Portal de Periódicos da CAPES

Transfusion‐associated graft‐versus‐host disease

2009; Wiley; Volume: 4; Issue: n2 Linguagem: Inglês

10.1111/j.1751-2824.2009.01242.x

1751-2824

Takeo Juji, Motoko Nishimura, Yuichiro Watanabe, Shigeharu Uchida, Hitoshi Okazaki, Kenji Tadokoro,

Erythrocyte Function and Pathophysiology

Transfusion-associated graft-versus-host disease (TA-GVHD) had been one of the most serious hazards of transfusion in Japan, because of the most frequent in the world, fulminant and rapidly fatal. In 1955, Shimoda described 12 cases of postoperative erythroderma (POE) [1]. These patients developed a skin rash, and high fever, a several days after surgical operation. Aoki et al. [2] reported the first case of TA-GVHD in an immunocompetent patient in 1984. The case was diagnosed initially as POE, and they changed diagnosis as GVHD, because they found that the infiltrating lymphocytes killed bone marrow stem cells. At that period of time, no body thought GVHD might develop in immunocompetent patients. This paper gave an extremely strong impact to Japanese scientists in transfusion medicine, because so many patients might have been suffered from this newly proposed pathological condition. A group of researchers of the Japanese Society of Transfusion Medicine proposed a collaborative investigation with the Japanese society of cardiovascular surgery, and examined retrospectively possible cases of TA-GVHD in the 63 257 cardiovascular patients operated in 137 hospitals between 1981 and 1986 [3]. Totally, 96 cases of TA-GVHD were diagnosed for these 6 years. It was a big surprise for us when it was suggested that a case of TA-GVHD will develop per 659 cases of cardiovascular patients operated and transfused. The second nation-wide-survey of TA GVHD was conducted by Japanese Red Cross [4]. Hundreds thousands of copies of a brochure describing the nature of TA-GVHD were distributed to all the physicians and surgeons who were working in the medical institutions where more than a thousand blood components were used per year in 1992, and accepted answers to the questionnaire on their previous knowledge and possible clinical experience with TA-GVHD. More than 14 000 answers were received. Based on these experiences, it was planned to establish a nation-wide system to collect and analyse serious hazard of transfusion in Japan. We (Tadokoro and Juji) move to Central Blood Center, Japanese Red Cross from Blood Transfusion Service, University of Tokyo Hospital in 1992, and started to establish Japanese Red Cross Hemovigilance System (medical information activity) in 1992. Then, we started our activity at the beginning of 1993. For suspected 32 cases of TA-GVHD, the differential diagnosis was made through the association of clinical manifestations combined with relevant laboratory findings, and nine cases were confirmed to be TA-GVHD in 1993. On request, each JRC blood centres could supply irradiated blood components to hospitals, after Japanese Red Cross Blood Centers were licensed to supply irradiated blood components on June 6,1998. However, there were four cases of TA-GVHD confirmed in 1999. So, it was finally decided to supply all the cellular blood components irradiated from blood centres in 2000. Fortunately, since then, we no longer have any case of TA-GVHD, as long as blood supplied by Japanese Red Cross Blood Centers, were used. Till the end of 1999, totally 66 cases of TA-GVHD had been analysed. Except one immunocompromised, SCID (severe combined immunodeficiency) patient, it was confirmed that HLA phenotypes of all the patients, were compatible to their donors’ HLA phenotypes. The majority of cases, the donors were homozygotes of common HLA haplotype shared with the patients. It was very interesting that the most of patients are elder than 60, and received transfusion for the first time. From peripheral blood of patients, several T-cell clones were established. These immunologically active cells play a major role in the manifestation of TA-GVHD. Murphy observed the first graft-versus-host reaction on chick embryos when inoculated with cells from adult animals in 1916 [5]. Simonsen [6], and Billingham [7] independently observed this immunological reaction also occurs in mice. In human, shortly after bone marrow transplantations introduced to perform, there were reports of a GVHD like disease with symptoms similar to those findings seen in ‘runt disease’ in treated patients by Mathe et al. [8] The first report of TA-GVHD was described by Hathaway et al. in 1965 [9]. Immunodeficient infants and fetuses were transfused blood containing viable lymphocytes, and all the patients in this report died. Ten years prior to this paper, Shimoda [1] reported 12 cases of Japanese patients who developed POE in 1955. These 12 patients developed erythroderma with fever, several days after surgical operation and simultaneous blood transfusion. Of these 12 patients, six patients died, and five showed severe leukopenia with concomitant bone marrow aplasia. According to the present diagnostic criteria, these five cases were supposed to be TA-G VHD. However, the remaining non-TA-GVHD POE cases remain to be investigated. Aoki et al. reported the first case of TA-GVHD in an immunocompetent patient in 1984 [2]; a patient developed a fever, skin rash, diarhhoea and pancytopenia and subsequently died. Aoki et al. reported the first case of TA-GVHD in an immunocompetent patient in 1984 [2]; a patient developed a fever, skin rash, diarhhoea and pancytopenia and subsequently died. The case was diagnosed initially as POE, and they changed diagnosis as GVHD, because they found the infiltrating lymphocytes killed bone marrow stem cells by histological examination. At that period of time, no body thought GVHD might develop in immunocompetent patients. At that period of time, no body thought GVHD might develop in immunocompetent patients. Simultaneously, an erythematous, maculopapular skin rash begin on the trunk and the extremities including the palm of hands and the sole of the feet., and it may progress to bullous lesions. The degree of liver dysfunction is variable, with an obstructive jaundice, elevated bilirubin and alkaline phosphatase associated with abnormal liver enzymes. The gastrointestinal complications are also variable, range from anorexia and nausea to massive diarrhoea. The final and severe picture of TA-GVHD is pancytopnia due to bone marrow aplasia, and the most common cause of death is overwhelming infections. Once it develops, the time course of the reactions is so rapid, and the mortality rate is as high as 98%. The three main requirements for the development of GVHD were defined by Billingham in 1966 [10]. They are; ‘(1) The graft must contain immunologically competent cells. (2) The host must possess important transplantation alloantigens that are lacking in the graft, so that the host appears foreign to the graft and is therefore capable of stimulating it antigenically. (3) The host itself must be incapable of mounting an effective immunological reaction against the graft, at least for sufficient time for the latter to manifest its immunological capabilities; that is, the graft must have the security of tenure’. The first two requirements are usually present in routine transfusion practice. For the third requirement, since Hathaway et al. first reported cases of TA-GVHD in immunodeficient patients in 1965, it had been thought that TA-GVHD could not develop in immunocompetent patients. Brubaker reviewed on TA-GVHD, and concluded that TA-GVHD occurred only in the patients with deficiency of cellular immunity in 1984. In this background, Aoki et al. reported the first case of TA-GVHD without any immune deficiency. If HLA phenotype of a blood donor is one-way match to HLA phenotype of the patient, the third requirement of Billingham will be fulfilled. Because MHC phenotypes in human are so diverse, it is reasonable to assume that HLA one-way match is extremely rare between blood donors and their patients. However, it was not extremely rare in Japanese, so many cases of TA-GVHD without immune deficiency have been reported. Relatively small numbers of Japanese ancestors migrated into these small islands and the population increased. The diversity of HLA phenotypes is so limited in Japanese. This might be a major reason of why TA-GVHD is frequent in Japan. Once, HLA one-way match immunocompetent cells in donor’s blood introduced and survived in patient’s body, these cells will attack patient’s tissue reacting against important transplantation alloantigens that are lacking on donor cells. The major target organs are skin, liver, digestive tracts, and bone marrow. In Japanese Hemovigilance system from 1993 to 1999, 66 cases of TA-GVHD with chimerism confirmed were accumulated. Except one SCID cases, HLA one-way match was observed in the rest of cases as far as HLA typing was performed. In the majority cases, the causative blood donors were homozygotes of the shared HLA haplotypes with the patients, and the patients were hetrozygotes of the shared haplotype and the other haplotypes. The signs and symptoms, and clinical course should be examined. The diagnosis of TA-GVHD is made through the association of clinical manifestation combined with relevant laboratory findings. Cytogenetic confirmation of donor lymphoid engraftment is essentially important. Skin, liver, and bone marrow biopsy should be included as relevant examinations. The final important point of diagnosis is to identify the chimerism of donor’s immune active cells in patient’s blood or tissues. In the early stage of research [11], selological HLA typing was used. Ito et al. [12] subsequently demonstrated that a patient’s HLA phenotype changed from his own, a heterozygote of HLA haplotypes to a homozygote of one of the HLA haplotypes, the donor’s phenotype. Matsushita et al. [13] reported two cases of female TA-GVHD. They demonstrated male lymphocytes with Y-chromatin, in the skin lesions of the female patients. The lymphocytes of male donors were shown to attack skin of female patients. Since HLA typing by DNA analysis has been introduced, the demonstration of donor cells or DNA in patient circulation or cellular infiltrates could confirm the diagnosis of TA-GVHD. In addition to the confirmation of diagnosis, HLA phenotypes of the patients and their blood donors, will give very important information for the better understanding of immunological background of TA-GVHD. Other methods to demonstrate the presence of donor cells in the patient include the comparison of polymorphic genetic markers, including variable number tandem repeat analysis (VNTR) and single nucleotide polymorphism (SNP). We employed an analysis of variable number tandem repeat of five human microsatellite markers with patient’s peripheral blood mononuclear cells and patient’s fingernail [14]. Donor DNA can be obtained from peripheral blood, however, pure host DNA may not be easily obtained from blood because of aplasia and donor-cell engraftment. Genomic DNA extracted from mononuclear cells of patient’s peripheral blood and patient’s fingernail was amplified, with a standard PCR method to detect polymorphisms of the dinucleotide and trinucleotide microsatellite repeats at the D6S89, INT2, HGH, APOCIII and ACTBP2 loci using specific oligonucleotide primers. The electrophoretic mobility of amplified DNAs was examined in 7% polyacrylamide gel. If different genetic markers from patient’s fingernail were obtained in the blood mononuclear cells, TA-GVHD is highly suggested. However, microchimerism (<2·5%) may observed in many clinical conditions, bone marrow transplantation, solid organ transplantation, even after transfusion. A diagnosis of TA-GVHD must include both the clinical features as well as evidence of blood donor’s lymphocyte engraftment. A nationwide monitoring system for transfusion-related adverse reactions was started to establish in Central Blood Center, Japanese Red Cross in 1992. Our major purpose was the evaluation of TA-GVHD. We employed totally more than 100 pharmaceutists as MR (medical representatives) in all the blood centres across the country, and educated them about transfusion-related adverse reactions for 1 year, and asked them to visit medical institutions, and to see and discuss with physicians and surgeons about cases with serious hazards of transfusion, and collect the clinical information and patients’ materials. Simultaneously, we established a special laboratory to analyse patients’ materials for identification the cause of the transfusion reactions, such as HLA typing, microsatellite analysis, antibodies related to transfusion reactions, and identifications of infectious agents after transfusion. Then, we started our activity at the beginning of 1993. In 1993, we received 228 cases of serious transfusion reactions including 32 suspected cases of TA-GVHD with precise clinical information, and patients’ and donors’ materials for analysis. For suspected 32 cases of TA-GVHD, the differential diagnosis was made through the association of clinical manifestations combined with relevant laboratory findings, including the comparison of tandem repeat numbers in microsatellite marker loci between patient’s peripheral blood mononuclear cells and finger nails. HLA phenotypes of them were determined with PCR-based methods. Of 32 suspected cases, nine cases were confirmed to be TA-GVHD in 1993. Since 1993–1999, totally 293 suspected cases of TA-GVHD were accepted to confirm chimerism of donor’s lymphocytes in patient’s blood samples by microsatellite polymorphism analysis. HLA DNA typing of patient’s blood lymphocytes (donor’s HLA), and patient’s fingernail (patient’s HLA) was performed. Of 293 suspected cases of TA-GVHD, the presence of chimerism with donor’s lymphocytes was confirmed in 66 cases. Of these, 62% was male, younger than 60 was 10%, and elder than 70 was 64%. Ageing was a significant risk factor. Interestingly, 96·2% of TA-GVHD patients were transfused for the first time. Except one SCID (7 years old, male) patient, all the patients were without any immunodeficiency. The underlying diseases of them were surgical patients with solid tumours, patients after cardiovascular surgery, patients with trauma by traffic accident, four patients received transfusion with bleeding gastric ulcer without surgery. There was an interesting case who recovered from TA-GVHD. The patient was transfused after massive bleeding with placenta previa, and developed TA-GVHD. The microsatellite analysis indicated that mononuclear cells of her peripheral blood had completely replaced by donor’s lymphocytes, however, after recovery, the microsatellite pattern had changed to her original pattern. We established T-cell clones which were considered to be the possible cause of TA-GVHD, from the peripheral blood mononuclear cell of patients [15–17]. In both cases, several CD4+ cytotoxic T-cell (CTL) clones were established. In case I, the target antigens of the established CD4+ clones was a HLA-DB1*0403-related antigen serologically typed as HLA-DR4, which was one of the patient HLA antigens. In case II, the target of four out of five established CD4+ CTL was a DRB1*1302-related antigen. One CD4+ CTL clone showed cytotoxicity against cells carrying HLA-A*2402, B:4403, Cw*1403 and DPB1*0401. A monoclonal antibody (mAb) blocking study showed only anti-DP mAb inhibited the cytotoxicity of this clone. Thus it might be considered that this clone recognizes HLA-DP with its binding peptides drove from either A:2402, B*4403, Cw*1403 or DRB1*1302. Our findings indicate that CD4+ CTLs may play important roles in the aetiology of TA-GVHD and that the antigens of patients recognized by donor-derived effector cells may no always recognize a single HLA antigen. From other patients, several CD8+ CTL were also established, and their target antigens were HLA-Class I antigens. Interestingly, a non-cytotoxic CD4+ T-cell clone was established. This clone proliferated with the stimulation by target HLA antigen, and produced and secreted tumour necrosis factor β. This type of T-cells is not directly cytotoxic to the target cells, however, cytokines they produce are cytotoxic to the target cells, and enhance the immune destruction of TA-GVHD. We established a B cell clone which produced complement-dependent cytotoxic antibody against HLA-DRB1*0405 included in the patient HLA phenotype [18]. These data indicate that HLA antigens play major roles as target antigens for development of TA-GVHD. For the engraftment of donor’s immune active cells, one of the following two fundamental requirements is necessary: (1) immunodeficiency in cellular immunity; (2) one-way match of HLA antigens between patients and blood donors. In addition to these requirements, additional factors might involve. Most of patients developed T-GVHD after surgical operations. There were four TA-GVHD patients with no surgical operation. They were transfused after massive gastric bleeding and trauma by traffic accident. They had no surgical operation, however, they received as strong stress as in surgical operation, and might have a similar cytokine shower. Ageing is one of the additional risk factors. 64% of our TA-GVHD patients were elder than 70 years old. It was noted that haematological disorders were relatively rare to develop TA-GVHD. Our data showed interesting evidence that the majority of our TA-GVHD patients, 96·2%, transfused for the first time in their life. Transfusion for the first time is one of the risk factors for development of TA-GVHD. Prevention of TA-GVHD is extremely important as it cannot be treated successfully. After TA-GVHD was disclosed to be a major problem for transfusion in Japan, the Japanese Society of Transfusion Medicine had organized a subcommittee to prevent TA-GVHD, and issued the first guidelines in January 1, 1992, and subsequently revised guide lines issued, the second guideline, on May12, 1995, the third guideline, on December 26, 1996. The historical background of guide lines issued by the subcommittee was reported by Asai T .et al. [19] The ministry of Health and Welfare of Japan issued an urgent warning about TA-GVHD in April, 1996, because the number of confirmed TA-GVHD cases by JRC was increasing such as, nine cases in 1993, 10 cases in 1994, and 11 cases in 1995. The guide lines recommended the identification of patients at risk and transfusion irradiated blood for these patients. In 1997, when confirmed TA-GVHD cases reached 14, the Ministry of Health sent the second ‘yellow card’ to all the medical institutes across the country, and recommended to use irradiated blood again. The number of cases of TA-GVHD decrease to 2 in 1998, however it increased again to four cases in 1999. The Ministry of Health and Welfare, and JRC discussed and decided to supply all the cellular blood components irradiated in JRC blood centres before shipment since the beginning of 2000. It was very difficult to select the best policy, however, we took a policy of universal blood component irradiation, because we estimated that at least 50 patients would die per year with TA-GVHD in Japan. Dr. Harvey G. Klein gave a kind comment on our decision in Transfusion [20] The two irradiation methods employed, γ-irradiation and X-ray irradiation. The irradiation dose was determined to be more than 15 Gy with no portion of the bag receiving less than 15 Gy, based on in vitro lymphocyte response tests (MLC) to allogeneic stimulating cells. By our more than 9 years’ experience, this irradiation dose was confirmed to be suitable and safe. Fortunately, since 2000, there is no case of TA-GVHD reported as long as blood supplied by JRC used. All blood products, which contain viable immunocompetent mononuclear cells, including red cell concentrates, platelet concentrates, granulocyte concentrates, and even fresh plasma have been implicated in TA-GVHD. However, according to JRC’s 9 years experience, no TA-GVHD case associated with fresh frozen plasma was documented.