Post on 08-Apr-2018
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Blood group incompatibility
inPeripheral Blood Stem Cell
Transplantation
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Introduction
Inheritance of HLA antigens independent of
ABO blood group system
HLA Matched donor need not be ABO
compatible
Pluripotent & very early committed stem cells
are devoid ofABH Antigens
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Hence ABO incompatibility is not an obstacle
for successful engraftment
But Prevention of immune hemolysis is important
in mismatched transplantations
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Major incompatibilityRECIPIENTDONOR
NIL
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Minor incompatibility
NIL
O,
A
O,B
O,A,
B
DONOR RECIPIENT
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Facts
Antibody titre
Cross matching
Transfusion of alternate group
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Incidence
Incidence of ABO Discordance-30-40%
Major 20%
Minor 22-24% Bidirectional 1-2%
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Major
1. Immediate hemolysis of RBC infused with the
graft
2. Delayed hemolysis by persistent recipient
isohemagglutinins
3. Delayed erythrocyte engraftment
4. Pure red cell aplasia
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Major
Immediate hemolysis
Depends on Nature,titre &avidity of recipient antibody
Volume of red cells in the donor stem cell product Antigenic expression on the red cells
PBSC relatively red cell depleted,yet hemolysis canoccur
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Major
Delayed hemolysis
As long as the recipient antibody persists
Several reports- no immediate but delayed
erythroid engraftment More chance with
High recipient titre
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Delayed erythroid engraftment
Increased transfusion requirement in major
Non myeloablative -more delay Less commonly delays
Neutrophil engraftment
Lymphocyte engraftment
Platelet engraftment
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PRCA
Recipient isohemagglutin against donor emerging RBC
Intramedullary precursor cell destruction
BFU E the first stage with ABH Ag
No evidence of influence on myeloid/megakaryocytic engraftment,
GVHD
Graft rejection
Rare
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Strategies to prevent hemolysis
Removal of RBC from PBSC
D
ecrease the concentration of isoagglutinins in plasma
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DONOR
RECIPIENT
GROUP&
CROSSMAT
CH
Major
incompatibility
Recipient
antibodytitre
1/16
Red cell depletion
if >20 ml RBCsPlasma exchange
Plasma adsorption
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Methods of removing red cells Centrifugation/sedimentation
Residual red cells
Stem cell cell loss
Goal
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High titer recipient
RBC reduction
Plasma exchange/infusion
Also used when risk of failure(MUD,partial
match,aplastic anemia) Infuse donor type plasma
Non cellular source of ABO soluble substances
3-4 days before HCT
Done after starting of immunosuppression to reducerebound increase
Final titre
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Plasma absorption
Recipienttitre Numberofdays
32-128 1d
256-512 2d
1024 3d
>2048 4d
Citrate toxicity
TTIPlateletdepletion
FNHTRTRALIVolumeoverload
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Red cell absorption
Rarely used technique
Small aliquot donor type red cell absorption
3-4 days prior transplantICU,Potential hemolysis
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Follow up
Iso agglutinin titres & ABO groups fortnightly
Titres should
titre+ transfusion reqirement-PRCA
Once titre
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Follow up
High Ab titre before HCT ?high probability of
return after transplant
Weekly titres
Rising titer heralds delayed onset of
erythropoiesis/hemolysis/both
Titre >1/16 post transplant remove Ab by plasma
exchange/absorption Trial of EPO-stimulating effect on precursors may
overcome the suppression
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Blood transfusion in Major mismatch
Before transplant
RBCs,platelets and FFP-recipient's blood type
After transplantRBCs only of the recipient's ABO group
Platelets and FFP -the donor's ABO type
Once blood group switching complete
Donor type blood products
All cellular products irradiated
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BLOOD GROUP CHOICE IN MAJORRECIPIENT DONOR BLOOD
PRODUCT
PRE
TRANSPLA
NT
POST
TRANSPLA
NT
After
RECIPIENT Ab
undetectable
O A RBC O O A
PLASMA/PC O A A
O B RBC O O B
PLASMA/PC O B B
A AB RBC A A AB
PLASMA/PC A AB AB
B AB RBC B B AB
PLASMA/PC B AB AB
O AB RBC O O AB
PLASMA/PC O AB AB
AB plasma&O packed washed cells can be used instead of any unavailable group
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Minor
More risk of clinically significant hemlysis In PBSCT -Tenfold more lymphoid cells
T cell depleted BMT
CSP prophylaxis without methotrexate
G CSF-T lymphocyte production of cytokines which promoteantibody formation by B lymphocytes
Rapid severe hemolysis
Coincides with early complete donor type
engraftment/appearance of a/c GVHD
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Early onset of hyperbilirubinemia-could be a cluebut non specific
M
assive delayed hemolysis-CSP alone Bystander hemolysis
Transfused O RBCs hemolysed
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In minor ,pretransplant titers doesnt predict
incidence/severity of delayed hemolysis
ApproachesRemoval of plasma from donor stem cell product
If titre >128; plasma removal by centrifugation
No substantial loss of stem cell
Pre transplant dilution of recipients RBC with Gp ORBCs(Prophylactic transfusion/exchange of RBC)
o RBC exchange More successful in donor with high titres
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Chance of hemolysis
Coinciding with engraftment DCT
Antibody screening Every 2 days during first 3 post transplant weeks
If DCT +ve elute and confirm donor specificity Reticulocyte, peripheral smear
If hemolysis suspected LDH,Bilirubin,Haptoglobin daily till patients
hematocrit stable
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Minor
Before transplant PRC &Plasma & Platelets- Recipients type
O washed cells can be used for dilution effect if
needed
After transplant RBC -donor's ABO group
Plasma and platelets -recipients Once blood group switching complete
Donor type blood products
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BLOOD GROUP CHOICE IN MINOR
RECIPIENT DONOR BLOOD
PRODUCT
PRE
TRANSPLANT
POST
TRANSPL
ANT
After
RECIPIENT
RBC
undetectable
A O RBC A O O
PLASMA/PC A A O
B O RBC B O O
PLASMA/PC B B O
AB O RBC AB O O
PLASMA/PC AB AB O
AB A RBC AB A A
PLASMA/PC AB AB A
AB B RBC AB B B
PLASMA/PC AB AB B
AB plasma&O packed washed cells can be used instead of any unavailable group
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Bidirectional
Do recipient & donor antibody titre
Red cell& plasma depletion
Patients RBC diluted to Gp O RBCs
If recipient antibody titre>1/256 plasma exchange
Gp O Red cell products and Gp AB plasma for
post transplant support
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Bidirectional
Gp O RBC and Gp AB plasma andplatelets for pre and post transplant support
Once recipients original Ab undetectable,donorredcells,plasma,platelets
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Rh incompatibility
Major mismatch
Recipient Rh D negative& sensitised
Donor rh D positive
Antibody titre Red cell removal /plasma exchange/absorption
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Minor mismatch
6-15% hemolysis
Recipient negative donor sensitised +ve
Prophylxis with Rh negative blood
Transfusion
Same in both major/minor
Post transplant Rh negative PRC,Rhpositive/negativeplasma
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THANK YOU