Canterbury DHB

Transfusion - Associated Graft-Versus-Host Disease

Pathophysiology

Transfusion-associated graft versus host disease (GvHD) is a rare complication, most often seen in severely immunocompromised patients. It may also occur in immunocompetent people exposed to blood from a donor with a similar HLA type. In this condition, blood donor lymphocytes which are viable and immunocompetent engraft in the patient. This causes an immune response in which proliferating donor lymphocytes recognise a host/patient tissue as foreign, causing GvHD. This form of the condition is the basis for irradiating directed donor blood given by family members, even if the patient is immunocompetent.

Risk Groups

• Recipients of intrauterine transfusion.
• Neonates who have previously received intrauterine transfusions.
• Patients with congenital immune deficiencies or Hodgkin lymphoma.
• Patients receiving nucleoside analogues, Bendamustine, or Alemtuzumab.
• Recipients of stem cell or bone marrow transplants.
• Recipients of directed donations from family members.
• Recipients of HLA-compatible single donor platelets and granulocyte transfusions.

Clinical Manifestations

Include fever, pancytopenia, diarrhoea, liver dysfunction, rash, and hepatosplenomegaly developing 1-4 weeks post transfusion.

The diagnosis can be confirmed by a skin biopsy showing histological features of graft versus host disease. HLA typing of patient and donor may also be helpful, and chimerism may be detectable using techniques based on DNA testing.

The prognosis of this condition is very poor with mortality in excess of 80%. These patients should be managed by a team with experience in managing GvHD, treatment of which includes immunosuppression and intensive supportive therapy.

Prevention

Preventable by irradiating cellular blood products to at least 25 Gy. Leucodepletion alone is not adequate to eliminate the risk of GvHD.

Patients at risk of GvHD must receive irradiated blood products only. This requirement must be notified to the Blood Bank. The Irradiated Blood Products Alert Form (CDHB) should be used for this purpose.

Further Reading

• Australian and NZ Society of Blood Transfusion Guidelines, 1st edition, 2011 (accessed 6th September 2015) at http://www.anzsbt.org.au/publications/PreventionofTA-GVHD.pdf.pdf ]
• Kopolovic, I., et al. (2015). "A systematic review of transfusion-associated graft-versus-host disease." Blood 126(3): 406-414.
• Treleaven, J., et al. (2011). "Guidelines on the use of irradiated blood components prepared by the British Committee for Standards in Haematology blood transfusion task force." Br J Haematol 152(1): 35-51.

Topic Code: 5128