Primary Autoimmune Hemolytic Anemia Research Articles

A rare combination of autoimmune hemolytic anemia and primary antiphospholipid syndrome evolving into systemic lupus erythematosus

The association of autoimmune hemolytic anemia (AIHA) with primary antiphospholipid antibody syndrome (primary APS) has not been well established. However, the occurrence of AIHA in primary APS may define a subgroup of patients with a significant risk for subsequent development of SLE. We report a case of 28 year old male who presented with clinical features of cerebral arterial thrombosis and symptomatic anemia. Subsequently the diagnosis of primary APS and warm type AIHA was made. Patient was treated for cerebral thrombosis along with glucocorticoids and least incompatible red cell concentrates. After a regular follow up of 20 months, the patient developed positivity for antinuclear antibody and oral mucosal ulcers confirming the diagnosis of SLE. This case emphasizes that patients with primary APS should always be evaluated for AIHA as this combination is not impossible, though rare. It poses a significant risk of development of SLE. Transfusion medicine specialist has a role to play in the diagnosis and management of AIHA.

Clinical characteristics and treatment outcomes of primary autoimmune hemolytic anemia: a single center study from South India.

BackgroundAutoimmune hemolytic anemia (AIHA) is a less recognized, potentially fatal condition. There is a scarcity of data on clinicoserological characteristics and response to therapy concerning this disease from South India.MethodsData for 33 patients with primary AIHA recorded from July 2009 to June 2015 were retrospectively analyzed for clinical presentation, response to frontline therapy, durability of response, time to next treatment (TTNT), and response to second-line agents.ResultsThe median follow-up period was 50 months. Among 33 patients, 48% of the cases were warm autoimmune hemolytic anemia (WAIHA), 46% were cold agglutinin disease (CAD), and 6% were atypical. Three-fourth of patients had severe anemia (<8 g/dL hemoglobin [Hb]) at onset; younger patients (age <40 yr) had more severe anemia. All of the patients who required treatment received oral prednisolone at 1.5 mg/kg/d as a frontline therapy, and the response rate was 90% (62% complete response [CR] and 28% partial response [PR]). The overall response to corticosteroids in WAIHA and CAD was 87% and 92%, respectively. The median corticosteroid duration was 14 months, and 50% of the patients required second-line agents. Fourteen patients received azathioprine as a second-line agent, and 11 of these patients responded well, with half of them not requiring a third agent. Four patients developed severe infections (pneumonia, sepsis, and soft tissue abscess) and two had life-threatening venous thrombosis. One case of death was recorded.ConclusionAIHA is a heterogeneous disease that requires care by physicians experienced in treating these patients.

Autoimmune hemolytic anemia

The diagnosis of autoimmune hemolytic anemia (AIHA) can be made with a stepwise approach that aims to identify laboratory and clinical evidence of hemolysis and then determine the immune nature of hemolysis with the direct anti-globulin test. Once alternative causes for these findings have been excluded, AIHA is established, and the clinician must search for secondary causes, as well as identify the type of AIHA. Rituximab is now the preferred second-line treatment for primary warm AIHA and first-line treatment for primary cold agglutinin disease (CAD), either as monotherapy or combined with bendamustine. Complement inhibitors have shown utility in stabilizing AIHA patients with acute severe hemolysis. Future prospects are discussed and include the C1s inhibitor BIVV009 (sutimlimab) that is now entering phase 3 studies for CAD.

Probability of remaining in unsustained complete remission after steroid therapy withdrawal in patients with primary warm-antibody reactive autoimmune hemolytic anemia.

Primary warm autoimmune hemolytic anemia (WAIHA) is a rare autoimmune disorder frequently responding to corticosteroid first-line treatment and effective second-line treatment options such as splenectomy or anti-CD20 antibody therapy. Disease management is frequently hampered by a lack of evidence. We have investigated the probability of sustained treatment-free remission after steroid induction to facilitate clinical decision making regarding timing and necessity of second-line treatments. Response data from 31 patients with primary WAIHA initially treated with steroids were retrospectively analyzed. All patients responded by achieving a hemoglobin of at least 10mg/dl. After steroid tapering and final withdrawal, 9 of 30 patients remained in unsustained complete remission (CR). The probability of remaining in CR after steroid treatment only was 38.2 % (2 SD 20.6 %) at 15 months. The median remission duration was 100 + months with a range of 12 + to 163 + months. Of note, none of the remaining patients still on steroids achieved CR beyond 15 + months. These data indicate that a considerable proportion of patients do not need further treatment and that relapses will not occur after 15 months in CR.

Emergence of long-lived autoreactive plasma cells in the spleen of primary warm auto-immune hemolytic anemia patients treated with rituximab

Primary warm autoimmune hemolytic anemia (wAIHA) is a rare autoimmune disease in which red blood cells are eliminated by IgG autoantibodies. We analyzed the antibody-secreting cells in the spleen and the peripheral blood of wAIHA patients in various contexts of treatment. Plasmablasts were observed in peripheral blood of newly diagnosed wAIHA patients and, accordingly, active germinal center reactions were present in the spleen of patients receiving short-term corticosteroid therapy. Long-term corticosteroid regimens markedly reduced this response while splenic plasma cells were able to persist, a fraction of them secreting anti-red blood cell IgG in vitro. In wAIHA patients treated by rituximab and who underwent splenectomy because of treatment failure, plasma cells were still present in the spleen, some of them being autoreactive. By using a set of diagnostic genes that allowed us to assess the plasma cell maturation stage, we observed that these cells displayed a long-lived program, differing from the one of plasma cells from healthy donors or from wAIHA patients with various immunosuppressant treatments, and more similar to the one of normal long-lived bone-marrow plasma cells. Interestingly, an increased level of B-cell activating factor (BAFF) was observed in the supernatant of spleen cell cultures from such rituximab-treated wAIHA patients. These results suggest, in line with our previous report on primary immune thrombocytopenia, that the B-cell depletion induced by rituximab promoted a suitable environment for the maturation and survival of auto-immune long-lived plasma cells in the spleen.

CXCL13, CCL4, and sTNFR as circulating inflammatory cytokine markers in primary and SLE-related autoimmune hemolytic anemia.

BackgroundA considerable proportion of autoimmune hemolytic anemia (AIHA) are secondary to underlying autoimmune disorders, especially syetemic lupus erythematosus (SLE), and the clinical and laboratory index for early discrimination between primary and SLE-related AIHA has yet to be defined. In the present study, we proposed novel cytokine patterns in the pathogenesis of AIHA as well as parameters for the timely identification of SLE-related patients.MethodsAIHA patients confirmed by immunohematology techniques from September 2010 to December 2012 in our facility were consecutively included and categorized into primary (n = 19) and SLE-related (n = 18) groups. Plasma cytokine profiles were measured in a single procedure by Quantibody Human Inflammatory Array 1 (RayBiotech, Norcross, GA).ResultsSLE-related AIHA patients demonstrated younger age (39 ± 20 vs.57 ± 16 years, p = 0.004), poorer reticulocyte compensation (6.8 ± 7.1 vs.12.2 ± 8.6%, p = 0.045), lower levels of lactate dehydrogenase [361 (265-498) vs. 622 (387-1154) U/L, p = 0.004], and higher occurrence of anticardiolipin antibody [9/18 (50%) vs. 2/19 (10.9%), p = 0.009]. MCP-1/CCL2, MIP-1β/CCL4, BLC/CXCL13, IL-8/CXCL8, sTNFRI, and sTNFRII were significantly up-regulated in both groups, while sTNFRII was remarkably higher in SLE-related patients. Among both groups, hemoglobin level was negatively correlated with CXCL13 (r = -0.332, p = 0.044), while reticulocyte count was positively correlated with CCL4 (r = 0.456, p = 0.005).ConclusionCXCL13 and CCL4 could act as circulating biomarkers in AIHA, and indicated disease severity and erythroid compensation, respectively. Higher plasma sTNFRII might favor the diagnosis of SLE-related instead of primary AIHA.

Concomitant Cases of Primary Biliary Cirrhosis and Autoimmune Hemolytic Anemia: Literature Review

Although autoimmune diseases are often concomitant, the coexistence of primary biliary cirrhosis (PBC) and autoimmune hemolytic anemia (AIHA) is not common. This is a review of the English and Japanese literature, regarding concomitant cases of PBC and AIHA. Among the 23 concomitant cases, PBC was diagnosed first in 10 cases and both diseases were almost simultaneously diagnosed in the remaining 13 cases. This suggests that there have been few concomitant cases in which AIHA developed first before the development of PBC. Moreover, there may be no correlation between the occurrence of AIHA and the staging or progression of PBC.

Tolerance to RBC antigens; pathogenesis of autoimmune haemolytic anaemia

Autoimmune haemolytic anaemia (AIHA) ensues when humoral tolerance is lost to antigens on red blood cells (RBCs), resulting in RBC autoantibodies and haemolysis. Haemolysis can be profound, and lead to substantial morbidity, and in some cases, mortality. The pathogenesis of primary AIHA remains poorly understood. Using murine models of RBC tolerance, we have recently described that baseline tolerance to RBC antigens is complete in the CD4+ compartment. However, the T cell tolerance is not due to thymic deletion; rather, autoreactive CD4+ T cells exist in the periphery, but in an anergic and non-functional state. In contrast, B cell tolerance to RBC antigens is incomplete. Moreover, autoreactive B cells rapidly differentiate into plasma cells secreting anti-RBC autoantibodies if provided CD4+ T cell help. Together, these data indicate that the stop-gap immunological safety measure for humoral autoimmunity to RBC antigens is anergy of autoreactive CD4+ T cells, in a murine model. This model predicts that factors that reverse CD4+ T cell anergy may be instrumental in the pathogenesis of AIHA. If translatable to human biology, these findings represent a fundamental shift in understanding of AIHA pathogenesis, which has heretofore assumed that tolerance in the B cell compartment was the determining factor. Autoimmune haemolytic anaemia (AIHA) ensues when humoral tolerance is lost to antigens on red blood cells (RBCs), resulting in RBC autoantibodies and haemolysis. Haemolysis can be profound, and lead to substantial morbidity, and in some cases, mortality. The pathogenesis of primary AIHA remains poorly understood. Using murine models of RBC tolerance, we have recently described that baseline tolerance to RBC antigens is complete in the CD4+ compartment. However, the T cell tolerance is not due to thymic deletion; rather, autoreactive CD4+ T cells exist in the periphery, but in an anergic and non-functional state. In contrast, B cell tolerance to RBC antigens is incomplete. Moreover, autoreactive B cells rapidly differentiate into plasma cells secreting anti-RBC autoantibodies if provided CD4+ T cell help. Together, these data indicate that the stop-gap immunological safety measure for humoral autoimmunity to RBC antigens is anergy of autoreactive CD4+ T cells, in a murine model. This model predicts that factors that reverse CD4+ T cell anergy may be instrumental in the pathogenesis of AIHA. If translatable to human biology, these findings represent a fundamental shift in understanding of AIHA pathogenesis, which has heretofore assumed that tolerance in the B cell compartment was the determining factor.

Clinical Characteristics and Long Term Outcomes of Warm Type Autoimmune Hemolytic Anemia

Back groundWarm type autoimmune hemolytic anemia (AIHA) is the disease which antibody reacts with self-antigen on red blood cell. Due to the uncommon of this disease, there is a little data about long term outcomes and response to therapy especially second line treatment.MethodsThis is a retrospective single center study from 2002 to 2013. The diagnosis of AIHA was made by positive direct Coombs’ test with clinical hemolysis and confirmed by Hematologist. Clinical data and long term outcome were reviewed and analyzed.ResultsDuring that period, 101 patients were reviewed, 77% were female, median age was 43 (15-83) years. The median hemoglobin level at diagnosis was 5.4 (2-10) g/dl. Primary AIHA was found in 61%. The secondary causes were SLE (64%), solid malignancy (13%), lymphoma (10%), drug (8%) and infection (5%). The secondary cause from SLE was commonly found in female (96%) (P<0.001). There was the difference of age between secondary cause from SLE (<50 years) and malignancy (>50 years) (p=0.013). These results showed the interesting data that secondary cause of AIHA needed to be searching especially SLE in young female and secondary cancer in elderly patients. Not only cause could be identified but also the specific treatment needed to be given according to secondary cause.Interestingly, most patients (96%) were initially response to steroid which was not different between primary and secondary AIHA. Second line treatments were required in 33 patients (33%). The indications were steroid dependent (58%), relapse (30%) and others (12%). The second line treatments were including cyclophosphamide (52%), azathioprine (21%), cyclosporine (6%), splenectomy (6%), danazol (6%) and others (9%). The overall response rate for second line was 93%. SLE group received second line therapy more than non SLE group (p<0.001). In the light of data from this study showed that this disease had a good prognosis in both frontline steroid and second line treatment. Relapse was occurred in 50 patients (50%). Most relapse occurred > 3 years after diagnosis (58%) and more common in SLE group (p<0.001). These findings illustrated the importance nature of the disease that need long follow up due to high relapse rate around half of patients.At the median follow up 53 months, the overall survival (OS) and event free survival (relapse and death) were 84% and 48%, respectively. The independent factor for decreasing OS was age >50 years with HR 3.09 (95% CI 1.09-8.73, p=0.03) and malignancy with HR 4.06 (95% CI 1.18-13.97, p=0.03). The only significant factor for relapse is age >50 years with HR 2.08 (95% CI 1.21-3.57, p = 0.008). Twenty patients were death. The common cause of death was sepsis (30%) due to heavily immunosuppressive treatment.ConclusionAIHA has good prognosis and long term survival especially in young patient without secondary malignancy. The search for secondary cause especially malignancy is important. Most patients have responded initially to steroid and high response rate to second line therapy. The most common cause of death was sepsis which related to treatment side effect. Carefully adjust and rapid taper immunosuppressant is considerable to avoid serious complication. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Emergence of Long-Lived Autoreactive Plasma Cells in the Spleen of Primary Warm Auto-Immune Hemolytic Anemia Patients Treated with Rituximab

Introduction: We recently proposed that B-cell depletion in immune thrombocytopenia (ITP) promotes the generation of long-lived plasma cells in the spleen, some of them being auto-reactive; but it remained possible that this observation was related to ITP itself rather than to B-cell depletion. Primary warm autoimmune hemolytic anemia (wAIHA) is a rare disease characterized by IgG auto-antibodies directed against antigens at the surface of red blood cells (RBCs) antigens, leading to their accelerated destruction. The use of B-cell depletion in wAIHA leads to 60 % to 70% of overall response at one-year and beyond. Nevertheless, 30-40 % of patients may resist to rituximab and then require a splenectomy. Nothing is known about antibody secreting cells (ASC) in the spleen of wAIHA patients, who have previously been treated or not with rituximab. In this study, we analyzed at the single cell level the splenic ASC from patients with chronic and active wAIHA, previously treated or not with rituximab (RTX), and we compared them with splenic ASC from ITP patients, and with splenic and bone marrow plasma cells from healthy donors (HD).Methods: We took advantage of the different therapeutic outcomes to analyze the splenic B-cell compartment of wAIHA patients, not previously treated with RTX (n=6), or after failure RTX treatment (n=3).Splenic tissues from organ donors and bone marrow from cardiovascular thoracotomy were used as controls. Blood samples from wAIHA (n=19), and (HD) (n=8) enrolled in this study were obtained after giving written informed consent in accordance with the Declaration of Helsinki.Results: We observed by flow cytometry and microscopy that the spleen from wAIHA patients who received less than 3 months of steroid therapy was the site of a B-cell response characterized by the presence of Bcl6+ germinal-center (GC) B-cells. Furthemore, splenic ASC secreted anti-red blood cell IgG in vitro. In line with this observation, we observed in the peripheral blood from patients with a newly diagnosed wAIHA (n=11), that short-lived IgG plasmablasts were increased compared with HD (n=8) (Mean 4.2 ± 0.84 % vs 0.99 ± 0.19% of CD19+ cells, p< 0.01). Moreover, for patients receiving long term steroid therapy (> 6 months) the plasmablast response was suppressed in the peripheral blood (Mean: 0.68 ± 0.2 % of CD19+ cells, n=8) and the splenic GC B-cell reaction was impaired (n=3). We conclude that short-lived IgG ASC result from an over-activity of GC reactions in wAIHA. We then analyzed the spleen of 3 patients who failed to respond to RTX, and observed a residual population of CD19+B-cells (median: 0.9% of lymphoid cells), including non-proliferative memory B-cells and plasma cells (PC). A fraction of these residual PC secreted anti-red blood cells IgG in vitro, thus accounting for the faillure of the B-cell depletion therapy. By using a single cell multiplex quantitative RT-PCR (Fluidigm dynamic arrays), we showed that such RTX-resistant plasma cells display a long-lived transcriptional program, which differs from PC from untreated wAIHA patients or HD, as well as from plasmablasts. Interestingly, the gene expression profile of wAIHA long-lived plasma cells segregated with long-lived PC previously observed in the spleen of ITP patients treated with rituximab. By a principal component analysis, we observed a gradient of maturation from plasmablasts to bone marrow plasma cells in which PC from RTX-treated spleens segregated close to bone marrow PC. We also observed that the cytokine BAFF was increased in the supernatants of spleen cell cultures from wAIHA patients treated with rituximab compared with controls (p< 0.05), suggesting, in keeping with our previous report in ITP, a role for BAFF in the differentiation of short-lived plasma cells into long-lived plasma cells.Conclusion: The presence of splenic long-lived autoreactive PC in wAIHA may explain why some patients cannot achieve a response after RTX. Our results show that, the B-cell depletion induced by rituximab itself, as opposed to the underlying auto-immune condition, promotes a suitable environment for the maturation of auto-immune long-lived plasma cells in the spleen. Targeting specifically some factors such as BAFF right after rituximab injection could be an interesting therapeutic option in the future. DisclosuresNo relevant conflicts of interest to declare.

Predictors of Outcome and Response to Therapy in Primary Autoimmune Hemolytic Anemia: A Gimema Study of 307 Patients

Autoimmune hemolytic anemia (AIHA) is a greatly heterogeneous condition both in terms of clinical presentation and response to treatment, usually classified as warm (WAIHA), cold (CAD), mixed, and atypical forms. The aim of this study was to identify predictors of outcome and response to therapy considering in particular the serological characteristics and the severity of anemia at onset. We evaluatedretrospectively 307 patients (112 M and 195 F, median age at diagnosis 63, range 1-97), diagnosed between 1978 and 2013 and followed-up for a median of 33 months (range 12-372); 60% of cases were WAIHA, 27% CAD, 8% mixed, and 5% atypical (14 DAT- and 1 DAT+ for IgA only). Hemoglobin values were lower in mixed (median 5.8, range 2-10.7 g/dL) atypical (6.2, 3-9), and in IgG+C3 DAT+ WAIHA (6.9, 2.9-11.5). Twenty-one subjects were diagnosed with Evans’ syndrome, the majority of them WAIHA, with a severe onset. Considering anemia at onset, 27% of cases had Hb levels <6, 36% Hb 6.1-8, 24% Hb 8.1-10, and 13% Hb>10 g/dL; the most severe cases were mainly mixed and atypical forms (P=0.0001).Regarding therapy, 47% of cases were treated with one therapy line only, 26% with two, 13% with three, and 4% with four or more lines. Sixty % of WAIHA received first line steroid therapy only, 20 CAD required no treatment, and patients with IgG+C DAT+ WAIHA, mixed, and atypical forms were more frequently treated with 2 or more therapy lines (P<0.0001); the gender- and age-adjusted cumulative incidence of relapse was significantly increased in more severe cases by Fine and Gray model (Figure). Response to steroids was observed in ~75% of cases, with lower rates in CAD and generally observed at high steroid dosages. Splenectomy (32 cases, mostly WAIHA or severe forms) had a response rate of 75%, but was ineffective in 2/3 CAD; the relapse rate was 8/24 (33%) after a median of 41 months. Regarding immunosuppressants (31 cases azathioprine, 40 cyclophosphamide, and 12 cyclosporine) the OR was 50-70% (PR 20-40), irrespective of serological type and severity of anemia, although the simultaneous administration of steroid in most cases may weaken these results; the relapse rate was 8/60 (13%) after a median of 11 months. Rituximab (55 cases at conventional, and in 19 at low doses (LD) of 100 mg /weekly x 4) had an 80% OR (35% PR). Predictors of response to LD were WAIHA, younger age, and shorter interval between diagnosis and rituximab therapy; at variance, OR to conventional doses occurred irrespectively of age, serological type, clinical severity at onset, and disease duration. The relapse rate was 5% (2/42, of whom 1 CAD) for standard and 38% (6/16, of whom 5 CAD) for LD, and relapses occurred mostly within the first year after treatment.As regards complications, infections occurred in 26 cases (10 grade 3, 11 grade 4, and 5 grade 5), irrespective of serological AIHA type and severity at onset, and of the number of therapy lines; on the contrary, they were observed more frequently in splenectomized cases. Acute renal failure was recorded in 6 cases and was not associated with AIHA clinical or serological characteristics. A thrombotic event was recorded in 11% and was associated with severe onset, higher median LDH levels, and previous splenectomy.At the time of the analysis 63 cases (21%) have died, of whom 11 because of AIHA (3.6%); death was not associated with the severity of anemia at onset, nor with the serological type of AIHA; at variance, it was associated with infections (HR 11.47, 95% CI 3.43-38.4, p=0.0004), acute renal failure (HR 17.99, 95% CI 4.73-68.40, p=0.001), Evans’ syndrome (HR 6.8, 95% CI 1.99-23.63, P=0.0074), previous splenectomy (HR 3.21, 95% CI 0.92-11.25), and multi-treatment (4 or more lines of therapy; HR 9.1, 95% CI 2.41-34.36, p=0.0076). Death was not associated with thrombotic events, nor with the type of treatment, in particular immunosuppressants or rituximab.In conclusion, we showed that AIHA cases with a severe onset, mostly mixed and atypical forms, are frequently refractory to different therapies. Although obtained retrospectively, our results suggest to put forward rituximab among second line options, given its efficacy and safety. In addition, standard rituximab doses should be preferred in CAD, whereas lower doses may be equally effective in WAIHA and mixed forms. Finally, we suggest to defer splenectomy after rituximab, given the increased risk of thromboembolism, infections and fatal outcome in splenectomized patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Long Term Outcomes of Warm and Cold Antibody-Mediated Autoimmune Hemolytic Anemia Treated with Rituximab from a 13 Year Retrospective Cohort

Background and objective: Autoimmune hemolytic anemia (AIHA) is mediated by warm and cold-reactive autoantibodies, with the treatment approach depending on the type of antibody. Corticosteroids, immunosuppressive agents and splenectomy are the commonly used therapies for AIHA. Over the last decade, rituximab has emerged as a preferred second line agent for treatment of AIHA, though evidence supporting its use in AIHA, especially cold antibody-mediated AIHA, is limited to case reports and small case series. We therefore conducted a 13 year retrospective cohort study of patients treated for AIHA at the Cleveland Clinic to evaluate the outcomes of patients with this disorder treated with rituximab.Methods: Adult patients presenting with newly-diagnosed diagnosis or relapsed AIHA were included.The clinical presentations, type of AIHA (warm, cold, mixed), treatment and outcomes were recorded. Frequencies of complete responses (CR) (non-transfused hemoglobin of ≥ 12 mg/dL, hemoglobin increase ≥ 2 mg/dL, and normalization of hemolytic markers), and partial responses (PR) (non-transfused hemoglobin of ≥ 10 mg/dL with hemoglobin increase of ≥ 2 mg/dL) were recorded. Time to relapse was estimated using the Kaplan Meier method. A p value of ≤ 0.05 was considered significant for all analyses.Results: We identified 180 patients with AIHA of which 50 patients (31 with warm AIHA and 19 with Cold AIHA) were treated with rituximab. The rates of primary and secondary AIHA (associated with autoimmune disease, malignancy or drugs) were similar in patients with warm and cold AIHA (p=0.660). Rituximab was used as first line therapy in combination with steroids in 15 patients and as second/third line treatment in 35 patients. Only 17 patients received rituximab monotherapy while 33 received combination therapy with steroids. Overall response rates for Rituximab were 74% (17% CR, 57% PR) and 80% (27% CR, 53% PR) for patients with warm and cold AIHA respectively (p =0.877). Median time to response was 0.7 months in warm AIHA and 1.1 months in cold AIHA (p=0.112). Seven (22.5%) patients with warm AIHA but none with cold AIHA required maintenance steroids after Rituximab treatment. Relapses occurred in 9 (29%) patients with warm and 5 (26%) patients with cold antibody-mediated AIHA after rituximab treatment (p=0.154). The median time to relapse was 8.5 months for warm and 55.2 months for cold AIHA (p=0.044) (Figure 1).Patients who received rituximab with or without concomitant steroids demonstrated lower rates of relapse (26%) than those who received corticosteroids alone (32.3%) [Relative Risk 1.35 (1.09-2.82), p=0.047] (Figure 2). There were no major adverse events due to Rituximab over a median follow up of 54 months.Conclusion: Rituximab is highly effective in both warm and cold AIHA with higher response rates and lower relapse rates than corticosteroid therapy alone. In this cohort, there was a high incidence of durable responses, especially in cold antibody-mediated AIHA. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Clinical heterogeneity and predictors of outcome in primary autoimmune hemolytic anemia: a GIMEMA study of 308 patients

AbstractThe clinical outcome, response to treatment, and occurrence of acute complications were retrospectively investigated in 308 primary autoimmune hemolytic anemia (AIHA) cases and correlated with serological characteristics and severity of anemia at onset. Patients had been followed up for a median of 33 months (range 12-372); 60% were warm AIHA, 27% cold hemagglutinin disease, 8% mixed, and 5% atypical (mostly direct antiglobulin test negative). The latter 2 categories more frequently showed a severe onset (hemoglobin [Hb] levels ≤6 g/dL) along with reticulocytopenia. The majority of warm AIHA patients received first-line steroid therapy only, whereas patients with mixed and atypical forms were more frequently treated with 2 or more therapy lines, including splenectomy, immunosuppressants, and rituximab. The cumulative incidence of relapse was increased in more severe cases (hazard ratio 3.08; 95% confidence interval, 1.44-6.57 for Hb ≤6 g/dL; P < .001). Thrombotic events were associated with Hb levels ≤6 g/dL at onset, intravascular hemolysis, and previous splenectomy. Predictors of a fatal outcome were severe infections, particularly in splenectomized cases, acute renal failure, Evans syndrome, and multitreatment (4 or more lines). The identification of severe and potentially fatal AIHA in a largely heterogeneous disease requires particular experienced attention by clinicians.

English

Autoimmune hemolytic anemia is uncommon. The estimated overall (not age-adjusted) annual incidence is about 1 case per 100,000 populations; after age 60 years, the annual incidence reaches 10 per 100,000. The disorder can occur at any age, but most patients are older than 40 years. About 65% of patients with primary autoimmune hemolytic anemia are women, and almost all cases that complicate systemic lupus erythematosus occur in women. A 65 years old male presented with generalized weakness, breathlessness on exertion, swelling of lower limbs and pain abdomen of 6 months duration. He was previously admitted elsewhere on several occasions (within past 3-4 months) with similar complaints, and had received multiple blood transfusions. On clinical examination, patient had pallor and bilateral pitting pedal edema. Abdominal examination revealed massive Splenomegaly (12 cm below left costal margin), moderate Hepatomegaly. Investigations revealed Hb% of 8.6 g/dl, Platelet count = 1 lakh/cmm, ESR = 120 mm, retic count -2.2 %. Peripheral smear showed evidence of hemolysis. Serum LDH was high, Serum bilirubin predominantly indirect hemoglobin= 2, S. Haptoglobin below 6.63. These findings suggested hemolysis as a cause of his anemia and splenomegaly. Further evaluation was done to find out the cause of hemolysis in this elderly male. Hb Quantification using HPLC was normal. Serum G6PD activity was normal. ANA was negative. Hams test was negative. Direct & Indirect Coomb's tests were positive. Bone marrow examination showed erythroid hyperplasia. CT Abdomen showed hepatosplenomegaly. Upper GI endoscopy and colonoscopy were normal. Based on these findings a diagnosis of warm antibody type auto immune haemolytic anaemia (AIHA), probably of idiopathic type, was made and patient was started on steroid therapy. After 2 weeks, repeat haemoglobin was 12.8 gm%, WBC count was 7020/cumm reflecting response to steroid therapy. Severe AIHA can be a medical emergency. Red cell transfusion poses a special problem as the transfused cells are rapidly destroyed, but can be life- saving and in the meantime steroids can exert their effect. This unique situation requires good liaison and understanding between the clinical unit and the serology lab. Thus it is very important to diagnose this condition and treat accordingly. Untreated, chronic auto immune hemolysis progresses to severe anaemia and associated complications. It is important to consider the diagnosis of autoimmune hemolysis in elderly males also, although this condition is usually seen in females. It is important to rule out malignancies and connective tissue disease in elderly presenting with

Pulse cyclophosphamide therapy in refractory warm autoimmune hemolytic anemia: a new perspective.

Treatment of steroid refractory autoimmune hemolytic anemia (AIHA) is challenging especially with no evidence based consensus guide lines and limited resources. The aim of this study was to evaluate the efficacy of pulse cyclophosphamide therapy in patients with severe refractory warm AIHA. The prospective study was designed to evaluate the efficacy of pulse cyclophosphamide-1g/month for four consecutive months-in 17 patients (10 males and 7 females) with severe refractory warm AIHA [13 primary AIHA and 4 (females) secondary to SLE], all studied patients failed to respond to high dose of steroid therapy±azathioprine±intravenous immunoglobulin±oral cyclophosphamide. Mean hemoglobin level, reticulocytic count and direct antiglobulin test were assessed before and after cyclophosphamide treatment every month. After the 4th cycle of cyclophosphamide (82%, 14 patients) achieved partial response while the remaining (17%, 3 patients) showed no response, while after 6months follow up 47% (8 patients) show complete response, while 53% (9 patients) showed partial response. The mean hemoglobin levels were significantly increased after the 1st, 2nd, 3rd and 4th months of pulse cyclophosphamide therapy when compared to before treatment (P<0.01, P<0.001, P<0.001 and P<0.001) respectively, and the mean reticulocyte (%) were significantly decreased after the 2nd, 3rd and 4th months (P<0.05, P<0.01 and P<0.001) respectively. We conclude that pulse cyclophosphamide therapy is well tolerated and induces good response in patients with severe refractory warm AIHA.

A multi‐centre retrospective study of rituximab use in the treatment of relapsed or resistant warm autoimmune haemolytic anaemia

This retrospective analysis assessed the response, safety and duration of response to standard dose rituximab 375 mg/m(2) weekly for four weeks as therapy for patients with primary or secondary warm autoimmune haemolytic anaemia (WAIHA), who had failed initial treatment. Thirty-four patients received rituximab for WAIHA in seven centres in the Republic of Ireland. The overall response rate was 70·6% (24/34) with 26·5% (9/34) achieving a complete response (CR). The time to response was 1 month post-initiation of rituximab in 87·5% (21/24) and 3 months in 12·5% (3/24) of patients. The median duration of follow-up was 36 months (range 6-90 months). Of the patients who responded, 50% (12/24) relapsed during follow up with a median time to next treatment of 16·5 months (range 6-60 months). Three patients were re-treated with rituximab 375 mg/m2 weekly for four weeks at relapse and responded. There was a single episode of neutropenic sepsis. Rituximab is an effective and safe treatment for WAIHA but a significant number of patients will relapse in the first two years post treatment. Re-treatment was effective in a small number of patients, suggesting that intermittent pulse treatment or maintenance treatment may improve long-term response.

Megadose Methyl-Prednisolone (MDMP) for Autoimmune Hemolytic Anemia.

We want to thank for the comments of Sinasi OZSOYLU, MD. The new diagnosis in primary (idiopathic) autoimmune hemolytic anemia patients is suggested as glucocorticoids (steroids), prednison 1 mg/kg/day or metilprednisolon intravenously. With this dosage it is recommended to continue the treatment until the target hemoglobin value >10 g/dl and hematocrit value >30% are reached and if the target values are not reached within 3 weeks, second step of treatment should be applied [2-1]. In our case after 3 weeks steroid treatment, both symptomatic splenic infarct development and due to no result of 3 weeks steroid treatment splenectomy is applied simultaneously as a second step treatment. In our case due to splenic infarct development in accordance with etiology trombophilia investigation are observed [2-2]. As Dr. Ozsoylu has already specified, due to the coagulation being dependant on the dynamic balance between procoagulant and fibrinolytic activity, fibrinolytic system could have been evaluated as well. However, because of the insufficient laboratory conditions, investigation about the fibrinolytic system couldn’t have been done.

Current Approaches for the Treatment of Autoimmune Hemolytic Anemia

Autoimmune hemolytic anemia (AIHA) is an infrequent group of diseases defined by autoantibody mediated red blood cell destruction. Correct diagnosis and classification of this condition are essential to provide appropriate treatment. AIHA is divided into warm and cold types according to the characteristics of the autoantibody involved and by the presence of an underlying or associated disorder into primary and secondary AIHA. Due to its low frequency, treatment for AIHA is largely based on small prospective trials, case series, and empirical observations. This review describes in detail the different treatment approaches for autoimmune hemolytic anemia. Warm antibody type AIHA should be treated with steroids, to which most patients respond, although relapse can occur and maintenance doses are frequently required. Splenectomy is an effective second line treatment and can provide long-term remission without medication. Rituximab is a useful alternative for steroid refractory patients, those requiring high maintenance doses and unfavorable candidates for surgery. Promising therapeutic modifications with this monoclonal antibody are emerging including drug combinations, lower doses, and long-term use. Primary cold agglutinin disease has been recognized as having a lymphoproliferative monoclonal origin. It is unresponsive to both steroids and splenectomy. Rituximab is currently the best therapeutic alternative for this condition, and several treatment regimens are available with variable responses.

Primary mixed-type autoimmune hemolytic anemia concomitant with acute splanchnic venous thrombosis of idiopathic origin in a young woman: an unexplained association

TO THE EDITOR: Mixed autoimmune hemolytic anemia (AIHA) is defined by the presence of both warm and cold types of autoantibodies [1, 2]. The diagnosis is based on the detection of these autoantibodies by using a monospecific direct antiglobulin test; a positive test result shows a pattern of IgG and complement C3d along with the presence of cold agglutinins. Mixed AIHA may be of idiopathic origin or associated with an underlying disease [1]. Venous thromboembolism is a common complication of AIHA, although it is not often identified [3, 4]. In some instances, its occurrence may be related to coexistent antiphospholipid antibodies. However, the association of primary mixed AIHA with idiopathic acute splanchnic venous thrombosis (SVT), as we recently observed, represents an exceptional occurrence; thus far, it has been reported for AIHA only in conjunction with splenectomy [5], but has never been reported as a concomitant manifestation. In the present report, we describe the case of a 19-year-old woman who presented with diffuse abdominal pain and severe anemia. At admission, she presented with life-threatening medical conditions due to severe anemia and critical abdominal features. Her medical history was unremarkable. Findings on clinical images and laboratory parameters were consistent with an acute and severe hemolytic disorder; her Hb level had decreased to 3.9 g/dL, whereas the reticulocyte count, indirect bilirubin level, and lactate dehydrogenase concentration were elevated. On admission, the patient was transfused with packed red blood cells (12 units). A strongly positive result on direct antiglobulin test (IgG3 and C3d) was detected; the indirect antiglobulin test indicated a positive result at 4℃ and a negative result at 22℃ and 39℃ in the presence of a cold panagglutinin antibody (IgM). The concomitant acute abdominal condition was investigated by a comprehensive radiological work-up, including an abdominal echography and a body computed tomography scan, and revealed complete thrombosis of the portal and splenic veins as well as partial occlusion of the superior mesenteric vein. A diagnosis of mixed AIHA associated with SVT was made, and treatment with prednisone (1 mg/kg body weight/day) was promptly initiated; in addition, therapeutic subcutaneous Fraxiparine injections with warfarin were also administered. Additional laboratory investigations revealed no other causes of anemia and ruled out the presence of autoimmune disorders, infections, and liver diseases. Investigations into the possible causes for the development of the thrombosis, including all genetic and acquired abnormalities associated with hypercoagulability states, as well as those aimed to identify a possible underlying neoplastic etiology, did not provide any useful findings. Similarly, the presence of a paroxysmal nocturnal hemoglobinuria clone or abnormal Hb chains was ruled out. The patient was discharged with continued warfarin treatment with a fraxiparine bridge. However, based on the patient's decision, the warfarin treatment was subsequently discontinued, whereas the fraxiparine was maintained for only 6 months, after which a careful reevaluation showed complete SVT resolution and full vein recanalization in the splanchnic area. Moreover, based on the clinical response, the prednisone dose was adjusted and tapered until the minimal effective maintenance dose was reached; immunohematological evaluations were regularly repeated and indicated completely negative results. However, an AIHA recurrence was observed 6 months after the reduction of prednisone to the lowest dosage. At this time, a second line treatment of rituximab (375 mg/m2, 4 weekly courses) was given. A complete response by rituximab was achieved. At approximately 1 year after the primary diagnosis was made, the patient is doing well. As AIHA and acute SVT may have been the initial manifestations of underlying occult disorders, the patient is carefully and regularly evaluated to promptly diagnose any recurrence of her hematological complaints. Thus, we report a rare and unexplained association of primary mixed AIHA with acute SVT, both of idiopathic origin that simultaneously occurred in a young patient.

Treatment of autoimmune hemolytic anemia at the departement of hematology of the UMC Ljubljana in the period from 2000–2011

Background: Autoimmune hemolytic anemia (AIHA) is an acquired hemolytic anemia and can be treated as an idiopathic or primary disease or can be associated with some other hematologic diseases (secondary). AIHA is a disease characterized by the presence of auto-antibodies directed against antigens on the red cell membrane, rare can the result of Coombs test be negative although there are all signs of AIHA present. Depending on the temperature at which auto-antibodies bind to the surface of an erythrocyte, we talk about AIHA with warm agglutinins and AIHA with cold agglutinins. Treatment is diverse as are also the causes of AIHA. The most important thing is to decrease the production of antibodies or to prevent the erythrocyte from decomposing with bound antibodies and to treat the disease symptomatically. Patients and methodes: With a retrospective analysis we searched through database of 70 patients with idiopathic (90 %) and secondary (10 %) autoimmune hemolytic anemia with warm (84.3 %) and cold (10 %) type agglutinin, who were treated at the Hematologic Department of the UMC Ljubljana during the period from 2000–2011. I processed the data with the SPSS program system. Results: Methylprednisolone was the first choice of treatment in 92. 5 % patients with primary and secondary AIHA with response rate of 79 % and 70.9 % complete remission rate. 22.7 % of the patients with complete remission after corticosteroids treatment , relapsed during the period of time and received a second-line treatment with cyclosporine (87 % response rate), rituximab or underwent splenectomy. Another attempt was made with methylprednisolone. The patients, who were refractory to the initial methylprednisolone treatment or required a higher maintenance dose, were treated in second line with cyclosporine (69 % response rate), rituximab (57 % responsee rate). One patient was treated successfully with mycophenolate mofetil and two patients, who were refractory to all other treatments, achieved a stable state of disease with splenectomy. The effective treatment for patients with cold agglutinin AIHA were corticosteroids and rituximab. We achieved an improvement of the condition in secondary AIHA when we treated the underlying disease. 6 % of all patients were refractory to any kind of treatment. Conclusions: Treatment with glucocorticoids is the most efficient treatment for patients with AIHA with warm and cold agglutinin. If the patients are refractory to the first-line therapy, we switch to a second-line therapy, which depends on etiology and concomitant diseases. Patients who are resistant to standard available treatments generally present with severe complications.