Transfusion Therapy in Solid Organ Transplantation

Transfusion medicine and solid organ transplant - Update and review of some current issues

Transfusion medicine holds a place of prime importance in organ transplant surgeries. There is a huge demand of organs worldwide with long waiting periods before the organ is available for transplant. Currently the dependency on ABO and HLA matching has decreased considerably with the use of modern immunosuppressant drugs and transplant techniques. The greatest advance in clinical implementation of ABO-incompatible transplants came about through desensitization and isoagglutinin elimination techniques with immunoadsorption and anti-CD20 antibodies becoming the norm, and spleenectomy fading out. The implications and practices of transfusion medicine in organ transplant are also undergoing drastic changes. The practice of infusion of one unit of donor's blood preoperatively for immunomodulation is no longer practiced. Use of leuco-reduced products has shown decreasing trends of alloimmunization and graft rejection in cases of multiple surgeries related to organ transplants. Worldwide donor and recipient registry programmes are being setup and existing ones are being upgraded. Such a registry system has been opened in India for kidney transplant cases very recently. Due to such registry programmes the dependency on siblings and directed donations have decreased considerably. This review deals with some of the current issues contributing to the successful outcome of mismatched transplants and the changing concepts of transfusion medicine related to it.

Outcomes after identical and compatible orthotopic liver transplantation for fulminant hepatic failure: a single center experience in UK

To analyze the outcomes between identical and compatible liver transplantation (OLT) for fulminant hepatic failure (FHF) from September 1984 to November 2005. The patients were divided in three groups; group 1 (identical), group 2 (compatible) and group 3 (incompatible), according to the donor-recipient blood type matching. We analyzed several outcomes regarding mortality, patient and graft survival, incidence of acute graft rejection during the first postoperative month (30 days), incidence of biliary complications and indications of re-transplantation. We also analyzed the relationship of Coomb's positive test with postoperative hemolysis to all the above mentioned factors. During the study period, 168 males and 112 females underwent their first OLT for FHF, with 37.1% overall mortality and 42.1% overall graft failure rate. The results between group 1 (203 patients) and group 2 (73 patients) were comparable. A statistically significant difference was recorded in 1 year and overall graft survival between group 1 and group 2 (P = 0.049 and log-rank = 0.035 respectively). Coomb's positive test did not influence the outcomes. OLT in FHF can be safely carried out whether the donor organs are identical or compatible. Hemolysis (Coomb's positive test) after identical or compatible OLT does not influence the outcomes.

Determinants of red blood cell transfusions in a pediatric critical care unit: A prospective, descriptive epidemiological study*

OBJECTIVE

To determine the incidence and to characterize the determinants of red blood cell transfusions in critically ill children.

DESIGN

Prospective, descriptive epidemiologic study.

SETTING

A single-center, multidisciplinary, tertiary care level, university-affiliated, pediatric intensive care unit (PICU).

PATIENTS

Critically ill children.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 1,047 consecutive admissions over a 1-yr period, 985 were retained for study. At least one transfusion was given in 139 cases (14%). Incidence rate of transfusion was 304 transfusions/1,000 cases. Possible determinants of red blood cell transfusions were identified and prospectively monitored during PICU stay until a first transfusion event (transfused cases) or up until the time of death or discharge from PICU (nontransfused cases). Four significant determinants of a first red blood cell transfusion event were retained in the multivariate analysis (odds ratio, 95% confidence interval, p): a hemoglobin level <9.5 g/dL during PICU stay (13.26, 8.04-21.88, p < .001), an admission diagnosis of cardiac disease (8.07, 5.14-14.65, p < .001), an admission Pediatric Risk of Mortality score >10 (4.83, 2.33-10.04, p < .001), and the presence of multiple organ dysfunction syndrome during the stay (2.06, 1.18-3.57, p = .01).

CONCLUSION

A significant proportion of critically ill children receive at least one red blood cell transfusion during their PICU stay. Presence of anemia, cardiac disease, severe critical illness, and multiple organ dysfunction syndrome are the most significant determinants of red blood cell transfusions in PICU.

Immune hemolysis associated with transplantation

Immune hemolysis is one of the adverse effects that can occur following hematopoietic cell or solid organ transplantation. Understanding the clinical settings and the various causes of immune hemolysis is necessary for prompt diagnosis and appropriate management. One of the important causes is the passenger lymphocyte syndrome, which occurs following minor ABO blood group incompatibility between donor and recipient. Hemolysis in this syndrome is often modest in severity but may be severe and even life-threatening. Major ABO blood group incompatibility is also associated with hemolysis, although this is relatively unusual and generally not severe. Autoimmune hemolytic anemia is a relatively common late complication of allogeneic transplantation and carries significant risk of mortality. Also, alloantibodies may be produced by engrafted cells of the donor's immune system or by residual cells of the patient's immune system following hematopoietic cell transplantation. Hemolysis may occur after solid organ transplantation, particularly as part of the passenger lymphocyte syndrome.