C3 inhibition with pegcetacoplan in subjects with paroxysmal nocturnal hemoglobinuria treated with eculizumab

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired, life-threatening hematologic disease characterized by chronic complement-mediated hemolysis and thrombosis. Despite treatment with eculizumab, a C5 inhibitor, 72% of individuals remain anemic. Pegcetacoplan (APL-2), a PEGylated C3 inhibitor, has the potential to provide more complete hemolysis control in patients with PNH. This open-label, phase Ib study was designed to assess the safety, tolerability, and pharmacokinetics of pegcetacoplan in subjects with PNH who remained anemic during treatment with eculizumab. Pharmacodynamic endpoints were also assessed as an exploratory objective of this study. Data are presented for six subjects in cohort 4 who received treatment for up to 2 years. In total, 427 treatment-emergent adverse events (TEAEs) were reported, 68 of which were possibly related to the study drug. Eight serious TEAEs occurred in two subjects; three of these events were considered possibly related to the study drug. Pegcetacoplan pharmacokinetic concentrations accumulated with repeated dosing, and steady state was reached at approximately 6-8 weeks. Lactate dehydrogenase levels were well controlled by eculizumab at baseline. Pegcetacoplan increased hemoglobin levels and decreased both reticulocyte count and total bilirubin in all six subjects. Improvements were observed in Functional Assessment of Chronic Illness Therapy Fatigue scores. Two subjects discontinued for reasons unrelated to pegcetacoplan. All four subjects who completed the study transitioned to pegcetacoplan monotherapy following eculizumab discontinuation and avoided transfusions. In this small study, pegcetacoplan therapy was generally well-tolerated, and resulted in an improved hematological response by achieving broad hemolysis control, enabling eculizumab discontinuation.

Protective Role of Selenium Against Hemolytic Anemia Is Mediated Through Redox Modulation

Selenium (Se), an essential trace element and potent nutritional antioxidant, exerts its biological effects through incorporation into selenoproteins like glutathione peroxidase (GPx). Modest decrement in the levels of GPx could be partly responsible for peroxidation of RBCs, which results into hemolytic anemia. Therefore, it is hypothesized that dietary Se, as selenoproteins (GPx), can maintain the homeostasis in RBCs and regulate the erythropoiesis by preventing oxidative stress-mediated hemolysis. Se-deficient (0.01 ppm), Se-adequate (0.1 ppm sodium selenite), and Se-supplemented (0.5 ppm sodium selenite) status were created in Balb/c mice by feeding yeast-based diets for 8 weeks and established by measuring Se levels in plasma and activities, expressions of Se-dependent selenoproteins. Fifty percent of mice from each differential Se group were treated with phenylhydrazine (PHZ, 20 mg/kg, i.p.) to induce hemolytic anemia. Results indicated that PHZ-treated Se-deficient animals demonstrated increased hemolysis, abnormal RBC morphology, increase in Heinz bodies and reticulocytes, and denaturation of hemoglobin to globin precipitates and methemoglobin. Se supplementation protected against these hemolytic changes and makes RBCs less fragile. These findings were consistent with dietary Se concentration-dependent changes in activity and expression of GPx indicating that ROS-mediated oxidative stress is integral to hemolysis. Protective effects of Se supplementation against increased levels of ROS, protein carbonyls, and peroxide damage to membrane lipids and enzymatic antioxidants validated these observations. In conclusion, dietary Se supplementation protected the RBCs against hemolysis by mitigating ROS-mediated oxidative stress.

Postponing Early intrauterine Transfusion with Intravenous immunoglobulin Treatment; the PETIT study on severe hemolytic disease of the fetus and newborn

BACKGROUND

Intrauterine transfusion for severe alloimmunization in pregnancy performed <20 weeks' gestation is associated with a higher fetal death rate. Intravenous immunoglobulins may prevent hemolysis and could therefore be a noninvasive alternative for early transfusions.

OBJECTIVE

We evaluated whether maternal treatment with intravenous immunoglobulins defers the development of severe fetal anemia and its consequences in a retrospective cohort to which 12 fetal therapy centers contributed.

STUDY DESIGN

We included consecutive pregnancies of alloimmunized women with a history of severe hemolytic disease and by propensity analysis compared index pregnancies treated with intravenous immunoglobulins (n = 24) with pregnancies managed without intravenous immunoglobulins (n = 28).

RESULTS

In index pregnancies with intravenous immunoglobulin treatment, fetal anemia developed on average 15 days later compared to previous pregnancies (8% less often <20 weeks' gestation). In pregnancies without intravenous immunoglobulin treatment anemia developed 9 days earlier compared to previous pregnancies (10% more <20 weeks), an adjusted 4-day between-group difference in favor of the immunoglobulin group (95% confidence interval, -10 to +18; P = .564). In the subcohort in which immunoglobulin treatment was started <13 weeks, anemia developed 25 days later and 31% less <20 weeks' gestation (54% compared to 23%) than in the previous pregnancy. Fetal hydrops occurred in 4% of immunoglobulin-treated pregnancies and in 24% of those without intravenous immunoglobulin treatment (odds ratio, 0.03; 95% confidence interval, 0-0.5; P = .011). Exchange transfusions were given to 9% of neonates born from pregnancies with and in 37% without immunoglobulin treatment (odds ratio, 0.1; 95% confidence interval, 0-0.5; P = .009).

CONCLUSION

Intravenous immunoglobulin treatment in mothers pregnant with a fetus at risk for hemolytic disease seems to have a potential clinically relevant, beneficial effect on the course and severity of the disease. Confirmation in a multicenter randomized trial is needed.

Using nitrofurantoin while breastfeeding a newborn

QUESTION

My patient has a urinary tract infection and is currently breastfeeding. Her son is only 3 weeks old. Is nitrofurantoin a safe antibiotic for treatment?

ANSWER

The use of nitrofurantoin in breastfeeding mothers is generally safe, as only small amounts transfer into the breast milk. Despite the lack of documented reports, there is a risk of hemolytic anemia in all newborns exposed to nitrofurantoin owing to their glutathione instability, especially in infants with glucose-6-phosphate dehydrogenase deficiency. Although some suggest that nitrofurantoin be avoided in infants younger than 1 month, studies have noted that glutathione stability might be established by the eighth day of life. In infants younger than 1 month, an alternative antibiotic might be preferred; however, if an alternative were not available, the use of nitrofurantoin would not be a reason to avoid breastfeeding. In any such case the suckling infant should be monitored by his or her physician.

Mass primaquine treatment to eliminate vivax malaria: lessons from the past

Recent successes in malaria control have put malaria eradication back on the public health agenda. A significant obstacle to malaria elimination in Asia is the large burden of Plasmodium vivax, which is more difficult to eliminate than Plasmodium falciparum. Persistent P. vivax liver stages can be eliminated only by radical treatment with a ≥ seven-day course of an 8-aminoquinoline, with the attendant risk of acute haemolytic anaemia in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Primaquine is the only generally available 8-aminoquinoline. Testing for G6PD deficiency is not widely available, and so whilst it is widely recommended, primaquine is often not prescribed. In the past, some countries aiming for vivax malaria eradication deployed mass treatments with primaquine on a massive scale, without G6PD testing. In Azerbaijan, Tajikistan (formerly USSR), North Afghanistan and DPR Korea 8,270,185 people received either a 14-day "standard" or a 17-day "interrupted" primaquine treatment to control post-eradication malaria epidemics. These mass primaquine preventive treatment campaigns were conducted by dedicated teams who administered the drugs under supervision and then monitored the population for adverse events. Despite estimated G6PD prevalences up to 38.7%, the reported frequency of severe adverse events related to primaquine was very low. This experience shows that with careful planning and implementation of mass treatment strategies using primaquine and adequate medical support to manage haemolytic toxicity, it is possible to achieve high population coverage, substantially reduce malaria transmission, and manage the risk of severe acute haemolytic anaemia in communities with a relatively high prevalence of G6PD deficiency safely.

The prevalence of G6PD deficiency in blood transfusion recipients

G6PD deficiency is the most common metabolic disorder of red blood cells, involving about 35 million people worldwide. Tropical and subtropical regions in the eastern hemisphere have the highest prevalence, up to 35% in some areas. The prevalence varies in different parts of the world. According to WHO, there is a 10-14.9% prevalence of G6PD deficiency in Iran. With this high prevalence, blood products are not still checked for G6PD deficiency. So, they may be used for transfusion in neonates with jaundice or for patients using oxidants. In this cross-sectional study, we have observed the effects of using this kind of blood in patients receiving blood in the Pediatric and Neonatology Departments of Imam Sajjad's Hospital in Yasuj. Samples were taken from 261 blood bags used for transfusion or exchange, and examined by spot fluorescence for G6PD deficiency. All of the patients receiving blood were examined for hemoglobin, hematocrit, and bilirubin before and after transfusion. They were also examined for hemoglobinuria, factors involved in hemolysis due to G6PD deficiency, and oxidants.

RESULTS

From the 261 blood transfusions, 37(14.17%) blood bags had G6PD deficiency. About 81% of these transfusion recipients had at least one risk factor for hemolysis. The complications associated with receiving these red cells were: insufficient rise in hemoglobin (55.9%), hemoglobinuria (35.3%) and rise in bilirubin (8.8%), which were significantly higher than the control group.

CONCLUSION

Considering the high prevalence and complications of transfusing G6PD deficient blood to high risk patients, it is recommended that in the form used for requesting blood products, there should be a place for checking G6PD enzyme so that the physician requesting blood could request the test to be done, depending on the risk factors.

Antenatal immunoglobulin for fetal red blood cell alloimmunization

BACKGROUND

Red blood cell alloimmunization in pregnancy can lead to fetal anaemia with potentially disastrous consequences. Traditional management involves the use of intrauterine transfusion, which is associated with significant procedure-related risks. An alternative treatment that has been trialled is the use of immunoglobulin administered intravenously to the mother.

OBJECTIVES

The objective of this review was to assess the efficacy and safety of the use of intravenous immunoglobulin antenatally to women with severe fetal red blood cell alloimmunization.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group trials register (19 December 2012), and reference lists of articles.

SELECTION CRITERIA

Randomized trials assessing the antenatal use of intravenous immunoglobulin administered at any dose, frequency or duration with a control group (using any other, or no treatment) in the management of fetal red blood cell alloimmunization.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the available evidence.

MAIN RESULTS

There are no included studies.

AUTHORS' CONCLUSIONS

No information is available from randomized trials to indicate whether the antenatal use of intravenous immunoglobulin is effective in the management of fetal red blood cell alloimmunization. Several case series suggest a beneficial role in delaying the onset of fetal anaemia requiring invasive intrauterine transfusion.

Impact of thyroid dysfunction on erythropoietin dosage in hemodialysis patients

BACKGROUND

Although thyroid diseases exist in patients with renal failure, thyroid function tests are not routine tests in patients on chronic hemodialysis (HD). Therefore, the impact of thyroid diseases on erythropoietin (EPO) dosage in HD patients is not well defined. This study evaluated the relationship between the dose of EPO and the presence or absence of thyroid dysfunction in HD patients.

METHODS

This study included 1013 adult patients on HD who did not have a malignancy, liver cirrhosis, thalassemia, iron deficiency, gastrointestinal bleeding, or a major operation within 6 months. Patients were characterized as being euthyroid, or having the sick euthyroid syndrome, primary hypothyroidism, subclinical hypothyroidism, hyperthyroidism, or subclinical hyperthyroidism based on thyroid function tests. Routine biochemistry profiles including an index of the efficiency of HD, along with clinical data over the previous 6-month period, were collected and analyzed. Multiple regression models were employed to assess the relationship between the dose of EPO and the presence or absence of thyroid status.

RESULTS

The mean monthly EPO dosages were 77.7±37.0, 70.2±40.6, 90.8±68.4, 78.5±46.7, and 82.3±41.2 μg, respectively, in the sick euthyroid syndrome, euthyroid patients, hypothyroidism, subclinical hypothyroidism, and subclinical hyperthyroidism groups (p<0.05). After adjustment of all other variables in multiple regression, the mean monthly EPO dosage was 19.00±8.59 μg more in hypothyroid patients compared with euthyroid patients (p=0.027). Further, considering an interaction with the presence of diabetes, the mean monthly EPO dosage in patients with either hypothyroidism or subclinical hypothyroidism and diabetes was 54.66±17.12 μg (p=0.001) and 31.51±10.38 μg more than that of euthyroid patients, respectively (p=0.002).

CONCLUSIONS

In HD patients, the EPO dosage required to maintain the target hemoglobin level is significantly higher in patients having both hypothyroidism or subclinical hypothyroidism and diabetes than in euthyroid patients.

ABO antibody titers are not predictive of hemolytic reactions due to plasma-incompatible platelet transfusions

BACKGROUND

The overall risk of hemolytic transfusion reactions (HTRs) from plasma (minor)-incompatible platelet (PLT) transfusions and the role of a critical anti-A or anti-B titer in predicting and preventing these reactions has not been clearly established.

STUDY DESIGN AND METHODS

We evaluated all apheresis PLT (AP) transfusions for 3 months. Using the gel titer method, we determined the anti-A and/or the anti-B immunoglobulin (Ig)G titer for all incompatible APs. Reported febrile transfusion reactions and HTRs were recorded; transfusions were not prospectively evaluated by the study team. A posttransfusion direct antiglobulin test (DAT) and eluate were performed after a reported febrile or hemolytic reaction for patients who received plasma-incompatible APs.

RESULTS

A total of 647 of 4288 AP transfusions (15.1%) were plasma incompatible. Group O APs (n = 278) had significantly higher anti-A and anti-B titers than group A or B APs (p < 0.0001). No group A or B APs had a titer of more than 128 (0/342). For group O APs, 73 had titers of 256 or greater (26.3%), and 27 had titers of 512 or greater (9.7%). No HTRs were reported to any plasma-incompatible AP transfusion during the study period. Two plasma-incompatible AP transfusions were associated with fever and chills and positive DATs, of which one had a positive eluate. The incidence of a DAT and eluate-positive febrile transfusion reaction in the plasma-incompatible AP population is 0.15% (95% confidence interval, 0.0%-0.86%).

CONCLUSION

A critical anti-A or -B titer is not sufficient to predict the risk of hemolysis in patients receiving plasma-incompatible APs, although underreporting of reactions to the blood bank may limit the generalizability of this study.

[Anesthetic management of a patient with paroxysmal nocturnal hemoglobinuria]

A 34-year-old man with paroxysmal nocturnal hemoglobinuria (PNH) was scheduled for emergency laparotomy. PNH is an acquired disorder of stem cells, and the common manifestations are complement mediated hemolytic anemia and deep venous thrombosis. Perioperative hemolysis occurs under the activation of complement induced by stress such as acidosis, infection, and insufficient pain control. Activation of complement secondary leads to platelet aggregation and hypercoagulability. We administrated remifentanil for the pain control during the operation and fentanyl after the operation. We avoided hypoventilation and dehydration to prevent acidosis. Washed red blood cells were given to reduce the chance of complement activation and we administrated low molecular weight heparin up to the seventh postoperative day to prevent deep venous thrombosis. The perioperative course was uneventful without complication.

The direct antiglobulin test: a critical step in the evaluation of hemolysis

The direct antiglobulin test (DAT) is a laboratory test that detects immunoglobulin and/or complement on the surface of red blood cells. The utility of the DAT is to sort hemolysis into an immune or nonimmune etiology. As with all tests, DAT results must be viewed in light of clinical and other laboratory data. This review highlights the most common clinical situations where the DAT can help classify causes of hemolysis, including autoimmune hemolytic anemia, transfusion-related hemolysis, hemolytic disease of the fetus/newborn, drug-induced hemolytic anemia, passenger lymphocyte syndrome, and DAT-negative hemolytic anemia. In addition, the pitfalls and limitations of the test are addressed. False reactions may occur with improper technique, including improper washing, centrifugation, and specimen agitation at the time of result interpretation. Patient factors, such as spontaneous red blood cell agglutination, may also contribute to false results.

Relationship between polymorphisms of the inosine triphosphatase gene and anaemia or outcome after treatment with pegylated interferon and ribavirin

BACKGROUND

A genome-wide association study revealed an association between variants of the inosine triphosphatase (ITPA) gene and ribavirin (RBV)-induced anaemia. The aim of this study was to replicate this finding in an independent Japanese cohort and to define a method to allow pretreatment prediction of anaemia in combination with other factors.

METHODS

Genotype 1b chronic hepatitis C patients (n=132) treated with pegylated interferon (PEG-IFN)-α and RBV for 48 weeks were genotyped for ITPA rs1127354 and examined for anaemia and treatment outcome.

RESULTS

Variants of the ITPA gene protected against severe anaemia throughout the 48-week treatment period and were associated with lower incidence of anaemia-related RBV dose reduction. A combination of the ITPA genotype with baseline haemoglobin (Hb) and creatinine clearance (CLcr) levels predicted severe anaemia with high accuracy (90% sensitivity and 62% specificity). Among a subset of patients with the IL28B genotype of TT at rs8099917, patients with variants of the ITPA gene were associated with a higher rate of receiving >80% of the expected RBV dose, a higher rate of sustained virological response (SVR), and a lower rate of relapse.

CONCLUSIONS

The variants of the ITPA gene, which could protect against haemolytic anaemia and RBV dose reduction, were associated with a high rate of SVR by standard PEG-IFN and RBV therapy in a subset of Japanese patients with the favourable TT genotype at rs8099917 of IL28B. A combination of ITPA genetic polymorphisms with baseline Hb and CLcr levels further improves the predictive accuracy of severe anaemia.

The Indian blood group system

The Indian blood group system (ISBT: IN/023) consists of two antithetical antigens: In(a) (IN1), which is present in approximately 10 percent of some Arab populations and in 3 percent of Bombay Indians, and its allelic antigen In(b) (IN2), an antigen of high incidence in all populations. In 2007, two new high-incidence antigens were identified as belonging to the IN blood group system, namely IN3 (INFI) and IN4 (INJA). The antigens in this system are located on CD44, a single-pass membrane glycoprotein that is encoded by the CD44 gene on chromosome 11 at position p13. The biologic function of CD44 is as a leukocyte homing receptor and cellular adhesion molecule. The In(a) and In(b) polymorphism represents a 252G>C substitution of CD44, encoding R46P, and lack of IN3 and IN4 results from homozygosity for mutations encoding H85Q and T163R in the CD44 gene. The high-frequency antigen AnWj (901009) has not been assigned to the Indian system, but either is located on an isoform of CD44 or is closely associated with it.

Management of A2B blood group in a patient for hypothermic cardiopulmonary bypass surgery--a case report

A2 is one of the rare subgroups in the ABO blood group system. Because of the weak antigenic power of A2 subgroup, the hemolytic reaction is not severe under normothermic situations. Under hypothermic conditions, however, such as in cardiac surgery under hypothermic cardiopulmonary bypass (CPB), lethal hemolytic reaction may occur. Autologous blood transfusion helps the anesthesiologist to avoid banked blood and thus avoid unwanted transfusion reactions. The following case report is a 59 yrs old man with an "A2B" negative blood group who underwent CABG under hypothermic CPB (28C, using cold cardioplegia 4C). Following induction, the anesthesiologist drew three units of patient's own blood (1200 cc) and replaced it with the same volume of colloid solution (Acute Normovolemic Hemodilution-ANH). The collected autologous blood was then re-transfused at the end of surgery. With the use of the ANH technique, the patient was successfully managed during hypothermic CPB without the risk of a hemolytic reaction.

Commentary to a paper by Flosadóttir & Bjarnason on full dapsone dose made possible by control of anaemia with darbepoetin-alpha

This article does not have an abstract

Ribavirin considerations in treatment optimization

Ribavirin is a guanosine analogue that has little antiviral activity when used alone, but considerably enhances the efficacy of conventional and pegylated interferon in the treatment of hepatitis C virus (HCV). The precise mode of action of ribavirin is not fully understood; however, it is crucial for the achievement of high sustained virological response (SVR) rates by enhancing virological response and reducing relapse rates. Data from several studies have confirmed that higher initial doses of ribavirin lead to higher SVR rates. Furthermore, intensified ribavirin dosing might also improve SVR rates in 'difficult-to-cure' patients. It is also important to minimize ribavirin dose reductions to promote high SVR rates and to maintain ribavirin levels throughout treatment to prevent viral breakthrough and relapse. The pharmacokinetic profile of ribavirin reveals a long elimination half-life due to accumulation in the blood, such that its side-effect profile includes haemolytic anaemia. Therefore, finding the optimal ribavirin dose requires a balance between efficacy and its associated side effects to ensure improved patient outcomes. Here, we discuss how optimizing the ribavirin component of combined therapy for HCV is an essential part of treatment optimization.

Hemolytic Transfusion Reaction After Preoperative Prophylactic Blood Transfusion for Sickle Cell Disease in Pregnancy

BACKGROUND

Preoperative transfusions are frequently given to prevent morbidity in nonpregnant patients with sickle cell disease. We describe a case of a life-threatening delayed hemolytic transfusion reaction with hyperhemolysis syndrome in pregnancy.

CASE

A multigravida with sickle cell disease underwent prophylactic blood transfusion before repeat cesarean delivery. Her immediate postpartum course was uneventful, but on postoperative day number 6 she presented in grave condition with what was thought initially to be an infection versus crisis. Delayed hemolytic transfusion reaction with hyperhemolysis was ultimately diagnosed.

CONCLUSION

In the gravida with sickle cell disease and known multiple red cell antibodies, blood transfusion may incur a higher risk for delayed transfusion reaction, hyperhemolysis syndrome, and possible death. Blood transfusion should be used cautiously in these patients.

Protective effects of quercetin against phenylhydrazine-induced vascular dysfunction and oxidative stress in rats

Oxidative stress is a major contributor to the development of vascular dysfunction found in various pathological conditions. Quercetin, one of the potent antioxidant bioflavonoid compounds, has been shown to alleviate oxidative injury by modulation of gene expression leading to suppression of production of reactive oxygen and nitrogen species and conferring an antiapoptotic activity. The aim of the present study was to investigate the protective effects of quercetin in a model of phenylhydrazine (PHZ)-induced oxidant stress, vascular dysfunction and hemodynamic disturbance in rats. Male Sprague-Dawley rats were administered quercetin orally (25 or 50mg/kg/day) for 6 days. On day four, all animals except those in the normal control group, were administered PHZ intraperitoneally. The results showed that PHZ induced severe hemolysis. The mean arterial pressure and hindlimb vascular resistance of PHZ-control rats were markedly decreased compared to normal controls. Treatment with quercetin significantly improved arterial blood pressure and peripheral vascular resistance. Vascular responsiveness to bradykinin, acetylcholine, and phenylephrine in PHZ-control rats was dramatically suppressed and quercetin restored these responses in a dose-dependent manner. Quercetin partially protected blood glutathione, suppressed plasma malondialdehyde levels, and largely suppressed nitric oxide metabolites and superoxide anion production. These results provide the first evidence for the role of the flavonoid, quercetin, in the alleviation of vascular dysfunction in an animal model of PHZ-induced oxidant stress.

Pyrazole and methylpyrazole for the treatment of 2-butoxyethanol poisoning

2-Butoxyethanol (BE) is a one member of a family of ethylene glycol monoalkyl ethers that are used in a variety of industrial and household products. The clinical features of human and animal BE intoxications mainly include metabolic acidosis, CNS depression and coma, hemolytic anemia, hematuria, and renal injury. It is believed that metabolic activation of BE to butoxyacetic acid (BAA) is responsible for these pathologic changes. The treatment of BE poisoning have been based on an inhibition of the metabolic pathway enzymes which convert BE to toxic metabolites. Therefore, a comparison was made between antidotal properties of pyrazole (PY) and 4-methylpyrazole (MP) in rats subcutaneously intoxicated with BE. It was found that both antidotes effectively protected animals against appearance of hemolytic anemia signs induced by BE. MP appears to be more efficient than PY. These data confirm the beneficial role of alcohol dehydrogenase (ADH) inhibitors in BE intoxication.

Acute massive haemolysis in children with glucose-6-phosphate dehydrogenase deficiency

We report seven consecutive episodes of acute massive haemolysis accompanied by symptomatic anaemia and gross haemoglobinuria in six boys with glucose-6-phosphate dehydrogenase deficiency seen in a regional hospital during a 12-year period. They presented at a mean age of 5.5 years (range, 1.5-11.3 years) with trough haemoglobin levels between 35 and 84 g/L. Two children developed transient renal impairment. Five children required erythrocyte transfusion, of whom one underwent exchange transfusion during the oliguric phase. Three patients required intensive care but all recovered from the haemolysis. The probable precipitating factors included consumption of fava beans (n=2), exposure to mothballs (n=1), treatment with herbal medicine or intramuscular injection of unknown nature (n=3), and upper respiratory tract infection (n=1). Although uncommon, acute massive haemolysis remains a life-threatening complication in children with glucose-6-phosphate dehydrogenase deficiency. Improvement in patient education and public health measures is suggested.

Safety and impact of donor-type red blood cell transfusion before allogeneic peripheral blood progenitor cell transplantation with major ABO mismatch

BACKGROUND

Changes within the ABO system are regularly observed phenomena in allogeneic bone marrow transplantation (BMT) and peripheral blood progenitor cell transplantation (PBPCT). Major ABO mismatch can lead to different clinical problems including acute hemolysis after infusion of the allograft, delay of red blood cell (RBC) engraftment, or even manifestation of pure red cell aplasia (PRCA).

STUDY DESIGN AND METHODS

This retrospective study demonstrates the safety and the impact of donor-type RBC transfusion before allogeneic PBPCT in major ABO settings as routinely performed at our transplantation unit. This study reports on transfusion of mismatched RBCs at the end of the conditioning period in 35 patients who underwent allogeneic PBPCT, which led to a decrease in isoagglutinin titers in most cases.

RESULTS

A decrease of isoagglutinin titer after donor-type RBC transfusion can significantly reduce the demand of RBC transfusion between transplantation and Day +30 (p = 0.003). Interestingly, patients who developed PRCA were not observed, a complication being regularly documented by other groups.

CONCLUSION

A decrease of isoagglutinin titers by in vivo immunoadsorption before allogeneic PBPCT does not only lack severe complication but also leads to a reduction in demand of RBC transfusion after engraftment and may reduce the incidence of PRCA in these patients.

[Annual Report 2004 - French National Reference Centre for Rare Blood Groups and Immunohaematology (CNRGS)]

In 2004, the French Reference Centre for Rare Blood Groups and Immunohaematology (CNRGS) developed 7 types of activities: 1) Studies of complex Immunohaematology issues (IH), 2) Studies of rare blood phenotypes, 3) the transfusion of patients showing complex issues, 4) IH reactive control in consistency with the 98/79/CE European Directive, 5) European studies and expertise on reactives and techniques, 6) Biotechnologies applied to blood groups, in particular RH, KEL, FY, JK, DO and CO, 7) Implementation of allo-immunization research programs (cellular immunology and grafting issues). The CNRGS efficiency is based on the 'reference-research' link thanks to the Inserm partnership and direct applications to patients allowing to a better risk management and control.

[Occurrence and prevention of adverse reaction induced by puerarin injection]

In this paper, literature about adverse reaction induced by Puerarin injection published in recent years were reviewed and analyzed. It was reported that Puerarin injection can not only induce adverse reactions on multiple systems, such as immune, blood, urinary, digestive and cardiovascular system, but so far as to cause death. Therefore, it should be administered rationally and strictly according to the direction and the course of medication should be rigorously monitored to prevent the occurrence of adverse reactions.

Prevention of garlic-induced hemolytic anemia using some tropical green leafy vegetables

Garlic (Allium sativum) is popularly consumed in Nigeria because of its health benefit in treatment and management of several disease conditions. However, excessive intake of garlic may cause hemolytic anemia. This project sought to investigate the ability of some commonly consumed tropical green leafy vegetables-namely, Amaranthus cruentus, Baselia alba, Solanum macrocarpon, Ocimum gratissimum, and Corchorus olitorius-to prevent garlic-induced hemolytic anemia. Wister strain albino rats were fed diet containing 4% garlic with or without 40% vegetable supplement. The study showed that there was a decrease in daily feed intake (6.7-7.2 g/rat/day), daily weight gain (0.7-1.5 g/rat/day), and digestibility (70.4-91.5%) of rats fed diet with garlic (4%), with or without vegetable (40%) supplement, compared with those rats fed the basal diet without garlic (4%) and vegetable (40%) supplement (digestibility, 95.5%; daily feed intake, 7.5 g/rat/day; and daily weight gain, 2.0 g/rat/day). However, there was a significant decrease (P < .05) in the packed cell volume (PCV) (31.0%), hemoglobin (Hb) (10.2 g/dL), red blood cells (RBCs) (4.3 x 10(6)/microL), and white blood cells (WBCs) (3.5 x 10(6)/microL) of rats fed diet with garlic (4%) but without vegetable compared with those rats fed diet without garlic (4%) and vegetable (40%) supplements (PCV, 38.2%; Hb, 13.0 g/dL; RBCs, 5.5 x 10(6)/microL; and WBCs, 4.0 x 10(6)/microL). Conversely, there was a significant increase in the PCV (33.5-35.6%), Hb (12.0-12.5 g/dL), and RBCs (4.9-5.3 x 10(6)/microL) of rats fed diet with garlic (4%) and vegetable (40%) supplement compared with rats fed diet with 4% garlic supplement (except S. macrocarpon and C. olitorius). Furthermore, there was a significant decrease (P < .05) in mean corpuscular volume (69.2-72.0 fL) of rats fed the basal and those fed diet with garlic and vegetable (except C. olitorus and S. macrocarpon) supplement compared with the rats fed diet with garlic but without vegetable supplement (74.5 fL). This therefore implies that garlic could induce hemolytic anemia in rats. However, such anemia could be prevented by some tropical green leafy vegetables such as A. cruentus, B. alba, and O. gratissimum.

Controlling the complement system for prevention of red cell destruction

PURPOSE OF REVIEW

Complement sensitization of red blood cells (RBCs) can lead to both intravascular and extravascular red cell destruction. Altered levels of naturally occurring complement regulatory proteins on red cells can result in hemolysis, while defective expression of these proteins on immune cells can cause breakdown of tolerance to self antigens and is associated with autoimmune disease.

RECENT FINDINGS

To date several complement inhibitors, including recombinant forms of complement regulatory proteins, humanized antibodies, and synthetic molecules have been described that limit complement activation by interfering with different steps in the complement cascade. However, few have been evaluated for prevention of complement-mediated RBC destruction. In this review, possible applications of these complement inhibitors for treatment of complement-mediated hemolysis in specific disease states are described. Furthermore, the implication of the regulatory role of complement in the development of autoimmune hemolytic anemia is discussed.

SUMMARY

Complement therapeutics has potential for effective and safe prophylactic use and treatment of hemolytic transfusion reactions and complement-mediated hemolytic diseases. Furthermore, the regulatory function of complement may be exploited to prevent and treat autoimmune hemolytic anemia.

Potential approaches to prevent uncommon hemolytic side effects of AB0 antibodies in plasma derivatives

Since hemolytic reactions in patients after administration of plasma derivatives like immunoglobulins or coagulation factor preparations have been described, titers of anti-A and anti-B-antibodies have to be below defined levels for batch release of these plasma-derived therapeutic products according to the European Pharmacopoeia. We have summarized clinical relevance of AB0 antibodies in plasma derivatives and related legal issues in the European Union, United States of America, and Japan. We have also discussed potential approaches for the prevention of hemolytic side effects with feasible steps in preparation of plasma derivatives, viz., (1) selection of donors, (2) exclusion of "dangerous donors", (3) optimizing ratio of the types of plasma, (4) removal of antibodies, (5) production of blood-group-specific plasma derivatives, (6) rejection of batches of plasma derivatives with high titers of antibodies, and (7) crossmatching before administration. For harmonization of standards for anti-A and anti-B in plasma-derived therapeutics the regulators and manufacturers will have to realistically deal with complex clinical, practical, and economic issues.

Prevention of complement-mediated immune hemolysis by a small molecule compound

Complement sensitization of red blood cells (RBCs) can result in transfusion reactions and hemolytic anemias. We hypothesized that manipulating the complement system using small organic molecules might prevent RBC destruction, thereby prolonging RBC survival in patients. Using a simple, rapid, large-scale hemolytic assay, we screened a 10,000 compound library, enriched in anti-inflammatory compounds at a final concentration of 25 microM, and identified a 549Da compound (C(34)H(24)N(6)O(2)) with a symmetrical structure containing two benzimidazole rings that, as compared to a known anti-complement molecule FUT-175, was more effective in reducing hemolysis by the classical pathway and had comparable anti-hemolytic activity against the alternative pathway. Furthermore, in a xenotransfusion mouse model, treatment of mice with 1.2mg/kg of the compound significantly prolonged the survival of transfused RBCs, reducing C3 deposition, but not the deposition of control IgG or IgM, for the first hour post-transfusion. These data suggest that further studies are warranted to determine if this compound has usefulness in a transfusion setting.

Orally administered Kampo medicine, Juzen-taiho-to, ameliorates anemia during interferon plus ribavirin therapy in patients with chronic hepatitis C

BACKGROUND

Interferon plus ribavirin (IFN/Rib) therapy is currently standard treatment for chronic hepatitis C. Hemolytic anemia, however, is a serious side effect of this treatment, requiring reductions in or complete withdrawal of ribavirin.

METHODS

We retrospectively investigated the effect of the Kampo medicine Juzen-taiho-to (TJ-48), which contains bone marrow-stimulating compounds, on anemia in 67 patients with chronic hepatitis C, who received IFN/Rib therapy.

RESULTS

The reduction in hemoglobin levels was significantly ameliorated in TJ-48-treated patients (P<0.05). Consequently, only 13% (4/32) of TJ-48-treated patients received altered doses of ribavirin, while the ribavirin dose had to be reduced or withdrawn in 43% (15/35) of patients in the absence of TJ-48 administration (P<0.001).

CONCLUSIONS

These results indicate the possibility that oral administration of TJ-48 supports IFN/Rib therapy without necessitating ribavirin reduction or withdrawal.

Significant numbers of apheresis-derived group O platelet units have "high-titer" anti-A/A,B: implications for transfusion policy

Transfusion of group O single-donor apheresis PLTs (SDP) to group A recipients has resulted in intravascular hemolysis and mortality. Owing to low availability of type-specific SDPs, transfusion services sometimes issue ABO-mismatched PLTs. After observing two cases of acute hemolysis following infusion of O SDPs to group A patients, where both recipient eluates revealed anti-A specificity, a prospective study to determine the prevalence of "high-titer" anti-A/A,B in group O SDPs was commenced. One hundred group O SDP samples were tested. Titers of at least 64 and/or 256 from either buffered (generally reflective of IgM antibodies) or anti-IgG gel cards, respectively, were considered critically high. Twenty-eight and 39 percent of samples revealed critically high anti-A/A,B IgM and IgG titers, respectively. IgM titers were at 1:64 (18%), 128 (6%), and 256 (4%), whereas IgG titers were at 1:256 (28%), 512 (7%), 1024 (2%), and 2048 (2%). The prevalence of critical anti-A/A,B titers in group O SDPs is relatively high. Thus, the risk of minor side ABO mismatch and potential intravascular hemolysis during group O SDP transfusion to group A recipients may be significant. Based on these data, a policy was instituted to test anti-A/A,B titers in O SDPs prior to "out-of-group" transfusion.

CR1-based inhibitors for prevention of complement-mediated immune hemolysis

Complement receptor 1 (CR1) is a single pass transmembrane glycoprotein that, through its ability to bind key components of the complement cascade, can inhibit both the classical and alternative pathways. Using several animal models, a recombinant form of CR1 has been documented to be effective in reducing tissue damage that occurs as a result of complement activation in various inflammatory conditions. This strategy is currently being explored in human clinical trials. Activation of complement cascade via the antibody-mediated classical pathway can initiate red blood cell destruction, causing transfusion reactions and hemolytic anemia. We discuss here our approach of using CR1 derivatives as therapeutic targets for prevention of complement-dependent immune hemolysis. Using a mouse model of hemolytic transfusion reaction, we have found that sCR1 treatment reduces complement activation and prolongs the survival of transfused red blood cells. Through structure-function analysis, we have identified a complement inhibitory domain located at the amino-terminal region of CR1 that mediates its antihemolytic activity in vivo. Collectively, our data highlight a potential use for CR1 to control complement-dependent immune hemolysis and identify its functional domains for the future design of CR1-based inhibitors.

[Immunomodulating activity of polyunsaturated phospholipids and regulators of energy metabolism in toxic anemia]

Possible potentiation of the immunomodulating effects of carbohydrate and lipid metabolism regulators by their use in combination with polyunsaturated phospholipids was studied. The polyunsaturated phospholipids in toxic anemia icreased the immunomodulating effects of thiamine and inosine which activated glucose catabolism in erythrocytes. The combined use of the polyunsaturated phospholipids and thiamine normalized the oxidation--energy status and lowered manifestation of the immunosuppressing properties of light erythrocytes in laboratory rats exposed to hemolytic poison. The use of the combination of the polyunsaturated phospholipids and inosine normalized the oxidation--energy status and induced manifestation of the immunomodulating properties in heavy erythrocytes of the poisoned rats. The globulin fraction of the rat serum containing antibodies to erythrocytes of the poisoned rats exposed to the polyunsaturated phospholipids and inosine increased the immunity status of the poisoned rats treated with the above mentioned agents. Carnitine and biotin in combination with the polyunsatured phospholipids showed no effect on the phagocytic and metabolic activity of leukocytes and the immunity status of the rats exposed to hemolytic poison.

Folic acid supplementation does not prevent ribavirin-induced anemia

Treatment of chronic hepatitis C consists of inteferon plus ribavirin. The major adverse effect of ribavirin is hemolytic anemia, a complication that limits therapy. Folic acid supplementation is used to improve erythropoiesis in chronic hemolytic anemia. The aim of this study was to evaluate the effectiveness of folic acid supplementation in the prevention of ribavirin-induced anemia in patients being treated for hepatitis C. Twenty one patients enrolled in treatment protocols for hepatitis C received folic acid 1 mg daily and 22 did not. Groups were similar in age, gender, ribavirin dose and baseline hemoglobin. Folic acid supplementation had no effect in the decrease in hemoglobin or the measured parameters of hemolysis. No difference between males and females was noted for hemoglobin decrease or lowest hemoglobin levels. In our study, folic acid showed no beneficial effect in the prevention of ribavirin-induced anemia.

Relationship between oxidative stress, pathology, and behavioral signs of lead poisoning in mallards

Some of the adverse effects of lead (Pb) may be associated with oxidative damage of lipids, proteins, or DNA. In a previous study a linkage was observed between the susceptibilities of waterfowl species to Pb poisoning with oxidative stress. To investigate this relationship among the individuals of a single species, for 3 wk 4 groups of 12 mallards were fed diets containing high or low levels of vitamin E (20 or 220 UI/kg) and high or low levels of Pb (0 or 2 g/kg). During the first week of Pb exposure, mallards developed hemolytic anemia, and during the second week, signs of neurological impairment. Histological findings in the Pb-exposed mallards were hemosiderosis, demyelinization of sciatic and brachial nerves, and tumefaction of renal tubular epithelium with the presence of intranuclear inclusion bodies. Lipid peroxidation increased with Pb exposure in blood, liver, bile, and brain, but decreased in nerves. Glutathione (GSH) increased with Pb exposure in liver and bile, and its oxidized/reduced ratio only increased in bile. Pb exposure inhibited GSH peroxidase activity (GPX) in plasma, liver, and brain, and decreased protein thiols (PSH) in blood and liver. Vitamin E resulted in significantly lower lipid peroxidation in nerves of control birds relative to unsupplemented controls, but did not alleviate any sign of lead posioning. Pb-induced pathological changes associated with hepatic and nervous functions were significantly correlated with lower GPX activity and PSH concentrations in these tissues rather than lipid peroxidation. Data suggest that inhibition of antioxidant enzymes and interaction with sulfhydryl groups of proteins may play a more important role in Pb poisoning of waterfowl than lipid peroxidation.

Influence on hazelnut oil administration on peroxidation status of erythrocytes and apolipoprotein B 100-containing lipoproteins in rabbits fed on a high cholesterol diet

Hazelnut oil (HO) is rich in monounsaturated fatty acids (MUFA). The effect of a high cholesterol (HC) diet with and without HO on lipids and lipid peroxide levels in plasma, apolipoprotein B 100-containing lipoproteins (VLDL + LDL), and erythrocytes as well as hematological data was investigated in rabbits. A HC diet caused significant increases in lipid peroxide levels in plasma and apo B-containing lipoproteins together with histopathological atherosclerotic findings in aorta. In addition, this diet resulted in hemolytic anemia associated with increased endogenous diene conjugate (DC) levels, but H(2)O(2)-induced malondialdehyde (MDA) levels remained unchanged in erythrocytes. HO supplementation reduced lipid peroxide levels in plasma and apolipoprotein B 100-containing lipoproteins as well as aortic atherosclerotic lesions in rabbits fed an HC diet without any decreasing effect on lipid levels. In addition, HO was found to reduce hemolytic anemia together with significant decreases in DC and H(2)O(2)-induced MDA levels.

Complement receptor 1 inhibitors for prevention of immune-mediated red cell destruction: potential use in transfusion therapy

Activation of complement cascade via the antibody-mediated classical pathway can initiate red blood cell (RBC) destruction, causing transfusion reactions and hemolytic anemia. In the present study, we have assessed the ability of a human recombinant soluble form of complement receptor 1 (sCR1) to inhibit complement-mediated RBC destruction in vitro and in vivo. Using an in vitro alloimmune incompatibility model, sCR1 inhibited complement activation and prevented hemolysis. Following transfusion of human group O RBCs into mice lacking detectable pre-existing antibodies against the transfused RBCs, systemic coadministration of 10 mg/kg sCR1, a dose well tolerated in human subjects for prevention of tissue injury, completely inhibited the in vivo clearance of the transfused RBCs and surface C3 deposition in the first hour after transfusion, correlating with the half-life of sCR1 in the circulation. Treatment with sCR1 increased the survival of transfused human group A RBCs in the circulation of mice with pre-existing anti-A for 2 hours after transfusion by 50%, reduced intravascular hemolysis, and lowered the levels of complement deposition (C3 and C4), but not immunoglobulin G (IgG) or IgM, on the transfused cells by 100-fold. We further identified potential functional domains in CR1 that can act to limit complement-mediated RBC destruction in vitro and in vivo. Collectively, our data highlight a potential use of CR1-based inhibitors for prevention of complement-dependent immune hemolysis.

Hemolytic transfusion reaction: safeguards for practice

Most hemolytic transfusion reactions result from administration of ABO-incompatible blood. Even a small amount of incompatible blood may initiate a reaction and cause devastating consequences leading to death. Careful monitoring of the anesthetized patient is important in recognizing symptoms of a transfusion reaction so that the reaction may be promptly detected and treatment quickly initiated. Many factors contribute to blood transfusion errors resulting from the misidentification of either the patient or the blood product. Nursing has opportunities to establish policies and procedures, design nursing practices, and educate staff to help avoid blood transfusion errors.

Glucose-6-phosphate dehydrogenase deficiency and hematopoietic stem cell transplantation

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked hemolytic enzymopathy affecting 3% of Southern Chinese males. Among 275 adult allogeneic hematopoietic stem cell transplantations (SCT), five cases (1.8%) each of donors and recipients were G6PD deficient. Among 107 autologous SCT, four patients (3.7%) were G6PD deficient. All subjects were male, except for two female patients with chronic myeloid leukemia (CML). The incidence of G6PD deficiency in female CML patients was significantly higher than the background female incidence (P = 0.004), but comparable with that in the males (P = 0.664). There was no significant hemolysis or delay in red cell engraftment, and all but one patient converted to donor G6PD screening status. One female patient achieved partial correction of her G6PD status and relapsed at 10 months. We suggest that G6PD deficiency should be tested for in all marrow donors and recipients in susceptible populations. From our data, there is a suggestion of increased clinical incidence of G6PD deficiency in female patients with multi-lineage clonal marrow disorders.

Erythropoietin can obviate the need for repeated heart valve replacement in high-risk patients with severe mechanical hemolytic anemia: case reports and literature review

BACKGROUND AND AIM OF THE STUDY

Brisk hemolysis due to perivalvular leak is usually an indication for valve re-replacement. Repeated surgery after multiple previous valve operations is associated with high mortality, morbidity and failure rates. The present study evaluated the role of erythropoietin (EPO) administration in deferring or obviating the need for repeated surgery.

METHODS

Three patients (two men, one woman; age range 62-76 years) with two mechanical valves each and two to four previous heart valve operations, who suffered from severe mechanical hemolytic anemia, were given subcutaneous EPO for 15-17 months.

RESULTS

A marked reduction in red blood cell consumption was achieved with a weekly EPO dose of 18,000 U in two patients, both of whom also had mild or moderate kidney malfunction. A third patient with normal renal function and extreme hemolysis showed a transient, partial response to 30,000 U of EPO per week, and eventually needed a fifth operation.

CONCLUSION

EPO may defer or even obviate the need for repeated valve surgery in patients with severe hemolysis due to perivalvular leak, especially those with inadequate EPO response, such as those with renal malfunction.

Antioxidant prevention of Heinz body formation and oxidative injury in cats

OBJECTIVE

To determine the effectiveness of 3 antioxidants in preventing Heinz body anemia in cats.

DESIGN

Prospective study.

ANIMALS

44 specific-pathogen-free healthy cats.

PROCEDURE

Cats were housed individually, divided randomly into 4 groups, and given the following orally every 12 hours: empty gelcaps (control cats), N-acetylcysteine (NAC, 100 mg/kg of body weight), vitamin E (d,l-alpha-tocopherol; 400 IU), or ascorbate (250 mg). After 2 weeks, Heinz bodies were induced by dietary onion powder (OP; 1% or 3% of dry matter) or propylene glycol (PG, 8% wt/vol in drinking water) for an additional 3 weeks. Intake of treated water or food was recorded daily. Body weight, PCV, Heinz body and reticulocyte percentages, reduced glutathione concentration, and total antioxidant status were measured twice weekly in all cats.

RESULTS

Heinz body percentage and degree of anemia did not differ significantly among cats receiving antioxidants and control cats except in cats that ingested water containing PG, in which antioxidant supplementation was associated with a decrease in water intake. Of cats that were fed a diet that contained OP, cats that received NAC had significantly higher reduced glutathione concentrations, compared with other cats in the experiment. Total antioxidant status did not consistently correlate with antioxidant supplementation or type of oxidant administered (ie, OP or PG).

CONCLUSIONS AND CLINICAL RELEVANCE

Although the effect of antioxidant supplementation on Heinz body anemia in cats was minimal, antioxidants may have subclinical biochemical effects such as GSH sparing that may be important against milder forms of oxidative stress.

Blood tacrolimus concentrations in bone marrow transplant patients undergoing plasmapheresis

Microangiopathic hemolytic anemia (MAHA) is a well-described complication of stem cell transplantation. Plasmapheresis is one modality utilized as therapy for patients who develop this complication. However, plasmapheresis may alter whole blood levels of certain medications and its effect on tacrolimus in bone marrow transplant patients is unknown. Because tacrolimus has a narrow therapeutic range, the effect of plasmapheresis on whole blood concentrations would be important to know. We report three allogeneic BMT patients who were receiving tacrolimus as acute GVHD therapy while undergoing plasmapheresis for MAHA. Tacrolimus levels seemed unaffected by plasmapheresis in these patients.

Perioperative management of glucose 6 phosphate dehydrogenase deficiency. A review of the literature

Glucose 6 phosphate dehydrogenase (G6PDH) deficiency is the most frequent cause of hemolytic anemias due to enzyme abnormality. Perioperative management must be careful to avoid the onset of hemolytic crisis. We present a complete review of the literature on this illness and describe the perioperative management of an adult with known G6PD deficiency and the pathogenesis and clinical manifestations of the disorder and its possible anesthetic implications are discussed. A 49-year-old patient had undergone varum osteotomy in her left knee due to genu valgum. She had been diagnosed as having G6PDH deficiency sixteen years earlier provoked by ingesting beans. The perioperative circumstances capable of causing autohemolysis are described and discussed. In spite of the fact that the pattern is self-limited, it provokes the onset of jaundice and anemia which can complicate the recovery. Simple elimination of those elements which precipitate with oxyhemoglobin will allow an uneventful anesthetic procedure.

Prophylactic splenectomy and cholecystectomy in mild hereditary spherocytosis: analyzing the decision in different clinical scenarios

OBJECTIVES

Patients with mild hereditary spherocytosis (HS), i.e. with haemolysis without anaemia. have an increased risk of gallstone formation, erythroid aplasia and haemolytic crisis. Since the effect of prophylactic splenectomy on life expectancy has not been established, we conducted a decision analysis comparing prophylactic splenectomy and cholecystectomy with no surgery.

DESIGN

The available data on surgery and disease outcomes were modelled to estimate the effects of the different interventions on the quality-adjusted life expectancy. The early phase outcomes depicted surgery-related mortality and incorporated compliance and the adverse effects of prophylaxis against post splenectomy infections. The late phase outcomes were framed by a Markov cohort analysis.

RESULTS

For patients without gallstones, surgery was of no benefit. For those with gallstones the preferred strategies were found to be splenectomy and cholecystectomy before the age of 39 when asymptomatic, and before 52 when accompanied by occasional biliary colic. Cholecystectomy alone proved to be the preferred strategy in older patients with occasional biliary colic. For patients of up to 52 years of age and candidates for cholecystectomy because of recurrent biliary colic, the best strategy was to combine this procedure with splenectomy. Sensitivity analysis showed that the results were sensitive to the incidence of post cholecystectomy syndrome. Most remarkably an extreme sensitivity to compliance with post splenectomy infection prophylaxis was demonstrated.

CONCLUSIONS

Our model suggested that combined prophylactic splenectomy and cholecystectomy provide a substantial gain in quality-adjusted life expectancy for young patients and adults with mild HS and gallstones.