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Successful management of sudden, massive immune hemolysis following ABO-incompatible allogeneic PBSCT despite methotrexate GvHD prophylaxis

Bone Marrow Transplantation volume 36, pages 1111–1112 (2005)Cite this article

We read with interest the recent article by Kim et al1 regarding the effects of ABO incompatibility on outcome of allogeneic peripheral blood stem cell transplant (PBSCT). In their series, no cases of massive immune hemolysis were seen. However, because PBSCT grafts contain a statistically significantly higher number of B lymphocytes2 and more activated B lymphocytes2 as compared to bone marrow stem cell grafts, the incidence of immune-mediated hemolysis due to passenger, donor B lymphocytes may be as high as 22% in patients receiving an ABO-incompatible graft,3, 4 depending on the post transplant immunosuppressive regimen employed.4, 5 In Kim's1 series, about two-thirds of the patients received methotrexate as part of their immunosuppression regimen, which suppresses both antibody production by, and proliferation of, B lymphocytes. Inclusion of methotrexate prophylaxis has been suggested to prevent immune hemolysis in the setting of ABO incompatibility.5

We report a case of immune-mediated hemolysis secondary to donor passenger B lymphocytes following myeloablative chemotherapy and HLA-matched, ABO-mismatched PBSCT from an unrelated donor. The case demonstrates that methotrexate prophylaxis does not completely protect against massive immune hemolysis and also illustrates a definitive management strategy, namely emergent red blood cell exchange transfusion.

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References

  1. Kim JG, Sohn SK, Kim DH et al. Impact of ABO incompatibility on outcome after allogeneic peripheral blood stem cell transplantation. Bone Marrow Transplant 2005; 35: 489–495.

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Authors and Affiliations

  1. Division of Hematology/Oncology, College of Medicine and Public Health, and the Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA

    D M Benson, L O'Donnell, D Krugh, T Grady, W Blum & G Marcucci

  2. Department of Pathology, College of Medicine and Public Health, The Ohio State University, Columbus, OH, USA

    J D Williams & M S Kennedy

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  1. D M Benson
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  2. L O'Donnell
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  3. D Krugh
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  4. T Grady
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  5. W Blum
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  6. J D Williams
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  7. M S Kennedy
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  8. G Marcucci
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Benson, D., O'Donnell, L., Krugh, D. et al. Successful management of sudden, massive immune hemolysis following ABO-incompatible allogeneic PBSCT despite methotrexate GvHD prophylaxis. Bone Marrow Transplant 36, 1111–1112 (2005). https://doi.org/10.1038/sj.bmt.1705188

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