Passenger lymphocyte syndrome after single lung transplantation: report of a case and literature review

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(1)124. Passenger Lymphocyte Syndrome After Single Lung Transplantation: Report of a Case and Literature Review 2. 1. 3. Ming-Li Lee, Liang-Wen Hang , Ping-Chun Lee , Shu-Fen Pai , Chih-Shiun Shih, Nan-Yung Hsu 1. Division of Chest Surgery, Division of Cardiovascular Surgery, Department of Surgery; 2. 3. Division of Chest Medicine, Department of Internal Medicine; Department of Nursing, China Medical College Hospital, Taichung, Taiwan, R.O.C.. Passenger lymphocyte syndrome (PLS) may occur when an organ from a blood group O donor is transplanted into a blood group A, B, or AB recipient. ABO-identical organs are used in the majority of transplants. However, because of the shortage of suitable donors, a minor ABOmismatch may occur when using blood group O donor organs in A, B, or AB recipients. Induction of red blood cell destruction by graft-derived antibodies after minor ABOmismatched single lung transplantation (SLT) is rare. We describe a blood group A recipient who had hemolysis of red cells, starting from day 8 and lasting up to day 11 after SLT, which necessitated transfusion from a blood type group O donor. ( Mid Taiwan J Med 2002;7:124-8). Key words ABO-mismatch, passenger lymphocyte syndrome, single lung transplantation. INTRODUCTION. This may induce passenger lymphocyte. Since the first successful single lung. syndrome (PLS), hemolysis of the recipient's. transplant (SLT) in 1983 [1], 11,148 lung. red cells by anti-A antibodies and/or anti-B. transplants have been reported to the. antibodies produced by grafted donor. International Lung Transplant Registry, and. lymphocytes [3]. In addition to bone marrow. 58% of them have been SLT. The overall. transplants [4,5], PLS can occur after transplant. survival rate is above 80% six months after. of any type of organ, such as liver [6], kidney. lung transplantation (bilateral or single). [7], heart and lung [3,8], and lung [9].. according to the registry [2]. Although ABO-. We describe a blood group A recipient. identical organs are used in the majority of. who had hemolysis of red cells, starting from. transplants, when a suitable ABO-identical. day 8 and lasting up to day 11 after SLT, which. donor is not found, universal group O donor. necessitated transfusion from a blood type. organs may be used in A, B, or AB recipients.. group O donor. We reviewed the literature, and, to our knowledge, this is the first. Received : December 2, 2001.. Revised : March 28, 2002.. reported case of PLS after SLT in Taiwan.. Accepted : March 29, 2002. Address reprint requests to : Nan-Yung Hsu, Division of Chest Surgery, Department of Surgery, China Medical College Hospital, No 2, Yuh-Der Road, Taichung 404, Taiwan, R.O.C.. CASE REPORT. The patient was a 43-year-old man with.

(2) Ming-Li Lee, et al.. 125. (adjusted to a whole blood level of 250 350 ng/mL) and azathioprine were administered intravenously in the immediate post-SLT period. The patient gradually received oral medication as tolerated. Antimicrobial prophylaxis, which included Vancomycin and Tienam was administered for five days, followed by cytomegalovirus prophylaxis with gancyclovir. Postoperatively, jaundice developed (peak total serum bilirubin 41.0 µmol/L (2.4 Flow chart shows hematologic and biochemical. mg/dL)), hemoglobin dropped from 120 g/L. evidence for hemolysis. Two units of packed red cells. (12 U/dL) to 96 g/L (9.6 g/dL), and lactic. were required to maintain the hemoglobin between day 11. dehydrogenase increased from 3.2 µKat/L (188. Figure.. and day 12 after operation.. U/dL) to 5.6 µKat/L (330 U/dL) between postoperative day 8 and 11 (Figure). Acute. end-stage emphysematous disease who underwent a left single lung transplant. His blood group was A, Rh-positive, and his human leukocyte antigen (HLA) serologic typing was A1101 A24 B54 B60 Cw7 DR4 DR12 DR52 DQ4 DQ7. There was no history of prior blood transfusion. Before surgery, hematologic values were within normal limits, and both the direct antiglobulin test (DAT) and red cell antibody screening were normal. The donor was a 16-year-old male with blood group O, Rh-positive, and HLA serologic typing A11 A24 B48 B75 Bw6 DR11 DR12 DR52, who died of intracerebral hemorrhage. No data on his red cell antibody screening could be obtained. The. hemolysis anemia was diagnosed. At the time of hemolysis, peripheral blood smear of the patient showed classic changes of immune hemolysis. with. spherocytes. and. polychromasia. However, subsequent DAT with anti-C3d and anti-IgG, and red cell antibody screening tests were normal. The patient was then given 2 units blood group O packed red cells which produced satisfactory hemoglobin increments. The patient was discharged on postoperative day 28. Nine months after transplantation, his clinical condition is excellent, pulmonary function test has improved significantly, and no evidence of hemolysis has been noted.. surgical procedure was uneventful, and the patient. received. left. single. lung. DISCUSSION. transplantation (SLT). A cardiopulmonary. We have performed SLT on four patients,. bypass was used during operation because. including three ABO-mismatched organs and. pulmonary artery pressure increased to 78/25. one ABO-identical match. This patient was the. (50) mmHg when the left pulmonary artery. only ABO-mismatched lung recipient who. was clamped. The ischemic time for the. encountered PLS after SLT. According to the. transplanted lung was 333 minutes. The bypass. literature, PLS can occur after transplantation. time was 70 minutes.. of bone marrow and any type of organ. He received a routine immunosup-. (Table) except cornea and heart, which. pression regimen which included pre-SLT:. probably reflects the successful removal of. azathioprine (2 mg/kg) and intraoperative 1 g. blood-borne lymphocytes at the time of. methylprednisolone. vascular. transplantation and/or the absence of. anastomosis; post-SLT: equine anti-human. lymphoreticular tissue in the heart and cornea. thymocyte. globulin. after. was. [3]. The reasons for PLS are explained by the. administered for five days, followed by. (2. mg/kg). fact that group O donor lymphoreticular tissue. prednisone (1 mg/kg/day). Cyclosporine A. and circulating lymphocytes continue to.

(3) 126. Passenger Lymphocyte Syndrome in Lung Transplantation. Table. Occurrence of passenger lymphocyte syndrome from solid organs and bone marrow transplantations in studied series Author/Year. Organ/BMT. Cases reported. References. Bird/1982 Ramsey/1984 Mangal/1984 Hows/1986 Hunt/1998. Lung Liver Kidney BMT Heart-lung. 1 5 3 6 6. 9 6 7 5 8. BMT = bone marrow transplantation.. produce anti-A antibodies and/or anti-B. monitored for signs of red cell destruction in. antibodies after transplantation which mount. the event of a hemolytic crisis due to donor. a secondary immune response following. ABO antibodies [3]. Furthermore, patients. antigenic stimulation by the recipient's. should be given group O red cell concentrates. differing ABO antigens [3]. It is possible that. to prevent exacerbations of hemolysis as was. anti-A and anti-B antibodies may not be. done in this patient. Fresh frozen plasma. detected in the patient's RBC by DAT, as the. should be of the recipient's group, and. findings in our studies and those of Hunt et al. platelets can be from either recipient or donor. have shown [3].. group.. In this study, we noted hemoglobin fall. Interestingly,. many. studies. have. from 120 g/L (12.0 g/dL) to 96 g/L (9.6 g/dL). mentioned that cyclosporine may enhance,. between postoperative day 8 and day 11. The. but not suppress, the production of anti-A and. occurrence of hemolysis due to PLS after. anti-B antibodies by donor lymphocytes. transplantation varies. In the study group of. [5,7,10]. Theoretically, cyclosporine is thought. nine heart and lung transplantation recipients,. to inhibit the response of T lymphocytes to. Hunt et al reported that a fall of hemoglobin. "new" antigens but not against antigens the. of 5 g/L/day (0.5 g/dL/day) occurred for a. immune system has already been primed to,. mean of 13 days, starting from days 4 12 and. such as the ABO antigens. Thus, cyclosporine. lasting up to day 27 [3]. It has been reported. will prevent the destruction and suppression. that in renal and hepatic transplants with. of donor lymphocytes (new antigens), while. minor ABO incompatiblitily, hemolysis is. allowing continued ABO antibody production. usually short-lived; it can be seen as early as. from the already primed donor lymphocytes. day 3 and can last up to three weeks, but. [3].. there is no evidence of incompatible ABO. Due to a shortage of donor organs, it is. antibody production persisting for longer than. inevitable to use ABO compatible, but not. three months after transplantation [3,6-10].. identical, blood group O donors in blood. Although the clinical problems usually can be. group A, B, or AB recipients. We think it is. solved successfully by transfusion, we think. essential to monitor the patients for anti-. that PLS should be a differential diagnosis for. recipient ABO antibodies after transplantation.. anemia and/or jaundice after transplantation,. If they appear, donor-type packed red cells. especially in ABO-mismatched transplantation.. should be given when needed throughout the. Concerning. the. management. of. period when the antibody is present [6].. hemolysis after a minor ABO-mismatched organ transplant, Hunt et al reported that one of the heart and lung transplant recipients had. ACKNOWLEDGMENTS. a maximal fall in hemoglobin of 5 g/L in 48. The authors would like to thank Miss. hours, and suggested that recipients of heart. Chiao Lin Lin for her assistance with the direct. and lung transplantation should be closely. antiglobulin and antibody screen tests..

(4) Ming-Li Lee, et al.. 127. 6.. REFERENCES 1.. Toronto Lung Transplant Group: Unilateral lung. 2.. Hosenpud JD, Bennett LE, Keck BE, et al. The. 2000. J Heart Lung Transplant 2000;19:909-31. 3.. incompatible marrow transplants. Transplantation 1978;26:233-8 5.. Hows J, Beddow K, Gordon-Smith E, et al. Donorderived red blood cell antibodies and immune hemolysis. after. allogenic. bone. transplantation. Blood 1986;67:177-81.. marrow. TE,. et. al.. Mangal AK, Logan D, Sinclair M, et al. Protection. Knoop C, Andrien M, Antoine M, et al. Severe hemolysis due to a donor anti-D antibody after. Hunt BJ, Yacoub M, Amin S, et al. Induction of red. Buckner CD, Clift RA, Sanders JE, et al. ABO-. Starzl. transplantation. Transfusion 1984;24:363-4. 8.. heart-lung transplantation. Association with lung and blood chimerism. Am Rev Respir Dis 1993;. after minor ABO-mismatched heart and lung 4.. J,. against hemolysis in ABO mismatched renal. blood cell destruction by graft-derived antibodies transplantation. Transplantation 1998;46:246-9.. Nusbacher. 1984;311:1167-70. 7.. Registry of the International Society for Heart and Lung Transplantation: seventeenth official report-. G,. unmatched liver transplantation. N Engl J Med. transplantation for pulmonary fibrosis. N Engl J Med 1986;314:1140-5.. Ramsey. Isohaemagglutinins of graft origin after ABO-. 148:504-6. 9.. Bird GW, Wingham J. Formation of blood group "autoantibodies" after transplantation. Transfusion 1982;22:400.. 10. Kozaki M, Oda T, Okochi Y, et al. Selection of donors in transplantation with cyclosporine treatment from the viewpoint of blood typing. Transplant Proc 1986;18:443..

(5) 128. 1. 2. 3 1. O. A. B. 2. AB ABO. A. B. AB. O. A 8. O. 11. 2002;7:124-8. ABO. 404 12/2/2001 3/29/2002. 2 3/28/2002. 3.

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