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Post-Transplant Isoagglutinin Induced Pure Red Cell Aplasia; Incidence and Clinic Outcomes
ABO incompatibility among patients (pts) undergoing allogeneic stem cell transplant (ASCT) is associated with delayed engraftment and post-transplant pure red cell aplasia (PT-PRCA).
After due IRB approval we retrospectively analyzed the prevalence and outcome of PT-PRCA among pts undergoing ASCT at Mayo Clinic, Rochester between 1/1/2000 and 9/30/2013. Out of 886 ASCT done during the period, we identified 53(6%) pts with major ABO and 24 (3%) pts with bi-directional ABO incompatibility. Twelve patients (1%) developed PT-PRCA; 11 had major ABO incompatibility while one had a bidirectional mismatch. All pts received red cell depleted stem cells and there were no cases of acute hemolysis. Six pts underwent reduced intensity conditioning.
Median time to diagnosis of PT-PRCA was 42 days (23-67), with reticulocytopenia and renewed transfusion dependance. Pts were initially managed with immunosuppression taper and EPO supplementation. Refractory cases were treated with plasmapheresis (4), rituximab (6) and DLI (1). One pt relapsed and 2 pts died (both sepsis) prior to resolution of PT-PRCA. After excluding these pts median time to resolution of PT-PRCA was 113 days (13-429).
PT-PRCA is not an uncommon complication of major ABO incompatible ASCT. However it is relatively less common in patients with bi-directional incompatibility. PT-PRCA results in renewed transfusion dependance. Immunosuppression taper and/or immunomodulation can serve as effective treatment strategies.
Age
| Δ
| Gender Mis match
| HLA ABO Bi Dir Mismatch | Cond. Regimen | Stem Cell
| GVHD Grade
| Pre Transplant titre
| Rx (In addition to Taper Immuno Suppression )
| PRCA Diagnosed (Day)
| Retci count at PRCA Diagnosis
| Time to resolution of PRCA (Days)
| #PRBC After PRCA Diagnosis
| Post-Transplant Survival (Days) *Died
|
43
| AML
| M-->F
| 10/10MUD A+/O+
| Flu/Bu
| PBSCT
| Skin 2 | 256
| PLX , Rituximab DLI
| +35
| 0.31
| 122
| 21
| 228
|
60
| AML
| M-->F
| 10/10MUD A+/O+
| Flu/Bu
| PBSCT
| No
| 1024
| Rituximab
| +23
| <.28
| 166
| 12
| 273
|
38
| AML
| M->M
| 9/10MUD A+/O+
| Flu TBI
| PBSCT
| No
| 512
| None
| +34
| <.28
| 109
| 18
| 225
|
44
| AML
| M-->F
| 10/10MRD AB+/O+
| Cy/TBI
| PBSCT
| No
| 64
| Rituximab , Darbepoetin
| +26
| <.28
| Relapsed | NA
| 1043
|
63
| AML
| F-->M
| 10/10MRD A+/O+
| Flu/Bu
| PBSCT
| No
| > 2048
| Rituximab, Darbepoetin
| +40
| <.28
| Transfusion Dependent
| NA
| 114*
|
57
| AML
| M->M
| 10/10MUD A+/O+
| Flu/Mel
| PBSCT
| Skin 1 | 1024
| Darbepoetin Rituximab, PLX
| +57
| <.28
| 429
| 72
| 1583
|
68
| AML
| M->M
| 10/10MUD B+/O+
| Flu/Mel
| PBSCT
| Skin 1 | 1024
| None
| +56
| <.28
| 145
| 14
| 867
|
51
| ALL
| M-->F
| 10/10MUD A+/O+
| Cy/TBI
| PBSCT
| No
| 1024
| Rituximab Darbepoetin
| +52
| <.28
| Transfusion Dependent
| NA
| 315*
|
63
| ALL
| M-->F
| 10/10MUD A+/O+
| Cy/TBI
| BMSCT
| Skin 1 | UK
| Darbepoetin
| +45
| <.28
| 18
| 4
| 2643
|
47
| CML
| M->M
| 10/10MUD B-/A+ Bi-Dir | Cy/TBI
| PBSCT
| No
| Neg
| PLX
| +67
| <.28
| 17
| 7
| 211*
|
41
| MDS
| M->M
| 10/10MUD AB+/O+
| Cy/Bu
| PBSCT
| No
| 256
| PLX
| +49
| <.28
| 116
| 17
| 614
|
33
| MDS
| M->M
| 10/10MUD A+/O+
| Pent/TBI
| PBSCT
| GI 1 | Neg
| Darbepoetin
| +37
| <.28
| 13
| 4
| 431*
|