Reduced Antibody Response in Patients with Chronic Renal Failure Undergoing Hemodialysis with Formaldehyde Sterilized Units R. SHARON From the Blood Bank. Hadassah University Hospital. Mount Scopus. Jerusalem, Israel
In M attempt to explain the relatively low incidence of antibody productbn seen in patients undergoingregui u hemodialyds, sera from 200 patknts were exposed to formaldehyde under conditions similarto those during dialysis. It was found that this pracedure substantially reduced antibody titers, except when the initial titer was very high. The dangerof missing low antibody titers after dialysis is pointed out.
ONEOF
THE PROBLEMS often occurring
in patients who need blood transfusions regularly is the production of antibodies by these patients to one or more of the more immunogenic antigens of the red blood cell. Patients with chronic renal failure are subject to hernodialysis treatment twice, or even three times, per week. Hemodialysis patients often receive a unit of red blood cells to replace the deficiency of red blood cells, usually before the first treatment, and afterwards, as often as the clinical conditions require. In view of the great number of transfusions, these patients would be expected to be good producers of antibodies toward antigens of the red blood cells.* A survey of hemodialysis patients in the Jerusalem area has revealed antibody production in a very low percentage of these patients.' We attempted to approach the question of why the antibody production was low, bearing in mind the fact that the hemodialysis units are sterilized using a 6% formaldehyde s o l ~ t i o n . ~
on the patients' blood while it flows through the hemodialysis unit, we used a concentration of 1% formaldehyde to treat human serum. Equal volumes of serum and 1% formaldehyde were incubated for 30 minutes at 37 C. A control of each experiment consisted of same serum incubated with saline at same dilution. The sera tested were individual sera of about 200 patients at Hadassah, Mount Scopus. Reagent red blood cells were Affirmigen or Selectogen by Ortho Diagnostics, New Jersey. Sera were incubated for one hour at a 50% dilution with 1% formaldehyde and compared to control sets diluted equally with saline. Reactivity of sera was tested according to specific optimal reactions expected.
Results All sera showed a decrease of their antibody reactivity after one hour incubation with 1% formaldehydesolution, at a dilution of 50% (equal volumes of serum and formaldehyde solution). The effect was found to be strong, both on isoagglutinins Anti-A and Anti-B as well as antibodies to other blood group antigens previously detected in the sera tested. Two hundred sera were tested for the effect of incubation with 1% formaldehyde on the activity of natural antibodies. Out of those 200 samples, 110 showed a total loss of activity, or a significant decrease, compared to control sera incubated under the same conditions with saline instead of formaldehyde. The remainder showed substantial decreased activity as shown in Table 1. Out of 200 sera of normal donors, only 20 (10%) were found to be unaffected by the treatment. The effect of the titer of antibodies on the reduction of activity was tested. It was seen that when the titer was above 1:64, formaldehyde had only a small effect, while at lower titers, antibodies were completely removed by the treatment. This finding did not apply to Anti-D, which completely disappeared even when initial titer was much higher. When other immune antibodies, such as Anti-K, Anti-Fys, Anti-S (result-
Materials and Methods The hemodialysis units used in the study were Multipoint or Cordis. In order to simulate the effect that the method of sterilization may have Received for publication August 8, 1978; accepted October 22, 1978.
0041-1132/79/1100/0754 $00.60 0 J. Transfusion November-December l!379
754
B. Lippincott Co. Volume 19 Number 6
Volume 19 Number 6
755
ANTIBODY IN HEMODIALYSIS
Table 1. Fall in Antibody Activity after Incubation with Formaldehyde
Remaining Activity (%)
Per Cent of Group
0 25 50 75
41.5 4 7 7.5
ing from pregnancies o r multiple transfusions), were tested, a neutralizing effect of formaldehyde was found o n 21 of 23 sera.
Discussion
The findings described indicate that even if these patients had produced antibodies, no ill effect of these antibodies would be detected.6 The results show that unless the antibody had a very high titer or else a very high affinity to the specific antigen, the reaction in v i m , and probably also in vivo, would be negligible. We think that the work described may explain the findings, previously described, of a relatively low incidence of antibody production in patients regularly undergoing hemodialysis. It should be noted that low titers resulting from formaldehyde exposure lp3p7
might be missed on routine crossmatching, and hence, be a potential source of danger to the patients. References 1. Fairley, G. H.. and R. J. Akers: Antibodiesto blood
group A and B substances in reticuloses. Br. J. Haematol. 8375, 1962. 2. Howell, E. D., and H. A. Perkins: Anti-N like antibodies in the sera of patients undergoing chronic hemodialysis. Vox Sang. 23291, 1972. 3. Huntley, C.C., A. D. Lyerly, and M.V. Patterson: Isohemagglutininsin parasitic infections. JAMA 208 1145, 1969. 4. Sandler, S. G., R. Sharon, and J. W. Czaszkes: Anti Formaldehyde and Anti N like antibodies in hemodialysis patients. Presented at The Second Meeting of the Mediterranean Blood Club, 1978. 5 . Spivey, M. A., and F. K. Widmann: Change to AxB phenotype in genetic A,B following carcinoma of the cervix. Transfusion 14:612, 1974. 6. Tovey, L. A. D., J. M.Taverner. and G. H. Longster: The effect of environment on ABO antibodies. Vox Sang. 1964, 1970. 7. Yunis. E. J.. N. Zegler. and S. Benson: Retrospective serologic diagnosis of hemolytic transfusion reactions. JAMA 189907, 1964.
Raphael Sharon, Ph.D., Head, Department of Blood Bank, Hadassah University Hospital, Mt. Scopus, Jerusalem, Israel.
In M attempt to explain the relatively low incidence of antibody productbn seen in patients undergoingregui u hemodialyds, sera from 200 patknts were exposed to formaldehyde under conditions similarto those during dialysis. It was found that this pracedure substantially reduced antibody titers, except when the initial titer was very high. The dangerof missing low antibody titers after dialysis is pointed out.
ONEOF
THE PROBLEMS often occurring
in patients who need blood transfusions regularly is the production of antibodies by these patients to one or more of the more immunogenic antigens of the red blood cell. Patients with chronic renal failure are subject to hernodialysis treatment twice, or even three times, per week. Hemodialysis patients often receive a unit of red blood cells to replace the deficiency of red blood cells, usually before the first treatment, and afterwards, as often as the clinical conditions require. In view of the great number of transfusions, these patients would be expected to be good producers of antibodies toward antigens of the red blood cells.* A survey of hemodialysis patients in the Jerusalem area has revealed antibody production in a very low percentage of these patients.' We attempted to approach the question of why the antibody production was low, bearing in mind the fact that the hemodialysis units are sterilized using a 6% formaldehyde s o l ~ t i o n . ~
on the patients' blood while it flows through the hemodialysis unit, we used a concentration of 1% formaldehyde to treat human serum. Equal volumes of serum and 1% formaldehyde were incubated for 30 minutes at 37 C. A control of each experiment consisted of same serum incubated with saline at same dilution. The sera tested were individual sera of about 200 patients at Hadassah, Mount Scopus. Reagent red blood cells were Affirmigen or Selectogen by Ortho Diagnostics, New Jersey. Sera were incubated for one hour at a 50% dilution with 1% formaldehyde and compared to control sets diluted equally with saline. Reactivity of sera was tested according to specific optimal reactions expected.
Results All sera showed a decrease of their antibody reactivity after one hour incubation with 1% formaldehydesolution, at a dilution of 50% (equal volumes of serum and formaldehyde solution). The effect was found to be strong, both on isoagglutinins Anti-A and Anti-B as well as antibodies to other blood group antigens previously detected in the sera tested. Two hundred sera were tested for the effect of incubation with 1% formaldehyde on the activity of natural antibodies. Out of those 200 samples, 110 showed a total loss of activity, or a significant decrease, compared to control sera incubated under the same conditions with saline instead of formaldehyde. The remainder showed substantial decreased activity as shown in Table 1. Out of 200 sera of normal donors, only 20 (10%) were found to be unaffected by the treatment. The effect of the titer of antibodies on the reduction of activity was tested. It was seen that when the titer was above 1:64, formaldehyde had only a small effect, while at lower titers, antibodies were completely removed by the treatment. This finding did not apply to Anti-D, which completely disappeared even when initial titer was much higher. When other immune antibodies, such as Anti-K, Anti-Fys, Anti-S (result-
Materials and Methods The hemodialysis units used in the study were Multipoint or Cordis. In order to simulate the effect that the method of sterilization may have Received for publication August 8, 1978; accepted October 22, 1978.
0041-1132/79/1100/0754 $00.60 0 J. Transfusion November-December l!379
754
B. Lippincott Co. Volume 19 Number 6
Volume 19 Number 6
755
ANTIBODY IN HEMODIALYSIS
Table 1. Fall in Antibody Activity after Incubation with Formaldehyde
Remaining Activity (%)
Per Cent of Group
0 25 50 75
41.5 4 7 7.5
ing from pregnancies o r multiple transfusions), were tested, a neutralizing effect of formaldehyde was found o n 21 of 23 sera.
Discussion
The findings described indicate that even if these patients had produced antibodies, no ill effect of these antibodies would be detected.6 The results show that unless the antibody had a very high titer or else a very high affinity to the specific antigen, the reaction in v i m , and probably also in vivo, would be negligible. We think that the work described may explain the findings, previously described, of a relatively low incidence of antibody production in patients regularly undergoing hemodialysis. It should be noted that low titers resulting from formaldehyde exposure lp3p7
might be missed on routine crossmatching, and hence, be a potential source of danger to the patients. References 1. Fairley, G. H.. and R. J. Akers: Antibodiesto blood
group A and B substances in reticuloses. Br. J. Haematol. 8375, 1962. 2. Howell, E. D., and H. A. Perkins: Anti-N like antibodies in the sera of patients undergoing chronic hemodialysis. Vox Sang. 23291, 1972. 3. Huntley, C.C., A. D. Lyerly, and M.V. Patterson: Isohemagglutininsin parasitic infections. JAMA 208 1145, 1969. 4. Sandler, S. G., R. Sharon, and J. W. Czaszkes: Anti Formaldehyde and Anti N like antibodies in hemodialysis patients. Presented at The Second Meeting of the Mediterranean Blood Club, 1978. 5 . Spivey, M. A., and F. K. Widmann: Change to AxB phenotype in genetic A,B following carcinoma of the cervix. Transfusion 14:612, 1974. 6. Tovey, L. A. D., J. M.Taverner. and G. H. Longster: The effect of environment on ABO antibodies. Vox Sang. 1964, 1970. 7. Yunis. E. J.. N. Zegler. and S. Benson: Retrospective serologic diagnosis of hemolytic transfusion reactions. JAMA 189907, 1964.
Raphael Sharon, Ph.D., Head, Department of Blood Bank, Hadassah University Hospital, Mt. Scopus, Jerusalem, Israel.
