Autoimmune

Hemolytic
Anemia

..

AHA3.PPT #

Definition


AIHA

Classification of Immune hemolytic anemia

3
alloantibody

1.

Alloimmune

2.

Autoimmune

autoantibody

red cell antigens

3.

antibody (drug
drug complex) DAT

Drug-induced

AHA3.PPT #

Autoantibody / Autoagglutinin
red cells (high incidence
(agglutination, lysis, sensitization)
antigens)
random donors
autoantibody immune
B lymphocyte antibody
response

(immunoglobulin, Ig) helper T cells

T lymphocyte suppressor T cells
excessive proliferation B cells over production
antibody foreign self antigens
suppressor
T cells B cells antibody
(autoantibody production)
AHA3.PPT #

blood grouping,
antibody screening, antibody identification compatibility test
coat autoantibody circulating autoantibody
Autoantibody

Characterization of AIHA
autoantibody
anemia
compensate
reticulocyte count
unconjugated bilirubin
haptoglobin
hemoglobinemia/hemoglobinuria (intravascular hemolysis)
AHA3.PPT #


hereditary spherocytosis, hemoglobinopathies etc.
AIHA

1. DAT polyspecific monospecific reagents
2. autoantibody serum eluate
serology clinical evaluation
AIHA 8% admit
DAT autoantibody serum
autoantibody

1. thermal amplitude of antibody reactivity

2. IgG subclass of antibody
3. amount of antibody bound to red cells
4. ability of antibody to fix complement in vivo
5. activity of individuals macrophages
AHA3.PPT #

 AIHA autoantibody
IgG
DAT IgA
polyspecific antihuman globulin reagents
anti-IgA anti-IgG anti-c3d

autoantibody

1.

4oC (cold autoantibody)

25 32oC

2.

37oC (warm autoantibody)

autoantibody
serology
AHA3.PPT #

Classification of AIHA
1. cold reactive AIHA

18%

Benign cold autoagglutinins (16%)

Pathologic cold autoagglutinins CHD, PCH (1 2%)

2. warm-reactive AIHA
3. drug-induced AIHA

70%
12%

AHA3.PPT #

Benign Cold Autoagglutinins

serologic tests
Autoantibody

ABO grouping

rbc

heavily coated with cold autoagglutinins spontaneous

agglutination

false positive reaction anti-A / anti-B

AHA3.PPT #


rbc NSS 1 2
elute rbc rbc

autoantibody

autoagglutinins rbc
incubate rbc 45oC 5 10 rbc
warm NSS (45oC) spontaneous agglutination

agglutination

thiol reagents (dithiothreitol)

disperse auto-

cold autoagglutinins
auto-adsorption
autoantibody
ABO discrepancy

AHA3.PPT #

ABO grouping cold autoagglutinin

anti-A anti-B A cells B cells Autologous
cells

1
O with auto antibody
rbc suspended in serum

rbc washed and suspended

in saline

4+

4+

2+

serum

autoadsorbed serum

2
AB with auto antibody
rbc suspended in serum

AHA3.PPT # 10

Rh typing

: anti-D + rbc

false positive reaction

rbc Rh control

rbc NSS warm NSS thiol reagents

cold agglutinin activate complement cascade
c
Du test false positive
monospecific anti-IgG reagents polyspecific
reagents

rbc in EDTA in vitro c activation

AHA3.PPT # 11

 D typing cold autoagglutinin

anti-D Rh control

NB

immediate spin

IAT (polyspecific reagent)

detects c components

IAT (anti-IgG reagent)

does not detect c

rbc collected in EDTA

c not bound to rbc

DAT
benign cold autoagglutinin Negative
false-positive result, c activated in vitro
false-positive antigen typing, when using clotted specimen and
polyspecific reagents
AHA3.PPT # 12

Antibody screening and identification

room temperature

auto Ab

37oC autoantibody

activate c
autoantibody
elute
incubate 37oC washing phase
c polyspecific
reagents anti-C3 agglutination
enzyme-treated rbc

AHA3.PPT # 13

 autoantibody
alloantibody prewarmed technique
autoadsorbed serum
rbc 45oC saline autoantibody rbc antigens c activation
monospecific anti-IgG reagent
cold autoagglutinin

AHA3.PPT # 14

Specificity of Cold Autoagglutinin

anti-I, anti-i

anti-H, anti-IH

Serologic reactions of cold autoagglutinins

Rbc phenotype

anti-I

anti-I

anti-H

anti-IH

O, I adult

4+

4+

4+

A1, I adult

4+

A2, I adult

4+

2+

2+

Oh, I adult

4+

2+

O, I cord

3+

4+

O, I adult

4+

4+

A1, i adult

4+

A2, i adult

4+

2+

Oh, i adult

4+

AHA3.PPT # 15

Pathologic Cold Autoagglutinin

Cold Hemagglutinin Disease (CHD)
(idiopathic cold AIHA, Cold agglutinin syndrome)

cold autoagglutinin hemolysis

hemolytic anemia

AHA3.PPT # 16

may be

chronic, idiopathic condition

acute, transient disease, associated with
Mycoplasma pneumoniae pneumonia
Infectious mononucleosis

16% AIHA

cold auto Ab

4oC

25 31oC

IgM immunoglobulin, activate c

AHA3.PPT # 17

Clinical Picture

> 50
Ab specificity : anti-I, anti-i, anti-Pr

chronic hemolytic anemia

acrocyanosis

28oC activation of cold auto Ab rbc
c capillary acrocyanois
intravascular hemolysis
hemoglobinuria acute renal insufficiency
PCH severe warm AIHA
jaundice Raynauds phenomenon ( )
AHA3.PPT # 18

DAT

Reticulocytosis

(c fixation)

Simple serum screening for agglutination in NSS

at 20oC, after room temperature incubation

Positive serum screening titration (saline/albumin)

Peripheral blood smear

rouleaux/autoagglutination
polychromasia
anisocytosis/poikilocytosis

autoagglutination of anticoagulated whole blood

AHA3.PPT # 19

Selection of blood for transfusion

CHD
cold autoantibody
crossmatching antibody
screening / identification

potent cold autoantibody

alloantibody
autoantibody
clinically significant alloantibodies

AHA3.PPT # 20

Secondary Cold AIHA

(Cold autoantibody related to infection)

transient episode 2 3
50% pneumonia
Mycoplasma pneumoniae
cold auto Ab titre > 64 (anti-I, IgM)
hemolysis

Infections mononucleosis

auto Ab

anti-I (IgM, wide thermal range)

AHA3.PPT # 21

 CHD


plasma exchange remove IgM
antibody
corticosteroid rbc sensitized
complement
splenectamy

AHA3.PPT # 22

Paroxysmal Cold Hemoglobinuria, PCH

1 2%
viral infection measle mump
chickenpox infectious mononucleosis
syphilis auto Ab
Treponema palladum
antibiotic PCH
syphilis
rbc PCH auto Ab
autohemolysin rbc


c fixation
AHA3.PPT # 23

 PCH

PCH infection
infection
steroid

AHA3.PPT # 24

COMPARISON
COMPARISON OF
OF CHARACTERISTICS
CHARACTERISTICS OF
OF NORMAL
NORMAL COLD
COLD AUTOANTIBODY
AUTOANTIBODY
AND
AND PATHOLOGIC
PATHOLOGIC COLD
COLD AUTOAGGLUTININ
AUTOAGGLUTININ
Characteristic

Healthy

Pathology

Thermal amplitude

< 22oC

Broad : up to 32oC

Visible agglutination

None

Huge mass of agglutinated

cells

(in anticoagulated tube of blood)

(disperse after incubation at 37oC)

Titer (concentration)

< 64

> 1000

(seldom > 16 at 4oC)

Albumin enhancement
Clonal production

Usually none
Polyclonal

Enhance reaction
Monoclonal

Clinical significance

None

Produces cold AIHA

Common antibody specificity

Anti-I

Anti-I

DAT (polyspecific)
Antihuman globulin sera

Neg / + or wk

2 to 3+

From Pittiglio and Sacher, with permission

AHA3.PPT # 25

Warm Reactive AIHA

auto Ab 37oC
70% AIHA
warm auto Ab
autoimmune
disease

AHA3.PPT # 26

Clinical Findings
Hb
precipitate infection, trauma,
surgery, pregnancy psychologic stress
idiopathic secondary pathologic
disorder
: CLL, Hodgkin s disease
RE neoplasma
non-Hodgkin

Collagen disease
Infectious disease

:
:

Immunologic disease

SLE, RA
viral

: immune deficiency syndrome,

hypogamma-globulinemia

Benign tumors

ovarian dermoid cyst

AHA3.PPT # 27

Warm autoantibody

warm AIHA Ab IgG (subclass 1 3)

hemolysis extravascular
80%

37oC, AGT
activate c enzyme enhance reaction

specificity Rh System
warm auto Ab

high-incidence antigen

potent warm auto Ab specificity

alloantibody

AHA3.PPT # 28

Detection and identification of auto Ab in warm AIHA

free warm auto Ab rbc

allo Ab allo

Ab auto Ab
Ag allo Ab incompatible blood

1.

test cells auto Ab specificity

auto-anti-e test cells e(-) allo Ab

AHA3.PPT # 29

2.

autoabsorption auto Ab
autologous cells 37oC enzyme treated rbc
1
auto Ab

3.

absorption auto Ab rbc selected

donors

4.

(serial) dilution
auto Ab dilution
allo Ab
allo Ab auto Ab

AHA3.PPT # 30

 warm AIHA
blood transfusion
auto Ab clearance Ab coated rbc macrophage
(steroid therapy) splenectomy immunosuppressive drug
steroid
(symptomatic anemia)
warm auto Ab rbc (DAT 4+) free auto Ab
(IAT 4+)
crossmatching

AHA3.PPT # 31

Reference
Harmening DM, Prihoda LA and Green REB.
Autoimmune hemolytic anemias.
In : Harmening DM. Ed.
Modern Blood Banking and Transfusion Practices.
4th ed. Philadelphia : F.A. Davis Company, 1999 : 436 - 64.

AHA3.PPT # 32

Thank You
AHA3.PPT # 33