Severe hemolytic anemia due to passenger lymphocytes after living‐related bowel transplant

Abstract

A severe hemolytic anemia due to PLS can occur in bowel transplantation. This complication should be considered when performing ABO-incompatible bowel transplant with a blood group O donor and an A or B recipient. Treatment with plasmapheresis, blood group O transfusion and rituximab has proved successful in our case.

Immune-mediated hemolytic anemia in children after liver and small bowel transplantation

“…Similarly, 2 case studies of hemolytic anemia after liver transplantation reported a less severe course of IHA. [4][5][6] After an unsuccessful initial treatment with methylprednisolone, the introduction of RX in the second week of IHA provided good control over the hemolysis in both cases. Unlike these case reports, for the children described in our report, there was no ABO incompatibility between the donors and the recipients, and the onset was later than the usual onset at 3 weeks.…”

“…1,2 The timing of the hemolysis with respect to transplantation and the clinical courses of the patients make PLS and bystander immune hemolysis unlikely; autoimmune hemolytic anemia is the most likely etiology. We suggest that a variety of investigations be carried out for such children suspected of having hemolysis according to the clinical circumstances; these investigations are described in Table 1. PLS was previously reported for small bowel transplantation 4 ; it occurred in the first week after living related small bowel transplantation (a blood group O donor and a blood group A recipient). The hemolysis was less aggressive than that seen in our patients and was well controlled by an O-negative red blood cell transfusion, double-volume plasmapheresis (twice), and a single dose of RX (an anti-CD20 monoclonal antibody) at 375 mg/m 2 .…”

Rituximab for passenger lymphocyte syndrome associated with allogeneic SCT

“…Only in the PLS case treated with rituximab, the duration of hemolysis lasted for 5 days and the number of PRBCs units transfused was seven. 5 Although the experience is very limited, these findings suggest that rituximab may be an effective therapy to minimize severe hemolysis associated with PLS. Further evaluation could better determine its efficacy and provide more insight into the mechanisms of action in this disease.…”

“…Rituximab has been successfully used in one pediatric solid organ transplantation case and in two pediatric cases of late onset hemolytic anemia. 5,9,10 Our patient displayed typical features of PLS for which rituximab, in addition to O þ PRBCs and steroids, aborted the massive intravascular hemolysis soon after its onset. MTX has also been shown to mitigate hemolysis secondary to PLS; however, pretreated patients with MTX and anti-thymocyte globulin still appear to be susceptible to the development of this clinical entity.…”

“…Immunocompetent donor B-lymphocytes transferred passively with the graft maintain their ability to generate antibodies, which bind to the recipient's RBCs causing hemolysis. [3][4][5][6] The treatment of PLS has been mainly supportive, with or without immunosuppression. 1,6 This report describes the first experience with the use of rituximab (Rituxan, Genentech, South San Francisco, CA, USA) for the treatment of PLS in an ASCT patient and reviews the accumulated data regarding the transfusion requirement for patients with PLS after ASCT.…”