Presentation on theme: "An Overview: Polyethylene glycol (PEG) - Adsorption of Auto-abs &"— Presentation transcript:
1An Overview: Polyethylene glycol (PEG) - Adsorption of Auto-abs & Detection of Allo-abs in WAIHACheng Chun Kwok
2What is Polyethylene glycol (PEG)? Linear, neutral, water-soluble, non-toxic, ethylene glycol polymer.Consistency (liquid to solid) depends on Mol. Wt.Surfactant in industry (food, cosmetics, pharmaceutics)Biomedicine (dispersing agents, solvents, ointment, suppository bases, vehicles, tablet excipients).
3How Does PEG Work?Macro-molecules remove water concentrate abs abs uptake.Test mixture cannot be centrifuged.Ab detection depends on IAT phase.Anti-IgG AHG is recommended.
4PEG in Blood Banking First described by Nance & Garratty in 1987. Mol. Wt. around 3, ,000.Two types of PEG solutions.20% PEG (20 g PEG / 100 mL NISS)(4 drops 20% PEG + 2 drops serum)PEG in LISS - commercial available(2 drops PEG + 2 drops serum)Liew & Duncan proposed to use in auto-abs adsorption & allo-abs detection in 1995.
5Auto-immune Hemolytic Anemia (1) 3 broad categories IHA: alloimmune, autoimmune, & drug-induced.AI: auto-abs on patient rbc in patient’s serum.Patient anemia ( Hb / Hct) / compensated?Anemia not present: DAT+ with free auto-abs.Anemia compensated: compensated WAIHA.Hemolytic anemia present: WAIHA.Difficult to distinguish bet them in BB.
6Auto-immune Hemolytic Anemia (2) Blood smear: spherocytes, reticulocytosis.Biochem: unconjugated bilirubin , LDH , Hp.Hemoglobinemia & hemoglobinuria.Serological tests: DAT, AS / abs id on serum &/or eluate.HA may due to structural membrane defect, erythrocytic enzyme deficient, abn Hb molecules.
7All Positive DAT Free Auto-abs present HA? No, affected not clearly understood.Positive DAT + free auto-abs - HA (not WAIHA).Positive DAT + free auto-abs + HA (WAIHA).Complicated.Lots of factors may involved.
8Possible Factors Influence an Antibody to cause Hemolytic Anemia (1) Thermal amplitude of abs reactivity.Titer in serum.Avidity for red cells antigen.amount of abs bound to red cells.Ability of abs to fix complement in vivo.Activity of individual’s macrophages.
9Possible Factors Influence an Antibody to cause Hemolytic Anemia (2) IgG subclass (IgG3 > IgG1 > IgG2 > IgG4)Rh abs mostly IgG1 & IgG3.Anti-K & anti-Fy usually IgG1.Anti-Jk mainly IgG3.Severe HDN mostly often associated with IgG1.
10Why Interested in WAIHA? Create problems in BB mask concomitant presence of clinically significant allo-abs.Identify clinically significant allo-abs to avoid HTR.Warm auto-abs adsorption procedures are tedious & time-consuming.Auto-abs react with all donor red cells compatible blood almost always impossible.Question: If we give phenotype matched blood, should we border the tedious auto-abs adsorption & allo-abs detection?
11What is Clinically Significant Ab? Known to cause HDN.Known to cause HTR.Unacceptably shorten survival of transfused red cells.Examples: ABO, Rh, Duffy, Kidd, Kell, SsU, & MUR.All of them are reactive at 37oC &/or IAT.
12All abs Reactive at 37oC &/or IAT are Clinically Significant? No.All clinically significant abs are reactive at 37oC &/or IAT.Abs reactive at 37oC &/or IAT may not be clinically significant.Can be distinguished in Blood Bank? not easy.When an allo-ab reactive at 37oC &/or IAT is identified antigen negative cells are selected for transfusion.
13Detection of allo-abs in patients with auto-abs (1) 1-in-5 dilute auto-abs to detect allo-abs is unreliable & should be strongly discouraged.“least incompatible” blood without allo-abs detection in urgent transfusion is unacceptable.Auto-adsorption is ideal but procedures are tedious, labor intensive & time-consuming.Urgent transfusion may be delay.Limitation: patient severely anemia or recently transfused.
14Detection of allo-abs in patients with auto-abs (2) Allogeneic adsorption is an alternative.Differential warm allogeneic adsorption.One-cell sample allogeneic adsorption.Patient phenotypes not known / uncertain.Patient recently transfused.Tedious, time-consuming & labor intensive.Abs to high-incidence antigen may be removed.Repeat the procedures in transfused patients.
15Detection of allo-abs in patients with auto-abs (3) One-cell sample allogeneic adsorption.Patient not recently transfused.Patient phenotypes known.Abs adsorption with phenotype-matched red cells.Serum insufficient.Recently transfused patient: phenotype with reticulocyte-riched region red cells gel(LISS-IAT).Young red cells: MCHC ; acetylcholinesterase activity .
16Evaluations of PEG in WAIHA Abs Adsorption & Detection Barron & BrownImmunohematoloty 1997;13:Cheng et alTransfusion 2001;41:13-7.Judd & DakeImmunohematology 2001;17:82-5.
17Barron & Brown Immunohematoloty 1997;13:119-22. 19 patients with warm auto-abs were tested.14/19 contained allo-abs / + auto-abs specificities.Adsorption: equal part papain-treated rbc & serum Vs equal part untreated rbc, serum, & 20% PEG in PBS.Detection: LISS (2 drops serum + 2 drops LISS + 1 drop 5% reagent cells). Vs PEG-IAT (6 drops serum/PEG mixture + 1 drop 5% reagent cells).?? Optimal reactivity of 20% PEG; serum:PEG:rbc = 2:4:1 (Nance & Garratty, Am J Clin Pathol 1987).
18Barron & Brown Immunohematoloty 1997;13:119-22. RefPEGserumserum20% PEGpapain-treatedred cellsred cells?? Optimal reactivity of 20% PEG; serum:PEG:rbc = 2:4:1 (Nance & Garratty, Am J Clin Pathol 1987).
19Barron & Brown (Result 1) Immunohematoloty 1997;13:119-22. Ref PEGTotal adsorption time hrs hrsTotal number of adsorption x xAverage time mins minsAbs reactivity stronger strongeranti-K, -Fya, 2 -E anti-E, -Jkb, 3 -CRemarks auto- ND auto- & 2 allo- NDND - Not Detected.Ref: 10 mins enzyme + 10 mins wash + 60 mins incubation + 5 mins harvest.PEG: 15 mins inucbation + 5 mins harvest.
20Barron & Brown (Result 2) Immunohematoloty 1997;13:119-22. 2 allo-abs not detected with PEG.Anti-K weak reactive with ref but non-reactive with PEG.Anti-Jkb microscopic positive but non-reactive with PEG.?? Optimal reactivity of 20% PEG; serum:PEG:rbc = 2:4:1 (Nance & Garratty, Am J Clin Pathol 1987).?? Macroscopic but not microscopic reading at all stages of LISS, + IAT reading, is recommended (Issit & Anstee, Applied blood group Serology).
21Barron & Brown (Result 3) Immunohematoloty 1997;13:119-22. Decreases in adsorption time.Efficient & cost-effective.Very weak allo-abs may not be detected.Option to reduce time & cost in adsorptions.When non-detection is suspected, use standard procedures.
22Cheng et al Transfusion 2001;41:13-7. 16 patients with warm auto-abs were tested.8/16 contained allo-abs / + auto-abs specificities.Adsorption: equal part untreated rbc & serum Vs equal part untreated rbc, serum, & PEG (PeG).Detection: gel (LISS-IAT) Vs PEG-IAT (4 drops serum/PEG mixture + 1 drop 5% reagent cells).
23Cheng et al Transfusion 2001;41:13-7. ConventionalPEGserumserumPeGuntreatedred cellsred cells
24Cheng et al (Result 1) Transfusion 2001;41:13-7. Conventional PEGTotal adsorption time ,400 hrs hrsMean time mins minsMean fold x xAuto-abs adsorption (3x) Not adsorbed All adsorbedAllo-abs detection All are demonstratedCon: 60 mins incubation.PEG: 15 mins incubation.
25Cheng et al (Result 2) Transfusion 2001;41:13-7. 3 allo-anti-E, 1 allo-anti-e, & 3 allo-anti-Mur were able to be demonstrated by both methods.Reactivity strength not mentioned & compared between the two methods.40% efficiency in number of adsorptions.85% decreases in adsorption time.Effective in allogeneic adsorption.
26Cheng et al (Result 3) Transfusion 2001;41:13-7. Method awaits standardization.Fully replace conventional method not recommended.Further studies on weak allo-abs loss during adsorption or IAT.Other techniques incorporated to enhance abs detection - gel (LISS-IAT).Safe to male has no recent transfusion history / female has not been pregnant or no recent transfusion history.
27Judd & Dake Immunohematology 2001;17:82-5. 11 warm reactive auto-abs selected to compare ZZAP & PEG adsorption.12 allo-abs were selected to compare abs detection after ZZAP- & PEG-adsorption.Adsorption: ZZAP adsorption (ficin) Vs equal part untreated rbc, serum, & PEG (PeG).Detection: NISS-IAT (3 drops serum + 1 drop 3-4 % reagent cells, 60 mins 37oC, PS-AHG) Vs PEG-IAT (4 drops serum/PEG mixture + 1 drop 5% reagent cells).?? NISS-IAT: serum to cell = 2 to 1 (Technical Manual).
28Judd & Dake Immunohematology 2001;17:82-5. ZZAPPEGserumserumPeGZZAP (ficin)-treated red cellsred cells
29Judd & Dake (Result 1) Immunohematology 2001;17:82-5. ZZAP PEGAuto-abs removal power ComparableAllo-abs studies rxn grade or more weakeranti-Fya S NDanti-c S weakanti-Jka S w - 1+wND - Not Detected.
30Judd & Dake (Test & Result 1) Immunohematology 2001;17:82-5. Two fold adsorption of 7 allo-abs (2 anti-D, 1 anti-E, 1 anti-K, 1 anti-Jka, & 1 anti-Jkb) with antigen negative red cells.PEG-serum parallel run with saline-serum.Titration studies on adsorbed sera with saline: 60 mins at 37oC with anti-IgG.5/7 were 2 folds lower with PEG.2/7 were 1 fold lower with PEG.Titers of PEG-serum Vs saline-serum : 2-8 Vs 4-32.?? Serially dilute PEG-serum mixture with saline.
31Judd & Dake (Test & Result 2) Immunohematology 2001;17:82-5. To demonstrate abs activity loss in PEG-adsorption procedure but not on post-adsorption storage.Incubate PEG-serum & saline-serum at 37oC, 15 mins, centrifuge & harvest the supernatants.Measure the IgG levels with nephelometer.PEG-serum mixture: mg/dL.Saline-serum mixture: mg/dL.IgG level of PEG-serum mixture was 50% lower.?? Compare IgG levels of ZZAP & PEG adsorbed serum.
32Judd & Dake (Result 2) Immunohematology 2001;17:82-5. PEG adsorption effective in removing auto-abs.Fail to detect allo-abs due to Ig precipitation.
34Leger RM, Ciesielski DC, & Garratty G (1) Transfusion 1999;39:1272-3. Investigate possible loss of ab reactivity of PEG-adsorbed sera upon storage.7 sera contain single ab specificitiesAnti-E, -K, -Fya, & -Jka.2 sham PEG-adsorptions with ag neg red cells.Fresh PEG-adsorbed serum reactivity:PEG-sera mixture left at 4oC for days.
35Leger RM, Ciesielski DC, & Garratty G (2) Transfusion 1999;39:1272-3. Stored sera mixture divided into 2 aliquots.‘Mixed’ & ‘Settled’‘Mixed’ was mixed before sampling.‘Settled’ was allowed ppt to form, settle, & sample the clear supernatant.PEG-adsorbed sera mixture were tested and compared to the adsorbed sera at the time of adsorption.
36Leger RM, Ciesielski DC, & Garratty G (2) Transfusion 1999;39:1272-3. PEG-adsorbed Sera4oC StoragePEG-unadsorbed Mix Before Centrifuge &Sera Sampling Sample Supernatant1 x anti-E S /2 +1 x anti-Fya5 x abs (day 0) Same Degree5 x abs (day 4 ) Same Degree abs Same degree1 anti-Fya weaken
37Leger RM, Ciesielski DC, & Garratty G (3) Transfusion 1999;39:1272-3. Precipitate formed in stored PEG-serum mixture.Once precipitate formed, DO NOT centrifuge.Remix the mixture before sampling.Test PEG-adsorbed serum on the day of preparation.
38What Make the Differences? Method to separate serum-PEG mixture after adsorption.?? Centrifugation force ???? Duration ???? Temperature ??
39How to Perform PEG-incorporated One-cell Sample Allogeneic Adsorption Mix equal parts ofpatient serum + PEG + phenotyped packed red cellsincubate at 37oC, minutescentrifuge & harvest adsorbed serum/PEG mixtureperform PEG-IAT with SC / PC4 drops serum/PEG mixture to 1 drop 5% red cells37oC, minutes, IAT(anti-IgG)
40Advantages of PEG Enhance auto-abs adsorption. Prior red cells treatment not necessary.Direct benefit: time saving, & minimize the delay of urgent transfusion in WAIHA patients.Indirect benefit: labor & cost effectiveness.
41Disadvantages of PEG Precipitates Ig. Weak allo-abs may not be detected after PEG adsorption.
42Remedy??Avoid overnight storage PEG-serum mixture at 4oC - precipitate formed.Adsorbed PEG-serum mixture should be tested as soon as possible.precipitate formed, mix thoroughly before sampling & DO NOT centrifuge.Other techniques may be incorporated to enhance abs detection after PEG adsorption gel (LISS-IAT)??Cells to PEG/serum mixture ratio.AHG in gel: MS/PS.
43ConclusionPotential technique in WAIHA auto-abs adsorption & allo-abs detection.Safe to male has no recent transfusion history / female has not been pregnant or no recent transfusion history.?Method to separate serum-PEG mixture after adsorption.
44Questions & Comments are welcome EndQuestions & Comments are welcome