A blood banker reports that his institution has a policy to irradiate cellular blood products for patients undergoing cardiac surgery to minimize the risk of transfusion-associated graft-versus-host disease (TA-GVHD). His hospital has adopted the policy in part because of the article entitled "Transfusion-associated GVHD in an immunocompetent patient following cardiac surgery" by Rososhansky et al. published in Vox Sang 1999;76:59-63. The inquiring blood banker also indicates the rationale their hospital uses in irradiating blood products for these patients is based on their receipt of medications with immunosuppressive properties. Their policy applies for products transfused up to 7 days after surgery; the only exceptions are when such products are not available during a crisis. It has become the responsibility of the blood bank to assure that issue of irradiated products to cardiac surgery patients is documented in the blood bank computer. Admittedly this is accomplished by crude methods such as recording the name of the patient's surgeon and/or the procedure on the elective schedule. The inquiring blood banker comments that the above methods of documentation are not foolproof. The inquiring blood banker wishes to know if others have similar policies requiring irradiation of blood products intended for transfusion to cardiac surgery patients, and if so, what those policies entail. In particular, do other blood banks have the responsibility to determine which patients should receive irradiated blood products, and if so, how are these patients identified and tracked?

The following responses were received:

1. According to a blood banker whose university basketball team is usually one of the best in the land, ANY surgery or transfusion can be complicated by TA-GVHD if the recipient has the misfortune to receive blood from a donor homozygous for one of his/her HLA alleles. However, this blood banker wonders whether it is logical to irradiate blood for cardiac surgery patients (who receive relatively little blood these days) and not irradiate blood for ALL other patients. What about patients who are on immunosuppressive therapy for conditions such as lupus and similar disorders? The responding blood banker's policy is not to irradiate blood except for neonates, directed donors, and per physician request. They have considered irradiating blood for sickle cell patients undergoing RBC exchange. (Editor's NOTE: For a discussion of irradiating blood for sickle cell patients visit the earlier topic in this forum.)

2. A blood banker from near the Gulf Coast said that their cardiac surgery patients all receive leukoreduced products, but there is no policy mandating irradiation of blood products for such patients.

3. Another blood banker said that at the hospitals he has worked at in Texas, none have have required routine irradiation for cardiac surgery patients unless the patient is a newborn. Their policy states that "the blood bank will be responsible for 'automatic' irradiation of blood intended for infants less than 4 months of age and directed donations from blood relatives. For all other uses the physician is instructed to order the irradiation as needed. Despite this, the blood bank does try to ensure consistency for a given patient by placing a flag on the patient's record if irradiation has been approved and is not ordered subsequently; should this occur the blood bank will call to check if irradiation is still appropriate". In response to the report from Vox Sang (cited in the opening paragraph above), this responding blood banker (like the responder in #1 above) wonders why this situation would be unique to cardiac surgery patients. If one believes such patients merit special concern, wouldn't you then have to irradiate blood for all patients? Further, it seems like the chance (in the US population) of having a random donor happen to be HLA matched to a patient to that degree (as stated in #1, above) is extremely small, unless it is a blood relative, someone of similar ancestry/origin, or the product was HLA-matched."

4. Another blood banker suggested that members of the e-network forum read the article by Triulzi D et al that exhaustively reviews the literature and finds a single case of TA-GVHD for each among liver and heart transplants, and concludes that in aggregate this does not justify routine irradiation of cellular components for solid organ transplant recipients. (AABB members may read the full article from Transfusion 2001;41:419-426.)

5. A blood banker from New York says that his hospital has not encountered a single case of TA-GVHD among over 14,000 cardiac surgery cases over a period of 16 years. He is interested in knowing which drugs being administered to cardiac surgery patients at the inquiring blood banker's institution are imputed to have immunosuppressive properties.

ADDENDA Dec. 7, 2001

6. At a University located in a state that boasts about the number of lakes (most of which are probably frozen in winter) they do not irradiate blood for cardiac surgery.  The only exception is if irradiated blood isrequested for congenital cardiac surgery performed near birth prior to knowing whether there is an associated congenital immunodeficiency (DiGeorge syndrome).

7. At a second medical center in the above state a blood banker had this to say. "In my view , it would be gross overkill to irradiate all cellular blood products for cardiac surgery.  The reports of GVHD have come from cases where the blood was from close family members and in some of the cases from Israel, was " fresh ". The Japanese cases were from a population with a very restricted HLA gene pool and were thus, in this respect,similar to the cases from Israel. It is entirely sufficient to irradiate all blood from "directed" donors to be sure that any units coming from close relatives get caught in the "safety net". This has been our policy since the first cases were reported from Israel. We knew that we could not always depend on the clinicians informing us of the exact family relationship that each directed donor might have with the recipient. Therefore, at our institution, all directed donor blood is automatically irradiated.

8. A Texan suggested (tongue in cheek) that if zero reported cases of blood-borne nvCJD is sufficient rationale to toss out donors from the UK, then a whopping two reported cases of TA-GVHD would be plenty of reason to irradiate every unit of blood before transfusion. He laments that at least that's what the risk-management philosophy of modern blood banking establishment would seem to dictate.

9. A California blood banker said that he is in agreement with the above colleagues who have responded thus far. He states "the article by Rososhansky, et al. documents a single case of TA-GVHD following transfusion of an immunocompetent cardiac surgery patient, in which much (perhaps all?) of the cause can be explained by two of the donors being homozygous for an HLA class I haplotype (A1; B8) for which the patient was heterozygous.&nbp; Nothing in this article points toward this unfortunate case having been precipitated by any kind of "cardiac surgery-related, immunodeficient state." That is not to say that such an immunodeficient state might not occur (thus setting a patient up for TA-GVHD). Anything is possible, and I think this is something that we should keep on our radar screens. However, at this time, I do not believe that any compelling evidence exists to support irradiating all blood products - "cellular" or otherwise - that are to be transfused into cardiac surgery patients."

ADDENDA Dec. 10, 2001

10. A British blood banker reports that "in the UK it is not standard practice to irradiate blood used for cardiac surgery.....this is not included as a recommendation in the British Committee of Standardisation (BCSH) Guidelines. Furthermore, where irradiated blood is recommended for given clinical conditions such as for fetal transfusions or patients with Severe Combined Immunodeficiency Disease (SCID), it is clearly stated that leucodepletion is NOT a substitute for irradiation. (However, it is interesting to note that no TA-GVHD has been reported since it became mandatory to use 100% leucodepleted blood products in the UK, and it will be interesting to see what happens over the next few years)."

ADDENDA Sept. 19, 2008

11. A Medical Group in Southern California is interested in both local community practice as well as national practice for transfusion support of the solid organ transplanted patients post transplant. Review of the literature (and the discussion above) would suggest that heart (and other selected) transplant patients do not need to receive irradiated products. Since the last posting to this discussion was in 2001, how are hospitals in 2008 supporting patients post-cardiac transplant (and other solid organ transplants), and if providing irradiated or CMV negative products, how long after transplant are these special needs supported?

ADDENDA Sept. 22, 2008

12. A colleague at the University of Michigan reports that solid organ transplantation is not an indication for irradiation of blood products at that medical center, unless the patient has a confounding medical condition (ex. history of BMT). They use CMV-safe products for all patients: The inventory is 100% pre-storage leukocyte reduced RBC and platelets.

ADDENDA Sept. 27, 2008

13. A Blood Bank 'Group Leader' at a hospital in Michigan reports that in contrast to the University of Michigan mentioned above, for at least the first year following the receipt of a solid organ transplant, all such patients receive irradiated cellular blood products that are leukocyte reduced (CMV safe).

ADDENDA Nov. 17, 2008

14. A children's hospital in Southern California reports that they are aware of recent events at other hospitals where children who were post-op from cardiac surgery became symptomatic/hyperkalemic following transfusion with irradiated red blood cells. These hyperkalemic events have stimulated consideration of various risk mitigation strategies, all of which have downsides (delays in blood availability vs. wastage of products vs. expenditure of staff time). The inquiring hospital would be interested to know if others have addressed this problem and what steps are being taken to reduce the risk of transfusion induced hyperkalemia in pediatric cardiac surgery patients.

ADDENDA Nov. 23, 2008

15. In the posting to this discussion on Nov. 17, 2008, a children's hospital in Southern California wants to know how other institutions avoid the problem of hyperkalemia following transfusion of irradiated RBC to pediatric cardiac surgery patients. As mentioned by several colleagues who have contributed to this discussion, one approach would be to NOT use irradiated RBC for pediatric cardiac surgery patients, unless the patient has a confounding medical indication for the use of such blood products.

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator