Transfusion Reaction

ReactionSymptom DescriptionPathophysiology
Febrile non-haemolytic transfusion reactionSymptoms include fever and dyspnoea. Such reactions are clinically benign, causing no lasting side effects or problems, but are unpleasant.Recipient antibodies reacting with white cell antigens or white cell fragments in the blood product or due to cytokines which accumulate in the blood product during storage
Bacterial infectionSymptoms include very high fever, rigors, profound hypotension, nausea and/or diarrhoea.Blood products can provide an excellent medium for bacterial growth, and can become contaminated after collection while they are being stored. The risk is highest with platelet transfusion, since platelets must be stored near room temperature and cannot be refrigerated.
AllergicSymptoms include urticarial rash, hives, pruritis and hypotensionSeen in approximately 1% of recipients and caused by foreign plasma proteins. On rare occasions they may be associated with laryngeal oedema and bronchospasm.
Acute haemolytic reactionThis is a medical emergency. It results from rapid destruction (haemolysis) of the donor red blood cells by host antibodies. The symptoms are fever and chills, sometimes with back pain and pink or red urine (haemoglobinuria).Haemoglobin released by the destruction of red blood cells can cause acute renal failure. Uncontrolled bleeding DIC may occurThe majority of haemolytic reactions are caused by transfusion of ABO incompatible blood, eg group A, B or AB red cells to a group O patient. Most haemolytic reactions are the result of human error such as the transfusion of properly labelled blood to the wrong patient, or improper identification of pretransfusion blood samples.
Anaphylactic reactionAnaphylactic and anaphylactoid reactions have signs of cardiovascular instability including hypotension, tachycardia, loss of consciousness, cardiac arrhythmia, shock and cardiac arrest. Sometimes respiratory involvement with dyspnoea and stridor are prominent. An anaphylactic reaction is a medical emergency, requiring prompt treatment, and may be life-threatening.These reactions are most common in people with selective IgA deficiency (although IgA deficiency is often asymptomatic, and people may not know they have it until an anaphylactic reaction occurs)
Transfusion-associated acute lung injury (TRALI)TRALI is a syndrome of acute respiratory distress, often associated with fever, non-cardiogenic pulmonary oedema, and hypotension. Symptoms can develop within 2 to 8 hours after a transfusion ranging from mild to life-threatening. Most patients recover fully within 96 hours, and the mortality rate from this condition is less than 10%.Pulmonary vascular effects are thought to occur secondary to cytokines in the transfused product or from interaction between patient white cell antigens and donor antibodies (or vice versa).
Transfusion Associated Circulatory Overload (TACO)Symptoms can be oedema, dyspnoea (shortness of breath), and orthopnoea (shortness of breath while lying flat), hypertensionPatients with impaired cardiac function (e.g. congestive heart failure) can become volume-overloaded as a result of blood transfusion.
Iron overloadOrgan toxicity begins when reticuloendothelial sites of iron storage become saturated. Liver and endocrine dysfunction creates significant morbidity and the most serious complication is cardiotoxicity which causes arrhythmias, and congestive heart failure.Most chronically transfused patients have their iron levels monitored. Some patients require iron chelation therapyEach transfused unit of red blood cells contains approximately 250 mg of elemental iron. Since elimination pathways for iron are limited, a person receiving numerous red blood cell transfusions can develop iron overload, which can in turn damage the liver, heart, kidneys, and pancreas. The threshold at which iron overload becomes significant is somewhat unclear, but is likely around 10-20 units of red blood cells transfused.
Delayed haemolytic reactionVarying from sub-clinical reaction, to severe life-threatening reaction. Features include fever, lower than expected blood haemoglobin concentration with associated jaundice and urobilinogenuria.Patients may develop antibodies to red cell antigens. Antibodies can occur naturally, or may arise as a consequence of previous transfusion or pregnancy. A delayed haemolytic reaction occurs when a patient develops an antibody directed against an antigen on transfused red cells. The antibody may cause shortened red cell survival, with clinical features of fever, jaundice and lower than expected haemoglobin following transfusion. Most delayed haemolytic reactions produce few symptoms and may go unrecognised; however there are reports of serious consequences in critically ill patients.
Transfusion-associated graft-vs.-host disease (GVHD)
GVHD refers to an immune attack by
transfused cells against the recipient. This is a
common complication of stem cell

GVHD refers to an immune attack bytransfused cells against the recipient. This is acommon complication of stem cell transplantation, but an exceedingly rare complication of blood transfusion. It can occur in immunosuppressed patients, primarily those with congenital immune deficiencies or intensive chemotherapy. When GVHD occurs in association with blood transfusion, it is almost uniformly fatal.

Transfusion-associated GVHD can be prevented by irradiating the blood products prior to transfusion.
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