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Anti-CD20 monoclonal antibody therapy for autoimmune hemolytic anemia following T cell-depleted, haplo-identical stem cell transplantation

Bone Marrow Transplantation volume 29, pages 365–366 (2002)Cite this article

Immune-mediated hemolytic anemia is relatively common following allogeneic bone marrow transplantation (BMT) but is generally related to either ABO or minor red blood cell incompatibilities between donor and recipient (alloimmune).1,2 Autoimmune hemolytic anemia (AIHA) has been described by several investigators following allogeneic BMT,3,4,5,6 and may be associated with other cytopenias as well.2 Dysregulated immune reconstitution of B and T cells post transplant may allow for the emergence of polyclonal proliferations of B lymphocytes that produce antibodies with activity against red cells, as has been demonstrated in a mouse model.7 The time frame that AIHA occurs post transplant is frequently related to the type of antibody causing the hemolysis, since IgM levels normalize earlier than IgG levels.8 Chen et al5 presented nine cases of patients with AIHA following allogeneic BMT, in which hemolysis occurred either early (2–8 months post BMT; associated with a cold antibody) or late (6–18 months post transplant; associated with warm antibodies). While the majority of patients responded to immunosuppressive therapy, two of nine patients had hemolysis refractory to corticosteroid therapy. Horn et al4 reported an incidence of 19.5% of AIHA in 41 patients with severe combined immunodeficiency syndrome who underwent a T cell-depleted haplo-identical transplant. Of these eight patients, only one was alive and off medications, and four of the eight died from infectious complications or their AIHA. Drobyski et al6 reported a 5% incidence of AIHA in patients receiving a T cell-depleted graft, and half of the patients in this series died due to infectious complications or disseminated intravascular coagulation secondary to cold-agglutinin disease.

In the setting of T cell-depleted BMT, the treatment of AIHA with immunosuppressive therapy could complicate already existing immune deficiency and render these patients at risk for infectious complications. Considering the exceptionally poor prognosis of AIHA in recipients of haplo-identical T cell-depleted transplants,4,6 alternate therapies beside systemic immunosuppression would be of benefit. Rituxan (IDEC Pharmaceuticals Corp., San Diego, CA, USA) is an IgG kappa chimeric mouse/human antibody that binds to the CD20 antigen, which is found on the surface of most normal and malignant B cells. The antibody successfully depletes B cells from the peripheral blood, lymph nodes, and bone marrow.9 Rituxan has been previously demonstrated to be useful in a non-transplant setting for cold agglutinin disease.10 Considering the very poor prognosis of T cell-depleted, haplo-identical stem cell transplant patients who develop this complication, we have applied this intervention to one such patient.

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  1. Pediatric Stem Cell Transplantation, University of Alabama at Birmingham, Children's Hospital of Alabama, Birmingham, AL, USA

    A Ship, W May & K Lucas

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Ship, A., May, W. & Lucas, K. Anti-CD20 monoclonal antibody therapy for autoimmune hemolytic anemia following T cell-depleted, haplo-identical stem cell transplantation. Bone Marrow Transplant 29, 365–366 (2002). https://doi.org/10.1038/sj.bmt.1703371

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