Pharm

Transfusion Hemolysis

search

Transfusion Hemolysis, Hemolytic Transfusion Reaction, Blood Transfusion Reaction, ABO Incompatibility, Red Blood Cell Type 2 Hypersensitivity Reaction

  • See Also
  1. Transfusion Reaction
  2. Blood Transfusion
  • Epidemiology
  1. Incidence: Up to 5 per 50,000 transfusions
  2. ABO incompatible transfusions are rare (213 events, and 24 deaths between 1996 and 2007)
    1. Vamvakas (2009) Blood 113(15): 3406-17 [PubMed]
  • Pathophysiology
  1. IgM or IgG Antibody-mediated Red Blood Cell destruction
  2. Type 2 Hypersensitivity Reaction
  3. Human error in type and cross match process is the most common cause of reaction
  • Types
  1. Intravascular Hemolytic Transfusion Reaction (Intravascular HTR)
    1. Major incompatibility: ABO
    2. Immediate and massive Hemolysis (acute, within 24 hours of transfusion)
    3. Group A Blood (AA or AO) patients have A-Antigens and Anti-B Antibody that reacts to Group B Blood Antigens
    4. Group B Blood (BB or BO) patients have B-Antigens and Anti-A Antibody that reacts to Group A Blood Antigens
    5. Group O Blood patients have no Antigens, but Anti-A and B Antibody that reacts to Group A and B Blood Antigens
    6. Group AB Blood patients have A and B Antigens, but no Antibody to react to major Antigens
      1. Group AB Blood is considered universal blood recipients (will not react to A, B or O Blood)
      2. Group O Blood is considered universal blood donor (can be given to A, B or O Blood Types without reaction)
  2. Extravascular Hemolysis (Extravascular HTR)
    1. Minor incompatibility: Rh, xKell, xDuffy, xKid
    2. Delayed RBC destruction in reticuloendothelial system (>24 hours after transfusion)
  • Findings
  • Intravascular Hemolysis (Major Incompatibility)
  1. Classic Triad: Fever, Flank Pain and Hemoglobinuria
  2. Rapid and massive Hemolysis to shock state
  3. Restlessness or Anxiety
  4. Fever
  5. Flushing
  6. Chest Pain
  7. Back or Flank Pain (renal pain)
  8. Tachypnea
  9. Tachycardia
  10. Nausea and Vomiting
  11. Headache
  12. Renal Failure (Acute Kidney Injury from myoglobin deposits)
  13. Jaundice
  14. Coagulopathy (Disseminated Intravascular Coagulation)
  • Findings
  • Extravascular Hemolysis (Minor Incompatibility)
  1. Less severe then Intravascular Hemolysis
  2. Malaise
  3. Fever
  4. Shock and Renal Failure are rare
  5. Initially red cell survival normal
  • Differential Diagnosis
  1. See Transfusion Reaction
  2. Non-Immune Hemolysis due to problem with storage or administration
    1. Results in Hemolysis due to physical factors (osmotic, heat, mechanical factors)
  • Labs
  1. Document Hemolysis
    1. Plasma Hemoglobin And Hematocrit
    2. Urine Hemoglobin
    3. Haptoglobin
    4. Lactate Dehydrogenase (LDH)
    5. Direct and Total Serum Bilirubin
    6. Direct Antiglobulin Test (Direct Coombs) positive
  2. Check Renal Function
    1. Urinalysis
    2. Serum Chemistry panel (risk of Hyperkalemia)
    3. Blood Urea Nitrogen (BUN)
    4. Creatinine
  3. Check coagulation status
    1. Platelet Count
    2. ProTime
    3. Partial Thromboplastin Time (PTT)
  • Management
  1. Avoid further transfusions if possible
  2. Replace Coagulation Factors as needed
  3. Supportive care
    1. Manage shock and Renal Failure
    2. Intravenous Fluids to target Urine Output 0.5 to 1 ml/kg/hour
    3. Vasopressors may be needed
  4. Other measures that have been studied
    1. Plasma exchange transfusion
    2. Monoclonal Antibodies
  • Complications
  1. Disseminated Intravascular Coagulation (DIC)
  • References
  1. Ackfeld (2022) J Clin Med 11(10): 2859 [PubMed]
  2. Jones (2024) Am Fam Physician 110(1): 58-64 [PubMed]
  3. Raval (2020) Am Fam Physician 102(1):30-8 [PubMed]
  4. Sharma (2011) Am Fam Physician 83(6): 719-24 [PubMed]