Introduction
Pereda et al. recently reported three cases in which daratumumab was utilized to reduce the burden of red blood cell (RBC) and human leukocyte antigen (HLA) alloantibodies (). These cases support the need for further investigation into the potential use of daratumumab and related plasma cell depletion therapies for patients with significant alloimmunization. However, the authors’ cases, particularly cases 1 and 2 in which the authors describe patients with sickle cell disease (SCD) and multiple RBC antibodies, lack sufficient immunohematology and transfusion details to reliably conclude the effectiveness and safety of daratumumab to reduce alloimmunization.
This therapeutic strategy, if indeed effective, would represent a significant advance in treating patients with high rates of RBC and/or HLA alloimmunization. However, the absence of details regarding blood transfusion compatibility and matching techniques employed, pre-transfusion testing and the specific methodology used, and patient RBC antigen status in these cases preclude the ability to definitively ascertain the effectiveness of daratumumab. We discuss issues that must be considered before considering this strategy as a viable option.
Discussion
The primary issue at hand relates to the transfusion of patients with historic RBC antibodies. Modern transfusion practice requires antibody screens every three days for hospitalized patients, and blood banks maintain exhaustive records to prevent mis-transfusion in patients with historic antibodies. A negative antibody screen via routine pre-transfusion testing does not completely rule out the presence of alloantibodies, and perhaps more importantly, does not exclude the existence of plasma cells primed to produce antibodies directed against RBC antigens. While the authors state that all RBC antibodies were undetectable in patient 1, with three months of follow-up assessment reported, they do not discuss the testing employed. More concerning, the patient received four RBC transfusions following completion of daratumumab, the compatibility of which is not described. As most delayed hemolytic transfusion reactions (DHTRs) are due to an anamnestic response, it is worrisome to insinuate that antigen positive RBCs were provided because there was absence of an historic corresponding antibody based on testing. It is unclear if patient 2 was transfused after daratumumab therapy.
Plasma cells are notoriously hardy, and despite anti-plasma cell therapy, the ability to mount an antibody response may remain, especially as patients receiving daratumumab have been shown to form RBC alloantibodies (). Also, suggesting that these alloantibodies are simply “negative”, especially without elaborating on the testing methodology by which they were not detected, is fraught with uncertainty, as different testing methods (e.g., tube testing, column agglutination, solid phase, or flow cytometry) have varying sensitivities, and some may be capable of detecting low-level antibodies while others cannot.
The effectiveness of daratumumab itself in these patients is unclear. While it does seem plausible that daratumumab was at least partially responsible for the disappearance of a portion of the alloantibodies, prior authors have shown that albeit uncommon, new antibodies can occur (), and existing alloantibodies can persist despite daratumumab treatment (–). Secondly, the authors fail to acknowledge the possibility that the alloantibodies may have disappeared naturally through the phenomenon of evanescence. Numerous studies have shown that many patients’ RBC alloantibodies will decline in titer to levels below a detectable threshold without further exposure (–). Though the loss of all antibodies due to evanescence may be less likely, not accounting for this potential mechanism of a waning antibody is concerning.
Furthermore, literature demonstrates that even if these antibodies have become undetectable, these patients may still be at risk for DHTRs (–). Both patient 1 and 2 had histories of DHTRs, though their descriptions lack pertinent details. DHTRs occur when a transfused unit stimulates an immune response with an antibody directed at RBCs, either anamnestic or de novo, and can range in severity from a positive direct anti-human globulin test (DAT) to clinically significant hemolysis. Therefore, antibody identification, DAT, elution studies, and antigen status of the RBC donor unit are crucial for the diagnosis and prevention of DHTR (, ). As DHTRs can precipitate destruction of the patient’s intrinsic RBCs as well in a potentially fatal process known as hyperhemolysis, it is important not to induce these reactions, especially as they occur most frequently in patients with SCD. For patients with SCD, many institutions also provide units that are matched to the patient’s extended RBC phenotype to help prevent antibody formation (). In a patient with a history of multiple DHTRs, it is essential to prevent further sensitization or additional reactions given the risk of hyperhemolysis. Significant cost and effort are undertaken to obtain antigen-matched, compatible blood for these patients, and the ability to premedicate with daratumumab would represent a substantial change in this fundamental practice.
In summary, we caution readers considering daratumumab or other antibody-depleting therapies for patients with significant RBC alloimmunization burden, and we would like to highlight the importance of a full assessment of RBC donor-recipient compatibility, thorough immunohematology testing, perhaps including a monocyte monolayer assay in certain cases, and careful planning with transfusion medicine professionals (). It is imperative that this use of daratumumab is carefully evaluated for both safety and efficacy, preferably in murine models or using thoughtfully planned prospective clinical trials that appropriately balance benefit and risk. While Pereda et al. demonstrate a novel application of daratumumab for patients with extensive RBC alloimmunization, current standard of care requires transfusion honoring historic RBC antibodies. Nonetheless, exploration of the potential for this, and other molecules, to impact alloimmunization is warranted.
Statements
Author contributions
JJ, GB, EA, and BA drafted and revised the manuscript. All authors approved the final version.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1
PeredaMAHosahalli VasannaSDesaiNJDengVOwusu-AnsahADallasMHet al. Case report: Daratumumab treatment in pre-transplant alloimmunization and severe hemolytic anemia. Front Immunol (2022) 13:1055473. doi: 10.3389/fimmu.2022.1055473
2
CushingMMDeSimoneRAGoelRHsuYSParraPRacine-BrzostekSEet al. The impact of daratumumab on transfusion service costs. Transfusion. (2019) 59(4):1252–8. doi: 10.1111/trf.15134
3
LeeESHendricksonJETormeyCA. RBC alloimmunization and daratumumab: Are efforts to eliminate interferences and prevent new antibodies necessary? Transfusion (2021) 61:3283–5. doi: 10.1111/trf.16736
4
TauscherCMoldenhauerSBryantSDiGuardoMJacobEK. Antibody incidence and red blood cell transfusions in patients on daratumumab. Transfusion (2021) 61:3468–72. doi: 10.1111/trf.16687
5
YeZWolfLAMettmanDPlappFV. Risk of RBC alloimmunization in multiple myeloma patients treated by daratumumab. Vox Sang (2020) 115:207–12. doi: 10.1111/vox.12864
6
PhouSCostelloCKopkoPMAllenES. Optimizing transfusion management of multiple myeloma patients receiving daratumumab-based regimens. Transfusion (2021) 61:2054–63. doi: 10.1111/trf.16425
7
TormeyCAStackG. The persistence and evanescence of blood group alloantibodies in men. Transfusion (2009) 49:505–12. doi: 10.1111/j.1537-2995.2008.02014.x
8
HauserRGEssermanDKarafinMSTanSBalbuena-MerleRSpencerBRet al. The evanescence and persistence of RBC alloantibodies in blood donors. Transfusion (2020) 60:831–9. doi: 10.1111/trf.15718
9
WilliamsLA3rdLorenzRGTahirAPhamHPMarquesMB. High percentage of evanescent red cell antibodies in patients with sickle cell disease highlights need for a national antibody database. South Med J (2016) 109:588–91. doi: 10.14423/SMJ.0000000000000528
10
Balbuena-MerleRHendricksonJE. Red blood cell alloimmunization and delayed hemolytic transfusion reactions in patients with sickle cell disease. Transfus Clin Biol (2019) 26:112–5. doi: 10.1016/j.tracli.2019.02.003
11
TormeyCAHendricksonJE. Transfusion-related red blood cell alloantibodies: induction and consequences. Blood (2019) 133:1821–30. doi: 10.1182/blood-2018-08-833962
12
VidlerJBGardnerKAmenyahKMijovicATheinSL. Delayed haemolytic transfusion reaction in adults with sickle cell disease: A 5-year experience. Br J Haematol (2015) 169:746–53. doi: 10.1111/bjh.13339
13
TheinSLPirenneFFasanoRMHabibiABartolucciPChonatSet al. Hemolytic transfusion reactions in sickle cell disease: Underappreciated and potentially fatal. Haematologica (2020) 105:539–44. doi: 10.3324/haematol.2019.224709
14
QuiroloK. How do I transfuse patients with sickle cell disease? Transfusion (2010) 50:1881–6. doi: 10.1111/j.1537-2995.2010.02774.x
15
JosephsonCDSuLLHillyerKLHillyerCD. Transfusion in the patient with sickle cell disease: a critical review of the literature and transfusion guidelines. Transfus Med Rev (2007) 21:118–33. doi: 10.1016/j.tmrv.2006.11.003
16
AllenESNelsonRCFlegelWA. How we evaluate red blood cell compatibility and transfusion support for patients with sickle cell disease undergoing hematopoietic progenitor cell transplantation. Transfusion. (2018) 58(11):2483–9. doi: 10.1111/trf.14871
Summary
Keywords
daratumumab, alloimmunization, transfusion medicine, immunohematology, pre-transfusion testing, red blood cell antibodies, alloantibody, sickle cell disease
Citation
Jacobs JW, Booth GS, Allen ES and Adkins BD (2023) Commentary: Case report: Daratumumab treatment in pre-transplant alloimmunization and severe hemolytic anemia. Front. Immunol. 14:1133382. doi: 10.3389/fimmu.2023.1133382
Received
28 December 2022
Accepted
18 January 2023
Published
27 January 2023
Volume
14 - 2023
Edited by
Ilias Doxiadis, University Hospital Leipzig, Germany
Reviewed by
France Pirenne, Université Paris-Est Créteil Val de Marne, France; Harold Cliff Sullivan, Emory University, United States
Updates
Copyright
© 2023 Jacobs, Booth, Allen and Adkins.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Jeremy W. Jacobs, Jeremy.jacobs@yale.edu
This article was submitted to Alloimmunity and Transplantation, a section of the journal Frontiers in Immunology
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.