Medscape is available in 5 Language Editions – Choose your Edition here.


Donath-Landsteiner Hemolytic Anemia Treatment & Management

  • Author: Trisha Simone Tavares, MD, FAAP; Chief Editor: Max J Coppes, MD, PhD, MBA  more...
Updated: Apr 07, 2014

Approach Considerations

Treatment of Donath-Landsteiner hemolytic anemia (DLHA) may not be necessary in children with stable mild anemia and normal renal function.

Indications for hospitalization in patients with DLHA include the following:

  • Worsening anemia
  • Severe anemia
  • Respiratory or circulatory compromise
  • Renal failure
  • Severe infection
  • Social situation that may preclude prompt access to care if the condition worsens

Transfer patients with severe anemia or complications to a facility where pediatric hematology physicians, blood banking, and pediatric intensive care services are available. Transfer severely ill patients to a facility where consultation with pediatric hematologists, pediatric nephrologists, and pediatric critical care specialists are available.

Anticipate severe anemia and/or acute renal failure. Manage symptoms of underlying infection, if present.

Monitor renal function and hemoglobin until normalized and stable.

Go to Pediatric Chronic Anemia, Anemia of Prematurity, Fanconi Anemia, Pediatric Acute Anemia, and Pediatric Megaloblastic Anemia for complete information on these topics.


Treatment of Severe Disease


Avoid unnecessary transfusions because of the expected transient nature of the condition. Risks of blood transfusion include transfusion reactions and transmission of infection. Blood transfusion is indicated only in selected individuals with Donath-Landsteiner hemolytic anemia (DLHA).

In patients with severe, symptomatic, or rapidly worsening anemia, transfusion of red blood cells (RBCs) must be provided. Guidelines for transfusions in neonates and older children have been established.[21]

For blood typing, perform compatibility testing using techniques to minimize the interference caused by the autoantibody. Consultation with a hematologist and a blood bank specialist may be helpful.

Although P antigen–negative RBCs are most efficacious, these units are extremely rare (most banked blood units are P antigen positive). Blood transfusion may be safely accomplished with P antigen–positive units in most cases, resulting in the expected hemoglobin increases based on the amount administered. Use blood warmers if possible to perform the RBC transfusion at 37°C.


The use of corticosteroids is controversial but responses have been reported. Corticosteroid therapy may be indicated in patients with DLHA and severe anemia.

Rituximab has been used to treat refractory autoimmune hemolytic anemia, including cold agglutinin disease. Although medical therapy of DLHA beyond the use of steroids is rarely required, rare refractory cases (particularly in adults) have been described in which rituximab was used successfully[22] and in which intravenous immunoglobulin (IVIG) has been used successfully.[2]


Plasmapheresis has been used successfully in extremely severe cases refractory to transfusion.[23] Anticipate the need for plasmapheresis early in the patient's clinical course.


Supportive Care

Although exposure to cold is not always clearly associated with disease presentation, supportive care recommendations include avoidance of extreme cold exposure based on an understanding of disease pathophysiology.

Supportive care may also include interventions to prevent or ameliorate renal failure if hemoglobinuria is present. Maintain adequate hydration and urine output. Consult a pediatric nephrologist if renal compromise is identified.

Folic acid supplementation is appropriate because active hemolysis can consume folate and result in megaloblastosis. Folic acid supplementation aids in the production of erythrocytes and in the resolution of anemia.


Management of Infection

Viral infections are self-limited. Treat syphilis and mycoplasmal infections with appropriate therapy. Hemolysis resolves with treatment of the underlying infection.

Splenectomy has no role in treatment of Donath-Landsteiner hemolytic anemia because the hemolysis is intravascular.


Deterrence and Prevention

Currently, prevention of Donath-Landsteiner hemolytic anemia is not possible.

For chronic idiopathic Donath-Landsteiner hemolytic anemia, avoidance of extreme cold exposure may prevent symptoms from recurring.


Long-Term Monitoring

Frequency of surveillance testing must be determined by the clinical course. Perform the following periodic evaluations until the values are normal and stable:

  • Clinical examination
  • CBC count
  • Reticulocyte count
  • Total bilirubin
  • Lactate dehydrogenase
  • Microscopic urinalysis
  • Direct antiglobulin test (DAT)

Repeat the above testing if the patient presents with similar signs or symptoms. Have a low threshold to evaluate the child for recurrent disease.

Contributor Information and Disclosures

Trisha Simone Tavares, MD, FAAP Attending Physician, Department of Pediatrics, Section of Hematology/Oncology, Cardon Children's Medical Center

Trisha Simone Tavares, MD, FAAP is a member of the following medical societies: Children's Oncology Group

Disclosure: Nothing to disclose.


M Monica Gramatges, MD Assistant Professor, Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine

M Monica Gramatges, MD is a member of the following medical societies: American Association for Cancer Research, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Children's Oncology Group

Disclosure: Nothing to disclose.

Chief Editor

Max J Coppes, MD, PhD, MBA Executive Vice President, Chief Medical and Academic Officer, Renown Heath

Max J Coppes, MD, PhD, MBA is a member of the following medical societies: American College of Healthcare Executives, American Society of Pediatric Hematology/Oncology, Society for Pediatric Research

Disclosure: Nothing to disclose.


Nicolas A Camilo, MD Consulting Staff, Division of Pediatric Hematology-Oncology, Mountain States Tumor Institute, St Luke's Regional Medical Center

Nicolas A Camilo, MD is a member of the following medical societies: American Society of Pediatric Hematology/Oncology

Disclosure: Nothing to disclose.

Gary D Crouch, MD Program Director of Pediatric Hematology-Oncology Fellowship, Department of Pediatrics, Associate Professor, Uniformed Services University of the Health Sciences

Gary D Crouch, MD is a member of the following medical societies: American Academy of Pediatrics and American Society of Hematology

Disclosure: Nothing to disclose.

Michael R Jeng, MD Associate Professor, Department of Pediatrics, Division of Hematology/Oncology, Stanford University School of Medicine

Michael R Jeng, MD is a member of the following medical societies: American Society of Hematology, American Society of Pediatric Hematology/Oncology, and Histiocyte Society

Disclosure: Nothing to disclose.

Gary R Jones, MD Associate Medical Director, Clinical Development, Berlex Laboratories

Gary R Jones, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Pediatric Hematology/Oncology, and Western Society for Pediatric Research

Disclosure: Nothing to disclose.

Thomas W Loew, MD Clinical Professor of Pediatrics, Division Director of Pediatric Hematology/Oncology, University of Missouri Children's Hospital

Thomas W Loew, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Pediatrics, American College of Physician Executives, American Medical Association, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, and Children's Oncology Group

Disclosure: Genzyme Grant/research funds Independent contractor; Genzyme Honoraria Speaking and teaching; Amicus Grant/research funds Independent contractor; Purdue Pharmaceuticals Grant/research funds Independent contractor

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

  1. Hayashi H, Yasutomi M, Hayashi T, et al. Paroxysmal cold hemoglobinuria caused by an IgM-class Donath-Landsteiner antibody. Pediatr Int. 2013 Oct. 55(5):664-6. [Medline].

  2. Karafin MS, Shirey RS, Ness PM, King KE, Keefer J. A case study of a child with chronic hemolytic anemia due to a Donath-Landsteiner positive, IgM anti-I autoantibody. Pediatr Blood Cancer. 2012 Nov. 59(5):953-5. [Medline].

  3. Ogose T, Wakata Y, Kaneko M, Shinahara K, Takechi T, Kotani H. A case of recurrent paroxysmal cold hemoglobinuria with the different temperature thresholds of Donath-Landsteiner antibodies. J Pediatr Hematol Oncol. 2007 Oct. 29(10):716-9. [Medline].

  4. Lichtman MA, Spivak JL, eds. Ueber paroxysmale Haemoglo- binurie [Concerning paroxysmal hemoglobinuria]. Hematology: Landmark Papers of the Twentieth Century. San Diego, Calif: Academic Press; 2000. 21.

  5. Donath J LK. Uber paroxysmale Hamoglobinurie. Munchener Medizinische Wochenschrift. 1904. 51:1590-3.

  6. Bird GW. Paroxysmal cold haemoglobinuria. Br J Haematol. 1977 Oct. 37(2):167-71. [Medline].

  7. Gehrs BC, Friedberg RC. Autoimmune hemolytic anemia. Am J Hematol. 2002 Apr. 69(4):258-71. [Medline].

  8. Sivakumaran M, Murphy PT, Booker DJ, Wood JK, Stamps R, Sokol RJ. Paroxysmal cold haemoglobinuria caused by non-Hodgkin's lymphoma. Br J Haematol. 1999 Apr. 105(1):278-9. [Medline].

  9. Sharara AI, Hillsley RE, Wax TD, Rosse WF. Paroxysmal cold hemoglobinuria associated with non-Hodgkin's lymphoma. South Med J. 1994 Mar. 87(3):397-9. [Medline].

  10. Lippman SM, Winn L, Grumet FC, Levitt LJ. Evans' syndrome as a presenting manifestation of atypical paroxysmal cold hemoglobinuria. Am J Med. 1987 May. 82(5):1065-72. [Medline].

  11. Sokol RJ, Booker DJ, Stamps R. Erythropoiesis: Paroxysmal Cold Haemoglobinuria: A Clinico-Pathological Study of Patients with a Positive Donath-Landsteiner Test. Hematology. 1999. 4(2):137-164. [Medline].

  12. Petz LD. Cold antibody autoimmune hemolytic anemias. Blood Rev. 2008 Jan. 22(1):1-15. [Medline].

  13. Sokol RJ, Hewitt S, Stamps BK. Autoimmune haemolysis associated with Donath-Landsteiner antibodies. Acta Haematol. 1982. 68(4):268-77. [Medline].

  14. Gottsche B, Salama A, Mueller-Eckhardt C. Donath-Landsteiner autoimmune hemolytic anemia in children. A study of 22 cases. Vox Sang. 1990. 58(4):281-6. [Medline].

  15. Wolach B, Heddle N, Barr RD, Zipursky A, Pai KR, Blajchman MA. Transient Donath-Landsteiner haemolytic anaemia. Br J Haematol. 1981 Jul. 48(3):425-34. [Medline].

  16. Taylor CJ, Neilson JR, Chandra D, Ibrahim Z. Recurrent paroxysmal cold haemoglobinuria in a 3-year-old child: a case report. Transfus Med. 2003 Oct. 13(5):319-21. [Medline].

  17. Heddle NM. Acute paroxysmal cold hemoglobinuria. Transfus Med Rev. 1989 Jul. 3(3):219-29. [Medline].

  18. Rosse WF, Hillmen P, Schreiber AD. Immune-mediated hemolytic anemia. Hematology Am Soc Hematol Educ Program. 2004. 48-62. [Medline].

  19. Hernandez JA, Steane SM. Erythrophagocytosis by segmented neutrophils in paroxysmal cold hemoglobinuria. Am J Clin Pathol. 1984 Jun. 81(6):787-9. [Medline].

  20. Win N, Stamps R, Knight R. Paroxysmal cold haemoglobinuria/Donath-Landsteiner test. Transfus Med. 2005 Jun. 15(3):254. [Medline].

  21. [Guideline] Gibson BE, Todd A, Roberts I, et al. Transfusion guidelines for neonates and older children. Br J Haematol. 2004 Feb. 124(4):433-53. [Medline]. [Full Text].

  22. Koppel A, Lim S, Osby M, Garratty G, Goldfinger D. Rituximab as successful therapy in a patient with refractory paroxysmal cold hemoglobinuria. Transfusion. 2007 Oct. 47(10):1902-4. [Medline].

  23. Roy-Burman A, Glader BE. Resolution of severe Donath-Landsteiner autoimmune hemolytic anemia temporally associated with institution of plasmapheresis. Crit Care Med. 2002 Apr. 30(4):931-4. [Medline].

Blood smear showing spherocytosis, polychromatophilia, and erythrophagocytosis by neutrophils.
Blood smear showing spherocytosis, polychromatophilia, and erythrophagocytosis by neutrophils.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.