Transfusion Reactions and HDFN

Most commonly occuring adverse transfusion reactions:

• Febrile Non-Hemolytic Transfusion Reaction

• Allergic Transfusion Reaction

Most Common Causes of Fatalities due to Adverse Transfusion Reaction:

• TRALI

• TACO

Steps and Responsibilities of Medtech in Evaluation of Suspected Transfusion Reaction

→Perform primary testing on postreaction sample

• Clerical check

• Hemolysis check

• Perform DAT

• Verify ABO type

→Report findings to transfusion service physician

→Perform additional testing as per transfusion service physician orders

ACUTE HTR

• signs and symptoms are associated with hemolysis and serologic evidence of RBC incompatibility occuring _ after transfusion

• antibodies associated: _

→causes intravascular hemolysis through C activation pathway

• signs and symptoms are associated with hemolysis and serologic evidence of RBC incompatibility occuring DURING OR WITHIN 24 HOURS after transfusion

• antibodies associated: ABO IGM ANTIBODIES

→causes intravascular hemolysis through C activation pathway

DELAYED HTR

• finding of positive DAT _ after transfusion with either positive eluate or newly identified alloantibody in plasma/ serum and evidence of hemolysis

• antibodies associated: _

→causes extravascular hemolysis

• finding of positive DAT 24 HOURS to 28 DAYS after transfusion with either positive eluate or newly identified alloantibody in plasma/ serum and evidence of hemolysis

• antibodies associated: IgG (kell, kidd, duffy, Rh)

→causes extravascular hemolysis

TRANSFUSION_RELATED ACUTE LUNG INJURY

• leading cause of mortality due to adverse reactions to transfusion

• clinical presentation includes acute respiratory distress, dyspnea, tachypnea, hypoxemia

• most frequently implicated antibodies are _ from passive transfusion of these antibodies from donors

• leading cause of mortality due to adverse reactions to transfusion

• clinical presentation includes acute respiratory distress, dyspnea, tachypnea, hypoxemia

• most frequently implicated antibodies are ANTI-HLA and ANTI-HNA from passive transfusion of these antibodies from donors

TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD (TACO)

• characterized by acute respiratory distress from pulmonary edema caused by increased intravascular volume due to excessive transfused fluid

• also caused by rapid infusion rate and inability of patient to accomodate volume

• measurement of _ is helpful in diagnosis (5x greater than pre-transfusion level supports diagnosis)

B-Type Natriuretic Peptide

Hypotensive Transfusion Reaction

• defined as drop in systolic BP by _, and a final systolic BP of _

• cases report implicated bedside _

• defined as drop in systolic BP by > or equal to 30 mmHg and a final systolic BP of < or equal to 80 mmHg

• cases report implicated bedside leukoreduction filters and ACE inhibitors

Febrile Non-Hemolytic Transfusion Reactions

• defined as fever greater than _ or a change of at least _ from the pretransfusion level occuring during or within _ hours after transfusion

• most cases are due to patient's _ trigerring release of proinflammatory cytokines

• recommended RBC unit: _

• defined as fever greater than 100.4 F (38 degree celcius) or a change of at least 1.8 degrees F (1 degree celcius) from the pretransfusion level occuring during or within 4 hours after transfusion

• most cases are due to patient's anti-WB trigerring release of proinflammatory cytokines

• recommended RBC unit: leukoreduced RBCs

ALLERGIC TRANSFUSION REACTIONS

• most common reactions seen with _ transfusions

• the terms _ are used to generally categorize ATRs

• the most common manifestations of ATRs are _ including urticaria, pruritusm and localized or generalized rash

• most IgA-related anaphylactic reactions occur in IgA-deficient persons with _

• recommended RBC unit: _

• most common reactions seen with PLATELET and PLASMA transfusions

• the terms ALLERGIC, ANAPHYLACTIC, ANAPHYLACTOID are used to generally categorize ATRs

• the most common manifestations of ATRs are MUCOCUTANEOUS REACTIONS including urticaria, pruritusm and localized or generalized rash

• most IgA-related anaphylactic reactions occur in IgA-deficient persons with ANTI-IgA

• recommended RBC unit: WASHED RBCs

TRANSFUSION-ASSOCIATED GRAFT-VERSUS-HOST DISEASE (TA-GVHD)

• rare but has a very high moratality rate

• develops from _ after transfusion characterized by typical skin rash, diarrhea, fever, enlarged liver, elevated liver enzymes, marrow aplasia, pancytopenia

• definite diagnosis is made by _

• donor immunologically competent CD8+ cytotoxic T lymphocytes are directed against recipient cell surface histocompatibility antigens and mediate cell destruction

• recommended unit: _

• rare but has a very high moratality rate

• develops from 2 days to 6 weeks after transfusion characterized by typical skin rash, diarrhea, fever, enlarged liver, elevated liver enzymes, marrow aplasia, pancytopenia

• definite diagnosis is made by skin or liver biopsy showing histologic features

• donor immunologically competent CD8+ cytotoxic T lymphocytes are directed against recipient cell surface histocompatibility antigens and mediate cell destruction

• recommended unit: irradiated blood products

POST-TRANSFUSION PURPURA

• rare transfusion reaction in which there is a sudden drop in _ usually occuring _ after transfusion due to alloimmunization to platelet-specific antibodies from prior transfusion or pregnancy

• the implicated alloantibodies are directed against human platelet antigens _ or _

• first line of treatment for PTP is _

• rare transfusion reaction in which there is a sudden drop in PLATELET COUNT usually occuring 5 to 10 DAYS after transfusion due to alloimmunization to platelet-specific antibodies from prior transfusion or pregnancy

• the implicated alloantibodies are directed against human platelet antigens HPA-1 or HPA-3a

• first line of treatment for PTP is INTRAVENOUS IMMUNOGLOBULIN (IVIG)

TRANSFUSION-TRANSMITTED BACTERIAL INFECTIONS

• occurs when bacteria-contaminated blood component is transfused

• more often associated with _ than RBCs

platelet concentrate

IRON OVERLOAD

• delayed, non-immune complication, presenting with multiorgan damage secondary to excessive iron accumulation (chronic transfusion)

• each unit of RBCs contains approx. _ of iron

• after _ rbc transfusion, excess iron is present in liver, heart, and endocrine organs

• chelating agents help in removal of irons include _

• delayed, non-immune complication, presenting with multiorgan damage secondary to excessive iron accumulation (chronic transfusion)

• each unit of RBCs contains approx. 250 mg of iron

• after 10 t 15 rbc transfusion, excess iron is present in liver, heart, and endocrine organs

• chelating agents help in removal of irons include DEFEROXAMINE, ORAL DEFERIPRONE, ORAL DEFERASIROX

• refers to the destruction of the RBC of a fetus and neonate by antibodies produced by the mother

• could be due to ABO incompatibility or RBC alloimmunization

HEMOLYTIC DISEASE OF THE NEWBORN

RH HDN

• Mother's type:

• Baby's type:

• First pregnancy:

• Antibodies involved:

• Clinical condition:

• Mother's type: RhD negative

• Baby's type: RhD positive

• First pregnancy: Not affected

• Antibodies involved: Immune Ab, IgG

• Clinical condition: Severe and life-threatening

ABO HDN

• Mother's type:

• Baby's type:

• First pregnancy:

• Antibodies involved:

• Clinical condition:

• Mother's type: Type O

• Baby's type: Type A or Type B

• First pregnancy: Affected

• Antibodies involved: Naturally-occuring, IgG (anti-A,B)

• Clinical condition: mild, not life-threatening

Manifestations of HDN

• Erythroblastosis fetalis

• Hydrops fetalis

• Hyperbilirubinemia

destruction of fetal RBCs and the resulting anemia stimulate the bone marrow to produce RBCs at an accelerated rate

Erythroblastosis fetalis

severe anemia and hypoproteinemia caused by decreased production of plasma proteins by hepatic cells leading to cardiac failure, generalized edema, effusions, ascites

hydrops fetalis

Hyperbilirubinemia

• toxic levels to infant's brain - _

• if left untreated could lead to _

• toxic levels to infant's brain - > 18 to 20 mg/dL

• if left untreated could lead to KERNICTERUS

Important Tests Done For Evaluation

→ Mother (7)

→ Newborn (3)

→ Mother (7)

• ABO, Rh typing

• antibody screening, identification

• antibody titer

• fetal DNA testing

• color doppler middle cerebral artery peak systolic velocity (MCA-PSV)

• cordocentesis

• amniocentesis

→ Newborn (3)

• ABO, Rh type

• DAT

• antibody titer

• reduces risk of maternal alloimmunization due to D antigen ( less than 0.1% chance)

• RhIg attaches to fetal Rh-positive RBCS, blocking immunization and production of anti-D

Rh Immune Globulin / RhIG (RhoGAM)

Rh Immune Globulin / RhIG (RhoGAM)

• storage and shelf-life: _

• should be given to RhD negative mothers

→antenatal: _

→postpartum: _

• storage and shelf-life: 1 to 6 degrees celcius, 2 years

• should be given to RhD negative mothers

→antenatal: 28 weeks of gestation

→postpartum: within 72 hours

Rh Immune Globulin / RhIG (RhoGAM)

• US regular dose vial (_ ug) - protects against _ mL of whole blood or _ mL PRBCs

• maternal sample should be obtained within _ hour of delivery and screened using _ technique for massive fetomaternal hemorrhage

• if positive, quantitation of hemorrhage must be done by _ or _

• US regular dose vial (300 ug) - protects against 30 mL of whole blood or 15 mL PRBCs

• maternal sample should be obtained within 1 hour of delivery and screened using ROSETTE technique for massive fetomaternal hemorrhage

• if positive, quantitation of hemorrhage must be done by KLEIHAUER-BETKE or FLOW CYTOMETRY ASSAYS

ROSETTTE TEST

→Purpose:

→Specimen:

→Reagent:

→Result:

→Purpose: screening test for fetomaternal hemorrhage

→Specimen: maternal red cells

→Reagent:

• Anti-D

• Ficin-treated R2R2 cells

→Result: microscopic rosette RBC formation

ROSETTTE TEST

→Purpose:

→Specimen:

→Reagent:

→Result:

→Purpose: quantitates volume of fetomaternal hemorrhage

→Specimen: maternal blood smear

→Reagent:

• weak citric acid

• wright's stain

→Result:

• pink cells - fetal RBCs (HbF)

• ghost cells - maternal RBCs (HbA)

Volume of Fetomaternal Hemorrhage (VOFMH) Formula

• % of fetal cells x 50 = VOFMH in mL

OR

• number of fetal cells x maternal blood volume / number of maternal cells

Number of required vials of RhIg Formula

VOFMH/30

*round the calculated dose and add one more vial for safety

ABO HDN

• first pregnancy:

• antibody IgG:

• disease predicted by titers:

• bilirubin at birth:

• anemia at birth:

• phototheraphy:

• exchange transfusion:

• intrauterine transfusion:

• spherocytosis:

• first pregnancy: yes

• antibody IgG: yes (anti-A,B)

• disease predicted by titers: no

• bilirubin at birth: normal range

• anemia at birth: no

• phototheraphy: yes

• exchange transfusion: rare

• intrauterine transfusion: none

• spherocytosis:yes

Rh HDN

• first pregnancy:

• antibody IgG:

• disease predicted by titers:

• bilirubin at birth:

• anemia at birth:

• phototheraphy:

• exchange transfusion:

• intrauterine transfusion:

• spherocytosis:

• first pregnancy: Rare

• antibody IgG: Yes (most common: Anti-D)

• disease predicted by titers:yes

• bilirubin at birth: elevated

• anemia at birth: yes

• phototheraphy: yes

• exchange transfusion: common

• intrauterine transfusion: sometimes

• spherocytosis: rare