Asian Journal of Transfusion Science
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A retrospective study to assess the impact of ABO incompatibility on outcomes of allogeneic peripheral blood stem cell transplants at a tertiary care hospital in Western Maharashtra

1 Department of Immunohematology and Blood Transfusion, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Pathology, Command Hospital (SC), Pune, Maharashtra, India
3 Department of Lab Sciences, Command Hospital, Lucknow, Uttar Pradesh, India
4 Department of Clinical Hematology, Command Hospital, Lucknow, Uttar Pradesh, India

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Date of Submission09-Sep-2021
Date of Decision21-Oct-2021
Date of Acceptance06-Nov-2021


BACKGROUND: Hematopoietic stem cell transplantation (HSCT) has emerged as a curative measure for life-threatening hematological disorders. It can be autologous or allogeneic depending on the disease characteristics. Providing transfusion support to the transplant patients can be challenging, especially in AB-mismatched allogeneic HSCT. In this study, we investigated the impact of ABO incompatibility in patients undergoing allogeneic HSCT.
MATERIALS AND METHODS: A retrospective review was conducted in 76 patients with hematological diseases who underwent allogeneic HSCT. Transfusion requirements, engraftment profile, incidence of graft versus host disease (GvHD), and mortality for a period of 1 year were analyzed.
RESULTS: ABO incompatibility between donor and the patient did not significantly affect the neutrophil and platelet (PLT) engraftment time (P = 0.389, 0.349, respectively), packed red blood cells transfusion requirement, and duration of initial hospital stay. However, patients of ABO-incompatible HSCT received more PLT transfusions posttransplant which was statistically significant. 29.1% of ABO compatible and 16.7% incompatible HSCT patients developed GVHD. Mortality rates in the two groups were 16.7% and 8.3%, respectively. However, differences in both the parameters were not statistically significant.
CONCLUSION: Our study showed that ABO incompatibility does not significantly affect the outcome and should not be a limiting factor for selection of donor. Donor availability and human leukocyte antigen (HLA) matching remain the critical selection criteria.

Keywords: ABO incompatibility, allogeneic stem cell transplant, transplant outcome

How to cite this URL:
Nalukettil BB, Biswas AK, Asthana B, Kushwaha N, Baranwal AK, Sharma S. A retrospective study to assess the impact of ABO incompatibility on outcomes of allogeneic peripheral blood stem cell transplants at a tertiary care hospital in Western Maharashtra. Asian J Transfus Sci [Epub ahead of print] [cited 2023 Mar 24]. Available from:

   Introduction Top

Hematopoietic stem cell transplantation (HSCT) has been established as a definitive treatment measure for many malignant and nonmalignant life-threatening hematological disorders.

HSCT can be autologous or allogeneic. In general, in diseases where bone marrow function is not actively compromised, an autologous and in cases where bone marrow function is defective or when tumor cells are extensively infiltrating bone marrow, an allogeneic transplant is carried out. Allogeneic stem cells not only restore hematopoietic functions but also mount immunological responses against the tumor cells called the graft versus leukemia effect to control the tumor.[1]

Human leukocyte antigen (HLA) compatibility between donor and recipient is recognized as the most critical factor affecting the outcome of a HSCT.[1] Since the inheritance of HLA genes is independent of the ABO blood group antigens, HLA-matched transplants may be performed with some degree of ABO incompatibility. Worldwide, approximately 30%–40% of the current allogeneic HSCTs are ABO incompatible.[2] Hematopoietic cell transplantation from HLA-matched siblings has become the treatment of choice for many hematologic diseases, but fewer than 40% of patients have an HLA-matched sibling.[3]

ABO incompatibility can be categorized into major (15%-20%), minor (15%-20%), and bidirectional (5%) of all allogeneic HSCTs. Major ABO-incompatible HSCT (A/B/AB group donor to O group recipient or AB group donor to A/B recipient) is characterized by the presence of preformed antidonor iso-agglutinins, minor ABO-incompatible HSCT (O group donor to A/B/AB recipient or A/B group donor to AB recipient) by the ability of the donor bone marrow to produce antirecipient iso-agglutinins and bidirectional incompatibility by a combination of both (A-group donor to B-group recipient or vice-versa).[4] It is believed that ABO incompatibility between the donor and the recipient increases the risk of hemolytic reactions in all groups. Other effects of ABO incompatibility on HSCT have been elaborated as delayed red blood cell (RBC) engraftment and pure red cell aplasia (PRCA) due to interactions between donor and recipient ABO antigens and antibodies.[5],[6] RBC precursors are hence destroyed leading to decreased reticulocyte and RBC production.[7] ABO-incompatible HSCT may also affect white blood cell (WBC) and platelet (PLT) engraftment, which is comprehensible as ABO antigens are expressed on the surface of all blood cells. However, there is no precise data about the effect of ABO incompatibility on WBC/PLT re-population.[8],[9],[10] The impact of ABO incompatibility on the incidence of acute and chronic graft-versus-host disease (GvHD) is also controversial.[11],[12]

In this study, we investigated the role of ABO incompatibility in outcomes of patients undergoing allogeneic HSCT, including the incidence of GvHD, transfusion requirements, engraftment status, and overall survival at the end of 1 year. We also assessed the impact of donor age, sex, and sibling donor-recipient pair, in the clinical outcomes of allogeneic HSCT.

   Materials and Methods Top

Design of study and patients

A retrospective study was conducted on 76 patients who underwent first time allogeneic HSCT (65 sibling donors and 11 nonsibling donors) between the years 2011 and 2018 in a tertiary care hospital in Maharashtra with hematological malignancies (chronic myeloid leukemia, acute leukemia, myelodysplastic syndrome) and nonmalignant conditions (aplastic anemia, thalassemia, chronic granulomatous disease, and paroxysmal nocturnal hemoglobinuria). They were followed up for a period of 12 months for their transfusion requirements, engraftment profile, incidence of GvHD, and mortality. The 76 allogeneic HSCTs included 47 ABO compatible and 29 ABO incompatible transplants. 63 patients received 6/6 HLA matched transplants, 8 with HLA mismatched at one locus, while 5 received haplo-identical transplants. Written informed consent was obtained from each donor and recipient. Ethical clearance was taken from Institutional Ethics Committee.

Preparative regimen

Fludarabine (180 mg/m2 over 6 days) and cyclophosphamide (100 mg/kg over 2 days) regimen was given for aplastic anemia and myelodysplastic syndrome cases. Anti-thymocyte globulin, 500 mg for 3 days, was added to this regimen in 8 cases. In 2 cases, ATG alone was used at a dose of 1250 mg/day for 5 days.

Intravenous (IV) fludarabine 30 mg/m2 for 5 days with melphalan 140 mg/m2 IV stat. regimen was delivered to most patients of AML. Another myeloablative conditioning regimen used was cyclophosphamide 60 mg/kg daily for 2 days and busulfan 0.8 mg/kg IV infusion 6 hourly, for 4 days in AML and CML cases.

A regimen consisting thiotepa 8 mg/kg stat on D-6 and treosulfan 14 g/m2/day for 3 days along with fludarabine 40 mg/m2/day for 4 days was used in thalassemia major patients.

Graft versus host disease prophylaxis

All patients received standard cyclosporin A (3 mg/kg/day, in two divided doses for 5 days) + methotrexate (5–10 mg/m2, for 4 days along with folinic acid) for GVHD prophylaxis. In the absence of ongoing GVHD, with the aim to stop immunosuppression by approximately 6 months after transplantation, tapering of immune suppression was initiated at 3 months after allogeneic HSCT. Prophylactic donor lymphocyte infusions were not given to any patient. Grading of GVHD was done according to Glucksberg criteria.[13] Acute and chronic GVHD was determined according to the National Institutes of Health criteria.[15] Follow-up of patients was carried out regularly at 1–3-week posttransplant for 6 months for all patients and up to 1 year for patients having long-term complications, to assess the status and disease response.

Infection prophylaxis

Antiviral prophylaxis with acyclovir against herpes simplex and varicella zoster and prophylaxis against Pneumocystis jirovecii with sulfamethoxazole and trimethoprim were continued for at least 6 months after allogeneic HSCT. Routine monitoring of cytomegalovirus infection was carried out after allogeneic HSCT and treated appropriately. Before neutrophil engraftment, recipients were given injection amphotericin B or injection caspofungin for the prevention of fungal infections.

Hematopoietic stem cell mobilization and harvesting

Injection granulocyte-colony stimulating factor (Filgastrin) was given subcutaneously (5–20 μg/kg/day), for 4–5 consecutive days. Enumeration of donor peripheral blood CD34 + cell count was performed by flow cytometry (BD FACS Calibur) on day 4 or 5 post-G-CSF treatment using ISHAGE protocol.[16] The ideal day for apheresis was determined based on the peripheral blood CD34 + cell count (at least >10/μL). The peripheral blood stem cells (PBSC) of the donor were harvested using a continuous flow cell separator (Com.Tec, Fresenius-Kabi, Hamburg, Germany). The CD34+ cell count in the harvested product was also enumerated.


Complete blood counts were checked daily post-PBSC infusion (day 0) to determine engraftment. For neutrophils, it was taken as the first of 3 consecutive days with an absolute neutrophil count of 0.5 × 109/L or more and for PLTs, the first of 3 consecutive days with a PLT count of 20 × 109/L or more without PLT transfusion.

Transfusion support

The hemoglobin threshold for RBC transfusion was 8 g/dL. PLTs were transfused if the counts were ≤20 × 109/L. All transfused blood products were leukodepleted and irradiated. Patients in the pretransplantation or postengraftment phase of HSCT were given transfusion based on their forward-and reverse typing results. Blood components were chosen as per AABB guidelines for posttransplant phase.[4]

Graft manipulation

For ABO minor-incompatible transplants, plasma (volume) reduction and for major and bidirectional incompatible grafts, RBC depletion of stem cell product was carried out. Hydroxyl ethyl starch 6% w/v (acuLIFE, India) was used for RBC depletion.[13],[14] After product manipulation, CD34+ cells were recounted by flow cytometry. Viability tests on all PBSC products were performed using trypan blue viability dye (Biowest, France) before transplantation. Viable cells exclude trypan blue stain uptake while dead cells appeared blue.

Statistical analysis

Statistical analyses were performed using SPSS for Windows (Version 19) (SPSS Inc., Chicago, IL, USA). Data were analyzed using Fisher's exact test, Chi-square test, and Kruskal–Wallis tests. All tests were two-sided with the type I error rate fixed at 0.05. Clinical characteristics and outcomes of the groups according to ABO compatibility were compared using Fisher's exact test.

   Results Top

Patient characteristics

A total of 76 patients with different hematological diseases who required allogeneic HSCT were included in this study. Cases were divided into four groups based on ABO blood group compatibility between donors and recipients; compatible, major incompatible, minor incompatible, and bidirectional ABO incompatible. 47 patients received PBSC from ABO compatible donors (61.8%), 12 from major ABO-incompatible donors (15.8%), 10 from Minor ABO-incompatible donors (13.2%), and 7 patients received bidirectional ABO-incompatible HSCT (9.2%). Donor's sex, age, donor-recipient relationship were almost equally distributed in these four groups. Patient, donor and transplant characteristics are summarized in [Table 1] and [Table 2].
Table 1: Patient, donor and transplant characteristics

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Table 2: Distribution of diagnosis in the two groups

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Effect of ABO compatibility on engraftment profile, transfusion requirement and length of initial hospital stay

Hematopoietic recovery and clinical outcomes of allogeneic HSCT patients receiving ABO match and mismatched grafts are summarized in [Table 3] and [Figure 1], [Figure 2], [Figure 3]. The median neutrophil engraftment day was day 14 (10–20) in ABO-matched patients and day 15 (10–18) in ABO-mismatched patients. The median PLT engraftment day was day 12 (7–25) in ABO-matched patients and day 13 (9–24) in ABO-mismatched patients. ABO incompatibility did not significantly affect the WBC and PLT engraftment time.
Table 3: Association between ABO compatibility and various parameters

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Figure 1: Association between compatibility and days for neutrophil and platelet engraftment

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Figure 2: Association between compatibility and red blood cell and platelet transfusion requirement

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Figure 3: Association between compatibility and length of hospital stay

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All the ABO minor incompatible patients required RBC and single donor platelets (SDP) transfusions while only 46.8% of ABO compatible, 41.6% of major incompatible group and 28.5% of bidirectional incompatible group required RBC Transfusions. However, this difference was not statistically significant.

The number of SDP units required for the ABO-incompatible patients was significantly more than that of ABO compatible patients, with a P = 0.001, however, the number of transplants in this category (n = 29) was lesser as compared to the ABO compatible group (n = 47).

Effect of ABO incompatibility on initial hospital stay was not statistically significant, however, a longer hospital stay was noticed for ABO minor incompatible patients.

Effect of compatibility on the occurrence of graft versus host disease and mortality

A total of 14 (29.8%) of ABO compatible and 4 (13.8%) ABO-incompatible patients developed GVHD during the follow-up period of 12 months. Statistically, no significant difference was found with respect to GVHD incidence among ABO compatible and incompatible HSCTs groups.

Mortality observed was 8 (17.0%) among ABO compatible and 2 (6.9%) among ABO-incompatible recipients within 12 months. Statistically significant differences were not observed for nonrelapse mortality among different ABO compatibility categories. Various parameters analysed in ABO-compatible and ABO-incompatible transplants are summarized in [Table 4].
Table 4: ABO compatible v/s ABO-incompatible on various parameters

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Effect of donor age, sex, and donor type (sibling or nonsibling) on outcomes of recipient

Donor age, donor sex and whether the donor was sibling or nonsibling has not shown any statistical significance in terms of neutrophil and platelet engraftment, SDP transfusion requirement, initial hospital stay, incidence of GVHD and mortality. However, nonsibling recipients required statistically significant a greater number of RBC transfusions. Lesser number of nonsibling transplants (n = 11) compared to sibling transplants (n = 65) may have been a confounding factor [Table 5].
Table 5: Association between donor age, gender, and relationship with various parameters

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   Discussion Top

The preferred source of stem cells for HSCT worldwide has seen a paradigm shift to PBSCs,[17],[18],[19] which contain high numbers of lymphocytes and erythrocyte precursors as well as significant number of RBCs. However, few studies have addressed the issue of ABO compatibility in patients receiving PBSCT, especially in India. Stem cell registries for matched unrelated donor transplants are still in their nascent stage in our country. Since HLA compatibility still remains the most critical consideration for HSCT,[1] establishing that ABO incompatibility does not have an adverse transplant outcome compared to ABO matched transplants, the allogeneic donor base for eligible HSCT recipients can be widened.[2]

The aim of this study was to evaluate the impact of donor/recipient ABO compatibility on engraftment kinetics of neutrophils and platelets, RBC and SDP transfusion support, length of initial hospital stay, GVHD incidence, and mortality rate. In addition, we compared the impact of donor age, gender, and relation of the donor (sibling/nonsibling) to the recipient, on patient recovery and outcome. Preparative regimen, antiviral prophylaxis, GVHD prophylaxis, hematologic monitoring, and transfusion threshold policies were similar for all patients who underwent transplant.

In our study, it was observed that time to neutrophil, platelet, and RBC engraftment, incidence of acute or chronic GVHD, and survival were not influenced by ABO incompatibility after allogeneic PBSCT from an HLA-matched sibling donor. These results are comparable with previous reports in the allogeneic setting.[20]

Of the total allogeneic transplants, 38% patients underwent ABO-incompatible HSCT in our study which is consistent with present medical literature, where 30%–50% of allogeneic transplants are ABO incompatible.[2]

Although ABO incompatibility between donor and recipient does not hinder a successful allogeneic HSCT, studies have reported that major ABO incompatibility can cause PRCA due to sustained destruction of erythrocytes produced by the donor marrow postengraftment. This in turn will prolong packed RBCs (PRBCs) transfusion requirements and perhaps hospital stay.[21],[22] In minor ABO incompatibility, immune hemolysis can occur because of passenger lymphocyte syndrome in approximately 10%–15% of cases.[23] Moreover, PBSC grafts harbor more B lymphocytes as compared to marrow grafts, which may cause delayed massive immune hemolysis after minor or bidirectional ABO-incompatible allogeneic HSCT.[23] However, in our study, PRCA was not seen in any patient, neither did any patient develop clinically significant hemolysis within the ABO-mismatched HSCT group when followed up the recipients for period of 12 months.

The key pathophysiology of GVHD is due to the reaction of donor T-cells against recipient cells expressing incompatible alloantigens. Since ABO antigens are expressed on all hematopoietic cells and tissues except cerebrospinal fluid, they act as immunological targets for ABO-incompatible donor or recipient lymphocytes, thus playing a role in engraftment and GVHD. Some researchers have reported greater incidence of GVHD after ABO-incompatible allogeneic HSCT, especially in bidirectional and minor ABO mismatch.[24],[25] In our study, GVHD incidence was similar between the two groups when followed them up for a period of 12 months. There were two cases each in major and bidirectional ABO-incompatible HSCTs whereas no case was reported in the minor incompatible group. However, this difference is not significant statistically. Based on these observations, it seems that ABO antigen and anti-A/B antibodies may have minor roles in the pathogenesis of GVHD, while HLA matching continues to play the major role.

ABO antibodies against RBC, platelet, and neutrophil precursors can result in delayed hematopoietic engraftment which often predicts unfavorable patient outcome. This has been reported in a large Japanese study.[21] Delayed engraftment in turn upsurges the transfusion requirements. Previous studies have reported increased PRBC and platelet consumption in ABO-incompatible HSCT groups.[26] In our study, there was no significant difference in the PRBC requirement between the ABO-compatible and ABO-incompatible groups. However, we observed increased platelet transfusion requirement in the ABO-incompatible group, mostly in major ABO incompatibility. In fact, the bidirectional ABO-incompatible group required the least PRBC and platelet transfusion support. Further, there was no significant difference in WBC and platelet engraftment duration between the ABO-compatible and ABO-incompatible groups or among the three ABO-incompatible categories.

Kimura et al. had reported worse overall survival in ABO-mismatched HSCT patients, however, our study showed no significant difference in mortality rate between ABO-matched and mismatched patients and corroborates with the findings of other previous studies.[21],[27],[28],[29]

Our study had a few limitations. It was a retrospective study with number of ABO-mismatched HSCT patients lower than ABO-matched HSCT patients. The diseases included in this study were heterogeneous which may have resulted in some bias. Overall sample size was less compared to the similar studies conducted in multicenter in the past.

   Conclusion Top

ABO incompatibility does not appear to have had a significant impact on the major outcomes after allogeneic HSCT, such as neutrophil engraftment, platelet engraftment, initial hospital stay, GVHD, mortality rate, and transfusion support except for increased platelet requirement in the incompatible group which should be foreseen before planning such a transplant. Donor availability and HLA matching remain the most critical clinical selection criteria for donors in allogeneic HSCT.

Multicenter studies with a larger number of patients categorized as per disease characteristics (malignant/nonmalignant, subgroups within malignant hematologic conditions) will further help in defining the effects of ABO incompatibility in various patient subsets.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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Correspondence Address:
Neerja Kushwaha,
Department of Transfusion Medicine, Command Hospital (CC), Lucknow . 226 002, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajts.ajts_134_21


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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