Journal of Applied Hematology

REVIEW ARTICLE
Year
: 2022  |  Volume : 13  |  Issue : 4  |  Page : 172--175

Blood and blood products to support allogeneic hematopoietic progenitor cell transplant recipients at king abdulaziz medical city-Riyadh – Transfusion medicine services


Ahmed Al Harbi, Abdullah Al-Anazi, Faisal Al Saqri, Haya Wasel 
 Department of Pathology and Lab Medicine, King Abdullah Specialist Children Hospital, King Abdulaziz Medical City-CR, Ministry of National Guard, Riyadh, Saudi Arabia

Correspondence Address:
Mr. Ahmed Al Harbi
Department of Pathology and Lab Medicine, King Abdullah Specialist Children Hospital, King Abdulaziz Medical City-Riyadh, Ministry of National Guard, Riyadh
Saudi Arabia

Abstract

Hematopoietic progenitor cell transplant (HPCT) is found throughout the body. HPCT is a set of undifferentiated cells that are capable of indefinite self-renewal and generation of a functional progeny of highly specialized cells. Allogeneic HPCT presents a distinct set of challenges for blood banks and transfusion services. When considering transfusion for an HPCT recipient, one has to take into account not only the complexities associated with the patient's underlying condition, but also potential problems associated with recipient alloantibodies, donor passenger lymphocytes, and the conversion of blood group substance after successful allogeneic HPCT. For an allogeneic HPCT recipient, it is vital that the blood transfusion service keep a detailed record of the donor and recipient's that include donor blood group and antibody screening results and recipient's pre- and posttransplant blood group and antibody screening results. The management of nonidentical and incompatible HPCT requires a unique strategies when major, minor, and bidirectional differences exist which have the potentiality to improve patient outcomes and allow for effective management of the blood and blood products inventory.



How to cite this article:
Al Harbi A, Al-Anazi A, Al Saqri F, Wasel H. Blood and blood products to support allogeneic hematopoietic progenitor cell transplant recipients at king abdulaziz medical city-Riyadh – Transfusion medicine services.J Appl Hematol 2022;13:172-175


How to cite this URL:
Al Harbi A, Al-Anazi A, Al Saqri F, Wasel H. Blood and blood products to support allogeneic hematopoietic progenitor cell transplant recipients at king abdulaziz medical city-Riyadh – Transfusion medicine services. J Appl Hematol [serial online] 2022 [cited 2022 Dec 4 ];13:172-175
Available from: https://www.jahjournal.org/text.asp?2022/13/4/172/358699


Full Text

 Introduction



Since the 1960s, hematopoietic progenitor cell transplant (HPCT) has dramatically evolved[1], and the use of HPCT has been an increasing over the time for patients with different types of hematological disorders.[2],[3]

Blood and blood products support the HPCT can be very challenging and demanding, and for that reasons, we established a policy and procedure at King Abdulaziz Medical City-Riyadh for HPCT recipients that address most important aspects related to blood products transfusion support. The complexity of transfusion support for patients receiving HPCT depends on the type of disease itself and the source of the stem cells, the preparative regimen applied before transplantation, and patient posttransplantation recovery period factors.[4]

HPCT patients usually require transfusion support secondary to ongoing chemotherapy and radiotherapy.[5] A clear policy regarding the blood and blood products supporting HPCT should be established. In addition to that, an appropriate coordination between the relevant departments can prevent the errors related to blood component selection for patient who has successful HPCT.[6]

Blood group incompatibility is not consider barrier when the human leukocyte antigens are matched between the recipient and donor, and it has less effect on the cells engraftment lines.[7]

HPCT requires considerable blood component support during transplantation phases. For effective management for utilization of blood and blood component, the collaboration and communications between the transfusion medicine services and clinical transplant team is essential.[8]

Blood group compatibility has an important impact for clinical outcomes as well as blood management in the pretransplantation (phase I), peritransplantation (phase II), and posttransplantation (phase III) time periods.[9]

In blood group incompatible stem cell transplant, both recipient and donor red blood cell (RBC) types may be present. As well, immune effector cells from both the donor and recipient also may be present.

 Discussion



To the best of the authors' knowledge, no local such article is published. So In this article, we will discuss and highlight our institution experience in supporting and selecting an appropriate blood and blood components need for patients undergoing HPCT recipient during different transplantation phases. Therefore, it is so imperative to determine the stages of transplantation, which include HPCT pretransplantation phase (I), peri transplantation phase (II), and posttransplantation phase (III). As important as to be taken in, the consideration is blood group incompatibility which includes major, minor, or bidirectional blood group incompatibility between the recipient and donor. Major ABO-incompatibility occurs when the hematopoietic progenitor cell recipient has a naturally occurring ABO antibodies against the ABO antigens present on HPCT donor RBCs, but minor ABO-incompatibility occurs when the HPCT donor has ABO antibodies against the ABO antigens present on the HPCT recipient RBCs, and bidirectional ABO-incompatibility exists in the presence of major and minor blood group incompatibility.

Pre transplantation phase (I)

Pretransplantation phase (I) start when the patient identified as candidate for transplantation and the donor as candidate for donation. Hence, before HPCT, the stem cell transplants team will send detailed information of patient and donor who was medically identified as eligible for a stem cell transplantations to transfusion medicine services. Theses information include the recipient and donor unique record number, blood group, pretransplant conditioning regimen, and products infusion date. Thereafter, all these details will be documented in the blood bank information system. Hence, it is important to have a clear way of communication and collaboration between the transfusion medicine services and stem cell transplant team in relation to that to effectively manage the patients' blood and blood products need. A guidelines and policies were officially adopted more restrictively; when transfusion is required, all hematological and oncology patients must receive an irradiated and leukocyte-depleted cellular blood products.[9]

Using leukocyte-depleted components reduces the risk of alloimmunization.[10] However, due to the risk of transfusion-associated graft versus host disease, it is highly essentials to transfuse the post-HPCT with irradiated and leukocyte-depleted cellular blood products.[11] In our institution, all HPCT patients must receive irradiated and leukocyte-depleted cellular blood products cellular for a lifetime.

Peritransplantation phase (II)

Peritransplantation phase (II) starts when the patient receives chemotherapy and/or irradiation and hematopoietic cell infusion. Chemotherapy regimens may be fully myeloablative or use reduced-intensity conditioning to partially ablate the patient's marrow; either regimen will cause the patient to be dependent on RBC and platelet transfusions until engraftment of those cell lines occurs.[12]

An appropriate blood transfusion support and selection during the different phases of HPCT process is an important part of blood group incompatible transplantation.[13] Routinely, each sample received from poststem cell transplant, will be tested for blood grouping and antibody screening, then the result will be entered in the blood bank system.

After infusion, the ABO discrepancy is expected with an ABO incompatibility transplantation, and if such ABO discrepancy is encountered, the blood group results will be entered in the system as undetermined blood group, and this continues until engraftment is successful or failed. In each encounter, the blood bank physician is involved in each consultation to approve any changes in the blood group and approve the selection of blood products that should be compatible with patient and donor. The selection of an appropriate blood and blood products begins from the conditioning regimen date. Furthermore, in the posttransplantation period, the frequency and extent of RBC and platelet transfusions are increased and most patients are blood and blood products transfusion dependent.

Pretransplantation transfusions in patients who are immunocompetent should be avoided because they are associated with increased graft failure rates.[14]

In the case of RBC transfusion, there should be no antibody against corresponding antigens, and in the case of plasma transfusion, the plasma-containing components should be compatible with the donor and the recipient whenever possible.[15]

There are other considerations, which include non-ABO antibodies whether current or history of potential clinical significant antibodies because antigens may remain in a recipient's peripheral circulation for many weeks following transplantation. Overall, these antibodies are generally frequently encountered because most of pretransplanted patients are commonly blood transfusion dependent. Therefore, in case of ABO incompatibility for major, minor, and bidirectional, the blood and blood components need to be selected in a dynamic way.

Selection of blood products for allogeneic HPCT recipients in an ABO incompatibility (major, minor, or bidirectional) depends on the type of incompatibility, transplant phase, and recipient and donor blood groups as illustrated in [Table 1].{Table 1}

Non-ABO antibodies may cause lysis when engrafted cells begin to produce new RBCs,[16] for that reasons, all patient with a confirmed non-ABO antibodies whether the antibody (ies) is active or history, patient must receive antigen negative RBC for corresponding antibodies. With regard to RH (D), the selection of blood products for allogeneic HPCT recipient in case of non-Rh (D) identical allogeneic HPCT, only Rh-negative RBC units should be transfused as shown in [Table 2].{Table 2}

The majority of HPCT recipients require RBCs transfusion support in the peritransplant period, regardless of incompatibilities or blood group antigen mismatches. More careful need to be taken regarding platelets transfusion support in case of ABO-incompatible HPCT.[13]

Post transplantation phase (III)

Begins when recipient blood group results are consistent with the donor blood group, patient's isohemagglutinins are no longer detectable, and the Direct Antiglobulin Test (DAT) is negative. In general, our department is more careful and more conservative regarding the decision of switching the patient blood group to the donor blood group type. However, when the fully engraftment is occurred, two consecutive samples for ABO/Rh group and antibody screening should be obtained to confirm the change in patient blood type to donor blood type. In addition to that, we will carry out further investigations that include the RBC direct antibody test (DAT), and if DAT is positive, the elution will be performed including reverse grouping cells A1 cells and B cells to detect the presence of patient's isohemagglutinins against donor RBC. As well as, patient's plasma will be tested for anti-A or anti-B, and the method may include an antiglobulin phase using reverse blood grouping reagent A1 cell and /or B red cells especially for group O recipient individuals because immune globulin G is the 'predominant isotype found in these individuals for anti-A and anti-B. If no ABO antibodies against donor cells are detected and no ABO antibodies coated donor cells, at this phase, we can switch the recipient blood group to the donor blood type and give specific blood and blood products for transfusion if requested.

In general, during HPCT, recipients have a special transfusion requirement in pretransplant, peritransplant, and possibly long-term posttransplant that need to be managed wisely by transfusion medicine service and by clinical transplant team.[18]

 Conclusion



In conclusion, this article is made to quantify the demand for transfusion to support poststem cell transplant patients. The stem cell transplantation is a clinical journey for the donor, patient, and transfusion medicine services. Besides that, the maintaining of the blood and blood products inventory is critically important for optimal supportive for immediate transplantation and later for postengraftment. A very close collaboration between stem cell transplant department and transfusion medicine services is vital and important to provide the best support and effective care. On the other hand, the availability of all blood group products all the time is impossible but, as indicated in [Table 1] and [Table 2], there are choices, first- and/or second-choice selections for platelets and plasma components. Undoubtedly, there are challenges to fulfill the needs of transfusion for certain patient but the efforts excreted by the donor center team and the transfusion medicine services can overcome all these challenges, so in our institution, nearly all the choices are available all the time.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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