Prevention and diagnosis of delayed haemolytic transfusion reactions.
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Anemia↗
Biomedical subjects
M R Combs
Publications and source records attributed to M R Combs.
Selecting an acceptable and safe antibody detection test can present a dilemma.
The Transfusion Service at Duke University Hospital has changed antibody detection methods from the use of albumin in indirect antiglobulin tests to low-ionic-strength solution (LISS), and from LISS to polyethylene glycol (PEG) in an effort to enhance the rapid detection of clinically significant antibodies. In 1996, staffing issues required the consideration of automation. Although previous studies indicated that the gel test was not as sensitive as PEG for detection of clinically significant antibodies, we chose to implement the gel test to be used with the Tecan MegaFlex-ID. We performed a retrospective analysis of identified antibodies and transfusion reactions to compare the outcomes of one year's experience with gel and PEG. We found comparable detection of potentially clinically significant antibodies by both methods and significantly fewer unwanted or clinically insignificant antibodies detected with the use of gel. Fewer delayed serologic transfusion reactions and no transfusion-associated hemolytic events occurred in the year that gel was used. Although we initially found the selection of the gel test to be a dilemma, our ultimate decision appears to have successfully protected patient safety and balanced sensitivity with specificity.
Journal Article↗
Large-scale use of red blood cell units containing alloantibodies.
Many transfusion services are reluctant to accept red blood cell (RBC) units containing antibodies. We evaluated the impact of accepting routine shipments of our region's inventory of alloantibody- positive RBC units over a 4-month period. All patients' samples received up to 30 days after transfusion of such units were evaluated for the presence of passively acquired antibody, and labor and reagent costs were determined. During the study period, we received 259 alloantibody-containing RBC units, and 253 of these were transfused to 187 patients. Follow-up samples were received on 99 of these 187 patients, and 10 of these patients had detectable passive antibody in posttransfusion antibody screening tests. Two patients had anti-C and -D and eight patients had anti-D. Due to our negotiation of a small discount for antibody-containing units and the use of 20 units based on labeled phenotype rather than antigen typing in our laboratory, we experienced a net savings of $3814 over the 4-month period. This savings was achieved despite some additional costs incurred, including costs of data entry and additional testing on patients' samples. We concluded that large-scale use of RBC units from donors with alloantibodies is safe and likely to have a minimal impact on a busy transfusion service's workload and costs. Furthermore, nationwide use of such units would help alleviate projected blood shortages.
Journal Article↗
Erythrocyte autoantibodies in paediatric patients with sickle cell disease receiving transfusion therapy: frequency, characteristics and significance.
The formation of erythrocyte autoantibodies following transfusion therapy has been described in case reports and small series. To determine the frequency, serological characteristics, and clinical significance of this phenomenon in paediatric patients with sickle cell disease, we analysed the patient database at the Duke University Pediatric Hematology Clinic. We identified children who received multiple erythrocyte transfusions, then reviewed clinical records to identify children who developed erythrocyte autoantibodies in association with transfusions. Among 184 paediatric patients who received multiple erythrocyte transfusions, 14 children (7.6%) developed warm (IgG) erythrocyte autoantibodies. Median transfusion exposure at the time of autoantibody formation was 24 erythrocyte units, range 3-341 units. The autoantibody reacted as a panagglutinin in 11 cases but had anti-e specificity in three patients. Surface complement also was detected in five patients. Clinically significant haemolysis was documented in four patients, each of whom had both surface IgG and C3 detected. The development of erythrocyte autoantibodies was associated with the presence of erythrocyte alloantibodies. Formation of warm erythrocyte autoantibodies in association with transfusions is not rare in paediatric patients with sickle cell disease. Clinicians should be aware of this complication and recognize that the presence of surface C3 is often associated with significant haemolysis.
Adolescent↗
Rh haplotypes that make e but not hrB usually make VS.
BACKGROUND AND OBJECTIVES: The Rh phenotypes hrB- and VS+ are both rare in Whites but more common in Blacks. The high-incidence antigen hrB is present on most red cells that are e+. The presence of VS on red cells is associated with an aberrant expression of e, often called eS. MATERIALS AND METHODS: Using conventional serologic methods, including a monoclonal anti-hrB-like antibody, we studied 65 e+ samples that were apparently hrB-. RESULTS: Of the 65, we found that 59 (91%) were VS+. Recent findings have indicated that in VS+ persons a change from leucine to valine occurs at amino acid 245 of the RHCE-encoded polypeptide. While this residue is predicted to lie within the red cell membrane bilayer, the change presumably affects alanine 226 (that is present when e is expressed) in such a way that eS is seen. CONCLUSIONS: Our findings suggest that the change from e to eS may result in nonexpression or marked depression of expression of hrB that is, perhaps, an epitope of e. While the molecular basis of the hrB-phenotype is not known, it is unlikely that the leucine-to-valine change at residue 245, resulting in the aberrant from of e, explains all hrB-samples. First, hrB-VS+ and hrB- VS- samples must differ. Second, some hrB- VS+ samples are C+, some are C-. Presumably diverse molecular bases are involved in hrB-phenotypes.
Black People↗
Studies of antibodies in the sera of patients who have made red cell autoantibodies.
BACKGROUND: In patients in whom autoantibodies of broad specificity (panagglutinins) are present in the serum, adsorption studies are often necessary to identify alloantibodies that are simultaneously present. STUDY DESIGN AND METHODS: Samples from 138 patients in whom the direct antiglobulin test was positive and antibody was present in the serum were studied. When antibody identification studies before or after initial adsorption suggested the presence of an alloantibody, additional alloadsorptions were performed. RESULTS: Among the samples from 138 patients, 71 contained only panagglutinating autoantibody, and another 19 contained either autoantibodies or alloantibodies that were not accompanied by panagglutinins. The remaining 48 samples contained both panagglutinins and a total of 62 antibodies that appeared to be alloimmune in nature. Alloadsorption with antigen-negative red cells showed that 29 (47%) of the apparent alloantibodies were in fact partially adsorbed autoantibodies that mimicked alloantibodies by their reactions. CONCLUSION: Initial autoadsorption often left unadsorbed alloantibodies and autoantibodies with mimicking specificities. Initial alloadsorption more often left only true alloantibodies unadsorbed. From the screening tests, it appeared that 43 percent of the 138 patients were alloimmunized. Recognition of the mimicking nature of the partially adsorbed autoantibodies found that the real incidence of alloimmunization in the patients was 23 percent. Recognition of this phenomenon considerably simplifies the selection of blood for transfusion to these patients.
Autoantibodies↗
Anti-Di(b) as a red cell autoantibody.
BACKGROUND: It is known that some "warm"-reactive autoantibodies are directed against epitopes on the red cell anion exchanger, protein band 3. Some such antibodies (but not all) recognize Wrb. It is also known that Dia and Dib represent an amino acid polymorphism of band 3. STUDY DESIGN AND METHODS: Autoantibodies from 119 patients were tested against Di(b-) red cells. Seventy-four of these autoantibodies were subsequently absorbed with Di(b-) red cells. RESULTS: All 119 autoantibodies initially reacted with the Di(b-) red cells, which showed that none contained only anti-Dib. Among the 74 adsorbed with Di(b-) red cells, two were found to contain an unadsorbed anti-Dib component. CONCLUSION: No example of autoanti-Dib as the only autoantibody present was found among the 119 samples tested. However, 2 (2.7%) of 74 autoantibodies subjected to adsorption with Di(b-) red cells were seen to contain an anti-Dib component. This low incidence of autoanti-Dib is in marked contrast to the high incidence of autoanti-Wrb, although both antibodies define epitopes associated with the red cell anion exchanger, band 3.
Anemia, Hemolytic↗
Lack of clinical significance of "enzyme-only" red cell alloantibodies.
In a retrospective study on samples from 10,000 recently transfused patients, 35 samples were found to contain an antibody that reacted with ficin-treated red cells but was not demonstrable by low-ionic-strength saline solution and indirect antiglobulin test (LISS-IAT). In those 35 patients, the specificity of the antibody was such that each patient would have been transfused with antigen-negative blood had the antibody reacted in LISS-IAT. Tests on red cells from the units already transfused showed that 19 patients had among them received, by chance, 32 antigen-positive and 74 antigen-negative units. The remaining 16 patients had among them received 57 units that were, again by chance, all antigen negative. One patient given antigen-positive blood suffered a delayed transfusion reaction; in two others the antibodies became LISS-IAT active after transfusion. However, similar changes to the LISS-IAT-active state were seen with two antibodies of patients given only antigen-negative blood. Also found in the 10,000 patients were 28 clinically insignificant antibodies, 77 sera in which the antibody was too weak to identify, and 216 autoantibodies that reacted only with ficin-treated red cells. These data support a belief, generally held in the United States but not necessarily elsewhere, that the use of protease-treated red cells for routine pretransfusion tests creates far more work than the accrued benefits justify.
Clinical Enzyme Tests↗
Characterization of 5-hydroxytryptamine1B receptors in rat spinal cord via [125I]iodocyanopindolol binding and inhibition of [3H]-5-hydroxytryptamine release.
The aim of the present study in rat spinal cord synaptosomes was to compare the pharmacological characteristics of the serotonin (5-HT)1B receptor defined by [125I]iodocyanopindolol [( 125I] ICYP) binding and the 5-HT autoreceptor defined by inhibition of [3H]-5-HT release. In Percoll gradient Fractions 3 and 4 of spinal cord synaptosomes, a single saturable binding site for [125I]ICYP with a maximum binding of 70 and 134 fmol/mg, respectively, was demonstrated in the presence of 30 microM isoproterenol. The Kd of 0.16 nM did not vary between fractions. Competition for [125I]ICYP binding by various 5-HT agonists and antagonists also indicated a single site model based on a Hill coefficient of approximately 1.0. The most potent compounds at displacing [125I]ICYP binding were RU 24969 (5-methoxy-3-[1,2,3,6-tetrahydropyridin-4-yl]-1H-indole), 5-carboxyamidotryptamine HCl, 5-methoxytryptamine, 5-HT and CGS 12066B (7-trifluoromethyl-4(4 methyl-1-pyrolo[1,2-a]-quinoxaline malate). [125I]ICYP binding was not altered by compounds with activity at 5-HT1A, 5-HT1C, 5-HT2, 5-HT3 or alpha-2 receptor sites. Similar to the pharmacological characteristics of the 5HT1B site defined by [125I]ICYP, compounds most active at inhibiting 15 mM K(+)-stimulated release of [3H]-5-HT were RU24969 = 5-carboxyamidotryptamine HCl = CGS 12066B greater than 5-methoxytryptamine greater than 5-HT. Compounds with activity at 5-HT1A, 5-HT1C, 5-HT2 or 5-HT3 sites were inactive. A correlation analysis of selective 5-HT1B compounds comparing the pKD for displacement of [125I]ICYP vs. the IC50 for inhibition of [3H]-5-HT release demonstrated the pharmacological similarity of the presynaptic inhibitory 5-HT autoreceptor and the 5-HT receptor site defined by [125I]ICYP binding in spinal cord synaptosomes (r = 0.791, P = .0193). Although [125I]ICYP binding was unaltered, alpha-2 agonists such as clonidine, norepinephrine and UK 14304 [5-bromo-6-[2-imidazolin-2-ylamino]-quinoxaline) as well as the alpha-2 antagonists rauwolscine and yohimbine also decreased the K(+)-stimulated release of [3H]-5-HT and phentolamine, an alpha-2 antagonist increased release. The action of these alpha-2 compounds to alter [3H]-5-HT release suggests the presence of heteroreceptors localized on 5-HT terminals in the spinal cord. These results point out that [125I]ICYP identifies the 5-HT1B receptor, and affinity of compounds for this site predicts action at the 5-HT1B autoreceptor.(ABSTRACT TRUNCATED AT 400 WORDS)
Animals↗
An auto-anti-M causing hemolysis in vitro.
A 64-year-old white man, who had never received a transfusion, was found to have anti-M in his serum. The antibody agglutinated all M+ red cells in room-temperature tests. When the ionic strength of the test milieu was reduced by use of an additive solution and the tests were incubated at 37 degrees C, the antibody hemolyzed M + N- but not M+N+ red cells. All M+ red cells reacted in indirect antiglobulin tests using polyspecific antiglobulin reagents when such tests followed an initial incubation at room temperature. When red cells and the patient's serum were warmed to 37 degrees C before being mixed, no antibody activity was demonstrable. The antibody was adsorbed to exhaustion onto M+N- and M+N+ red cells (including the patient's own), and its activity was destroyed by dithiothreitol. There was no evidence of in vivo red cell destruction by the autoantibody. No previously reported example of anti-M has been shown to activate complement in conventional in vitro tests. This example was extraordinary in that it caused sufficient complement activation to present as an in vitro hemolysin.
Antibody Specificity↗
A case report: IgG autoanti-N as a cause of severe autoimmune hemolytic anemia.
A 21-year-old white worn was referred for evaluation of hemolytic anemia after a 9-day history of marked hemoglobinuria, jaundice, and weakness. The patient's hematocrit was 18%, despite at least eight transfusions over the previous week, and the reticulocyte count was < 1%. Serologic evaluation revealed a weakly positive direct antiglobulin test with anti-C3 only The serum contained cold and warm-reacting anti-N Dithiothreitol had no effect on either the cold- or the warm-reacting anti-N activity, and radioimmunoassay with monoclonal anti-IgG was strongly positive, indicating that both the cold- and the warm-reacting anti-N reactivity resided in the IgG fraction. The patient was treated with N - 'N' + red cell transfusions, prednisone, and azathioprine and gradually became transfusion independent. Postrecovery typing revealed her red cells to be M+N+S+s+. This constitutes the third case of autoimmune hemolytic anemia associated with IgG autoanti-N. The marked hemoglobinuria and reticulocytopenia are unique features of this case.
Journal Article↗
JMH variants: serologic, clinical, and biochemical analyses in two cases.
BACKGROUND: JMH is a high-frequency red cell blood group antigen that resides on a 76- to 80-kDa glycosylphosphatidylinositol-linked protein also known as CDw108. Antibodies with JMH specificity are often autoimmune and are usually, if not always, clinically benign. Some individuals with JMH-variant antigen produce alloantibodies to JMH, but little evidence concerning their clinical significance is available. This article reports on two patients who express a JMH-variant antigen and produced alloanti-JMH. STUDY DESIGN AND METHODS: Murine monoclonal antibodies and human antibodies to JMH were used in hemagglutination, radioimmunoassay, and Western blot testing of red cells from two JMH-variant patients; antiserum from one of these patients was also used in biochemical studies. In addition, in vivo survival of JMH-positive red cells was studied in the same patient. RESULTS: Biochemically, both examples of red cells with the JMH-variant phenotype expressed a JMH protein with a molecular weight similar to that of the normal JMH protein. For both patients, family studies suggested an autosomal recessive pattern of inheritance. Survival study demonstrated reduced in vivo red cell survival in one patient. CONCLUSION: JMH-variant phenotypes express a protein of normal molecular weight and are inherited in an autosomal recessive pattern. Furthermore, individuals with this phenotype can produce clinically significant antibodies.
Aged↗