A Case of Near Total Rh(D) Expression Loss in a Sickle Cell Patient Following Aplastic Anemia and Development of a Transient Auto-Anti-D

Introduction/Objective

Red blood cell (RBC) antigens are inherited traits and, and their expression is consistent throughout the life of most individuals. Changes in RBC antigen expression rarely occur in association with hematologic malignancies. We report a case of Rh(D) antigen change in a patient with sickle cell disease (HbSS) after developing aplastic anemia (AA).

Methods/Case Report

Patient is a 21-year-old female with HbSS who developed progressively worsening anemia and severe thrombocytopenia over 1 month requiring frequent RBC and platelet transfusions. She was initially treated for idiopathic thrombocytopenic purpura with no significant improvement. Bone marrow examination demonstrated severe AA; additional viral, rheumatological, and hematologic studies were all non-informative. Subsequently, she was treated with corticosteroids, cyclosporin, anti-thymocyte immunoglobin and eltrombopag with minimal improvement. She has been non-compliant with maintenance cyclosporine and continued to be transfusion dependent in the past 2.5 years. She had always strongly typed 4+ Rh(D) positive at immediate spin (IS) before this event, but approximately about 1.5 years after the AA diagnosis her reactions became weaker (2-3+ at IS). She had a short-lived auto-anti-D identified on one occasion which has never been re-identified, but she has had very weak Rh(D) typings since this time with negative reactions at IS and only microscopically positive reactions at the anti-human globulin phase. The same pattern of reaction is present across a variety of commercial anti-D reagents. Molecular analysis reveals a normal RHD*01 hemi- or homozygous allele and no mutations known to cause a weak or partial Rh(D) type. No other antigen change is detected, and her extended phenotype matches a recently obtained genotype. She has been treated as both type O+ and O- in the last year by different facilities and transfused both types of RBCs without incident.

Results (if a Case Study enter NA)

NA.

Conclusion

We believe this is the first reported case of decreased Rh(D) expression following aplastic anemia and a transient auto-anti-D.

Survey of Clinical and Anatomic Pathology Laboratory Infrastructure in Mozambique

OBJECTIVES

Pathology services are limited in most areas of sub-Saharan Africa. This study's aim was to survey anatomic and clinical pathology services and laboratory infrastructure in Mozambique.

METHODS

A survey was conducted from October-December 2018 across the four central hospitals of Mozambique to determine infrastructure and pathology services available.

RESULTS

Most laboratory/pathology services in Mozambique are limited to the four central hospitals. Only 14 pathologists practice in the country despite a population of 29.5 million for the world's fifth worst workforce/population ratio. Approximately 35,000 anatomic pathology specimens are evaluated annually. Standard services across chemistry, hematology, microbiology, and blood bank are available at the four central hospitals. Esoteric laboratory testing and immunohistochemistry are generally only available in Maputo.

CONCLUSIONS

While most pathology services are available in Mozambique, many are available only at the Maputo laboratory. Expansion of pathology services and infrastructure will improve provision of effective and efficient health care as access to timely and accurate clinical diagnoses increases in Mozambique.

Does Gender Matter: A Multi-Institutional Analysis of Viscoelastic Profiles for 1565 Trauma Patients With Severe Hemorrhage

BACKGROUND

Viscoelastic tests including thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are being used in patients with severe hemorrhage at trauma centers to guide resuscitation. Several recent studies demonstrated hypercoagulability in female trauma patients that was associated with a survival advantage. The objective of our study was to elucidate the effects of gender differences in TEG/ROTEM values on survival in trauma patients with severe hemorrhage.

METHODS

A retrospective review of consecutive adult patients receiving massive transfusion protocol (MTP) at 7 Level I trauma centers was performed from 2013 to 2018. Data were stratified by gender and then further examined by TEG or ROTEM parameters. Results were analyzed using univariate and multi-variate analyses.

RESULTS

A total of 1565 patients were included with 70.9% male gender (n = 1110/1565). Female trauma patients were older than male patients (43.5 ± .9 vs 41.1 ± .6 years, P = .01). On TEG, females had longer reaction times (6.1 ± .9 min vs 4.8 ± .2 min, P = .03), increased alpha angle (68.6 ± .8 vs 65.7 ± .4, P < .001), and higher maximum amplitude (59.8 ± .8 vs 56.3 ± .4, P < .001). On ROTEM, females had significantly longer clot time (99.2 ± 13.7 vs 75.1 ± 2.6 sec, P = .09) and clot formation time (153.6 ± 10.6 sec vs 106.9 ± 3.8 sec, P < .001). When comparing by gender, no difference for in-hospital mortality was found for patients in the TEG or ROTEM group (P > .05). Multivariate analysis showed no survival difference for female patients (OR 1.11, 95% CI .83-1.50, P = .48).

CONCLUSIONS

Although a difference between male and females was found on TEG/ROTEM for certain clotting parameters, no difference in mortality was observed. Prospective multi-institutional studies are needed.

A Comparison of Growth Factors and Cytokines in Fresh Frozen Plasma and Never Frozen Plasma

BACKGROUND

Fresh frozen plasma (FFP) contains proinflammatory mediators released from cellular debris during frozen storage. In addition, recent studies have shown that transfusion of never-frozen plasma (NFP), instead of FFP, may be superior in trauma patients. We hypothesized that FFP would have higher levels of inflammatory mediators when compared to NFP.

MATERIALS AND METHODS

FFP (n = 8) and NFP (n = 8) samples were obtained from an urban, level 1 trauma center blood bank. The cytokines in these samples were compared using a Milliplex (Milliplex Sigma) human cytokine magnetic bead panel multiplex assay for 41 different biomarkers.

RESULTS

Growth factors that were higher in NFP included platelet-derived growth factor-AA (PDGF-AA; 8.09 versus 108.00 pg/mL, P < 0.001) and PDGF-AB (0.00 versus 215.20, P= 0.004). Soluble CD40-ligand (sCD40L), a platelet activator and pro-coagulant, was higher in NFP (31.81 versus 80.45 pg/mL, P< 0.001). RANTES, a leukocyte chemotactic cytokine was higher in NFP (26.19 versus 1418.00 pg/mL, P< 0.001). Interleukin-4 (5.70 versus 0.00 pg/mL, P= 0.03) and IL-8 (2.20 versus 0.52 pg/ml, P= 0.03) levels were higher in were higher in FFP.

CONCLUSIONS

Frozen storage of plasma may result in decrease of several growth factors and/or pro-coagulants found in NFP. In addition, the freezing and thawing process may induce release of pro-inflammatory chemokines. Further studies are needed to determine if these cytokines result in improved outcomes with NFP over FFP in transfusion of trauma patients.

Single Institution Trial Comparing Whole Blood vs Balanced Component Therapy: 50 Years Later

BACKGROUND

Early close ratio transfusion with balanced component therapy (BCT) has been associated with improved outcomes in patients with severe hemorrhage; however, this modality is not comparable with whole blood (WB) constituents. We compared use of BCT vs WB to determine if one yielded superior outcomes in patients with severe hemorrhage. We hypothesized that WB would lead to reduced in-hospital mortality and blood product volume if given in the first 24 hours of admission.

STUDY DESIGN

This was a 1-year, single institution, prospective, observational study comparing BCT with WB in adult (18+y) trauma patients with active hemorrhage who required blood transfusion upon arrival at the emergency department. Primary endpoint was in-hospital mortality. Secondary endpoints included 24-hour transfusion volumes, in-hospital clinical outcomes, and complications.

RESULTS

A total of 253 patients were included; 71.1% received BCT and 29.9% WB. The WB cohort had significantly more penetrating trauma (64.4% vs 48.9%; p = 0.03) and higher Shock Index (1.12 vs 0.92; p = 0.04). WB patients received significantly fewer units of packed red blood cells (PRBCs) (p < 0.001) and fresh frozen plasma (FFP) (p = 0.04), with a lower incidence of ARDS (p = 0.03) and fewer ventilator days (p = 0.03). Kaplan Meier survival analysis revealed no difference in survival between the 2 transfusion strategies (p = 0.80). When adjusted for various markers of injury severity and critical illness in Cox regression analysis, WB remained unassociated with mortality (hazard ratio 1.25; 95% CI 0.60-2.58; p = 0.55).

CONCLUSIONS

There was no difference in survival rates when comparing BCT with WB. In the WB group, the incidence of ARDS, duration of mechanical ventilation, massive transfusion protocol (MTP) activation, and transfusion volumes were significantly reduced. Further research should be directed at analyzing whether there is a true hemorrhage-related pathophysiologic benefit of WB when compared with BCT.

Chemerin in coronary artery disease patients

Background

Chemerin – a recently described hormone is secreted by adipose tissue. It exerts proinflammatory action, leads to insulin resistance, but also has potentially favorable effects: it increases eNOS activity and is pro-angiogenic. Increased serum concentrations of chemerin was observed in patients with coronary artery disease (CAD). The role of chemerin in pathogenesis of CAD is not well understood.

Purpose

The aim of this pilot study was to assess the role of chemerin in pathogenesis of atherosclerosis, its impact on condition of large arteries and prognosis in CAD.

Methods

We included in the study patients with stable CAD who underwent percutaneous coronary intervention (PCI) in the past. Chemerin levels were measured with ELISA method. All patients had routine blood tests and insulin levels measured. Patients without history of diabetes also had OGTT. Status of large arteries was evaluated with carotid ultrasound, pulse-wave velocity (PWV) and ankle-brachial index (ABI). Body composition was assessed wit DEXA method. Anatomical severity of CAD was evaluated with SYNTAX score. One-year composite endpoint included death, myocardial infarction, revascularization, stroke and hospitalization for cardiovascular reasons.

Results

The study group comprised 163 patients (mean age 59.8± years, 26% of females, n=43). Mean chemerin level was 284.8 ng/ml. There was no significant difference in chemerin concentrations between patients with diabetes and remaining ones (with prediabetes and with normal glucose levels) 306.8±121 vs 274.15±109 pg/ml, p=0.1. In Spearman test chemerin level correlated with total fat mass (R=0.15, p=0.047), trunk fat mass (R=0.16, p=0.039), android fat mass (R=0.16, p=0.036), and BMI (R=0.18, p=0.028). Chemerin also correlated with white blood cells (WBC) count (R=0.34, p&lt;0.0001), hsCRP (R=0.16, p=0.03), total cholesterol (R=0.17, p=0.028), LDL cholesterol (R=0.19, p=0.01), HDL cholesterol (R=−0.21, p=0.006), triglicerides (R=0.3, p&lt;0.0001), platelet count (R=0.23, p=0.002), fasting insulin (R=0.22, p=0.004) and c-peptide (R=0.26, p=0.0005). There was no significant difference in chemerin levels between patients with carotid atherosclerosis (n=93) and patients with normal carotid arteries (n=70), (300±124 vs 263±94 ng/ml, p=0.07). There were no significant associations between chemerin levels and PWV, ABI measurements, SYNTAX score, or 1-year prognosis.

Conclusions

This is the first study to show that in patients with CAD chemerin levels correlate with WBC and with android fat tissue mass. Additionally, chemerin levels positively correlated with other inflammation or insulin resistance markers, and with unfavourable lipid profile.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The National Science Centre

Mild Allergic Transfusion Reactions: Impact of Associated Clinical Symptoms?

Objectives

Transfusions are often needlessly aborted after occurrence of a mild allergic transfusion reaction (ATR), leading to wastage and reexposure of recipients to additional blood products (with potential alloimmunization). We aimed to determine the symptoms associated with such reactions (along with other parameters) as a possible reason of concern for transfusionists aborting such transfusions.

Methods

We reviewed the symptomology of all mild ATRs (as well as the associated wastage and costs of aborted transfusions) at an academic medical center that occurred over a period of 1 year.

Results

Of the patients, 52.3% had nonatopic-associated symptoms. The most common associated symptom was tachycardia (37.8%), followed by dyspnea (28.9%), hypotension (17.8%), and hypertension (13.3%). More than half of patients (54.7%) required retransfusion. The estimated cost of product wastage was $12,507.

Conclusions

Understanding symptoms associated with mild ATRs may lead to improved management of patients, with fewer unnecessary transfusions and less wastage.

Indwelling ports for prophylactic RBC exchanges in sickle cell patients: Comparison of bard and vortex ports

INTRODUCTION

Red blood cell exchange (RCE) procedures are commonly used for stroke prevention in sickle cell disease (SCD) patients. We compared two different dual lumen ports used for RCE because differences between the port and catheter design may lead to functional variance.

METHODS

We reviewed the RCE parameters of SCD patients following implantable port placement encountered at a single institution. Five Vortex and four Bard ports were used and compared. Patients were followed for 1-24 exchange procedures over 3-26 months performed between 2013 and 2015.

RESULTS

Nine patients underwent 124 RCE procedures with no failures. A total of 74 exchanges used Vortex ports with a mean flow rate of 45.2 mL/min while 50 exchanges used Bard ports with a mean flow rate of 42.1 mL/min which was a significant difference (P = .002). A total of 85 exchanges with tPA administration preprocedure had a mean flow rate of 43.8 mL/min while 39 exchanges without had a mean flow rate of 45.4 mL/min which was not a significant difference (P = .19).

CONCLUSION

Both the Bard and Vortex ports functioned well during our study period with no treatment failures, no significant complications requiring removal or replacement, and adequate mean flow rates. While the difference in mean flow rates was statistically significant between Vortex and Bard ports, there may not be a practical difference in performance. There also does not appear to be a significant benefit in flow rates with preprocedure tPA. We conclude that both ports may be a satisfactory choice for vascular access in SCD patients expected to undergo regularly scheduled RCE.

Jk3 alloantibodies during pregnancy-blood bank management and hemolytic disease of the fetus and newborn risk

BACKGROUND

The Kidd-null phenotype, Jk(a-b-), occurs in individuals who do not express the JK glycoprotein. Jk(a-b-) individuals can make an antibody against the Jk3 antigen, a high-incidence antigen present in more than 99.9% of most populations. This presents many challenges to the blood bank including identification of the antibody, masking of other antibodies, and how to provide transfusion support given the rarity of Jk3-negative blood products. Kidd antibodies may cause acute and delayed hemolytic reactions as well as hemolytic disease of the fetus and newborn (HDFN). In this article, we present a series of four practical cases of pregnant women with the anti-Jk3 alloantibody that demonstrate a range of clinical presentations of Kidd-related HDFN.

STUDY DESIGN AND METHODS

We retrospectively reviewed the clinical and blood bank records for four patients and their newborns encountered at institutions in Tennessee, Missouri, Hawaii, and Guam with an anti-Jk3 identified during pregnancy.

RESULTS

Two cases showed no significant evidence for HDFN, while two cases were of mild-to-moderate severity requiring early delivery due to elevated middle cerebral artery (MCA) flow velocities but requiring only phototherapy for hyperbilirubinemia. No intrauterine or neonatal transfusions were necessary. Anti-Jk3 alloantibody titers ranged from 2 to 128.

CONCLUSION

Clinical manifestations of anti-Jk3 HDFN are generally mild to moderate. Anti-Jk3 titers were not found to correlate directly with HDFN severity. We suggest a titer of 16 to 32 as a cutoff for implementing enhanced monitoring of fetal MCA flow velocities, as such titers may be indicative of elevated HDFN risk.