Red blood cell alloimmunization mitigation strategies Jeanne E. Hendrickson, Christopher A. Tormey, Beth H. Shaz PII: DOI: Reference:

S0887-7963(14)00047-9 doi: 10.1016/j.tmrv.2014.04.008 YTMRV 50401

To appear in:

Transfusion Medicine Reviews

Received date: Revised date: Accepted date:

3 April 2014 24 April 2014 26 April 2014

Please cite this article as: Hendrickson Jeanne E., Tormey Christopher A., Shaz Beth H., Red blood cell alloimmunization mitigation strategies, Transfusion Medicine Reviews (2014), doi: 10.1016/j.tmrv.2014.04.008

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Red blood cell alloimmunization mitigation strategies

T

Jeanne E. Hendrickson, MD1, Christopher A. Tormey, MD1,2, Beth H. Shaz, MD3

Yale University School of Medicine, New Haven, CT, USA

2

VA Connecticut Healthcare System; West Haven, CT, USA

3

New York Blood Center, New York, NY; Emory University School of Medicine, Atlanta, GA,

SC

RI P

1

NU

USA

MA

Corresponding author: Beth Shaz, MD

ED

New York Blood Center, 310 E 67th St, New York, NY 10065, USA

Fax: +1-212-570-3092

PT

Tel: +1-212-570-3460

AC

CE

E-mail: [email protected]

Funding: Some discussed studies were funded in part by NIH/NHLBI and by the Emory Egleston Children’s Research Center (to JEH).

Conflict of interest: JEH and CAT have sponsored research agreements with Terumo. BHS has no conflict of interest.

ACCEPTED MANUSCRIPT ABSTRACT Hemolytic transfusion reactions due to red blood cell (RBC) alloantibodies are a leading cause

T

of transfusion associated death. In addition to reported deaths, RBC alloantibodies also cause

RI P

significant morbidity in the form of delayed hemolytic transfusion reactions. These alloantibodies may also cause morbidity in the form of anemia, with compatible RBC units at

SC

times being unable to be located for highly alloimmunized patients, or in the form of hemolytic disease of the newborn. Thus, preventing RBC alloantibodies from developing in the first place,

NU

or mitigating the dangers of existing RBC alloantibodies, would decrease transfusion associated

MA

morbidity and mortality. A number of human studies have evaluated the impact on RBC alloimmunization rates of providing partially phenotypically or genotypically matched RBCs for transfusion, and a number of animal studies have evaluated the impact of single variables on

ED

RBC alloimmunization. The goal of this review is to take a comprehensive look at existing

PT

human and animal data on RBC alloimmunization, focusing on strategies that may mitigate this serious hazard of transfusion. Potential factors that impact initial RBC alloimmunization, on

CE

both the donor and recipient side, will be discussed. These factors include, but are not limited to, exposure to the antigen and an ability of the recipient’s immune system to present that

AC

antigen. Beyond these basic factors, co-existing “danger signals,” which may come from the donor unit itself, or which may be present in the recipient, also likely play a role in determining which transfusion recipients may become alloimmunized following RBC antigen exposure. In addition to better understanding factors that influence the development of RBC alloantibodies, this review will also briefly discuss strategies to decrease the dangers of existing RBC alloantibodies.

Keywords: Alloimmunization, red blood cell, transfusion.

ACCEPTED MANUSCRIPT INTRODUCTION Red blood cell (RBC) alloimmunization can result in delayed or acute hemolytic transfusion

T

reactions (HTRs), resulting in significant morbidity and mortality. Fifteen % of transfusion related

RI P

fatalities in the United States are due to non-ABO related HTRs, and the risk of delayed hemolytic transfusion reactions (DHTRs) being 1:20,569 and the risk of non-ABO acute HTRs

SC

being 1:124,525 components transfused[1, 2]. In addition to being detrimental in transfusion settings, transfusion acquired RBC alloantibodies may also be detrimental in pregnancy

MA

NU

settings, potentially putting a developing fetus at risk of hemolytic disease of the newborn.

Recipients with multiple alloantibodies impair the ability of blood banks to provide antigennegative, compatible RBCs for transfusion because of the need to phenotype many times the

ED

number of units necessary to find an appropriate product[3]. The numbers of products screened

PT

multiplies depending on the RBC antigen prevalence and the number of negative antigens necessary, placing a burden on the hospitals and donor centers needing to identify such

CE

products. Donor centers currently screen and stock RBC products to keep a pool of frequently needed antigen-negative products. However, batch serologic screening is time-intensive, typing

AC

reagents are expensive, and appropriate controls are required. As a result, donor centers may perform automated high throughput serologic screening using FDA approved reagents to type for E, e, C, c, and K as well as ABO and D. Many blood centers are now also performing mass scale genotyping, which enables the expansion of phenotyped/genotyped products[4].

Regardless of the work involved, it cannot be disputed that preventing primary alloimmunization is instrumental in reducing the risk of HTRs and improving transfusion safety. Furthermore, regardless of the logistics involved in identifying or recording antibodies, it cannot be disputed that avoiding repeat exposures to the cognate antigen against which a patient is alloimmunized is critical in preventing acute and delayed HTRs. However, optimal strategies to: 1) decrease

ACCEPTED MANUSCRIPT primary RBC alloimmunization and to 2) mitigate the dangers of existing RBC alloantibodies are not clearly defined. The goal of this review is to take a comprehensive look at existing human

T

and animal data on RBC alloimmunization, exploring factors that contribute to this serious

RI P

hazard of transfusion and discussing potential mitigation strategies.

SC

MECHANISMS OF ALLOIMMUNIZATION

In order to develop strategies to mitigate RBC alloimmunization, factors influencing the

NU

development of RBC alloantibodies must be considered.

Some potential factors to consider

MA

include the differences between donor and recipient red cell antigens, recipient genetic factors, and recipient inflammatory state at the time of initial antigen exposure. Table 1 lists potential

ED

factors influencing RBC alloimmunization, separated by donor and recipient.

PT

The best described factor associated with alloimmunization risk is donor and recipient RBC antigen disparity. If a transfusion recipient is never exposed to a particular foreign RBC antigen,

CE

then they are not at risk of making an alloantibody. Studies have reported alloimmunization rates of patients with sickle cell disease (SCD) in the range of 19-43% in the absence of

AC

phenotypic matching[5]. One study reported alloimmunization rates of 29% in pediatric and 47% in adult SCD patients, with more females than males being alloimmunized[6]. In contrast, multiply-transfused non-SCD patients had alloimmunization rates of approximately 5%. The most common antibodies found were against K, E, C, and Jk(b), which are related to the antigenic frequencies in donors versus SCD patients (K: 9% versus 2%, E: 35% versus 24%, C: 68% versus 28%, and Jk(b): 72% versus 39% are positive, respectively)[7].

Genetic factors may also result in some patients being more likely to be responders than nonresponders to RBC antigens. Using mathematical models based on both adult and pediatric patients, it was determined that 13% of patients were responders, with a 30% chance of

ACCEPTED MANUSCRIPT making additional alloantibodies with each transfusion event[8]. A recent study evaluated 27 single nucleotide polymorphisms in the CD81, CHRNA10, and ARHG genes of SCD patients

T

who had formed or not formed alloantibodies; two SNPs in the CD81 genes were found to be

RI P

strongly associated with alloimmunization[9]. Other than genetic polymorphisms that may predispose a transfusion recipient to be a responder, it must also be considered that certain

SC

RBC antigens are likely HLA restricted[10-13]. Transfusion recipients would only be predicted

NU

to be capable of responding to RBC antigens that their individual HLA antigens could present.

MA

Another consideration in the development of RBC alloantibodies is the inflammatory status of the transfusion recipient at the time of antigen exposure, with data from murine as well as human studies supporting a correlation between inflammation and RBC alloimmunization. In

ED

multiple murine models, recipient inflammation with polyinosinic polycytidylic acid has been

PT

shown to enhance the magnitude of the RBC alloimmune response[14-16], or to turn nonresponders into responders[17].

In a retrospective review of transfused humans, a febrile

CE

reaction within 10 days of RBC transfusion was associated with higher RBC alloimmunization rates.[18] In a different retrospective review, inflammatory bowel disease patients had higher

AC

alloimmunization rate than controls and in the multivariate analysis immunomodulatory therapy was associated with a decreased risk (p=0.01) and number of transfusions increased risk (p=0,04) of alloimmunization[19]. Another study demonstrated reduced Treg activity or increased Th2 responses in SCD or thalassemia patients in alloantibody responders versus nonresponders[20], with similar results being reported in a murine model[21]. Lastly, data was recently presented in abstract form suggesting that children with sickle cell disease transfused in a state of inflammation (e.g., during an episode of acute chest syndrome) had higher RBC alloimmunization rates than patients transfused in non-inflamed states (e.g. during routine chronic transfusion)[22].

ACCEPTED MANUSCRIPT MITIGATION METHODS Methods to reduce RBC alloimmunization are derived from factors that increase risk. In order to

T

decrease alloimmunization rates due to donor and recipient antigen disparities, patients may be

RI P

transfused with RBCs that are phenotypically matched, i.e., RBC products that are negative for the most immunogenic antigens the recipient lacks. Genotyping may also be used to predict

SC

phentotypes of patients as well as donors. Methods to decrease RBC alloimmunization associated with the inflammatory state may include modification of the transfused product itself

NU

or recipient immunomodulation (Table 2 briefly outlines potential mitigation strategies based on

MA

murine data, to be discussed in more detail below). Selection of products in part based on recipient HLA type or other genetic attributes may also be useful in the future to decrease rates of RBC alloimmunization and to conserve resources. Lastly, in instances in which RBC

ED

alloantibodies are already present, a number of potential strategies can be utilized to minimize

PT

re-exposure to these antigens and other dangers of these existing alloantibodies.

CE

Phenotype/genotype matched products In the US, the current practice for most transfusion recipients is to only match for the ABO and

AC

D antigens, while outside the US matching for K antigen in potentially child-bearing females also occurs[23]. However, there are situations when multiple antigen-negative RBC products are requested in order to prevent alloimmunization, such as in patients with SCD and βthalassemia. In other cases, phenotypically-matched products may be requested for patients with autoimmune hemolytic anemia; such a practice may prevent future alloimmunization and DHTRs and may also circumvent the need for absorption studies[24]. Phenotype-matched products can be limited to the C, E and K antigens (termed limited phenotype-matched) or extended to include Fya, Jka, Jkb, S, and other antigens (termed extended phenotype-matched). The fundamental reason to phenotype match products is to prevent alloantibody formation and the subsequent negative consequences of HTRs. The downside of this precise matching

ACCEPTED MANUSCRIPT practice is that it makes routine transfusion more difficult for both the donor center and transfusion service. Therefore, phenotype matching is usually only applied to specific patient

RI P

T

populations.

Providing partially phenotyped-matched RBC products for the transfusion of patients with

SC

hemoglobinopathies has been advocated to minimize the likelihood of RBC alloimmunization[25]. One such study showed a decrease in alloimmunization rates in SCD

NU

patients from 35% to 0% with the exclusive use of phenotype-matched RBCs (C, c, E, e, K, S,

MA

Fya, and Fyb) in a 12.5 year period[26]. Another study showed a decrease in alloimmunization rates in SCD patients from 34% (3.4 antibodies/100 units transfused) to 7% (0.1 antibodies/100 units transfused) with extended phenotype-matched products; the antibodies formed after

ED

extended matching were anti-D in D variant patients, and anti-L3(a), Kp(a) and M[27].

PT

Phenotypic matching for Rh and Kell decreased the alloimmunization rates from 33% to 2.8% in one cohort of patients with β-thalassemia major at Children's Hospital Oakland[28], and from

CE

23.5% to 3.7% in another cohort of patients at Aghia Sophia Children's Hospital[29]. For patients in any such matching program, however, failures occur when non-phenotypically

AC

matched RBCs are transfused at institutions that do not provide matched RBCs.

A recently published study showed that despite limited phenotypic matching, SCD patients receiving RBCs from predominantly African-American donors had a high rate of complex Rh antibodies and antibodies to low incidence antigens[30]. In a cohort of 182 transfused patients, 15% of episodic and 58% of chronically transfused patients were alloimmunized; 94/146 antibodies identified in the 80 patients were to Rh antigens. Fifty –six of the antibodies identified in 45 patients were to partial Rh antigens, defined as antibodies to Rh antigens in patients who phenotyped positive for that antigen. Therefore, antigen matching based on

ACCEPTED MANUSCRIPT phenotype alone using African American donors to African American SCD recipients may not, in

T

fact, decrease alloimmunization rates.

RI P

The value of genotyping RBC antigens in patients with hemoglobinopathies is increasingly being realized. Castilho et al. found discrepancies in 6 out of 40 patients between the serologic RBC

SC

phenotype and phenotype predicted by the genotype in the SCD patients but not the control group. The serologic phenotype mistypes were secondary to recent transfusion. The six

NU

patients who then were switched to the correct antigen-matched RBCs had improved RBC

MA

survival with diminished frequency of transfusions[31]. A recent study by da Costa et al, demonstrated the use of molecular matching in SCD patients[32]; 21/35 patients had discrepancies or mismatches between their genotype and phenotype due to phenotyping errors

ED

or Rh variants. With donor and patient genotyping results, more extensive matching was

PT

feasible and resulted in increased time between transfusions and no new alloantibody formation. These studies and others highlight the use of genotyping SCD patients for antigen-

AC

Splenectomy

CE

matched RBC transfusions and the resulting improved patient care[33, 34].

In the1950s, Rowley et al described decreased alloantibody rates to sheep RBCs following intravenous infusion into splenectomized humans[35]. Subsequent studies in murine models also suggested lower response rates to sheep RBCs in splenectomized compared to sham splenectomized rodents[36]. More recent studies completed using transgenic murine mHEL, HOD, or KEL RBCs[37] also support very low response rates in splenectomized animals, assuming that splenectomy occurs prior to initial antigen exposure. As has been suggested in other models, the timing of antigen exposure with respect to splenectomy is presumably critical with regards to recipient immune response. Initial antigen exposure prior to splenectomy results

ACCEPTED MANUSCRIPT in the generation of memory cells, which are then able to mount secondary immune responses

T

following splenectomy[38].

RI P

There has been a renewed interest in the role of splenectomy on RBC alloimmunization rates in humans, following the publication of data demonstrating higher rates of RBC alloantibodies in

SC

splenectomized than non-splenectomized thalassemia major patients living in the US and the UK[39]. However, these findings have not been observed outside the US or UK thalassemia

NU

patient population, with splenectomized thalassemia major patients in Iran, India, and Hong

MA

Kong having rates of alloimmunization that are not higher (and in some instances even lower) than non-splenectomized patients[40-43]. Furthermore, Higgins and Sloan did not identify splenectomy as being a statistically significant risk factor for increased or decreased RBC

ED

alloimmunization rates in a study of more than 13,000 patients without hemoglobinopathies.[8]

PT

Likewise, McPherson et al failed to find increased alloimmunization rates in surgically splenectomized children with sickle cell disease[44].

Thus, at the present time, splenectomy

CE

after initial RBC antigen exposure should not be considered as a therapeutic approach to

AC

decrease rates of RBC alloimmunization.

Immunosuppression

In the late 1980s and early 1990s, a number of papers were published demonstrating that the immunosuppressive regimens associated with organ transplantation (typically consisting of corticosteroids and cyclosporine) appeared to eliminate alloimmunization to the highly immunogenic D antigen[45, 46]. Since that time, there has been interest in determining whether immunosuppressive drugs given during transfusion could prevent (or limit) non-ABO RBC alloimmunization. Taking into consideration murine data that: 1)a spleen impacts RBC alloimmunization[47], 2) animals depleted of marginal zone B-cells fail to respond to RBC antigens[48], and 3) co-stimulatory molecule blockade decreases platelet alloimmunization[49],

ACCEPTED MANUSCRIPT it is plausible that recipient immunosuppression may decrease rates of RBC alloimmunization in humans. One obvious practical obstacle to any immunosuppressive regimen would be the side-

T

effects of these therapies in transfusion recipients. As such, more data is needed to determine if

RI P

immunosuppressive drugs can be efficacious in preventing alloimmune responses to non-ABO RBC antigens and, moreover, if such therapies can be implemented with minimal clinical impact

SC

to the transfusion recipient.

NU

Past Non- RBC Exposures

MA

Two manuscripts, one focusing on humans and the other focusing on mice, have presented the idea that prior exposure to organisms with similarities to RBC antigens may prime individuals for responses to RBCs. In a study of non-alloimmunized humans, relatively high background

ED

memory responses to the immunodominant 1M (179-193) KEL epitope were observed. These

PT

data suggest that priming of antigens that crossreact with the KEL1 antigen may be relatively common, with a number of environmental antigens sharing sequences that span the KEL1 Support for these data is in the identification of naturally occurring anti-

CE

polymorphic site[50].

K.[51] Similar findings were described in a murine model, with blood group antigen exposure

AC

through microbes containing relevant amino acids to prime an individual for an enhanced alloantibody response upon future exposure to an RBC antigen with homology to the non-RBC antigen[52]. Of note, any past exposure and priming, which may result in more rapid or robust responses following initial RBC exposure, would not be detected by current blood bank serologic testing.

Recipient Age It is known that elderly patients are relatively immunocompromised and neonates and infants have immature immune systems., Immune responses of the very young to transfused RBCs have been described to blunted[53]. Studies in a murine model have also shown very low rates

ACCEPTED MANUSCRIPT of RBC alloantibody generation in juvenile mice compared to adult mice[54]. Antibody detection guidelines and lack of required crossmatching in neonates born to non-RBC alloimmunized

T

mothers rely on infants being unlikely to form RBC alloantibodies. With this low likelihood of

RI P

RBC alloantibody formation in mind, it has been hypothesized that initial RBC antigen exposure during infancy may lead not only to non-responsiveness to that particular transfusion, but also to

SC

future non-responsiveness/tolerance. Retrospective studies have reported lower rates of RBC alloimmunization in patients with hemoglobinopathies exposed to RBCs at early ages,

NU

compared to those who initiated chronic transfusion therapy at later ages[55-57]. However,

MA

randomized studies demonstrating the efficacy of such strategies have not been published.

Leukoreduction

ED

It has been suggested that leukoreduction may decrease rates of RBC alloimmunization,

PT

potentially by decreasing the “danger signal” present in the recipient at the time of RBC antigen presentation. However, this relationship has been difficult to test in modern prospective studies,

CE

due in part to the widespread adoption of leukoreduced RBCs in many countries. One retrospective study suggests that leukoreduced RBCs are less immunogenic than non-

AC

leukoreduced RBCs[58]. One part of this study evaluated 195 patients with AML undergoing chemotherapy in an era prior to leukoreduction. These patients had an 8.2% RBC alloimmunization rate, compared to a significantly different alloimmunization rate of 2.8% in 215 patients undergoing chemotherapy at the same institution in an era after near-universal leukoreduction. Potential confounding variables in this data set include other changes in therapy for AML patients over the course of the two distinct time periods studied. Another study described lower rates of RBC alloimmunization in thalassemia major patients receiving leukoreduced RBCs compared to those receiving non-leukoreduced RBCs[29]. However, other changes, including limited phenotypic matching, were also put into place around the same time period that leukoreduction was introduced.

ACCEPTED MANUSCRIPT

Two studies have compared RBC alloimmunization rates in recipients of buffy coat

T

leukoreduced RBCs to those of filter leukoreduced RBCs, with no statistically significant

RI P

differences in rates noted between the two groups. One study, by van de Watering prospectively randomized 374 cardiac surgery patients to receive buffy coat leukoreduced

SC

RBCs, pre-storage filter leukoreduced RBCs, or post-storage filter leukoreduced RBCs, with rates of RBC alloimmunization after a single transfusion event noted to be 7.1%, 3.4%, and

NU

5.4% between the three groups (p not significant)[59]. A larger retrospective, multicenter study

MA

by Schonewille et al involving 4115 patients and 19 hospitals also failed to find a statistically significant difference in the incidence or the prevalence of RBC alloimmunization in buffy coat

ED

leukoreduced compared to filter leukoreduced RBCs[60].

PT

The impact of leukoreduction on RBC alloimmunization was recently investigated in a reductionist murine model[61]. Blood from donors expressing the triple fusion HOD antigen on

CE

an H2q genetic background was collected in CPDA-1 and filter leukoreduced using a neonatal filter. Mice on an H2b genetic background were transfused with fresh leukoreduced or non-

AC

leukoreduced RBCs; leukoreduced HOD RBCs resulted in significantly lower amounts of alloantibodies than non-leukoreduced RBCs. This change in immunogenicity could not be attributed to changes in the HOD antigen expression after filter leukoreduction, nor could it be accounted for by alterations in post-transfusion RBC survival or recovery. Realizing that results in the HOD system may not be applicable to all antigen systems in mice or in humans, these murine studies support the conclusions drawn by Blumberg and Singer about leukoreduction decreasing RBC alloimmunization rates.

RBC Storage

ACCEPTED MANUSCRIPT During their storage, whole-blood derived RBCs undergo a number of physical and biochemical changes[62]. On the basis that these changes may be pro-inflammatory to a transfusion

T

recipient[63], studies were completed in murine models to investigate the impact of the storage

RI P

duration on RBC alloimmunogenicity. Evidence in one murine model (HOD) suggests that the duration of RBC storage can, in fact, influence the magnitude of alloantibody development. An

SC

initial study demonstrated that immune responses to HOD RBCs were significantly higher following transfusion of RBCs stored for 14 days as compared to freshly-infused units; in fact,

NU

fresh units were associated with virtually no alloimmune response[64]. Moreover, this study

MA

showed that additional units of aged RBCs further increased immune responses (as reflected by alloantibody mean fluorescence)[65]. Of note, it has also been shown that the immune response to stored HOD RBCs can be reduced by the concurrent administration of fresh red cells[65].

ED

Hence, such a transfusion strategy presents one potential mechanism to mitigate the immune

PT

effects of aged RBCs. Another strategy that has been shown to reduce the alloimmunogenicity of stored HOD RBCs is the addition of ascorbic acid (vitamin C) to red cell units. Under the

CE

hypothesis that the antioxidant properties of ascorbic acid could prevent RBC injury during storage, Stowell and colleagues demonstrated that alloimmune responses to stored HOD RBCs

AC

were blunted with vitamin C doses between 4-11 mmol/L to RBC units[66]. Therefore, this study suggests that modifications to the storage milieu to limit oxidative red cell damage may lessen the immunogenicity of aged RBCs.

There have been only a handful of human studies (to date) which have examined the potential impact of RBC storage duration on alloimmunization. One of the earliest, performed by Strauss and colleagues, examined blood group antigen alloimmunization as a function of RBC storage age in pre-term infants[53]. In this randomized trial, pre-term infants received fresh (i.e., nonleukoreduced RBCs stored in CPDA-1 and transfused within 7 days of collection) or random (i.e., leukoreduced RBCs stored in AS-1 or AS-3 and transfused anytime throughout 42 days of

ACCEPTED MANUSCRIPT storage) transfusions. All products were group O and underwent gamma-irradiation at the time of issue. The authors found that no infants in either study arm developed an alloantibody.

T

However, this result does not necessarily imply that storage age is non-contributory to

RI P

alloimmunization, as pre-term and/or very young infants generally demonstrate poor

SC

responsiveness to humoral challenges[53].

In addition to this pediatric study, investigations of RBC storage age and alloimmunization risk in

NU

adults have been completed. Yazer and Triulzi retrospectively examined alloimmunization to

MA

the D antigen following the transfusion of AS-5 RBCs stored up to 42 days; an estimated 35% of RBC units were leukoreduced. No significant difference was found in age of units between responders (i.e., those developing anti-D) and non-responders[67]. However, the authors did

ED

find that non-responders trended toward receiving more units 21 days old.

At present, there is little compelling evidence from human studies suggesting that fresh or “younger” RBC units mitigate the risk for non-ABO RBC alloimmunization, and it is clear that more work needs to be done to better elucidate the role (if any) played by RBC storage duration as well the impact of storage on individual antigen characteristics. Future, prospective studies which control for important variables such as the volume of products given spanning different

ACCEPTED MANUSCRIPT age ranges, as well as the duration of follow-up testing after transfusion, should help to increase

T

an understanding of the relationship between RBC storage duration and alloimmunization.

RI P

MITIGATION OF ALLOIMMUNIZATION RISK AFTER ALLOANTIBODY DEVELOPMENT While the main focus of this review article has been unraveling pathways for the prevention or

SC

mitigation of primary alloimmune responses to non-ABO RBC antigens, it is also important to consider the clinical ramifications of an alloantibody once it has developed. As discussed in

NU

more detail earlier, alloimmunization is important for large numbers of transfusion recipients [6,

MA

39, 69, 70]. Given that HTRs due to non-ABO alloantibodies were the 2nd leading cause of transfusion-associated death reported to the FDA from 2005-2013[2, 71], alloimmunization mitigation strategies would improve transfusion outcome and potentially decrease transfusion

PT

ED

related mortality.

There are several unique aspects surrounding non-ABO RBC alloantibodies which warrant brief

CE

further discussion; such factors may help to explain some of the morbidity/mortality risk associated with blood group alloantibodies. Perhaps the most significant among these is

AC

alloantibody evanescence, a phenomenon in which antibodies disappear from detection over time. Reports have shown that up to 70% of alloantibodies become undetectable within a few years of their initial development[72-74]. Another complexity associated with alloimmunization is the need for well-timed testing to detect non-ABO alloantibodies. In some cases, patients may not ever undergo repeat testing following transfusion. Even if follow-up testing is performed, it may be too early (i.e., before a primary immune response) or too late (i.e., after an antibody has already dropped below levels of detection). The problems of inadequate alloimmunization surveillance and antibody evanescence are further compounded by transfusion record fragmentation, i.e. the lack of complete transfusion records at all facilities where a patient may seek medical care. Data from Unni and colleagues demonstrated that about one-quarter of

ACCEPTED MANUSCRIPT patients undergoing type and screen testing at one facility had been transfused at another[75]. When comparisons between transfusion records at two nearby facilities were made,

T

discrepancies were noted in 64% of alloimmunized patients. The most common discrepancy

RI P

was lack of documentation of an antibody detected at the other facility[75].

SC

With the recognition that evanescence, inadequate follow-up testing, and transfusion record fragmentation are important risk factors for alloantibody-associated morbidity/mortality, some

NU

strategies have been developed to counter or limit their effects. Furthermore, other clinical

MA

approaches (e.g., apheresis and immunosuppression) may be viable options to further mitigate the impact of circulating blood group alloantibodies when an incompatible transfusion is unavoidable. The data and/or clinical experiences associated with each of these approaches will

ED

be briefly outlined below. Of note, phenotypic and/or genotypic matching of RBC antigens on a

PT

prophylactic basis is yet another strategy to thwart the formation of additional alloantibodies in

CE

an already alloimmunized patient.

Increased Alloantibody Screening and Portability of Alloantibody Information

AC

Based on prospective data suggesting that alloantibody responses are typically induced between 4 and 16 weeks after transfusion[69], one mechanism to increase detection of alloantibodies would be to introduce routine follow-up testing after transfusion after this window period. While it would be difficult to have patients return every 1-2 weeks to perform alloantibody screen testing, a well-designed program to have patients tested at about 6 weeks posttransfusion should capture a high percentage of newly-developed alloantibodies[69]. Even with such a follow-up testing system in place, there would still be a need to increase the portability of alloantibody data to counter the problems of record fragmentation and evanescence. This could be accomplished by providing alloimmunized patients with wallet cards, medical bracelets, or other devices which increase awareness of their underlying alloantibodies. A limitation of such

ACCEPTED MANUSCRIPT approaches is that patients may forget or fail to present such information to their treating physician upon arrival at another hospital. As such, there is increasing interest in the

T

development of non-ABO alloantibody registries. Schwickerath and colleagues showed that the

RI P

establishment of a regional, web-based registry helped to prevent four DHTRs following the first year of implementation[76]. Other studies have shown similar benefits of centralized blood bank

SC

databases among networked hospitals[72, 77]. As such, alloantibody registries represent a promising tool to improve transfusion safety via increased record portability. Antibody registries

NU

could decrease healthcare cost by preventing hemolytic reactions, costly work-ups, or delayed

MA

transfusion. However, reliable data must be available to prevent restricting patients to antigennegative RBCs when unnecessary. Also information technology infrastructure must be

ED

developed to support such registries.

PT

Active Removal of Circulating Incompatible RBCs or Alloantibodies In some circumstances, patients will inadvertently be exposed to incompatible RBCs as a result

CE

of medical necessity, medical error, or evanescent blood group antibodies. In such scenarios, one approach to limiting the damage done by alloantibodies is active removal of the

AC

incompatible transfused RBCs. The practice of prophylactic RBC exchange therapy to limit immune hemolysis has been reported in stem cell transplants associated with minor or bidirectional ABO incompatibility[78]. Using similar principles of active removal of incompatible RBCs, Tormey and Stack reported a prophylactic RBC exchange which prevented hemolysis associated with a developing anamnestic response in a massively-transfused individual with five evanescent non-ABO alloantibodies[79]. In addition to prophylactic erythocytapheresis, at least two other groups have reported the use of RBC exchange to limit end organ damage and symptoms in patients suffering severe DHTRs[80, 81]. As an alternative to removing RBCs, Wright and colleagues reported the use of plasma exchange therapy to reduce circulating antiJka titers in two cases of severe, delayed hemolysis[82]. While active removal of RBCs and/or

ACCEPTED MANUSCRIPT alloantibodies may not be necessary for every anamnestic alloantibody response/DHTR, the above reports indicate that severe or life-threatening forms of delayed hemolysis may be

RI P

T

successfully addressed via plasma- or erythrocytapheresis.

Immunosuppression

SC

Another potential approach to limiting the effects of a previously-developed alloantibody is to use immunosuppression. For instance, in the setting of hyperhemolysis associated with non-

NU

ABO alloantibodies, the administration of intravenous immune globulin (IVIg) and corticosteroids

MA

has been reported to reduce the rate of RBC destruction and stabilize hemoglobin/hematocrit[83, 84]. There has also been growing interest in the use of the antiCD20 therapy, rituximab, to target circulating B-cells and prevent DHTRs/hyperhemolysis. To

ED

date, there have been several intriguing reports involving anti-CD20 therapy in alloimmunized

PT

patients[85-87]. Noizat-Pirenne and colleagues were the first group to effectively use rituximab to overcome hyperhemolysis in a patient with sickle cell disease[86], while others have

CE

subsequently reported similar success in a variety of clinical settings[85, 87, 88]. It is important to note that rituximab appeared to limit the production of autoantibodies that arose in parallel to

AC

the RBC alloantibodies. Such autoantibodies have been hypothesized to mediate bystander hemolysis in some severe DHTR/hyperhemolysis cases. Thus, while rituximab may not directly impact non-ABO alloantibody titers, it may play a potentially important role in selected cases where an anamnestic response initiates hemolysis which is then further sustained via a newlyinduced autoantibody.

In addition to rituximab, there are several monoclonal antibody therapies (e.g., the C5 inhibitor, eculizumab) which could be beneficial in limiting alloantibody-mediated hemolysis[89]. At present, further studies are needed to determine the potential efficacy of such drugs in this setting. It should also be noted that IVIg has been used to suppress maternal alloantibodies in

ACCEPTED MANUSCRIPT the setting of hemolytic disease of the fetus and newborn. While this topic is outside the scope of this review on transfusion-associated alloimmunization, a thorough review on the efficacy of

RI P

T

this approach was recently published by Wong et al[90].

SUMMARY

SC

Over the past century, much effort has been dedicated to defining RBC antigens, to characterizing alloantibody development, and to documenting the sequelae of cognate RBC

NU

antigen/antibody binding. More recently, efforts have shifted to understanding the genetics of

MA

responder/non-responder patient populations, to considering the economic burden of alloantibody detection and prevention, and to developing strategies to incorporate phenotypic and/or genotypic matching for certain patient populations. As our understanding of factors

ED

influencing RBC alloimmunization continues to unfold, the number of potential primary and

PT

secondary mitigation strategies to prevent or to decrease the dangers of this serious hazard of transfusion will also expand. A continued multidisciplinary collaborative effort by investigators,

CE

using a bench to bedside and back approach will allow for evolving questions (Table 3) to be investigated, for additional RBC alloimmunization mitigation strategies to be developed, and for

AC

transfusion safety to be improved.

ACCEPTED MANUSCRIPT Table 1. Factors that may* influence the development of RBC alloantibodies. Antigen exposure and disparity between donor and recipient

RI P

T

Ability of the recipient’s HLA to present the foreign antigen(s) Genetic predisposition to “respond”

SC

Recipient Factors

NU

Health status at the time of antigen exposure

Prior exposures, including non-RBC exposures

MA

Method of exposure (e.g., transfusion vs. pregnancy)

PT

ED

Genetic factors that may inherently impact RBC storage characteristics

AC

CE

Donor Factors

Length of RBC storage Presence of contaminating white cells and/or platelets Damage to RBCs resulting from processing and/or storage Antigen dose

*Some factors listed have been shown in animal studies to impact RBC alloimmunization; others have been shown in human studies to impact RBC alloimmunization. Future studies are needed to investigate the clinical impact in humans of factors shown to influence RBC alloimmunization in animals.

ACCEPTED MANUSCRIPT Table 2. Interventions based on animal model data that may* influence RBC alloimmunization. Hypothesized Mechanism Innate/adaptive immune activation Immunostimulatory RBC consumption and antigen presentation with generation of memory Bacteria or other pathogens with crossreactive antigens prime the immune system for a more robust response after RBC exposure

Therapies targeting “functional” spleen status at time of initial antigen exposure

RI P

Presence of a spleen

Mitigation Strategy Anti-inflammatory therapies

T

Factor Recipient inflammation

NU

SC

Prior non-RBC antigen exposures

RBC damage

MA

RBC damage increases clearance rates post-infusion and/or provides a “danger” signal via mediators (e.g., cytokines, iron) Leukocytes and/or their released mediators may contribute to an inflammatory “danger” signal

ED

Donor leukocytes

Awareness of this phenomenon; limiting of crossreactive exposures (as feasible); recognition that such exposures would not be detected by routine serologic testing Modification of RBC processing, storage, and/or donor unit selection strategies

Highly-stringent leukoreduction and/or leukocyte inactivation

AC

CE

PT

*These interventions are hypothesized to impact RBC alloimmunization in animals, based on animal data. Future studies are needed to investigate the clinical efficacy of interventions extrapolated primarily from animal model data.

ACCEPTED MANUSCRIPT Table 3. Future research directions and questions to consider, regarding mitigation of RBC alloimmunization risks.

RI P

T

Will it be possible to identify “responders” a priori by genetic markers, and should transfusion strategies/products be altered for such patients? Could splenectomy prior to initial antigen exposure minimize alloimmunization? If so, would antigen exposure need to be continuous for tolerance to persist? Will immunomodulatory therapies be useful for preventing alloimmunization?

SC

Recipient Questions

NU

How does health status at the time of antigen exposure, including degree of inflammation, age, and general immune function, impact alloimmunization?

MA

What inflammatory markers may contribute to alloimmunization? Could vascular inflammation be a risk?

CE

ED

PT

Donor Questions

Recipient/Donor Interaction Questions

AC

How does RBC dose or duration of RBC exposure impact immunogenicity? Could these factors influence the duration of a humoral response or evanescence? What inflammatory markers may contribute to alloimmunization? Could contaminating platelets impact the alloimmune response? Do blood collection and processing methods impact RBC alloimmunization? How will genotyping of recipients/donors affect RBC alloimmunization, and which strategies are most cost effective? Should genotyping/phenotyping strategies consider HLA restriction, such that matching for some antigens is omitted if a recipient has an HLA incapable of presenting that particular antigen?

ACCEPTED MANUSCRIPT REFERENCES

AC

CE

PT

ED

MA

NU

SC

RI P

T

[1] Whitaker B, Hinkins S. The 2011 National Blood Collection and Utilization Survey Report. In: Department of Health and Human Services, editor.2013. [2] Administration FaD. Fatalities reported to FDA following blood collection and transfusion: Annual summary for fiscal year 2013. In: FDA, editor.: FDA; 2014. [3] Hillyer CD, Shaz BH, Winkler AM, Reid M. Integrating molecular technologies for RBC typing and compatibility testing into blood centers and transfusion services. Transfusion Medicine Reviews 2008;22:117-32. [4] Denomme GA. Prospects for the provision of genotyped blood for transfusion. British Journal of Haematology 2013;163:3-9. [5] Josephson CD, Su LL, Hillyer KL, Hillyer CD. Transfusion in the patient with sickle cell disease: A critical review of the literature and transfusion guidelines. Transfusion Medicine Reviews 2007;21:118-33. [6] Aygun B, Padmanabhan S, Paley C, Chandrasekaran V. Clinical significance of RBC alloantibodies and autoantibodies in sickle cell patients who received transfusions. Transfusion 2002;42:37-43. [7] Vichinsky EP, Earles A, Johnson RA, Hoag MS, Williams A, Lubin B. Alloimmunization in Sickle-Cell-Anemia and Transfusion of Racially Unmatched Blood. New England Journal of Medicine 1990;322:1617-21. [8] Higgins JM, Sloan SR. Stochastic modeling of human RBC alloimmunization: evidence for a distinct population of immunologic responders. Blood 2008;112:2546-53. [9] Tatari-Calderone Z, Tamouza R, Le Bouder GP, Dewan R, Luban NL, Lasserre J, et al. The association of CD81 polymorphisms with alloimmunization in sickle cell disease. Clinical & developmental immunology 2013;2013:937846. [10] Chu CC, Ho HT, Lee HL, Chan YS, Chang FJ, Wang CL, et al. Anti-"Mi(a)" immunization is associated with HLA-DRB1*0901. Transfusion 2009;49:472-8. [11] Chiaroni J, Dettori I, Ferrera V, Legrand D, Touinssi M, Mercier P, et al. HLA-DRB1 polymorphism is associated with Kell immunisation. Br J Haematol 2006;132:374-8. [12] Picard C, Frassati C, Basire A, Buhler S, Galicher V, Ferrera V, et al. Positive association of DRB1 04 and DRB1 15 alleles with Fya immunization in a Southern European population. Transfusion 2009;49:2412-7. [13] Reviron D, Dettori I, Ferrera V, Legrand D, Touinssi M, Mercier P, et al. HLA-DRB1 alleles and Jk(a) immunization. Transfusion 2005;45:956-9. [14] Hendrickson JE, Roback JD, Hillyer CD, Easley KA, Zimring JC. Discrete Toll-like receptor agonists have differential effects on alloimmunization to transfused red blood cells. Transfusion 2008;48:1869-77. [15] Hendrickson JE, Desmarets M, Deshpande SS, Chadwick TE, Hillyer CD, Roback JD, et al. Recipient inflammation affects the frequency and magnitude of immunization to transfused red blood cells. Transfusion 2006;46:1526-36. [16] Stowell SR, Girard-Pierce KR, Smith NH, Henry KL, Arthur CM, Zimring JC, et al. Transfusion of murine red blood cells expressing the human KEL glycoprotein induces clinically significant alloantibodies. Transfusion 2014;54:179-89. [17] Smith NH, Hod EA, Spitalnik SL, Zimring JC, Hendrickson JE. Transfusion in the absence of inflammation induces antigen-specific tolerance to murine RBCs. Blood 2012;119:1566-9.

ACCEPTED MANUSCRIPT

AC

CE

PT

ED

MA

NU

SC

RI P

T

[18] Yazer MH, Triulzi DJ, Shaz B, Kraus T, Zimring JC. Does a febrile reaction to platelets predispose recipients to red blood cell alloimmunization? Transfusion 2009;49:1070-5. [19] Papay P, Hackner K, Vogelsang H, Novacek G, Primas C, Reinisch W, et al. High risk of transfusion-induced alloimmunization of patients with inflammatory bowel disease. Am J Med 2012;125:717 e1-8. [20] Bao W, Zhong H, Li X, Lee MT, Schwartz J, Sheth S, et al. Immune regulation in chronically transfused allo-antibody responder and nonresponder patients with sickle cell disease and beta-thalassemia major. Am J Hematol 2011;86:1001-6. [21] Yu J, Heck S, Yazdanbakhsh K. Prevention of red cell alloimmunization by CD25 regulatory T cells in mouse models. American Journal of Hematology 2007;82:691-6. [22] Booth GS, Miles MR, Du L, Koyama T, Meier ER, Luban NLC. Red Blood Cell Alloimmunization Is Influenced By Recipient Inflammatory State At Time Of Transfusion In Patients With Sickle Cell Disease. Blood 2013;122:40. [23] JPAC- Joint United Kingdom Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee. Transfusion Handbook. Basics of blood groups and antibodies. http://www.transfusionguidelines.org.uk/transfusion-handbook/2basics-of-blood-groups-and-antibodies. Accessed: May 8, 2014. [24] Shirey RS, Boyd JS, Parwani AV, Tanz WS, Ness PM, King KE. Prophylactic antigen-matched donor blood for patients with warm autoantibodies: an algorithm for transfusion management. Transfusion 2002;42:1435-41. [25] Afenyi-Annan A, Bandarenko N. Transfusion practices for patients with sickle cell disease at a major academic center. Immunohematology 2006;22:103-7. [26] Tahhan HR, Holbrook CT, Braddy LR, Brewer LD, Christie JD. Antigen-Matched Donor Blood in the Transfusion Management of Patients with Sickle-Cell Disease. Transfusion 1994;34:562-9. [27] Lasalle-Williams M, Nuss R, Le T, Cole L, Hassell K, Murphy JR, et al. Extended red blood cell antigen matching for transfusions in sickle cell disease: a review of a 14year experience from a single center (CME). Transfusion 2011;51:1732-9. [28] 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.[see comment]. Blood 2000;96:3369-73. [29] 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. [30] Chou ST, Jackson T, Vege S, Smith-Whitley K, Friedman DF, Westhoff CM. High prevalence of red blood cell alloimmunization in sickle cell disease despite transfusion from Rh-matched minority donors. Blood 2013;122:1062-71. [31] Castilho L, Rios M, Bianco C, Pellegerino J, Alberto FL, Saad STO, et al. DNAbased typing of blood groups for the management of multiply-transfused sickle cell disease patients. Transfusion 2002;42:232-8. [32] da Costa DC, Pellegrino J, Jr., Guelsin GA, Ribeiro KA, Gilli SC, Castilho L. Molecular matching of red blood cells is superior to serological matching in sickle cell disease patients. Revista brasileira de hematologia e hemoterapia 2013;35:35-8.

ACCEPTED MANUSCRIPT

AC

CE

PT

ED

MA

NU

SC

RI P

T

[33] Bakanay SM, Ozturk A, Ileri T, Ince E, Yavasoglu S, Akar N, et al. Blood group genotyping in multi-transfused patients. Transfus Apher Sci 2013;48:257-61. [34] O'Suoji C, Liem RI, Mack AK, Kingsberry P, Ramsey G, Thompson AA. Alloimmunization in sickle cell anemia in the era of extended red cell typing. Pediatr Blood Cancer 2013;60:1487-91. [35] Rowley DA. The formation of circulating antibody in the splenectomized human being following intravenous injection of heterologous erythrocytes. Journal of Immunology (Baltimore, Md : 1950) 1950;65:515-21. [36] Rozing J, Brons NH, Bennner R. Effects of splenectomy on the humoral immune system. A study in neonatally and adult splenectomized mice. Immunology 1978;34:909-17. [37] Hendrickson JE, Stowell, S.R., Smith, N.H., Girard-Pierce, K.R., Hudson K.E., Zimring, J.C. Transfused RBCs can be immunogenic in splenectomized mice: of inflammation, adjuvants, and anamnestic responses. Transfusion 2012;52(Supplement):P1-030A. [38] Benner R, van Oudenaren A. Antibody formation in mouse bone marrow. IV. The influence of splenectomy on the bone marrow plaque-forming cell response to sheep red blood cells. Cellular immunology 1975;19:167-82. [39] Thompson AA, Cunningham MJ, Singer ST, Neufeld EJ, Vichinsky E, Yamashita R, et al. Red cell alloimmunization in a diverse population of transfused patients with thalassaemia. Br J Haematol 2011;153:121-8. [40] Azarkeivan A, Ansari S, Ahmadi MH, Hajibeigy B, Maghsudlu M, Nasizadeh S, et al. Blood transfusion and alloimmunization in patients with thalassemia: multicenter study. Pediatr Hematol Oncol 2011;28:479-85. [41] Pahuja S, Pujani M, Gupta SK, Chandra J, Jain M. Alloimmunization and red cell autoimmunization in multitransfused thalassemics of Indian origin. Hematology (Amsterdam, Netherlands) 2010;15:174-7. [42] Gupta R, Singh DK, Singh B, Rusia U. Alloimmunization to red cells in thalassemics: emerging problem and future strategies. Transfus Apher Sci 2011;45:167-70. [43] 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. [44] McPherson ME, Anderson AR, Castillejo MI, Hillyer CD, Bray RA, Gebel HM, et al. HLA alloimmunization is associated with RBC antibodies in multiply transfused patients with sickle cell disease. Pediatr Blood Cancer 2010;54:552-8. [45] Casanueva M, Valdes MD, Ribera MC. Lack of alloimmunization to D antigen in Dnegative immunosuppressed liver transplant recipients. Transfusion 1994;34:570-2. [46] Ramsey G, Hahn LF, Cornell FW, Boczkowski DJ, Staschak S, Clark R, et al. Low rate of Rhesus immunization from Rh-incompatible blood transfusions during liver and heart transplant surgery. Transplantation 1989;47:993-5. [47] Hendrickson J, Saakadze N, Cadwell CM, Upton JW, Mocarski ES, Hillyer CD, Zimring JC. The spleen plays a central role in primary humoral alloimmunization to transfused mHEL red blood cells. Transfusion 2009;49:1678-84.

ACCEPTED MANUSCRIPT

AC

CE

PT

ED

MA

NU

SC

RI P

T

[48] Girard-Pierce K, Stowell SR, Smith NH, Henry KL, Zimring JC, Hendrickson JE. Marginal zone B cells mediate alloantibody formation to a clinically significant human RBC antigen in a murine model. Blood 2012;2012 ASH abstract 843. [49] Gilson CR, Patel SR, Zimring JC. CTLA4-Ig prevents alloantibody production and BMT rejection in response to platelet transfusions in mice. Transfusion 2012;52:220919. [50] Stephen J, Cairns LS, Pickford WJ, Vickers MA, Urbaniak SJ, Barker RN. Identification, immunomodulatory activity, and immunogenicity of the major helper T-cell epitope on the K blood group antigen. Blood 2012;119:5563-74. [51] Judd WJ, Walter WJ, Steiner EA. Clinical and laboratory findings on two patients with naturally occurring anti-Kell agglutinins. Transfusion 1981;21:184-8. [52] Hudson KE, Lin E, Hendrickson JE, Lukacher AE, Zimring JC. Regulation of primary alloantibody response through antecedent exposure to a microbial T-cell epitope. Blood 2010;115:3989-96. [53] Strauss RG, Cordle DG, Quijana J, Goeken NE. Comparing alloimmunization in preterm infants after transfusion of fresh unmodified versus stored leukocyte-reduced red blood cells. J Pediatr Hematol Oncol 1999;21:224-30. [54] Patel SR, Hendrickson JE, Smith NH, Cadwell CM, Ozato K, Morse HC, 3rd, et al. Alloimmunization against RBC or PLT antigens is independent of TRIM21 expression in a murine model. Mol Immunol 2011;48:909-13. [55] Vichinsky E, Neumayr L, Trimble S, Giardina PJ, Cohen AR, Coates T, et al. Transfusion complications in thalassemia patients: a report from the Centers for Disease Control and Prevention. Transfusion 2014;54:972-81. [56] Spanos T, Karageorga M, Ladis V, Peristeri J, Hatziliami A, Kattamis C. Red cell alloantibodies in patients with thalassemia. Vox Sang 1990;58:50-5. [57] Rosse WF, Gallagher D, Kinney TR, Castro O, Dosik H, Moohr J, et al. Transfusion and Alloimmunization in Sickle-Cell Disease. Blood 1990;76:1431-7. [58] Blumberg N, Heal JM, Gettings KF. WBC reduction of RBC transfusions is associated with a decreased incidence of RBC alloimmunization. Transfusion 2003;43:945-52. [59] van de Watering L, Hermans J, Witvliet M, Versteegh M, Brand A. HLA and RBC immunization after filtered and buffy coat-depleted blood transfusion in cardiac surgery: a randomized controlled trial. Transfusion 2003;43:765-71. [60] Schonewille H, Brand A. Alloimmunization to red blood cell antigens after universal leucodepletion. A regional multicentre retrospective study. Br J Haematol 2005;129:1516. [61] Hendrickson J, Hod EA, Spitalnik SL, Hillyer CD, Zimring JC. Leukoreduction Decreases Alloimmunogenicity of Transfused Murine HOD RBCs. ASH Annual Meeting Abstracts 2009;114:640. [62] D'Alessandro A, Liumbruno G, Grazzini G, Zolla L. Red blood cell storage: the story so far. Blood Transfus 2010;8:82-8. [63] Hendrickson JE, Hod EA, Cadwell CM, Eisenbarth SC, Spiegel DA, Tormey CA, et al. Rapid clearance of transfused murine red blood cells is associated with recipient cytokine storm and enhanced alloimmunogenicity. Transfusion 2011;51:2445-54.

ACCEPTED MANUSCRIPT

ED

MA

NU

SC

RI P

T

[64] Hendrickson JE, Hod EA, Spitalnik SL, Hillyer CD, Zimring JC. Storage of murine red blood cells enhances alloantibody responses to an erythroid-specific model antigen. Transfusion 2010;50:642-8. [65] Hendrickson JE, Hod EA, Hudson KE, Spitalnik SL, Zimring JC. Transfusion of fresh murine red blood cells reverses adverse effects of older stored red blood cells. Transfusion 2011;51:2695-702. [66] Stowell SR, Smith NH, Zimring JC, Fu X, Palmer AF, Fontes J, et al. Addition of ascorbic acid solution to stored murine red blood cells increases posttransfusion recovery and decreases microparticles and alloimmunization. Transfusion 2013;53:2248-57. [67] Yazer MH, Triulzi DJ. Receipt of older RBCs does not predispose D-negative recipients to anti-D alloimmunization. Am J Clin Pathol 2010;134:443-7. [68] Zalpuri S, Schonewille H, Middelburg R, van de Watering L, de Vooght K, Zimring J, et al. Effect of storage of red blood cells on alloimmunization. Transfusion 2013;53:2795-800. [69] Redman M, Regan F, Contreras M. A prospective study of the incidence of red cell allo-immunisation following transfusion. Vox Sanguinis 1996;71:216-20. [70] Tormey CA, Fisk J, Stack G. Red blood cell alloantibody frequency, specificity, and properties in a population of male military veterans. Transfusion 2008;48:2069-76. [71] US Food and Drug Administration. Fatalities reported to FDA following blood collection and transfusion: annual summary for fiscal year 2009. In: US Department of Health and Human Services, editor. Rockville 2010.

AC

CE

PT

[72] Harm SK, Yazer MH, Monis GF, Triulzi DJ, Aubuchon JP, Delaney M. A centralized recipient database enhances the serologic safety of RBC transfusions for patients with sickle cell disease. Am J Clin Pathol 2014;141:256-61. [73] Reverberi R. The persistence of red cell alloantibodies. Blood Transfus 2008;6:22534. [74] Tormey CA, Stack G. The persistence and evanescence of blood group alloantibodies in men. Transfusion 2009;49:505-12. [75] Unni N, Peddinghaus M, Tormey CA, Stack G. Record fragmentation due to transfusion at multiple health care facilities: a risk factor for delayed hemolytic transfusion reactions. Transfusion 2014;54:98-103. [76] Schwickerath V, Kowalski M, Menitove JE. Regional registry of patient alloantibodies: first-year experience. Transfusion 2010;50:1465-70. [77] Delaney M, Dinwiddie S, Nester TN, Aubuchon JA. The immunohematologic and patient safety benefits of a centralized transfusion database. Transfusion 2013;53:7716. [78] Worel N, Greinix HT, Supper V, Leitner G, Mitterbauer M, Rabitsch W, et al. Prophylactic red blood cell exchange for prevention of severe immune hemolysis in minor ABO-mismatched allogeneic peripheral blood progenitor cell transplantation after reduced-intensity conditioning. Transfusion 2007;47:1494-502. [79] Tormey CA, Stack G. Limiting the extent of a delayed hemolytic transfusion reaction with automated red blood cell exchange. Arch Pathol Lab Med 2013;137:861-4. [80] Kalyanaraman M, Heidemann SM, Sarnaik AP, Meert KL, Sarnaik SA. Anti-s antibody-associated delayed hemolytic transfusion reaction in patients with sickle cell anemia. J Pediatr Hematol Oncol 1999;21:70-3.

ACCEPTED MANUSCRIPT

AC

CE

PT

ED

MA

NU

SC

RI P

T

[81] von Zabern I, Ehlers M, Grunwald U, Mauermann K, Greinacher A. Release of mediators of systemic inflammatory response syndrome in the course of a severe delayed hemolytic transfusion reaction caused by anti-D. Transfusion 1998;38:459-68. [82] Wright RD, Larison PJ, Cook LO. Plasma exchange in the management of delayed hemolytic transfusion reaction. Transfusion Science 1990;11:91-6. [83] Win N, Sinha S, Lee E, Mills W. Treatment with intravenous immunoglobulin and steroids may correct severe anemia in hyperhemolytic transfusion reactions: case report and literature review. Transfus Med Rev 2010;24:64-7. [84] Win N, Yeghen T, Needs M, Chen FE, Okpala I. Use of intravenous immunoglobulin and intravenous methylprednisolone in hyperhaemolysis syndrome in sickle cell disease. Hematology 2004;9:433-6. [85] Mota M, Bley C, Aravechia MG, Hamerschlak N, Sakashita A, Kutner JM, et al. Autoantibody formation after alloimmunization inducing bystander immune hemolysis. Immunohematology 2009;25:9-12. [86] Noizat-Pirenne F, Bachir D, Chadebech P, Michel M, Plonquet A, Lecron JC, et al. Rituximab for prevention of delayed hemolytic transfusion reaction in sickle cell disease. Haematologica 2007;92:e132-5. [87] Sigler E, Shvidel L, Yahalom V, Berrebi A, Shtalrid M. Clinical significance of serologic markers related to red blood cell autoantibodies production after red blood cell transfusion-severe autoimmune hemolytic anemia occurring after transfusion and alloimmunization: successful treatment with rituximab. Transfusion 2009;49:1370-4. [88] Cattoni A, Cazzaniga G, Perseghin P, Zatti G, Gaddi D, Cossio A, et al. An Attempt to Induce Transient Immunosuppression Pre-erythrocytapheresis in a Girl With Sickle Cell Disease, a History of Severe Delayed Hemolytic Transfusion Reactions and Need for Hip Prosthesis. Hematol Rep 2013;5:36-8. [89] Stowell SR, Winkler AM, Maier CL, Arthur CM, Smith NH, Girard-Pierce KR, et al. Initiation and regulation of complement during hemolytic transfusion reactions. Clin Dev Immunol 2012;2012:307093. [90] Wong KS, Connan K, Rowlands S, Kornman LH, Savoia HF. Antenatal immunoglobulin for fetal red blood cell alloimmunization. Cochrane Database Syst Rev 2013;5:CD008267.

ACCEPTED MANUSCRIPT

T

RI P SC NU MA ED PT



CE



RBC alloantibodies result in delayed and acute hemolytic transfusion reactions, which are a leading cause of transfusion related mortality. Recipient factors influencing RBC antibody formation include antigen exposure, genetic predisposition to antibody formation, and health status. Donor factors influencing RBC antigen formation may include presence of white blood cells, antigen dose, and RBC damage.

AC

