In Burkina Faso, red blood cell (RBC) transfusion remains the crucial anaemia treatment following chronic renal failure (CRF) as erythropoietin and its analogues are unavailable. However, blood group matching beyond the ABO and Rhesus is not common in Burkina Faso. Thus, alloimmunisation is a potential issue for transfused patients.
Our study aimed to identify anti-erythrocyte antibodies in multi-transfused CRF patients at the Yalgado Ouedraogo Teaching Hospital, Ouagadougou, Burkina Faso.
This cross-sectional study, conducted from October 2018 to November 2019, included CRF patients who had received at least two RBC units. We screened patients for the presence of RBC antibodies using three commercial Cells panels and identified antibody specificities for positive screenings using 11 Cells panels for an indirect antiglobulin test (IAT) in a low ionic strength microcolumn gel-card system.
Two hundred and thirty-five patients (45.1% female; average age: 41.5 years) were included. The median number of blood units received per patient was 10 (interquartile range: 5–20). The overall alloimmunisation rate was 5.9% (14/235). Antibodies identified included: anti-D (1 case), anti-C (1 case), anti-D+C (4 cases), anti-CW (1 case), anti-E (1 case), anti-S (1 case) and anti-Lea (1 case). In four positive patients, the specificity of the antibodies was indeterminate. No risk factors were associated with alloimmunisation.
In Burkina Faso, screening for RBC alloantibodies should be mandated for patients at risk. The high rate of indeterminate antibodies suggests the need to develop a local RBC antibody panel adapted to the local population.
Blood transfusion, specifically the transfusion of red blood cells (RBC), significantly contributes to the modern healthcare system. Every day, blood transfusion saves lives in developing countries where acute anaemia caused by malaria, sickle cell disease (SCD), pregnancy-related events and other trauma remains high or is on the rise. For example, in Burkina Faso, around 103 731 RBC units were used in 2017.
Besides the chronic blood shortage, developing countries also face poor quality of blood products and their unsafe use.
Anaemia is highly prevalent in end-stage renal disease patients, often non-regenerative normochromic normocytic anaemia caused by inadequate renal erythropoietin production. Erythropoietin infusions or other erythropoietin-stimulating agents manage anaemia in end-stage renal disease patients. The United States Food and Drug Administration recommends an erythropoietin haemoglobin target range of 100 g/L – 120 g/L
However, erythropoietin-stimulating agents treatments are out of reach for most patients in our context. Therefore, RBC transfusion is used to manage CRF-related anaemia and SCD patients. Meanwhile, our country faces poor pre-transfusion compatibility practices; ABO and RhD matching is the only mandatory screening for RBC transfusions. No other blood group is considered, and no alloantibody screening or compatibility test is performed.
Both the Yalgado Ouedraogo Teaching Hospital direction and the internal ethical committee of the national blood transfusion centre (Authorisation no. 015/CNTS/DG/CIRS, 03/23/2018) approved the study. The nurses and the medical doctor in charge of the interview and other data collection obtained verbal informed consent. Also, the data were password protected and accessible only by the first author. Results were shared with staff and patients and used to influence patients’ future transfusions.
This study was conducted in the nephrology and haemodialysis unit of the teaching hospital Yalgado Ouedraogo of Ouagadougou, Burkina Faso, where about 400 patients with chronic kidney failure undergo haemodialysis yearly.
We conducted this cross-sectional study from January 2018 to December 2019 and included haemodialysis end-stage chronic kidney failure patients who had ever received RBC transfusions at least twice. Socio-demographic information, clinical data, and medical history of each included patient were recorded on a standardised survey form during an in-person interview with the medical doctor responsible for the study or trained nurses. Data collected include gender, age, date of the first transfusion, date of the last transfusion received, number of transfusions, the total number of blood units received since CRF started, and number and type of adverse reactions related to transfusions reported. Additionally, the number of pregnancies, live and still births, abortions, and anti-D injection use were also reported for female patients. Five mililitres of blood was drawn from each patient into ethylenediaminetetraacetic acid tubes. The sample was centrifuged, and the obtained plasma was used for alloantibodies screening and identification.
We used the indirect antiglobulin test method with the gel column agglutination card technique (Invitrogel AHG, MTC Invitro Diagnostics AG, Bensheim, Germany). In this technique, the gel column contains an anti-human antibody that traps irregular antibodies present in a patient’s plasma and fixed on RBC. Agglutinated RBCs are trapped in the gel column, making the agglutination easy to read.
In the first step, a panel of three RBC reagents (Invitrocell Screen I-II-II, MTC Invitro Diagnostics AG, Bensheim, Germany), that targets antigens D, C, c, E, e, V, CW, K, k, Kpa, Kpb, Jsa, Jsb, Fya, Fyb, Jka, Jkb, Lea, Leb, P
We used EPI-INFOTM software (version 7.2.2.2, Centers for Disease Control and Prevention, Atlanta, Georgia, United States) for data analysis. The frequencies and percentages are given with a 95% confidence interval. We used the chi-square test to compare proportions, and differences were considered significant for
During the study period, 235 patients with CRF were included, comprising 45.1% (106/235) female patients. The mean age was 41.9 (standard deviation 14.5 years; median 41 years; range 15–86 years). The mean number of received RBC units was 18 units ranging from two to 160 RBC, while the median number of received blood units per patient was 10 (interquartile range: 5–20). About 55.2% (128/232) had received more than 10 RBC units (
Social and demographic characteristics of patients with chronic renal failure, Yalgado Ouedraogo Teaching Hospital of Ouagadougou, Burkina Faso, 2018.
Characteristics | Total number of patients | Number of subject in each group | Frequency (%) |
---|---|---|---|
235 | 100.0 | ||
< 20 | 8 | 3.4 | |
20–29 | 46 | 19.6 | |
30–39 | 55 | 23.4 | |
40–49 | 47 | 20.0 | |
50–59 | 47 | 20.0 | |
≥ 60 | 32 | 13.6 | |
235 | 100.0 | ||
Male | 129 | 54.9 | |
Female | 106 | 45.1 | |
106 | 100.0 | ||
0–1 | 27 | 26.7 | |
At least 2 | 74 | 73.3 | |
231 | 100.0 | ||
2–9 | 103 | 44.6 | |
10–19 | 65 | 28.1 | |
20–29 | 32 | 13.9 | |
At least 30 | 31 | 13.4 | |
228 | 100.0 | ||
Less than 3 months | 120 | 52.6 | |
More than 3 months | 108 | 47.4 | |
235 | 100.0 | ||
AB | 11 | 4.7 | |
A | 72 | 30.6 | |
B | 50 | 21.2 | |
O | 102 | 43.5 | |
235 | 100.0 | ||
Negative | 9 | 3.8 | |
Positive | 226 | 96.2 | |
218 | 100.0 | ||
Present | 71 | 32.6 | |
Absent | 147 | 67.4 |
Of the 235 patients included, 14 had alloantibodies, representing an overall positivity rate of 5.9%. Four of the 14 patients (28.6%) had indeterminate antibody specificity. In 10 patients, 14 antibodies were identified: 5 anti-D, 5 anti-C, 1 anti-E, 1 anti-Cw, 1 anti S, 1 anti-Lea; four patients were positive for both anti-D and anti-C (
Characteristics of patients with red blood cell alloimmunisation, Yalgado Ouedraogo Teaching Hospital of Ouagadougou, Burkina Faso, 2018.
Patient ID | Antibodies specificity | Gender | Age (years) | Number of red blood cell units received | Number of pregnancies |
---|---|---|---|---|---|
76 | Anti-D + -C | Female | 20 | 20 | 0 |
101 | Anti-Cw | Female | 29 | 12 | 3 |
119 | Anti-S | Female | 56 | 12 | 8 |
173 | Anti-C | Female | 49 | 21 | 3 |
178 | Anti Lea | Female | 52 | 8 | 4 |
185 | Anti-D + -C | Male | 33 | 20 | - |
199 | Anti-E | Female | 70 | 1 | 6 |
235 | Anti-D + -C | Female | 21 | 15 | 0 |
255 | Anti-D + -C | Male | 30 | 10 | - |
262 | Anti-D | Male | 73 | 11 | - |
128 | Undetermined | Male | 38 | 35 | - |
213 | Undetermined | Male | 61 | 6 | - |
225 | Undetermined | Male | 60 | 55 | - |
238 | Undetermined | Male | 45 | 15 | - |
, This analysis included 14 of the 235 patients with chronic renal failure included in the study.
Most antibodies (12 of 14; 85.7%) were of the anti-RH blood group antigens, with anti-D and anti-C being the most prevalent, each accounting for 35.7% (
Specificity and frequency of alloantibodies found among multi-transfused patients of the Yalgado Ouedraogo Teaching Hospital of Ouagadougou, Burkina Faso, 2018.
Type of Antibody | Number | Frequency (%) |
---|---|---|
Anti-D | 5 | 2.1 |
Anti-C | 5 | 2.1 |
Anti-E | 1 | 0.4 |
Anti-c | - | - |
Anti-e | - | - |
Anti-Cw | 1 | 0.4 |
Anti-S | 1 | 0.4 |
Anti-Lea | 1 | 0.4 |
Undetermined | 4 | 1.7 |
All | 14 | 5.9 |
, This analysis included all 235 patients with chronic renal failure included in the study.
There were no differences in the mean age (43.3 vs 41.8 years,
Factors associated with alloimmunisation in multi-transfused patients with chronic renal failure, Yalgado Ouedraogo Teaching Hospital, Ouagadougou, Burkina Faso, 2018.
Characteristic | Number of patients |
Positive patients | Percentage (%) | Statistical significance | |
---|---|---|---|---|---|
231 | 0.62 | Not significant | |||
≤ 30 | 65 | 4 | 3.6 | ||
> 30 | 166 | 6 | 6.1 | ||
231 | 0.21 | Not significant | |||
Female | 106 | 7 | 6.6 | ||
Male | 125 | 3 | 2.4 | ||
101 | 1.00 | Not significant | |||
0–1 | 27 | 2 | 7.4 | ||
≥ 2 | 74 | 5 | 6.8 | ||
228 | 0.12 | Not significant | |||
≤ 10 | 133 | 3 | 2.3 | ||
> 10 | 95 | 7 | 7.4 | ||
226 | 0.28 | Not significant | |||
≤ 3 | 120 | 6 | 5.0 | ||
> 3 | 106 | 2 | 1.9 |
, Total numbers for these group is < 235 due to missing data;
, This analysis included only adult female patients.
Our study aimed at determining the frequency and the specificity of alloantibodies among the multi-transfused haemodialysis CRF patients at the teaching hospital Yalgado Ouedraogo of Ouagadougou (Burkina Faso). We found an alloimmunisation rate of 5.9% with antibodies mainly of the anti-Rh blood group antigens specificity.
This study overviews of RBC immunological risks among patients with chronic diseases who are lifelong blood transfusion patients. Although there have been recent changes in the blood transfusion system in Burkina Faso, including the replacement of multiple hospital-based blood banks with a centralised system, standardisation and harmonisation of practices,
This study was the first in the country to use the gel column card method, one of the current best methods for alloantibody screening. Nevertheless, the study presents some limitations as complementary antibody identification techniques, such as enzyme-treated red cells reagents panels (papain, bromelain or other) or wide-range panels, were not used. The lack of complementary identification can explain the high rate (4 of 14; 28.7%) of alloantibody undetermined specificity (inconclusive antibody identification).
The overall alloimmunisation rate of 5.9% among CRF patients undergoing haemodialysis on our study is consistent with the findings of two systematic reviews and meta-analysis studies conducted by Ngoma et al. in 2015 and Boateng et al. in 2019. These studies reported an overall alloimmunisation rate of 6.95% and 7.5% in sub-Saharan Africa.
Alloimmunisation rates observed in our study and other studies from sub-Saharan Africa are lower than those observed in Europe and North America when they only screened for ABO and RhD. Prevalences ranged from 18% to 76% in the United Kingdom and United States.
In Burkina Faso, blood group antigen distribution is established for ABO and RhD within blood donors and patients.
In our study, the antibody specificity of four participants of 14 (28.6%) was indeterminate. This impairment could be due to the discrepancy between the European-sourced red cell reagent panel and our population. This situation highlights the need to implement local panels for RBC alloantibodies testing as with some other low- and middle-income countries.
The majority (85.7%) of the alloantibodies found in this study were anti-Rh group antigens. Anti-D and anti-C antibodies accounted for 35.7%, followed by anti-E and anti-Cw. In a previous study of children who received transfusions in Burkina Faso, anti-C and anti-E were the most frequent.
This study tried to identify the risk factors associated with alloimmunisation. Neither gender, age, nor the number of blood units received was associated with alloimmunisation in our study. However, Ifeoma et al.
One limitation of this study was that we could not screen for antibodies within a reasonable time after each transfusion. For many patients, screening occurred months or years after the last transfusion event. This delay may have impacted the alloimmunisation rate.
This study showed that RBC alloimmunisation is a reality in multi-transfused patients in Burkina Faso. Therefore, exhaustive donor-patient blood matching beyond ABO and RhD is necessary for lifelong transfused patients, such as CRF and SCD patients. Further investigations are needed to efficiently establish the distribution of RBC antigens and phenotypes among blood donors and patients in the country, which may facilitate RBC reagent manufacturing.
Salfo Kellé for patients interview, data and sample collection.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
K.N. designed the study, collected data, participated in samples testing, contributed to data analysis and drafted the manuscript. Salam Sawadogo, Salifo Sawadogo, J.K., J.B., H.Y.A.L. and A.G.S. contributed to designing the study, data analysis and interpretation. M.K., S.D. and E.K. critically reviewed and revised the manuscript. All of the authors approved the final version of the manuscript.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data are available from the corresponding author, K.N., upon request.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.