of 69 /69
1 Autoimmune Hemolytic Anemia: Overview and Serologic Case Studies Helene DePalma, MS, MT(ASCP)SBB, CQA(ASQ) Associate Professor, CUNY-York College Clinical Laboratory Sciences Program Lead Technologist NYBC Transfusion Services

Autoimmune Hemolytic Anemia: Overview and Serologic …nybloodcenter.org/media/filer_public/2016/04/11/helene_depalma... · Autoimmune Hemolytic Anemia: Overview and Serologic Case

Embed Size (px)

Text of Autoimmune Hemolytic Anemia: Overview and Serologic...

  • 1

    Autoimmune Hemolytic Anemia: Overview and Serologic Case Studies

    Helene DePalma, MS, MT(ASCP)SBB, CQA(ASQ)

    Associate Professor, CUNY-York College Clinical Laboratory Sciences Program

    Lead Technologist NYBC Transfusion Services

  • 2

    AUTOIMMUNE HEMOLYTIC ANEMIA

    Autoantibodies are directed against red blood cell membrane antigens Produced against a variety of self-antigens Follows a failure in the self/non-self

    discrimination mechanism of the immune system

  • 3

    Autoantibodies May result in RBC survival and acquired immune

    hemolytic anemia through: activation of complement system and/or removal within the reticuloendothelial

    system Identification of an autoantibody may explain

    decreased RBC survival in vivo If a patients RBCs are coated with autoantibody, the

    patient may present with: a serologic ABO discrepancy a positive Rh control a positive direct antiglobulin test (DAT)

  • 4

    Direct Antiglobulin Test (DAT)

  • 5

    DAT evaluation Clinical picture Clinical history

    recent transfusion neonate, transplant, medication

    Reagent Polyspecific (anti-IgG and anti-C3d)

    Method tube, gel, solid phase

    Further serological work up Antibody identification (if IAT positive) Eluate

  • 6

    Causes of a Positive DAT

    Autoantibodies to intrinsic RBC antigens Alloantibodies

    recent transfusion HDFN

    Passively transfused antibodies IVIG or Rh immune globulin (RhIg)

    Drugs Nonspecifically adsorbed proteins Antibodies derived from passenger lymphocytes (solid organ or HPC transplant)

  • 7

    AIHA CLASSIFICATION

    Warm autoimmune hemolytic anemia

    Cold agglutinin disease

    Mixed type autoimmune hemolytic anemia

    Paroxysmal cold hemoglobinuria

    Drug-induced hemolytic anemia

  • 8

    WHEN CAN WE EXPECT HEMOLYSIS? Antibody class and characteristics

    Concentration, antigen affinity, ability to fix complement, thermal amplitude

    IgG antibodies are associated with extravascular hemolysis IgM antibodies are associated with complement activation and

    potentially intravascular hemolysis

    Not all autoantibodies (or positive DATs) detected are associated with hemolysis or anemia

    1:1000-14,000 healthy blood donors have positive DATs 1:17-100 hospitals patients have positive DATs

    Evaluation of hemolysis should include: CBC, reticulocyte count, bilirubin, lactate dehydrogenase,

    haptoglobin; peripheral blood smear; and urinalysis

  • 9

    RBC Destruction

    Immune RBC destruction may produce either compensated or uncompensated anemia Compensated anemia: rate of RBC

    production will nearly equal the rate of RBC destruction.

    Uncompensated anemia: rate of RBC destruction exceeds the rate of RBC production.

  • 10

  • 11

    Warm Autoimmune Hemolytic Anemia (WAIHA)

    Incidence: 1/100,000 adults DAT positive for IgG

    DAT mostly IgG only, but may be IgG+C3 and rarely C3 only

    Rarely IgA or IgM Eluate and plasma: panagglutinin

    Antigen specificity: May have broad Rh specificity

  • 12

    WAIHA

    Extravascular hemolysis Laboratory findings:

    Decreased H/H Increased reticulocyte count Increased LDH, decreased haptoglobin,

    increased bilirubin Urine negative for heme

    Disease associations B-cell neoplasia, lymphoproliferative, collagen-

    vascular diseases

  • 13

    WAIHA: Serologic findings

    Autoantibodies present in serum in 80% of patients

    Positive autocontrol

  • 14

    Differential: Antibody to a high frequency antigen

    Negative autocontrol

  • 15

    Further Work-Up of Positive DAT/IAT

    Elution Removes antibodies bound to patient RBCs, concentrates the antibodies and helps to determine

    specificity

    Adsorption Sponge patient RBCs are used to soak up antibodies in

    serum remaining antibodies may be alloantibodies

    These processes can take many hours!!

  • 16

    Warm autoimmune hemolytic anemia: Immunohematology tests

    Test Result

    Direct antiglobulin test, broad spectrum

    Positive

    Rh Rh Rh

    Eluate

    Red cells

    Rh Rh Rh

    Serum

    Direct antiglobulin test, anti-IgG Positive (90%)

    Direct antiglobulin test, anti-C3 Positive (30%)

    Eluate Positive - panagglutinating antoantibody

    Antibody screen (serum, plasma) Positive - panagglutinating autoantibody

    Complex Complex Complex

    Complex Complex Complex

  • 17

    Alloimmune hemolysis transfusion reaction due to anti-K: Immunohematology tests

    Test Result

    Direct antiglobulin test, broad spectrum

    Positive

    Eluate

    Red cells

    Serum

    Direct antiglobulin test, anti-IgG Positive

    Direct antiglobulin test, anti-C3 Negative

    Eluate Anti-K (eluted off of transfused, not self RBCs)

    Antibody screen (serum, plasma) Anti-K

    K

    K

    K

    K

    K

    K K K

    K

  • 18

    Elution Techniques

    Acid elution kit Digitonin plus acid Heat Freeze/thaw Ether

  • 19

    Warm autoadsorption of autoantibodies

    K K

    K

    K

    Rh

    K

    Complex

    Rh Complex

    Rh Complex

    Rh Complex

    K

    K

    The patients serum: autoantibodies plus alloantibodies to K

    The patients red cells: coated with autoantibodies

  • 20

    1) Wash and heat patients cells (56oC) to remove autoantibodies

    2) Treat with ficin to enhance Rh complex exposure

    Warm autoadsorption

  • 21

    Warm autoadsorption

    3) Add patients serum to an aliquot of treated cells; incubate, then remove serum

    4) Repeat with a new aliquot of patients treated red cells

    5) Remove serum for testing

  • 22

    Alloadsorption

    Cant do autoadsorptions in recently transfused patients

    Risk of transfused donor RBCs absorbing an alloantibody

    Instead perform alloadsorption Use reagent RBCs with known antigen specificity to rule

    out the majority of clinically significant antibodies

  • 23

    Autoantibodies and Alloantibodies

    Up to 30% of patients with RBC autoantibodies also have underlying alloantibodies

    Some centers phenotype or genotype patients

    with autoantibodies and provide phenotypically matched RBCs

    C, c, E, e, K, Jka, Jkb, Fya, Fyb, S, s

  • 24

    RBC phenotype challenges

    Monoclonal reagents Dissociate IgG from RBC before testing with IAT reagent Chloroquine diphosphate EGA

    Prediction of phenotype by DNA analysis

  • 25

    Transfusion Considerations When to release least incompatible RBCs?

    Requires medical director and/or ordering physician approval

    Realize blood bank may crossmatch units in LISS or albumin to obtain compatible crossmatch

    What to explain to clinician?

    Transfused RBCs, although crossmatch incompatible, will likely have a similar lifespan as the patients own RBCs (assuming alloantibodies have been ruled out)

    Indications for transfusion include symptomatic anemia (compromise in cardiac or cerebral function) or unstable hematocrit

  • 26

    Warm AIHA: Treatment Medication

    Steroids Decrease macrophage clearance of IgG or C3b coated

    RBCs; eventually decrease antibody production IVIG

    Saturates Fc receptors on macrophages Rituximab

    Anti-CD20; mechanism complex (plasma cells are CD20 negative)

    Other immunosuppressive drugs (cytoxan, etc) Plasma exchange

    Large extravascular IgG distribution decrease the efficacy of plasma exchange

    Splenectomy 50-60% response rate Increased risk of sepsis lifelong after splenectomy

  • 27

  • 28

    Cold Agglutinin Disease

    Epidemiology: 1-2 per million incidence; typically in middle-aged or elderly patients

    Associations: Lymphoproliferative disorders

    Clinical features: hemoglobinuria and acrocyanosis after cold exposure

    Laboratory features: anemia, reticulocytosis, autoagglutination of cooled blood samples

  • 29

    Cold Agglutinin Disease

    Chronic Patients in 5th-8th decade of life Often have B-cell neoplasms, CLL, or

    Waldenstrom macroglobulinemia Monoclonal (IgM) cold agglutinins

    Transient Younger patient population Abrupt onset, often secondary to infectious

    disease (Mycoplasma pneumoniae; EBV) Polyclonal cold agglutinins

  • 30

    Cold Agglutinin Disease is NOT:

    Raynauds phenomenon Vasospasm at cool temperatures No associated autoantibody

    Cryoglobulinemia Monoclonal IgMs that self-associate or

    associate with IgG and precipitate from solution May be polyclonal, may be IgGs

  • 31

    Cold Agglutinin Titers

    Sample requirements Collect sample in a prewarmed tube Keep warm until clot retracts

    Titer is the highest serum dilution at which agglutination of RBCs in the cold is seen

    Less than 1 in 10 in healthy patients Greater than 1 in 10,000 in patients with cold

    agglutinin disease Thermal amplitude (more than titer) predicts

    severity of disease (>30C) I or i (rarely Pr specficity)

  • 32

    4oC

    I

    I

    I

    I

    I 4oC

    I

    I

    I

    I

    4oC I

    I

    I

    4oC

    I

    I

    I

    I

    I 4oC

    I

    I

    I

    I

    4oC

    I

    I

    I

    I

    I

    4oC

    I

    I

    I

    I

    I

    4oC

    I

    I

    I

    I

    I

    Low titer (1:4): common

    Moderate titer (1:64): infectious mono, mycoplasma pneumonia

    High titer (>1:512): cold agglutinin disease

    NO HEMOLYSIS HEMOLYSIS RARE HEMOLYSIS COMMON

    4oC

    Cold agglutinin disease

    (Antibodies preferentially bind at 4-20C)

  • 33

    Typical panel seen with cold reacting antibodies

    Some automated techniques omit IS phase

    Cold antibody may not be picked up until IS crossmatch.

  • 34

    Cold Antibodies

    i = EBV Cord cells are i positive

    I = Mycoplasma

    Adult cells are I positive

    May lead to ABO discrepancy Test i, I, A1 cells May need to prewarm sample

    Cold screen typically includes:

    Group A1, B, O, I negative, and autocontrol cells If broad thermal range

    Prewarm technique Cold autoadsorption REST adsorption

  • 35

    Cold agglutinin disease: Immunohematology tests

    Test Result

    Direct antiglobulin test, broad spectrum

    Positive

    Red cells

    Serum

    Direct antiglobulin test, anti-IgG Negative

    Direct antiglobulin test, anti-C3 Strongly positive

    Eluate Negative

    Antibody screen (serum, plasma)

    Positive - panagglutinating cold autoantibody if done at IS

    4oC

    I

    I

    I

    I

    I

    I

    I I

  • 36

    Classic Complement Pathway IgM binds RBCs activating the classic complement pathway

    Full assembly of membrane attack complex resulting in intravascular hemolysis

    Complement activation may not be sufficient to activate full MAC assembly, complement activation only to C3 C3 coated RBCs

    Phagocytized by macrophages (extravascular hemolysis)

    Require 500-800 C3b molecules for clearance

    May have normal life span

  • 37

    Cold Agglutinins: Pathogenesis of Autoantibody Formation

    Immune dysfunction Antigens sharing between infectious agent and RBC (antigen mimicry)

    Infection induced antigenic changes resulting in increased antigenicity

  • Cold Agglutinin Disease: Treatment

    Avoid cold exposure (cold weather, cold drinks) Immunosuppression: chorambucil, cyclophosphamide

    Treat the underlying illness! Prednisone and splenectomy typically NOT effective

    Consider plasma exchange in severe cases

  • 39

  • 40

    Combined Cold and Warm AIHA (Mixed AIHA)

    Serologic findings characteristic of WAIHA and has a cold agglutinin of high titer and thermal amplitude

    Both WAIHA and CAD

    IgG antibody is usually more pathogenic Patients often present with hemolysis

  • 41

  • 42

    Paroxysmal Cold Hemoglobinuria (PCH; Donath-Landsteiner)

    Biphasic IgG autoantibody Binds in the cold, lyses in the warm DAT positive only for complement Antibody screen negative P specificity

    Intravascular hemolysis Often acute and severe

  • 43

    Eder et al, Immunohematology, 21 (2): 2005.

    Syphilis

  • 44

    Eder et al, Immunohematology, 21 (2): 2005.

  • 45

    PCH

    Diagnosis tricky due to temperature issues

    Sample must be collected in a prewarmed tube, and transported to the blood bank in a heel warmer or cup of warm fluid

    Clot must be allowed to retract at a warm temperature

    Serum is then evaluated for antibody

  • 46

    Normal serum is a source of complement

    Donath-Landsteiner Test

  • 47

  • 48

    Proposed Unifying Theory of Drug-Induced Antibody Reactions

  • 49

    Drug-Associated Immune Hemolytic Anemia

    Hapten hypothesis (drug adsorption): Antibodies against a drug (PCN), which is RBC bound

    Negative antibody screen DAT positive for IgG

    Eluate negative against panel RBCs Positive against drug coated RBCs

    Immune complex: Antibodies (IgM) against a drug/plasma protein immunogenic complex

    Most common mechanism of drug-induced hemolytic anemia

    DAT positive for complement only Serum reacts with RBCs only in the presence of

    the drug (ex. quinine, quinidine)

  • 50

    Drug-Associated Immune Hemolytic Anemia (2)

    Non-immunologic protein adsorption: Membrane modification Positive DAT without hemolysis Cephalothin, cisplatin

    Autoantibody induction (drug independent) Induction of authentic antibodies against RBCs by the drug (methyldopa, fludarabine) Positive DAT, with little hemolytic anemia Stopping the drug leads to gradual

    disappearance in autoantibody

  • 51

  • 52

    Drug Induced Hemolytic Anemia is NOT Caused by Daratumumab (DarzalexTM)

    Human monoclonal anti-CD38 to treat multiple myeloma

    CD38 is expressed on many cells, including RBCs

    Anti-CD38 interferes with antibody screening by direct binding to CD38 on RBCs

    Uniform reactions with all cells Variable strength (1-3+) depending on method

    DAT results variable Further testing: DTT-treated RBCs; genotyping

  • 53

    Drug-Associated Immune Hemolytic Anemia

    Practical considerations:

    Stop potential offending drugs! Convey any concerns about drugs to

    reference laboratory May need hospital pharmacy to supply offending drug for testing

  • Case 1 59-year-old white male Diagnosis: Anemia (Hgb 6 g/dL; AIHA suspected) No transfusion within 3 months Preliminary laboratory testing:

    ABO/Rh: O Rh-negative Direct antiglobulin test: Positive

    Polyspecific= 3+; IgG= 3+; C3d= NEG Antibody screening test:

    Cell I IAT: 3+ Cell II IAT: 3+ Cell III IAT: 3+

  • Case 1: Initial Antibody Panel Rh-hr Kell Kidd Duffy Lewis MNSs P LISS Ficin

    Cell D C E c e K k Jka Jkb Fya Fyb Lea Leb M N S s P1 37C IAT AHG

    1 + + 0 0 + 0 + + 0 0 + + 0 0 + 0 + + 0 3+ 4+

    2 + + 0 0 + + + 0 + + 0 0 + + + 0 + + 0 3+ 4+

    3 + 0 + + 0 0 + + + + + + 0 0 + + + 0 0 3+ 4+

    4 + 0 + + 0 0 + 0 + + 0 0 0 + 0 + 0 + 0 3+ 4+

    5 + 0 + + + 0 + + + 0 + 0 + 0 + 0 + 0 0 3+ 4+

    6 0 0 0 + + 0 + 0 + 0 + + 0 + 0 + 0 0 0 3+ 4+

    7 0 0 0 + + + + + 0 + 0 0 + + + + + + 0 3+ 4+

    8 0 0 0 + + 0 + + 0 + + 0 + 0 + + + + 0 3+ 4+

    9 + 0 0 + + 0 + + + 0 + 0 0 + 0 0 + + 0 3+ 4+

    10 + 0 0 + + 0 + + 0 0 0 + 0 + + + 0 0 0 3+ 4+

    Auto 0 3+ 4+

  • Case 1: Autoadsorbed serum tested with selected RBC panel

    Rh-hr Kell Kidd Duffy Lewis MNSs P LISS Cell D C E c e K k Jka Jkb Fya Fyb Lea Leb M N S s P1 37C IAT

    1 + + 0 0 + 0 + + 0 0 + + 0 0 + 0 + + 0 0

    2 + + 0 0 + + + 0 + + 0 0 + + + 0 + + 0 0

    3 + 0 + + 0 0 + + + + + + 0 0 + + + 0 0 0

    4 + 0 + + 0 0 + 0 + + 0 0 0 + 0 + 0 + 0 0

    5 + 0 + + + 0 + + + 0 + 0 + 0 + 0 + 0 0 0

    6 0 0 0 + + 0 + 0 + 0 + + 0 + 0 + 0 0 0 0

    7 0 0 0 + + + + + 0 + 0 0 + + + + + + 0 0

    8 0 0 0 + + 0 + + 0 + + 0 + 0 + + + + 0 0

    9 + 0 0 + + 0 + + + 0 + 0 0 + 0 0 + + 0 0

    10 + 0 0 + + 0 + + 0 0 0 + 0 + + + 0 0 0 0

    Auto

    All check cells OK

  • Case 1: Eluate Tested with RBC Panel

    Rh-hr Kell Kidd Duffy Lewis MNSs P Eluate Last

    Wash Cell D C E c e K k Jka Jkb Fya Fyb Lea Leb M N S s P1 IAT IAT

    1 + + 0 0 + 0 + + 0 0 + + 0 0 + 0 + + 2+ 0

    2 + + 0 0 + + + 0 + + 0 0 + + + 0 + + 2+ 0

    3 + 0 + + 0 0 + + + + + + 0 0 + + + 0 2+ 0

    4 + 0 + + 0 0 + 0 + + 0 0 0 + 0 + 0 + 2+ 0

    5 + 0 + + + 0 + + + 0 + 0 + 0 + 0 + 0 2+ 0

    6 0 0 0 + + 0 + 0 + 0 + + 0 + 0 + 0 0 2+ 0

    7 0 0 0 + + + + + 0 + 0 0 + + + + + + 2+ 0

    8 0 0 0 + + 0 + + 0 + + 0 + 0 + + + + 2+ 0

    9 + 0 0 + + 0 + + + 0 + 0 0 + 0 0 + + 2+ 0

    10 + 0 0 + + 0 + + 0 0 0 + 0 + + + 0 0 2+ 0

    All check cells OK

  • Case 1 Interpretation:

    Warm autoantibody Panagglutinin detected in plasma and eluate No underlying alloantibody after autoadsorption

  • Case 2 68-year-old female Diagnosis: CLL Multiple RBC transfusions in the last month Preliminary laboratory testing:

    ABO/Rh: A Rh-positive Direct antiglobulin test: Positive

    Polyspecific= 2+; IgG= 2+; C3d= NEG Antibody screening test:

    Cell I IAT: 3+ Cell II IAT: 3+ Cell III IAT: 3+

  • Case 2: Initial Antibody Panel Rh-hr Kell Kidd Duffy Lewis MNSs P Albumin Ficin

    Cell D C E c e K k Jka Jkb Fya Fyb Lea Leb M N S s P1 37C IAT AHG

    1 + + 0 0 + 0 + + 0 0 + + 0 0 + 0 + + 0 3+ 4+

    2 + + 0 0 + + + 0 + + 0 0 + + + 0 + + 0 3+ 4+

    3 + 0 + + 0 0 + + + + + + 0 0 + + + 0 1+ 3+ 4+

    4 + 0 + + 0 0 + 0 + + 0 0 0 + 0 + 0 + 1+ 3+ 4+

    5 + 0 + + + 0 + + 0 0 + 0 + 0 + 0 + 0 1+ 3+ 4+

    6 0 0 0 + + 0 + 0 + 0 + + 0 + 0 + 0 0 0 3+ 4+

    7 0 0 0 + + + + + 0 + 0 0 + + + + + + 0 3+ 4+

    8 0 0 0 + + 0 + + 0 + + 0 + 0 + + + + 0 3+ 4+

    9 + 0 0 + + 0 + 0 + 0 + 0 0 + 0 0 + + 0 3+ 4+

    10 + 0 0 + + 0 + + 0 0 0 + 0 + + + 0 0 0 3+ 4+

    Auto + 0 0 + + 0 + 0 0 0 + 0 + + + 0 0 0 3+ 4+

  • Case 2: Alloadsorbed serum tested with selected RBC panel

    Rh-hr Kell Kidd Duffy Lewis MNSs P Albumin Cell D C E c e K k Jka Jkb Fya Fyb Lea Leb M N S s P1 37C IAT

    1 + + 0 0 + 0 + + 0 0 + + 0 0 + 0 + + 0 0

    2 + + 0 0 + + + 0 + + 0 0 + + + 0 + + 0 0

    3 + 0 + + 0 0 + + + + + + 0 0 + + + 0 0 2+

    4 + 0 + + 0 0 + 0 + + 0 0 0 + 0 + 0 + 0 2+

    5 + 0 + + + 0 + + 0 0 + 0 + 0 + 0 + 0 0 2+

    6 0 0 0 + + 0 + 0 + 0 + + 0 + 0 + 0 0 0 0

    7 0 0 0 + + + + + 0 + 0 0 + + + + + + 0 0

    8 0 0 0 + + 0 + + 0 + + 0 + 0 + + + + 0 0

    9 + 0 0 + + 0 + 0 + 0 + 0 0 + 0 0 + + 0 0

    10 + 0 0 + + 0 + + 0 0 0 + 0 + + + 0 0 0 0

    Auto

    All check cells OK

  • Case 2: Eluate Tested with RBC Panel

    Rh-hr Kell Kidd Duffy Lewis MNSs P Eluate Last

    Wash Cell D C E c e K k Jka Jkb Fya Fyb Lea Leb M N S s P1 IAT IAT

    1 + + 0 0 + 0 + + 0 0 + + 0 0 + 0 + + 3+ 0

    2 + + 0 0 + + + 0 + + 0 0 + + + 0 + + 3+ 0

    3 + 0 + + 0 0 + + + + + + 0 0 + + + 0 3+ 0

    4 + 0 + + 0 0 + 0 + + 0 0 0 + 0 + 0 + 3+ 0

    5 + 0 + + + 0 + + 0 0 + 0 + 0 + 0 + 0 3+ 0

    6 0 0 0 + + 0 + 0 + 0 + + 0 + 0 + 0 0 3+ 0

    7 0 0 0 + + + + + 0 + 0 0 + + + + + + 3+ 0

    8 0 0 0 + + 0 + + 0 + + 0 + 0 + + + + 3+ 0

    9 + 0 0 + + 0 + 0 + 0 + 0 0 + 0 0 + + 3+ 0

    10 + 0 0 + + 0 + + 0 0 0 + 0 + + + 0 0 3+ 0

    All check cells OK

  • Case 2 Interpretation:

    Allo anti-E Warm autoantibody Panagglutinin detected in plasma and eluate

  • Case 3

    Diagnosis: Sepsis Transfused 2 units a month ago Preliminary laboratory testing: ABO/Rh: B Positive Direct antiglobulin test: Polyspecific = 2+ IgG = Negative C3d = 2+

  • Case 3: Serum tested with selected RBC panel

    Rh-hr Kell Kidd Duffy Lewis MNSs P Albumin Cell D C E c e K k Jka Jkb Fya Fyb Lea Leb M N S s P1 RT IAT

    1 + + 0 0 + 0 + + 0 0 + + 0 0 + 0 + + 2+ 2+

    2 + + 0 0 + + + 0 + + 0 0 + + + 0 + + 2+ 1+

    3 + 0 + + 0 0 + + + + + + 0 0 + + + 0 2+ 1+

    4 + 0 + + 0 0 + 0 + + 0 0 0 + 0 + 0 + 2+ 1+

    5 + 0 + + + 0 + + 0 0 + 0 + 0 + 0 + 0 2+ 2+

    6 0 0 0 + + 0 + 0 + 0 + + 0 + 0 + 0 0 2+ 1+

    7 0 0 0 + + + + + 0 + 0 0 + + + + + + 2+ 2+

    8 0 0 0 + + 0 + + 0 + + 0 + 0 + + + + 2+ 2+

    9 + 0 0 + + 0 + 0 + 0 + 0 0 + 0 0 + + 2+ 1+

    10 + 0 0 + + 0 + 0 + 0 0 + 0 0 + + 0 0 2+ 1+

    Auto 2+ 1+

    All check cells OK

  • Case 3: REST adsorbed serum tested with selected RBC panel

    Rh-hr Kell Kidd Duffy Lewis MNSs P Albumin Cell D C E c e K k Jka Jkb Fya Fyb Lea Leb M N S s P1 RT IAT

    1 + + 0 0 + 0 + + 0 0 + + 0 0 + 0 + + 0 2+

    2 + + 0 0 + + + 0 + + 0 0 + + + 0 + + 0 0

    3 + 0 + + 0 0 + + + + + + 0 0 + + + 0 0 1+

    4 + 0 + + 0 0 + 0 + + 0 0 0 + 0 + 0 + 0 0

    5 + 0 + + + 0 + + 0 0 + 0 + 0 + 0 + 0 0 2+

    6 0 0 0 + + 0 + 0 + 0 + + 0 + 0 + 0 0 0 0

    7 0 0 0 + + + + + 0 + 0 0 + + + + + + 0 2+

    8 0 0 0 + + 0 + + 0 + + 0 + 0 + + + + 0 2+

    9 + 0 0 + + 0 + 0 + 0 + 0 0 + 0 0 + + 0 0

    10 + 0 0 + + 0 + 0 + 0 0 + 0 0 + + 0 0 0 0

    Auto

    All check cells OK

  • Case 3 Interpretation

    Cold autoantibody Anti-Jka detected

  • 68

    AIHA Take Home Messages Evaluate all pertinent clinical information

    Evidence of hemolysis? Transfusion or pregnancy history? Is there a potential for alloantibodies in addition to the

    autoantibody? Diagnosis? Medications?

    Determine if an underlying alloantibody is present Obtain an RBC phenotype (or genotype for predicted

    phenotype) Whats in your toolkit?

    Elution kit, monoclonal reagents, enzymes, EGA Know when to seek help!

    Send to an Immunohematology Reference Lab for specialized tests

  • Acknowledgements

    Beth H. Shaz, MD, Chief Medical Officer-NYBC Sharing her slides

    Dalisay Charles-Pierre, Manager, NYBC Immunohematology Laboratory Sharing her case studies

    Autoimmune Hemolytic Anemia:Overview and Serologic Case Studies AUTOIMMUNE HEMOLYTIC ANEMIAAutoantibodiesSlide Number 4DAT evaluationCauses of a Positive DAT AIHA CLASSIFICATIONWHEN CAN WE EXPECT HEMOLYSIS?RBC DestructionSlide Number 10Warm Autoimmune Hemolytic Anemia (WAIHA)WAIHAWAIHA: Serologic findingsDifferential: Antibody to a high frequency antigenFurther Work-Up of Positive DAT/IATWarm autoimmune hemolytic anemia: Immunohematology testsSlide Number 17Elution TechniquesSlide Number 19Slide Number 20Slide Number 21AlloadsorptionAutoantibodies and AlloantibodiesRBC phenotype challengesTransfusion ConsiderationsWarm AIHA: TreatmentSlide Number 27Cold Agglutinin DiseaseCold Agglutinin DiseaseCold Agglutinin Disease is NOT:Cold Agglutinin TitersCold agglutinin diseaseSlide Number 33Cold AntibodiesSlide Number 35Classic Complement PathwayCold Agglutinins: Pathogenesis of Autoantibody FormationCold Agglutinin Disease: TreatmentSlide Number 39Combined Cold and Warm AIHA (Mixed AIHA)Slide Number 41Paroxysmal Cold Hemoglobinuria (PCH; Donath-Landsteiner)Slide Number 43Slide Number 44PCHSlide Number 46Slide Number 47Slide Number 48Drug-Associated Immune Hemolytic AnemiaDrug-Associated Immune Hemolytic Anemia (2)Slide Number 51Drug Induced Hemolytic Anemia is NOT Caused by Daratumumab (DarzalexTM)Drug-Associated Immune Hemolytic AnemiaCase 1Case 1: Initial Antibody PanelCase 1: Autoadsorbed serum tested with selected RBC panelCase 1: Eluate Tested with RBC PanelCase 1 Interpretation:Case 2Case 2: Initial Antibody PanelCase 2: Alloadsorbed serum tested with selected RBC panelCase 2: Eluate Tested with RBC PanelCase 2 Interpretation:Case 3Case 3: Serum tested with selected RBC panelCase 3: REST adsorbed serum tested with selected RBC panelCase 3 InterpretationAIHA Take Home MessagesAcknowledgements