Guidelines on the use of irradiated blood components

Abstract

This guideline was compiled according to the British Society for Haematology (BSH) process at https://b-s-h.org.uk/media/16732/bsh-guidance-development-process-dec-5-18.pdf. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) nomenclature was used to evaluate levels of evidence and to assess the strength of recommendations. The GRADE criteria can be found at http://www.gradeworkinggroup.org. The last guideline covering this topic was published in 2012. Publications were searched systematically in English between 2008 and August 2019 covering the period since the last publication (Appendices 2 and 3). Review of the manuscript was performed by the BSH Guidelines Committee Transfusion Task Force, the BSH Guidelines Committee and the Transfusion and Malignant Haematology sounding board of BSH, and relevant specialists including paediatric cardiac anaesthetists and haematologists specialising in malignant diseases. It was also on the members section of the BSH website for comment. To provide healthcare professionals with clear guidance on situations when the use of irradiated blood components is indicated. The term ‘blood component’ means the therapeutic constituents of human blood (red cells, white cells, platelets and plasma) that can be prepared by various methods (JPAC https://www.transfusionguidelines.org/red-book/definitions). The multidisciplinary writing group developed evidence-based clarification and practical guidance in clinical areas of ambiguity. Publications relating to patients of all age groups have been assessed. The guidance may not be appropriate in all patient situations and assessment of individual circumstances with the appropriate risk assessments and patient involvement may lead to alternative decisions. Transfusion-associated graft-versus-host disease (TA-GvHD) is a rare, usually fatal, complication of transfusion of blood components containing lymphocytes. There are no published clinical trials, and evidence for the prevention mostly relies on case reports, haemovigilance data and laboratory methods aiming to inactivate or eliminate lymphocytes in the transfused components. Attempts have been made in the literature to understand recipient susceptibility based on retrospective epidemiological data and information about the level of immunosuppression, not specific for the pathophysiology of TA-GvHD. The clinical and laboratory features of TA-GvHD and the relative contribution of recipient and component factors remain poorly understood. The condition was first recognised in immunocompromised recipients transfused with cellular blood components containing viable lymphocytes.1-3 Subsequently it was evident that non-immunosuppressed patients could also develop the condition, particularly if the blood components transfused derived from an human leucocyte antigen (HLA)-haploidentical unrelated donor or family member.4-7 The current hypothesis is that the risk associated with an individual transfusion depends on the number and viability of contaminating lymphocytes, susceptibility of the recipient's immune system to their engraftment and degree of immunological (HLA) disparity between donor and patient. The minimum number of transfused lymphocytes necessary to provoke a GvHD reaction is unknown and may vary by clinical setting. A systematic review8 of the world literature relating to TA-GvHD examined some of the features of TA-GvHD. The sharing of HLA antigens between donor and recipient was the strongest risk factor for development of the condition (71% of reported cases with available HLA data) among recipients without other typical indications for component irradiation. The review included 348 cases and suggested that the incidence in recipients is very much in keeping with transfusion rates rather than with patient characteristics. The authors concluded that immune incompetence as a risk for TA-GvHD is less significant than previously thought. Components were typically whole blood and red cells. Component storage time was reported in the same review in 158 cases (45·4%) reviewed. In these, the component was as or as in cases cases reported a storage time of with no cases components for 2 were reported by the in of TA-GvHD with no case reported with components for been as a TA-GvHD to be reported the of leucocyte with of the 348 cases reported between and In some patients were transfused with blood components with no available for the of leucocyte of TA-GvHD in the review or and with the time from transfusion to first The of reported cases in is reported to be of the literature for this the authors all cases of TA-GvHD reported in the literature from 2008 to and are in the information and are that cases in patients use of components. with transfusion blood transfusion 2 cases of TA-GvHD blood to patients transfusion family transfusion transfusion transfusion for to blood for transfusion transfusion for TA-GvHD in patient blood to and with transfusion evidence of TA-GvHD to patient with previously with with TA-GvHD not red from a A developed TA-GvHD and with based on is usually made by of or The of donor can be by in or blood and from and in the and blood from the in can be used for the of TA-GvHD in cases with of The data on to transfusion of all blood components. A retrospective of of to found cases of to the of that was by of have been reported in the literature other than in the data are included in the cases have been reported since of of the cases reported the period of of red it is not clear if the was the reported in cases to be between and from the case of transfusion of the cases in patients at risk of TA-GvHD at the time of and not have irradiated may have been In the the of cases of TA-GvHD were reported to the first was a patient with in and the was in a an of blood in This is reported of in patients as at It is to that of patients are to blood components on than A retrospective was to review cases the specific for was not between and by to This included The of patients were with a of and with patients the for was The number of components by an individual was reported in and from to patients between and components. the patient blood components this was to a to a of from the the of reported cases in the since the of with cases reported in recipients in the it that is to or TA-GvHD at in the recipients with not not HLA with the In the the of Components in by the Committee on and storage time of cellular blood components was recognised as a significant with no cases of TA-GvHD reported in the literature components for In an the of red or platelets not be by irradiated components for patients with the appropriate blood or platelets be from the blood components are used in this of this be and clinical made for evidence of TA-GvHD the In situations irradiated components are blood red and BSH for transfusion of and for a suggested of blood component to use in of TA-GvHD a to risk factors for the development of the It of an for of lymphocytes in the transfused of HLA are to be between donor and and of the is It is that in to provide the of vary in as it can be by the of the in of HLA of cellular blood components and and of be TA-GvHD is a condition with significant and no It be that the literature is and levels of evidence are In and for the development of blood components vary among is in between The writing group to guidance on of the for of lymphocytes on the transfused of components or for and of The guideline is based on information from the data from the is since and cases reported to The authors to guidance for rather than of the risk of TA-GvHD that the condition be a complication of blood transfusion that be when are no risk the of lymphocytes in the transfused red methods in the not the leucocyte and to be irradiated for The as of the literature and as alternative to TA-GvHD. The for TA-GvHD is of blood components to inactivate lymphocytes. and are in their to inactivate lymphocytes in blood components at a There is in from for to with to blood are have been used in and are also used the Transfusion data that the in red found between and components are not by the Transfusion Committee on blood components irradiated the concluded that and can be as and are and for clinical use (JPAC Guidelines for the Transfusion in the or of blood by is the to TA-GvHD that a of at the of a The of for and Transfusion a of to the of the component with no no The Society of Guidelines a In the a minimum of is with the to in the not To this is with is as is and of in with relevant Guidelines for the Transfusion in the are available the of in of on are The minimum in the be with no The be and be of In the all cellular components are This the of in to is necessary to TA-GvHD. It is not to and all blood components for and the for is based on from a of typically The current is that of components and with The process of and the for the risk of a the time of the of a of red containing than is and is platelets are and and for platelets and of and in the of in the risk of a component and clinical that that TA-GvHD is usually when it In a systematic review of 348 cases of components were in of cases was reported in about of cases the level of leucocyte was current in the are not of that relies on leucocyte for prevention of TA-GvHD. There is evidence to leucocyte to TA-GvHD in patients to inactivate platelets are in to their of as as and also inactivate The that can be used as an alternative to for the prevention of and that have this have are by some authors as for prevention of are not used in the and in development for red are not with data of blood components a The is to with relevant of the to and the appropriate as a according to the and of red in significant in some of red and no significant on red or can levels of with no The of this of on red is the age of red to of and of storage of red in the last of their by for and Transfusion and of to the and of in of red and red is the minimum as by the and red can be irradiated to and for a of a without significant of or and is in in in the it is that red are irradiated from and for a of irradiation. and of red in of and an in the level of at rates not a risk of when to may be in as blood transfusion or and the of the components is to and by the of from to the risk of are also for other as for cardiac or are particularly to of to their to and the for transfusion rates relative to of and of irradiated red is not of irradiated red for patients with could to the development of data it is to transfusion of irradiated blood for patients with irradiated blood is indicated. patients and irradiated red cells, red can be irradiated at time to to the of the of and on red the of red is than red (JPAC Guidelines for the Transfusion in the In a published retrospective storage of irradiated red was associated with a significant in transfusion the irradiated red to with red with the of reaction transfusion included in this could be irradiated at time the and could be for to or to This not been in the haemovigilance is with of the reported transfusion irradiated components from may be irradiated at time to and for a from irradiation. the patient is at risk from or or other transfusion of and it is that red are transfused of red are be transfused as as and according to Transfusion Guidelines components not used for the recipient can be to to be used for recipients not irradiated components laboratory that may in in not been to significant clinical in can be irradiated at storage and can be to their The evidence for to is in be transfused as as and as with be irradiated be transfused with minimum components be by the and in that are to and a to their irradiated are available and are a of to irradiation. The at the to irradiated be on the It be that that the been to and their use not the for and for irradiated be as an be a and the be or by TA-GvHD been reported transfusion of whole red cells, platelets and and use of blood components on is also In the a of at of in for irradiated by or and used of all blood as a of TA-GvHD been reported to HLA TA-GvHD not been transfusion of red cells, are of TA-GvHD not been transfusion of or as factor and is not in the In to contaminating lymphocytes can remain viable in the component storage and the component been in cases of this be for platelets may the for based on the of to inactivate lymphocytes. and from the of be to the of and prevention of TA-GvHD. all all red and components be red It is not necessary to or of the sharing of HLA from family members a risk of TA-GvHD. cells, platelets and previously have all been in TA-GvHD transfusion from family and is an risk with from and cases of TA-GvHD have been reported from of HLA in the the of a transfusion recipient blood from a or are of for patients from members of to donor This be to the risk of if the donor is for of the recipient HLA to or groups of Transfusion of donor lymphocytes HLA antigens are all by the recipient was recognised as the strongest risk factor for the development of TA-GvHD in the review8 of the world There are no of TA-GvHD transfusion of red cells. it is for the risk to be to the transfusion of of cellular components and from or be if the patient is The risk of TA-GvHD in the and if is to be than in factors are the immunological the use of and transfusion of in situations as lymphocytes have been found in the to and cases of TA-GvHD have been in and cases were in the of risk with or without and transfusion from blood on TA-GvHD in were to the of to have a on TA-GvHD for of components for and in the the same for the period have been in since In some and is for blood for of of to be the to use for to donor practical in the if irradiated by blood and the risk of transfusion of irradiated blood to a The of for patients with for all is to be to all TA-GvHD in the it is for and to a of of in and section on in and It also be that of TA-GvHD may in than in A case of TA-GvHD of blood in an BSH that blood not be used for to this for are used by the of of current of and the reported cases of TA-GvHD from unrelated is the of transfusion of blood to a very red for be used and be in for use in BSH have that irradiated components to be for with for This was based on the of or immune and the of cases of TA-GvHD in the of by rather than on specific and was made to in the to be in to between and have been to from to red was for transfusion in TA-GvHD. is evidence to a degree of immune red the clinical is the risk of TA-GvHD is to be very the to of cellular blood components to that were cases of TA-GvHD in the reported with and without it to with guidance to blood for this the of for by the is for be irradiated for be irradiated red for and be transfused of irradiation. may of lymphocytes, the relevant for red transfusion also to for be irradiated are transfused are of the immune system in the of associated with been reported case of could have been associated with a It is not necessary to components for a is or if the a of red for transfusion to or term than for is not been a in case irradiated components be the of for or term is not been a in case irradiated components be the TA-GvHD been reported in with by an of lymphocytes or a of In the the features of cardiac may be unrelated to the immune and a of is particularly in with or or In of the case of TA-GvHD in an with it is to irradiated cellular blood components for patients with and been To have been no of TA-GvHD in patients with of with significant or be as indications for of cellular blood components a of been irradiated components be are A clinical be for in cases is There have been published of TA-GvHD in and patients There be a of cardiac and in blood be irradiated a is components are if an the risk of TA-GvHD is as the that may be associated with or of with or have a and of the be the first of the of patients with the or of a by not an associated immunological assessment including or lymphocytes, and be performed to cardiac for all with the this is not to cardiac irradiated cellular blood components be with a of of are lymphocytes, and no other evidence of immune of blood is to without a significant of the risk of TA-GvHD be for this age group it is to the for and immunological and use of irradiated cellular blood components. 2 of age without a significant of it is to the for in the of immunological it is cardiac that the patient no In this is no specific evidence to it is to for irradiated blood to if this is not to if this a significant clinical that all blood in the is and with to cardiac the is of are lymphocytes, is no to red or it is not to to irradiated cellular blood components be immunological have been and 2 without a significant of for cardiac for associated with as and or in is not to irradiated cellular blood is a significant with as the risk of TA-GvHD is of can and in the of and TA-GvHD not been reported in situations and of blood components is not the in human no cases of TA-GvHD have been in or There is no for of cellular blood components for or with of as the of a There is also no for of cellular blood components for or are or have immune of irradiated components for patients is and literature not cases of TA-GvHD to it is if of cellular blood components is for and this been in the their of blood components to patients patients were to blood with no cases of some that the risk of TA-GvHD is not in recipients of the of and the of the in this patient is no evidence that the current guidance be recipients and of irradiated blood components from the time of of The for all is of the GvHD is or is irradiated blood components be with irradiated blood components if this is based on disease or of or cellular blood components transfused to and blood of all to or the also be irradiated of immune for no cases of TA-GvHD were found in literature review and of reported cases and current remain and or blood for irradiated cellular blood components for to and the to the of viable lymphocytes, can patients of or for this irradiated cellular blood components from of if was used in disease or for of or with are to be at risk for TA-GvHD unrelated to or disease or for and with are to irradiated blood components for This guidance is to and of to irradiated components to patients with of have been reported to with no The guideline authors to evidence from literature to of the use of irradiated the and with the recommendations. review and are as TA-GvHD been reported in patients with the of patients are in from may blood component transfusion the relative risk for TA-GvHD in patients is to In the literature case of TA-GvHD of it be this was in the of TA-GvHD been reported in patients in the that it is not to the of was relevant or with in the immune including in all of immune in this condition were published to the and the methods used were not as specific as available included of and in assessment of It is relevant that was to be in patients with that to antigens were to antigens as the may be in by or to with is a of in patients with are of with with the is a that a number of patients with a of have blood components with no without of the clinical of including the of of and time from of it is to provide guidance about for individual In of the of TA-GvHD the and patients with irradiated blood components and with at of the disease have irradiated red and platelets The and with that may for There are case of TA-GvHD of with and no cases of TA-GvHD to have been reported in the since the of is no evidence in the literature to of current recommendations. It a that cellular blood components be irradiated for patients of been as an for of blood components. This was based on a reported in a and a of and by in in with the to be to a for The risk for development of TA-GvHD for patients with is no evidence to for patients for of or It is not based on to a on irradiated blood components be used for this group of The risk of development of TA-GvHD for patients with with is to be it if the of reported cases is to the risk or the current guidance for irradiated blood components is In of the of and evidence current guidance and irradiated blood components are for patients also This is in with the BSH and for and It is not the use of irradiated blood components be it is to patients are are used for of is the use of for of patients irradiated components. is no evidence from the the authors this as a patients for immune is evidence of immune immunological patients with and irradiated blood components with or other with irradiated components with with or irradiated blood components or other for of immune irradiated blood components is a and and it is in the for the of some cases of and A are and to antigens on the of specific can lead to significant In to the associated with the process of development of by the could viable lymphocytes, could the and lead to TA-GvHD. it is that the guidance for also be for cells. It to be that no cases of TA-GvHD to have been reported to were cases found in the literature it is that patients have other indications for blood component irradiation. and blood for irradiated cellular blood components for to and the to the of viable lymphocytes. blood components to be used disease or of or and paediatric patients the of are not to have susceptibility for TA-GvHD and no cases have been by the literature or reported to patients with transfusion of irradiated cellular components is not for transfusion of from or or relevant of irradiated blood components is not for or for or for from or or if patients with or This is with and paediatric in the with no cases of TA-GvHD reported since 2012. of that some features of as is no current evidence to that is of irradiated components for patients or for or with is not for transfusion of from or or to current or are used with for patients with or in the of The writing group the evidence for when is used for of patients with and with the and recommendations. was as a for in and in to the level of is based on the of clinical and the incidence of and other in to are at patients are when according to the published and current for on at and at and not be at risk of TA-GvHD. There are no reported cases of TA-GvHD with for The of for as for not a for of cellular blood components. been used for and since in It is as a in the data are available from development of and other as as have been A of been have not in or from with other There been no risk of or risk of and no cases of TA-GvHD have been GvHD is a complication of reported cases have been in and the the the of recipients have immunosuppression, with 2 or or The of is typically and a of of the is that patients irradiated cellular blood in is A retrospective review of transfused patients with for in not risk of cellular blood components according to the blood not blood with for of irradiated cellular blood components for recipients with as a or for of not been in and it is not included at the indications for used of There have been no cases of TA-GvHD in the since of blood components in patients have an since is no for of cellular blood components to or of irradiated cellular blood components is not with the for or of irradiated cellular blood components is not for patients have or as or for of of irradiated components with is not and no case of TA-GvHD been reported in the literature or to this of the of patients with is not an for use of irradiated cellular blood components this is for a of component or the development and of no cases of TA-GvHD have been reported in the The authors are to for and that be It is the of the clinical with the to patients at risk of to the transfusion and to and cellular blood components as This appropriate and specific are information be to information specific and of cellular components appropriate have been patients clinical areas and transfusion about the for irradiated components. irradiated components be of the and the for patients to of appropriate components. patients irradiated cellular blood components be and as irradiated including for irradiated blood be of the to of all blood components with of areas and transfusion and to specific and of irradiated cellular blood components are for patients irradiated cellular blood components appropriate patients to of appropriate components The authors to for in the literature The BSH Transfusion members at the time of writing this guideline were and The authors to the BSH sounding and the BSH for their in this The BSH the the writing of this authors have made a of to the BSH and Task may be on with and from and from and from and The members of the writing group and have no of to of the writing group the writing group if evidence available that the strength of the made in this or it The be by the relevant Task and the literature be to systematically for evidence that may have been The be and from the BSH current website if it are made an be published on the BSH website the and information in are to be and at the time of to the the BSH the for the of the The for this factors or and and of of 2 of searched from relevant to clinical from not to be included methods indications cases of relevant based on TA-GvHD or or graft-versus-host or disease of of 2 of searched from 2 relevant to clinical included relevant of to English of of 2 of searched from 2 relevant to clinical included relevant of relevant based on to English available this term have been have been or or have been have been have been this term have been this term or have been or have been or have been or or have been have been have been this term have been or have been have been all have been all have been or or or or or or or or or or or or or or or or or or or all have been or have been and or and from 2008 to of 2019 of 2019 searched from relevant to clinical from not to be included methods cases of 2019 of 2019 searched from relevant to clinical included relevant of 2019 of 2019 searched from relevant to clinical included

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