Irradiated components

The primary cause of TA-GVHD is the proliferation and engraftment of transfused donor T-lymphocytes in the bone marrow of susceptible recipients.

The minimum expected dose of irradiation is 25 Gy and no part of the component should receive more than 50 Gy.

When can products be irradiated?

Red cells may be irradiated at any time up to 14 days after collection, and then stored for a further 14 days from the date of irradiation.

Platelets can be irradiated at any stage in their shelf life and then stored up to their normal 7-day expiry.

Granulocytes should be irradiated as soon as possible after manufacture, and transfused with minimal delay.

What are the side effects and hazards?

Ionising irradiation of red cells causes an increase in the level of extracellular potassium. The clinical significance of the potassium load depends on the speed and volume of the transfusion, as well as the age of the blood.

Blood for intrauterine and exchange transfusion should be transfused within 24 hours of irradiation.

When should I use irradiated components?

The following list provides health professionals with guidance on the use of irradiated cellular components. This guidance, which is based on current national guidelines, may not cover all clinical scenarios or evolving best practice, and may require an alternative approach.

Haematology
  • Hodgkin lymphoma 
    • Patients should receive irradiated cellular components throughout entire disease management. 
  • Patients receiving alemtuzumab for malignant and non-malignant disorders and transplants 
    • Patients should receive irradiated cellular components. 
    • Duration for which patients require irradiated cellular components is not well defined. 
  • Patients receiving purine analogues for malignant and non-malignant disorders 
    • Purine analogues which can cause immune suppression include fludarabine, deoxycoformycin (pentostatin), chlorodeoxyadenosine (cladribine), clofarabine and bendamustine. 
    • Patients should receive irradiated cellular components during treatment and for at least one year following treatment. 
  • Allogeneic haematopoietic stem cell transplants (HSCT) 
    • Allogeneic HSCT patients must receive irradiated cellular blood components from the time of initiation of conditioning chemotherapy/radiotherapy.  
    • Irradiated cellular blood components should be used while the patient remains on post-transplant GVHD prophylaxis, usually for a minimum of 12 months or until lymphocytes are >1x109/L.  
    • Patients with active chronic transplant-related GVHD should continue to receive irradiated cellular blood components. 
  • Autologous haematopoietic stem cell transplants (HSCT) 
    • Autologous HSCT should receive irradiated cellular components during and 7 days prior to bone marrow/stem cell harvest.  
    • Must receive irradiated cellular components from the time of initiation of conditioning chemotherapy/radiotherapy for minimum 3 months post-transplant. 
  • Non-Hodgkin lymphoma 
    • Consideration should be given to transfusing irradiated cellular components to patients with B and T cell NHL. 
  • Patients receiving long-term or high doses of chemotherapy and/or irradiation sufficient to cause lymphopenia <0.5 x 109/L 
    • Consideration should be given to transfusing irradiated cellular components. 
  • Patients with B cell malignancy who receive non-nucleoside analogue containing chemotherapy and/or radiotherapy leading to lymphopenia <0.5 x 109/L 
    • Consideration should be given to transfusing irradiated cellular components. 
  • T-cell malignancy 
    • Consideration should be given to transfusing irradiated cellular components. 
  • Acute leukaemia 
    • No definitive recommendations can be made, therefore consideration should be given to transfusing irradiated cellular components to patients. 
    • Refer to your local policy. 
  • Patients receiving long-term or high dose steroids as therapy for malignancy 
    • Routine use of irradiated cellular components is not indicated unless other risk factors are present including autologous HSCT and the use of nucleoside analogues. 
  • Aplastic anaemia receiving immunosuppressive therapy 
    • No definitive recommendations can be made, but consideration should be given to patients with aplastic anaemia who are receiving immunosuppressive therapy. 
Oncology
  • Patients receiving alemtuzumab for malignant and non-malignant disorders and transplants 
    • Patients should receive irradiated cellular components. The duration for how long patients require irradiated cellular components is not well defined. 
  • Patients receiving purine analogues for malignant and non-malignant disorders 
    • Purine analogues which can cause immune suppression include fludarabine, deoxycoformycin (pentostatin), chlorodeoxyadenosine (cladribine), clofarabine and bendamustine. 
    • Patients should receive irradiated cellular components for a least 1 year following treatment. 
  • Patients receiving long-term or high doses of chemotherapy and/or irradiation sufficient to cause lymphopenia <0.5 x 109/L 
    • Consideration should be given to transfusing irradiated cellular components. 
  • Patients receiving long-term or high dose steroids as therapy for malignancy
    • Routine use of irradiated cellular components is not indicated unless other risk factors are present, including autologous HSCT and the use of nucleoside analogues.
  • Non-Hodgkin lymphoma:
    • Consideration should be given to transfusing irradiated cellular components to patients with B and T cell NHL.
Obstetrics & neonatal
  • Intrauterine and neonatal exchange transfusions 
    • All red cells and platelets for intrauterine transfusion (IUT) must be irradiated. 
    • For exchange transfusions where there has been a previous intrauterine transfusion, irradiated cellular components are essential. For other exchange transfusions, irradiation is recommended provided this doesn’t delay transfusion. 
    • Red cells transfused must be <5 days old and should be transfused within 24 hours of irradiation. 
  • Top-up transfusions 
    • Not necessary to irradiate cellular components for routine small volume “top-up” transfusions in premature or term infants unless there has been a previous intrauterine transfusion, in which case irradiated cellular components should be used until six months post expected birth date. 
    • However, some institutions may choose to adopt specific irradiation criteria for newborns and in particular for premature or very low birth weight infants. For example, in line with clinical considerations described in the ANZSBT Guidelines for prevention of TA-GvHD. 
  • Congenital immunodeficiencies 
    • Irradiation of cellular components is recommended for all infants/children with suspected or diagnosed T-cell immune deficiencies. 
Transfusion
  • Directed donations from blood relatives 
    • Directed donations should be irradiated. 
    • Directed donations pose an increased risk of TA-GVHD due to the possibility of shared HLA haplotypes within families. 
    • Directed donations are discouraged. 
  • HLA-matched platelet transfusions 
    • HLA-matched platelets should be irradiated due to shared HLA haplotypes between recipient and donor. 
  • Granulocyte transfusions 
    • There is conflicting evidence as to whether irradiation damages the granulocytes. 
    • Granulocytes should be irradiated and must be transfused as soon as possible following irradiation. 
    • Lymphocytes must not be irradiated. 
Immunology
  • Congenital cellular immunodeficiency disorders 
    • The following congenital cellular immunodeficiency disorders should receive irradiated cellular components: 
      • Severe combined immunodeficiency 
      • DiGeorge syndrome 
      • Wiskott-Aldrich syndrome 
      • Ataxia telangiectasia 
  • HIV/AIDS (with no other indications) 
    • Not necessary to transfuse with irradiated cellular components. 
  • Congenital humoral deficiency disorders 
    • Not necessary to transfuse with irradiated cellular components. 
Transplants
  • Solid organ transplant (with no other indications) 
    • Not necessary to transfuse with irradiated cellular components. 
    • Continued observation of new immunosuppressive regimes is required and guidelines updated in accordance with emerging data.  
    • Refer to local policy. 
  • Renal/Kidney transplant (with no other indications) 
    • Not necessary to transfuse with irradiated cellular components. 
    • Continued observation of new immunosuppressive regimes is required and guidelines updated in accordance with emerging data.  
    • Refer to local policy. 
  • Lung transplant (with no other indications) 
    • Not necessary to transfuse with irradiated cellular components. 
    • Continued observation of new immunosuppressive regimes is required and guidelines updated in accordance with emerging data.  
    • Refer to local policy. 
  • Heart transplant (with no other indications) 
    • Not necessary to transfuse with irradiated cellular components. 
    • Continued observation of new immunosuppressive regimes is required and guidelines updated in accordance with emerging data.  
    • Refer to local policy. 
  • Liver transplant (with no other indications) 
    • Not necessary to transfuse with irradiated cellular components. 
    • Continued observation of new immunosuppressive regimes is required and guidelines updated in accordance with emerging data.  
    • Refer to local policy.  
Cardiothoracic surgery
  • There is no recommendation regarding whether to transfuse irradiated cellular components. 
Orthopaedic surgery
  • There is no recommendation regarding whether to transfuse irradiated cellular components. 
Trauma
  • There is no recommendation regarding whether to transfuse irradiated cellular components. 

 

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