Delayed blood transfusion reaction |

DELAYED BLOOD TRANSFUSION REACTION

Vineet Goel,

Post graduate resident, department of medicine, LHMC

DELAYED HEMOLYTIC TRANSFUSION REACTION

DHTR are usually milder than immediate hemolytic transfusion reactions. These are predominantly extravascular and occur in reticuloendothelial cells. It usually occurs after 2-10 days of transfusion and transfused red cells are destroyed. The direct antiglobulin test is often positive. If the test is performed too late may become negative as incompatible cells are removed from circulation. Clinical features include fever, falling hematocrit, and jaundice. Rarely renal failure can also occur. On investigation, presence of previously undetected red cell autoantibodies. No specific therapy is indicated as reaction is mild usually. In case of a severe reaction, adequate hydration should be maintained. If further transfusions are indicated, cross-matched compatible blood negative for offending antigen is administered to prevent such reactions.

POST TRANSFUSION PURPURA

It is the development of life-threatening thrombocytopenia 5-10 days after transfusion. It occurs due to the development of alloantibodies against platelet-specific antigens, most commonly anti-HPA 1a. Clinical manifestations include purpura, bleeding from mucus membrane and rarely intra-cranial bleed may also occur. It may also be associated with passive administration of platelet specific antigens. Therefore, it is important to recognize these donors to prevent reaction in future.

Treatment includes high dose IVIG, corticosteroids or plasma exchange.

TRANSFUSION ASSOCIATED GRAFT VERSUS HOST DISEASE

It usually occurs in the immunocompromised recipients. When viable T lymphocytes in the transfused component are engrafted in the recipient and react against tissue antigen in the recipient lead to the clinical syndrome of transfusion associated GVHD. Although rare, but has also been reported in immunocompetent recipients especially those who received transfusion from family members or if donor is homozygous for shared HLA haplotype. Higher incidence in Japan whose populations are genetically similar. It is usually associated with transfusion of leukocyte or platelet concentrate or fresh blood. Usually occurs within 1 to 2 weeks of transfusion. Clinical manifestations include fever, maculopapular rash (centrifugal), hepatic dysfunction. Nausea and bloody diarrhea. Laboratory test shows: leukopenia followed by pancytopenia. Usually, severe systemic infection is the cause of death. Diagnosis is done by HLA typing of donor and patient cells by cytogenetic analysis and demonstrating the donor lymphocytes in the patient. Despite aggressive treatment fatality rate is >90%. Corticosteroids, ATG, cyclosporine have all been shown minimal success. Lymphocyte directed antibody therapy (anti CD3, anti IL2 Receptor) have also been used. Prevention can be done by pretransfusion irradiation of all the bloods administered to patient at risk to inhibit proliferation of donor lymphocytes. Recommended dose is 1500-2500 cGy. However, irradiation may cause changes in the red cell membrane result in loss of potassium from the cell and limiting the storage time of irradiated red cells to 28 days.

TRANSFUSION RELATED IMMUNOMODULATION (TRIM)

TRIM occurs due to cytokines released by donor white cells, which leads to immunomodulation. There are no specific signs and symptoms. Two potential harmful TRIM associated effects: cancer recurrence and post operative bacterial infection. It can be prevented by the use of leuco- reduced blood and autologous blood transfusion.

IRON OVERLOAD

Each unit of packed red cells contain 250 mg of iron, while body excrete 1mg/day. In chronically transfused patient (thalassemic patient), body cannot excrete iron quickly. Hence iron accumulated in RES, liver, heart , spleen and endocrine organs. Iron chelating agent like deferoxamine, deferasirox, deferiprone can be prescribed for prevention and management.

INFECTIOUS COMPLICATION OF BLOOD TRANSFUSION

Infections associated with blood transfusion are following:

Transfusion associated hepatitis: hep A/B/C
HIV 1 and HIV 2
Syphilis
Malaria
Dengue virus
Others like WNV, CMV, T cruzi, babesiosis

Prevention

Screening tests for donors’ blood prior to transfusion.

Syphilis	VDRL/RPR/TPHA
HepB /C	HbsAg /anti HCV
HIV	HIV 1&2 ab (ELISA/Rapid)
Malaria	Malaria card test

Solvent and detergent treatment can be applied to plasma derivatives that inactivates lipid enveloped viruses such as HIV, HCV and HBV. It cannot be applied on cellular products.

REFERENCES

1 Susan A. Galel, Magali J Fontaine, Maurene K Viele, Christopher L. Gonzalez, Lawrence T. Goodnough. Transfusion medicine. Chapter 21.

2.Wintrobes clinical hematology 13^th edition. Philadelphia, PA. Lippincott Williams and Wilkins;2014.572-580p