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Blood transfusion reactions
Acute transfusion reactions
Acute transfusion reactions are those that occur within 24 hours of the transfusion being administered. They can be broadly categorised into immune and non-immune causes.
Immune
- Acute haemolytic transfusion reaction (ABO incompatibility)
- Transfusion-related acute lung injury (TRALI)
- Febrile non-haemolytic transfusion reaction (FNHTR)
- Anaphylaxis
Non-immune
- Bacterial infection
- Transfusion-associated circulatory overload (TACO)
Delayed transfusion reactions
Delayed transfusion reactions are those that occur after 24 hours of the transfusion being administered. They can be broadly categorised into immune and non-immune causes.
Immune
- Delayed haemolytic transfusion reaction (DHTR)
- Post-transfusion purpura (PTP)
- Graft versus host disease (GvHD)
Non-immune
- Viral infections
- Malaria
- Prions
Immune-mediated
Acute haemolytic transfusion reaction (ABO incompatibility)
ABO incompatibility results in anti-A/B antibodies activating the complement pathway and triggering the release of inflammatory cytokines.
Early clinical features include fever, hypotension, anxiety and red-coloured urine (haemoglobinuria).
Late clinical features include hypotension and widespread haemorrhage secondary to disseminated intravascular coagulation.
Transfusion-related acute lung injury (TRALI)
The pathophysiology of TRALI is not fully understood, but antibodies to human neutrophil antigens and human leukocyte antigens have been implicated.
The typical presentation of TRALI is the sudden development of dyspnoea, severe hypoxaemia, hypotension and fever that develop within 6 hours after transfusion and usually resolve with supportive care within 48 to 96 hours.
Febrile non-haemolytic transfusion reaction (FNHTR)
The typical clinical features of FNHTR include fever during blood transfusion with no associated haemolysis.
FNHTR is most commonly caused by antibodies directed against donor leukocytes and HLA antigens. This is in contrast to transfusion-associated acute lung injury, in which the donor plasma has antibodies directed against the recipient HLA antigens, mediating the characteristic lung damage.
FNHTR typically develops in patients who have received multiple transfusions or in women who have had multiple previous pregnancies.
Anaphylaxis
Anaphylaxis occurs when the recipient is allergic to protein components present in the donor transfusion.
Typical clinical features include an itchy rash, angioedema, shortness of breath, vomiting, lightheadedness, and hypotension.
Anaphylaxis typically develops over minutes to hours and can quickly become life-threatening.
Delayed haemolytic transfusion reaction (DHTR)
Delayed haemolytic reactions are caused by antibodies to antigens such as Rhesus or Kidd.
A delayed haemolytic reaction can occur between 3 to 14 days after the transfusion.
Typical clinical features include a sudden drop in haemoglobin level, fever, jaundice and haemoglobinuria.
Post-transfusion purpura (PTP)
PTP is an adverse reaction to a blood transfusion or platelet transfusion that occurs when the body produces alloantibodies to the introduced platelets’ antigens.
These alloantibodies destroy the patient’s platelets, leading to thrombocytopenia.
PTP usually presents 5–12 days after transfusion.
Graft versus host disease (GvHD)
Graft versus host disease is a medical complication following the receipt of transplanted tissue from a genetically different individual.
Immune cells (white blood cells) in the donated tissue (the graft) recognize the recipient (the host) as foreign (nonself). The transplanted immune cells then attack the host’s cells.
GvHD can occur after a blood transfusion if the blood products used have not been irradiated or treated with an approved pathogen reduction system.
Non-immune-mediated
Transfusion-associated circulatory overload (TACO)
TACO is a common reaction with acute/worsening respiratory compromise and/or worsening pulmonary oedema up to 12 hours after transfusion. It results from volume excess and circulatory overload as a result of the transfusion.
Typical clinical features include dyspnoea, orthopnoea, tachypnoea and hypoxaemia, particularly in those with pre-existing cardiac failure or a significantly positive fluid balance.
Management is similar to that of acute pulmonary oedema, with oxygen and diuretics. Coconmittant diuretics and a slow infusion rate can be used to reduce the risk of TACO.
Infection
Transfusion-transmitted infection results from the transmission of a pathogen from the contaminated blood product. Platelet transfusions have a greater risk for bacterial infection as they are stored at room temperature.
Bacterial infection typically presents with features of sepsis, with viral (e.g. hepatitis B/C, HIV) and prion (e.g. Creutzfeldt-Jakob disease) infections typically being asymptomatic and presenting with their respective clinical features months-years later.
Management of suspected bacterial infection includes culture of the transfused blood product, peripheral blood cultures, and broad-spectrum antibiotics. Treatment for viral/prion infection is dependent on the transmitted infection.
References
- Covin RB, Evans KS, Olshock R, Thompson HW. Acute hemolytic transfusion reaction caused by anti-Coa. 2001. Available from: [LINK].
- Noizat-Pirenne F, Bachir D, Chadebech P, et al. Rituximab for prevention of delayed hemolytic transfusion reaction in sickle cell disease. 2007. Available from: [LINK].
- Silliman C, Paterson A, Dickey W, et al. The association of biologically active lipids with the development of transfusion-related acute lung injury: a retrospective study. 1997. Available from: [LINK].
- Addas-Carvalho M, Salles TS, Saad ST. The association of cytokine gene polymorphisms with febrile non-hemolytic transfusion reaction in multitransfused patients. 2006. Available from: [LINK].
- Tobian A. Transfusion-associated circulatory overload. UpToDate. 2024. Available from: [LINK].
- Bloch EM. Transfusion-transmitted bacterial infection. UpToDate. 2023. Available from: [LINK].
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