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. Author manuscript; available in PMC: 2025 May 1.
Published in final edited form as: Transfusion. 2024 Mar 20;64(5):800–807. doi: 10.1111/trf.17800

Post-transfusion biotin-labeled red blood cell survival studies in pediatric sickle cell disease with antibodies of uncertain significance

Marianne EM Yee 1,2, Patricia E Zerra 1,2,3, James W McCoy 3, Mischa L Covington 4, Sean R Stowell 4, Clinton H Joiner 1,2, Christopher M Lough 5, Bhaveshkumar B Delvadia 6, Cassandra D Josephson 7,8, John D Roback 3, Ross M Fasano 1,3
PMCID: PMC11088511  NIHMSID: NIHMS1977486  PMID: 38506450

Abstract

Background:

Red blood cell (RBC) antibodies are common in multiply transfused patients with sickle cell disease (SCD). Unlike RBC alloantibodies, the potential of autoantibodies to cause post-transfusion hemolysis may be uncertain. Biotin-labeling provides a direct measurement of red cell survival (RCS) over time, thus can be used to assess the clinical significance of RBC antibodies. Antibodies to biotinylated RBC (B-RBC) occasionally are detected after exposure, which may impact B-RBC survival in subsequent RCS studies.

Study Design and Methods:

Pediatric patients with SCD receiving monthly chronic transfusions underwent RCS studies, receiving aliquots of allogeneic RBC labeled at distinct densities of biotin (2–18 µg/mL). B-RBC survival was followed for 4 months post-transfusion, and B-RBC antibody screening for 6 months. Patients with warm autoantibodies (WAA) or B-RBC antibodies are reported here.

Results:

RBC antibodies were detected during RCS in 4 patients: 1 with warm autoantibodies (WAA), 1 with WAA followed by B-RBC-specific antibodies, and 2 with transient B-RBC antibodies within the first 5 weeks of exposure. B-RBC half-lives (T50) ranged 37.6 – 61.7 days (mean 47.8 days). There was no evidence of increased hemolysis or accelerated B-RBC clearance in the presence of WAA or B-RBC antibodies.

Discussion:

Biotinylation of allogenic RBC can be used to assess the possible effects of RBC antibodies on transfusion survival in individual cases, particularly when it is uncertain if the detected antibodies may result in hemolysis. In the cases presented here, neither WAA nor B-RBC antibodies were associated with significant shortening of B-RBC survival in individuals with SCD.

Keywords: Sickle cell disease, biotin, red cell survival, RBC autoantibodies

Background

Patients with sickle cell disease (SCD) who receive multiple red blood cell (RBC) transfusions frequently demonstrate RBC alloantibodies and autoantibodies. The reported frequency of warm autoantibodies (WAA) is approximately 5 – 8% of children who receive episodic transfusion, and up to 28 – 50% of those receiving chronic transfusion therapy.1–4 There is a substantially higher frequency of RBC autoantibody development in patients with RBC alloimmunization in SCD, transfusion-dependent thalassemia, and the general population of transfused patients.3,5–7 RBC autoantibodies also may be more prevalent among patients who have undergone splenectomy and those with a higher number of past transfusions.5,6,8 Additionally, some RBC antibodies in SCD have unclear clinical significance, such as Rh antibodies in patients with variant RH genotypes, where it may be unclear if the antibody represents an allo- or autoantibody. In many of these cases, the potential clinical consequences of transfusion of antigen-positive RBCs remains unclear, leading to challenges in selection of suitable donor RBC units.

Antibodies of unclear clinical significance may result in extensive donor searches for antigen-negative or genotype-matched RBCs, or caution against transfusion due to concerns that the risk of hemolysis is not clear. RBC autoantibodies have the potential to cause significant hemolysis or contribute to hyper-hemolytic transfusion reactions, typically with both IgG and C3 surface binding.1,2 However, more commonly, warm autoantibodies, with IgG binding only, may be present in transfused patients with SCD without clinically notable hemolysis.

The monocyte monolayer assay (MMA) has been used to predict a potential clinically significant immune response to transfusion with antigen-positive RBC in the setting of an incompatible crossmatch; however this in vitro test only provides a potential short-term prediction of donor hemolysis and does not predict transfusion survival or efficacy over a longer time period.9–11 Additionally, numerous factors impact the reliability and feasibility of the MMA.11

Biotin-labeling of RBCs provides a sensitive and accurate means of directly measuring the survival of different populations of transfused or autologous cells over time within a patient.12–15 Biotinylation has been used to measure survival kinetics of autologous RBC in healthy adult controls and allogeneic donor RBCs in chronically transfused adults with SCD and β-thalassemia.14,16,17 Chronically transfused patients with hemoglobinopathies may show an increase in the proportion of circulating biotinylated RBC (B-RBC) in the first 24 hours, followed by more rapid decline in donor cells. To date, biotin studies in SCD have only tracked survival for 3–8 weeks (until the next red cell exchange transfusion) and have not assessed longer survival or full potential RBC lifespan.

Biotin survival studies have a number of potential uses in patients with SCD receiving transfusion. Precise measurement of labeled RBCs allows for the assessment for accelerated clearance of potentially incompatible RBCs, particularly in settings of RBC antibodies. Additionally, red cell kinetics measurements over time allow for determination of the red cell half-life and lifespan which are characteristics that may impact overall transfusion efficacy for those receiving chronic transfusion therapy for disease control or stroke prevention. Antibodies to B-RBC are an important consideration for red cell survival (RCS) studies. In autologous RCS studies in healthy adults, 14% demonstrated B-RBC antibodies, appearing between 12–24 weeks post exposure, with no impairment in B-RBC survival observed during the initial exposure; however subsequent exposures in immunized patients may lead to accelerated clearance of B-RBC.16 In a single study of allogeneic B-RBC transfusion in SCD and transfusion-dependent thalassemia (TDT), B-RBC antibodies were detected at a similar frequency (1 SCD, 1 TDT), however the impact on the survival of circulating B-RBC has not been determined in SCD.17

Here we present findings from 4 patients with SCD on chronic transfusion therapy (CTT), who received B-RBC as part of an ongoing clinical trial, who expressed RBC antibodies of uncertain clinical significance during the B-RBC survival period.

Methods

An observational trial of B-RBC transfusion in adolescent and young adult patients with SCD receiving monthly chronic transfusion therapy was undertaken with aims of studying the impact of donor and recipient factors on RBC survival. This study was approved by the Institutional Review Board of Emory University, with Food and Drug Administration (FDA) investigational new drug approval for the research use of biotinylation of allogeneic RBC. Enrolled patients received 2 or 3 RBC units per transfusion episode (depending on body weight and starting hemoglobin), with a goal to suppress HbS below 30%.

For a single transfusion episode, an aliquot of approximately 50 mL was separated from each unit by the blood supplier (Lifesouth Community Blood Centers). Following routine crossmatch, aliquots were washed in a saline-dextrose-bicarbonate-phosphate buffer and incubated with N-hydroxysulfosuccinimidobiotin (sulfo-NHS-biotin) under sterile cGMP conditions to achieve distinct densities of biotin labeling (2, 6, or 18 µg/mL). For the transfusion episode, patients received the main unit immediately followed by the aliquot of B-RBC. Per Mock et al., total biotin dose exposure was calculated as: (density of surface biotinylation in µg/mL x B-RBC volume transfused. Prior publication of this recommendation, total biotin dose exposure did not exceed 20 mL B-RBC per individual biotin density (≤20 mL x (2 µg/mL + 6 µg/mL + 18 µg/mL); however immediately following publication, total biotin dose per subject was limited to ≤7 mL per individual biotin density (≤182 µg/mL total).16

Blood samples were obtained approximately 15 minutes (day 0) and day 1 post-transfusion, and weekly thereafter through 16–18 weeks post B-RBC transfusion. Flow cytometry was performed on samples obtained in EDTA tubes and stained with streptavidin-phycoerythrin (PE). Samples were run in triplicate on a Cytek Northern Lights flow cytometer and 0.5 × 106 total RBCs were gated on for the analysis. B-RBC concentration for each time point was expressed as a percentage of biotinylated RBC (averaged for each unique density) multiplied by the total RBC concentration (106 cells/mL). B-RBC survival at each time point was expressed as a percentage compared to the initial Day 0 post-transfusion B-RBC concentration. Patients continued to receive non-labeled RBC transfusions monthly, as part of their individual ongoing chronic transfusion therapy plan, impacting total blood volume and thereby B-RBC total concentration during the survival study. Survival measurements quantified included: post-transfusion recovery at 24 hours (PTR-24), half-life (T50, time point at which B-RBC were present at 50% of the concentration immediately post-transfusion), and the approximate RCS 28 days and 90 days post-transfusion. B-RBC enrichment was the percentage of total B-RBC (all densities) present immediately post-transfusion. Differences in RCS measurements between patients with RBC antibodies expressed during the survival study vs. those without antibodies detected during the study were compared by Student’s t-test, using SAS version 9.4 (Cary, NC).

Screening for B-RBC antibodies was performed using IgG Gel card technique (Grifols), similar to that described by Schmidt et al.18 A 3-cell panel of reagent RBCs (Search-Cyte TCS 0.8±0.1%, Grifols) was biotinylated to density 250 µg/mL (B-RBC-250), a density >13 times higher than the highest density of transfused B-RBC, in order to provide high sensitivity for B-RBC antibody detection. Gel card screens were performed with patient plasma using unlabeled and B-RBC-250 reagent cells before B-RBC transfusion, at 1 week, then every 2 weeks through week 12, then every month through 6 months post B-RBC exposure. If reactivity to B-RBC-250 was observed, plasma samples were then screened against reagent cells labeled at a lower density of 50 µg/mL (B-RBC-50).

Routine antibody screen was performed as clinically indicated for subsequent transfusions using solid phase testing. Monitoring for hemolysis within the first 4 weeks of B-RBC transfusion included weekly lactate dehydrogenase (LDH), hemoglobin, reticulocyte count, and direct antiglobulin test (DAT).

Results

Four pediatric patients (3 HbSS, 1 HbS/β0-thalassemia) who received B-RBC transfusion expressed RBC antibodies of uncertain clinical significance during the B-RBC survival study. Subject identifier corresponds to antibody expression during study (Au = autoantibody, B = B-RBC antibody). Two subjects expressed WAAs and 3 subjects expressed B-RBC antibodies. Table 1 summarizes the patients’ historic and initial RBC antibody screen findings prior to B-RBC transfusion and the timeline for appearance of WAA and/or B-RBC antibodies after transfusion. RBC count and hemoglobin were not stable over the course of each B-RBC survival study, with cyclic variation of the course of multiple, subsequent transfusions. Changes in donor hemoglobin (HbA) and recipient hemoglobin (HbS and HbF) are presented in Supplementary material.

Table 1.

RBC antibody histories before and during exposure to BRBC transfusion.

Subject Historic RBC Antibodies Pre-biotin Antibody screen Biotin exposure Post-biotin Antibody screens
Allo Auto WAA B-RBC Ab
Au-1 Kpa WAA (e) WAA 520 µg Throughout study None
Au/B-1 None None Negative 400 µg Week 7 to end of study Week 12 to end of study
B-2 Jsa WAA (pan) Negative 520 µg None Weeks 1–3
B-3 C, K, Fya, Kpa, Goa WAA (e), anti-D Negative 173 µg None Weeks 3–5
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Subjects are identified by antibody responses during the biotinylated RBC (B-RBC) survival study as Au = auto, B= biotin. Subjects Au-1 and Au/B-1 had WAA detectable on screening during the time course of the study. Participants Au/B-1, B-2, and B-3 had reactivity to B-RBC observed at different time points after B-RBC transfusion. For Au/B-1, due to the presence of WAA, B-RBC antibody was confirmed by alloadsorption.

BRBC = biotinylated RBC; WAA = warm autoantibody; (e) = relative specificity for the e antigen; pan = panagglutinin.

Subject Au-1 had a history of RBC alloimmunization and an active WAA (panagglutinin with relative specificity for the e antigen) that had been intermittently identified over a 7-year period prior to B-RBC transfusion, and was re-identified throughout the B-RBC survival study. RH genotyping of this patient revealed RHCE genotype RHCE*ce/ce(254G). All donor units received for the study (biotin-labeled) and after (conventional) were phenotype C-c+E-e+. Antibody screens throughout the study showed 1+ to 2+ reactivity in 2 of 3 panel cells (e+ cells) with no reactivity to e-negative cells. Reactivity to B-RBC-250 reagent cells was consistently absent in e-negative reagent cells and weaker than the unlabeled cells (0 or 1+) in e+ cells. DAT ranged from 1+ to microscopic with anti-IgG, negative with anti-C3; eluates showed a panagglutinin, consistent with WAA. Hemolysis markers remained in expected range over 4 weeks post B-RBC transfusion, with no increase in LDH (779 U/L pre vs. 330–628 U/L post), no increase in reticulocytes (592 × 109/L pre vs. 162 – 355 × 109/L post), and no significant decline in Hb (8.4 g/dL pre vs. 12.4 to 9.6 g/dL over 4 weeks post-transfusion).

Subject Au/B-1 had no history of RBC alloimmunization or autoantibodies. At week 6 post B-RBC transfusion, a new warm autoantibody (DAT 1+ IgG, negative C3) was identified with reactivity initially weaker against biotinylated reagent cells (B-RBC-250) vs. unlabeled cells. At week 12, reactivity appeared to 3 of 3 B-250 reagent cells, stronger than in unlabeled reagent RBCs, leading to suspicion for a developing B-RBC antibody. An alloadsorption performed on the sample from week 20 showed 1+ reactivity to B-RBC-250 only (no reactivity to unlabeled RBC or B-RBC-50), providing evidence of weak B-RBC antibody. Hemolysis markers remained in expected range over 4 weeks post B-RBC transfusion, with no increase in LDH (425 U/L pre vs. 316 – 374 U/L post), no increase in reticulocytes (592 × 109/L pre vs. 115 – 291 × 109/L post), and no significant decline in Hb (9.9 g/dL pre vs. 11.0 to 9.9 g/dL over 4 weeks post-transfusion).

Subject B-2 had alloimmunization and a remote history of WAA with relative specificity for the e antigen that was not detected during the biotin survival study. Pre-transfusion B-RBC antibody screen was negative. At weeks 1–3, anti-B-RBC reactivity was observed (1+ reactivity to B-RBC-250; weak reactivity to B-RBC-50; no reactivity to unlabeled RBC). DAT remained negative, with no evidence of increased hemolysis through week 3. Subsequent screens from weeks 4–28 showed no reactivity to biotinylated or unlabeled reagent RBC. Hemolysis markers remained in expected range over 4 weeks post B-RBC transfusion, with normal LDH values (165 U/L pre vs. 150 – 226 U/L post), no significant increase in reticulocytes (37.4 × 109/L pre vs. 9.3 – 85 × 109/L post), and no significant decline in Hb (8.4 g/dL pre vs. 11.6 to 8.2 g/dL over 4 weeks post-transfusion).

Subject B-3 had alloimmunization and a remote history of anti-D autoantibody (wild type RhD) and of WAA with relative specificity for the e antigen (RHCE genotype: RHCE*ceS/cE), neither of which were expressed at the time of B-RBC survival study. Transfusion requirements at time of B-RBC transfusion included RBC units negative for e (prophylactic matching to patient genotype), C, K, Fya, Kpa, and Goa (to which the patient was alloimmunized). Pre-transfusion B-RBC antibody screen was negative. At weeks 3–5, anti-B-RBC reactivity was observed (weak to 1+ reactivity to B-RBC-250; weak reactivity to B-RBC-50; no reactivity to unlabeled RBC). DAT was microscopically positive for IgG (negative for C3, negative eluate). Hemolysis markers remained in expected range over 4 weeks post B-RBC transfusion, with no significant increase in LDH (467 U/L pre vs. 328 – 472 U/L post), no significant increase in reticulocytes (372 × 109/L pre vs. 112 – 415 × 109/L post), and no significant decline in Hb (9.1 g/dL pre vs. 11.3 to 8.7 g/dL over 4 weeks post-transfusion).

B-RBC Survival Studies

RBC survival curves for each subject, including time ranges of antibody detection are shown in Figure 1. Table 2 shows the mean survival measurements for each subject (B-RBC enrichment, PTR-24, T50, and estimated survival at days 28 and 90, as well as a comparison to other subjects in the larger RCS trial (n=11). There were no significant differences in PTR-24 (p=0.99), T50 (p=0.44), 28-day RCS (p=0.57), or 90-day RCS (p=0.28) between the 4 subjects with RBC antibodies during the study period vs. those without RBC antibodies detected during the study period.

Figure 1.

Figure 1.

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Kinetics of B-RBC clearance in 4 subjects expressing autoantibodies or B-RBC antibodies. Aliquots from 2–3 allogeneic RBC units were biotinylated at distinct densities (2, 6, or 18 µg/mL) and transfused. Post-transfusion peripheral blood samples were obtained through 16–18 weeks post transfusion, to identify the percentage of B-RBC by flow cytometry.

Table 2.

Mean B-RBC survival measurements. Each participant received multiple (2–3) transfusions of biotinylated RBC. The mean survival measurement for each participant is shown.

Subject B-RBC enrichment PTR-24 T50 (days) Day 28 Survival (%) Day 90 Survival (%)
Au-1 5.68% 96.5% 37.7 65% 9%
Au/B-1 4.37% 95.3% 56.0 72% 19%
B-2 5.55% 107.7% 61.7 84% 22%
B-3 1.81% 91.6% 35.7 61% 11%
Subjects without WAA or B-RBC antibodies 1.42 – 5.74% 86.6 – 103.0% 30.3 – 75.0 52 – 97% 3 – 38%
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B-RBC: biotinylated red blood cells; PTR-24: post-transfusion recovery at 24 hours; T50: time of 50% survival (half-life); WAA: warm autoantibody.

Discussion

Red cell survival studies in patients with SCD is being evaluated to assess individual donor and recipient characteristics which may affect RBC transfusion efficacy, as well as to identify scenarios where accelerated RBC clearance may be clinically relevant. Patients with a history of delayed hemolytic transfusion reactions (DHTRs) may be at risk for hemolysis with future transfusions, particularly in scenarios where a definitive new alloantibody was not identified. In situations where transfusion is necessary but there is clinical uncertainty about transfusion safety (such as historic DHTR or RBC autoantibodies), biotin-RCS studies may provide in vivo information on whether donor RBC clearance is significantly greater than anticipated.

In this study, four patients with SCD who received B-RBCs had antibodies of unclear significance that were reactive to the transfused cells (panagglutinin, WAA with relative specificity for e, B-RBC antibodies). As expected, variation in donor RBC survival was observed among different recipients. Recipient splenic and reticuloendothelial function as well as past alloimmunization responder status have been shown to influence the rate of clearance of donor Hb in recipients with SCD receiving chronic transfusion therapy.19 While the 4 subjects presented here demonstrate a wide range of B-RBC survival times, these are not outside the range of what has been observed in other subjects with SCD who did express RBC autoantibodies or biotin antibodies. Furthermore, there was no change in the slope of the survival curves associated with the appearance or disappearance of antibody reactivity This provides evidence that the expression of these RBC antibodies was not associated with rapid hemolysis such as that observed with DHTR.

The B-RBC survival curves presented here also demonstrate the role of donor variability in transfusion survival. Subjects received multiple donor units labeled at distinct biotin densities, allowing the survival of different donors to be assessed under identical clinical circumstances within a single patient. In most subjects, survival of different donor RBC was very similar, suggesting no significant differences between RBC donors. However subject Au-1 had significantly difference survival of 3 different donor units despite extended phenotype matching of each unit. We have previously shown that donor characteristics are associated with increased clearance of donor Hb.20–22 Ongoing and future studies are needed to continue to understand the survival variability among different RBC donors.

Patients with SCD who require transfusion often present with complex RBC antibody findings which may result in concerns for transfusion safety due to immune-mediated hemolysis. Identification of DHTR risk is challenging, as up to 30% of DHTR in SCD may be negative for new or causative RBC antibodies,23 making it difficult to predict whether future transfusions may precipitate hyperhemolysis. RBC autoantibodies also are commonly detected in multiply transfused patients with SCD. Unlike in classic warm autoimmune hemolytic anemia, these antibodies might not be associated with strong evidence of hyperhemolysis; however, the inherent chronic hemolysis present in SCD may make this difficult to determine. Antibody engagement of RBCs can have diverse outcomes, from mediated RBC clearance to inducing loss of the target antigen.24 Antibody isotype, antigen density and other features of transfused RBCs likely influence the overall consequences of RBC alloantibody engagement on RBC removal. 25–28 Furthermore, while RBCs can induce alloantibodies in the absence of a WAA,29–33 autoantibody engagement of transfused RBCs can also impact the likelihood of alloimmunization.25,34

Autoantibodies, which may be pan-reactive or have auto-antigen specificity, can cause crossmatch incompatibility, resulting in clinical uncertainty about the safety of transfusion. Lastly, alloantibodies that are often clinically insignificant (e.g. high-titer low avidity antibodies) may raise concern in patients with SCD who are more likely to have post-transfusion hemolysis, and potentially lead to withholding transfusions when they are critically needed. Routine blood bank testing in these scenarios cannot always reassure against potential hemolytic transfusion reactions or predict the post-transfusion RBC survival.

The MMA may provide indirect evidence for potential phagocytosis of donor RBC; however, this in vitro test is technically complex, can only be done when an antibody is present, may lack reproducibility, and does not predict the in vivo rate of RBC clearance.9,11 In contrast, biotinylation followed by transfusion of a small aliquot of allogeneic RBC provides direct, prospective measurement of allogeneic RBC clearance over the span of many weeks post transfusion. For patients with SCD who have complex alloimmunization or hyperhemolysis concerns, RBC biotinylation could provide a sensitive method to assess for DHTR and in vivo compatibility, particularly in situations of negative DAT or antibody screen.

Formation of antibodies to biotinylated RBC is the main limitation to this technique for assessing transfusion efficacy. Mock et al. reported the experience of autologous B-RBC transfusion in 42 healthy volunteers, with B-RBC antibody development in 6 (14%) at 12–22 weeks post transfusion. Among those who formed B-RBC antibodies, B-RBC survival was not shortened after the initial exposure; however, in re-exposure studies, anamnestic B-RBC antibody responses occurred within 7 days, and autologous B-RBC survival was shortened in a dose-dependent manner, associated with both the number (frequency) of B-RBC re-exposures as well as higher density of biotin labeling. Based on these findings, to minimize the risk of B-RBC antibody formation, the authors presented guidelines for limiting B-RBC exposure to (density x volume) ≤180 µg.16 In our study this dose limitation protocol was associated with a lower incidence of B-RBC antibody formation (occurring in 3/5 subjects who received >180 µg vs. 1/10 subjects who received <180 µg). Similar to the experience in autologous recipients, B-RBC antibodies identified in this allogeneic transfusion study were weak and showed no association with accelerated B-RBC clearance. However, unlike the autologous experience, 2 of the 3 recipients with SCD in this study had earlier B-RBC antibody appearance within 1–3 weeks of initial exposure, potentially suggestive of an anamnestic response from previous biotin exposure despite no prior B-RBC transfusion. Gerritsma et al. had a similar finding in allogeneic B-RBC transfusion studies in patients with hemoglobinopathies. In that study, 2/14 patients (1 with SCD, 1 with thalassemia) formed B-RBC antibodies within 10–12 days of transfusion, without IgM or IgG opsonization or apparent impact on the survival of B-RBC survival to the time of subsequent transfusion.17 While no adverse consequences have been observed with initial B-RBC antibody formation in either this or other studies, these antibodies do appear to accelerate B-RBC clearance with repeated exposures, in a dose-dependent fashion in autologous, healthy donor studies.16 Based on this evidence, screening for antibodies before and after B-RBC transfusion should be performed in all subjects, in order to exclude subjects with known antibodies from repeat B-RBC exposure.

Biotin labeling of allogeneic RBCs has potential clinical as well as research applications for assessing RBC transfusion survival and efficacy in patients with antibodies of uncertain clinical significance. In scenarios where transfusion compatibility is uncertain (such as warm autoantibodies or alloimmunized patients with histories of severe post-transfusion hemolysis), the addition of biotinylation to a clinically necessary transfusion may aid clinicians in assessing transfusion efficacy and the safety of providing subsequent transfusions.

Supplementary Material

Supinfo

Supplemental Figure: Changes in total hemoglobin, donor hemoglobin (HbA) and recipient hemoglobin (sickle and fetal, HbS and HbF) over the time course of each B-RBC survival are shown. The time points of each subsequent non-biotin-labeled transfusion (provided as part of prophylactic chronic transfusion or for treatment of acute complication) are indicated with arrows.

Acknowledgements

Marianne Yee received funding from the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K23HL146901. The authors thank Lifesouth Community Blood Centers for their support and assistance with this study.

Support:

National Heart, Lung, and Blood Institute of the National Institutes of Health, award number K23HL146901 (PI: Yee, M.)

Footnotes

Conflict of Interest statement: SRS has consulted for Novartis, Cellics, Argenex, and Alexion, receives research support from Alexion, and has received speaking honoraria from Grifols. CDJ receives unrestricted grant funding for research from Medtronics, and is a consultant for Westat. RMF serves on a medical advisory board and receives research funding from Cerus; he serves as a consultant for REDSIV-Pediatric which is funded by the NIH/NHLBI.

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Supplementary Materials

Supinfo

Supplemental Figure: Changes in total hemoglobin, donor hemoglobin (HbA) and recipient hemoglobin (sickle and fetal, HbS and HbF) over the time course of each B-RBC survival are shown. The time points of each subsequent non-biotin-labeled transfusion (provided as part of prophylactic chronic transfusion or for treatment of acute complication) are indicated with arrows.

NIHMS1977486-supplement-Supinfo.tiff (3.8MB, tiff)

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