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Rituximab for passenger lymphocyte syndrome associated with allogeneic SCT

Bone Marrow Transplantation volume 42, pages 67–69 (2008)Cite this article

Immune-mediated hemolytic anemia is one of the possible complications after both solid organ and allogeneic SCT (ASCT), potentially associated with significant morbidity, including severe hemolysis and acute renal failure.1 Death from massive hemolysis has also been reported in the literature.2 Passenger lymphocyte syndrome (PLS) is occasionally a cause of hemolysis in these patients. PLS occurs between day 5 and 15 post transplant when a minor ABO incompatibility exists between the donor and the recipient (most common A+ recipient, O+ donor). Immunocompetent donor B-lymphocytes transferred passively with the graft maintain their ability to generate antibodies, which bind to the recipient's RBCs causing hemolysis.3, 4, 5, 6 The treatment of PLS has been mainly supportive, with or without immunosuppression.1, 6 This report describes the first experience with the use of rituximab (Rituxan, Genentech, South San Francisco, CA, USA) for the treatment of PLS in an ASCT patient and reviews the accumulated data regarding the transfusion requirement for patients with PLS after ASCT.

PLS is an intriguing immunological phenomenon described both in solid organ and ASCT.1 Several risk factors for the development of PLS have been postulated in the literature including the degree of mismatch, peripheral stem cell source, amount of lymphoid tissue transplanted and the use of CYA/tacrolimus without MTX for GVHD prophylaxis.1, 6, 8 Treatment has been transfusion with donor ABO compatible PRBCs (O+ PRBCs are used in this setting) and steroids, occasionally plasma or red cell exchange and adequate kidney perfusion.1, 6 Rituximab, a chimeric monoclonal antibody directed against CD 20+ B-lymphocytes, has been tried in hemolytic anemia of other causes and its use in PLS would make intuitive sense. Rituximab has been successfully used in one pediatric solid organ transplantation case and in two pediatric cases of late onset hemolytic anemia.5, 9, 10 Our patient displayed typical features of PLS for which rituximab, in addition to O+ PRBCs and steroids, aborted the massive intravascular hemolysis soon after its onset. MTX has also been shown to mitigate hemolysis secondary to PLS; however, pretreated patients with MTX and anti-thymocyte globulin still appear to be susceptible to the development of this clinical entity.3, 8 A lower dose of MTX as in the miniMTX regimen received by this patient could be less efficacious in preventing PLS. Such patients may benefit from the use of rituximab in case severe hemolysis develops.

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Authors and Affiliations

  1. Department of Internal Medicine, Long Island Jewish Medical Center, Albert Einstein School of Medicine, New Hyde Park, NY, USA

    H J Lee

  2. Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA

    A Gulbis, L De Padua Silva, C Hosing, I Khouri, M de Lima, R E Champlin & S O Ciurea

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  1. H J Lee
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  2. A Gulbis
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  3. L De Padua Silva
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  4. C Hosing
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  6. M de Lima
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  8. S O Ciurea
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Correspondence to S O Ciurea.

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Lee, H., Gulbis, A., De Padua Silva, L. et al. Rituximab for passenger lymphocyte syndrome associated with allogeneic SCT. Bone Marrow Transplant 42, 67–69 (2008). https://doi.org/10.1038/bmt.2008.79

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