H O W D O I . . . ?

How do I approach patients with warm-reactive autoantibodies?_2985 14..17

Douglas P. Blackall
W
arm-reactive autoantibodies are the most
common cause of autoimmune hemolytic
anemia, with the incidence of these anti-
bodies increasing with patient age.
1
They
have been reported in children as young as a few months
of age, and there are two case reports of neonates who
seem to have developed warm-reactive autoantibodies in
utero.
2,3
They are a relatively common nding at Arkansas
Childrens Hospital, accounting for approximately 15% of
all antibodies evaluated in the laboratory.
4
Although
warm-reactive autoantibodies are sometimes idiopathic,
there are a number of common disease associations
including hematopoietic malignancies (e.g., lymphomas
and leukemias, especially chronic lymphocytic leukemia),
autoimmune disorders (e.g., systemic lupus erythemato-
sus), and chronic inammatory conditions (e.g., Crohns
disease and ulcerative colitis).
1
On occasion, a warm-
reactive autoantibody may be the harbinger of one of
these disorders, which only presents in overt form later.
This review will focus on the transfusion service labora-
tory approach to these autoantibodies and applies to
pediatric and adult patients equally.
I am usually rst consulted about a new warm-
reactive autoantibody by a blood bank technologist. Ini-
tially, I strive to obtain information about the serologic
nature of the antibody and the clinical status of the
patient. With regard to the former, I turn my attention rst
to the reactive nature of the antibody in the serum (i.e.,
How strongly reactive is the antibody? Are all of the red
blood cells [RBCs] on the antibody identication panel
reactive? Are the cells on the panel equally reactive?). I
next consider the reactive nature of the direct antiglobulin
test (DAT; i.e., What is coating the RBCs in excess: IgG, C3,
or both? What is the strength of reactivity of the anti-IgG
and anti-C3 reagents?). Having knowledge of the serologic
reactivity of the patients antibody helps to conrm that it
is, indeed, a warm-reactive autoantibody. It also provides
important insight into the likelihood that the antibody is
resulting in hemolysiswarm autoimmune hemolytic
anemia (WAIHA). As examples, it has been well demon-
strated that more strongly reactive warm autoantibodies
are more likely to be associated with overt hemolysis,
although this is by no means a perfect correlation.
4,5
Simi-
larly, warm-reactive IgGautoantibodies that are also asso-
ciated with demonstrable C3 on the RBC membrane are
more likely to be hemolytic via a synergistic effect.
6
Once I understand the serological presentation of the
warm-reactive autoantibody, I turn my attention to deter-
mining the clinical signicance of the antibody and
understanding the patients clinical condition. Most
important is determining if the antibody is associated
with hemolysis. This is a key consideration as this will be
the primary determinant of whether or not the patient will
need transfusion (now and into the future). This will, in
turn, drive the extent to which the antibody is evaluated in
the laboratory. To determine the clinical signicance of
warm-reactive autoantibodies, a number of ancillary
laboratory tests are required including the hemoglobin
(Hb) and hematocrit (low), the reticulocyte count (gener-
ally elevated, but reticulocytopenia can be a harbinger of a
difcult patient course), the lactate dehydrogenase value
(elevated), and the bilirubin level, particularly the indirect
fraction (elevated). A visual inspection of the plasma or
urine is lowcost and can provide helpful information as to
whether hemolysis (if present) is intravascular or extravas-
cular. The latter is expected in cases of WAIHA. A hapto-
globin value can be useful (low), but in many laboratories
this test is not readily available. In addition, haptoglobin is
an acute-phase reactant, so a single value, especially one
that is in the normal reference range for the laboratory,
may not be useful. Finally, it is always advisable to assess
the RBC morphology on review of the peripheral blood
smear, because spherocytes are typically identied in
cases of WAIHA.
If a patient is experiencing hemolysis to the extent
that transfusion support is necessary, additional serologic
work may be required. The most basic question is this:
From the Department of Pathology, University of Arkansas for
Medical Sciences College of Medicine and Arkansas Childrens
Hospital, Little Rock, Arkansas.
Address reprint requests to: Douglas P. Blackall, MD,
Department of Pathology, Arkansas Childrens Hospital, 1 Chil-
drens Way, Little Rock, AR 72202; e-mail: dougandcaron@
att.net.
Received for publication July 27, 2010; revision received
September 10, 2010, and accepted October 15, 2010.
doi: 10.1111/j.1537-2995.2010.02985.x
TRANSFUSION 2011;51:14-17.
14 TRANSFUSION Volume 51, January 2011
How much does one need to do? Before approaching this
question, it is important to remember that when the blood
bank is faced with a warm-reactive autoantibody and a
patient requires transfusion, the primary concern is the
identication of underlying blood group alloantibodies.
As I explain to rotating residents, we may not be able to
do anything about an autoantibody and its consequences,
but we dont want to contribute to further hemolysis by
transfusing a patient with an underlying alloantibody.
Since alloantibodies form as a result of RBC exposure, via
transfusion or pregnancy, an important task for blood
bank staff is to obtain history. We are benetted in the
pediatric setting by generally having very accessible and
reliable transfusion histories on our patients. In addition,
most of the patients that we serve have no history of preg-
nancy. Thus, many patients with new presentations of
WAIHA have no reasonable likelihood of having underly-
ing autoantibodies, so no special studies (e.g., adsorption)
are required before transfusion. On the other hand, if a
patient has been transfused or pregnant and there is time
to perform an adsorption study (based on the clinical
status of the patient), then the safest practice is to com-
plete the study before transfusing. Very importantly, it is
critical to communicate with transfusion services that
may have evaluated the patient in the past. Early knowl-
edge of a previously identied blood group antibody can
be extremely helpful.
There are a number of additional serologic issues that
the transfusion service should consider in any patient pre-
senting with a warm-reactive autoantibody.
Adsorption studies: These studies are important in
uncovering underlying alloantibodies in those
patients who have a history of pregnancy or transfu-
sion, if time allows for such a study. In those who have
not been transfused in the preceding 3 months, an
autologous adsorption is indicated. For those with a
history of recent transfusion, a more demanding allo-
geneic study is required. Whether either of these
studies will be able to be performed in house or
referred out depends on a number of factors includ-
ing the overall sophistication of the laboratory, the
number of such studies the laboratory encounters,
and general nancial considerations (e.g., relative
cost of testing in house vs. referring out).
Phenotyping: This refers to establishing which of the
major, clinically signicant antigens are or are not
present on the patients RBCs. This can be a powerful
resource for the laboratory as it denes the possible
alloantibodies that a patient can make. While pheno-
typing is a routine part of the initial work-up of
patients highly prone to alloimmunization (e.g., those
with sickle cell disease), it is not performed com-
monly for other patients. However, patients with
WAIHA who will likely require frequent transfusions
over time are an exception. The phenotype can be
used to select units of blood for transfusion that will
prevent alloimmunization and can also be used to
avoid antigen reexposure if the patient is already
alloimmunized. Depending on the ease or difculty
encountered, it may be possible to provide units of
blood for transfusion that are matched to the
patients phenotype (i.e., Rh, Kell, Duffy, Kidd, and
MNS system antigens). Such a strategy would gener-
ally preempt the need to perform adsorption studies.
However, even partially antigen-matched units can
be effective in preventing alloimmunization in
patients with WAIHA.
7
Matching for the most immu-
nogenic and/or clinically signicant antigens (e.g., Rh
system, K antigen, Kidd system) makes the most
sense. Finally, it is important to note the increasing
availability of blood group antigen genotyping. Geno-
typic analysis may be particularly important in those
cases in which a clean phenotype cannot be
obtained, usually as a result of insufcient dissocia-
tion of autoantibodies from the RBC membrane.
Elution studies: These studies are usually undertaken
to identify new blood group alloantibodies, resulting
from recent transfusions, that are not yet demon-
strable in a patients plasma. Elution studies have
very little place in the evaluation of warm-reactive
autoantibodies. Typically, if the plasma demonstrates
a pan-reactive antibody, the eluate will only conrm
the same but the reactivity is generally stronger due to
a concentration of the eluted antibody. Thus, one is
even more unlikely to identify an alloantibody in the
eluate than in the plasma. I reserve elution testing for
patients with reactive DATs who have very weakly-
reactive antibodies in their plasma that I suspect to be
autoantibodies but do not react with all panel cells. In
such cases, due to the concentration effect of the
eluate, it is usually possible to demonstrate pan-
reactivity, thus conrming that the antibody in ques-
tion is an autoantibody.
Crossmatching: Crossmatches are almost invariably
reactive in patients with warm-reactive autoantibod-
ies, as these antibodies generally react with all RBCs
tested. Crossmatching excessive numbers of units to
identify those that are least incompatible provides
no proven clinical benet for patients.
8
In other
words, incompatible is incompatible. Although
there is no disadvantage to selecting a unit for trans-
fusion that reacts less strongly, since there is also no
evidence to suggest a patient benet, the least incom-
patible terminology and associated clinical practice
should be discouraged. Although space does not
allow for a detailed discussion, the use of the in vivo
crossmatch (transfusion of a small aliquot of RBCs
with serologic reassessment, visual assessment of the
plasma for free Hb, and clinical evaluation) should
PATIENTS WITH WARM AUTOANTIBODIES
Volume 51, January 2011 TRANSFUSION 15
also be discouraged.
1
There is no practical benet to
be gained by its performance given what we under-
stand about the hemolytic nature of warm-reactive
autoantibodies. Similar to the release of least incom-
patible units, the in vivo crossmatch may make the
blood bank specialist and the clinician feel more at
ease, but it is wasteful of resources and may delay
transfusion therapy. In the end, the incompatible
units associated with warm-reactive autoantibodies
should be transfused judiciously knowing that as long
as alloantibodies have been investigated, these units
should have the same survival as the patients own
RBCs, even if diminished.
9
Autoantibodies with dened specicities: Warm-
reactive autoantibodies typically react with all
reagent RBCs with the same general strength of reac-
tivity. However, they less commonly demonstrate
specicity for a blood group antigen in a relative or
absolute sense. Most such antibodies demonstrate
enhanced reactivity for certain antigens in the Rh
blood group system (e.g., e). More commonly, there is
a relative specicity for an antigen, meaning that the
patients autoantibody reacts more strongly with
reagent RBCs carrying the antigen and less strongly
with antigen-negative RBCs. Sometimes, however,
the antibody has apparent absolute specicity for a
blood group antigen (e.g., autoanti-D). Although it is
tempting to honor the specicity of these autoanti-
bodies by providing antigen-negative units of blood,
it is unclear if these RBCs have enhanced survival in
the recipient.
1
It pays to remember that warm-
reactive autoantibodies are polyclonal immune
responses.
10
Although there may be a prevailing clone
of cells generating an antibody with a dened in vitro
specicity, the in vivo reality is likely more compli-
cated. In practice, if it is easy to provide an antigen-
negative unit and the crossmatch is actually
compatible (not at all a given), then I sometimes do
this simply to avoid the confusion that can accom-
pany the release of an incompatible unit. However, I
would not transfuse a rare antigen-negative unit (e.g.,
e) for this reason. These units should be reserved for
alloimmunized patients.
Autoantibodies associated with weakly reactive or
nonreactive DATs: Occasionally, a patient is encoun-
tered with laboratory evidence of hemolysis but a
very weakly reactive or even nonreactive DAT is seen.
In other words, the degree of hemolysis is dispropor-
tionate to the serologic character of the DAT. This can
be particularly vexing when the IAT ndings do not
point clearly to a warm-reactive autoantibody. In
cases such as these, I consider other, less common
etiologies of hemolysis: for example, drug-associated
hemolysis; hemolysis due to an IgA autoantibody, a
Donath-Landsteiner autoantibody (as with paroxys-
mal cold hemoglobinuria), or warm-reactive autoan-
tibodies with unusual thermal amplitudes; or even
hemolysis that is not actually immune mediated (e.g.,
associated with a hemolytic toxin, as with a brown
recluse spider envenomation, or an overwhelming
bacterial infection). The evaluation of these possibili-
ties starts with a thorough review of the patient. Most
important are a medication history and a determina-
tion of any preceding or coexisting illnesses. If the
patient is taking, or has recently taken, a medication
that has been associated with hemolysis (e.g., a
second-generation cephalosporin), then an evalua-
tionfor drug-dependent antibodies is warranted. This
will almost always take place in an immunohematol-
ogy reference laboratory. Testing for IgA autoantibod-
ies, Donath-Landsteiner antibodies, and warm-
reactive autoantibodies with unusual thermal
amplitudes will likely transpire in the same setting.
On the other hand, hemolysis resulting from a toxin
exposure is usually evident after reviewing the
patients clinical history.
Follow-up studies: Patients who have persistent
warm-reactive autoantibodies represent a potential
resource sink for the transfusion service. On the
conservative side, one can make the argument that all
such patients, with subsequent transfusions, either
require an adsorption study or require phenotypic
matching to assure that alloantibodies, if present, are
avoided. With strongly reactive autoantibodies that
are hemolytic, this is the safest course of action to
take. On the other hand, some patients have very
weakly reactive but persistent warm autoantibodies.
At Arkansas Childrens Hospital, sickle cell patients
most frequently have this nding. We have a relatively
large cohort of patients who developed weakly reac-
tive warm autoantibodies after alloimmunization.
Although not clinically signicant, with respect to
hemolysis, they create anxiety in the laboratory as
with any warm-reactive autoantibody. However, we
rarely perform follow-up adsorption studies on these
patients. Instead, we carefully monitor the strength of
the DAT. If it remains weak and stable over time, we
simply transfuse the patient releasing the incompat-
ible units that are available to us. This has proven to
be a very safe practice, possibly because these
patients already receive units matched for Rh system
antigens and the K antigen.
In conclusion, warm-reactive autoantibodies are
fairly commonly seen in all patient ages and require
careful evaluation. On initial presentation, it is important
to understand the serologic and clinical features of the
autoantibody as these will be helpful in determining the
breadth of the blood bank investigation, both at presenta-
tion and with follow-up testing. It is important to make
BLACKALL
16 TRANSFUSION Volume 51, January 2011
judicious use of effective ancillary studies, such as adsorp-
tion and phenotyping, but those studies that have no
demonstrated value for patient care (e.g., reliance on units
that are least incompatible, elution studies, in vivo cross-
matching) should be discouraged and avoided. Patients
with warm-reactive autoantibodies are challenging, but
with a little extra effort on the front end, they can be
managed successfully. The laboratory and the clinical
team can be condent that units released for transfusion,
although they are incompatible, have a high likelihood of
being safe and efcacious for the patient.
CONFLICT OF INTEREST
The author declares that he has no conicts of interest relevant to
the manuscript submitted to TRANSFUSION.
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Volume 51, January 2011 TRANSFUSION 17