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