Multiple Alloantibodies Research Articles

EDAS Procedure for Sickle Cell Anemia with Stroke: Report of Four Cases.

Children with sickle cell anemia (SCA) and stroke receive chronic transfusions to prevent a recurrent stroke. Despite transfusions, 10–20% have a recurrent stroke and 43% develop moyamoya changes. One treatment option for moyamoya changes is encephaloduroarteriosynangiosis (EDAS) procedure. We report four children with SCA and stroke who have undergone EDAS procedure for progressive clinical and/or imaging findings.Case 1. Five -year-old female with SCA presented with left sided weakness. MRI showed acute infract in the right frontal and parietal areas. She was treated with chronic transfusions. Two years later MRI/MRA showed stenosis in bilateral supraclinoid internal carotid arteries (ICA) and bilateral M1 segments. Patient underwent bilateral EDAS procedures 6 months apart. She tolerated both procedures well and is clinically stable 6 months post second surgery.Case 2. 5-year-old female with SCA presented with right-sided weakness. MRI showed acute infarct in the left middle cerebral artery (MCA) distribution. She was treated with monthly transfusions. Twenty-two months after the initial stroke she presented with left sided weakness. MRI/MRA showed an acute infarct in the right frontal lobe with significant stenosis in bilateral ICA's, and left MCA. She was started on Hydroxyurea in addition to transfusions. She underwent EDAS on the right side. Patient tolerated procedure well. She is one year post surgery and is clinically stable. MRI done 10 months post surgery showed no new infarcts.Case 3. Four year old male with SCA presented with right facial palsy and right-sided weakness. MRI/MRA showed an infarct in the left frontal area and left MCA stenosis. He developed multiple alloantibodies after the initial partial exchange transfusion and was started on Hydroxyurea. His HbF increased to 20%. Repeat MRI/MRA 3 years after the initial stroke showed occlusion of the left MCA and prominent transganglionic collaterals. He underwent EDAS procedure on the left side. Five years after the initial stroke patient had a repeat MRI/MRA that showed occlusion of bilateral posterior cerebral arteries. He was still on Hydroxyurea with HbF level at 35%. He underwent EDAS procedure on the right side. He is clinically doing well one month after the second procedure.Case 4. Five-year-old male with HbSS disease presented with seizures and right-sided weakness. An MRI showed right parietal infarct, and occlusion of the supraclinoid ICA's bilaterally. He was treated with monthly transfusions. Despite being compliant with transfusion therapy, he had a repeat stroke 26 months after the initial stroke. MRI revealed marked stenosis of the bilateral ICA's, middle and anterior cerebral arteries. Patient underwent a left sided EDAS procedure. He is on chronic transfusions along with Hydroxyurea. He is clinically stable 6 months post surgery. In summary, we report 4 cases of sickle cell anemia with stroke, who have undergone EDAS procedure. All patients tolerated the procedure well. However, the effect of this procedure on long-term neuropsychological outcome remains to be seen.Clinical characteristics of sickle cell patients undergoing EDAS procedure for strokePatient numberAge at strokeTreatment for strokeRepeat strokeMoya moya changesAge at EDASTreatment after EDASTime elapsed since EDAS (months)15TxNoYes8 (R), 8 (L)Tx12 (R), 6 (L)25TxYesYes8Tx, HU1234HUNoYes7 (L), 9 (R)Tx25 (L), 1 (R)45TxYesYes8Tx, HU6EDAS: encephaloduroarteriosynangiosis, Tx: treatment, HU: Hydroxyurea, R:right, L: left

Vybrant™ DiO, DiI and DiD Dyes for Multiple Labeling of Red Blood Cell Populations for In Vivo Survival Studies.

Background: Studies of the circulatory time of red blood cells (RBCs) or drug delivery vehicles such as liposomes require a radiolabel (e.g., 51Cr), a fluorescent probe or an affinity tag (e.g., biotin). These techniques may be complicated by progressive loss of the probe from the labeled cells, transfer to other cells, and sometimes by the development of an immune response to the label. Long chain dialkylcarbocyanines (Vybrant DiO, DiI and DiD) are bright, stable lipophilic membrane fluorescent labels that can exhibit fluorescence resonance energy transfer (FRET) and are easily observed by flow cytometry using standard filters (FL1, FL2 and FL4 detection channels respectively). The staining is very stable in vivo and is dose-dependent, thus populations of labeled cells may have discrete fluorescence intensities. We recognized that use of these dyes in combination could permit the simultaneous observation of several different populations of cells within the same subject, together with one or more internal controls. To evaluate this technique, we developed procedures suitable for the fluorescent labeling up to 14 discrete populations of human or rabbit RBCs. The properties of the rabbit RBCs were then evaluated in vivo.Methods: Washed human RBCs were suspended at a 10% hematocrit in 20mM HEPES buffer, and added to an equal volume of freshly prepared 1, 4 or 8 μM DiO, DiI, DiD, or mixtures of two labels; 36 different combinations in total. The cells were incubated with the dye for 60 minutes at 37°C, washed twice in HEPES with 0.1% albumin and examined by flow cytometry. Aliquots from 6 to 15 differently-labeled samples were then combined, and the mixtures re-examined. For in vivo studies, the labeling procedure was repeated with autologous rabbit RBCs at dye concentrations of 1.5, 6, and 12 μM. The labeled rabbit RBCs were washed, suspended in saline and reinfused via the ear vein. Small blood samples were drawn daily for 4 days and weekly for 5 weeks, and the number of fluorescently labeled cells of each color remaining was determined by flow cytometry.Results: Of the 36 possible combinations, 14 discrete populations could be clearly distinguished from “dot-plots” of FL1 vs. FL2, FL1 vs. FL4 and FL2 vs. FL4. FRET was observed for all cells stained with two labels. In vivo evaluation of 8 different labeled rabbit RBC populations showed normal survival. A 10–20% reduction in fluorescence intensity was observed over the study period; this reduction did not compromise the clear identification of each discrete population. Rabbits that were repeatedly exposed to Vybrant-labeled autologous RBCs (up to 15 exposures over 3 years) showed no evidence of accelerated clearance, suggesting that these fluorescent labels do not exhibit significant immunogenicity.Conclusion: The use of two long-chain dialkylcarbocyanines in combination is ideal for studies which require multiple cell populations to be followed within the same experiment, and additionally allows for one or more internal controls to correct for any variability of circulation times. The technique is presently being used for studies of RBC senescence in which multiple discrete density populations of RBCs are individually labeled. If these dyes can be shown to have an acceptably low toxicity, the ability to track multiple populations could also be useful for some clinical applications, e.g., to simultaneously evaluate the survival of RBCs from many different donors in patients with multiple alloantibodies, to identify compatible units for transfusion.

Delayed hemolytic transfusion reaction due to anti-S antibody in patient with anti-Jk a autoantibody and multiple alloantibodies

We describe the case of a 60-year-old woman with a delayed hemolytic transfusion reaction (DHTR). She had a history of an ulcerative colitis, blood transfusion because of rectal bleeding, and surgical removal of descendent and sigmoid colon. At admission, laboratory data showed Hb 6.3 g/dL, reticulocytes 120 x 10(9)/L, serum total bilirubin 1.2 mg/dL (direct bilirubin: 0.2 mg/dL). Pretransfusion antibody screening procedures were positive. A monospecific autoanti-Jk(a) and three alloantibodies (anti-c, -E, -K) were identified by immunohematologic studies. The patient received two units of crossmatch compatible concentrated red blood cells. Six days later biochemical serum values showed Hb 6.2 g/dL, LDH 975 I.U./L and total bilirubin 2.95 mg/dL (direct 0.35 mg/dL). Crossmatches with red cell suspension of transfused blood units and a post-transfusion serum were repeatedly positive. Laboratory tests showed the presence of anti-S alloantobody in the serum and eluate. Moreover, pre-transfusion serum of the patient was retrospectively retested: anti-S was not detected. These data suggested a DHTR. The present case is unusual and interesting because of the association of a rare autoanti-Jk(a), non responsible for anemia, and four alloantibodies of which anti-S involved in a DHTR.

Acute Hemolytic Transfusion Reactions due to Multiple Alloantibodies Including Anti-E, Anti-c and Anti-Jkb

We report a case of two consecutive episodes of acute hemolytic transfusion reactions (HTRs) due to multiple alloantibodies in a 34-yr-old man who suffered from avascular necrosis of left femoral head. He received five units of packed red blood cells (RBCs) during surgery. Then the transfusion of packed RBCs was required nine days after the surgery because of the unexplained drop in hemoglobin level. The transfusion of the first two units resulted in fever and brown-colored urine, but he received the transfusion of another packed RBCs the next day. He experienced even more severe symptoms during the transfusion of the first unit. We performed antibody screening test, and it showed positive results. Multiple alloantibodies including anti-E, anti-c and anti-Jkb were detected by antibody identification study. Acute HTRs due to multiple alloantibodies were diagnosed, and the supportive cares were done for 6 days. We suggest the antibody screening test should be included in the panel of pretransfusion tests for safer transfusion, and it is particularly mandatory for the patients with multiple transfusions, pregnant women, and preoperative patients.

DNA analysis to find rare blood donors when antisera is not available.

In order to screen for antigen-negative blood donors, it is necessary to have appropriate, potent antisera in sufficient volume. Anti-Do(a) and anti-Do(b) are notoriously weakly reactive antibodies, available only in small volumes, usually in sera containing other alloantibodies, and often deteriorate on storage. Thus, it has not been possible to test large numbers of blood samples to find Do (a-) or Do (b-) blood donors. At the NYBC, we now type selected donors for DOA and DOB by DNA analysis. Initially, we tested DNA prepared from donors who had been typed by hemagglutination for one or both antigens. We found that four donors, whose RBCs previously typed as Do (a+b-), had both DOA and DOB alleles, and when retested, the RBCs were Do (a+b+w). We have now tested over 300 donors for DO by PCR-RFLP using either Eam1105 I or BseRI restriction enzymes. Blood from DOA/DOA donors has survived better than "crossmatch compatible" blood for patients with anti-Do(b) and such results suggest that anti-Do(b) is a more frequent cause of transfusion reactions than reported. Furthermore, we have demonstrated that PCR-RFLP can be used to screen for antigen-negative donors in other blood group systems when appropriate antisera are not available. When interpreting the results, it is important to remember that the genotype may not reflect the phenotype. Our strategy has been to perform DNA analysis for the DO alleles on those donors who have been shown by hemagglutination to lack antigens corresponding to multiple alloantibodies in patients' plasma. In this way, we have been able to supply rare blood to numerous patients, whose serum contained at least 5 additional alloantibodies of clinical significance.

Detection of multiple passively acquired alloantibodies following infusions of IV Rh immune globulin.

Passively acquired blood group alloantibodies are detected regularly after infusions of IV Rh immune globulin (RhIG) for the treatment of immune thrombocytopenic purpura (ITP) in D+ patients. Blood samples from 16 D+ patients with ITP were tested after treatment with IV RhIG for the presence of passively acquired alloantibodies. Similar studies were conducted for three D- patients after injections of IM RhIG for Rh immunoprophyl-axis. Four production lots of IV RhIG and 2 lots of IM RhIG were tested for the presence of alloantibodies. All 16 D+ patients with ITP developed a positive DAT, as well as positive antibody detection test results, after infusions of IV RhIG. All postinfusion plasma samples contained anti-D, as well as one or more additional antibodies, usually anti-C, -E, -G, -V, or -Fy(a). Eluates from patients' RBCs with positive DAT results contained multiple passively acquired alloantibodies. Multiple alloantibodies were detected in samples of different production lots of IV RhIG or IM RhIG. No acute transfusion reactions were observed in five D+ patients with ITP who had been treated with IV RhIG and had been given serologically incompatible D+ RBCs. After injections of IM RhIG, the only passively acquired alloantibody detected was anti-D. Plasma samples from D+ patients with ITP treated with IV RhIG regularly contained anti-D and multiple other passively acquired Rh, Duffy, or Kidd system alloantibodies. Postinfusion RBC samples all had positive DAT results with eluates containing anti-D and multiple other Rh, Duffy, or Kidd system antibodies. The consistent detection of multiple passively acquired alloantibodies after IV RhIG, in contrast to the detection of anti-D only after IM RhIG, reflects the immediate effect of the entire (bolus) dose of RhIG by the IV route, the dose for treating ITP that is approximately 10 times the dose for Rh immunoprophylaxis, and the expected serologic incompatibility with recipients' D+ RBCs.

Management of sickle cell disease: recent advances and controversies.

Management of sickle cell disease: recent advances and controversies.

A Delayed Hemolytic Transfusion Reaction (DHTR) with Multiple Alloantibodies (Anti-E, Jka, Dia, Fyb, and S) Induced by E-Antigen-Negative, Crossmatch-Compatible Blood

We describe the case of a 44-year-old woman with a delayed hemolytic transfusion reaction (DHTR). She had a history of two pregnancies and a blood transfusion, the details of which were unknown. At the time of her first vascular surgery on November 15, 1989, she received 1200 ml of crossmatch-compatible concentrated red blood cells (CRC). Before the first operation, screening for anti-RBC antibodies (Ab) was negative. At the time of the second admission on Feburary 15, 1996, anti-E Abs were detected by indirect antiglobulin test. She received 560 ml of E-antigen-negative, crossmatch-compatible, CRC for treatment of anemia on March 1 and 2, 1996. After this transfusion, total bilirubin (1.6 mg/dl) and lactate dehydrogenase (1355 IU/ml) were elevated on March 12, 1996. She had no evidence of clinical hemolysis. We suspected DHTR from these data, and therefore screened for anti-RBC Abs. Anti-E, Jka, Dia, Fyb, and S Abs were detected in blood samples obtained from the patient on March 12, 1996. Anti-E, Jka, Dia, and S Abs were present more than 1 month and anti-Fyb Ab was disappeared at 18 days after transfusion.

Delayed Hemolytic Transfusion Reaction Due to Anti-Jsain an Alloimmunized Patient With a Sickle Cell Syndrome

Delayed hemolytic transfusion reactions occur via an anamnestic immune response in patients previously alloimmunized by certain RBC antigens. Conventional pretransfusion antibody screening tests and crossmatches are unable to detect certain antibodies that potentially can cause these reactions because they may be present in low concentrations or have low affinity for their respective antigen or their indicator antigen may be absent from test RBCs. We report the second case of a delayed hemolytic transfusion reaction caused by an undetectable (by routine methods) anti-Js(a) in a patient with a sickle cell syndrome (hemoglobin SC disease) and multiple alloantibodies, in whom retrospective indirect antiglobulin tests enhanced by polyethylene glycol revealed the presence of weakly reactive anti-Js(a).

Preoperative Autologous Blood Donation

THE IMPORTANCE of autologous blood to medical practice has fluctuated considerably over the last century. One hundred years ago, autologous blood transfusion practices offered the only hope for an exsanguinating patient. The principies of compatibility had not been discovered, and transfusions of blood from one individual to another appeared foolhardy; but surgeons could collect blood shed after delivery, strain it through eloth, and return it to the patient. In some cases, this salvaged autologous blood was lifesaving. Autologous blood donation in advance of surgery became a natural extension of this practice in the early part of the 20th century, once it was possible to anticoagulate and store blood in glass containers. The primary purpose of autologous blood was to provide a source of blood, at frrst because homologous blood transfusions were risky, and later to augment marginal homologous supplies. As the safety and availability of blood improved, interest in collecting autologous blood waned. Other advantages of autologous blood, such as the elimination of transfusion-transmitted diseases and immune-mediated reactions, were not seen as sufficiently important to warrant the effort inyolved in autologous donations. Sporadic reports conceming the use of autologous blood continued to appear, ineluding a useful monograph reviewing an assortment of applications for autologous blood collections. 1 Nonetheless, for most programs autologous blood was considered primarily for the patient with multiple alloantibodies, or ąntibodies to high-frequency antigens, for whom homologous donor blood was in limited supply. The identification of the human immunodeficiency virus in the 1980s, and the recognition that it was efficiently spread through blood transfusions, led to a rapid renewal of interest in autologous blood techniques. Between 1982 and 1988, American Association of BloOO Banks (AABB) member surveys found that the number of units of autologous blood collected annually increased each year (from 18,737 in 1982 to 337,773 in 1988 [Fig 1]). New advances, such as the use ofrecombinant human erythropoietin, may catalyze additional growth in autologous collections. Such rapid growth over a very short time period

An Example of Mild Hemolytic Disease of the Newborn Caused by Anti-Cob

Abstract A woman whose serum contained multiple alloanti-bodies delivered a full-term infant with mild hemolytic disease of the newborn. The direct antiglobulin test performed on the cord cells was positive with monospecific anti-IgG. An acid elution performed on the cord cells yielded anti-Cob. These findings were consistent with the presence of anti-Cob in the maternal serum. Neonatal clinical findings showed a mildly affected infant who demonstrated a moderate rise in total bilirubin and slight jaundice. The infant experienced no further complications and was discharged.

A Case Report: Identification of Multiple Alloantibodies in a Patient’s Serum

A Case Report: Identification of Multiple Alloantibodies in a Patient’s Serum

A New Reagent (ZZAP) Having Multiple Applications in Immunohematology

A reagent (ZZAP) containing a mixture of 0.1 M dithiothreitol (DTT) plus 0.1% cysteine-activated papain was found to dissociate IgG immunoglobulin from red blood cells (RBC) of patients having a positive direct antiglobulin test (DAT) although this could not be achieved with either chemical alone. In all 67 patients tested, ZZAP treatment of IgG sensitized RBC reduced the strength of the DAT, and in all 52 instances tested, this allowed for accurate Rh phenotyping using slide/rapid tube typing reagents. This included five examples in which spontaneous agglutination that occurred in saline or 6% albumin was eliminated by ZZAP. Thus, all red blood cell typing for Rh-Hr antigens was accomplished using slide/rapid tube reagents making unnecessary the use of saline reactive or chemically modified antisera. Kidd antigen typing is also possible after ZZAP treatment of IgG sensitized RBC. In regard to warm autoabsorption tests, ZZAP treatment of 14 RC samples having a positive DAT proved preferable to heat elution technics since equal or greater amounts of IgG were removed by ZZAP and little or no hemolysis resulted. ZZAP has no effect on ABH, Rh or Kidd antigens but denatures Duffy, MNSs and all Kell antigens tested (K:1-K:7, K:11-K:14, K:18, K:19). This should prove valuable in certain investigations of multiple alloantibodies and, moreover, may allow for better characterization of Kell antigens.

A new reagent (ZZAP) having multiple applications in immunohematology.

A reagent (ZZAP) containing a mixture of 0.1 M dithiothreitol (DTT) plus 0.1% cysteine-activated papain was found to dissociate IgG immunoglobulin from red blood cells (RBC) of patients having a positive direct antiglobulin test (DAT) although this could not be achieved with either chemical alone. In all 67 patients tested, ZZAP treatment of IgG sensitized RBC reduced the strength of the DAT, and in all 52 instances tested, this allowed for accurate Rh phenotyping using slide/rapid tube typing reagents. This included five examples in which spontaneous agglutination that occurred in saline or 6% albumin was eliminated by ZZAP. Thus, all red blood cell typing for Rh-Hr antigens was accomplished using slide/rapid tube reagents making unnecessary the use of saline reactive or chemically modified antisera. Kidd antigen typing is also possible after ZZAP treatment of IgG sensitized RBC. In regard to warm autoabsorption tests, ZZAP treatment of 14 RC samples having a positive DAT proved preferable to heat elution technics since equal or greater amounts of IgG were removed by ZZAP and little or no hemolysis resulted. ZZAP has no effect on ABH, Rh or Kidd antigens but denatures Duffy, MNSs and all Kell antigens tested (K:1-K:7, K:11-K:14, K:18, K:19). This should prove valuable in certain investigations of multiple alloantibodies and, moreover, may allow for better characterization of Kell antigens.

The Patient With Multiple Alloantibodies

To the Editor.— A recent report by Patten and Conti inThe Journal(1982;247:209) described collection of 10 units of blood in a 17-week period from a woman who was said to be the only compatible donor for the patient, her sister. The data given leave doubts as to whether the heroic efforts on the part of the donor were really necessary. First, a week after infusion of 3 units of blood, the patient suffered a delayed hemolytic transfusion reaction. Her serum was found to contain anti-C, anti-E, anti-Jk b and an antibody of uncertain specificity that reacted with an antigen of high incidence. This last antibody was believed to be the most likely cause of the reaction, but no data on which this conclusion was based are given. Did the anti-Jk b play any role in the reaction? Antibodies in the Kidd system have many times caused delayed transfusion

The patient with multiple alloantibodies

The patient with multiple alloantibodies

The Patient With Multiple Alloantibodies

PATIENTS with multiple alloantibodies pose a problem when they require transfusions. Blood may be obtained from a rare donor file if the specificities of the antibodies are known. Under certain circumstances the recipient may be able to serve as his own donor. We describe here a patient who, because of traumatic cardiac hemolytic anemia, was not a candidate for autologous transfusion and had only one available compatible donor. Ten units of blood were collected from this donor during a 17-week period so that the patient might have her dysfunctional aortic valve prosthesis replaced. Report of a Case The patient, a 32-year-old woman, gravida 2, para 2, underwent aortic valve replacement with a cloth-covered Starr-Edwards prosthesis in 1974 for acute bacterial endocarditis. During the surgery she received 5 units of whole blood. She was transfused again in 1976 (3 units of RBCs) and in 1978 (4 units of RBCs) for anemia

The patient with multiple alloantibodies. One possible answer to meeting blood needs

PATIENTS with multiple alloantibodies pose a problem when they require transfusions. Blood may be obtained from a rare donor file if the specificities of the antibodies are known. Under certain circumstances the recipient may be able to serve as his own donor. We describe here a patient who, because of traumatic cardiac hemolytic anemia, was not a candidate for autologous transfusion and had only one available compatible donor. Ten units of blood were collected from this donor during a 17-week period so that the patient might have her dysfunctional aortic valve prosthesis replaced. <h3>Report of a Case</h3> The patient, a 32-year-old woman, gravida 2, para 2, underwent aortic valve replacement with a cloth-covered Starr-Edwards prosthesis in 1974 for acute bacterial endocarditis. During the surgery she received 5 units of whole blood. She was transfused again in 1976 (3 units of RBCs) and in 1978 (4 units of RBCs) for anemia

Antifertility effects from immunization of female baboons with C-terminal peptides of HCG beta subunit

Anecdotal evidence has suggested an association of intravenous drug abuse with alloimmunization; however, published data are limited to case reports.The purpose of this study was to determine whether women with a history of intravenous drug abuse have an increased risk of alloimmunization.A retrospective cohort study was performed with the use of data from a single-center blood bank and perinatal database from 2008–2014. Blood bank data were used to identify women with alloimmunization, which was defined as a positive antibody screen in pregnancy not due to naturally occurring antibodies, agglutinins, autoantibodies, or Rh immunoglobulin administration. Intravenous drug abuse was ascertained from a comprehensive database that has captured all drug abuse in pregnancy since 2008. For women who contributed >1 pregnancy to the database, only the most recent pregnancy was included. The rates of alloimmunization among women with a history of intravenous drug abuse and general obstetric populations were calculated and compared. The distribution of alloantibody types, proportion of Rh-group alloantibodies, and patient Rh status were assessed for intravenous and non–intravenous drug abuse–associated alloimmunization. Characteristics and outcomes between intravenous and non–intravenous drug abuse–associated alloimmunization were assessed for women with clinically significant alloantibodies.Alloimmunization was more common in women with a history of intravenous drug abuse (11/305 women; 3.6%) compared to women without a history of intravenous drug abuse (288/16,022 women; 1.8%; relative risk, 2.00; 95% confidence interval, 1.11–3.62). Needle-sharing was present in 7 and suspected in 4 women with an intravenous drug abuse history. Among women with a history of intravenous drug abuse, none had a history of transfusion or traditional risk factor for alloimmunization. The distribution of alloantibodies was different between intravenous drug abuse– and non–intravenous drug abuse–associated alloimmunization. Rh group alloantibodies and Rh-negative status were more common in women with a history of intravenous drug abuse. Among Rh-negative women with a history of intravenous drug abuse, 50% of RhD alloimmunization cases occurred in nulliparous women. The rate of multiple alloantibodies was not different between intravenous drug abuse– and non–intravenous drug abuse–associated alloimmunization.Maternal history of intravenous drug abuse is associated with an increased risk of alloimmunization. Approximately 1 in 30 intravenous drug abuse women may be diagnosed with an alloantibody in pregnancy. Given the current US opioid epidemic, increased vigilance in screening is required. Needle-sharing represents a possible mechanism for intravenous drug abuse–associated alloimmunization; however, limited obstetric care, failure to obtain Rh immunoglobulin, or failure to identify early pregnancy loss cannot be excluded.