Diagnostic approaches to acute transfusion reactions

Abstract

The erroneous transfusion of ABO-incompatible red cells may lead to life-threatening hemolysis and complement-induced shock, resulting in death in less than 10% of cases (acute hemolytic transfusion reaction, AHTR). Identification of the cause of an erroneous transfusion is accomplished in nearly all incidents merely by checking the identity of the patient, blood sample and blood bag. The erroneous transfusion is confirmed by serological and—in the case of a fatality- immunohistochemical methods. The differential diagnosis should rule out transfusion-related acute lung injury (TRALI), other immunologically triggered causes such as febrile nonhemolytic transfusion reaction (FNHTR) or allergic reactions, but also nonimmunological causes such as bacterial contamination of the blood components, transfusion-associated circulatory overload (TACO) and other rare events such as citrate overload or embolism (by air or debris). In the case of a fatality, evaluation of a patient′s medical records, serological and microbiological analyses, autopsy and histology, taken together, clarify questions of causality.

Appendices

CME Questionnaire

• 1. Which one of the mentioned transfusion reactions belongs to the category of acute transfusion reactions?

  • □ Febrile, nonhemolytic transfusion reaction (FNHTR)

  • □ Hepatitis C-Infection

  • □ Post transfusion Purpura (PTP)

  • □ Transfusion-associated GvHD

  • □ Hepatitis B-infection

• 2. Which statement does NOT apply for the acute hemolytic transfusion reaction (AHTR)?

  • □ In most cases AHTR is the result of a confusion (patient, component)

  • □ In most cases, the hemolysing antibodies are only detectable after transfusion

  • □ AHTR is fatal in < 30% of cases

  • □ AHTR may be detected by immunohistochemistry

  • □ Clinical symptoms are chills, hypotonia and back pain

• 3. The most frequent cause for the AHTR is:

  • □ The transfusion of blood group A red cells to a blood group O recipient

  • □ The transfusion of a bacterially contaminated platelet concentrate

  • □ The presence of anti-leukocyte antibodies in the recipient

  • □ The transfusion of blood group O red cells to a blood group A recipient

  • □ The transfusion of an outdated red cell unit

• 4. Which statement does NOT apply for the transfusion-related acute lung injury (TRALI)?

  • □ TRALI may be triggered by donor antibodies against leukocytes of the recipient

  • □ Clinically, TRALI resembles the ARDS

  • □ TRALI may be triggerd by biological resonse modifiers (BRMs) in the blood component.

  • □ In histology, TRALI impresses with the pattern of a shock lung

  • □ There is a discrepancy between striking lung x-ray and normal or nearly normal blood gas analysis

• 5. Immunohistochemistry is a helpful diagnostic tool in fatal cases of

  • □ TRALI

  • □ FNHTR

  • □ Sepsis after transfusion of a bacterially contaminated blood component

  • □ Allergic reaction after transfusion

  • □ AHTR

• 6. Which bacterial species is seen most common in sepsis due to the bacterial contamination of a red cell concentrate:

  • □ Staphylococcus aureus

  • □ Staphylococcus aureus

  • □ Klebsiella pneumoniae

  • □ Escherichia coli

  • □ Yersinia enterocolitica

  • □ Haemophilus influenzae

• 7. Which of the following statements does NOT apply for the febrile, nonhemolytic trasfusion reaction (FHNTR):

  • □ The FNHTR is an immunologically triggered event

  • □ The FNHTR, as the result of a bacteremia, is to be treated with antibiotics

  • □ The risk for a FNHTR is reduced by use of leukocyte-depleted blood components

  • □ The FNHTR is typically observed in multi-transfused patients

  • □ The risk for a FNHTR increases with the age of the blood component

• 8. In IgA-deficient recipients there is an increased risk for

  • □ An AHTR

  • □ An allergically mediated anaphylactic shock

  • □ TRALI

  • □ Bacterial infection

  • □ FNHTR

• 9. A hemolytic episode in ABO-minor-incompatibility is seen most frequently in

  • □ Transfusion of a blood group A red cell concentrate to a blood group O recipient

  • □ Transfusion of a blood group O red cell concentrate to a blood group A recipient

  • □ Transfusion of a blood group O platelet concentrate to a blood group A recipient

  • □ Transfusion of a blood group A platelet concentrate to a blood group O recipient

  • □ Transfusion of a blood group A fresh frozen plasma to a blood group O recipient

• 10. In which type of transfusion reaction do antibodies against leukocytes of the recipient play a major role?

  • □ TRALI

  • □ FNHTR

  • □ ABO-minor-incompatibility

  • □ Allergic reaction

  • □ AHTR

CME Questionnaire Answers

• 1. Febrile, nonhemolytic transfusion reaction (FNHTR)

• 2. In most cases, the hemolysing antibodies are only detectable after transfusion

• 3. The transfusion of blood group A red cells to a blood group O recipient

• 4. There is a discrepancy between striking lung x-ray and normal or nearly normal blood gas analysis

• 5. AHTR

• 6. Yersinia enterocolitica

• 7. The FNHTR, as the result of a bacteremia, is to be treated with antibiotics

• 8. An allergically mediated anaphylactic shock

• 9. Transfusion of a blood group A red cell concentrate to a blood group O recipient

• 10. TRALI