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Wiersum-Osselton JC, Slomp J, Frederik Falkenburg JH, Geltink T, van Duijnhoven HLP, Netelenbos T, Schipperus MR. Guideline development for prevention of transfusion-associated graft-versus-host disease: reduction of indications for irradiated blood components after prestorage leukodepletion of blood components. Br J Haematol 2021; 195:681-688. [PMID: 34490619 DOI: 10.1111/bjh.17822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/29/2022]
Abstract
Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare, commonly fatal complication of transfusion preventable by irradiation of blood units. The revision of the Dutch transfusion guideline addressed the question whether irradiation is still necessary if blood components are prestorage leukodepleted. We searched for published cases of TA-GVHD following transfusion of prestorage leukodepleted blood and through contacting haemovigilance systems. Six presumed cases were found, dating from 1998 to 2013. Four out of six patients had received one or more non-irradiated units despite recognised indications for irradiated blood components. In the countries providing information, over 50 million prestorage leukodepleted, non-irradiated, non-pathogen-reduced cellular components were transfused in a 10-year period. Potential benefits of lifting indications for irradiation were considered. These include reduced irradiation costs (€ 1.5 million annually in the Netherlands) and less donor exposure for neonates. Findings were presented in an invitational expert meeting. Recommendations linked to human leukocyte antigen similarity between donor and recipient or intra-uterine transfusion were left unchanged. Indications linked to long-lasting deep T-cell suppression were defined with durations of 6 or 12 months after end of treatment (e.g. autologous or allogeneic stem cell transplantation). Need for continued alertness to TA-GVHD and haemovigilance reporting of erroneous non-irradiated transfusions was emphasised.
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Affiliation(s)
- Johanna C Wiersum-Osselton
- TRIP (Transfusion and Transplantation Reactions in Patients) Hemovigilance and Biovigilance Office, Leiden, The Netherlands
| | | | | | - Tessa Geltink
- Knowledge Institute of Medical Specialists, Utrecht, The Netherlands
| | | | | | - Martin R Schipperus
- Department of Hematology, University Medical Center UMCG, Groningen, The Netherlands
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Elliot J, Narayan S, Poles D, Tuckley V, Bolton-Maggs PHB. Missed irradiation of cellular blood components for vulnerable patients: Insights from 10 years of SHOT data. Transfusion 2020; 61:385-392. [PMID: 33219533 PMCID: PMC7894557 DOI: 10.1111/trf.16189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 12/17/2022]
Abstract
Background Irradiation of cellular blood components is recommended for patients at risk of transfusion‐associated graft‐vs‐host disease (TA‐GvHD). Prestorage leucodepletion (LD) of blood components is standard in the UK since 1999. Study Design and Methods Analysis of 10 years' reports from UK national hemovigilance scheme, Serious Hazards of Transfusion (2010‐2019), where patients failed to receive irradiated components when indicated according to British Society for Haematology guidelines (2011). Results There were 956 incidents of failure to receive irradiated components all due to errors. One hundred and seventy two incidents were excluded from analysis, 125 of 172 (72.7%) because of missing essential information. No cases of TA‐GvHD were reported in this cohort. The 784 patients received 2809 components (number unknown for 67 incidents). Most failures occurred in patients treated with purine analogues (365) or alemtuzumab (69), or with a history of Hodgkin lymphoma (HL) (192). Together these make up 626 of 784 (79.9%). Poor communication is an important cause of errors. Conclusion Leucodepletion appears to reduce the risk for TA‐GvHD. None of 12 cases of TA‐GvHD reported to SHOT prior to introduction of LD occurred in patients with conditions recommended for irradiated components by current guidelines. Irradiation indefinitely for all stages of HL is not based on good evidence and is a difficult guideline to follow. Further research on long‐term immune function in HL is required. Variation between different national guidelines reflects the very limited evidence.
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Affiliation(s)
- Johnathon Elliot
- Serious Hazards of Transfusion Office, Manchester Blood Center, UK
| | - Shruthi Narayan
- Serious Hazards of Transfusion Office, Manchester Blood Center, UK
| | - Debbi Poles
- Serious Hazards of Transfusion Office, Manchester Blood Center, UK
| | - Victoria Tuckley
- Serious Hazards of Transfusion Office, Manchester Blood Center, UK
| | - Paula H B Bolton-Maggs
- Serious Hazards of Transfusion Office, Manchester Blood Center, UK.,Faculty of Biology, Medicine and Health, University of Manchester, UK
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Zhao XF, Lin DD, Li N, Wu JS, Guo QL, Wang L. Diagnosis and treatment of acute graft-versus-host disease after liver transplantation: A report of 11cases. Transpl Immunol 2020; 62:101307. [DOI: 10.1016/j.trim.2020.101307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 12/19/2022]
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Foukaneli T, Kerr P, Bolton‐Maggs PH, Cardigan R, Coles A, Gennery A, Jane D, Kumararatne D, Manson A, New HV, Torpey N. Guidelines on the use of irradiated blood components. Br J Haematol 2020; 191:704-724. [DOI: 10.1111/bjh.17015] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Theodora Foukaneli
- NHS Blood and Transplant Cambridge Cambridge UK
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Paul Kerr
- Department of Haematology Royal Devon & Exeter NHS Foundation Trust Exeter UK
| | - Paula H.B. Bolton‐Maggs
- Faculty of Biology, Medicine and Health University of Manchester Manchester UK
- Serious Hazards of Transfusion Office Manchester Blood Centre Manchester UK
| | - Rebecca Cardigan
- Haematology University of Cambridge Cambridge Biomedical Campus Cambridge UK
| | - Alasdair Coles
- Clinical Neuroscience University of Cambridge Cambridge Biomedical Campus Cambridge UK
| | - Andrew Gennery
- Department of Paediatric Immunology Institute of Cellular Medicine Newcastle University Cambridge Newcastle upon Tyne UK
| | - David Jane
- Department of Medicine University of Cambridge Cambridge Biomedical Campus Cambridge Cambridge UK
| | - Dinakantha Kumararatne
- Department of Clinical Immunology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Ania Manson
- Department of Clinical Immunology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Helen V. New
- NHS Blood and Transplant London UK
- Department of Haematology Imperial College London London UK
| | - Nicholas Torpey
- Department of Clinical Nephrology and Transplantation Cambridge University Hospitals NHS Foundation Trust Cambridge UK
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Salomao M, Dorritie K, Mapara MY, Sepulveda A. Histopathology of Graft-vs-Host Disease of Gastrointestinal Tract and Liver: An Update. Am J Clin Pathol 2016; 145:591-603. [PMID: 27247365 DOI: 10.1093/ajcp/aqw050] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Graft-vs-host disease (GVHD) is a donor T-cell-mediated disorder affecting the recipient's skin, gastrointestinal tract, lungs, and liver. It complicates up to 70% of hematopoietic cell transplantation and is associated with high morbidity and mortality rates. METHODS An extensive review of the literature has been performed to include the most current consensus on the histopathologic diagnosis of gastrointestinal and liver GVHD. RESULTS In this review, we present an overview of GVHD, with emphasis on the histopathologic evaluation of gastrointestinal and liver specimens, including the most important differential diagnoses and possible pitfalls. CONCLUSIONS Histopathologic examination remains the mainstay of diagnosis of gastrointestinal and liver GVHD and is interpreted in conjunction with clinical and laboratory data.
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Affiliation(s)
- Marcela Salomao
- From the Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY;
| | - Kathleen Dorritie
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center and the University of Pittsburgh Cancer Institute, Pittsburgh, PA
| | - Markus Y Mapara
- Department of Medicine, Division of Hematology/Oncology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Antonia Sepulveda
- From the Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
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Treleaven J, Gennery A, Marsh J, Norfolk D, Page L, Parker A, Saran F, Thurston J, Webb D. Guidelines on the use of irradiated blood components prepared by the British Committee for Standards in Haematology blood transfusion task force. Br J Haematol 2010; 152:35-51. [DOI: 10.1111/j.1365-2141.2010.08444.x] [Citation(s) in RCA: 160] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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van der Mast BJ, van den Dorpel MA, Drabbels JJM, Claas FHJ, Weimar W. Transfusion-associated graft vs. host disease after donor-specific leukocyte transfusion before kidney transplantation. Clin Transplant 2003; 17:477-83. [PMID: 14703935 DOI: 10.1034/j.1399-0012.2003.00074.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Transfusion-associated graft vs. host disease (TA-GVHD) is a well-known but rare complication that follows infusion of histo-incompatible lymphoid cells, often seen in individuals with impaired cellular immunity. However, we present here a case report of fatal TA-GVHD in a 'presumed' immunocompetent patient after transfusion of a freshly isolated buffycoat from a relative as part of our protocol to prepare the patient for living-related kidney transplantation. To confirm the diagnosis of TA-GVHD, a polymerase chain reaction was used to detect donor cells in various affected tissues. Furthermore, the immune reactivity of the patient against donor and vice versa was tested on samples taken before transfusion using limiting dilution assays. Our patient received a transfusion with blood from a donor who was homozygous at the human leukocyte antigen (HLA) class I loci. Despite incompatibility for HLA class II, infused donor T lymphocytes were not rejected and became engrafted. The patient did not have cytotoxic T lymphocytes to reject the donor cells. DNA polymorphism studies on several organ biopsies confirmed the presence of infiltrating cells of donor origin. This report illustrates the possibility, in the general patient population, of developing TA-GVHD from whole blood transfusion. In the case of pre-transplant blood transfusion, the patient and donor have to be HLA-typed and special care should be taken in the situation of donor homozygosity for HLA class I, even in the presence of HLA class II incompatibility. Protocols in which donor-specific blood or bone marrow transfusions are given in an attempt to modulate the immune system should exclude these combinations.
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Munro LR, Culligan DJ, Grant A, Johnston PW, Watson HG. Transfusion-associated graft-versus-host disease in a patient with Waldenstrom's macroglobulinaemia. Vox Sang 2002; 83:279-81. [PMID: 12366774 DOI: 10.1046/j.1423-0410.2002.00202.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Routine irradiation of cellular blood products is not presently recommended for patients with non-Hodgkin's lymphoma (NHL). MATERIALS AND METHODS We report the case of a 72-year-old-man with Waldenstrom's macroglobulinaemia who developed transfusion-associated graft-versus-host disease (TA-GvHD) 13 days following a non-irradiated red cell transfusion. RESULTS The patient had not previously received purine analogues and none of the donors was homozygous for a human leucocyte antigen (HLA) haplotype that was shared by the recipient. Therefore, his only apparent risk factor was lymphoplasmacytoid NHL. CONCLUSIONS This case further strengthens the argument that NHL per se is a risk factor for TA-GvHD and supports the proposal that the guidelines for prophylactic irradiation of cellular blood products be extended to include all cases of NHL.
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Affiliation(s)
- L R Munro
- Department of Haematology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK.
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Affiliation(s)
- Marlis L Schroeder
- Department of Pediatrics and Child Health, University of Manitoba, 2011-675 McDermot Avenue, Winnipeg, Manitoba, Canada R3E 0V9.
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Gelly KJ, Kerr R, Rawlinson S, Norris A, Bowen DT. Transfusion-associated graft vs. host disease in a patient with high-grade B-cell lymphoma. Should cellular products for patients with non-Hodgkin's lymphoma be irradiated? Br J Haematol 2000; 110:228-9. [PMID: 10931004 DOI: 10.1046/j.1365-2141.2000.02176.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We present the case of a 64-year-old man who died from transfusion-associated graft vs. host disease (TA-GVHD) having been treated 2 years earlier for a high-grade, non-Hodgkin's lymphoma (NHL). We suggest that he was at increased risk of developing TA-GVHD as a result of the NHL and its subsequent treatment, and propose that patients with NHL should be added to those 'at risk' groups who receive irradiated cellular blood components.
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Affiliation(s)
- K J Gelly
- Department of Haematology and ESBTS, Ninewells Hospital, Dundee, UK.
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Chapman J, Finney RD, Forman K, Kelsey P, Knowles SM, Napier JAF, Phillips P, Mitchell R, Murphy MF, Waters AH, Wood JK, Williamson LM, Baglin T, Copplestone A, Dendy P, Forman K, Gibson B, Knowles S, Morgan G, Norfolk D, Richards A, Todd A, Warwick R, Webb D. Guidelines on gamma irradiation of blood components for the prevention of transfusion-associated graft-versus-host disease. Transfus Med 1996. [DOI: 10.1111/j.1365-3148.1996.tb00078.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Transfusion-associated graft-versus-host disease is a rare but usually fatal complication of transfusion of cellular blood components, caused by multiorgan engraftment and proliferation of donor T lymphocytes. The classical features of skin rash, diarrhoea and hepatitis, along with striking bone-marrow failure, are seen 1-2 weeks after transfusion. Although early reports described the condition only in immunosuppressed individuals, sharing of an HLA haplotype between donor and an immunocompetent recipient can also result in transfusion-associated graft-versus-host disease. The condition is entirely preventable by gamma irradiation of cellular blood components to 25 Gy, although this results in some reduction of red-cell viability and increased loss of red-cell potassium. The major indications for irradiated blood components include bone marrow/stem cell auto- or allografting, Hodgkin's disease, intrauterine transfusions, and transfusions from relatives or HLA-selected platelet donors.
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Affiliation(s)
- L M Williamson
- Division of Transfusion Medicine, University of Cambridge and East Anglian Blood Centre, UK
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Hull RJ, Bray RA, Hillyer C, Swerlick RA. Transfusion-associated chronic cutaneous graft-versus-host disease. J Am Acad Dermatol 1995; 33:327-32. [PMID: 7615879 DOI: 10.1016/0190-9622(95)91427-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Transfusion-associated graft-versus-host disease (TAGVHD) occurs in immunocompromised persons who receive nonirradiated blood products containing immunologically competent donor lymphocytes. TAGVHD occurs almost exclusively as an acute illness and has a very high mortality rate. We describe a patient with a long history of non-Hodgkin's lymphoma in whom acute TAGVHD developed after transfusion of packed red blood cells from two unrelated donors. TAGVHD developed despite pretreatment of the transfused units with white blood cell filters. The patient survived and subsequently had clinical manifestations typical of chronic cutaneous graft-versus-host disease. HLA phenotyping studies suggested that elements from both transfusion donors engrafted. TAGVHD is a rare but probably underdiagnosed disorder that, although usually fatal, may evolve into chronic graft-versus-host disease. Treatment of blood products with white blood cell filters does not appear adequate to prevent TAGVHD.
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Affiliation(s)
- R J Hull
- Department of Medicine, Emory University School of Medicine, GA 30322, USA
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van der Mast BJ, Hornstra N, Ruigrok MB, Claas FH, van Rood JJ, Lagaaij EL. Transfusion-associated graft-versus-host disease in immunocompetent patients: a self-protective mechanism. Lancet 1994; 343:753-7. [PMID: 7907730 DOI: 10.1016/s0140-6736(94)91836-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare but hazardous complication caused by transfusion of leucocyte-containing blood. It is not clear why some patients are at risk for TA-GVHD, but others are not. We studied TA-GVHD in immunocompetent individuals by looking at donor-anti-host reactivity after transfusion of leucocyte-containing blood. We tested reactivity in 62 donor-recipient combinations in vitro before and at different times after blood transfusion with mixed lymphocyte culture. One patient was studied in more detail. Reactivity of blood donors against hosts gradually decreased after blood transfusion. This decrease significantly correlated with time (p < 0.001). Studies in a single patient showed that absence of donor-host reactivity was due to host T cells that inhibited the response. These data indicate that an active mechanism exists in immunocompetent individuals which inhibits the graft-versus-host reaction of the donor against the host. This mechanism might be exploited in organ transplantation by pre-transplant blood transfer.
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Affiliation(s)
- B J van der Mast
- Department of Immunohaematology and Blood Bank, University Hospital Leiden, Netherlands
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Kobayashi H, Kitano K, Kishi E, Hara K, Ishida F, Saito H, Ota M, Furuta S. Transfusion-associated graft-versus-host disease in an immunocompetent patient following accidental injury. Am J Hematol 1993; 43:51-3. [PMID: 8317463 DOI: 10.1002/ajh.2830430112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We report a case of transfusion-associated graft-vs.-host disease (TA-GVHD) in a previously healthy, 58 year old Japanese man following an accidental injury. Despite intensive treatment, the patient died 22 days after the transfusion. Although many cases of fatal TA-GVHD have been reported in immunocompetent patients, only two are known to have developed this disorder unrelated to a surgical procedure. This is the first such case to be confirmed by HLA typing. Our report suggests that TA-GVHD can occur even in a healthy, immunocompetent recipient. Thus, it seems necessary to establish guidelines for the irradiation of cellular blood products before transfusion.
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Affiliation(s)
- H Kobayashi
- Second Department of Internal Medicine, Shinshu University School of Medicine, Nagano-Ken, Japan
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