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2372 Part XIII: Transfusion Medicine Chapter 138: Blood Procurement and Red Cell Transfusion 2373

and/or minor HLA antigens that are present in the transplant organ. In recipient; these include TA-GVHD and passenger lymphocyte syn-
addition, all RBC and platelet transfusions should be irradiated as the drome (PLS). Another complication, pure red cell aplasia (PRCA),
risk for transfusion-associated graft-versus-host disease (TA-GVHD) occurs when the patient’s residual antibodies attack the transplanted
is high in HSCT patients (see section Transfusion-Associated-Graft- red cells. Standard transfusion reactions, such as allergic or febrile
versus-Host Disease below for more in-depth discussion of TA-GVHD). nonhemolytic reactions, are frequently seen in this heavily transfused
RBC engraftment is difficult to assess, but may be defined by the patient population; however, these “standard” transfusion reactions are
appearance of 1 percent reticulocytes in the peripheral blood, or as the discussed more fully later in this chapter in the section Adverse Effects
day of the last RBC transfusion, with no transfusion given in the follow- of Red Cell Transfusions.
ing 30 days. In general, engraftment time is shortest when hematopoi-
etic progenitor cells are obtained by apheresis (HPC-A), and greatest Major and Minor ABO Mismatches
when hematopoietic progenitor cells are obtained from umbilical cords Complications from ABO incompatibility depend upon whether a
(HPC-C) are used; however, considerable patient-to-patient variability major or minor ABO mismatch is present (see Table 138–6). A major
exists. Prolonged engraftment directly translates into higher transfusion mismatch occurs when the transplant contains RBCs that are incom-
rates for RBCs and platelets. patible with the recipient’s plasma. Conversely, a minor mismatch is
When an ABO incompatible transplant is used, group O red cells present when the donor plasma contains isohemagglutinins against the
are used to avoid incompatibility issues. The ABO type of plasma prod- recipient’s RBCs. Bidirectional transplants (e.g., group A transplant into
ucts may be different from the red cell type (Table 138–6). Once the group B recipient) carry both major and minor mismatches.
patient begins to produce “donor-type” erythrocytes, their blood type Major ABO Mismatch When a major ABO mismatched trans-
should be reassessed. The decision to switch a patient’s blood type is plant is given, immediate hemolysis may occur during the infu-
highly variable across institutions. In our hospital, when a patient is sion. This complication is more commonly seen when the HSCT is
RBC transfusion independent for 100 days, and no incompatible iso- derived from marrow, because more red cells are present; however,
hemagglutinins against the new RBC phenotype can be detected in two RBC depletion techniques have effectively eliminated this compli-
consecutive blood samples, the patient’s native blood type is switched to cation. Because HPC-A units contain a minimal volume of RBCs
the donor type for future transfusions. (8 to 15 mL), clinically significant cases of immediate hemolysis
have not been identified. Most HPC-C units are RBC-depleted
44
TRANSFUSION-RELATED COMPLICATIONS prior to cryopreservation, and the residual erythrocytes lyse during
There are transfusion-related complications that are specific to, or more cryopreservation, therefore immediate hemolysis is not a problem
frequently seen, in the HSCT population. Some of these complications with cord blood transplants.
arise when lymphocytes within the transplant are activated against the Preformed antibodies against non-ABO RBC antigens can remain
in a recipient’s peripheral circulation for many weeks after transplanta-
tion. These antibodies may cause lysis when engrafted cells begin to pro-
duce new RBC. Also chimeric patients may develop antibodies against
TABLE 138–6. Component Type Selection for Hematopoietic ABO or non-ABO RBC antigens, resulting in delayed hemolysis. When
Stem Cell Transplantations That Cross the ABO Barrier recipients have isohemagglutinins specific for the ABO type of the
Transplant Transfuse transplant, delayed erythrocyte engraftment and PRCA may ensue. This
is seen most frequently when group O patients receive a group A trans-
Mismatch Donor Recipient Red Blood Platelets*/ plant, or with bidirectional mismatches. PRCA develops when anti-
Type Type Cell Plasma
ABO antibodies destroy erythrocyte progenitor cells in the marrow.
Major A O O A, AB Minor Mismatches When lymphocytes within the HSCT recog-
mismatch nize the recipient RBCs as foreign, antibodies may be produced that are
B O O B, AB specific for ABO or minor RBC antigens. This PLS usually presents 7
to 14 days after the transplant with the abrupt onset of hemolysis. The
AB O O AB
hemolysis ranges from mild to severe, and may be intra- or extravascu-
AB A A, O AB lar, depending upon the nature of the antibody involved. These “pas-
AB B B, O AB senger lymphocytes” are reported most frequently in transplants that
use a group O donor with a group A recipient. Antibodies against
45
Minor O A O A, AB
mismatch minor RBC antigens are less frequently reported, and cause less-severe
hemolysis. 45
O B O B, AB In cases involving the ABO system, the Hgb level may drop precip-
O AB O AB itously. The laboratory signs of intravascular hemolysis, that is, hemo-
globinemia, hemoglobinuria and an elevated lactate dehydrogenase
A AB A, O AB
(LDH) should be used to follow the course of disease. In most cases a
B AB B, O AB DAT will be positive, unless all antibody bound cells have already been
Bidirectional A B O AB lysed. The hemolysis can persist as long as incompatible RBCs are pres-
mismatch ent, but usually subsides within 5 to 10 days. 45
B A O AB Nonmyeloablative conditioning regimens carry a greater risk
for PLS than when full ablation is used. Because HPC-A preparations
*Platelets stored in additive solution reduce the volume of incompat- carry a greater lymphocyte load when compared to hematopoietic cell
ible plasma transfused. concentrate-marrow (HPC-M) and hematopoietic cell concentrate-cord
Modified with permission from Cohn CS: Transfusion support issues (HPC-C) collections, recipients of peripheral blood stem cells are at an
in hematopoietic stem cell transplantation. Cancer Control 22(1): increased risk of developing PLS. The authors are not aware of a case of
52–59, 2015. PLS that has been reported with an umbilical cord stem cell transplant.

Kaushansky_chapter 138_p2365-2380.indd 2373 9/18/15 11:13 AM