Passenger lymphocyte syndrome in a bidirectional ABO-mismatched renal transplant

Abstract

Passenger lymphocyte syndrome (PLS), a subtype of graft-versus-host disease, is due to the production of antibodies by the donor “passenger” B lymphocytes against recipient's red cells. It is a rare disorder encountered mostly in ABO blood group-mismatched solid organ transplantation. The present case report illustrates the clinical presentation and the mode of management of PLS in a bidirectional ABO-incompatible renal transplantation. A 43-year-old male diagnosed with chronic kidney disease Stage 5-D (diabetic nephropathy) Type-2 hypertension with ischemic heart disease underwent ABO bidirectional-mismatched renal transplantation. The blood group of the patient was B Rh D positive and that of the donor (patient's wife) was A Rh D positive. In the pretransplantation phase, immunoglobulin G anti-A titer was 64 by column agglutination method, which was subsequently brought down to 4 by therapeutic plasma exchange and immunosuppression. Good graft function was established in the posttransplantation phase, but a significant drop in the hemoglobin (Hb) was noted. A fall in Hb, peripheral smear findings suggestive of hemolysis, and direct antiglobulin test positivity along with raised lactate dehydrogenase suggested the diagnosis of PLS; the patient was managed successfully for the same by transfusion of O blood group packed red blood cell transfusion and immunosuppression. PLS is a rare but important cause of immune-mediated hemolytic anemia in ABO-mismatched transplants.

Reaching New Heights: A Comprehensive Study of Hand Transplantations in Korea after Institutionalization of Hand Transplantation Law

“…Although passenger lymphocyte syndrome is a rare complication resulting from ABO-mismatched organ transplantation, we were concerned about the possibility. 45 46 …”

Gastrointestinal involvement of passenger lymphocyte syndrome followed by minor ABO‐incompatible renal transplantation: A case report

“…TPE has been reportedly used for the treatment of PLS. 6,[15][16][17] However, a lack of clear clinical guidelines has been observed regarding the end point of TPE for the treatment of PLS. Based on the ideas of the pathogenic mechanism of PLS, donor-derived lymphocytes produced antibodies against the recipient's RBCs, resulting in hemolysis.…”

“…We managed the patient with TPE to deplete the circulating anti‐A IgG antibodies. TPE has been reportedly used for the treatment of PLS 6,15–17 . However, a lack of clear clinical guidelines has been observed regarding the end point of TPE for the treatment of PLS.…”