Severe Hemolysis Due to Passenger Lymphocyte Syndrome in Three Recipients of Organs from a Donor with Multiple Red Cell Alloantibodies.
Authors: Shortt Jake , Polizzotto Mark N. , Roxby David , Magrin Geoff , Webb Andrew , Borosak Marija , Westall Glen , Street Alison M. , Cole-Sinclair Merrole F. 
Published: October 2019

Abstract
Passenger lymphocyte syndrome (PLS) is rare following solid organ transplantation. We describe 3 transplant recipients who developed severe hemolysis after receiving organs from a single donor with multiple red cell (RC) alloantibodies. The donor was a 54 y.o. male, blood group O Rh(D) negative (rr) with a positive antibody screen due to anti-D, anti-C and anti-k. His Cellano negative and RC alloantibody status was well characterized antemortem, given that he was a rare RC phenotype donor for the Australian Red Cross Blood Service (ARCBS). The lungs and the liver were offered for organ donation. The right single lung recipient was a 61 y.o. male with emphysema (blood group O Rh(D) positive [R2r]). From post transplant day (PTD) 0 to 10 his hemoglobin (Hb) fell from 126g/L to 69g/L without bleeding and with elevated hemolytic markers. A positive direct antiglobulin test (DAT) due to IgG was noted and anti-D eluted. Management included increased immunosuppression and transfusion of 2 RC units (rr, k positive). Ongoing hemolysis required a second transfusion at PTD 24. To facilitate tapering of corticosteroids, intravenous immunoglobulin (IVIG; 2g/kg in divided doses) was administered. The patient subsequently stabilized and 3 months post-transplant has mild compensated hemolysis with persisting anti-D. The left single lung recipient was a 59 y.o. female with emphysema (blood group O Rh(D) positive [R1r]). From PTD 0 to 10, Hb fell from 91g/L to 73g/L with elevated hemolytic markers. The antibody screen and elution demonstrated anti-D, and she was transfused with 2 RC units (rr, k positive). Three months post transplant she has ongoing evidence of mild compensated hemolysis with persisting anti-D. The liver recipient was a 45 y.o. male with Hepatitis B (blood group B Rh(D) positive [R1R1]). From PTD 0 to 13 Hb fell from 102g/L to 64g/L without bleeding. The DAT was positive (IgG) at day 4. Anti-D+B+C were detected in the plasma and anti-C+D+k+B were found in eluates. He was managed with increased immunosuppression and transfusion of 2 RC units (rr, k negative). Fresh Cellano negative units were accessed through the ARCBS rare RC register. The patient has subsequently also stabilized, despite ongoing seropositivity for anti-D (but not anti-k). These cases highlight the potential for severe hemolysis due to PLS following solid organ transplant. This is the first apparent description of PLS where anti-k has been implicated, with significant hemolysis in all recipients of organs from the same donor. We conclude that the identification of donor RC alloantibodies at the time of transplant should prompt close surveillance for development of PLS. Consideration of strategies to ameliorate hemolysis, such as early use of IVIG, is suggested. Where an antibody to a high incidence antigen (such as Cellano) is detected, early notification of central blood bank services may facilitate call up of phenotyped donors and provision of rare units.