Mary Berg, M.D. Medical Director, Transfusion Services Associate Professor of Pathology University of Colorado Hospital

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1 Transfusion Reactions/Complications Mary Berg, M.D. Medical Director, Transfusion Services Associate Professor of Pathology University of Colorado Hospital

2 Acute Transfusion Reactions Can be seen with as little as 10 ml infused Up to 24 hours after transfusion is complete Typically within 4 hours of transfusion Not mutually exclusive (may be mixed) Different incidence with different component types Early symptoms are similar for different types of reactions, so always stop the transfusion

3 Investigation of Adverse Events Patient history Signs & symptoms (including serial vital signs) Underlying diagnosis Previous transfusion reactions Clerical check Did the patient get the unit intended for them? Clerical error is the most common cause of acute hemolysis due to ABO incompatibility Testing of a post-transfusion specimen Repeat ABO/Rh type(s), DAT(s), repeat antibody screen, visual inspection for gross hemolysis

4 Acute Hemolytic (AHTR) Incidence = 1:38,000-1:70,000 RBC txns Cause = RBC incompatibility Symptoms = chills, fever, hemoglobinuria, hypotension, oliguric renal failure, DIC, back pain, pain at infusion site, anxiety Patient management = IV fluids to maintain urine output, analgesics, pressors, coagulation support

5 Febrile Non-hemolytic (FNHTR) Incidence = 1:200-1:17 RBC transfusions 1:100-1:3 platelet transfusions Cause = cytokines or antibodies to donor WBCs Symptoms = fever, chills, rigors, headache, vomiting Patient management = premedicate with antipyretic medication Lower incidence with leuko-reduced components

6 Urticarial Incidence = 1:100-1:33 of all transfusions Cause = antibody to donor plasma protein Symptoms = hives, pruritis, flushing Patient management = treat or premedicate with anti-histamine The only reaction for which infusion may be restarted, if symptoms resolve with treatment If symptoms recur, discontinue the transfusion

7 Anaphylactic Incidence = 1:20,000-1:50,000 of all txns Cause = antibody to donor plasma protein Symptoms = hypotension, urticaria, bronchospasm (respiratory distress, wheezing), local edema (tracheal), anxiety Patient management = anti-histamines, corticosteroids, beta-2-agonists, epinephrine, IV fluids, Trendelenberg position

8 Transfusion-Related Acute Lung Injury (TRALI) Incidence = 1:5,000-1:190,000 of all txns Cause = antibodies in donor unit directed against recipient WBC or HLA antigens Symptoms = hypoxemia, respiratory failure, hypotension, fever, bilateral pulmonary edema Patient management = supportive care (including mechanical ventilation) Defer the implicated donor

9 Transfusion-Associated Sepsis Cause = bacterial contamination Platelets Normal skin flora, usually Gram-positive Incidence = 1:1,000-1:2,000 transfusions Clinical sepsis: 10-40% RBCs Yersinia enterocolitica, Serratia liquifaciens, Pseudomonas fluorescens Incidence = 1:1,000,000 transfusions Mortality: 60% Symptoms = fever, chills, hypotension, DIC Patient management = supportive care for complications (shock), antibiotics

10 Transfusion-Associated Circulatory Overload (TACO) Incidence = <1% of transfusions Cause = rapid (inadequately compensated) volume expansion Symptoms = dyspnea, orthopnea, cough, tachycardia, hypertension, headache Patient management = diuretic medication, upright posture, oxygen supplementation, mechanical ventilation, (?phlebotomy)

11 Less Common Acute Events Hypotension associated with ACE inhibitors Nonimmune hemolysis Improper storage of RBC units Inappropriate IV fluids or drug added to IV Air embolism Hypocalcemia Hypothermia

12 Delayed Transfusion Reactions 24 hours or more after transfusion is complete Not accurately reported & so incidence is not really known

13 Alloimmunization Delayed hemolytic transfusion reaction (DHTR) or delayed serologic transfusion reaction (DSTR) Incidence = RBC alloimmunization 1:100 Delayed hemolysis 1:11,000-1:5,000 HLA alloimmunization 1:10 Cause = antibody made that is directed against a foreign antigen in the transfused unit Patient management = phenotypicallymatched RBC units

14 Less Common Delayed Immune- Associated Complications Transfusion-associated Graft Versus Host Disease (TA-GVHD) Transfused immune-competent lymphocytes attack recipient immune system Post-transfusion Purpura (PTP) Antibody directed against foreign platelet antigen Transfusion-related Immuno-modulation (TRIM) Immune suppression

15 Other Less Common Delayed Complications Iron Overload Infections Viruses Hepatitis (HAV, HBV, HCV, HGV) HIV HTLV CMV EBV HHV-6 HHV-8 Parvovirus WNV Rabies Parasites Chagas disease Babesiosis Malaria Toxoplasma Other CJD and vcjd Syphilis Bacteria RMSF Borrelia

16 Regulatory Issues All transfusion-transmitted infections must be reported to the FDA All reports of possible transfusion-transmitted infection must be investigated Implicated donor must be tested & deferred, if pos. Lookback investigations must be carried out for all transfusions from donors who are later found to have viral infections (hepatitis & HIV) All transfusion-related fatalities must be reported to FDA, State Health Department & JCAHO (sentinel event)

17 Review Questions

18 Which acute transfusion reactions can present with respiratory distress? Anaphylactic TRALI TACO Air embolism

19 Which acute transfusion reactions can present with hypotension? Hemolytic Anaphylactic TRALI Transfusion-associated sepsis Hypotension associated with ACE inhibitors Air embolism

20 Which acute transfusion reactions can present with fever? Hemolytic FNHTR TRALI Transfusion-associated sepsis Delayed transfusion reactions? font DHTR TA-GVHD

21 Which delayed transfusion reactions can cause problems for something other than the red blood cell line? HLA alloimmunization Platelet refractoriness, NAIT TA-GVHD PTP TRIM Iron overload

22 The End! Questions?