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Screening for and confirming the diagnosis of paroxysmal nocturnal hemoglobinuria (PNH)
Monitoring patients with PNH
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired hematologic disorder characterized by nocturnal hemoglobinuria, chronic hemolytic anemia, thrombosis, pancytopenia, and, in some patients, acute or chronic myeloid malignancies.
PNH appears to be a hematopoietic stem cell disorder that affects erythroid, granulocytic, and megakaryocytic cell lines. The abnormal cells in PNH have been shown to lack glycosylphosphatidylinositol (GPI)-linked proteins in erythroid, granulocytic, megakaryocytic, and, in some instances, lymphoid cells. Mutations in the phosphatidylinositol glycan A gene, PIGA, have been identified consistently in patients with PNH, thus confirming the biological defect in this disorder.
A flow cytometric-based assay can detect the presence or absence of these GPI-linked proteins in granulocytes, monocytes, erythrocytes, and/or lymphocytes, thus avoiding the problems associated with red cell-based diagnostic methods (Ham's test) in which recent hemolytic episodes or recent transfusions can give false-negative results. A partial list of known GPI-linked proteins include CD14, CD16, CD24, CD55, CD56, CD58, CD59, C8-binding protein, alkaline phosphatase, acetylcholine esterase, and a variety of high frequency human blood antigens. In addition, fluorescent aerolysin (FLAER) binds directly to the GPI anchor and can be used to evaluate the expression of the GPI linkage.
Our studies, as well as others in the literature, have shown that flow cytometry-based assays will detect all Ham's-positive PNH cases, as well as some Ham's-negative PNH cases. This assay replaces the sugar water test and the Ham's test for the evaluation of patients with possible PNH.
Patients with PNH should be transfused with ABO-specific RBCs, which do not need to be washed. If, for some reason, they need to receive non-ABO type-specific (type O) cells, these RBC units should be washed. Since recipient antibodies to granulocyte antigens can trigger hemolytic episodes in PNH, these patients should receive leukoreduced RBCs and platelets if they have such antibodies.
An interpretive report will be provided.
RED BLOOD CELLS:
PNH RBC-Partial Antigen loss: 0.00-0.99%
PNH RBC-Complete Antigen loss: 0.00-0.01%
PNH Granulocytes: 0.00-0.01%
PNH Monocytes: 0.00-0.05%
Individuals with paroxysmal nocturnal hemoglobinuria (PNH) have absent or decreased expression of all the glycosylphosphatidylinositol (GPI)-linked antigens and fluorescent aerolysin (FLAER) on peripheral blood cells derived from the PNH clone.
Recent data showed that small PNH clones can be detected in a relatively high percentage of cases of aplastic anemia and myelodysplastic syndrome. While the significance of this finding is still uncertain, it appears that these patients may benefit from immunosuppressive therapy.
This test incorporates a sophisticated technique of separating different cell populations using gating on antigen-positive cells, as well as the sensitivity to enable detection of small PNH clones. In addition, this test detects a partial loss of CD59 on RBCs (type II RBC). Patients with large proportion of type II RBC are unlikely to show high levels of hemolysis, unlike patients with complete loss of GPI-linked proteins (predominantly type III cells). While PNH is a disorder of hematopoietic stem cells and all lineages are affected, the percentage of affected cells can differ between lineages, most commonly due to RBC hemolysis and/or transfusion.
Individuals without PNH have normal expression of FLAER (neutrophils and monocytes) and normal expression of all GPI-linked antigens-CD14 (monocytes), CD16 (neutrophils and NK cells), CD24 (neutrophils), and CD59 (RBCs).
The sugar water test and the Ham's test are no longer recommended for the evaluation of patients with possible paroxysmal nocturnal hemoglobinuria.
Recent transfusion can decrease the sensitivity of this test and interfere with accuracy.
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