Transfusion-associated graft versus host disease

Transfusion-associated graft-versus-host-disease
Classification and external resources
Specialty	emergency medicine
ICD-10	T80.8
ICD-9-CM	999.8

Transfusion-associated graft-versus-host disease (TA-GvHD) is a rare complication of blood transfusion, in which the donor T lymphocytes mount an immune response against the recipient's lymphoid tissue.^[1] Donor lymphocytes are usually identified as foreign and destroyed by the recipient's immune system. However, in situations where the recipient is immunocompromised (inborn immunodeficiency, acquired immunodeficiency, malignancy), or when the donor is homozygous and the recipient is heterozygous for an HLA haplotype (as can occur in directed donations from first-degree relatives), the recipient's immune system is not able to destroy the donor lymphocytes. This can result in graft-versus-host disease.

Epidemiology and pathogenesis

The incidence of TA-GvHD in immunocompromised patients receiving blood transfusions is estimated to be 0.1 - 1.0%, and mortality around 80 - 90%. Mortality is higher in TA-GvHD than in GvHD associated with bone marrow transplantation, where the engrafted lymphoid cells in the bone marrow are of donor origin and therefore the immune reaction is not directed against them.

The most common causes of death in TA-GvHD are infections and hemorrhages secondary to pancytopenia and liver dysfunction.

Presentation and diagnosis

Clinical manifestations

The clinical presentation is the same as GvHD occurring in other settings, such as bone marrow transplantation. TA-GvHD can develop four to thirty days after the transfusion. Typical symptoms include:

fever
erythematous maculopapular rash, which can progress to generalised erythroderma
toxic epidermal necrolysis in extreme cases

Other symptoms can include cough, abdominal pain, vomiting, and profuse diarrhea (up to 8 liters/day).

Laboratory manifestations

Laboratory findings include pancytopenia, abnormal liver enzymes, and electrolyte imbalance (when diarrhea is present).

Diagnosis

TA-GvHD can be suspected from a biopsy of the affected skin, and established by HLA analysis of the circulating lymphocytes. This testing can identify circulating lymphocytes with a different HLA type than the tissue cells of the host.

Treatment and prevention

Treatment is only supportive, as no available form of therapy has proven effective in treating TA-GvHD.

Prevention includes gamma irradiation of the lymphocyte-containing blood products. This procedure should be performed in transfusions when:

The recipient is immunocompromised.
The blood components are from a family donor.
HLA-matched platelets are transferred.

Another means of prevention is the use of third- or fourth-generation leukoreduction filters, although the efficacy of this procedure has not yet been documented.

References

↑ "Complications of Transfusion: Transfusion Medicine: Merck Manual Professional". Retrieved 2009-02-09.

Anwar M, Bhatti F (2003). "Transfusion associated graft versus host disease.". J Ayub Med Coll Abbottabad 15 (3): 56–8. PMID 14727344. Full text
Gupta, A; Bansal, D; Dass, R; Das, A (2004). "Transfusion Associated Graft versus Host Disease.". Indian Pediatr 41 (12): 1260–1264. PMID 15623910. Full text (PDF)
Darrell J. Triulzi: Transfusion associated graft vs. host disease and irradiated blood components
Eric Kardon, eMedicine: Transfusion Reactions

Transfusion medicine

General concepts	Apheresis (plasmapheresis, plateletpheresis, leukapheresis) Blood transfusion Coombs test (direct and indirect) Cross-matching Exchange transfusion International Society of Blood Transfusion Intraoperative blood salvage ISBT 128 Transfusion reactions

Blood group systems / blood types	ABO Chido-Rodgers Colton Cromer Diego Dombrock Duffy Er FORS Gerbich GIL GLOB Hh Ii Indian JR JMH Kell (Xk) Kidd Knops Lan Lewis Lutheran LW MNS OK P Raph Rh and RHAG Scianna T-Tn Vel Xg Yt Other

Blood products / blood donation	Whole blood Platelets Red blood cells Plasma / Fresh frozen plasma / PF24 (Cryoprecipitate + Cryosupernatant) Blood substitutes

Complications of surgical and medical care (T80–T88, 996–999)

Transfusion reactions	Transfusion hemosiderosis TRALI TACO TA-GvHD FNHTR Acute/Delayed hemolytic transfusion reaction

Vaccine injury	Eczema vaccinatum

Other	Serum sickness Malignant hyperthermia Herxheimer reaction Graft-versus-host disease

Hypersensitivity and autoimmune diseases (279.5–6)

Type I/allergy/atopy
(IgE)

Foreign	Atopic eczema Allergic urticaria Allergic rhinitis (Hay fever) Allergic asthma Anaphylaxis Food allergy common allergies include: Milk Egg Peanut Tree nut Seafood Soy Wheat Penicillin allergy

Autoimmune	Eosinophilic esophagitis

Type II/ADCC

- IgM
- IgG

Foreign

Hemolytic disease of the newborn

Autoimmune

Cytotoxic	Autoimmune hemolytic anemia Immune thrombocytopenic purpura Bullous pemphigoid Pemphigus vulgaris Rheumatic fever Goodpasture's syndrome Guillain–Barré syndrome

"Type V"/receptor	Graves' disease Myasthenia gravis Pernicious anemia

Type III
(Immune complex)

Foreign	Henoch–Schönlein purpura Hypersensitivity vasculitis Reactive arthritis Farmer's lung Post-streptococcal glomerulonephritis Serum sickness Arthus reaction

Autoimmune	Systemic lupus erythematosus Subacute bacterial endocarditis Rheumatoid arthritis

Type IV/cell-mediated
(T cells)

Foreign	Allergic contact dermatitis Mantoux test

Autoimmune	Diabetes mellitus type 1 Hashimoto's thyroiditis Multiple sclerosis Coeliac disease Giant-cell arteritis Postorgasmic illness syndrome Reactive arthritis

GVHD	Transfusion-associated graft versus host disease

Unknown/
multiple

Foreign	Hypersensitivity pneumonitis Allergic bronchopulmonary aspergillosis Transplant rejection Latex allergy (I+IV)

Autoimmune	Sjögren's syndrome Autoimmune hepatitis Autoimmune polyendocrine syndrome APS1 APS2 Autoimmune adrenalitis Systemic autoimmune disease

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