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Evangelidis P, Evangelidis N, Vlachaki E, Gavriilaki E. What is the role of complement in bystander hemolysis? Old concept, new insights. Expert Rev Hematol 2024; 17:107-116. [PMID: 38708453 DOI: 10.1080/17474086.2024.2348662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/24/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION Bystander hemolysis occurs when antigen-negative red blood cells (RBCs) are lysed by the complement system. Many clinical entities including passenger lymphocyte syndrome, hyperhemolysis following blood transfusion, and paroxysmal nocturnal hemoglobinuria are complicated by bystander hemolysis. AREAS COVERED The review provides data about the role of the complement system in the pathogenesis of bystander hemolysis. Moreover, future perspectives on the understanding and management of this syndrome are described. EXPERT OPINION Complement system can be activated via classical, alternative, and lectin pathways. Classical pathway activation is mediated by antigen-antibody (autoantibodies and alloantibodies against autologous RBCs, infectious agents) complexes. Alternative pathway initiation is triggered by heme, RBC microvesicles, and endothelial injury that is a result of intravascular hemolysis. Thus, C5b is formed, binds with C6-C9 compomers, and MAC (C5b-9) is formulated in bystander RBCs membranes, leading to cell lysis. Intravascular hemolysis, results in activation of the alternative pathway, establishing a vicious cycle between complement activation and bystander hemolysis. C5 inhibitors have been used effectively in patients with hyperhemolysis syndrome and other entities characterized by bystander hemolysis.
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Affiliation(s)
- Paschalis Evangelidis
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Evangelidis
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efthymia Vlachaki
- Adult Thalassemia Unit, 2nd Department of Internal Medicine, Aristotle University of Thessaloniki, Hippocration General Hospital, Thessaloniki, Greece
| | - Eleni Gavriilaki
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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2
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Dronamraju S, Irshad VS, Acharya S, Shukla S, Kumar S. Hyperhemolysis syndrome in a case of sickle cell disease. Asian J Transfus Sci 2024; 18:155-156. [PMID: 39036684 PMCID: PMC11259338 DOI: 10.4103/ajts.ajts_148_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 06/05/2022] [Indexed: 07/23/2024] Open
Affiliation(s)
- Sameera Dronamraju
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
| | - V. S. Irshad
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
| | - Samarth Shukla
- Department of Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
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3
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Pirenne F. Alloimmunization and hyperhemolysis in sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:653-659. [PMID: 38066873 PMCID: PMC10727070 DOI: 10.1182/hematology.2023000499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Alloimmunization against red blood cell antigens and delayed hemolytic transfusion reaction (DHTR) are major barriers to transfusion in sickle cell disease (SCD). In SCD, DHTR is a potentially life-threatening. Blood group polymorphism in SCD patients, who are of African ancestry and frequently exposed to antigens they do not carry; an inflammatory clinical state; and occasional transfusion in acute situations are risk factors for alloimmunization and DHTR. In patients at risk, the transfusion indication must be balanced against the risk of developing DHTR. However, when transfusion is absolutely necessary, protocols combining the prevention of exposure to immunogenic antigens with immunosuppressive treatments must be implemented, and patients should be carefully monitored during posttransfusion follow-up. This close monitoring makes it possible to diagnose hyperhemolysis as soon as possible; to avoid retransfusion, which can exacerbate hemolysis; and to administer specific treatments, such as anticomplement therapy, in severe cases. Finally, in patients with severe disease, hematopoietic stem cell transplantation may be indicated. However, transfusion is also required in this context, and its management is complex because these risks must be taken into account.
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Affiliation(s)
- France Pirenne
- Université Paris Est Créteil, INSERM U955, IMRB, Créteil, France
- Etablissement Français du Sang, Saint Denis, France
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Abanyie F, Ng J, Tan KR. Post-artesunate Delayed Hemolysis in Patients With Severe Malaria in the United States-April 2019 Through July 2021. Clin Infect Dis 2023; 76:e857-e863. [PMID: 36052468 DOI: 10.1093/cid/ciac719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/17/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Studies have demonstrated the safety and efficacy of intravenous artesunate (IVAS) for treatment of severe malaria in endemic and nonendemic countries. However, post-artesunate delayed hemolysis (PADH) is an increasingly recognized phenomenon after its administration. This study describes the prevalence and outcomes of PADH events among severe malaria cases treated with IVAS in the United States. METHODS Patients diagnosed with severe malaria and treated with IVAS from April 2019 to July 2021 were included. Demographic, clinical, laboratory, therapeutic, and outcome measures were described using proportions, medians, and interquartile range. Patients reported to experience PADH were compared with those not reported to have PADH, and tests of significance were performed. RESULTS Of 332 patients included in our analysis, 9 (2.7%) experienced PADH. The majority of infections in both groups were in non-Hispanic Black individuals. Parasite density (11.0% vs 8.0%), admission hemoglobin (11.0 g/dL vs 11.8 g/dL) were similar in the 2 groups. Total bilirubin levels at admission (4.7 mg/dL vs 2.2 mg/dL) and within 8 hours after completion of IVAS (2.6 mg/dL vs 1.2 mg/dL) were notably higher in PADH patients. Cumulative IVAS dose of >9.5 mg/kg and >3 doses of IVAS were risk factors for PADH. The majority (7 of 9) of PADH cases were diagnosed within 2 weeks after initiation of IVAS. Five patients (56%) required blood transfusions, and all recovered without sequelae. CONCLUSIONS PADH is an uncommon and self-limiting adverse event in many cases; weekly monitoring of hemoglobin and hemolytic markers may identify cases requiring intervention in a timely manner.
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Affiliation(s)
- Francisca Abanyie
- Division of Parasitic Diseases and Malaria, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Joanna Ng
- College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Kathrine R Tan
- Division of Parasitic Diseases and Malaria, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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5
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Genotyping and the Future of Transfusion in Sickle Cell Disease. Hematol Oncol Clin North Am 2022; 36:1271-1284. [DOI: 10.1016/j.hoc.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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6
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Ferreira de Matos C, Comont T, Castex MP, Lafaurie M, Walter O, Moulis G, Dion J, Cougoul P. Risk of vaso-occlusive episodes in patients with sickle cell disease exposed to systemic corticosteroids: a comprehensive review. Expert Rev Hematol 2022; 15:1045-1054. [PMID: 36412212 DOI: 10.1080/17474086.2022.2149488] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Sickle cell disease (SCD) is the most frequent inherited disorder in the world. It is caused by a single amino acid mutation on the beta-globin chain, which lead to red blood cell deformation, haemolysis, and chronic inflammation. Clinical consequences are vaso-occlusives crisis, acute chest syndrome, thrombosis, infection, and chronic endothelial injury. AREAS COVERED Corticosteroids are an old therapeutic class, that are inexpensive and widely available, which can be administered in different forms. Their adverse effects are numerous and well-known. This class could appear to be useful in SCD treatment due to its anti-inflammatory effect. Moreover, corticosteroids remain an essential therapeutic class for many indications, besides SCD. Although specific adverse effects of corticosteroids have been suspected in SCD patients for decades, recent papers has reported strong evidence of specific and severe adverse effects in this population. Based on a literature review, we will discuss pathophysiological considerations, consequences, and practical use of corticosteroids in SCD. EXPERT OPINION High corticosteroid doses, for any indication , induce vaso-occlusive crises, acute chest syndrome, and re-hospitalization in patients with SCD. There is no evidence of any benefits of corticosteroid use in the SCD acute events. Prevention by hydroxyurea and/or red blood cell transfusion or exchange should be discussed when corticosteroid use is indispensable.
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Affiliation(s)
| | - Thibault Comont
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France
| | - Marie-Pierre Castex
- Pediatric Oncology Immunology Hematology Unit, Children's University Hospital - Toulouse University Hospital, Toulouse, France
| | - Margaux Lafaurie
- CIC 1436, Team Pharmacologie en Population, Cohortes, Biobanques (PEPSS), Toulouse, France.,Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France
| | - Ondine Walter
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France.,CIC 1436, Team Pharmacologie en Population, Cohortes, Biobanques (PEPSS), Toulouse, France
| | - Guillaume Moulis
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France.,CIC 1436, Team Pharmacologie en Population, Cohortes, Biobanques (PEPSS), Toulouse, France
| | - Jérémie Dion
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France
| | - Pierre Cougoul
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France
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7
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Rollins MR, Chou ST. Adverse events of red blood cell transfusions in patients with sickle cell disease. Transfus Apher Sci 2022; 61:103557. [PMID: 36064527 PMCID: PMC10149091 DOI: 10.1016/j.transci.2022.103557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Blood transfusion is a common medical intervention for patients with sickle cell disease (SCD) and disease related complications. While patients with SCD are at risk for all transfusion related adverse events defined by the National Healthcare Safety Network (NHSN) Biovigilance Component Hemovigilance Module Surveillance Protocol, they are uniquely susceptible to certain adverse events. This review discusses risk factors, mitigation strategies, and management recommendations for alloimmunization, hemolytic transfusion reactions, hyperviscosity and transfusion-associated iron overload in the context of SCD.
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Affiliation(s)
- Margo R Rollins
- Children's Healthcare of Atlanta, Department of Pathology and Laboratory Medicine, 1405 Clifton Rd NE, 1st Floor, Atlanta, GA 30322, USA; Emory University School of Medicine, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, 1405 Clifton Rd NE, Atlanta, GA 30322, USA
| | - Stella T Chou
- The Children's Hospital of Philadelphia, Departments of Pediatrics and Pathology and Laboratory Medicine, The School of Medicine at the University of Pennsylvania, 3615 Civic Center Boulevard, Abramson Research Building Room 316D, Philadelphia, PA 19104, USA.
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8
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Trivedi K, Abbas A, Kazmi R, Shaaban H, Miller R. Hyperhemolytic Crisis Following Transfusion in Sickle Cell Disease With Acute Hepatic Crisis: A Case Report. Cureus 2022; 14:e27844. [PMID: 36110470 PMCID: PMC9461243 DOI: 10.7759/cureus.27844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/05/2022] Open
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9
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Menakuru SR, Priscu A, Dhillon V, Salih A. Acute Hyperhemolysis Syndrome in a Patient with Known Sickle Cell Anemia Refractory to Steroids and IVIG Treated with Tocilizumab and Erythropoietin: A Case Report and Review of Literature. Hematol Rep 2022; 14:235-239. [PMID: 35893156 PMCID: PMC9326715 DOI: 10.3390/hematolrep14030032] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 11/21/2022] Open
Abstract
Patients with sickle cell anemia often receive multiple red blood cell (RBC) transfusions during their lifetime. Hyperhemolysis is a life-threatening phenomenon of accelerated hemolysis and worsening anemia that occurs when both transfused RBCs and autologous RBCs are destroyed. The level of hemoglobin post-transfusion is lower than pre-transfusion levels, and patients are usually hemodynamically unstable. Hyperhemolysis must be differentiated from a delayed hemolytic transfusion reaction during which destruction of transfused RBC is the cause of anemia. Hyperhemolysis syndrome can be differentiated into acute (within seven days) and chronic forms (after seven days) post-transfusion. The authors present a case of acute hyperhemolysis syndrome in a patient with sickle cell anemia refractory to steroids and IVIG, which are the treatment of choice. The patient was treated with tocilizumab, combined with supportive measures of erythropoietin, iron, vitamin B12, and folate.
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10
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Spring J, Munshi L. Hematology Emergencies in Critically Ill Adults. Chest 2022; 161:1285-1296. [DOI: 10.1016/j.chest.2021.12.650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/14/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022] Open
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Abstract
Blood transfusions are generally safe but can carry considerable risks. This review summarizes the different types of transfusion reactions and ways to diagnose and manage them. Symptoms are often overlapping and nonspecific. When a reaction is suspected, it is critical to stop the transfusion immediately and report the reaction to the blood bank, as this can affect the patient's outcome. New evidence-based algorithms of transfusion, newer blood screening methods and donor policies and deferrals, new laboratory testing, electronic verification systems, and improved hemovigilance lead to the avoidance of unnecessary transfusions and decrease the incidence of serious transfusion reactions.
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Affiliation(s)
- Rim Abdallah
- Department of Transfusion Medicine, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Herleen Rai
- Department of Transfusion Medicine, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Sandhya R Panch
- Department of Transfusion Medicine, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA.
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12
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Gerritsma J, Bongaerts V, Eckhardt C, Heijboer H, Nur E, Biemond B, van der Schoot E, Fijnvandraat K. Extended phenotyping does not preclude the occurrence of delayed haemolytic transfusion reactions in sickle cell disease. Br J Haematol 2021; 196:769-776. [PMID: 34632580 DOI: 10.1111/bjh.17875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/12/2021] [Accepted: 07/30/2021] [Indexed: 01/29/2023]
Abstract
Delayed haemolytic transfusion reaction (DHTR) is a potentially life-threatening complication of red blood cell (RBC) transfusions in sickle cell disease (SCD) and is classically induced by reactivation of previously formed antibodies. Improved antigenic matching has reduced alloimmunization and may reduce DHTR risk. We conducted a retrospective cohort study to investigate the incidence rate of DHTR in SCD patients receiving extended matched units (ABO/RhDCcEe/K/Fya /Jkb /S). Occasional transfusion episodes (OTE) between 2011 and 2020 were reviewed for occurrence of DHTR symptoms using four screening criteria: decreased Hb, increased lactate dehydrogenase (LDH), pain, and dark urine. We included 205 patients who received a cumulative number of 580 transfusion episodes of 1866 RBC units. During follow-up, 10 DHTR events were observed. The incidence rate of DHTR was 13·8/1000 OTEs [95% confidence interval (CI): 7·37-22·2], with a cumulative incidence of 15·2% (95% CI: 8·4-24·0%) after 25 patients having received RBC units. One DHTR event was fatal (10%). Symptoms were misdiagnosed in four DHTR events (40%) as other acute SCD complications. Despite a lower incidence rate compared to most other studies, the incidence rate of DHTR in SCD remains high, in spite of extended matching of donor RBCs. Increased awareness of DHTR is of utmost importance to facilitate early diagnosis and, consequently, improve outcome.
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Affiliation(s)
- Jorn Gerritsma
- Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands.,Immunopathology, Sanquin Research and Landsteiner Laboratory, UMC, University of Amsterdam, Amsterdam, Amsterdam, the Netherlands
| | - Vera Bongaerts
- Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Corien Eckhardt
- Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Harriet Heijboer
- Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Erfan Nur
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bart Biemond
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ellen van der Schoot
- Immunohematology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Karin Fijnvandraat
- Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands.,Molecular and Cellular Haemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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13
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Starr D, Hermelin D, Blackall D. Hyperhemolysis Syndrome Following Red Cell Exchange in a Newly Diagnosed Sickle Cell Disease Patient With Spinal Cord Infarction. J Med Cases 2021; 11:263-266. [PMID: 34434408 PMCID: PMC8383669 DOI: 10.14740/jmc3541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/10/2020] [Indexed: 11/29/2022] Open
Abstract
Hyperhemolysis syndrome (HS) is a rare red blood cell (RBC) transfusion reaction that shares similarities with other hemolytic transfusion reactions. Because of this, it is important to recognize key presenting clinical and laboratory features in order to guide therapy. In this case report, a patient with a sickling hemoglobinopathy who developed HS is presented. The atypical nature of this case resides in the clinical presentation of paraplegia secondary to spinal cord infarction, increasingly complex blood group serological findings, and multiple RBC exchanges prior to the HS reaction. Once the patient was diagnosed with probable HS, approximately 4 weeks into her clinical course, RBC transfusion (including exchange transfusion) was withheld. Instead, corticosteroids and erythropoietin were initiated without complication. The patient remained stable with this treatment modality until her care was transferred to a hospital with a comprehensive sickle cell center. This case highlights the need to withhold transfusion in HS patients, barring exceptional circumstances, and the efficacy of initiating immunomodulatory and erythropoiesis stimulating therapies.
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Affiliation(s)
- David Starr
- Department of Pathology, Saint Louis University School of Medicine, Saint Louis, MO 63104, USA
| | - Daniela Hermelin
- Department of Pathology, Saint Louis University School of Medicine, Saint Louis, MO 63104, USA
| | - Douglas Blackall
- Department of Pathology, Saint Louis University School of Medicine, Saint Louis, MO 63104, USA
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14
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Chen F, Booth C, Barroso F, Bennett S, Kaya B, Win N, Telfer P. Salvage of refractory post-transfusion hyperhaemolysis by targeting hyperinflammation and macrophage activation with tocilizumab. Transfus Med 2021; 32:437-440. [PMID: 34046955 DOI: 10.1111/tme.12793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/18/2021] [Accepted: 05/03/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Frederick Chen
- Department of Clinical Haematology, Royal London Hospital, Barts Health NHS Trust, London, UK.,Queen Mary University London, London, UK
| | - Catherine Booth
- Department of Clinical Haematology, Royal London Hospital, Barts Health NHS Trust, London, UK.,NHS Blood and Transplant, London, UK
| | - Filipa Barroso
- Department of Clinical Haematology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Sarah Bennett
- Department of Clinical Haematology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Banu Kaya
- Department of Clinical Haematology, Royal London Hospital, Barts Health NHS Trust, London, UK.,Queen Mary University London, London, UK
| | - Nay Win
- NHS Blood and Transplant, Tooting Centre, London, UK
| | - Paul Telfer
- Department of Clinical Haematology, Royal London Hospital, Barts Health NHS Trust, London, UK.,Queen Mary University London, London, UK
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15
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Antigen density dictates RBC clearance, but not antigen modulation, following incompatible RBC transfusion in mice. Blood Adv 2021; 5:527-538. [PMID: 33496748 DOI: 10.1182/bloodadvances.2020002695] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/17/2020] [Indexed: 12/17/2022] Open
Abstract
Incompatible red blood cell (RBC) transfusion can result in life-threatening transfusion complications that can be challenging to manage in patients with transfusion-dependent anemia. However, not all incompatible RBC transfusions result in significant RBC removal. One factor that may regulate the outcome of incompatible RBC transfusion is the density of the incompatible antigen. Despite the potential influence of target antigen levels during incompatible RBC transfusion, a model system capable of defining the role of antigen density in this process has not been developed. In this study, we describe a novel model system of incompatible transfusion using donor mice that express different levels of the KEL antigen and recipients with varying anti-KEL antibody concentrations. Transfusion of KEL+ RBCs that express high or moderate KEL antigen levels results in rapid antibody-mediated RBC clearance. In contrast, relatively little RBC clearance was observed following the transfusion of KEL RBCs that express low KEL antigen levels. Intriguingly, unlike RBC clearance, loss of the KEL antigen from the transfused RBCs occurred at a similar rate regardless of the KEL antigen density following an incompatible transfusion. In addition to antigen density, anti-KEL antibody levels also regulated RBC removal and KEL antigen loss, suggesting that antigen density and antibody levels dictate incompatible RBC transfusion outcomes. These results demonstrate that antibody-induced antigen loss and RBC clearance can occur at distinct antigen density thresholds, providing important insight into factors that may dictate the outcome of an incompatible RBC transfusion.
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16
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Madu AJ, Ugwu AO, Efobi C. Hyperhaemolytic Syndrome in Sickle Cell Disease: Clearing the Cobwebs. Med Princ Pract 2021; 30:236-243. [PMID: 33176303 PMCID: PMC8280419 DOI: 10.1159/000512945] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 11/10/2020] [Indexed: 12/23/2022] Open
Abstract
Sickle cell disease (SCD) presents with a dynamic background of haemolysis and deepening anaemia. This increases the demand for transfusion if any additional strain on haemopoiesis is encountered due to any other physiological or pathological causes. Patients with cerebrovascular accidents are placed on chronic blood transfusion; those with acute sequestration and acute chest syndrome are likewise managed with blood transfusion. These patients are prone to develop complications of blood transfusion including alloimmunization and hyperhaemolytic syndrome (HHS). This term is used to describe haemolysis of both transfused and "own" red cells occurring during or post-transfusion in sickle cell patients. Hyperhaemolysis results in worsening post-transfusion haemoglobin due attendant haemolysis of both transfused and autologous red cells. The mechanism underlying this rare and usually fatal complication of SCD has been thought to be secondary to changes in the red cell membrane with associated immunological reactions against exposed cell membrane phospholipids. The predisposition to HHS in sickle cell is also varied and the search for a prediction pattern or value has been evasive. This review discusses the pathogenesis, risk factors and treatment of HHS, elaborating on what is known of this rare condition.
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Affiliation(s)
- Anazoeze Jude Madu
- Department of Haematology and Immunology, University of Nigeria Ituku-Ozalla Campus, Ituku-Ozalla, Nigeria,
| | - Angela Ogechukwu Ugwu
- Department of Haematology and Immunology, University of Nigeria Ituku-Ozalla Campus, Ituku-Ozalla, Nigeria
| | - Chilota Efobi
- Department of Haematology, Nnamdi Azikiwe University, Nnewi, Nigeria
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17
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Wu Y, Ji Y, Dai B, Guo F, Wu Y, He Z, Mo C, Wu S, Hu Y. A case of hyperhaemolysis syndrome in a pregnant Chinese woman with β-thalassemia during perinatal transfusion. Transfus Med 2020; 31:24-29. [PMID: 33331032 DOI: 10.1111/tme.12748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/01/2020] [Accepted: 12/06/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To report a case of hyperhaemolysis syndrome (HHS) that occurred during perinatal blood transfusion in a pregnant Chinese woman with β-thalassemia to deepen the understanding of HHS and the risk of transfusion therapy for patients with thalassemia. BACKGROUND Most HHS cases occur in people with sickle cell disease. So far, no cases of HHS have been reported in the Chinese population. Here, we report a pregnant Chinese women with β-thalassemia experiencing HHS. METHODS The patient received ABO- and RhD-matched red blood cell transfusion from six blood donors in four perinatal transfusions. Haemoglobinuria and lower haemoglobin levels compared to those before transfusion were observed after each transfusion, and the lactate dehydrogenase was consistently elevated. The blood samples were collected at different time points during the hospitalisation for direct antiglobulin test (DAT), antibody screening test and acid elution test. The antigens of six blood donors were identified, and the cross-matching tests were repeated using the blood sample of the patient with specific irregular antibodies after the last transfusion. RESULTS The DAT of the patient was negative for anti-IgG and positive (1+) for anti-C3d, and no red blood cell antibodies were detected in the eluent before, between and after transfusions. Before and between transfusions, blood samples were negative for red blood cell irregular antibodies, whereas IgM anti-P1 and IgG anti-Jka were detected in blood samples the next day after the last transfusion. In the six donors, two were negative for P1 and Jka , one was positive for P1 and negative for Jka , and three were negative for P1 and positive for Jka . The tentative cross-matching tests using the indirect antiglobulin method in saline showed that only agglutination occurred in the blood samples of the patient collected after last transfusion and the three Jka -positive blood donors. DISCUSSION The clinical manifestations and laboratory test results suggested that HHS occurred in this patient with β-thalassemia after each transfusion. Clinicians should be aware that HHS can occur with compatible blood transfusion.
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Affiliation(s)
- Yuanjun Wu
- Department of Blood Transfusion, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Yanli Ji
- Institute of Clinical Blood Transfusion, Guangzhou Blood Center, Guangzhou, China
| | - Bingmei Dai
- Department of obstetrics, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Faliang Guo
- Department of Critical Care Medicine, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Yong Wu
- Department of Blood Transfusion, Affiliated Tungwah Hospital of Sun yat-sen University, Dongguan, China
| | - Ziyi He
- Blood Transfusion Research Center, Dongguan City Blood Station, Dongguan, China
| | - Chunyan Mo
- Institute of Clinical Blood Transfusion, Guangzhou Blood Center, Guangzhou, China
| | - Shujie Wu
- Department of Blood Transfusion, Dongguan Maternal and Child Health Hospital, Dongguan, China
| | - Yingming Hu
- Blood Transfusion Research Center, Dongguan City Blood Station, Dongguan, China
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18
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Chadebech P, de Ménorval MA, Bodivit G, Jouard A, Pakdaman S, Lelong F, Habibi A, Galactéros F, Lecron JC, Pirenne F. Cytokine changes in sickle-cell disease patients as markers predictive of the onset of delayed hemolytic transfusion reactions. Cytokine 2020; 136:155259. [PMID: 32920319 DOI: 10.1016/j.cyto.2020.155259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/27/2020] [Accepted: 08/17/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Changes in cytokine production are known to contribute to the pathogenesis of sickle-cell disease (SCD), particularly in painful acute complications (crises) and episodes of post-transfusion hemolysis. Little is known about cytokine profiles in patients with these complications. STUDY DESIGN AND METHODS We investigated possible associations between cytokine profile and the onset of delayed hemolytic transfusion reactions (DHTRs), particularly during acute-phase episodes, to improve characterization of the biological parameters predictive of such events. We included SCD patients with severe acute symptoms (n = 36) or steady-state disease (n = 31), both possibly leading to a DHTR (n = 18) event. Luminex® technology was used to determine the plasma concentrations of 23 cytokines. RESULTS Regardless of clinical context, the concentrations of interleukin (IL)-6, IL-10, inducible protein-10, and macrophage inflammatory protein-1β were higher in plasma samples from SCD patients than in those from healthy controls. IL-6 and IL-10 concentrations were even higher in acute-phase plasma samples from SCD patients. In addition, IL-27 and TNFα levels were higher, and IL-6 and RANTES levels were lower in acute-phase SCD patients just before the onset of DHTR than in patients experiencing painful occlusive episodes. CONCLUSION In addition to reporting the plasma cytokine profiles of SCD patients in various clinical phases of the disease, we provide the first evidence of a significant association between low plasma TNFα concentration, high plasma IP-10 concentration and the onset of DHTR in SCD patients.
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Affiliation(s)
- Philippe Chadebech
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor, Créteil, France; Inserm U955 Equipe 2 « Transfusion et Maladies du Globule Rouge », Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Laboratoire d'excellence GR-Ex, F75739 Paris, France.
| | - Marie-Amélie de Ménorval
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor, Créteil, France; Inserm U955 Equipe 2 « Transfusion et Maladies du Globule Rouge », Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Gwellaouen Bodivit
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor, Créteil, France; Inserm U955 Equipe 2 « Transfusion et Maladies du Globule Rouge », Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Laboratoire d'excellence GR-Ex, F75739 Paris, France
| | - Alicia Jouard
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor, Créteil, France; Inserm U955 Equipe 2 « Transfusion et Maladies du Globule Rouge », Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Laboratoire d'excellence GR-Ex, F75739 Paris, France
| | - Sadaf Pakdaman
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor, Créteil, France; Inserm U955 Equipe 2 « Transfusion et Maladies du Globule Rouge », Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Laboratoire d'excellence GR-Ex, F75739 Paris, France
| | - Francoise Lelong
- Laboratoire d'analyses en Immuno-Hématologie et Immunologie, AP-HP, Centre Hospitalier Intercommunal de Créteil (CHIC), Créteil, France
| | - Anoosha Habibi
- Centre de Référence des Syndromes Drépanocytaires Majeurs, Hôpital Henri-Mondor, AP-HP, Université Paris-Est, Créteil, France
| | - Frédéric Galactéros
- Inserm U955 Equipe 2 « Transfusion et Maladies du Globule Rouge », Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Laboratoire d'excellence GR-Ex, F75739 Paris, France; Université Paris-Est-Créteil (UPEC), Créteil, France; Centre de Référence des Syndromes Drépanocytaires Majeurs, Hôpital Henri-Mondor, AP-HP, Université Paris-Est, Créteil, France
| | - Jean Claude Lecron
- Université de Poitiers, UPRES EA4331, Laboratoire « Inflammation, Tissus Epithéliaux et Cytokines », CHU de Poitiers et Pôle Biologie Santé, Poitiers, France
| | - France Pirenne
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor, Créteil, France; Inserm U955 Equipe 2 « Transfusion et Maladies du Globule Rouge », Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Laboratoire d'excellence GR-Ex, F75739 Paris, France; Université Paris-Est-Créteil (UPEC), Créteil, France.
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19
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The cause and pathogenesis of hemolytic transfusion reactions in sickle-cell disease. Curr Opin Hematol 2020; 26:488-494. [PMID: 31589171 DOI: 10.1097/moh.0000000000000546] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The current review aims to summarize the epidemiology, cause, pathophysiology, and management of hemolytic transfusion reactions in sickle-cell disease (SCD). RECENT FINDINGS Patients undergoing occasional, isolated transfusions have been shown to have a higher risk of developing this condition. Despite the identification of well known risk factors, including alloimmunization, the pathophysiology of this syndrome remains unclear, as very severe forms with hyperhemolysis may develop in the absence of detectable antibodies, or with antibodies that are not considered to be clinically significant. Complement plays a crucial role in this reaction, particularly in cases of intravascular hemolysis. Complement triggers the reaction, but it also amplifies the inflammatory response and aggravates tissue damage. Free heme and hemoglobin are released and interact with complement, causing tissue damage. SUMMARY Hemolytic transfusion reactions are the most feared complications of blood transfusion in patients with SCD. This reaction is underdiagnosed because it mimics a vaso-occlusive crisis. Alloimmunization against red blood cell antigens is known to be a major trigger of this reaction, but abnormal complement activation and the underlying condition in patients with chronic hemolysis, may amplify the reaction. There is an urgent need to develop evidence-based approaches for preventing and treating this reaction.
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20
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Cid J, Fernández J, Palomo M, Blasco M, Bailó N, Diaz-Ricart M, Lozano M. Hyperhemolytic Transfusion Reaction in Non-Hemoglobinopathy Patients and Terminal Complement Pathway Activation: Case Series and Review of the Literature. Transfus Med Rev 2020; 34:172-177. [PMID: 32703665 DOI: 10.1016/j.tmrv.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/13/2020] [Accepted: 06/24/2020] [Indexed: 12/12/2022]
Abstract
Hyperhemolytic transfusion reaction (HHTR) is a severe, life-threatening hemolytic transfusion reaction where hemoglobin value after red blood cell (RBC) transfusion is lower than the pre-transfusion value. When HHTR occurs, mainly in patients with hemoglobinopathy, complement activation up to membrane attack complex (MAC) is strongly suspected. However, our knowledge of HHTR in patients without hemoglobinopathy is limited. In the present study, we retrospectively reviewed patients with the diagnosis of HHTR who were attended at our hospital between 2013 and 2016. We also performed a literature search to identify other reported cases of HHTR. Finally, the role of terminal complement pathway activation in the pathogenesis of HHTR was assessed by exposing endothelial cells in vitro to activated-patient plasma to analyze C5b-9 deposits by immunofluorescence. HHTR was diagnosed in 3 patients according to current criteria. Patients were treated with intravenous immunoglobulins (alone or in conjunction with rituximab and plasma exchange), and all of them recovered successfully. We retrieved from literature search 10 patients without hemoglobinopathy who developed HHTR. A marked increase of C5b-9 (MAC) deposition on endothelial cells (almost 2.5-fold increase versus control, P < .05) was observed with the plasma sample obtained from one of our patients. In conclusion, HHTR was a rare transfusion reaction that occurred in patients without hemoglobinopathy. We add more evidence that complement cascade activation up to MAC might play a role in the pathogenesis of HHTR.
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Affiliation(s)
- Joan Cid
- Apheresis & Cellular Therapy Unit, Department of Hemotherapy and Hemostasis, ICMHO, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Javier Fernández
- Liver ICU, Liver Unit, IMDiM, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Marta Palomo
- Josep Carreras Leukaemia Research Institute, Barcelona, Spain; Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Barcelona Endothelium Team, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Kidney Transplantation Department, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Spain; Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties nefro-urològiques i Trasplantament Renal, Barcelona, Spain
| | - Noemí Bailó
- Apheresis & Cellular Therapy Unit, Department of Hemotherapy and Hemostasis, ICMHO, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Barcelona Endothelium Team, Barcelona, Spain
| | - Miquel Lozano
- Apheresis & Cellular Therapy Unit, Department of Hemotherapy and Hemostasis, ICMHO, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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21
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Chou ST, Alsawas M, Fasano RM, Field JJ, Hendrickson JE, Howard J, Kameka M, Kwiatkowski JL, Pirenne F, Shi PA, Stowell SR, Thein SL, Westhoff CM, Wong TE, Akl EA. American Society of Hematology 2020 guidelines for sickle cell disease: transfusion support. Blood Adv 2020; 4:327-355. [PMID: 31985807 PMCID: PMC6988392 DOI: 10.1182/bloodadvances.2019001143] [Citation(s) in RCA: 225] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/20/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Red cell transfusions remain a mainstay of therapy for patients with sickle cell disease (SCD), but pose significant clinical challenges. Guidance for specific indications and administration of transfusion, as well as screening, prevention, and management of alloimmunization, delayed hemolytic transfusion reactions (DHTRs), and iron overload may improve outcomes. OBJECTIVE Our objective was to develop evidence-based guidelines to support patients, clinicians, and other healthcare professionals in their decisions about transfusion support for SCD and the management of transfusion-related complications. METHODS The American Society of Hematology formed a multidisciplinary panel that was balanced to minimize bias from conflicts of interest and that included a patient representative. The panel prioritized clinical questions and outcomes. The Mayo Clinic Evidence-Based Practice Research Program supported the guideline development process. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to form recommendations, which were subject to public comment. RESULTS The panel developed 10 recommendations focused on red cell antigen typing and matching, indications, and mode of administration (simple vs red cell exchange), as well as screening, prevention, and management of alloimmunization, DHTRs, and iron overload. CONCLUSIONS The majority of panel recommendations were conditional due to the paucity of direct, high-certainty evidence for outcomes of interest. Research priorities were identified, including prospective studies to understand the role of serologic vs genotypic red cell matching, the mechanism of HTRs resulting from specific alloantigens to inform therapy, the role and timing of regular transfusions during pregnancy for women, and the optimal treatment of transfusional iron overload in SCD.
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Affiliation(s)
- Stella T Chou
- Division of Hematology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mouaz Alsawas
- Mayo Clinic Evidence-Based Practice Research Program, Mayo Clinic, Rochester, MN
| | - Ross M Fasano
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Joshua J Field
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine and
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Jo Howard
- Department of Haematological Medicine, King's College London, London, United Kingdom
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Michelle Kameka
- Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL
| | - Janet L Kwiatkowski
- Division of Hematology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - France Pirenne
- INSERM-U955, Laboratory of Excellence, French Blood Establishment, Créteil, France
| | | | - Sean R Stowell
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Swee Lay Thein
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Connie M Westhoff
- Laboratory of Immunohematology and Genomics, New York Blood Center, New York, NY
| | - Trisha E Wong
- Division of Hematology/Oncology, Department of Pediatrics, Oregon Health and Science University, Portland, OR; and
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
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22
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Lee LE, Beeler BW, Graham BC, Cap AP, Win N, Chen F. Posttransfusion hyperhemolysis is arrested by targeting macrophage activation with novel use of Tocilizumab. Transfusion 2019; 60:30-35. [DOI: 10.1111/trf.15562] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/12/2019] [Accepted: 10/02/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Lauren E. Lee
- Department of Medicine, Division of Hematology/OncologySan Antonio Military Medical San Antonio Texas
| | - Bradley W. Beeler
- Department of Medicine, Division of Hematology/OncologySan Antonio Military Medical San Antonio Texas
| | - Brendan C. Graham
- Department of Pathology, Transfusion ServiceSan Antonio Military Medical San Antonio Texas
| | - Andrew P. Cap
- Department of Medicine, Division of Hematology/OncologySan Antonio Military Medical San Antonio Texas
| | - Nay Win
- Department of HematologyRed Cell Immunohematology, NHS Blood and Transplant London UK
| | - Frederick Chen
- Department of Hematology, Royal London HospitalBarts Health NHS Trust London UK
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23
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Sivapalaratnam S, Linpower L, Sirigireddy B, Agapidou A, Jain S, Win N, Tsitsikas DA. Treatment of post-transfusion hyperhaemolysis syndrome in Sickle Cell Disease with the anti-IL6R humanised monoclonal antibody Tocilizumab. Br J Haematol 2019; 186:e212-e214. [PMID: 31368112 DOI: 10.1111/bjh.16103] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Suthesh Sivapalaratnam
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK.,Department of Haematology, University of Cambridge, Cambridge, UK.,QMUL, London, UK
| | - Lisa Linpower
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Bala Sirigireddy
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Alexandra Agapidou
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Susan Jain
- Intensive Care Unit, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Nay Win
- National Health Service Blood and Transplant, Tooting Centre, London, UK
| | - Dimitris A Tsitsikas
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK
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24
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Merrill SA, Brodsky RA, Lanzkron SM, Naik R. A case-control analysis of hyperhemolysis syndrome in adults and laboratory correlates of complement involvement. Transfusion 2019; 59:3129-3139. [PMID: 31292968 DOI: 10.1111/trf.15445] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/10/2019] [Accepted: 06/18/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hyperhemolysis syndrome (HS) is a poorly understood, severe hemolytic anemia provoked by transfusion. Both host and donor RBCs are destroyed in HS; thus, transfusion paradoxically worsens anemia. Risk factors and mechanism of HS are unknown. STUDY DESIGN AND METHODS A retrospective case-control analysis was performed on adults with HS. Patients with HS were matched 1:1 with matched, transfused controls, and HS risk factors were analyzed with multivariable logistic regression. HS samples were analyzed for complement deposition by flow cytometry, and an in vitro model of bystander hemolysis was developed. RESULTS Forty-one patients with 54 episodes of HS were identified in a 26-year period from 1992 to 2018. Of the HS episodes, only 18.5% were associated with a new alloantibody, and such patients were more tolerant of additional transfusion in the acute episode (p = 0.005). Thirteen percent of episodes were fatal, and HS recurred in 52.6%. Alloimmunization (odds ratio [OR], 17.3), non-B blood type (OR, 9.8), D antigen (OR, 9.1), and infection (OR, 5.5) were associated with HS on multivariable analysis. Hyperbilirubinemia was predictive of fatal HS (OR, 33.6). Increased complement was observed on RBCs during HS episodes, and the in vitro model of bystander hemolysis recapitulated complement decoration of sickled RBCs. CONCLUSIONS HS is associated with significant morbidity, mortality, and recurrence. Risk factors such as known alloimmunization, blood group, and infection predispose to HS. Bystander complement activation may drive HS. These factors may help physicians refine risk-benefit assessments for transfusion and guide further therapeutic development.
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Affiliation(s)
- Samuel A Merrill
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sophie M Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rakhi Naik
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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25
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Epstein SS, Hadley TJ. Successful management of the potentially fatal hyperhaemolysis syndrome of sickle cell anaemia with a regimen including bortezomib and Hemopure. J Clin Pharm Ther 2019; 44:815-818. [PMID: 31237703 DOI: 10.1111/jcpt.12998] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/03/2019] [Accepted: 05/16/2019] [Indexed: 01/01/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Hyperhaemolysis syndrome (HHS) of sickle cell anaemia (SCA) is a life-threatening condition characterized by accelerated destruction of red blood cells typically following blood transfusions. Optimal treatment strategies have not been determined; therefore, reports utilizing novel therapies are needed. CASE DESCRIPTION A 19-year-old African American man with SCA experienced HHS following a partial red cell exchange transfusion. He was treated with methylprednisolone, rituximab, darbepoetin, Hemopure and bortezomib, with resolution of the syndrome. WHAT IS NEW AND CONCLUSION The HHS of SCA is thought to be immune-mediated even in the absence of detectable red cell alloantibodies. New therapies, including bortezomib and Hemopure, may be useful in this syndrome.
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Affiliation(s)
- Stacy S Epstein
- Norton Cancer Institute, Norton HealthCare, Louisville, Kentucky
| | - Terence J Hadley
- Norton Cancer Institute, Norton HealthCare, Louisville, Kentucky
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26
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Banks M, Shikle J. Hyperhemolysis Syndrome in Patients With Sickle Cell Disease. Arch Pathol Lab Med 2019; 142:1425-1427. [PMID: 30407854 DOI: 10.5858/arpa.2017-0251-rs] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Sickle cell disease is a genetic disease commonly affecting people of African, Indian, and Mediterranean descent. Patients with this chronic disease often require lifelong red blood cell transfusions. Formation of alloantibodies and autoantibodies are well-known complications that can arise with multiple transfusions. Another rare, but serious complication associated with transfusion is hyperhemolysis syndrome. The acquisition of new and/or rare alloantibodies can make it more difficult to find compatible blood products for patients with sickle cell disease. Genotyping and national donor registries are useful tools for finding appropriate blood products for these patients. This review will describe the clinical and laboratory findings of sickle cell disease, including hyperhemolysis syndrome. The challenges associated with locating compatible blood for patients with various red blood cell antibodies will be reviewed.
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Affiliation(s)
| | - James Shikle
- From the Department of Pathology, Augusta University Medical Center, Augusta, Georgia
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27
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Srinivasan A, Gourishankar A. A Differential Approach to an Uncommon Case of Acute Anemia in a Child With Sickle Cell Disease. Glob Pediatr Health 2019; 6:2333794X19848674. [PMID: 31106251 PMCID: PMC6506923 DOI: 10.1177/2333794x19848674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 04/05/2019] [Accepted: 04/10/2019] [Indexed: 01/19/2023] Open
Abstract
Introduction: Hyperhemolytic crisis is a rare and dangerous
complication of sickle cell disease where the hemoglobin level drops rapidly.
This can quickly lead to organ failure and death. In the literature, most cases
of hyperhemolysis in sickle cell patients followed a red cell transfusion.
Case Summary: In this article, we report a case of a
6-year-old African American boy with sickle cell disease who presented with
fever, increased work of breathing, and consolidation in the left lower lobe of
the lung on chest X-ray. He initially improved with oxygen, fluids, and
antibiotics but his hemoglobin acutely dropped from 7.6 to 6 g/dL the next day
of admission. He was not previously transfused, and his reticulocyte count
remained high. Subsequent transfusion recovered his hemoglobin.
Conclusion: This case demonstrates that in the background
of the chronic hemolysis of sickle cell disease, an acute anemia should warrant
exploration of aplastic crisis (parvovirus infection), immune hemolytic anemia,
hepatic sequestration crisis, splenic sequestration crisis, and hyperhemolytic
crisis as possible etiologies. Ongoing reticulocytosis and a source of infection
may direct suspicion especially toward hyperhemolytic crisis even without
preceding red cell transfusion. We propose that the optimum management should
include full supportive care (including transfusions if necessary) and treatment
of the underlying cause of hemolysis (such as infections or drug exposure).
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28
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Coleman S, Westhoff CM, Friedman DF, Chou ST. Alloimmunization in patients with sickle cell disease and underrecognition of accompanying delayed hemolytic transfusion reactions. Transfusion 2019; 59:2282-2291. [PMID: 31021439 PMCID: PMC8177758 DOI: 10.1111/trf.15328] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 04/03/2019] [Accepted: 04/08/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with sickle cell disease (SCD) often require red blood cell (RBC) transfusions but alloimmunization remains a significant complication. Alloantibodies can lead to delayed hemolytic transfusion reactions (DHTRs) days to weeks after a RBC transfusion, but may be underrecognized in patients with chronic hemolysis. STUDY DESIGN AND METHODS This retrospective study aimed to determine the incidence and severity of DHTRs associated with new antibody detection in a cohort of 624 patients with SCD who received transfusion with C-, E-, and K-matched RBCs from primarily African American donors over a 14-year period. We identified potential DHTRs by the change in hemoglobin (Hb) and %HbS at baseline, before transfusion, and up to 30 days after the transfusion that preceded new antibody identification. RESULTS Laboratory evidence of a DHTR was associated with 54 of 178 evaluable antibodies at first detection (30%), among which less than half were recognized by the patient or provider at the time of the event. A DHTR was associated with 26% of Rh antibodies identified in patients receiving serologic Rh-matched RBCs, and 38% of non-Rh antibodies. Twenty-one of the 54 DHTRs (39%) were associated with a Hb decline greater than 1 g/dL lower than pretransfusion values. Among these 21 severe DHTRs, Rh specificities were identified in 10 of 12 DHTRs in chronically transfused patients, while non-Rh specificities were associated with seven of nine DHTRs in episodically transfused patients. CONCLUSION High clinical suspicion and monitoring for DHTRs is warranted, as they may be more common in patients with SCD than previously appreciated.
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Affiliation(s)
- Sarita Coleman
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Connie M Westhoff
- Immunohematology and Genomics, New York Blood Center, New York, New York
| | - David F Friedman
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stella T Chou
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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29
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Win N, Lucas S, Hebballi S, McKernan A, Hamilton R, Robinson I, Chen F. Histopathological evidence for macrophage activation driving post‐transfusion hyperhaemolysis syndrome. Br J Haematol 2019; 186:499-502. [DOI: 10.1111/bjh.15925] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/26/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Nay Win
- NHS Blood and TransplantLondon UK
| | - Sebastian Lucas
- Department of Histopathology St Thomas’ HospitalGuy's and St Thomas' NHS Foundation Trust & King's College London School of MedicineLondon UK
| | | | | | | | - Ivan Robinson
- Derby Teaching Hospitals NHS Foundation TrustLondon UK
| | - Frederick Chen
- The Royal London HospitalBarts Health NHS TrustLondon UK
- The Blizard instituteQueen Mary University London London UK
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30
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Chonat S, Arthur CM, Zerra PE, Maier CL, Jajosky RP, Yee MEM, Miller MJ, Josephson CD, Roback JD, Fasano R, Stowell SR. Challenges in preventing and treating hemolytic complications associated with red blood cell transfusion. Transfus Clin Biol 2019; 26:130-134. [PMID: 30979566 DOI: 10.1016/j.tracli.2019.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Red blood cell (RBC) transfusion support represents a critical component of sickle cell disease (SCD) management. However, as with any therapeutic intervention, RBC transfusion is not without risk. Repeat exposure to allogeneic RBCs can result in the development of RBC alloantibodies that can make it difficult to find compatible RBCs for future transfusions and can directly increase the risk of developing acute or delayed hemolytic transfusion reactions, which can be further complicated by hyperhemolysis. Several prophylactic and treatment strategies have been employed in an effort to reduce or prevent hemolytic transfusion reactions. However, conflicting data exist regarding the efficacy of many of these approaches. We will explore the challenges associated with predicting, preventing and treating different types of hemolytic transfusion reactions in patients with SCD in addition to describing future strategies that may aid in the management of the complex transfusion requirements of SCD patients.
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Affiliation(s)
- Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Connie M Arthur
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, 101, Woodruff Circle, 30322 Atlanta, GA, USA
| | - Patricia E Zerra
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, 101, Woodruff Circle, 30322 Atlanta, GA, USA
| | - Cheryl L Maier
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, 101, Woodruff Circle, 30322 Atlanta, GA, USA
| | - Ryan P Jajosky
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, 101, Woodruff Circle, 30322 Atlanta, GA, USA
| | - Marianne E M Yee
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Maureen J Miller
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, 101, Woodruff Circle, 30322 Atlanta, GA, USA
| | - Cassandra D Josephson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA; Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, 101, Woodruff Circle, 30322 Atlanta, GA, USA
| | - John D Roback
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, 101, Woodruff Circle, 30322 Atlanta, GA, USA
| | - Ross Fasano
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA; Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, 101, Woodruff Circle, 30322 Atlanta, GA, USA.
| | - Sean R Stowell
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, 101, Woodruff Circle, 30322 Atlanta, GA, USA.
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Dean CL, Maier CL, Chonat S, Chang A, Carden MA, El Rassi F, McLemore ML, Stowell SR, Fasano RM. Challenges in the treatment and prevention of delayed hemolytic transfusion reactions with hyperhemolysis in sickle cell disease patients. Transfusion 2019; 59:1698-1705. [PMID: 30848512 DOI: 10.1111/trf.15227] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/13/2018] [Accepted: 01/08/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Delayed hemolytic transfusion reactions (DHTRs) are serious complications of RBC transfusion that can occur in previously alloimmunized patients. Patients who require episodic transfusions during heightened inflammatory states, such as patients with sickle cell disease (SCD), are particularly prone to alloimmunization and developing DHTRs with hyperhemolysis. While efforts to mitigate these hemolytic episodes via immunosuppressive drugs can be employed, the relative efficacy of various treatment options remains incompletely understood. CASE REPORTS In this study, we explored five patients with SCD and multiple RBC alloantibodies who received various forms of immunosuppressive therapy in an attempt to prevent or treat severe DHTRs. RESULTS The clinical course for these five patients provides insight into the difficulty of effectively treating and preventing DHTRs in patients with SCD with currently available immunosuppressive therapies. CONCLUSION Based on our experience, and the current literature, it is difficult to predict the potential impact of various immunosuppressive therapies when seeking to prevent or treat DHTRs. Future mechanistic studies are needed to identify the optimal treatment options for DHTRs in the presence or absence of distinct alloantibodies in patients with SCD.
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Affiliation(s)
- Christina L Dean
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Cheryl L Maier
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Satheesh Chonat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Andres Chang
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Marcus A Carden
- Department of Pediatrics and Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Fuad El Rassi
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Morgan L McLemore
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Sean R Stowell
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ross M Fasano
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
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Fasano RM, Miller MJ, Chonat S, Stowell SR. Clinical presentation of delayed hemolytic transfusion reactions and hyperhemolysis in sickle cell disease. Transfus Clin Biol 2019; 26:94-98. [PMID: 30837199 DOI: 10.1016/j.tracli.2019.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Red blood cell (RBC) transfusion therapy is a key component in the comprehensive management of patients with sickle cell disease (SCD). Consequently, most adult SCD patients will receive at least one, and many will receive more than a hundred RBC transfusions in their lifetime. SCD patients develop RBC alloantibodies much more frequently than non-SCD transfused patients, which often make the selection of compatible RBCs extremely difficult, in addition to placing patients at significantly higher risk of suffering from delayed hemolytic transfusion reactions (DHTRs). Similar to alloimunization, DHTRs are much more common in patients with SCD compared to other heavily transfused populations, and are particularly consequential due to their propensity to cause hyperhemolysis, a life-threatening phenomenon in which both transfused RBCs in addition to the patient's own sickle-erythrocytes are destroyed. In this review, we highlight the incidence and pathophysiology of DHTRs; illustrate common presentations, appropriate evaluations and outcomes of DHTRs in patients with SCD; and discuss strategies for preventing or reducing the likelihood of DHTRs from occurring.
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Affiliation(s)
- R M Fasano
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, USA.
| | - M J Miller
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, USA
| | - S Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics and Hematology/Oncology, Emory University School of Medicine, Atlanta GA, USA
| | - S R Stowell
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, USA
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33
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Khan J, Delaney M. Transfusion Support of Minority Patients: Extended Antigen Donor Typing and Recruitment of Minority Blood Donors. Transfus Med Hemother 2018; 45:271-276. [PMID: 30283277 DOI: 10.1159/000491883] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/06/2018] [Indexed: 01/16/2023] Open
Abstract
One of the most important and persistent complications of blood transfusion is red blood cell (RBC) alloimmunization. When a patient is exposed to RBC antigens that differ from their own they can form alloantibodies to these foreign antigens. Blood group antigens are highly conserved and follow ancestral patterns of inheritance that may demonstrate population restriction. Minority populations who require chronic transfusion are at particularly high risk of alloimmunization when the blood donor population does not share the same ancestral background, resulting in exposure to non-self RBC antigens. It is incumbent on blood collectors to support patients with risk factors for alloimmunization as well as patients who have already formed alloantibodies. Increasing utilization of RBC genotyping may represent an opportunity to improve access to RBC units from donors that match the extended RBC phenotype of all possible patients.
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Affiliation(s)
- Jenna Khan
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Meghan Delaney
- Pathology & Laboratory Medicine Division, Children's National Health System, Washington, DC, USA.,Department of Pathology & Pediatrics, The George Washington University, Washington, DC, USA
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34
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Hyperhemolysis syndrome: theory and practice. Fam Med 2018. [DOI: 10.30841/2307-5112.2.2018.145510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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How I safely transfuse patients with sickle-cell disease and manage delayed hemolytic transfusion reactions. Blood 2018; 131:2773-2781. [PMID: 29724898 DOI: 10.1182/blood-2018-02-785964] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/01/2018] [Indexed: 12/15/2022] Open
Abstract
Transfusions can be a life-saving treatment of patients with sickle-cell disease (SCD). However, availability of matched units can be limiting because of distinctive blood group polymorphisms in patients of African descent. Development of antibodies against the transfused red blood cells (RBCs), resulting in delayed hemolytic transfusion reactions (DHTRs), can be life-threatening and pose unique challenges for this population with regard to treatment strategies and transfusion management protocols. In cases where the transfused cells and the patient's own RBCs are destroyed, diagnosis of DHTR can be difficult because symptoms may mimic vaso-occlusive crisis, and frequently, antibodies are undetectable. Guidelines are needed for early diagnosis of DHTR because treatment may need to include temporarily withholding any new transfusions to avoid further hemolysis. Also needed are case-control studies to optimally tailor treatments based on the severity of DHTR and develop preventive transfusion strategies for patients at DHTR risk. Here, we will review gaps in knowledge and describe through case studies our recommended approach to prevent alloimmunization and to diagnose and treat symptomatic DHTRs for which complementary mechanistic studies to understand their pathogenesis are sorely needed.
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36
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Narbey D, Habibi A, Chadebech P, Mekontso-Dessap A, Khellaf M, Lelièvre JD, Godeau B, Michel M, Galactéros F, Djoudi R, Bartolucci P, Pirenne F. Incidence and predictive score for delayed hemolytic transfusion reaction in adult patients with sickle cell disease. Am J Hematol 2017; 92:1340-1348. [PMID: 28924974 DOI: 10.1002/ajh.24908] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 09/14/2017] [Indexed: 01/20/2023]
Abstract
Delayed hemolytic transfusion reaction (DHTR) is a life-threatening complication of transfusion in sickle cell disease (SCD). The frequency of DHTR is underestimated because its symptoms mimic those of vaso-occlusive crisis and antibodies (Abs) are often not detectable. No predictive factors for identifying patients likely to develop DHTR have yet been defined. We conducted a prospective single-center observational study over 30 months in adult sickle cell patients. We included 694 transfusion episodes (TEs) in 311 patients, divided into occasional TEs (OTEs: 360) and chronic transfusion program (CTEs: 334). During follow-up, 15 cases of DHTR were recorded, exclusively after OTEs. DHTR incidence was 4.2% per OTE (95% CI [2.6; 6.9]) and 6.8% per patient during the 30 months of the study (95% CI [4.2; 11.3]). We studied 11 additional DHTR cases, to construct a predictive score for DHTR. The DHTR mortality is high, 3 (11.5%) of the 26 DHTR patients died. The variables retained in the multivariate model were history of DHTR, number of units previously transfused and immunization status before transfusion. The resulting DHTR-predictive score had an area under the ROC curve of 0.850 [95% CI: 0.780-0.930], a negative-predictive value of 98.4% and a positive-predictive value of 50%. We report in our study population, for the first time, the incidence of DHTR, and, its occurrence exclusively in occasionally transfused patients. We also describe a simple score for predicting DHTR in patients undergoing occasional transfusion, to facilitate the management of blood transfusion in SCD patients.
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Affiliation(s)
- David Narbey
- Etablissement Français du Sang; Créteil 94000 France
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
| | - Anoosha Habibi
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
- Reference Center for Sickle Cell Disease, Hôpital Henri Mondor; Créteil France
| | - Philippe Chadebech
- Etablissement Français du Sang; Créteil 94000 France
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
| | - Armand Mekontso-Dessap
- Intensive Care Unit, Hôpital Henri Mondor; Créteil France
- IMRB, Groupe de recherche clinique CARMAS; Créteil France
- Université Paris Est Créteil, Faculté de Médecine
| | - Mehdi Khellaf
- Université Paris Est Créteil, Faculté de Médecine
- Emergency Unit, Hôpital Henri Mondor; Créteil France
| | - Jean-Daniel Lelièvre
- Université Paris Est Créteil, Faculté de Médecine
- Clinical Immunology Department; Hôpital Henri Mondor; Créteil France
| | - Bertrand Godeau
- Intensive Care Unit, Hôpital Henri Mondor; Créteil France
- Internal Medicine Department; Hôpital Henri Mondor; Créteil France
| | - Marc Michel
- Université Paris Est Créteil, Faculté de Médecine
- Internal Medicine Department; Hôpital Henri Mondor; Créteil France
| | - Frédéric Galactéros
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
- Reference Center for Sickle Cell Disease, Hôpital Henri Mondor; Créteil France
- Université Paris Est Créteil, Faculté de Médecine
| | - Rachid Djoudi
- Etablissement Français du Sang; Créteil 94000 France
| | - Pablo Bartolucci
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
- Reference Center for Sickle Cell Disease, Hôpital Henri Mondor; Créteil France
- Université Paris Est Créteil, Faculté de Médecine
| | - France Pirenne
- Etablissement Français du Sang; Créteil 94000 France
- Institut Mondor de Recherche Biomédicale, lnserm U955, Equipe 2; Créteil 94000 France
- Laboratory of Excellence GR-Ex; Paris F75739 France
- Université Paris Est Créteil, Faculté de Médecine
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37
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Pirenne F, Bartolucci P, Habibi A. Management of delayed hemolytic transfusion reaction in sickle cell disease: Prevention, diagnosis, treatment. Transfus Clin Biol 2017; 24:227-231. [DOI: 10.1016/j.tracli.2017.05.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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38
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Gehrie EA, Ness PM, Bloch EM, Kacker S, Tobian AAR. Medical and economic implications of strategies to prevent alloimmunization in sickle cell disease. Transfusion 2017; 57:2267-2276. [PMID: 28653325 PMCID: PMC5695925 DOI: 10.1111/trf.14212] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 04/13/2017] [Accepted: 05/15/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND The pathogenesis of alloimmunization is not well understood, and initiatives that aim to reduce the incidence of alloimmunization are generally expensive and either ineffective or unproven. In this review, we summarize the current medical literature regarding alloimmunization in the sickle cell disease (SCD) population, with a special focus on the financial implications of different approaches to prevent alloimmunization. STUDY DESIGN AND METHODS A review of EMBASE and MEDLINE data from January 2006 through January 2016 was conducted to identify articles relating to complications of SCD. The search was specifically designed to capture articles that evaluated the costs of various strategies to prevent alloimmunization and its sequelae. RESULTS Currently, there is no proven, inexpensive way to prevent alloimmunization among individuals with SCD. Serologic matching programs are not uniformly successful in preventing alloimmunization, particularly to Rh antigens, because of the high frequency of variant Rh alleles in the SCD population. A genotypic matching program could offer some cost savings compared to a serologic matching program, but the efficacy of gene matching for the prevention of alloimmunization is largely unproven, and large-scale implementation could be expensive. CONCLUSIONS Future reductions in the costs associated with genotype matching could make a large-scale program economically feasible. Novel techniques to identify patients at highest risk for alloimmunization could improve the cost effectiveness of antigen matching programs. A clinical trial comparing the efficacy of serologic matching to genotype matching would be informative.
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Affiliation(s)
- Eric A Gehrie
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Paul M Ness
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Evan M Bloch
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Seema Kacker
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
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39
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Karafin MS, Singavi A, Johnson ST, Field JJ. A Fatal Case of Immune Hyperhemolysis with Bone Marrow Necrosis in a Patient with Sickle Cell Disease. Hematol Rep 2017; 9:6934. [PMID: 28286630 PMCID: PMC5337824 DOI: 10.4081/hr.2017.6934] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 11/19/2016] [Accepted: 11/21/2016] [Indexed: 11/28/2022] Open
Abstract
In patients with sickle cell disease, hyperhemolysis is a rare but life-threatening complication of transfusion. In this case report, we describe a 61 year-old woman with hemoglobin sickle cell (SC) disease and history of alloimmunization who developed hyperhemolysis associated with a transfusion. She was found to have a warm and a clinically-significant cold autoantibody. Severe anemia (Hb 2.7 g/dL) with reticulocytopenia and thrombocytopenia prompted a bone marrow biopsy, which demonstrated extensive bone marrow necrosis. Despite treatment, the bone marrow failure did not improve and the patient died on hospital day 38. This case illustrates the potential risks of transfusion in a patient with sickle cell disease, especially one with previous hemolytic reactions. While uncommon, hyperhemolysis can cause death, in this case by extensive bone marrow necrosis. In patients with sickle cell disease, judicious use of red cell transfusions with phenotypically-matched units can diminish, but never completely abrogate, the risks associated with transfusion.
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Affiliation(s)
- Matthew S Karafin
- Medical Sciences Institute, Blood Center of Wisconsin, Milwaukee, WI; Medical College of Wisconsin, Milwaukee, WI, USA
| | - Arun Singavi
- Medical College of Wisconsin , Milwaukee, WI, USA
| | - Susan T Johnson
- Medical Sciences Institute , Blood Center of Wisconsin, Milwaukee, WI
| | - Joshua J Field
- Medical Sciences Institute, Blood Center of Wisconsin, Milwaukee, WI; Medical College of Wisconsin, Milwaukee, WI, USA
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40
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Delaney M, Wendel S, Bercovitz RS, Cid J, Cohn C, Dunbar NM, Apelseth TO, Popovsky M, Stanworth SJ, Tinmouth A, Van De Watering L, Waters JH, Yazer M, Ziman A. Transfusion reactions: prevention, diagnosis, and treatment. Lancet 2016; 388:2825-2836. [PMID: 27083327 DOI: 10.1016/s0140-6736(15)01313-6] [Citation(s) in RCA: 246] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Blood transfusion is one of the most common procedures in patients in hospital so it is imperative that clinicians are knowledgeable about appropriate blood product administration, as well as the signs, symptoms, and management of transfusion reactions. In this Review, we, an international panel, provide a synopsis of the pathophysiology, treatment, and management of each diagnostic category of transfusion reaction using evidence-based recommendations whenever available.
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Affiliation(s)
- Meghan Delaney
- Bloodworks NW, Seattle, WA, USA; University of Washington, Department of Laboratory Medicine, Seattle, WA, USA.
| | | | | | - Joan Cid
- Department of Hemotherapy and Hemostasis, CDB, IDIBAPS, Hospital Clínic, UB, Barcelona, Spain
| | - Claudia Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Nancy M Dunbar
- Department of Pathology and Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Torunn O Apelseth
- Laboratory of Clinical Biochemistry and Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | | | - Simon J Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Alan Tinmouth
- Department of Medicine and Department of Laboratory Medicine & Pathology, University of Ottawa, Ottawa, ON, Canada; University of Ottawa Centre for Transfusion Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Jonathan H Waters
- Department of Anesthesiology & Bioengineering, University of Pittsburgh & McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
| | - Mark Yazer
- Division of Transfusion Medicine, Department of Pathology, University of Pittsburgh, Institute for Transfusion Medicine, Pittsburgh, PA, USA
| | - Alyssa Ziman
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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41
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Davis BA, Allard S, Qureshi A, Porter JB, Pancham S, Win N, Cho G, Ryan K. Guidelines on red cell transfusion in sickle cell disease. Part I: principles and laboratory aspects. Br J Haematol 2016; 176:179-191. [DOI: 10.1111/bjh.14346] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
| | - Shubha Allard
- Barts Health NHS Trust & NHS Blood and Transplant; London UK
| | - Amrana Qureshi
- Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - John B. Porter
- University College London Hospitals NHS Foundation Trust; London UK
| | - Shivan Pancham
- Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
| | - Nay Win
- NHS Blood and Transplant; London UK
| | | | - Kate Ryan
- Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
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42
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Habibi A, Mekontso-Dessap A, Guillaud C, Michel M, Razazi K, Khellaf M, Chami B, Bachir D, Rieux C, Melica G, Godeau B, Galacteros F, Bartolucci P, Pirenne F. Delayed hemolytic transfusion reaction in adult sickle-cell disease: presentations, outcomes, and treatments of 99 referral center episodes. Am J Hematol 2016; 91:989-94. [PMID: 27348613 DOI: 10.1002/ajh.24460] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 06/22/2016] [Indexed: 11/08/2022]
Abstract
Delayed hemolytic transfusion reaction (DHTR) is one of the most feared complications of sickle-cell disease (SCD). We retrospectively analyzed the clinical and biological features, treatments and outcomes of 99 DHTRs occurring in 69 referral center patients over 12 years. The first clinical signs appeared a median of 9.4 [IQR, 3-22] days after the triggering transfusion (TT). The most frequent DHTR-related clinical manifestation was dark urine/hemoglobinuria (94%). Most patients (89%) had a painful vaso-occlusive crisis and 50% developed a secondary acute chest syndrome (ACS). The median [IQR] hemoglobin-concentration nadir was 5.5 [4.5-6.3] g/dL and LDH peak was 1335 [798-2086] IU/L. Overall mortality was 6%. None of the patients had been receiving chronic transfusions. Among these DHTRs, 61% were developed in previously immunized patients, 28% in patients with prior DHTR. Among Abs detected after the TT in 62% of the episodes, half are classically considered potentially harmful. No association could be established between clinical severity and immunohematological profile and/or the type and specificity of Abs detected after the TT. Management consisted of supportive care alone (53%) or with adjunctive measures (47%), including recombinant erythropoietin and sometimes rituximab and/or immunosuppressants. Additional transfusions were either ineffective or worsened hemolysis. In some cases, severe intravascular hemolysis can be likely responsible for the vascular reaction and high rates of ACS, pulmonary hypertension and (multi)organ failure. In conclusion, clinicians and patients must recognize early DHTR signs to avoid additional transfusions. For patients with a history of RBC immunization or DHTR, transfusion indications should be restricted. Am. J. Hematol. 91:989-994, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Anoosha Habibi
- Unité des Maladies Génétiques du Globule Rouge, APHP, Hôpitaux Universitaire Henri-Mondor; Créteil France
- UPEC, Institut Mondor de Recherche Biomédicale (IMRB), Institut National de la Santé et de le Recherche Médicale (INSERM) U955; DHU A-TVB Créteil France
| | - Armand Mekontso-Dessap
- Service de Réanimation Médicale, Créteil, APHP, Hôpitux Universitaire Henri-Mondor, DHU A-TVB; France
- Faculté de Médecine, Groupe de Recherche CARMAS, Université Paris-Est Créteil; Créteil France
| | - Constance Guillaud
- Service de Médecine Interne, APHP, Hôpitaux Universitaire Henri-Mondor; Créteil France
| | - Marc Michel
- Service de Médecine Interne, APHP, Hôpitaux Universitaire Henri-Mondor; Créteil France
| | - Keyvan Razazi
- Service de Réanimation Médicale, Créteil, APHP, Hôpitux Universitaire Henri-Mondor, DHU A-TVB; France
| | - Mehdi Khellaf
- UPEC, Institut Mondor de Recherche Biomédicale (IMRB), Institut National de la Santé et de le Recherche Médicale (INSERM) U955; DHU A-TVB Créteil France
- Service des Urgences, APHP, Hôpitaux Universitaire Henri-Mondor; Créteil France
| | - Btissam Chami
- Faculté de Médecine Créteil, Établissement Français du Sang (EFS) Île-de-France; Créteil France
| | - Dora Bachir
- Unité des Maladies Génétiques du Globule Rouge, APHP, Hôpitaux Universitaire Henri-Mondor; Créteil France
| | - Claire Rieux
- Service d'Hémovigilance, APHP, Hôpitaux Universitaire Henri-Mondor; Créteil France
| | - Giovanna Melica
- Service d'Immunologie Clinique, APHP, Hôpitaux Universitaire Henri-Mondor; Créteil France
| | - Bertrand Godeau
- Service des Urgences, APHP, Hôpitaux Universitaire Henri-Mondor; Créteil France
| | - Frédéric Galacteros
- Unité des Maladies Génétiques du Globule Rouge, APHP, Hôpitaux Universitaire Henri-Mondor; Créteil France
- UPEC, Institut Mondor de Recherche Biomédicale (IMRB), Institut National de la Santé et de le Recherche Médicale (INSERM) U955; DHU A-TVB Créteil France
| | - Pablo Bartolucci
- Unité des Maladies Génétiques du Globule Rouge, APHP, Hôpitaux Universitaire Henri-Mondor; Créteil France
- UPEC, Institut Mondor de Recherche Biomédicale (IMRB), Institut National de la Santé et de le Recherche Médicale (INSERM) U955; DHU A-TVB Créteil France
| | - France Pirenne
- UPEC, Institut Mondor de Recherche Biomédicale (IMRB), Institut National de la Santé et de le Recherche Médicale (INSERM) U955; DHU A-TVB Créteil France
- Faculté de Médecine Créteil, Établissement Français du Sang (EFS) Île-de-France; Créteil France
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Etiopathological mechanisms and clinical characteristics of hyperhemolysis syndrome in Spanish patients with thalassemia. Ann Hematol 2016; 95:1419-27. [DOI: 10.1007/s00277-016-2733-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/15/2016] [Indexed: 10/21/2022]
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Chadebech P, de Ménorval MA, Bodivit G, Mekontso-Dessap A, Pakdaman S, Jouard A, Galactéros F, Bierling P, Habibi A, Pirenne F. Evidence of benefits from using fresh and cryopreserved blood to transfuse patients with acute sickle cell disease. Transfusion 2016; 56:1730-8. [PMID: 27184475 DOI: 10.1111/trf.13636] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/26/2016] [Accepted: 03/27/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND The transfusion of red blood cell (RBC) concentrates is the main treatment for acute vaso-occlusive symptoms in sickle cell disease (SCD). Units of packed RBCs (pRBCs) must retain optimal characteristics for transfusion throughout the storage period. Transfused RBCs interact with the plasma and the endothelium that lines blood vessels and may be the target of immune-hematologic conflict if the patient produces antibodies against RBCs. Questions remain concerning the benefit-risk balance of RBC transfusions, in particular about the shelf-life of the units. STUDY DESIGN AND METHODS Plasma samples from 33 hemoglobin SS patients with SCD who had severe acute-phase symptoms or were in steady-state were put in contact with 10 fresh-stored and older stored samples from the same 10 RBC units. The factors affecting RBC survival (phosphatidylserine exposure, cytosolic calcium influx, cell size reduction) were analyzed. RESULTS We show that the effects of plasma samples from patients with SCD on pRBCs depend on the clinical condition of the patients and the duration of red cell storage. Signs of RBC senescence were correlated with the clinical status of the patient from whom the plasma sample was obtained. A decrease in RBC size and an increase in phosphatidylserine exposure were correlated with the duration of RBC storage. The behavior of cryopreserved pRBCs was similar to that of fresh refrigerated RBCs when challenged with patient plasma samples. CONCLUSION The key points of this study are that the clinical condition of patients with SCD can negatively affect the integrity of pRBCs for transfusion, and those effects increase with longer storage. Also, cryopreserved pRBCs behave similarly to fresh RBCs when challenged with plasma samples from patients with SCD in acute phase. Our data provide the first evidence that fresh RBCs stored for short periods may be of greater benefit to patients with SCD than RBCs that have been refrigerated for longer periods, particularly for those who have acute symptoms of SCD.
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Affiliation(s)
- Philippe Chadebech
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor.,IMRB-INSERM U955, Equipe 2-Transfusion et Maladies du Globule Rouge, Institut Mondor, Créteil, France.,Laboratoire d'Excellence GR-Ex, Paris, France
| | - Marie-Amélie de Ménorval
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor.,IMRB-INSERM U955, Equipe 2-Transfusion et Maladies du Globule Rouge, Institut Mondor, Créteil, France.,Laboratoire d'Excellence GR-Ex, Paris, France
| | - Gwellaouen Bodivit
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor.,IMRB-INSERM U955, Equipe 2-Transfusion et Maladies du Globule Rouge, Institut Mondor, Créteil, France.,Laboratoire d'Excellence GR-Ex, Paris, France
| | | | - Sadaf Pakdaman
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor.,IMRB-INSERM U955, Equipe 2-Transfusion et Maladies du Globule Rouge, Institut Mondor, Créteil, France.,Laboratoire d'Excellence GR-Ex, Paris, France
| | - Alicia Jouard
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor.,IMRB-INSERM U955, Equipe 2-Transfusion et Maladies du Globule Rouge, Institut Mondor, Créteil, France.,Laboratoire d'Excellence GR-Ex, Paris, France
| | - Frédéric Galactéros
- Centre de Référence des Syndromes Drépanocytaires Majeurs, Hôpital Henri-Mondor, AP-HP, Université Paris-Est
| | - Philippe Bierling
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor.,IMRB-INSERM U955, Equipe 2-Transfusion et Maladies du Globule Rouge, Institut Mondor, Créteil, France.,Laboratoire d'Excellence GR-Ex, Paris, France
| | - Anoosha Habibi
- Centre de Référence des Syndromes Drépanocytaires Majeurs, Hôpital Henri-Mondor, AP-HP, Université Paris-Est
| | - France Pirenne
- Etablissement Français du Sang, Île-de-France, Hôpital Henri-Mondor.,IMRB-INSERM U955, Equipe 2-Transfusion et Maladies du Globule Rouge, Institut Mondor, Créteil, France.,Laboratoire d'Excellence GR-Ex, Paris, France.,UPEC, Université Paris-Est, Créteil, France
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45
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Ibanez C, Habibi A, Mekontso-Dessap A, Chadebech P, Chami B, Bierling P, Galactéros F, Rieux C, Nataf J, Bartolucci P, Peyrard T, Pirenne F. Anti-HI can cause a severe delayed hemolytic transfusion reaction with hyperhemolysis in sickle cell disease patients. Transfusion 2016; 56:1828-33. [PMID: 27145018 DOI: 10.1111/trf.13611] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 02/02/2016] [Accepted: 02/02/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Delayed hemolytic transfusion reaction (DHTR) is a life-threatening condition in sickle cell disease (SCD) patients that is frequently complicated by hyperhemolysis. Antibodies resulting from antigen disparity between donors of European ancestry and patients of African ancestry are common, but situations involving antibodies not classically of clinical significance are also encountered. Anti-HI is generally considered to be an innocuous naturally occurring antibody. STUDY DESIGN AND METHODS We describe two cases of hyperhemolysis with anti-HI and provide details of the reported cases. RESULTS Both SCD patients were polyimmunized and belonged to blood group B. They developed anti-HI that was reactive at 37°C, after the transfusion of group O red blood cell units matched for all known and produced antibodies classically considered to be clinically significant. Both patients developed DHTR with hyperhemolysis. In the first case, a pregnant woman, a second transfusion was unavoidable and the patient died from cardiac arrest. The state of the second patient improved without the need for further transfusion. CONCLUSION Three other cases of DHTR with anti-HI have been described in the literature in SCD patients. The two additional cases reported here definitively demonstrate that anti-HI is dangerous in SCD patients. As a result, ABO-identical matching (including A1 status) must be considered in SCD patients with anti-HI.
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Affiliation(s)
- Clara Ibanez
- Établissement Français du Sang, Ile de France, Hôpital Henri Mondor
| | - Anoosha Habibi
- IMRB, INSERM U955, Equipe 2: Transfusion et maladies du globule rouge, Institut Mondor de Recherche Biomédicale, UPEC, Créteil, France.,Centre de Référence des Syndromes Drépanocytaires Majeurs, Hôpital Henri Mondor, AP-HP, UPEC, Créteil.,Laboratoire D'Excellence GR-Ex, F-75015 Paris, France
| | | | - Philippe Chadebech
- Établissement Français du Sang, Ile de France, Hôpital Henri Mondor.,IMRB, INSERM U955, Equipe 2: Transfusion et maladies du globule rouge, Institut Mondor de Recherche Biomédicale, UPEC, Créteil, France.,Laboratoire D'Excellence GR-Ex, F-75015 Paris, France
| | - Btissam Chami
- Établissement Français du Sang, Ile de France, Hôpital Henri Mondor
| | - Philippe Bierling
- Établissement Français du Sang, Ile de France, Hôpital Henri Mondor.,IMRB, INSERM U955, Equipe 2: Transfusion et maladies du globule rouge, Institut Mondor de Recherche Biomédicale, UPEC, Créteil, France
| | - Frédéric Galactéros
- IMRB, INSERM U955, Equipe 2: Transfusion et maladies du globule rouge, Institut Mondor de Recherche Biomédicale, UPEC, Créteil, France.,Centre de Référence des Syndromes Drépanocytaires Majeurs, Hôpital Henri Mondor, AP-HP, UPEC, Créteil.,Laboratoire D'Excellence GR-Ex, F-75015 Paris, France
| | - Claire Rieux
- Unité de Sécurité Transfusionnelle et d'Hémovigilance, Hôpital Henri Mondor, AP-HP, Créteil, France
| | - Joëlle Nataf
- Institut National de la Transfusion Sanguine, Département Centre National de référence pour les Groupes Sanguins
| | - Pablo Bartolucci
- IMRB, INSERM U955, Equipe 2: Transfusion et maladies du globule rouge, Institut Mondor de Recherche Biomédicale, UPEC, Créteil, France.,Centre de Référence des Syndromes Drépanocytaires Majeurs, Hôpital Henri Mondor, AP-HP, UPEC, Créteil.,Laboratoire D'Excellence GR-Ex, F-75015 Paris, France
| | - Thierry Peyrard
- Laboratoire D'Excellence GR-Ex, F-75015 Paris, France.,Institut National de la Transfusion Sanguine, Département Centre National de référence pour les Groupes Sanguins.,INSERM UMR_S1134, F-75015 Paris, France
| | - France Pirenne
- Établissement Français du Sang, Ile de France, Hôpital Henri Mondor.,IMRB, INSERM U955, Equipe 2: Transfusion et maladies du globule rouge, Institut Mondor de Recherche Biomédicale, UPEC, Créteil, France.,Laboratoire D'Excellence GR-Ex, F-75015 Paris, France
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Novelli EM, Gladwin MT. Crises in Sickle Cell Disease. Chest 2015; 149:1082-93. [PMID: 26836899 DOI: 10.1016/j.chest.2015.12.016] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/04/2015] [Accepted: 12/11/2015] [Indexed: 12/16/2022] Open
Abstract
In spite of significant strides in the treatment of sickle cell disease (SCD), SCD crises are still responsible for high morbidity and early mortality. While most patients initially seek care in the acute setting for a seemingly uncomplicated pain episode (pain crisis or vaso-occlusive crisis), this initial event is the primary risk factor for potentially life-threatening complications. The pathophysiological basis of these illnesses is end-organ ischemia and infarction combined with the downstream effects of hemolysis that results from red blood cell sickling. These pathological changes can occur acutely and lead to a dramatic clinical presentation, but are frequently superimposed over a milieu of chronic vasculopathy, immune dysregulation, and decreased functional reserve. In the lungs, acute chest syndrome is a particularly ominous lung injury syndrome with a complex pathogenesis and potentially devastating sequelae, but all organ systems can be affected. It is, therefore, critical to understand the SCD patients' susceptibility to acute complications and their risk factors so that they can be recognized promptly and managed effectively. Blood transfusions remain the mainstay of therapy for all severe acute crises. Recommendations and indications for the safest and most efficient implementation of transfusion strategies in the critical care setting are therefore presented and discussed, together with their pitfalls and potential future therapeutic alternatives. In particular, the importance of extended phenotypic red blood cell matching cannot be overemphasized, due to the high prevalence of severe complications from red cell alloimmunization in SCD.
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Affiliation(s)
- Enrico M Novelli
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Abstract
Abstract
The lack of a strong evidence base to guide the management of adults with sickle cell disease (SCD) makes it difficult for patients to receive high quality care outside of specialty centers. As there is a dearth of providers with sickle cell expertise, the purpose of this article is to identify some of the key things every provider who manages the care of adults with SCD should know. Managing adults with SCD requires excellent clinical skills, as it can affect every organ and cause life-threatening complications but it also requires a willingness to manage patients who often have psychosocial issues that are complex and impact care and care delivery in very significant ways. We have chosen topics for which there is a limited evidence base but which have significant clinical consequences if left unrecognized or poorly managed. The topics that will be addressed include chronic pain, neurocognitive dysfunction, renal disease, venous thromboembolism, and avoiding the inappropriate use of red cell transfusions.
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48
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Nickel RS, Horan JT, Fasano RM, Meyer E, Josephson CD, Winkler AM, Yee ME, Kean LS, Hendrickson JE. Immunophenotypic parameters and RBC alloimmunization in children with sickle cell disease on chronic transfusion. Am J Hematol 2015; 90:1135-41. [PMID: 26361243 DOI: 10.1002/ajh.24188] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 09/03/2015] [Accepted: 09/09/2015] [Indexed: 12/16/2022]
Abstract
Alloimmunization against red blood cell (RBC) antigens is a cause of morbidity and mortality in transfused patients with sickle cell disease (SCD). To investigate distinguishing characteristics of patients who develop RBC alloantibodies after transfusion (responders) versus those who do not (non-responders), a cross-sectional study of 90 children with SCD on chronic RBC transfusion therapy at a single institution was conducted in which 18 immune parameters (including T and B cell subsets) were tested via flow cytometry, and medical records were reviewed. RBC alloimmunization was present in 26/90 (29%) patients, with anti-E, K, and C among the most commonly detected alloantibodies despite prophylactic matching for these antigens at the study institution. In addition, RBC autoantibodies had been detected in 18/26 (69%) of alloimmunized versus 7/64 (11%) of non-alloimmunized patients (P < 0.0001). Alloimmunized patients were significantly older (median 13.0 years vs. 10.7 years, P = 0.010) and had more RBC unit exposures (median 148 U vs. 82 U, P = 0.020) than non-alloimmunized patients. Sex, age at initiation of chronic transfusion, splenectomy, stroke, and transfusion outside of the study institution were not significantly associated with RBC alloimmunization. Alloimmunized patients had a significantly increased percentage of CD4+ T memory cells compared to non-alloimmunized patients (57% vs. 49%, P = 0.0047), with no other significant differences in immune cell subsets or laboratory values detected between these groups. Additional research of RBC alloimmunization is needed to optimize transfusion therapy and to develop strategies to prevent alloimmunization.
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Affiliation(s)
- Robert S. Nickel
- Division of Hematology; Children's National Health System; Washington District of Columbia
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine; Emory University; Atlanta Georgia
| | - John T. Horan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
| | - Ross M. Fasano
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine; Emory University; Atlanta Georgia
| | - Erin Meyer
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine; Emory University; Atlanta Georgia
| | - Cassandra D. Josephson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine; Emory University; Atlanta Georgia
| | - Anne M. Winkler
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine; Emory University; Atlanta Georgia
| | - Marianne E.M. Yee
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
| | - Leslie S. Kean
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Department of Pediatrics, University of Washington, and the Fred Hutchinson Cancer Research Center; Seattle Washington
| | - Jeanne E. Hendrickson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University; Atlanta Georgia
- Department of Laboratory Medicine; Yale University; New Haven Connecticut
- Department of Pediatrics; Yale University; New Haven Connecticut
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49
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Nickel RS, Hendrickson JE, Fasano RM, Meyer EK, Winkler AM, Yee MM, Lane PA, Jones YA, Pashankar FD, New T, Josephson CD, Stowell SR. Impact of red blood cell alloimmunization on sickle cell disease mortality: a case series. Transfusion 2015; 56:107-14. [DOI: 10.1111/trf.13379] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/29/2015] [Accepted: 08/06/2015] [Indexed: 12/21/2022]
Affiliation(s)
- Robert Sheppard Nickel
- Center for Transfusion and Cellular Therapy, Department of Pathology; Emory University; Atlanta Georgia
- Division of Hematology; Children's National Health System; Washington DC
| | - Jeanne E. Hendrickson
- Center for Transfusion and Cellular Therapy, Department of Pathology; Emory University; Atlanta Georgia
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta; Emory University; Atlanta Georgia
- Department of Pediatrics; Yale University; New Haven Connecticut
- Department of Laboratory Medicine; Yale University; New Haven Connecticut
| | - Ross M. Fasano
- Center for Transfusion and Cellular Therapy, Department of Pathology; Emory University; Atlanta Georgia
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta; Emory University; Atlanta Georgia
| | - Erin K. Meyer
- Center for Transfusion and Cellular Therapy, Department of Pathology; Emory University; Atlanta Georgia
| | - Anne M. Winkler
- Center for Transfusion and Cellular Therapy, Department of Pathology; Emory University; Atlanta Georgia
| | - Marianne M. Yee
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta; Emory University; Atlanta Georgia
| | - Peter A. Lane
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta; Emory University; Atlanta Georgia
| | - Yuritzi A. Jones
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta; Emory University; Atlanta Georgia
| | | | - Tamara New
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta; Emory University; Atlanta Georgia
| | - Cassandra D. Josephson
- Center for Transfusion and Cellular Therapy, Department of Pathology; Emory University; Atlanta Georgia
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta; Emory University; Atlanta Georgia
| | - Sean R. Stowell
- Center for Transfusion and Cellular Therapy, Department of Pathology; Emory University; Atlanta Georgia
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50
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Hyperhemolysis in Patients With Hemoglobinopathies: A Single-Center Experience and Review of the Literature. Transfus Med Rev 2015. [DOI: 10.1016/j.tmrv.2015.06.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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