Background: Blood transfusion is a medical procedure that consists in administering total blood or blood products to requiring patients. In case of transfusion incompatibility, de-immunization occurs in the recipient. Objectives: The aim of this investigation was to determine the post-transfusion frequency of anti-erythrocyte alloimmunisation developed in patients with terminal renal disease. Methods: For this purpose, a cross-sectional descriptive study was conducted for two months at the Yaoundé I University Teaching Hospital. The participants were patients enrolled at the Department of Nephrology and Hemodialysis of this health facility. Alloantibodies were detected and identified by the direct Coombs and red blood cell tests. Data analysis was conducted with tools from the statistical software R-version 4.1.1. Results: Forty-six patients with terminal renal disease were enrolled out of which 41% were women and 59% were men with the overall prevalence of anti-erythrocyte alloimmunisations (anti-rhesus alloimmunisations), at 47.82%. The frequencies of antigens from the Rh system were 89.13%, 67.39%, 78.26%, 32.61% and 30.43% for “D”, “E”, “e”, “C”, and “c” antigens, respectively. Further findings revealed the “O” group as the most common blood group (43.47%) while the rates of alloantibodies were 60% for IgG, 32% for IgM and 8% for IgA. Conclusion: According to these foundings and aiming at reducing anti-erythrocyte alloimmunisation, it appears crucial to limit blood transfusions to their strict indications and to ensure that extended phenotyping is conducted prior to isogroup blood transfusions, otherwise, the best indicated.
Blood transfusion refers to a medical procedure that consists in administering total blood or specific components of the blood to needy individuals [
One of the major immunohematological risks of transfusional therapy in polytransfused patients is anti-erythrocyte alloimmunisation, which can cause serious hemolytic accidents and lead to cases of transfusional impasses [
Anti-erythrocyte alloimmunisation is regarded as aserious public health issue, source of post-transfusion accidents and therapeutic failures, especially in countries with limited resources. This piece of work is a contribution to the overall struggle at improving the immuno-hematological blood transfusion safety and preventing alloimmunisation in patients with terminal renal disease.
This cross-sectional study was conducted over a period of 2 months (July 22nd through September 19th, 2021) in the Department of Nephrology and Hemodialysis of the Yaounde I UTH, a health unit with 40 beds. The target population consisted of patients with terminal renal disease of all ages admitted in the department of nephrology. Consecutive sampling was accordingly conducted and, patients who consented were enrolled.
Sampling was consecutive. Patients defined as having end-stage renal disease and polytransfused, regularly followed at the Hemodyalysis Department of the University Hospital of Yaoundé (CHUY) were included; Monotransfused patients followed outside the CHUY were not included.
Three milliliters of venous blood were collected in a dry test tube containing ethylene diamine tetra acetic acid. All specimens were thereafter conveyed without delay to the Immunohematology laboratory for analysis.
The ABO blood grouping was performed according to Beth Vincent and Simonin protocoles. Determination of Rhesus antigen “D” was achieved with monoclonal antibodies supplied by Cypress® and a rhesuscope.
Semi-extensive phenotyping consisted in testing patients’ red blood cells for Rh-system antigens other than D, C, c, E and e. The antibodies test indicators used were provided by Cypress Diagnostics®.
The test for irregular agglutinin was used to identify the antibodies that are responsible for alloimmunisations. Detection of irregular antibodies was performed by direct Coombs’ with polyvalent Coombs reagent provided by Cypress Diagnostic®. Antibodies identification in Coombs-positive patients was performed with the “ionic strength solution” (LISS-Coombs) that identified the type of the immunoglobulin or C3D fraction of complement, alongside with an ID-DiaPanel red cell panel.
The collected data were recorded with Microsoft Excel software 2016 and the statistical analysis of the data was performed with the R version 4.1.1 statistical tool. The variables studied were sex, age, the average of packed units of red cells transfused, frequency of transfusions, ABO and HR phenotype; frequency of alloimmunisations and the type of antibodies identified. Qualitative variables were presented as frequencies while quantitative ones were presented in terms of means ± standard deviation. A comparison of proportions was done with the Chi2 test when the expected number of patients was greater than 5, and Fisher’s test was otherwise. The Student test was used to compare the means of the different groups in the study population. All these tests were carried out at α = 5% threshold.
Overall, 46 patients were enrolled. The table below gives the distribution of the study population according to socio-demographic characteristics and clinical history:
From
・ Distribution according to “ABO” and Rh D antigens
It reveals that the overwhelming characteristics were D positive (≈90%) and A group that was almost four times as frequent as B group.
| Parameters | Men M ± Et | Women M ± Et | Total M ± Et |
|---|---|---|---|
| Years (M ± SD) | 47.93 ± 15.93 | 47.42 ± 17.23 | 47.73 ± 16.29 |
| Mean of transfused units/per month (per year or per transfusion) | 2.89 ± 1.15 | 2.84 ± 1.12 | 2.87 ± 1.13 |
| Mean of frequency de transfusion/Month | 2.74 ± 1.43 | 1.84 ± 0.90 | 2.37 ± 1.31 |
M ± SD = Mean ± Standard Deviation.
| Rh D GS ABO | D (positive) n (%) | D (negative) n (%) | Total n (%) |
|---|---|---|---|
| A | 10 (21.73) | 0 | 10 (21.73) |
| AB | 8 (17.40) | 1 (2.17) | 9 (19.58) |
| B | 5 (10.87) | 2 (4.34) | 7 (15.21) |
| O | 18 (39.13) | 2 (4.34) | 20 (43.47) |
| Total | 41 (89.13) | 5 (10.87) | 46 (100) |
| Antigen RH | Men n (%) | Women n (%) | Total n (%) |
|---|---|---|---|
| D | 25 (54.35) | 16 (34.78) | 41 (89.13) |
| C | 7 (15.22) | 8 (17.39) | 15 (32.61) |
| c | 19 (70.37) | 12 (30.43) | 31 (67.39) |
| E | 22 (47.82) | 14 (30.43) | 36 (78.26) |
| e | 8 (17.39) | 6 (13.04) | 14 (30.43) |
| Antibodies | Men n (%) | Women n (%) | Total n (%) |
|---|---|---|---|
| Ig A | 1 (4.54) | 1 (4.54) | 2 (9.09) |
| Ig G | 9 (40.91) | 4 (18.18) | 13 (59.09) |
| Ig M | 4 (18.18) | 3 (13.64) | 7 (31.82) |
| Total | 14 (63.64) | 8 (36.36) | 22 (100) |
・ Semi-extended phenotyping
Investigation through the semi-extended phenotyping revealed sets of data that were summarized as displayed in
Overall, the D and E overwhelmed the rates of detection in both males and females, with a relative higher frequency in male.
Alloimmunisation in the present survey affected 22 patients with a frequency of 47.8%. Out of the 22 patients affected, 8 (17.39%) were male and 14 (30.43%) were female.
・ Frequency of alloantibodies during alloimmunisations
Likewise,
According to the table above, IgG was the most frequent immunoglobulin (60%), followed by IgM (32%); which immunoglobulins are characteristic of immunizations in CKD patients.
Anti-erythrocyte alloimmunisation is the body response expressed subsequent to administration of foreign erythrocyte antigens (which are not present on the surface of the recipient’s red blood cells) [
The frequency of anti-erythrocyte alloimmunisation recorded in patients with kidney failure was 47.82%. This high rate reflects the high frequency of blood transfusions in chronic renal disease patients and can also be justified by the limitation in the pre-transfusion immuno-hematological screening tests panel at the Yaoundé I UTH. In fact, the absence of systematic extensive phenotyping prevents the total identification of donor antigens in the least immunogenic systems, favouring thereby, incompatibilities in the recipient. This frequency is higher compared to the one reported by Habibi et al. [
Data analysis also revealed that the “O-group” associated with Rh-positive predominated (39.13%). This is likely due to the antigenic diversity within the study population; while the O-group is known to be most common in general. Findings from Malaysia (Shahini Mohamed et al., 2018) [
Alloantibody testing in the present investigation was performed after the semi-phenotyping for Rhesus system antigens (D, C, c, E, and e). Blood grouping in this system revealed the following frequencies: 89.13% D, 32.61% C, 67.39% c, 78.26% E and 30.43%; overall 89.13% of Rhesus-positive individuals and 10.87% of Rhesus-negative with a predominance of D antigens, followed by E and c antigens for further details. The target alloantibodies tested by the direct Coombs test revealed alloimmunisation rate of 47.82%. The detected alloantibodies underwent further identification for more specificity. Related findings indicated IgG (59.09%) and IgM (31.82%). This could be explained by the fact that IgG (warm antibody detectable at 37˚C - 40˚C) is the main antibody detected during erythrocyte alloimmunization. The major cause of hemolysis is followed by IgM (optimum temperature of 4˚C). This observation was also made in 2017 by Achargui et al. [
These results suggest the importance of systematic screening for extensive erythrocyte phenotyping before any blood transfusion in order to mitigate or prevent incompatibilities events, the risk of rejection and therapeutic failure.
Limitation of the StudyThe purpose of this study is to explore post-transfusion frequency of antiérythrocyte alloimmunisations developed in patients with a terminal renal disease. A longitudinal study on a larger population should be done to better elucidate the long-term consequences in chronic kidney patients who should undergo incompatible blood transfusions in the least immunogenic blood group systems.
The overall frequency of alloimmunisation amongst patients with terminal renal disease at the Yaoundé I Teaching Hospital was 47.82%. O-group predominated (43.47%) while the rates of antigens within the Rhesus system were 89.13% “D”, 67.39% “E”, 78.26% “e”, 32.61% “C” and 30.43% “c”. Identified alloantibodies were IgG (60%) and IgM (32%). It comes with the necessity to implement preventive strategies through EBCs phenotyped transfusion to patients with the least immunogenic systems (including Rh, Kell, Duffy); and to carry out a systematic search for irregular agglutinins in all patients prior to any blood transfusion for optimal transfusion safety.
The authors would like to thank the staff of the laboratory of the University Teaching Hospital Center of Yaoundé I and of the University of Mountains for their help in the realisation of this study.
Kévine Nelly Dedjo carried out the collection of biological data, its interpretation and the writing of the manuscript. Romaric De Manfouo Tuono and Peguy Martial Mbianda Tchuessi, supervised the experimental phase, interpreted the data and made a major contribution to the writing and revision of this piece of work, just as Maryline Seuko Njopwouo, Foutse Yimta and Pierre René Fotsing Kwetche. Josué Simo Louokdom contributed in the interpretation of data, the statistical analysis and the writing of the manuscript.
Written informed consent was obtained from parents/guardians, and assent by the minor were obtained.
This study was approved by the Committee of the Institutional Ethics and Research of the Université des montagnes (Reference N˚ 2021/120/UdM/PR/CIE). Authorisation for data collection and analysis of samples from eligible patients was obtained from the UTH of Yaounde I (Refernce N˚ 4582/AR/CHUY/DG/ DGA/CM/PRC). Before starting the study, an informative letter on the objectives of the study, its benefits and risks were given to the participants. For eligible participants, we obtained their free informed consent with signature on the form. Confidentiality of the research results was respected by using a unique code for each patient.
The data used during our study for the write-up of this article are carefully kept by the corresponding author.
The authors declare that they have no conflicts of interest.
Louokdom, J.S., De Manfouo Tuono, R., Dedjo, K.N., Tekam, P.Y.M., Yimta, F., Tchuessi, P.M.M., Njopwouo, M.S. and Kwetche, P.R.F. (2023) Anti-Erythrocyte Alloimmunisation in the RH System during Chronic Kidney Disease: Frequency in Patients at the Yaoundé I University Teaching Hospital. Open Access Library Journal, 10: e9932. https://doi.org/10.4236/oalib.1109932