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Transfusion Management of Patients Undergoing Hematopoietic Stem Cell and Solid Organ Transplantation
Transfusion in Patients Undergoing Hematopoietic Stem Cell Transplantation
Human leukocyte antigen (HLA) compatibility is of greater importance than ABO compatibility in donor selection for HSC transplantation (HSCT). As such, ABO incompatibility may be present in up to 50% of donor/recipient HSCT pairs. Major ABO incompatibility occurs when the recipient expresses an antibody to A or B antigen present on the donor cells. Minor ABO incompatibility occurs when the donor has an antibody to A or B antigen present on recipient cells. The type of ABO incompatibility must be considered for transfusion product selection in the pretransplant, peritransplant, and posttransplant periods. Other considerations for predicting the duration of needed transfusion support include the source of donor HSCs and the type of recipient preparative conditioning.
Product Selection
Leukoreduction
Leukocyte reduction of RBCs and platelets decreases febrile nonhemolytic transfusion reactions, transmission of viruses such as cytomegalovirus (CMV), and HLA alloimmunization. Therefore, it is recommended that HSCT recipients receive leukoreduced products.
Cytomegalovirus Safe Products
HSCT recipients are susceptible to multiple viruses, and thus strategies to minimize transfusion transmitted viral transmission are recommended. Leukoreduced products are considered “CMV safe” for transplant recipients, and the approach of selecting both leukoreduced and CMV seronegative products is not necessary.
Irradiation
HSCT recipients are considered at risk for transfusion-associated graft versus host disease (TA-GVHD) and should receive irradiated cellular blood products (i.e., red blood cell, platelet, and granulocyte transfusions). Unlike GVHD associated with transplantation, TA-GVHD is nearly uniformly fatal due to bone marrow involvement producing pancytopenia, as well as skin, liver, and intestinal involvement.
ABO/RhD Compatibility
Careful selection of compatible blood components is required in the pre-, peri-, and posttransplant period ( Table 53.1 ). For RhD mismatched HSCTs, some centers provide RhD negative RBCs regardless of the direction of the mismatch to prevent anti-D alloimmunization.
Table 53.1
Transfusion Support for Patients Undergoing Hematopoietic Stem Cell Transplantation According to the ABO Incompatibility and the Stage of the Transplant
Modified from Fung, M. K., Eder, A. F., Spitalnik, S. L., & Westhoff, C. M. (Eds.). (2017). Technical manual (19th ed.). Bethesda, MD: AABB Press, with permission.
| Type of Incompatibility | Transplant Stage | ABO Blood Group Selection | |
|---|---|---|---|
| RBCs | Platelets a /Plasma | ||
| Major incompatibility | Preparative regimen | Recipient | Donor |
| Transplantation | Recipient | Donor | |
| Recipient antibodies detected | Recipient | Donor | |
| Recipient antibodies no longer detected | Donor | Donor | |
| Minor incompatibility | Preparative regimen | Donor | Recipient |
| Transplantation | Donor | Recipient | |
| Recipient cells circulating | Donor | Recipient | |
| Recipient cells no longer circulating | Donor | Donor | |
| Bidirectional incompatibility | Preparative regimen | Group O | Group AB |
| Transplantation | Group O | Group AB | |
| Recipient antibodies detected/recipient cells circulating | Group O | Group AB | |
| Recipient antibodies no longer detected/recipient cells no longer circulating | Donor | Donor | |
a Because of a short shelf life, and the generally limited availability of group AB platelets, it may not always be possible to provide identically matched ABO platelet products, as outlined in this table. In some instances, blood banks and transfusion services may consider providing either a limited number of units of ABO mismatched platelets per day or ABO mismatched units that have been volume reduced to diminish plasma content.
Red Blood Cell Transfusion
Many HSCT recipients are transfused at threshold hematocrits of 21%–25%, with few studies to date investigating the optimal transfusion threshold. A recent subanalysis of oncology patients in the platelet dosing trial showed that a hematocrit <25% was associated with an increased risk of bleeding (OR 1.29). The end goals of transfusion must be taken into consideration while awaiting future trials to refine best practices for RBC transfusion thresholds in HSCT recipients.
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