Differentiating Warm vs. Drug-induced AIHA

Transcription

1 Differentiating Warm vs Drug-induced AIHA South Central Association of Blood Banks Pre-Meeting Symposium June 6, 2012 Susan T Johnson, MSTM, MT(ASCP)SBB BloodCenter of Wisconsin Milwaukee, WI Objectives Describe the initial serologic results observed in a patient with warm autoimmune hemolytic anemia and drug-induced immune hemolytic anemia Explain the serologic test results that differentiate WAIHA from DIIHA List drugs most commonly associated today with drug-induced immune hemolytic anemia SERUM/PLASMA COLOR Typical WAIHA Sample Usually normal color Yellow/Straw etc 1

2 Typical DIIHA Sample Serum/Plasma Coke Colored? INITIAL SEROLOGIC RESULTS Direct Antiglobulin Test Eluate Serum/Plasma Reactivity 2

3 DIRECT ANTIGLOBULIN TEST J O Connor WAIHA DAT RESULTS Polyspecific AHG 3-4+ Anti-IgG 3-4+ Anti-C Control 0 WARM AUTOANTIBODY IN PLASMA 3

4 WARM AUTOANTIBODY COATING RBCs WARM AUTOANTIBODY IN PLASMA (1+) WARM AUTOANTIBODY IN PLASMA (3+) 4

5 WARM AUTOANTIBODY IN PLASMA (4+) DIIHA DAT Results Reactivity depends on time of testing compared to presentation Polyspecific AHG 3-4+ Anti-IgG 3-4+ Anti-C Control 0 DAT RESULTS IN DIIHA AABB Technical Manual, 15 th ed, 2005 Drug-dependent antibodies detected by the immune complex method complement may be the only globulin easily detected on the red cells, but IgG may be present 5

6 DAT RESULTS IN DIIHA AABB Technical Manual, 17 th ed, 2011 Drug-dependent antibodies reacting in the presence of drug complement may be the only protein easily detected on the red cells, but IgG may be present DAT STRENGTH & SPECIFICITY Transfusion 2007;47: IgG + C3 IgG Only C3 Only < Total of 71 patients had negative DAT Typical DAT Results - DIIHA Drug is discontinued On Day 3 Day 7 Day 14 Presentation DAT

7 Typical DAT Results - WAIHA On Day 3 Day 7 Day 14 Presentation DAT ELUTION IN WAIHA On initial evaluation Confirms autoantibody is coating RBCs Rules-out or identifies presence of drug-dependent antibody Performing an Acid Elution J O Connor 7

8 ELUATE Last Eluate Wash D C c E e K Fy a Fy b Jk a Jk b S s IAT IAT Auto NT ELUATE RESULTS IN DIIHA Rapid Acid Most are negative Few are disproportionately t weaker as compared to strength of DAT ELUATE Last Eluate Wash D C c E e K Fy a Fy b Jk a Jk b S s IAT IAT Auto NT 8

9 ELUATE Last Eluate Wash D C c E e K Fy a Fy b Jk a Jk b S s IAT IAT w w w w w w w w-2 Auto NT INITIAL ELUATE REACTIVITY Transfusion 2007;47: Negative 49 < Not Tested 3 WAIHA vs DIIHA Eluate WAA strongly positive DDA is negative or weak 9

10 ANTIBODY DETECTION TEST IN WAIHA Test Tube - Saline IS 37C IAT I II ANTIBODY DETECTION TEST IN WAIHA Test Tube - LISS IS 37C IAT I II ANTIBODY DETECTION TEST IN WAIHA Test Tube - PEG IS 37C IAT I 0 NH w-4+ II 0 NH w-4+ 10

11 ANTIBODY DETECTION TEST IN WAIHA Gel or Solid Phase I II IAT w-4+ w-4+ Antibody Identification in WAIHA Gel Gel D C c E e K Fy a Fy b Jk a Jk b S s IAT Auto 3-4 Antibody Identification in WAIHA Solid Phase SP D C c E e K Fy a Fy b Jk a Jk b S s IAT Auto ND 11

12 SERUM REACTIVITY IN DIIHA Reactivity depends on time of testing compared to presentation Saline IAT - some positive PEG or Ficin IAT - many ypositive Gel many positive /scholarships/documents/10kirchnerpdf SPRCA similar to saline IAT IS few positive ANTIBODY DETECTION TEST IN DIIHA Test Tube - Saline IS 37C IAT I II SERUM REACTIVITY WITHOUT ADDITION OF DRUG Drug-Dependent Antibody Drug remains in patient s circulation Drug is present in test method Trimethoprim & Sulfamethoxazole (gel test) Drug-Independent Autoantibody Serum is reactive after drug has cleared 12

13 SERUM DIALYSIS Drug TESTING OF DIALYZED SERUM IS 60 37C IAT Pre-Dialysis Serum + RBCs Dialyzed Serum + RBCs Dialyzed Serum +RBCs + Drug Typical IAT Results - DIIHA Drug is discontinued On Day 3 Day 7 Day 14 Presentation IAT

14 Typical IAT Results - WAIHA On Day 3 Day 7 Day 14 Presentation IAT PATIENT HISTORY Thorough investigation Signs & symptoms of hemolysis Medication/Drug History DRUG HISTORY Prescription drugs Over-The-Counter drugs Alternative ti (herbal) medications 14

15 DRUG HISTORY Timing and dosage of medication History of surgical procedures requiring antibiotics History of pain requiring NSAIDS UNIFYING THEORY (Habibi & Garratty) Hapten-dependent antibody Type I *Drug-independent antibody Type II *Drug-dependent antibody Type III Type I Penicillin-Type Hapten-Type (Drug Adsorption) Drug binds covalently to membrane proteins and stimulates hapten-dependent antibodies Antibody reacts with normal RBCs pretreated with drug 15

16 Type I Drug Treated RBCs Hapten-Dependent Antibody Type I Drug Treated RBCs Hapten-Dependent Antibody Hapten-dependent antibody Drug-independent antibody Drug-dependent antibody 16

17 DDA REACTING WITH DRUG-TREATED RBCs Cephalosporins 31 Cefotetan 26 Cefuroxime 1 Cefotaxime 1 Cefoxitin 1 Ceftazidime 1 Cefazolin 1 Penicillin/Penicillin Derivatives 7 Piperacillin 5 Ampicillin 1 Nafcillin 1 Total 38 Cases/Fatalities of DIIHA over 10 years G Garratty, Blood Reviews 24 (2010) Drug Number* Percentage Cefotetan 36 (4) 43 Ceftriaxone 17 (5) 21 Piperacillin 14(1) 17 β-lactamasel t 6 7 inhibitors Other 11 Cephalosporins Others 9 # 11 Total 83 (10) 100 * Columns contain number (fatalities) of cases associated with each drug # Oxaliplatin (3), carboplatin (1), rifampin (1), diclofenac (1), cimetidine (1), sulfamethoxazole (1), and trimethoprime (1) Type II Drug-Independent Antibody (Autoantibody) Through an unknown mechanism, drug induces autoantibodies specific c for RBC membrane proteins Antibody reacts with normal RBCs in the absence of drug 17

18 Hapten-dependent antibody Drug-independent d antibody Drug-dependent antibody Type III Nonpenicillin-Type Neoantigen Type ( Immune Complex ) Through an unknown mechanism, drug induces antibodies that t bind to RBC only when drug is present in soluble form Antibody reacts with RBCs when soluble drug is present Type III IPOD Drug-Dependent Antibody 18

19 Type III IPOD Drug-Dependent Antibody Hapten-dependent antibody Drug-independent antibody Drug-dependent antibody BCW EXPERIENCE DDA REACTING IN PRESENCE OF DRUG Quinine/Quinidine 7 Others 15 Ceftriaxone 5 Ceftazidime 1 Zosyn (piperacillin & tazobactum) 5 Oxaliplatin 2 Carboplatin 1 Bactrim/Trimethoprim 1 19

20 BCW EXPERIENCE DDA REACTING IN PRESENCE OF DRUG NSAIDs 11 Tolmetin 3 Sulindac 2 Ibuprofen 1 Diclofenac* 2 Etodolac* 1 Nabumetone* 1 Indomethacin* 1 *Urine-metabolite dependent Others 7 Probenecid 1 Levafloxacin 1 Mefoxin 1 Carboplatin 1 Oxaliplatin 2 Bactrim 1 NON-IMMUNOLOGIC ADSORPTION OF PROTEIN ONTO RBCs Cephalosporins Cisplatin/Carboplatin/Oxaliplatin Diglycoaldehyde (INOX) Suramin β-lactamase inhibitors Sulbactam (in Unasyn) Clavulanate (in Augmentin and Timentin) Tazobactam (in Zosyn/Tazocin) Garratty 20

21 NON-IMMUNOLOGIC ADSORPTION OF PROTEIN ONTO RBCs Not thought to cause DIIHA when first described with cephalothin-treated RBCs Since then, suggestions in the literature that certain drugs that cause nonspecific protein uptake (eg, cisplatin, sulbactam, clavulanate) can cause HA DRUG EVALUATION Check for previous implications of causing hemolysis Physicians Desk Reference Drug Facts and Comparison AABB Technical Manual Judds Methods in Immunohematology Published articles & abstracts TESTING DRUG-TREATED RBCs Untrtd RBCs Patient Serum Pos Con Normal Serum NEAT 1:2 1:4 1:8 1:20 NEAT 1:2 1:4 1:8 1:20 15 RT C IAT RT C 0 IAT 0 21

22 TESTING IN PRESENCE OF DRUG e+ RBCs 30 RT 60 37C IAT Patient Serum + Drug Patient Serum + Drug + C Patient Serum + Diluent Patient Serum + Diluent + C C + Drug C + Diluent Diluent + Drug Eluate + Drug Eluate + Diluent Positive Control + Drug TESTING IN PRESENCE OF DRUG Autoantibody Present Patient Serum (No Drug Added) Patient Serum + Drug NEAT 1:2 1:4 1:8 1:16 NEAT 1:2 1:4 1:8 1:16 30 RT C IAT wwwbelearningbcwedu b 22

23 TYPICAL INITIAL SEROLOGIC RESULTS Polyspecific AHG 3-4+ Anti-IgG 3-4+ Anti-C Control 0 IS 37C IAT I II TYPICAL INITIAL SEROLOGIC RESULTS Polyspecific AHG 3-4+ Anti-IgG 0 Anti-C Control 0 IS 37C IAT I II DIIHA vs AIHA Eluate DDA is negative or weak WAA strongly positive WAA strongly positive Serum DDA disappears within days if drug is discontinued WAA persists 23

24 Objectives Describe the initial serologic results observed in a patient with warm autoimmune hemolytic anemia and drug-induced immune hemolytic anemia Explain the serologic test results that differentiate WAIHA from DIIHA List drugs most commonly associated today with drug-induced immune hemolytic anemia Thank You suejohnson@bcwedu 24