Resolution of the complexity of transfusion support by alloadsorption in a patient of thalassaemia intermedia with multiple alloantibodies

Gopal Krushna Ray; Somnath Mukherjee; Dibyajyoti Sahoo; Debasish Mishra; Suman Sudha Routray; Satya Prakash

doi:10.4103/joah.joah_23_20

CASE REPORT

Year : 2020 | Volume : 11 | Issue : 4 | Page : 195-198

Resolution of the complexity of transfusion support by alloadsorption in a patient of thalassaemia intermedia with multiple alloantibodies

Gopal Krushna Ray, Somnath Mukherjee, Dibyajyoti Sahoo, Debasish Mishra, Suman Sudha Routray, Satya Prakash
Department of Transfusion Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission	14-Mar-2020
Date of Decision	13-Apr-2020
Date of Acceptance	25-May-2020
Date of Web Publication	17-Nov-2020

Correspondence Address:
Dr. Satya Prakash
Department of Transfusion Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/joah.joah_23_20

Abstract

Thalassemia intermedia (TI) patients are generally more prone to alloimmunization against red blood cell antigen. Laboratory diagnosis of multiple alloantibodies faces challenges due to history of recent transfusion, lack of infrastructure, and skilled workforce. Alloadsorption is commonly used for a recently transfused patient suspected of having multiple alloantibodies. In this case, alloadsorption was performed with rr cells only to rule out the presence of allo-anti-E. Blood transfusion is the mainstay of treatment, and transfusion dependence is the primary measure for determining the severity. A 12-year-old young female patient, already diagnosed case of TI, presented with anemia, jaundice, and abdominal pain (on ultrasonography, hepatosplenomegaly and cholelithiasis) and planned for splenectomy with cholecystectomy. Cross-match was incompatible with the group-specific A-positive red cell unit in the antihuman globulin phase. Antibody screening and antibody identification (AI) revealed the possibility of anti-c and anti-E. Repeated alloadsorption with c+E-(rr) red cells, and further AI with remaining serum, confirmed the presence of both anti-c and anti-E. The patient was transfused with two units of c and E antigen-negative, A-positive compatible unit and operated without any transfusion-related adverse event. Here, we depicted the importance of alloadsorption as a tool to resolve multiple alloantibodies.

Keywords: Active immunity, adsorption, blood transfusion, thalassemia intermedia

How to cite this article:
Ray GK, Mukherjee S, Sahoo D, Mishra D, Routray SS, Prakash S. Resolution of the complexity of transfusion support by alloadsorption in a patient of thalassaemia intermedia with multiple alloantibodies. J Appl Hematol 2020;11:195-8

How to cite this URL:
Ray GK, Mukherjee S, Sahoo D, Mishra D, Routray SS, Prakash S. Resolution of the complexity of transfusion support by alloadsorption in a patient of thalassaemia intermedia with multiple alloantibodies. J Appl Hematol [serial online] 2020 [cited 2020 Dec 3];11:195-8. Available from: https://www.jahjournal.org/text.asp?2020/11/4/195/300764

Introduction

Thalassemia is a disorder of defective synthesis of either alpha or beta globin chains of hemoglobin (Hb), with a high prevalence in all over the world including India (4%), and about 50% of the patients with hemoglobinopathy have this disorder in the state of Odisha.^[1],[2] Transfusion dependence is one of the primary criteria in determining the severity and thalassemia phenotypes. Nontransfusion-dependent thalassemia (NTDT) does not require regular transfusion regimen though, in certain conditions (e.g., infection, pregnancy, surgery), they may require frequent transfusions. Beta-thalassemia intermedia (β-TI), Hb E/beta-thalassemia, and Hb H disease are primarily considered under the entity of NTDT.^[3] However, the study also suggests that regular blood transfusion requirements in TI patients prevent life-threatening complications.^[4] The rate of alloimmunization among transfusion-dependent thalassemia (TDT) patients is varying from 2.5% to 37% in different parts of the world.^[5],[6],[7]

Alloantibodies could be identified using screening and identification panel. However, sometimes, it becomes challenging to rule out multiple alloantibodies, where extended cell panel or selective cell is required. These selected cells can be picked up from previously used screening and antibody identification (AI) panel or phenotyped allogenic blood donor units. Allogenic donor red cells (R1R1, R2R2, and rr) are used for adsorption elution to identify the multiple alloantibody in recently transfused patients. The antibody of interest could be adsorbed using respective antigen-positive red cells. The adsorbed sera can be tested to detect the presence of remaining alloantibody, and further, confirmation can be performed with eluate from the adsorbed cell. Hence, alloimmunization among these patients increases the turnaround time and the cost of transfusion support. The present report emphasizes the utilization of alloadsorption to provide blood transfusion support in a TI patient with multiple alloantibodies and a history of recent transfusion.

Case Report

A 12-year-old young female patient of β-TI had presented with pain abdomen and jaundice to the pediatric surgery department. She was diagnosed as β-TI at the age of 10 years and transfused with one unit of the blood. Both the parents of this patient were known cases of thalassemia trait. Her transfusion frequency was one unit per month but increased to one unit per 15 days for the last 6 months that might be due to splenomegaly. The last transfusion was 6 days back, and the Hb was raised from 6 to 12 g/dl with three units of A-positive packed red blood cell (PRBC). On examination, the patient had icterus with hepatosplenomegaly. The hematological parameters were Hb 12 g/dl, total bilirubin was 2.3 mg/dl, and direct bilirubin was 0.6 mg/dl. Hepatosplenomegaly with cholelithiasis was evident in ultrasonography. Splenectomy and cholecystectomy were planned, and one unit of PRBC was requested. As per the requisition, blood grouping and cross-matching were performed in the antihuman globulin (AHG) gel card (Tulip diagnostic (P) Ltd., India). The blood group (BG) was A positive, and the cross-match was incompatible.

Immunohematology workup

All the immunohematological (IH) procedures such as blood grouping, direct Coombs test (DCT), antibody screening [AS, [Table 1], and AI [Table 2] were performed with cell panel (Bio-Rad Laboratories, India Pvt. Ltd., Lot No. of Screening Cells and Identification Panel as 45330.44.y and 45171.46.x, respectively). Variable strength in AI [Table 1] was suggestive of multiple alloantibody anti-c and anti-E. DCT and autocontrol were negative. Red blood cells of c-E+ phenotype among A-positive BG were required to exclude the presence of anti-E, which we could not be able to find out. Thus, to differentiate these antibodies, gentle heat alloadsorption and then elution technique was performed with c+E-(rr) cells from A-negative BG donor units.^[8] The patient's serum was incubated at 37°c with c+E-(rr) cell for 1 hour (hr) without using any enhancer-like polyethylene glycol. Completeness of adsorption was revealed by indirect Coombs test after three consecutive adsorptions. Then, AI was performed with adsorbed serum, and anti-E alloantibody was detected [Figure 1] and [Table 1]. The adsorbed cell was tested for DCT, which was positive, and gentle heat elution was performed at 45°C for 10 min. The eluate was then tested for AI and confirmed to be anti-c alloantibody [Figure 2].

Table 1: Antibody screening cell panel using patient's serum

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Table 2: Antibody identification panel using patient's serum showing the possibility of anti-c and anti-E alloantibody. Further antibody identification of anti-E was confirmed by adsorbed sera

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Figure 1: Antibody identification with adsorbed serum to confirm the presence of anti-E

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Figure 2: Antibody identification from the eluate of adsorbed rr (c+E-) cells to confirm anti-c

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The patient was transfused with A-positive, c-E-blood unit during the operation, and splenectomy with cholecystectomy was performed safely. No adverse transfusion events were reported during or after transfusion. IH report was given describing the presence of anti-c and anti-E along with the advice of c-PRBC and E-PRBC for future transfusion if required, to prevent hemolytic transfusion reaction.

Discussion

Identification of alloantibody in this patient of β-TI was resolved by simple alloadsorption, and the surgical procedure was performed safely with antigen-negative units. In thalassemia, the goals of transfusion are to use the donor blood with Hb content of at least 40 g to get optimal recovery, the achievement of appropriate Hb level, and avoidance of adverse reactions, including transfusion-transmitted infection.^[9] Leukoreduced PRBC stored for a period of maximum two weeks should be used for transfusion to reduce the frequency of transfusion and thus avoid alloimmunization with a goal to maintain Hb level of 9-10g/dl.^[9],[10] Phenotypically severe TI patients sometimes need regular transfusion both with advancing age or growth failure, during infectious periods, pregnancy, surgery and with the development of hypersplenism, making transfusion therapy necessary.^[11] Regulation of HbF expression by BCL11A, KLF-1, MYB gene, and novel transcription factor LYAR also modulates the transfusion requirement of TI patients.^[12] Increased transfusion requirement, hypersplenism, and symptomatic splenomegaly are the indications for splenectomy.^[10]

Our patient had increased transfusion frequency, impaired growth and development, symptomatic splenomegaly, and gallbladder stone. Splenectomy with concurrent cholecystectomy was planned, and one unit of PRBC was requested. AS and AI were performed in view of incompatible cross-match. The possibility of anti-E could not be ruled out with the available cell panel. To differentiate multiple alloantibodies, selected cells, neutralization, titration, enzyme technique, and adsorptions are helpful.^[13] As per the literature from our country, the distribution and frequencies of C, c, E, and e antigens are 84%–95%, 52%–69%, 15%–21%, and 98%–99%, respectively.^{[14],[15],[16]} Thus, 100 units of A-positive blood would be required to get two units of c-E+ selected red cells (A-positive, c-negative, E-positive = 0.2 × 0.48 × 0.20 = 0.0192) to rule out the presence of anti-E, which we were unable to find. Hence, we performed alloadsorption by taking c + E-(rr) cell.

The prevalence of anti-E, anti-c, and anti-c with anti-E in the Indian population is about 22%–36%, 6.4%–38.8%, and 6.4%, respectively, as reported by Zaman et al. and Thakral et al.^[16],[17] This patient had alloantibody against both “c” and “E” red cell antigen confirmed by gentle heat adsorption and elution technique. The patient was transfused with A-positive c-E-(R1R1) PRBC unit. The etiopathogenesis of alloimmunization in these patients is complex, and the factors responsible are the antigenic difference between recipient and donor, the immunomodulatory effect of blood transfusion, and the immune system of the recipient.^[5] A study done by Spanos et al. found that early onset of transfusion (age <3 years) is associated with a lower frequency of alloantibody formation.^[18] This delineates the lesser chances of alloimmunization in cases of thalassemia major compared to TI. Apart from the AHG phase cross-matched blood, phenotype-matched blood unit reduces the chances of alloimmunization in multitransfused patients such as thalassemia.^[19] Multitransfused patients, as well as patients with previously identified alloantibody, should be screened to rule out the development of new antibodies. These patients need transfusion with Rh and Kell antigen-matched PRBC units.

Conclusion

TDT patients could well be managed in blood centers with a facility of IH work-up. Simple, gentle heat alloadsorption and elution technique can be used as a tool to resolve multiple alloantibodies, and AS should be performed prudently in multi-transfused patients along with the provision of phenotype-matched red cells.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's guardian has given her consent for her clinical information to be reported in the journal. The patient's guardian understands that her names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Agarwal S, Gupta A, Gupta UR, Sarwai S, Phadke S, Agarwal SS. Prenatal diagnosis in beta-thalassemia: An Indian experience. Fetal Diagn Ther 2003;18:328-32.
2.	Ray GK, Jena RK. Spectrum of hemoglobinopathies: A new revelation in a tertiary care hospital of Odisha. Indian J Hematol Blood Transfus 2019;35:513-7.
3.	Mukherjee S, Das RR, Raghuwanshi B. Non-transfusion dependent thalassemias: A developing country perspective. Curr Pediatr Rev 2015;11:87-97.
4.	Aessopos A, Kati M, Meletis J. Thalassemia intermedia today: Should patients regularly receive transfusions? Transfusion 2007;47:792-800.
5.	Singer ST, Wu V, Mignacca R, Kuypers FA, Morel P, Vichinsky EP. Alloimmunization and erythrocyte autoimmunization in transfusion-dependent thalassemia patients of predominantly Asian descent. Blood 2000;96:3369-73.
6.	Wang LY, Liang DC, Liu HC, Chang FC, Wang CL, Chan YS, et al. Alloimmunization among patients with transfusion-dependent thalassemia in Taiwan. Transfus Med 2006;16:200-3.
7.	Sirchia G, Zanella A, Parravicini A, Morelati F, Rebulla P, Masera G. Red cell alloantibodies in thalassemia major. Results of an Italian cooperative study. Transfusion 1985;25:110-2.
8.	Judd WJ, Johnson ST, Storry JR. Judd's Methods in Immunohematology. 3^rd ed. Bethesda: American Association of Blood Banks; 2008. p. 147-50.
9.	Cappellini MD. Guidelines for the management of transfusion dependent thalassaemia (TDT). In: Cohen A, Porter J, Taher A, Viprakasit V, editors. Nicosia, Cyprus: Thalassaemia International Federation; 2014.
10.	Cohen A, Markenson AL, Schwartz E. Transfusion requirements and splenectomy in thalassemia major. J Pediatr 1980;97:100-2.
11.	Tarentino AL, Maley F. A comparison of the substrate specificities of endo-beta-N-acetylglucosaminidases from Streptomyces griseus and Diplococcus Pneumoniae. Biochem Biophys Res Commun 1975;67:455-62.
12.	Chen D, Zuo Y, Zhang X, Ye Y, Bao X, Huang H, et al. A genetic variant ameliorates β-thalassemia severity by epigenetic-mediated elevation of human fetal hemoglobin expression. Am J Hum Genet 2017;101:130-8.
13.	Barnes BC, Hertenstein EG. Immunohematology and blood transfusion medicine. In: Graeter L, Hertenstein E, Accurso C, Labiner G, editors. Elsevier's Medical Laboratory Science Examination Review. 1^st ed. St. Louis, Missouri: Elsevier Saunders; 2015.
14.	Lamba DS, Kaur R, Basu S. Clinically Significant Minor Blood Group Antigens amongst North Indian Donor Population. Adv Hematol. 2013;2013:215454. doi:10.1155/2013/215454.
15.	Thakral B, Saluja K, Sharma RR, Marwaha N. Phenotype frequencies of blood group systems (Rh, Kell, Kidd, Duffy, MNS, P, Lewis, and Lutheran) in North Indian blood donors. Transfus Apher Sci 2010;43:17-22.
16.	Zaman S, Chaurasia R, Chatterjee K, Thapliyal RM. Prevalence and Specificity of RBC Alloantibodies in Indian Patients Attending a Tertiary Care Hospital. Adv Hematol 2014;2014:749218. doi: 10.1155/2014/749218.
17.	Thakral B, Saluja K, Sharma RR, Marwaha N. Red cell alloimmunization in a transfused patient population: A study from a tertiary care hospital in north India. Hematology 2008;13:313-8.
18.	Spanos T, Karageorga M, I adis V, Peristeri J, Hatziliami A, Kattamis C. Red cell alloantibodies in patients with thalassaemia. Vox Sang 1990;58:50-5.
19.	Ho HK, Ha SY, Lam CK, Chan GC, Lee TL, Chiang AK, et al. Alloimmunization in Hong Kong Southern Chinese transfusion-dependent thalassemia patients. Blood 2001;97:3999-4000.