Transfusion Reactions PDF

TRANSFUSION REACTIONS transfusion of blood or blood products exposes patients to risks regardless of precautions approximately 3% of all transfusions result in an adverse reaction most reactions are mild death is rare (1:300,000 or 1:500,000 transfusions) and usually the re...

TRANSFUSION REACTIONS transfusion of blood or blood products exposes patients to risks regardless of precautions approximately 3% of all transfusions result in an adverse reaction most reactions are mild death is rare (1:300,000 or 1:500,000 transfusions) and usually the result of an ABO incompatibility; most cases - clerical error, misidentification of patient or donor unit Pre-transfusion testing will not ensure a transfusion without any risk transmission of infectious diseases antibodies to other blood components (white cells, platelets, etc.) red cell alloantibodies which are below detectable level alloimmunization - primary response to a foreign antigen no guarantee of normal survival of transfused red cells Immediate (acute) vs. Delayed reactions Immune vs. Non-Immune Hemolytic vs. Non-Hemolytic Type of hemolysis: Intravascular vs. Extravascular Immune Hemolytic Immediate: occur during or within 24 hours of transfusion blood groups: ABO Delayed: due to an anamnestic response (secondary response) previous sensitization to a red cell antigen antibody is not detected by serological tests restimulated by the transfusion (2nd exposure) reaction occurs 2-7 days post transfusion blood groups: Rh, Kell, Duffy, Kidd Intravascular destruction of red cells IgM or IgG complement to C9 release of hemoglobin into the circulation symptoms: ▪ fever and chills ▪ shock ▪ burning at the site of infusion ▪ bleeding ▪ chest restriction ▪ renal failure ▪ joint pain ▪ DIC ▪ decrease in blood pressure ▪ Lecture Notes 1 140-531-DW  lab results: ▪ plasma hemoglobin (hemoglobinemia) ▪ hemoglobin in the urine (hemoglobinuria) ▪ ↓ haptoglobin (binds to free hemoglobin in plasma) ▪ ↑ methemalbumin (albumin bound to hemoglobin) ▪ ↑ bilirubin blood groups: ▪ ABO, Kidd Extravascular destruction of red blood cells IgG if complement - only to C3 red cells are sensitized by antibody or complement; removed from the circulation by macrophages in the spleen and liver symptoms: ▪ fever ▪ anemia (unexplained drop in hemoglobin) ▪ mild jaundice lab results: ▪ DAT positive (mixed field) ▪  bilirubin (hyperbilirubinemia) ▪  hemoglobin or hematocrit blood groups: ▪ Rh, Kell, Duffy, Kidd Investigation: Specimens: ▪ pre and post - patient ▪ donor segment ▪ donor unit bag ▪ urine post - patient First steps: 1. Check for clerical errors (mistake in transcription) 2. Check for hemolysis o pre and post patient specimen, donor segment, urine 3. Perform a DAT o pre and post patient specimen 4. Retest for ABO and Rh o pre and post patient specimen, donor segment Second steps: 5. Repeat crossmatch o pre and post patient specimen and donor segment 6. Repeat antibody screen with identification, if necessary o pre and post patient specimen 7. culture the donor unit bag for bacterial contamination 8. Urine hemoglobin - 1st specimen post transfusion Other tests: 9. Serum bilirubin 10. Haptoglobin 11. Methemalbumin (Schumm's test) Lecture Notes 2 140-531-DW  IMMUNE TRANSFUSION REACTIONS Type of reaction cause immediate intravascular ABO Hemolytic delayed intravascular Kidd delayed extravascular Rh, Kell, Duffy, Kidd febrile (immediate) recipient antibodies to HLA antigens on donor WBC cytokines produced by donor WBC during storage allergic: uticarial plasma proteins (allergens) (immediate) allergic: anaphylactic plasma proteins (immediate) anti-IgA Non-Hemolytic post transfusion purpura platelet antibodies (delayed) graft vs. host donor lymphocytes (delayed) alloimmunization red cell antigens white cell antigens (HLA) platelet antigens IgA TRALI: Transfusion Antibodies in donor plasma related acute lung injury against HLA antigens on recipient WBC cause pulmonary damage Lecture Notes 3 140-531-DW  NON-IMMUNE TRANSFUSION REACTIONS type of reaction cause Septicemia bacterial contamination (immediate) infected blood products Hemolytic physical / chemical outdated blood hemolysis improper storage (immediate) (heat, cold) improper transfusion (hypotonic solution) disease transmission HIV, Hep.B or C, (delayed) syphilis, Tcell leukemia, CMV, malaria, babesiosis (parasite) circulatory overload volume and speed of Non-hemolytic (immediate) transfusion TACO: Transfusion Overload associated with associated circulatory an accumulation of overload transfusion products iron overload multiple transfusions (long term) Lecture Notes 4 140-531-DW  SUMMARY OF TRANSFUSION REACTIONS Immunological Transfusion Reactions Constituent Type of Reaction acute hemolytic transfusion reaction delayed transfusion reaction Red Blood Cells transfusion of red cell alloantibodies (passive alloimmunization) alloimmunization febrile transfusion reaction White Blood Cells leukoagglutinin-associated pulmonary edema alloimmunization alloimmunization Platelets post transfusion purpura leukopenia urticaria Serum Proteins anaphylaxis Other graft-versus-host disease (GVHD) Non-Immunological Transfusion Reactions Condition Cause hepatitis B hepatitis non-A, non-B infectious mononucleosis Disease Transmission cytomegalic inclusion disease malaria acquired immune deficiency syndrome (AIDS) associated with the infusion of infected blood Septicemia products, particularly platelets Dilution of Blood thrombocytopenia Constituents clotting factor deficiencies air embolism Embolic microemboli iron Overload fluid electrolytes (i.e. hyperkalemia) Lecture Notes 5 140-531-DW IMMUNE NON-HEMOLYTIC TRANSFUSION REACTIONS Febrile non-hemolytic reactions (FNHTR or NHFTR) most frequent transfusion reaction usually begins immediately at the end or 1-2 hours following the transfusion must be differentiated from an acute hemolytic transfusion reaction or bacterial contamination (i.e., absence of red cell destruction) cause: ▪ recipient antibody to the HLA antigens on the donor leukocytes or platelets; recipient must have been previously immunized, producing antibodies to foreign HLA antigens ie., previous transfusions or pregnancies ▪ cytokines accumulated in the stored unit of red cell (or platelets) units; produced by viable donor leukocytes during storage; prevention: ▪ Beginning June 1999, all packed cell and platelet units supplied by Hema Quebec will be leukocyte reduced prior to storage Allergic reactions: uticarial uticaria - hives erythema - redness of the skin fairly common - 2nd most frequent cause: ▪ IgE antibodies of the recipient against an allergen in the plasma of the donor unit (usually plasma proteins) transfusion does not need to stop; antihistamines are given; prevention: ▪ antihistamines can be given just before a transfusion Allergic reactions: anaphylactic shock more severe allergic reaction rare life threatening occurs immediately, after only a small amount of blood has been transfused ▪ skin flushing ▪ nausea, abdominal cramps ▪ vomiting ▪ bronchospasm ▪ hypotension, shock, loss of consciousness ▪ no fever; no red cell destruction cause: ▪ anti-IgA in an IgA deficient recipient reacting with IgA in the plasma of the donor unit; prevention: ▪ transfusion of washed cells Lecture Notes 6 140-531-DW Post transfusion purpura patient has been previously immunized to platelet-specific antigens (through previous pregnancies or transfusions); platelet antibodies react to the platelets of the donor; sometimes the patient’s own platelets are destroyed as well (even if they are antigen negative). rare occurs 5-10 days following the transfusion ▪ thrombocytopenia ▪ red discoloration of skin caused by hemorrhaging resulting from the destruction of platelets prevention: o transfuse washed cells Graft vs. host disease donor T lymphocytes establish a graft in the recipient host respond to the HLA (human leukocyte antigens) or other histocompatibility antigens (on all nucleated cells) donor lymphocytes begin to attack cells, tissues and organs of the host; ▪ must be immunocompetent, cytotoxic CD8 T lymphocytes recipients at risk: ▪ immunodeficient ▪ bone marrow transplant recipients ▪ blood transfusion from a relative ▪ fetus (intrauterine transfusion) ▪ premature neonate (exchange transfusion) prevention: ▪ transfusion of irradiated blood Alloimmunization result of primary response to foreign red cell, leukocyte, platelet and protein antigens; possible consequence of any transfusion usually does not cause a problem for the present transfusion ▪ primary response - antibody production is too slow and low titer ▪ antibody level may not reach detectable level (20-120 days) ▪ may not effect the survival rate of the transfused cells will cause a problem in subsequent transfusions ▪ secondary response prevention: ▪ cannot prevent alloimmunization ▪ pre-transfusion testing can prevent the second exposure Lecture Notes 7 140-531-DW TRALI - TRANSFUSION RELATED ACUTE LUNG INJURY Acute lung injury, which can progress to the acute respiratory distress syndrome (ARDS). Occurs during or within six hours after transfusion ETIOLOGY: ▪ Antibodies directed toward Human Leukocyte Antigens (HLA) or Human Neutrophil Antigens (HNA) in the donor plasma reacts with recipients WBC. Causing Neutrophil aggregation and sequestration in the pulmonary microvasculature resulting in endothelial damage. PRODUCTS IMPLICATED: ▪ Women who are multiparous (have had more than one child) develop these antibodies through exposure to fetal blood ▪ Associated with plasma products such as FFP, but can occur in recipients of packed red blood cells due to the residual plasma present in the unit PREVENTION: ▪ Producing FFP/Plat from only male donors Hema-Quebec: Donors Platelets Apheresis Plasma Fractionated Female without from whole Accepted for Accepted for Accepted history of blood donations transfusion transfusion pregnancy accepted (20 april 2008) Not accepted No. Except no Accepted Female with except for plat HLA history of typed for compatible pregnancies platelet antigens plat or plat (20 oct 2008) typed for plat ags (20 april 2008) Accepted for Accepted for Accepted for Accepted Males transfusion transfusion transfusion for transfusion No exceptions will be made for group “AB” donors for cryo, plasma deficient in IgA or plasma collected from directed donors. Lecture Notes 8 140-531-DW NON- IMMUNE HEMOLYTIC TRANSFUSION REACTIONS Septicemia (bacterial contamination) bacterial contamination can occur from: ▪ an asymptomatic bacteremia in the donor ▪ improper disinfection of the skin during phlebotomy ▪ opening the system in component preparation platelets are most at risk because of the pooling of units and their storage at room temperature; all platelet units are now cultured for bacterial contamination endotoxins produced by gram negative bacteria (Citrobacter, E. coli, Yersinia) reactions occur during or immediately after transfusion; the transfusion must be stopped ▪ high fever ▪ hypotension, shock ▪ hemoglobinemia ▪ renal failure ▪ DIC reaction must be differentiated from a hemolytic intravascular reaction caused by a red cell antibody (similar symptoms) prevention: ▪ strict adherence to aseptic techniques ▪ proper storage and component preparation conditions ▪ packed cell transfusions should not exceed 4 hours NON- IMMUNE NON-HEMOLYTIC TRANSFUSION REACTIONS Transmission of infectious disease infectious agents which may be transmitted by blood transfusion: ▪ HIV and other human retroviruses ▪ Human T-cell Lymphotropic Virus (HTLV I/II) ▪ Hepatitis B and C ▪ Cytomegalovirus (herpes virus) ▪ Epstein-Barr virus (mononucleosis) others infectious complications include: ▪ Babesiosis, Chagas disease, Creutzfeldt-Jakob disease, Leishmaniasis, Parvovirus infections, Malaria, Toxoplasmosis, Syphilis prevention: ▪ careful donor selection criteria to eliminate possible carriers reviewed and approved by the Bureau of Biologics ▪ screening of donor specimens: o Hepatitis B surface antigen (HBs Ag) and core antibody (HBc Ab) o Hepatitis C antibody (HCV) and nucleic acid o HIV-1 antibody o HIV-2 antibody o HIV-1-nucleic acid test o HTLV-I and II antibody o Syphilis (Treponema pallidum) NOTE: screening tests do not eliminate the risk of transmitting retroviruses or other infectious agents. Lecture Notes 9 140-531-DW Circulatory overload hypervolemia caused by transfusion which is too rapid or excessive volume is administered pulmonary edema and congestive heart failure susceptible patients: ▪ very young or small ▪ elderly ▪ patients with cardiac disease or chronic anemia prevention: ▪ use of packed cells TACO: Transfusion Associated Circulatory Overload complications arising from a combination of many labile blood products and accumulated volume (edema, increase blood pressure, dyspnea) Iron overload hemosiderosis one unit of blood contains approximately 250 mg of iron patients at risk: ▪ chronically transfused ▪ beta-thalassemia ▪ congenital hemolytic anemias (sickle cell) ▪ aplastic anemia excess iron is deposited in liver, heart and endocrine glands prevention: ▪ chelating agents ▪ alternatives to transfusions Lecture Notes 10 140-531-DW