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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 5  |  Issue : 1  |  Page : 84-86

Importance of red cell serology in optimizing transfusion strategy for patients undergoing allogeneic hematopoietic stem cell transplant


1 Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission07-Jan-2020
Date of Decision08-Feb-2020
Date of Acceptance29-Feb-2020
Date of Web Publication17-Apr-2020

Correspondence Address:
Ashish Jain
Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_2_20

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  Abstract 


In ABO-incompatible allogeneic hematopoietic stem cell transplant (HSCT) monitoring for the appearance of donor-derived ABO antigens on red blood cells (RBCs) is a valuable tool for deciding the transfusion strategy. It was a retrospective study (6 months) where the patients undergoing ABO-incompatible (major/minor/bidirectional) allogenic HSCT were followed up for blood grouping, direct antiglobulin test (DAT), and antibody screen (ABS). Blood grouping (ABO and RhD) and ABO antibody titers were done by tube technique; DAT and ABS were done using gel technique (Bio-Rad, Switzerland). A total of six patients underwent ABO-incompatible transplant including three major (1 case AB→B; 2 cases B→O), two minor (A→AB; O→B), and one bidirectional (A→B) transplants. ABS and DAT were negative. In major ABO-incompatible transplants, the recipient anti-A/anti-B titers varied from 2 to 16 (immunoglobulin M [IgM]: 2–8; immunoglobulin G [IgG]: 2–16), and in minor ABO-incompatible transplants, the donor anti-B titer ranged from 8 to 32 (IgM: 8–16; IgG: 8–32). In the bidirectional case, the recipient anti-A titer was 32 (IgM = IgG). No plasma/red cell reduction was done in the product before the transplant. A mixed-field agglutination (MFA) was observed with anti-B on posttransplant day 44 in one major ABO-incompatible transplant, with anti-B on posttransplant day 31 in one minor ABO-incompatible transplant, and with anti-A as well as anti-B on posttransplant day 36 in the bidirectional ABO-incompatible transplant, which indicated RBC engraftment. A total of 30 (median: 4.5) packed RBC units were transfused in the posttransplant phase. In conclusion, pretransplant immunohematology work-up and the monitoring of blood group for MFA are important tools for optimizing the transfusion strategy of patients undergoing ABO-incompatible allogeneic HSCT.

Keywords: Graft-versus-host disease, hematopoietic stem cell transplantation, human leukocyte antigen, intravenous immunoglobulin, mixed-field agglutination


How to cite this article:
Tripathi PP, Jain A, Sharma RR, Khadwal A. Importance of red cell serology in optimizing transfusion strategy for patients undergoing allogeneic hematopoietic stem cell transplant. Glob J Transfus Med 2020;5:84-6

How to cite this URL:
Tripathi PP, Jain A, Sharma RR, Khadwal A. Importance of red cell serology in optimizing transfusion strategy for patients undergoing allogeneic hematopoietic stem cell transplant. Glob J Transfus Med [serial online] 2020 [cited 2020 Oct 29];5:84-6. Available from: https://www.gjtmonline.com/text.asp?2020/5/1/84/282727




  Introduction Top


Hematopoietic stem cell transplant (HSCT) procedures, both peripheral and bone marrow, are used to treat hematological malignancies, solid tumors, and bone marrow failure syndromes including aplastic anemia and inherited immunodeficiency and metabolic diseases.[1] Due to the separate inheritance of the human leukocyte antigen (HLA) system from the blood group systems, most of the HSCTs are performed across the ABO blood group barrier. Based on the ABO incompatibility between the donor and the recipient, HSCT may be: (i) major ABO-incompatible (presence of preformed anti-donor A/B antibody[ies] against donor ABO antigens expressed on the red blood cells [RBCs] within the graft infused to a recipient), (ii) minor ABO-incompatible (the recipient expresses the ABO antigens lacking on the donor RBCs, with a risk of production of anti-recipient ABO antibody[ies] by the donor lymphocytes), and (iii) bidirectional ABO-incompatible (a combination of major and minor ABO incompatibility which puts the recipient at risk for both host-versus-graft and graft-versus-host [GvH] reactions).[1],[2] The outcomes of the HSCT procedures can be compromised with transfusion due to the influence of immunosuppression associated with HSCT, the immunohematological repercussion of ABO-incompatible HSCT, and HLA alloimmunization from the transfused products.[3] Recent studies demonstrated that there is an increased risk of hemolytic reactions and transplant-related mortality among ABO-incompatible HSCTs;[4],[5],[6] thus, a regular immunohematological testing becomes vital in all the phases of transplant and may serve as a valuable tool for deciding the transfusion strategy, especially in the posttransplant phase.[7]


  Case Report Top


It was a retrospective study over a period of 6 months (February to July 2018) where the blood requisitions received for the patients undergoing allogeneic HSCT were analyzed. Ethics: The study was approved by the institutional ethics committee of our institute (No. INT/IEC/2019/002599 dated December 16, 2019). The cases were classified as major, minor, and bidirectional ABO-incompatible transplants based on the type of ABO incompatibility between the patient and the donor. ABO (including forward and reverse grouping) and RhD typing were performed for both patients and donors by tube technique. During the follow-up of recipients, in addition to blood grouping, a direct antiglobulin test (DAT) and an antibody screen (ABS) and identification (ID) were also performed using column agglutination technique (LISS Coombs AHG card, Bio-Rad, Switzerland). ABO antibody titers were performed using tube technique wherever indicated. The statistical analysis was performed using Excel (Microsoft 2016, USA), and the variables were measured as mean ± standard deviation or as median.

A total of 30 patient requisitions were received for pretransplant work-up, of which 6 (20%) patients underwent allogeneic HSCT. This included three major ABO-incompatible (one case of AB donor to B recipient and two cases of B donor to O recipient), two minor ABO-incompatible (one case of A donor to AB recipient and one case of O donor to B recipient), and one bidirectional ABO-incompatible (A donor to B recipient) transplants. For all the major and minor ABO-incompatible cases (n = 5), the ABS and DAT were negative in all the phases of transplant. In the case of bidirectional ABO-incompatible HSCT, the recipient had anti-E alloantibody before the transplant itself. In the major ABO-incompatible transplants (n = 3), the recipient anti-A/anti-B titers varied from 2 to 16 (immunoglobulin M [IgM]: 2–8; immunoglobulin G [IgG]: 2–16), and in the minor ABO-incompatible transplants (n = 2), the donor anti-B titer ranged from 8 to 32 (IgM: 8–16; IgG: 8–32). In the bidirectional case, the recipient anti-A titer was 32 (IgM as well as IgG). No plasma/red cell reduction was done in the product before the transplant in any of the cases. A mixed-field agglutination (MFA) was observed with anti-B on posttransplant day 44 in one major ABO-incompatible transplant, with anti-B on posttransplant day 31 in one minor ABO-incompatible transplant, and with anti-A as well as anti-B on posttransplant day 36 in the bidirectional ABO-incompatible transplant, which indicated RBC engraftment. For the remaining three patients (two major ABO-incompatible and one minor ABO-incompatible transplants), the samples were not sent for immunohematology testing around the engraftment phase, as they might have not required transfusion at that point of time. In the bidirectional ABO-incompatible transplant recipient, there was also a gradual increase in strength of agglutination along with negative result with anti-B on day 62, which was vital for deciding the ABO type of the packed RBC (PRBC) to be selected for transfusion. The trend of appearance of MFA (n = 3) as depicted in [Table 1], was indicative of either existence of donor ABO type RBCs or the residual recipient ABO type RBCs, and thus aided in deciding about the choice of PRBC to be selected for transfusion. In both major and minor ABO-incompatible transplant patients, hemoglobin was around 6 ± 1 g/dl at the time of engraftment which was indicated by the appearance of MFA in the forward grouping. A total of 30 (median: 4.5) PRBC units, irradiated, were transfused to all the six recipients in the posttransplant phase, with maximum number (12 units) being transfused in the bidirectional ABO-incompatible recipient who received E antigen-negative compatible PRBCs but suffered from severe GvH disease (GvHD) and expired on day 102 posttransplant. The other HSCT recipients are currently on follow-up.
Table 1: Immunohematology findings in the posttransplant phase

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  Discussion Top


In all types of HSCTs, recipients can show different immunohematological encounters in the posttransplant phase. For analyzing the meticulous diagnosis and treatment plan including transfusion support, the recognition of changes in both forward and reverse grouping in posttransplant phases in all types of HSCTs is obligatory.[8] The presence of isohemagglutinin antibodies to nonself-antigens is the main cause of delayed red cell engraftment, especially in cases of major ABO-incompatible posttransplant phase.[8] Delayed red cell engrafting depends on the suppression of a recipient's immune system. Various modalities can be used to achieve this suppression including myeloablative regimen or pretransplant plasma exchange or use of intravenous immunoglobulin.[9] Different studies showed different clinical endpoint outcomes in posttransplant phases of all types of transplants in relation to GvHD, neutrophil and platelet engraftment, disease relapses, cell source, nonrelapse mortality, and survival whether it goes in good or bad response.[9] The immunohematological status of both patients and donors must be scrutinized for transfusion support in ABO-incompatible HSCT recipients.[10] The appearance of MFA was an important observation for deciding about the choice of ABO PRBC and other blood components for transfusion support in the posttransplant phase. Red cell serological testing, especially the monitoring of the change in blood group of the patients for MFA reactions, serves as a guiding tool for deciding transfusion strategy for patients undergoing allogeneic ABO-incompatible HSCT.[7],[11] However, due to smaller sample size of our study, the definitive role of “MFA” observation in transfusion decisions could not be ascertained, and thus, a bigger cohort needs to be studied to evaluate the overall outcomes of the patient with respect to the appearance of mixed-field reaction in the posttransplant phase.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Harmening DM, Firestone D. In: Harmening DM. Modern Blood Banking and Transfusion Practices. 5th ed. Philadelphia, PA (USA): F.A. Davis Company; 2005.  Back to cited text no. 2
    
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Gajewski JL, Johnson VV, Sandler SG, Sayegh A, Klumpp TR. A review of transfusion practice before, during, and after hematopoietic progenitor cell transplantation. Blood 2008;112:3036-47.  Back to cited text no. 3
    
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Seebach JD, Stussi G, Passweg JR, Loberiza FR Jr., Gajewski JL, Keating A, et al. ABO blood group barrier in allogeneic bone marrow transplantation revisited. Biol Blood Marrow Transplant 2005;11:1006-13.  Back to cited text no. 4
    
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Shokrgozar N, Tamaddon G. ABO blood grouping mismatch in hematopoietic stem cell transplantation and clinical guides. Int J Hematol Oncol Stem Cell Res 2018;12:322-8.  Back to cited text no. 5
    
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Worel N. ABO-Mismatched allogeneic hematopoietic stem cell transplantation. Transfus Med Hemother 2016;43:3-12.  Back to cited text no. 6
    
7.
Basu S, Dhar S, Mishra D, Chandy M. Clinico-serologic co-relation in bi-directional ABO incompatible hemopoietic stem cell transplantation. Asian J Transfus Sci 2015;9:181-4.  Back to cited text no. 7
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8.
Santiago M, Freiría C, Villalba A, Gómez I, Carpio N, Sanz G, et al. Immunohaematological events related to changes in haematic and seric ABO group in patients undergoing haematopoietic stem cell transplantation with major ABO mismatch. Transfus Med 2019;29:136-7.  Back to cited text no. 8
    
9.
Rowley SD, Donato ML, Bhattacharyya P. Red blood cell-incompatible allogeneic hematopoietic progenitor cell transplantation. Bone Marrow Transplant 2011;46:1167-85.  Back to cited text no. 9
    
10.
Lapierre V, Kuentz M, Tiberghien P. Allogeneic peripheral blood hematopoietic stem cell transplantation: Guidelines for red blood cell immuno-hematological assessment and transfusion practice. Bone Marrow Transplant 2000;25:507-12.  Back to cited text no. 10
    
11.
Chowdhury F, Dawson H, Robertson B. When do mixed field reactions appear in major and bi–directional ABO-incompatible stem cell transplants?. Vox Sang 2018;2:287.  Back to cited text no. 11
    



 
 
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