Lab investigations of Transfusion Reactions

Types of reactions
Acute (<24 hours) Delayed (> 24 hours)

DDx: Acute Reactions

Immunologic
Hemolytic Fever/chill non hemolytic Urticarial Anaphylactic TRALI

Non immunologic
Transfusion-associated sepsis Hypotension due to ACE-I Circulatory overload Nonimmune hemolysis Air embolus Hypocalcemia

Sx Immunologic Acute Reactions

*Hemolytic Fever, chills, hypotension, oliguria, DIC, back pain, hemoglobinuria Fever, chills, vomit, HA Urticaria, pruritus, flushing Hypotension, bronchospasm, urticaria

*Fever, nonhemolytic Urticarial Anaphylactic

*TRALI

Hypoxia, respiratory failure, fever, hypotension, pulmonary edema

Sx Nonimmunologic Acute Reactions

*Sepsis Air embolus Hypothermia Nonimmune hemolysis Fever, chills, hypotension Acute SOB, pain, cough, hypotension, cardiac arrhythmia Cardiac arrhythmia Hemoglobinuria, hemoglobinemia

Circulatory overload
ACEIs Hypocalcemia

Dyspnea, orthopnea, cough, headache, hypertension

Flush, hypotension Tetany, arrhythmia, paresthesia

Acute reactions: The role of the clinical team

In all non-allergic reactions STOP the transfusion Keep IV line open with NS (0.9% NaCl) RNs: check all labels, armband, forms (did the right patient get the right blood?) Send a post transfusion blood sample (drawn carefully so as not to hemolyze the sample) Send the rest of the blood bag and tubing to the lab Clinical Dr. to evaluate patient:
Signs consistent with anaphylaxis? (bronchospasm) TRALI? (hypoxia/respiratory failure/pulmonary edema) Hemolysis? (brown urine)

ATRs: The lab

Do 3 steps ASAP:
Check for clerical errors Check for visual hemolysis Posttransfusion sample: Reconfirm ABO, do a DAT (is there antibody on the cells?)

The Clerical Check

All labels are checked:
Pretransfusion sample Returned unit All paperwork

How common are mistakes?

Study in NYC over 10 years: 47% involved errors of identification of patient or blood at bedside

Most common errors:

Misidentification of patient when pretransfusion sample drawn Mix up of samples in the lab Misidentification of recipient when transfusion is given

The Visual Check

Whats checked:
Plasma or serum postreaction & compare with pretransfusion As little as 2.5 mL of hemolysis can be visible 0.2 g/L Hb = pink 1 g/L Hb or greater = red Old sample = may be bilirubin Crush injuries = may be myoglobin Open heart bypass machines Infusion under pressure, small needles Drugs added to lines Heating or freezing improperly Bacterial contamination

Other causes of hemolysis

The serologic check

On posttransfusion sample:
Re-test ABO: Perform DAT

Positive (usually mixed field) DAT on pretransfusion sample Positive Missed on initial Negative AHTRs, others

Negative

Cells rapidly destroyed

(hemolysis)

Non hemolytic transfusion reaction

MORE TESTS

testing?

NEEDED!!!

More tests

1. 2. 3.

When to do more testing?

If any of the 3 tests (clerical check, hemolysis, repeat ABO, and DAT) has positive or suspicious results Or may be policy of BB to do all or some of the following in all cases: ABO: returned bag or segment, pre and post Ab screen: pre and post Repeat x-match: pre and post samples

Note: It may be the policy of the BB to call the Pathologist after the first 3 tests to ask what to do next. Some BB policies are to do 1-3 in all cases.

Antibody screen
What if there is now an antibody in the postreaction sample that wasnt there before?
Clerical or technical error Pretransfusion: screening cells represented a single dose (FNs) Passive transfer of antibody from a recently transfused component Amnestic response: Appearance of alloantibodies can occur within hours of exposure (see DHTR later)

Repeat x-match
Pre and post
Positive x-match but negative ab screen = may be antibody against low incidence ag not in screening cells

ID antibody
DAT positive cells: perform elution
Get ab off of cells, run against a panel to determine specificity

DAT negative + hemolysis = rapid destruction

Perform elution, but there may not be ab left on cells Do ab screen on serum, but all ab may have attached to the RBCs May have to perform serial DATs and ab screens: the screen may become positive once all the ag positive cells are destroyed

When might you get additional testing?

Febrile reactions, >1oC: Just fever = some stop here
Drop in Hct, visual hemolysis, other testing suspicious or positive:
LDH Haptoglobin Bilirubin (unconjugated) Urine for free Hb If > 20, other signs of shock: Gram stain/culture of blood bag; suggest patient BCs

Anaphylactic (nonhemolytic):

Concern about TRALI

Anti-IgA Ab & quantitative IgA WBC antibody screen in donor and recipient CXR for infiltrates

Causes of AHTR
1:38,000-70,000
(mortality 1: 1,000,000 transfusions)

Usually due to pre-formed antibody in serum:

ABO incompatibility = #1 4 most common abs = anti-A, anti-Kell, anti-Jka, antiFya These bind complement = usually intravascular
C3a, C5a = anaphylatoxins C3b = phagocytes remove Membrane attack complex

Can rarely be due to a very fast amnestic response (hrs)

Extravascular hemolysis = Think Rh

For complement fixation, need 2 IgGs in close proximity Rh ags arent close enough on the RBC

ABO incompatible platelets

5 fatalities from ABO incompatible platelets over 4 year period Occurred in cardiac surgery
A, B, or AB patients receiving multiple nongroup specific platelets over a short period of time Anti-A and anti-B in plasma w/platelets Wash platelets Remove extra plasma by further concentrating ABO matched platelets

Solutions for at risk patients:

DDx: Delayed Reactions

Immunologic:
Alloimmunization
RBC antigens HLA antigens

Nonimmunologic
Fe overload

Hemolytic GVHD Post transfusion purpura Immunomodulation

Sx: Delayed Reactions

*Alloimmunization: RBC antigens *Alloimmunization: HLA antigens *Hemolytic GVHD None, just DAT positive Delayed hemolysis, platelet refractoriness, HDN Fever, decreasing Hb, mild jaundice, new positive DAT or ab screen N/V/D, hepatitis, fever, pancytopenia, rash

Posttranfusion purpura
Immunomodulation Fe overload

Thrombocytopenic purpura, bleeding

Better survival for renal grafts, increased infection and tumor recurrence Diabetes, cardiomyopathy, cirrhosis

Delayed Rxns: Lab role

Same work up as acute hemolytic transfusion reaction:
Immediate procedures:
Clerical check, visual hemolysis, compare positive posttransfusion DAT to pretransfusion DAT (AABB standards)

As required procedures (up to discretion of BB or medical director):

Was there a drop in Hct, clinical signs of hemolysis (fever?)can do hapto, bili, LDH Post antibody screen to ID ab, elution of DAT (+) cells Re-do pre antibody screen (tech error?)

Development of an Alloantibody
Usual cause: Secondary, amnestic response
Abs become undetectable, then increase rapidly after exposure (3-7d) Notorious example: anti-Jka and anti-Jkb may be undetectable in a few weeks to months **Records, patient education important
In 10 mo: 29% of Kidd abs not detectable In 5 yrs: 41% not detectable

Rare causes: Primary allosensitization

Time frame: 3d-2wks

New antibody made while sensitizing cells still circulating

Pathophysiology of DHTR
1:5,000-1:11,000 Usual abs: Kidd, Rh (E,C,c), Kell (K), and Duffy (Fy) Hemolysis typically extravascular Delayed serologic transfusion reaction
Amnestic antibody production does not cause detectable hemolysis Just means patient now has new antibody and must have ag neg cells

Thank you