Transfusion Reactions: Types and Their Treatments

Transfusion reactions are defined as any adverse reaction associated with transfusion of blood products. As Blood transfusion is one of the most common procedures which patients go through in the hospital. There is always a risk of an adverse event associated with administration of the blood products. These range from mild to life-threatening events. Transfusion reactions can be classified based on etiology but all the reactions are immunological.  

Transfusion Reactions Types

• Anaphylactic Reactions
• Acute Hemolytic Reactions
• Febrile Non-Hemolytic Reaction
• Urticarial Reaction
• Transfusion-Related Acute Lung Injury
• Delayed Hemolytic Reaction
• Transfusion Associated Circulatory Overload
• Transfusion-Transmitted Bacterial Infection
• Graft versus host 

Anaphylactic Reactions

The cause of anaphylactic reaction is recipient’s anti-IgA antibodies (IgG or IgE). The onset is within seconds to minutes. The clinical features are

• Angiodedema
• Hypotension
• Respiratory distress /wheezing
• Shock
• Hives

Anaphylactic Reactions Treatment

• There should be an Immediate cessation of transfusion.
• Administer Epinephrine
• Antihistamines
• Oxygen, fluids and vasopressors

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Urticarial Reactions

The cause of urticarial reaction is preformed recipient IgE antibodies against blood product components ( Soluble allergen in donated plasma). The onset is within 2-3 hours. The clinical features are 

• Hives
• Itching

Urticarial Reactions Treatment

• Immediate cessation of transfusion
• Antihistamines 
• We can resume the transfusion if patient is otherwise asymptomatic

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Acute Hemolytic Transfusion

The cause of Acute hemolytic reaction is ABO incompatibility. The most common reason for this is clerical error due to patient misidentification. The onset of this reaction occurs within one hour. The Clinical features are:

• Fever
• Chills
• Hypotension
• Hemoglobinuria
• Flank pain
• Disseminated intravascular coagulation

The Lab Findings

• Positive direct Coombs test
• Hemolysis (eg. Increased LDH , increased indirect bilirubin)

Acute Hemolytic Transfusion Treatment

• Immediate cessation of transfusion
• Aggressive IV fluid adminitered 
• Supportive care

Acute Hemolytic Transfusion Complications

• Acute renal failure
• Disseminated intravascular coagulation

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Febrile Non-Hemolytic Reaction

It is the most common type of Blood transfusion reaction. The onset is within 1-6 hours. The cause of this reaction is cytokine accumulation during blood storage. The clinical features are fever and chills.

Febrile Non-Hemolytic Reaction Treatment

• Stop the transfusion to rule out acute hemolytic reaction
• Antipyretics 

Febrile Non-Hemolytic Reaction Prevention

Leukoreduction- It includes saline washing, freezing and deglycerolizing or buffy coat removal. It reduces the number of transfused leukocytes. It reduces the risk of HLA alloimmunization. It has a risk of transmission of CMV (resides in leukocytes).

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Delayed Hemolytic Transfusion Reaction

The cause is an anamnestic antibody response against a minor RBC antigen that leads to delayed mild hemolysis 2-10 days after transfusion. Sickle cell patients are at high risk of DHTR due to repeated transfusions. They experience sickle-cell related intravascular hemolysis and the DHTR-related extravascular hemolysis.

Clinical Findings

• The onset>24 hours to a month after tranfusion
• Often asymptomatic
• Fatigue, dyspnea and tachycardia
• Jaundice
• Low-grade fever

Lab Findings

• Hemolytic anemia- Increased indirect bilirubin, increased LDH and Increased Reticulocyte count.
• Decreased Hemoglobin and haptoglobin
• New positive direct antiglobin (Coombs test)

The treatment is mainly supportive by giving fluids.

Delayed Hemolytic Transfusion Reaction Prevention

• To review the transfusion history and prior antibody screen.
• Transfuse when necessary with extended-antigen cross-matched blood.

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Transfusion-related acute lung injury (TRALI)

The cause of TRALI is due to transfusion of donor anti-leukocyte antibodies. The onset is within 6 hours.The clinical features are:

• Respiratory distress
• Noncardiogenic pulmonary edema with bilateral pulmonary infiltrates.

Transfusion-related acute lung injury (TRALI) Treatment

• Immediate Transfusion cessation
• Respiratory supportive care
• Some patients recover in 24-48 hours but upto 50% expire.

Transfusion-associated Circulatory overload (TACO)

The volume overload secondary to the transfusion of blood products. The onset is usually within the first 6 hours of transfusion.

Risk Factors

• Respiratory distress (Acute dyspnea)
• Increased heart rate 
• Increased blood pressure
• Pulmonary edema ( Eg. Rales)
• Jugular venous distension
• Chest X-Ray diffuse bilateral infiltrates

Transfusion-associated Circulatory overload (TACO) Treatment

• Respiratory support ( Eg. Oxygen)
• Diuresis (Eg. Furosemide)

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Transfusion-transmitted Bacterial reaction

It is the severe complication of transfusion. The cause is the transfusion of contaminated blood products ( Platelets mainly). The clinical features are :

• Fever
• Chills
• Septic shock
• DIC
• Hypotension

The management is done by obtaining cuture from the transfused product and to find the potential source of infection respectively.

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Graft Versus Host Reaction

It is mainly caused due to Donor T-lymphocytes. The onset is within weeks. The clinical features are Rash, Fever, Gastrointestinal symptoms and Pancytopenia.

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