Comparison of methods for in-house screening of HLA*B57:01 to prevent abacavir hypersensitivity in HIV-1 care

Abacavir is a nucleoside reverse transcriptase inhibitor used as part of combination antiretroviral therapy in HIV-1-infected patients. Because this drug can cause a hypersensitivity reaction that is correlated with the presence of the HLA-B*57:01 allotype, screening for the presence of HLA-B*57:01 is recommended before abacavir initiation. Different genetic assays have been developed for HLA-B*57:01 screening, each with specific sensitivity, turnaround time and assay costs. Here, a new real-time PCR (qPCR) based analysis is described and compared to sequence specific primer PCR with capillary electrophoresis (SSP PCR CE) on 149 patient-derived samples, using sequence specific oligonucleotide hybridization combined with high resolution SSP PCR as gold standard. In addition to these PCR based methods, a complementary approach was developed using flow cytometry with an HLA-B17 specific monoclonal antibody as a pre-screening assay to diminish the number of samples for genetic testing. All three assays had a maximum sensitivity of >99. However, differences in specificity were recorded, i.e. 84.3%, 97.2% and >99% for flow cytometry, qPCR and SSP PCR CE respectively. Our data indicate that the most specific and sensitive of the compared methods is the SSP PCR CE. Flow cytometry pre-screening can substantially decrease the number of genetic tests for HLA-B*57:01 typing in a clinical setting

Allogeneic Hematopoietic Stem Cell Transplantation After Prior Lung Transplantation for Hereditary Pulmonary Alveolar Proteinosis: A Case Report

Pulmonary alveolar proteinosis (PAP) is a rare, diffuse lung disorder characterized by surfactant accumulation in the small airways due to defective clearance by alveolar macrophages, resulting in impaired gas exchange. Whole lung lavage is the current standard of care treatment for PAP. Lung transplantation is an accepted treatment option when whole lung lavage or other experimental treatment options are ineffective, or in case of extensive pulmonary fibrosis secondary to PAP. A disadvantage of lung transplantation is recurrence of PAP in the transplanted lungs, especially in hereditary PAP. The hereditary form of PAP is an ultra-rare condition caused by genetic mutations in genes encoding for the granulocyte macrophage-colony stimulating factor (GM-CSF) receptor, and intrinsically affects bone marrow derived-monocytes, which differentiate into macrophages in the lung. Consequently, these macrophages typically display disrupted GM-CSF receptor-signaling, causing defective surfactant clearance. Bone marrow/hematopoietic stem cell transplantation may potentially reverse the lung disease in hereditary PAP. In patients with hereditary PAP undergoing lung transplantation, post-lung transplant recurrence of PAP may theoretically be averted by subsequent hematopoietic stem cell transplantation, which results in a graft-versus-disease (PAP) effect, and thus could improve long-term outcome. We describe the successful long-term post-transplant outcome of a unique case of end-stage respiratory failure due to hereditary PAP-induced pulmonary fibrosis, successfully treated by bilateral lung transplantation and subsequent allogeneic hematopoietic stem cell transplantation. Our report supports treatment with serial lung and hematopoietic stem cell transplantation to improve quality of life and prolong survival, without PAP recurrence, in selected patients with end-stage hereditary PAP

Are we underestimating reverse TRALI?

BACKGROUND: Transfusion-related acute lung injury (TRALI) is a rare but serious adverse transfusion reaction and is known to be related to anti-human leukocyte antigen (HLA) or anti-human neutrophil antigen (HNA) antibodies in donor plasma. In 2016, four of eight reported TRALI cases could not be explained by donor antibodies. It is assumed that fewer than 10% of TRALI cases are triggered by anti-HLA or anti-HNA antibodies in the patient's plasma (reverse TRALI). STUDY DESIGN AND METHODS: Three cases of red blood cell (RBC)-associated and one case of granulocyte-associated TRALI were investigated. Data were collected on the clinical aspects of the patient and the concerned blood product. Patient's HLA antibodies were determined and the implicated donor was contacted for HLA typing. The HLA antibody identification and strength were assessed using a bead assay (Luminex Single Antigen bead assay, Immucor). For HLA typing, a polymerase chain reaction-sequence-specific oligonucleotide method was used that also included Luminex detection. RESULTS: In three RBC-associated TRALI cases, HLA Class I and II antibodies found in the patient's plasma were specific for the HLA type of the transfused leukoreduced blood product. In a fourth case, HLA antibodies were found in a patient who developed TRALI after repeated granulocyte infusions. The HLA antibodies were directed against HLA antigens present on the donor WBCs. CONCLUSION: The diagnosis of reverse TRALI was retained in four cases, suggesting that reverse TRALI is more frequent than described in the literature, especially in patients with an increased risk for having HLA antibodies.status: publishe

Histological picture of ABMR without HLA-DSA: Temporal dynamics of effector mechanisms are relevant in disease reclassification

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Is it safe for people with epilepsy to donate blood? A systematic review

OBJECTIVE: In many countries people with epilepsy are temporarily or permanently excluded from blood donation. This exclusion is based on the assumption that they are more likely to experience adverse donor reactions such as epileptic seizures, and not on scientific evidence. A systematic review was therefore performed to critically examine the evidence with regard to adverse effects of blood donation on epilepsy patients. METHODS: Five databases (MEDLINE, Embase, The Cochrane Library, Web of Science and CINAHL) were searched for studies from the date of inception until December 2014. Two of the authors screened the articles and extracted the data independently and used the GRADE approach to assess the quality of evidence. RESULTS: The literature search yielded 7283 references. Following title and abstract screening in the first phase, and full text screening in the second phase, only three observational studies were finally withheld: one cohort study and two case series. None of the three studies could demonstrate that a blood donation resulted in adverse events in epilepsy patients. However, the studies were of poor methodological quality and lacked a solid statistical analysis. CONCLUSIONS: Limited low quality studies could not demonstrate that blood donors with epilepsy are at an increased risk of adverse events. Further research is necessary to determine whether and how long epilepsy patients have to be excluded from blood donation.status: publishe

Donor-specific and -nonspecific HLA antibodies and outcome post lung transplantation

Donor-specific antibodies (DSAs) against human leukocyte antigen (HLA) are associated with chronic lung allograft dysfunction (CLAD) and mortality post lung transplantation, but data concerning prevalence, time of onset, persistence and effects on long-term outcome remain scarce.We assessed the association between HLA antibodies and CLAD-free and graft survival in a cohort of 362 patients. We stratified our analysis according to DSA status, persistence of antibodies and timing of antibodies (pre-transplant, early or late post-transplant).Within our cohort, 61 (17%) patients developed DSAs (mostly against HLA-DQ), which was associated with worse CLAD-free and graft survival (p<0.0001 and p=0.059, respectively). Persistent (hazard ratio (HR) 3.386, 95% CI 1.928-5.948; p<0.0001) as well as transient (HR 2.998, 95% CI 1.406-6.393; p=0.0045) DSAs were associated with shorter CLAD-free survival compared with patients without DSAs. Persistent DSAs (HR 3.071, 95% CI 1.632-5.778; p=0.0005) but not transient DSAs were negatively associated with graft survival compared with patients without DSAs, likely due to the higher incidence of restrictive CLAD. HLA non-DSAs and pre-transplant HLA antibodies had no effect on post-transplant outcome.We demonstrated an important difference in prognosis between persistent and transient DSAs. Moreover, the observed association between DSAs and restrictive CLAD suggests an overlap between antibody-mediated rejection and restrictive CLAD that needs further investigation.status: publishe

Screening for HLA antibodies in plateletpheresis donors with a history of transfusion or pregnancy

BACKGROUND : Transfusion-related acute lung injury(TRALI) is known as a life-threatening complication oftransfusion. HLA and HNA antibodies have been asso-ciated with the immune pathway of TRALI. Sincedonors with a history of transfusion and/or pregnancyare presumed to have an increased risk of carryingsuch antibodies, we investigated the association of ahistory of transfusion or pregnancy with the occurrenceof HLA alloimmunization in our donor population. STUDY DESIGN AND METHODS : A total of 1018female plateletpheresis donors and maleplateletpheresis donors with a history of transfusionwere enrolled in the study. Included donors were sys-tematically screened, using Luminex technology, foranti-HLA Class I and II. The association of donor historywith HLA alloimmunization status was analyzed. RESULTS : The overall alloimmunization rate was20.2%. In 0.0% of the nulliparous transfused femaledonors and in 1.3% of the transfused male donors, anti-HLA were detected. Thirty-one percent of the parouswomen versus 4.2% of the nulliparous women screenedpositive for anti-HLA. The rate of HLA alloimmunizationincreased with parity. CONCLUSION : Our data indicate that a history oftransfusion is a minor risk factor for immunizationagainst HLA antigens. In contrast, former pregnanciesconstitute a major risk factor for the development ofHLA antibodies. Since HLA alloimmunization rateincreases with parity, TRALI risk reduction measuresshould focus on this particular donor population.Repeated testing of female plateletpheresis donors aftereach pregnancy is implemented in our blood service