Transplant‐associated thrombotic microangiopathy and immune haematological complications following intestine‐containing organ transplantation: experience from over 100 consecutive cases

Abstract

Descriptions of passenger lymphocyte syndrome (PLS), immune cytopenias and transplant-associated thrombotic microangiopathy (TA-TMA) after intestine-containing transplants remain scarce. We describe our centre's experience of these complications from 2007 to 2019. Ninety-six patients received 103 transplants. PLS occurred in 9 (9%) patients (median 12 days post-transplant); all due to ABO antibodies. There were 31 minor ABO mismatch transplants. No patient required change in immunosuppression. Immune cytopenias (excluding PLS) occurred in six patients at an incidence of 1Á7/100 patient years; three immune haemolysis, one immune thrombocytopenia, one acquired Glanzmann's and one immune neutropenia; 50% occurred with other cytopenias. All cases eventually responded to treatment, with a median of four treatments (range 1-8) and 5/6 were treated with rituximab. One patient with immune haemolysis required bortezomib. Complications were common in patients with immune cytopenias; 4/6 with infection needing intravenous antibiotics and 3/6 with venous thromboembolism. In 3/6 cases, a secondary cause for the immune cytopenia was evident. Switching from tacrolimus to ciclosporin was not necessary. There were five cases of transplant-associated thrombotic microangiopathy (TA-TMA; 1Á5/100 patient years) requiring calcineurin inhibitor withdrawal; two cases associated with acute rejection. Two cases were managed with plasma exchange, one with plasma infusions and one with eculizumab. Further research in this patient group is required.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice – Evidence‐Based Approach from the Writing Committee of the American Society for Apheresis: The Ninth Special Issue

“…It is associated with a high degree of morbidity or mortality and can result in loss of the graft. The value of TPE following SOT remains controversial, but small CS are published (Thomas, 2021). Complement blockade with eculizumab is also utilized.…”

Gastrointestinal involvement of passenger lymphocyte syndrome followed by minor ABO‐incompatible renal transplantation: A case report

“…TPE has been reportedly used for the treatment of PLS. 6,[15][16][17] However, a lack of clear clinical guidelines has been observed regarding the end point of TPE for the treatment of PLS. Based on the ideas of the pathogenic mechanism of PLS, donor-derived lymphocytes produced antibodies against the recipient's RBCs, resulting in hemolysis.…”

“…We managed the patient with TPE to deplete the circulating anti‐A IgG antibodies. TPE has been reportedly used for the treatment of PLS 6,15–17 . However, a lack of clear clinical guidelines has been observed regarding the end point of TPE for the treatment of PLS.…”

Thrombotic Microangiopathy After Hematopoietic Stem Cell and Solid Organ Transplantation: A Review for Intensive Care Physicians

“…1 Although infections and graft-versus-host disease (GVHD) have historically been the major contributors to transplant-related nonrelapse mortality, 2,3 transplant-associated thrombotic microangiopathy (TA-TMA) has increasingly become recognized as an independent entity with incidence rates of 8.2% to 39%. [4][5][6][7] It is characterized by the development of post-transplant hemolysis with schistocytes, thrombocytopenia, and organ dysfunction. Kidneys are the most common organs to become involved; intestinal involvement is also recognized.…”