Rh-incompatible hemolytic disease of the newborn in Hefei

BACKGROUND Anti-D antibody is not the common cause of Rh-isoimmunization in Chinese neonatal jaundice.Recent change in national population policy has followed by an increase in Rh-isoimmunization related hemolytic disease of the newborn(HDN).Unfortunately,regional status of Rh-HDN is unavailable.We hypothesize that Rh-HDN in our region is most commonly due to anti-E antibody.AIM To investigate the prevalence of hemolytic disease of the newborn due to Rhisoimmunization in Hefei City.METHODS Retrospective review of data obtained from Children’s Hospital of Anhui and Hefei Blood Center between January 2017 and June 2019.Status of minor blood group antibody was studied in the corresponding mothers.RESULTS Totally 4138 newborns with HDN admitted during the study period and 116(2.8%)received blood exchange transfusion(BET).Eighteen newborns(0.43%)with proven Rh-incompatible HDN were identified.All were not the first-born baby.Thirteen mothers were RhD(+)(72%)and five were RhD(-).The distribution of Rh-related antibodies in mothers was ten anti-E(55%),five anti-D(27%),and for one anti-C,anti-c,and anti-E/c(6%)each.Thirteen(72.2%)were qualified for BET,relative risk for BET was 28.9 as compared to other types of HDN,but only 10 received due to parenteral refusal.All(100%)RhD related HDN received BET which is not significantly different from RhE related HDN(81.8%).CONCLUSION As expected,all Rh-incompatible HDN newborns were not the first-born.Contrary to the Caucasian population,anti-D induced HDN is not the most common etiology.In our region,anti-E(11/18,61%)is the most common cause of Rh-HDN.

Acute liver failure with hemolytic anemia in children with Wilson’s disease:Genotype-phenotype correlations?

BACKGROUND Wilson’s disease(WD)is a rare autosomal recessive inherited disorder of copper metabolism.Acute liver failure(ALF)and hemolytic anemia represent the most severe presentation of WD in children.No clear genotype-phenotype correlations exist in WD.Protein-truncating nonsense,frame-shift,or splice-site variants may be associated with more severe disease.In contrast,missense variants may be associated with late-onset,less severe disease,and more neurological manifestations.Recently,a gene variant(HSD17B13:TA,rs72613567)with a possible hepatic protective role against toxins was associated with a less severe hepatic phenotype in WD.AIM To analyze the possible genotype-phenotype correlations in children with WD presented with ALF and non-immune hemolytic anemia.METHODS The medical records of children with WD diagnosed and treated in our hospital from January 2006 to December 2020 were retrospectively analyzed.The clinical manifestations(ALF with non-immune hemolytic anemia or other less severe forms),laboratory parameters,copper metabolism,ATP7B variants,and the HSD17B13:TA(rs72613567)variant were reviewed to analyze the possible genotype-phenotype correlations.RESULTS We analyzed the data of 51 patients with WD,26 females(50.98%),with the mean age at the diagnosis of 12.36±3.74 years.ALF and Coombs-negative hemolytic anemia was present in 8 children(15.67%),all adolescent girls.The Kayser-Fleisher ring was present in 9 children(17.65%).The most frequent variants of the ATP7B gene were p.His1069Gln(c.3207A>G)in 38.24% of all alleles,p.Gly1341Asp(c.4021G>A)in 26.47%,p.Trp939Cys(c.2817G>T)in 9.80%,and p.Lys844Ter(c.2530A>T)in 4.90%.In ALF with hemolytic anemia,p.Trp939Cys(c.2817G>T)and p.Lys844Ter(c.2530A>T)variants were more frequent than in other less severe forms,in which p.His1069Gln(c.3207A>G)was more frequent.p.Gly1341Asp(c.4021G>A)has a similar frequency in all hepatic forms.For 33 of the patients,the HSD17B13 genotype was evaluated.The overall HSD17B13:TA allele frequency was 24.24%.Its frequency was higher in patients with less severe liver disease(26.92%)than those with ALF and hemolytic anemia(14.28%).CONCLUSION It remains challenging to prove a genotype-phenotype correlation in WD patients.In children with ALF and hemolytic anemia,the missense variants other than p.His1069Gln(c.3207A>G)and frame-shift variants were the most frequently present in homozygous status or compound heterozygous status with site splice variants.As genetic analysis is usually time-consuming and the results are late,the importance at the onset of the ALF is questionable.If variants proved to be associated with severe forms are found in the pre-symptomatic phase of the disease,this could be essential to predict a possible severe evolution.

A CASE OF HEMOLYTIC DISEASE OF THE NEWBORN CAUSED BY ANTI-HRO AND ANTI-E

A Chinese woman of blood group B,D-and her husband of blood group AB,CCDeewere examined.The woman had not been transfused before.Their first two babiesdied.Anti-Hro and anti-e were found in the mother’s serum.During her third pregnancy,the titer of antibodies went up quickly,approximately one titer per month.After 36 weeksof pregnancy,the baby was delivered by Caesarean section.The cord blood Hb was 88g/L,his red blood cell count 2.7×1012/L,and total biIirubin 114.6 mol/L.The baby was ofblood group AB,and CDe-D-genotype.Exchangetransfusion was begun 2.5 hours afterbirth.O,ccDEE washed red cells together with group AB plasma were used.Two dayslater,7Oml washed O,ccDEE concentrated red cells were administered.The baby is aliveand in good health.

Efficacy of Whole Blood Reconstituted (WBR) in Exchange Transfusion (ET) in Hemolytic Disease of New Born (HDN) —A Study of 110 Cases

Aim: This study was aimed to review and establish the practice of exchange transfusion (ET) with whole blood reconstituted (WBR) in hemolytic disease of newborn (HDN). Objectives: To observe fall in indirect serum bilirubin, correction of anemia and comparison with related studies. Background: Hemolytic disease of the Newborn is characterized by presence of IgG antibodies in maternal circulation, which causes hemolysis in the fetus by crossing the placenta and sensitizing red cells for destruction by macrophages in the fetal spleen with consequent hyperbilirubinemia. Exchange transfusion with or without phototherapy is the method of choice for treating the newborn with on going hemolysis Methods/Materials: Sample size consisted of 110 neonates in whom 119 exchange transfusions were carried out with WBR. WBR was prepared by suspending O Rhesus-D (RhD) positive/negative cells (compatible with neonate’s/ mother’s serum) in AB plasma. Double volume exchange transfusion(s) were carried out through umbilical vein by push-pull technique. Results: Out of 110 cases, 61 (55.5%) were of RhD HDN whereas ABO and other group HDN cases were 30 (27.3%) and 19 (17.3%) respectively. An average post-ET fall in indirect serum bilirubin by 54.6% and correction of anemia by3.7 gm/dl were reported in the study. Conclusion: An average post-ET fall in indirect serum bilirubin and correction of anemia was found to be more significant when compared to other studies. Hence we recommend exchange transfusion in HDN with WBR to obtain reasonable fall in indirect serum bilirubin and high average rate of correction of anemia.

Erythrocytic transglutaminase inhibition hemolysis at presentation of celiac disease

Celiac disease (CD) is a common autoimmune condition.Previously it was considered to be a rare childhood disorder,but is actually considered a relatively common condition,present at any age,which may have multiple complications and manifestations.Hematological disorders of the disease are not uncommon.Among these disorders,the most frequently reported are anemias as a result of iron deficiency,often associated with folate and/or B12 deficiency.Anemias caused by hemolysis are very rarely reported in celiac patients.An 11-year-old girl with a previous uneventful medical history presented with severe hemolytic anemia.Hemolysis was Coombs negative,accompanied by inappropriate low reticulocyte count,despite exaggerated bone marrow hyperplasia of the erythroid precursors which showed normal maturation.Serology for recent infections,including EpsteinBarr virus,parvovirus B19,cytomegalovirus and mycoplasma,were all negative.Levels of serum IgA,IgG and IgM,were all within normal ranges for age.Screeningfor anti-DNA,antinuclear,antineutrophil cytoplasmic,antimicrosomal,antithyroglobulin,and antimitochondrial antibodies and lupus anticoagulants,was negative.She was also negative for human immunodeficiency virus.Conventional therapy with corticosteroids and intravenous immunoglobulin failed.CD was serendipitously discovered upon screening for anti-tissue transglutaminase autoantibodies.The disease was confirmed by biopsy of the small intestine mucosa.The patient recovered with gluten-free diet.A unique case of CD is presented.CD should be serologically screened in each patient with Coombs negative "immune"hemolytic anemia,particularly if accompanied by "reticulocytopenia".A new hemolytic mechanism and very speculative explanation for "reticulocytopenia"are discussed.

Complement related kidney diseases:Recurrence after transplantation

The recurrence of renal disease after renal transplantation is becoming one of the main causes of graft loss afterkidney transplantation. This principally concerns some of the original diseases as the atypical hemolytic uremic syndrome(HUS), the membranoproliferative glomerulonephritis(MPGN), in particular the MPGN now called C3 glomerulopathy. Both this groups of renal diseases are characterized by congenital(genetic) or acquired(autoantibodies) modifications of the alternative pathway of complement. These abnormalities often remain after transplantation because they are constitutional and poorly influenced by the immunosuppression. This fact justifies the high recurrence rate of these diseases. Early diagnosis of recurrence is essential for an optimal therapeutically approach, whenever possible. Patients affected by end stage renal disease due to C3 glomerulopathies or to atypical HUS, may be transplanted with extreme caution. Living donor donation from relatives is not recommended because members of the same family may be affected by the same gene mutation. Different therapeutically approaches have been attempted either for recurrence prevention and treatment. The most promising approach is represented by complement inhibitors. Eculizumab, a monoclonal antibody against C5 convertase is the most promising drug, even if to date is not known how long the therapy should be continued and which are the best dosing. These facts face the high costs of the treatment. Eculizumab resistant patients have been described. They could benefit by a C3 convertase inhibitor, but this class of drugs is by now the object of randomized controlled trials.

High rate of complicated idiopathic gallstone disease in pediatric patients of a North American tertiary care center

AIM: To assess spectrum and etiology of gallstones and biliary sludge in the pediatric population of a North American tertiary care centre. METHODS: Retrospective review of abdominal ultraso- unds recorded at Saint Justine Hospital over a period of 24 mo (8/2003 to 8/2005) in patients < 19 years of age. Patients < 2 years of age were analyzed separately. RESULTS: The presence of gallstones was noted in 127 patients. In 107 it was a new diagnosis, in 48/105 (45.7%) patients > 2 years of age idiopathic gallstone disease was found. These 48 patients represent 2.1% of the population who required ultrasound for abdominal pain. Complicated gallstone disease occurred in 28/48 with idiopathic disease, mainly adolescent girls. Patients with hemolytic disorders, cystic fibrosis, oncologic diseases or kidney transplantation and gallstones were asymptomatic and stones were detected during routine abdominal ultrasound. Twenty two patients < 2 years of age not consulting for abdominal pain had gallstone disease of diverse etiology. Biliary sludge was seen in 84 patients, 78.5% on total parenteral nutrition. In 4 patients, sludge progressed to gallstones. CONCLUSION: Idiopathic gallstone disease and its rate of complication are more frequent in our cohort than expected from previous studies. Adolescent girls with abdominal pain and idiopathic gallstones require special attention for complicated disease course.

Autoimmune Diseases and Acquired Von Willebrand Disease in Two Cases of Progeria

Ammar A., a 23-year-old male patient, who lives in Babylon, Haswa District, and his mother describes symptoms of growth retardation, skin changes, hair changes early graying and alopecia. These manifestation started early during his childhood period. There is canseguanity between the patient’s mother & father also one of the patient’s sister has similar illness and one male brother died few months following his birth. We admit the patient to hospital due acute pulmonary infection in Jan 2009, which is controlled after a course of antibiotic and after 5 months he develops generalised mucocuteneous bullous eruption which shows partial response to oral prednisolone 2 mg/Kg. The patient has normal IQ and he is in the secondary school and he has normal blood picture and the only abnormal biochemical abnormalities is mild hyperlipidemia Serum cholestrol of 5.8 mmol/L and Serum Triglyceride of 260 mg/dl. Ammar’s Sister Qawthar A., who has a similar phenotypic manifestations, presented skin vitiligo and hepatosplenomegaly associated with sever anemia and jaundice and her presentation suggestive of autoimmune haemolytic anemia improved following blood transfusion, corticosteroid and azothioprim. In February 2014 Ammer presented with multiple and diffuse cuteneous ecchymymosis with markedly prolonged PTT and slightly proloned bleeding time highly consistent with acquired Von Willebrand’s disease. In conclusion premature aging is a predisposing factor for disturbed immunity and development of autoimmune diseases.

Combined liver-kidney transplantation for rare diseases

Combined liver and kidney transplantation(CLKT)is indicated in patients with failure of both organs,or for the treatment of end-stage chronic kidney disease(ESKD)caused by a genetic defect in the liver.The aim of the present review is to provide the most up-to-date overview of the rare conditions as indications for CLKT.They are major indications for CLKT in children.However,in some of them(e.g.,atypical hemolytic uremic syndrome or primary hyperoxaluria),CLKT may be required in adults as well.Primary hyperoxaluria is divided into three types,of which type 1 and 2 lead to ESKD.CLKT has been proven effective in renal function replacement,at the same time preventing recurrence of the disease.Nephronophthisis is associated with liver fibrosis in 5%of cases and these patients are candidates for CLKT.In alpha 1-antitrypsin deficiency,hereditary C3 deficiency,lecithin cholesterol acyltransferase deficiency and glycogen storage diseases,glomerular or tubulointerstitial disease can lead to chronic kidney disease.Liver transplantation as a part of CLKT corrects underlying genetic and consequent metabolic abnormality.In atypical hemolytic uremic syndrome caused by mutations in the genes for factor H,successful CLKT has been reported in a small number of patients.However,for this indication,CLKT has been largely replaced by eculizumab,an anti-C5 antibody.CLKT has been well established to provide immune protection of the transplanted kidney against donor-specific antibodies against class I HLA,facilitating transplantation in a highly sensitized recipient.

抗-M致胎儿新生儿溶血病实验室检测及预防策略分析

目的分析血清学检测结果在抗-M致胎儿新生儿溶血病(HDFN)诊断和治疗中的应用,探讨HDFN预防策略。方法对2017年1月—2023年12月本实验室确诊的12例抗-M引起的HDFN血清学检测结果进行回顾性分析,包括母亲和患儿的血型鉴定,血清总胆红素、血红蛋白、抗体效价检测,新生儿溶血3项实验。收集患儿和母亲的临床资料,包括妊娠史、输血史、产前抗体检测、宫内输血史、分娩孕周,并随访患儿预后。结果12例抗-M引起的HDFN中,患儿母亲均为RhD+NN表型,患儿均为RhD+MN表型,母子MN血型均不相容。在ABO血型系统中,母子ABO血型不相容占41.7%(5/12)。患儿母亲皆无输血史,在4℃检测效价中位数32,37℃效价中位数4。3例患儿母亲有多次宫内输血史,发生率为25%(3/12)。1例为首胎妊娠异常,占比8.3%(1/12),7例为异常妊娠流产,不良孕产史发生率58.3%(7/12)。6例患儿母亲早产,占比50%(6/12)。3例患儿母亲定期产检,并鉴定抗体特异性,占比25%(3/12)。12例患儿游离抗体在4℃检测效价中位数6,37℃效价中位数2。2例患儿抗-M在37℃检测无反应,阴性率16.7%(2/12)。患儿直抗阳性率8.3%(1/12),放散阳性率16.7%(2/12)。血红蛋白最低值中位数75 g/L,12例患儿均接受了输血治疗。总胆红素峰值中位数157.5μmol/L,均未达到换血阈值。患儿迟发性贫血率16.7%(2/12),患儿出生后死亡率8.3%(1/12),11例患儿预后无生长和神经发育迟缓情况。结论抗-M能引起严重的HDFN,也可发生于第1胎,抗体效价强度与疾病的严重程度不相关,容易引起迟发性贫血,应根据抗-M血清学特征和临床症状定期监测,及时干预治疗。

单核细胞单层试验在预测IgG抗-M相关胎儿新生儿溶血病中的应用

目的探讨单核细胞单层实验(monocyte monolayer assay,MMA)是否能够用于IgG抗-M相关胎儿新生儿溶血病(hemolytic disease of fetus and newborn,HDFN)的预测。方法选取8例含有IgG抗-M的孕妇并采集血浆标本,其中有胎儿水肿等严重临床症状及无明显临床症状的各4例;8份血浆用二硫苏糖醇(dithiothreitol,DTT)灭活,与M抗原阳性红细胞孵育致敏后,将致敏红细胞与单核细胞混合进行吞噬试验,同时设立阳性及阴性对照,并计算吞噬率;采用t检验对2组吞噬率进行比较。结果4例发生严重抗-M相关HDFN的孕妇的MMA吞噬率分别为15.37%、13.05%、9.17%和24.50%,均值为15.52%;检出IgG抗-M但未发生HDFN的孕妇,其MMA吞噬率分别为8.74%、11.07%、5.12%和6.23%,均值为7.79%,2组吞噬率无差异(P>0.05)。2组吞噬率分别与阴性对照比较均无差异(P>0.05),但均明显低于阳性对照(P<0.05)。结论IgG抗-M介导单核细胞吞噬的能力较低,提示抗-M导致胎儿水肿的机制可能并非红细胞被吞噬破坏而发生的溶血,因此体外单核细胞单层实验可能不适用于IgG抗-M相关HDFN的预测。对于检出IgG抗-M的孕妇,现仍需通过定期监测胎儿大脑中动脉血流,来判断胎儿宫内贫血情况。

罕见抗-Di^(b)致严重胎儿新生儿溶血病的实验室检测与相关研究

目的对1例高频抗体导致的胎儿新生儿溶血病(hemolytic disease of the fetus and newborn,HDFN)进行检测、鉴定及配血。方法对患儿进行新生儿溶血试验,对母亲进行血清学意外抗体鉴定,并对母亲红细胞进行常见高频抗原鉴定;对检出抗体进行IgG分型检测,并用流式细胞术进行单核细胞体外吞噬致敏红细胞试验,以检测抗体相关的吞噬率;对患儿母亲、父亲及舅舅进行相关红细胞血型基因测序;利用稀释的母亲血浆和抗人球卡法,在献血者中进行大规模相合血液的筛选。结果产妇鉴定为Di(b-)稀有血型,产生了抗-Di b(效价512)并导致了严重的HDFN;抗-Di b亚型分型为IgG1和IgG2型,单核细胞体外吞噬效率为88.83%(74.7/84.09);产妇亲属中没有相合献血者,后续从5520名献血者中筛选到2例Di(b-)相合血液,患儿接收输血治疗后康复出院。后续在51334名献血者中筛查到17名Di(b-)献血者,该数据表明Di(b-)在广州地区献血者中的分布频率约为三千分之一(0.033%,17/51334)。结论综合利用血型血清学及分子生物学方法诊断了抗-Di b所致的严重HDFN,建立了1种有效大规模筛查Di(b-)稀有血型的方法并找到相合血液,为建立Di(b-)稀有血型库奠定了基础。

RhD阴性孕产妇与HDFN发生的相关性及影响因素分析

目的 通过对RhD阴性孕产妇腹中胎儿和分娩的新生儿发生胎儿新生儿溶血病(hemolytic disease of the fetus and newborn,HDFN)的相关指标对比分析,为预防和治疗HDFN提供参考和指导。方法 收集我院2018年1月—2022年12月分娩的RhD阴性孕产妇737名,比较新生儿是否发生RhD血型不合、ABO血型不合导致的HDFN及其影响因素,发生RhD-HDFN和发生ABO-HDFN的相关影响因素。分析发生RhD-HDFN和发生ABO-HDFN患儿的实验室指标差异;分析IgG抗-D效价≤16和≥32的孕产妇分娩的新生儿发生RhD-HDFN的实验室指标差异。结果 737名RhD阴性孕产妇中,发生RhD-HDFN的母婴ABO血型相同或相容者比率88.89%(40/45)显著高于母婴ABO血型不相容者11.11%(5/45)。母体二次妊娠及以上发生RhD-HDFN比率93.33%(42/45)显著高于ABO-HDFN 60.66%(37/61)者。母体IgG抗-D效价≥32者分娩的新生儿血红蛋白(hemoglobin,Hb)最低值低于母体IgG抗-D效价≤16者(χ^(2)=5.61,P<0.05),母体IgG抗-D效价≥32者分娩的新生儿血清总胆红素(total bilirubin,TBil)峰值高于IgG抗-D效价≤16者(χ^(2)=4.471,P<0.05)。结论 RhD阴性孕产妇中,母婴ABO血型相同或相容及孕产次≥2者,相应新生儿更易发生RhD-HDFN,母体IgG抗-D效价≥32者发生新生儿溶血的严重程度显著高于抗-D效价≤16者。

微柱凝胶技术与凝聚胺技术在ABO新生儿溶血病输血前检测中应用对比

目的对比分析微柱凝胶技术与凝聚胺技术在ABO新生儿溶血病输血前检测中的应用。方法将郑州市第一人民医院2020年1月至2023年5月ABO新生儿溶血病患儿(88例)作为研究对象,依据区间随机法将其分为对照组、研究组,各纳入44例,对照组行输血治疗前开展凝聚胺技术检验血型配血,研究组输血治疗前开展微柱凝胶技术检验血型配血。比较两组检验符合率、一次性交叉配血成功率。结果研究组正定型、反定型符合率(100.00%、100.00%)均高于对照组(86.36%、86.36%),两组差异有统计学意义(P<0.05);研究组交叉配血成功率(100.00%)高于对照组(86.36%),两组差异有统计学意义(P<0.05)。结论对比凝聚胺技术,微柱凝胶技术在ABO新生儿溶血病输血前检测中的应用价值更高,有利于提升输血安全,值得应用。