What type of blood products should patients with lymphoma receive?

Blood Product Requirements for Lymphoma Patients

Patients with lymphoma should receive irradiated blood products (minimum 25 Gy) to prevent transfusion-associated graft-versus-host disease (TA-GvHD), particularly those with Hodgkin's lymphoma or those receiving immunosuppressive therapies such as fludarabine or alemtuzumab. 1

Irradiation Requirements

Mandatory Indications for Irradiated Blood Products

• Hodgkin's lymphoma patients at all stages require irradiated cellular blood components due to severe immunosuppression associated with the disease itself 1, 2
• Patients receiving purine nucleoside analogs (fludarabine, cladribine, pentostatin) must receive irradiated products 1
• Patients treated with alemtuzumab (anti-CD52) require irradiated components 1
• Recipients of autologous or allogeneic stem-cell transplants need irradiated products 1
• Patients receiving blood from first-degree relatives must receive irradiated products regardless of lymphoma type 1

Irradiation Specifications

• Minimum dose of 25 Gy is recommended by the British Commission for Standards in Hematology 1
• Irradiation should be performed pretransfusion using gamma irradiation 1
• All cellular blood components (red blood cells, platelets, granulocytes) require irradiation; plasma products do not 1, 3

Important Caveat About Non-Hodgkin's Lymphoma

• Routine irradiation is NOT recommended for patients with non-Hodgkin's lymphoma (including diffuse large B-cell lymphoma) receiving standard chemotherapy regimens like R-CHOP 1
• Irradiation becomes necessary only if these patients receive the specific immunosuppressive agents listed above (fludarabine, alemtuzumab) or undergo stem-cell transplantation 1

Leukoreduction Requirements

When Leukoreduced Products Are Indicated

• Patients with lymphoma requiring long-term, repetitive transfusion support should receive leukoreduced blood products 1, 4
• Prestorage leukoreduction is preferred over bedside filtration for consistent quality control 4
• Target leukocyte reduction to less than 5 × 10⁶ leukocytes per transfusion 1

When Leukoreduction Is NOT Routinely Necessary

• Patients undergoing high-dose chemotherapy with peripheral-blood stem-cell transplantation who require only a few transfusions do not need routine leukoreduction 1
• Most lymphoma patients receiving standard chemotherapy (e.g., R-CHOP for DLBCL) fall into this category and do not require leukoreduced products unless they develop alloimmunization 1

Key Distinction

• Leukoreduction does NOT prevent TA-GvHD; irradiation is still required for at-risk patients even if products are leukoreduced 1

RhD Compatibility Considerations

• RhD-negative female patients of childbearing potential being treated with curative intent should receive RhD-negative platelets or anti-D immunoprophylaxis to prevent alloimmunization 1
• This approach is optional, not mandatory, given the low rate of RhD alloimmunization in cancer patients 1

Transfusion Thresholds and Product Selection

Red Blood Cell Transfusions

• Transfuse when hemoglobin falls below 7 g/dL or when symptomatic (tachycardia >110 bpm, dyspnea, chest pain) 1, 5
• Use packed red blood cells (PRBCs) as the preferred product 1
• Each unit typically increases hemoglobin by 1 g/dL 1, 5

Platelet Transfusions

• Standard prophylactic threshold is platelet count <10,000/mm³ in stable patients 1
• Maintain platelets >30,000/mm³ for patients on anticoagulation or with active bleeding risk 1
• Use single-donor apheresis platelets or pooled platelet concentrates; both are equally effective when leukoreduced 1

Critical Safety Measures

CMV-Negative Products

• CMV-negative or leukoreduced products should be used for stem-cell transplant candidates to prevent CMV transmission 1

Volume Considerations

• Volume reduction of platelet products should be limited to pediatric patients requiring severe volume restriction or patients with severe plasma-mediated allergic reactions 1

Communication Pitfalls to Avoid

• Poor communication between clinical teams and blood banks is a leading cause of errors in providing irradiated products 2
• Clinicians must verify irradiation policies with their local blood supplier, as practices vary significantly between institutions 1
• Some centers routinely irradiate all products for cancer patients to ensure vulnerable recipients receive appropriate products 1

Summary Algorithm

1. Determine lymphoma type: Hodgkin's vs. non-Hodgkin's
2. Assess immunosuppression level: Check for purine analogs, alemtuzumab, or transplant status
3. If Hodgkin's lymphoma OR receiving high-risk immunosuppressive therapy: Order irradiated (≥25 Gy) cellular blood products 1
4. If standard non-Hodgkin's lymphoma on conventional chemotherapy: Standard (non-irradiated) blood products are appropriate 1
5. Consider leukoreduction only if patient requires prolonged, repetitive transfusion support 1, 4
6. Confirm with blood bank that irradiation will be performed when indicated 1, 2