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Complications of Blood Transfusion
Immune Complications
Occur due to
Collection site Definition
Preparation Sensitization of recipient to donor blood cells, platelets, plasma proteins
Storage Transfused cells/ serum may mou nt an immune response against recipient
Cross matching (less commonly)
Collection from blood bank Classified
Ward – Mislabelling, Fail to identify, Clerical Haemolytic – Destruction of transfused blood cells by recipient’s antibodies
(Transfused antibodies ↓ commonly cause hemolysis of recipient’s blood cells)
Hazards of Transfusion (Acute/ Intravascular)(Delayed/ Extravascular)
Immune complications Non-immune complications
Non-Haemolytic – Sensitization of Recipient to Donor White cells, Platelets,
Acute Febrile non-haemolytic Bacterial – Acute sepsis/ Plasma proteins
(Reactions – Febrile, Urticarial, Anaphylactic, Pulmonary Edema (non-
transfusion reactions Endotoxic shock
cardiogenic), Graft vs. Host, Purpura, Immune Suppression )
Acute haemolytic Hypothermia
transfusion reactions –
Intravascular (IgM), Hypocalcaemia Non-Immune Complications
Extravascular (IgG) ↓ Ca2+ in infants
Classified
Allergic reactions (urticarial) Air embolism (rare) Associated with Massive Blood Transfusion
Infectious complications
Anaphylactic reactions
(anti-IgA)

TRALI
(transfusion -related acute
lung injury)
Delayed Delayed haemolytic HIV
(days → years) transfusion reactions Hepatitis C
Hepatitis B
Post-transfusion purp ura CMV
(PTP)
Others – parvovirus B19,
Transfusion-ass ociated Hepatitis A, Malaria,
graft-versus-host disease Chagas’ disease, Brucellosis,
(TA-GvHD) Syphilis, vCJD

Immune modulation

Viral Transmission
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Immune Complications

Immune Haemolytic Transfusion Reaction (Immune HTR)

Definition Features depend on
Premature destruction of red cells in recipient of a transfusion caused by red cells Site of red cell destruction – Circulation or RES
immune alloantibodies Strength
Class/ Subclass of Antibody
Red cell alloantibodies (response to exposure) Nature of Antigen
Previous transfusions Number of incompatible red cells transfused
Previous pregnancies Clinical state of patient
Not naturally occurring

Sensitization of red cell antigens

ABO, Rh antigens routinely matched
Other red cell antigens
Immediate HTR (Intravascular) Delayed
Life-threatening Mild in comparison
Main cause – Error (transfusion of incorrect blood compone nt) Caused by
SHOT (Serious Hazard of Transfusion) Antibodies to non-D Antigens of Rh system
30% - Clerical error – Laboratory Foreign alleles in other systems – eg. Kell, Duffy, Kidd antigens
70% - Ward error Following Normal, Compatible transfusion
Collection of blood from blood bank 1 - 1.6% chance of developing Antibodies to these foreign antibodies
Mislabelling Takes weeks → months to happen
Fail to confirm patient identity (original transfused cells have already been cleared)
Transfusing Blood
Major incompatibility (ABO group) Re-exposure to same foreign antigen
Associated with massive intravascular haemolysis Cause an immune respon se
Complement -activating Ab of IgM class (usually ABO specificity) Typically delayed from 2 → 21 days after transfusion
Anaphylatoxins Majority of cases, Individual has been
C3a & C5a previously sensitized to one (or more) Red cell Antigen
↓ ↓
Smooth muscle contraction Pretransfusion level of Ab is too low to be detected in crossmatch
Platelet aggregation ↓
↑ Capillary permeability Reimmunize d by Incompatible Red cells → Delayed Transfusion Reaction
Release – Vasoactive amines & Hydrolases With rapid clearance of Red cells (provoked anamnestic response )
↓ ↓
Heat/pain at cannulated vein Within days, Ab response ↑
Throbbing headache ↓
Flushing of face Transfused cells are removed from circulation
Chest tightness
Nausea
Lumbar pain
In anesthetized patients Triad Findings
↑ Temperature Fever ↓ in Hb level after transfusion
Unexplained Tachycardia Hyperbilirubinaemia Jaundice
Hypotension Anaemia Progressive anaemia
Haemoglobinuria (HbUria) Fever
Oozing in surgical field Arthralgia
DIC Myalgia
Shock, Renal shutdown Serum-sickness like illness
Intravascular destruction or RBC
↓
Liberates Hb into circulation
↓
Taken by Haptoglobin, once saturated
↓
Haemoglobinuria, if severe
↓
Haemosiderinuria
Symptoms Signs
Doom Fever
Agitation Hypotension
Flushing Unexpected bleeding
Restlessness Dark coloured urine
Dyspnoea Renal shutdown
Pain in abdomen, Flank, Chest
Vomiting
Diarrhoea
Immediate HTR (Extravascular)
IgG Antibody
Anti-Rh, Kell, S Antibodies
Immune Ab of Rh system (unable to activate complement)
Coated with IgG, removed by RES
↓ severe but can be life threatening
Hburia, Hbnaemia – seen in severe reaction (after transfusing lysed red cells)
Accompanied by
Hyperbilirubinaemia
Fever
Fail to achieve expected ↑ in Hb level
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Clinical
Haemolytic shock phase
After only few ml of blood transfused/ up to 1-2h post transfusion
Clinical
• Urticaria,
• Pain – Lumbar region
• Flushing, Headache
• Precordial pain
• SOB
• Vomiting
• Rigors
• Pyrexia
• ↓ BP
Laboratory
• Red cell destruction, HbUria
• Jaundice
• DIC
• Moderate Leucocytosis
Oliguric phase
Renal Tubular Necrosis with Acute Renal Failure (ARF)
Diuretic phase
Fluid & Electrolyte imbalance
(during recovery from ARF)

Investigation (Immediate Transfusion Reaction)

Unit of Donor blood & Post transfusion sample of Recipient Blood
Regrouping
Re-cross match
DAT (Direct Antiglobulin Test)(Direct Coombs test)
Check Plasma for Haemoglobinaemia
DIC tests
Donor sample
• Direct examination of gross bacterial contamination
• Blood culture (if sus pected for bacterial contamination) – patient’s
sample need to be sent for blood culture as well
Patient’s sample
Post transfusion urine – HbUria
Repeat sample 6h and/ or 24h after transfusion
• FBC/ FBP
• Bilirubin
• RFT – Electrolytes, Full profile
• Free Hb & Methaemalbumin estimations
Absence of +ve finding, Patient’s serum is examined after 5-10 days
(red/ white cell antibodies)
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Non-Immune Complications

Febrile Non-Haemolytic Transfusion Reactions Massive Transfusion

Definition Need to Transfuse 1-2X Patient’s Normal Blood volume
↑ Temperature ≥ 1°C associated with Transfusion (without other explanation) Equivalent to 10-20 units (Normal adult)
Frequently – due to sensitization to White Cell Antigen (rarely platelet antigen) Complications
Anti Leukocyte Antibody (Directed against HLA antigen) in those previously Coagulopathy – Dilutional thrombocytopenia
immunized by Pregnancy or previous Transfusion Citrate toxicity – Hepatic dysfunction
Reaction delay – 30-90 mins (after start of transfusion) Hypothermia
(depend on Strength of Antibody & Speed of transfusion ) Acid-Base Disturbances – Metabolic alkalosis (most commonly)
Diagnosis by Exclusion of other causes of transfusion reaction Changes in serum Potassium concentration
Clinical
Fever Post-Transfusion Circulatory Overload
Shivering Particularly in
Flushing Pregnant
Palpitation Severe anaemia patient
Tachycardia Elderly – compromised CV (cardiovascular) fun ction
Headache Cannot tolerate Increase in Plasma volume
Rigors ↓
Urticaria APO (Acute Pulmonary Oedema)
Management Management of Cardiac Failure
If during transfusion Slow transfusion
• Give Antipyretic Accompany with Diuretic Therapy
• Slow transfusion
If experienced 2 or more Bacterial Contamination
• PCM (paracetamol) before transfusion Rare
• Slow transfusion & keep patient Warm Occurs during - Collection, Storage (fautly)
• Leuco-depleted blood components Present with Febrile reaction & Circulatory collapse (septicaemic shock)
Bacteria associated with red cell transfusion
TRALI (Transfusion Related Acute Lung Injury) Usually cold-growing (Pseudomonas, Yersinia)
Transfusion of Leucoagglutinin in Donor Plasma Skin contaminant
(from Don ors of Multiparous women) – react with WBC Proliferate in platelet concentrates stored at 20-22 °C
Endothelial & Epithelial injury, Alveolar damage, Inflammatory changes Gram –ve psychrophilic, endotoxin producing contaminants (dirt, soil, faeces)
Clinical Grow under storage condition (more rapid at room temperature)
(Pulmonary infiltrates with chest symptoms depending on severity) Symptoms (Transfusion of heavily contaminated blood)
Fever Collapse
Non-prod uctive cough ↑ Fever
Hypotension Shock
Tachypnoea DIC with Haemorrhagic phenomena
Dyspnoea
Non-cardiogenic P ulmonary Edema (within 6h initiating transfusion) Iron Overload
Repeated red cell transfusions (in absence of blood loss )
Post-Transfusion Purpura 1 unit of Packed Cell → 200mg Iron
Rare problem Daily excretion – 1mg only (not other way of excretion)
Suspect if Overload
Thrombocytopenia after 7-10 days of platelet-containing product transfusion Adults ≥ 50 units
(usually red cells) Children – lesser units
Generalized purpura after 5-9 days of Red cells or Platelet transfusion Deposition in RES
Recipient Antibody Anti HPA-1a (previously transfused or pregnancy) against Damage to Liver, Myocardium, Endocrine glands
Platelet Specific Antigen (HPA-1a Antigen in Donors)
Both Transfused & Re cipient Platelets – Prematurely destroyed Viral Transmission
Hepatitis – B, C
Reaction due to Plasma Protein Hbs Antigen testing will not exclude Window Period
Mild urticarial reaction (sensitivity of available technique – remain undetected)
Mediated by IgE Use Anti-HBc/ HBV DNA test
(usually against plasma protein/ other allergens present in Donor Plasma) HIV
Anaphylactic reaction Transmitted - Intracelluar, Plasma components
Fatal Most infected - Transfusion be fore introduction of s creening for HIV Antibody
Associated with – Anti-IgA in IgA deficient recipient Good routing screening, Established Donor Education, Self-deferral scheme
Anti-IgA in recipient react with IgA in transfused plasma CMV
↓ Infection – subclini cal
Complement activated Group at risk
↓ • Premature baby (weight < 1.5kg)
Release of anaphylatoxin C3a & C5a • BM or other transplant recipient
• Pregnant lady
TAGVHD (Transfussion-Associated Graft Versus Host Disease) Cell associated – Leucodepleted provide similar safety as serological testing
Transfusion of competent Lymph ocytes from cellular blood component Toxoplasmosis
engrafting in immunocompromised patients/ immun ologically normal patient Malaria
After transfusion of a relative’s blood Parasites remain viable in blood stored at 4°C
Acute/ Chronic Tranismissible by Blood Transfusion
Suspected if Syphilis
Fever Survive at 4°C (transmitted in platelet concentrate)
Skin rash nvCJD
Diarrhoea UK
↑ Liver enzymes Human form of bovine spongifor m encephalopathy (BSE)
Pancytopenia (1-6 weeks after transfusion)
Prevent
Irradiation of blood product
Avoid directed donation from a relative