Commentary: Case report: Daratumumab treatment in pre-transplant alloimmunization and severe hemolytic anemia.

Abstract

Pereda et al. recently reported three cases in which daratumumab was utilized to reduce the 36 burden of red blood cell (RBC) and human leukocyte antigen (HLA) alloantibodies (1). These 37 cases support the need for further investigation into the potential use of daratumumab and related 38 plasma cell depletion therapies for patients with significant alloimmunization. However, the 39 authors' cases, particularly cases 1 and 2 in which the authors describe patients with sickle cell 40 disease (SCD) and multiple RBC antibodies, lack sufficient immunohematology and transfusion 41 details to reliably conclude the effectiveness and safety of daratumumab to reduce and existing alloantibodies can persist despite daratumumab treatment (3-6). Secondly, the 80 authors fail to acknowledge the possibility that the alloantibodies may have disappeared naturally 81 through the phenomenon of evanescence. Numerous studies have shown that many patients' 82 RBC alloantibodies will decline in titer to levels below a detectable threshold without further 83 exposure (7-9). Though the loss of all antibodies due to evanescence may be less likely, not 84 accounting for this potential mechanism of a waning antibody is concerning. 85 86 Furthermore, literature demonstrates that even if these antibodies have become undetectable, 87 these patients may still be at risk for DHTRs (10-13).