honoring BMT special needs

[slsmith 55]

When a patient has had a bone marrow transplant and it has been several years and they have totally engrafted( is that a word?) when is it safe to give blood products that are no longer irradiated ? Or is it a life time requirement. My pathologist is investigating this and so far any literature I have read is vague. 

[Malcolm Needs ★ 4,890]

The British Society for Haematology (BSH) have just issued an updated version of their "Guidelines on the use of irradiated blood components" (actually on 9th October 2020).

The recommendations for patients who have received allogeneic haematopoietic stem cell transplantation (HSCT) is as follows.

"All recipients (adult and paediatric) of allogeneic HSCT should receive irradiated blood components from the time of initiation of conditioning chemo/radiotherapy.  The recommendation applies for all conditions where HSCT is indicated regardless of the underlying diagnosis.

Irradiated components should be continued until all of the following criteria are met:

1.  >6 months have elapsed since the transplant date.
2. The lymphocyte count is .1.0 x109/L.
3. The patient is free of active chronic GvHD.
4. The patient is off all immunosuppression.

If chronic GvHD is present or continued immunosuppression treatment is required, irradiated blood components should be given indefinitely.

Treatment with irradiated blood components should continue indefinitely if this is required based on transplant conditioning, underlying disease or previous treatment, e.g. previous diagnosis of Hodgkin's Lymphoma (HL) or previous purine analogue treatment.

As far as patients who have undergone an autologous stem cell transplantation (ASCT) are concerned, all patients undergoing ASCT irrespective of underlying diagnosis or indication for this treatment should receive irradiated cellular blood components from initiation of conditioning chemo/radiotherapy until 3 months post-transplant (6 months if total body irradiation was used in conditioning) unless conditioning, disease or previous treatment determine indefinite duration, for example previous diagnosis of HL, or previous purine analogue treatment."

The Guideline is actually quite lengthy (and, of course, is for use in the UK, and not the USA), but can be found (for free) on the BSH website.

I hope this helps.

[Neil Blumberg 246]

No one knows what to do for sure. We keep such patients on irradiated for life, since these recipients are not immunologically normal in many cases.  But there are no data to support or refute this practice.  Seems low risk and prudent to us.

[Cliff 437]

We're a large facility with many oncology patients.  We made the decision to move to 100% irradiated cellular products a long time ago.  Not an issue for us.  We put in patient instructions for special requests like irradiated, I do not believe we have ever removed that instruction from a patient.

[Malcolm Needs ★ 4,890]

3 hours ago, Cliff said:

We're a large facility with many oncology patients.  We made the decision to move to 100% irradiated cellular products a long time ago.  Not an issue for us.  We put in patient instructions for special requests like irradiated, I do not believe we have ever removed that instruction from a patient.

We have hospitals that do this in the UK.

[Neil Blumberg 246]

We used to do universal irradiation but then became aware of two things.  One, irradiation of red cells causes increased hemolysis during storage.  That's been known for some time. But in recent years, the toxic effects of infusing free hemoglobin or increasing hemolysis in vivo have become evident (e.g., sickle cell anemia; levels of hemolysis correlating with morbidity in surgical patients). So we stopped irradiating everything at that point.  Just per protocol.  Leukoreduction reduces GVH in the British data.

[Malcolm Needs ★ 4,890]

7 minutes ago, Neil Blumberg said:

Leukoreduction reduces GVH in the British data.

Agreed; hugely reduced, but not entirely eliminated.