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Metafuni E, Busnego Barreto MT, Valentini CG, Giammarco S, Limongiello MA, Sorà F, Bianchi M, Massini G, Piccirillo N, Putzulu R, Frioni F, Bacigalupo A, Teofili L, Chiusolo P, Sica S. Pure red cell aplasia among ABO mismatched hematopoietic stem cell transplant recipients: a 13-years retrospective study and literature review. Front Oncol 2024; 14:1386670. [PMID: 39015495 PMCID: PMC11250070 DOI: 10.3389/fonc.2024.1386670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 06/10/2024] [Indexed: 07/18/2024] Open
Abstract
Background Pure red cell aplasia (PRCA) is a possible complication after allogeneic hematopoietic stem cell transplantation (HSCT) with major ABO incompatibility. Patients experience delayed engraftment of the erythroid series, with prolonged transfusion-dependent anemia and iron overload. Methods We performed a revision of the most recent literature about post-HSCT PRCA treatment procedures. Moreover, we conducted a retrospective study, over the last 13-years, which included all consecutive major ABO mismatched HSCT performed in our unit, with the aim to assess PRCA incidence, risk factors, and response to different treatments. Overall, 194 patients received a major ABO mismatched transplant from 2010 to 2022. For each patient, data about demographic and transplant characteristics, engraftment, blood transfusion, and possible treatment received were collected. Results The literature review returned 23 eligible papers on PRCA treatment, with high success rate using plasma-exchange (PEX) and immunoadsorption procedures, daratumumab, and eltrombopag. Our study identified a total of 24 cases of PRCA. Among risk factors for PRCA development, we have found older recipient age (p=0.01), high pre-HSCT IgG and IgM IHA titer (p<0.0001), major rather than bidirectional ABO incompatibility (p=0.02), low T CD8 lymphocyte count in the graft (p=0.006), relative donor (p=0.02) and bone marrow as stem cell source (p=0.002). However, multivariate analysis confirmed only pre-HSCT IgG IHA titer as the unique risk factor for PRCA occurrence. The optimal cut-off value of pre-HSCT IgG IHA for PRCA development, resulted to be 1/64, with a 100% sensitivity and 68.8% specificity (p<0.0001). All patients with PRCA had received rhEPO and transfusion support and 20 patients received additional treatments like PEX, rituximab, and more recently daratumumab. Comprehensively, PEX and rituximab obtained a response in half of the cases, at a variable time, while the few cases of patients we treated with daratumumab suggest promising results. The overall response rate in our cohort was 75%, with significantly better survival (94.4% vs. 16.7%) and lower transplant-related mortality (6.3% vs. 80%) for PRCA responders. Conclusions Standardized guidelines on when and how to treat PRCA are necessary because the current treatment is controversial among centers.
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Affiliation(s)
- Elisabetta Metafuni
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Teresa Busnego Barreto
- Hematology and Hemotherapy Service, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Caterina Giovanna Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sabrina Giammarco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Assunta Limongiello
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Federica Sorà
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Bianchi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuseppina Massini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Nicola Piccirillo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rossana Putzulu
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Filippo Frioni
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luciana Teofili
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
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Vo AK, Hervig T, Reikvam H. Pure red cell aplasia after hematopoietic stem cell transplantation - experimental therapeutic approaches. Expert Opin Investig Drugs 2022; 31:881-884. [PMID: 35975626 DOI: 10.1080/13543784.2022.2113055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Not relevant.
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Affiliation(s)
- Anh Khoi Vo
- Section Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Tor Hervig
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Irish Blood Transfusion Service, Dublin, Ireland
| | - Håkon Reikvam
- Section Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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3
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Mehta P, Ramprakash S, Raghuram CP, Trivedi D, Dhanya R, Agarwal RK, Faulkner L. Pre-transplant donor-type red cell transfusion is a safe and effective strategy to reduce isohemagglutinin titers and prevent donor marrow infusion reactions in major ABO-mismatched transplants. Ann Hematol 2021; 100:2071-2078. [PMID: 34148110 DOI: 10.1007/s00277-021-04571-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 06/04/2021] [Indexed: 11/29/2022]
Abstract
ABO incompatibility is not a barrier to allogeneic stem cell transplant but may result in acute hemolytic reactions. As stem cell product manipulation is cumbersome, we are reporting the effectiveness and safety of donor-type red cell infusion as a method of reducing acute hemolytic reaction while using marrow as stem cell source. In major ABO-mismatched bone marrow transplants, manipulation of marrow product requires expertise and expensive equipment, which may not be readily available to transplant centers in low- and middle-income regions. The aim behind our study is to report a safe and effective strategy to reduce isohemagglutinin titers and prevent donor marrow infusion reactions in major ABO-mismatched transplants. We retrospectively analyzed 303 consecutive allogeneic bone marrow transplants (BMTs) for beta thalassemia major, between August 2015 and March 2020, with either major (n = 41) or bidirectional (n = 14) mismatches. When isohemagglutinin titers were 1:32 or higher, donor-type packed red blood cell was divided into 4 aliquots, irradiated and administered over 4 days at incremental volumes. Patients were observed for hemolytic reaction, and if no reaction, bone marrow was infused without manipulation. Out of 55 patients, 20 received donor-type blood infusion. Twelve patients showed evidence of mild hemolysis. None developed severe hemolytic or anaphylactic reaction. Titers were rechecked in 14 patients and all had reduction in titers, except for one. Our experience demonstrated that donor-type PRBC infusion is safe and effective in preventing acute hemolysis in major ABO-mismatched stem cell transplants even with bone marrow as graft source.
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Affiliation(s)
- Pallavi Mehta
- Sankalp-People tree Paediatric Bone Marrow Transplant Unit, People Tree Hospital, Bangalore, India. .,Hemato-Oncology and Stem Cell Transplant Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, New Delhi, 110085, India.
| | - Stalin Ramprakash
- Sankalp-People tree Paediatric Bone Marrow Transplant Unit, People Tree Hospital, Bangalore, India
| | - C P Raghuram
- Sankalp-People tree Paediatric Bone Marrow Transplant Unit, People Tree Hospital, Bangalore, India
| | - Deepa Trivedi
- Care Institute of Medical Sciences, Sankalp-CIMS Centre for Pediatric BMT, Ahmedabad, India
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Longval T, Galimard JE, Leprêtre AC, Suarez F, Amiranoff D, Cazaux M, Kaphan E, Michonneau D, Dhedin N, Coman T, Nguyen Quoc S, Peffault de Latour R, Resche-Rigon M, Sicre de Fontbrune F. Treatment for pure red cell aplasia after major ABO-incompatible allogeneic stem cell transplantation: a multicentre study. Br J Haematol 2021; 193:814-826. [PMID: 33844842 DOI: 10.1111/bjh.17463] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/12/2021] [Indexed: 11/30/2022]
Abstract
Pure red cell aplasia (PRCA) following allogeneic haematopoietic stem cell transplantation (aHSCT) with major ABO incompatibility is responsible for transfusion dependent anaemia, impaired quality of life and iron overload. We conducted a retrospective study, over a 10-year period, which included all consecutive patients who received a major ABO mismatched aHSCT, to assess the impact of specific treatment on PRCA. We did not observe any PRCA in the 57 aHSCT issued from cord blood. Among the remaining 631 patients, cumulative incidence of PRCA was 10·5% [range 8·2-13.0]. The median duration of resolved PRCA was 171 days [IQR 116; 261]. Pre-transplant high isohaemagglutinins titre was associated with an increased risk of PRCA (P < 10-4 ). PRCA did not affect overall survival (P = 0·95). Twenty-two patients (33·3%) received at least one specific treatment. The most commonly used treatments were rituximab (17 patients) and donor lymphocyte infusion (DLI; seven patients). Regarding PRCA resolution, we did not observe a significant difference between treated or untreated subjects (HR = 0·93, 95% confidence interval (CI) 0·48- 1·80; P = 0·82). Similar results were observed with erythropoietin treatment (22 patients, HR = 0·86 95% CI: [0·47-1·57] P = 0·62). Our data do not support the use of erythropoietin, rituximab or DLI for the treatment of PRCA.
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Affiliation(s)
- Thomas Longval
- Haematology Transplant Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Jacques-Emmanuel Galimard
- Centre of Research in Epidemiology and Statistics, Sorbonne Paris Cité, INSERM, UMR-1153, ECSTRRA Team, Paris, France
| | | | - Felipe Suarez
- Adult Haematology Department, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Denise Amiranoff
- Établissement Français du Sang (EFS), Necker-Enfants Malades Hospital, Paris, France
| | - Marine Cazaux
- Haematology Transplant Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Eleonore Kaphan
- Haematology Transplant Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - David Michonneau
- Haematology Transplant Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Nathalie Dhedin
- Haematology Transplant Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Tereza Coman
- Haematology Department, Gustave-Roussy, Villejuif, France
| | | | - Régis Peffault de Latour
- Haematology Transplant Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Matthieu Resche-Rigon
- Centre of Research in Epidemiology and Statistics, Sorbonne Paris Cité, INSERM, UMR-1153, ECSTRRA Team, Paris, France.,Biostatistics Unit, SBIM, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Flore Sicre de Fontbrune
- Haematology Transplant Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
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5
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Ma YR, Wang WJ, Cheng YF, Zhang YY, Mo XD, Han TT, Wang FR, Yan CH, Sun YQ, Chen YH, Wang JZ, Tang FF, Han W, Wang Y, Zhang XH, Huang XJ, Xu LP. Impact of ABO incompatibility on outcomes after haploidentical hematopoietic stem cell transplantation for severe aplastic anemia. Bone Marrow Transplant 2020; 55:1068-1075. [PMID: 31932654 DOI: 10.1038/s41409-020-0779-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 12/11/2019] [Accepted: 01/02/2020] [Indexed: 12/15/2022]
Abstract
The impact of ABO incompatibility on transplantation outcomes in severe aplastic anemia (SAA) patients receiving haploidentical hematopoietic stem cell transplantation (HSCT) remains controversial without published data. A total of 199 SAA patients receiving haploidentical HSCT from ABO-matched (n = 114), minor ABO-incompatible (n = 47), or major ABO-incompatible donors (n = 38) were included in this study. The median time and cumulative incidences of both myeloid and platelet engraftment in the ABO-compatible and ABO-incompatible groups were similar, and pure red cell aplasia was absent. Minor ABO incompatibility increased the rate of grade III-IV acute graft-versus-host disease (aGVHD) (ABO compatible: 6.14 ± 0.05%, minor incompatible: 19.15 ± 0.34%, and major incompatible: 10.53 ± 0.25%; P = 0.051), but did not influence the rates of grade II-IV aGVHD or chronic GVHD (cGVHD). Minor ABO-incompatibility was identified as an independent risk factor for grade III-IV aGVHD by multivariate analysis (hazard ration (HR) = 4.00 (1.48-10.80), P = 0.006). Chronic GVHD, mortality, and treatment failure were not increased in the minor ABO-incompatible group. For SAA patients receiving haploidentical HSCT, ABO compatible donors are better than ABO minor incompatible donors if several haploidentical donors are available.
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Affiliation(s)
- Yan-Ru Ma
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Wen-Jing Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yi-Fei Cheng
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Ting-Ting Han
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Chen-Hua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu-Qian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Fei-Fei Tang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, 100044, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.
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6
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Quek J, Lee JJ, Lim FL, Diong C, Goh YT, Gopalakrishnan S, Ho A, Hwang W, Koh M, Loh Y, Linn YC. Donor-type fresh frozen plasma is effective in preventing hemolytic reaction in major ABO incompatible allogeneic stem cell transplant. Transfusion 2018; 59:335-339. [PMID: 30467850 DOI: 10.1111/trf.15053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 08/26/2018] [Accepted: 08/28/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hemolysis at the time of graft infusion is one of the immediate complications in major ABO-incompatible allogeneic hematopoietic stem cell transplants (HSCTs). We conducted a retrospective analysis to evaluate the efficacy of donor-type fresh frozen plasma (FFP) in reducing isohemagglutinin titer and preventing hemolysis, as well as its effect on delayed red cell engraftment. MATERIALS AND METHODS This is a single-center study on a series of 380 allogeneic HSCT between 2005 and 2015; of which 99 were either major (n = 74) or bidirectional (n = 25) ABO mismatched. Pre-transplant infusion of FFP, post-transplant complications and transfusion requirements were determined by retrospective review of individual medical records. Laboratory results were also reviewed for evidence of hemolysis and pure red cell aplasia (PRCA). RESULTS Clinical manifestation of hemolysis attributable to ABO mismatch was present in one recipient of major ABO-incompatible peripheral blood stem cell (PBSC) with a titer of 64. Another recipient of major ABO-incompatible PBSC with a titer of 64 showed biochemical evidence of hemolysis. Both patients recovered with supportive treatment. Hemolysis did not occur in any patients with titer of 32 or less at the time of stem cell infusion. We were unable to demonstrate the influence of any variables on the incidence of PRCA. CONCLUSION Our experience demonstrated that donor-type FFP is safe and effective in preventing acute hemolysis in major ABO-mismatched HSCT. We have also established the titer of 64 as the threshold that may cause hemolysis and therefore efforts should be made to reduce titer to below this level.
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Affiliation(s)
- Jeffrey Quek
- Department of Hematology, Singapore General Hospital, Singapore
| | - Jing Jing Lee
- Department of Hematology, Singapore General Hospital, Singapore
| | | | - Colin Diong
- Department of Hematology, Singapore General Hospital, Singapore
| | - Yeow Tee Goh
- Department of Hematology, Singapore General Hospital, Singapore
| | | | - Aloysius Ho
- Department of Hematology, Singapore General Hospital, Singapore
| | - William Hwang
- Department of Hematology, Singapore General Hospital, Singapore
| | - Mickey Koh
- Blood Service Group, Health Science Authority, Singapore
| | - Yvonne Loh
- Department of Hematology, Singapore General Hospital, Singapore
| | - Yeh Ching Linn
- Department of Hematology, Singapore General Hospital, Singapore
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7
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Hefazi M, Litzow M, Hogan W, Gastineau D, Jacob E, Damlaj M, Hashmi S, Al-Kali A, Patnaik MM. ABO blood group incompatibility as an adverse risk factor for outcomes in patients with myelodysplastic syndromes and acute myeloid leukemia undergoing HLA-matched peripheral blood hematopoietic cell transplantation after reduced-intensity conditioning. Transfusion 2015; 56:518-27. [PMID: 26446051 DOI: 10.1111/trf.13353] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/06/2015] [Accepted: 08/13/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND ABO incompatibility is not a contraindication to hematopoietic cell transplantation (HCT), but it has been associated with additional risks including delayed engraftment, pure red cell aplasia (PRCA), and higher transfusion needs. Data on these events and on patient survival after reduced-intensity conditioning (RIC) HCT are limited. STUDY DESIGN AND METHODS A total of 127 consecutive patients, 86 with acute myeloid leukemia and 41 with myelodysplastic syndromes, who underwent HLA-matched peripheral blood RIC allogenic HCT between 2005 and 2014 were retrospectively analyzed. RESULTS Eighty ABO-compatible, 26 major/bidirectional, and 21 minor-ABO-mismatch HCT were identified. Compared to the ABO-compatible group, major/bidirectional mismatches had increased red blood cell (RBC) transfusion requirement during the first 100 days (p = 0.009), delayed RBC and PLT engraftment (p = 0.0011 and p = 0.005, respectively), and higher incidence of grade II to IV acute graft-versus-host disease (aGVHD; p = 0.037). In multivariable analysis, major/bidirectional mismatches had significantly higher non-relapse mortality (NRM) and inferior disease-free survival (DFS) and overall survival (OS) compared with ABO-compatible patients (p = 0.01, p = 0.04, and p = 0.035, respectively). Minor ABO mismatch had no impact on survival (p = 0.99). Four (15%) of 26 major/bidirectional mismatches developed PRCA. There was a significant association between fludarabine plus busulfan conditioning and PRCA (p = 0.0046). CONCLUSION Major/bidirectional ABO mismatch is associated with higher NRM and shortened DFS and OS in the setting of RIC HCT. Increased transfusion need, delayed RBC and platelet engraftment, PRCA, and increased severity of aGVHD are additional complications contributing to the morbidity.
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Affiliation(s)
- Mehrdad Hefazi
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark Litzow
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - William Hogan
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Dennis Gastineau
- Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota
| | - Eapen Jacob
- Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota
| | - Moussab Damlaj
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Aref Al-Kali
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
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8
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Basu S, Dhar S, Mishra D, Chandy M. Clinico-serologic co-relation in bi-directional ABO incompatible hemopoietic stem cell transplantation. Asian J Transfus Sci 2015; 9:181-4. [PMID: 26420941 PMCID: PMC4562142 DOI: 10.4103/0973-6247.154257] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The ABO blood group system is of prime significance in red cell transfusion and organ transplantation. However, ABO compatibility is not critical in allogenic hemopoietic stem cell transplantation (HSCT) and approximately 40-50% of hemopoietic stem cell transplants are ABO incompatible. This incompatibility may be major, minor or bi-directional. Though there are descriptions of transfusion practice and protocols in ABO incompatible HSCT, there are considerable variations and transfusion support in these patients can be very challenging. AIMS The immunohematologic observations in two cases of bi-directional ABO incompatible HSCT have been described, and clinico-serologic correlation has been attempted. MATERIALS AND METHODS In both cases, peripheral blood stem cell harvests were obtained using the Cobe spectra cell separator. Immunohematologic assessments in the donor and recipient were done as a part of pre HSCT evaluation. Both the standard tube technique and column agglutination method (Ortho Biovue Micro Bead System) was used. Antibody screen was done by column agglutination method using three cell panel (Surgiscreen cells). Isoagglutinin titration was done by the master dilution method and standard validated techniques were used. RESULTS The pattern of laboratory findings in the two cases was different and so were the clinical outcomes. Although there was early engraftment in the first case, the second case developed pure red cell aplasia and this was well-reflected in the immunohematologic assessments. CONCLUSION Immunohematologic assessment correlated well with the clinical picture and could be used to predict clinical outcome and onset of complications in ABO incompatible HSCT.
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Affiliation(s)
- Sabita Basu
- Department of Transfusion Medicine, Tata Medical Center, Kolkata, West Bengal, India
| | - Supriya Dhar
- Department of Transfusion Medicine, Tata Medical Center, Kolkata, West Bengal, India
| | - Deepak Mishra
- Department of Laboratory Hematology, Tata Medical Center, Kolkata, West Bengal, India
| | - Mammen Chandy
- Department of Clinical Hematology, Tata Medical Center, Kolkata, West Bengal, India
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9
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Booth GS, Gehrie EA, Savani BN. Response to “What Is the Optimal Approach to Major ABO-Incompatible Allogeneic Stem Cell Transplantation”. Biol Blood Marrow Transplant 2013; 19:1760-1. [DOI: 10.1016/j.bbmt.2013.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 10/04/2013] [Indexed: 10/26/2022]
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10
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Watz E, Remberger M, Ringden O, Lundahl J, Ljungman P, Mattsson J, Wikman A, Uhlin M. Analysis of donor and recipient ABO incompatibility and antibody-associated complications after allogeneic stem cell transplantation with reduced-intensity conditioning. Biol Blood Marrow Transplant 2013; 20:264-71. [PMID: 24274982 DOI: 10.1016/j.bbmt.2013.11.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 11/13/2013] [Indexed: 10/26/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) can be performed across the ABO blood group barrier. The impact of ABO incompatibility on clinical outcome is controversial. A retrospective analysis of 310 patients who underwent HSCT with reduced-intensity conditioning between 1998 and 2011 was performed to investigate the frequency and clinical implications of anti-RBC antibodies in passenger lymphocyte syndrome (PLS) after minor ABO mismatch (mm), persistent or recurring recipient type ABO antibodies (PRABO) after major ABO mm HSCT, and autoimmune hemolytic anemia (AIHA). Transplantation characteristics and clinical outcome were analyzed by univariate and multivariate analysis for groups with or without anti-RBC antibodies. ABO blood group incompatibility did not affect clinical outcome despite an increased requirement of blood transfusion. Twelve patients with AIHA, 6 patients with PLS, and 12 patients with PRABO post-HSCT were identified. AIHA did not affect overall survival (OS) or transplant-related mortality (TRM), but patients with AIHA had a lower incidence of grades II to IV acute graft-versus-host disease (P = .05). OS in the PLS group was 0% compared with 61% in the whole group receiving minor ABO mm transplants (P < .001). Comparing PRABO patients with those receiving a major ABO mm HSCT, the OS was 17% versus 73% (P = .002) and TRM was 50% versus 21% (P = .03). At our center, PLS after minor ABO mm and PRABO antibodies after major ABO mm HSCT are significant risk factors for decreased OS and TRM. Our results suggest that occurrence of unexpected ABO antibodies after HSCT warrant a wider investigation individual to find the underlying cause.
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Affiliation(s)
- Emma Watz
- Therapeutic Immunology Unit, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden.
| | - Mats Remberger
- Therapeutic Immunology Unit, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Olle Ringden
- Therapeutic Immunology Unit, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Joachim Lundahl
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Per Ljungman
- Department of Hematology, Karolinska University Hospital and Division of Hematology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Mattsson
- Therapeutic Immunology Unit, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Wikman
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden; Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Michael Uhlin
- Therapeutic Immunology Unit, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden; Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
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11
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Hirokawa M, Fukuda T, Ohashi K, Hidaka M, Ichinohe T, Iwato K, Kanamori H, Murata M, Sakura T, Imamura M, Adachi S, Suzuki R, Morishima Y, Sakamaki H. Efficacy and Long-Term Outcome of Treatment for Pure Red Cell Aplasia after Allogeneic Stem Cell Transplantation from Major ABO-Incompatible Donors. Biol Blood Marrow Transplant 2013; 19:1026-32. [DOI: 10.1016/j.bbmt.2013.04.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 04/05/2013] [Indexed: 10/27/2022]
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12
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Aung FM, Lichtiger B, Bassett R, Liu P, Alousi A, Bashier Q, Ciurea SO, de Lima MJ, Hosing C, Kebriaei P, Nieto Y, Oran B, Parmar S, Qazilbash M, Shah N, Khouri I, Champlin RE, Popat U. Incidence and natural history of pure red cell aplasia in major ABO-mismatched haematopoietic cell transplantation. Br J Haematol 2013; 160:798-805. [PMID: 23330820 DOI: 10.1111/bjh.12210] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 11/12/2012] [Indexed: 11/30/2022]
Abstract
Major ABO mismatching is not considered a contraindication to allogeneic haematopoietic stem cell transplantation (HSCT). Modern reduced-intensity conditioning and reduced-toxicity regimens cause much less myeloablation than conventional myeloablative regimens, such as cyclophosphamide with busulfan or total body irradiation, which may affect the incidence of pure red cell aplasia (PRCA). We estimated the incidence and described the natural history of PRCA in patients with major ABO-mismatched donor stem cells. Between 2007 and 2008, 161 (27% of all patients undergoing HSCT) underwent allogeneic HSCT with major ABO-mismatched stem cells and 12 (7·5%) of these patients developed PRCA. Thirty and ninety day T-cell and myeloid cell chimerism and neutrophil and platelet engraftment did not differ between patients who developed PRCA and those who did not. The only risk factor associated with PRCA was the use of a fludarabine/busulfan conditioning regimen. All patients with PRCA needed red cell transfusion for several months after HSCT resulting in significant iron overload. Pure red cell aplasia resolved spontaneously in the majority (seven patients) but only resolved after stopping tacrolimus in three patients. Hence, after major ABO-mismatched HSCT, the incidence of PRCA was 7·5% and it resolved spontaneously or after withdrawal of immunosuppression in the majority of patients.
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Affiliation(s)
- Fleur M Aung
- Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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13
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Curley C, Pillai E, Mudie K, Western R, Hutchins C, Durrant S, Kennedy GA. Outcomes after major or bidirectional ABO-mismatched allogeneic hematopoietic progenitor cell transplantation after pretransplant isoagglutinin reduction with donor-type secretor plasma with or without plasma exchange. Transfusion 2012; 52:291-7. [PMID: 21848968 DOI: 10.1111/j.1537-2995.2011.03295.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Major ABO mismatch in hematopoietic progenitor cell transplantation (HPCT) is associated with a range of immunohematologic consequences including progenitor cell infusion (PCI)-related hemolysis, delayed red blood cell engraftment, and pure red cell aplasia (PRCA). Although pretransplant (recipient) isoagglutinin reduction may be associated with decreased immunohematologic complications in this setting, there is no consensus with respect to strategies for isoagglutinin reduction. STUDY DESIGN AND METHODS This observational study assessed the efficacy of a standardized pretransplant isoagglutinin reduction strategy incorporating donor-type secretor plasma infusions with or without plasma exchange to prevent PCI-associated hemolysis and PRCA in major or bidirectional ABO-mismatched peripheral blood HPCT. All major or bidirectional ABO-mismatched HPCTs performed between 1999 and 2010 were identified from an institutional database. Immunohematologic outcomes were determined retrospectively by review of individual medical records. RESULTS In total 110 major or bidirectional ABO-mismatched HPCTs had been performed. No patient developed hemolysis after PCI. With respect to PRCA incidence, 16 patients (15%) were excluded due to early mortality and three (3%) due to incomplete data; of the remaining 91 patients, five (5%) developed PRCA. Patients with PRCA had significantly higher pretransplant isoagglutinin titers (p = 0.0001) compared to those who did not develop PRCA. CONCLUSIONS Use of a standardized pretransplant isoagglutinin reduction strategy including donor-type secretor plasma infusions is both safe and efficient in preventing PCI-associated hemolysis and is associated with low rates of posttransplant PRCA.
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Affiliation(s)
- Cameron Curley
- Department of Haematology, Royal Brisbane and Women's Hospital, Brisbane, Australia.
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14
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Ozkurt ZN, Yegin ZA, Yenicesu I, Aki SZ, Yagci M, Sucak GT. Impact of ABO-incompatible donor on early and late outcome of hematopoietic stem cell transplantation. Transplant Proc 2010; 41:3851-8. [PMID: 19917400 DOI: 10.1016/j.transproceed.2009.06.189] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 06/19/2009] [Indexed: 10/20/2022]
Abstract
ABO incompatibility is not a barrier to allogeneic hematopoietic stem cell transplantation (HSCT). However, the impact of an ABO mismatch on the outcome of the HSCT remains controversial. We analyzed whether ABO incompatibility leads to an increased risk of early/late complications, mortality, or increased transfusion requirements. The 147 consecutive allogeneic HSCTs includes 80 ABO-identical and 25 major, 30 minor, and 12 bidirectional ABO-mismatched grafts. The four groups were balanced with respect to disease status at transplantation. Transplantation-related mortality was significantly greater (P < .01) and overall survival significantly shorter (P = 0.2) among HSCT recipients with minor ABO-mismatched grafts. The relapse rate, progression-free survival, and transfusion requirements until discharge were not different between ABO-identical and ABO-mismatched groups. Pure red cell aplasia (PRCA); (P < .0001) and delayed red blood cell (RBC) engraftment (P < .001) were more frequent in HSCT recipients with major mismatched donors. Delayed RBC engraftment was associated with posttransplantation hyperferritininemia and increased mortality risk (P = .05). The greater frequency of sinusoidal obstruction syndrome and graft-versus-host disease (GVHD) in patients with minor mismatched transplants, did not show statistical significance. In contrast severe GVHD was significantly more frequent among minor mismatched patients (P = .04). ABO-mismatched HSCT might have an unfavorable impact on transplant outcomes. Selection of ABO-compatible donors when possible, strategies to prevent and treat PRCA, modifications in transfusion practice, and effective iron chelation are among the measures that can improve transplant outcomes.
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Affiliation(s)
- Z N Ozkurt
- Gazi University Faculty of Medicine, Besevler, Ankara, Turkey
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15
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Stussi G, Halter J, Bucheli E, Valli PV, Seebach L, Gmür J, Gratwohl A, Schanz U, Passweg JR, Seebach JD. Prevention of pure red cell aplasia after major or bidirectional ABO blood group incompatible hematopoietic stem cell transplantation by pretransplant reduction of host anti-donor isoagglutinins. Haematologica 2009; 94:239-48. [PMID: 19144657 DOI: 10.3324/haematol.13356] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Persistent anti-donor isoagglutinins after major ABO blood group incompatible hematopoietic stem cell transplantation may cause delayed red blood cell engraftment and post-transplant pure red cell aplasia. DESIGN AND METHODS We investigated the effect of pretransplant anti-donor isoagglutinin reduction by in vivo absorption and/or plasmapheresis on the incidence of pure red cell aplasia and the time to red blood cell engraftment in 153 hematopoietic stem cell transplant recipients with major ABO incompatibility. RESULTS Twelve patients (8%) developed pure red cell aplasia, 3/98 (3%) with, and 9/55 (16%) without prior isoagglutinin reduction (p=0.009). Red blood cell engraftment was faster in patients with isoagglutinin reduction; in addition, peripheral blood hematopoietic stem cell transplantation, acute graft-versus-host disease, and younger age were associated with faster red blood cell engraftment in Cox regression analysis. In patients with pure red cell aplasia the mean red blood cell engraftment occurred after 225 days (p<0.001) and was associated with a simultaneous decrease of anti-donor isoagglutinins. Patients with pure red cell aplasia had higher pretransplant anti-donor isoagglutinin titers (p=0.001) and received more post-transplant red blood cell transfusions (p<0.001). CONCLUSIONS Following major ABO incompatible hematopoietic stem cell transplantation, pure red cell aplasia and delayed red blood cell engraftment depend on the levels of anti-donor isoagglutinins and are efficiently prevented by the pretransplant removal of these isoagglutinins. The benefits of reducing the time of transfusion-dependency and transfusion-associated risks must be carefully balanced against the potential side effects of isoagglutinin reduction.
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Affiliation(s)
- Georg Stussi
- Clinic for Hematology and Laboratory for Transplantation Immunology, Department of Internal Medicine, University Hospital, Zürich, Switzerland.
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16
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Stussi G, Halter J, Schanz U, Seebach JD. ABO-histo blood group incompatibility in hematopoietic stem cell and solid organ transplantation. Transfus Apher Sci 2006; 35:59-69. [PMID: 16935028 DOI: 10.1016/j.transci.2006.05.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2006] [Accepted: 05/19/2006] [Indexed: 02/01/2023]
Abstract
In contrast to solid organ transplantation (SOT), ABO-histo blood group incompatibility is of minor importance for hematopoietic stem cell transplantation (HSCT). Patients receiving ABO-incompatible HSCT are at an increased risk for immune-mediated hematological complications including immediate and delayed hemolysis, late red blood cell engraftment and pure red cell aplasia, but seem not to have a worse overall survival or increased transplant-related mortality. This review gives an overview of the immunological mechanisms leading to complications associated with ABO-incompatible HSCT and describes approaches to prevent them. The current organ shortage in SOT stimulates the exploration of new strategies to expand the donor pool including ABO-incompatible SOT and xenotransplantation. Here, we discuss the hypothesis that ABO-incompatible transplantation may be viewed as a human in vivo model for the humoral immune mechanisms of antigen-mismatched transplantation. ABO-incompatible HSCT and SOT provide excellent possibilities to analyze graft accommodation and transplantation tolerance. Understanding the underlying mechanisms of graft survival in ABO-incompatible transplantation may facilitate new strategies to overcome the immunological barriers in SOT and xenotransplantation.
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Affiliation(s)
- Georg Stussi
- Department of Internal Medicine, University Hospital, Basel, Switzerland
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