A case of passenger lymphocyte syndrome following minor ABO incompatible renal transplantation
Here we report one such case of PLS in a 27-year-old male renal allograft recipient of the B Rh D-positive blood group who received a kidney from a donor of the O Rh D-positive blood group. Indication for transplantation was end-stage renal disease and basiliximab induction was given. The patient was transfused with B Rh D-positive packed RBCs (PRBCs), 4 units during the surgery and 2 units postoperatively in the next 24 hours. The postoperative course of the patient was uneventful and graft function was normal by day 5. However, day 10 onwards, the patient showed a declining hemoglobin (Hb) level from 7.4 to 6.6 g%. His blood sample was sent to the blood bank, requesting for 1 unit of PRBCs. It showed no group discrepancy or unexpected antibody. The patient was transfused with 1 U of cross-match-compatible PRBCs of the B Rh D-positive blood group, following which there was a steep fall in his Hb level from 6.6g to 3.2g% over a period of 12 hour. Investigations showed that platelet count and coagulation parameters were normal, reticulocyte count was 11.1%, lactate dehydrogenase (LDH) level was 990 U/l and unconjugated bilirubin level was 2.4 mg/dl. The treating unit suspected hemolytic uremic syndrome associated with tacrolimus administration in the patient, which was excluded on the basis of absence of fragmented red cells on peripheral blood smear.\nA request for 2 units of PRBCs was again sent to the blood bank. ABO and Rh grouping were performed using the conventional test tube technique at room temperature, which showed no discrepancy; however, cross-match with B Rh D-positive PRBCs using the LISS Coomb column agglutination technique (Bio-Rad, Diamed GmbH, Cressier FR, Switzerland) at 37°C showed incompatibility. On performing direct anti-globulin test (DAT) using the LISS Coomb column agglutination technique (Bio-Rad, Diamed GmbH, Cressier FR, Switzerland), the patient's red cells were found to be strongly positive (4+). Elution was performed using the gentle heating method and the eluate showed the presence of anti-B. Indirect anti-globulin test of the patient's serum using a three-cell panel of O group (Diacell, Bio-Rad, Diamed GmbH, Cressier FR, Switzerland) was negative, ruling out the presence of any unexpected antibody and anti-B was detectable in the serum. Titration of anti-B using B-group red cells showed a titer of 32 in the indirect anti-globulin test phase. The antibody was probably of IgG class. The antibody was reactive only at 37°C and was unaffected by dithiothreitol treatment. The cross-match showed compatibility with O group so 2 units of O Rh D-positive PRBCs were issued for the patient and a provisional diagnosis of PLS was made.\nSerial titration of the kidney donor's serum in the indirect anti-globulin test phase showed anti-A and anti-B titers of 64 and 1024, respectively. Hemolysin test showed a positive result with B cells, indicating that the donor's blood group was the dangerous O-type.\nThe patient was treated with three doses of intravenous methylprednisolone. His Hb level did not show significant elevation and investigations showed a persistently raised reticulocyte count, LDH and creatinine []. He was subsequently transfused with PRBCs of O group and underwent two sessions of plasmapheresis. One volume exchange was done every alternate day and replacement was done with 5% albumin solution. The patient was serially monitored and the sequence of events that followed is depicted in . Nineteen days postoperatively, his Hb rose to 6.7 g% and anti-B titer was 2. Thereafter, his condition improved gradually and was discharged on day 29 in stable condition with good urine output, a serum creatinine level of 1.2 mg %, Hb level of 8 g% and an anti-B titer of 2.