Rituximab for passenger lymphocyte syndrome associated with allogeneic SCT

Passenger lymphocyte syndrome following minor ABO-mismatched liver transplantation

Passenger lymphocyte syndrome is an immunologic disorder observed in solid organ and haematopoietic stem cell transplantation in which B lymphocytes within a donor graft are transferred to the recipient and subsequently produce circulating antibodies against host red blood cell antigens. The syndrome is most likely to occur in minor ABO blood group mismatched or Rh incompatible transplantation. Although generally mild and self-limited, the resulting haemolytic burden has the potential to increase the risk of infection, graft failure and death. The phenomenon is observed in the transplantation of any solid organ with lymphoid tissue, including the liver. We present a structured case report of passenger lymphocyte syndrome following minor ABO-mismatched liver transplantation, which was initially complicated by blood loss anaemia early in the postoperative period. By reviewing the limited literature of this disorder following liver transplantation, we emphasise common clinical findings and treatment strategies as well as introduce chimerism analysis to confirm resolution.

An atypical case of refractory passenger lymphocyte syndrome after renal transplantation

BACKGROUND

Passenger lymphocyte syndrome (PLS) causes immune-mediated hemolysis in solid and bone marrow transplant recipients. Donor-derived antibodies against the recipient erythrocyte drive the pathogenesis. It is a rare entity in kidney transplantation, and most of the cases are self-limited.

CASE PRESENTATION

A 36-year-old woman presented with fatigue 13 days after living donor renal transplantation. The operation was uneventful, and she was discharged with normal graft functions on the 11th day of transplantation Findings were consistent with cold agglutinin disease at her admission. However, the cold agglutinin test was negative. Eventually, she was diagnosed with PLS. Refractory intravascular hemolysis and frank hemoglobinuria were also present in the patient. Hemolysis was resistant to steroids, intravenous immunoglobulin (IVIG), and Rituximab. Because of life-threatening anemia related to refractory PLS, mycophenolate and tacrolimus were interrupted. However, hemolysis persisted. Following that, immunoadsorption (IA) treatment was obtained. Unfortunately, graft loss occurred due to rejection despite the resolution of PLS after IA.

CONCLUSION

PLS is a rare and usually self-limited entity. Our case was an atypical refractory PLS that resembled cold agglutinin disease. Also, frank hemoglobinuria was observed related to severe intravascular hemolysis. These features have not been described before in PLS, to the best of our knowledge. Additionally, IA treatment had never been reported in the literature for PLS, as far as we know. Treatment and management could be a challenge in refractory PLS. Rituximab, IVIG, and extracorporeal treatments could be beneficial. It should be borne in mind that refractory PLS can cause graft and patient loss.

Passenger Lymphocyte Syndrome and Autoimmune Hypothyroidism Following Hematopoietic Stem Cell Transplantation

We present the case of a 24-year-old male, who received a minor ABO-incompatible allogeneic hematopoietic stem cell transplant (HSCT, blood group O⁺ ⟶ A⁺) from an HLA-matched unrelated female donor, as consolidation therapy for relapsed precursor-B-cell acute lymphoblastic leukemia. The donor had a known history of Hashimoto's thyroiditis before HSCT. At day +10 posttransplant, the patient developed severe hemolysis, which required emergent red blood cell exchange. Additionally, about a year posttransplant, he had circulating antithyroglobulin antibodies, decreased free-T4 (fT4) and increased serum thyroid-stimulating hormone (TSH). The potential causes of the posttransplant hemolytic episode and hypothyroidism are discussed. While the hemolysis was worsened by the transfusion of A red blood cells (RBCs) in the context of passenger lymphocyte syndrome, the thyroid dysfunction might be explained by an autoimmune disease transferred from the donor. The case highlights the possibility of several non-relapse-related complications of HSCT occurring in the same patient. It is critical that such adverse outcomes are distinguished from classical graft-versus-host disease (GVHD) for adequate recipient counseling, posttransplant screening, and prompt treatment.

Passenger lymphocyte syndrome after ABO-incompatible allogeneic hematopoietic stem cell transplantation; dynamics of ABO allo-antibody and blood type conversion

Passenger lymphocyte syndrome (PLS) is a specific subtype of graft versus host disease (GVHD) following allogeneic hematopoietic stem cell transplantation (allo-HSCT) characterized by an immune-mediated hemolysis caused by donor-derived B cells. However, precise nature of PLS has not been well characterized due to its rarity. We herein report two cases of PLS following ABO-incompatible HSCT whose clinical course and dynamics of anti-ABO allo-antibody and blood type conversion were closely examined. Both cases demonstrated acute hemolysis upon engraftment, and the presence of high titer allo-antibody against recipients' red blood cells (RBCs) helped us to reach the diagnosis of PLS. Hemolysis in both cases showed spontaneous improvement with prednisolone and supportive therapy including transfusion and fluid support. In one case with blood type O, the patient recursively developed PLS in the second and the third HSCT from ABO-mismatch donors, leading to a hypothesis that original blood type O may serve as a background for acute elevation of serum anti-ABO antibody and therefore a risk for developing PLS in multiple ABO-incompatible HSCTs. When hemolysis is noted following ABO-incompatible HSCTs, PLS should be considered and measurement of anti-ABO antibodies is warranted.

ABO subgroup incompatibility with severe hemolysis after consecutive allogeneic stem cell transplantations

Allogeneic hematopoietic stem cell transplantations (HSCTs) represent a curative strategy for treating hematologic malignancies yet bear dangerous and frequently life‐threatening complications including the development of graft‐versus‐host disease. Here, we present a case of a patient that suffered from relapsed/refractory multiple myeloma, a hematologic neoplasm characterized by clonal proliferation of malignant plasma cells in the bone marrow. During the course of his disease, the patient underwent consecutive allogeneic HSCTs, during which he developed a clinical meaningful and hitherto unreported ABO subgroup incompatibility, leading to persistent hemolysis. Testing for ABO subgroups during donor selection, especially after consecutive allogeneic HSCTs, may therefore aid to prevent these complications.

Transfusion support for stem cell transplant recipients

Hematopoietic stem cell patients regularly require transfusion support. Indications for transfusion in this population are similar to other patients being treated with chemoradiation; however, special considerations must be made in regards to pretransfusion testing, ABO compatibility, product modifications, and anticipated challenges while patients undergo engraftment. Additionally, infusion of hematopoietic stem cells requires acute understanding of product collection, modification, and potential side effects. As these patients often require numerous platelet transfusions, platelet refractoriness may be encountered and practice options are discussed. We review current indications and guidelines for transfusion in hematopoietic stem cell patients and make recommendations for best practice based on current literature.

Nonhemolytic passenger lymphocyte syndrome

BACKGROUND

An 8-month-old recipient of a liver segment transplant had anti-D detected for the first time in her Day 5 posttransplant plasma and anti-C detected for the first time in her Day 55 posttransplant plasma. The donor's plasma contained anti-C and anti-D. Clinical and laboratory findings established a diagnosis of passenger lymphocyte syndrome (PLS). Hemolysis did not occur, because the recipient's blood group phenotype was, by chance, D- C-.

STUDY DESIGN AND METHODS

To evaluate contemporary practice for diagnosing PLS, we conducted a retrospective 10-year literature review.

RESULTS

There were 31 studies (63 cases) of PLS of which eight cases (four studies) were hematopoietic stem cell and 55 (27 studies) were organ transplants. All eight (100%) hematopoietic stem cell and 52 (95%) organ transplants were associated with hemolysis. Of the four studies of hematopoietic stem cell PLS, three actively screened for posttransplant blood group antibodies. Of 27 studies of organ PLS, one actively screened for antibodies. Antibody screens detected five cases of hematopoietic stem cell PLS before hemolysis was apparent and two cases of organ PLS with antibodies without hemolysis.

CONCLUSION

Focusing on hemolysis, without a comparable effort to detect donor-derived antibodies diverts from the primary pathophysiology of PLS and limits capturing the full scope of the syndrome. Recognition of hemolytic and nonhemolytic subcategories of PLS is recommended. When feasible, an antibody screen performed on the donor's plasma when collecting the hematopoietic stem cells or before an organ harvest could result in an alert that the donor has formed an alloantibody(s) and the recipient is a risk for PLS. Alternatively, a routine antibody screen performed on the recipient's plasma 1 week posttransplant and, if negative, repeated 3 to 5 weeks posttransplant would detect any donor-derived antibodies and improve alignment of clinical practice with the pathophysiology of PLS.

Passenger Lymphocyte Syndrome (PLS): A Single-center Retrospective Analysis of Minor ABO-incompatible Liver Transplants

Background and Aims: Due to the shortage of donor livers, minor ABO-incompatible liver transplantations are commonly performed. Together with the allograft, immunocompetent B-lymphocytes, called passenger lymphocytes, are transplanted. In case of minor ABO-incompatibility, these passenger lymphocytes produce antibodies directed towards the recipient's red blood cells, which causes immune-mediated hemolysis, also known as the passenger lymphocyte syndrome (PLS). Although this is a self-limiting disorder, serious complications can occur, including graft failure. Retrospectively, we evaluated the role of PLS in minor ABO-incompatible liver transplantations performed at our center. Methods: A retrospective analysis was conducted for all minor ABO-incompatible liver transplantations performed at the Antwerp University Hospital between 2003 and 2015. All patient files were inspected for clinical and laboratory findings. In cases of PLS diagnosis, the applied treatment was also studied. Results: In total, 10 patients underwent a minor ABO-incompatible liver transplantation and 4 showed signs of PLS. All 4 PLS patients were treated with different therapeutic strategy, corresponding to the severity of hemolysis. In all 4 cases, PLS resolved following treatment. Conclusion: When performing minor ABO-incompatible liver transplantations, knowledge of PLS is elemental. Next to a high index of clinical suspicion, we suggest routine screening for markers of hemolysis, with emphasis on haptoglobin level and direct antiglobulin test, weekly in the first 4 weeks post-transplantation as well as in case of a sudden hemoglobin drop within the first 3 months after transplantation. Peri- and postoperative transfusion support using donor-compatible blood has been suggested to prevent the occurrence or limit the extent of hemolysis.

Is Efficacy of the Anti-Cd20 Antibody Rituximab Preventing Hemolysis Due to Passenger Lymphocyte Syndrome?

Passenger lymphocyte syndrome (PLS) often occurs after ABO-mismatched solid organ and/or bone marrow transplantation between a donor and recipient. Viable donor B-lymphocytes transferred during organ transplantation produce antibodies against recipient red cell antigens, leading to hemolysis. The incidence of PLS has been reported to be around 9% after renal transplantation. A previous report showed that rituximab (Rit) was useful for treatment of PLS in allogeneic stem cell transplantation, bowel transplant and severe cases of hemolysis. However, the effectiveness of Rit in preventing PLS after renal transplantation has not yet been evaluated. The participants in this study were 85 patients who had undergone ABO-mismatched renal transplantation from January 2005 to April 2013. Rit was administered to these patients before transplantation. None of the patients that received Rit treatment developed PLS. Thus administration of Rit before transplantation effectively controlled the production of antibodies by B-lymphocytes, which probably prevented the development of PLS.

Complex Transfusion Issues in Pediatric Hematopoietic Stem Cell Transplantation

Advances in the fields of pediatric transfusion medicine and hematopoietic stem cell transplant have resulted in improved outcomes but also present new questions for research. The diagnostic capabilities involved in transfusion medicine have improved in recent times, now including methods for determination of red blood cell minor antigens, detection of anti-human leukocyte antigen antibodies, and noninvasive iron quantification. At the same time, transplants are being performed for more indications including nonmalignant disease and with less intense conditioning regimens that allow some recipient blood cells to persist after transplant. We are therefore faced with new opportunities to understand the implications of transfusion medicine testing and to develop data-driven guidelines relevant to the current-day approach to transfusion and transplantation.

An update on ABO incompatible hematopoietic progenitor cell transplantation

Hematopoietic progenitor cell (HPC) transplantation has long been established as the optimal treatment for many hematologic malignancies. In the setting of allogenic HLA matched HPC transplantation, greater than 50% of unrelated donors and 30% of related donors demonstrate some degree of ABO incompatibility (ABOi), which is classified in one of three ways: major, minor, or bidirectional. Major ABOi refers to the presence of recipient isoagglutinins against the donor's A and/or B antigen. Minor ABOi occurs when the HPC product contains the isoagglutinins targeting the recipient's A and/or B antigen. Bidirectional refers to the presence of both major and minor ABOi. Major adverse events associated with ABOi HPC transplantation includes acute and delayed hemolysis, pure red cell aplasia, and delayed engraftment. ABOi HPC transplantation poses a unique challenge to the clinical transplantation unit, the HPC processing lab, and the transfusion medicine service. Therefore, it is essential that these services actively communicate with one another to ensure patient safety. This review will attempt to globally address the challenges related to ABOi HPC transplantation, with an increased focus on aspects related to the laboratory and transfusion medicine services.

Passenger lymphocyte syndrome in liver transplant recipients: a description of 12 cases

BACKGROUND

Passenger lymphocyte syndrome is an important cause of immune haemolysis after solid organ transplantation. It mainly occurs in minor ABO and Rh mismatched transplants. The haemolysis is usually mild and self-limited. We present our experience in passenger lymphocyte syndrome and liver transplantation and review the literature.

MATERIALS AND METHODS

We reviewed liver transplants performed in our centre from January 2002 to September 2013, searching for ABO or Rh incompatibility and serological findings of haemolysis. A direct antiglobulin test was systematically performed in each pre-transfusion assessment.

RESULTS

A total of 1,217 liver transplants were performed and 12 passenger lymphocyte syndromes were detected: of the 56 cases with minor ABO incompatibility, ten patients developed passenger lymphocyte syndrome (17.9%) and of 147 cases with minor Rh incompatibility, two patients developed the syndrome (1.40%). All patients with passenger lymphocyte syndrome had haemolysis, a decrease of haemoglobin (median 6.8 g/dL) and an increase of bilirubin (median 5.15 mg/dL). The treatment of passenger lymphocyte syndrome consisted of increasing the dose of corticosteroids that the patients were receiving as post-transplantation immunosuppressive therapy and, in the majority of cases, transfusion of donor compatible red blood cells.

DISCUSSION

Passenger lymphocyte syndrome in liver transplantation has significant clinical consequences. It is, therefore, important to make the diagnosis rapidly, performing pre-transfusion direct antiglobulin tests, and manage the problem correctly with donor compatible red blood cell transfusions and/or immunosuppressive treatment.

Passenger lymphocyte syndrome: a forgotten cause of postliver transplant jaundice and anemia

A 48-year-old man with cirrhosis secondary to nonalcoholic steatohepatitis and chronic hepatitis C infection underwent a successful orthotopic liver transplant from a B+ donor without intraoperative complications. His postoperative course was complicated by hemolytic anemia, and he was ultimately diagnosed as having passenger lymphocyte syndrome. Passenger lymphocyte syndrome is a complication of both solid-organ and stem cell transplants. It is caused by donor B lymphocyte production of antibodies causing a primary or secondary immune response to recipient erythrocytes. Most commonly, it is in the setting of minor ABO mismatches, such as with a group B liver transplanted into a group AB recipient. Typically, passenger lymphocyte syndrome presents as a mild, self-limiting hemolytic anemia. Laboratory findings are consistent with other forms of hemolytic anemia including decreased hemoglobin and haptoglobin, elevated reticulocyte count, and indirect hyperbilirubinemia There is no definitive treatment for passenger lymphocyte syndrome or strong evidence to favor a particular treatment regimen. Passenger lymphocyte syndrome has been successfully treated with supportive care and blood transfusions matched to the liver donor. It is prudent that physicians caring for patients who receive ABO mismatched organs have a high index of clinical suspicion for passenger lymphocyte syndrome during the early postoperative period when posttransplant patients present with jaundice and anemia.

Cellular therapy of cancer with natural killer cells-where do we stand?

Although T-lymphocytes have received most of the attention in immunotherapy trials, new discoveries around natural killer (NK) cells suggest that they also should be suitable effector cells for cellular therapy of cancer. In addition to direct cytotoxicity, NK cells produce an array of immune-active cytokines, among them interferons and granulocyte-macrophage colony-stimulating factor, which places them at the crossroads of innate and adaptive immunity. They also augment monoclonal antibody activity through antibody-mediated cellular cytotoxicity and can be transfected with chimeric antigen receptors. One of the stumbling blocks for NK cell-based therapies has been the inability to predictably obtain and expand larger numbers from donors, but also to achieve sufficiently high transfection efficiency of target genes. The first clinical trials with NK cells suggest some benefit, but more definite evidence is needed to justify this relatively expensive treatment.

Fetal and Neonatal Illnesses Caused or Influenced by Maternal Transplacental IgG and/or Therapeutic Antibodies Applied During Pregnancy

The human fetus is protected by the mother’s antibodies. At the end of the pregnancy, the concentration of maternal antibodies is higher in the cord blood, than in the maternal circulation. Simultaneously, the immune system of the fetus begins to work and from the second trimester, fetal IgM is produced by the fetal immune system specific to microorganisms and antigens passing the maternal-fetal barrier. The same time the fetal immune system has to cope and develop tolerance and T_REG cells to the maternal microchimeric cells, latent virus-carrier maternal cells and microorganisms transported through the maternal-fetal barrier.

The maternal phenotypic inheritance may hide risks for the newborn, too. Antibody mediated enhancement results in dengue shock syndrome in the first 8 month of age of the baby.

A series of pathologic maternal antibodies may elicit neonatal illnesses upon birth usually recovering during the first months of the life of the offspring. Certain antibodies, however, may impair the fetal or neonatal tissues or organs resulting prolonged recovery or initiating prolonged pathological processes of the children.

The importance of maternal anti-idiotypic antibodies are believed to prime the fetal immune system with epitopes of etiologic agents infected the mother during her whole life before pregnancy and delivery.

The chemotherapeutical and biological substances used for the therapy of the mother will be transcytosed into the fetal body during the last two trimesters of pregnancy. The long series of the therapeutic monoclonal antibodies and conjugates has not been tested systematically yet. The available data are summarised in this chapter.

The innate immunity plays an important role in fetal defence. The concentration of interferon is relative high in the placenta. This is probably one reason, why the therapeutic interferon treatment of the mother does not impair the fetal development.

A review of transfusion practice before, during, and after hematopoietic progenitor cell transplantation

The increased use of hematopoietic progenitor cell (HPC) transplantation has implications and consequences for transfusion services: not only in hospitals where HPC transplantations are performed, but also in hospitals that do not perform HPC transplantations but manage patients before or after transplantation. Candidates for HPC transplantation have specific and specialized transfusion requirements before, during, and after transplantation that are necessary to avert the adverse consequences of alloimmunization to human leukocyte antigens, immunohematologic consequences of ABO-mismatched transplantations, or immunosuppression. Decisions concerning blood transfusions during any of these times may compromise the outcome of an otherwise successful transplantation. Years after an HPC transplantation, and even during clinical remission, recipients may continue to be immunosuppressed and may have critically important, special transfusion requirements. Without a thorough understanding of these special requirements, provision of compatible blood components may be delayed and often urgent transfusion needs prohibit appropriate consultation with the patient's transplantation specialist. To optimize the relevance of issues and communication between clinical hematologists, transplantation physicians, and transfusion medicine physicians, the data and opinions presented in this review are organized by sequence of patient presentation, namely, before, during, and after transplantation.

Treatment of acute cellular kidney allograft rejection with T10B9.1A-31A anti T-cell monoclonal antibody

The authors reviewed the passenger lymphocyte syndrome (PLS) that has appeared after transplantation. The definition, mechanism, serological, clinical features, and treatment for PLS after solid organ transplantation, especially liver transplantation, are described. The PLS refers to the clinical phenomenon of alloimmune hemolysis resulting from the adoptive transfer of viable lymphocytes from donor during solid organ or hematopoietic stem cell transplant. Sometimes, it is very severe and may cause “unexplained” hemolysis during the postoperative period. The authors reviewed literature about the PLS in liver transplantation.