Transfusion medicine

• Acute hemolysis due to incompatible RBC transfusion
• Most commonly ABO incompatible; it can also be caused by non-ABO antigens, such as Kell, Kidd and Duffy
• All of these antibodies strongly bind complement and cause intravascular hemolysis

• Due to antibodies:
  • Infant girl suffered massive hemolysis (J Clin Apher 2005;20:225)
  • 18 year old woman with anti-IH in a patient with sickle cell disease (Transfusion 2000;40:828)
  • 28 year old woman anti-Jka not detected by polybrene screen (Ann Clin Lab Sci 2006;36:101)
  • 37 year old woman with anti-Bg HLA antibodies (Transfusion 2003;43:753)
  • 58 year old man with anti-Coa (Immunohematol 2001;17:45)
  • 69 year old Japanese man with anti-Jra (Transfusion 2004;44:197)
  • 74 year old woman with anti-P1 (Transfusion 1998;38:373)
  • 81 year old man with anti-Dombrock (a) (Transfusion 2006;46:244)
  • 82 year old African American woman with anti-Fy3 in a non sickle cell disease patient (Immunohematol 2005;21:48)
  • ABO incompatible platelet products (Am J Clin Pathol 1999;111:202)
• Due to nonantibodies:
  • 61 year old man with chimeric red cells in a donor who was a twin (Transfusion 2003;43:1449)
  • Two cases of severe HTR in sickle cell disease (Transfusion 2001;41:323)

D. The patient is exhibiting acute hemolytic transfusion reaction. The dramatic symptoms and signs presenting early in a transfusion reaction represent an AHTR until proven otherwise. Immediate cessation of the transfusion and prompt evaluation are called for, often while normal saline is being given in an effort to maintain urine flow and prevent severe renal damage. The vast majority of these reactions are caused by incompatibilities involving the ABO system. These are overwhelmingly caused by improper identification of the recipient or through mislabeled samples. Laboratory error in ABO typing has become a rare event through the efforts of laboratory regulatory agencies which require maintenance of staff proficiency and competency as well as quality controls systems for sample processing and reporting results. Antibodies with specificity for the A and B antigen occur naturally and are expected to be present in antigen negative individuals. These antibodies are always IgM class and, although reactive at colder temperatures like most IgM antibodies, making their detection at room temperature possible, they bind to antigen positive red cells at 37°C. This leads to rapid onset of intravascular hemolysis and activation of complement and other inflammatory cascades, releasing vasoactive peptides. The symptoms experienced by this patient may overlap with other adverse reactions that can present early in transfusion but the red urine is a clue that IVH is present. Rh antibodies rarely fix complement and cause chiefly EVH, with paucity of most other symptoms. Besides, Rh negative blood lacks the RhD antigen and can be safely given to Rh positive individuals. Bacterial contamination is commonly associated with platelets products, which must be stored at 22°C, rather than in the refrigerator like red cell units. Storage under refrigerated conditions keeps the incidence of reactions to contaminated red cells extremely low. Although cytokine mediated reactions may present early in transfusion and cause some overlapping symptoms, especially fever and hypotension, they are not associated with hemolysis.

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Reference: Acute hemolytic transfusion reaction (AHTR)

B. In routine adult transfusion practice, platelets are transfused without regard to ABO compatibility (ABO incompatible hematopoietic stem cell transplantation recipients are the exception). Platelets are suspended in plasma. Not surprisingly, ABO antibodies in incompatible plasma occasionally cause a hemolytic transfusion reaction (with a positive DAT) after platelet transfusions. The patient is typically group A and the platelet component group O (minor incompatibility). This patient is symptomatic from the anemia so the priority should be to be transfuse RBC that are crossmatch compatible. A positive DAT is seen in autoimmune hemolytic anemia (AIHA), for which crossmatch incompatible units may need to be transfused (answer D) and corticosteroids initiated (answer E); this patient does not have AIHA. Future platelet transfusions should be restricted to ABO identical components; if group A platelets are not available for this patient, group O platelets should be washed (plasma depleted) prior to transfusion.

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Reference: Acute hemolytic transfusion reaction (AHTR)