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Adkins BD, Jacobs JW, Booth GS, Savani BN, Stephens LD. Transfusion Support in Hematopoietic Stem Cell Transplantation: A Contemporary Narrative Review. Clin Hematol Int 2024; 6:128-140. [PMID: 38817704 PMCID: PMC11086996 DOI: 10.46989/001c.94135] [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: 12/01/2023] [Accepted: 02/05/2024] [Indexed: 06/01/2024] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a cornerstone of modern medical practice, and can only be performed safely and effectively with appropriate transfusion medicine support. Patients undergoing HSCT often develop therapy-related cytopenia, necessitating differing blood product requirements in the pre-, peri-, and post-transplant periods. Moreover, ensuring optimal management for patients alloimmunized to human leukocyte antigens (HLA) and/or red blood cell (RBC) antigens, as well as for patients receiving ABO-incompatible transplants, requires close collaboration with transfusion medicine and blood bank professionals. Finally, as updated transfusion guidelines and novel blood product modifications emerge, the options available to the transplant practitioner continue to expand. Herein, we detail contemporary blood transfusion and transfusion medicine practices for patients undergoing HSCT.
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Affiliation(s)
- Brian D. Adkins
- PathologyThe University of Texas Southwestern Medical Center
| | | | - Garrett S. Booth
- Pathology, Microbiology, and ImmunologyVanderbilt University Medical Center
| | - Bipin N. Savani
- Internal Medicine, Division of Hematology/ OncologyVanderbilt University Medical Center
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Cigna M, Leiva-Torres GA, Baillargeon N, Yanez JC, Robitaille N. Management of a patient with sickle cell disease and multiple red blood cell alloantibodies in preparation for a hematopoietic stem cell transplantation. Transfusion 2024; 64:554-559. [PMID: 38205646 DOI: 10.1111/trf.17715] [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: 09/11/2023] [Revised: 11/29/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Hematopoietic stem cell transplant (HSCT) is currently the only widely available curative option for patients with sickle cell disease (SCD). Alloimmunization in this population is frequent and can complicate transfusion management during the HSCT period. The case of a pediatric patient with severe SCD clinical phenotype, multiple alloantibodies (9), and hyperhemolysis syndrome who underwent haploidentical HSCT is described. STUDY DESIGN AND METHODS The patient was known for an anti-e, despite RHCE*01.01 allele, which predicts a C- c+ E- weak e+ phenotype. Donors matching the patient's extended phenotype were targeted for RHCE genotyping. RESULTS Donors homozygotes or heterozygotes for RHCE*01.01 were selected for compatibility analyses and ranked based on strength of reactions. Discordance between zygosity and strength of reactions was observed, as the most compatible donors were heterozygotes for RHCE*01.01. In total, the patient received seven RBC units from two different donors during HSCT process without transfusion reaction or development of new alloantibodies. Six months post-HSCT, his hemoglobin level is stable at around 120 g/L and his chimerism is 100%. DISCUSSION This case highlights the complexity of transfusion management during HSCT of alloimmunized patients with SCD. Collecting sufficient compatible units requires early involvement of transfusion medicine teams and close communication with the local blood provider. Genotyping of donors self-identifying as Black is useful for identifying compatible blood for those patients but has some limitations. HSCT for heavily alloimmunized patients is feasible and safe with early involvement of transfusion medicine specialists. Further research on the clinical impact of genotypic matching is needed.
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Affiliation(s)
- Maude Cigna
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Canada
| | | | | | | | - Nancy Robitaille
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Canada
- Transfusion Medicine, Hema-Quebec, Montreal, Canada
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Malbora B, Sarbay H, Dogusan Z, Atay AA. Effect of serum panel reactive antibodies on allogeneic hematopoietic stem cell transplantation in pediatric thalassemia patients: A single-center experience. Pediatr Transplant 2024; 28:e14648. [PMID: 38063291 DOI: 10.1111/petr.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/09/2023] [Accepted: 11/06/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND The aim of this study was to assess the impact of serum panel reactive antibodies (PRA) on the outcomes of allogeneic hematopoietic stem cell transplantation (HSCT) in pediatric thalassemia patients. METHODS A total of 73 pediatric patients with thalassemia were included in this single-center study. Pre-transplant PRA levels were evaluated, and the patients were divided into two groups: PRA-negative (group 1; n = 44) and PRA-positive (group 2; n = 29). Patient characteristics, including age, gender, donor type, stem cell source, and HLA compatibility, were analyzed. Transplant outcomes, including engraftment, transfusion requirements, and transplant-related complications, were compared between the two groups. Further subgroup analysis was performed based on MFI values. RESULTS At the time of transplantation, patients in group 1 were younger than those in group 2 (p = .008). The number of fully matched donors within the family (MSD and MFD) was significantly higher in group 1 (p = .049). Additionally, Rh blood group incompatibility was higher in group 2 (p = .03). There was no statistically significant difference in the engraftment days of neutrophils, platelets, and erythrocytes between the two groups. The frequency of poor graft function and graft failure was higher in the group 2, but there was no statistically significant difference. Post-transplant transfusion requirements for platelets and red blood cells were significantly higher in the group 2 (p < .001). Transplant-related complications such as VOD, PRES, and aGvHD were more common in the group 2, but no statistical significance was detected. CONCLUSIONS Serum PRA in pediatric thalassemia patients may impact the outcomes of HSCT. PRA-positive patients had higher rates of blood product transfusion requirements. Although poor graft function, graft failure, and post-transplant complications were more common in the group 2, statistical significance was not observed. Identifying patients with high PRA levels can assist in optimizing transplant strategies and post-transplant care, leading to improved outcomes for the patients.
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Affiliation(s)
- Baris Malbora
- Department of Pediatric Hematology and Oncology, Yeni Yuzyil University Faculty of Medicine, Gaziosmanpasa Hospital, Istanbul, Turkey
| | - Hakan Sarbay
- Department of Pediatric Hematology and Oncology, Yeni Yuzyil University Faculty of Medicine, Gaziosmanpasa Hospital, Istanbul, Turkey
| | - Zeynep Dogusan
- Bone Marrow Transplantation Center, Yeni Yuzyil University Faculty of Medicine, Gaziosmanpasa Hospital, Istanbul, Turkey
| | - Abdullah Avni Atay
- Department of Pediatric Hematology and Oncology, Yeni Yuzyil University Faculty of Medicine, Gaziosmanpasa Hospital, Istanbul, Turkey
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John T, Namazzi R, Chirande L, Tubman VN. Global perspectives on cellular therapy for children with sickle cell disease. Curr Opin Hematol 2022; 29:275-280. [PMID: 36206076 PMCID: PMC10107365 DOI: 10.1097/moh.0000000000000738] [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: 11/25/2022]
Abstract
PURPOSE OF REVIEW Low-income and middle-income countries (LMICs), primarily in sub-Saharan Africa (SSA), predominantly experience the burden of sickle cell disease (SCD). High frequency of acute and chronic complications leads to increased utilization of healthcare, which burdens fragile health systems. Mortality for children with limited healthcare access remains alarmingly high. Cellular based therapies such as allogeneic hematopoietic stem cell transplant (HSCT) are increasingly used in resource-rich settings as curative therapy for SCD. Broad access to curative therapies for SCD in SSA would dramatically alter the global impact of the disease. RECENT FINDINGS Currently, application of cellular based therapies in LMICs is limited by cost, personnel, and availability of HSCT-specific technologies and supportive care. Despite the challenges, HSCT for SCD is moving forward in LMICs. Highly anticipated gene modification therapies have recently proven well tolerated and feasible in clinical trials in resource-rich countries, but access remains extremely limited. SUMMARY Translation of curative cellular based therapies for SCD should be prioritized to LMICs where the disease burden and cost of noncurative treatments is high, and long-term quality of life is poor. Focus on thoughtful modifications of current and future therapies to meet the need in LMICs, especially in SSA, will be especially impactful.
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Affiliation(s)
- Tami John
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX 77030
- Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lulu Chirande
- School of Medicine, The Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Venée N. Tubman
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX 77030
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
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Abstract
Red blood cell (RBC) transfusion is critical in managing acute and chronic complications of sickle cell disease. Alloimmunization and iron overload remain significant complications of transfusion therapy and are minimized with prophylactic Rh and K antigen RBC matching and iron chelation. Matched sibling donor hematopoietic stem cell transplant (HSCT) is a curative therapeutic option. Autologous hematopoietic stem cell (HSC)-based gene therapy has recently shown great promise, for which obtaining sufficient HSCs is essential for success. This article discusses RBC transfusion indications and complications, transfusion support during HSCT, and HSC mobilization and collection for autologous HSCT with gene therapy.
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Affiliation(s)
- Yan Zheng
- Department of Pathology, St. Jude Children's Research Hospital, MS 342, 262 Danny Thomas Place, Memphis, TN 38105, USA
| | - Stella T Chou
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 3615 Civic Center Boulevard, Abramson Research Center Room 316D, Philadelphia, PA 19010, USA.
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Nickel RS, Flegel WA, Adams SD, Hendrickson JE, Liang H, Tisdale JF, Hsieh MM. The impact of pre-existing HLA and red blood cell antibodies on transfusion support and engraftment in sickle cell disease after nonmyeloablative hematopoietic stem cell transplantation from HLA-matched sibling donors: A prospective, single-center, observational study. EClinicalMedicine 2020; 24:100432. [PMID: 32637902 PMCID: PMC7327930 DOI: 10.1016/j.eclinm.2020.100432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) is curative for patients with sickle cell disease (SCD). Prior to HSCT, patients with SCD commonly receive RBC transfusions with some becoming RBC or HLA alloimmunized. This alloimmunization may impact post-HSCT transfusion requirements and donor engraftment. METHODS The study population included patients with SCD transplanted on a single-center nonmyeloablative, HLA-matched sibling HSCT trial at the National Heart, Lung, and Blood Institute (NHLBI) who had a pre-HSCT sample available for HLA class I antibody testing. We evaluated transfusion requirements and engraftment outcomes comparing patients with and without pre-existing HLA and RBC antibodies. FINDINGS Of 36 patients studied, 10 (28%) had HLA class I antibodies and 11 (31%) had a history of RBC alloantibodies. Up to day +45 post-HSCT, patients with HLA antibodies received more platelet transfusions (median 2.5 vs 1, p = 0.042) and those with RBC alloantibodies received more RBC units (median 7 vs 4, p = 0.0059) compared to respective non-alloimmunized patients. HLA alloimmunization was not associated with neutrophil engraftment, donor chimerism, or graft rejection. However, RBC alloimmunization correlated with a decreased donor T cell chimerism at 1 year (median 24% vs 55%, p = 0.035). INTERPRETATION Pre-existing HLA and RBC alloantibodies are clinically significant for patients undergoing HLA-matched nonmyeloablative HSCT. Testing for both HLA and RBC antibodies is important to help estimate transfusion needs peri‑HSCT. The association of lower donor T cell chimerism and pre-existing RBC alloantibodies needs further investigation. FUNDING NIH Clinical Center and NHLBI Intramural Research Program (Z99 CL999999, HL006007-11) and the Thrasher Research Fund.
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Affiliation(s)
- Robert Sheppard Nickel
- Children's National Hospital, Division of Hematology, 111 Michigan Ave NW, Washington, DC 20010, United States
- The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
- Corresponding author at: Children's National Hospital, Division of Hematology, 111 Michigan Ave NW, Washington, DC 20010, United States.
| | - Willy A. Flegel
- Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Sharon D. Adams
- Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Jeanne E. Hendrickson
- Departments of Laboratory Medicine and Pediatrics, Yale School of Medicine, New Haven, CT, United States
| | - Hua Liang
- The George Washington University, Department of Statistics, Washington, DC, United States
| | - John F. Tisdale
- Cellular and Molecular Therapeutics Branch, National Institutes of Health, Bethesda, MD, United States
| | - Matthew M. Hsieh
- Cellular and Molecular Therapeutics Branch, National Institutes of Health, Bethesda, MD, United States
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De Santis GC, Costa TCM, Santos FLS, da Silva-Pinto AC, Stracieri ABPL, Pieroni F, Darrigo-Júnior LG, de Faria JTB, Grecco CES, de Moraes DA, Elias Dias JB, Oliveira MC, Covas DT, Cunha R, Simões BP. Blood transfusion support for sickle cell patients during haematopoietic stem cell transplantation: a single-institution experience. Br J Haematol 2020; 190:e295-e297. [PMID: 32419156 DOI: 10.1111/bjh.16703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Gil C De Santis
- Center for Cell-based Therapy and Regional Blood Center of Ribeirão Preto, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Thalita C M Costa
- School of Medicine, Bone Marrow Transplantation Unit, Hospital das Clínicas, University of São Paulo, Ribeirão Preto, Brazil
| | - Flávia L S Santos
- Center for Cell-based Therapy and Regional Blood Center of Ribeirão Preto, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Ana C da Silva-Pinto
- Center for Cell-based Therapy and Regional Blood Center of Ribeirão Preto, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Ana B P L Stracieri
- School of Medicine, Bone Marrow Transplantation Unit, Hospital das Clínicas, University of São Paulo, Ribeirão Preto, Brazil
| | - Fabiano Pieroni
- School of Medicine, Bone Marrow Transplantation Unit, Hospital das Clínicas, University of São Paulo, Ribeirão Preto, Brazil
| | - Luiz G Darrigo-Júnior
- School of Medicine, Bone Marrow Transplantation Unit, Hospital das Clínicas, University of São Paulo, Ribeirão Preto, Brazil
| | - Joana T B de Faria
- School of Medicine, Bone Marrow Transplantation Unit, Hospital das Clínicas, University of São Paulo, Ribeirão Preto, Brazil
| | - Carlos E S Grecco
- School of Medicine, Bone Marrow Transplantation Unit, Hospital das Clínicas, University of São Paulo, Ribeirão Preto, Brazil
| | - Daniela A de Moraes
- School of Medicine, Bone Marrow Transplantation Unit, Hospital das Clínicas, University of São Paulo, Ribeirão Preto, Brazil
| | - Juliana B Elias Dias
- School of Medicine, Bone Marrow Transplantation Unit, Hospital das Clínicas, University of São Paulo, Ribeirão Preto, Brazil
| | - Maria C Oliveira
- School of Medicine, Bone Marrow Transplantation Unit, Hospital das Clínicas, University of São Paulo, Ribeirão Preto, Brazil
| | - Dimas T Covas
- Center for Cell-based Therapy and Regional Blood Center of Ribeirão Preto, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Renato Cunha
- School of Medicine, Bone Marrow Transplantation Unit, Hospital das Clínicas, University of São Paulo, Ribeirão Preto, Brazil
| | - Belinda P Simões
- School of Medicine, Bone Marrow Transplantation Unit, Hospital das Clínicas, University of São Paulo, Ribeirão Preto, Brazil
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Nickel RS, Horan JT, Abraham A, Qayed M, Haight A, Ngwube A, Liang H, Luban NLC, Hendrickson JE. Human leukocyte antigen (HLA) class I antibodies and transfusion support in paediatric HLA‐matched haematopoietic cell transplant for sickle cell disease. Br J Haematol 2019; 189:162-170. [DOI: 10.1111/bjh.16298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/19/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Robert S. Nickel
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
| | - John T. Horan
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Allistair Abraham
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Ann Haight
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders Phoenix Children's Hospital Phoenix AZUSA
| | - Hua Liang
- Department of Statistics The George Washington University Washington DCUSA
| | - Naomi L. C. Luban
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
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Abstract
Pediatric oncology patients will likely require numerous transfusions of blood products, including red blood cell, platelet, and plasma transfusions, during the course of their treatment. Although strong evidence-based guidelines for these products in this patient population do not exist, given the morbidities associated with the receipt of blood products, practitioners should attempt to use restrictive transfusion strategies.
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Allen ES, Nelson RC, Flegel WA. How we evaluate red blood cell compatibility and transfusion support for patients with sickle cell disease undergoing hematopoietic progenitor cell transplantation. Transfusion 2018; 58:2483-2489. [PMID: 30403414 DOI: 10.1111/trf.14871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 12/23/2022]
Abstract
Multiple hematopoietic progenitor cell (HPC) transplantation options for patients with sickle cell disease (SCD) are currently under investigation. Patients with SCD have a high rate of alloimmunization to red blood cell antigens, often complicating transfusion support. Transfusion reactions, including acute and delayed hemolytic reactions, have been observed despite immunosuppressive regimens. Allogeneic donor transplants have been shown to carry a risk of prolonged reticulocytopenia and acute hemolysis with severe anemia in nonmyeloablative regimens. We discuss our experience providing transfusion support to patients with SCD undergoing HPC transplantation, propose an outline for a complete pretransplantation evaluation, and discuss donor/recipient compatibility issues and their implications.
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Affiliation(s)
- Elizabeth S Allen
- Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland.,Department of Pathology, University of California at San Diego, La Jolla, California
| | - Randin C Nelson
- Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland.,Department of Pathology, Montefiore Medical Center, Bronx, New York
| | - Willy A Flegel
- Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland
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11
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Recommendations on RBC Transfusion Support in Children With Hematologic and Oncologic Diagnoses From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S149-S156. [PMID: 30161070 PMCID: PMC6126910 DOI: 10.1097/pcc.0000000000001610] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the recommendations and supporting evidence for RBC transfusions in critically ill children with hematologic and oncologic disease from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations and research priorities for RBC transfusions in critically ill children. The hematologic/oncologic subgroup included seven experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS The hematologic/oncologic subgroup developed 14 recommendations (seven clinical, seven research); all achieved greater than 80% agreement. In patients with sickle cell disease, Transfusion and Anemia Expertise Initiative recommends: 1) RBC transfusion to achieve a target hemoglobin concentration of 10 g/dL rather than hemoglobin of less than 30% prior to surgical procedures requiring general anesthesia and 2) exchange transfusion over simple (nonexchange) transfusion if the child's condition is deteriorating (based on clinical judgment), otherwise a simple, nonexchange RBC transfusion is recommended. There is insufficient evidence to make recommendations on transfusion thresholds for patients with sickle cell disease prior to minor procedures, with acute stroke or with pulmonary hypertension. For patients with oncologic disease or undergoing hematopoietic stem cell transplant, a hemoglobin concentration of 7-8 g/dL is recommended. Due to lack of evidence, research is needed to clarify the appropriate transfusion thresholds in these patients. CONCLUSIONS Transfusion and Anemia Expertise Initiative developed specific pediatric recommendations regarding RBC transfusion management in critically ill children with sickle cell disease, oncologic disease, and hematopoietic stem cell transplant and recommendations to help guide future research priorities.
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12
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Immunohaematological complications in patients with sickle cell disease after haemopoietic progenitor cell transplantation: a prospective, single-centre, observational study. LANCET HAEMATOLOGY 2018; 4:e553-e561. [PMID: 29100558 DOI: 10.1016/s2352-3026(17)30196-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/09/2017] [Accepted: 09/14/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Haemopoietic progenitor cell (HPC) transplantation can cure sickle cell disease. Non-myeloablative conditioning typically results in donor-derived erythrocytes and stable mixed chimerism of recipient-derived and donor-derived leucocytes. Exposure to donor antigens from the HPC graft and new red cell antibodies induced by transfusion can lead to immunohaematological complications. We assessed the incidence of such complications among HPC transplant recipients with sickle cell disease. METHODS The study population was all patients with sickle cell disease enrolled before March 31, 2015, in the three clinical trials of non-myeloablative HPC transplantation at the National Institutes of Health. We assessed formation of new red cell antibodies after transplantation and red cell incompatibility between donors and recipients. FINDINGS 61 patients were enrolled, 42 were HLA matched and 19 were haploidentical. Nine (15%) had immunohaematological complications. Before HPC transplantation, three patients had antibodies incompatible with their donors. After HPC transplantation, new red cell antibodies were seen in six patients (11 alloantibodies and two autoantibodies), among whom three developed antibodies incompatible with donor or recipient red cells and three developed compatible antibodies. The clinical course of complications was highly variable, from no severe effects attributable to antibodies, to sustained reticulocytopenia, to near-fatal haemolysis. We found no significant correlation between immunohaematological complications and graft failure, graft rejection, or death. INTERPRETATION Clinical effects ranged from seemingly not clinically important to potentially fatal. In patients with sickle cell disease, donor and recipient red cell phenotypes should be carefully assessed before transplantation to minimise and manage the risk of immunohaematological complications. FUNDING Intramural Research Program and National Institutes of Health.
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13
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Yee MEM, Josephson CD, Winkler AM, Webb J, Luban NLC, Leong T, Stowell SR, Roback JD, Fasano RM. Hemoglobin A clearance in children with sickle cell anemia on chronic transfusion therapy. Transfusion 2018; 58:1363-1371. [PMID: 29664198 DOI: 10.1111/trf.14610] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/24/2018] [Accepted: 01/29/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chronic transfusion therapy for sickle cell anemia reduces disease complications by diluting sickle-erythrocytes with hemoglobin A (HbA)-containing erythrocytes and suppressing erythropoiesis. Minor antigen mismatches may result in alloimmunization, but it is unknown if antigen mismatches or recipient characteristics influence HbA clearance posttransfusion. STUDY DESIGN AND METHODS Children with sickle cell anemia on chronic transfusion therapy were followed prospectively for 12 months. All patients received units serologically matched for C/c, E/e, and K; patients with prior red blood cell (RBC) antibodies had additional matching for Fya , Jkb , and any previous alloantibodies. Patients' RBC antigen genotypes, determined by multiplexed molecular assays (PreciseType Human Erythrocyte Antigen, and RHCE and RHD BeadChip, Immucor) were compared to genotypes of transfused RBC units to assess for antigen mismatches. Decline in hbA (ΔHbA) from posttransfusion to the next transfusion was calculated for each transfusion episode. RESULTS Sixty patients received 789 transfusions, 740 with ΔHbA estimations, and 630 with donor Human Erythrocyte Antigen genotyping. In univariate mixed-model analysis, ΔHbA was higher in patients with past RBC antibodies or splenomegaly and lower in patients with splenectomy. RBC antigen mismatches were not associated with ΔHbA. In multivariate linear mixed-effects modeling, ΔHbA was associated with RBC antibodies (2.70 vs. 2.45 g/dL/28 d, p = 0.0028), splenomegaly (2.87 vs. 2.28 g/dL/28 d, p = 0.019), and negatively associated with splenectomy (2.46 vs. 2.70 g/dL/28 d, p = 0.011). CONCLUSIONS HbA decline was increased among patients with sickle cell anemia with prior immunologic response to RBC antigens and decreased among those with prior splenectomy, demonstrating that recipient immunologic characteristics influenced the clearance of transfused RBCs.
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Affiliation(s)
- Marianne E M Yee
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics and Hematology/Oncology, Emory University School of Medicine and the
| | - Cassandra D Josephson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics and Hematology/Oncology, Emory University School of Medicine and the.,Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia; the
| | - Anne M Winkler
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia; the
| | - Jennifer Webb
- Center for Cancer and Blood Disorders, Children's National Medical Center, Departments of Hematology and Laboratory Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Naomi L C Luban
- Center for Cancer and Blood Disorders, Children's National Medical Center, Departments of Hematology and Laboratory Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Emory University, Rollins School of Public Health, Atlanta, Georgia
| | - Sean R Stowell
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia; the
| | - John D Roback
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia; the
| | - Ross M Fasano
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia; the
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14
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Webb J, Abraham A. Complex Transfusion Issues in Pediatric Hematopoietic Stem Cell Transplantation. Transfus Med Rev 2016; 30:202-8. [PMID: 27439965 DOI: 10.1016/j.tmrv.2016.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/15/2016] [Indexed: 12/13/2022]
Abstract
Advances in the fields of pediatric transfusion medicine and hematopoietic stem cell transplant have resulted in improved outcomes but also present new questions for research. The diagnostic capabilities involved in transfusion medicine have improved in recent times, now including methods for determination of red blood cell minor antigens, detection of anti-human leukocyte antigen antibodies, and noninvasive iron quantification. At the same time, transplants are being performed for more indications including nonmalignant disease and with less intense conditioning regimens that allow some recipient blood cells to persist after transplant. We are therefore faced with new opportunities to understand the implications of transfusion medicine testing and to develop data-driven guidelines relevant to the current-day approach to transfusion and transplantation.
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Affiliation(s)
- Jennifer Webb
- Division of Transfusion Medicine, Children's National Medical Center, Washington, DC.
| | - Allistair Abraham
- Division of Blood and Marrow Transplantation, Children's National Medical Center, Washington, DC
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Bercovitz RS, Josephson CD. Transfusion Considerations in Pediatric Hematology and Oncology Patients. Hematol Oncol Clin North Am 2016; 30:695-709. [DOI: 10.1016/j.hoc.2016.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Fasano RM, Leong T, Kaushal M, Sagiv E, Luban NLC, Meier ER. Effectiveness of red blood cell exchange, partial manual exchange, and simple transfusion concurrently with iron chelation therapy in reducing iron overload in chronically transfused sickle cell anemia patients. Transfusion 2016; 56:1707-15. [PMID: 26997031 DOI: 10.1111/trf.13558] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/27/2016] [Accepted: 02/02/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic transfusion therapy (CTT) is indicated for stroke prevention in children with sickle cell anemia (SCA) and is complicated by iron overload and alloimmunization. CTT is performed by simple transfusion (ST), partial manual exchange (PME), or erythrocytapheresis (RCE). Although small case series have demonstrated RCE in combination with iron chelation therapy stabilizes and/or decreases ferritin, there are no reports comparing the effect of ST, PME, and RCE on liver iron concentration (LIC). CTT modality effect on serum ferritin and LIC were compared in SCA patients on iron chelation, with hemoglobin (Hb)S goal of 30%. STUDY DESIGN AND METHODS Medical records of SCA patients on CTT and deferasirox (≥25 mg/kg/day) were retrospectively reviewed. Mean HbS%, change in ferritin and LIC, and alloimmunization rate were determined for each CTT group. RESULTS Twenty-eight patients were included; six crossed over (one from ST to PME, one from ST to PME then to RCE, three from ST to RCE, and one from PME to RCE) to include 36 transfusion modality intervals. Median pretransfusion HbS% levels were 32.7% (ST), 36.2% (PME), and 34.7% (RCE; p = 0.732). Median ferritin changes were +15 (-17 to +45), +38 (+24 to +105), and -91 (-141 to -48) ng/mL/month (p = 0.003), and median LIC changes (available in 22 patient transfusion modality intervals) were +1.3 (-1.6 to +4.3), +2.3 (-6.5 to +8.9), and -5.7 (-10.7 to -0.5) mg/g/year (p = 0.024) in ST, PME, and RCE, respectively. There was no significant difference in alloimmunization rate between ST/PME and RCE groups. CONCLUSION We recommend RCE plus chelation as an effective method for reducing iron overload, while maintaining HbS at 30% to 35%.
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Affiliation(s)
- Ross M Fasano
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine.,Departments of Hematology and Clinical Pathology, Children's Healthcare of Atlanta
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Emory University, Rollins School of Public Health, Atlanta, Georgia
| | - Megha Kaushal
- Department of Hematology/Oncology and the Department of Laboratory Medicine, Center for Cancer and Blood Disorders, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Eyal Sagiv
- Department of Hematology/Oncology and the Department of Laboratory Medicine, Center for Cancer and Blood Disorders, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Naomi L C Luban
- Department of Hematology/Oncology and the Department of Laboratory Medicine, Center for Cancer and Blood Disorders, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC.,Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| | - Emily Riehm Meier
- Department of Hematology/Oncology and the Department of Laboratory Medicine, Center for Cancer and Blood Disorders, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC.,Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
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Polymer-mediated immunocamouflage of red blood cells: Effects of polymer size on antigenic and immunogenic recognition of allogeneic donor blood cells. SCIENCE CHINA-LIFE SCIENCES 2011; 54:589-98. [DOI: 10.1007/s11427-011-4190-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 04/25/2011] [Indexed: 11/27/2022]
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McPherson ME, Anderson AR, Castillejo MI, Hillyer CD, Bray RA, Gebel HM, Josephson CD. HLA alloimmunization is associated with RBC antibodies in multiply transfused patients with sickle cell disease. Pediatr Blood Cancer 2010; 54:552-8. [PMID: 19890898 PMCID: PMC3722881 DOI: 10.1002/pbc.22327] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Alloimmunization to minor red blood cell (RBC) antigens occurs commonly in sickle cell disease (SCD). Patients with alloimmunization demonstrate increased risk for new alloantibody formation with subsequent transfusion. Alloimmunization to human leukocyte antigens (HLA) can occur with RBC transfusion and may result in graft rejection during stem cell or organ transplantation. The prevalence and risk factors for HLA alloimmunization in multiply transfused pediatric SCD patients are unknown. PROCEDURE A cross-sectional study of HLA alloimmunization in SCD patients aged 3-21 years with a history of >or=3 RBC transfusions was performed to test the hypothesis that HLA alloimmunization is associated with RBC alloimmunization. Antibodies to class I and class II HLA were measured by Flow Panel Reactive Antibody (FlowPRA). RESULTS Seventy-three SCD patients (30 with RBC antibodies) were tested. HLA antibodies were detected in 25/73 (34%) patients; class I HLA antibodies occurred in 24/73 (33%) and class II HLA antibodies occurred in 3 (4%). Among patients with RBC antibodies, 16/30 (53%) had HLA antibodies, while 9/43 (21%) patients without RBC antibodies had HLA antibodies (OR 4.32 [1.6-12.1]). In a multivariate analysis, antibodies to RBC antigens were an independent predictor of HLA alloimmunization (P = 0.041). The association of RBC and HLA immunization was strongest among patients with no history of chronic transfusion therapy. CONCLUSIONS This analysis is the first description of HLA alloimmunization in pediatric SCD patients who receive primarily leukoreduced RBC transfusions and demonstrates that HLA alloimmunization tendency is associated with antibodies to RBC antigens.
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Affiliation(s)
- Marianne E. McPherson
- Aflac Cancer Center and Blood Disorders Services, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia,Correspondence to: Marianne E. McPherson, 2015 Uppergate Rd. NE, 4th floor, Atlanta, GA 30322.
| | - Alan R. Anderson
- Aflac Cancer Center and Blood Disorders Services, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Marta-Inés Castillejo
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia
| | - Christopher D. Hillyer
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia
| | - Robert A. Bray
- Department of Pathology, Emory University, Atlanta, Georgia
| | | | - Cassandra D. Josephson
- Aflac Cancer Center and Blood Disorders Services, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia,Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia
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Safety and efficacy of targeted busulfan therapy in children undergoing myeloablative matched sibling donor BMT for sickle cell disease. Bone Marrow Transplant 2010; 46:27-33. [PMID: 20305698 DOI: 10.1038/bmt.2010.60] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Busulfan influences engraftment and toxicities during hematopoietic stem cell transplantation (HSCT). We report our single-institution experience of targeted busulfan therapy for myeloablative, matched sibling donor (MSD) HSCT for sickle cell disease (SCD) and assess the relationships of busulfan levels to engraftment and toxicities. Twenty-seven patients with SCD underwent MSD HSCT from 1993 to 2007, 25 with busulfan measurements. The conditioning regimen was busulfan (initial dose 0.875 mg/kg for 16 doses), CY and antithymocyte globulin. Busulfan area under curve (AUC) was determined with the first dose, and dose adjustments were made to target the desired AUC range. Median AUC was 963 μmol min/L (range 780-1305 μmol min/L). Engraftment occurred in all cases: 21 (84%) full donor chimerism (> 95% donor cells), 4 (16%) partial donor chimerism. Hepatic veno-occlusive disease (VOD) occurred in 8 (32%) patients. Lower AUC was seen with partial donor chimerism (862 ± 73 μmol min/L) versus full donor chimerism (AUC 1018 ± 122 μmol min/L) (P = 0.022). VOD was not associated with busulfan AUC (P = 0.153). Of 25 patients, 24 survived with median follow-up of 4.9 years. Our experience shows that targeting busulfan AUC above the range used in previous multicenter trials appears safe and may contribute to sustained engraftment in SCD.
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