EDITORIAL COMMENT: We accepted this case for publication because it seems to link graft versus host disease with intrauterine transfusions. Since the association of transfusion with graft versus host disease is exceedingly rare it would seem to the editorial subcommittee that it is reasonable to support the recommendation of the authors that irradiated blood should be used for intrauterine transfusions but as far as we can see the case for doing so for transfusions after birth is yet to be sustained. It seems important to study the fetal maturity at the time of intrauterine transfusions that are known to have been associated with graft versus host disease, the occurrence of which is presumably related to immune tolerance of the fetus to the transfused blood products. Our paediatrician reviewer informed us that at the Royal Women's Hospital, Melbourne, blood for fetal transfusions has always been irradiated since the early 1980s when intravascular transfusions were commenced. However, at this institution they do not irradiate blood for transfusions to infants after birth either for exchange transfusions, when the dose of lymphocytes transfused must be enormous, or for simple transfusions, with a reduced dose of lymphocytes.
Reply to Editorial Comment: The comments by the paediatrician reviewer are noted.
However the decision not to irradiate blood for transfusions to a neonate, be it for an exchange transfusion or a top up transfusion is contrary to current accepted practice.
Indeed, the “dose of lymphocytes must be enormous”. Because of this, the British Blood Transfusion Task Force (A) and the American Association of Blood Banks (B) state that the indications for irradiation of blood are ABSOLUTE for the following:
- (i) Intrauterine and all subsequent transfusions and neonatal exchange transfusions.
- (ii) Premature/very low birth-weight infants (<1,500 g).
It would therefore seem prudent to follow the British and AABB Standards.
A. Guidelines on Gamma irradiation of blood components for the prevention of transfusion-associated graft versus host disease. B.C.S.H. Blood Transfusion Task Force, Transfusion Medicinef 1996; 6: 261–271.
B. AABB Standards for Blood Bank and Transfusion Services 16th.