Modern Blood Banking & Transfusion Practices

6th Edition

Chapter 16

Adverse Effects of Blood Transfusion

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Introduction
 A transfusion reaction is defined as any
transfusion-related adverse event that occurs
during or after the transfusion of whole blood,
blood components, or human-derived plasma
products.
 Acute transfusion reactions
 Delayed transfusion reactions
 Immune versus non-immune reactions
 Infectious versus non-infectious reactions

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Transfusion Risks
 Transfusion reactions have different
associated outcomes that can be the cause of
increased morbidity or even mortality.
 Some transfusion-associated adverse events
can be prevented, others cannot.
 The diagnosis and treatment of a transfusion
reaction is a multidisciplinary task.

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Recognition, Evaluation and

Resolution
 The initial step involves the patient, the
transfusionist, and the physician responsible
for the patient at the time of transfusion.
 The intermediate step and final steps involve
the Transfusion Service technical staff and
the Transfusion Service physician.

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Basic Immunohematology Testing

 The initial transfusion reaction work-up by
the technical staff consists of steps to rule out
a hemolytic transfusion reaction.
 Presence of hemolysis/hemolysis ruled out and
subsequent testing and evaluation

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Basic Immunohematology Testing

(cont’d)
 Secondary testing performed according to the
presenting signs/symptoms and evolution of
the transfusion reaction as requested by the
Transfusion Service physician
 Tasks of medical personnel in transfusion
reaction recognition, evaluation, and resolution

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Acute Transfusion Reactions

 A reaction in which signs and symptoms
present during or within 24 hours of a
transfusion
 Most can be grouped according to the
common etiology that gives similar
presenting signs and symptoms

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Acute Hemolytic Transfusion Reaction

(AHTR)
 Consists of acute hemolysis with
accompanying symptoms during/within 24
hours of transfusion
 Accompanying signs and symptoms of
immune mediated acute hemolytic
transfusion reaction

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Acute Hemolytic Transfusion Reaction

(AHTR) (cont’d)
 Reaction process
 IgM or IgG antibodies in the recipient recognize
corresponding donor red cell antigens.
 Immune complexes are formed.
 The complement cascade is activated.
 Vasoactive amines and inflammatory mediators are
released.
 The coagulation cascade is activated.

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Immune Mediated Acute Hemolytic

Transfusion Reaction
 The activated lytic arm (membrane attack
complex) of the complement cascade causes
hemoglobinemia and hemoglobinuria, the
hallmarks of intravascular hemolysis.

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Nonimmune Acute Hemolytic

Transfusion Reaction
 Most frequently presents as asymptomatic
hemoglobinuria; occasional renal
dysfunction; rarely death
 Pathophysiology independent of the
presence of antibodies
 Possible causes

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Immune Mediated Acute Hemolytic

Transfusion Reaction (Immune AHTR)
 When an immune AHTR is suspected, the
transfusion must be discontinued
immediately, a clerical verification performed,
and the patient’s physician notified.
 Required notification and documentation actions
 Required blood and urine samples
 Gather documents, samples, component bag(s)

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Immune Mediated Acute Hemolytic

Transfusion Reaction (Immune AHTR)
(cont’d)
 If the post-reaction blood sample appears
hemolyzed upon inspection, a second sample should
be requested to verify hemolysis.
 If the DAT performed in the post-reaction sample
shows a “new” or stronger positivity than the pre-
reaction sample DAT, further work-up is needed.
 Required samples/testing for time frames for the
indicators affected by intravascular hemolysis
Copyright © 2012 F.A. Davis Company
Modern Blood Banking & Transfusion Practices
6th Edition

Transfusion-Associated Sepsis (TAS)

 Acute non-immune transfusion reaction with
fever, usually with greater than 2C increase in
body temperature and rigors that can be
accompanied by hypotension
 Occurs when a bacteria-contaminated blood
component is transfused
 Mortality risks

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Transfusion-Associated Sepsis (TAS)

(cont’d)
 Commonly implicated bacterial organisms
 TAS and bacterially contaminated platelets
 Laboratory workup for the diagnosis of TAS
 Treatment of TAS

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Febrile Non-Hemolytic Transfusion

Reaction (FNHTR)
 An acute complication of transfusion presenting
with 1°C (1.8°F) increase in body temperature
that can be accompanied by chills, nausea
and/or vomiting, tachycardia, increase in blood
pressure and tachypnea
 Asymptomatic rise in body temperature in a
hypothermic patient not considered FNHTR

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Febrile Non-Hemolytic Transfusion

Reaction (FNHTR) (cont’d)
 Etiology attributed to two different white cell
related mechanisms
 Immune-mediated mechanism
 Platelet storage changes and cytokines
released from white cells present in the
component
 Treatment and prevention of FNHTR
Copyright © 2012 F.A. Davis Company
Modern Blood Banking & Transfusion Practices
6th Edition

Allergic Transfusion Reactions (ALTR)

 Acute, immune complications of transfusion
presenting with a variety of symptoms and severity
of the reaction
 Occurs as a response of recipient antibodies to an
allergen present in the blood component
 Symptoms associated with ALTR
 Pathophysiology of ALTR
 Treatment and prevention of ALTR

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Transfusion Related Acute Lung Injury

(TRALI)
 Consists of an acute transfusion reaction presenting
with respiratory distress and severe hypoxemia during
or within 6 hours of transfusion in the absence of other
recognized causes of acute lung injury
 Can be accompanied by fever and/or hypotension
 Considered the leading cause of transfusion-associated
fatalities

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Transfusion Related Acute Lung Injury

(TRALI) (cont’d)
 Patients with specific clinical diagnoses (infection, surgery,
trauma) have increased risk
 Two different hypothetical pathways have been postulated
for the pathogenesis of TRALI
 Immune TRALI
 Implicated leukocyte antibodies and components
 Non-immune TRALI
 Individual predisposition of the patient

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Transfusion Related Acute Lung Injury

(TRALI) (cont’d)
 Both pathways lead to a final common pathway that
causes damage to the endothelium, leading to
pulmonary capillary permeability and resulting in
non-cardiogenic pulmonary edema
 Management/treatment of TRALI
 Management of donor implicated in TRALI
 Preventive interventions

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Transfusion Associated Circulatory

Overload (TACO)
 Acute non-immune complication of transfusion
presenting with respiratory distress, hypoxemia that
can be accompanied by other symptoms during or
after transfusion
 Occurs when the ability of the patient’s cardiovascular
system to handle additional workload is exceeded,
manifesting as congestive heart failure
 Symptoms associated with TACO

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Transfusion Associated Circulatory

Overload (TACO) (cont’d)
 Chest radiography findings
 Utility of brain natriuretic peptide (BNP)
assay
 Treatment of TACO, including transfusion
rate
 Patients at risk of developing TACO

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Adverse Events Associated with

Massive Transfusions
 Comorbid factors
 Patient monitoring for development of signs
and symptoms and changes in laboratory
values
 Appropriate use of medications and blood
components

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Delayed Serologic/Hemolytic
Transfusion Reaction (DSHTR)
 The detection of "new" red cell antibodies after 24
hours of transfusion
 Occurs most commonly secondarily to an amnestic
response but may also occur during a primary
immune response
 May (delayed hemolytic) or may not (delayed
serologic) be associated with shortened survival of
the transfused cells

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Delayed Serologic/Hemolytic
Transfusion Reaction (DSHTR) (cont’d)
 Often noted when a new sample is tested during
a request for a type and crossmatch and the
hemoglobin levels are lower than anticipated
 Implicated antibody specificity, thermal activity
and ability to fix complement
 Immunohematology evaluation

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Transfusion-Associated Graft Versus

Host Disease (TAGVHD)
 A delayed immune transfusion reaction due
to an immunologic attack by viable donor
lymphocytes contained in the transfused
blood component against the transfusion
recipient
 Symptoms of TAGVHD
 Laboratory test results in GVHD

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Transfusion-Associated Graft Versus

Host Disease (TAGVHD) (cont’d)
 Conditions leading to development of TAGVHD
 HLA haplotypes of donor and recipient
 Patient populations at risk for TAGVHD
 Recommended diagnostic testing
 Gamma irradiation of cellular blood
components
Copyright © 2012 F.A. Davis Company
Modern Blood Banking & Transfusion Practices
6th Edition

Post-Transfusion Purpura (PTP)

 A delayed immune complication of transfusion
presenting with profound thrombocytopenia
1–24 days post transfusion
 Mechanism of PTP
 Standard of treatment
 Considerations for subsequent transfusions

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

Iron Overload
 A delayed, non-immune complication of
transfusion, presenting with multi-organ
(liver, heart, endocrine organs) damage
secondary to excessive iron accumulation
 Chelation therapy for iron overload

Copyright © 2012 F.A. Davis Company

Modern Blood Banking & Transfusion Practices
6th Edition

“Silent” Transfusion-Related Adverse

Events
 Incidents/errors not necessarily presenting with
transfusion-associated symptoms
 Potential to cause adverse effects
 Sample collection errors
 Red blood cell alloimmunization
 Platelet alloimmunization
 Transfusion overdosing and underdosing
Copyright © 2012 F.A. Davis Company
Modern Blood Banking & Transfusion Practices
6th Edition

Transfusion-Related Adverse Events

in Special Patient Scenarios
 Special patient populations and transfusion
circumstances warranting discussion
 Infusion of plasma derivatives
 Therapeutic apheresis
 Neonatal transfusions
 Autologous blood transfusions

Copyright © 2012 F.A. Davis Company