Canterbury DHB

Blood Component Therapy and SCT

• All blood products must be irradiated (25 Gy) from 14 days before transplant and for 6 months following autologous BMT and 12 months following allogeneic BMT (longer if significant GvHD).
• Re-suspended red cells are given to maintain a Hb above 80 g/L (higher targets may be more appropriate depending on clinical context) and platelets to maintain a count of above 10 x 10⁹/L, or 20 x 10⁹/L if febrile.

Within NZBS all donor products are now leucodepleted at source, which is deemed sufficient to limit CMV exposure via blood products.

Refer to the NZBS clinical guideline: NZBS Policy on the Provision of CMV Antibody Negative Blood Components (111P067)

• See also the CDHB Blood and Blood Product Policy.
• If the patient becomes refractory to random donor platelets, single donor platelets, or platelets from an HLA A and B matched or similar volunteer unrelated donors or family members may be given. These should be irradiated (25 Gy) before infusing.

Guidelines for ABO Incompatibility

Refer to Types of Donor-Recipient ABO Incompatibilities.

Reference

Booth G, Gehrie E, Bolan C, Savani B. Clinical Guide to ABO-Incompatible Allogenic Stem Cell Transplantation. Biology of Blood and Marrow Transplantation. 2013 August;19(8):1152-59.

Rhesus Incompatibility

* Only if anti-D present.

Major ABO Incompatibility i.e., A, B, or AB donor and O recipient

• Check IgG isoagglutinin titres.
• Assess red cell content in PBSC product if ABO titre >1:32:
  • If red cell contaminate is below 20 mL and product is PBSC, infuse at slow rate (see below).
  • If red cell contaminate is above 20 mL and product is PBSC, consider RBC depletion as well as plasma exchange of the recipient.
  • If titre is >1:32 and product is marrow, consider RBC depletion as well as plasma exchange of the recipient.
  • If titre is below 1:16, infuse product with no manipulation as slow rate (see below).
• 1000 mL 0.9% sodium chloride prehydration:
  • 20mL/h for first 30 mins
  • Then give 40mL/h for next 30 mins
  • Then continue at 40-80mL/h until completion

  Have adrenaline, hydrocortisone, and antihistamine available.

  ABO incompatible bone marrow from overseas donor facilities (outside of Australasia) requires discussion with the transplant consultant.

• Transfuse with recipient group or group O red cells until donor group established (ABO antibody to donor negative and DAT negative) then give donor group red cells. Give donor group plasma and platelets from beginning of conditioning. If only group O platelets available, consider volume reduction, especially if child recipient (see table below).
• Check DAT and ABO antibody to donor type from Day +5 until red cell engraftment.
• Monitor isohaemagglutinin titres monthly until non-reactive, do weekly if baseline >256. A rising titre usually heralds delayed onset of erythropoiesis, haemolysis, or both.

Minor Incompatibility, i.e. O donor and A, B, AB recipient or A1 donor and A2 Recipient

• Check issoagultinin titres:
  • If titre >256, assess red cell content in PBSC / marrow products.
    • Consider plasma depletion of the graft (replace with 4% albumin or group AB plasma).
  • Target <10 mL. If >10 mL infuse as below, increase the infusion rate if the patient has no reaction.
• 1000 mL 0.9% sodium chloride prehydration:
  • Give 20 mL/h for first 30mins.
  • Then give 40 mL/h for next 30 mins.
  • Continue at 80 mL/h increasing slowly up to 500 mL/hr (double infusion rate every hour up to a maximum of 500 mL/hr).

  Have adrenaline, hydrocortisone, and antihistamine available.

• Transfuse with group O red cells from start of conditioning. Give group A platelets/plasma to A and AB recipients until their own red cells are undetectable. Give group O platelets/plasma to B recipients until their own red cells are undetectable (see table below).
• Check DAT and antibody screen to donor type every 7 days for 3 weeks.
• The emergence of anti-recipient isohaemagglutinins may indicate the development of haemaolysis. Consider weekly monitoring for first 4 weeks.

Note: Delayed haemolysis due to isohaemagglutinins produced by donor lymphocytes, clinically significant 15-71% of cases; onset is abrupt at 9-16 days, DAT positive. Usually self-limiting without serious morbidity; may be serious in 10-15%. Note that haemolysis may also affect transfused blood group O red blood cells, by an innocent bystander mechanism.

Mixed, Major and Minor Incompatibility i.e., A Donor to B Recipient, Or B Donor to A Recipient

• Treat as above as appropriate.
• Give O red cells, group O platelets, and group AB plasma (as first choice) from start of conditioning, until ABO antibody undetectable and DAT negative, then donor’s group red cells. When recipient red cells are undetectable give donor plasma and platelets.
• Check DAT and ABO antibody to donor type around day 21.

Rh (D) incompatibility

• For major Rh(D) incompatibilities give Rh(D) negative red cells.
• Patients with minor Rh incompatibility (recipient Rh positive, donor Rh negative) are at risk of delayed haemolytic transfusion reactions due to passenger lymphocyte syndrome.
• Patients with major or minor Rh mismatch (recipient Rh negative, donor Rh positive) who have been previously alloimmunised (e.g. anti-D positive) must receive a red cell depleted graft. To prevent the occurrence of severe delayed haemolysis in post-transplant period, prophylactic removal of Rh antibody by plasma exchange or plasma absorption can be considered.

Minor ABO Incompatibility with Donor PBSC Product

Anecdotal reports of severe (including fatal) delayed haemolytic transfusion reactions have been reported with the use of cytokine primed donor PBSC products, where donor lymphocyte numbers are much higher than those found in marrow stem cell products. Experience, however suggests that such events rarely occur when immunosuppression, for GvHD prophylaxis with 2 or more drugs are given (e.g. CSA + MTX, CSA + MMF).

Transfusion Support Recommendations for ABO-Incompatible HPC Transplantation.

Reference

S Booth, Garrett & Gehrie, Eric & D Bolan, Charles & N Savani, Bipin. (2013). Clinical Guide to ASO-Incompatible Allogeneic Stem Cell Transplantation. Biology of blood and marrow transplantation: journal of the American Society for Blood and Marrow Transplantation. 19. 10.1016/j.bbmt.2013.03.018.

Topic Code: 9332