How do I approach patients with warm-reactive autoantibodies?_2985 14..17
Douglas P. Blackall W arm-reactive autoantibodies are the most common cause of autoimmune hemolytic anemia, with the incidence of these anti- bodies increasing with patient age. 1 They have been reported in children as young as a few months of age, and there are two case reports of neonates who seem to have developed warm-reactive autoantibodies in utero. 2,3 They are a relatively common nding at Arkansas Childrens Hospital, accounting for approximately 15% of all antibodies evaluated in the laboratory. 4 Although warm-reactive autoantibodies are sometimes idiopathic, there are a number of common disease associations including hematopoietic malignancies (e.g., lymphomas and leukemias, especially chronic lymphocytic leukemia), autoimmune disorders (e.g., systemic lupus erythemato- sus), and chronic inammatory conditions (e.g., Crohns disease and ulcerative colitis). 1 On occasion, a warm- reactive autoantibody may be the harbinger of one of these disorders, which only presents in overt form later. This review will focus on the transfusion service labora- tory approach to these autoantibodies and applies to pediatric and adult patients equally. I am usually rst consulted about a new warm- reactive autoantibody by a blood bank technologist. Ini- tially, I strive to obtain information about the serologic nature of the antibody and the clinical status of the patient. With regard to the former, I turn my attention rst to the reactive nature of the antibody in the serum (i.e., How strongly reactive is the antibody? Are all of the red blood cells [RBCs] on the antibody identication panel reactive? Are the cells on the panel equally reactive?). I next consider the reactive nature of the direct antiglobulin test (DAT; i.e., What is coating the RBCs in excess: IgG, C3, or both? What is the strength of reactivity of the anti-IgG and anti-C3 reagents?). Having knowledge of the serologic reactivity of the patients antibody helps to conrm that it is, indeed, a warm-reactive autoantibody. It also provides important insight into the likelihood that the antibody is resulting in hemolysiswarm autoimmune hemolytic anemia (WAIHA). As examples, it has been well demon- strated that more strongly reactive warm autoantibodies are more likely to be associated with overt hemolysis, although this is by no means a perfect correlation. 4,5 Simi- larly, warm-reactive IgGautoantibodies that are also asso- ciated with demonstrable C3 on the RBC membrane are more likely to be hemolytic via a synergistic effect. 6 Once I understand the serological presentation of the warm-reactive autoantibody, I turn my attention to deter- mining the clinical signicance of the antibody and understanding the patients clinical condition. Most important is determining if the antibody is associated with hemolysis. This is a key consideration as this will be the primary determinant of whether or not the patient will need transfusion (now and into the future). This will, in turn, drive the extent to which the antibody is evaluated in the laboratory. To determine the clinical signicance of warm-reactive autoantibodies, a number of ancillary laboratory tests are required including the hemoglobin (Hb) and hematocrit (low), the reticulocyte count (gener- ally elevated, but reticulocytopenia can be a harbinger of a difcult patient course), the lactate dehydrogenase value (elevated), and the bilirubin level, particularly the indirect fraction (elevated). A visual inspection of the plasma or urine is lowcost and can provide helpful information as to whether hemolysis (if present) is intravascular or extravas- cular. The latter is expected in cases of WAIHA. A hapto- globin value can be useful (low), but in many laboratories this test is not readily available. In addition, haptoglobin is an acute-phase reactant, so a single value, especially one that is in the normal reference range for the laboratory, may not be useful. Finally, it is always advisable to assess the RBC morphology on review of the peripheral blood smear, because spherocytes are typically identied in cases of WAIHA. If a patient is experiencing hemolysis to the extent that transfusion support is necessary, additional serologic work may be required. The most basic question is this: From the Department of Pathology, University of Arkansas for Medical Sciences College of Medicine and Arkansas Childrens Hospital, Little Rock, Arkansas. Address reprint requests to: Douglas P. Blackall, MD, Department of Pathology, Arkansas Childrens Hospital, 1 Chil- drens Way, Little Rock, AR 72202; e-mail: dougandcaron@ att.net. Received for publication July 27, 2010; revision received September 10, 2010, and accepted October 15, 2010. doi: 10.1111/j.1537-2995.2010.02985.x TRANSFUSION 2011;51:14-17. 14 TRANSFUSION Volume 51, January 2011 How much does one need to do? Before approaching this question, it is important to remember that when the blood bank is faced with a warm-reactive autoantibody and a patient requires transfusion, the primary concern is the identication of underlying blood group alloantibodies. As I explain to rotating residents, we may not be able to do anything about an autoantibody and its consequences, but we dont want to contribute to further hemolysis by transfusing a patient with an underlying alloantibody. Since alloantibodies form as a result of RBC exposure, via transfusion or pregnancy, an important task for blood bank staff is to obtain history. We are benetted in the pediatric setting by generally having very accessible and reliable transfusion histories on our patients. In addition, most of the patients that we serve have no history of preg- nancy. Thus, many patients with new presentations of WAIHA have no reasonable likelihood of having underly- ing autoantibodies, so no special studies (e.g., adsorption) are required before transfusion. On the other hand, if a patient has been transfused or pregnant and there is time to perform an adsorption study (based on the clinical status of the patient), then the safest practice is to com- plete the study before transfusing. Very importantly, it is critical to communicate with transfusion services that may have evaluated the patient in the past. Early knowl- edge of a previously identied blood group antibody can be extremely helpful. There are a number of additional serologic issues that the transfusion service should consider in any patient pre- senting with a warm-reactive autoantibody. Adsorption studies: These studies are important in uncovering underlying alloantibodies in those patients who have a history of pregnancy or transfu- sion, if time allows for such a study. In those who have not been transfused in the preceding 3 months, an autologous adsorption is indicated. For those with a history of recent transfusion, a more demanding allo- geneic study is required. Whether either of these studies will be able to be performed in house or referred out depends on a number of factors includ- ing the overall sophistication of the laboratory, the number of such studies the laboratory encounters, and general nancial considerations (e.g., relative cost of testing in house vs. referring out). Phenotyping: This refers to establishing which of the major, clinically signicant antigens are or are not present on the patients RBCs. This can be a powerful resource for the laboratory as it denes the possible alloantibodies that a patient can make. While pheno- typing is a routine part of the initial work-up of patients highly prone to alloimmunization (e.g., those with sickle cell disease), it is not performed com- monly for other patients. However, patients with WAIHA who will likely require frequent transfusions over time are an exception. The phenotype can be used to select units of blood for transfusion that will prevent alloimmunization and can also be used to avoid antigen reexposure if the patient is already alloimmunized. Depending on the ease or difculty encountered, it may be possible to provide units of blood for transfusion that are matched to the patients phenotype (i.e., Rh, Kell, Duffy, Kidd, and MNS system antigens). Such a strategy would gener- ally preempt the need to perform adsorption studies. However, even partially antigen-matched units can be effective in preventing alloimmunization in patients with WAIHA. 7 Matching for the most immu- nogenic and/or clinically signicant antigens (e.g., Rh system, K antigen, Kidd system) makes the most sense. Finally, it is important to note the increasing availability of blood group antigen genotyping. Geno- typic analysis may be particularly important in those cases in which a clean phenotype cannot be obtained, usually as a result of insufcient dissocia- tion of autoantibodies from the RBC membrane. Elution studies: These studies are usually undertaken to identify new blood group alloantibodies, resulting from recent transfusions, that are not yet demon- strable in a patients plasma. Elution studies have very little place in the evaluation of warm-reactive autoantibodies. Typically, if the plasma demonstrates a pan-reactive antibody, the eluate will only conrm the same but the reactivity is generally stronger due to a concentration of the eluted antibody. Thus, one is even more unlikely to identify an alloantibody in the eluate than in the plasma. I reserve elution testing for patients with reactive DATs who have very weakly- reactive antibodies in their plasma that I suspect to be autoantibodies but do not react with all panel cells. In such cases, due to the concentration effect of the eluate, it is usually possible to demonstrate pan- reactivity, thus conrming that the antibody in ques- tion is an autoantibody. Crossmatching: Crossmatches are almost invariably reactive in patients with warm-reactive autoantibod- ies, as these antibodies generally react with all RBCs tested. Crossmatching excessive numbers of units to identify those that are least incompatible provides no proven clinical benet for patients. 8 In other words, incompatible is incompatible. Although there is no disadvantage to selecting a unit for trans- fusion that reacts less strongly, since there is also no evidence to suggest a patient benet, the least incom- patible terminology and associated clinical practice should be discouraged. Although space does not allow for a detailed discussion, the use of the in vivo crossmatch (transfusion of a small aliquot of RBCs with serologic reassessment, visual assessment of the plasma for free Hb, and clinical evaluation) should PATIENTS WITH WARM AUTOANTIBODIES Volume 51, January 2011 TRANSFUSION 15 also be discouraged. 1 There is no practical benet to be gained by its performance given what we under- stand about the hemolytic nature of warm-reactive autoantibodies. Similar to the release of least incom- patible units, the in vivo crossmatch may make the blood bank specialist and the clinician feel more at ease, but it is wasteful of resources and may delay transfusion therapy. In the end, the incompatible units associated with warm-reactive autoantibodies should be transfused judiciously knowing that as long as alloantibodies have been investigated, these units should have the same survival as the patients own RBCs, even if diminished. 9 Autoantibodies with dened specicities: Warm- reactive autoantibodies typically react with all reagent RBCs with the same general strength of reac- tivity. However, they less commonly demonstrate specicity for a blood group antigen in a relative or absolute sense. Most such antibodies demonstrate enhanced reactivity for certain antigens in the Rh blood group system (e.g., e). More commonly, there is a relative specicity for an antigen, meaning that the patients autoantibody reacts more strongly with reagent RBCs carrying the antigen and less strongly with antigen-negative RBCs. Sometimes, however, the antibody has apparent absolute specicity for a blood group antigen (e.g., autoanti-D). Although it is tempting to honor the specicity of these autoanti- bodies by providing antigen-negative units of blood, it is unclear if these RBCs have enhanced survival in the recipient. 1 It pays to remember that warm- reactive autoantibodies are polyclonal immune responses. 10 Although there may be a prevailing clone of cells generating an antibody with a dened in vitro specicity, the in vivo reality is likely more compli- cated. In practice, if it is easy to provide an antigen- negative unit and the crossmatch is actually compatible (not at all a given), then I sometimes do this simply to avoid the confusion that can accom- pany the release of an incompatible unit. However, I would not transfuse a rare antigen-negative unit (e.g., e) for this reason. These units should be reserved for alloimmunized patients. Autoantibodies associated with weakly reactive or nonreactive DATs: Occasionally, a patient is encoun- tered with laboratory evidence of hemolysis but a very weakly reactive or even nonreactive DAT is seen. In other words, the degree of hemolysis is dispropor- tionate to the serologic character of the DAT. This can be particularly vexing when the IAT ndings do not point clearly to a warm-reactive autoantibody. In cases such as these, I consider other, less common etiologies of hemolysis: for example, drug-associated hemolysis; hemolysis due to an IgA autoantibody, a Donath-Landsteiner autoantibody (as with paroxys- mal cold hemoglobinuria), or warm-reactive autoan- tibodies with unusual thermal amplitudes; or even hemolysis that is not actually immune mediated (e.g., associated with a hemolytic toxin, as with a brown recluse spider envenomation, or an overwhelming bacterial infection). The evaluation of these possibili- ties starts with a thorough review of the patient. Most important are a medication history and a determina- tion of any preceding or coexisting illnesses. If the patient is taking, or has recently taken, a medication that has been associated with hemolysis (e.g., a second-generation cephalosporin), then an evalua- tionfor drug-dependent antibodies is warranted. This will almost always take place in an immunohematol- ogy reference laboratory. Testing for IgA autoantibod- ies, Donath-Landsteiner antibodies, and warm- reactive autoantibodies with unusual thermal amplitudes will likely transpire in the same setting. On the other hand, hemolysis resulting from a toxin exposure is usually evident after reviewing the patients clinical history. Follow-up studies: Patients who have persistent warm-reactive autoantibodies represent a potential resource sink for the transfusion service. On the conservative side, one can make the argument that all such patients, with subsequent transfusions, either require an adsorption study or require phenotypic matching to assure that alloantibodies, if present, are avoided. With strongly reactive autoantibodies that are hemolytic, this is the safest course of action to take. On the other hand, some patients have very weakly reactive but persistent warm autoantibodies. At Arkansas Childrens Hospital, sickle cell patients most frequently have this nding. We have a relatively large cohort of patients who developed weakly reac- tive warm autoantibodies after alloimmunization. Although not clinically signicant, with respect to hemolysis, they create anxiety in the laboratory as with any warm-reactive autoantibody. However, we rarely perform follow-up adsorption studies on these patients. Instead, we carefully monitor the strength of the DAT. If it remains weak and stable over time, we simply transfuse the patient releasing the incompat- ible units that are available to us. This has proven to be a very safe practice, possibly because these patients already receive units matched for Rh system antigens and the K antigen. In conclusion, warm-reactive autoantibodies are fairly commonly seen in all patient ages and require careful evaluation. On initial presentation, it is important to understand the serologic and clinical features of the autoantibody as these will be helpful in determining the breadth of the blood bank investigation, both at presenta- tion and with follow-up testing. It is important to make BLACKALL 16 TRANSFUSION Volume 51, January 2011 judicious use of effective ancillary studies, such as adsorp- tion and phenotyping, but those studies that have no demonstrated value for patient care (e.g., reliance on units that are least incompatible, elution studies, in vivo cross- matching) should be discouraged and avoided. Patients with warm-reactive autoantibodies are challenging, but with a little extra effort on the front end, they can be managed successfully. The laboratory and the clinical team can be condent that units released for transfusion, although they are incompatible, have a high likelihood of being safe and efcacious for the patient. CONFLICT OF INTEREST The author declares that he has no conicts of interest relevant to the manuscript submitted to TRANSFUSION. REFERENCES 1. Petz LD, Garratty G. Immune hemolytic anemias. Philadelphia: Churchill Livingstone; 2004. 2. Blackall DP, Liles LH, Talati A. In utero development of a warm-reactive autoantibody in a severely jaundiced neonate. Transfusion 2002;42:44-7. 3. Erler BS, Smith L, McQuiston D, Pepkowitz SH, Goldnger D. Red cell autoantibody production in utero: a case report. Transfusion 1994;34:72-4. 4. Blackall DP. Warm-reactive autoantibodies in pediatric patients: clinical and serologic correlations. J Pediatr Hematol Oncol 2007;29:792-6. 5. Wheeler C, Calhoun L, Blackall DP. Warm reactive autoantibodies: clinical and serologic correlations. Am J Clin Pathol 2004;122:680-5. 6. Zupanska B, Sokol RJ, Booker DJ, Stamps R. Erythrocyte autoantibodies, the monocyte monolayer assay and in vivo haemolysis. Br J Haematol 1993;84:144-50. 7. Shirey RS, Boyd JS, Parwani AV, Tanz WS, Ness PM, King KE. Prophylactically antigen-matched donor blood for patients with warm autoantibodies: an algorithm for trans- fusion management. Transfusion 2002;42:1435-41. 8. Petz LD. Least incompatible units for transfusion in autoimmune hemolytic anemia: should we eliminate this meaningless term? A commentary for clinicians and trans- fusion medicine professionals. Transfusion 2003;43:1503-7. 9. Salama A, Berghofer H, Mueller-Eckhardt C. Red blood cell transfusion in warm-type autoimmune haemolytic anaemia. Lancet 1992;340:1515-7. 10. Gehrs BC, Friedberg RC. Autoimmune hemolytic anemia. Am J Hematol 2002;69:258-71. PATIENTS WITH WARM AUTOANTIBODIES Volume 51, January 2011 TRANSFUSION 17