Massive delayed hemolysis following peripheral blood stem cell transplantation with minor ABO incompatibility

Abstract

After hematopoietic stem cell transplantation, delayed immune hemolysis may occur when donor-derived B lymphocytes carried with the graft produce immune antibodies against the recipient's incompatible red cells. We report the occurrence of this syndrome in the context of minor blood group incompatibility between donor and recipient after peripheral blood stem cell (PBSC) transplantation. On day 12 post-transplant there was abrupt onset of hemolysis necessitating supportive treatment with hydration and transfusions. Because, as compared to bone marrow, PBSC grafts are enriched with lymphocytes, more frequent and intense delayed immune hemolysis may be anticipated when using PBSC. This complication is described most often when cyclosporine alone is used for immunosuppression following the graft. The addition of methotrexate, which with CyA forms the classic regimen for the prevention of graft-vs-host disease, may diminish the frequence and severity of this adverse reaction.

Hematopoietic stem cell transplantation between red cell incompatible donor–recipient pairs

“…Authors of several recently published case reports of hemolysis occurring after minor or bidirectional ABO-incompatible PBSC transplantation suggest that PBSC recipients are at greater risk of this complication than are marrow recipients, and that both the frequency of occurrence and severity of the hemolysis may be explained by the much greater number of lymphocytes contained in a PBSC inoculum. [17][18][19][20][21] However, an increased risk of delayed hemolysis after PBSC transplantation has not been observed by this author for a large series of patients, 22 but these patients received methotrexate or similar medication as part of the GVHD regimen.…”

Delayed massive immune hemolysis mediated by minor ABO incompatibility after allogeneic peripheral blood progenitor cell transplantation

“…[8][9][10][11][12] Most cases occurred in the context of the transplant of group A PBPCs to group O recipients (Table 2). Although it theoretically could further increase the risk of hemolysis, a high antibody titer in the donor does not appear to be required for this to happen.…”

“…[8][9][10][11][12] Two additional considerations may have accentuated the phenomenon in our patient: 1) a gestational sensitization and 2) a high lymphocyte content in the graft. This type of hemolytic reaction could be minimized by the inclusion of methotrexate in the program of GVHD prophylaxis, as well as by the elimination of B-lymphocytes from the graft-for instance, through CD34 selection.…”

“…Laurencet Oziel Moog Bornhaüser Our patient et al 8 et al 9 et al 10 et al 11 et al 12 Disease * AML = acute myeloblastic leukemia; MM = multiple myeloma; ALL = acute lymphoblastic leukemia; CML = chronic myelogenous leukemia ; Cy = cyclophosphamide; Bu = busulfan; TBI = total body irradiation; MTX = methotrexate; mPDN = methylprednisolone; MOF = multi-organ failure; PMNs = polymorphonuclear neutrophils ; LDH = lactate dehydrogenase.…”

Allogeneic peripheral blood hematopoietic stem cell transplantation: guidelines for red blood cell immuno-hematological assessment and transfusion practice

“…7 In addition, several potentially lethal cases of severe cases of acute intra-vascular hemolysis have been described after PBSCT. [8][9][10][11][12][13] These are due to the production of donorderived antibodies (Ab) directed against red blood cell (RBC) antigens (Ag) present on recipient RBC and not on donor RBC ('minor' ABO incompatibility). This suggests an influence of the HSC graft on post-transplantation immuno-hematological (IH) reconstitution.…”