LETTER TO THE EDITOR Cholestasis in a neonate with ABO haemolytic disease of newborn following transfusion of ABO group-specific red cells compatible with neonatal serum: inspissated bile syndrome Ashish Jain1, Ujjal Poddar2, Priti Elhence1, Archana Tripathi1, Upendra Shava2, Surender K. Yachha2 Department of Transfusion Medicine, 2Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India 1
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hyperbilirubinaemia was caused by conjugated bilirubin. In view of t h e conjugated hyperbilirubinaemia, ursodeoxycholic acid (UDCA) was started. On day 24, the day of admission to our institute, her investigation results were haemoglobin 6.2 g/dL, total leucocyte count 9.4×109/L, reticulocytes 9% and mean corpuscular volume 104.8 fL. Her liver function tests showed total serum bilirubin 26 mg/dL, conjugated bilirubin 14 mg/dL, aspartase amino transferase 175 U/L, alanine amino transferase 102 U/L and gamma glutamyl transpeptidase (GGT) 237 U/L. The baby's serum lactate dehydrogenase level was elevated (922 U/L), suggesting haemolytic anaemia. Because of her anaemia, at this hospital the baby was transfused with 50 mL of group O RhD-positive packed red cells compatible with her mother's serum, as determined by an AHG gel column agglutination test (CAT). Her haemoglobin increased and remained stable following the transfusion (Figure 1). The work-up for neonatal cholestasis included DAT for alloimmune haemolysis, urine for non-glucose reducing substances, free haemoglobin in urine, fundus examination for cataract and choreoretinitis, an abdominal ultrasound to look for features of biliary atresia and a hydroxy-iminodiacetic acid (HIDA) scan. Except for the DAT and HIDA scan, all other investigations were non-contributory. Her HIDA scan was non-excretory, suggestive of cholestasis. The neonate's blood group was confirmed to be A RhD-positive and her red cells were found to be DAT positive (+2) in AHG gel CAT (Diamed GmbH, Cressier, Switzerland). Eluate prepared by heat elution was reactive (+3) with A RhD positive cells by IAT by AHG gel CAT. The IAT done on the neonate's serum was negative with ID Diacell I-II-II (Diamed GmbH, Cressier) as well as with group A red cells by AHG gel technique indicating no free antibodies in the serum. The mother's blood group was O RhD positive. The titres of IgG anti-A and anti-B antibodies in the mother were found to be 512 and 1,028, respectively, by AHG gel CAT.
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Dear Sir, Alloimmune Rh haemolytic disease of newborn (HDN) has been reported to be a significant risk factor for cholestasis with the published prevalence of cholestasis in neonates with Rh HDN being 13-60%1. However, reports of neonatal cholestasis associated with ABO HDN are rare2. We describe here an interesting case of cholestasis in a blood group "A" neonate born to a group "O" mother; the cholestasis was precipitated by exaggerated haemolysis of transfused blood group "A" red cells which were compatible with the neonate's serum. A 24-day old female neonate, blood group A RhD-positive, was brought to the paediatric gastroenterology unit of our hospital with severe pallor and jaundice. She was born to a 24-year old, gravida 2, para 1, blood group O positive mother at term by spontaneous vaginal delivery. Her elder sibling had died at 45 days of age with clinical jaundice although the exact cause of death was not known. As shown in Figure 1, jaundice was n oticed on the baby's 3rd day of life and increased progressively, with a slight improvement after phototherapy. A direct antiglobulin test (DAT) done on the neonate's red cells using the test-tube technique was found to be negative. On day 5 hyperbilirubinaemia was present, caused mainly by unconjugated bilirubin (22.8 mg/dL), which decreased to 9.1 mg/dL on day 8 with phototherapy. The levels of conjugated bilirubin were low and almost constant during the first week. However, on day 8 the neonate's haemoglobin was found to be 7.2 g/dL and she was transfused two aliquots of 50 mL of group "A" whole blood, which had been found to be compatible with the neonate's serum by an indirect antiglobulin test (IAT) done using the test-tube technique. Following the transfusion there was a transient rise in the haemoglobin followed by a fall along with increase in unconjugated bilirubin to 11.7 mg/dL, suggesting haemolysis of the transfused group "A" red cells. The baby's conjugated bilirubin level rose to 33.8 mg/dL on day 11 indicating cholestasis and in the subsequent days the majority of the
Blood Transfus 2014; 12: 621-3 DOI 10.2450/2014.0099-14 © SIMTI Servizi Srl
621 All rights reserved - For personal use only No other uses without permission
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Jain A et al
Figure 1 - Serial haemoglobin and bilirubin values of the patient.
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Gp: group; PRBC: packed red blood cells.
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As a result of these investigations, ABO HDN was diagnosed, where transfusion of ABO group-specific blood (which was compatible with the neonate's serum as there was no free maternal anti-A in the neonate's serum) had led to exaggerated haemolysis. This caused inspissated bile syndrome due to bilirubin overload which triggered cholestasis and conjugated hyperbilirubinaemia. The patient was continued on UDCA (30 mg/kg/day), hydrated and given fat-soluble vitamins along with a medium-chain triglyceride-rich formula. Her jaundice decreased during the follow up. The DAT decreased to 1+ on day 32. At discharge at the age of 42 days her total and conjugated bilirubin levels were 12 mg/dL and 10.4 mg/dL, respectively and at 4.5 months of age her bilirubin was just 1.6 mg/dL and her GGT 82 U/L. In Rh HDN cholestasis is mostly attributed to iron overload due to excessive haemolysis and intrauterine transfusions3. However, risk factors for cholestasis in ABO HDN are not known. In view of the immunohaematological investigations done at our centre our case was diagnosed as ABO HDN. The DAT was however reported to be negative when done earlier at another centre; this could have been because of removal of all DAT-positive neonatal red blood cells by haemolysis or, more likely, because of
low sensitivity of the test done by the test-tube method. It is recommended that for all neonates less than 4 months of age pre-transfusion compatibility tests should be performed with maternal serum or, if that is not available, with neonate's serum or eluate from neonate's cells4. In keeping with the guidelines, the neonate had received a group A whole blood transfusion which had been cross-matched and found compatible with the neonate's serum. Nevertheless, the transfused red cells were destroyed extravascularly thereby increasing the hyperbilirubinaemia and indicating the presence of passively acquired maternal IgG anti-A antibodies which were not detected in the neonate's serum. It is possible that there were no free maternal anti-A antibodies remaining in the neonate's serum due to adsorption onto the neonate's red blood cells and group A antigen on vascular endothelium and other tissues. Other reasons could be a false negative test-tube IAT or low sensitivity of the test. However, the fact that the IAT on neonate's serum done at the time of admission to our centre, in this case using gel CAT, also did not find free maternal anti-A antibodies favours the first explanation. The haemolysis of group A red cells could be more pronounced because adult group A red blood cells express more antigen than do neonatal red blood cells.
Blood Transfus 2014; 12: 621-3 DOI 10.2450/2014.0099-14 622 All rights reserved - For personal use only No other uses without permission
Cholestasis in a neonate with ABO HDN
Authorship contributions All authors confirm that they contributed to the intellectual content of this paper and met the following three requirements: (i) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (ii) drafting or revising the article for intellectual content; and (iii) final approval of the published article. The Authors declare no conflict of interest.
References
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Smits-Wintjens VE, Rath ME, Lindenburg IT, et al. Cholestasis in neonates with red cell alloimmune hemolytic disease: incidence, risk factors and outcome. Neonatology 2012; 101: 306-10. Sivan Y, Merlob P, Nutman J, Reisner S. Direct hyperbilirubinemia complicating ABO hemolytic disease of the newborn. Clin Pediatr (Phila) 1983; 22: 537-8. Rath ME, Smits-Wintjens VE, Oepkes D, et al. Iron status in infants with alloimmune haemolytic disease in the first three months of life. Vox Sang 2013; 108: 328-33. Josephson C. Neonatal and paediatric transfusion practice. In: Roback JD, Grossman BJ, Harris T, Hillyer CD, editors. Technical Manual. Bethesda, MD: AABB; 2011. p. 645-670. Miloh T, Rosenberg HK, Kochin I, Kerkar N. Inspissated bile syndrome in a neonate treated with cefotaxime. Sonography aid to diagnosis, management, and follow-up. J Ultrasound Med 2009; 28: 541-4.
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Because of excessive haemolysis, the excess bilirubin can densify as calcium bilirubinate sludge in bile ducts, leading to cholestasis (inspissated bile duct syndrome)5. Although the ultrasound done 17 days after the incompatible transfusion did not show features of inspissated bile duct syndrome (dilated bile ducts with sludge or echogenic material in the lumen) other features, such as raised levels of liver enzymes, including GGT, the non-excretory HIDA scan and the response to hydration and UDCA are all suggestive of inspissated bile duct syndrome. The response to UDCA may be as early as 2 days and sonographic response has been documented in 6 days. The reason why biliary dilatation was not detected by ultrasound examination in our case could be that the examination was done after 17 days while the baby was receiving UDCA. Other predisposing factors for the development of inspissated bile in neonates include prematurity, parenteral nutrition, sepsis and diuretic therapy5. In most cases removal of the precipitating cause can lead to spontaneous resolution of biliary sludge. However, r efractory cases may require surgery or other endoscopic procedures5. In our case no other predisposing factors, except haemolysis, were present. ABO HDN is a relatively mild disease with low morbidity and mortality; however, failure to diagnose and to follow compatibility requirements can complicate the outcome by precipitating neonatal cholestasis. In summary, this case demonstrates that, in ABO HDN, blood found to be compatible with the neonate's serum may actually be incompatible and become haemolysed. Thus, prior to transfusion of ABO-specific red blood cells in neonates less than 4 months of age compatibility testing should be done by IAT, preferably using the mother's serum or eluate from neonate's red cells; otherwise, only group O red blood cells should be transfused.
Arrived: 09 April 2014 - Revision accepted: 17 April 2014 Correspondence: Priti Elhence Department of Transfusion Medicine Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow-226014, India e-mail: [email protected]
Blood Transfus 2014; 12: 621-3 DOI 10.2450/2014.0099-14 623 All rights reserved - For personal use only No other uses without permission
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hyperbilirubinaemia was caused by conjugated bilirubin. In view of t h e conjugated hyperbilirubinaemia, ursodeoxycholic acid (UDCA) was started. On day 24, the day of admission to our institute, her investigation results were haemoglobin 6.2 g/dL, total leucocyte count 9.4×109/L, reticulocytes 9% and mean corpuscular volume 104.8 fL. Her liver function tests showed total serum bilirubin 26 mg/dL, conjugated bilirubin 14 mg/dL, aspartase amino transferase 175 U/L, alanine amino transferase 102 U/L and gamma glutamyl transpeptidase (GGT) 237 U/L. The baby's serum lactate dehydrogenase level was elevated (922 U/L), suggesting haemolytic anaemia. Because of her anaemia, at this hospital the baby was transfused with 50 mL of group O RhD-positive packed red cells compatible with her mother's serum, as determined by an AHG gel column agglutination test (CAT). Her haemoglobin increased and remained stable following the transfusion (Figure 1). The work-up for neonatal cholestasis included DAT for alloimmune haemolysis, urine for non-glucose reducing substances, free haemoglobin in urine, fundus examination for cataract and choreoretinitis, an abdominal ultrasound to look for features of biliary atresia and a hydroxy-iminodiacetic acid (HIDA) scan. Except for the DAT and HIDA scan, all other investigations were non-contributory. Her HIDA scan was non-excretory, suggestive of cholestasis. The neonate's blood group was confirmed to be A RhD-positive and her red cells were found to be DAT positive (+2) in AHG gel CAT (Diamed GmbH, Cressier, Switzerland). Eluate prepared by heat elution was reactive (+3) with A RhD positive cells by IAT by AHG gel CAT. The IAT done on the neonate's serum was negative with ID Diacell I-II-II (Diamed GmbH, Cressier) as well as with group A red cells by AHG gel technique indicating no free antibodies in the serum. The mother's blood group was O RhD positive. The titres of IgG anti-A and anti-B antibodies in the mother were found to be 512 and 1,028, respectively, by AHG gel CAT.
©
SI
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Dear Sir, Alloimmune Rh haemolytic disease of newborn (HDN) has been reported to be a significant risk factor for cholestasis with the published prevalence of cholestasis in neonates with Rh HDN being 13-60%1. However, reports of neonatal cholestasis associated with ABO HDN are rare2. We describe here an interesting case of cholestasis in a blood group "A" neonate born to a group "O" mother; the cholestasis was precipitated by exaggerated haemolysis of transfused blood group "A" red cells which were compatible with the neonate's serum. A 24-day old female neonate, blood group A RhD-positive, was brought to the paediatric gastroenterology unit of our hospital with severe pallor and jaundice. She was born to a 24-year old, gravida 2, para 1, blood group O positive mother at term by spontaneous vaginal delivery. Her elder sibling had died at 45 days of age with clinical jaundice although the exact cause of death was not known. As shown in Figure 1, jaundice was n oticed on the baby's 3rd day of life and increased progressively, with a slight improvement after phototherapy. A direct antiglobulin test (DAT) done on the neonate's red cells using the test-tube technique was found to be negative. On day 5 hyperbilirubinaemia was present, caused mainly by unconjugated bilirubin (22.8 mg/dL), which decreased to 9.1 mg/dL on day 8 with phototherapy. The levels of conjugated bilirubin were low and almost constant during the first week. However, on day 8 the neonate's haemoglobin was found to be 7.2 g/dL and she was transfused two aliquots of 50 mL of group "A" whole blood, which had been found to be compatible with the neonate's serum by an indirect antiglobulin test (IAT) done using the test-tube technique. Following the transfusion there was a transient rise in the haemoglobin followed by a fall along with increase in unconjugated bilirubin to 11.7 mg/dL, suggesting haemolysis of the transfused group "A" red cells. The baby's conjugated bilirubin level rose to 33.8 mg/dL on day 11 indicating cholestasis and in the subsequent days the majority of the
Blood Transfus 2014; 12: 621-3 DOI 10.2450/2014.0099-14 © SIMTI Servizi Srl
621 All rights reserved - For personal use only No other uses without permission
rv
iz i
Sr l
Jain A et al
Figure 1 - Serial haemoglobin and bilirubin values of the patient.
Se
Gp: group; PRBC: packed red blood cells.
©
SI
M
TI
As a result of these investigations, ABO HDN was diagnosed, where transfusion of ABO group-specific blood (which was compatible with the neonate's serum as there was no free maternal anti-A in the neonate's serum) had led to exaggerated haemolysis. This caused inspissated bile syndrome due to bilirubin overload which triggered cholestasis and conjugated hyperbilirubinaemia. The patient was continued on UDCA (30 mg/kg/day), hydrated and given fat-soluble vitamins along with a medium-chain triglyceride-rich formula. Her jaundice decreased during the follow up. The DAT decreased to 1+ on day 32. At discharge at the age of 42 days her total and conjugated bilirubin levels were 12 mg/dL and 10.4 mg/dL, respectively and at 4.5 months of age her bilirubin was just 1.6 mg/dL and her GGT 82 U/L. In Rh HDN cholestasis is mostly attributed to iron overload due to excessive haemolysis and intrauterine transfusions3. However, risk factors for cholestasis in ABO HDN are not known. In view of the immunohaematological investigations done at our centre our case was diagnosed as ABO HDN. The DAT was however reported to be negative when done earlier at another centre; this could have been because of removal of all DAT-positive neonatal red blood cells by haemolysis or, more likely, because of
low sensitivity of the test done by the test-tube method. It is recommended that for all neonates less than 4 months of age pre-transfusion compatibility tests should be performed with maternal serum or, if that is not available, with neonate's serum or eluate from neonate's cells4. In keeping with the guidelines, the neonate had received a group A whole blood transfusion which had been cross-matched and found compatible with the neonate's serum. Nevertheless, the transfused red cells were destroyed extravascularly thereby increasing the hyperbilirubinaemia and indicating the presence of passively acquired maternal IgG anti-A antibodies which were not detected in the neonate's serum. It is possible that there were no free maternal anti-A antibodies remaining in the neonate's serum due to adsorption onto the neonate's red blood cells and group A antigen on vascular endothelium and other tissues. Other reasons could be a false negative test-tube IAT or low sensitivity of the test. However, the fact that the IAT on neonate's serum done at the time of admission to our centre, in this case using gel CAT, also did not find free maternal anti-A antibodies favours the first explanation. The haemolysis of group A red cells could be more pronounced because adult group A red blood cells express more antigen than do neonatal red blood cells.
Blood Transfus 2014; 12: 621-3 DOI 10.2450/2014.0099-14 622 All rights reserved - For personal use only No other uses without permission
Cholestasis in a neonate with ABO HDN
Authorship contributions All authors confirm that they contributed to the intellectual content of this paper and met the following three requirements: (i) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (ii) drafting or revising the article for intellectual content; and (iii) final approval of the published article. The Authors declare no conflict of interest.
References
3) 4)
rv
5)
Sr l
2)
Smits-Wintjens VE, Rath ME, Lindenburg IT, et al. Cholestasis in neonates with red cell alloimmune hemolytic disease: incidence, risk factors and outcome. Neonatology 2012; 101: 306-10. Sivan Y, Merlob P, Nutman J, Reisner S. Direct hyperbilirubinemia complicating ABO hemolytic disease of the newborn. Clin Pediatr (Phila) 1983; 22: 537-8. Rath ME, Smits-Wintjens VE, Oepkes D, et al. Iron status in infants with alloimmune haemolytic disease in the first three months of life. Vox Sang 2013; 108: 328-33. Josephson C. Neonatal and paediatric transfusion practice. In: Roback JD, Grossman BJ, Harris T, Hillyer CD, editors. Technical Manual. Bethesda, MD: AABB; 2011. p. 645-670. Miloh T, Rosenberg HK, Kochin I, Kerkar N. Inspissated bile syndrome in a neonate treated with cefotaxime. Sonography aid to diagnosis, management, and follow-up. J Ultrasound Med 2009; 28: 541-4.
iz i
1)
©
SI
M
TI
Se
Because of excessive haemolysis, the excess bilirubin can densify as calcium bilirubinate sludge in bile ducts, leading to cholestasis (inspissated bile duct syndrome)5. Although the ultrasound done 17 days after the incompatible transfusion did not show features of inspissated bile duct syndrome (dilated bile ducts with sludge or echogenic material in the lumen) other features, such as raised levels of liver enzymes, including GGT, the non-excretory HIDA scan and the response to hydration and UDCA are all suggestive of inspissated bile duct syndrome. The response to UDCA may be as early as 2 days and sonographic response has been documented in 6 days. The reason why biliary dilatation was not detected by ultrasound examination in our case could be that the examination was done after 17 days while the baby was receiving UDCA. Other predisposing factors for the development of inspissated bile in neonates include prematurity, parenteral nutrition, sepsis and diuretic therapy5. In most cases removal of the precipitating cause can lead to spontaneous resolution of biliary sludge. However, r efractory cases may require surgery or other endoscopic procedures5. In our case no other predisposing factors, except haemolysis, were present. ABO HDN is a relatively mild disease with low morbidity and mortality; however, failure to diagnose and to follow compatibility requirements can complicate the outcome by precipitating neonatal cholestasis. In summary, this case demonstrates that, in ABO HDN, blood found to be compatible with the neonate's serum may actually be incompatible and become haemolysed. Thus, prior to transfusion of ABO-specific red blood cells in neonates less than 4 months of age compatibility testing should be done by IAT, preferably using the mother's serum or eluate from neonate's red cells; otherwise, only group O red blood cells should be transfused.
Arrived: 09 April 2014 - Revision accepted: 17 April 2014 Correspondence: Priti Elhence Department of Transfusion Medicine Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow-226014, India e-mail: [email protected]
Blood Transfus 2014; 12: 621-3 DOI 10.2450/2014.0099-14 623 All rights reserved - For personal use only No other uses without permission
