Transfusion medicine
Transfusion reactions & complications
Graft versus host disease

Topic Completed: 1 September 2011

Minor changes: 19 February 2021

Copyright: 2002-2021,, Inc.

PubMed Search: Transfusion associated graft versus host disease [title] "loattrfree full text"[sb]

Huy Phu Pham, M.D., M.P.H.
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Cite this page: Pham HP Graft versus host disease. website. Accessed April 19th, 2021.
Definition / general
  • Rare but almost universally fatal complication of transfusion
  • Goal: identify patients at risk for Ta-GVHD so that appropriate products can be given
  • Similar to acute GVHD after hematopoietic progenitor cell transplantation
  • Viable donor CD8+ T cells proliferate and attack recipient's bone marrow cells and possibly other organs (Osaka City Med J 1999;45:37) and recipient's immune system does not attack these donor T cells
  • May be less likely in blood stored 4+ days due to WBC inactivation (Br J Haematol 2000;111:146)
  • Appears to have been reduced after universal leukoreduction in UK (Transfusion 2007;47:1455)
  • Recipient may have normal immunity if homozygous for a HLA haplotype and donor is heterozygous with one shared haplotype, which causes donor cells to see recipient cells as foreign but recipient cells don't see donor cells as foreign (high risk if directed donations from first or second degree relatives); also risk factor in rural areas where gamma radiation is not possible (Transfusion 2007;47:1405, Indian Pediatr 2004;41:1260)
  • Diagnosis based on clinical findings and laboratory and biopsy results
  • Easily confused with severe viral illness or adverse reaction in severely ill patients if Ta-GVHD is not suspected - considered to be underdiagnosed and underreported
  • Confirm diagnosis by finding donor lymphocytes or DNA in patient's peripheral blood or tissue biopsy, with the appropriate clinical symptoms
Case reports
  • Most treatment options are unsuccessful and are only palliative
  • Steroids, antithymocyte globulin and cyclosporin
  • Nafmostat mesilate gives transient improvement
  • Almost universally fatal - usually due to infections
Clinical manifestation
  • Usually occurs at ~ 4 weeks after transfusion
  • Fever (day 28), skin rash (day 30), diarrhea, abnormal liver function tests
  • Death (day 51), usually due to sepsis because of leukopenia and pancytopenia
  • Identify patients at risk and transfuse them ONLY with irradiated blood products
  • Leukoreduction does NOT prevent Ta-GVHD
  • Indications for irradiating blood products for Ta-GVHD prevention:
    • Absolute:
      • Chemotherapy with purine analogs, Campath (anti CD52) or other drugs that affect T cells
      • Congenital cellular immunodeficiency (severe combined immunodeficiency, DiGeorge syndrome) - suspected or known
      • Hematopoietic progenitor cell transplantation (both allo and autologous)
      • Granulocyte transfusion
      • Hodgkin lymphoma
      • Neonates who have received intrauterine transfusions
      • Transfusions from blood relatives
      • HLA matched or partially HLA matched products
    • Relative:
      • Neonates or infants < 1200 g
      • Neonate exchange transfusions
      • Non-Hodgkin lymphoma / leukemia (Vox Sang 2002;83:279)
      • High dose chemotherapy, radiation therapy or aggressive immunotherapy due to leukemia or solid tumor
      • Aplastic anemia
    • Controversial:
      • Solid organ transplants, large volume or exchange transfusions in infants who did not receive intrauterine transfusion
      • Absolute lymphopenia
    • Probably NOT required:
      • HIV infection
      • Healthy newborn or term infants
      • Hemophilia, humoral immunodeficiency (common variable immunodeficiency)
      • Small volume transfusions in term infant who did not receive intrauterine transfusion
      • Elderly, immunosuppression other than purine analogs, pregnancy, red cell disorders (hemoglobin, membrane or metabolic)
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