Late onset haemolysis and red cell autoimmunisation after allogeneic bone marrow transplant

Abstract

Summary:would be expected for non-BMT patients. The patients reported here fall into two groups, an early onset group associated with cold autoantibodies and a late onset group We reviewed the medical records of 293 patients who underwent allogeneic bone marrow transplants at the associated with warm antibodies. In the early group the antibodies occurred between 2 to 8 months and in the late Hammersmith Hospital between 1989 and 1994. There was clinical evidence of an autoimmune reaction against onset group between 6 and 18 months post-transplant. We discuss the relationship between these phenomena and the red cells in nine patients. Seven of these patients had significant haemolysis; the other two had red cell autorole of factors such as GVHD, relapse, CMV and immunosuppression and also the association with the regenerating agglutination. Haemolysis was resistant to treatment in three cases. Six of the nine patients had monoclonal Ig immune system following BMT. bands identified within 1 year of transplant. The autoimmune reaction could be classified broadly into two types: an early onset type (n = 4) beginning 2 to 8Patients and methods months post-transplant associated with a cold antibody, and a late onset type (n = 5) beginning 6 to 18 months From the 293 patients who underwent allogeneic BMT at post-transplant associated with warm antibodies. The the Hammersmith Hospital, we identified nine patients with predominant antibody in the two categories described documented anti-red cell autoantibodies (red cell autoimmay reflect the kinetics of immune reconstitution postmunisation, RCAI). These patients were identified because transplant, since serum IgM levels typically return to they had clinically evident haemolysis (falling Hb with normal 2 to 6 months post-transplant, while IgG levels elevated bilirubin and reticulocytosis) or blood film abnormay not reach normal levels until 12-18 months postmality (eg agglutination). Patient and BMT details are transplant. We speculate that unbalanced reconstitution shown in Table 1. Two donor-recipient pairs had minor of B and T cell lymphopoiesis post-transplant may fav-ABO mismatch, one a major and one a bidirectional ABO our emergence of oligoclonal proliferation and that mismatch. All were matched for Rh D type. Haemolytic some of the resulting antibodies may have activity episodes attributable to ABO and Rh incompatibility are against red cells. not included in this report. One of the cases (No. 4) has

Autoimmune cytopenias after umbilical cord blood transplantation in adults with hematological malignancies: a single-center experience

“…2,13,14 Only in the study by Page et al, 15 a substantially higher frequency was reported; however, this study focused on very young infants that were transplanted for nonmalignant diseases. These two factors were recently associated with an increased risk of autoimmune disorders after UCBT.…”

“…This is surprising and seems to be different to what was previously reported. In fact, most series have described a predominance of IgG warm antibodies directed against antigens of the rhesus system, 14,19,20 whereas Chen et al 13 suggested that the presence of IgM antibodies was restricted to AIHA with early onset. We do not have a definite explanation for the above mentioned findings, but they could be due to a delayed and singular humoral reconstitution after UCBT compared with that seen with BMT.…”

Successful donor-lymphocyte infusion for extreme immune-hemolysis following unrelated BMT in a patient with X-linked chronic granulomatous disease and McLeod phenotype

“…Autoimmune hemolysis is reported [4][5][6][7][8] to occur at a median of 7 months post transplant, 40/56 AIHA were of warm-type IgG, remission of hemolysis was reported in only 16 patients (pharmacological treatment [4][5][6][7][8] ) and in six patients who received a second hematopoietic SCT or DLI 4,8 for disease relapse or graft failure. AIHA occurred exclusively 4,5,8 or preferentially 6,7 in unrelated hematopoietic SCT.…”

“…AIHA occurred exclusively 4,5,8 or preferentially 6,7 in unrelated hematopoietic SCT. Children o10 years and children transplanted for metabolic disorders had an increased risk for AIHA, 4 as had adults with extensive chronic GVHD, 5,7 whereas T-cell depletion, ABO mismatch and CMV status were not risk factors.…”

Dramatic response to rituximab in a child with severe cold autoimmune hemolytic anemia arising after allogeneic hematopoietic SCT

“…Compared with the incidence of one to two cases per 100 000 in the normal adult population, 1 AIHA is estimated to occur in 3-5% of adult HSCT patients. 2,3 In the largest study of pediatric patients to date, published in 2004, the incidence of all types of AIHA was 6% at 1 year after transplant. 4 The cause for this increased incidence post transplant is poorly understood, but is likely because of an incomplete reconstitution of the immune system and immune dysregulation.…”