Volume 19 Number 3
CORRESPONDENCE
Greendyke and Banzhaf incorrectly cite us as having reported a case of acquired hemolytic anemia caused by auto-anti-Wra. In addition, the title of our paper’ is incorrectly cited in their bibliography. It must be pointed out that in the case we reported the causative antibody was auto-anti-Wrh not auto-anti-WP. In a subsequent study on 150 individuals with a positive direct antiglobulin test (87 with autoimmune hemolytic anemia, 33 with a positive DAT due to alpha-methyldopa therapy, and 30 “normal” donors with a positive DAT) we demonstrated that auto-anti-Wrh is common.2 In the 150 individuals we studied, 46 (3 1%) had made autoanti-Wrh, most often in conjunction with other autoantibodies of complex specificity. In those individuals who had made anti-dl ( 1 10 of the 150 studied) the incidence of auto-anti- Wrh, as revealed by adsorption studies, was 42 per cent. In tests on the 150 patients described, and on many hundreds of others, we have never seen an example of auto-anti-Wr”.To our knowledge, no other workers have ever found autoantibody of such a specificity although studies on thousands of individuals with a positive DAT have been reported.-Peter D . Issitt. F.I.M.L.S.. L.I.Biol.. M.R.C.Puth., Director of Luborutories and Associate Professor in Reseurch Surgery. The Puul I . Hoxworth Blood Center, Cincinnati. O H , und Dennis Goldfinger. M . D . . Associute Pathologist und Director of the Blood Bunk, Cedurs-Sinai Medicirl Center. Lou Angeles. C A 90048. References 1. Goldfinger, D.. H. Zwicker. G . A . Belkin, and
P. D. Issitt: An autoantibody with antiWr” specificity in a patient with warm autoimmune hemolytic anemia. Transfusion 15: 351, 1975. 2. Issitt, P. D., B. G. Pavone. D. Goldfinger, H . Zwicker. C. H. Issitt, J. A. Tessel, S. W. Kroovand. and C. A . Bell: Anti-Wr”, and other autoantibodies responsible for positive direct antiglobulin tests in 150 individuals. Br. J . Haematol. 34:s. 1976.
Note: The foregoing letter b t w s submitted to Dr. Greendyke. who upologizes to Mr. Issitt j h r overlooking the typogruphicd error in the prooji of the urticle cited. -Ed. Granulocyte Transfusions To the Editor: Appelbaum, Trapani and Craw, in their article “Consequences of Prior Alloimmunization during Granulocyte Transfusion” (Transfusion
35 1
17:460, 1977), indicate that recovery of transfused granulocytes in animals immunized to leukocyte antigens was considerably worse than recovery in nonimmunized animals. They also point out that sensitized animals developed profound thrombocytopenia after receiving “incompatible” leukocytes. While it might appear logical that animals immunized to leukocytes would have impaired recovery of subsequently transfused incompatible granulocytes, and that platelets might be consumed in the intravascular antigen-antibody reaction, there appears to be a flaw in this study, which makes interpretation difficult. This is because the animals also were immunized to erythrocytes and then transfused with incompatible red blood cells. It is well known that transfusion of animals or humans with incompatible red blood cells results in rapid development of profound thrombocytopenia and leukopenia.’ This occurs because platelets and granulocytes possess surface receptors for antigen-antibody complexes. Complement activation also helps mediate the cell destruction. The technique for leukocyte immunization used by Appelbaum et ul. employed the transfusion of buffy coats, which would have been heavily contaminated with red blood cells. The subsequently transfused granulocyte concentrates were obtained by continuous flow centrifugation, which produces a product that is massively contaminated with red blood cells. The animals. therefore, would be transfused with large numbers of red blood cells to which they had previously been immunized. The poor leukocyte recovery and associated severe thrombocytopenia would, most probably, be the result of an acute hemolytic transfusion reaction. These effects can be seen with transfusion of even small numbers of incompatible red blood cells. In a previous report, Craw et ~ 1 showed . ~ that ABO incompatible granulocytes transfused to humans gave much poorer recoveries than ABO-compatible white blood cells. In this study, also, the granulocyte concentrates were obtained by the continuous flow centrifuge, and were heavily contaminated with ABO-incompatible red blood cells. This study has been interpreted by most to indicate that the ABO incompatibility of the white blood cells was responsible for the poor recovery, when, indeed, the ABO incompatible red blood cells would be more than sufficient cause for destruction of transfused granulocytes. It seems that evaluation of anti-leukocyte antibodies as a mechanism for poor recovery of transfused granulocytes must take into account the powerful effects of an acute hemolytic
Transfusion
CORRESPONDENCE
352
transfusion reaction, resulting from concomitant transfusion of incompatible red blood cells. In order to evaluate the isolated role of antileukocyte antibodies, it will be necessary either to prevent immunization to red blood cells during the process of leukocyte immunization, or to prepare granulocyte concentrates for transfusion which are largely free of red blood cells. Otherwise, it will be impossible to judge the true significance of specific anti-leukocyte antibodies, and serious misconceptions may result concerning the immunologic considerations attending granulocyte transfusion therapy. -Dennis Goldjinger. M . D . . Associate Pothologist. Section o n Blood Banking, CiJdurs-Sinui Medical Center. Los Ange1i.s. CA 90048. References 1. Goldfinger, D.: Acute hemolytic transfusion reac-
tions-a fresh look at pathogenesis and considerations regarding therapy. Transfusion 17: 85. 1977. 2. Graw, R. G. Jr., G. Herzig, S. Perry, and E. S. Henderson: Normal granulocyte transfusion therapy. Treatment of septicemia due to gramnegative bacteria. N. Engl. J. Med. 287: 367, 1972.
The Foregoing Letter I~YLS sent f?)r Comment t o Drs. Appelbuum und Deisseroth who Reply us Follows: To the Editor: Dr. Dennis Goldfinger suggests that our observations' could be the result of an acute hemolytic transfusion reaction caused by antibodies directed against red blood cells rather than leukocytes. While it is surely correct that hemolytic transfusion reactions can cause decreased leukocyte and platelet levels, we do not feel that this explains the findings in our study. In our study, we used only closed-colony animals; all donors and recipients, although DLA mismatched, were matched for red blood cell type, being A-negative in all cases (not to be confused with blood type A in man). Complete red blood cell phenotyping could not be done because the red blood cell antigenic system in dogs is yet to be totally defined. The experience of workers in the field is that only anti-A antibodies react as lysins in the dog.' Further, the method we used to prepare buffy coats for immunization was dextran sedimentation, thus keeping red blood cell contamination at a minimum. Workers attempting to immunize dogs with pooled purposefully mismatched red
May-June 1Y7Y
blood cells could detect no antibody until animals received five injections (our animals were given only two injections) and even then only one-third of the animals developed any detectable lysins.' For these reasons, then, we doubt that acute hemolytic transfusion reactions would have occurred in our study. Dr. Goldfinger also refers to an earlier article from our laboratory which demonstrated that ABO-incompatible granulocytes transfused to humans gave poorer recoveries than ABO-cornpatible white blood cells. Again, he suggests that decreased recovery might be due to either ABO expression on granulocytes or to the transfusion of ABO-incompatible red blood cells. Here we can only agree, and, in fact, this very point was made in the article cited. Poor recovery . . may be interpreted as indirect evidence for the expression of antigens of the ABO system on the WBC surface, or as a mild transfusion reaction produced by contaminating RBCs that affect the WBCs as 'innocent bystanders.':' The importance of the observation for the clinician faced with selecting a granulocyte donor is the same, however: an ABO compatible donor remains preferable. We certainly agree that the true significance of specific antileukocyte antibodies is yet to be settled, and, in fact, we have recently reported that assays of preformed anti-leukocyte antibodies in man do not accurately predict the outcome of individual granulocyte transfusions.' This may be due to the small numbers of granulocytes transfused, to the great variability from patient to patient, or, as Dr. Goldfinger suggests, to antibodies other than specific anti-leukocyte antibodies. Nonetheless, we feel that the study in dogs clearly demonstrates in a controlled way that granulocytes transfused to heavily alloimmunized, red blood cell compatible recipients neither circulate intravascularly nor migrate to skin windows in their new host. Further, such transfusions may cause severe thrombocytopenia.-Frederick R . Appelbuum. M . D . . Albert B . Deisseroth, M . D . . P h . D . . Experimentul Hemutology Section. Nutionul Concer Institute. National Institutes of Health, Bethesda, M D 20014. 'I.
References I . Applebaum, F. R., R. J. Trapani, and R. G. Graw: Consequences of prior alloimmunization during granulocyte transfusion. Transfusion 17:460, 1977. 2. Suzuki, Y.,C. Stormont, B. G. Moms, M.Shifrine, and R. Dobrucki: New antibodies in dog blood groups. Transplant. R o c . 8:365, 1975.
CORRESPONDENCE
Greendyke and Banzhaf incorrectly cite us as having reported a case of acquired hemolytic anemia caused by auto-anti-Wra. In addition, the title of our paper’ is incorrectly cited in their bibliography. It must be pointed out that in the case we reported the causative antibody was auto-anti-Wrh not auto-anti-WP. In a subsequent study on 150 individuals with a positive direct antiglobulin test (87 with autoimmune hemolytic anemia, 33 with a positive DAT due to alpha-methyldopa therapy, and 30 “normal” donors with a positive DAT) we demonstrated that auto-anti-Wrh is common.2 In the 150 individuals we studied, 46 (3 1%) had made autoanti-Wrh, most often in conjunction with other autoantibodies of complex specificity. In those individuals who had made anti-dl ( 1 10 of the 150 studied) the incidence of auto-anti- Wrh, as revealed by adsorption studies, was 42 per cent. In tests on the 150 patients described, and on many hundreds of others, we have never seen an example of auto-anti-Wr”.To our knowledge, no other workers have ever found autoantibody of such a specificity although studies on thousands of individuals with a positive DAT have been reported.-Peter D . Issitt. F.I.M.L.S.. L.I.Biol.. M.R.C.Puth., Director of Luborutories and Associate Professor in Reseurch Surgery. The Puul I . Hoxworth Blood Center, Cincinnati. O H , und Dennis Goldfinger. M . D . . Associute Pathologist und Director of the Blood Bunk, Cedurs-Sinai Medicirl Center. Lou Angeles. C A 90048. References 1. Goldfinger, D.. H. Zwicker. G . A . Belkin, and
P. D. Issitt: An autoantibody with antiWr” specificity in a patient with warm autoimmune hemolytic anemia. Transfusion 15: 351, 1975. 2. Issitt, P. D., B. G. Pavone. D. Goldfinger, H . Zwicker. C. H. Issitt, J. A. Tessel, S. W. Kroovand. and C. A . Bell: Anti-Wr”, and other autoantibodies responsible for positive direct antiglobulin tests in 150 individuals. Br. J . Haematol. 34:s. 1976.
Note: The foregoing letter b t w s submitted to Dr. Greendyke. who upologizes to Mr. Issitt j h r overlooking the typogruphicd error in the prooji of the urticle cited. -Ed. Granulocyte Transfusions To the Editor: Appelbaum, Trapani and Craw, in their article “Consequences of Prior Alloimmunization during Granulocyte Transfusion” (Transfusion
35 1
17:460, 1977), indicate that recovery of transfused granulocytes in animals immunized to leukocyte antigens was considerably worse than recovery in nonimmunized animals. They also point out that sensitized animals developed profound thrombocytopenia after receiving “incompatible” leukocytes. While it might appear logical that animals immunized to leukocytes would have impaired recovery of subsequently transfused incompatible granulocytes, and that platelets might be consumed in the intravascular antigen-antibody reaction, there appears to be a flaw in this study, which makes interpretation difficult. This is because the animals also were immunized to erythrocytes and then transfused with incompatible red blood cells. It is well known that transfusion of animals or humans with incompatible red blood cells results in rapid development of profound thrombocytopenia and leukopenia.’ This occurs because platelets and granulocytes possess surface receptors for antigen-antibody complexes. Complement activation also helps mediate the cell destruction. The technique for leukocyte immunization used by Appelbaum et ul. employed the transfusion of buffy coats, which would have been heavily contaminated with red blood cells. The subsequently transfused granulocyte concentrates were obtained by continuous flow centrifugation, which produces a product that is massively contaminated with red blood cells. The animals. therefore, would be transfused with large numbers of red blood cells to which they had previously been immunized. The poor leukocyte recovery and associated severe thrombocytopenia would, most probably, be the result of an acute hemolytic transfusion reaction. These effects can be seen with transfusion of even small numbers of incompatible red blood cells. In a previous report, Craw et ~ 1 showed . ~ that ABO incompatible granulocytes transfused to humans gave much poorer recoveries than ABO-compatible white blood cells. In this study, also, the granulocyte concentrates were obtained by the continuous flow centrifuge, and were heavily contaminated with ABO-incompatible red blood cells. This study has been interpreted by most to indicate that the ABO incompatibility of the white blood cells was responsible for the poor recovery, when, indeed, the ABO incompatible red blood cells would be more than sufficient cause for destruction of transfused granulocytes. It seems that evaluation of anti-leukocyte antibodies as a mechanism for poor recovery of transfused granulocytes must take into account the powerful effects of an acute hemolytic
Transfusion
CORRESPONDENCE
352
transfusion reaction, resulting from concomitant transfusion of incompatible red blood cells. In order to evaluate the isolated role of antileukocyte antibodies, it will be necessary either to prevent immunization to red blood cells during the process of leukocyte immunization, or to prepare granulocyte concentrates for transfusion which are largely free of red blood cells. Otherwise, it will be impossible to judge the true significance of specific anti-leukocyte antibodies, and serious misconceptions may result concerning the immunologic considerations attending granulocyte transfusion therapy. -Dennis Goldjinger. M . D . . Associate Pothologist. Section o n Blood Banking, CiJdurs-Sinui Medical Center. Los Ange1i.s. CA 90048. References 1. Goldfinger, D.: Acute hemolytic transfusion reac-
tions-a fresh look at pathogenesis and considerations regarding therapy. Transfusion 17: 85. 1977. 2. Graw, R. G. Jr., G. Herzig, S. Perry, and E. S. Henderson: Normal granulocyte transfusion therapy. Treatment of septicemia due to gramnegative bacteria. N. Engl. J. Med. 287: 367, 1972.
The Foregoing Letter I~YLS sent f?)r Comment t o Drs. Appelbuum und Deisseroth who Reply us Follows: To the Editor: Dr. Dennis Goldfinger suggests that our observations' could be the result of an acute hemolytic transfusion reaction caused by antibodies directed against red blood cells rather than leukocytes. While it is surely correct that hemolytic transfusion reactions can cause decreased leukocyte and platelet levels, we do not feel that this explains the findings in our study. In our study, we used only closed-colony animals; all donors and recipients, although DLA mismatched, were matched for red blood cell type, being A-negative in all cases (not to be confused with blood type A in man). Complete red blood cell phenotyping could not be done because the red blood cell antigenic system in dogs is yet to be totally defined. The experience of workers in the field is that only anti-A antibodies react as lysins in the dog.' Further, the method we used to prepare buffy coats for immunization was dextran sedimentation, thus keeping red blood cell contamination at a minimum. Workers attempting to immunize dogs with pooled purposefully mismatched red
May-June 1Y7Y
blood cells could detect no antibody until animals received five injections (our animals were given only two injections) and even then only one-third of the animals developed any detectable lysins.' For these reasons, then, we doubt that acute hemolytic transfusion reactions would have occurred in our study. Dr. Goldfinger also refers to an earlier article from our laboratory which demonstrated that ABO-incompatible granulocytes transfused to humans gave poorer recoveries than ABO-cornpatible white blood cells. Again, he suggests that decreased recovery might be due to either ABO expression on granulocytes or to the transfusion of ABO-incompatible red blood cells. Here we can only agree, and, in fact, this very point was made in the article cited. Poor recovery . . may be interpreted as indirect evidence for the expression of antigens of the ABO system on the WBC surface, or as a mild transfusion reaction produced by contaminating RBCs that affect the WBCs as 'innocent bystanders.':' The importance of the observation for the clinician faced with selecting a granulocyte donor is the same, however: an ABO compatible donor remains preferable. We certainly agree that the true significance of specific antileukocyte antibodies is yet to be settled, and, in fact, we have recently reported that assays of preformed anti-leukocyte antibodies in man do not accurately predict the outcome of individual granulocyte transfusions.' This may be due to the small numbers of granulocytes transfused, to the great variability from patient to patient, or, as Dr. Goldfinger suggests, to antibodies other than specific anti-leukocyte antibodies. Nonetheless, we feel that the study in dogs clearly demonstrates in a controlled way that granulocytes transfused to heavily alloimmunized, red blood cell compatible recipients neither circulate intravascularly nor migrate to skin windows in their new host. Further, such transfusions may cause severe thrombocytopenia.-Frederick R . Appelbuum. M . D . . Albert B . Deisseroth, M . D . . P h . D . . Experimentul Hemutology Section. Nutionul Concer Institute. National Institutes of Health, Bethesda, M D 20014. 'I.
References I . Applebaum, F. R., R. J. Trapani, and R. G. Graw: Consequences of prior alloimmunization during granulocyte transfusion. Transfusion 17:460, 1977. 2. Suzuki, Y.,C. Stormont, B. G. Moms, M.Shifrine, and R. Dobrucki: New antibodies in dog blood groups. Transplant. R o c . 8:365, 1975.
