Prompt recognition of an immune-mediated transfusion reaction is fundamental to improving patient outcome.
Immune-mediated transfusion reactions can be classified as acute or delayed. Acute reactions occur within 24 hours of transfusion and include acute hemolytic, febrile nonhemolytic, allergic, and transfusion-related acute lung injury (TRALI). Delayed reactions occur days to weeks after the transfusion and include delayed hemolytic transfusion reactions, transfusion-associated graft-versus-host disease, and post-transfusion purpura.
Although infrequent, nonimmune transfusion reactions, including hemolysis, transfusion-associated sepsis, and circulatory overload, should be considered in the differential diagnosis.
Acute hemolytic transfusion reactions are most often the result of clerical error. Identification is critical because of the high probability of a second patient receiving the wrong blood product at the same time.
Treatment depends upon the type of transfusion reaction. Although pretransfusion prophylactic acetaminophen and diphenhydramine are often routinely administered, there is little evidence to support this practice.
This topic will mainly address immune-mediated transfusion reactions, which comprise an array of distinct adverse clinical responses to transfusion. They are mediated by the interaction of recipient antibodies to foreign antigens contained in any allogeneic blood products. Acute immune-mediated transfusion reactions occur immediately following, or within 24 hours of, transfusion. They include acute hemolytic, febrile nonhemolytic, allergic (with or without anaphylaxis), and transfusion-related acute lung injury (TRALI). Delayed immune-mediated transfusion reactions occur within days to weeks of transfusion and include delayed hemolytic transfusion reaction, graft-versus-host disease, and post-transfusion purpura.
History and exam
Key diagnostic factors
- chest, abdominal, flank, and back pain
- bleeding from mucous membranes, GI tract, or urinary tract
Other diagnostic factors
- nausea and vomiting
- pain along the infused extremity
- red urine
- stridor or bronchospasm
- maculopapular rash
- disseminated purpura
- exfoliative dermatitis with mucocutaneous involvement
- prior pregnancy
- previous transfusion
- history of transplantation
- IgA deficiency
- history of transfusion reaction
1st investigations to order
- direct antiglobulin test
- visual inspection of post-transfusion blood sample
- repeat ABO testing on post-transfusion blood sample
- post-transfusion urinalysis
Investigations to consider
- serum IgA levels
- anti-IgA antibody testing
- serum alloantibody screen
- serum LDH
- serum bilirubin
- Gram stain and culture of component and post-transfusion recipient samples
- skin biopsy
- HLA typing
- platelet antibody screen
- serum haptoglobin
- serum potassium
- serum bicarbonate
- serum calcium
- serum creatinine
- PT and PTT
- chest x-ray
- arterial blood gas
acute transfusion reaction
delayed transfusion reaction
Jordan A. Weinberg, MD, FACS
Associate Professor of Surgery
Creighton University School of Medicine
St. Joseph’s Hospital and Medical Center
JAW declares that he has no competing interests.
Christoph Pechlaner, MD
Associate Professor of Medicine
Innsbruck Medical University
CP declares that he has no competing interests.
Marisa Marques, MD
Professor of Pathology
University of Alabama at Birmingham Hospital
MM declares that she has no competing interests.
- Transfusion-associated sepsis
- Nonimmune-mediated hemolysis
- Transfusion-associated circulatory overload
- A compendium of transfusion practice guidelines
- Transfusion handbook
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