Transfusion-associated graft-versus-host disease (TA-GVHD)

This is a delayed (>24 hours), immunological transfusion reaction.
 

When to suspect this adverse reaction?

TA-GVHD is rare and transfused patients present with fever, rash and diarrhoea commencing 1-2 weeks post-transfusion. Laboratory findings include pancytopaenia and liver function abnormalities.

Unlike GVHD after allogeneic marrow transplantation, TA-GVHD leads to profound marrow aplasia with a mortality rate >90%. Survival is rare with death typically occurring within 1–3 weeks of first symptoms.(1,2)

TA-GVHD has also been reported in transfused recipients with intact immune systems.(1) This can occur after transfusion from a donor who is homozygous for a HLA haplotype to a heterozygous recipient.

The recipient’s immune system is unable to recognise the homozygous HLA transfused lymphocytes as foreign, whereas the transfused lymphocytes recognise the host cells as foreign and mount an immunological attack. This situation can arise in directed donations from family members due to shared HLA haplotypes.
 

Usual causes?

Viable T lymphocytes in the transfused component engraft in the recipient and react against tissue antigens in the recipient.

The 3 primary risk factors for developing TA-GVHD are:

  • Degree of recipient immunodeficiency
  • Number of viable T lymphocytes transfused (affected by component age, level of leucodepletion and irradiation status)
  • Genetic diversity in HLA expression between donor and recipient
     

Investigation

Request for skin biopsy and HLA typing. Demonstrate donor leucocyte engraftment.
 

What to do?

Provide supportive care, corticosteroids and cytotoxic agents, however this is largely ineffective.

For patients at risk, it is critical to gamma irradiate cellular blood components (including related donor and HLA matched components).
 

References
  1. Roback JD (ed). Non-infectious complications of blood transfusion. Chapter 27, AABB Technical Manual, 17th edition. AABB, Bethesda, 2011.
  2. Callum JL, Lin Y, Pinkerton PH, Karkouti K, Pendergrast JM, Robitaile N et al. Chapter 5, Transfusion Reactions. Bloody Easy 3: Blood Transfusions, Blood Alternatives and Transfusion Reactions: A Guide to Transfusion Medicine, 3rd edition. Canada: Ontario Regional Blood Coordinating Network, 2011. [cited 2012 Sep 13]. Available from: http://transfusionontario.org/en/cmdownloads/categories/bloody_easy/