ELP protocol: an original approach for the mitigation of anti-CD38 interference.

BACKGROUND: Transfusion medicine is facing new challenges from therapies which interfere with pre-transfusional tests, such as monoclonal antibodies targeting blood-cell antigens. Anti-CD38 monoclonal antibodies, widely used to treat multiple myeloma, cause panreactivity of indirect antiglobulin test; this can be resolved by treating cells with dithiothreitol to disrupt the CD38 disulphide bonds expressed on red blood cell surfaces. Interference mitigation strategy with dithiothreitol, however, has some drawbacks: it entails losing the traceability of results and the denaturation of blood group systems sensitive to reducing agents; it takes time to perform and quality controls are lost. MATERIALS AND METHODS: Panels were treated with 0.2 mol/L dithiothreitol and stored for 30 days with a commercial preservative solution. On day 30, we measured the hemolysis indices and ability to eliminate daratumumab and isatuximab interference in the treated cells using indirect antiglobulin test. We also tested the stability of erythrocyte antigenic structure by screening 42 samples with known antibodies; tests were repeated on day 1, 7, 15 and 30. All indirect antiglobulin testing was performed on gel card. RESULTS: After 30 days from treatment, panels preserved in preservative solution showed hemolysis indices comparable to untreated panels: all cases of interference by anti-CD38 in pre-transfusional tests were successfully mitigated. All antibodies were detected after 30 days, except for KEL system antibodies, as expected, although there was a detectability of anti-Kell antibodies in high titer samples (the first detection in dithiothreitol-treated cells since 1983). DISCUSSION: We propose the Extended Lifetime Protocol; a simple card-based method which is cheap and traceable, that combines the strengths of anti-CD38 mitigation strategies. It makes it possible to treat and store, at the same time, a sufficient volume of red blood cells, that can be used for the following 30 days, to avoid any delay in transfusional requests.

Congenital heart block not associated with anti-Ro/La antibodies: comparison with anti-Ro/La-positive cases.

OBJECTIVE: To study anti-Ro/La-negative congenital heart block (CHB). METHODS: Forty-five fetuses with CHB were evaluated by analysis of anti-Ro/La antibodies using sensitive laboratory methods. RESULTS: There were 9 cases of anti-Ro/La-negative CHB; 3 died (33.3%). Only 3 (33.3%) were complete in utero and 5 (55.5%) were unstable. No specific etiology was diagnosed. Six infants (66.6%) were given pacemakers. There were 36 cases of anti-Ro/La-positive CHB. All except 2 infants (94.4%) had complete atrioventricular block in utero. Ten died (27.8%), one (2.7%) developed severe dilated cardiomyopathy, and 26 (72.2%) were given pacemakers. CONCLUSION: Nine of the 45 consecutive CHB cases (20%) were anti-Ro/La-negative with no known cause. They were less stable and complete than the anti-Ro/La positive cases.

Case reports of the use of immunoadsorption or plasma exchange in high-risk pregnancies of women with antiphospholipid syndrome.

Conventional treatment of antiphospholipid syndrome (APS) pregnancies with aspirin and/or heparin is sometimes unable to counteract maternal and/or fetal complications. In this article we report the cases of two patients who were unresponsive to conventional treatment for APS during their first pregnancy, and who were treated in the following pregnancy with plasma exchange and immunoadsorption respectively, in addition to conventional therapy. Both patients had a history of thrombotic events, a previous pregnancy loss at the 11th week of gestation and the same antiphospholipid antibody profile (lupus anticoagulant activity and high titers of immunoglobulin G (IgG) anti-beta2 glycoprotein I and IgG anticardiolipin antibodies). Patient 1 was treated from the fourth week of her second pregnancy with weekly plasma exchange. Due to fetal growth restriction and oligohydramnios in the 26th week she delivered, by cesarean section, a healthy female infant weighing 730 g who survived. Patient 2 was treated from the seventh week of her second pregnancy with twice a week protein A immunoadsorption. The pregnancy proceeded normally until the 36th week, when, due to slight intrauterine growth restriction, she delivered a healthy baby girl weighing 2375 g by cesarean section. Anti-beta2 glycoprotein I antibody trends were similar during both types of treatment. On the basis of our findings obtained from only two cases it is impossible to define the best aphaeretic treatment of APS high risk pregnancies. Nevertheless, as a whole these data suggest better disease control using the immunoadsorption technique as compared to plasma exchange, despite their apparently similar anti-beta2 glycoprotein I antibody removal capabilities.

Recovery from catastrophic antiphospholipid syndrome by a plasma exchange procedure: report of four cases and review of the literature.

Catastrophic Antiphospholipid Syndrome (CAPS) is a rare (1%), life-threatening variant of Antiphospholipid Syndrome (APS). It has been found that the recovery rate is best when the treatment protocol includes anticoagulants, steroids and therapeutic plasma exchange (TPE). The treatment of CAPS with TPE is not, however, well defined as procedure modalities have not yet been standardized, and the best replacement fluid for TPE is still a controversial issue. Although the most commonly used one, fresh frozen plasma (FFP), contains natural anticoagulants, it is also made up of clotting factors, complement activation products and cytokines which could worsen CAPS' "thrombotic storm". The successful management of 4 CAPS patients, including TPE sessions initiated in the 1st week from diagnosis and using albumin solution as the replacement fluid, is described here. TPE was performed daily for the first 3 days, then tapered off, and withdrawn on the basis of patient's clinical condition. One of the patients was also treated with anticoagulants, while the others received anticoagulants plus high doses of steroids in addition to TPE. Our results indicate that, when initiated promptly and albumin solution is used as the replacement fluid, TPE can be considered an effective, safe treatment for CAPS.

An analysis of experimental conditions influencing the anti-beta2-glycoprotein I ELISA assay results.

Five components of the anti-beta(2)-glycoprotein I (abeta(2)GPI) enzyme-linked immunosorbent assay (ELISA) (coating buffer, microplate brand, blocking buffer, dilution buffer, and conjugate) were analyzed to evaluate how they affect variability in test results. Thirty-two samples from patients with antiphospholipid syndrome (APS) positive for abeta(2)GPI IgG antibodies and three calibrators (a pool of abeta(2)GPI-positive patients, the monoclonal HCAL antibody, and a home-made calibrator) were tested. No differences with regard to the blocking step were noted. Differences were found between the neutral and basic coating buffer when HCAL was used. There were significant differences between Maxisorp and all the other brands of tested microplates. Differences were found between phosphate-buffered saline (PBS) and all the other dilution buffers examined, with exception of TRIS when HCAL or the home-made calibrator was used. There were differences between our routine conjugate and one of the other four conjugates tested when using two of the three calibrators. There were also significant differences between the routine and another conjugate analyzed when using the third calibrator. As variations in abeta(2)GPI ELISA conditions determine significant differences in the results, selecting the appropriate test variables is an important step toward abeta(2)GPI assay standardization.

Plasma exchange in the management of high risk pregnant patients with primary antiphospholipid syndrome. A report of 9 cases and a review of the literature.

A second-line treatment protocol including plasma exchange (PE) in addition to the standard therapies was scheduled and utilized in our hospital with the intent of improving the outcome of high risk pregnancies of women with primary antiphospholipid syndrome (APS). This paper chronologically reports and discusses the results obtained in these patients over a 15-year period. Between April 1991 and September 2006, 142 pregnancies of patients with APS were followed by us. Nine of these (6.3%), who did not respond to the conventional procedures or showed complications during the treatments were shifted to a PE protocol management. All these women had a history of previous thromboembolism associated to triple antiphospholipid antibody positivity. Nine pregnancies of 7 patients (2 women were treated twice) were thus followed using PE therapy, which has undergone modification over the years. In the cases studied the outcome of pregnancy varied according to the different PE therapy conditions. This study suggests that prophylactic PE treatment administered along with full anticoagulation and IVIG therapy could be a valuable therapeutic option in high risk pregnant APS women. Further studies in this type of patients are certainly warranted.

[Urticaria and angioedema]. / Orticaria e angioedema.

Urticaria is a common complaint characterized by the eruption of cutaneous wheals, accompanied by redness and itching and in which mast cells are thought to play a central role. Wheals range from a few millimeters to several centimeters in diameter and are usually short lasting, except in case of urticarial vasculitis in which they last longer than 24 hours. Urticaria may occur alone or be associated with angioedema, that can be defined as a deep dermal and subcutaneous edema typically affecting the lips, face, hands, feet, penis or scrotum. Angioedema may also involve the submucosal tissue, and when the swellings occur in the oropharynx they can be alarming and occasionally life-threatening. In many cases the cause of acute urticaria or angioedema may be determined, whilst the pathogenetic and diagnostic aspects of the chronic forms are more complex and variable. The clinical features of, as well as the diagnostic and therapeutic approaches to the different forms of urticaria and angioedema are here reviewed, focusing on chronic idiopathic urticaria.