|Year : 2016 | Volume
| Issue : 2 | Page : 78-80
Safe red cell transfusion, a challenge in auto-immune hemolytic anemic patients
Biplabendu Talukdar1, Subrata Das1, Sandip Chanda1, Rony Roy Chaudhury1, Prasun Bhattacharjya2
1 Department of Immuno-haematology and Blood Transfusion Peoples Blood Bank, Asutosh Mukherjee Road, Kolkata, West Bengal, India
2 Department of IHBT, MCH, Kolkata, West Bengal, India
|Date of Web Publication||6-Sep-2016|
Department of Immuno-haematology and Blood Transfusion Peoples Blood Bank, Asutosh Mukherjee Road, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
The definition of Auto-Immune Hemolytic Anemia (AIHA) is an increment of anti erythrocyte antibodies (AEA) which mediate the destruction of circulating erythrocyte antigens. Antibodies develop against one's own erythrocyte antigens. Diagnosis of AIHA is made on the basis of auto-agglutination and direct anti-globulin test (DAT). The specificity of erythrocyte antibody is often difficult to identify especially in emergency. This study is based on a case of AIHA on a 62 years old female patient. She also had underlying hypothyroidism, diabetes mellitus and Hypertension.
Keywords: Auto-agglutination, auto-immune hemolytic anemia, direct antiglobulin test
|How to cite this article:|
Talukdar B, Das S, Chanda S, Chaudhury RR, Bhattacharjya P. Safe red cell transfusion, a challenge in auto-immune hemolytic anemic patients. Glob J Transfus Med 2016;1:78-80
|How to cite this URL:|
Talukdar B, Das S, Chanda S, Chaudhury RR, Bhattacharjya P. Safe red cell transfusion, a challenge in auto-immune hemolytic anemic patients. Glob J Transfus Med [serial online] 2016 [cited 2019 Mar 25];1:78-80. Available from: http://www.gjtmonline.com/text.asp?2016/1/2/78/189848
| Introduction|| |
Autoimmune hemolytic anemia (AIHA) is a development of anti-erythrocyte autoantibodies (AEA) against antigens on the surface of patients own erythrocytes. AIHA can be classifiable as primary (idiopathic) or secondary to other autoimmune diseases, lymphoid malignancies, infections, etc., AEA can also be classified as cold or warm. Warm AEAs are mostly IgG in nature but sometimes it may be IgA and/or IgM in type/s, react above 37°C. Warm AEAs neither require complement for activities nor produce agglutination in vitro. Cold antibodies in AIHA are IgM in nature and react below 37°C, require complement for activities and produce spontaneous agglutination of erythrocytes in vitro.
Diagnosis of AIHA is made on the basis of auto-agglutination and direct anti-globulin test (DAT). Typically, hemolytic anemia is estimated to occur in about 4 cases per 1000/year, and the annual incidence of AIHA is estimated to about 1–3 cases/100,000/year., AIHA is a rare disease, which can affect infants to elderly, but majority of the patients are over the age of 40 years with peak incidence at 70 years.
A 62-year-old female patient was admitted in a hospital with gradually progressive breathing difficulty on mild physical exertion along with a background history of hypothyroidism, diabetes mellitus, and hypertension for the past 10 years. On physical examination, she had marked pallor, tachycardia, tachypnea, and mild jaundice. There was no lymphadenopathy edema, rash, petechiae, or bruises on physical examination. She had nontender soft palpable liver of 4 cm and soft spleen of 3 cm below the costal margins. She had bilateral normal vesicular breath sounds, and neurological examination was also normal.
The details of laboratory investigations are shown in [Table 1] and [Table 2]. Her peripheral smear observed fragmented red blood cells (RBCs), pencil cells, and tear drop cells, with features of microcytosis and anisocytosis.
| Methodology|| |
A request for four units of red cells transfusion along with ethylenediaminetetraacetic acid and clotted blood samples was sent for blood group test and cross-matching accordingly. Her blood samples on physical examination showed a mild hemolysis. Her blood group was O Rh (D)-positive by conventional tube technique using 5% of patient's cell suspension in normal saline, but neither of the five donor red cell units from the inventory were compatible with the patient's serum. All of them showed 3+ to 4+ agglutination on column agglutination technology on poly-specific gel cards (Tulip Diagnostics Pvt. Ltd, Goa, India). Her direct antiglobulin test (DAT) and auto-control (37°C) were strongly positive.
Considering the patient's history and laboratory profile, her blood sample was worked up as AIHA, likely to be of the warm type.
Procedure of auto-adsorption
The autologous red cells were washed by warm (37°C) normal saline three times; after the last wash, red cells are centrifuged at 1000 ×g for 5 min and as much as possible supernatant saline was removed. Washed red cells are equally distributed in five aliquots, then an equal volume of packed red cells with equal amount of patient's serum was mixed and incubated at 37°C for 45 min. After centrifugation of the mixture at 1000 ×g for 5 min, the supernatant serum was further transferred in another aliquot, and the procedure was repeated four times.
After the last centrifugation, the serum was separated for cross-matching with donor RBCs, and we found two compatible donor O Rh (D)-positive RBC units for transfusion. Two units of concentrated red cell transfusion improved her Hb status (increment of Hb – 6.4 g/dl [after the 1st unit] and 7.2 g/dl [after the 2nd unit]). The treating physician was informed of the patient's diagnoses, and she was managed accordingly in the line of warm AIHA. Oral prednisolone (2 mg/kg/day) was started in divided doses, and the patient had an uneventful course of recovery and blood transfusion. She was discharged after 3 days with an Hb of 7.6 g/dl and without any symptoms.
| Discussion|| |
AIHA is an acquired hemolytic anemia, which results from the development of autoantibodies directed against antigens on the surface of patient's own red cells. Majority of cases were mediated by warm autoreactive antibodies where cold-reactive antibodies are less common.
AIHA is diagnosed on the evidence of clinical symptoms such as anemia, jaundice, splenomegaly, raised serum bilirubin, and a positive DAT at laboratory examination. In the present case, we conclude that AIHA in this patient is warm antibody type because no ABO- blood group discrepancy was noted on reverse grouping in tube method, and saline control was negative at normal room temperature (20–24°C). During cross-matching, it was observed that none of the units were compatible with the recipient's serum, and DAT and auto-control of the recipient were positive.
Warm AEAs are mostly IgG in nature, which bind with erythrocytes by the fab end of immunoglobulin and Fc part usually recognized by Fcγ receptors of the cells of monocyte- macrophage phagocytic system, which is present in the spleen and liver, resulting in IgG-opsonized erythrocytes destruction.,,
Naïve T-cells differentiate at thymus gland and self-reactive T-cell clones delete on contact with thymic antigens. Self-reactive mature T-cells react with self-antigens present on the surface of erythrocytes followed by the autoimmune destruction of RBCs. Elimination of self-reactive T-cells mediates by pro-apoptotic pathways, of which Fas-mediated apoptosis is most prominent. T-lymphocytes express Fas receptors, but Fas ligand (FasL) expresses only the repetitive exposure of antigens or nonspecific stimulation via the CD3/TCR complex., Ligation of Fas with FasL results in activation-induced cell death (AICD). Fas mediates AICD in mature T-cells, controlled by interleukin (IL) 2, which prime the activated T-cells to undergo apoptosis via the Fas pathway. Defective Fas mediates AICD due to the mutation of Fas or FasL or disruption of Fas and IL2 interaction, which also relate to autoimmunity in AIHA.
CD47 (integrin-associated protein) is a cell surface glycoprotein, which maps to chromosome 3q13.1-q13.2 in humans. Erythrocytes do not express integrins, but erythrocyte cell's surfaces express a high level of CD47. CD47 can function as a ligand for the inhibitory macrophage receptor signal regulatory protein alpha (SIRPα), which prevents the phagocytosis of circulatory erythrocytes by splenic macrophages. CD47-deficient erythrocytes are unable to control IgG opsonize and Fcγ receptor-mediated activated cells' phagocytosis by splenic macrophages due to the absence of CD47-SIRPα signals.
CD47 deficiency on the cell surface is induced by the autoimmune destruction of thyroid gland, pancreatic β cells, and other endocrine glands associated with AIHA.
| Conclusion|| |
Corticosteroid therapy is the mainstay of treatment in warm AIHA. Transfusions are transient-benefit and may be required initially during severe anemia. Transfusion of erythrocytes in AIHA may be complicated because of cross-match incompatibility in vitro examination due to the presence of autoantibodies. We encounter the problems by washing autologous cells by normal warm saline, the washed autologous cells are equally distributed in five aliquots, and then an equal amount of serum was added to the 1st aliquot for 45 min followed by the transfer of absorbed serum consecutives in four aliquots for further absorption of autologous antibodies. The last absorbed sera was collected and used for cross-matching with donor cells. Out of the three donor units, two units are compatible with the recipient's absorbed serum. There were no post-transfusion hemolytic episodes. Immunosuppressive agents including monoclonal anti-CD20 (rituximab) may be beneficial in the refractory cases of warm AIHA. Splenectomy may also be beneficial in refractory warm AIHA.
The authors would like to thank Bratish Neogi, Tirthamoy Chatterjee, and Smarajit Roy for their support in successfully bringing out this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Engelfriet CP, Overbeeke MA, von dem Borne AE. Autoimmune hemolytic anemia. Semin Hematol 1992;29:3-12.
Böttiger LE, Westerholm B. Acquired haemolytic anaemia. I. Incidence and aetiology. Acta Med Scand 1973;193:223-6.
Packman CH, Leddy JP. Aquired hemolytic anemia due to warm-reacting autoantibodies In: Williams WJ, Beutler E, Erslev AJ, Lichtman MA, editors. Hematology. New York: McGraw-Hill, Inc.; 1990. p. 666-75.
Judd WJ, Jhnson S, Storry J. Judd's Methods in Immunohematology. 3rd
ed. Bethesda, MD: AABB Press; 2008.
De Gruchy's Clinical Haematology in Medical Practice. Edinburgh: Blackwell Science Ltd.; 1989. p. 172-215.
Clynes R, Ravetch JV. Cytotoxic antibodies trigger inflammation through Fc receptors. Immunity 1995;3:21-6.
Meyer D, Schiller C, Westermann J, Izui S, Hazenbos WL, Verbeek JS, et al.
FcgammaRIII (CD16)-deficient mice show IgG isotype-dependent protection to experimental autoimmune hemolytic anemia. Blood 1998;92:3997-4002.
Pottier Y, Pierard I, Barclay A, Masson PL, Coutelier JP. The mode of action of treatment by IgG of haemolytic anaemia induced by an anti-erythrocyte monoclonal antibody. Clin Exp Immunol 1996;106:103-7.
Nagata S. Apoptosis by death factor. Cell 1997;88:355-65.
Russell JH, White CL, Loh DY, Meleedy-Rey P. Receptor-stimulated death pathway is opened by antigen in mature T cells. Proc Natl Acad Sci U S A 1991;88:2151-5.
Russell JH, Rush BJ, Abrams SI, Wang R. Sensitivity of T cells to anti-CD3-stimulated suicide is independent of functional phenotype. Eur J Immunol 1992;22:1655-8.
Shenoy S, Mohanakumar T, Chatila T, Tersak J, Duffy B, Wang R, et al.
Defective apoptosis in lymphocytes and the role of IL-2 in autoimmune hematologic cytopenias. Clin Immunol 2001;99:266-75.
Oldenborg PA, Zheleznyak A, Fang YF, Lagenaur CF, Gresham HD, Lindberg FP. Role of CD47 as a marker of self on red blood cells. Science 2000;288:2051-4.
[Table 1], [Table 2]