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Blackwell Publishing IncMalden, USATRFTransfusion0041-11322006 American Association of Blood Banks** ****7••••Original ArticleLOWER Hb LEVELS IN HIV+ PATIENTS WITH POSITIVE DATLAI ET AL.

ABBREVIATION: CAT = column agglutination technology.

From the Immunohematology Laboratory Transfusion Center,

Institute of Hematology, the Department of Infectious Diseases,

and the Clinical Hematology Institute of Hematology, Catholic

University, Rome, Italy.

Address reprint request to: Marco Lai, MD, Immuno-

hematology Laboratory, Transfusion Center, Catholic University

of Sacred Heart, Largo A, Gemelli 8, 00168 Rome, Italy; e-mail:

marco_lai@fastwebnet.it.

Received for publication September 11, 2005; revision

received November 20, 2005, and accepted November 29, 2005.

doi: 10.1111/j.1537-2995.2006.00876.x

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I M M U N E H E M A T O L O G I C D I S E A S E

Lower hemoglobin levels in human immunodeficiency virus–infected patients with a positive direct antiglobulin test (DAT):

relationship with DAT strength and clinical stages

Marco Lai, Elena Visconti, Giuseppe D’Onofrio, Enrica Tamburrini, Roberto Cauda, and

Giuseppe Leone

BACKGROUND: There are conflicting opinions regarding the effect of positive direct antiglobulin test (DAT) on hemoglobin (Hb) levels in human immunodeficiency virus–infected (HIV+) patients.STUDY DESIGN AND METHODS: A total of 166 samples from HIV+ outpatients were studied. The DAT was performed with the tube test and column agglutination technology (CAT).RESULTS: The DAT was positive in 18.67 percent with the tube method and 33.73 percent with the CAT. Patients with DAT-positive results showed lower Hb levels than DAT-negative patients, 12.3 g per dL versus 14.3 g per dL (p = 0.0002). The univariate logistic regression enabled us to study the phenomenon better and fit the probability of having a DAT-positive result on the basis of the Hb levels. The relationship between the CAT and the tube test when washing the red blood cells (RBC) at 4°C was stronger than when washing these at room temperature (φ = 0.8156; p = 0.000). The Hb levels were significantly lower in the positive DATs of Stage C (acquired immune deficiency syndrome [AIDS]) and Stage B (symptomatic non-AIDS patients), which showed decreasing Hb values for increasing agglutination strengths (p = 0.000). Anemia was related with the DAT results (odds ratio [OR], 8.005; p = 0.000) but not to the AIDS condition (OR, 1.741; p = 0.221).DISCUSSION: Our study indicates that the DAT-positive results may be specifically related to lower Hb levels in HIV+ patients. The immunologic RBC clearance could be part of the anemic multifactorial condition in HIV+ patients.

he occurrence of positive direct antiglobulin test(DAT) in human immunodeficiency virus–infected (HIV+) patients is higher than in normalsubjects, having an indicated rate of approxi-

mately 18 to 43 percent.1,2 Anemia, leukopenia, andthrombocytopenia all characterize the HIV+ condition.Causes of the cytopenias can be: autoimmune phenom-ena, hemopoietic maturative block, infections, and drugtherapy.3-7 At the moment, the role of the positive DAT ineffecting the Hb levels of HIV+ patients has not been wellestablished.1,2,8-12 We studied the DAT-positive results inHIV+ patients with both the tube test method and columnagglutination technology (CAT). The results showed aclear relationship between the Hb levels and the positiveDAT result.

MATERIALS AND METHODS

Patients

All samples were obtained from 166 consecutive HIV+patients who attended the outpatients service of the clinicfor infection diseases in our hospital. In each case, signed,informed consent was obtained from the patient. All the

T

LAI ET AL.

2 TRANSFUSION Volume **, ** **

clinical data were obtained from review of the files. Thepatients’ clinical classification was performed followingthe Center for Disease Control (CDC93) revised classifica-tion system for HIV infection.13

• Clinical Category A (asymptomatic disease): acuteinfection with HIV; persistent generalized lymphade-nopathy. Conditions in B and C must be absent.

• Clinical Category B (symptomatic disease): any symp-tomatic conditions not included in Category C(examples are bacterial infections, candidiasis [oral orvulvovaginal] for more than 1 month, cervical dyspla-sia or carcinoma, constitutional symptoms, or oralhairy leukoplakia); two distinct episodes of herpeszoster or involving more than one dermatome, idio-pathic thrombocytopenia purpura, mycobacteriumtuberculosis, or peripheral neuropathy.

• Clinical Category C: any condition that meets the1987 CDC/WHO case definition for AIDS.

Patients were treated for HIV infection following the“Updated Recommendations of the International AIDSSociety-USA Panel.”14 The patients were classified as hav-ing been on anemic state with a Hb level of 13 g per dL formen and less than 12 g per dL for women following theWHO classification.15

DAT

The DAT using the CAT was performed by dispensing10 µL of the 3 percent red blood cell (RBC) saline suspen-sion in the microcolumns having anti-immunoglobulin G(IgG) plus anti-C3d (Polyspecific Cards, Ortho Diagnos-tics, Raritan, NJ). All the DATs using the CAT were carriedout with a fully automated system (AutoVue, Ortho Diag-nostics). The results and the agglutination strengths wereobtained with the AutoVue system software. All the bio-cards after the test were observed to analyze the accuracyof the results given by the instrument. The tube DAT wasperformed dispensing one drop of the patient’s 2 to5 percent RBC suspension in each tube, washing withsaline at room temperature three times with a completedecantation of the final wash. Immediately after the lastwash, two drops of the antisera (anti-human globulinanti-IgG-C3d polyspecific, Immucor Inc., Norcross, GA)were added to each tube and then mixed. This was thencentrifuged at 900 to 1000 × g for 15 to 30 seconds, mixedgently, and examined for macroscopic and microscopicagglutination. The tube DAT was performed in one sup-plementary mode, by washing the 2 to 5 percent RBCpatient suspension with saline at 4°C. For each patientsample, the 2 to 5 percent RBC suspension washed at 4°Cwas dispensed in two supplementary tubes. In the firsttube the RBC suspension pure was observed for sponta-neous agglutination after centrifugation. In the secondtube a 6 percent bovine albumin solution was added to

RBC suspension, centrifuged, and observed for macro-scopic and microscopic agglutination. The test for spon-taneous agglutination was carried out also for the DATperformed washing the RBC at room temperature. Theagglutination strengths for the manual tests were classi-fied following the UK Blood Transfusion and Tissue Trans-plantation Guidelines: 0 = negative result; 1 = cell buttondislodges into fine granules, microscopically visible;2 = cell button dislodges into finely granular but definite,small clumps, macroscopically visible; 3 = cell button dis-lodges into many small clumps, macroscopically visible;4 = cell button dislodges into numerous large clumps,macroscopically visible; and 5 = cell button remains inone clump or dislodges into a few large clumps, macro-scopically visible.

Immunoglobulins class detection by the CAT

The immunoglobulin class and complement detectionin the RBC surface was performed gel cards (DC Screening1 ID Cards, DiaMed, Cressier, Switzerland), which col-umns are equipped with monospecific antisera againstIgG, IgA, IgM, C3c, and C3d. The test was performed asindicated in the manufacturer’s instructions.

Statistical analysis

The tests and graphs were performed with computer soft-ware (Stata 8.2 SE [StataCorp, College Station, TX],Statistica 6 [StatSoft, Tulsa, OK], and SPSS 12 (SPSS Inc.,Chicago, IL]). The comparison between groups was per-formed by use of the U test and the Kruskal-Wallis analysisof variance by ranks for more than two groups. The com-parison between frequencies for categorical data wasperformed by the Pearson chi-square 2 × 2 tables. Therelationship between variables for categorical data wasestablished performing the phi for the 2 × 2 table. Multi-variate logistic regression was performed with the back-ward stepwise selection (likelihood ratio). The logisticunivariate regression was performed with maximum like-lihood and the quasi-Newton estimation methods. Trendsin central tendency across conditions were evaluated bythe Jonckheere-Terpstra test for ordered alternatives. Thistest can be used when the alternative hypothesis statedmedian1 ≤ median2 ≤ . . . ≤ mediank or this in the oppositedirection. All the Hb values are detailed as the median(range).

RESULTS

The samples were obtained from patients belonging to thefollowing clinical stages: 72 (43.37%) were from Stage A,asymptomatic patients; 45 (27.1%) were from Stage B,symptomatic non-AIDS; and 49 (29.51%) from Stage C,AIDS patients.

LOWER Hb LEVELS IN HIV+ PATIENTS WITH POSITIVE DAT

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Of 166 samples analyzed, 56 (33.73%) were DAT-pos-itive with the CAT and 31 (18.67%) with the tube test. Inthe HIV Stage A, we detected 17 (23.6%) DAT-positive sam-ples with the CAT and 9 (12.5%) with the tube method. InStage B, we detected 18 (40%) DAT-positive samples withthe CAT and 11 (24.4%) with the tube method. In Stage C,we detected 21 (42.9%) DAT-positive samples with the CATand 11 (22.4%) with the tube method. The DAT specificity(IgG, IgA, IgM, C3c, C3d, control, gel columns) was posi-tive in 53 (31.93%) samples for IgG and in 1 (0.6%) samplewith C3d. We studied the correlation of the results (posi-tive or negative), between the tube test and the CAT. Thestrongest relationship was foundbetween the CAT and the tube test,washing the RBCs at 4°C (φ (2 × 2tables) = 0.8156; p = 0000). The CATresults correlated with the standardtube test (washing at room temperature;with φ= 0.65; p = 0.000). Of the 56 sam-ples that were DAT-positive with theCAT, 24 (14.46%) had agglutinationstrength of 0.5+, 20 (12.05%) had agglu-tination strength of 1, and 12 (7.23%)had agglutination strength of 2+. Thetube test agglutination strengths were23 (13.85%) samples had 1+ and 8(4.81%) had 2+. The tube test agglutina-tion strengths washing at 4°C were 27samples (16.26%) had 1+, 13 (7.83%) had2+, and 2 samples (1.2%) had 3+. Thecomparison between DAT with the tubewashing at room temperature andwashing at 4°C gave the followingresults (see Fig. 1): in the 135 samplesthat were DAT-negative with the tubetest at room temperature, washing at4°C we detected 122 samples negative, 9samples positive with 1+, 2 samples pos-itive with 2+, and 2 samples positivewith 3+. In the 23 samples that had 1+with the tube DAT (room temperature),washing at 4°C we detected 2 samplesthat were negative, 13 samples with 1+,and 8 samples that were positive with2+. The 8 samples that were positivewith 2+ washing at room temperature,washing at 4°C gave 1+ in 5 samples and2+ in 3 samples.

In patients’ tubes that were DAT-positive, the Hb levels were significantlylower than those negative, respectively,12.3 g per dL (7.3-16.3) versus 14.3 g perdL (7.7-17.7; p = 0.0.00001). Significantdifferences in the Hb levels were foundalso when employing the CAT and the

tube test washing at 4°C (Table 1). There were no signifi-cant differences between female or male percentages inthe DAT-positive and -negative patient groups (2 × 2 tableFisher exact test p = 0.7). When comparing the Hb levelsbetween the DAT-positive and -negative having the sameclinical stage, differences were significant in Stages B andC with, respectively, p values of 0.00006 and 0.02 (seeFig. 2). In our study, Hb levels did not significantly differamong Stage A 14.25 g per dL (7.7-17.7), Stage B 14.4 gper dL (8.2-17.4), and Stage C 13.75 g per dL (7.3-17;p = 0.126). In Clinical Stage A there was no significantdifference in the Hb levels between the DAT-positive and

Fig. 1. Scatterplots of Hb (ordinate) versus the agglutination strengths (abscissa). (A)

Distribution of the DAT agglutination strengths washing at 4∞C in the samples that

were negative washing at room temperature (�). (B) Distribution of the DAT aggluti-

nation strengths washing at 4∞C in the samples that were positive 1+ washing at room

temperature (�). (C) Distribution of the DAT agglutination strengths washing at 4∞C

in the samples that were positive 2+ washing at room temperature (�). Gate B indi-

cates the samples that were positive 2+ washing at 4∞C and were 1+ washing at room

temperature. The legends with the symbols (�, �, � bottom left of each graph) indi-

cate the frequency of a given agglutination strength for each Hb value detailed in the

ordinate.

0 1 2 3

A

7.7

9.0

10.8

11.8

12.8

13.8

14.8

15.8

16.8

Hb level(g/dL)

1 2 3 4 5

0 1 2 3

B

7.3

8.1

9.0

10.5

11.5

12.3

13.8

14.7

16.3

1 2

0 1 2 3

C

8.0

10.9

11.9

12.7

14.4

1

TABLE 1. Hb values in HIV+ patients with DAT-negative and -positive results (total n = 166)

MethodNumberpositive

Percentpositive

Hb DAT resultsp ValueNegative Positive

TT room 31 18.67 14.3 (7.7-17.7) 12.3 (7.3-16.3) 0.00001CAT 56 33.73 14.4 (7.7-17.7) 13 (7.3-17.4) 0.0002TT 4°C 42 25.3 14.25 (7.7-17.7) 13 (7.3-17.2) 0.002

* Hb levels from the comparison between the samples that were DAT-positive and -negative. The Hb values are detailed for the tube test at room temperature (TT room), for the CAT, and for the tube test washing at 4°C (TT 4°C). The Hb values are detailed as median (range).

LAI ET AL.

4 TRANSFUSION Volume **, ** **

-negative samples (p = 0.731). Significantly lower Hb levelswere detected in Stage B and C with DAT-positive samples,also with the CAT and the tube test washing at 4°C(p = 0.00).

The samples from women with DAT-positive results(n = 14) showed significantly lower Hb levels when com-pared with those from women with DAT-negative results(n = 54), 11.3 g per dL (14.7-8.1) versus 13.1 g per dL (16.7-7.7; p = 0.01). The samples from men with DAT-positiveresults (n = 17) showed significantly lower Hb levels whencompared with those with DAT-negative results (n = 81),13 g per dL (16.3-7.3) versus 14.9 g per dL (17.7-9.1;p = 0.001).

The anemia condition (Hb levels of <13 g/dL in menand <12 g/dL in women, WHO classification) was signifi-cantly associated with the DAT-positive odds ratio [OR] of8.006 (3.252-19.711; p = 0.000), but not with the AIDS ORof 1.741 (0.714-4.246; p = 0.221; see Table 2). In symptom-atic patients, the anemia condition was significantly asso-ciated with the DAT-positive OR of 12.250 (4.018-37.343;p = 0.000), but not with the AIDS OR of 1.612 (0.522-4.979;p = 0.406; see Table 2).

To define the relationship better between the Hb andthe DAT results (positive negative), we performed theunivariate logistic regression in those cases belonging toClinical Stages B and C. The logistic regression was per-formed for the tests with the CAT, the tube at room tem-perature, and the tube washing at 4°C. The logisticregression parameters are detailed on Table 3. The fitobtained with univariate logistic regression showed a

clear relationship expressed in terms ofprobability, between the Hb levels andthe DAT results with the different meth-ods (see Fig. 3).

Selecting only those samplesbelonging to Clinical Stages B and C(symptomatic), we analyzed the influ-ence of the different CAT agglutinationstrengths (0, 0.5, 1, 2) on the Hb levels.The differences detected among thefour groups were significant: for 0 (neg-ative), the median Hb value was 14.5(n = 55; 11.8-17); for 0.5+ (n = 19), 13 (9-17.4); for 1+ (n = 11), 11.6 (8-14.7); andfor 2+ (n = 9), 11.1 (7.3-15.3; Kruskal–Wallis test H = 23.34; p = 0000; seeFig. 4). The Jonckheere-Terpstra trendtest for the Hb median values catego-rized on the basis of CAT agglutinationstrength was significant (p = 0.000). Dif-ferences in the Hb levels between thetube test agglutination strengthsdetected when washing at 4°C were sig-nificant (p = 0.008). When washing atroom temperature the differences in the

TABLE 2. Multivariate logistic regressionVariable Anemic Nonanemic p Value OR [exp(B)] 95% CI [exp(B)]All patients (n =166)Number 36 130DAT result

Positive 17 (47.2) 14 (10.8) 0.000 8.006 3.522-19.711Negative 19 (52.8) 116 (89.2)

SexMale 14 (38.9) 84 (64.6) 0.007 0.314 0.136-0.726Female 22 (61.1) 46 (35.4)

AIDS conditionAIDS 13 (36.1) 36 (27.7)Non-AIDS 23 (63.9) 94 (72.3) 0.221 1.741 0.714-4.246

Symptomatic patients (n = 94)Number 23 71DAT result

Positive 14 (60.9) 8 (11.3) 0.000 12.250 4.018-37.343Negative 9 (39.1) 63 (88.7)

SexMale 13 (56.5) 47 (66.2) 0.341 0.579 0.188-1.782Female 10 (43.5) 24 (33.8)

AIDS conditionAIDS 13 (56.5) 36 (50.7) 0.406 1.612 0.522-4.979Non-AIDS 10 (43.5) 35 (49.3)

* Results of the multivariate logistic regression between anemia as dependent variable, taking DAT results AIDS condition and sex as factors. In the anemic and nonanemic rows, the numbers (%) for DAT results, AIDS condition, and sex are indicated. The analysis was performed on symptomatic patients.

Fig. 2. Different Hb levels in HIV+ patients classified on the

basis of the Clinical Stages A, B, and C and the results of the DAT

with standard tube test, positive or negative. In Clinical

Stages B and C the significance level was, respectively,

p = 0.00006 and p = 0.02. In Clinical Stage A, the difference was

not significant (p = 0.73). Numbers in middles of bars are medi-

ans; the bars are the 25th to 75th percentiles; and the perpen-

dicular lines are nonoutlier ranges.

CBAHIV Clinical Stages

6,000

8,000

10,000

12,000

14,000

16,000

18,000

14,10014,300

14,900

14,100

12,60012,550

DATNegativePositive

Hb

leve

l (g

/dL

)

LOWER Hb LEVELS IN HIV+ PATIENTS WITH POSITIVE DAT

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Hb levels between the different agglutination strengthsremained significant (Kruskal-Wallis test, p = 0.0001). Nodifferences were detected, however, in the Hb median val-ues between the agglutination strength 1+ and 2+.

DISCUSSION

This study shows that Hb levels were significantly lower inHIV+ patient with DAT-positive results for all the methodsused and in spite of the different occurrences detected.The occurrence of the positive DAT with the CAT was

33.73 percent, but with the tube test itwas 18.67 percent. Washing the RBCs at4°C, the tube DAT showed a higher per-centage of positive results than whenwashing the cells at room temperature,showing a better correlation with theCAT results (φ = 0.8). It is possible thatthe antibody elution phenomena givenby the washing steps and manipulationsmay be reduced by washing the RBCs at4°C and avoided with no-wash methodssuch as the CAT.16,17

In our data the median value ofHb in patients with positive DAT resultswas 12.3 g per dL, and in DAT-negativeresults it was 14.3 (p = 0.000; tube test).In previous reports such difference inthe Hb levels was ascribed to the preva-lence of DAT-positive results and ane-

mia in the poor clinical stages.8,10 In view of this theysuggested that the differences detected in the Hb levelsrepresented the differences in Hb between the differentclinical stages. This observation was based on the fact thatthe difference in Hb between DAT-positive and -negativeresults in the same clinical stage was not significant.8

In our study, however, we detected significantly lowerHb levels in cases with DAT-positive results in Stages Band C considered separately. An interesting study was car-ried out by Inada and colleagues.18 They found that thepositive DAT was predictive for a progression to AIDS orthe AIDS-related complex. In our study a specific relation-ship between DAT and Hb was supported by the observa-tion that decreasing Hb levels corresponded to increasingagglutination strengths. We demonstrated that lower Hblevels were in relationship to high agglutination strengths(Kruskall-Wallis p = 0.00003) and that this trend was sig-nificant (Jonckheere-Terpstra p = 0.000). This analysis wasperformed on symptomatic patients, avoiding the inter-ference given by patients in better clinical conditions andhaving a lower incidence of positive DATs. For this pur-pose, we studied preferentially the agglutination strengthsgiven by fully automated system interpretation software,because the results were standardized. Furthermore, thesame trend between Hb levels and agglutination strengthswas observed for the tube test washing at 4°C. When wash-ing at room temperature instead there were no differencesin the Hb levels between the samples with microscopicagglutination (1+) and macroscopic (2+). This was proba-bly due to the fact that agglutination strengths that were2+ at 4°C migrated to a value of 1+ when washing at roomtemperature (gate in Fig. 1). A possible explanation for theassociation between Hb levels and agglutination strengthsis the relationship between the immunoglobulin amountin the RBC membrane and the Hb levels. This explanationis in agreement with the correlation described by Bordin

TABLE 3. Parameters of the univariate logistic regression*Methods Significance Const.B0 (SE) Hb (SE)CAT (n = 94) Final loss 50.21 7.8 −0.6

χ2 = 23.241 (2.1) (0.152)p = 0.00000 p = 0.0000 p = 0.0001

Tube test room temperature (n = 94) Final loss 38.49 7.18 −0.638χ2 = 23.679 (2.06) (0.159)p = 0.0000 p = 0.0000 p = 0.0001

Tube test 4°C (n = 94) Final loss 47.09 6.38 −0.53χ2 = 19.721 (1.89) (0.141)p = 0.00001 p = 0.0000 p = 0.0002

Tube test room temperature (n = 166) Final loss 68.26 4.15 −0.45χ2 = 22.056 (1.35) (0.10)p = 0.00000 p = 0.001 p = 0.00003

* Parameters of the univariate logistic regression performed between the Hb values and the DAT results with the CAT and the tube test washing the RBCs at room temperature and at 4°C, considering the samples from Clinical Stages B and C (symptomatic). In the last row, the parameters of the logistic regression performed on all of the samples are detailed.

Fig. 3. Fits of the univariate logistic regression taking the DAT

results (positive, negative) as the dependent variable and the

Hb levels as the continuous variable. The fit indicates the prob-

ability of having the DAT-positive result (ordinate) on the basis

of the Hb levels (abscissa). (— —) Fit plotted with the CAT

results; (—) fit for DAT washing at 4∞C; (· · ·) fit for the DAT wash-

ing at room temperature.

6 8 10 12 14 16 18

Hb level (g/dL)

Probability

1.2

1.0

0.8

0.6

0.4

0.2

0.0

–0.2

LAI ET AL.

6 TRANSFUSION Volume **, ** **

and colleagues2 between the Hb levels and IgG number inthe RBCs.2 Furthermore, in our study there were no signif-icant differences between the Hb levels in Stages A, B, andC, probably in consequence of new treatments for HIV+patients.14 In our study the comparison between the DATbinary data and the Hb level with logistic univariateregression indicated a clear relationship between the twoparameters including all the cases observed. The associa-tion between the DAT results and the Hb levels is welldescribed by the fit of the univariate logistic regressionperformed including Clinical Stages B and C. The fitclearly showed that the probability of having a DAT-posi-tive result is very high for low Hb levels. The probability ofhaving a DAT-positive increase from 0.4 for Hb values of12 g per dL to 0.9 for Hb values of 8 g per dL.

The importance of the DAT-positive results from theclinical point of view is well demonstrated by the asso-ciation of anemia with the positive DATs (OR, 8.001;p = 0.000), but not with the AIDS condition. The absenceof a significant association between anemia and AIDS,which for definition includes the poor clinical stages,agrees with our thinking that there is a specific associationbetween positive DATs and low Hb levels. By includingonly symptomatic patients in our analysis, the associationbetween anemia and positive DAT was increased (OR,12.250; p = 0.000), but the anemia remained unrelated tothe AIDS. The condition of being male was advantageousin the anemia condition considering all patients (OR,0.314; p = 0.007); however, this advantage was lost consid-

ering the symptomatic patients only. Aprevious study detailed the importanceof the antibiotic treatments in gen-erating drug-dependent autoimmunehemolytic anemia in AIDS patients.19 Animportant point must be consideredregarding the patients observed in ourstudy. All were outpatients and thereforethe poor clinical conditions thatrequired hospitalization and massivedrug treatments were not represented inour study.

In conclusion, our study clearlydemonstrated a relationship betweenthe positive DAT and low Hb levels andthat this relationship is linked to theimmunoglobulin presence in the RBCsurface. This condition could be theconsequence of a specific bond11,20 ofimmunoglobulin in RBC surface orthe deposition of immunocomplexes.20

Independently from the cause, we thinkthat in some of the cases, the presenceof immunoglobulin in the RBCs canplay a specific role, starting mild RBCdestruction.

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Fig. 4. Hb levels of HIV+ patients including Stages B and C classified on the basis of the

agglutination strength of the DAT performed with the CAT. In the graph the Hb values

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12.3

0 1 2 3

4°C

6

8

10

12

14

16

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20

Kruskal-Wallis p = 0.0223

14.5

13

11.6

11.1

0 0.5 1 2

CAT

6

8

10

12

14

16

18

Kruskal-Wallis p = 0.00003

14.3

12.3 12.3

0 1 2

Room temperature

6

8

10

12

14

16

18

20

Kruskal-Wallis p = 0.0001

Hb level (g/dL)

Hb level (g/dL)

Hb level (g/dL)

LOWER Hb LEVELS IN HIV+ PATIENTS WITH POSITIVE DAT

Volume **, ** ** TRANSFUSION 7

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