Red Blood Cell Immunization and Contributing Factors in 685 Thalassemia Patients.

Background: An analysis of red blood cell alloimmunization in patients with thalassemia can help to devise specific strategies to decrease the alloimmunization rate. This study explored the frequency and specificity of alloantibodies and autoantibodies against red blood cell (RBC) antigens in patients with thalassemia referring to the Iranian Blood Transfusion Organization (IBTO) Immunohematology Reference Laboratory (IRL) in Tehran. Materials and Methods: This study first examined the laboratory records of 23,113 patients suffering from different diseases referring to IBTO's IRL for pretransfusion testing in the 2008-2015 period. ABO and Rh(D) typing and antibody screening tests were performed for all 23,113 patient records and 685 (2.97%) beta-thalassemia patients with positive pre-transfusion test results (antibody screening and/or DAT) were selected for further investigation. Results: The antibody screening test was positive in 640 out of 685 thalassemic patients (93.4%). DAT was performed for 529 patients, 226 (33%) of which showed positive results. Meanwhile, 161 out of 685 beta-thalassemia patients (23.5%) had positive auto control test results, reflecting the possible presence of allo- and/or autoantibodies. The most common antigen-specific alloantibodies were directed against K and E RBC antigens with a frequency of 25% (Anti-K) and 11.91% (Anti-E), respectively. The development of two antibodies (double antibodies) in one patient was observed in 80 individuals (11.46%). Conclusion: Age, gender, history of pregnancy, and splenectomy were not contributing factors to the antibody presence in the patient population under study. Extended red blood cell phenotyping should be considered as an essential procedure for expected multi-transfused thalassemia patients before blood transfusion. Considering the high frequency of anti-K and anti-E observed in this study, it is recommended that thalassemia patients in Iran are tested through phenotyping of RBC units for K and E antigens before transfusion.

miRNA96 expression level within red blood cells is probably associated with RSL indicators during the storage of red blood cell units.

BACKGROUND AND OBJECTIVES: Many biochemical and hematological changes occur during the storage of RBC units. Collectively, these changes are known as RSLs. Previous studies found miRNA96 as non-coding RNA that its expression level changed during RBC storage. However, its correlation with mechanical and biochemical RSL indicators is not yet determined. Therefore, this study aimed to assess possible correlations between miRNA96a and some RSLs indicators to clarify its biomarker capability for evaluating the storage quality of RBC units. MATERIALS AND METHODS: Samples were collected from ten leuko-reduced RBC units on days 0, 14, 28, and 42 of storage. miRNA96 gene expression level and RSLs indicators including hemolysis, mechanical fragility index (MFI), total antioxidant capacity (TAC), lipid peroxidation (TBARs), thiol groups, and RBC indices were measured on the days mentioned above. RESULTS: Significant correlations were found between the changes in miRNA96 expression level and the levels of hemolysis, TAC, TBARs, and MFI indices (p values < 0.05). The donors were classified into the high risk group and low risk group, according to four important characteristics and lifestyle habits (smoking, physical activity, age, and BMI). The high risk group had a significantly lower rate of hemolysis, free hemoglobin, MFI, TAC, and a higher rate of lipid peroxidation compared to low risk group (p values < 0.05). CONCLUSION: The finding suggested that upregulation of miRNA96 could prevent hemolysis of RBCs, despite the accumulation of oxidative injuries in them. The miRNA96 expression level was probably a potential predictor for mechanical and biochemical RSL indicators.

The Effect of Pre-Storage Irradiation Blood on Quality of Red Blood Cells.

Background: Irradiation leads to increased storage lesions that may have harmful effects if transfused. Various storage lesions research has been carried out, and only very few articles are available on the impact of gamma irradiation on RBC storage lesions. Since there has been no study about finding the best time for irradiation, we decided to investigate the effect of irradiation on Red blood cells at different storage times after blood collection Materials and Methods: A total of 40 units of red blood cells divided into two groups, irradiated and non-irradiated. Irradiated RBCs were divided into three groups and each group containing ten units. The remaining ten units were considered as non-irradiated controls. Sampling from these irradiated and non-irradiated blood units was performed weekly to evaluate biochemical parameters and free plasma hemoglobin/Hemolysis index levels. Results: A significant increase in the mean values of plasma potassium, plasma Hb/Hemolysis index, and LDH, as well as a significant reduction in the mean value of 2,3 DPG and plasma sodium, were observed in both groups. Although the reduction of 2,3 DPG is extremely remarkable, it is compensated 24-48 hours after transfusion. Hence, the clinical result of 2,3-DPG-depleted RBC transfusion is known to be negligible. The irradiation group alteration was more notable than the non-irradiated one and the changes in the parameters were most significant in the group having been stored for a longer period after irradiation. Conclusion: Our investigation on the impact of gamma irradiation on RBCs makes it possible to suggest a storage time up to 28 days after irradiation is permissible and the best time for irradiation after blood collection is up to 14 days. It is pointed out that the blood unit should be transfused as soon as possible after the irradiation.

Association between -221 X/Y polymorphism of mannose-binding lectin (MBL) gene and susceptibility to HTLV-1 infection among people from an endemic region in the Northeast of Iran.

BACKGROUND: The role of (MBL) gene single nucleotide polymorphisms (SNPs) has been well documented in susceptibility to several infectious diseases. This study aimed to investigate the association between two MBL promoter variants, -550 H/L and -221 X/Y, and susceptibility to HTLV-1 infection. METHODS: A total of 153 subjects infected with HTLV-1 and 169 healthy controls were recruited. SSP-PCR method was applied to genotype -550 H/L and -221 X/Y polymorphisms. Associations between genotypes or alleles and susceptibility to HTLV-1 infection were analyzed by Pearson's Chi-Square. p ≤ .05 was considered statistically significant. RESULTS: Statistical analysis revealed significant differences between the two groups in the -221 position (χ2 = 19.709; p = .000). The MBL YX genotype was significantly associated with increased susceptibility to HTLV-1 (OR = 2.73, %95 CI = 1.74-4.30). Combined genotype of the two loci showed that the HYHX genotype (OR = 2.20, 95% CI = 1.95-2.48) and LYLX (OR = 1.97, 95% CI = 1.13-3.45) were associated with an increased risk of HTLV-1 infection. CONCLUSION: Our results represent the importance of -221 X > Y variants in acquisition of HTLV-1 as this is the case for several other viral and bacterial infections.

Intra-familial Transmission of Chronic Hepatitis B Infection: A Large Population-Based Cohort Study in Northern Iran.

AIM: The aim of this study was to investigate the intra-familial transmission of chronic hepatitis B (CHB) in Golestan province, that has the highest prevalence of CHB in Iran. METHODS: The Golestan Cohort Study (GCS) is a population-based prospective study of 50045 individuals, 40 years or older, initially set-up to study upper GI cancers in Northern Iran. In 2008, a baseline measurement of hepatitis B surface antigen (HBsAg) on the stored serum of all GCS participants identified 3505 HBsAg+ individuals. In 2011, we assessed HBV serological markers in 2590 initially HBsAg+ individuals and their first-degree relatives including spouses (1454) and children (3934). RESULTS: The median (IQR) age of spouses and children were 52 (12) and 25 (12) years respectively. Out of 5388 family members, 2393 (44.5%) had no HBV markers, indicating susceptibility to infection. Of these, 378 (15.8%) were fully-vaccinated children with no apparent response to primary immunization. HBsAg was positive in 2.2% (n = 33) of spouses and 8.2% (n = 325) of children (overall rate of 6.6%). HBcAb was positive in 761 (52.3%) and 914 (23%) spouses and children, respectively. The rate of spontaneous loss of HBsAg (HBsAg-, HBsAb+ and HbcAb+) was 41.3% and 13.9% in spouses and children, respectively. A higher rate of HBsAg+ children (10.2%) was found in families in which the mother was positive for HBsAg compared with families where the father was positive for HBsAg (6.3%) (P < 0.001). When both parents were positive for HBsAg, the rate of HBsAg positivity was high (23.5%, P < 0.001). Despite high virus exposure rates between spouses (52.6 %), the prevalence of HBsAg positivity among them was very low (2.3 %). CONCLUSION: Sexual and parent-to-child transmission are important routes of CHB spread in this population from northern Iran despite the fact that 24 years have passed since the beginning of hepatitis B vaccination in infants. Low percentage of HBsAg positivity in spouses is related to high HBsAg clearance rate among them.

Epidemiological Profile of Hepatitis B Virus Infection in Iran in the Past 25 years; A Systematic Review and Meta-analysis of General Population Studies.

BACKGROUND Chronic hepatitis B virus (HBV) infection is one of the most important health problems worldwide with a high rate of morbidity and mortality. It is a major risk factor for cirrhosis and liver cancer. Currently, Iran is located in the intermediate HBV zone; however, recent studies have provided some evidence indicating an epidemiological change in the country. The aim of this study was to estimate the prevalence of HBV in Iran. METHODS A systematic review was conducted to evaluate the studies performed in the past 25 years that have reported the prevalence of HBV infection and its associated factors in the Iranian general population (1990-2014). Any study assessing and reporting serum Hbs Ag levels was included in this review. RESULTS After excluding all impertinent studies, 19 eligible studies were included in the analysis. The overall prevalence of HBV was 3% (95% CI 2% to 3%). Its distribution showed that the prevalence of HBV varies in different provinces from 0.87% to 8.86%. The HBV rate was highest in the Golestan (8.86%) and lowest in the Kurdistan (0.87%) provinces. CONCLUSION This study provides some evidence about the prevalence of HBV in Iran. However, the collected data was very heterogenic, even within a single province, which made it hard to estimate a single-point prevalence. High quality studies are needed to find reliable information about HBV prevalence and to decrease the heterogeneity of results in the country.

Seroepidemiology of human T-cell lymphotropic virus type-I in blood donors of Northeastern Iran, Sabzevar.

BACKGROUND AND OBJECTIVES: Human T-cell lymphotropic virus type-I (HTLV-I) infection is considered as a public health challenge in endemic areas. The virus is associated with severe diseases, such as adult T-cell leukemia/lymphoma, and HTLV-I-associated myelopathy/tropical spastic paraparesis. One of the major routes of the HTLV-I transmission includes blood transfusion. Sabzevar is located in the endemic region of HTLV-I infection. The aim of the present study was to determine the seroprevalence of HTLV-I infection in the blood donors in Sabzevar. MATERIALS AND METHODS: A total of 35,067 blood donors in Sabzevar from March 2009 to April 2012 who were screened with HTLV-I on the enzyme-linked immunosorbent assay screening test were included in this survey. Reactive samples that confirmed by western blot were considered to be seropositive cases. The required data were obtained from blood donors' database of blood transfusion service. RESULTS: The overall prevalence of HTLV-1 based on the positive result of western blot test was 0.14%. The seropositive donors aged 17-59 years with a mean age of 38.10 ± 11.82. The prevalence rates of HTLV-I infection in 3 years of study were 0.19%, 0.14%, and 0.09%, respectively. A significant relation between age, sex, educational level, and history of blood donation was observed with seropositivity of HTLV-I. CONCLUSION: The improvement of donor selection and laboratory screening caused a decline in the prevalence of infection in blood donors. Given the lower prevalence of infection in regular donors with lower age and higher educational level, more efforts should be done to attract blood donors from these populations.

The incidence of hepatitis C in patients with thalassemia after screening in blood transfusion centers: a fourteen-year study.

BACKGROUND: Blood safety is important in all transfusion centers. The aim has always been to try to guarantee the recipient's safety through careful screening and examination of donors' blood samples. In Iran the hepatitis C virus (HCV) screening test became mandatory for blood donations from 1996. We decided to determine the incidence of new cases of HCV in patients with thalassemia, after screening of blood bags was initiated. STUDY DESIGN AND METHODS: The study was done on patients with complete files for anti-HCV test results. Only cases that had a confirmed positive anti-HCV result after a negative result were considered as new cases. The incidence rate was estimated and expressed in person-years (PY). Also, for increased accuracy and comparison of incidence in recent years, the incidence rate was calculated at two 7-year intervals (1996-2002 and 2003-2009). RESULTS: A total of 395 files were studied with a mean age of 27.5 years (SD ± 7.99 years). We had 109 (27.5%) anti-HCV positive, of which 21 (19.2% of positive cases) were exposed after 1996 and considered as new cases. The incidence of HCV cases in 14 years (1996-2009) was 4.2/1000 PY. The incidence in the first 7-year period (1996-2002) was 6.2/1000 PY and 1.3/1000 PY in the second 7-year period (2003-2009). CONCLUSION: The incidence of HCV is on the decline in Iran, both in blood donors and in recipients. We owe this to the improved blood safety in our transfusion center that has taken up better strategies. Even though the residual risk will never reach zero and we may still have new cases of HCV, it will definitely be with a lower rate. The fact that we have had no new cases among our patients with thalassemia since 2005 bears witness to this matter.

Blood transfusion and alloimmunization in patients with thalassemia: multicenter study.

One of transfusion's side effects is alloimmunization against red blood cell (RBC) antigens. Early diagnosis by antibody screening is an important step in the detection of these alloantibodies. The authors studied the frequency of alloimmunization in thalassemic patients of 4 centers (2 adult and 2 pediatric centers) and compared the rates in children (up to 15 years) and adults. Antibody screening tests were performed by gel method according to its standard pattern and respective program. In positive cases, antibody identification test by gel method was performed. Eight hundred thirty-five patients were studied; 548 (65.6%) were adults (mean age = 24.5), and 287 (34.4%) cases were pediatrics (mean age = 10.05). Of these patients, 74.1% had no history of transfusion reaction, whereas 21 (2.5%) had hemolytic complications. Seventy-eight (9.3%) exhibited allergic symptoms, and 117 (14%) cases experienced febrile reactions during transfusion. Antibody screening showed positive results in 22 pediatric cases (7.7%) and 79 adults (14.4%); 72 (71.3%), 19 (18.8%), 3 (3%), and 1 (1%) cases exhibited single, double, triple, and autoantibodies, respectively. Anti-Kell antibody was seen in 34 (33.7%) cases, anti-D was seen in 11 (10.9%) cases, and anti-E in was seen in 10 (9.9%) cases. The authors observed 8 anti-D+C (7.9%) cases, 1 anti-D+E (1%), 3 anti-Kell+E, 3 anti-Kell+Kpa (3%), and 1 anti-Kell+D double antibodies. These antibodies were also a combination of Rh subgroups or Rh and Kell subgroups. The authors observed meaningful relations between history of transfusion reactions and age with antibody screening results (P = .005). Based on alloantibodies types, more than two thirds of them were Rh subgroups and Kell groups. Phenotype determination of RBCs before beginning chronic blood transfusion and careful cross-matching with Kell and Rh subgroups in addition to ABO may help reduce alloimmunization in chronic transfusion patients.

Antibody titration and immune response of Iranian beta-thalassemic patients to hepatitis B virus vaccine (booster effect).

BACKGROUND: Thalassemia is hereditary anemia with lifelong transfusion as treatment and hepatitis B virus (HBV) infection is one of the transfusion transmitted infections (TTI). HBV vaccination is obligatory for these patients by 3 double-dose injections. The authors studied the HBV status and immune response to vaccination by hepatitis B surface antibody (HBsAb) titration in their thalassemic patients. They also compared these results with their previous study to find out the effectiveness of a booster dose in the immunity of patients against HBV. MATERIALS AND METHODS: Hepatitis B surface antigen (HBsAg), HBsAb, and hepatitis B core antibody (HBcAb) were detected in sera of 416 patients at the Tehran Adult Thalassemia Clinic. The immune status was classified into 4 categories: (1) immune to HBV via the vaccination (positive vaccinal)--if HBs Ag: negative, HBsAb: positive, HBcAb: negative; (2) immune to HBV via the natural disease (past infection)--if HBs: negative, HBsAb and HBcAb: both positive; (3) nonimmune to HBV (negative)--if all three parameters were negative; (4) carrier of HBV (carrier state)--if HBs Ag was positive and HBsAb and HBc Ab: both negative. Also grading of immunity done by HBsAb titration as positive if HBsAb titer was more than 100 IU/mL, negative if HBsAb titer was less than 10 IU/mL, and weakly positive if antibody level was 10-100 IU/mL. RESULTS: There were 416 patients: 302 (72.5%) with thalassemia major (TM), 104 (25%) thalassemia intermedia (TI), 7 (1.6%) sickle thalassemia (ST), and 3(0.7%) alpha-thalassemia (HbH disease). The mean age was 25.6 +/- 8.3 yr and median age was 24 yr; there were 247 (59.4%) males and 169 (40.6%) females. A total of 257 patients (61.7%) were splenectomized. According to our classification 289 (69.4%) were immunized by vaccination; 80 (19.2%) were immunized by past infection; 44 (10.5%) were negative, and 3 (0.7%) were in carrier state of HBV. In grading of immunity to HBV vaccination, 319 (76.6%) patients had HBsAb > 100 IU/mL (positive), 77 (18.5%) between 10 and 100 IU/mL (weakly positive), and 20 (4.8%) less than 10 IU/mL (negative). There was no significant correlation between the level of HBsAb and splenectomy or type of thalassemia. CONCLUSION: Response rate to vaccination is more than 95% after complete course (3 doses) in healthy individuals but failure to fulfill vaccination seems a problem in chronic transfused patients. These results reflect advantages of a booster dose of vaccine, which increased the protection level among these high-risk patients from 46.9% (in the authors' previous data) up to 69.4% in this study.