Transplantation-mediated alloimmune thrombocytopenia: Guidelines for utilization of thrombocytopenic donors

Abstract

Transplantation-mediated alloimmune thrombocytopenia (TMAT) is donor-derived thrombocytopenia following solid-organ transplantation. To date, no clear consensus on the appropriateness of organ utilization from cadaver donors with a history of idiopathic thrombocytopenia purpura (ITP) has emerged. Herein is reported a devastating case of TMAT following liver transplantation utilizing an allograft from a donor with ITP that resulted in allograft failure. The literature is reviewed in this context to propose preliminary guidelines regarding utilization of allografts from cadaver donors with a history of ITP. Liver Transpl 14:1803-1809, 2008. © 2008 AASLD. Received January 22, 2008; accepted April 15, 2008.Donor-derived autoimmune disease following solidorgan transplantation has been described. 1-3 Morbidity results from allograft passenger lymphocytes remaining functional following transplantation. 1 Idiopathic thrombocytopenia purpura (ITP) is an autoimmune disorder characterized by autoantibody-mediated autologous platelet destruction. The principal antigens stimulating autoantibody production include platelet membrane-bound glycoproteins IIb and IIIa of the fibrinogen receptor, glycoprotein Ib/V/IX of the von Willebrand factor complex, and the platelet adhesin I glycoprotein. 4-11 Phagocytosis of autoantibody-coated platelets by the reticuloendothelial system incites thrombocytopenia. 4,12 Donor-derived thrombocytopenia from solid-organ transplantation is termed transplantation-mediated alloimmune thrombocytopenia (TMAT). 1,3 Previous authors have demonstrated that donor-origin antibodies produced by passenger B-cells are directed against the recipient platelet alloantigen [human platelet antigen 1a (HPA-1a)]. 1,3,8 A review of the English literature has revealed 3 cases of TMAT following orthotopic liver transplantation (OLT) 1-3 ; however, the implications, management, and outcomes of OLT recipients diagnosed with TMAT vary widely. No clear consensus on the appropriateness of organ utilization from a cadaver donor with a history of ITP has emerged.We report a devastating case of TMAT following OLT using an allograft from a donor with ITP. Thrombocytopenia was resistant to medical and surgical therapy, resulting in allograft failure from a massive subcapsular hematoma (Fig. 1). We review the literature in this context to

Cynomolgus monkeys are successfully and persistently infected with hepatitis E virus genotype 3 (HEV-3) after long-term immunosuppressive therapy

“…Regarding haematological features, the WBC count was not reduced by tacrolimus treatment, as expected [45] and platelets account could not be associated with HEV chronicity, as previously reported in SOT patients infected with HEV [19]. Mild to moderate thrombocytopenia after transplantation can be observed due to many factors, such as reduced hepatic thrombopoietin production, allograft sequestration, hypersplenism, haemorrhage, heparin-induced thrombocytopenia, immunologic reactions, hemolysis, drugs, infections, and sepsis [46, 47]. However, in the present study, the animal model was not submitted to the surgical procedures that could result in mild to moderate thrombocytopenia in SOT patients.…”

Severe thrombocytopenia in liver transplantation

“…Many factors can contribute, such as reduced hepatic thrombopoietin production, allograft sequestration, hypersplenism (1,3,4), hemorrhage, heparin-induced thrompocytopenia, immunologic reactions, hemolysis, drugs, infections, platelet consumption secondary to DIC and sepsis (3,4). However most of these factors are not usually the cause of severe thrombocytopenia.…”

“…The pre-LT ultrasound showed signs of cirrhosis, with partial thrombosis of the portal vein, splenomegaly and ascites. The platelet count was 90.000/mm 3 . The past medical history of the patient included type 2 diabetes mellitus, and hysterectomy with bilateral oophorectomy.…”

“…The HCV viral load was 11,000,000 UI/mL and the CMV viral load was undetectable in a CMV PCR test. On POD 14 the platelet count grew up to 12.000/mm 3 . At this moment the treatment with immunoglobulins was discontinued, the corticosteroid doses were reduced and the tacrolimus therapy was reinitiated.…”

Genetic, hematological, and immunological disorders transmissible with liver transplantation

“…ITP is a chronic autoimmune disorder characterized by the destruction of autologous platelets by autoantibodies directed against platelet‐surface constituents. ITP commonly manifests as asymptomatic thrombocytopenia, muco‐cutaneous bleeding, and/or bruising . The incidence of post‐LT ITP is approximately 0.7% .…”