transfusions to refractory patients An evaluation of ...

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1987 70: 23-30

An evaluation of crossmatching, HLA, and ABO matching for platelet transfusions to refractory patients JM Heal, N Blumberg and D Masel

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An

Evaluation

of Crossmatching,

HLA,

Transfusions

Refractoriness platelet assess gle

occurs

the

We

utility

donor

Of the

in 222

posttransfusion, matches

had

of the

matching

outcome. crossmatch grade

10,00O/sL

for

transfusions

of

influences was

BX,

and

plasma compatible,

antibodies. the

INCE THE l960s, platelet become vital to the prophylaxis disorders in patients with leukemia, solid tumors.’ products

bleeding

patients.2

in these

fused

patients

become

refractoriness

to

immunological,5 tion

may

that

has

approach

been

donor

platelets

other

role.6 fruitful

The

appear

to

than

HLA-A,B

because bleeding,

mechanisms.8 the patients coagulopathy,

nologic

factors

survival.

now

are

Such

doubts

are

known

to decrease

platelet

and specific crossmatch for detection of IgG and 1gM

Sensitive

available

‘ These

platelets.9’

tests

platelets

appear

survival

of

platelets. patients

However, many with the previously

in patients

contribute to increased platelet a very small subset of refractory in detail. We developed assay,

and

used

spectively

in typical

any tory

patients, patients

has

been

that does assessment

a

sensitive

it to evaluate refractory

because the preselected

clearly

to with

refrac-

patients.

infection, nonimmu-

recovery

to

studies common has

and

donor

Therefore, only been examined

not exclude any of the potential

We patients benefits

reasoned

did

retro-

Vol 70. No 1 (July).

1987:

pp 23-30

by

and

& Stratton.

and meth-

HLA-A.B

and and

complex

With

our

match

in

ABO some-

or

other

crossmatching

grades

therapy

In

HLA-A,B

of donor

immune

ABO

by Grune

to

plasma

an

ill patients.

crossmatch

destruction

mechanism. transfusion

limited

to patients

remain

some

role-

refractory

tially

Inc.

who

were

alloimmunized

as defined

antibodies.

In addition, matching

we analyzed

because

no

important

the

analysis

role

of HLA-A,B

encompassing

immunologic

factors

and

all

has

these

been

ABO poten-

reported.

METHODS

selection.

Single

HLA-A,B

matched,

unrelated

spectively

against

donor

platelets

individual

recipient

collected were

plasma

in

from a closely

crossmatched

5 1 consecutive

retrorefractory

patients for 316 transfusions. All patients had received RBC products from which leukocytes had not been removed, as well as numerous random donor platelet transfusions. All patients had had at least two previous transfusions of pooled random donor platelet concentrates that failed to yield satisfactory corrected platelet count increments (7,500/zL at I to 4 hours). Lymphocytotoxicity screening

for

formed,

anti-HLA-A,B

but all patients

enzyme-linked

antibodies

was

had detectable

immunosorbent

that

a study

would yield a realistic of crossmatching in

the Hematology

cine,

Department

not

antiplatelet

assay

(ELISA)

routinely

per-

antibody technique.

by our Only

one

sity

of Rochester

Unit ofthe

of Pathology Medical

and

Center,

Department

oflnternal

Laboratory

Medicine,

and

American

Red

MediUniver-

Cross

Blood

Services, Rochester Region, NY. Submitted July 25, 1986; accepted February 5, 1987. Supported in part by Dynatech Laboratories, Chantilly, VA, New York State AIDS Institute (AO-107), and American Red Cross Blood Services, Bethesda, MD. Published and

not exclude

typical clinical practice. It might also provide useful insights into the refractory state that could be missed if the study

Blood,

less

to be mechanisms

related

of that

stable,

current

soluble

platelets

by lymphocytotoxic

antiglobulin

utility of crossmatching in refracon the basis of alloimmunization

demonstrated.9

to the

platelet

From

excluded factors that

crossmatching We

that

contribute

HLA-A,B

1987

were

posttransfusion

enzyme-linked platelet

refracbasis of

reasonable

alloantibodies

consumption. patients

hypothesize

than

appear

are with

value

less

techniques are binding to donor

predict

published mentioned

that

bystander”

to

with

detected

recipient

Patient

is one

some

in question often have fever, and splenomegaly. These

not

of

tory

immunologic

We

vant

primarily

as to whether purely on the

are

predictive

predictive

be considerably there

destruction

but

the

in

followed

independent

that

studies patients,

factor

crossmatch,

having

may

increment

patients.

alloimmuniza-

with

platelet

the

the

important

trans-

matching

in dealing

patients.7 Recently, questions have been raised toriness to platelet transfusion occurs

each

in previous

most

was

demonstrate

crossmatch

antigens

Ia

causes

be

ABO.

data

technique,

the

contained

of multiply

refractory.3’4

factors

an important

5,900

Platelet

platelets,

The

survival

refractory

times

recipient’s

(8,200/zL). and

“innocent

with

plasma

50%

transfusion

play

A/BU

C. Increments

transfusion therapy has and therapy of bleeding aplastic anemia, some

Perhaps

although

for

and

to the

These

ABO ods.

transfusion

for

Masel

platelet

reported of

and

for

predicting

typical

The availability of effective has decreased mortality from

clinically

platelet

the

donor

S

lymphomas, and platelet transfusion

.001).

incompatible

When

but

(P
99#{176}F, sepsis or systemic infection, splenomegaly, consumption coagubopathy, bleeding, or a previous history of autoimmune thrombocytopenia. Determination of these factors was made by the physicians caring for the patient and was documented in the medical record. The presence or absence of these factors was not determined for each individual platelet transfusion. The primary diagnoses were acute nonlymphocytic leukemia (21), solid

tumor

(5),

acute

lymphocytic

leukemia

(4),

chronic

myelogenous leukemia (3), preleukemia lymphoma (2), and other hematological

(3), aplastic anemia (2), conditions such as myebofibrosis, erythroleukemia, multiple myeloma, etc. (1 1 ). Three of the patients were children aged 2 SD above the control means described above. Titers of four randomly selected anti-HLA-A,B antibodies were I to 2 orders of magnitude higher with this k-ELISA technique than by lymphocytotoxicity assays. Titers oftwo anti-Pl” antibodies were 1 to 3 orders

of magnitude

greater

by k-ELISA

than

by complement

fixation techniques or 5’Cr release platelet cytotoxicity methods. Thus, we believe that the technique is probably of similar sensitivity to radioimmune9 or immunofluorescent” methods previously shown to be useful as platelet crossmatches. Although anti-A and -B blood group antibodies are detected by this assay, many patients nonetheless exhibit negative crossmatch results with ABO-incompatible platelets.

All patient plasmas were routinely tested (crossmatched) against four to six randomly selected normal donor platelets at the same time that the crossmatch was performed with the HLA-A,B matched platelets that were transfused. All patients had at least one positive crossmatch incompatibility

during

the course with

several

of these non-HLA-A,B

tests,

with

almost

matched

all showing platelets.

All

matched platelets for transfusion were also crossmatched with two to four normal plasmas. This approach allowed us to detect donor platelets that might have significantly elevated levels of IgG or 1gM. Such platelets yield positive crossmatches even with normal donor plasmas. Donor platelets with elevated platelet-associated IgG (PAIgG) or 1gM occurred very rarely and were excluded from the data reported. Platelets were stored no more than I to 5 days at 4#{176}C prior to crossmatching. Such storage does not alter the level of platelet surface lgG or 1gM, or the binding of plasma IgG or 1gM during a crossmatch (data not shown). Measurement ofPAlgG. PAIgG assay is a technical variant of that described for the detection of plasma anti-platelet antibody.’3 HLA-A,B


PLATELET

TRANSFUSIONS

TO REFRACTORY

25

PATIENTS

PAIgG or soluble IgG standards compete with solid-phase lgG for binding to an alkaline phosphatase-linked anti-IgG antiglobulin reagent. The principle of the assay is that increased concentrations of soluble IgG or PAIgG will compete for anti-IgG and reduce anti-IgG binding to the solid-phase IgG. This assay can reproducibly detect changes of -50 molecules per platelet of lgG. Definitions of HLA and ABO match grades. For HLA, A matches are identical at all four HLA-A,B loci; BU matches are those sharing only two or three HLA-A,B antigens present on recipient cells yet possessing no HLA-A,B antigens that differ from those of the recipient due to being homozygous at one or both HLA-A,B loci; BX matches are those with one donor HLA-A,B antigen differing but cross-reactive with one of those of the recipient; C matches are those in which there is one non-cross-reactive antigen present on the donor cells that differs from those of the recipient. BUX

matches

were

classified

For ABO, identical recipient are of the recipient); which

ABO the

as BX.

transfusions same ABO

are those in which both donor and type (eg, an A donor to an A

“plasma-incompatible”

platelets

do not carry

transfusions antigens

are

incompatible

those

with

microcomputer

(Cupertino,

CA)

and

NCSS

ABO ABO carry A to

chi-square

being

further

addition,

contingency

compared

a three-way

tables,

to each analysis

with

other

individual

with

ofvariance

Apple

software

frequencies

Fisher’s

exact

(ANOVA)

was

test.

In

performed

to assess the independent contributions of crossmatch results, H LAA,B and ABO match grades to platelet count increments, and any interactions

between

these

There

fusion

variables.

the

corrected

The

1gM

was

crossmatches

no clear

and

success

rate

at

1 to

significantly

even

for

crossmatch-negative

(43%).

These 0.03),

(P

patible

and for 0.01).

=

ABO

and

time

data

(Fig

4).

match were

At

these

later

transfusions significantly

matches.

The

degree

significantly posttransfusion,

time

yielded inferior

with

of ABO

was

points,

crossmatch-negative in platelet of A/BU

compatibility

did

increments toward better

was

observed. ofcrossmatching,

these dictive formed and

twothe

matching in predicting and three-way ANOVAS

independent

factors. factor

1 to 4 hours ABO).

and

Crossmatching for corrected HLA

(P

=

.02

that BX

not correlate at

>5 results

hours with match-

count increperformed to

contributions

was the most platelet count

(P

C count and

HLA

platelet were

interactional

posttransfusion matching

examined

increments to those

roles

assess

notable

were

platelets

ments,

platelets

particularly

the relative

ABO

to

transfusions.

identical

posttransfusion

To assess and

not statistiaccording

3)

ABO

ABO-identical ing,

was observed was

(Fig

posttransfusion although a trend

C

v

incom-

for crossmatch-negative

results,

hours

5

trend this

arranged

crossmatch-positive

periods

A/BU

increments arranged crossmatch-negative

but

are shown

of the crossmatch

The match A/BU

for

I . A similar

Corresponding match

.001).

ABO

platelets

v ABO

transfusions,

ofABO