A colleague in the Pacific Northwest wonders what institutions do regarding transfusion support of patients who require transplantation of ABO incompatible solid organs.

Specifically,

1. For those places performing ABO incompatible heart transplantation in infants, do they plasma reduce or wash the red cells used to support a group O recipient receiving a group A donor heart?
2. For those places performing ABO incompatible liver transplantation, would red cell support for a group O recipient receiving a group A liver require washing or plasma reduction of the red cells? What if the patient is 11 years old and weighs 30 Kg?

And finally, are there data available on the importance of passive isoagglutinin transfer from red cells and organ survival?

The following responses have been received.

ADDENDA Sept. 10, 2005

1. A transfusion medicine physician in Boston reports that they have had experience with heart transplantation in infants. They will plasma reduce red cells prior to transfusion to an infant who has received an ABO incompatible heart transplant. He is not aware of good data to support this practice in infants, one way or the other, but they do know that incompatible plasma can cause a problem in adults and older childrens, so it theoretically could cause problems for hearts used to transplant infants. He adds that the Hospital for Sick Children in Toronto are pioneers in this area and have published good results (West LJ, et al, NEJM 2001, 344:793-800). They removed the incompatible plasma and follow titers and use plasmapheresis to remove the antibodies.

2. Dr. Deborah A. Sesok-Pizzini reports that at the Children's Hospital of Philadelphia (attribution used with permission), they support ABO-incompatible heart transplants with AB plasma and washed RBCs. She states "We begin this at the time of listing. However, there is no published data that I could find to support the necessity to begin using AB plasma and washed RBCs prior to the actual transplant surgery. I could not find data that suggested that passive transfer of isohemagglutinins in additive solution RBCs could result in a hyperacute rejection. However, my concern was always that raising the titer, even passively, prior to transplant may preclude an infant from receiving an ABO-incompatible heart due to a medically defined titer "cut-off". However, I also could not find published data supporting or refuting this claim. Our approach is to wash RBCs and use AB plasma for ABO-incompatible hearts. In the OR, the Anesthesia team performs an exchange which appears to reduce the titer of both passive and natural antibodies. The Hospital for Sick Children in Toronto has published experience with their ABO-incompatible infant hearts." She adds that her experience with livers in an adult setting is to provide unwashed RBCs that are compatible with both the donor liver and the liver recipient.

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