ORIGINAL ARTICLE
AFONSO, Thaynara Freitas [1], OLIVEIRA, Amanda Ribeiro De [2], ALVES, Mauricio Drummond [3], VASCONCELLOS, Christiane Mariotini Moura [4]
AFONSO, Thaynara Freitas. Et al. Alloimmunization Profile in Oncology Patients. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 06, Ed. 05, Vol. 13, pp. 05-19. May 2021. ISSN: 2448-0959, Access link: https://www.nucleodoconhecimento.com.br/health/alloimmunization-profile
ABSTRACT
Blood transfusion is a procedure that puts donor antigens in contact with receptor antibodies. Although this process is an effective therapy, there are risks caused by inadequate procedures, errors or omissions. Irregular antibodies (alloantibodies) are related to most reported fatal hemolytic transfusion reactions, being the second leading cause of transfusion-related death. To avoid these reactions, the phenotypic pouch is a fundamental tool, however, it is not always available in a timely manner, where transfusion is often emergency. The present study aimed to evaluate the frequency of irregular antibodies and describe the phenotypic profile of patients treated at Muriaé cancer hospital. There were 149 protocols for the care of cancer patients with positive results for Irregular Antibody Research (PAI). The profile of these patients corresponded to that observed for the Brazilian population, with females prevailing (59.7%) and individuals over 50 years of age. The most prevalent blood group was type O (34.9%). Leukemias and lymphomas prevailed (18.8%). Approximately 23% of alloimmunized patients developed anemia and 33.6% had already undergone blood transfusions. Among the antibodies detected, 29.7% were equivalent to antibodies without specificity, 25.5% autoantibodies and 45% are antibodies of determined specificity, where anti-E > anti-c > anti-D > anti-K > anti-M were the most frequent. Regarding antibody systems, the most frequent were: Rh (37.6%), Kidd (26.2%), Duffy and MNS (21.5%). We observed that alloimmunization occurred already in the first contacts with transfusion, differently from what other studies report, where most alloimmunized patients were polytransfused. The presence of these antibodies poses a risk for transfusion practice. We believe that the performance of immunophenotyping in the hospital itself would bring greater agility and safety in the transfusion process, especially for alloimmunized patients.
Keywords: Alloimmunization, Irregular antibodies, Neoplasms.
INTRODUCTION
Anti-erythrocitic antibodies are classified as natural or regular and immune or irregular. Regulars develop naturally after birth, from spontaneous stimuli of bacteria from the normal microbiota of the intestine expressing homologous molecules to erythrocytic antigens, as in the ABO system generating anti-A and anti-B antibodies. Irregulars (Rh, Kell, MNS, Lewis, Duffy, Kidd and others) systems are not normally found and develop due to incompatible transfusions or heterospecific pregnancies (ALBERTI; VASCONCELLOS; PETROIANU, 2006).
In addition, antibodies can be classified as alloantibodies or autoantibodies. When an individual undergoes exposure to alloantibodies (foreign erythrocytes), with different phenotype, through blood transfusions, pregnancies and transplants of organs/tissues or grafts for example, an erythrocyte alloimmunization occurs, considered an immune response of his body to these foreign antigens, with production of specific alloantibodies (ALVES, 2012). Autoantibodies are produced by the immune system against one or more proteins of the individual himself.These autoantibodies are responsible for triggering autoimmune diseases such as Lupus, Purpura and hemolytic diseases (ANVISA, 2007).
Blood transfusion is a procedure that puts donor antigens, be they cell or plasma membranes, in contact with receptor antibodies. Although the transfusion process is a form of safe and effective therapy, there are risks caused by inadequate procedures, errors or omissions of the professionals responsible for the transfusion. Some adverse effects should be taken into account: transmission of infectious diseases, transfusion reaction, acute hemolysis secondary to ABO incompatibility, iron overload, immunosuppression, graft-versus-host disease (DECH), inhibition of endogenous production of erythropoietin and alloimmunization (BATISTETI et al., 2007).
According to the Ministry of Health (2010), the development of these reactions is associated with different factors, such as errors in the identification of patients, samples or products, use of inadequate insums, factors related to the recipient and/or donor, such as the existence of irregular antibodies not detected in routine pre-transfusion tests.
In cancer individuals, this prevention is paramount for the clinical status of the patient since the treatment of the disease is considerably more aggressive and the patient’s immune system becomes more weakened (BRANTLEY and RAMSEY, 1988). The knowledge of patients and the factors that lead to transfusion reactions can provide a greater basis for the establishment of preventive measures, contributing to the improvement of hemotherapy services and the care offered to these patients.
This research was carried out at the Muriaé Cancer Hospital, the largest cancer complex in the state of Minas Gerais, covering about 270 municipalities with more than seven million inhabitants.The objective of this work was to evaluate the frequency of irregular antibodies and analyze the phenotypic profile of cancer patients (recipients) through data analysis of immunohematology service protocols, provided by the transfusion agency of the Cristiano Varella Foundation in Muriaé- MG between 2015 and 2018.
DEVELOPMENT
A cross-sectional study was conducted in which we analyzed all data from immunohematology service protocols of cancer patients related to erythrocyal phenotyping, provided by the transfusion agency of the Cristiano Varella Foundation between 2015 and 2018. The main objective of this research was to analyze the frequency of irregular antibodies and to trace a more frequent phenotypic profile among PAI-positive patients.
The inclusion criteria were patients with positive PAI results, between 2015 and 2018 at the Cancer Hospital. Patients with incomplete data for the study were excluded.
This study was submitted to plataforma Brasil and approved (CAAE: 11356519.6.0000.5105. The statistical analyses of the data emitted by the protocols of the services made available were performed through the Software SPSS®, version 17 and the construction of graphs by the Microsoft Excel program.
The transfusion agency of the Muriaé Cancer Hospital – Cristiano Varella Foundation identifies the presence of irregular antibodies through the gel column agglutination methodology, but it is not possible to identify the specificity of these antibodies. Thus, the determination of irregular antibodies or associations is performed in a support hemocenter (Hemominas), where identification is performed according to the specificity of each antibody found.
For this study, data from transfusion care protocols of cancer patients with positive results for Irregular Antibody Research (PAI) were analyzed, totaling a sample of 149 patients, during the period 2015 to 2018.
Twenty-two irregular antibodies were detected among the patients analyzed. Among them, 29.7% corresponded to antibodies of undetermined specificity, 25.5% autoantibodies and the other 45% are antibodies characteristic of alloimmunized individuals, of determined specificity. Among them the antibodies that presented the highest frequency were: anti-E (19.4%), anti-c (11.4%), anti-D (10.1%), followed by anti-K (8.3%) and anti-M (6%) (table 1).
Table 1 – Identification of the detected antibodies and their respective frequencies in PAI-positive patients.
| Irregular Antibodies | Frequency (n) | Percentage (%) |
| Antibody without specificity | 44 | 29,7% |
| Autoantibodies | 38 | 25,5% |
| Anti-E | 29 | 19,4% |
| Anti-C | 17 | 11,4% |
| Anti-D | 15 | 10,1% |
| Anti-K | 12 | 8,3% |
| Anti-IgM | 11 | 7,4% |
| Anti-IgG | 10 | 6,7% |
| Anti-M | 9 | 6% |
| Anti-Jka | 8 | 5,4% |
| Anti-e | 7 | 4,6% |
| Anti-C | 6 | 4,0% |
| Anti-Fya | 3 | 2% |
| Anti-S | 3 | 2% |
| Anti-Lea | 3 | 2% |
| Anti-Dia | 2 | 1,3% |
| Anti-IgA | 1 | 0,7% |
| Anti-PP1PK (anti-J)a | 1 | 0,7% |
| Anti-F | 1 | 0,7% |
| Anti-Bga | 1 | 0,7% |
| Anti-Lua | 1 | 0,7% |
| Anti-Dib | 1 | 0,7% |
Source: Own authorship.
After the identification of the antibodies, they were grouped according to the systems to which they belong. Thus, among the 9 identified systems, the most frequent were: Rh (37.6%), Kidd (26.2%), Duffy and MNS (21.5%) (table 2).
Table 2 – Distribution of antibodies detected according to their respective systems.
| Antibody Systems | Frequency (n) | Percentage (%) |
| Rh | 56 | 37,6% |
| KIDD | 39 | 26,2% |
| DUFFY | 32 | 21,5% |
| MNS | 32 | 21,5% |
| LEWIS | 9 | 6% |
| KELL | 4 | 2,7% |
| P | 1 | 0,7% |
| LUTHERAN | 1 | 0,7% |
| Di | 1 | 0,7% |
Source: Own authorship.
To describe a phenotypic profile of the 149 patients studied, some variables such as: gender and gestational history were analyzed; blood types; age group; types of neoplasms; history of anemia and transfusion history. And for some statistical analyses, fisher’s exact association test was performed and the significance value adopted was p <0,05.
As for gender, the profile of cancer patients with positive PAI among the 149 patients analyzed was characterized by a higher frequency in females with 59.7% (89) compared to males with 40.3% (60). In this study, anti-D was the most frequent antibody in females, with a significantly higher proportion than males (Table 3). And by correlating sex with the presence of anti-D, it was possible to observe a significant p (Fisher’s exact test; p=0.027).
Table 3 – Correlation of sex with the presence of anti-D antibody.
| Anti-D | Female (n) Male (n) | Percentage (n) | |
| absence | 56,7% (76) | 43,3% (58) | 100% (134) |
| presence | 86,7% (13) | 13,3% (2) | 100% (15) |
| total: | 59,7% (89) | 40,3% (60) | 100% (149) |
Source: Own authorship.
Regarding blood types, blood group O (44.3%) was more frequent in relation to the others: A (38.9%), B (13.4%) and AB (3.4%) (table 4).
Table 4 – Classification of the frequency of blood groups detected in patients.
| Blood Group | Frequency (n) | Percentage (%) |
| O | 66 | 44,3% |
| A | 58 | 38,9% |
| B | 20 | 13,4% |
| AB | 5 | 3,4% |
| total: | 149 | 100% |
Source: Own authorship.
The age group of most patients analyzed was between 54 and 69 years of age (38.9%) and over 70 years (32.2%) (table 5).
Table 5 – Age group of patients analyzed.
| age group | Frequency (n) | Percentage (%) |
| 0 – 15 years | 2 | 1,3% |
| 16 – 31 years old | 8 | 5,4% |
| 32 – 47 years old | 18 | 12,1% |
| 48 – 53 years old | 15 | 10,1% |
| 54 – 69 years old | 58 | 38,9% |
| Over 70 years | 48 | 32,2% |
| total: | 149 | 100% |
Source: Own authorship.
Regarding the type of neoplasm, this study proved to be quite diverse, since more than 50 types of cancer distributed among the analyzed population were identified. We observed that of the total of 149 patients, leukemias and lymphomas stood out, with 28 cases (18.8%), followed by malignant neoplasia of the breast, with 22 cases (14.8%), malignant neoplasia of the colon of the uterus, with 12 cases (8.1%) (table 6).
Table 6 – Incidence of neoplasms in the patients analyzed.
| Types of Neoplasms | Frequency (n) | Percentage (%) |
| Leukemia and lymphomas | 28 | 18,8% |
| Malignant neoplasm of the breast | 22 | 14,8% |
| Malignant neoplasm of the uterus colon | 12 | 8,1% |
| Malignant neoplasm of the rehest | 11 | 7,4% |
| Myelodysplasias | 11 | 7,4% |
| Malignant lung neoplasia | 8 | 5,4% |
| Other neoplasms with n < 8* | 57 | 38,3% |
| total: | 149 | 100% |
*Neoplasms that had an incidence <8 were grouped for better data visualization.
Source: Own authorship.
34 patients had a history of anemia, representing 22.8% of the total PAI positive patients. In addition, all individuals who were found to have anemia in this study needed to undergo transfusion procedures. As for the transfusion history, of the 149 patients analyzed, 66.4% had positive PAI results prior to transfusion procedures, while 33.6% of the patients had positive PAI after one or more transfusions (Table 7).
Table 7 – Transfusion history of the patients analyzed.
| Transfusion History | Frequency (n) | percentage |
| 0 | 99 | 66,4% |
| 1 | 46 | 30,9% |
| 2 | 4 | 2,7% |
| Total | 149 | 100% |
Source: Own authorship.
From the analyses of the frequencies of irregular antibodies present in the 149 cancer patients of the Cristiano Varella Foundation, it was observed that 29.7% of antibodies of undetermined specificity, 25.5% autoantibodies and 45% antibodies of determined specificity, characteristic of alloimmunized individuals, where (anti-E > anti-c > anti-D > anti-K > anti-M) were the most frequent, in this order. Studies conducted by Martins et al., (2008) and Trenti (2011), evaluated alloimmunized patients from a hospital and observed similar results, where the most commonantibodies were anti-D (24.8%), anti-E (18.5%), anti-K (13.87%) and anti-M (10.4%).
The prevalence of 29.7% antibodies without specificity was a characteristic found in this study. In some cases, this occurs due to its own characteristics or very low tide, alloantibody is only detected with the use of special techniques such as prolonged incubation, the use of red blood cell treated with enzymes or with medium of low ionic concentration (NOVARETTI et al., 2000; FABRON, 2001; MURAO and VIANA, 2005). In addition, similar studies conducted in different cities also showed a higher prevalence of antibodies of undetermined specificity in relation to other antibodies detected (TRENTI, 2011; WINTERS et al., 2001; BRANTLEY and RAMSEY, 1998).
The high frequency of autoantibodies (25.5%) in relation to alloantibodies can be justified by the fact that autoantibodies are found freely in plasma and not only linked to red blood cells and, thus, they can interfere with pre-transfusion tests, which use plasma concentrates (SHIREY et al., 2002). In addition, the presence of autoantibodies may also be related to the clinical characteristics of patients, since these autoantibodies may manifest as a transient and self-limited complication of infection by certain agents. High tides arise in infections by Mycoplasma pneumoniae, influenza, Epstein-Barr virus,as well as in collagen diseases, neoplasms, lymphomas and occasionally the use of excess drugs (HEMOCENTRO, 2008).
Regarding antibody systems, the most frequent were: Rh (37.6%), Kidd (26.2%), Duffy and MNS (21.5%), they are considered characteristic systems of alloimmunized patients. Previous studies have indicated that the high frequency of Rh system antibodies is characteristic of patients who have already undergone transfusion and that this is due to the high degree of antigen immunogenicity (BAIOCHI and NARDOZZA, 2009; CRUZ et al., 2011; PINTO et al., 2011; RODRIGUES et al., 2013; NOVARETTI et al., 2000; ALVES et al., 2012).
The profile of cancer patients with positive PAI among the 149 patients analyzed was characterized by the higher frequency in females with 59.7% (89) compared to males with 40.3% (60). This higher frequency of females is also confirmed in other studies (WALKER et al., 1989, WINTERS et al., 2001 and SCHONEWILLE et al., 2006).
The fact that the high frequency of alloimmunization among females can be explained by the higher frequency of anti-D in women, due to its involvement with the occurrence of sensitization during pregnancy and, in addition, this antibody is considered the most immunogenic in cases of maternal-fetal incompatibility (BAPTISTA-GONZÁLEZ et al., 1991).
The prevalence of blood group O in relation to the other groups of the ABO system can be explained by the fact that it is a characteristic of the Brazilian population, where the most common groups are O and A, covering 87% of the population, while group B corresponds only 10% of the Brazilian population and AB only 3% (BEIGUELMAN, 2003). This finding is also characteristic of a similar study, in which blood donor records from the Hemotherapy service were analyzed, and it was found that the blood group most frequently in the ABO system was group O (47.1%), followed by groups A (36.9%), B (12.3%) and group AB (3.6%) (SILVA, 2011).
A study conducted in the city of São Paulo where phenotypic frequencies for the ABO blood group system were analyzed also showed a higher frequency of group O (46.5%), followed by groups A (39.4%), B (11.5%) and AB (2.52%) (NOVARETTI et al., 2000).
Regarding age group, this study demonstrated that the cancer patients analyzed are over 50 years of age. Recently Oliveira and Braga (2015), Mendes and Paula (2015) and Shin (2013), found similar data, in which they observed that alloimmunized cancer patients were over 50 years of age.
It is important to emphasize that individual characteristics may determine the fall of antibody titer after alloimmunization. Some factors such as the occurrence of sensitization already in adulthood can be explained due to the decay of immune responses of T and B lymphocytes, resulting in decreased immune protection consequently affecting the persistence of alloantibodies formed (COZAC, 2009).
Regarding the type of neoplasm, according to the transfusion protocol issued by the Federal Government of Brasília, there are some pathologies in which blood transfusion and blood components are used as a supportive treatment and not for curing the disease, by itself. Thus, the pathologies that fit this group are those that at some point in its evolution, will have the potential to require hemotherapy support. According to the International Classification of Diseases (CID-10), there are neoplasms that are included in this group, such as: neoplasms in general including malignant hematological diseases (leukemias, lymphomas, Hodgkin’s disease and Multiple Myeloma), hemoglobinopathies, myelodysplastic syndromes and other hematological diseases (MINISTÉRIO DA SAÚDE, 2010).
From this information it can be said that the neoplasms that stood out are characterized as pathologies that at some point in the evolution of the disease require transfusion and hemotherapeutic support. This fact may justify the appearance of irregular antibodies more frequently in these patients, since they are submitted to successive transfusions, being exposed to non-own antigens.
The history of anemia of the patients in this study was equivalent to 22.8% and all of these patients required to undergo transfusion procedures. This percentage was similar to another study in which about 39% of all patients who had acute and chronic anemias needed blood transfusion (FERREIRA and JÚNIOR, 2015).
Anemia affects more than 90% of cancer patients and more than 60% undergo blood transfusions (ALBERTI; VASCONCELLOS AND PETROIANU, 2006). Thus, transfusion therapy in cancer patients can cause immunization and result in the formation of irregular antibodies, especially in polytransfused patients and, thus, individuals with anemia are more subject to this sensitization.
Among the 99 patients with a transfusion history equal to 0, there was a higher female frequency 61 (62%) and most of these women (47) have had one or more pregnancies, so the occurrence of alloimmunization in these patients can be partly explained by the presence of anti-D antibodies that was more present in most women in this study.
Regarding the other patients, the information about transfusions available in the protocols was reported by the patient himself or family member, and may be justified by a possible ignorance on the part of the patient or family member that at some point in life he underwent a transfusion that was not informed or by forgetfulness, being a limitation for our study.
Regarding the 34% of patients who had between 1 and 3 transfusions, it indicates that the patients in this study had as characteristic to be alloimmunized already in the first contact with transfusion, differently from what they reported in other studies (TRENTI, 2011), where most alloimmunized patients were polytransfused. This fact can be explained by the clinical characteristic of the cancer patient and because the presence of autoantibodies are more prevalent in these patients due to the production of uncontrolled cells stimulating the appearance of these autoantibodies
In studies conducted in Brazil, it was noted that most studies addressing blood transfusions occur in cancer patients. This fact may be associated with the peculiarities of cancer patients regarding their immunohematological status, which makes numerous blood transfusions necessary during their treatment (CALLERA et al., 2004; BELÉM et al., 2011 e FREITAS et al., 2014).
Erythrocitic alloimmunization is a phenomenon resulting from chronic transfusions, that is, several patients would become alloimmunized during their primary exposure shone to antigens. Other factors may contribute to the sensitization of the transfused patient, such as individual predisposition, possibly of inherited character, which could manifest itself already in the first exposures to the foreign antigen (BLUMBERG et al., 1984). Thus, it is important to detect a patient with irregular antibodies (positive PAI) it is necessary to confirm the absence of the respective antigen in the red blood cell cell of the receptor, as well as transfuse red blood cells also negative for such antigens avoiding the occurrence of a possible alloimmunization (WALKER, 1989).
FINAL CONSIDERATIONS
In view of the results presented in this research, we believe that it would be ideal to perform immunophenotyping in the transfusion agency itself, since it would speed up the blood transfusion process for alloimmunized patients. Such a measure would certainly be necessary to reduce the rates of erythrocyclastic alloimmunizations in these red blood cell concentrate receptors, since physicians would not need to opt for an incompatible transfusion in cases of emergencies in alloimmunized patients, reducing the risk of transfusion reactions, with positive repercussions on transfusion safety and the quality of hemotherapy provided by the Hospital.
Finally, it is essential to highlight that the identification of irregular antibodies is of great clinical importance for transfusion practice. Moreover, the theme discussed throughout the research constitutes a public health problem. We reiterate the importance of discussing the theme and recognizing its relevance, so that more studies are conducted and improvements in transfusion practice are implemented in order to ensure transfusion safety. Thus, we hope to contribute to the reduction of morbidity and mortality related to hemotherapy procedures, especially in cancer patients who are more immunocompromised.
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[1] Postgraduate in Hematology, Graduation in Biomedicine.
[2] Graduation in Biomedicine.
[3] Graduation in Medicine.
[4] Guidance counselor.
Submitted: October, 2020.
Approved: May, 2021.
