Transplant of Rhesus-Positive Bone Marrow in a Rhesus-Negative Woman Having Anti-Rhesus D Alloantibodies

Abstract

A woman affected by acute myeloblastic leukemia was grafted with HLA A, B and D compatible rhesus-positive bone marrow from her brother. Before grafting, she had anti-D alloantibodies (1/512 IAT, 2.9 μg/ml). To prevent the destruction of donor red blood cells, four plasma exchanges and a conditioning regimen (total-body irradiation 800 rad, cyclophosphamide, methotrexate) were carried out to decrease anti-D from 2.9 to < 0.02 μg/ml on day 0. The anti-D level was 0.8 μg/ml on day 12 and was decreased to 0.2 μg/ml by eight plasma exchanges until day 35. Anti-D antibodies were undetectable with Lalezari’s technique on day 45. Engraftment was obtained on day 25 (3,000 leukocytes/mm³ and 50% erythroblasts in bone marrow). The patient died from aspergillosis and graft-versus-host disease on day 54. This observation shows that an engraftment of rhesus-positive bone marrow in a recipient with anti-D antibody is possible.

Mitigation strategies for anti‐D alloimmunization by platelet transfusion in haematopoietic stem cell transplant patients: a survey of NCCN® centres

“…Limited studies suggest that the presence of an anti‐D in a D‐negative recipient may result in increased red‐blood‐cell transfusions after transplantation with an D‐positive graft . However, an anti‐D does not appear to impact granulocyte or megakaryocytic engraftment and there are limited anecdotal data describing negative outcomes . Certain patient populations, such as patients with sickle cell anaemia, may be more severely affected by immunohaematological complications from alloimmunization after transplantation with minor red‐blood‐cell antigen incompatible grafts .…”

Non-ABO red blood cell alloantibodies following allogeneic hematopoietic stem cell transplantation

“…Although bone marrow transplants with Rh incompatibility involving C, c and E antigens have been described in the medical literature, 7,10,11 most reports regard the D antigen. [12][13][14][15][16] Like ABO incompatibility, RhD incompatibility can cause hemolytic anemia after BMT. 9 A major RhD incompatibility between donor and recipient of a BMT may lead to a severe delayed hemolytic anemia.…”

Optimizing the use of limited rare red cells for hematopoietic cell transplant recipients

“…Rigel and colleagues 15 described a case with a strongly reactive existing anti‐D where plasma exchanges were performed to eliminate the antibody. Additionally, the patient received D+ transfusions to deliberately adsorb the remaining anti‐D.…”