Lab

investigations of
Transfusion
Reactions
 Types of reactions
• Acute (<24 hours)
• Delayed (> 24 hours)
 DDx: Acute Reactions

• Immunologic • Non immunologic

– Hemolytic – Transfusion-associated
– Fever/chill non sepsis
hemolytic – Hypotension due to
– Urticarial ACE-I
– Anaphylactic – Circulatory overload
– TRALI – Nonimmune hemolysis
– Air embolus
– Hypocalcemia
 Sx Immunologic
Acute Reactions
*Hemolytic Fever, chills, hypotension,
oliguria, DIC, back pain,
hemoglobinuria
*Fever, Fever, chills, vomit, HA
nonhemolytic
Urticarial Urticaria, pruritus, flushing
Anaphylactic Hypotension, bronchospasm,
urticaria
*TRALI Hypoxia, respiratory failure,
fever, hypotension, pulmonary
edema
 Sx Nonimmunologic
Acute Reactions
*Sepsis Fever, chills, hypotension

Air embolus Acute SOB, pain, cough, hypotension,

cardiac arrhythmia
Hypothermia Cardiac arrhythmia
Nonimmune Hemoglobinuria, hemoglobinemia
hemolysis
Circulatory overload Dyspnea, orthopnea, cough, headache,
hypertension
ACEIs Flush, hypotension

Hypocalcemia 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
• What’s 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
• Other causes of hemolysis
– Open heart bypass machines
– Infusion under pressure, small
needles
– Drugs added to lines
– Heating or freezing improperly
– Bacterial contamination
 The serologic check
On posttransfusion sample:
– Re-test ABO:
– Perform DAT

Positive (usually mixed field) Negative

DAT on pretransfusion
Cells rapidly Non hemolytic
sample
destroyed transfusion reaction
(hemolysis)
Positive Negative

Missed on initial AHTRs, others MORE TESTS

testing? NEEDED!!!
 More tests
• 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:
1. ABO: returned bag or segment, pre and post
2. Ab screen: pre and post
3. 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 wasn’t
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
– If > 20, other signs of shock: Gram stain/culture of blood bag;
suggest patient BCs
• Drop in Hct, visual hemolysis, other testing suspicious or
positive:
– LDH
– Haptoglobin
– Bilirubin (unconjugated)
– Urine for free Hb
• Anaphylactic (nonhemolytic):
– Anti-IgA Ab & quantitative IgA
• Concern about TRALI
– 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, anti-
Fya
– 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 aren’t 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 non-
group specific platelets over a short period of
time
– Anti-A and anti-B in plasma w/platelets
• Solutions for at risk patients:
– Wash platelets
– Remove extra plasma by further concentrating
– ABO matched platelets
 DDx: Delayed Reactions
• Immunologic: • Nonimmunologic
– Alloimmunization – Fe overload
• RBC antigens
• HLA antigens
– Hemolytic
– GVHD
– Post transfusion
purpura
– Immunomodulation
 Sx: Delayed Reactions
*Alloimmunization: None, just DAT positive
RBC antigens
*Alloimmunization: Delayed hemolysis, platelet refractoriness,
HLA antigens HDN
*Hemolytic Fever, decreasing Hb, mild jaundice, new
positive DAT or ab screen
GVHD N/V/D, hepatitis, fever, pancytopenia, rash

Posttranfusion Thrombocytopenic purpura, bleeding

purpura
Immunomodulation Better survival for renal grafts, increased
infection and tumor recurrence
Fe overload 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
• In 10 mo: 29% of Kidd abs not detectable
• In 5 yrs: 41% not detectable
**Records, patient education important
• Rare causes: Primary allosensitization
– New antibody made while sensitizing cells still
circulating
• Time frame: 3d-2wks
 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