Use of Human Leukocyte Antigen (HLA)–Incompatible Platelet Units in HLA Platelet-Refractory Patients With Limited Number of or Low-Level HLA Donor-Specific Antibodies Results in Permissive Transfusions

Abstract

Context.— In human leukocyte antigen (HLA)–mediated alloimmune platelet refractoriness, HLA-incompatible platelets may produce adequate posttransfusion corrected count increment (“permissive transfusion”) and increase the donor pool. Objective.— To determine if a lower number of or low-level anti-HLA donor-specific antibodies (DSAs) predict permissive transfusion and could be used to prioritize platelet selection. Design.— We categorized platelets administered from 2016 to 2018 as HLA-compatible or HLA-incompatible based on presence of DSAs against the donor unit. We further divided HLA-incompatible units based on the number of DSAs and the level of DSAs (measured by mean fluorescence intensity [MFI]), where cumulative MFI ≥6000 defines high-level DSA. We compared posttransfusion corrected count increments (CCIs) and transfusion reactions among these transfusions. Results.— Of 279 HLA-selected units transfused into 26 platelet-refractory patients, we resorted to using 39 HLA-incompatible units (14%). Posttransfusion CCI and transfusion reaction frequency were similar among units targeted by 1 or low-level DSAs and HLA-compatible units. Units targeted by ≥2 distinct or high-level DSAs produced lower CCIs. Regardless of ABO compatibility, similarly HLA-categorized units yielded comparable CCIs and comparable frequency of transfusion reactions. Conclusions.— HLA-incompatible platelets transfused across 1 or low-level DSAs were commonly permissive, whereas those transfused across ≥2 DSAs or high levels of DSA (MFI ≥6000) were nonpermissive. The use of such donor units offers transfusion services alternative platelet units for support of platelet-refractory patients.