(P-TS-88) To Wash or Not to Wash: Managing Transfusion Expectations in a Transplant Patient with Severe IgA Deficiency

Background/Case Studies: A 67-year-old female patient was scheduled for a single lung transplant to manage COPD and emphysema. Her relevant past medical history included several pulmonary emboli, Takotsubo cardiomyopathy, and severe IgA deficiency without transfusion history. There was concern for adverse reaction to any transfused blood products during the lung transplant surgery, of which there were multiple donor lungs which became available for her over many months. In addition, the logistics requiring potentially washed or IgA negative units were limited by available resources and geography. Ultimately, she did not end up requiring any blood products during or after her lung transplant.

Study

Design/Methods: Her IgA deficiency was evaluated along with potential IgG anti-IgA antibody presence. Discussions in multidisciplinary meetings established the inclusion of blood and blood products to her allergies list in the EMR. Inventory assessments and ability to acquire IgA negative plasma and washed/volume reduced cellular products at time of potential transplantation were done with coordination between our regional blood centers.

Results/Findings: The recipient’s blood type was group B, Rh positive with no reacting RBC specific antibodies. In regards to her IgA deficiency, she was found to have an IgA level of 0.1 mg/dL (reference range 72-321 mg/dL) and anti-IgA levels < 99 U/mL (reference range < 99 U/mL), which was consistent with IgA deficiency without sensitization. Even though she was not at risk for an acute reaction to blood products, it was decided to try and prevent sensitization and future IgA-mediated anaphylactoid adverse events by providing washed RBC units, volume-reduced platelets, and IgA negative plasma. As per the interdisciplinary protocol established, the patient was monitored for IgA antibodies and anti-IgA antibodies post-transplant due to anything which may be made by the transplanted lung, which currently remain undetectable.

Conclusions: IgA deficiency is a relatively common, but highly complicating condition in the transfusion service management of patients. Considerations for blood and blood product modification to include IgA negative or washed/volume-reduced units is a mainstay of management. Patients undergoing surgeries which require potentially large amounts of transfused products (i.e. transplant) require close collaboration between clinical and transfusion services as soon as the patient is listed. Based on her lack of anti-IgA antibodies, the concern in this case was not the current product requirements, but the prevention of future IgA-mediated anaphylactoid events. Concomitant evaluation of the patient’s IgA antibody status in this case allowed for some flexibility in providing the safest course of intraoperative transfusion management.

Importance of research: This research presents a critical discussion on interdisciplinary communication in the context of adverse transfusion events and patient safety. A known history of IgA deficiency is enough to prompt considerations for IgA deficient or washed blood and blood products. However, in the setting of limiting geography, shelf life, and limited resources, considerations for sensitization and prevention can become complicated. Rapid evaluation of the patient's anti-IgA status is key.