MLS 4130 - EXAM 4

An acute hemolytic transfusion reaction (AHTR) may be caused by which of the following?

Exposure to a red cell antigen when the corresponding antibody is present

Leukocyte-reduced blood components are associated with the development of febrile nonhemolytic transfusion reactions (FNHTR)

false

A febrile nonhemolytic transfusion reaction (FNHTR) is characterized by which of the following symptoms?

Increase in temperature of >1°C above the baseline during transfusion or up to two hours following transfusion

Premedication with antihistamines may prevent an allergic reaction in patients with a history of multiple urticarial transfusion reactions

true

Which type of antibodies are known to cause transfusion-related acute lung injury (TRALI) reactions?

HLA antibodies

Which type of blood component is most often implicated in bacterial contamination?

platelets

Evaluating B-type natriuretic peptide (BNP) levels can be helpful in distinguishing transfusion-related acute lung injuries (TRALI) from transfusion-associated circulatory overload (TACO)

true

Delayed hemolytic transfusion reactions (DHTR) typically occur 3 hours after transfusion

false

Which of the following patients are not at risk for transfusion-associated graft versus host disease (TA-GVHD) and would not require cellular components prepared by a method known to prevent the disease?

Patients with chronic anemias

Post-transfusion purpura (PTP) is characterized by all of the following except

fever

Patients with diseases that require chronic transfusions are at risk for iron overload

true

Delayed transfusion reactions occur at what time post cessation of transfusion?

More than 24 hours after transfusion

Bacterial contamination is most likely in which of the following blood products?

platelets

Which listed transfusion reaction is most often associated with transfused patients lacking IgA?

Anaphylaxis

Which type of blood components should a patient with two or more documented febrile nonhemolytic transfusion reactions (FNHTRs) receive?

Leukoreduced

Of the antibodies listed, which is most often implicated as a cause of delayed hemolytic transfusion reaction (DHTR)?

Anti-Jk^a

A patient experiences a mild allergic reaction to a transfusion, including urticaria, erythema (skin redness), and itching. What is the most likely source of the allergen?

Donor plasma proteins

A patient transfused with two units of red blood cells spiked a fever of 99.5°F and complained of chills five days after transfusion. The direct antiglobulin test (DAT) was positive with anti-IgG, but negative with anti-C3d. Compatibility testing was performed on the pre- and post-transfusion specimens. The post-transfusion specimen was incompatible with one of the donor units transfused. An antibody screen was done on both the pre- and post-transfusion specimens. An antibody was detected in the post-transfusion specimen only and identified by panel studies as anti-Jk^a. This transfusion reaction is most likely caused by

A delayed hemolytic transfusion reaction

Transfusion-associated graft-versus-host disease (TA-GVHD) may be prevented by which of the following?

Irradiation of cellular products

Which of the following would not be included in a hemolytic transfusion reaction investigation?

leukocyte antigen studies

A 40-year-old female receives two units of red blood cells during a surgical procedure. The patient has no prior history of transfusions. Seven days later, she presents with extensive bruising of the extremities and bleeding of the gums, with no additional symptoms. Her platelet count is 5 × 10³/mcL (reference interval 150–400 × 10³/mcL). What is the most likely diagnosis?

Post transfusion purpura (PTP)

The most commonly reported cause of severe/fatal TRALI is

Donor HLA antibodies transfused into recipients with the corresponding antigen

TACO

Not associated with fever, Increase in systolic blood pressure, Significant response to diuretics

TRALI

Fever often present, Hypotension, Donor WBC antibodies generally present

Which of the following components would be suitable for a recipient with a high-titer class-specific anti-IgA antibody?

Fresh Frozen Plasma from an IgA-deficient donor

Who must be notified immediately if a patient experiences an acute transfusion reaction and TRALI is suspected?

the transfusion service, the donor center, the patient’s physician

Which components would suit a patient with a history of severe anaphylactic reactions to Red Blood Cell transfusion associated with haptoglobin antibodies?

RBCs, saline-washed

Which of the following recipient antibodies is associated with the most frequent and severe anaphylactic reactions?

IgG antibodies that react with both IgA₁ and IgA₂

Which ABO type of FFP would be the best choice for a group A recipient?

Group A

Which of the following components is not addressed by the AABB TRALI mitigation standard?

RBCs

A patient had a pretransfusion factor V activity of 20%. Immediately after administration of one dose of FFP (20 mL/kg), approximately what should the factor V level be?

40%

An 86-year-old patient presented with shortness of breath and systolic hypertension 2 hours after receiving 6 units of FFP. The patient responded well to diuresis, and the symptoms subsided within 2 hours. Which of the following reactions is most probable?

TACO

Which of the following is not one of the published indications for FFP transfusion?

volume replacement

Which of the following practices would not be in conformance with the AABB TRALI mitigation standard?

Taking donor pregnancy histories at the initial donation only and using those with no history of pregnancy for FFP production at all subsequent donations

Which of the following adverse reactions to plasma transfusion are theorized to involve both donor and recipient factors (two-hit type of mechanism)?

broth TRALI and anaphylaxis

All transfusion reaction initial workups must include which of the following?

checking records and labels for identifications errors

Fatal transfusion reactions are mostly caused by

clerical errors

A suspected transfusion-related death must be reported to

FDA

How are mild allergic transfusion reactions with isolated symptoms or hives and urticaria treated?

Transfusion is stopped and antihistamines administrated; when symptoms improve, transfusion is restarted

The only presenting sign most often accompanying a delayed hemolytic transfusion reaction is:

unexplained decrease in hemoglobin

TRALI presents with the following symptoms:

respiratory distress, fever, severe hypoxemia and hypotension

transfusion reaction

defined as any transfusion-related adverse event that occurs during or after the transfusion of whole blood, blood components, or human-derived plasma products

transfusion reactions examples

acute transfusion reactions, delayed transfusion reactions, immune vs. non-immune reactions, infectious vs. non-infectious reactions

signs and symptoms of a transfusion reaction

fever (>39 C or 2 C rise), hematuria, bronchospasm, hypoxemia (O2 sat <90%), hemoglobinuria, pulmonary edema, tachycardia (>120/min or >40/min rise), nausea or vomiting, chills/rigors, tachypnea (>28/min), urticaria, pain (abdominal, back, chest, infusion site, headache), hypertension (rise in BP >30mmHg), pruitis, oliguria and anuria, hypotension (drop in BP > 30 mmHg), rash, DIC

steps to investigation a potential transfusion reaction

stop the transfusion, send appropriate specimens to lab for investigation (urine for hemoglobin, post-transfusion blood sample for BBK testing), lab investigation

immune hemolysis

alloimmune acute and delayed HTR, autoimmune hemolytic anemia, cold agglutinin disease, drug-induced hemolytic anemia, paroxysmal cold hemoglobinuria, paroxysmal nocturnal hemoglobinuria, IVIG administration

nonimmune hemolysis

osmotic (incompatible fluids, improper deglycerolizing), thermal (malfunctioning blood warmer, improper storage or transport), mechanical (small needles, malfunctioning infusion pumps, artificial heart valves), hemoglobinopathies (HbS, HbC disease), RBC membrane or enzyme disorders (HS, G6PD), microangiopathic hemolytic anemias (TTP, HUS), infections (clostridial sp., malaria, babesiosis)

acute transfusion reactions with fever

AHTR, FNHTR, TAS, TRALI

acute transfusion reactions without fever

allergic, hypotensive, TAD, TACO, acute pain

delayed transfusion reactions with fever

DHTR, TA-GVHD

delayed transfusion reactions without fever

DSHTR, PTP, iron overload

acute transfusion reactions

a reaction in which signs and symptoms present during or within 24 hours of a transfusion, most can be grouped according to the common etiology that gives similar presenting signs and symptoms

acute hemolytic transfusion reaction (AHTR)

consists of acute hemolysis with accompanying symptoms during/within 24 hours of transfusion, accompanying signs and symptoms of immune mediated acute hemolytic transfusion reaction (fever most common symptom with chills or rigors, flank pain, hypotension, renal dysfunction due to hemolysis

reaction process for AHTR

IgM or IgG antibodies in the recipient recognize corresponding donor RBCs, immune complexes are formed, the complement cascade is activated, vasoactive amines and inflammatory mediators are released, the coagulation cascade is activated

common causes of AHTR

RBC transfusion of incompatible cells (severity of reaction depends on amount of unit transfused), minor ABO mismatch in platelet transfusion (titer of anti-A is a factor in AHTR)

tests confirming hemolysis

decreased fibrinogen, decreased/absent haptoglobin, elevated bilirubin, elevated LDH, hemoglobinemia, hematuria or hemoglobinuria, spherocytes, inadequate rise of post transfusion hemoglobin or rapid fall of hemoglobin post transfusion

serologic evidence of immune-mediated HTR

positive DAT for polyspecific anti-IgG or anti-C3, positive elution test with ID of one or more alloantibodies

DHTR

occurs most commonly secondarily to an amnestic response but may also occur during a primary immune response, may (delayed hemolytic) or may not (delayed serologic) be associated with shortened survival of the transfused cells, often noted when a new sample is tested during a request for a type and crossmatch and the hemoglobin levels are lower than anticipated

non-hemolytic transfusion reactions

TRALI, TACO, TAD, hypotensive, FNHTR, ATR, TA-GVHD, PTP, transfusion-transmitted bacterial infections

non-hemolytic transfusion reactions

TRALI, TACO, TAD, hypotensive transfusion reaction, FNHTR, ATRs, TA-GVHD, PTP

TRALI

consists of an acute transfusion reaction presenting with respiratory distress and severe hypoxemia during or within 6 hours of transfusion in the absence of other recognized causes of acute lung injury, can be accompanied by fever and/or hypotension, considered the leading cause of transfusion-associated fatalities, patients with specific clinical diagnoses (infection, surgery, trauma) have increased risk

immune TRALI

implicated leukocyte antibodies and components

non-immune TRALI (2-hit model)

individual predisposition of the patient

diagnosis of TRALI

absence of acute lung injury prior to transfusion, ALI during or within 6 hours post-transfusion, hypoxemia evidence via blood gas or oxygen saturation testing, radiographic evidence of bilateral pulmonary edema, exclusion of circulatory overload and other causes of PE

management/treatment of TRALI

respiratory and circulatory support, oxygen supplementation and possible vent in severe patients

management of donor implicated in TRALI

testing donor for HNA (anti-human neutrophil antibodies) and anti-HLA

preventive interventions for TRALI

plasma units from multiparous females implicated in having increased anti-HLA antibodies, avoiding donors who have previous TRALI implications

TACO (transfusion associated circulatory overload)

acute non-immune complication of transfusion presenting with acute respiratory distress, elevated BNP, evidence of left ventricular heart failure, evidence of fluid overload (central venous pressure, positive fluid balance, pulmonary edema), occurs when the ability of the patient’s cardiovascular system to handle additional workload is exceeded manifesting as congestive heart failure

symptoms associated with TACO

dyspnea, hypoxia, chest radiography sees infiltrates relating to pulmonary edema

treatment of TACO

stop transfusion, slow the rate of infusion in patients at higher risk of developing TACO

patients at risk of developing TACO

pediatric patients, patients with severe anemia, CHF patients

multiphasic model of TACO

shows the relationship between transfusion and the body’s response to infusion

transfusion associated dyspnea (TAD)

predominant symptom, diagnosis occurs within 24 hours post-transfusion, all other diagnoses are excluded

hypotensive transfusion reaction

hypotension is seen alone during or within 1 hour after transfusion is finished, drop in systolic BP > 30 mmHg and systolic BP is < 80 mmHg, pathophysiology is unknown, potentially caused by increased bradykinin levels in stored blood products

febrile non-hemolytic transfusion reaction (FNHTR)

an acute complication of transfusion presenting with a fever >100.4 F or 1 C (1.8 F) increase in body temperature, can be accompanied by chills, nausea and/or vomiting, tachycardia, increase in blood pressure and tachypnea, asymptomatic rise in body temperature in a hypothermic patient not considered, two different WBC related mechanisms (immune-mediated or platelet storage changes and cytokines released from WBCs present in the component)

FNHTR treatment

antipyretics, rule out more serious transfusion reaction causes

prevention of FNHTR

leukoreduction of products

allergic transfusion reactions (ATR)

acute immune complications of transfusion presenting with a variety of symptoms and severity of the reaction, occurs as a response of recipient antibodies to an allergen present in the blood component (mostly seen in platelet and plasma transfusions)

ATR treatment and prevention

antihistamines or corticosteroids prior to transfusion or during, given as a prophylactic in patients that have a history of allergic reactions

mucocutaneous signs of ATRs

urticaria, pruritis, facial or generalized flushing, maculopapular rash, erythema and ocular swelling, lips or tongue swelling, localized angioedema

gastrointestinal signs of ATRs

nausea, vomiting, abdominal pain or cramps, diarrhea

respiratory signs of ATRs

throat tightness, hoarseness, stridor, wheezing, chest tightness, dyspnea

cardiovascular signs of ATRs

hypotension, tachycardia, shock

transfusion associated graft vs host disease (TA-GVHD)

a delayed immune transfusion reaction due to an immunologic attack by viable donor lymphocytes contained in the transfused blood component against the transfused recipient

Why/how does TA-GVHD happen?

transfused T-lymphocytes mount immune response against “foreign” HLA host tissues, normal response (host lymphocytes will counteract and neutralize transfused T-cells), immunocompromised response (lack of host lymphocytes lead to continued T-cell attack on host tissues)

signs of TA-GVHD

rash, fever, increased liver enzymes, pancytopenia, diarrhea, typically presents 11 days post transfusion, rash starts as maculopapular rash on trunk, spreading to limbs, mortality rate of 90%

why HLA matters

donor sees heterozygous HLA as foreign and mounts an attack, recipient does not recognize donor as foreign due to matching HLA and does not mount a counterattack

diagnosis of TA-GVHD

biopsy for presence of donor lymphocytes in host tissue, histology features of chronic inflammation at junction between epidermis and dermis, apoptosis, clusters of lymphocytes

TA-GVHD treatment options

immunosuppressive medications, HSC transplantations (potentially successful)

TA-GVHD prevention

irradiation of units, radiating T-cells in units makes them lazy and ineffective at mounting immune response on host tissues

post-transfusion purpura (PTP)

a delayed immune complication of transfusion presenting with profound thrombocytopenia 1-24 days post transfusion

mechanism of PTP

alloantibody (PI^A1) towards platelets

treatment of PTP

IVIg, plasma exchange for patients that do not respond to IVIg

iron overload

a delayed non-immune complication of transfusion, presenting with multi-organ (liver, heart, endocrine organs) damage secondary to excessive iron accumulation

iron overload treatment

chelation therapy

transfusion-transmitted bacterial infections

acute non-immune transfusion reaction with fever usually with greater than 2 C increase in body temperature (typically high, 101.5 F), rigors, hypotension, tachycardia, nausea, vomiting, abdominal pain, respiratory complaints, occurs when a bacteria-contaminated blood component is transfused (primarily from platelet units), septic shock and DIC are common complications

diagnosis of transfusion-associated sepsis (TAS)

evidence of pathogen in the recipient and demonstration of pathogen in either component transfused, donor at the time of collection, another blood component prepared from same donation, another recipient who received a component prepared from the same donation

common pathogens in TAS

platelet units see S. aureus, S. epidermidis, S. lugdunensis, RBC units see E. cloacae, E. coli, K. oxytoca, K. pneumonia, P. aeruginosa, S. marcescens

silent transfusion-related adverse events

incidents/errors not necessarily presenting with transfusion-associated symptoms, potential to cause adverse effects, sample collection errors, RBC alloimmunization, platelet alloimmunization, transfusion overdosing and underdosing

hemolytic disease of the newborn and fetus (HDFN)

is the destruction of the RBCs of a fetus and/or neonate by antibodies produced by the pregnant individual