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Transfusion Reactions

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Introduction

• Blood transfusion is safe, effective way to correct hematology defects and crucial part of supportive care of some patients

• Sometimes unwanted results may occur during or after transfusion

• One of these is transfusion reactions

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Transfusion Reactions

• They are adverse reactions associated with the transfusion of blood and its components

• 3% of individuals receiving blood transfusions have a transfusion reaction

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Transfusion reactions

• Non-threatening to fatal (Fatal ~ 1/50000)• Immunological or Non-immunological• May or may not cause RBC destruction• Immediate to delayed

– Immediate – rapid onset (<24 hours) – Delayed – >24 Hours,Occur days, weeks,

• May involve infectious agents

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Transfusion Reactions

• Most common causes of transfusion related DEATHS:

1. Improper specimen identification2. Improper patient identification3. Antibody identification error4. Crossmatch procedure error

• Most transfusion reactions (not all) are the result of human error.

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Immediate

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Immediate Hemolytic Reactions

• Most common cause is ABO incompatibility (clerical error)

• Red cell destruction due to complement activation by IgM

• RBCs hemolysed due to reaction between Abs in recipient (A & B) & Ags on donor’s RBCs

• As little as 10-15 mL can trigger a reaction

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Symptoms • Fever• Pain at infusion site• Back/chest pain

• Physical signs– Fever– Hypotension– Bleeding– Renal failure– Hemoglobinuria

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Steps taken if hemolytic reaction is suspected

• Stop transfusion

• Keep IV line open with physiologic saline

• Perform bedside clerical checks

• Contacts patient’s physician & blood bank

• Return unit, set & attached solutions to Lab

• Collect suitable blood samples for evaluation– Microbiological on unit, culture of patient’s blood,

Check for DIC, Renal function

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Treatment

• Treat hypotension by fluid replacement• Maintenance of renal blood flow• Replacement of depleted coagulation

factors• Dialysis in case of renal failure

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Transfusion of RBCs Allo-Abs

• Rarely, patient’s red cells can be hemolyzed by Abs in transfused whole blood or plasma

• Caused by anti-A or Anti-B in certain plasma products– Cryoprecipitate– Factor VIII or IX

• Positive DAT, Anti-A or Anti-B can be eluted from red cells

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Transfusion Induced Alloimmunization

• Ags are administered during transfusion• In 1st transfusion Induce alloantibodies• This will cause problems in subsequent

transfusions• Prior transfusion beneficial in some cases

– E.g. renal transplantation is more successful in patients with prior multiple transfusions

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Pseudo-Hemolytic Reactions

• Some transfusions may appear to be immediate HTR, but they are not due to immune RBC destruction

• These are called pseudo-hemolytic TR

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Manifestation Possible Mechanism

Hemolysis 1- Excessive Infusion pressure

2- Infusion through small pre needles

3- Overheating of donor red cells

4- Infusion of congenitally abnormal red cells

5- Freezing of red cells prior to infusion

6- Infusion of RBCs damaged by microorganisms

Hypotension or Shock

1- Infusion of infected blood products

2- Anaphylactic reactions

Fever 1- Febrile reaction

2- Infusion of infected blood

Hyperbilirubinemia 1- Infusion of large quantities of blood stored for 4-5 weeks2- Infusion of hemolysed blood

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Delayed Hemolytic Transfusion Reactions

• DHTRs occur at least 24 hrs after transfusion

• Mediated by IgG antibodies– Patient previously exposed to RBC antigen

and has low antibody titer until exposed again

• Cannot be detected in crossmatch– Rh, Kidd, Duffy, and Kell

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• Patients have no symptoms• The only indication is a fall in hemoglobin• Diagnosis made by re-crossmatch

– DAT is usually positive• Elutions are performed to identify Ab

Delayed Hemolytic Transfusion Reactions

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White Cell ReactionsFebrile Reactions

• Most common, 2% of all transfusions• Caused from HLAs on the WBCs of the donor

that react with the recipient antibody• Any component that contains WBCs could

cause FNHTRs• Cytokines IL-1, 6,8 and Tnf-alpha generated in

stored blood/products.• Determining factor is age of blood products• Leukocytes reduced units may be given

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Pulmonary Infiltrates• Transfusion Related Acute Lung Injury• Can be due to:

– Hypervolemia– Donor antibodies that react with the recipient’s

granulocytes or vice versa• which cause embolism to blood vessels in lung tissue• Then fluids and proteins leak into alveolar space/ interstitium

• The lungs fill with a high-protein fluid• Patient displays acute respiratory insufficiency

with x-ray showing pulmonary edema without cardiac failure

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Graft-versus-Host Disease

• Rare but fatal condition that has a 90% mortality rate

• May be caused by donor lymphocytes transfused into an immunocompromised recipient– acute graft-versus-host-disease is characterized by

selective damage to the liver, skin and mucosa, and the gastrointestinal tract

• Any components that contain T-lymphocytes should be irradiated to prevent GVHD

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Platelet ReactionsPost Transfusion Purpura (PTP)

• PTP characterized by severe consumptive thrombocytopenia

• Typically in women with a history of pregnancy, immunized with Human platelet Specific Alloantigen (HPA)

• Thrombocytopenia is self-limiting and lasts for 2-6 weeks

• Occur in patients who are negative for HPA-1a

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Plasma Protein ReactionsAnaphylaxis

• Cause• Infusion of IgA proteins into Pt with IgA

antibodies• IgA deficiency about 1 in 700• Hypotension and bronchospasm• Transfusion should be stopped immediately• IgA deficient patients should be transfused with

blood products lacking IgA

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Urticaria• Second most comon type of TR• Characterized by a pruritic rash during or

following transfusion• Allergic reactions are IgE mediated. • These reactions are usually attributed to

hypersensitivity to soluble allergens found in the transfused blood component.

• Associated with anti-IgA in recipients who are IgA deficient.

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Urticaria• If not accompanied by other signs or

symptoms, transfusion can be continued• Anti-histamines are given