Anti-thymocyte globulin-induced hyperbilirubinemia in patients with myelofibrosis undergoing allogeneic hematopoietic cell transplantation.

Allogeneic hematopoietic cell transplantation (allo-HCT) remains the only curative treatment option for myelofibrosis (MF) despite the emergence of novel targeted therapies. To reduce graft rejection and graft-versus-host disease (GvHD), current allo-HCT protocols often include in vivo T lymphocyte depletion using polyclonal anti-thymocyte globulin (ATG). Shortly after ATG administration, an immediate inflammatory response with fever, chills, and laboratory alterations such as cytopenias, elevation of serum C-reactive protein, bilirubin, and transaminases can develop. Here, we explore whether MF patients, who commonly exhibit extramedullary hematopoiesis in the liver, might be particularly susceptible to ATG-induced liver toxicity. To test this hypothesis, we analyzed 130 control and 94 MF patients from three transplant centers treated with or without ATG during the allo-HCT conditioning regimen. Indeed, hyperbilirubinemia was found in nearly every MF patient treated with ATG (MF-ATG 54/60 = 90 %) as compared to non-ATG treated MF (MF-noATG 15/34 = 44.1 %, p < 0.001) and respectively ATG-treated non-MF patients of the control group (control-ATG, 43/77 = 56 %, p < 0.001). In contrast, transaminases were only inconsistently elevated. Hyperbilirubinemia was in most cases self-limiting and not predictive of increased incidence of non-relapse mortality, hepatic sinusoidal obstruction syndrome (SOS) or liver GvHD. In sum, awareness of this stereotypic bilirubin elevation in MF patients treated with ATG provides a relatively benign explanation for hyperbilirubinemia occurring in these patients during the early transplant. However, attention to drug levels of biliary excreted drugs is warranted, since altered bile flow may influence their clearance and enhance toxicity (e.g., busulfan, antifungal agents).

Hemolytic Anemia and Heart Failure Caused by Anti-C and Anti-E Immunization.

Many different blood group systems, such as Rh, ABO, Kell, Kidd, Duffy, MNS, have been reported as causes of hemolytic disease of the newborn. Hemolysis due to minor blood group incompatibility in the fetus or newborn has been determined in isolated case reports. Here, we report a case of a patient who had received red cell transfusion due to severe Rh c and E incompatibility, leading to hemolytic anemia with heart failure. The mother and the baby were grouped B and B, respectively, both being positive for RhD antigen. The baby's blood group type was C+, c+, E+, e+, K-, while her mother's blood group type was C+, c-, E-, e+, K-. Our patient was diagnosed as Rh c and E incompatibility, leading to the hemolytic anemia. Minor blood group incompatibility should be considered in infants with prolonged jaundice and severe anemia, leading to heart failure.

Increased regulatory T cells in patients with liver cirrhosis correlated with hyperbilirubinemia and predict bacterial complications.

BACKGROUND AND AIM: Patients with liver cirrhosis (LC) were regarded as immunocompromised status with high incidence of bacterial infection. Regulatory T cell (Treg cell) is known as an immune suppressor and also plays an important role in patients with sepsis. This paper aims to study the role of Treg cells in patients with liver cirrhosis and their correlations to bacterial complications. METHODS: Thirty-three normal controls (NC) and 82 cirrhotic patients were enrolled for the case-control study. The Treg cells, defined as CD4+ CD25+ Foxp3+ T cells, in peripheral blood of these patients were evaluated. RESULTS: The percentage of Treg cells increased significantly in patients with liver cirrhosis when compared with normal volunteers. Furthermore, this increase of Treg cells was mainly memory phenotype defined as CD45RO+ Treg cells and was significantly correlated with serum bilirubin levels as evaluated by multiple linear regression analysis. In addition, the tumor necrosis factor (TNF)-α receptor II (TNFRII) expression also significantly increased on Treg cells in these patients. Interestingly, these membranous TNFRII would be shed and released into supernatant. Lastly, this increased percentage of Treg cells in cirrhotic patients correlate well with and predict subsequent bacterial complications. CONCLUSION: The Treg cells, mainly with memory phenotype and with high TNFRII expression, increased significantly in patients with liver cirrhosis and significantly correlated with the serum bilirubin levels. Furthermore, this increased Treg cells correlate with and predict subsequent bacterial complications in cirrhotic patients.

Cellular-mediated immune responses in the liver tissue of patients with severe Plasmodium falciparum malaria.

The immune responses against Plasmodiumfalciparum malaria infections are complex and poorly understood. No published studies have yet reported the lymphocyte subsets involved in the human liver tissue of P. falciparum malaria patients. To understand the cellular-mediated immune responses in the liver during malaria infection, we determined the numbers of the various lymphocyte subsets in tissue samples obtained at autopsy from patients who died with P. falciparum malaria infection. All the liver tissue specimens had been stored at the Department of Tropical Pathology, Faculty of Tropical Medicine, Mahidol University, Thailand. On the basis of total bilirubin (TB) levels prior to death, patients were divided into 2 groups: those with hyperbilirubinemia [total bilirubin (TB) > or =51.3 micromol/l) (n = 9)] and those without hyperbilirubinemia (TB < 51.3 micromol/l) (n = 12). Normal liver specimens (n = 10) were used as controls. An immunohistochemistry method was used to analyze the types and numbers of lymphocytes (T and B lymphocytes), and Kupffer cells, using specific antibodies against CD3+, CD4+, CD8+, CD20+, and CD68+. Our findings reveal the numbers of T lymphocytes (CD3+ T-cells) and their subsets (CD4+ and CD8+ T-cells) were significantly greater in the portal tracts and sinusoids of liver tissue obtained from P. falciparum malaria cases with hyperbilirubinemia than those without hyperbilirubinemia or controls. CD8+ T-cells were the major lymphocyte subset in the liver tissue of patients with severe falciparum malaria. A significant positive correlation was seen between the numbers of CD4+ and CD8+ T-cells and the liver enzyme levels among P. falciparum malaria patients. The number of CD68+ cells (Kupffer cells) was significantly greater in the liver sinusoids of P. falciparum malaria cases with hyperbilirubinemia than those without hyperbilirubinemia. These findings suggest T-cells, especially CD8+ T-cells and Kupffer cells are an important part of the cellular immune response in the liver tissue of P. falciparum infected patients.

Hemolytic disease of the newborn caused by irregular blood subgroup (Kell, C, c, E, and e) incompatibilities: report of 106 cases at a tertiary-care centre.

OBJECTIVE: To determine the clinical spectrum of hemolytic disease due to irregular blood subgroup incompatibility in hospitalized neonates. STUDY DESIGN: The medical records of the all hospitalized newborn patients diagnosed with indirect hyperbilirubinemia due to subgroup incompatibility in Kell, C, c, E, and e systems were included in the study. Data from 106 newborns with hemolytic jaundice due to irregular blood subgroups were retrospectively evaluated, and clinical and laboratory findings were compared between patients . The treatment modalities given to the patients of each subgroup types and the laboratory findings and treatment modalities of the cases according to Coombs tests results were also analyzed. Fetal affection of the hemolysis and also fetal losses due to irregular red-cell alloimmunization were not detected in prenatal course, as there was no follow-up of these pregnancies. RESULTS: The mean postnatal hospitalizing age was 6.1 ± 5.2 days after birth. The mean total bilirubin level and the mean hemoglobin value on hospitalization were 343.7 ± 63.3 µmol/L (=20.1 ± 3.7 mg/dL) and 14.9 ± 3.4 g/dL, respectively. Of 106 patients identified with irregular subgroup incompatibility, 40 infants (37.7%) were associated with C, 22 (20.8%) with c, 30 (28.3%) with E, 9 (8.5%) with e, and 5 (4.7%) with Kell subgroup system. Positive Coombs tests (either direct and/or indirect) occurred in 28.3% of the study cases. Hydrops fetalis was determined in 5 of 106 neonates (4.7%). Twenty-two of 106 (20.8%) patients required total exchange transfusion. Positive Coombs test in cases required total exchange transfusion was 63.6%. CONCLUSION: Our data expose the magnitude and spectrum of the potential developing severe hemolytic disease and immune hydrops due to irregular subgroup incompatibility. Minor group antibody screening is recommended both in the mother and the high-risk infants with hyperbilirubinemia and hemolytic disease of the newborn.

Transient hepatitis B surface antigen circulation after Infanrix-Hexa: a case report and review of the literature.

The authors describe the case of a 70-day-old boy who was mistakenly diagnosed as suffering from acute hepatitis B, when he presented with persistent unconjugated hyperbilirubinemia and transaminasemia and was found to be seropositive for the hepatitis B surface antigen. The antigenemia was transient and related to his recent immunization with Infanrix-Hexa. Caution is required during interpretation of a positive HBsAg test that is obtained within 28 days after vaccination against hepatitis B.

Complement activation and disease: protective effects of hyperbilirubinaemia.

Complement, an important effector mechanism of the immune system, is an enzymatic cascade of approx. 30 serum proteins leading to the amplification of a specific humoral response. It can be activated through the classical or alternative pathways, or through the mannose-binding lectin pathway. The activation of the classical pathway is initiated by the binding of the C1 component to antigen-bound antibodies, known as immunocomplexes. C1 is a complex of one molecule of C1q, two molecules of C1r and two molecules of C1s. C1q contains three copies of a Y-shaped fundamental unit with globular heads included in its structure, which play a major role in the interaction with the Fc portion of immunoglobulins. Deficient or exacerbated activation of the complement system leads to diseases of variable severity, and pharmacological inhibition of the complement system is considered as a therapeutic strategy to ameliorate the inflammatory effects of exacerbated complement activation. Bilirubin is a product of haem degradation by the concerted action of haem oxygenase, which converts haem into biliverdin, and biliverdin reductase, which reduces biliverdin to UCB (unconjugated bilirubin). UCB exerts both cytoprotective and cytotoxic effects in a variety of tissues and cells, acting either as an antioxidant at low concentrations or as an oxidant at high concentrations. In the present review, we describe in detail the anti-complement properties of bilirubin, occurring at levels above the UCB concentrations found in normal human serum, as a beneficial effect of potential clinical relevance. We provide evidence that UCB interferes with the interaction between C1q and immunoglobulins, thus inhibiting the initial step in the activation of complement through the classical pathway. A molecular model is proposed for the interaction between UCB and C1q.

Bilirubin impairs bactericidal activity of neutrophils through an antioxidant mechanism in vitro.

BACKGROUND: Liver failure accompanied by hyperbilirubinemia after major hepatic resection is profoundly associated with septic complications. Although the immune dysfunction in cholestasis has been intensively investigated, the contribution of increased serum bilirubin to the impaired resistance to bacterial infection remains to be elucidated. Because bilirubin possesses an antioxidant activity, we hypothesized that bilirubin may scavenge reactive oxygen species (ROS) produced by neutrophils and consequently impair neutrophil bacterial killing. To address this, we evaluated the effects of bilirubin on the bactericidal activity of ROS or of neutrophils in vitro. MATERIALS AND METHODS: The antioxidant activity of bilirubin was determined using an ROS-sensitive fluorophore, dichlorofluorescin diacetate (DCFH-DA). Bilirubin concentration in the buffer solution was monitored spectorophotometrically after incubation with ROS. The effect of bilirubin on killing of Escherichia coli by ROS or by isolated human neutrophils was determined by counting the viable E. coli after incubation on nutrient agar. RESULTS: The bilirubin concentration in the buffer solution was decreased by the addition of hydrogen peroxide, especially in the presence of peroxidase or ferrous iron. DCFH-DA oxidation by ROS or activated neutrophils was inhibited by bilirubin in a dose-dependent manner. The bactericidal activity of ROS or of isolated neutrophils was significantly attenuated by bilirubin. CONCLUSIONS: Bilirubin impairs bactericidal activity of neutrophils through scavenging ROS. Increased levels of serum bilirubin may well be responsible for the impaired bacterial clearance in patients with hyperbilirubinemia.

[Hemolytic disease of the newborn and irregular blood group antibodies in the Netherlands: prevalence and morbidity]. / Hemolytische ziekte van de pasgeborene en irregulaire-bloedgroepantagonisme in Nederland: prevalentie en morbiditeit.

OBJECTIVE: To inventory prevalence and morbidity of haemolytic disease of newborn caused by irregular anti-erythrocyte antibodies other than antirhesus-D. DESIGN: Prospective registration study. METHOD: All paediatricians (n = 380) in general hospitals and contact persons (n = 79) in university hospitals were asked for monthly reports of clinical cases of haemolytic disease of newborn during 2 years (1996-1997). RESULTS: Response was 97%. A total of 130 reports were received in two study years, 49 of which could not be confirmed as non-RhD-non-AB0 antagonism. In the group of which the transfusion history was known (n = 60), 29 pregnant women (48%) had received transfused blood at some time. Of the antibodies found, anti-c, anti-E and anti-K were the most frequent. The direct antiglobulin test was positive in 61 of the 81 cases, negative in 10 cases, while in 10 cases it was unknown or false-negative due to earlier intrauterine transfusions (in three neonates). The highest bilirubin levels recorded were 572, 559 and 520 mumol/l (all three with maternal anti-c antagonism). Therapeutic data were known concerning 80 of the 81 newborn: 21 (16%) received no treatment, 24 (29%) only phototherapy and the others--in addition to phototherapy if any--also blood transfusion, exchange transfusion or intrauterine transfusion, or a combination of these. CONCLUSION: It was calculated that the actual prevalence of irregular anti-erythrocyte antibodies in Dutch pregnant women probably amounts to approximately 0.25%. This finding may possibly be confirmed since starting 1 July 1998 all pregnant women in the country are screened for the presence of these antibodies. It is recommended that girls and women in the reproductive age group should receive primary prevention of development of irregular anti-erythrocyte antibodies by application of a selective blood transfusion policy, taking into account the occurrence of the antigens c, E and K.

Concentration of anti-D antibodies in Rh(D) alloimmunized pregnant women, as a predictor of anemia and/or hyperbilirubinemia in their newborn infants.

OBJECTIVES: To define a simple, safe and reliable program for the monitoring of anti-D alloimmunized pregnancies by analysis of the covariation between antenatal values of the titer and the concentration of anti-D antibodies in maternal serum, the deltaOD(450 nm) in amniotic fluid samples, and the levels of B-hemoglobin and S-bilirubin in the newborns at birth. SUBJECTS: Ninety-three Rh(D) negative women with anti-D antibody titers > or = 16 who, after the completed 34th gestational week, gave birth to Rh(D) positive babies with a positive direct antiglobulin test. METHODS: The titers and the concentrations of anti-D antibodies in maternal serum were determined by standard procedures every second week from the 25th week of gestation. In 47 of the 93 women, deltaOD(450 nm) in amniotic fluid was determined at least once. All antenatal values used in the study were determined within 14 days before delivery. RESULTS AND CONCLUSION: Maternal serum antibody titers < or = 32 or > or = 1000 could in themselves well predict unaffected and affected newborns. Antibody titers between 64 and 512 could not accurately predict newborns with or without hemolytic disease. As a complementary monitoring test, determination of the deltaOD(450 nm) was found to be less accurate when compared to determination of the concentration of anti-D antibodies. In order to monitor Rh(D) alloimmunized pregnancies, determination of the concentration of anti-D antibodies may possibly replace determination of deltaOD(450 nm).

Insertion of the adenoviral E3 region into a recombinant viral vector prevents antiviral humoral and cellular immune responses and permits long-term gene expression.

Recombinant adenoviruses (Ads) are highly efficient at transferring foreign genes to the liver in vivo; however, the duration of gene expression is limited by the host antiviral immune response, which prevents expression upon readministration of the virus. To test whether overexpression of the immunomodulatory products of the early Ad genome region 3 (E3) could prevent the antiviral immune response and prolong expression of foreign genes delivered by Ad vectors, we injected a recombinant Ad (Ad-E3-hBUGT), containing both E3 and the human bilirubin-uridine-diphosphoglucuronate-glucuronosyltransferase (BUGT) genes, into BUGT-deficient hyperbilirubinemic Gunn rats. Control Gunn rats received Ad-hBUGT, which expresses human BUGT alone. An initial injection of either virus resulted in hepatic expression of human BUGT as evidenced by excretion of bilirubin glucuronides in bile and a reduction of mean serum bilirubin levels from 7.0 mg/dl to 1.9-2.7 mg/dl within 7 days. In Ad-E3-hBUGT-injected rats, serum bilirubin levels increased to 4.5 mg/dl by 84 days after infection, but a second administration of the virus on that day resulted in a hypobilirubinemic response similar to that seen with the first injection. In contrast, rats receiving Ad-hBUGT had serum bilirubin levels of 7 mg/dl on day 84 after infection, but showed no reduction of serum bilirubin by reinjection of the virus on that day. In the rats injected with Ad-E3-hBUGT, but not in the ones injected with Ad-hBUGT, there was a marked inhibition of the antiviral antibody and Ad-specific cytotoxic T lymphocyte responses. This is the first demonstration that insertion of E3 genes in recombinant Ads facilitates readministration of a functional vector for long-term correction of an inherited metabolic disorder.

Aspectos imunohematologicos, genéticos e clínicos da aloimunizaçäo por anticorpos anti-C: relato de dois casos / Imunohematologics, genetics and clinics aspects of two cases about aloimunization of antibody anti-C

Os autores estudaram dois casos de recém-nascidos que apresentaram hiperbilirrubinemia por antigeno irregular do sistema Rh - c - sendo analisados seus aspectos imunohematologicos, genéticos e clínicos

Relationship between donor-recipient blood group incompatibility and serum bilirubin after allogeneic bone marrow transplantation from HLA-identical siblings.

Data on 477 patients with hematologic malignancies undergoing allogeneic bone marrow transplantation from HLA-identical siblings were analyzed for correlation between donor-recipient ABO blood group incompatibility and the development of elevated bilirubin levels (over 17 mmol/l) after transplantation. The median bilirubin on day 15 after transplant and the maximum bilirubin in the first 100 days were significantly higher in 155 patients with ABO-mismatched donors compared with 322 patients with ABO-matched donors. In univariate analysis, age > 16 years (P = 0.000006), ABO incompatibility (P = 0.0004), a conditioning regimen other than cyclophosphamide-total body irradiation (P = 0.0005) and a diagnosis other than acute leukemia (P = 0.01) were associated with a higher probability of developing elevated bilirubin. Incidence of clinically diagnosed graft-versus-host disease (GVHD), and transplant-related mortality, relapse rates and overall survival were not influenced by ABO incompatibility. The hyperbilirubinemia was therefore unlikely to be the result of an increased incidence of hepatic complications such as GVHD or veno-occlusive disease. We suggest that studies on serious transplant-related complications such as GVHD and veno-occlusive disease which rely on bilirubin values for diagnosis should take donor-recipient ABO incompatibility into account.

Hyperbilirubinemia, jaundice and anergy.

A prospective study of delayed hypersensitivity response was carried out in jaundiced patients. One hundred and seventy-seven subjects were studied. Fifty-nine were controls and one hundred and eighteen were patients with hepato-pancreato-biliary pathology and biliary tract obstruction. A multitest technique was used to evaluate the delayed hypersensitivity response, classifying the subjects into one of three groups: immunocompetent, relatively anergic and anergic. In the control group 76.3 per cent of the subjects were immunocompetent as opposed to 16.1 per cent of the patients (p less than 0.0001). Twenty-four per cent of the control subjects and eighty-four per cent of the patients presented anergy or relative anergy (p less than 0.0001). Among the patients no difference could be found in the index of anergy between malignant and benign pathology. We have found, moreover, that patients with a mean bilirubin level of 12 mg/dl showed a change in the delayed hypersensitivity response, with development of anergy or relative anergy.

The potential immunosuppressive effect of bilirubin.

The effect of bilirubin on the cells of the immune system was studied using various in vitro and in vivo systems. Bilirubin was found to inhibit the in vitro chemotactic (migratory) activity of human granulocytes; on the other hand, a temporary stimulation of phagocytic activity of both granulocytes and monocytes was found in mice injected with a single i.p. injection of bilirubin. Continuous i.v. infusion of bilirubin produced a significant decrease of antibody (plaque) forming cells in the spleens of mice immunized with sheep red blood cells. In newborns suffering from hyperbilirubinaemia, enhanced proportion of "activated" lymphocytes occurred. Finally, bilirubin possessed a significant in vitro cytotoxic effect in human adult and newborn blood lymphocytes and granulocytes. A brief survey of so far known immunological effects of bilirubin is discussed.

The unreliability of amniotic fluid bilirubin measurements in isoimmunized pregnancies in sickle cell disease patients.

Amniotic fluid spectrophotometric analysis for bilirubin (delta optical density [delta OD450], at 450 nm) is used to assess the severity of fetal involvement in isoimmunized pregnancies. Two patients presented with sickle cell anemia and hyperbilirubinemia who also were isoimmunized. The first patient had anti-kell and anti-e antibodies, whereas the second patient had anti-Lewisa and anti-Coltonb antibodies. Delta OD450 was elevated in both patients. The difficulty in interpretation of high delta OD450 in the presence of maternal hyperbilirubinemia is stressed. Sickle cell diseased patients are particularly prone to present with this problem. These patients always have hyperbilirubinemia and a relatively high incidence of irregular antibodies because of the numerous blood transfusions they receive. The management of these two patients is presented with suggestions for the use of alternative modalities of monitoring isoimmunized pregnancies in patients with hyperbilirubinemia.

[Hepatitis B viral markers in the liver tissue of HBs-antigen carriers]. / Markery virusa gepatita B v tkani pecheni nositelei HBs-antigena.

It is established that the liver tissue of HBs antigen carriers, apart from the persistence of two hepatitis B virus antigens, contains morphological alterations ranging from the benign hyperbilirubinemia to the minimal and chronic persisting hepatitis. The authors claim that the minimal structural liver alterations in these patients are due to the tolerance of the immunocompetent system and deficiency of the macrophageal function of star-like endotheliocytes.

False-positive rubella hemagglutination-inhibition (HAI) titers in neonates and children with conjugated hyperbilirubinemia.

Two neonates, one with extrahepatic biliary atresia and one with cystic fibrosis, and a 9-year-old child with atresia of the common bile duct had conjugated hyperbilirubinemia and elevated rubella HAI titers when kaolin pretreatment of serum was used. A beta-lipoprotein fraction of the serum that is frequently found in association with biliary obstruction was shown to be the probable source of the rubella HAI inhibitor. This beta-lipoprotein was not removed by standard kaolin treatment of serum, but was removed almost completely by dextran sulfate--calcium chloride treatment. In the presence of conjugated hyperbilirubinemia, routine kaolin pretreatment of serum is an inadequate measure for the removal of interfering substances, as false-positive rubella HAI results are obtained consistently.