You have a chemo patient who’s been feeling weak and was sent by their oncologist to the ED for further evaluation. They look pale, maybe a little tachy, but otherwise stable. A preliminary VBG comes back with a Hct of 10%…what do you do?
Let’s talk about blood transfusions in the immunocompromised patient! Shout out to Dr. Allie Kornblatt for the clinical question!
Irradiation
What is irradiation?
Process to inactivate lymphocytes in the RBC product.
Why is it important?
Viable donor lymphocytes can attack recipient cells in individuals who are unable to mount an immune response against them, causing transfusion-associated graft-versus-host disease (ta-GVHD). Ta-GVHD can target all hematopoietic cells as well as other tissues, leading to bone marrow aplasia and other complications that are ultimately fatal.
Who should get irradiated blood?
Recipients of intrauterine or neonatal exchange transfusion; premature neonates
Individuals with congenital cell-mediated immunodeficiency states
Individuals treated with specific types of potent immunosuppressive therapies (purine analogs, antithymocyte globulin [ATG], certain monoclonal antibodies); this may include those being treated for non-Hodgkin lymphoma (NHL) or other hematologic malignancies
Recipients of hematopoietic stem cell transplant (autologous or allogeneic)
Individuals with Hodgkin lymphoma (any stage of disease)
Individuals at risk for partial HLA matching with the donor due to directed donations, HLA-matched products, or genetically homogeneous populations
Additional Considerations
Blood ultimately has a reduced shelf life and may have a delay in arriving to the patient for transfusion.
Leukoreduction
What is leukoreduction?
Removal of leukocytes from the red cell product.
Why is it important?
These cells are present due to co-purification and do not provide any known benefit to the recipient and can potentially cause immunological mediated effects, infectious disease transmission, and repercussion injury. Some countries require universal leukoreduction of cellular blood components (RBCs and platelets), but this is not mandatory in the United States.
Who should get leukoreduced blood?
If cost wasn’t a factor, EVERYONE should get leukoreduced blood!
Patient’s that suffer from frequent febrile nonhemolytic transfusion reactions, especially if fever in these patients (e.g. immunocomprised) necessitates inpatient evaluation for occult infection
Patient’s awaiting organ or bone marrow transplantation and have a history of platelet refractoriness caused by Human leukocyte antigen (HLA) alloimmunization
Decrease the risk of postoperative infection and occult bacterial contamination
Patient’s with cardiac injury to prevent reperfusion injury
Additional Considerations
They have no role in preventing ta-GVHD.
CMV-Seronegative Red Cells
What are they?
RBC components that test negative for the presence of CMV using serologic methods (antibody testing).
Why is it important?
Certain immunocompromised individuals who are themselves CMV-negative may be at risk for serious infection if they receive a CMV-positive unit of blood.
Who should get CMV-seronegative blood?
Solid organ transplant recipients
Hematopoietic stem cell transplant (HCT) recipients
Low birth weight neonates
Individuals infected with HIV
Pregnant women
References