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{{Autoimmune hemolytic anemia}}
{{Autoimmune hemolytic anemia}}


{{CMG}} '''Assosciate Editor(s)-In-Chief:''' [[User: Prashanthsaddala|Prashanth Saddala M.B.B.S]]
{{CMG}} '''Assosciate Editor(s)-In-Chief:''' [[User: Prashanthsaddala|Prashanth Saddala M.B.B.S]]; {{shyam}}, [[User:Irfan Dotani|Irfan Dotani]] [3]


==Overview==
==Overview==
The pathophysiology of autoimmune hemolytic anemia is different for warm-antibody type and cold-antibody type anemia. The pathophysiology of warm-antibody type autoimmune hemolytic anemia involves the coating of [[Red blood cell|red blood cells]] with [[IgG]], followed by extravascular hemolysis by [[splenic]] [[macrophages]]. The pathophysiology of cold-antibody type autoimmune hemolytic anemia involves the coating of red blood cells with IgM, followed by intravascular hemolysis. The [[complement system]] has a significant role in autoimmune hemolytic anemia and involves the binding of classical complement proteins on the [[red blood cell]] surface, followed by [[cell lysis]] by the [[membrane attack complex]]. In summary, a variety of cell-mediated immunologic mechanisms underlie the pathophysiology of autoimmune hemolytic anemia.


==Pathophysiology==
==Pathophysiology==
A hemolytic state exists whenever the red cell survival time is shortened from the normal average of 120 days. Hemolytic anemia is the hemolytic state in which anemia is present, and bone marrow function is inferentially unable to compensate for the shortened life-span of the red cell. Immune hemolytic states are those, both anemic and nonanemic, which involve immune mechanisms consisting of antigen-antibody reactions. These reactions may result from unrelated antigen-antibody complexes that fix to an innocent-bystander erythrocyte, or from related antigen-antibody combinations in which the host red cell or some part of its structure is or has become antigenic. The latter type of antigen-antibody reaction may be termed "autoimmune", and hemolytic anemias so produced are autoimmune hemolytic anemias.<ref name="pmid5267234">{{cite journal |author=Sawitsky A, Ozaeta PB |title=Disease-associated autoimmune hemolytic anemia |journal=[[Bulletin of the New York Academy of Medicine]] |volume=46 |issue=6 |pages=411–26 |year=1970 |month=June |pmid=5267234 |pmc=1749710 |doi= |url= |accessdate=2012-07-25}}</ref>
===Warm autoimmune hemolytic anemia===
The pathophysiology of warm autoimmune hemolytic anemia involves [[immunoglobulin G]] ([[IgG]]) antibodies binding to [[red blood cells]] at a temperature of 37 degrees Celsius. <ref name="pmid15637139">{{cite journal| author=Mqadmi A, Zheng X, Yazdanbakhsh K| title=CD4+CD25+ regulatory T cells control induction of autoimmune hemolytic anemia. | journal=Blood | year= 2005 | volume= 105 | issue= 9 | pages= 3746-8 | pmid=15637139 | doi=10.1182/blood-2004-12-4692 | pmc=1895013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15637139  }} </ref> The designation of ''warm'' is based on the fact the optimal binding temperature is 37 degrees Celsius, or normal body temperature. The IgG antibodies are typically [[polyclonal]], meaning that they recognize a variety of [[antigens]].<ref name="pmid26696798">{{cite journal| author=Berentsen S| title=Role of Complement in Autoimmune Hemolytic Anemia. | journal=Transfus Med Hemother | year= 2015 | volume= 42 | issue= 5 | pages= 303-10 | pmid=26696798 | doi=10.1159/000438964 | pmc=4678321 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26696798  }} </ref> [[Macrophages]] bind to the antibody-coated [[red blood cells]] via the Fc receptors and result in extravascular destruction. The Fc receptors include Fc-gammaRI ([[CD64 (biology)|CD64]]), Fc-gammaRII ([[CD32]]), and Fc-gammaRIII ([[CD16]]). In 15-20% of cases, the autoantibody involved is IgA.<ref name="pmid26696798">{{cite journal| author=Berentsen S| title=Role of Complement in Autoimmune Hemolytic Anemia. | journal=Transfus Med Hemother | year= 2015 | volume= 42 | issue= 5 | pages= 303-10 | pmid=26696798 | doi=10.1159/000438964 | pmc=4678321 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26696798  }} </ref> It has been shown that induction of autoimmune hemolytic anemia is controlled by an [[Immunosuppression|immunosuppressive]] population of [[T lymphocytes]] known as [[regulatory T cells]].<ref name="pmid15637139">{{cite journal| author=Mqadmi A, Zheng X, Yazdanbakhsh K| title=CD4+CD25+ regulatory T cells control induction of autoimmune hemolytic anemia. | journal=Blood | year= 2005 | volume= 105 | issue= 9 | pages= 3746-8 | pmid=15637139 | doi=10.1182/blood-2004-12-4692 | pmc=1895013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15637139  }} </ref>


AIHA can be caused by a number of different classes of antibody, with [[IgG]] and [[IgM]] antibodies being the main causative classes. Depending on which is involved, the [[pathology]] will differ. As IgG is poor at activating [[complement system|complement]] but effectively binds the [[Fc receptor]] (FcR) of [[phagocytosis|phagocytic cells]],<ref>{{cite journal |author=Abramson N, Gelfand EW, Jandl JH, Rosen FS |title=The interaction between human monocytes and red cells. Specificity for IgG subclasses and IgG fragments |journal=J. Exp. Med. |volume=132 |issue=6 |pages=1207–15 |year=1970 |month=December |pmid=5511570 |pmc=2180500 |doi=10.1084/jem.132.6.1207 }}</ref> AIHA involving IgG is generally characterized by phagocytosis of RBCs. IgM is a potent activator of the [[classical complement pathway]], thus, AIHA involving IgM is characterized by complement mediated lysis of RBCs. IgM also leads to phagocytosis of RBCs however, because phagocytic cells have receptors for the bound complement (rather than FcRs as in IgG AIHA). IgG AIHA generally takes place in the [[spleen]], while IgM AIHA takes place in [[Kupffer cells]] – phagocytic cells of the [[liver]]. Phagocytic AIHA is termed extravascular, while complement mediated lysis of RBCs is termed intravascular AIHA. In order for intravascular AIHA to be recognizable it requires overwhelming complement activation, therefore most AIHA is extravascular – be it IgG or IgM mediated.<ref name="pmid11921020">{{cite journal |author=Gehrs BC, Friedberg RC |title=Autoimmune hemolytic anemia |journal=[[American Journal of Hematology]] |volume=69 |issue=4 |pages=258–71 |year=2002 |month=April |pmid=11921020 |doi= |url=http://dx.doi.org/10.1002/ajh.10062 |accessdate=2012-07-25}}</ref>
===Cold autoimmune hemolytic anemia===
The pathophysiology of cold autoimmune hemolytic anemia, or [[cold agglutinin disease]], involves [[immunoglobulin M]] ([[IgM]]) antibodies binding to ''Ii'' carbohydrate antigens of [[red blood cells]] at a temperature of 3-5 degrees Celcius. [[Agglutination]] typically occurs in the distal aspects of the extremities, such as the fingers and toes, because these areas have the lowest temperature.<ref name="pmid25705656">{{cite journal| author=Berentsen S, Sundic T| title=Red blood cell destruction in autoimmune hemolytic anemia: role of complement and potential new targets for therapy. | journal=Biomed Res Int | year= 2015 | volume= 2015 | issue= | pages= 363278 | pmid=25705656 | doi=10.1155/2015/363278 | pmc=4326213 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25705656  }} </ref> Clinical manifestations of this pathophysiology includes [[Raynaud's phenomenon]] and [[acrocyanosis]].<ref name="pmid25705656">{{cite journal| author=Berentsen S, Sundic T| title=Red blood cell destruction in autoimmune hemolytic anemia: role of complement and potential new targets for therapy. | journal=Biomed Res Int | year= 2015 | volume= 2015 | issue=  | pages= 363278 | pmid=25705656 | doi=10.1155/2015/363278 | pmc=4326213 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25705656  }} </ref> The IgM molecules will trigger activation of the [[complement]] system, which results in [[red blood cell]] lysis.<ref name="pmid25705656">{{cite journal| author=Berentsen S, Sundic T| title=Red blood cell destruction in autoimmune hemolytic anemia: role of complement and potential new targets for therapy. | journal=Biomed Res Int | year= 2015 | volume= 2015 | issue= | pages= 363278 | pmid=25705656 | doi=10.1155/2015/363278 | pmc=4326213 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25705656  }} </ref> When IgM-bound [[red blood cells]] circulate towards warmer areas of the body, such as the trunk, [[IgM]] will dissociate from the [[red blood cells]] and [[complement]] C3b will remain bound.


AIHA cannot be attributed to any single autoantibody. To determine the autoantibody or autoantibodies present in a patient, the [[Coombs test]], also known as the antiglobulin test, is performed . There are two types of Coombs test, direct and indirect; more commonly, the direct antiglobulin test (DAT) is used. Classification of the antibodies is based on their activity at different temperatures and their aetiology. Antibodies with high activity at physiological temperature (approximately 37°C) are termed warm autoantibodies. Cold autoantibodies act best at temperatures of 0–4°C. Patients with cold-type AIHA, therefore, have higher disease activity when body temperature falls into a hypothermic state. Usually, the antibody becomes active when it reaches the limbs, at which point it opsonizes RBCs. When these RBCs return to central regions, they are damaged by complement. Patients may present with one or both types of autoantibodies; if both are present, the disease is termed "mixed-type" AIHA.
===Role of the complement system===
The [[complement]] system is partially involved in the pathophysiology of warm autoimmune hemolytic anemia. There is a stronger role for the complement system in certain types of autoimmune hemolytic anemia, such as [[paroxysmal cold hemoglobinuria]], [[cold agglutinin disease]], and [[cold agglutinin syndrome]].<ref name="pmid25705656">{{cite journal| author=Berentsen S, Sundic T| title=Red blood cell destruction in autoimmune hemolytic anemia: role of complement and potential new targets for therapy. | journal=Biomed Res Int | year= 2015 | volume= 2015 | issue=  | pages= 363278 | pmid=25705656 | doi=10.1155/2015/363278 | pmc=4326213 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25705656  }} </ref> The complement system plays a role in both extravascular hemolysis and intravascular hemolysis in [[autoimmune hemolytic anemia]].


When DAT is performed, the typical presentations of AIHA are as follows. Warm-type AIHA shows a positive reaction with [[antiserum|antisera]] to IgG antibodies with or without complement activation. Cases may also arise with complement alone or with [[IgA]], IgM or a combination of these three antibody classes and complement. Cold type AIHA usually reacts with antisera to complement and occasionally to the above antibodies. This is the case in both cold agglutinin disease and cold paroxysmal hematuria. Mixed warm and cold AIHA generally shows a positive reaction to IgG and complement, sometimes IgG alone and sometimes complement alone. Mixed type can, like the others, present unusually with positive reactions to other antisera.<ref name=Sokol81>{{cite journal |author=Sokol RJ, Hewitt S, Stamps BK |title=Autoimmune haemolysis: an 18-year study of 865 cases referred to a regional transfusion centre |journal=Br Med J (Clin Res Ed) |volume=282 |issue=6281 |pages=2023–7 |year=1981 |month=June |pmid=6788179 |pmc=1505955 |doi=10.1136/bmj.282.6281.2023 }}</ref>
*'''Complement activation by immunoglobulin subclasses''': The immunoglobulin type that is most potent in activating complement is [[immunoglobulin M]] (IgM). However, [[IgM]] is not typically detected in the [[Coombs test|Coombs' test]], so IgM-mediated hemolysis will likely manifest as a Coombs'-negative hemolytic anemia. Immunoglobulin G (IgG) can activate complement, and the different IgG subclasses have differentially ability to activate complement. IgG3, for example, is a more potent activator of complement than IgG1. IgG4 and immunoglobulin A (IgA) are unable to activate complement.<ref name="pmid25705656">{{cite journal| author=Berentsen S, Sundic T| title=Red blood cell destruction in autoimmune hemolytic anemia: role of complement and potential new targets for therapy. | journal=Biomed Res Int | year= 2015 | volume= 2015 | issue=  | pages= 363278 | pmid=25705656 | doi=10.1155/2015/363278 | pmc=4326213 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25705656  }} </ref>
 
*'''[[Extravascular hemolysis]]''': The pathophysiology of extravascular hemolysis in autoimmune hemolytic anemia involves destruction of [[red blood cells]] outside the blood vessels and inside the [[liver]] and [[spleen]]. This is largely due to complement protein C3b-mediated [[phagocytosis]] of [[red blood cells]]. This process begins with the [[C3-convertase|C3 convertase]], which leads to production of complement protein C3b. This protein normally functions to [[opsonize]] bacteria and prevent infection, as part of the innate immune system. However, in pathological conditions such as autoimmunity, C3b binds to the surface of [[red blood cells]]. Opsonization by C3b triggers the macrophages of the [[reticuloendothelial system]] to phagocytose these opsonized cells via complement receptors on the surface of macrophages. This [[phagocytosis]] occurs extravascularly, typically in the liver or spleen. In some cases, [[ectoenzymes]] that are located on the surface of macrophages can perforate [[red blood cell]] membranes and create spherocytes.<ref name="pmid25705656">{{cite journal| author=Berentsen S, Sundic T| title=Red blood cell destruction in autoimmune hemolytic anemia: role of complement and potential new targets for therapy. | journal=Biomed Res Int | year= 2015 | volume= 2015 | issue=  | pages= 363278 | pmid=25705656 | doi=10.1155/2015/363278 | pmc=4326213 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25705656  }} </ref> When the amount of [[red blood cell]] membrane removed exceeds the intracellular volume removed, the biconcave disc shape becomes a spherocytic shape. This is the pathophysiologic basis for spherocytes in autoimmune hemolytic anemia.<ref name="pmid25705656">{{cite journal| author=Berentsen S, Sundic T| title=Red blood cell destruction in autoimmune hemolytic anemia: role of complement and potential new targets for therapy. | journal=Biomed Res Int | year= 2015 | volume= 2015 | issue=  | pages= 363278 | pmid=25705656 | doi=10.1155/2015/363278 | pmc=4326213 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25705656  }} </ref> Upon passage through the splenic vasculature, spherocytes can destroyed.
 
*'''[[Intravascular hemolysis]]''': The pathophysiology of [[intravascular hemolysis]] in autoimmune hemolytic anemia involves destruction of [[red blood cells]] inside the blood vessels. This is largely due to activation of the terminal [[complement system]].<ref name="pmid26696798">{{cite journal| author=Berentsen S| title=Role of Complement in Autoimmune Hemolytic Anemia. | journal=Transfus Med Hemother | year= 2015 | volume= 42 | issue= 5 | pages= 303-10 | pmid=26696798 | doi=10.1159/000438964 | pmc=4678321 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26696798  }} </ref> This complement cascade begins with complement protein [[C5]], which is activated to [[C5a]] and [[C5b]] by the C5 convertase. C5a is a potent anaphylactic molecule, C5b is a membrane-bound protein that binds to downstream complement molcules, such as C6 though C9. The union of C5b and C6 though C9 forms the membrane attack complex. This complex can exert direct cytotoxic activity via the creation of pores in [[red blood cell]] membranes, resulting in cell lysis intravascularly.<ref name="pmid26696798">{{cite journal| author=Berentsen S| title=Role of Complement in Autoimmune Hemolytic Anemia. | journal=Transfus Med Hemother | year= 2015 | volume= 42 | issue= 5 | pages= 303-10 | pmid=26696798 | doi=10.1159/000438964 | pmc=4678321 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26696798  }} </ref>
 
===Excess complement activation===
* In some cases, the [[complement system]] can become activated very strongly, resulting in excess immune activation and [[red blood cell]] destruction, which can be lethal. This is due in part to a [[feedforward]] loop or positive feedback system, in which activation of the initial components of the [[complement cascade]] triggers activation of additional complement components.<ref name="pmid26696798">{{cite journal| author=Berentsen S| title=Role of Complement in Autoimmune Hemolytic Anemia. | journal=Transfus Med Hemother | year= 2015 | volume= 42 | issue= 5 | pages= 303-10 | pmid=26696798 | doi=10.1159/000438964 | pmc=4678321 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26696798  }} </ref>


==References==
==References==
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{{Reflist|2}}
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Latest revision as of 19:51, 22 May 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Assosciate Editor(s)-In-Chief: Prashanth Saddala M.B.B.S; Shyam Patel [2], Irfan Dotani [3]

Overview

The pathophysiology of autoimmune hemolytic anemia is different for warm-antibody type and cold-antibody type anemia. The pathophysiology of warm-antibody type autoimmune hemolytic anemia involves the coating of red blood cells with IgG, followed by extravascular hemolysis by splenic macrophages. The pathophysiology of cold-antibody type autoimmune hemolytic anemia involves the coating of red blood cells with IgM, followed by intravascular hemolysis. The complement system has a significant role in autoimmune hemolytic anemia and involves the binding of classical complement proteins on the red blood cell surface, followed by cell lysis by the membrane attack complex. In summary, a variety of cell-mediated immunologic mechanisms underlie the pathophysiology of autoimmune hemolytic anemia.

Pathophysiology

Warm autoimmune hemolytic anemia

The pathophysiology of warm autoimmune hemolytic anemia involves immunoglobulin G (IgG) antibodies binding to red blood cells at a temperature of 37 degrees Celsius. [1] The designation of warm is based on the fact the optimal binding temperature is 37 degrees Celsius, or normal body temperature. The IgG antibodies are typically polyclonal, meaning that they recognize a variety of antigens.[2] Macrophages bind to the antibody-coated red blood cells via the Fc receptors and result in extravascular destruction. The Fc receptors include Fc-gammaRI (CD64), Fc-gammaRII (CD32), and Fc-gammaRIII (CD16). In 15-20% of cases, the autoantibody involved is IgA.[2] It has been shown that induction of autoimmune hemolytic anemia is controlled by an immunosuppressive population of T lymphocytes known as regulatory T cells.[1]

Cold autoimmune hemolytic anemia

The pathophysiology of cold autoimmune hemolytic anemia, or cold agglutinin disease, involves immunoglobulin M (IgM) antibodies binding to Ii carbohydrate antigens of red blood cells at a temperature of 3-5 degrees Celcius. Agglutination typically occurs in the distal aspects of the extremities, such as the fingers and toes, because these areas have the lowest temperature.[3] Clinical manifestations of this pathophysiology includes Raynaud's phenomenon and acrocyanosis.[3] The IgM molecules will trigger activation of the complement system, which results in red blood cell lysis.[3] When IgM-bound red blood cells circulate towards warmer areas of the body, such as the trunk, IgM will dissociate from the red blood cells and complement C3b will remain bound.

Role of the complement system

The complement system is partially involved in the pathophysiology of warm autoimmune hemolytic anemia. There is a stronger role for the complement system in certain types of autoimmune hemolytic anemia, such as paroxysmal cold hemoglobinuria, cold agglutinin disease, and cold agglutinin syndrome.[3] The complement system plays a role in both extravascular hemolysis and intravascular hemolysis in autoimmune hemolytic anemia.

  • Complement activation by immunoglobulin subclasses: The immunoglobulin type that is most potent in activating complement is immunoglobulin M (IgM). However, IgM is not typically detected in the Coombs' test, so IgM-mediated hemolysis will likely manifest as a Coombs'-negative hemolytic anemia. Immunoglobulin G (IgG) can activate complement, and the different IgG subclasses have differentially ability to activate complement. IgG3, for example, is a more potent activator of complement than IgG1. IgG4 and immunoglobulin A (IgA) are unable to activate complement.[3]
  • Extravascular hemolysis: The pathophysiology of extravascular hemolysis in autoimmune hemolytic anemia involves destruction of red blood cells outside the blood vessels and inside the liver and spleen. This is largely due to complement protein C3b-mediated phagocytosis of red blood cells. This process begins with the C3 convertase, which leads to production of complement protein C3b. This protein normally functions to opsonize bacteria and prevent infection, as part of the innate immune system. However, in pathological conditions such as autoimmunity, C3b binds to the surface of red blood cells. Opsonization by C3b triggers the macrophages of the reticuloendothelial system to phagocytose these opsonized cells via complement receptors on the surface of macrophages. This phagocytosis occurs extravascularly, typically in the liver or spleen. In some cases, ectoenzymes that are located on the surface of macrophages can perforate red blood cell membranes and create spherocytes.[3] When the amount of red blood cell membrane removed exceeds the intracellular volume removed, the biconcave disc shape becomes a spherocytic shape. This is the pathophysiologic basis for spherocytes in autoimmune hemolytic anemia.[3] Upon passage through the splenic vasculature, spherocytes can destroyed.
  • Intravascular hemolysis: The pathophysiology of intravascular hemolysis in autoimmune hemolytic anemia involves destruction of red blood cells inside the blood vessels. This is largely due to activation of the terminal complement system.[2] This complement cascade begins with complement protein C5, which is activated to C5a and C5b by the C5 convertase. C5a is a potent anaphylactic molecule, C5b is a membrane-bound protein that binds to downstream complement molcules, such as C6 though C9. The union of C5b and C6 though C9 forms the membrane attack complex. This complex can exert direct cytotoxic activity via the creation of pores in red blood cell membranes, resulting in cell lysis intravascularly.[2]

Excess complement activation

  • In some cases, the complement system can become activated very strongly, resulting in excess immune activation and red blood cell destruction, which can be lethal. This is due in part to a feedforward loop or positive feedback system, in which activation of the initial components of the complement cascade triggers activation of additional complement components.[2]

References

  1. ↑ 1.0 1.1 Mqadmi A, Zheng X, Yazdanbakhsh K (2005). "CD4+CD25+ regulatory T cells control induction of autoimmune hemolytic anemia". Blood. 105 (9): 3746–8. doi:10.1182/blood-2004-12-4692. PMC 1895013. PMID 15637139.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Berentsen S (2015). "Role of Complement in Autoimmune Hemolytic Anemia". Transfus Med Hemother. 42 (5): 303–10. doi:10.1159/000438964. PMC 4678321. PMID 26696798.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Berentsen S, Sundic T (2015). "Red blood cell destruction in autoimmune hemolytic anemia: role of complement and potential new targets for therapy". Biomed Res Int. 2015: 363278. doi:10.1155/2015/363278. PMC 4326213. PMID 25705656.


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