti-E was demonstrable exclusively by MPT. 51Cr-labeled Jk(a-), C-, E- RBCs had normal 24-hour survival. The patient's hemoglobin rose to 11 g per dl following transfusions of Jk(a-), C-, E- RBCs, and he was discharged. In vitro studies employing the patient's purified IgM paraprotein revealed no interference with alloantibody binding or detection.

Anti-B-mediated rejection of an ABO-incompatible cardiac allograft despite aggressive plasma exchange transfusion

A group A recipient received a group B cardiac allograft. Aggressive plasma exchange with replacement by group AB FFP initially reduced the recipient's anti-B titer to a low level. Once a secondary anti-B response was mounted, plasma exchange was ineffective and IgM and IgG anti-B titers rose to high levels. Associated with the increased anti-B titers, cardiac function deteriorated and on day 13 the group B heart was replaced by a group A allograft. The compatible allograft functioned well initially but was eventually rejected, and the patient died 51 days after the initial transplantation. Histologic examination of the first allograft revealed a delayed form of typical antibody-mediated rejection with destruction of the microvasculature associated with antibody deposition and acute inflammation. By contrast, the histopathology of the second compatible allograft was typical of cell-mediated allograft rejection. Extracts of myocardium from the incompatible heart contained IgM and IgG anti-B, while no anti-B alloantibody was demonstrable in the extracts of the ABO-compatible allograft and a control heart. The utility of plasma exchange with group AB FFP replacement in such a circumstance requires further study.

Frozen storage of 11 units of sickle cell red cells for autologous transfusion of a single patient

A patient with sickle cell disease and multiple alloantibodies required frozen storage of autologous red cells (RBC) to provide the RBC volume equivalent of 6 units of normal donor blood for an orthopedic surgical procedure. Eleven 600-ml donations were made at 4-week intervals, without significant change in hemoglobin concentration, hematocrit, or reticulocyte count, and with only small decreases in serum iron and ferritin concentrations. Minor modifications of a glycerolization and deglycerolization procedure described recently were used. We report in vitro recoveries of deglycerolized RBC from the 11 units following frozen storage for 27 to 391 days. Despite use of a single donor and adherence to a standardized processing protocol, considerable variation in the percent in vitro RBC recovery was observed (51-81%). In vivo survival of an aliquot following frozen storage for 27 days was identical with fresh autologous RBC (100% at 1 hr, 88% at 24 hr, one-half disappearance of 7.5 days). Autologous transfusion of RBC recovered from 7 units after storage for as long as 126 days was uneventful.

Acute intravascular hemolytic anemia in the black rhinoceros: hematologic and immunohematologic observations

To investigate the syndrome of acute intravascular hemolytic anemia in the black rhinoceros (Diceros bicornis), laboratory techniques used in the differential diagnosis of hemolytic anemias were performed on blood samples from 6 black rhinoceroses: 3 nonrelated healthy rhinoceroses, 1 rhinoceros with iron deficiency anemia, and 2 rhinoceroses with intravascular hemolysis. Osmotic fragility, erythrocyte membrane protein composition, hemoglobin electrophoresis, and hemoglobin stability did not distinguish between healthy and affected (anemia or hemolysis) rhinoceroses. Polyclonal antiglobulin reagents were prepared in rabbits, using whole rhinoceros serum and purified rhinoceros immunoglobulin G. These reagents were nonreactive against erythrocytes of the healthy and iron-deficient rhinoceroses. Reactions with RBC from the rhinoceros with fatal hemolytic anemia indicated increased membrane coating by the third component of complement; this was not evident in a second rhinoceros that survived a hemolytic event.

Comparisons of pooled polyclonal rabbit anti-human C3d with four monoclonal mouse anti-human C3ds. II. Quantitation of RBC-bound C3d, and characterization of antiglobulin agglutination reactions against RBC from 27 patients with autoimmune hemolytic anemia

Labelled polyclonal IgG anti-C3d and monoclonal IgM and IgG anti-C3d antibodies (MAs) were employed at increasing antibody excess to measure the number of C3d molecules on human red blood cells (RBC) coated by complement in vitro and in vivo. Values for the number of C3d sites per cell determined with polyclonal anti-C3d were at least 4-fold higher than when MAs were used. The results suggest that the molar combining ratio for polyclonal anti-C3d with a single RBC-bound C3d fragment is more likely greater than 4.0 than 1.0 as previously assumed. Antiglobulin agglutination studies compared polyclonal and monoclonal anti-C3d antibodies against C3d-coated RBC from 27 patients with autoimmune hemolytic anemia. All four MAs showed striking prozones, requiring their use over a 25-fold higher range of dilutions than polyclonal anti-C3d. Polyclonal anti-C3d produced stronger agglutination reactions than any of the IgG MAs. Only the IgM MA produced agglutination as strong as, or stronger than, polyclonal anti-C3d. While IgM MA always gave the strongest MA agglutination reactions, no consistent ranking of the three IgG MAs was observed. Agglutination was not enhanced when all IgG MAs were combined; addition of IgG MAs to IGM MA reduced the strength of agglutination seen with IgM alone, suggesting blocking of IgM binding by competing IgG anti-C3d.

Comparisons of pooled polyclonal rabbit anti-human C3d with four monoclonal mouse anti-human C3ds. I. Preparation, purification and binding properties

Performance characteristics of pooled rabbit IgG polyclonal anti-C3d are compared with one mouse IgM and three mouse IgG monoclonal anti-C3d antibodies (MAs). IgG MA,s employed singly or in combination, failed to precipitate C3d; by contrast, IgM MA and polyclonal anti-C3d precipitated C3d. Measurements of polyclonal anti-C3d concentration by chemical means and by 125I-C3d radioimmunoassay (RIA) agreed closely. RIA values were 50% of chemical measurement values for three of the four MAs. Use of sucrose density gradient ultracentrifugation to assess MA C3d/anti-C3d molar combining ratios for soluble anti-C3d/C3d was not possible because fast-sedimenting multimeric C3d/anti-C3d complexes did not form. Dissociation and competitive binding studies indicate that (1) two MAs had substantially lower affinities than the other anti-C3d antibodies, and (2) polyclonal anti-C3d recognizes more C3d epitopes than are recognized by individual MAs. The results demonstrate antigenic complexity of C3d fragment and illustrate the difficulties of predicting individual MA performance based on prior experience with polyclonal antibodies.

Clinically significant allo-anti-I in an I-negative patient with massive hemorrhage

A 37-year-old white man who had never been transfused was admitted as an emergency patient with a ruptured spleen and a falling hematocrit (19% on admission). All crossmatches were incompatible. His serum contained anti-I, and his red cells (RBCs) were I-negative and strongly i-positive. Only 4 units of crossmatch-compatible I-negative frozen RBCs were available immediately. Because of the likelihood that more than 4 units would be required, chromium survival studies were performed using I-positive cells. Samples obtained at 15 and 30 minutes after injection revealed less than 1 percent survival of the donor RBCs. He received the 4 units of I-negative RBCs during the operation in addition to reinfusion of RBCs harvested from 1800 ml of blood aspirated from the abdominal cavity. The postoperative hematocrit remained greater than 30 percent and the bilirubin less than 1.5 mg per dl. Before recommending frozen storage of autologous RBCs, 51Cr labeled I-positive RBCs from the patient's daughter (obligate li heterozygote) were infused. Survival was 100 percent at 15 and 30 minutes, 90 percent at 3 hours, 85 percent at 26 hours; the remaining RBCs disappeared at a normal rate (T 1/2 27 days) over the succeeding 2 weeks. A repeat 51Cr-labeled RBC study with the original I-positive donor confirmed greater than 92 percent destruction in 90 minutes. The clinical significance of this allo-anti-l (apparently primarily against RBCs from homozygous I-positive donors) is in marked contrast to reported findings with auto-anti-l antibodies.

Long-term in vivo survival of Rh(D)-negative donor red cells in a patient with anti-LW

The present study documents immediate and long-term survival of crossmatch-incompatible Rh(D)-negative donor red cells in a patient with anti-LW. A 67-year-old group A Rh(D)-positive man was admitted for urgent coronary artery bypass surgery. The direct antiglobulin test (DAT) was weakly positive in two of five laboratories. His serum contained anti-LW (two laboratories); his red cells were LW negative (three antisera). Two siblings were LW-positive. Surgery was delayed, and 3 ml Rh(D)-negative crossmatch-incompatible red cells stored in citrate-phosphate-dextrose-adenine-one were labeled with 25 microCi of 51Cr and injected. Immediate survival was approximately 100 percent with 92 percent survival at 20 hours. Six daily blood samples showed a decreased red cell lifespan, (T 1/2 = 14 days). Because of medical complications, 4 units of Rh(D)-negative crossmatch-incompatible blood were then transfused without clinical or hemolytic reaction. The anti-IgG DAT became stronger. In vivo survival of the remaining 51Cr-RBCs became normal (T 1/2 28 days over the succeeding 20 days). Following transfusion, no change in serum antibody strength was demonstrated by double-blind titration of seven coded samples. The observations support modest reduction of lifespan for 3 ml of LW-positive red cells, but normal survival following subsequent transfusion of approximately 700 ml of LW-positive red cells.

Alloimmunization in patients with warm autoantibodies. A retrospective study employing three donor alloabsorptions to aid in antibody detection

We examined the value of performing alloabsorptions to detect clinically significant alloantibodies in patients with warm autoantibodies who must receive crossmatch-incompatible blood. One hundred and twenty-five (125) patients were evaluated using alloabsorption with red cells (RBCs) from three donors: R1R1, R2R2, and rr, whose phenotypes other than Rh were selected to exclude 98 percent of clinically significant alloantibodies. This technic was selected rather than autoabsorption due to insufficient quantities of patient cells available and to the possible presence of transfused cells in some instances. Patients were divided into three risk categories: I--no prior pregnancy or transfusion; II--history of pregnancy and/or one to five transfusions; and III--greater than five transfusions. No significant alloantibodies were found in 32 category I patients. Of 74 category II patients, 13 (17.5%) had significant alloantibodies detectable after absorption. Six of 19 (31.5%) category III patients had alloantibodies. The majority showed Rh specificity: anti-E (13), -C (6), -c (2), -D (1). Anti-K was found in five samples. Forty-two (42%) percent of the alloantibodies were undetectable prior to the alloabsorptions. We conclude that category II and particularly category III patients are at significant risk of allosensitization and should be evaluated by an absorption procedure prior to the transfusion of crossmatch-incompatible red cells.

In vivo instability of red-blood-cell-bound C3d and C4d

Until now, there have been no measurements of the in vivo stability of red-blood-cell-bound C3d and C4d subfragments of the third and fourth components of human complement. We have recently described a radiolabeled antiantiglobulin method for measuring RBC-bound C3d and have demonstrated that small amounts of C3d are present on RBC of all normal subjects tested. In the present study, the method was applied to follow the increments above baseline of RBC-bound C3d and C4d produced by autotransfusing 3 normal volunteers with 160-200 ml of RBC strongly coated in vitro by C3d and C4d. Posttransfusion measurements were carried out over 21-34 days. Immediate and long-term in vivo survival of the transfused RBC was unimpaired by C3d and C4d coating. Of the bound C3d antigen, 85%-95% disappeared from circulating RBC in 5-8 days; the remainder disappeared more slowly, with half-times in the range of 8-29 days. C4d antigen disappeared substantially more slowly, describable by a single exponential function in 2 of the 3 subjects, with half-times in the range of 12-31 days. Recognition of the in vivo instability of RBC-bound C3d helps in interpreting steady-state and changing levels of RBC C3d coating in a variety of alloimmune and autoimmune disorders.

Further studies of the C3g component of the alpha 2D fragment of human C3

Recent studies employing sheep red cells, rabbit anti-sheep cell IgM, guinea-pig R3 reagent and purified human C3, factor I, factor H and human serum have led to the discovery of a new C3b breakdown product antigen, C3g, which is present on the alpha 2D fragment of C3 but is removed by trypsinization. The present studies were undertaken to confirm the above findings in entirely human red cell and serum systems, including studies on cells from nine patients with a variety of complement-mediated autoimmune haemolytic anemias. The results confirm the recently reported findings in every respect. The presence of both C3d and C3g on all patient's red cells so far tested supports the concept that red cells coated by C3d alone are likely to be a laboratory artefact and that the alpha 2D fragment (C3d,g) is the natural end product of cell bound C3b breakdown in vivo.

Lymphoma in primary chronic cold hemagglutinin disease treated with chlorambucil

Two patients with primary chronic cold hemagglutinin disease (CHAD) were treated with chlorambucil for ten and 7 1/2 years, with cumulative doses of 14 and 6.6 g, respectively. Both responded favorably, and malignant lymphoma eventually developed in both of them. An attempt to assess the incidence of lymphoma as part of the natural course of untreated CHAD failed for want of proof. Literature since 1970 reported no chlorambucil-associated lymphoma. Of 77 responses to a questionnaire mailed to 135 US hematology-oncology programs, 76 reported no examples of chlorambucil-associated lymphoma. One response, however, did relate that diffuse histiocytic lymphoma developed in three of 141 patients receiving prolonged chlorambucil therapy for polycythemia vera. Alkylating-agent therapy for CHAD might be associated with development of lymphoma.

Weak "false positive" direct antiglobulin test reactions with polyspecific antiglobulin reagents: lack of correlation with red-blood-cell-bound C3d

The investigation explored whether weak positive or "rough" direct antiglobulin test (DAT) reactions observed with commercial polyspecific reagents could be correlated with the amount of C3d bound to normal donor red blood cells (RBC). Employing a radiolabeled anti-antiglobulin method, RBC-bound C3d was measured on 101 normal donor samples. In a second phase of the study, RBC-bound C3d plus igG were measured on an additional 141 donor samples. In neither phase of the study was a correlation observed between weak positive antiglobulin reactions and the amount of RBC-bound serum globulins.

Reproducible in vitro preparation of intermediate C3d coated red blood cells

As a standardizing reagent and/or as a positive control for the anti-C3d reactivity of antiglobulin reagents, test red blood cells (RBC) reproducibly coated with "C3d only" (i.e. lacking other complement components and immunoglobulins) are essential. We have prepared RBC coated by intermediate amounts of C3d. Two approaches to varying the amount of C3d bound to RBC were studied: a) variation in Mg++ concentration and b) dilution of donor plasma. The amount of C3d bound to RBC was assessed both by agglutination reactions with serial dilutions of a standard anti-C3d serum and by quantitation of bound anti-C3d with 125I-labeled anti-antiglobulin serum. Marked individual donor differences were encountered in response to varying Mg++ concentration and to dilution of donor plasma; no single set of conditions could be employed to produce a desired intermediate C3d-coated RBC from all donors. Examples of variations to be expected with both manipulations are illustrated, along with studies of conditions under which the standard deviation for bound C3d on intermediate C3d-coated RBC made from 5-donor pools was less than 10%.

Radioimmunoassay evaluation of anti-C3d reactivity in broad spectrum commercial antiglobulin reagents

The study was undertaken to assess the potential of a labeled C3d radioimmunoassay method as a standardization criterion for antiglobulin reagents containing anti-C3d reactivity. Over an 18-month interval, four different lots of broad-spectrum antiglobulin reagents were purchased from each of seven United States manufacturers. Anti-C3d antibody concentration and Ko in each lot were assayed initially and at four-month intervals over 16 to 21 months storage at 4 degrees C. The results permitted 1) comparison of anti-C3d antibody concentrations among different manufacturers, 2) comparison among different lots from the same manufacturer, and 3) assessment of stability of anti-C3d during storage. In addition, serial dilutions of reagents in each manufacturer's diluent were compared for their anti-C3d agglutinating properties by the spin-antiglobulin method against red blood cells (RBC) coated by C3d in vitro and against in vivo C3d-coated RBC from 16 patients. Most reagents were shown also to contain anti-C3c, anti-C4c and anti-C4d reactivities when tested against suitably coated RBC. Anti-C3d antibody concentrations ranged from approximately 1 to 3.5 microgram/ml for 27 of the 28 reagents and were stable over 16 to 21 months of storage. Anti-C3d agglutination titer scores showed a general correlation with anti-C3d antibody concentrations when tested against in vitro C3d-coated RBC; correlations were less good against C3d-coated cells from patients. The radioimmunoassay provided reproducible objective measurements and appeared to have merit as a standardization criterion.

Combined sickle cell disease and autoimmune hemolytic anemia

Four patients experienced combined sickle cell disease and autoimmune hemolytic anemia within the past ten years. A fifth patient had positive direct antiglobulin test results without verified autoimmune hemolysis. Severely accelerated hemolysis was observed in four patients; anemia was severe, and the reticulocyte count rose into the 60% to 88% range. During the period of active autoimmune hemolysis, decline of the reticulocyte count rose into the 60% to 88% range. During the period of active autoimmune hemolysis, decline of the reticulocyte count into the 6% to 16% range was associated with rapid decrease in the hemoglobin level, requiring transfusion. All five patients were already alloimmunized by transfusions administered before onset of the autoimmune hemolytic anemia; two or more allospecificities were identified in four of five patients. The presence of autoantibody notably compromised compatibility testing; three patients experienced posttransfusion hemoglobinuria, and in vivo cross matching with 51Cr-labeled donor RBCs was employed on three occasions. All patients responded to corticosteroids; mercaptopurine was also administered to one patient. The direct antiglobulin test result reverted to negative in all patients after hospital discharge.