Delayed Blood Transfusion Reactions
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Transcript of Delayed Blood Transfusion Reactions
DELAYED BLOOD TRANSFUSION COMPLICATIONS
classification
IMMUNOLOGICAL NON_IMMUNOLOGICAL
Alloimmunisation (RBC Antigen)(1:10)
Iron overload requiring chelationtherapy (>10-20 RBC units)
Alloimmunisation (HLA Antigen)(1:100)
Iron overload with organ dysfunction(>50-100 RBC units)
Delayed Hemolytic Transfusion reaction (1:2500-11000)
Transfusion transmissible infections
Post-trasfusion purpura
Transfusion-associated Graft vs Host Disease (TA-GVHD)
Transfusion-related immune modulation (TRIM)
Alloimmunisation
Alloimmunisation to RBC, WBC and/or platelets may result from prior exposure by the recipient to blood components, tissue transplantation or pregnancy
Moderate amount of IgG and IgM may be produced during first exposure.
On second exposure, rapid production of IgGin few days will attach to antigenic surface of blood cells and causing ‘delayed transfusion reaction’
Symptoms and Signs
Mild to moderate fever
Anemia due to decreased Hemoglobin
Bleeding tendencies due to decreased platelets
Investigations
History of transfusion, transplantations or pregnancies
Ab screen test to recipient plasma to detect clinically significant HLA or RBC antibodies
Management
Cannot be prevented, usually mild reaction
If antibody is identified, transfused antigen-negatives blood if further transfusion is needed
Give phenotyped blood early in long-term chronic support (e.g Thalassemia) to minimize reaction
Delayed Hemolytic Transfusion Reaction Might be due to alloimmunisation or
transfusion transmitted malaria
Blood group antibodies associated with DHTRs include those of the Kidd, Duffy, Kelland MNS systems
Symptoms and Signs
Fever and anemia after 2 – 14 days of transfusion
Jaundice
Investigations
high bilirubin, high LDH, reticulocytosis, spherocytosis, positive antibody screen and positive Direct Antiglobulin Test (DAT)
Management
Usually benign and no treatment needed
Sometime, life-threatening anemia or renal failure can occur
If further transfusion is needed, transfused antigen-negative blood
Post-transfusion Purpura
Caused by alloimmunisation to platelet-specific antigen, usually Human Platelet Antigen (HPA 1a)
Can also caused by HPA 1b or other type of HPA and HLA
Signs and Symptoms
Purpura and Bleeding tendencies
Occurs 7-10 days post transfusion
Bleeding from mucous membrane, GIT and GUT. ICB can also occurred.
Investigations
dramatic, sudden and self-limiting Thrombocytopenia
Antibody against platelet in recipient plasma
Management
Self limiting, rarely causing mortality
IV immunoglobulin at 1 g/kg as a single dose and repeat as necessary. Platelet count is expected to rise in the next 4 days
Transfusion-Associated Graft vs Host Disease (TA-GVHD)Viable T lymphocytes in the transfused component
engraft in the recipient and react against tissue antigens in the recipient.
The 3 primary risk factors for developing TA-GVHD are:
Degree of recipient immunodeficiency
Number of viable T lymphocytes transfused
Genetic diversity in HLA expression between donor and recipient
Signs and Symptoms
Fever, rash and diarrhea 1-2 weeks post transfusion
Mortality rate >90%, 1-3 weeks after first symptoms
Can occur in patient with intact immune system or donor from family member
Investigations
Skin biopsy and HLA-typing
Demonstrate donor leukocyte engraftment
Management
supportive care
corticosteroids and cytotoxic agents (largely ineffective)
For patients at risk, it is critical to gamma irradiate cellular blood components
Transfusion-related immune modalities (TRIM) Donor white cells releasing cytokines, which
leads to immune modulation.
Signs and Symptoms
transient immunosuppression in recipients
No specific signs and symptoms
Incidence: not known
Management
Leucodepletion to decrease risk of TRIM
Iron overload
Each unit of red cells contains 250mg of iron, while body excreting 1mg/day
In chronically transfused patient, body cannot excrete iron quickly
Hence, iron accumulated in reticuloendothelial system, liver, heart, spleen and endocrine organs
Signs and Symptoms
Thalassemia or red cell aplasia patient who needed chronic transfusion
Muscle weakness, fatigue, weight loss
Later: skin pigmentation, arthropathy, diabetes and hepatic dysfunction may occur
Investigations
Serum ferritin
Organ specific marker (RFT, LFT)
Iron quantification by MRI
Management
Iron chelating agent can be prescribed for prevention and management
Deferoxamine, deferasirox, deferiprone
Transfusion Transmissible InfectionCapable Infection Agents
Bacteria (TTBI)
HIV, Hepatitis, West Nile Virus, Cytomegalovirus etc
Plasmodium genus causing Malaria
Prions: Creutzfeldt-Jakob disease
Transfusion-Transmitted Bacterial Infection (TTBI) Bacteria is most common infective agent.
(1:5000 in platelet transfusion, 1:30,000 in red cell transfusion)
Caused by aseptic technique (via skin or contaminated environment) and/or blood preparations/storage.
High grade fever with rigors, tachycardia or systolic hypotension. May also present with backache, abdominal pain, vomiting and hypothermia
Investigations
Blood culture and sensitivity from blood donor and recipient
Branula or Catheter culture and sensitivity
Increased WBC, or CRP
Management
Stop the transfusion
Hydrate and resuscitate patient
Rule out other immunological causes (missmatch, clerical errors)
Repeat cross-match
Start empirical antibiotic until specific organism narrowed down or isolated
References
1. Roback JD (ed). Non-infectious complications of blood transfusion. Chapter 27, AABB Technical Manual, 17th edition. AABB, Bethesda, 2011.
2. Callum JL, Lin Y, Pinkerton PH, Karkouti K, PendergrastJM, Robitaile N et al. Chapter 5, Transfusion Reactions. Bloody Easy 3: Blood Transfusions, Blood Alternatives and Transfusion Reactions: A Guide to Transfusion Medicine, 3rd edition. Canada: Ontario Regional Blood Coordinating Network, 2011. [cited 2012 Sep 13
3. Transfusion reactions, 3rd edition. AABB Press, Bethesda, 2007.
4. Brohi K. Shock and Blood Transfusion. Chapter 2. Bailey and Love’s Short Practice of Surgery, 25th edition. HodderArnold, London, 2008