TABLE 9: TRANS FUS ION-AS S OCIATED GRAFT VERSUS HOST DISEASE (TA-GVHD) ALL PATIENTS SHOULD RECEIVE INFORMATION ON POTENTIAL TRANSFUSION REACTIONS AND HOW TO REPORT A SUSPECTED TRANSFUSION REACTION

Signs & Symptoms Suggested Laboratory Possible Etiology Suggested Treatment & Actions Clinical Presentation Investigations . Fever TA-GVHD results from the infusion . Consult Physician . Monitor HGB, platelets & white cell Gastrointestinal tract: of viable T lymphocytes within . Detailed transfusion history count . Anorexia cellular blood components (RBC . Implement therapeutic interventions as . Monitor LFT . Nausea/Vomiting and platelets) into patients who are ordered by physician . Abdominal pain highly immunosuppressed or cannot . Continue to monitor patient for: . Diagnosis can be made by biopsy of . Profuse watery diarrhea which may be recognize the donor lymphocytes as . emerging S&S skin, liver, or bone marrow bloody foreign and reject them, allowing the . deterioration in patient’s condition Skin: donor lymphocytes to engraft in the . Definitive diagnosis of TA-GVHD . response to interventions . Erythematous, maculopapular rash patient. TA-GVHD occurs when the requires identification of donor derived that starts on the trunk & extends to patient HLA antigens are . 1 EDTA tube to Hematology for Complete lymphocytes in the patient peripheral the extremities, palms of hands & soles recognized as foreign by the blood count blood or tissues (by HLA typing) of feet engrafted donor lymphocytes, which . 1 (green) tube to Chemistry for LFT’s Liver: then attack the patient’s cells. . Complete Transfusion Reaction Report Form** . Elevated liver function tests . Document event in patient records . Hepatocellular damage Immunocompetent patients may . Suggest referral to hematologist Bone marrow: develop TA-GVHD if they have . Pancytopenia (an abnormal reduction heterozygous HLA haplotypes and Prevention receive cellular blood products from in the number of red blood cells, white Prevention of TA-GVHD is of paramount importance as it cannot be treated successfully. This a donor who is homozygous for one blood cells, and blood platelets in the is accomplished by providing irradiated cellular blood products (RBC and platelets) to patients of the patients HLA haplotypes. The blood) with bleeding and infectious who are at risk of TA-GVHD (refer to PBCO guidelines for full details). patient’s immune system does not complications . Patients who should receive irradiated blood products include: recognize the HLA antigens on the . Rapid progression . Patients with congenital immunodeficiency states affecting T-cells donor cells as being foreign and is . Death usually occurs within 3 to 4 . Patients undergoing bone marrow or stem cell transplants therefore incapable of eliminating weeks from irreversible pancytopenia, . Recipients of directed transfusions from family members them. In contrast, the donor-derived leading to bleeding, infection and other . Recipients of HLA-matched platelets T cells (graft) may recognize those complications . Patients treated with purine analogs (e.g., fludarabine), purine antagonists (e.g., patient (host) HLA antigens that are . Mortality rate is > 90% bendamustine), alemtuzumab & anti-thymocyte globulin encoded by haplotype that is not . Patients with lymphoproliferative disorders, especially Hodgkin lymphoma shared as being foreign resulting in Usual Timing . a graft versus host response and Intrauterine transfusions (IUT) . Symptoms typically appear 8-10 days . Neonates who previously received IUT TA-GVHD. following transfusion (range 3-30 days) . Neonatal exchange transfusions . Onset is delayed in neonates (median . Low birth weight neonates (<1200 g) onset of 28 days) . Patients who are receiving highly immunosuppressive chemotherapy regimens for acute leukemia or solid tumour And . Appropriate & timely communication of patient’s transfusion requirements . Robust systems for noting patient’s transfusion requirements . A pre-transfusion check for patient’s transfusion requirements: . in the patient record, . on the transfusion record & tag, and . on the blood component bag Delayed transfusion reactions may occur while patient is in hospital or after the patient has been discharged. The patient may be readmitted to hospital at a later date due to a delayed reaction. ** All suspected transfusion reactions (including delayed transfusion reactions) should be reported to Transfusion Medicine Laboratory using a Transfusion Reaction Report Form 00055606 Sept 2012.

C&W Transfusion Manual 1 of 1