Transfusionsmedizinische Versorgung von Patienten nach allogener Blutstammzelltransplantation

Zusammenfassung

Im Rahmen einer allogenen Blutstammzelltransplantation kommt es häufig zu immunhämatologischen Phänomenen, die im Rahmen der Diagnostik und der supportiven Hämotherapie berücksichtigt werden müssen. Durch Diskrepanzen der AB0-Merkmale von Spender und Empfänger können verschiedene Komplikationen auftreten. Die wesentlichsten sind ein verzögertes Engraftment der Erythropoese nach major-inkompatibler Transplantation (sogenannte Pure-red-Cell-Aplasie, PRCA) und die verzögerte Hämolyse durch Aktivierung von minor-inkompatiblen Lymphozyten im Transplantat, das sogenannte Passenger-Lymphocyte-Syndrom (PLS). Durch ein gezieltes immunhämatologisches Monitoring der Patienten können diese Phänomene zeitgerecht erkannt und adäquat therapiert werden. Ein Wechsel im Bereich des Rhesusantigens D ist ebenfalls bei der Hämotherapie allogen transplantierter Patienten zu berücksichtigen, verursacht allerdings nur selten Komplikationen. Hinsichtlich der Thrombozytenversorgung sollte rechtzeitig vor Konditionierungsbeginn eine gezielte Diagnostik von Immunisierungen gegen HLA- (humane Leukozyten-Antigene) und Plättchen-spezifische Antigene erfolgen, um die Thrombozytenversorgung mit ausgewählten Spendern in der Aplasiephase zuverlässig gewährleisten zu können. Bei sehr breit und hochtitrig immunisierten Patienten kann eine Immunsuppression mit Rituximab und Immunadsorption vor Transplantation die Inkremente nach Thrombozytensubstitution verbessern und im Falle von einem HLA-Mismatch des Transplantats auch das Engraftment unterstützen.

Abstract

Allogeneic hematopoietic stem cell transplantations frequently cause immunohematological phenomena that require specific diagnostics and transfusion support. Crossing the AB0 blood group barrier between donor and recipient can elicit various complications. The most important challenges are the pure red cell aplasia, PRCA, a delayed red blood cell engraftment that can occur after major AB0 mismatch transplantations, and the passenger lymphocyte syndrome, PLS, a delayed hemolysis due to activated, transplant-derived minor AB0 mismatch lymphocytes. Focussed immunohematological monitoring allows diagnosing these complications permitting therapeutic decisions. RhD factor mismatches have to be considered regarding the transfusion strategy but rarely account for complications. Screening for alloimmunisation against human leukocyte antigens (HLA) or human platelet antigens (HPA) should take place before the conditioning starts to ensure that compatible platelet concentrates will be available during the aplasia phase. In patients with exceptionally high immunization, immunosuppression with rituximab and pre-transplant immunoadsorption may improve the post-transfusion platelet counts and support engraftment in the case of a crossmatch-positive HLA mismatch transplant.

Schlüsselwörter

Blutstammzelltransplantation - Hämolyse - Refraktärzustand bei Thrombozytentransfusion - Transfusionsstrategie

Key words

blood stem cell transplantation - hemolysis - refractoriness to platelet transfusion therapy - transfusion strategy

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