Rare and transient anti-D antibody response in D(-) liver transplant recipients transfused with D(+) red blood cells

Lack of alloimmunization to the D antigen in D-negative orthotopic liver transplant recipients receiving D-positive red blood cells perioperatively

BACKGROUND AND OBJECTIVES

D-negative patients undergoing orthotopic liver transplantation (OLT) might require a large number of red blood cell (RBC) units, which can impact the inventory of D-negative blood. The blood bank might need to supply these patients with D-positive RBCs because of inventory constraints. This study evaluates the prevalence of anti-D formation in D-negative OLT patients who received D-positive RBCs perioperatively, as this will assist in successful patient blood management.

MATERIALS AND METHODS

This was a retrospective study performed at a single academic medical centre. Electronic medical records for all 1052 consecutive patients who underwent OLT from January 2007 through December 2017 were reviewed. D-negative patients who were transfused perioperatively with D-positive RBCs and had antibody screening at least 30 days after transfusion were included.

RESULTS

Of a total of 155 D-negative patients, 23 (14.8%) received D-positive RBCs perioperatively. Seventeen patients were included in the study. The median age was 54 years (range 36-67 years); 13 (76.5%) were male. The median number of D-positive RBC units transfused perioperatively was 7 (range 1-66 units). There was no evidence of D alloimmunization in any patient after a median serologic follow-up of 49.5 months (range 31 days to 127.7 months). The average number of antibody screening post OLT was 7.29.

CONCLUSION

Our study showed that transfusion of D-positive RBCs in D-negative OLT recipients is a safe and acceptable practice in the setting of immunosuppression. This practice allows the conservation of D-negative RBC inventory.

Rh(D) Alloimmunization Risk After Rh(D)-Incompatible Solid Organ Transplantations in Rh(D)-Negative Recipients

OBJECTIVES

Rh(D)-incompatible (Rh-i) solid organ transplantations are not considered for organ matching, but no consensus guidelines exist regarding the need for anti-D immunoglobulin (RhIG) prophylaxis.

METHODS

We reviewed 35 Rh(D)-negative patients who had received Rh-i solid organ transplantation. We divided the patients into a RhIG-administered group and a nonadministered group. All patients also underwent an antibody screening test to assess Rh alloimmunization. Graft function was monitored with serum creatinine or bilirubin and kidney or liver biopsy whenever a rejection was suspected. Overall survival was also assessed.

RESULTS

The median (range) age of transplant recipients was 48.5 (4-69) years, and 73.5% of patients were male. Median (range) follow-up time after transplantation was 60 (2-246) months. In the RhIG nonadministered group (n = 16), anti-D was not detected in any of the patients. More rejection episodes occurred in the RhIG-administered group among those undergoing kidney transplant (P = .0278).

CONCLUSIONS

The low rate of Rh(D) alloimmunization is associated with the immunosuppressive state of the patients. RhIG prophylaxis seems to have no clinical benefit in Rh-i solid organ transplantation.

Incidence of anti-D alloimmunization in D-negative individuals receiving D-positive red blood cell transfusion: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

The transfusion of D-negative red blood cells (RBCs) to D-negative patients has been widely adopted to prevent anti-D alloimmunization, especially in women of childbearing age. Still, transfusion of D-positive RBCs to D-negative recipients is occasionally inevitable in practice, and the resulting incidence of anti-D in different D-negative groups of patients has not been well summarized.

MATERIALS AND METHODS

We searched the relevant literature using PubMed, Cochrane Library, and Embase databases from inception date to 30 September 2021. We looked for studies of anti-D occurring in D-negative recipients who received D-positive RBC transfusions. The anti-D incidence was summarized with 95% confidence intervals (CIs). Data with similar characteristics were combined using a random-effects model.

RESULTS

About 42 studies (2226 cases), which found anti-D, the exact volume of D-positive RBC transfused, and the follow-up time for anti-D detection, met the inclusion criteria. The pooled anti-D incidence was 64% (95% CI, range 55%-74%) in volunteers receiving small volumes of D-positive RBCs, 84% (95% CI, 74%-94%) in those receiving whole units, 26% (95% CI, 19%-32%) in mixed patients, 12% (95% CI, 8%-16%) in oncology patients, 27% (95% CI, 13%-40%) in trauma patients, 4% (95% CI, 0%-8%) in immune-compromised transplant patients, and 6% (95% CI, 1%-39%) in those with AIDS.

CONCLUSION

Compared with the high frequency of anti-D in healthy D-negative volunteers given D-positive RBCs, we found a lower rate of anti-D immunization in various D-negative patients and almost none in transplant and AIDS patients.

Safety assessment of RhD-positive red cell transfusion in RhD-negative liver-transplant recipients: Single-centre report from India

Background & objectives:

The number of blood components required during a liver-transplant surgery is significant. It is challenging for blood transfusion services to provide the required RhD-negative red blood cells (RBCs) for recipients during the peri-operative period. This retrospective study presents safety data of transfusing RhD-positive RBCs in RhD-negative living donor liver-transplant (LDLT) recipients during the peri-operative period with six-month follow up for risk of developing alloantibodies.

Methods:

All RhD-negative patients who underwent LDLT and were transfused ABO-compatible but RhD-positive RBC units between January 2012 and May 2018 were included in the study. Twenty one RhD-negative patients who received a total of 167 RhD-positive RBCs peri-operatively were chosen for alloantibody screening. All the patients were started on triple immunosuppression drugs as per the standard hospital protocol. Blood grouping, cross-match and antibody screening were done by column agglutination technique.

Results:

Post-transplant antibody screen (weekly for 12 wk) was negative, and none of the patients developed anti-D alloantibodies till their last follow up (mean 21 months).

Interpretation & conclusions:

Our observations suggest that it may be safe to use RhD-positive RBCs peri-operatively in RhD-negative LDLT recipients with low risk of alloimmunization.

Transfusion of D positive red cells to selected D-negative patients

BACKGROUND

To transfuse packed red blood cells isogroup ABO D is a usual transfusion practice. However, when there is not enough D negative blood available, we can transfuse positive red blood cells to negative patients. Immunocompetent D negative individuals may develop serologically detectable anti-D antibodies within 3 months after exposure to D positive red blood cells.

MATERIAL AND METHOD

Over the last 18 years, we have experienced situations of D negative blood cell scarcity. In these situations, we have applied a clinical assistance protocol, selecting patients with lower risk of alloimmunization and chronic transfusion requirements. We have retrospectively evaluated this policy for the use of D positive red blood cells in D negative patients, focussing on alloinmunization and mortality.

RESULTS

Applying the protocol, 3% of D negative patients were transfused with D positive units, with an alloimmunization rate of 12.3%. The rate of alloimmunization was higher in the younger age group and in those transfused with more units. No haemolytic reactions were reported. Mortality in the alloimmunized group was lower.

CONCLUSION

The use of D positive red blood cells in selected D negative patients does not induce adverse reactions, is a safe practice and allows saving of a product that is sometimes limited.

Predisposing factors for anti-D immune response in D- patients with chronic liver disease transfused with D+ platelet concentrates

BACKGROUND

Recent reports have indicated that the risk of anti-D alloimmunization following D-incompatible platelet (PLT) transfusion is low in hematology and oncology patients. We investigated the rate of anti-D alloimmunization in RhD-negative (D^- ) patients with chronic liver disease transfused with D⁺ platelet concentrates (PCs) and the factors involved, at a liver transplant (LT) center.

STUDY DESIGN AND METHODS

We reviewed the blood bank database from January 2003 to October 2016. D^- patients who had received D⁺ PLT transfusions were eligible if they had undergone antibody screening at least 28 days after the first D⁺ PC transfusion, had no previous or concomitant exposure to D⁺ blood products, and had not received anti-D immunoglobulins.

RESULTS

Six of the 56 eligible patients (10.7%) had anti-D antibodies. All had received whole blood-derived PCs. Four of 20 patients (20%) untransplanted or transfused before LT and only two of 36 patients (5.6%) transfused during or after LT produced anti-D antibodies. These two patients were on maintenance immunosuppression based on low-dose steroids and tacrolimus. The factors identified as significantly associated with anti-D immune response were the presence of red blood cell immune alloantibodies before D⁺ PLT transfusion (p = 0.003), and D⁺ PLT transfusion outside the operative and postoperative (5 days) periods for LT (p = 0.023).

CONCLUSION

D^- patients with chronic liver disease transfused with D⁺ PLTs before LT are at high risk of developing anti-D antibodies. Preventive measures should be considered for these patients.