FATAL TRANSFUSION-ASSOCIATED GRAFT-VERSUS-HOST DISEASE IN THE PATIENT AFTER AORTOCORONARY BYPASS (Clinical case)

Goal: to demonstrate the rare case of transfusion-associated graft-versus-host disease (TA-GvHD) after transfusion of blood components. The cause of TA-GvHD is implantation of donor lymphocytes, contained in blood components, which is related to immunological HLA-homology between the donor and recipient, that does not eliminate the donor cells. Mortality makes 90-100%. 68 year old patient had planned surgery - aortocoronary bypass. In the post-operative period under pressure anemia three doses of unirradiated packed red blood cells were transfused. On the 17th day after transfusion the patient developed febrile fever and manifested erythematous cutaneous rush. On the 24th day after transfusion neutropenia developed. Evaluation results of allele discrimination of high-polymorphic markers confirmed the diagnosis of TA-GvHD. HLA-typing of the donor's and recipient's blood was done retrospectively. The donor was homozygous in five loci in low resolution and in loci of HLA-А*, HLA-В*, HLA-DRB1* he had the gene common with the patient. On the 34th day after the transfusion the patient died of infectious complications. X-ray or gamma-irradiation of blood components in order to inactivate the donor's viable T-lymphocytes is considered to be the only way to guarantee the prevention of TA-GvHD. Since there is no effective therapy for TA-GvHD, prevention of risk to develop the disease, strict indications to blood transfusions and capacity for early diagnosis become crucial.

1. Brody J.I., Pickering N.J., Fink G.B., Behr E.D. Altered lymphocyte subsets during cardiopulmonary bypass. Am. J. Clin. Pathol., 1987, vol. 87, pp. 626-628.

2. Ide H., Kakiuchi T., Furuta N. et al., The effect of cardiopulmonary bypass on T cells and their subpopulations. Ann. Thorac. Surg., 1987, vol. 44, pp. 277-282.

3. Jankovicova K. , Kudlova M.T., Kolackova M. et al. The effect of cardiac surgery on peripheral blood lymphocyte populations. Acta Medica, 2008, vol. 51, no. 1, pp. 25-29.

4. Juji T., Nishimura M., Watanabe Y. et al. Transfusion-associated graft-versus-host disease. ISBT Science Series, 2009, no. 4, pp. 236-240.

5. Leães P.E., Neumann J., Jung L.A. et al., Lymphocyte's activation and apopto-sis after coronary artery bypass graft: a comparative study of two membrane oxygenators-one with and another without a venous-arterial shunt.ASAIO J., 2004, vol. 50, no. 6, pp. 611-618.

6. McMonigal K., Horwitz C.A., Henle W. et al. Post-perfusion syndrome due to Epstein–Barr virus: report of two cases and review of the literature. Transfusion, 1983, vol. 23, pp. 331-335.

7. Pollack R., Ames F., Rubio P. et al. All protracted severe immune dysregulation induced by cardiopulmonary bypass: a predisposing etiologic factor in blood transfusion-related. AIDS& Clin. Lab. Immunol., 1987, vol. 22, pp. 1-5.

8. Roth J.A., Golub S.H., Cukingnan R.A. et al. Cell-mediated immunity is deoressed following cardiopulmonary bypass. An. Cardiovasc. Surg., 1980, vol. 31, pp. 350-356.

9. Rudensky B., Yinnon A.M., Shutin O. et al. The cellular immunological responses of patients undergoing coronary artery bypass grafting compared with those of patients undergoing valve replacement. Eur. J. Cardiothorac. Surg., 2010, vol. 37, no. 5, pp. 1056-1062.

10. Ryhanen P., Herva E., Hollmen A. et al. Changes in peripheral blood leukocyte counts, lymphocyte subpopulations, and in vitro transformation after heart valve replacement: effects of oxygenator type and postoperative parenteral nutrition. J. Thorac. Cardivasc. Surg., 1989, vol. 77, pp. 259-266.

11. Thaler M., Shamiss A., Orgad S. et al. The role of blood from HLA-homozygous donors in fatal transfusion-associated graft-versus-host disease after open-heart surgery. N. Engl. J. Med., 1989, vol. 321, no. 1, pp. 25-28.

12. Tønnesen E., Brinkløv M.M., Christensen N.J. et al. Natural killer cell activity and lymphocyte function during and after coronary artery bypass grafting in relationto the endocrine stress response. Anesthesiology, 1987, vol. 67, no. 4, pp. 526-533.

13. Van Velzen-Blad H., Dijkstar Y.J., Heijnen C.J. et al. Cardiopulmonary bypass and host defense functions in human beings. Lymphocyte function. Ann. Thorac. Surg., 1985, vol. 39, pp. 212-217.