Reactions
Which of the following is most likely to cause TRALI?
--anti-human leukocyte antigens in the RECIPIENT
--anti-human neutrophil antigens from the DONOR
--anti-human platelet antigens in the RECIPIENT
--anti-IgA from IgA-deficient blood donors
Anti-HNA (human neutrophil antigens) from the donor
AML patient undergoes allogeneic transplant from a matched unrelated donor. He achieved complete response from induction chemo. The recipient has blood group A and the donor is blood group B.
He needs a transfusion 27 days post-transplant. Recipient antibodies are detected. What blood group product should be given to him?
(A, B, AB, O, or are transfusions contraindicated?)
O
When recipient antibodies are no longer circulating, he can get transfusions compatible with the donor
What electrolyte abnormality commonly arises from massive transfusion?
Hypocalcemia
It's chelated by citrate (a preservative) in the blood products. The liver usually metabolizes citrate, but if the liver is compromised (shock), it can have reduced clearance.
Give IV calcium gluconate for Ca <7.5 or ionized Ca <3.6.
Cumulative doses as few as _____ (# RBC units) are associated with increased morbidity and mortality.
20 units
Increased morbidity has been observed after 20 rbc unit transfusions. Iron chelation and therapeutic phlebotomy have been shown to prolong survival
Define platelet refractoriness
suboptimal response to transfusion on MORE than one occasion (failure to increase by 10k)
Patient has been receiving several transfusions per year for MDS, which have been complicated by febrile non-hemolytic reactions. What can you do with his transfusion to reduce his chances of developing another febrile non-hemolytic reaction?
Leukoreduction
A 28-year-old female gives birth to a baby boy. Three days after birth, the team notices hemolytic anemia in the newborn. The mother is blood group O, D-negative. The child is blood group A. Which of the following is the most likely culprit etiology for this clinical situation?
A. Rh (D) alloimmunization
B. IgG anti-A isohemagglutinin
C. IgM anti-A isohemagglutinin
D. IgM anti-B isohemagglutinin
E. IgG anti-Kell antibody
B. IgG anti-A isohemagglutinin
IgM does not cross the placenta.
Type O people make mostly IgG-class antibodies
Type A/B people make mostly IgM-class antibodies
What is the most likely infection to contract from a blood transfusion?
(CMV, HBV, HCV, HIV, HTLV-1, syphilis)
Hepatitis B (1 in 1-1.5 million)
fyi:
Hepatitis C is 1 in 2-2.6 million
HIV is 1 in 1.6-2.3 million
HTLV virus is 1 in 2.7 million
How many mg of iron are in each unit of pRBC?
200-250 mg of iron
Cryoprecipitate contains mostly fibrinogen and which factor?
Factor VIII
Irradiated red blood cells. What condition does it prevent?
Transfusion assocated GVHD
In the case of a bi-directional or major ABO-mismatched transplant, transfusions of ____ blood group RBCs and ____ blood group platelets/plasma are needed.
Blood group **O**
Platelet/plasma group **AB**
Transfusion related sepsis presents with _____-grade fever and is more severe with gram-_____ bacteria. Most commonly seen with transfusion of what blood product? _____
HIGH GRADE, GRAM NEGATIVE
Transfusion related sepsis usually presents during or shortly after transfusion with marked fever (101F) and is more SEVERE with gram negative sepsis (can cause shock, renal failure, DIC).
Most commonly associated with platelet transfusions.
What's the target ferritin for hemochromatosis patients undergoing phlebotomy?
Generally between 50 and 150 ng/mL
What can be done with transfusions to help prevent platelet alloimmunization in recipients who get frequent transfusions?
Leukoreduction of platelets
Reduces exposure to different HLA antigens (usually HLA-A and HLA-B)
What are the 6 diagnostic criteria for TRALI (name at least 5)?
- acute onset (during or within 6hrs of transfusion)
- hypoxemia
- CXR findings (bilateral infiltrates)
- no evidence of overload
- no pre-existing acute lung injury or ARDS
Outside of the ABO and Rh group system, what is the most common alloantibody directed against RBC antigens that patients can develop? (anti-______)
Anti-Kell
What is the leading cause of transfusion-related mortality? (AHTRs, DHTRs, TRALI, TACO, TA-GVHD)
TACO has been the leading cause of mortality reported to the FDA since 2016, accounting for nearly 1/3 of fatalities.
Before 2016, it was TRALI. Efforts to reduce plasma collection from multiparous females has led to a decrease of TRALI incidence.
Acute/delayed hemolytic transfusion reactions may be fatal, but are less common. TA-GVHD is almost uniformly fatal, but occurrence is rare.
1000 ug/L
What medication is typically used to control RIGORS in febrile non-hemolytic transfusion reactions?
meperidine
In post-transfusion purpura, an antibody is directed against WHICH donor platelet antigen?
HPA-1a
Starts as destruction to the donor platelets, but then can evolve when the patient destroys their own platelets. Preferred treatment is IVIG x5 days. Exchange transfusion can also help.
Name 3 indications for irradiated blood components.
- those with certain hematologic malignancies or solid tumor (neuroblastoma, sarcoma, Hodgkin disease) -- LIFELONG
- patients treated with purine analogs (fludarabine, cladribine, bendamustine, pentostatin) -- LIFELONG
- peripheral blood/stem cell marrow transplantation
- all donations from family members or that are HLA-matched
- congenital immunodeficiencies
- all components for intrauterine transfusions
- all components for prematurity, low birthweight (<1200g), or erythroblastosis fetalis in newborns
Patients taking ACE inhibitors have higher relative risk or hhypotensive transfusion reactions due to accumulation of vasoactive kinins. What is another transfusion risk of increased concentrations of bradykinins?
Negatively charged leukocyte reduction filters.
For patients with hereditary hemochromatosis, what is the initial phlebotomy frequency?
What is the maintenance phlebotomy frequency?
Most experts recommend once-weekly phlebotomy initially.
Typically, removal of one unit of blood three to six times per year is required (approx once every two to four months).
Patients can donate their blood at NYBC (not at MEETH).
What class of transfusion reaction is hyperhemolysis and what is the treatment?
Delayed hemolytic transfusion reaction.
Treatment = IVIG and steroids