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Passenger Lymphocyte Syndrome After Pediatric Liver Transplantation

Woolfson, Jessica P.*,†; Vandriel, Shannon M.*,†; Stephens, Derek†,‡; Dharmaraj, Blossom G.*,†; De Angelis, Maria†,§; Cattral, Mark S.†,§,||,¶; Ghanekar, Anand†,§,||,¶; Grant, David R.†,§,||,¶; Avitzur, Yaron*,†,§; Ng, Vicky L.*,†,§

Journal of Pediatric Gastroenterology and Nutrition: July 2019 - Volume 69 - Issue 1 - p 95–101
doi: 10.1097/MPG.0000000000002337
Original Articles: Hepatology

Background: Passenger lymphocyte syndrome (PLS) is a less known etiology of acute onset anemia following ABO-compatible (ABO-c) liver transplantation (LT). Available literature on PLS after pediatric LT is limited. Therefore, we evaluated the prevalence, clinical course, and risk factors of PLS in children following ABO-c LT.

Methods: A single-center retrospective review of all children who underwent LT between 2000 and 2017 was performed. PLS was defined as a drop-in hemoglobin >20 g/L within 30 days of LT, with positive direct antiglobulin test and 1 laboratory test confirming hemolysis. Chi square and student t tests compared variables between subjects with and without PLS.

Results: Amongst 333 pediatric LT performed, 51 children received an ABO-c graft. PLS was diagnosed in 7 (14%) subjects at a median of 10 days after LT. There were no significant differences in patient demographics, graft type, or immunosuppression between those who did and did not develop PLS. Recipient blood group A+ receiving a donor O+ graft was a risk factor for PLS (P = 0.015). All PLS subjects recovered with blood transfusions (median 2), and no additional interventions. Three subjects initially received recipient (instead of donor) blood group red cells.

Conclusions: We report a 14% prevalence of PLS following pediatric ABO-c LT. Recipient blood group A+ receiving a donor O+ graft is a risk factor for PLS. Recognition of PLS as a cause of early acute anemia in pediatric ABO-c LT enables timely transfusion with donor (rather than recipient) blood group red cells.

*Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children

The University of Toronto

Department of Biostatistics, Design and Analysis

§Division of Transplant and Regenerative Medicine

||Division of General Surgery, The Hospital for Sick Children

Division of General Surgery, University Health Network, Toronto, Ontario, Canada.

Address correspondence and reprint requests to Vicky L. Ng, MD, Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Ave, Black Wing, Room 8262, Toronto, ON M5G 1X8, Canada (e-mail:

Received 26 November, 2018

Accepted 22 February, 2019

This work was presented in part as an Oral E-Poster at the 2017 European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) meeting in Geneva, Switzerland.

Clinical Hepatology Fellowship awarded to J.P.W. from The Canadian Liver Foundation and the Canadian Association for the Study of Liver (CASL). The other authors report no conflicts of interest.

© 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,