Prevention and diagnosis of delayed haemolytic transfusion reactions.
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Biomedical subjects
Publications and source records attributed to H Seyfried.
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BACKGROUND: This report describes the characterization of polyagglutinable red cells (RBCs), identified in two generations of a Polish family. CASE REPORT: Untreated and modified RBCs of the proposita (TS) were tested by serologic methods, using human sera, antibodies, lectins, and inhibitors of agglutination. Moreover, glycophorins were characterized by sodium docecyl sulfate-polyacrylamide gel electrophoresis and Western blotting, and glycolipids were purified, fractionated by thin-layer chromatography, and detected with Ricinus communis agglutinin I (RCA-I, specific for galactose residues) and Griffonia simplicifolia IB4 lectin (GSL-IB4, specific for Gal alpha1-3Gal- structure). Some of the experiments were also performed on RBCs of members of TS's family. RESULTS: Polyagglutination, found in four members of TS's family, was identified as the second case of an earlier described NOR polyagglutination. The polyagglutination was decreased by treating the RBCs with alpha-galactosidase and was inhibited by a neutral glycolipid fraction from NOR+ RBCs. Detection of neutral glycolipids of TS's RBCs on the thin-layer plate by RCA-I and GSL-IB4 revealed the presence of components that were not detectable in control RBCs. Moreover, Western blotting of RBC membranes from five family members with glycophorin monoclonal antibodies and agglutination assays with anti-St(a) and anti-Dantu sera identified the presence of St(a) glycophorin in four members of the family, two of whom were NOR+ and two NOR-. CONCLUSION: Our results showed that two rare features of TS's RBCs, NOR polyagglutination and St(a) glycophorin, are inherited independently, and that NOR+ RBCs contain neutral glycolipids with an abnormal oligosaccharide structure, most likely terminated with alpha-galactosyl residues.
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Three methods for detection of warm type IgG autoantibody were evaluated using 400 blood samples from 147 patients suspected of autoimmune haemolytic anaemia (AIHA). Three direct antiglobulin techniques (DAT) were used: conventional tube DAT, gel-DAT by micromethod and gel-DAT enzyme linked antiglobulin test (ELAT). Eluate examinations confirmed the presence of autoantibodies on red cells. These tests were compared directly using 126 selected blood samples from 85 patients with IgG molecules on their red cells detected by the gel test. In 106 of these samples, collected from 65 patients with clinical symptoms of AIHA, the presence of autoantibody was confirmed by acid elution. The ELAT was positive in 100 samples (94%), 87 samples for tube DAT (82%). The ELAT as well as the tube DAT was negative in 20 samples with non-reactive eluates by gel test. The gel-DAT was therefore not fully specific and detected IgG on red cells of patients with hypergammaglobulinaemia. However, due its higher sensitivity it proved useful as a screening test. The ELAT allowed changes in the number of IgG molecules per red cell to be monitored quantitatively. Both methods play a part in the diagnosis and monitoring patients with warm type IgG auto-antibody.
An enzyme-linked antiglobulin test (ELAT) was adapted to the assessment of IgG autoantibodies on red cells. Due to the worked out standard curve and the performance of the test on microplates, ELAT became a simple and inexpensive technique. It can be used for the detection of IgG within the range from 70 to 37,500 molecules per red cell. This is a simple quantitative method that can be used in immunohaematological studies of red cells.
Engerix B vaccine was administered to 54 children with leukemias and lymphomas aged from 2 to 15 years. In 36 cases chemotherapy was completely stopped, and 18 cases were receiving maintenance treatment. Engerix B was given at 0, 1, 2 and 6 months in a dose of 20 micrograms to children < 10 years, and 40 micrograms to older patients. The effectiveness of active immunization was demonstrated after complete therapy cessation in 88% of cases. The levels of antibodies determined 1 year after primary vaccination remained high, and in most of the vaccinated children they were > 1000 mIU/mL. In children vaccinated in the course of maintenance treatment the levels of antibodies did not give sufficient protection against infection.
Screening for antibodies to hepatitis C virus (HCV) in blood donors by second generation tests was started on May 1991. On July 1992 obligatory testing of every blood or plasma donation was implemented. The incidence of anti-HCV evaluated in the first period (236.590 sera) was 1.4%. In the second period (296,573 sera) the incidence dropped to 0.9%. 489 sera repeatedly positive in screening were examined by a complementary test, 4-RIBA. Compatible positive results were obtained in 72.8% of the sera. 9.4% of the sera were negative and 17.8% gave indeterminate results. Reactivity was most frequently (95.7%) encountered to the structural core HCV peptide. The value of 4-RIBA was discussed. In conclusion, it was pointed out, that blood donors deferral should be based on repeated screening.
While screening activities have already been performed in a wide range in adults in Austria, extensive investigations in children and juveniles have so far only been done in a very limited number. In 1094 out of 1732 juveniles attending agricultural schools all lipid parameters were fully documented and thus could be evaluated. On an average, the total cholesterol (169 mg/dl) was too high; the worst findings for lipid parameters cholesterol, HDL-cholesterol, triglycerides, apolipoprotein-A1 were found in pupils of Burgenland. The cholesterol/HDL-cholesterol ratio in Burgenland was significantly (p < 0.01) higher than in Lower Austria. Female participants had a higher total cholesterol, HDL-cholesterol, and apolipoprotein-A1, but lower triglycerides and also lower blood pressure. Juveniles with a positive family history showed lower total cholesterol, but higher triglycerides as well as HDL-cholesterol. In heavy smokers, but also in occasional smokers, a lower total cholesterol, but decreased HDL-cholesterol and apolipoprotein-A1 and increased triglycerides were found. These findings underline the high prevalence of hypercholesterolemia in juveniles justifying screening activities and possibly therapeutic intervention at this young age.
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In order to prevent the hepatitis virus B (HBV) infection, in 66 children aged from 6 months to 14 years with acute and chronic leukaemias, Hodgkin's and non-Hodgkin's lymphomas, testicular tumours, and aplastic anaemia a specific immunoglobulin was used intravenously (Hepatect made by Biotest). Hepatect was given every month to children with proliferative diseases throughout the whole time of intensive chemotherapy, and to children with aplastic anaemias during the administration of antilymphocytic globulin, prednisone, and Anapoln. Fourteen children were excluded from the analysis due to lack of systematic follow-up. Among 52 studied children, in most cases considerable fluctuations were observed of antibody concentration, the maximal values of which were of 150 mIU/ml. In 35 children, with the exception of sporadic falls, the anti-HBs antibody level remained level was noted, in two cases the presence of antibodies was revealed only sporadically. One of these children was infected with HBV. In all, three children were infected (5.76% of all children in the studied group). Perhaps the use of higher doses of Hepatect and its more frequent administration in children showing low anti-HBs level after routine doses might reduce further the incidence of infection.
Comparisons have been made between the serological and immunological characteristics of 42 blood group alloantibodies (other than D) covering twelve systems using a monocyte-monolayer assay (MMA), a radiometric antiglobulin test for antibody binding and IgG subclass determinations. The results of the MMA correlated well with the level of IgG molecules bound on incompatible cells, and the highest levels in both cases were associated with the presence of the IgG3 subclass. However, limited clinical data shows that, while in general the MMA clearly identifies the clinically significant antibodies, the correlation with the degree of clinical outcome is less well defined, and in some instances other factors may be operating to ameliorate the in vivo effect of the antibody.
A number of factors were analyzed for their predictive value in indicating the severity of haemolytic disease of the newborn (HDN) in 72 infants. The factors investigated were: maternal antibody titre in the indirect antiglobulin test, the number of antibody molecules on sensitized standard red cells evaluated by a radiometric antiglobulin test, the IgG subclass specificity and the reactivity in monocyte-monolayer assay (MMA) and in the rosette assays with lymphocytes and granulocytes from healthy individuals. The results of the MMA correlate much better with the severity of HDN than the antibody titre. In clinically unaffected infants the reactivity in the MMA never exceeded 20%, while in the severe/very severe group it was always greater than 20% (in 95% of very severe cases even above 50%). The number of IgG-bound molecules was also shown to closely correlate with the clinical severity and there was a much greater proportion of severe/very severe cases exhibiting combined IgG1 and IgG3 specificity. Of all the evaluations performed the rosette assays with lymphocytes and granulocytes were found to be less useful in predicting the severity of HDN.
Sera of 520 multitransfused haemophiliacs were examined for antibody to HIV; 447 patients had haemophilia A and 73 had haemophilia B. In 382 patients with haemophilia A and in 62 with haemophilia B solely Polish-made blood products were used for replacement therapy. The remaining haemophiliacs had also received imported clotting factor concentrates prior to the investigation. Only 8 patients (haemophilia A - 7, haemophilia B - 1) developed anti-HIV and all of them had been exposed to commercial concentrates. The analysis of T-cell subsets demonstrated an inverted T4/T8 ratio (less than 1.0) in 7 (30%) of the 23 haemophiliacs treated solely with domestic cryoprecipitate and in 3 (37%) of the 8 seropositive recipients of commercial concentrates. The most frequent alteration in both subgroups was a reduced ratio with either normal absolute numbers or an increase in T8 cells. Increased serum IgG levels were found in 82% of the users of cryoprecipitate and in 75% of the seropositive patients. Serum beta-2-microglobulin level was elevated in 69 and 62% of each subgroup, respectively. The observed immunological abnormalities, at least in the cryoprecipitate treated subgroup, may be causally related to factors other than HIV infection.
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Monocyte-erythrocyte interaction in patients with autoimmune haemolytic anaemia (AIHA) was assessed by phagocytosis and rosette assays. In most patients, a relationship was observed between haemolysis and the phagocytosis of their own erythrocytes by allogenic peripheral monocytes. An evaluation of the number of immunoglobulins on patient erythrocytes and IgG subclasses of autoantibodies shows that in patients with only IgG1 antibody or with additional IgG2 or/and IgG4, phagocytosis was always observed when the number of erythrocyte-bound IgG molecules was above 2,000. On the other hand, in all patients where IgG3 was detectable, phagocytosis was observed even if the amount of IgG was as low as 230 molecules per erythrocyte. Similar observations were made in the rosette assay. Generally, the number of erythrocyte-bound IgG and the presence of phagocytosis were correlated with the degree of haemolysis, but there were exceptions, i.e. the amount of IgG and phagocytosis were high but there was no evidence of haemolysis, or where there was little IgG, no phagocytosis but haemolysis was present. Our data do not indicate that erythrocytes from AIHA are preferentially bound to autologous monocytes.