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Determination of allo- antibodies in Multiple Transfused Thalassemia, Sickle cell anemia and Hb C disease among Sudanese patients Nariman Y.Osman1, Abdesalam I. Bashir 2, Sana E. Abdalla 3*

Al Neelain University, Faculty of Medical Laboratory Science. University of Khartoum, Faculty of Medicine. Al Neelain University, Faculty of Medicine.

* Corresponding author Mobile: 00249912359969 Email sanaseed@hotmail.com

ABSTRACT Blood transfusion is important for patients who need blood for survival, when determine the ABO and RhD groups of patients the screening for unexpected allo-antibodies should be done to select a suitable blood, to avoid the complications of blood transfusion. The most serious complications are haemolytic transfusion reactions in which there is increased red cell destruction which produced by blood transfusion, allergic reactions & febrile reactions are due to antigen antibody reaction. Diseases like thalassemia, sickle cell anemia and HbC disease usually treated by repeated blood transfusion. The aim of this study is to determine the allo antibodies in patients who receive repeated blood transfusion in Khartoum and Wad Madani. Methods: This is an analytical descriptive study to determine the allo-antibodies in 193 patients with repeated blood transfusion in thalassemia , sickle cell anemia and Hb C diseases in Khartoum and wad Medani teaching hospitals, 5 ml of venous blood was

collected from each patients (Hb electrophoresis, sickling test, Antibodies screening and identification tests) were done for each sample. Antibody identification was done by ID card method. Results: 19% Thalassemia patients, 71% sickle cell anemia and 10% HbC diseases 3% were developed allo antibodies, the common antigen were identified, one patient had anti
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K, one patient had anti E, one patient had anti c, and two patients had anti e. Conclusion: Antibody screening showed that patients who received repeated blood transfusion developed allo antibodies, mainly anti K, anti E, anti c and anti e.

INTRODUCTION Blood transfusion is important for patients as basic therapy, it is used to treat and prevent the complications of many diseases. Blood transfusion is the process of receiving blood and blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace blood and components. Early transfusions used whole blood, but modern medical practice commonly uses only components of the blood, such as red blood cell, white blood cells, plasma, clotting factors, and platelets.(1) There are many studies done to receive safe blood transfusion and avoid the risk of complications. In parallel with determine the ABO and RhD groups all patients should be screened for unexpected allo-antibodies other than anti A anti B this facility of the selections of suitable blood for patients requiring transfusion.
(2, 3)

When patient receive blood

transfusion, their immune system will attack any donor red blood cells contain antigens that differ from their self antigens. Therefore, ensuring that antigens of transfused red blood cells match these of the patient's, red blood cells is essential for safe blood transfusion (4, 5) Blood transfusion has many complications; it can be immune or non immune reactions. The immune reactions occur by the development of antibodies against RBCs antigens, the most serious complications are haemolytic transfusion reactions in which there is increased red cell destruction which produced by blood transfusion, allergic reactions, febrile reactions, and post transfusion purpura. (5) Blood was once regarded as a fluid of infinite complexity, which contain hemoglobin made up of globin chains most often alpha and beta; it is synthesis is dependent on balance production of the heme and globin chains. There are groups of inherited disease that are caused mutations in the globin chains lead to requiring blood transfusion for survival, such as thalassemia in which result from a reduced rate of synthesis of or chains that lead to
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decrease the production of hemoglobin synthesis which is dependent on a balance production of the hem and globin chains. (2, 3)And sickle cell anemia in which the globin abnormality is caused by forming substitution of valine for glutamic acid in position 6 in the chain HbS, which is insoluble and forms crystals when exposed to low oxygen tension. The red cells sickle may block different areas of the microcirculation or large vessels causing infarct of various organs. (4, 5) Moreover Hb C disease when hemozygosity for the mutation that causes HbC disease is also referred to as "HbCC" (2). In parallel with determine the ABO and RhD groups all patients should be screened for unexpected allo-antibodies other than anti A anti B like Kell, Duffy, Kidd, and Lewis systems and other antibodies, this facility of the selections of suitable blood for patients requiring transfusion (2,6).When patient receive blood transfusion, their immune system will attack any donor red blood cells contain antigens that differ from their self antigens. Therefore, ensuring that antigens of transfused red blood cells match those of the patient's red blood cells are essential for safe blood transfusion (3,7). Objectives: General objective Determination of allo antibodies in patients who receives repeated blood transfusion in Khartoum and Wad Madani teaching hospitals. Specific objectives 1. To determine the allo-antibodies in thalassemia & sickle cell anemia patients and Hb C diseases who received repeated blood transfusion. 2- To identify different types of antibodies and to compare the frequency of antibodies in thalassemia, sickle cell anemia and Hb C diseases patients.

MATERIALS AND METHODS

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This is an analytical descriptive study was done in Khartoum and Wad Madani teaching hospitals during January 2010 to August 2012. (193) patients with repeated blood transfusion, 36 Thalassemia, 137 sickle cell anemia and 20 Hb C diseases were studied, both sexes and all age groups were included to determine the allo-antibodie. Data was collected by using

designed Questionnaire, and ethical consent was taken from patients and care takers. Five ml of venous blood were collected from patients and divided into 2 portions; 2.5 ml of blood was collected into EDTA anticoagulant for screening hematology tests and 2.5 ml of blood separated into serum for antibody screening tests. Data was recorded and analyzed by a computer program statistical package from the social sciences (SPSS). CBC was done by using automated blood counter Sysmex 21, Hb electrophoresis by using cellulose acetate electrophoresis at alkaline pH (8.48.6) and sickling test was done. Antibodies screening and identification tests were done using ID card microtyping system method, with set of fully phenotype group O panel cells Diad Med-ID. RESULTS The frequency of study population according to gender and age group, the highest frequency seen in age group (1-10), in thlassemia patients 17 were males and 19 were females, while in sickle cell anemia 40 were males, and 97 were females, and in Hb C disease were 8 were males and 12 were females as shown in table (1). Hb electrophoresis showed abnormal bands of Hemoglobin's as follows, 12 showed AF bands, 2 were AFS, 42 were AS, 6 were FF, 18 were FS, 23 were SS, and 20 showed CC bands as seen in table (2) and figure (1). Antibodies screening using ID Card method, according to frequency of transfusion showed that five patients were positive, with frequency of blood transfusion (5-7 Times) as shown in Table(3), while188 patients were negative with frequency of transfusion (1-16 Times) as shown in Table(4) and figure (2). Antibody identification by using ID card method in thalassemia, showed one patient had anti-K, one patient had anti-e, and in sickle cell anemia, one patient had anti-E, one patient had anti-c, one patient had anti-e, as shown in Table (5) and figure (3).
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Table (1): Distribution of study population according to gender & age group

Age (1-10) years Thalassaemia Sickle cell HbC

Males 17 40 8

Females 19 97 12

Table (2) Hemoglobin electrophoresis in study population Types of band AF AFS FF FS SS CC Total Frequency 12 2 6 18 65 20 123

HbAS

18

HbSC
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HbSS

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Figure (1): Hb electrophoresis showed abnormal bands of Hemoglobin's Table (3): Screening Test with ID Cards Method in Positive patients according to frequency of transfusion Patients Frequency of Blood transfusion for Positive Patients Four times Five times 1 Thalassamia 1 Six times Seven times 2 Total

Sickle anemia

cell -

Hb C disease Total

5 3%

Table (4): Screening Test with ID Cards Method in Negative patients repeated according to frequency of transfusion Patients frequency of Blood transfusion for Negative patients Total

Once twoic Thre Four

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Five times

Six times

Seven times

Sixtee n

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e times

time s 5 12 5 2 -

times

Thalassamia Sickle anaemia Hb C disease Total cell

12 58

9 35

8 21

34 134

10 70

2 46

3 32

1 29

1 7

1 4

1 1

1 1

20188 % 97

Figure (2): Screening test with ID Cards method Table (5): Antibody Identification with ID Cards Method Patients Allo antibodies Anti-E Anti-e Anti-c Anti-k Total p-value

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Thalassemia

1 20%

1 20%

2 40% 3 60% 0.41

Sickle anemia

cell 1 20% 1 20%

1 20% 2 40%

1 20% 1 20%

Total

1 20%

5 100%

DISCUSSION Thalassemia and sickle cell anemia were described as a form of severe anemia occurring in children treated by blood transfusion therapy, therefore screening for allo antibodies is important for safe blood transfusion and avoiding the complications of transfusions reaction. In this study we observed that sickle cell anemia patients were much more common than thalassemia, and this were concur with previous retrospective and cooperative studies, in American region,(8) Italian(9) Saudi,(10,11) Sudan,(12) while thalassemia were increase in Egypt patients
(13)

and Iran (14) and affected females were more existed similar in two types of

patients. In this study, the frequency of allo antibodies were increased in sickle cell anemia than thalassemia, by ID card method five patients (2.9%) having allo-antibodies, two with thalassemia and three with sickle cell anemia, in contrast with value of 15%-30% in sickle cell anemia in American region
(8)

and 5.2% in Italian thalassemia major patients, 22.06%

thalassemia and sickle cell anemia, 13.7 % sickle cell anemia in Saudi,(10) 19.5% thalassemia patients in Egypt,(13) and 15% in Sudan. (21) The most common allo-antibodies detected in this study in Rh system were 80%, 20% were anti-E, 40% were anti-e, 20% were anti-c, and 20% were anti-kell, by ID card method, while Hb C disease showed no antibodies. This is in contrast to study done in the American Red Cross with sickle cell anemia who received transfusions, 30 % of the patients with sickle cell anemia became alloimmunized. Antibodies against the K, E, C, and Jkb
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antigens

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accounted for 82 % of the allo-antibodies. (8) While in retrospective studies were done in Saudi Arabia 68 multi-transfused patients, the overall frequency of alloantibody formation in patients was 22.06%.(10) Also in King Fahd another study was done, found that

48 patients had developed alloantibodies (13.7%). The most common alloantibodies detected were: 18.8% were anti-E alone (18.8%), 10.4% were anti-K, and 6.3% were anti-c. (11) When in Egypt regularly transfused patients with thalassemia were studied, forty-six (19.5%) patients developed RBC alloantibodies. The most common clinically significant alloantibodies were directed against antigens in the Kell and Rh systems. (13) This study disagreed with another study done in Sudan which involved 60 patients with repeated blood transfusions. Nine patients (15%) of studied patients were having alloantntibodies according to the immunodiffusion test. (12) The low level of antibodies detected in this study may be due to improper blood transfusion in these patients. Conclusion: Antibody screening showed that patients who received repeated blood transfusion developed allo antibodies, mainly anti-K, anti-E, anti-c and anti-e. Antibody screening was detected Sudanese patients having allo-antibodies by using ID Card method, presence of allo-antibodies in thalassemia and sickle cell anemia who received repeated blood transfusion was (2.9 %) in Sudan. This study was done in small size of population in Sudan; therefore other studies for thalassemia and Hb C disease with larger populatin size are important.

REFERENCES 1. Weatherall D, et al. (2008), disease control priorties in developing countries. 2th edition Washington P66-80. 2. Hoffbrand A.v, et al. (2002), Essential Hematology .4th edition, London, p. 73. 3. Garratty G, Glynn. (2004), ABO and Rh (D) phenotype frequencies of different racial/ ethnic group in us-transfusion.P 44: 703 6 [Pub-Med].

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4. Pagana, Ka Thleen Deska , (1998), Mosby's Manual of Diagnostic and laboratory test. St. Louis: Mosby, Inc 5. Mitchell Lewis, et al, (2001), Dacie and Lewis practical hematology, 9th edition, London, pp. 478 481. 6. Daniels G, (2002), Human blood groups. Second ed. Black Well Science 3: 8. 7 .Phillips Pk, et . al. (1992), Transfusion l Med P111-113 Pub Med 8. Sirchia G, et al. (1990), Red cell alloantibodies in thalassemia major. Italian cooperative study .U.S.National Library of Medicine,U S A. 9. Gader A, et al. (2004), Allo-antibodies to red blood cells in multi-transfused patients in Saudi Arabia. The Blood Bank, King Khalid University Hospital, Riyadh 11461, Saudi Arabia 10. L.A.M. Bashawri, (2004), Red cell allo-immunization in sickle-cell anemia patients in Saudi Arabia. Red cells allo-immunization in sickle cell anemia patients in Saudi Arabia. 11. A. Bolad1, et al (2011), Reliability of agglutination test to detect alloantibodies in patients with repeated blood transfusion. Sudan Journal of Medical Science Vol 5, No4:P299302. 12. Danasoury AS, et al. (2011), Red blood cell alloimmunization in transfusion-dependent Egyptian patients with thalassemia, Department of Clinical Pathology, Ain Shams University, Cairo, Egypt. 13. Sadeghian MH, et al, (2009), Alloimmunization among transfusion-dependent thalassemia patients, Asian J Transfus Sci, 199-204 14. Rosse WF, et al, (2004) Transfusion and Alloimmunization in Sickle cell disease. International Journal of Pathology 1431-1437, Pakistan Institute of Medical Sciences, Islamabad.

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Hematological Changes Among Tuberculous Sudanese patients in Kassala Area Eastern Sudan Mubarak I Idriss 1, Hiba B Khalil 2, Abbashar O Abbashar 3, Sara Widaah 3 & Mamoun Magzoub*4

1. Laboratories & Blood Bank Directorate, Kassala Teaching Hospital, Kassala, Sudan. 2. Faculty of Medical Laboratory Sciences, Alneelain University, Khartoum, Sudan. 3. Tuberculosis Unit, Kassala Teaching Hospital, Kassala, Sudan. 4. Faculty of Medicine, Kassala University, Kassala, Sudan. *Corresponding Author: Dr Mamoun Magzoub, PhDAssistant Professor, Department of Microbiology & Parasitology, Faculty of Medicine, (West Bank of Gash River) University of Kassala, Kassala, Sudan. P.O.Box 266 Fax 00249411823501 Phone: 00249912913999

ABSTRACT Background: Tuberculosis is a major public health problem in Kassala eastern Sudan. Haematological changes associated with tuberculosis have been incompletely investigated. To the best of our knowledge, there is no comprehensive study assessing the haematological changes in Sudanese patients. Anaemia is a one of common findings of haematological changes in patient with tuberculosis, and it may be an indicator of disease activity and or duration. Methods: A cross-sectional, hospital based study was conducted during June to August 2012 at Kassala Teaching Hospital, Kassala, eastern Sudan. 2.5 venous blood collected in EDTA containers from 98 tuberculous patients. Tuberculosis diagnosis had been established by clinical, radiological, and sputum examining with Zeil Neelson stain. All our patients were sputum positive for acid fast bacilli to start with and on antitubercoulos treatment. Full blood cell count (CBC) were undertaken. Direct Coombs' test (AHGT) was performed for all samples. Results: Ninety eight (98) patients. 88 patients of them with pulmonary tuberculosis. 8 patients with abdominal tuberculosis and 2 patients with bone tuberculosis. 72 (73.5 %) patient with haemoglobin less than 11 g/100ml. Sixty three (64.3 %) with haemoglobin between 7g/100ml and11g/100ml, 9 (9.2 %) with haemoglobin less
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