Graft-versus-host disease blood transfusion

Contamination of blood products with lymphocytes can lead to transfusion-induced reactions ranging from a mild fever to severe reactions such as alloimmunization and graft versus host disease (GvHD), in which the transfused lymphocytes (graft) survive the defensive immune reaction of the patient (host) and start a reaction which destroys the cells of the host. The patient also may develop an immune response to the human leukocyte antigen (HLA) type of the graft s cells and reject all platelet transfusions that do not match their own HLA system. The HLA system, found on blood platelets and lymphocytes, is more compHcated than, but similar to, the ABO blood group system of red cells. 

Transfusion-associated graft-versus-host disease A serious residual risk of blood transfusion Higgins, M.J., Blackall, D.P. (2005). Curr Hematol Rep, 4 (6) 470-6. 

Pflieger H. Graft-versus-host disease following blood transfusions. Blut 1983 46(2) 61-6. 

Schmitz N, Kayser W, Gassmann W, Huhn A, Kruger G, Sachs V, Loffler H. Two cases of graft-versus-host disease following transfusion of nonirradiated blood products. Blut 1982 44(2) 83-8. 

Weiden PL, Zuckerman N, Hansen JA, Sale GE, Remlinger K, Beck TM, Buckner CD. Fatal graft-versus-host disease in a patient with lymphoblastic leukemia following normal granulocyte transfusion. Blood 1981 57(2) 328-32. 

The standard UK definition of leucocyte-depletion is less than 5 x 106 residual leucocytes per unit of red cells or platelets (Pamphilon et al., 1999). Thus, if blood products are used, they should always be irradiated to 2 Gy prior to use, to ensure that the immunosuppressed recipient does not develop transfusion-mediated graft-versus-host disease because of the presence of residual viable lymphocytes in the donated blood product. Such graft-versus-host disease is usually fatal (Aoun et al., 2003 Schroeder, 2002), and causes overwhelming skin desquamation, diarrhoea and liver failure secondary to fibrosis of the biliary system. Even if immunosuppression is given, this is usually insufficient to overcome the problem once allogeneic lymphocytes have engrafted in the recipient. 

Two new pathogen reduction techniques for blood components have been developed. With the INTERCEPT technique (amotosa-len and light), no cases of graft-versus-host disease in transfused patients have been reported [92 ]. 

If blood or platelet transfusion are necessary for the above immunodeficiency disorders they must always be irradiated to prevent the risk of life-threatening Graft versus host disease (GVHD). 

Adverse events related to transfusion of blood components have been reported, including febrile non-hemolytic transfusion reactions, mild febrile reactions, acute and delayed hemolytic transfusion reactions, transfusion-related acute lung injury (TRALl), anaphylactic and other allergic reactions, graft-versus-host disease (GvHD), transfusion-associated circulatory overload (TACO), viral infections, post-transfusion bacteremia, transfusion-associated sepsis (TAS), hemosiderosis, post-transfusion purpura, and new allo-antibody formation [18 , 19 ]. Whole blood, erythrocytes, leukocytes, platelets, and plasma for transfusion (fresh frozen plasma, FFP) are involved. Quite a number of these adverse effects, such as TRALl, TACO, TAS, and allergic/anaphylactic reactions can be difficult to evaluate. 

Leukocyte-depleted blood products, particularly red blood cell concentrates, are clinically used to avoid negative side effects in recipients after transfusion. Possible leukocyte-associated post-transfusion complications include human leukocyte antigen alloimmunization, graft-versus-host disease, platelet refractoriness, and transmission of viruses. Amongst the various existing techniques for the selective removal of leukocytes from blood, filtration has become a popular method, because of its convenience and lowcosts. Leukocyte filters have been specially developed for the purpose they generally consist of fibrous materials made of Nylon, PAN, cotton wool, cellulose acetate,or polyester. Currendy available filters... 

Another interesting possibihty in blood product treatment stems from the high sensitivity of T cells to photosensitized inactivation. T cells were shown to be more sensitive than viruses using phenothiazines as photosensitizers, and this may provide a means by which to inhibit transfusion-associated graft-versus-host disease, because T cells play an important role in this disease process. 

A fatal case of graft versus host disease has been described in a patient with malignant lymphoma. Because of pancytopenia, which had developed after cytostatic therapy and irradiation, he received 2 units of fresh blood and 2 units of platelet-iich plasma. Six days later an exanthema was noticed and other signs of graft versus host disease followed. The patient died 3 weeks after the transfusions. 

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