- Comparison of Transfusion Associated GvHD to Bone Marrow GvHD
- Patients at Risk for TA-GvHD
- Prevention of TA-GvHD
Transfusion-associated graft versus host disease (ta-GVHD) does not occur after most transfusions because the donor lymphocytes are destroyed by the recipient's immune system before they can mount a response against the host. However, this protective response does not occur in two settings:
- when the recipient is immunodeficient, and
- when there is a specific type of partial HLA matching between the donor and recipient.
Implicated products — Ta-GVHD has been reported after the administration of
- nonirradiated whole blood,
- packed red cells, platelets,
- granulocytes, and
- fresh, non-frozen plasma.
In comparison, ta-GVHD does not appear to be induced by
- frozen, deglycerolized red cells,
- fresh frozen plasma, or
Presentation and diagnosis —
Ta-GVHD develops 4 to 30 days after blood transfusion. Patients typically present with fever and rash. Other symptoms include anorexia, vomiting, abdominal pain, profuse diarrhea, and cough.
The main laboratory findings are pancytopenia due to a strikingly hypocellular marrow, abnormal liver function tests, and electrolyte abnormalities induced by diarrhea.
The diagnosis is suggested from biopsy of affected skin, which classically reveals vacuolization of the basal layer and a histiocytic infiltrate, which is also seen in the aplastic bone marrow. The definitive diagnosis is established if the circulating lymphocytes are shown to have a different HLA phenotype from host tissue cells (ie, from the donor).
Management — Ta-GVHD is almost universally fatal; there is no effective treatment.
Prevention can be best achieved by inactivating transfused lymphocytes by exposing all lymphocyte-containing components to gamma irradiation. This procedure should be followed for patients who are immunosuppressed, who have received a hematopoietic cell transplant (HCT), who are getting blood components from a family donor, or who are given HLA-matched platelets.
Certain pathogen reduction technologies, capable of reducing the active pathogen load as well as abrogating selected white cell immune functions and preventing T cell proliferation, are in current use in some countries, and serve as alternatives to gamma irradiation. (See 'Other methods for WBC inactivation' above.)
Leukodepletion should not be used as an alternative to gamma irradiation for those patients at increased risk of ta-GVHD
|Onset||35-70 days||2-30 days|
|Response to Therapy||80-90%||None|
- Hx of bone marrow/stem cell transplant (allogenic or autologous)
- Current or past treatment with alemtuzumab (Campath) or a purine analogue, including fludarabine (Fludara), cladribine (Leustatin), and pentostatin/deoxycoformycin
- Congenital immunodeficiency syndromes (cellular or combined)
- Hodgkins disease (current or past)
- B cell malignancy (current or past)
- attenuates Donor Lymphocytes in blood products
- Gamma radiation of 1500-3000 rads
- does NOT kill viruses, bacteria, or protozoa
If you have a Patient At Risk, let the Blood Bank know you need:
Irradiated Blood Components
UpToDate (through MMC or Mercy Medical Library or by subscription) has a nice synopsis and list of references.