II. Epidemiology
- Incidence: Up to 5 per 50,000 transfusions
- ABO incompatible transfusions are rare (213 events, and 24 deaths between 1996 and 2007)
III. Pathophysiology
- IgM or IgG Antibody-mediated Red Blood Cell destruction
- Type 2 Hypersensitivity Reaction
- Human error in type and cross match process is the most common cause of reaction
IV. Types
- Intravascular Hemolytic Transfusion Reaction (Intravascular HTR)
- Major incompatibility: ABO
- Immediate and massive Hemolysis (acute, within 24 hours of transfusion)
- Group A Blood (AA or AO) patients have A-Antigens and Anti-B Antibody that reacts to Group B Blood Antigens
- Group B Blood (BB or BO) patients have B-Antigens and Anti-A Antibody that reacts to Group A Blood Antigens
- Group O Blood patients have no Antigens, but Anti-A and B Antibody that reacts to Group A and B Blood Antigens
- Group AB Blood patients have A and B Antigens, but no Antibody to react to major Antigens
- Group AB Blood is considered universal blood recipients (will not react to A, B or O Blood)
- Group O Blood is considered universal blood donor (can be given to A, B or O Blood Types without reaction)
- Extravascular Hemolysis (Extravascular HTR)
- Minor incompatibility: Rh, xKell, xDuffy, xKid
- Delayed RBC destruction in reticuloendothelial system (>24 hours after transfusion)
V. Findings: Intravascular Hemolysis (Major Incompatibility)
- Classic Triad: Fever, Flank Pain and Hemoglobinuria
- Rapid and massive Hemolysis to shock state
- Restlessness or Anxiety
- Fever
- Flushing
- Chest Pain
- Back or Flank Pain (renal pain)
- Tachypnea
- Tachycardia
- Nausea and Vomiting
- Headache
- Renal Failure (Acute Kidney Injury from myoglobin deposits)
- Jaundice
- Coagulopathy (Disseminated Intravascular Coagulation)
VI. Findings: Extravascular Hemolysis (Minor Incompatibility)
- Less severe then Intravascular Hemolysis
- Malaise
- Fever
- Shock and Renal Failure are rare
- Initially red cell survival normal
VII. Differential Diagnosis
- See Transfusion Reaction
- Non-Immune Hemolysis due to problem with storage or administration
- Results in Hemolysis due to physical factors (osmotic, heat, mechanical factors)
VIII. Labs
- Document Hemolysis
- Plasma Hemoglobin And Hematocrit
- Urine Hemoglobin
- Haptoglobin
- Lactate Dehydrogenase (LDH)
- Direct and Total Serum Bilirubin
- Direct Antiglobulin Test (Direct Coombs) positive
- Check Renal Function
- Urinalysis
- Serum Chemistry panel (risk of Hyperkalemia)
- Blood Urea Nitrogen (BUN)
- Creatinine
- Check coagulation status
IX. Management
- Avoid further transfusions if possible
- Replace Coagulation Factors as needed
- Supportive care
- Manage shock and Renal Failure
- Intravenous Fluids to target Urine Output 0.5 to 1 ml/kg/hour
- Vasopressors may be needed
- Other measures that have been studied
- Plasma exchange transfusion
- Monoclonal Antibodies