Low Hemoglobin

Hi all,

Today is a transfusion day for us and we are informed that my daughter's hg came only 59g/dl which is very low. Last transfusion in July, her hg came 79g/dl which is low for her standard (she hovers around 100-105g/dl after five weeks) at that time the doctor gave her extra blood to compensate for the low hg but this time its a surprise.

We are not sure at this time, the nurse is investigating if there is something wrong with the preservatives in the blood or the blood is old for the last two times. We are told that today she will be transfused as usual and sent home but will be called back in two weeks time, at which time the hospital will run few tests to investigate the matter. This is a concern for us, please provide your input as to what are the other causes of low hg, i.e. increased hemolysis process etc.

Hi all :
i thought that i must have to contribute in it  ... soo :

Did you know that ?...
My doctor told me that it willl much better for thalasemics to take not more than 15 days  old blood bcoze fresh blood it llast longer .

Hi C.F :
i think it is the answer of your question.... i mean to say in this quote that.... fresh blood last longner than the 2 weeks or more than 2 weeks old bloood..... it could b a reason of dropping down the  HB of your daughter a little quickly....

Take Care:
Best Regards :
UMAIR

In addition to the blood itself being old or even less than the correct volume, there is the possibility of antibody reactions which cause hyperhemolysis, or more rapid destruction of the red blood cells. These can be either alloantibodies and autoantibodies. Alloantibody reactions are the more common and occur in many patients. The reactions are not really dangerous but do result in more frequent transfusions, and thusly, more iron to deal with. Treatment with prednisone will often clear it up. I do believe that in the future we will see more genotype matching of blood in order to getter better matches, as phenotype matching alone, may not accurately match the patient's own blood as previously received transfusions alter the phenotype.

One other contributing factor can be that pre-transfusion Hb levels are typically lower in the summer time.

http://www.ncbi.nlm.nih.gov/pubmed/16179377

Borgna-Pignatti C, Ventola M, Friedman D, Cohen AR, Origa R, Galanello R, Lindeman R, Francis S, Reverberi R, Volpato S.

Clinica Pediatrica, Università di Ferrara, Via Savonarola 9, 44100 Ferrara, Italy. c.borgna@unife.it

Patients with thalassemia major often report that they do not maintain their usual pretransfusion hemoglobin concentration during the summer season. We collected 3977 pretransfusion hemoglobin values, amount of blood transfused, and intertransfusion intervals for 94 patients with thalassemia major from 4 centers worldwide. We also assessed the hematocrits of blood donors, the hemoglobin content of units transfused in one center, and the local mean monthly temperatures during the periods of data collection. Pretransfusion hemoglobin levels were significantly lower during the summer in all centers except the one center where monthly temperatures have the least variation throughout the year. A similar relationship to temperature was observed for the hematocrits of blood donors and the hemoglobin content of donor units. This study confirms that pretransfusion hemoglobin levels in patients with thalassemia major are lower in the summertime. Possible mechanisms include expansion of plasma volume with resultant hemodilution in the patient and lower hemoglobin content in donor blood.

It is always important to determine why the transfusion isn't lasting as long as normal, but this time of year there is a good chance it is summer related.

Oh Dear,

I wish she gets well soon

Thank you for your replies.

Andy,

Your response is very comprehensive, it puts our minds to some ease. The question is there a test to check if alloantibodies and autoantibodies reaction is occuring in the patient. Upon some further investigation we found that the hospital has changed its process to preserve the blood and its a possibility that this has caused the low hg, (I didn't buy this theory from the nurse) but we will sure ask to test if the alloantibodies and autoantibodies reaction is occuring (if there is any). Our next appointment is Thursday, August 21, 2008. Also, the reactions mentioned above, is this a continuous process or can subside with time, that is when is the treatment with prednisone is initiated.

Thanks..

Hi C.F,

Wish you the best of luck and i hope everything will turn out alright, i hope it's not an antibody problem as we saw it created a hassle in Sharmin's son's case.

ZAINI. 

Canadian Family,

I am sure that your daughter's hg drop is probably transient, and things will return to normal soon.

As you know my son developed antibodies - in most cases the antibodies are alloantibodies and if this is the case with your daughter - she can be better matched to reduce hemolysis.  If there are alloantibodies - I also hope that the doctors will do a genotype matching very soon because you want to prevent further allo antibody production and you definitely want to prevent autoantibody production.  Also, your lab should do a work up of any possible antibodies your daugther may have.

If there is an autoantibody, even in that case many times a short duration of prednisone will clear it up and genotype matching will prevent future problems.  My son's case was a bit rare in which the antibodies became chronic.  We are hoping that the rituximab will clear that up for good now.  Thank god we were able to meet with Dr. Vichinsky and able to get on the right track. 

I do wish that we had done some of this earlier - in your case IF there are antibodies you have plenty of time to prevent a more difficult situation - multiple antibodies, iron overload etc.  I hope that you can contact Dr. Vichinsky right away to get a better opinion. 

As Andy said, most likely it is because of the summer weather.  I wish you the best - and please feel free to PM me if I can be of any assistance.  God bless.

Sharmin

Thank you Sharmin,

I am drafting a letter to the doctor based on replies from you and Andy. It is almost impossible to see the doctors without appointment and our transfusion appointment is next thursday. We can ask the nurse to deliver this letter to the doctor to put some ideas into her mind, although she may be thinking about the same possibilities but this letter will help re-inforce the thinking process.

Thanks again.

I do think the hospital's change in the method of preserving blood does need to be investigated. Together with the lower Hb's of both donor and patient, it could explain the big drop in Hb level.

If it is new antibodies that have developed, they should be apparent in an antibody screening.

Canadian Family,

Andy is right - antibodies are apparent in the cross match screening procedure.   Is this also the case if the titers are low - such that they can cause significant hemolysis but are difficult to detect?  Also, can the autoantibody take a while to identify - or was that just the case with us?  In any case, I hope that your daughter does not have these pesky antibodies. 

I am surprised that your doctor is not present at the transfusions.  My son's pediatrician/hematologist always checks him and spends time with us at every transfusion no matter how frequent they are.  Perhaps I should knock on wood -  is this not the case for everyone? 

I hope that our experience helps you Canadian Family - and I hope everyone is able to get genotype matching tests done in the near future to prevent these problems. 

Sharmin

Most antibodies will be found with antibody screening but not all are readily apparent.

http://xpedio02.childrensmn.org/stellent/groups/Public/@XCP/@Manuals/@Lab/@TransfusionSvc/documents/PolicyReferenceProcedure/web012712.asp

Abnormal proteins and cold agglutinins may interfere and cause delays in interpretation. Test will not detect all antibodies (e.g. antibodies in low titer, antibodies to low-incidence antigens). In some instances of autoimmune hemolytic anemia, the antibody may be completely adsorbed into the erythrocytes and is not detectable by the indirect antiglobulin test. 2 - 4% of patients with clinical autoimmune hemolytic anemia have a negative Direct Coombs Test.

More information about the identification of antibodies and the limitations of the screening can be seen at
http://xpedio02.childrensmn.org/stellent/groups/Public/@xcp/@manuals/@lab/@transfusionsvc/documents/policyreferenceprocedure/web019100.asp

Antibody may be too weak to detect or identified. Antibodies to low incidence antigens may not be detected.

The problem with using phenotyping only to match for blood is that it does not distinguish between a patient's own blood and the previously transfused blood. Genotyping examines only the patient's genetic characteristics and can provide a much closer match.

Thanks Andy and Sharmin,

Apparently, this is a case with most patients in HSC. We found that after the change in preservation method, the hg is dropping in almost all patients, although it dropped a lot in my daughter's case but it is a wide case. We can raise this concern in our letter.

Andy, The articles are very insightful and I will refer them in my letter.

Sharmin, we rarely see the doctor, i.e. only if there is an emergency. Honestly, the thalassemia clinic is associated with oncology department in Hospital for sick children and the doctor has to run both oncology and thalassemia clinic same time. They don't have enough time to dedicate the efforts solely to thalassemia.

Hi all,

A week after the last transfusion, we had our appointment today. Its a relief that her hg came 97g/dl, I hope that was a temporary situation. She was transfused today.

Thank you all for the concerns and input, it helped us understand the possible scenarios better.

Best Regards.

Glad to hear that C.F

Canadian Family,

I hope that the situation is temporary - most times it is.  Sometimes when the hg has been low it takes a while to catch up, so more transfusions are required than usual.  Once you are caught up things will hopefully be fine.  Please keep us posted - our prayers are with you:) 

All the best,

Sharmin