A man meets with an accident while crossing the road. He is immediately rushed to the hospital. He is bleeding and needs blood urgently. Finally, his son's blood is given to the man. The man recovers after a successful operation. After three weeks, the man dies.The doctor who operated on him investigates the cause of the death as a complication due to blood transfusion from a relative, which in this case was his son, called as Transfusion Associated Graft Versus Host Disease (TA-GVHD). TA-GVHD, as the name suggests, is the engraftment and proliferation of T-lymphocytes from the donor's blood in transfusion recipients, leading to tissue damage and death, eventually.
Even with the advent of safer blood supply management methods and newer technologies in blood transfusion, safety in blood transfusion is under a cloud of doubt with tranfusion related complications. The mortality rate due to TA-GVHD is over 90 per cent, say experts.
Says Dr S B Rajadhyaksha, head, department of Transfusion Medicine, Tata Memorial Hospital, "Contrary to the popular belief, that relative's blood is safest for patients, blood or blood products, especially from first degree relatives, can result in the fatal complication called TA-GVHD. The complication generally arises in immuno-suppressed patients like cancer patients and new-born babies."
Based on the symptoms following transfusion of blood or any cellular blood component, the doctors have to be made aware that TA-GVHD is one of differential diagnosis. Such cases are therefore grossly under reported. Says Dr Sunil Parekh, haematologist, Bombay hospital, "TA-GVHD is often misdiagnosed and under-reported because the primary manifestations of TA-GVHD are skin rash, fever, bone marrow depression (lowering of blood counts), diarrhoea and jaundice."
Besides this, the unavailability of gamma irradiation facility in remote parts of the country has posed a hindrance. According to Dr Rajesh B Sawant, Tata Memorial hospital, irradiation is recommended for bone marrow Transplant patient, patient's suffering from Hodgkins disease (lymphnode cancer), transfusion to new born infants, Intrauterine transfusions, cases of congenital immuno deficiency and patients receiving HLA matched blood components. "Only anecdotal case reports of individual cases scattered all over the world are available in medical literature.", he added.
The need of the hour is therefore to educate the doctors about such a complication and to upgrade infrastructure for gamma irradiation facility in the hospitals, suggest experts.
For patients having good immunity, the chances of developing TA- GVHD is less because the blood cells called T-lymphocytes from the transfused donor blood are recognised as foreign and therefore rejected by the recipient's immune system. In patients, whose immunity is not good, TA-GVHD develops due to the inability to reject these T-lymphocytes, which result in their proliferation, which then attack the liver, skin, gastrointestinal tract and the bone marrow. "Although a rare complication of transfusion, it can occur even in patients whose immunity is not suppressed (immuno-competent). This happens when a patient receives blood from their first degree relatives (siblings, parents or children) or second degree relatives. In these cases, the donor's T- lymphocytes may not be rejected as the Human Leucocyte Antigen (HLA) type of the recipient is haploidentical or bears similarity with that of the donor," said Dr Rajadhyaksha.
HLA is an important blood matching parameter, which has an important role in blood transfusion. HLA type is a genetically inherited unique marker for each individual present on the lymphocytes or white blood cells(WBC). T-Lymphocyte is a category of WBC responsible for immunity. Various treatments have been tried in patients with TA-GVHD including corticoteriods, cyclosporine, methotrexate and ATG (anti-thymocyte globulin) etc. Till date, none has proved adequately successful. Therefore Gamma irradiation of the blood or blood components from the relative's donor is the best current technology to reduce the risk of TA-GVHD to the recipients. The usual dosage is 2500-3500 rads and requires an expensive equipment that can deliver Gamma Irradiation, currently available in very few institutions in India like CMC Hospital, Vellore, All India Institute of Medical Sciences (AIIMS), New Delhi. Sanjay Gandhi Post Graduate Institute, Lucknow, Gujarat Cancer Research Institute,Ahmedabad, Tata Memorial Hospital, Mumbai, Hinduja Hospital, Mumbai, Jaslok Hospital, Mumbai, Bombay Hospital, Mumbai etc.
World Health Organisation's (WHO) research findings from a number of countries also indicate that blood from family donors presents a greater risk to the safety of the blood supply than blood from voluntary non-remunerated donors.