IMMUNE HEMOLYTIC

ANEMIA
IMMUNE HEMOLYTIC ANEMIA
General Principles
All require antigen-antibody reactions
Types of reactions dependent on:
Availability of complement
Environmental Temperature
Functional status of reticuloendothelial system
Manifestations
Intravascular hemolysis
Extravascular hemolysis
IMMUNE HEMOLYTIC ANEMIA
General Principles - 2
Antibodies combine with RBC, & either
1. Activate complement cascade, &/or
2. Opsonize RBC for immune system
If 1, if all of complement cascade is
fixed to red cell, intravascular cell lysis
occurs
If 2, &/or if complement is only
partially fixed, macrophages recognize
Fc receptor of Ig &/or C3b of
complement & phagocytize RBC,
causing extravascular RBC destruction
IMMUNE HEMOLYTIC ANEMIA
Coombs Test - Direct
Looks for immunoglobulin &/or complement
of surface of red blood cell (normally neither
found on RBC surface)
Coombs reagent - combination of anti-human
immunoglobulin & anti-human complement
Mixed with patients red cells; if
immunoglobulin or complement are on
surface, Coombs reagent will link cells
together and cause agglutination of RBCs
IMMUNE HEMOLYTIC ANEMIA
Coombs Test - Indirect
Looks for anti-red blood cell antibodies in
the patients serum, using a panel of red
cells with known surface antigens
Combine patients serum with cells from a
panel of RBCs with known antigens
Add Coombs reagent to this mixture
If anti-RBC antigens are in serum,
agglutination occurs

HEMOLYTIC ANEMIA - IMMUNE
Autoimmune Hemolysis
Warm autoimmune hemolysis
Cold autoimmune hemolysis
Alloimmune Hemolysis
Hemolytic Transfusion Reaction
Hemolytic Disease of the Newborn
Drug-Related Hemolysis
Autoimmune hemolytic anemia (AHA)
Autoimmune hemolytic anemia (AHA) is
characterized by shortened red blood
cell (RBC) survival and the presence of
autoantibodies directed against
autologous RBCs.
AUTOIMMUNE HEMOLYSIS
Due to formation of autoantibodies that
attack patients own RBCs
Type characterized by ability of
autoantibodies to fix complement & site
of RBC destruction
Often associated with either
lymphoproliferative disease or collagen
vascular disease
Autoimmune Hemolytic Anemia
Classified by thermal reactivity
Warm react near 37
o
C, Cold at 0-4
o
C
Serologic evidence is positive DAT (direct
Coombs test) with IgG or C3d present
Indirect Coombs test and specificity (serum /
eluate)
Diagnostic Criteria-
serologic evidence and laboratory or clinical
hemolysis

AIHA Classification
Warm autoimmune hemolytic anemia
Idiopathic, Secondary
(Lymphoproliferative disorders, autoimmune diseases)
Cold autoimmune hemolytic anemia
Cold agglutinin syndrome
(Idiopathic, Secondary- mycoplasma, infectious mono, LPD)
Paroxysmal cold hemoglobinuria
(Idiopathic, Secondary- measles, mumps, syphilis)
Drug-induced IHA
(Autoimmune, Drug adsorption, Neoantigen)
AUTOIMMUNE HEMOLYSIS
Warm Type
Usually IgG antibodies
Fix complement only to level of C3,if at all
Immunoglobulin binding occurs at all temps
Fc receptors/C3b recognized by
macrophages;
Hemolysis primarily extravascular
70% associated with other illnesses
Responsive to steroids/splenectomy
Diagnosis

2 Anaemia.
2 Spherocytes on peripheral blood film.
2 Reticulocytes are increased.
2 Neutrophilia common.
2 RBC coated with IgG, complement or both (detect
using DAT).
2 Autoantibody often pan-reacting but specificity in
1015% (Rh,
mainly anti-e, anti-D or anti-c).
Diagnosis

LDH increased.
2 Serum haptoglobin decreased.
2 Exclude underlying lymphoma (BM,
blood and marrow cell markers).
2 Autoimmune profileto exclude SLE or
other connective tissue disorder.
AUTOIMMUNE HEMOLYSIS
Cold Type
Most commonly IgM mediated
Antibodies bind best at 30 or lower
Fix entire complement cascade
Leads to formation of membrane attack
complex, which leads to RBC lysis in
vasculature
90% associated with other illnesses
Poorly responsive to steroids, splenectomy;
responsive to plasmapheresis
Diagnosis

2 Anaemia.
2 Reticulocytes are increased.
2 Neutrophilia common.
2 Positive DATC3 only.
2 Autoantibodies IgG or IgM
Monoclonal in NHL.
Polyclonal in infection-related CHAD.
2 IgM antibodies react best at 4C (thermal
amplitude 432C).
2 Specificity
Diagnosis

Anti-I (Mycoplasma).
Anti-i (infectious mononucleosis)causes little
haemolysis in adults
since RBCs have little anti-i (cf. newborn i >> I).
2 LDH increased.
2 Serum haptoglobin decreased.
2 Exclude underlying lymphoma (BM, blood and marrow cell
markers).
2 Autoimmune profile to exclude SLE or other
connective tissue disorder.

IMMUNE HEMOLYSIS
Drug-Related
Immune Complex Mechanism
Quinidine, Quinine, Isoniazid
Haptenic Immune Mechanism
Penicillins, Cephalosporins
True Autoimmune Mechanism
Methyldopa, L-DOPA, Procaineamide,
Ibuprofen
DRUG-INDUCED HEMOLYSIS
Immune Complex Mechanism
Drug & antibody bind in the plasma
Immune complexes either
Sit on red blood cell
Antigen-antibody complex recognized by RE
system
Red cells lysed as innocent bystander of
destruction of immune complex
REQUIRES DRUG IN SYSTEM
DRUG-INDUCED HEMOLYSIS
Haptenic Mechanism
Drug binds to & reacts with red cell
surface proteins
Antibodies recognize altered protein,
drug, as foreign
Antibodies bind to altered protein &
initiate process leading to hemolysis
DRUG-INDUCED HEMOLYSIS
True Autoantibody Formation
Certain drugs appear to cause
antibodies that react with antigens
normally found on RBC surface, and do
so even in the absence of the drug
Drug-Induced Autoimmune Hemolytic Anemia
Prototype
Drugs
Clinical
Findings
Detection of
Drug-Induced
Antibody
Proposed
Mechanism
Stibophen

Acute
Intravascular
Hemolysis
Serum +
Drug + Red
Cells
Neoantigen
Penicillins/
Cephalosporin
Subacute
Extravascular
Hemolysis
Serum + Drug-
Coated Red
Cells
Drug Adsorption
-methyldopa

Warm antibody
autoimmune
hemolytic
anemia
Serum + Normal
Red Cells
Autoimmune
Drug-Induced Positive Antiglobulin Tests
Mechanism DAT Serum and Eluate
Neoantigen
-Drug +RBC complex


C3 (sometimes IgG also) Serum reacts with rbcs
only in the presence of
drug; eluate non-reactive

Drug Adsorption (DA)
-Drug binds to RBC
IgG (sometimes C3 also) React with drug-coated
RBCs but not untreated
RBCs- Ab to drug
Autoantibodies
-WAIHA
IgG (rarely C3 also)
11-36% of pts
React with normal RBCs in
absence of drug
Treatment AIHA
WAIHA CAD PCH Drug-IHA
Folate
Corticosteroids
20% complete
response
Folate
Avoid cold
Treat secondary cause
Folate
Avoid cold
Treat if hemolysis
present
Splenectomy
60-75% response rate

Chlorambucil
Cytoxan,
-Interferon
Treat infection Folate
Stop drugs
Cytotoxic drugs-
Cytoxan, Rituxan
Plasmapheresis ? Plasmapheresis Corticosteroids-severe
cases
Transfuse least
incompatible
Transfuse-I+, blood
warmer
Transfuse- P+, blood
warmer
Transfuse
ALLOIMUNE HEMOLYSIS
Hemolytic Transfusion Reaction
Caused by recognition of foreign antigens on
transfused blood cells
Several types
Immediate Intravascular Hemolysis (Minutes) - Due to
preformed antibodies; life-threatening
Slow extravascular hemolysis (Days) - Usually due to
repeat exposure to a foreign antigen to which there
was a previous exposure; usually only mild symptoms
Delayed sensitization - (Weeks) - Usually due to 1st
exposure to foreign antigen; asymptomatic
ALLOIMMUNE HEMOLYSIS
Testing Pre-transfusion
ABO & Rh Type of both donor &
recipient
Antibody Screen of Donor & Recipient,
including indirect Coombs
Major cross-match by same procedure
(recipient serum & donor red cells)
Manifestations of Delayed Hemolytic
Transfusion Reactions
Clinical
Fevers
Chills
Symptoms of anemia
Jaundice
Oliguria or anuria (uncommon)
Generalized Bleeding (Rare)
Laboratory
Unexplained anemia (or decrease in hemoglobin)
Positive direct antiglobulin test
Hemoglobinemia
Hemoglobinuria (Uncommon)
Hemosiderinuria
Decreased haptoglobin
Responsible antibody in post-transfusion RBC eluate
ALLOIMMUNE HEMOLYSIS
Hemolytic Disease of the Newborn
Due to incompatibility between mother
negative for an antigen & fetus/father
positive for that antigen. Rh incompatibility,
ABO incompatibility most common causes
Usually occurs with 2nd or later pregnancies
Requires maternal IgG antibodies vs. RBC
antigens in fetus
HYDROPS FETALIS
ALLOIMMUNE HEMOLYSIS
Hemolytic Disease of the Newborn - #2
Can cause severe anemia in fetus, with
erythroblastosis and heart failure
Hyperbilirubinemia can lead to severe brain
damage (kernicterus) if not promptly treated
HDN due to Rh incompatibility can be almost
totally prevented by administration of anti-Rh
D to Rh negative mothers after each
pregnancy