Altered Expression Levels of CD59, but Not CD55, on Red Blood Cells in Stored Blood.

OBJECTIVE: Red blood cells (RBCs) in storage undergo structural and biochemical changes that may cause functional effects. Studies exploring structural changes affecting the expression levels of CD55 and CD59 on RBCs are limited. The aim of this study was to investigate the pattern of CD55 and CD59 expression on RBCs in stored blood from Arab donors. MATERIALS AND METHODS: Flow-cytometric analysis was performed on RBCs from 92 packed RBC (PRBC) units, stored for varying times, and from 56 nonstored RBC from healthy controls using the commercial REDQUANT kit. RESULTS: The proportions of CD55- and CD59-deficient RBCs from stored PRBC units did not significantly differ when compared with those from healthy controls; however, the mean fluorescent intensity (MFI) of CD59 expression, but not MFI of CD55 expression, on RBCs from stored PRBC units was significantly reduced when compared to the expression of RBCs from healthy controls (p = 0.02). MFI of CD55 expression on RBCs from PRBC units did not significantly differ among the 3 groups of stored RBC; however, there was a statistically significant time-dependent preferential decline in MFI of CD59 expression on RBCs from stored PRBC units (p < 0.01). CONCLUSION: There is a preferential time-dependent decline in the expression of CD59, but not of CD55, on stored RBCs, the in vivo significance of which in relation to the response to PRBC transfusion needs further investigation.

Altered Expression Pattern of CD55 and CD59 on Red Blood Cells in Anemia of Chronic Kidney Disease.

OBJECTIVE: The aim of this study was to investigate the expression pattern of CD55 and CD59 on red blood cells (RBCs) in anemic chronic kidney disease (CKD) patients, and factors that might influence their expression. SUBJECTS AND METHODS: Nighty-one adult anemic CKD patients and 80 healthy controls (HCs) were enrolled. Anemic CKD patients were divided into 3 subgroups based on receiving erythropoietin and renal replacement therapies. Flow cytometric analysis of CD55 and CD59 expression was performed on RBCs from blood samples obtained from CKD patients and HCs. RESULTS: CD59 deficiency was significantly higher among CKD patients than HCs (n = 68, 74.7%, vs. n = 13, 16.3%, respectively; p < 0.001). The median proportions of CD55- and CD59-deficient RBCs in CKD patients were significantly higher compared to HCs (0.34 vs. 0.15, and 4.3 vs. 2.0, p < 0.001 and p < 0.001, respectively). The mean fluorescence intensity (MFI) of CD55 and CD59 expression was significantly lower in CKD patients compared to HCs (1.2 vs. 2.8, and 17.0 vs. 20.3, p < 0.04 and p < 0. 001, respectively). The hemoglobin level was inversely correlated with the proportions of CD55- and CD59-deficient RBCs (r = -0.37, p < 0.001, and r = -0.22, p < 0.02, respectively). The number of CD59-deficient patients was significantly different between the 3 subgroups of CKD patients (p = 0.001), and a significant difference was present in the MFI of CD55 and CD59 expression among the 3 subgroups (p = 0.04 and p = 0.03, respectively). CONCLUSION: The expression pattern of CD55 and CD59 on RBCs is altered in anemic CKD patients, which could play a role in the pathogenesis of anemia in CKD.

Expression pattern of CD55 and CD59 on red blood cells in sickle cell disease.

OBJECTIVES: To investigate the pattern of CD55 and CD59 expression on RBCs of SCD patients, and its association with anemia, biochemical parameters of hemolysis, level of erythropoietin, and pro-inflammatory markers. METHODS: Flow cytometric analysis was performed on RBCs from 71 adult SCD patients and 53 healthy controls, using the commercial REDQUANT kit. RESULTS: CD59 deficiency was significantly higher among SCD patients than among healthy controls. The proportions of CD55-deficient and CD59-deficient RBCs from SCD patients were significantly higher when compared with those from healthy controls (0.17 vs. 0.09 and 2.1 vs. 1.2, respectively). The MFI of CD55 and CD59 expression on RBCs in SCD was significantly reduced when compared to the expression in healthy controls (5.2 vs. 6.4 and 19.4 vs 20.3, respectively). The pattern of CD55 and CD59 expression was not correlated with anemia, biomarkers of hemolysis, erythropoietin level, or other pro-inflammatory markers. DISCUSSION: There is an altered pattern of CD55 and CD59 expression on RBCs of SCD Patients; however, it does not seem to play a causal role in the pathophysiology of anemia, and is unlikely to be influenced by the level of erythropoietin or other inflammatory mediators.

Circulating cell-free DNA in sickle cell disease: is it a potentially useful biomarker?

CONTEXT: Vascular occlusion in sickle cell disease causes increased levels of plasma cell-free DNA as a result of cell death and tissue damage. OBJECTIVES: This study investigates plasma cell-free DNA concentrations in sickle cell disease patients, and aims at exploring the significance of plasma cell-free DNA as a potential biomarker in predicting its complications. DESIGN: Plasma cell-free DNA levels were measured using real-time quantitative polymerase chain reaction to quantitatively measure ß-globin gene in blood samples from 57 sickle cell disease patients with acute vaso-occlusive crisis, 42 patients in steady state, 16 individuals with sickle cell trait, and 40 healthy controls. RESULTS: Plasma cell-free DNA level was significantly elevated in samples from patients with acute vaso-occlusive crisis when compared with those in steady state (P = .002), and was significantly higher both in crisis and in steady state when compared with individuals with sickle cell trait and healthy controls (P < .001). There was no difference in cell-free DNA levels between individuals with sickle cell trait and healthy controls. There was no association between plasma cell-free DNA levels and various clinical complications of sickle cell disease and comorbidity. CONCLUSIONS: Plasma cell-free DNA, as quantified by polymerase chain reaction amplification of the ß-globin and human telomerase reverse transcriptase genes, is increased in sickle cell disease patients in vaso-occlusive crisis and in steady state compared with individuals with sickle cell trait and healthy controls, and may be used as a tool to diagnose and monitor the sickle cell crisis and differentiate post-packed red cell transfusion sickle cell disease patients from individuals with sickle cell trait.

Blood transfusion practice in critically ill patients: a single institutional experience.

OBJECTIVES: To assess the transfusion practice in the intensive care unit (ICU) in a general hospital in Kuwait relative to indications, pretransfusion hemoglobin, red blood cell (RBC) use and outcome. SUBJECTS AND METHODS: 475 patients were admitted to the ICU during the study period (January 2009 to February 2010). Ninety-nine received RBC transfusion. Demographic, clinical and transfusion data were prospectively collected for the 99 patients who were followed up for 30 days, until hospital discharge, or death, whichever occurred first. Indications for RBC transfusion included hemorrhage in 39 patients, improving oxygen-carrying capacity in 55, and hemolysis in 5. RESULTS: Of the 99 transfused patients, 22 (22.22%) were also transfused after discharge from the ICU. Transfusions were more frequent in patients admitted with respiratory failure (30, 30.3%), hemorrhagic shock (24, 24.2%), and septic shock (18, 18.4%). The mean pretransfusion hemoglobin in ICU transfusions was statistically different (70.9 ± 12.7 g/l) from transfusions after discharge (79.7 ± 9.4 g/l) (p < 0.001). Longer ICU stay was associated with more RBC units transfused per transfusion episode per patient (p < 0.001). The Sequential Organ Failure Assessment (SOFA) score was significantly associated with the number of RBC units transfused per patient (p = 0.006). Mortality was significantly associated with Acute Physiology and Chronic Health Evaluation II and SOFA scores, the need and duration for mechanical ventilation, and the length of stay in hospital. CONCLUSION: Intensivists in our center followed a restrictive transfusion practice, by adopting a low pretransfusion hemoglobin threshold. Decisions on RBC transfusions seemed in most cases to be based on a 'transfusion trigger' rather than a physiologic need.

Genotypic and phenotypic differences between nodal and extranodal diffuse large B-Cell lymphomas.

Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous group of diseases that have diverse clinical, pathological, and biological features. Here, it is shown that primary nodal and extranodal DLBCLs differ genomically and phenotypically. Using conventional comparative genomic hybridization (CGH), the authors assessed the chromosomal aberrations in 18 nodal, 13 extranodal, and 5 mixed DLBCLs. The results demonstrate significantly distinct chromosomal aberrations exemplified by gains of chromosomal arms 1p, 7p, 12q24.21-12q24.31, and 22q and chromosome X and loss of chromosome 4, 6q, and 18q22.3-23 in extranodal compared with nodal DLBCLs. Nodal DLBCLs showed an increased tendency for 18q amplification and BCL2 protein overexpression compared with extranodal and mixed tumors. Using a panel of five antibodies against GCET1, MUM1, CD10, BCL6, and FOXP1 proteins to subclassify DLBCLs according to the recent Choi algorithm, the authors showed that the genomic profiles observed between the nodal and extranodal DLBCLs were not due to the different proportions of GCB vs ABC in the two groups. Further delineation of these genomic differences was illuminated by the use of high-resolution 21K BAC array CGH performed on 12 independent new cases of extranodal DLBCL. The authors demonstrated for the first time a novel genome and proteome-based signatures that may differentiate the two lymphoma types.

Hypercoagulable state and methylenetetrahydrofolate reductase (MTHFR) C677T mutation in patients with beta-thalassemia major in Kuwait.

INTRODUCTION: Patients with thalassemia major often present with a hypercoagulable state, the pathogenesis of which is still not understood. MATERIALS AND METHODS: This study evaluates the risk factors for hypercoagulability in 50 beta-thalassemia major patients and 50 healthy controls. Fasting total homocysteine, protein C (PC), protein S (PS), antithrombin (AT), activated protein C resistance (APCR) and lupus anticoagulant (LA) were assessed. MTHFR C677T mutation was determined. RESULTS: Significant reductions in PC, PS and AT were noted in patients. Only 4% of the patients had hyperhomocysteinemia. Thirty-two percent of the patients were heterozygous and 4% were homozygous for MTHFR C677T mutation. CONCLUSION: The natural coagulation inhibitors PC, PS and AT were significantly reduced in patients with beta-thalassemia major and were thus important risk factors for the hypercoagulable state, but hyperhomocysteinemia and MTHFR mutation do not seem to be significant risk factors for thromboembolic events.

Global Risk Profile Verification in Patients with Venous Thromboembolism (GRIP VTE) in 5 Gulf countries.

BACKGROUND: The Global Risk Profile Verification in Patients with Venous Thromboembolism was the first prospective multicenter registry conducted in Arabian Gulf countries to explore the epidemiology of venous thromboembolic (VTE) disorders and to provide data on diagnosis and disease management. METHODS: Data on 242 patients with confirmed VTE were submitted between September 2003 and November 2003 from 28 contributing hospitals in the Arabian Gulf region. Differences between groups were assessed by the chi(2) test or Fisher exact test for categorical variables. The Student's t test was used for testing proportions. RESULTS: The frequency of VTE cases is deep vein thrombosis (DVT), 187 (77.27%); pulmonary embolism (PE), 35 (14.46%); and DVT with PE, 20 (8.26%). The most common symptoms of DVT and DVT/PE patients were calf pain (72%), calf swelling (63.8%), and localized tenderness (52.2%). The most common symptoms in patients with PE alone and DVT/PE were dyspnea (83.6%), thoracic pain (69.1%), and cough (40%). Risk factors for VTE were immobilization (41.3%), age >65 years (28.9%), a history of VTE (20.7%), and trauma (19%). Among surgical interventions, orthopedic procedures induced the greatest number of VTE cases, followed by general surgery and gynecological procedures. Low-molecular-weight heparins were chosen to treat 33.7% of DVT cases, whereas unfractionated heparin was used in 21.9% of cases. CONCLUSION: VTE remains a common problem in medical and surgical patients in the Arabian Gulf states. Recognition of the common risk factors is of extreme importance to implement the appropriate prophylactic strategy according to the published guidelines.

Determinants and associations of homocysteine and prothrombotic risk factors in Kuwaiti patients with cerebrovascular accident.

OBJECTIVE: The objective of this study was to evaluate the determinants and associations of some prothrombotic risk factors in patients with cerebrovascular accidents (CVAs). SUBJECTS AND METHODS: In this case-control study, plasma total homocysteine (tHcy), lupus anticoagulant, protein C, protein S, activated protein C resistance (APC-R) and antithrombin were measured in 102 patients (60 males and 42 females) and 167 controls (87 males, 80 females). Serum vitamin B(12), folate, red cell folate, creatinine, lipid profile and glucose were also determined. Glomerular filtration rate (GFR) was calculated. RESULTS: 13 (22%) of the 60 male patients, and 16 (39%) of the 42 female patients had hyperhomocysteinemia. Median (interquartile range) tHcy was higher in male patients [11.22 micromol/l (9.60-15.40)] than female patients [10.05 micromol/l (8.72-17.54)]. On binary logistic regression analysis, the significant (p < 0.05) determinants of tHcy were urea, creatinine and GFR. Comparing patients with control subjects showed that tHcy, age, fasting glucose, urea, serum creatinine, white blood cell count, protein S, APC-R and factor VIII were significantly higher, while protein C, factor II, total cholesterol, high-density lipoprotein cholesterol and low-density lipoprotein cholesterol were significantly lower in patients. Lupus anticoagulant was not associated with tHcy and not detected in patients and controls. Low concentrations of vitamins B(12) and folate were not associated with tHcy. Logistic regression analysis showed a significant association of tHcy with CVA (OR = 9.55; p = 0.047) in males in the presence of other traditional CVA risk factors but tHcy is not independently associated with CVA in females. CONCLUSION: Hyperhomocysteinemia is common in Kuwaiti patients with CVA and tHcy probably interacts with prothrombotic factors (protein C, APC-R and factor VIII) to increase CVA risk. The main determinants, age and GFR markers, should be kept in mind when determining the risk associated with tHcy.

Plasma homocysteine and hematological factors in patients with venous thromboembolic diseases in Kuwait.

BACKGROUND: Venous thromboembolic disease (VTE) is a common cause of morbidity in Kuwait, but the risk factors have not been studied. Hyperhomocysteinemia has been suggested as one of the risk factors. We postulate that hyperhomocysteinemia acts synergistically with hematological variables to increase VTE risk. This study evaluates the roles of hyperhomocysteinemia and hematological variables in patients with VTE. METHODS: We measured fasting plasma total homocysteine (tHcy), activated protein C resistance, protein C (PC), protein S (PS) and antithrombin (AT) in 201 patients with VTE and 166 healthy controls. We also measured factor VIII, factor II, lupus anticoagulant, anticardiolipin, serum vitamin B12, folate, creatinine, lipid profile, glucose, full blood count and red cell folate. The glomerular filtration rate (GFR) was calculated from creatinine. RESULTS: When patients on warfarin were excluded, 13.1% of patients (18 out of 137) had a deficiency in PC, 16.8% (23 out of 137) had a deficiency in PS, and when patients on heparin were excluded, 8.3% of patients (14 out of 168) had low AT. Spearman's rank correlation analysis showed that tHcy had significant correlations with age, creatinine and PS, and significant inverse correlations with GFR, high-density lipoprotein cholesterol and serum folate. Partial correlation analysis after correcting for age and sex showed that tHcy retained a significant correlation with creatinine, GFR and serum folate. Binary logistic regression analyses of the determinants of hyperhomocysteinemia included age, creatinine, GFR and serum folate. Multivariate logistic regression analysis showed significant association of tHcy with VTE (OR = 5.6; p < 0.0001) in the presence of known risk factors for VTE. CONCLUSION: We conclude that elevated tHcy is a significant risk factor for the development of VTE, and therefore, it should be included in the workup for patients at risk of VTE, but the determinants of tHcy should be kept in mind.

Determinants of plasma homocysteine in relation to hematological and biochemical variables in patients with acute myocardial infarction.

BACKGROUND: Elevated plasma total homocysteine (tHcy) is a risk factor for coronary artery disease (CAD), but the mechanism is not known. This study evaluates the determinants and associations of tHcy in patients presenting with acute myocardial infarction (AMI). METHODS: Plasma concentration of tHcy, protein C, protein S, and antithrombin were measured in 210 (177 males and 33 females) patients with first AMI and 167 (87 males and 80 females) controls. Serum vitamin B12, folate, creatinine, lipid profile, fasting glucose, full blood count and red cell folate were determined. Creatinine clearance was calculated using the modification of diet in renal disease formula. Univariate and multivariate analyses were used to determine the associations of tHcy. RESULTS: Mean tHcy was higher in male than female patients. On logistic regression analysis, the most important determinants oftHcy in the patients were age, creatinine, creatinine clearance, vitamin B12 and red cell folate. When study patients were compared with the controls, tHcy, fasting glucose and serum creatinine were significantly higher, while creatinine clearance and HDL cholesterol were significantly lower in the study patients. Logistic regression analysis showed significant association of tHcy with AMI, odds ratio = 1.39, in the presence of other confounding factors. CONCLUSIONS: Our results show that tHcy is a significant risk factor for CAD in our patient population. The determinants in the patients are age, glomerular filtration rate and the status of vitamins B12 and folate. The above determinants should be kept in mind when using tHcy as a risk factor for CAD.

Hodgkin's disease: Kuwait experience.

OBJECTIVE: To describe histologic subtypes, clinical presentation and treatment outcome of Hodgkin's lymphoma in Kuwait. SUBJECTS AND METHOD: Patients older than 15 years, diagnosed with Hodgkin's lymphoma between 1980 and 1998, were included in this retrospective analysis. Data were collected using a standardized form that included demographics, histologic subtypes, clinical presentation, stage, extranodal involvement, treatment modality and follow-up. Histology reports were obtained from hospital records. RESULTS: There were 83 (59%) males and 57 (41%) females. Dominant histologic subtypes were nodular sclerosis 65 (46.4%) and mixed cellularity 42 (30%). Constitutional symptoms were reported by 54 (38.6%) of the cases. Two thirds (64%) of the cases were advanced. Primary extranodular involvement included liver (8%), gastrointestinal tract (7%), lung and bone marrow (4% each). Disease-free survival according to treatment groups were: radiotherapy alone 100%, chemotherapy alone 88%, and combined modality 65%. The 5-year Kaplan-Meier estimates of overall disease-free survival was 84%. CONCLUSION: In the cohort of 137 patients with Hodgkin's disease the treatment with combined radiotherapy and chemotherapy had a remarkable outcome. However, evaluation of long-term treatment complications is needed.

Familial Diamond-Blackfan anemia. Case reports and a review of the related literature.

We present the case of three sisters with Diamond-Blackfan anemia (DBA) from a consanguineous marriage. These sisters presented within the first 2 months of age with anemia without hepatosplenomegaly together with complete blood count and bone marrow pictures compatible with the diagnosis of DBA syndrome. They were given blood transfusions and then started on prednisolone 2 mg/kg/day in divided doses, tapering the dose to a minimum to keep Hb around 90 g/l. DBA in these three sisters from a consanguineous marriage clearly illustrates the autosomal recessive mode of inheritance. The importance of early diagnosis and management with steroid is highlighted along with the need for consideration of other modalities of treatment in those cases not responding to steroid therapy.

RBC alloimmunization and autoimmunization among transfusion-dependent Arab thalassemia patients.

BACKGROUND: Thalassemia major is a common hemoglobinopathy in the Arabian Gulf region. However, limited data are available on the frequency of RBC alloimmunization and autoimmunization in transfusion-dependent Arab thalassemia patients. STUDY DESIGN AND METHODS: A total of 190 thalassemia major patients were classified as Kuwaiti Arab and non-Kuwaiti Arab. Pretransfusion investigation records were reviewed for the presence of RBC alloantibody and autoantibody, and the age at which RBC alloantibody was developed. RESULTS: Fifty-seven (30%) patients developed RBC alloantibodies. The most common clinically significant alloantibodies were directed against antigens in the Kell and Rh systems. Anti-K developed in 41 (72%) patients followed by anti-E in 26 (45.6%). RBC autoantibodies developed in 21 (11%) patients with and without underlying RBC alloantibodies. Sixty-six (49.6%) RBC alloantibodies developed between the ages of 2 and 10 years. CONCLUSION: Several factors might have contributed to the high alloimmunization and autoimmunization rate observed in this study, including the heterogeneity of the population living in Kuwait, lack of better-matched donors for those patients, and the use of poststorage leukodepleted blood. It is recommended that thalassemia patients receive blood matched for Rh and Kell antigens and prestorage leukodepleted RBCs.

Radiotherapy for early stage of Hodgkin's disease at Kuwait Cancer Control Center, Kuwait.

OBJECTIVE: To evaluate the outcome of using radiotherapy (RT) alone to treat patients with early-stage Hodgkin's disease (HD). METHOD: The records of 28 patients with HD treated with RT alone at Kuwait Cancer Control Center between 1980 and 1998 were reviewed. RESULTS: Twenty-three patients had stage I HD and 5 stage II. Two patients had B symptoms, 12 (42.9%) patients lymphocyte-predominant histology, 9 (32.1%) nodular sclerosis and 7 (25%) mixed cellularity. Overall survival and relapse-free survival at 10 years were 100 and 83%, respectively. CONCLUSION: Our data indicate that the use of RT alone for treatment of early stages of HD appears to be effective.