Autoimmune hemolytic anemia (AIHA) due to the presence of warm agglutinins is almost always due to IgG antibodies that react with protein antigens on the red blood cell (RBC) surface at body temperature. For this reason, they are called “warm agglutinins” even though they seldom directly agglutinate the RBCs. IV Gammaglobulin blocks this process.
I some cases, AIHA can be characterised by a chronic course and an unsatisfactory control of haemolysis, thus requiring prolonged immunosuppressive therapy. Sometimes when medical measures fail, it may be necessary to surgically remove the spleen (splenectomy). The clinical course of the disease may show either resistance to steroids or dependence on high-dose steroids with subsequent development of severe side effects on growth, bone mineralisation, and the endocrine system. Splenectomy is effective in about 50 to 60 percent of the time in IgG antibody diseases but is not usually effective in IgM antibody haemolysis. Splenectomy is of benefit in these people because the spleen behaves like a sieve and if it is removed, even though the RBCs are coated by antibodies, they are no longer caught and destroyed in the spleen.
IVIG is an accepted treatment for autoimmune hemolytic anemia. Unlike steroids, it does not induce remissions but is a temporizing measure until a definitve treatment can be planned and delivered. IVIG is not as effective in AIHA as it is in ITP. Other treatments can sometimes be used.
Plasma exchange (plasmapheresis), is a procedure in which blood is removed and its components (red blood cells, platelets, and plasma) separated. The plasma is discarded while the blood cells and platelets are transfused into the patient along with a plasma substitute. Plasmapheresis is used in several autoimmune conditions to reduce immunoglobulins. For AIHA, there are several case reports of it being effective in refractory cases but no prospective studies have been performed.
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Fabio Aglieco et al, A Case Report of Refractory Warm Autoimmune Hemolytic Anemia Treated With Plasmapheresis and RituximabTherapeutic Apheresis and Dialysis Therapeutic Apheresis and Dialysis Volume 12 Issue 2, Pages 185 – 189