FRCPath Haem Part 1 MCQs-Transfusion 460

A 46-year-old man with end-stage renal disease undergoes a living-donor kidney transplant. The donor is group O RhD positive, while the recipient is group A RhD positive. Immunosuppression consists of tacrolimus, mycophenolate mofetil and prednisolone.

On day 10 post-transplant, he develops worsening jaundice, dark urine and fatigue.

Investigations:

• Hb: 58 g/L (pre-transplant 108 g/L)

• LDH: 1680 U/L

• DAT: Strongly positive (IgG only)

• Blood film: Marked spherocytosis.

Despite receiving group O red cells, his Hb continues to fall over the next 24 hours to 47 g/L, requiring repeated transfusions. Laboratory markers of haemolysis continue to worsen.

Which ONE of the following is the MOST appropriate next step in management?

A. Continue supportive transfusion with donor-compatible (group O) red cells and await spontaneous resolution because PLS is self-limiting.

B. Increase tacrolimus dose and administer high-dose methylprednisolone alone.

C. Perform therapeutic plasma exchange together with rituximab while continuing donor-compatible red cell transfusions.

D. Exchange transfusion using recipient-compatible (group A) red cells.

E. Splenectomy to remove the major site of red cell destruction.