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hemolytic transfusion reaction

Classification: 1) immediate immunologic transfusion reactions a) acute intravascular hemolysis (acute hemolytic transfusion reaction) b) urticarial reactions c) anaphylaxis d) febrile non-hemolytic reactions e) platelet alloantibodies f) transfusion-related acute lung injury 2) delayed immunologic transfusion reactions a) delayed immune hemolysis b) graft vs host disease c) transfusion-related immune suppression d) immune-mediated thrombocytopenia (ITP) Etiology: 1) acute intravascular hemolysis (acute hemolytic transfusion reaction) a) clinical errors: misidentification of patient or patient's blood specimen accounts for the majority of fatal transfusion reactions b) caused by ABO incompatible plasma or red cells c) involves complement-fixing IgG & IgM antibodies 2) delayed immune hemolysis - sensitization to RBC antigens (not ABO): - esp. Rh, Kidd, Duffy, MNS antigens - anamnsetic production of non-complement fixing IgG antibodies - extravascular removal of antibody-coated RBCs Epidemiology: - delayed immunologic transfusion reactions a) delayed immune hemolysis - incidence: 1 in 5000 (occurs in previously transfused patients or multiparous women) Pathology: 1) immediate immunologic transfusion reactions - acute intravascular hemolysis (acute hemolytic transfusion reaction) - disseminated intravascular coagulation - renal failure 2) delayed immunologic transfusion reactions - delayed immune hemolysis - sensitization to RBC antigens (not ABO) - anamnsetic production of non-complement fixing IgG - extravascular removal of antibody-coated RBCs Clinical manifestations: 1) acute intravascular hemolysis (acute hemolytic transfusion reaction) a) fever b) tachycardia c) hypotension d) dyspnea e) acute renal failure f) pain at infusion site g) chest pain h) flank pain & abdominal pain i) incidence < 1:50,000 2) delayed immune hemolysis a) anemia; fever; arthralgia; renal failure (mild) b) delayed hemolytic reaction typically occurs 4-13 days (2-10 days) [4] after transfusion Laboratory: 1) immediate immunologic transfusion reactions - acute intravascular hemolysis (acute hemolytic transfusion reaction) - urine appearance: red urine - hemoglobin in urine: hemoglobinuria - plasma free hemoglobin positive (red plasma, hemoglobinemia) - direct antiglobulin test (Coomb's test) is positive - serum bilirubin & DIC panel - repeat cross match 2) delayed immunologic transfusion reactions - delayed immune hemolysis - complete blood count (CBC): drop in hemoglobin - serum LDH: increased - serum bilirubin: hyperbilirubinemia - positive direct antiglobulin (Coomb's) test - reticulocyte count: increased - serum haptoglobin: decreased - a new alloantibody appears in - type & screen - type & crossmatch Management: 1) immediate immunologic transfusion reactions - acute intravascular hemolysis (acute hemolytic transfusion reaction) - stop transfusion - clotted & EDTA-treated blood specimens along with patient's blood & tubing should be sent to lab - send freshly voided urine to lab for free hemoglobin - intravenous hydration - support blood pressure - maintain urine output at 100 mL/hr with IV fluids, diuretics, & mannitol if necessary - NaHCO3 to alkalinize urine may aid in excretion of hemoglobin 2) delayed immunologic transfusion reactions - delayed immune hemolysis - prevention - wallet card identifying alloantibodies - transfusion with compatible blood - patient education

Specific

hemolytic disease of the newborn

General

blood transfusion reaction hemolysis

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 615-616
  2. The Washington Manual of Medical Therapeutics, 29th edition, Carey, CF et al (eds), Lippincott-Raven, Philadelphia, 1998, pg 272-73
  3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 790
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2022.
  5. Vamvakas EC, Blajchman MA. Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention. Blood. 2009 Apr 9;113(15):3406-17. PMID: 19188662
  6. Panch SR, Montemayor-Garcia C, Klein HG. Hemolytic Transfusion Reactions N Engl J Med 2019; 381:150-162 PMID: 31291517 https://www.nejm.org/doi/full/10.1056/NEJMra1802338