Transfusion-associated graft-versus-host disease

Background

• > 24 hr, delayed complication of transfusion
• Mortality > 90%, usually within 1-3 weeks of onset
• Donor lymphocytes mount response against recipient tissue
• Risk factors (see also Blood products):
  • Cellular components (whole blood, pRBCs)
    • Less incidence in platelet products
    • Almost none in FFP
  • Recipient immunodeficiency
  • Non-leukocyte irradiated blood products
  • Donor HLA homozygosity with recipient heterozygosity
  • Non-HLA matched blood products
  • Blood products stored less than 11 days
    • Longer shelf time associated with less incidence
    • In review of ~350 cases, only 10 identified between 11-14 days

Clinical Features

• Signs and symptoms include:
  • Rash ~70-80%
  • Diarrhea ~40%
  • Hepatomegaly ~15%
  • Liver injury ~70%
  • Pancytopenia ~65%
• Transfusion usually within 1-2 weeks prior to symptom onset
• By definition, can be between 2 days - 6 weeks from transfusion

Differential

Transfusion Reaction Types

• Acute
  • Intravascular hemolytic tranfusion reaction
  • Febrile nonhemolytic tranfusion reaction
  • Allergic tranfusion reaction
  • Transfusion-associated circulatory overload (TACO)
  • Transfusion-related acute lung injury (TRALI)
  • Transfusion-associated graft-versus-host disease
  • Fluid overload
  • Sepsis
• Delayed
  • Extravascular hemolytic tranfusion reaction
  • Graft-vs-host disease
  • Transfusion infections

Evaluation

Diagnosis

• Skin biopsy will suggest this pathology
• Definitive diagnosis if patient's lymphocytes are found to have a different HLA phenotype from host tissue cells

Management

• Preventative
  • Identify vulnerable populations
  • Use leukocyte reduced, irradiated blood products
• Supportive
• Immunosuppressants, corticosteroids, cytotoxic agents have questionable efficacy
• Stem cell transplantation rescue

See Also

• Acute transfusion reaction
• GVHD

External Links

• Bloody Easy 3: Blood Transfusions, Blood Alternatives and Transfusion Reactions - A Guide to Transfusion Medicine