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Bone Marrow Transplant


jojo808

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Prior to transplant patient was a B+ and eventually got A+ cord blood units. Anyway pt was admitted to our hospital and forward typed as an A+, backtype was non-reactive (AB). Antibody screen was negative. We didn't know about the transplant and initially thought maybe an A subgroup but after we found out about the transplant (through progress notes, you'd think the nurses/md's would have given us that kind of info!) we gave O+ rbc's (2 irradiated/ cmv neg units). Progress notes said100% chimerism. we gave one A+ rbc unit. On the next crossmatch specimen the screen was still negative but the immediate spin crossmatch with an A+" unit had a 1+ reaction. We tried an O+ unit and it was negative so we are back with O+ units.

 

Question: Were we wrong in giving that A+ unit? Should we always transfuse group O rbc's to bm transplant recipients?

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I will give O rbc's in case like this. Because O cells is not so rare and it is safer in this situation.I guess the DAT of this patient is pos. As for the transfused A rbc caused the 1+reaction with A rbc, I don't know if the cord is A2 type, and the transfused cells is A1 .

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Interesting enough my hospital had a situation just like this less than a year ago.  We were not informed of the bone marrow transplant but saw that the doctor was an oncologist and when we typed them (previous B) and we saw they were now an A, we thought we needed to do some digging.  When we finally found out that they had a transplant we gave them O cells as we could not fix the ABO discrepancy even though we had a reason why. 

 

As Shily said, O cells are not rare so we kept as such to not cause any potential effects since no one had ever experienced something like this before. 

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Just curious BloodBankGuy, in what way could you not fix the discrepancy?  Was it in the reverse group?  If so, what was this discrepancy?

 

I was meaning the ABO discrepency as we had a previous and the current ABO did not match.  The only thing I cannot remember off hand was the back type results.  But I do believe that, like the OP, it was non reactive.

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Thanks for that BloodBankGuy.

 

The reason I asked was because if, say, a group A Secretor is transplanted with a group O donor, the chances are that the recipient may never make an anti-A (although they may make an anti-A1).

 

I am probably "teaching my grandmother to suck eggs", but this is because the recipient will continue to produce Type 1 (soluble) A antigen.  This Type 1 antigen can adsorb onto the group O red cells (although this may only be detectable by very sensitive elution techniques), but can also interfere with the production of anti-A, either by inhibition of any anti-A that may be produced, or by immune tolerance (or both, of course) - see my first ever publication - Needs ME, McCarthy DM, Barrett J.  ABH and Lewis antigen and antibody expression after bone marrow transplantation.  Acta Haematologica 1987; 78: 13-16 - and apologies for the ego trip!!!!!!!!!!!!!!

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"teaching my grandmother to suck eggs" ???????

 

Have you never heard of that one before? It's a bit like 'Preaching to the choir' but on experience rather than belief. Where are you from? If you aren't from the UK - we have soooo many of these phrases it is ridiculous!

 

http://en.wikipedia.org/wiki/Teaching_grandmother_to_suck_eggs

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Basically, it means trying to teach something to you that you already knew (or learned at your grandmother's knee, on the grounds that people in the UK would, in the old days, suck the contents out of an egg through a pin hole, but your grandmother would know how to do this long before you tried to explain to her how to do it).

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Thanks for that BloodBankGuy.

 

The reason I asked was because if, say, a group A Secretor is transplanted with a group O donor, the chances are that the recipient may never make an anti-A (although they may make an anti-A1).

 

I am probably "teaching my grandmother to suck eggs", but this is because the recipient will continue to produce Type 1 (soluble) A antigen.  This Type 1 antigen can adsorb onto the group O red cells (although this may only be detectable by very sensitive elution techniques), but can also interfere with the production of anti-A, either by inhibition of any anti-A that may be produced, or by immune tolerance (or both, of course) - see my first ever publication - Needs ME, McCarthy DM, Barrett J.  ABH and Lewis antigen and antibody expression after bone marrow transplantation.  Acta Haematologica 1987; 78: 13-16 - and apologies for the ego trip!!!!!!!!!!!!!!

Malcolm, if the recipient is A1 Secretor transplanted by group O donor, will they produce anti-A or only anti-A1?

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At 1 place I worked, we would restrict a patient like this (ABO mismatch transplant) to group O RBCs until 2 consecutive types in which they had forward typed as the new type (and they should not reverse type in this case; unless they relapse; they are being immunosuppressed due to incompatible transplant).  At least that is all as I recall it.....we get very few transplanst where I work now (and like you, find out the hard way.....not because someone was kind enough to tell us that information up front).

Brenda Hutson

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  • 1 year later...

Thanks for that BloodBankGuy.

 

The reason I asked was because if, say, a group A Secretor is transplanted with a group O donor, the chances are that the recipient may never make an anti-A (although they may make an anti-A1).

 

I am probably "teaching my grandmother to suck eggs", but this is because the recipient will continue to produce Type 1 (soluble) A antigen.  This Type 1 antigen can adsorb onto the group O red cells (although this may only be detectable by very sensitive elution techniques), but can also interfere with the production of anti-A, either by inhibition of any anti-A that may be produced, or by immune tolerance (or both, of course) - see my first ever publication - Needs ME, McCarthy DM, Barrett J.  ABH and Lewis antigen and antibody expression after bone marrow transplantation.  Acta Haematologica 1987; 78: 13-16 - and apologies for the ego trip!!!!!!!!!!!!!!

I just experiencied this today: Patient has a history of B pos, BM transplant in july 2014 from an A pos donor, it is now A pos without any reaction with A1 cells and B cells. I transfused O pos units (Invalid ABO type in Meditech), but my question is that patient will ever have anti-B in her plasma? Should I keep giving her O pos and AB plasma forever?

Thanks, Helen

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I honestly don't know if this will go on forever, but it will certainly last for some considerable time, particularly if your patient is a secretor.  One way of telling this is to look at the patient's Lewis type.  If the patient is Le(a-b+), then, of course, they are a secretor.  If they are Le(a+b-), then they are a non-secretor (if they are Le(a-b-), then they could be either, and you would have to look at their saliva to see if it will inhibit anti-A or anti-B human reagents).

 

The patient's Lewis type will remain as it was prior to the BMT, as the Lewis antigens are not integral to the red cells, but rather are adsorbed onto the red cell surface from the plasma, having been produced elsewhere in the body, and not in the bone marrow per se.  Equally, any blood that has been transfused will, within a few days, also take on the Lewis type of the patient, as the patient's own Lewis substance will "coat" these transfused red cells.

 

Similarly, AB and H substance, on the Type 1 backbone, is produced elsewhere in the body, and not in the bone marrow per se.  Again, this secreted substance will "coat" the patient's red cells (whether they be autologous, derived from the transplanted BM or the transfused red cells), and so these red cells will have a "coating" of group B substance (but the red cells derived from the transplanted marrow will type as group A in this instance, as the Type 2 backbone that carries the A antigen is integral to the red cell membrane and will, therefore, be expressed).

 

Do not be at all surprised if you cannot detect the B substance on any of the red cells by normal grouping techniques.  It is a very weak "coating" of group B substance that can usually only be detected by adsorbing anti-B onto the red cell surface (in vitro) and then eluting the anti-B back off, and testing the eluate with known group B reagent red cells).  However, the immune system is much more sensitive than are our normal grouping techniques, and so the cells involved in the immune system will "sniff out" this "coating" of B substance, and (probably) recognise it as "self".

 

As I said in my earlier post, I don't think that anyone is quite certain whether the "transplanted immune system" actually never makes anti-B, because it recognises this as "self", or whether it does make a weak anti-B, but this anti-B is adsorbed by the B substance in the plasma.

 

This may be slightly different to the process of "accommodation" described in ABO mismatched solid organ transplants.  In such a situation, let us say that the recipient is group O, and receives a renal transplant from a group A2 donor.  The kidney will continue to express group A on its cells (as AB and H antigens are histoantigens, as well as red cell antigens), and the recipient will continue to produce anti-A in their immune system, but by the process of "accommodation", the anti-A produced by the recipient does not appear to lead to rejection of the kidney (at least, not acutely, although there may be some long term chronic rejection - certainly, there is a life long requirement for immunosuppressive drugs).

 

Personally, now that the patient's red cells are clearly expressing the Type 2 A antigen, I would have thought that you could switch to donor type for transfusion, as long as your crossmatch is compatible.

 

I hope that explanation helps a bit!

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