When are irradiated red blood cells (RBCs) administered?

From the Guidelines

Irradiated red blood cells (RBCs) should be given to patients with specific high-risk conditions, including congenital immunodeficiency states, allogeneic bone marrow transplant recipients and donors, autologous bone marrow-transplanted patients, Hodgkin’s lymphoma, and those receiving purine analogue therapy or antithymocyte globulin (anti-CD52) therapy, to prevent transfusion-associated graft-versus-host disease (TA-GVHD) 1. These conditions increase the risk of TA-GVHD, a rare but often fatal complication of blood transfusion. The use of irradiated RBCs is recommended in these cases to inactivate donor T-lymphocytes and prevent them from attacking the recipient's tissues. Some of the key patient populations that require irradiated RBCs include:

• Patients with congenital immunodeficiency disorders, such as Di-George’s syndrome 1
• Allogeneic bone marrow transplant recipients and donors 1
• Autologous bone marrow-transplanted patients 1
• Patients with Hodgkin’s lymphoma 1
• Patients receiving purine analogue therapy, including clofarabine and bendamustine 1
• Patients receiving antithymocyte globulin (anti-CD52) therapy, such as alemtuzumab 1 It is essential to note that the decision to use irradiated RBCs should be based on the individual patient's risk factors and medical history, and clinicians should consult with the patient's clinical team to determine the best course of treatment 1.

From the Research

Indications for Irradiated RBC Transfusion

• Patients who are heavily immunosuppressed, such as those undergoing intensive anti-cancer chemotherapy, are at risk for development of accidental engraftment and graft-versus-host disease when they undergo transfusion with cellular blood components 2
• High-risk categories include congenital and acquired immunodeficiency, younger age, transfusion of blood donated by family members, and transfusion with fresh whole blood 3
• Children at risk for the development of TA-GVHD include neonates, infants, and children with congenital heart disease, not restricted to children with "classic" DiGeorge syndrome 3
• Indications linked to long-lasting deep T-cell suppression were defined with durations of 6 or 12 months after end of treatment (e.g. autologous or allogeneic stem cell transplantation) 4

Prevention of TA-GVHD

• Blood product irradiation is the only established and widely available method to prevent TA-GVHD 3
• Certain pathogen reduction technologies (PRT) for platelets have been approved by regulatory authorities and endorsed by professional societies as an alternative to irradiation for reducing the risk of TA-GVHD, and PRT for RBCs and whole blood are in development 5
• Prestorage leukodepletion of blood components may reduce the need for irradiation, but continued alertness to TA-GVHD and haemovigilance reporting of erroneous non-irradiated transfusions is still necessary 4

Special Considerations

• The minimum irradiation dose required to prevent TA-GVHD is uncertain, and the development of probable TA-GVHD has been reported in a patient who received irradiated blood components at a nominal dose of 15 Gy 2
• Graft-versus-host disease remains a major treatment-related risk in patients undergoing stem cell transplantation, and the importance of immunological effects on the malignant disease necessitating transplantation must be considered when treating GvHD 6