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BLOOD TRANSFUSION SUPPORT IN STEM CELL

TRANSPLANT

Salwa HindawiDirector of Blood Transfusion Services

KAUH, Jeddah Saudi Arabia

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Introduction

Bone Marrow Transplant can be either: Allogeneic Autologous PBSCT Cord Blood

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Diseases Treatable by BMT

· Non-Hodgkin's Lymphoma· Hodgkin’s Disease· Multiple Myeloma· Acute Leukemias· Chronic Leukemias· Myelodysplasia· Testicular Cancer· Aplastic Anemia

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Basic transplant issues that impact Basic transplant issues that impact blood bank policies.blood bank policies.

Recognize common serologic problems Recognize common serologic problems encountered in transplant recipientsencountered in transplant recipients

Appropriate blood products when Appropriate blood products when transfusion is needed.transfusion is needed.

Role of transfusion servicesRole of transfusion services

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Basic transplant issues

Recipient-Donor ABO compatibility.Recipient-Donor ABO compatibility.

ABO and Rh compatibility are not required ABO and Rh compatibility are not required for the successful outcome of BMTfor the successful outcome of BMT

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BASIC TRANSPLANT ISSUES Special Blood Requirement

• Irradiated• CMV Negative• Leukocyte-Reduced• Saline-washed or volume reduced

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Is this a major or minor ABO incompatibility? How high the patient’s antibody titers against

the donor’s ABO group? How high the donor’s antibody titers against

the patient’s ABO group?

Will the patient require special conditioning? Will the HPC collection require processing?

Pre-Transplant Considerations

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Compatible transplantCompatible transplant

Immunohemtologic complicationsImmunohemtologic complications

Major incompatibility Major incompatibility Minor incompatibilityMinor incompatibilityMajor & minor incompatibilityMajor & minor incompatibility

RECIPIENT-DONOR ABO COMPATIBILITYRECIPIENT-DONOR ABO COMPATIBILITY

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Recipient- Donor ABO Compatibility

 ABO Major Mismatch: Recipient is O-Donor is A   -Acute hemolysis at infusion.   -Delayed hemolysis from persistent patient

antibodies.   -Delayed onset of hematopoiesis.

ABO Minor Mismatch: Recipient is A- Donor is O   -Acute hemolysis at infusion.    -Delayed hemolysis from donor antibodies.

ABO Major-Minor Mismatch: Recipient is A-Donor is B

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Blood Group O A B AB

O Compatible Major Major Major

A Minor Compatible Major and minor

Major

B Minor Major and minor

Compatible Major

AB Minor Minor Minor Compatible

REC

IPIENT

ABO COMPATIBILITYDONOR

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TRANSFUSIONS FOLLOWING BONE MARROW TRANSPLANTATIONbeginning with preparative regimen

ABO compatibility is not required between bone marrow donor and recipient.

Compatible transplant no special requirements Minor incompatibility recipient type plasma and platelet until

recipient cells have disappeared

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TRANSFUSIONS FOLLOWING BONE MARROW TRANSPLANTATION

Major incompatibility recipient type red cells until recipient

isoagglutinins have disappeared Major and minor incompatibilities group AB plasma, group AB or washed

platelets until recipient cells gone; group O red cells until recipient isoagglutinins have disapeared.

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Patient ABO

Donor ABO RBC FFP

1st Choice plt 2nd Choice plt

OAB

AB

OOO

A,ABB,ABAB

B,OA,O

A,B,O

AOB

AB

OO

A,O

A,ABABAB

B,OB,A,OA,B,O

BOA

AB

OO

B,O

B,ABABAB

A,OA,B,OB,A,O

ABOAB

OA,OB,O

ABABAB

A,B,OA,B,OA,B,O

Blood Selection when recipient/donor are not ABO identical

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major Rh-incomp.,patient anti-D antibodies against engrafted donor Rh+ RBCs.

Mismatches involving Rh system may cause hemolysis, do not affect survival.

Kidd,M,N and S.

NON-ABO MISMATCHES

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Complications Related to Blood Transfusion

Haemolysis

Alloimmunization to red cell antigens

Infection (CMV)

Graft-Verses Host Disease (GVHD)

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Delayed hemolysis 7-14 days post transplant

Mediated by donor lymphocytes carried in the HSC component

Immune hemolysis of the recipient’s red cells as results of anti A and/or anti B production

PBSC at greater risk than marrow Abrupt onset may be severe with signs of IV

hemolysis

Passenger B lymphocyte syndrome

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Worsen with transfusion ,due to hemolysis of transfused group O RBCs .

Methotrexate as anti-proliferative agent use to suppress the proliferation of donor lymphocytes in HSC inoculum.

Passenger B lymphocyte syndrome

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Transfusion of Group O red cells Occasional red cell exchange transfusion

is indicated to replace the recipient’s incompatible red cells with Group O.

Recipient ABO plts type

PROPHYLAXIS

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Red cell depletion and/or plasma depletion ONLY performed on BM collection.

Red cell depletion: Recipient has Ab against Donor red cells.

To avoid hemolysis of donor red blood cells in HPC collection.

Plasma depletion: Donor has AbS against Recipient red cell .

To avoid hemolysis of red blood cells in recipient’s circulation.

Marrow Processing

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Alloimmunization

Prevention of Febrile Non Haemolytic Transfusion Reaction.

Replacement of CMV negative blood components.

Leucodepletion of Blood Components

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Irradiation of blood products All cellular components should be gamma

irradiated (25 Gy or 2500 cGy) this inactivates the T lymphocytes in the donor unit and prevents graft versus host disease in an immunocompromised recipient.

Start at conditioning for 6month in Allogeneic BMT 3 month for Autologous BMT

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Indications for Gamma Irradiated Blood Components

congenital immunodeficiency syndromes. intrauterine transfusions. All neonates who received intrauterine

transfusion. transfusions from all blood relatives. bone marrow transplant recipients.

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Cord Blood The multipotent-stem-cell-rich blood found in the

umbilical cord has proven useful in treating the same types of diseases as those treated using bone marrow stem cells and PBSCs.

Umbilical cord blood stem cell transplants are less prone to rejection than either bone marrow or peripheral blood stem cells.

Umbilical cord blood lacks well-developed immune cells

the cells have not yet developed the features that can be recognized and attacked by the recipient's immune system

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Conclusions: Bone marrow transplantation (BMT) is rapidly

expanding as a practical and therapeutic modalities.

the transfusion medicine professional must take into account the series of immunohematological changes and complications that may arise in such patients.

We must apply techniques, methods, and approaches not routinely used in the general blood-banking environment.

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