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| CASE REPORT |
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| Year : 2020 | Volume
: 5
| Issue : 2 | Page : 225-227 |
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Resolving crossmatch incompatibility due to daratumumab in multiple myeloma
S Anuragaa, Dibyajyoti Sahoo, B Abhishekh
Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| Date of Submission | 28-Jul-2020 |
| Date of Decision | 12-Oct-2020 |
| Date of Acceptance | 14-Oct-2020 |
| Date of Web Publication | 13-Nov-2020 |
Correspondence Address:
Dibyajyoti Sahoo
Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/GJTM.GJTM_78_20
Daratumumab (DARA) is an anti-CD38 monoclonal antibody which has promising results in relapsed and refractory multiple myeloma. DARA interferes with blood compatibility testing by causing panagglutination in the indirect antiglobulin test. In all incompatibilities, immunohematology workup must be done to rule out allo- or autoantibody and to issue compatible unit to the patient. Transfusion support is vital for all these patients with incompatibility and should not be delayed. We encountered one such patient who was undergoing treatment with DARA for refractory multiple myeloma and had incompatibility during crossmatching. Many methods are available to sort out this problem. These include anti-CD38 idiotypes, cord blood, trypsin, papain, dithiothreitol (DTT) treatment, phenotyping, and genotyping. We hereby report resolving the above discrepancy by one of the simplest, cheapest, and feasible methods, i.e., DTT treatment in our blood centers.
Keywords: Daratumumab, dithiothreitol, incompatibility
How to cite this article:
Anuragaa S, Sahoo D, Abhishekh B. Resolving crossmatch incompatibility due to daratumumab in multiple myeloma. Glob J Transfus Med 2020;5:225-7 |
| Introduction | |  |
Multiple myeloma (MM) is a B-cell malignancy characterized by the accumulation of terminally differentiated clonal plasma cells that produce monoclonal proteins. Current treatment for newly diagnosed MM includes bortezomib, thalidomide, lenalidomide, and dexamethasone. The patients with relapsed/refractory multiple myeloma (RRMM) often do not respond well with even high doses of the therapeutic drugs. After years of clinical trials, the United States Food and Drug Administration finally approved daratumumab (DARA) in November 2015.[1] DARA showed significant anti-MM activity as monotherapy in heavily treated patients with relapsed or refractory disease.[2],[3] It is an immunoglobulin (Ig) G1k human monoclonal antibody (MoAb) that specifically targets human CD38, which is highly expressed on myeloma cells. DARA has emerged as a promising treatment for MM.
DARA interferes with blood compatibility testing by causing panagglutination in the indirect antiglobulin test (IAT).[4] Any crossmatch incompatibility should thus be worked out meticulously to rule out possible alloantibodies and autoantibodies. We encountered one such patient who was undergoing treatment with DARA for refractory MM and had incompatibility during crossmatching. We hereby report resolving the above discrepancy by one of the simplest, cheapest, and feasible methods in blood centers.
| Case Report | | |
A 47-year-old male was admitted to our hospital with a diagnosis of MM. His hemoglobin was 6.7 g/dl. In view of symptomatic anemia, one unit of packed red blood cell (PRBC) was requested to the Department of Transfusion Medicine. Blood grouping was done by conventional tube technique and found to be “AB” RhD positive with no grouping discrepancy.
Forward grouping showed agglutination with anti-A, anti-B, and anti-D antisera (Tulip, Goa, India) while reverse grouping showed no agglutination with A-cells, B-cells, and O-cells. Routine compatibility testing was done with two units of “AB” positive PRBC bags by column agglutination technology using polyspecific antihuman globulin (anti-IgG + C3d) gel cards (Bio-Rad, Switzerland). Both units were found to be incompatible [Figure 1]. In view of incompatible crossmatch, further immunohematological workup was initiated. IAT was performed using pooled “O” cells and found to be positive (2+). Direct antiglobulin test (DAT) including auto control (AC) was negative. Antibody screening and identification were done using a three-cell panel and eleven-cell panel (Bio-Rad, Switzerland). The result showed pan positive with all cells with a strength of 2+. All possible causes of the above positivity were elicited. The patient had no history of blood transfusion or transplantation in the past. A detailed history of the patient was obtained. The patient was on the drug DARA for MM.
There are various options to sort out this problem, namely phenotyping, genotyping, anti-CD38 idiotypes, cord blood, trypsin, papain, and dithiothreitol (DTT) treatment. We preferred DTT treatment procedure as it was feasible and simple. Randomly, four units of AB-positive, Kell-negative units were selected for crossmatch. Cell suspension was prepared as per the flowchart [Figure 2]. We also treated our “O” pooled cells with DTT. Again, IAT and crossmatch were repeated with DTT-treated cell suspension. This time IAT was negative, and all the units were compatible [Figure 1]. Two units were transfused to the patient, and the transfusion was uneventful. This patient was taken for autologous stem cell transplant due to underlying MM. During pretransplant, transplant, and posttransplant phases, he required several units of PRBC transfusion. In all instances, we could provide compatible units with uneventful transfusions. | Figure 2:Flowchart to resolve discrepancy caused by daratumumab using dithiothreitol
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| Discussion | | |
DARA, a MoAb directed against CD38, has been successful in depleting CD38-expressing myeloma cells. Along with myeloma cells, there are low levels of CD38 expression on red blood cells (RBCs). Patients receiving DARA treatment are supposed to be protected from hemolysis by downregulation of CD38. This results in negative direct antiglobulin testing and a negative AC in these patients. However, low levels of CD38 expression on RBCs result in panagglutination of RBCs during serological testing. This results in difficulty in alloantibody detection and compatibility testing. In our case, workup showed incompatibility during crossmatch, IAT was positive, and DAT and AC were negative. IAT positivity generally indicates alloimmunization to foreign antigens. Our patient did not have any transfusion or transplant history. False-positive IAT due to MoAbs has surged because of their increased usage in patient management due to their promising results. Many drugs DARA and rituximab cause problems in pretransfusion testing.[5]
Anti-CD38 MoAb interference with IAT can be overcome by DTT, trypsin, papain, anti-idiotype antibodies, RBC phenotyping, and genotyping.[4] Each method acts in a different way. DTT denatures CD38 antigen on reagent cells. Trypsin and papain cleave CD38 antigen on reagent RBCs. Anti-idiotype antibody neutralizes anti-CD38 before IAT. Phenotype- and genotype-matched blood can also be given to the patient. Depending on the feasibility and resources available, each blood bank can sort out issues caused by CD38 antibodies using any one of the methods.
In our facility, we used DTT to overcome these incompatible issues due to DARA. DTT is a reducing agent which acts by cleaving disulfide bonds present on CD38 receptors on red cell and preventing the antigen–antibody interaction. DTT is easily available, less time-consuming, user-friendly, no need for high technological equipment, and can be accessed in all poor-resource settings. DTT gives promising results in cleaving the CD38 receptors from RBC and abolishing the positivity due to DARA binding to CD38 receptors. Chapuy et al. did the validation of DTT-based method to resolve DARA interference with blood compatibility testing.[6] At the same time, DTT denatures clinically significant Kell antigen which is responsible for hemolytic transfusion reaction. Hence, the patient must be given Kell-negative blood. Kell status of the patient should be known before any transfusion and before starting DARA. DTT also destroys less immunogenic antigens such as Lutheran, Yt, Cromer, Dombrock, and knops.[7] Schmidt et al. reported that cord blood could also be used for patients receiving DARA treatment.[8] Cord blood cells have very low or no CD38 receptors on their cells. The patient's plasma tested against cord blood showed no reactivity. However, cord blood shows a slight variation in the antigenic expression than the adult RBC. Cord blood has i antigen instead of I antigen.
Carreño-Tarragona et al. showed that papain could also be used as an alternative method.[9] Papain, a proteolytic enzyme, is extracted from the raw fruit of the papaya plant. Papain is generally used in immunohematology workup. It is used in screening irregular antibodies and in identifying alloantibodies. Its usage has both merits and demerits. Demerits are it destroys many clinically significant antigen expression on the RBC such as Duffy a, b, M, N, S, and JMH (John Milton Hagen).[9] Antibodies against these antigens cannot be ruled out, and it may lead to hemolytic transfusion reaction. However, papain identifies Kell antigen which is destroyed by DDT. Since papain destroys many clinically significant antigens, it is considered secondary to DDT treatment in the evaluation of DARA. We did not use papain due to these reasons. Anti-CD38 idiotypes may also be used which neutralize the anti-CD38 antibodies in the patient's serum so that there is no interference in the IAT.[10] Once the anti-CD38 antibodies are removed by the idiotypes, routine crossmatch can be done without any problem. The use of idiotypes is expensive and not easily available.
Giving phenotypically matched blood to the patients on DARA therapy can prevent alloimmunization and hemolytic reaction. Genotyping of the patient's blood is done only in reference laboratories, and it is costly. Proper communication between the treating physician and the blood bank is a must. The patient should also be informed about the drug and the difficulties in getting a compatible unit. Before the start of the DARA therapy, the patient's blood grouping (ABO, Rh & Kell) must be done. If possible red cell phenotyping and genotyping should be done. These patients will need multiple transfusions because of infiltration of marrow with myeloma cells, chemotherapy-induced anemia, and low erythropoietin levels because of renal failure in the disease.
| Conclusion | | |
DARA therapy in modern medicine has provided efficient treatment for patients with RRMM; however, it also has created complexities in routine immunohematological workup. DTT treatment of red cells has emerged as a cheap, simple, and feasible technique to overcome these challenges. Proper communication between transfusion medicine consultant and treating physician before and during DARA therapy will ensure safe and uninterrupted transfusion to patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 9. | Carreño-Tarragona G, Cedena T, Montejano L, Alonso R, Miras F, Valeri A, et al. Papain-treated panels are a simple method for the identification of alloantibodies in multiple myeloma patients treated with anti-CD38-based therapies. Transfus Med 2019;29:193-6. |
| 10. | Chari A, Arinsburg S, Jagannath S, Satta T, Treadwell I, Catamero D, et al. Blood transfusion management and transfusion-related outcomes in daratumumab-treated patients with relapsed or refractory multiple myeloma. Clin Lymphoma Myeloma Leuk 2018;18:44-51. |
[Figure 1], [Figure 2]
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