Foetal/neonatal alloimmune thrombocytopenia in Egypt; human platelet antigen genotype frequencies and antibody detection and follow-up in pregnancies

BACKGROUND AND OBJECTIVES

Foetal and neonatal alloimmune thrombocytopenia (FNAIT) is studied mainly in Caucasian populations. Severe thrombocytopenia (<50×10(9)/L) gives risk of haemorrhage and the most feared complication is intracranial haemorrhage (ICH). In Caucasian populations anti-human platelet antigen (HPA)-1a antibodies are the cause of FNAIT in >80% of the cases. The aims of this project were to study the gene frequencies of HPA-1-5 and 15 alleles in an Egyptian population (Arabic), and to determine the frequency of HPA-1a and -5b immunisations in a cohort of Egyptian pregnant women.

MATERIALS AND METHODS

Altogether 6974 pregnant women were included in the study. Genotyping was performed by polymerase chain reaction and antibodies were detected by flow cytometry and enzyme-linked immunosorbent assay. HPA-1-5 and 15 alleles were studied in 367 individuals.

RESULTS

The HPA genotypes differed from genotypes published from different Caucasian and Chinese (Han) populations in HPA-1, -2, -3, and -5 systems with significant higher frequency of HPA-1b, -2b and -5b. The rate of HPA-1a alloimmunisation was found comparable to Caucasian populations. Severe thrombocytopenia was found in two newborns. No bleeding complication was reported. Anti-HPA-5b antibodies were detected in 4.4% of the pregnant women. Clinical consequences of these antibodies were not studied.

CONCLUSION

The HPA-1bb and -5bb genotypes are more frequent in the Egyptian Arabic population studied compared to Caucasian populations. FNAIT due to anti-HPA-1a and -5b antibodies must be suspected in cases of neonatal thrombocytopenia. Further large prospective studies are needed to increase the knowledge of clinical complications related to HPA alloantibodies in populations with different genetic backgrounds.

Neonatal alloimmune thrombocytopenia is not what it was: a lesson learned from a large prospective screening and intervention program

Controversies regarding the pathophysiology of neonatal alloimmune thrombocytopenia (NAIT) has hampered the development of consensus about how to identify, follow up and treat the women and children with this serious complication. One reason for this is that knowledge about the condition derived from previous retrospective studies do not necessarily conform with data derived from prospective investigations. The main obstacle to introduction of general screening programs to identify the pregnancies to treat, have been lack of reliable risk factors, and an effective treatment. Now, several recent prospective screening programs including up to 100,000 pregnant women has changed the understanding of the NAIT-pathology, and has shown that we are close to answering these critical questions.

Cost-effectiveness of antenatal screening for neonatal alloimmune thrombocytopenia

OBJECTIVES

To estimate the costs and health consequences of three different screening strategies for neonatal alloimmune thrombocytopenia (NAIT).

DESIGN

Cost-utility analysis on the basis of a decision tree that incorporates the relevant strategies and outcomes.

SETTING

Three health regions in Norway encompassing a 2.78 million population.

POPULATION

Pregnant women (n = 100,448) screened for human platelet antigen (HPA) 1a and anti-HPA 1a antibodies, and their babies.

METHOD

Decision tree analysis. In three branches of the decision tree, pregnant women entered a programme while in one no screening was performed. The three different screening strategies included all HPA 1a negative women, only HPA 1a negative, HLA DRB3*0101 positive women or only HPA 1a negative women with high level of anti-HPA 1a antibodies. Included women underwent ultrasound examination and elective caesarean section 2-4 weeks before term. Severely thrombocytopenic newborn were transfused immediately with compatible platelets.

MAIN OUTCOME MEASUREMENTS

Quality-adjusted life years (QALYs) and costs.

RESULTS

Compared with no screening, a programme of screening and subsequent treatment would generate between 210 and 230 additional QALYs among 100,000 pregnant women, and at the same time, reduce health care costs by approximately 1.7 million euros. The sensitivity analyses indicate that screening is cost effective or even cost saving within a wide range of probabilities and costs.

CONCLUSION

Our calculations indicate that it is possible to establish an antenatal screening programme for NAIT that is cost effective.

Differential expression of major histocompatibility complex class II variants in cells infiltrating the meth A sarcoma

CD4+ T cells are involved in immune responses against the Meth A sarcoma and infiltrate tumours arising from Meth A cells inoculated intradermally in (BALB/c x C57BL/6)F1 (H-2d/b) mice. In order to investigate whether the prerequisites for tumour antigen presentation to CD4+ T cells are fulfilled within the malignant lesion, expression of class II major histocompatibility complex (MHC) molecules and the costimulatory ligand B7 were examined. The I-Ab and I-Ed allomorphs were abundantly expressed by virtually all B cells and 50% of macrophages infiltrating the tumours. In striking contrast, the I-Ad variant was hardly detectable. This pattern of class II expression appeared to be unique for the tumour microenvironment. Thus the proportion of I-Ad+ spleen B cells and peritoneal macrophages did not significantly differ from the proportion expressing I-Ab and I-Ed, and these extratumoral I-Ad+ cells stained as brightly as did cells from healthy mice. Expression of B7 was weak by tumour-infiltrating cells. The profound capacity of the Meth A sarcoma to confer low local I-Ad and B7 expression might preclude T-cell-dependent anti-tumour immune responses and thus promote survival of malignant cells. Whereas MHC class II genes are generally found to be co-ordinately transcribed, this study demonstrates that the expression of MHC class II allelic variants can be differentially regulated in vivo.

Conjugates of Tremella polysaccharides with microbeads and their TNF-stimulating activity

A mannan (A) and a heteroglycan (D) were prepared by partial acidic hydrolysis of T3, a major polysaccharide fraction of the fungus Tremella fuciformis Berk. Methylation analysis of A and D showed that they contained a 1-->3 linked mannosyl main chain, to which were linked different side chains at position 2, 4, or 6 of the mannosyl residues. A and D were conjugated to albumin microbeads (AM) by reductive amination. The conjugates showed significant cytokine-stimulating activity in vitro whereas unconjugated AM had no activity. Not conjugated A and D showed cytokine-stimulating activity only in about 100 times higher concentrations.

Characterization and cytokine-stimulating activities of acidic heteroglycans from Tremella fuciformis

Four acidic heteroglycans, T2a-T2d, were isolated from the body of Tremella fuciformis Berk. They contained 1.9%-2.9% of acetyl groups and were composed of mannose (Man), glucuronic acid (GlcA), and small amounts of xylose (Xyl), glucose (Glc), and fucose (Fuc). According to methylation analysis they had a mannan backbone consisting of 3-linked Man, and side chains containing glucosyl, mannosyl, fucosyl, xylosyl, and glucuronic acid residues. The side chains were attached through O-2, O-4, or O-6 in about 40 percent of backbone mannosyl residues. Molecular masses of the four polysaccharides were 410, 250, 34, and 20 kDa, respectively. T2a-T2d induced human monocytes to produce interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor (TNF) in vitro. The products of Smith degradation (T2a-S) and lithium degradation (T2a-L) of T2a and the product of deacetylation (T2b-D) of T2b also induced monocytes to secret IL-1 as efficiently as the original polysaccharides, indicating that xylosyl and glucuronic acid residues as well as acetyl groups were not important to promote the cytokine-stimulating activity.

Cytokine-Stimulating (In Vitro) Effect on Human Monocytes of Conjugates of Soluble Curdlan and Albumin Microbeads

Four kinds of conjugates (BSA-M-SC-Ra, BSA-M-SC-Re, AP-M-SC-Ra, and AP-M-SC-Re) composed of soluble fragments of [β](1 ± 3)-D-glucan (SC) and bovine serum albumin (BSA) or amine-modifled polystyrene (AP) microbeads were prepared: the contents of SC on the microbeads were found to be 13.6, 8.0, 3.6, and 2.6 μg per 1 X 10(8) microbeads, respectively. Unconjugated BSA and AP microbeads and SC did not show cytokine-stimulating activity. BSA-M-SC-Re, BSA-M-SC-Ra, and AP-M-SC-Re showed strong cytokine-stimulating activity in vitro, indicating that conjugates composed of inactive fragments of polysaccharides and microbeads are able to induce cytokine release from mononuclear phagocytes. Conjugates with the SC linked to BSA microbeads by the reducing terminal (BSA-M-SC-Re) showed a stronger effect than conjugates in which SC was linked with BSA microbeads at random positions (BSA-M-SC-Ra).