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Rh D alloimmunization in allogeneic HSCT

Bone Marrow Transplantation volume 48, pages 459–460 (2013)Cite this article

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Incompatibility between donor and recipient for the Rhesus D (Rh D) red cell antigen occurs commonly in the setting of allogeneic hematopoietic SCT. Donor-derived immune reactions against host antigens or host immunity that persists despite the conditioning treatment may compromise the success of allogeneic transplantation. When such immune reactions involve RBC antigens, transfusion therapy for the patient may be complicated. Moreover, immunological tolerance between host and recipient occurs more gradually and may remain incomplete following reduced-intensity conditioning (RIC) compared with myeloablative regimens, and it remains unclear if alloimmunization occurs more commonly following Rh D-incompatible transplants in the RIC setting. Previous reports describe only occasional instances of Rh D alloimmunization after Rh D-incompatible transplants.1, 2 We recently encountered a case of persistent anti-Rh D alloimmunization following allogeneic hematopoietic SCT, and reviewed our institutional experience for patients undergoing myeloablative conditioning and RIC allogeneic hematopoietic SCT to gain current insight regarding the incidence and potential clinical significance of Rh D alloimmunization in this setting.

A 56-year-old woman, diagnosed with AML in second CR, underwent allogeneic transplantation following myeloablative conditioning with CY, BU and antithymocyte antiglobulin. The patient, blood group A Rh D-negative, received PBSC from an unrelated HLA mis-matched (6/8) donor, blood group O Rh D-positive. The patient had evidence of prior Rh D alloimmunization before transplant, which was possibly related to transfusions administered following chemotherapy. The patient’s blood group remained in transition for 4 months following transplantation and became donor type, blood group O Rh D-positive, thereafter. Following transplant, the patient developed significant hemolysis with a peak total bilirubin of 696 μmol/L on day 17 (direct bilirubin 619 μmol/L) after transplant that normalized by day 43. The peripheral blood film in the corresponding post-transplant period was characterized by abundant schistocytes, contracted RBC and ovalocytes without significant spherocytosis. The international normalized ratio and partial thromboplastin time, however, remained normal, and fibrinogen levels remained at or above the normal range, while repeated direct antiglobulin tests were positive for the presence of IgG. The lactate dehydrogenase peaked at 494 μmol/L on day 19 and was normalized by day 29. The aspartate aminotransferase and alanine transaminase levels remained less than twice the upper limit of normal. The patient required transfusion of 20 units of packed RBC within the first 22 days following transplant before RBC engraftment occurred. The patient did not exhibit any evidence of hemolysis in further follow-up, despite the persistence of a weak anti-Rh D that was +2 (on a scale of 0–4) at the time of last follow-up,16 months post transplant.

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Acknowledgements

We wish to acknowledge the assistance of Dr L Huebsch and S McDiarmid for access to data from the BMT database at the Ottawa Hospital. The BMT database and a stipend for JC was supported by the Ottawa Hospital Foundation, BMT Research and Education Fund. DA is supported by a New Investigator Award from Canadian Institutes of Health Research and through the Department of Medicine, University of Ottawa.

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Authors and Affiliations

  1. Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada

    J Y S Chan, J Tay & D S Allan

  2. Department of Pathology and Laboratory Medicine, Transfusion Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada

    M Tokessy, E Saidenberg & A Giulivi

  3. Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

    A Giulivi, J Tay & D S Allan

  4. Blood and Marrow Transplant Program, The Ottawa Hospital, Ottawa, Ontario, Canada

    J Tay & D S Allan

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  1. J Y S Chan
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  2. M Tokessy
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Correspondence to D S Allan.

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Chan, J., Tokessy, M., Saidenberg, E. et al. Rh D alloimmunization in allogeneic HSCT. Bone Marrow Transplant 48, 459–460 (2013). https://doi.org/10.1038/bmt.2012.152

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