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Use of anti‐D immunoglobulin prophylaxis in solid organ transplants

Dear Sir, The revised British Committee for Standards in Haematology (BCSH) guidelines for the use of anti-D prophylaxis for the prevention of haemolytic disease of the foetus and newborn are focused on recommendations for sensitisation events during pregnancy (Qureshi et al., 2014). It should be stressed, however, that there are other potential events for the formation of anti-D antibodies in women of childbearing age, such as transfusion of RhD-positive blood components or solid organ transplantation (SOT) (British Committee for Standards in Haematology 2009). We report a case of possible immune anti-D formation after liver transplantation. A 13-year-old girl underwent a living related liver transplant for ornithine-carbamyl transferase deficiency. She was blood group B RhD negative while the liver donor was O RhD positive. Prior to transplantation, the recipient developed humoral immunodeficiency, presumed to be due to previous phenytoin anticonvulsant therapy and required regular four weekly intravenous immunoglobulin (IVIG). Post-transplantation, she received long-term immunosuppression with tacrolimus and prednisolone. The humoral immunodeficiency resolved and IVIG therapy was discontinued 5 weeks post-transplant. The patient did not receive blood component transfusions at any time during her treatment or anti-D immunoglobulin (anti-D Ig) prophylaxis after the transplant. The red blood cell (RBC) antibody screen on day 0 was negative. Eleven weeks post-transplant and 6 weeks post the last IVIG infusion, the antibody screen was positive. An anti-D antibody was identified by indirect antiglobulin (IAT) and enzyme techniques at a titre 1 : 2. On repeating the test 2 months later (13 weeks after the last IVIG), the anti-D was still detectable, albeit by enzyme technique only. Eight months post-transplant, the antibody was no longer detectable. There are published cases of haemolytic anaemia after IVIG treatment due to anti-D in the products, and the possibility of passive transfer of antibody was considered in our case (Yin et al., 2008). The patient received two doses from two different batches of IVIG following the transplant and the last IVIG infusion was 42 days prior to testing, which equates to the equivalent of more than 1·5 half-lives of IVIG. In addition, the strength of anti-D was greater than would be expected from potentially contaminated IVIG. Hence, we conclude that anti-D in this case is