[Refractory thrombocytopenia by HLA alloimmunization in a multitransfused patient]

A case is reported of 60-year-old woman who developed transfusion refractoriness after having been transfused several times. This patient who had been transfused with 4 standard packed red cell packs (PRC) for a surgical repair of a hiatal hernia, required three further operations within two months for postoperative complications. After the first operation, she had developed anti-JK1 and anti-CW alloantibodies. Seven phenotype compatible PRC and five fresh frozen plasma (FFP) were transfused during the surgery carried out on day 32. Massive haemorrhage occurred during the fourth operation on day 48, and the patient was transfused with 31 phenotype compatible PRC, 21 fresh frozen plasma, 36 standard platelet concentrates (SPC), fibrinogen, factor VIII and anti-thrombin III. Postoperative disseminated intravascular coagulation occurred, with thrombocytopaenia (45 G.l-1). Major thrombocytopaenia persisted for 6 days (12 G.l-1 on day 52), after the other signs of intravascular coagulation had been corrected, and despite the transfusion of 40 SPC. Platelet counts progressively returned to normal (195 G.l-1 on day 56). An HLA alloimmunization was discovered, which may have been induced by leukocytes contaminating the transfused red blood cell and platelet concentrates. A fifth operation carrying a high risk of haemorrhage was therefore prepared by harvesting autologous platelet rich plasma two days before and on the morning of the operation. These were transfused intraoperatively, together with phenotyped and leukocyte-free PCR, thus avoiding massive and expensive homologous platelet transfusions. In patients with a high risk of HLA immunization (previous pregnancies, multiple transfusions), autotransfusion or leukocyte-poor blood products should be used.