Management of hemolytic transfusion reactions

Abstract

Delayed hemolytic transfusion reactions (DHTRs) in patients with sickle cell disease are underappreciated and potentially fatal. Patients with DHTRs typically have symptoms of pain or dark urine days to weeks following a red blood cell (RBC) transfusion. In instances of DHTRs with hyperhemolysis, the patient's hemoglobin (Hgb) may be significantly lower than it was pretransfusion, and the Hgb A may drop by more than 50%. In most cases, at least 1 RBC alloantibody and sometimes multiple RBC alloantibodies can be identified during the DHTR, with those antibodies presumably having fallen below the level of detection at the time of the implicated transfusion. However, in up to one-third of cases, no new RBC alloantibodies can be identified posttransfusion. Complement is increasingly being appreciated to play a role in DHTRs and hyperhemolysis, not only due to classic pathway activation (with complement fixed antibody bound to RBCs) but also due to alternative pathway activation (resulting in part from plasma free heme). As such, anti-C5 inhibition has recently been reported to be effective at mitigating hemolysis in the setting of some severe DHTRs. Transfusion avoidance during DHTRs is recommended if possible, with long-term transfusion support advice being less clear; for example, a history of a severe DHTR may lead to questions regarding the safety of transfusions prior to curative therapies such as stem cell transplantation or gene therapy. A better understanding of antibody-positive and antibody-negative DHTRs, including patient- or disease-specific risk factors, is necessary to improve transfusion safety.

Complex delayed blood transfusion reaction: A case report

“…Concurrently, enhanced detection of C/c, E/e, K, Fya/Fyb, Jka/Jkb, M/N, and S/s is recommended to minimize harm caused by DHTR. [ 8 , 9 ]…”

Transfusional Approach in Multi-Ethnic Sickle Cell Patients: Real-World Practice Data From a Multicenter Survey in Italy

“…Since alloimmunizations remains a barrier for safe and effective transfusion of patients with SCD, a careful evaluation of RBC transfusion guidelines transfusion becomes a key factor, along with the implementation of transfusion protocols (such as phenotypically-matched RBCs: RhCDE and Kell), genotyping of patients and donors to identify RBC antigenic variants and maintenance of records on patient transfusion history ( 59 , 60 ). In addition, dissemination of the knowledge on management of DHTR in patients with SCD, might positively impact patients' outcome ( 61 ). These measures are expected to reduce the occurrence of alloimmunization as well as the incidence of delayed hemolytic transfusion reactions, optimizing the management of SCD subjects of different descent throughout the patients' journey.…”

Complicaciones y reacciones agudas durante la transfusión masiva de sangre

“…Al considerar las otras causas y las malas prácticas de transfusión, como almacenamiento prolongado, sobrecalentamiento o congelamiento excesivo, hemólisis mecánica por instrumentación y equipo, hemólisis osmótica o por soluciones hipotónicas, hemólisis por contaminación parasitaria o bacteriana y condiciones que predisponen a hemólisis como deficiencia de glucosa-6-fosfato deshidrogenasa o anemia falciforme. Por lo tanto, es vital que un banco de sangre tenga buenas prácticas para poder prevenir esta complicación y garantizar el éxito y los beneficios de la transfusión (Boyd & Welsby, 2017;Goel et al, 2019;Hendrickson & Fasano, 2021;Panch et al, 2019;Raval et al, 2020;Tormey & Hendrickson, 2019).…”