Autoimmune hemolytic anemia: From lab to bedside

Abstract

Autoimmune hemolytic anemia (AIHA) is not an uncommon clinical disorder and requires advanced, efficient immunohematological and transfusion support. Many AIHA patients have underlying disorder and therefore, it is incumbent upon the clinician to investigate these patients in detail, as the underlying condition can be of a serious nature such as lymphoproliferative disorder or connective tissue disorder. Despite advances in transfusion medicine, simple immunohematological test such as direct antiglobulin test (DAT) still remains the diagnostic hallmark of AIHA. The sensitive gel technology has enabled the immunohematologist not only to diagnose serologically such patients, but also to characterize red cell bound autoantibodies with regard to their class, subclass and titer in a rapid and simplified way. Detailed characterization of autoantibodies is important, as there is a relationship between in vivo hemolysis and strength of DAT; red cell bound multiple immunoglobulins, immunoglobulin G subclass and titer. Transfusing AIHA patient is a challenge to the immunohematologist as it is encountered with difficulties in ABO grouping and cross matching requiring specialized serological tests such as alloadsorption or autoadsorption. At times, it may be almost impossible to find a fully matched unit to transfuse these patients. However, transfusion should not be withheld in a critically ill patient even in the absence of compatible blood. The "best match" or "least incompatible units" can be transfused to such patients under close supervision without any serious side-effects. All blood banks should have the facilities to perform the necessary investigations required to issue "best match" packed red blood cells in AIHA. Specialized techniques such as elution and adsorption, which at times are helpful in enhancing blood safety in AIHA should be established in all transfusion services.

Keywords: Alloadsorption; alloantibody; autoadsorption; autoantibody; autoimmune hemolytic anemia; best match blood; flow cytometry; gel technology.

Figure 1

Hematological and biochemical parameters of autoimmune hemolytic anemia patients with different grades of in vivo hemolysis *P = 0.000, **P = 0.007: Mann-Whitney U-test. Hb: Hemoglobin concentration (g/dl), Retic: Reticulocyte count (%), S. Bili: Serum Bilirubin (mg/dl), LDH: Lactate dehydrogenase (×10³ IU/ml)

Figure 2

Multiple autoantibodies, immunoglobulin G (IgG) subclass and severity of in vivo hemolysis in Autoimmune hemolytic anemia(a) Compares single versus multiple autoantibodies in relation to the severity of hemolysis (P = 0.000), (b) subclass of IgG and its correlation with severity of in vivo hemolysis (P = 0.035). Chi-square test

Figure 3

Process flow of immunohematological work-up for issuing “best match” blood in autoimmune hemolytic anemia