Mollison’s Blood Transfusion in Clinical Medicine - part 6 pptx

These authors investigated four severe haemolytic reactions in group A patients lowing the transfusion of group O blood and showedthat in all four cases the donor’s plasma containedanti-

one had already formed anti-E and another formed

anti-Fya

Fourteen additional subjects, all of whom were K

negative, were injected with K-positive blood Four

showed a collapse curve and all of these were given a

second injection from their first donor: in two cases the

red cells were more rapidly destroyed and one of the

two formed anti-E; in the other two recipients the

sur-vival of a second injection was normal or only slightly

subnormal Eight out of the 14 who showed normal

survival of the first lot of red cells were given a second

injection; one showed rapid destruction and formed

anti-K

In summary, collapse curves were noted following

14 out of 45 first injections of red cells and occurred on

average on the sixteenth day after injection (range

6 –33 days) In 13 out of these 14 cases a second

injec-tion was given Normal or only slightly subnormal

survival was found in eight cases and in these no

alloantibodies were found In the remaining five,

red cell destruction was observed following a second

injection and in three of these, alloantibodies (two

examples of anti-E and one of anti-Fya) were detected

Several other studies in humans have shown an

incid-ence of collapse curves similar to that observed by

Adner and co-workers (1963) For example, in one

series the incidence was reported as 20% (Brown and

Smith 1958) When further cases were added to the

series the incidence of collapse curves became 15 out

of 40 survival measurements in 32 subjects who had

almost always received 10 –20 ml of blood (5 –10 ml of

red cells) The diminished survival at first appeared

to be related to passage of red cells through a pumpoxygenator, but this factor was later deemed irrelevant(GS Eadie, personal communication) In a series studied by ER Giblett (1956, unpublished), red cellsfrom 1– 8 ml of blood obtained from the placenta ofnormal infants were labelled with 51Cr and injectedinto normal adults ‘Collapse’ was observed in three

of nine cases and none of these cells was circulating at

20 days (see Fig 10.20) In another series, ‘collapse’occurred in 10 out of 41 crosstransfusions of small volumes of 51Cr-labelled red cells, usually at about thefourteenth day after transfusion The remaining cellswere usually eliminated within the following week(Kaplan and Hsu 1961)

In summary, when transfusions of 1–10 ml of Rh D-compatible red cells are given to previously untrans-fused subjects, collapse curves are observed in approx-imately 30% of cases (Table 10.3)

When therapeutic amounts of blood are transfused

to previously untransfused subjects, premature ment of survival is much less common From a review

curtail-of more than 100 cases in which the survival curtail-of fused red cells had been followed for not less than

trans-60 days after the transfusion of at least 400 ml of blood,unexpected shortening of survival was found in about5% of cases (Mollison 1954) A similar incidence wasapparent in a series described by Szymanski and Valeri(1971) Forty-four survival studies were carried out byautomated differential agglutination in 39 subjects fol-lowing a transfusion of 450 ml of blood Two collapsecurves were observed: accelerated destruction devel-oped on about the tenth day after transfusion and all

Table 10.3 Incidence of collapse of the red cell survival curve following the transfusion of 1–10 ml of red cells to previously

untransfused adult recipients.

transfused (ml) collapse

Unpublished observations made by ER Giblett Newborn infants 1–8 3/9

32/110 (29.1%)

* Following the red cell injections, alloantibodies were detected in three cases in the series of Adner et al (1963) and in three

cases in the series of Brown and Smith (1958), but in no cases in the other series.

† Not included in total above because 40 experiments were carried out in 32 recipients.

the cells had been eliminated by day 30 There is

some evidence that collapse curves are less common

in non-responders to Rh D than in responders,

pos-sibly indicating that non-responders to Rh D lack

some recognition mechanism for allogeneic red cells

(Mollison 1981)

What causes subnormal red cell survival without

demonstrable antibodies?

It is tempting to suppose that collapse curves represent

primary immunization In support of this belief, the

following observations can be cited: (1) in the series of

Adner and co-workers (1963), a collapse curve

follow-ing a first injection of red cells was sometimes followed

by the rapid clearance of a second dose of red cells

from the same donor with production of an

alloanti-body; (2) following a first injection of D-positive red

cells to D-negative subjects, collapse curves are

com-monly observed in responders, whereas they are found

rarely or not at all in non-responders (Mollison 1981)

Evidence opposed to the hypothesis that collapse

curves represent primary immunization is the

follow-ing: (1) in the series of Adner and co-workers (1963),

in about 50% of cases, a collapse curve following a

first injection of red cells was followed by normal

sur-vival of a second dose of red cells from the same donor;

(2) collapse curves are not found invariably during

primary immunization to strong alloantigens, such as

D and K – examples of the normal survival of a first

dose of D-positive red cells at 28 days despite the

formation of anti-D within the following 6 months

were supplied by Samson and Mollison (1975), and

an example of the normal survival of a first dose of

K-positive red cells for at least 47 days in a subject

who formed anti-K within 10 days of a second

injec-tion was described by Adner and co-workers (1963);

and (3) in rabbits, when Hg (A+) red cells were

trans-fused to Hg (A–) animals, the incidence of collapse

curves was 41 out of 51 (Smith and Mollison 1974),

but was also high (10 out of 16) when Hg (A–) red cells

were transfused to Hg (A–) rabbits

The possible role of cell-bound antibody in

causing red cell destruction in the absence of

detectable antibody in the serum

Griffiths and co-workers (1994) have suggested that in

circumstances in which the ratio of specific antibody

to non-specific plasma IgG is expected to be high,macrophages may become ‘armed’ with antibody inthe spleen where antibody-secreting plasma cells and FcR-bearing macrophages are in close proximity.This idea is an extension of the previous suggestionthat antibody-mediated destruction may be favoured

in the spleen because plasma IgG has less of an opportunity to compete with IgG-coated red cells forbinding to Fc receptors on macrophages (Engelfriet

et al 1981) The concept that there may be

macro-phages to which antibody has been bound would provide an explanation for the specific destruction

of red cells in the absence of detectable antibody in the plasma

Destruction of recipient’s red cells by transfused antibodies

Passively acquired antibodies may destroy the recipient’sown red cells or, when blood from more than onedonor is transfused, the red cells of another donor Ineither case, the mechanism of red cell destruction issimilar to that brought about by actively producedantibodies, although the effects tend to be much lesssevere due to dilution of the transfused antibody by therecipient’s plasma and, in the case of anti-A and anti-B,

by the inhibiting effect of A and B substances in theplasma and in tissues other than red cells

In this chapter, some experimental observations aredescribed; haemolytic reactions arising accidentallyare considered in the following chapter

Destruction of recipient’s red cells following the transfusion of plasma containing potent anti-A or anti-B

Ottenberg (1911) first suggested that persons of group

O could be used as ‘universal donors’ He argued that the anti-A and anti-B agglutinins in the donor’splasma, although theoretically capable of damagingthe patient’s red cells if the patient belonged to group

AB, A or B, would in fact be so diluted in the recipient’splasma as to be harmless The use of group O blood fortransfusion to patients of all groups spread rapidly.Throughout the Second World War, enormous numbers of transfusions of group O blood were given

to patients of all groups, without any preliminarymatching tests In the vast majority of cases there was

no evidence of undesirable effects Any risks that the

procedure carried were considered small compared

with the potential problems of attempting to group

recipients and crossmatch blood under the extremely

hazardous field conditions Nevertheless, the

transfu-sion of group O plasma to group A recipients sometimes

causes severe red cell destruction Acute haemolysis

has been reported following ABO-incompatible

single-donor platelet concentrates and may be more

com-mon than is appreciated (Larsson et al 2000; see also

Chapter 11)

Transfusion to human volunteers

The first systematic attempt to assess the effect of

transfusions of incompatible plasma was made by

Aubert and co-workers (1942), who transfused plasma

containing potent anti-A alloagglutinins to volunteers

of group A By eliminating the complicating factor of

the donor’s red cells the investigators could be certain

that any haemolysis was due to destruction of the

patient’s own cells They observed varying degrees

of haemoglobinaemia, ‘intravascular agglutination’

and hyperbilirubinaemia followed by a progressive

reduction in red cell count The lowest titre of anti-A

agglutinin associated with signs of blood destruction

was 512 In their hands, such anti-A titres were found

in the plasma of 40% of group O donors and they

con-cluded that only about 60% of group O individuals

could be considered suitable as universal donors

Similar findings were reported by Tisdall and

co-workers (1946a) In their hands, about 23% of group

O persons had anti-A or anti-B titres of 640 or higher

The transfusion of 250 ml of plasma with an

alloagglu-tinin titre of 600 – 4000 frequently caused

haemoglobi-naemia In one case, a volunteer who received plasma

with a titre of only 600 developed a sufficient degree

of haemoglobinaemia to produce haemoglobinuria

Many patients developed elevation of serum bilirubin,

although none became jaundiced Tisdall and

co-workers also noted the phenomenon described by

Aubert and co-workers (1942) as ‘intravascular

agglu-tination’, the presence of agglutinates in saline

suspen-sions of blood taken from patients immediately after

the transfusions

In a further series of experiments Tisdall and

col-leagues (1946b) took blood from a group B volunteer

who had been immunized by the injection of group A

substance, so that his anti-A titre was 2500 On one

occasion, injection of as little as 25 ml of this plasma

into a group A volunteer produced haemoglobinuria.However, after the addition of group-specific sub-

stances to the plasma in vitro, as much as 250 ml could

be injected without producing signs or symptoms Asthe donor of the plasma was group B, the anti-A wasprobably mainly IgM In a series of cases, 10 ml of the group-specific substances were added to 250-mlamounts of plasma containing potent agglutinins andtransfused to volunteers No signs of red cell destruc-tion were observed in any of the recipients

One of the difficulties in interpreting these tions is the uncertainty as to whether the high-titreagglutinins were IgM or IgG IgM anti-A and anti-Bare far more easily inhibited by soluble blood groupsubstances than are IgG antibodies, so that it would beunwise to conclude that plasma from group O donors,containing potent anti-A and anti-B, can necessarily

observa-be rendered safe by the addition of blood group substances In fact in at least one case a haemolytictransfusion reaction in a group A patient transfusedwith group O blood occurred despite the addition of

AB substance to the plasma before transfusion (Ervinand Young 1950)

Observations made by Ervin and co-workers (1950)first called attention to the importance of ‘immune’characteristics of anti-A and anti-B in causing red cell

destruction in vivo These authors investigated four

severe haemolytic reactions in group A patients lowing the transfusion of group O blood and showedthat in all four cases the donor’s plasma containedanti-A, which was difficult to inhibit and had a higherindirect antiglobulin titre than saline–agglutinin titre.Signs of red cell damage persisted for relatively longperiods after transfusion Thus osmotic fragility wasincreased for 8–11 days and microspherocytes wereseen on blood films for approximately 2 weeks aftertransfusion The same authors reported the results oftwo transfusions of group O plasma to a group A volunteer The first transfusion was of plasma with

fol-a moderfol-ate sfol-aline–fol-agglutinin titre (640), which wfol-as

readily inhibited by A substance in vitro and was

pre-sumably wholly or predominantly IgM No signs ofred cell destruction developed By contrast, when thesame volunteer received plasma that had a scarcelyhigher saline–agglutinin titre (1280) and probablycontained a potent IgG antibody, as it was not readilyinhibited by AB substance, the recipient developedsevere intravascular haemolysis and his haematocritfell from 43% to 24% in 5 days

Summary of effects of incompatible plasma

(anti-A and anti-B)

The following summary is based partly on the

experi-mental work described above, partly on unpublished

observations made with H Chaplin, H Crawford

(Morton) and M Cutbush (Crookston) in 1952 and

partly on various transfusion accidents described in

the following chapter

Haemoglobinaemia tends to be slight and

haemo-globinuria is unusual

Jaundice occurring within a few hours of

trans-fusion has been noted occasionally; see, for example,

the infants observed by Gasser (1945), referred to in

the following chapter

Progressive anaemia is the most commonly

observed sign of red cell destruction; PCV may

con-tinue to fall for at least 1 week after transfusion; see

Fig 11.1

Spontaneous agglutination of whole blood samples

withdrawn from the recipient is an invariable feature

Agglutination occurs even when plasma containing

relatively weak anti-A is transfused (In a group A

subject transfused over 20 min with 340 ml of blood

from a donor whose serum had a saline–agglutinin

titre of 64 and a haemolysin titre of 4, a sample of

blood taken immediately after transfusion showed

strong spontaneous agglutination; this was best

demonstrated by spreading a drop of blood on an

opal tile; 3 h later, the sign was still present but was

weaker; the next day it was not present In patients

transfused with potent anti-A, spontaneous

agglutina-tion of blood samples in vitro may persist for more

than 24 h.)

The direct antiglobulin test becomes positive in

group A subjects transfused with plasma containing

even weak immune anti-A In the subject referred to in

the paragraph above, the DAT was definitely positive

immediately after transfusion, was weakly positive

the next day and was negative thereafter In patients

transfused with potent immune anti-A the DAT may

remain positive for as long as 1 week

The osmotic fragility of the patient’s red cells

increases when incompatible plasma is transfused

After transfusion, maximal osmotic fragility occurs

after 24 h and is almost maximal after 3 h (Ervin et al.

1950) It may remain elevated for at least 11 days

and during this period peripheral blood films show

microspherocytosis

Destruction of recipient’s red cells by transfused

or injected anti-DOnly experimental observations are described in thissection; for accidents in clinical practice see Chapter 11

Transfusion of plasma containing anti-D

The transfusion, to D-positive subjects, of 200 ml ofplasma containing anti-D with a titre of 256 (IAT) pro-duced a positive DAT and spherocytosis within 24 h,and a fall in Hb concentration of 2.5 g /dl during thefollowing week In a second case, in which 250 ml ofplasma with a titre of 128 was transfused, the recipient’sbilirubin concentration rose to 2.5 mg /dl at the end of

5 h and the Hb concentration fell by 2.6 g /dl in 1 week

In several recipients who were transfused with plasmacontaining antibodies with titres between 8 and 16, nodefinite evidence of red cell destruction was detected(Jennings and Hindmarsh 1958)

In a series in which normal volunteers received

250 ml of plasma containing moderately potent anti-D(or anti-c or anti-K or anti-M), there were no definite

signs of red cell destruction (Mohn et al 1961) The

blood volume of these recipients was considerablygreater than that of the subjects studied by Jenningsand Hindmarsh (1958) In one subject who was transfused with serum containing an exceptionallypotent anti-D (indirect antiglobulin titre of 1000;serum albumin titre of 400 000), the PCV fell from0.48 to 0.22 in 12 days, and spherocytosis and mildhaemoglobinaemia persisted for 2 weeks (Bowman

et al 1961).

Injections of anti-D immunoglobulin

In one series of D-positive adults with AITP, who wereinjected with 750– 4500 µg of intramuscular or intra-venous anti-D over a period of 1–5 days, the red cellsbecame coated with 3.2–7.7 µg of IgG/ml cells, butonly minimal signs of red cell destruction developed

(Salama et al 1986) In another series, in which the

AITP was related to AIDS, 13 µg of IgG anti-D/kg weregiven daily for 3 days, followed by 6–13 µg/kg weekly

In five out of six patients, Hb fell by 6–44 g/l (Cattaneo

et al 1989).

As described in Chapter 5, the intravenous tion of anti-D in doses between 10 and 15 µg/ml of redcells is sufficient to clear 200 – 600 ml of D-positive red

injec-cells from the circulation of D-negative subjects in

2–8 days In a case in which approximately 3000 µg

of anti-D were infused to a man with AITP over the

course of 3 days, corresponding to a dose of less than 2

µg of anti-D/ml red cells, Hb concentration fell from

155 to 74 g / l and it was estimated that about 1600 ml

of red cells had been destroyed No cause could be

determined for this surprising amount of red cell

destruction (Barbolla et al 1993), although in a patient

with severe thrombocytopenia, internal haemorrhage

is difficult to exclude

IVIG preparations may contain potent anti-D (titre

64 –256) and unexpected haemolytic reactions have

been reported (Thorpe et al 2003) Other red cell

alloantibodies that cause sensitization but minimal

haemolysis have been detected in these preparations as

well (Moscow et al 1987).

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incom-Halima D, Postoway N, Brunt DEA (1982) Haemolytic transfusion reactions (HTR) due to a probable anti-C, not detectable by multiple techniques (Abstract) Transfusion 22: 405

Harrison CR, Hayes TC, Trow LL (1986) Intravascular lytic transfusion reaction without detectable anti-bodies: a case report and review of literature Vox Sang 51: 96 –101 van der Hart M, Engelfriet CP, Prins HK (1963) A haemolytic

hemo-transfusion reaction without demonstrable antibodies in vitro Vox Sang 8: 363

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Heistö H, Myhre K, Börresen W (1962) Another case of haemolytic transfusion reaction due to incompatibility without demonstrable antibodies Vox Sang 7: 470 Hewitt WC Jr, Wheby M, Crosby WH (1961) Effect of pred- nisolone on incompatible blood transfusions Transfusion 1: 184

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a strong anti-E reacting in vitro almost exclusively with

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thalassaemia major Vox Sang 6: 583

Wallas CH, Tanley PC, Gorrell LP (1980) Recovery of

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332–336

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Surg 11: 276

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Woodrow JC, Bowley CC, Gilliver BE et al (1968)

Preven-tion of Rh immunizaPreven-tion due to large volumes of tive blood BMJ i: 148

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Yates J, Howell P, Overfield J (1996) IgG Kidd antibodies are unlikely to fix complement Transfusion Med 6 (Suppl 2): 29

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trans-1940) Destruction of red cells throughout the tion (intravascular haemolysis) is brought about bythose antibodies that activate the entire classical com-plement cascade, leading to the production of pores inthe red cell membrane followed by rupture of the cell(see Chapter 3) In contrast, antibodies that either fail

circula-to activate complement or activate it only circula-to the C3stage destroy red cells by mediating interaction withcells of the MPS Traditional teachings attributed thisreaction to phagocytosis alone, but when the inter-action of antibody-coated red cells with monocytes was

studied in vitro, red cell lysis outside of the monocyte

was established This finding explained previous

observations that red cell destruction in vivo by a

non-complement-activating antibody such as anti-Rh Dmight be accompanied by haemoglobinaemia Thus,both Hb and bilirubin may be liberated into theplasma following ‘extravascular destruction’ In thiscontext ‘extravascular’ means ‘outside the main bloodvessels’, for example within the hepatic and splenicsinusoids, and does not mean ‘intracellular’ Indescribing red cell destruction caused by alloantibodies,

‘C8–9 mediated’ and ‘macrophage mediated’ are moreaccurate terms than are intravascular and extravascu-lar, but this chapter will opt for the traditional termsinstead of these awkward circumlocutions

Intravascular destruction may be produced by bodies such as anti-A and anti-B that are readily lytic

anti-in vitro, although not all of the red cells are lysed anti-in

the plasma; some are sensitized and removed from thecirculation by erythrophagocytosis, mainly in the liver(see Chapter 10) Other causes of intravascular lysisinclude osmotic damage to red cells by preliminarycontact with 5% dextrose during or prior to infusion

11

A haemolytic transfusion reaction is one in which

signs and symptoms of increased red cell destruction

are produced by transfusion A distinction is made

between an immediate reaction (IHTR), in which

destruction begins during transfusion, and a delayed

reaction (DHTR), in which destruction begins only

after there has been an immune response, provoked

by the transfusion Almost invariably, DHTRs are

caused by secondary (anamnestic) immune responses

Although physicians assume as if by reflex that

haemolysis in the setting of transfusion must be

immune mediated, non-immune causes such as

ther-mal, mechanical and osmotic stress, infection and

intrinsic red cell defects should remain part of the

differential diagnosis Medication-associated

auto-immune intravascular haemolysis may mimic an acute

haemolytic reaction (Stroncek et al 2000).

The previous chapter was concerned principally

with patterns of removal of incompatible red cells

from the circulation rather than with clinical signs and

symptoms The present chapter deals with the various

syndromes produced by the transfusion of

incompat-ible blood and also considers haemolytic reactions

due to causes other than incompatibility

Intravascular and extravascular destruction

By convention, red cell destruction is classified as either

intravascular, characterized by rupture of red cells

within the bloodstream and liberation of haemoglobin

(Hb) into the plasma, or as extravascular,

character-ized by phagocytosis of red cells by macrophages of

the mononuclear phagocyte system (MPS), with

sub-sequent liberation of bilirubin into the plasma (Fairley

and the injection of water into the circulation High

levels of plasma Hb may be produced by the infusion

of red cells that have been lysed in vitro, for example

by accidental overheating, freezing or exposure to some

microbial pathogens such as Clostridium welchii

Anti-bodies that are non-lytic in vitro bring about

destruc-tion that is predominantly extravascular, although,

as mentioned above, the process may be accompanied

by some degree of haemoglobinaemia The destruction

of non-viable stored red cells is a strictly intracellular

process

Intravascular destruction

Red cell destruction by anti-A, anti-B and other

rapidly lytic antibodies

The importance of haemolysins as opposed to mere

agglutinins was recognized very early in the practice

of human transfusion Indeed, Crile (1909) expressed

the opinion that agglutinins could be disregarded

Similarly, crosstransfusion experiments in cats, some

of which developed agglutinins and some lysins,

demonstrated absolute correspondence between lysis

in vitro and lysis in vivo The authors concluded that

‘similar tests for human transfusion can be relied on

completely to prevent haemolytic accidents’ (Ottenberg

and Thalheimer 1915)

By far and away the most important lytic antibodies

in human plasma are anti-A and anti-B About

three-quarters of all fatal acute haemolytic reactions are

associated with ABO incompatibility Haemolytic

antibodies of other specificities, for example

anti-PP1Pk, anti-P1 and anti-Vel, have been known to

produce similar effects in vivo, but are rare Lewis

antibodies, which are relatively common, produce

slow lysis in vitro and infrequently produce lysis in

vivo Kidd antibodies may also lyse untreated red cells,

but usually extravascular destruction predominates;

these antibodies are therefore considered in a later

section A number of other antibodies, including

anti-bodies to HLA antigens (anti-Bga) have reportedly

caused severe intravascular haemolysis and in some

cases have not been detected by routine techniques

(Benson et al 2003) Haemolytic antibodies such as

anti-A1and anti-P1may lyse enzyme-treated red cells

in vitro but, even when active at 37°C, are usually

non-lytic for untreated red cells Haemonon-lytic reactions

caused by these antibodies are described in the section

on extravascular destruction, even although someinstances of active intravascular haemolysis have beenreported

As described in the previous chapter, up to 90% ofthe cells may be lysed in the blood stream when a verysmall volume of incompatible red cells is injected, and50% or more of the circulating transfused cells may

be lysed when a relatively large volume of blood istransfused

Examples of ABO-incompatible transfusions

Administration of ABO-incompatible red cells maytrigger an abrupt, life-threatening syndrome charac-terized by anxiety (the ominous ‘sense of impendingdoom’), flushing followed by cyanosis, fever, rigors,pain at the infusion site, lumbar spine and flanks, nausea, vomiting and shock Coagulopathy with dif-fuse bleeding and renal failure complete the ‘classic’description Holmesian diagnostic acumen is notrequired when these signs and symptoms are present.However, reactions often present in a more subtlefashion, with little more than fever encountered duringthe course of transfusion

In the following case, a plasmapheresis donor ofgroup O was inadvertently given the red cells of a dif-ferent donor, who was group A

Mrs H was a regular plasmapheresis donor On the day in question, after she had given blood and before her red cells were returned to her, she was asked to confirm that the signa- ture on the unit was her own She nodded in agreement, but afterwards admitted that although she had not seen the signa- ture clearly, she felt that, in any case, she could trust the doctor Within 2 min of the start of the red cell infusion she

‘blacked out’, felt very frightened and had pain all over, cially over the sternum and lower abdomen The develop- ment of the symptoms was ascribed by the medical attendant

espe-to overly rapid infusion, the rate was slowed, and infusion completed in about 25 min After a rest, Mrs H drove home One and a half hours later Mrs H felt very unwell and developed diarrhoea and vomiting She passed a large amount

of urine, but did not notice the colour Three and a half hours after receiving the red cells she was visited by her own doctor, who administered an injection of furosemide Six hours after receiving the red cells she passed a large volume (about 1 l)

of red urine The urine Hb concentration was 0.4 g/l and the plasma Hb concentration was 2.6 g/l A blood specimen con- tained about 1.7% of group A red cells, the rest being group

O The concentration of fibrin degradation products in the

serum was 80 µg/ml, suggesting a mild consumption

coagulo-pathy On the following morning plasma Hb was 0.55 g/l and

the customary urine colour had returned Three weeks after

the episode, creatinine clearance was normal.

A change in the colour of urine may be the earliest or

sole clue that a surgical patient under general

anaes-thesia has received an ABO-incompatible unit, and

even this sign may be masked by haematuria in the

patient undergoing genitourinary procedures Early

recognition is essential – to prevent transfusion of

additional incompatible blood and to avoid possible

administration of a second unit to other than the

intended recipient

As described later in this chapter, episodes of

intravascular haemolysis following the transfusion of

incompatible red cells are sometimes followed by renal

failure and by the production of various other

unto-ward signs In patients whose serum contains non-lytic

or only very weakly lytic anti-A or anti-B, following

the transfusion of ABO-incompatible blood the level

of plasma Hb may be less than 1 g/l and no Hb is

passed in the urine In fact, only when A and

anti-B are relatively potent is destruction predominantly

intravascular

After the transfusion of incompatible blood,

erythrophagocytosis may be observed in samples of

peripheral blood (Hopkins 1910; Ottenberg 1911)

Striking leucopenia may result from the adherence

of leucocytes to red cells and to one another In one

investigation, after the injection of 10 ml of

ABO-incompatible red cells, the total leucocyte count

some-times fell from 9000 to 4000 per microlitre in 5 min

The principal effect was on the mature granulocytes

and monocytes In further experiments, the injection

of as little as 0.05 ml of incompatible red cells (5 × 108

cells) caused a significant fall in leucocytes A

calcu-lated 15 leucocytes per injected incompatible red cell

was removed Infusion of the stroma of compatible

cells produced no effect, but the infusion of the

stroma of incompatible cells produced leucopenia

Incidentally, the injection of A substance into O

sub-jects produced leucopenia in six out of seven instances

(Jandl and Tomlinson 1958)

Haemolysis with a unit from a chimera

A 61-year-old male patient typed as blood group O

received two units of group O red cells after elective

kidney surgery Immediately following transfusion, hedeveloped evidence of intravascular haemolysis (Pruss

et al 2003) Serological re-examination revealed a

mixed-field pattern of agglutination of red cells in one

of the two transfused units The donor of this unitproved to be a 24-year-old man with a twin sister Bothsiblings showed an identical mixture of roughly 95%group O and 5% group B red cells and chimerism wasconfirmed by genotyping

Red cells present as ‘contaminants’

When the donor is ABO incompatible, acute sis may be provoked by red cells present in transfusedplatelet preparations, granulocyte concentrates or inbone marrow and progenitor cell suspensions, evenwhen these suspensions have been treated with a sedi-menting agent to remove the bulk of the red cells

haemoly-(Dinsmore et al 1983) In the latter circumstance,

significant reactions may develop when the recipienthas a high-titre isoagglutinin and unmanipulatedincompatible grafts are infused rapidly

Transplacental haemorrhage

When the fetus is ABO incompatible, a large placental haemorrhage (TPH) may be associated withhaemoglobinuria in the mother In one such episodethat followed an easy external cephalic version undergeneral anaesthesia, the mother (group O) passed fetal

trans-Hb in the urine (0.2 g of trans-Hb/dl) Four weeks later, agroup A infant was born The placenta showed a smallarea of separation Of 14 further cases of external ver-sion, fetal cells were found in only one and in this case the mother’s blood had not been examined beforeversion (Pollock 1968)

In another case, abruptio placentae followed a caraccident after which the mother (group A) gave birth

to a stillborn group B infant The mother exhibitedhaemoglobinaemia and haemoglobinuria (Glasser

et al 1970) In one more case, the group O mother of a

B infant developed haemoglobinuria, acute tubularnecrosis and disseminated intravascular coagulation(DIC) (Samet and Bowman 1961)

Frequency of ABO-incompatible transfusionsData regarding the frequency of ABO-incompatiblered cell transfusions are hard to come by Almost all

surveys start with reported clinical episodes, such as

haemoglobinuria following transfusion For obvious

reasons, such episodes are not always reported Even

then, the signs may be attributed to a cause other than

the transfusion Furthermore, transfusions of

ABO-incompatible blood may not cause clinically obvious

effects, particularly if the patient is anaesthetized

Therefore, the reported frequency with which

ABO-incompatible blood is given must seriously

under-estimate the true frequency Of course, the frequency

with which the ‘wrong’ blood is given must be

several-fold greater than that with which ABO-incompatible

blood is given, as a random unit of blood will be ABO

incompatible with a random patient about 36% of the

time in Western nations (Linden et al 1992).

Some estimates of the frequency of ABO-incompatible

transfusion, based on the reporting of clinical episodes,

are as follows: one in 10 000 units or one in 3000

patients (Wallace 1977); one in 18 000 transfusions,

a figure based on almost half a million transfusions

(Mayer 1982); one per 30 000 units transfused in a

survey in which one-half of the participants relied on

memory rather than written record (McClelland and

Phillips 1994); and one in 33 000 transfusions (Linden

et al 1992) In an analysis of transfusion errors over a

10-year period in New York State (1990 –99), Linden

and co-workers (2000) documented erroneous blood

administration as 1 in 19 000 red cell units,

ABO-incompatible transfusions as 1 in 38 000, and acute

haemolytic reactions or laboratory evidence of

reac-tions as 1 in 76 000 red cell units transfused This

experience is similar to that of several national

haemo-vigilance surveillance systems in Europe

Another approach to discovering the incidence of

giving the wrong blood is to start with records of blood

issued by the laboratory and to discover from records

to whom each unit was transfused This may be

described as the descending method of enquiry,

con-trasted with the ascending method already described

Of 2772 units, seven (0.25%) were transfused to

unin-tended patients Not a single one out of the seven had

been reported, although at least three of the units were

ABO incompatible (Baele et al 1994) The estimate

that one in 400 units is given to the wrong recipient

may be atypically high; however, it does not include

errors in labelling the sample taken from the patient

or laboratory errors Incredible as it sounds, the

fre-quency of mislabelled and miscollected samples in an

international survey of 62 hospitals (690 000 samples),

was 1 out of every 165 samples, and in a subset of hospitals, miscollected samples containing the wrongblood in the tube occurred in 1 out of every 1986

samples (Dzik et al 2003) These appalling findings

(including the failures of reporting) emphasize thatestimates that start from clinical episodes must be fartoo low

It has long been possible to devise systems of ing the identity of units and patients that lead to a verylow error rate At the Mayo Clinic, blood bank person-nel have total control of blood units from the timewhen they are withdrawn from the donor to the timewhen they are given to the patient, the ‘vein-to-vein’principle Blood bank nurse transfusionists administeralmost all blood that is transfused to patients in theirrooms, and monitor all transfusions administered in

check-operating theatres (Taswell et al 1981, supplemented

by personal communication from HF Taswell) In theperiod 1964 –73, in the course of transfusing 268 000units of blood, there was only one occasion on whichABO-incompatible blood was known to have been

transfused (Pineda et al 1978a) Systems approaches

and evolving technology, from the lowly identificationbracelet to bar codes and bedside computers, havereduced labour and improved safety and efficiency

(Turner et al 2003) The presence of national patient

identification systems in Sweden and Finland has beenassociated with rates of miscollected samples that were

too low to estimate (Dzik et al 2003).

Mortality associated with ABO-incompatibletransfusions

Statistics regarding frequency and mortality of earlytransfusions are incomplete and suspect In the 25years before frequent transfusion began in the SecondWorld War, Kilduffe and DeBakey (1942) assembled aseries of 43 284 transfusions with 80 haemolytic reac-tions (0.18%) and 32 deaths (0.07%) from haemolyticshock An independent estimate from the same eraquotes a mortality of 39 out of 19 275 for direct trans-fusions and 9 out of 8236 for transfusions of bloodcollected into citrate (Wiener and Moloney 1943).Some of these deaths may have resulted from volumeoverload rather than from acute haemolysis, so anaccurate percentage cannot be calculated Both approx-imations suffer at the very least from ‘positive event’reporting bias However, it is evident that from thetime of these pre-modern era reports to the present,

improved procedures, compatibility testing and

posit-ive identification methods have reduced dramatically

the risk of acute haemolytic reactions and death

Unfortunately, progress in this area seems to have

halted during the last several decades (see below)

Mortality estimates in the modern era

Three later estimates of the mortality of

ABO-incompatible transfusion have been published: (1) in

a hospital in the USA between 1960 and 1977, 0 out

of 13; although three patients received 50 ml or less,

five received 0.5 units or more, and five received 1 unit

or more (sixth edition, p 573); (2) in the State of

New York in 1990 –91, 3 out of 54 (Linden et al.

1992); and (3) in a series collected in London between

1940 and 1980, 0 out of 12; three patients received

less than 50 ml, six received 200 – 600 ml, and three

received 1– 4 l (seventh edition, p 649)

In December 1975, the USA FDA established

mandatory reporting ‘when a complication of blood

collection and transfusion is confirmed to be fatal’

The information collected between 1976 and 1978

was reviewed by Schmidt (1980a,b) who considered

that in only 39 out of the 69 cases could transfusion be

regarded as the primary cause of death In 24 out of the

39, death was due to an incompatible transfusion; 22

out of the 24 were immediate reactions due to

transfu-sion of ABO-incompatible blood, and the remaining

two were DHTRs associated with anti-c or anti-E

Almost the same series of cases was reviewed by Honig

and Bove (1980), in an analysis that stressed the errors

that had led to the transfusion of incompatible blood

They concluded that out of 44 acute haemolytic

reactions, 38 were due to ABO incompatibility Both

reviews emphasized that the commonest cause of

ABO-incompatible transfusion is failure to identify

the recipient correctly and that the commonest place

where incompatible blood is transfused is the

operat-ing theatre

Deaths reported to the FDA in the 10-year period

from 1976 to 1985 (inclusive) were reviewed by

Sazama (1990) Of the cases attributed to red cell

incompatibility, 158 were due to acute haemolysis

(ABO incompatibility in 131) and 26 to delayed

haemolysis (mainly anti-c and anti-Jka) Mortality

cal-culated from the number of units of red cells

trans-fused during this decade approximates 1 in 250 000

transfusions, although deaths are almost certainly

under-reported The previously referenced 10-yearstudy of transfusion errors in New York State reportedfive deaths, 4% of all patients with acute haemolytictransfusion reactions, for an average of 0.5 events per

year or 1 per 1.8 million transfusions (Linden et al.

2000) Although improved procedures and intensivecare may have reduced the mortality since the reports

of the 1940s, from the number of cases reported in thelast 25 years, it is not possible to conclude that anysignificant reduction in these avoidable deaths hastaken place

Factors determining outcome

Two important factors in determining the outcome of

an ABO-incompatible transfusion are the potency ofthe anti-A (or anti-B) in the patient’s plasma and thevolume of blood transfused Rate of infusion may be athird For example, in the case illustrated later in thetext (see Fig 11.6) in which virtually no ill-effects fromthe transfusion of A blood to an O subject occurred,the anti-A agglutinin titre before transfusion was 32

and the antibody was only very faintly lytic in vitro.

Few adverse effects were noted in 12 carefully tored patients who received entire units of incompatiblered cells intentionally, albeit slowly, as part of a pre-paratory regimen for ABO-incompatible bone marrow

moni-transplantation (Nussbaumer et al 1995) (see below).

Although striking reactions may develop during thefirst few minutes of transfusion with incompatibleblood, the clinical severity generally depends on theamount of blood transfused Most fatalities have been associated with transfusions of 200 ml or more,and mortality approaches 44% for infusions exceed-ing 1000 ml However, volumes as small as 30 ml havebeen implicated (Honig and Bove 1980; Sazama1990) Small volumes of ABO-incompatible bloodmay pose a higher risk for children and adolescents.This belief, although intuitive, finds little support inthe published literature One author (HGK) is aware

of a mistransfusion of approximately 25 ml of group

A red cells that proved fatal to a 6-year-old, group O,28-kg child

Role of disseminated intravascular coagulation

Transfusion of ABO-incompatible blood may provelethal by precipitating a shock syndrome, initiatingDIC or causing renal failure In one series of 40

patients who received incompatible blood, four died as

a direct result of the transfusion This is the basis of the

oft-quoted 10% mortality statistic All four patients

had been transfused during or immediately after major

surgery Severe and persistent hypotension was the

main clinical manifestation All four patients

devel-oped DIC; two died within 24 h from irreversible

shock and two after about 4 days when evidence of

acute uraemia appeared (Wallace 1977) The

serious-ness of DIC as a complication of ABO-incompatible

transfusion is emphasized by an earlier series: of five

patients transfused, who developed a haemorrhagic

diathesis, all died (Binder et al 1959) Nevertheless, in

the majority of patients who receive ABO-incompatible

blood, DIC is mild or undetectable and renal failure

does not develop

Destruction of recipient’s own red cells by

transfused anti-A or anti-B

On occasion, clinical signs of red cell destruction

develop after the transfusion of group O blood or

plasma to recipients of other ABO groups As a rule,

destruction is predominantly extravascular but, as these

events are part of the spectrum of ABO haemolytic

reactions, they will be discussed below

Transfusion of group O blood to recipients of

other ABO groups

Levine and Mabee (1923) coined the term ‘dangerous

universal donor’ to describe group O donors whose

plasma contained agglutinins of high titre

Neverthe-less, in the early years of the Second World War, group

O blood was used for all emergency transfusions in

the UK, usually without any crossmatching or other

serological testing Adverse reactions were rare In a

series in the USA in which patients of groups A, B or

AB were transfused with group O blood the frequency

of frank haemolytic reactions was 1% (Ebert and

Emerson 1946)

Experimental work on the transfusion of group O

blood containing potent anti-A and anti-B to

recipi-ents of other groups has been described in the previous

chapter In the present section, a few examples will be

given of accidental haemolytic transfusion reactions

following the transfusion of ABO-incompatible

plasma, either in the form of group O blood or as

plasma alone

The following case illustrates many of the features

of a severe haemolytic transfusion reaction in a group

A patient after the transfusion of blood from a

‘dangerous’ group O donor:

The patient was a woman aged 23, who had a postpartum haemorrhage, estimated at 800 ml of blood The placenta was removed manually under anaesthesia While the patient was recovering from the anaesthetic and during the transfusion

of a second unit of group O blood, she developed seizures; her blood pressure was 80/40 mmHg The transfusion was stopped after 800 ml had been given; the patient was treated conservatively and recovered rapidly Investigation of a blood sample 12 h after transfusion showed that the patient was group A Rh D positive with approximately 0.9 × 10 9 group O red cells per litre As Fig 11.1 shows, over the fol- lowing 9 days, the concentration of group O cells scarcely decreased, but PCV fell progressively due, evidently, to destruction of the patient’s own red cells The direct anti- globulin test (DAT) was strongly positive for about 48 h after transfusion and more weakly positive for the following week; the test was negative on the tenth day after transfusion The plasma of the first unit of blood was shown to have an extremely high anti-A titre and to be strongly lytic for group

Days after transfusion

10 9

7 8 6 5 4 3 2 1 0

Fig 11.1 Destruction of recipient’s own (group A) red cells

following the transfusion of group O blood, the plasma of which contained potent anti-A The transfused cells survived normally and the progressive fall in the recipient’s packed cell volume (PCV) was therefore due entirely to the destruction of the patient’s own cells.

A cells The donor had received an injection of (horse)

anti-tetanus serum contaminated with Hog A substance 38 days

before giving blood (first edition, p 286).

Plasma that has a comparatively low anti-A

agglu-tinin titre (64 –256) but contains potent IgG anti-A

(IAT titre 1000 –5000) may cause serious haemolytic

reactions (Grove-Rasmussen et al 1953; Stevens and

Finch 1954)

Transfusion of red cells from group O blood to

recipients of other ABO groups

The injection of as little as 25 ml of plasma containing

potent anti-A may produce haemoglobinuria in a

group A subject It is therefore not surprising that

haemoglobinuria may occur after the transfusion of

a unit of O red cells to a group A, B or AB subject In

a case in which the recipient was group A, the unit,

which had a packed cell volume (PCV) of 0.70,

con-tained estimated 95 ml of plasma After

‘neutraliza-tion’ by group A- and B-specific substances, the plasma

had an anti-A indirect antiglobulin test (IAT) titre of

8192 Apart from developing haemoglobinuria, the

patient suffered a rigor and vomited, but made an

uneventful recovery (Inwood and Zuliani 1978) In

another case, a group B newborn infant with Escherichia

coli sepsis developed fever and haemoglobinuria after

exchange transfusion with red cells from group O

blood suspended in AB plasma The IgG anti-B titre of

the group O donor was 64 000 and was not

neutral-ized by AB substance (Boothe et al 1993).

Transfusions of group O plasma from single

donors

In three group A (or AB) infants, weighing 3.5– 4.5 kg,

who received 50 –90 ml of group O plasma, jaundice

developed within a few hours Examination of films of

peripheral blood showed striking microspherocytosis

In one case an increase in osmotic fragility was

demon-strated An interesting point in two cases was that

plasma from the same donor had been given on the

previous day without producing reactions This

sug-gested that the capacity of the body to inhibit anti-A

had been saturated by the first plasma transfusion so

that a second transfusion within a short time had a

more damaging effect (Gasser 1945)

Renal failure has been described in a 3-year-old

haemophiliac given a transfusion of 300 ml of group Oplasma before dental treatment The patient vomitedbefore and after the subsequent anaesthetic By the following morning he was deeply jaundiced and had passed a small amount of almost black urine His

Hb concentration was about 60 g/l and the DAT wasstrongly positive The patient recovered after treat-ment with peritoneal dialysis The transfused plasmaproved to have a haemolysin titre of 128 and an agglu-

tinin titre of 256 (Keidan et al 1966).

Transfusion of large amounts of low-titre or pooled plasma

In some patients with burns, haemoglobinuria oped 12–48 h after transfusion of an amount of pooledplasma equivalent to more than three times their plasmavolume More than 40% of the recipient’s red cellswere destroyed The plasma used was prepared fromthe blood of 10 donors of different ABO groups (fourgroup O, four group A and two group B or AB) andtherefore had only low titres of anti-A and -B

devel-In a series of haemophiliacs who were transfusedwith large amounts of pooled plasma, haemolyticepisodes characterized by an elevated serum bilirubinconcentration and a positive DAT were common.Pooled plasma frequently had anti-A titres of ‘immune’(non-inhibited) antibody as high as 64 (Delmas-

Marsalet et al 1969).

Anti-A or anti-B in factor VIII concentrates

A haemolytic reaction, characterized by a fall in the PCV to 0.20, microspherocytosis and haemo-globinaemia was caused by the administration of largeamounts of a factor VIII concentrate to a group A

patient (Rosati et al 1970) In another group A

patient, with a factor VIII inhibitor, who was givenapproximately 170 000 units of factor VIII, the DATbecame positive, Hb fell to 50 – 60 g/l and the reticulo-cyte count rose to 54%; batches of the factor VIIIpreparation had anti-A IAT titres of 128–512 (Hach-

transplants following the infusion of an

immuno-globulin preparation (‘Gamimune’), later shown to

contain anti-B with a titre of 32, as well as anti-A (Kim

et al 1988).

Anti-A or anti-B in platelet concentrates

A severe haemolytic reaction in a group A subject

fol-lowing the transfusion of 4 units of platelets from a

group O donor suspended in 200 ml of the donor’s

plasma was shown to be due to anti-A in the donor’s

plasma with an IAT titre of 8192 and the ability to lyse

A1red cells The recipient developed haemoglobinuria

and the PCV fell from 0.22 before transfusion to 0.16

8 h later; the DAT became positive (Siber et al 1982).

Severe haemolysis is a particular risk when platelet

concentrates are administered to infants and children

The increasing use of single-donor platelets

col-lected by apheresis and containing 200 –300 ml of

plasma has resulted in reports of haemolysis during

ABO-incompatible transfusions, even with low-titre

agglutinins (Mair and Benson 1998; Larsson et al.

2000; Josephson et al 2004) The frequency of such

reactions is poorly documented Platelet concentrates

are not ordinarily screened for high-titre agglutinins:

A 44-year-old woman of blood group A received a unit of

group O single-donor platelets for severe thrombocytopenia

during induction chemotherapy for acute myeloid leukaemia.

During this treatment, she had received several units of

single-donor platelets of blood groups A and O as well as group A

red cells Five minutes after the beginning of the transfusion

of group O platelets, the patient developed shortness of

breath and felt ‘flushed behind the ears’ The transfusion was

stopped and the patient evaluated by a physician After the

administration of 50 mg of intravenous hydrocortisone, the

transfusion was resumed Forty minutes into the transfusion,

the patient complained of back pain radiating into the legs

and tingling of the fingers of both hands The transfusion was

again halted and the patient evaluated After the infusion of

25 mg of diphenhydramine, the transfusion was resumed and

completed without further incident The 371-ml volume of

the platelet unit was transfused over 55 min Blood pressure,

pulse and respirations all remained normal throughout the

transfusion, and temperature did not increase.

The patient reported a transient feeling of nausea 1 h after

the transfusion and at 2 h after transfusion passed ‘bloody’

urine The patient’s urine remained red for 24 h after the

reaction Despite transfusion of 2 units of compatible group

A red cells, her Hb dropped by 23 g/l, from 77 g/l before the

transfusion to 54 g/l 6 h after the reaction There was no pairment of renal function after the transfusion and no evid- ence of disseminated intravascular coagulation The patient

im-recovered without further difficulty (Larsson et al 2000).

Haemolysis has also been reported with ‘dryplatelets’, apheresis platelets that are resuspended insynthetic preservative media and contain no more than

25–30 ml of plasma (Valbonesi et al 2000).

Destruction of transfused A 1 red cells by passively acquired anti-A

In an A2patient transfused with 5 units of A1blood, followed by 1 unit of group O blood containingimmune anti-A, all the A1 red cells were eliminatedwithin about 2 days of transfusion and anti-A1could

be demonstrated in the recipient’s plasma (Ervin andYoung 1950) In this case there was no evidence ofadverse effects, but in another case in which a patient

of subgroup A2was transfused with 3 units of group

A1and 1 unit of group O blood, jaundice and anuriadeveloped and the patient died (Grove-Rasmussen1951)

Pathophysiology of acute haemolytic reactions

Haemoglobin release, complement activation and liberation of cytokines

Although clinical descriptions of acute haemolyticreactions were described in detail at the beginning ofthe twentieth century, and in fact as early as the seven-teenth century (see below), the mechanisms remainincompletely understood The reactions are triggered

by the binding of antibody to the surface of the patible red cells, activation of complement and lysis

incom-of cells with release incom-of Hb Progression incom-of the tion then involves, to differing degrees, simultaneous activation of phagocytic cells, the coagulation cascadeand the systemic inflammatory response involvingboth cellular and humoral components The unpre-dictability of the response, the controlling factors ofwhich remain maddeningly obscure, accounts for thediffering signs and symptoms as well as the variableseverity of these reactions

reac-Haemoglobin released into the bloodstream has

cyto-toxic and inflammatory effects (Wagener et al 2001).

Plasma haemoglobin has been associated with increased

platelet adhesion and aggregation as well as vascular

inflammation and obstruction in vivo (Simionatto

et al 1988) Nitric oxide binding by free haemoglobin

may lead to smooth muscle dystonia with resultant

hypertension, gastrointestinal contraction and

vaso-constriction (Rother et al 2005).

Activation of complement results in assembly of the

membrane attack complex and liberation of the potent

anaphylatoxins C3a and C5a, small polypeptides that

increase vascular permeability, act directly on smooth

muscle and interact with various cells Complement

fragments stimulate mast cells to degranulate and release

vasoactive substances such as histamine and serotonin

Complement-coated cells bind to macrophages and

other phagocytic cells, which, in turn, liberate

inter-leukin 1 (IL-1) and other cytokines Receptors for

C3a and C5a are present on a wide variety of cells

(leucocytes, macrophages, endothelial cells, smooth

muscle cells), so that complement activation may be

accompanied by production of free radicals and nitric

oxide, release of leukotrienes and granule enzymes,

and synthesis of interleukins (Butler et al 1991;

Davenport et al 1994) C3a and C5a play a major role

in producing the adverse effects of ABO-incompatible

transfusions, but the release of cytokines may be

equally important (Davenport 1995) Activation of

the kallikrein system leads to further production of

bradykinin with its powerful vascular effects (Capon

and Goldfinger 1995)

In vitro, the incubation of A or B red cells with

group O whole blood leads to the release of IL-8 and

tissue necrosis factor (TNF) (Davenport et al 1990,

1991) IL-8 has chemotactic and activating properties

for neutrophils and is released by various cells,

includ-ing monocytes IL-8 production may be complement

dependent (Davenport et al 1990) TNF is one of the

cytokines that plays a significant role in septic shock,

a syndrome that shares many clinical characteristics

with acute HTR TNF activates the intrinsic

coagula-tion cascade and may thus take part in initiating DIC

(Davenport et al 1991, 1992) TNF not only causes

endothelial cells to increase tissue factor production

but also decreases production of thrombomodulin,

which, in turn, suppresses protein C activity Thus,

coagulation is promoted and anticoagulation inhibited

(Capon and Goldfinger 1995)

The role of cytokines liberated from leucocytes in

causing febrile transfusion reactions is discussed in

trans-‘After one or one and a half minutes the patient becomes less, breathes deeply and complains of a feeling of oppression, perhaps also of sternal pain The patient may also have abdominal discomfort and may vomit The pulse becomes weaker and one often sees a characteristic change in colour; a pale patient may suddenly become strikingly red’.

rest-Oehlecker pointed out that all symptoms usually side rapidly, but that if more blood is infused the samesymptoms recur within 1–2 min The constricting pain

sub-in the chest may be due to a spasm of coronary vessels

or to vascular occlusion by agglutinated cells

Similar symptoms were noted in some of the earlytransfusions given to patients from animal donors Forexample, the effects of transfusing calf blood to a humansubject were reported as follows: after about 200 ml ofblood had been transfused, the patient ‘found himselfvery hot along his arm and under the armpits’ After asecond larger transfusion on the following day (of about

450 ml of blood) ‘he felt the like heat along his arm andunder his armpits which he had felt before and hecomplained of great pains in his kidneys and that hewas not well in his stomach and that he was ready tochoke unless they gave him his liberty’ (Denis 1667).Towards the end of the nineteenth century, lambswere in vogue as donors and a certain Dr Champneys(1880) reported that he had witnessed more than adozen transfusions given directly from the carotid ves-sels of a lamb into the forearm veins of human subjectssuffering from phthisis After a short interval subjectsdeveloped difficult breathing along with a feeling ofoppression, then flushing, followed by sweating Onthe next day and for a few days subsequently, ‘haem-atinuria’ and, in nearly all cases, urticaria were noted.Although constricting pain in the chest and pain inthe lumbar region have been observed following theinjection of 0.7 ml of A1red cells to a subject whoseserum contained potent lytic anti-A (fifth edition,

p 549), the intravascular lysis of approximately 1 ml

of ABO-incompatible red cells does not necessarily

cause symptoms (tenth edition, p 365) Similarly,

when 10 ml of washed ABO-incompatible red cells

were injected, only a few subjects developed transient

symptoms: lumbar pain, dyspnoea, hyperperistalsis,

flushing of the face and neck (Jandl and Tomlinson

1958) Several millilitres of incompatible cells are

infused routinely with out-of-group allogeneic stem

cell grafts, and are usually well tolerated (Braine et al.

1982; Dinsmore et al 1983) These patients frequently

undergo extensive plasmapheresis to reduce the

anti-body titre and receive heavy premedication, including

corticosteroids, prior to the infusions However, 12

patients received deliberately mismatched donor-type

red cell transfusions (1 unit over 8 h on each of two

consecutive days) to adsorb isoagglutinins from the

recipient The units were well tolerated, although one

patient with pre-existing impaired renal function

developed reversible renal failure after the stem cell

transplant Recipient antibody titre ranged from 32

to 1024 (Nussbaumer et al 1995) Nevertheless, the

experience with a relatively few cases may owe as much

to good fortune as to low risk, and this procedure has

not received wide acceptance (Davenport 1995)

In another series of experiments, an immediate

reaction occurred only when intravascular red cell

destruction occurred In this series, 51Cr-labelled

group B red cells were injected into a group A patient

with hypogammaglobulinaemia whose serum

con-tained no detectable anti-B The B red cells initially

underwent only slow destruction corresponding to a

T50Cr of about 5 days After 5 days, various amounts

of anti-B were injected, and only when the amount of

anti-B was sufficient to produce intravascular lysis

were any symptoms noted; facial flushing began 2 min

after injection, lasted 4 or 5 min, and was followed

7 min after injection by pain in the groin, thighs and

lower back lasting 45 min Subjects receiving small

injections of red cells of incompatible ABO groups

developed a small rise in body temperature but no

chills (Jandl and Kaplan 1960)

Strongly lytic antibodies, other than A and

anti-B, which produce similar effects in vivo are rare In the

first subject in whom anti-PP1Pk(-Tja) was identified,

a test injection of 25 ml of incompatible blood

was followed by an immediate severe reaction with

haemoglobinaemia (Levine et al 1951) In a

sub-ject with haemolytic anti-Vel, transfusion produced a

rigor, lumbar pain and anuria (Levine et al 1961).

As noted earlier, signs and symptoms of acutehaemolysis may vary The ‘classic’ presentation is adramatic, life-threatening syndrome characterized by

a feeling of dread, flushing, fever and chills, pain at the infusion site, lumbar spine and flanks, nausea,vomiting and shock Patients may hyperventilate anddevelop cyanosis, or chest and abdominal pain maypredominate, possibly as a result of occlusion andischaemia in the microvasculature Dyspnoea is commonand the lung is an early, important, perhaps under-appreciated target organ Goldfinger and co-workers(1985) had the opportunity to observe a patient whoreceived 20 ml of ABO-incompatible blood at the time

of intensive haemodynamic monitoring The earliestevent, an increase in pulmonary vascular resistance,occurred within the circulation of the lung Somepatients will have minimal symptoms, and the first cluesmay be pallor, icterus and a fall in circulating Hb

In patients who are anaesthetized or are heavilymedicated during transfusion, the two signs that maycall attention to the possibility that incompatible bloodhas been transfused are hypotension, despite appar-ently adequate replacement of blood, and abnormalbleeding

Disseminated intravascular coagulationassociated with intravascular haemolysis

In dogs, the infusion of autologous haemolysed redcells leads to intravascular coagulation (Rabiner andFriedman 1968) Thromboplastic substances in stromaappear to be responsible In monkeys, the infusion

of sonicated stroma, free of Hb, produces a fall inplatelets, fibrinogen and factors II, V and VIII

In experiments in monkeys in which incompatible

plasma was transfused, evidence of mild DIC wasobserved in two animals in which plasma Hb levelsreached 6 g/l or more No bleeding was observed inanimals in which the plasma Hb level was below 1 g/l

(Lopas et al 1971) In other experiments in which

incompatible allogeneic red cells were transfused,equivalent in amount to 250 ml of blood to a human

adult, DIC was observed in three out of five cases in

which intravascular haemolysis (average plasma Hb

6.5 g/l) associated with haemolytic antibodies The main

features were a fall in factors V, VIII and IX and a less

consistent fall in fibrinogen concentration and in platelet

count Intravascular coagulation was not observed

in two cases in which destruction was predominantly

extravascular and associated with predominantly

incomplete non-haemolytic antibodies; in these latter

cases there was a slow rise of plasma Hb, reaching a

peak of about 0.5 g/l in 4 h (Lopas and Birndorf 1971)

Following the transfusion of ABO-incompatible

blood, a haemorrhagic state may develop after as little

as 100 ml If the patient is undergoing operation,

uncontrollable bleeding from the wound develops;

epistaxis and bleeding from the site of venepuncture

have also been observed A fibrinogen level as low as

15 mg/dl has been reported, with virtually

incoagul-able blood Fibrin degradation products (FDPs) have

been found in the serum, usually in concentrations

in the range of 250 to 450 µg/ml, but as high as

1900 µg/ml in one case (Sack and Nefa 1970)

Various interactions have been demonstrated between

the complement, kinin, coagulation and fibrinolytic

systems (Kaplan et al 2002) For example,

low-molecular-weight fragments of factor XIIa (Hageman

factor) may mediate C1 activity (Ghebrehiwet et al.

1981) The possible role of cytokines in precipitating

DIC has been discussed above

After predominantly extravascular destruction, DIC

occurs only very occasionally There are two reports

in the literature of abnormal bleeding following

incompatible transfusion due to antibodies that are

not haemolytic in vitro: one due to anti-c (Wiener

1954) and one due to anti-Fya(Rock et al 1969).

Renal failure following intravascular haemolysis

Destruction of red cells within the bloodstream

liber-ates Hb into the circulation and is sometimes followed

by a decline in renal function The postulated direct

nephrotoxicity of Hb itself, although widely taught,

has not been unequivocally demonstrated, remains

hotly debated (Viele et al 1997) and probably does not

exist outside of the vasoconstriction mediated by nitric

oxide binding (see below) Of 41 cases of renal failure

related to haemolytic reactions, 21 were related to ABO

incompatibility (Bluemle 1965) Almost all instances

of renal failure associated with ABO incompatibility

occur in group O patients, although only about 70%

of ABO mismatched transfusions involve group O

patients (Doberneck et al 1964; Bluemle 1965).

The infusion of large volumes of stroma-free Hb has

no effect on renal function in dogs and monkeys

(Rabiner et al 1970; Birndorf et al 1971) On the

other hand, when 250 ml of a preparation of Hb taining only 1.2% stromal lipid was administered atthe rate of 4 ml/min to six well-hydrated healthy men,urinary output fell by 81%, mean creatinine clearancedeclined, and transient bradycardia and hypertension

con-developed (Savitsky et al 1978) In several studies,

the infusion of Hb has been associated with strictor effects such as increased blood pressure and

vasocon-reduced cardiac output (Hess et al 1993; Thompson

et al 1994) Vasoconstriction may be produced by the

interference of Hb with the action of nitric oxide Hb

is presumed to leak across the endothelial layer intothe extravascular space Hb is thought to interferewith nitric oxide function as nitric oxide diffuses fromendothelial cells to smooth muscle, where it exerts itsvasodilatory effects by regulating smooth muscle tone(Patel and Gladwin 2004) Hb breakdown products,for example metHb, may also play a role in generatingdamaging oxygen radicals (see also Ogden andMacDonald 1995)

Renal damage associated with intravascular tion is relatively common when destruction is caused

destruc-by potent lytic antibodies, and unusual when caused destruc-bynon-lytic antibodies Consumption coagulopathy withmicrovasculature clot deposition may compromise thefunction of several organs In experiments in monkeys,

in which haemolytic transfusion reactions were duced, fibrin thrombi were widespread and in at least

pro-one case were found in renal tufts (Lopas et al 1971).

Hypotension is doubtless another factor in ing renal failure Potent complement activation leads

precipitat-to the release of large amounts of C3a and C5a, which,

in turn, release vasoactive peptides from mast cells

Renal failure following the infusion of stroma

There is evidence that the infusion of stroma fromincompatible red cells is followed by renal failure Inone case, in an attempt to depress the titre of a panag-glutinin in a patient’s plasma, stroma from 4 units ofred cells was infused One hour later, the patient feltapprehensive and sustained a fall in blood pressure,

a rapid decrease in urinary output, granulocytopenia

and thrombocytopenia Following an infusion of

man-nitol (25%), urinary flow was rapidly restored In a

second case, a patient whose serum contained anti-K

was infused with stroma from 1 unit of K-positive red

cells and 3 units of K-negative red cells There followed

a rigor and severe oliguria lasting 5 days The authors

stated that in 12 other cases in which stroma had

been infused, no complications occurred (Schmidt

and Holland 1967) These experiments reinforce the

conclusion that transfusion of incompatible red cells

produces its damaging effect on the kidney not by

releasing Hb but by activating complement, liberating

cytokines and triggering DIC

Effect of incompatible transfusion in an anuric

patient A patient of group O with presumed tubular

necrosis following severe injury 1 month earlier was

given one-third of a unit of group AB blood over 4 min

The patient felt unwell and temporarily lost

conscious-ness At 1 h, plasma Hb had risen to 4.8 g/l, 1.82 g

bound to haptoglobin (Hp) and the rest free The

plasma was cleared of Hb in about 10 h, during which

time the patient excreted 8 ml of faintly orange urine

The episode may have delayed slightly the onset of

diuresis, but ultimately renal function was only slightly

impaired (Hoffsten and Chaplin 1969)

Management of suspected acute haemolytic

transfusion reactions with intravascular

haemolysis

Methods of diagnosing acute haemolytic transfusion

reactions and the immediate steps to be taken when

acute haemolysis is suspected are described later in this

chapter; the serological investigations to be

under-taken are discussed in Chapter 8

Management of acute haemolytic reactions is

both expectant and supportive Early recognition and

interdiction of further incompatible blood may be the

single most important step Although several

treat-ment protocols have been proposed, there is no

evid-ence that the supportive measures should differ from

those administered for shock, renal failure and DIC

from any cause The degree of intensive medical

sup-port will depend on the severity of the reactions

Hypotension is usually managed by aggressive fluid

resuscitation, and when pressors are indicated, drugs

that preserve renal blood flow, for example dopamine

infused at 3–5 µg/kg per minute, are preferred Timely

intervention may limit the degree of renal ment Both prophylaxis and immediate treatment

impair-of renal insufficiency traditionally include mannitol 20% (100 ml/m2) and diuretics to maintain a min-imal urinary output of 0.5 ml/kg per hour, but little scientific evidence supports this recommendation.Further management depends on the clinical response.Alkalinization of the urine is routinely recommended,may be helpful and is unlikely to cause harm

Appropriate management of the consumption ulopathy in acute haemolytic transfusion reactions,

coag-as in other conditions, is fiercely debated There is noevidence that prophylactic anticoagulation prevents orlessens the microvascular thrombosis or the bleeding.Heparin administration has been advocated by someonce the diagnosis of DIC has been established, and ifprescribed, a dose of 5000 units immediately, followed

by a continuous infusion of 1500 units/hour for 6–24 hhas been recommended (Goldfinger 1977) Heparintreatment carries the risk of exacerbating the bleeding.Few reports address the role of heparin during acutehaemolytic transfusion reactions, although two appar-ent successes were reported by Rock and co-workers(1969) Use of blood components such as plasma,platelets and cryoprecipitate are equally controversial,but should in any case be limited to patients with life-threatening bleeding As acute haemolytic transfusionreactions so often result from a transfusion error, special effort must be undertaken to ensure that anyblood component selected has been determined to becompatible

Non-immunological intravascular haemolysis

Haemolysis due to osmotic effects

Damage produced by exposure to 5% dextrose

Haemolytic transfusion reactions have been observed

in patients receiving transfusions of whole bloodpassed through a bottle containing 5% dextrose and

0.225% saline [Ebaugh et al 1958, cited by DeCesare

and co-workers (1964)] Similarly, red cells suspended

in excess 5% dextrose or in 4.3% dextrose with0.18% saline were almost completely lysed after 24 h

at room temperature (Noble and Abbott 1959) Onthe other hand, when blood was mixed with 5% dex-trose in normal saline, no lysis was found even after

15 h at 37°C (Ryden and Oberman 1975) The small

number of agglutinates with negligible haemolysis that

is sometimes observed in the intravenous tubing when

a 5% dextrose solution follows transfusion of red cells

is rapidly diluted in the patient’s circulation and has

not been associated with adverse events

Injection of water into the circulation:

best be a rabbit

Infusion of 100 ml of water into an adult produces

only slight haemoglobinaemia (0.1– 0.2 g/l), but the

injection of 300 –900 ml, infused over a period of

1– 4 h, produces plasma Hb levels of 2 – 4 g/l Water

may gain entrance to the circulation if the bladder is

irrigated with water rather than with saline during

transurethral prostatectomy (TURP) Acute renal

failure after TURP may be caused by hypotonicity

and hypervolaemia with subsequent increased vascular

leakage leading to hypotension and rapidly impaired

renal function Acute renal failure caused by haemolysis

after TURP has been reported, but is rare (Gravenstein

1997) In patients who already have renal ischaemia,

the entry of water into the circulation may precipitate

renal failure (Landsteiner and Finch 1947)

Injection of water into the circulation can be lethal

Two patients who were accidentally given 1.5 and

2 l, respectively, of distilled water by rapid infusion

developed rigors, haemoglobinuria and persistent

hypotension, and both patients became oliguric and

died (J Wallace, personal communication) Despite

the evidence that infusion of large amounts of water is

dangerous in humans, very large amounts have been

given to rabbits without producing ill effects (Bayliss

1920)

Insufficiently deglycerolized red cells

Osmotic stress may cause lysis of red cells that have

been cryopreserved with glycerol but inadequately

washed free of the cryoprotectant after thaw In most

cases, haemolysis is minimal and patients may note a

change in urine colour, but no other signs or symptoms

A nine-year-old boy of blood group B with thalassaemia major

was supported on a chronic outpatient transfusion programme

with red cell transfusions at 3-week intervals His Hb level

prior to transfusion was 86 g/l and he received two units of

frozen deglycerolized red cells (high-glycerol technique) that

had been prepared according to a manual protocol The patient had no atypical antibodies and the blood was compatible by a standard crossmatch technique Transfusion was performed without incident and the patient was discharged Three hours later, the parents called to report that the patient passed dark red urine, but had no fever or other signs or symptoms of illness A post-transfusion specimen revealed an Hb of 111 g/l The DAT was negative and no discrepancies were found after careful clerical check of transfusion records The urine con- tained free Hb, but no red cells Analysis of residual blood in one of the transfused red cell units revealed an osmolarity of

> 2000 mOsm, suggesting incomplete removal of glycerol by washing, and haemolysis of a small amount of cells due to osmotic shock The osmolarity of a specimen from the second unit was 310 mOsm The patient suffered no clinical sequelae (HGK, personal observation).

Clinical symptoms of a haemolytic reaction occurred

in one of two patients with sickle cell anaemia after

in vivo haemolysis of transfused deglycerolized red cells (Bechdolt et al 1986) Instrumentation that con-

trols automated deglycerolization should reduce thisrisk in the future

Transfusion of haemolysed blood

If enough free Hb is injected into the circulation theresultant haemoglobinaemia may be misinterpreted as

a sign of intravascular haemolysis Appreciable ities of free Hb may be injected in any of the followingcircumstances

quant-Transfusion of overheated blood

Red cells are damaged and destroyed if warmed to

a temperature of 50°C or more Most heat-relatedaccidents happen when a unit of blood is placed in

a vessel containing hot water with the intention ofwarming the blood to body temperature The trans-fusion of approximately 2.5 l of blood that had beenaccidentally overheated, and haemolysed, was asso-ciated with irreversible renal failure and death of the patient (J Wallace, personal communication) One

of the authors (HGK) is aware of a similar tragicoccurrence following transfusion of a unit of red cellsthat had been “warmed like a baked potato” in a com-mercial microwave oven As discussed in Chapter 15,blood should not be warmed before transfusion except

in special circumstances and using methods in whichthe temperature is carefully monitored

Transfusion of blood haemolysed by accidental

freezing

Blood may be accidentally frozen, either by storage

in an unmonitored refrigerator or by inadvertent

placement in a freezer In one reported case, 3 units of

autologous blood, donated 2– 4 weeks previously, had

been accidentally frozen at –20°C and were transfused

during hip surgery Six hours later, the patient’s urine

was noted to be dark red and oliguria developed

There were no signs of shock The patient required

repeated haemodialysis, but eventually recovered

(Lanore et al 1989).

Blood forced through a narrow orifice: easier to

pass through the eye of a needle

Forcing blood through a narrow opening such as a

narrow-gauge needle has been incriminated as the

cause of haemolysis in several different circumstances:

1 Haemoglobinuria was observed in a 1-month-old

infant, 1 h after a scalp vein transfusion of 55 ml of a

partially packed suspension of red cells The cells had

been injected through a fine-gauge needle and

consid-erable pressure was needed to infuse the blood When

stored blood was subsequently injected through a

needle of similar gauge in vitro, substantial lysis

oc-curred when the rate of injection exceeded about 0.3 ml/s

(Macdonald and Berg 1959)

2 Haemoglobinuria was noted in a donor who was

undergoing plateletpheresis on a continuous-flow cell

separator as blood was pumped through partially

obstructed tubing (Howard and Perkins 1976)

3 After the unexpected death of several infants

fol-lowing intrauterine transfusion, case analysis revealed

that all deaths had occurred after the usual infusion

catheter had been replaced with a model that had

a much smaller side opening When red cells were

injected through the new type of catheter, substantial

haemolysis occurred (Bowman and Pollack 1980)

4 Blood forced through a leucocyte reduction filter

may haemolyse, and transfusion of such blood has

been responsible for haemoglobinuria (Gambino et al.

1992; Ma et al 1995).

Transfusion of infected blood – and of infected

patients

Blood that has been contaminated with certain bacteria

and stored may become grossly haemolysed Thetransfusion of such blood does produce haemoglobi-naemia and haemoglobinuria, but these signs pale intoinsignificance when compared with the very toxiceffects of bacterial toxins (see Chapter 16) Haemolysisdue to bacterial sepsis may mimic a haemolytic trans-fusion reaction (Felix and Davey 1987)

Transfusion of red cells with intrinsic defects – and of patients with red cell defects

Transfusion of cells with certain enzyme or membranedefects may result in acute haemolytic transfusionreactions, although in most instances haemolysis isasymptomatic, delayed or appreciated only in retro-spect by a shortened interval between transfusions.Exchange transfusion with G6PD-deficient blood has

resulted in acute haemolysis in infants (Kumar et al.

1994) Immediate post-transfusion haemolysis wasdocumented in 6 out of 10 Israeli adults who receivedG6PD-deficient blood, although the degree of red celldestruction was minimal and no symptoms were noted

(Shalev et al 1993) The risk and degree of haemolysis

depend on the particular enzyme variant and may beexacerbated by the concurrent administration of med-ications associated with oxidative stress (Beutler 1996;see also Chapter 1) Acute haemolysis related to enzymedeficiencies may mimic acute haemolytic transfusionreactions, particularly in the surgical setting (Sazama

et al 1980) Units from donors with hereditary

spherocytosis and poikilocytosis may also result inhaemolysis either during storage or post transfusion

(Weinstein et al 1997).

Autoimmune haemolytic anaemia

Haemoglobinuria following transfusion in autoimmunehaemolytic anaemia (AIHA) seems most likely to becaused by increasing the red cell mass subject to auto-immune destruction in patients with a very severehaemolytic process (Chaplin 1979) Haemoglobinuriafollowing transfusion in patients with complement-mediated AIHA may be due to the initial destruction of

‘unprotected’ red cells that, unlike the patient’s ownred cells, have little C3dg on them Intravascular lysisdue to the increased supply of complement in thetransfused blood is probably an unusual cause of post-transfusion haemoglobinuria in patients with AIHA;however two possible cases, both in patients with cold

haemagglutinin disease, were described by Evans and

co-workers (1965)

Paroxysmal nocturnal haemoglobinuria:

dispelling the washing myth

Patients with paroxysmal nocturnal haemoglobinuria

(PNH) may develop haemoglobinuria after

trans-fusion The postulated mechanism involves activation

of the complement cascade to which PNH red cells

are abnormally sensitive (Rosse and Nishimura 2003)

Customary practice for transfusing PNH patients has

been to wash the red cells free of plasma in an effort

to minimize complement and alloantibodies in the

transfusion However, in a 38-year experience at the

Mayo Clinic, 23 patients with PNH were transfused

with 556 blood components that included 94 units of

whole blood, 208 units of red cells, 80 units of white

cell-poor red cells, 38 units of washed red cells, 5 units

of frozen red cells and 6 units of red cells salvaged

during surgery Only one documented episode of

post-transfusion haemolysis related to PNH was confirmed

That episode was associated with the transfusion of a

unit of group O whole blood with ABO-incompatible

plasma to an AB-positive patient and probably involved

antibody-mediated complement fixation on the red cell

membrane (Brecher and Taswell 1989) This analysis

suggests that the routine use of washed cells for PNH

patients is unnecessary as long as ABO-identical blood

components are transfused But complement can be

activated by antigen–antibody reactions not localized

to the susceptible red cell membrane Sporadic reports

do suggest that leucocyte antibodies in transfused

com-ponents may precipitate haemolysis in PNH recipients

(Sirchia et al 1970; Zupanska et al 1999) If such

anti-bodies are present, prudence dictates washing the cells

free of plasma

A recombinant humanized monoclonal antibody

(eculizumab) that inhibits activation of terminal

complement components has been shown to reduce

haemolysis and transfusion requirement for six men

and five women with chronic haemolysis of type II

PNH cells (Hillmen et al 2004) The long-term effects

of such treatment are unknown

Sickle-cell (SS) disease and sickle cell haemolytic

trans-fusion reaction syndrome Patients with SS disease

may develop rapid destruction of transfused red cells

consistent with either acute or delayed reactions The

classic description of this syndrome emphasized thepresence of typical SS crisis pain and rapid destruc-tion of large volumes of transfused cells despite com-patible crossmatch results (Chaplin and Cassell 1962;

Diamond et al 1980) Symptoms suggestive of a sickle

cell pain crisis develop or are intensified during thehaemolytic reaction and may result in more severeanaemia after the transfusion than was present origi-nally Patients may have either marked reticulocytosis

or severe reticulocytopenia The syndrome(s) have been

referred to collectively as the sickle cell haemolytic transfusion reaction syndrome (Petz et al 1997) The

pathophysiology of the so-called ‘hyperhaemolysis’that appears to destroy autologous as well as trans-

fused cells is not predictable (Petz et al 1997), and the

appropriate clinical management of this life-threateningcomplication is yet to be established (Telen 2001).Immune-mediated haemolysis is not always demon-strable when hyperhaemolysis occurs in the setting of

recent transfusion (Aygun et al 2002).

Bleeding into soft tissues

Massive but occult bleeding into soft tissues, typicallyretroperitoneal bleeding or haemorrhage into the thighafter femoral artery puncture, may mimic acute orDHTRs Rapid fall in Hb concentration may be followed by elevation in serum bilirubin, lactate dehydrogenase and fibrin degradation products as clot

is resorbed (HG Klein, personal observation)

Clearance of haemoglobin from the plasma (Fig 11.2)

Haemoglobin liberated into the plasma dissociates

into dimers that bind to haptoglobin (Hp) (see Bunn

et al 1969) Unbound Hb is partly processed by the

liver and partly excreted (as dimers) in the urine Free

Hb is readily oxidized in the plasma to metHb; afterdissociation from globin, haem binds preferentially

to haemopexin The globin split off from Hb is bound

by Hp Hb catabolism and other laboratory ments during a representative acute haemolytic trans-

measure-fusion reaction are displayed in Fig 11.2 (Duvall et al.

1974)

Haptoglobin (Hp) is a normal plasma protein,

cap-able of binding about 1.0 g of Hb per litre of plasma.When amounts of Hb not exceeding this level areinfused or liberated into the bloodstream, the Hb

circulates as a complex with Hp The molecular weight

of Hp varies according to phenotype, and is about

100 kDa for Hp 1–1 and about 220 kDa for Hp 2–1

(Giblett 1969) Molecules of Hp tend to bind with

dimers of Hb rather than with whole molecules

(tetramers) of Hb to give a complex with a molecular

weight (for Hp 1–1) of 135 kDa When Hb tetramers

are bound, the complex has a molecular weight (for

Hp 1–1) of 169 kDa

The complex Hb–Hp is taken up by hepatic

parenchymal cells When the amount of Hb liberated

into the plasma corresponds to only a few grams per

litre, the Hb complex is cleared exponentially with a

half-time on the order of 20 min (Garby and Noyes

1959), but at higher Hb levels the clearance system is

saturated and a constant amount of approximately

0.13 g of Hb per litre of plasma is cleared per hour

(Laurell and Nyman 1957; Faulstick et al 1962) After

the injection of amounts of Hb calculated to suppress

the Hp level to zero, the Hp level rose to 50% of the

pre-injection level in 36 h and to 100% in 7–9 days

(Noyes and Garby 1967)

Haemopexin (Hx) is a protein present in plasma in

low concentration, to which methaem, derived from

circulating free metHb, binds preferentially Hx also

binds haem from methaemalbumin and may provide

the primary clearance route for haem complexed in

this way (Muller-Eberhard et al 1969).

Methaemalbumin is a pigment formed by haem

(methaem) that is not bound to Hx, bound with albumin Apart from acute haemolytic incidents,methaemalbumin is found in the plasma only when the amount of Hp has been reduced to a negligible

level, less than 5 mg /dl (Nyman et al 1959) The rapid

infusion of 14 g of Hb into an adult will lead to the formation of sufficient methaemalbumin to give a positive Schumm’s test, although about three timesthis amount of pigment must be present before it can

be detected spectroscopically Methaemalbumin can

be detected about 5 h after injecting Hb and remainsdetectable for 24 h or more (Fairley 1940)

Haemoglobinuria

When the amount of Hb not bound by Hp reachesabout 0.25 g /l, some is excreted in the urine The clear-ance of Hb by the kidney is only 5% of that of water or

6 ml of plasma per minute per 1.73 m2of body surfacecompared with 100 ml plasma per minute for insulin(Lathem 1959) Some Hb is reabsorbed by the renal

tubules (Lathem et al 1960) At plasma Hb levels

of approximately 1.8 g /l induced in normal males, the amount of Hb reabsorbed was approximately 1.4 mg /min, which was about one-third of the amount

being filtered by the glomeruli (Lowenstein et al.

Plasma haemochromagen (mg% × 100) Platelets ×10 3 /mm 3

Fig 11.2 Time course of changes in

anti-A titre, plasma Hb (mg/100 ml × 10), total bilirubin (mg/100 ml), platelets and fibrinogen following transfusion of 140 ml of incompatible (group A2) red blood cells to a group

O patient Modified from Duvall and co-workers (1974).

The fact that in most subjects haemoglobinuria

occurs only when the plasma level exceeds about 1.5 g/l

was known long before the role of Hp was appreciated

(Ottenberg and Fox 1938; Gilligan et al 1941) The

latter investigators found that when the initial plasma

Hb concentration was 0.4 – 0.6 g / l, the plasma was

cleared in 5 h; when the initial level was 1.0 –2.25 g / l

the period was 8 h; and when the initial level was

2.8–3.0 g / l the plasma was not cleared for 12 h

After the infusion or liberation of relatively large

amounts of Hb into the circulation, up to one-third

may be excreted in the urine In six subjects receiving

rapid injections of 12–18 g of Hb, the average amount

excreted was about 18% of the amount injected

(Amberson et al 1949) In dogs transfused with

incompatible blood in amounts equivalent to giving

200 –1000 ml to an adult human, the amount of Hb

excreted in the urine varied from 10% to 40% of the

amount in the transfused red cells (Yuile et al 1949).

Haemosiderinuria When free Hb is filtered through

the glomeruli, some or all of it is reabsorbed by the

renal tubules and the iron released is stored as

haemosiderin If this process continues for a long

period, iron-laden cells and free haemosiderin are

found in the urine (see Bothwell and Finch 1962,

p 413) Haemosiderinuria is invariably found in adults

whose plasma Hb concentration exceeds 0.25 g/l Only

microscopic amounts are found when the plasma Hb is

below 0.20 g/l, but larger amounts are found when the

level exceeds 0.50 g/l (Crosby and Dameshek 1951)

Bilirubinaemia following infusions of

haemoglobin

The serum bilirubin concentration rises by about

0.5 mg/dl (1 mg/dl = 17 µmol/l) after an infusion of

14 –21 g of Hb, and the maximum concentration is

reached 3 – 6 h after injection (Fairley 1940) A similar

rise was noted in a subject injected with 16 g in whom

the maximum plasma Hb concentration was 3.8 g/l

(Gilligan et al 1941) One gram of Hb is converted

to 40 mg of bilirubin (With 1949) Therefore the

catabolism of 16 g of Hb should yield 640 mg of

biliru-bin If this were liberated into the plasma of an adult

who was incapable of excreting bilirubin, the plasma

bilirubin concentration would rise by about 10 mg/dl

(170 µmol/l), assuming that about one-half of the

liberated bilirubin diffused rapidly into the

extra-vascular fluid space (Weech et al 1941) In practice

the bilirubin is delivered to the circulation over a period

of several hours and excretion almost keeps pace withproduction

Extravascular destruction

Destruction by antibodies that are slowly lytic or

only occasionally lytic in vitro Lewis antibodies

Many examples of anti-Lea and a few examples of anti-Leblyse untreated red cells in vitro although lysis

occurs only slowly When small amounts of Le(a+) red cells are injected into the circulation of a patientwith potent anti-Lea the cells are normally cleared

by the mononuclear phagocyte system (MPS) with the liberation of only traces of Hb in the plasma.Haemoglobinuria has been observed after the trans-fusion of relatively large amounts of Le(a+) red cells,perhaps because the amount of Hb released is greater,

or possibly because, owing to slow clearance, the cellshave time to undergo lysis in the circulation beforeclearance by the ‘overloaded’ MPS can occur

In a patient, WB, whose serum contained anti-Le a , capable

of causing slow but appreciable lysis of Le(a+) red cells in

vitro, 2 ml of Le(a+) red cells labelled with 51 Cr were infused and found to be cleared with a half-time of approximately

2 min The maximum amount of 51 Cr found in the plasma during the following 40 min was 2% of the total injected

as intact red cells A few weeks previously, this same patient had developed haemoglobinuria following the transfusion

of 250 ml of Le(a +) blood It is possible that the globinuria developed because clearance of the large volume

haemo-of Le(a +) red cells was substantially slower, so that there was time for intravascular haemolysis to occur A second factor may have been the low Hp level in this patient, which would have led to haemoglobinuria at relatively low levels of haemoglobinaemia.

A similar phenomenon was observed during ments with stored red cells in rabbits by Hughes-Jonesand Mollison (1963) The red cells used for the experi-ments were rendered non-viable by storage at 37°C

experi-in trisodium citrate for 24 or 48 h In vitro these red

cells underwent rapid spontaneous haemolysis (5%per hour) When small numbers of red cells wereinfused, they were cleared rapidly by the MPS without

liberation of Hb into the plasma However when very

large amounts of the red cells were transfused, so that

the MPS was overloaded and complete clearance

took more than 24 h, gross haemoglobinaemia and

haemoglobinuria developed, presumably because the

red cells were destroyed within the bloodstream before

they could be phagocytosed by the MPS

Other cold alloantibodies

As described in the previous chapter, cold

alloanti-bodies cause in vivo red cell destruction only when they

are active at 37°C in vitro Because such antibodies

should be detected in compatibility testing, it is not

surprising that the literature contains only two

ex-amples of immediate haemolytic reactions due to

anti-P1(Moureau 1945; Arndt et al 1998) and only

five due to anti-M (Broman 1944; Wiener 1950; Strahl

et al 1955) or anti-N (Yoell 1966; Delmas-Marsalet

et al 1967) In fact, in four out of the seven cases just

referred to, no crossmatching at all was carried out

before transfusion and in one of the remaining three

(Strahl et al 1955) only an agglutination test was

carried out; subsequent testing showed that the

anti-body was readily detectable by IAT The thermal range

of cold alloantibodies occasionally increases after

transfusion and in rare cases these antibodies have

been the cause of DHTRs (see below)

Anti-Jk a and anti-Jk b

Anti-Jkaand anti-Jkbare occasionally weakly lytic in

vitro Although tests with small doses of incompatible

red cells indicate that destruction is usually

extravas-cular, incompatible transfusions due to these antibodies

are sometimes characterized by haemoglobinuria and

C8–9-mediated destruction is almost certainly involved

Haemolytic reactions due to anti-Jkaare characterized

by difficulty in detecting the antibody and by the

occurrence of haemoglobinuria

In one case, a woman who had been transfused

twice previously (4–5 years earlier) received two

trans-fusions at an interval of 9 days The first of these

two produced no obvious ill effects However, 30 min

after the start of the second unit, the patient developed

nausea and shivering and passed red urine A further

blood transfusion 3 days later produced a similar

clinical picture and this time haemoglobinaemia

and methaemalbuminaemia were demonstrated The

patient’s serum contained a typical binding anti-Jka(Kronenberg et al 1958) In another

complement-case, a 60-year-old woman who had never been transfused before but had had five pregnancies wastransfused with 300 ml of blood and developed asevere febrile reaction with haemoglobinuria Theblood had been screened as compatible but on repeattesting, a very weak anti-Jka was discovered (Degnanand Rosenfield 1965) In one case mentioned inChapter 10, 50% of the radioactivity of an infusion

of 51Cr-labelled red cells was found in the plasma,clearly indicating intravascular lysis

Destruction by antibodies that fail to activatecomplement or activate it only to the C3 stage Antibodies that fail to activate complement includevirtually all antibodies of the Rh, MNSs and Lu sys-tems and some of the antibodies in the Kell, Fy, Di andvarious other systems Conversely, some Kell, Fy, etc.antibodies activate complement, but only to the C3stage Although the binding of C3 determines destruc-tion in the liver (and spleen) rather than in the spleenalone (see Chapter 10), it is not associated with

‘intravascular lysis’ Release of Hb into the plasma in

‘extravascular’ lysis is caused by the destruction of redcells by lysozymes derived from macrophages Factorsthat determine the extent of this lysis have yet to bedetermined In the case of some antibodies such as Rh

D in hyperimmunized subjects, there seems to be an

association with in vitro antibody potency (Wiener and Peters 1940; Wiener 1941a; Vogel et al 1943).

Some instances of haemoglobinuria followingdestruction by non-complement-binding antibodiesare not well understood, as in the case of those asso-ciated with anti-C or -Ce of low titre

Although the foregoing discussion has focused onthe release of Hb into the circulation in extravasculardestruction, most incompatible transfusions due to theantibodies considered in this section are not character-ized by haemoglobinuria but by hyperbilirubinaemia

Destruction of donor’s red cells by passively acquired antibodies

Anti-Rh D There is substantial experience with the

effect of giving anti-D in an attempt to suppress ary RhD immunization of D-negative subjects whohave been accidentally transfused with D-positive red

prim-cells During the rapid destruction of D-positive red

cells, some release of free Hb into the plasma occurs,

but haemoglobinuria is observed only when the

anti-body is relatively potent, and even then not uniformly

Following the inadvertent transfusion of about 200 ml

of D-positive red cells to a D-negative woman, anti-D

was given intravenously, resulting in the destruction

of almost all of the D-positive cells within 30 h The

plasma Hb concentration reached a maximum of

1.5 g/l at about 12 h after the onset of the red cell

destruction (Eklund and Nevanlinna 1971)

Anti-K Several cases have been reported in which

reactions in K-negative subjects have been caused

by the transfusion, either simultaneously or after an

interval of only a few days, of K-positive red cells from

one donor and of K-negative blood containing anti-K

from a second donor: (1) a patient was transfused

uneventfully with a K-positive unit but, following the

transfusion of 1 unit of K-negative blood 12–24 h

later, developed a severe febrile reaction; the patient

was found to have a positive DAT Serum from the

K-negative donor was shown to contain anti-K with

an IAT titre of 2048 (Zettner and Bove 1963); (2) a

patient developed anuria after being transfused with

3 units of blood, two of which were K positive and

a third K negative with potent anti-K (titre 2000) in the

plasma (Franciosi et al 1967); (3) a patient who was

bleeding was transfused with 10 units of blood over a

period of 24 h During the transfusion of the tenth

unit, chills and fever developed A few hours later,

haemoglobinaemia and signs of DIC were detected

but the patient rapidly improved thereafter One of

the 10 units of blood was found to be K positive and

another unit contained anti-K with a titre of more than

1000 (Abbott and Hussain 1970); and (4) a patient

with acute leukaemia developed hypotension, malaise

and a severe febrile reaction after the transfusion of a

unit of granulocytes suspended in 400 ml of plasma

with an anti-K titre of 128 Investigations showed that

transfusions of granulocytes given during the previous

2 days contained about 30 ml of K-positive red cells

(Morse 1978)

Destruction of recipient’s red cells by passively

acquired antibodies

Very few haemolytic transfusion reactions due to the

accidental transfusion of plasma containing anti-D

have been described In one case, a patient whoreceived 250 ml of fresh-frozen plasma followingcoronary artery bypass surgery developed a haemor-rhagic syndrome 6 h later and was found to have a positive DAT One of the units of fresh-frozen plasmacontained anti-D with a titre of 1000 The patientdeveloped renal failure and acute hepatic necrosis but

eventually recovered (Goldfinger et al 1979).

In 12 infants, injection of an IgM concentrate, containing about 10% IgM and 90% IgG, intended

to protect against Gram-negative bacterial infections,produced mild jaundice and a positive DAT Thepreparation was found to have an anti-D titre of 1000

circulation within about 1 h (Chaplin et al 1956).

Similarly the injection of 50 ml of red cells renderednon-viable by storage at 37°C for 48 h did not producechills, although 90% of the red cells were removedfrom the circulation within 20 min (Jandl andTomlinson 1958)

In contrast, in subjects whose serum containedincomplete anti-D, the injection of 10 ml of washed D-positive red cells produced chills and fever after about

1 h in four out of four cases (Jandl and Kaplan 1960)

A severe reaction, with shivering, has been observed in

a volunteer injected with only 1 ml of anti-D-sensitizedred cells; most of the cells were cleared within 1 h andthe reaction, accompanied by generalized aching,developed about 2 h after the injection of the cells(fourth edition, p 576) Similarly, a D-negative subjectwhose serum contained approximately 40 µg of anti-D/ml developed a feeling of malaise and coldness, shiver-ing and back pain 2–3 h after the injection of 0.25 ml

of red cells of the probable genotype DcE/DcE The

same subject had developed similar symptoms on a

previous occasion following the injection of 0.5 ml of

red cells of the probable genotype Dce/dce, when his

anti-D concentration was only about 10 µg/ml On the

other hand, many other volunteers with anti-D levels

of 40 µg/ml or more had no reactions following the

injection of 0.5 ml of D-positive red cells (HH Gunson,

personal communication) Similarly, no symptoms

have been observed in some 30 subjects injected with

0.5–1.0 ml of red cells heavily coated with anti-D

(PL Mollison, personal observations)

The fever that may develop in association with

extravascular red cell destruction is presumed to result

from liberation of cytokines into the circulation In

experiments in which human monocytes were

incub-ated with anti-D-sensitized red cells, various cytokines

became detectable in the culture supernatants

Cell-associated IL-1β, IL-8 and TNF were detectable at

2 h and clearly identifiable at 4 h The level of TNF

reached a peak at 6 h (Davenport et al 1993) In view

of the slight rise in temperature (0.3°C) and absence of

chills after the injection of 10 ml of washed A or B red

cells to subjects whose serum contains anti-A or anti-B

Jandl and Tomlinson (1958) and Jandl and Kaplan

(1960) some have suggested that the development of

severe febrile reactions following red cell destruction

by anti-D may be related to events that occur during

splenic sequestration

Oliguria associated with extravascular

destruction

Oliguria is unusual after Rh-incompatible

transfu-sions In one series, oliguria developed in none out of

four cases caused by anti-D and in only one out of six

cases due to anti-c (Pineda et al 1978a), and in another

series in only 2 out of 10 cases due to anti-D (Vogel

et al 1943) The latter series was exceptional in that

(1) most subjects were presumed to have had

excep-tionally potent anti-D following many transfusions of

D-incompatible blood and (2) 7 out of 10 developed

haemoglobinuria, an uncommon finding after

trans-fusion of Rh D-incompatible blood Anuria was not

observed in any of the foregoing cases but occurred in

3 out of 10 cases due to anti-K and in 1 out of nine

cases due to anti-Jkain a Mayo Clinic series (Pineda

et al 1978a).

The cause of the renal damage when incompatibility

is associated with antibodies other than anti-A and

anti-B is a matter of speculation Some of the antibodiesconcerned activate complement but are either non-

lytic or only weakly lytic in vitro, and bring about extravascular destruction in vivo As these cases

suggest an association between renal failure andhaemoglobinuria, it is possible that circulating Hbtriggers renal failure, possibly by binding nitric oxide.Alternatively, the release of endothelin following the generation of IL-1 may be a precipitating factor(Capon and Goldfinger 1995) The patients concernedare often already seriously ill and may have problemssuch as hypotension that contribute to the develop-ment of renal failure

Destruction of red cells rendered non-viable

by storageThe removal of non-viable red cells from the blood-stream is not associated with the liberation of anydetectable amount of Hb into the plasma This conclu-sion is based on observations with 51Cr-labelled redcells (Jandl and Tomlinson 1958; see also Fig 11.3)and on sensitive measurements of plasma Hb (Cassell

0

100 80 60 40

20

10 8

Minutes

Fig 11.3 Rate of destruction of ‘non-viable’ stored red cells.

A sample of blood was taken from a normal subject and stored at 4°C with trisodium citrate for 2 weeks The red cells were then washed, labelled with 51 Cr, washed again and injected As the figure shows, over 90% of the red cells were removed from the circulation in 2 h The amount

of radioactivity in the plasma never exceeded a level corresponding to 0.2% of the total dose injected.

and Chaplin 1961), and applies to red cells stored in

the frozen as well as in the liquid state (Valeri 1965)

After transfusion of non-viable stored red cells, the

serum bilirubin concentration normally reaches a peak

about 5 h after transfusion (Mollison and Young 1942;

Vaughan 1942) Jaundice is commonly observed in

subjects with severe injuries who receive transfusions

of large volumes of stored blood In a series of 16

care-fully studied cases, hyperbilirubinaemia reached a

maximum about 5 days after the initial transfusion

All the subjects had bilirubin as well as elevated

uro-bilinogen in the urine, indicating some interference

with liver function In these circumstances a

trans-fusion of stored blood acts as a crude measure of liver

function (Sevitt 1958)

Does loading of the mononuclear phagocyte

system with non-viable red cells increase

susceptibility to infection?

Experiments in mice suggest that loading with

erythro-cytes has some effect on the cells of the MPS, which

makes them less effective in killing engulfed bacteria

(Kaye and Hook 1963) It is not known whether

this finding can be extrapolated to indicate that

trans-fusion of large amounts of non-viable red cells is

potentially harmful However, a small number of

observational studies of different patient populations

have demonstrated a statistical association between

prolonged storage of allogeneic blood and (1) rate

of infection in trauma patients, (2) mortality in the

intensive care unit and (3) postoperative pneumonia in

open-heart surgery patients (Klein 2003)

Delayed haemolytic transfusion

reactions

When incompatible red cells are transfused, the

amount of antibody in the recipient’s serum may be

too low to effect rapid red cell destruction or even

to be detected by sensitive compatibility tests

How-ever, the transfusion may provoke an anamnestic

immune response so that, a few days after transfusion,

a rapid increase in antibody concentration develops

and rapid destruction of the transfused red cells

occurs

Hédon (1902) was the first to describe a DHTR After finding

that rabbit serum that agglutinated and lysed red cells from

pigs, horses and humans had scarcely any effect on dog red cells, he tried transfusing washed dog red cells to rabbits After removing 120 ml of blood from a rabbit over a period

of 1 h, he transfused it with 50 ml of a saline suspension of dog red cells For the next 3 days the rabbit passed urine of

a normal colour, but on the fourth day haemoglobinuria developed By the fifth day the urine had turned black On the sixth day the urine was deep yellow and by the eighth day after the transfusion had returned to a normal colour Hédon noted that on about the fourth day after transfusion the serum of the rabbit became haemolytic and strongly agglutinating for dog red cells When a second transfusion

of dog red cells was given to rabbits immediate globinuria developed and, if a sufficient amount of red cells was transfused, rapid death ensued.

haemo-Virtually all DHTRs are due to secondaryresponses Most commonly, the recipient has beenimmunized by one or more transfusions or pregnan-cies Occasional DHTRs are observed following thetransfusion of ABO-incompatible blood to a subjectwho has not been transfused previously, but subjectslacking A or B display typical secondary responseswhen exposed to these antigens and can be regarded

as being always primarily immunized In theory, aDHTR could be caused by a primary immune responsebut this event is expected to be rare The most potentred cell alloantigen apart from A and B is Rh D.Following the transfusion of D-positive blood to a D-negative recipient, anti-D is seldom detectable before

4 weeks and even then is present only in low tration No case of a DHTR due to primary immuniza-tion to Rh D has been described but two suggestive casesinvolving immunization to K:6 and C, respectively,have been reported In both, the interval betweentransfusion and the onset of red cell destruction wasfar longer than in the usual DHTR and, in one case

concen-at least, previous immunizconcen-ation was unlikely

1 A white woman who had had four pregnancies by her

K:6-negative husband, but who had had no earlier fusions, developed a haemolytic syndrome 23 days after being transfused with 3 units of blood, one of which was K:6 positive The unit was from a black donor; the frequency

trans-of the K:6 phenotype is 19% in black people but only 0.1% in white people The patient’s PCV, which, 5 days earlier had been 30%, fell to 25%, her reticulocyte count rose to 16% and her serum bilirubin to 2.1 mg/dl; spherocytosis was present Her serum was found to contain anti-K6 Although the DAT was negative, anti-K6 was eluted from her red cells

(Taddie et al 1982).

2 A previously untransfused woman of probable Rh

geno-type DcE/dce with a husband of probable genogeno-type DCe/DCe

was transfused with 12 units of blood after her first delivery.

Five days later, her Hb concentration was 104 g/l Four weeks

later she developed haemoglobinuria; her Hb at that time

was 80 g / l and her DAT was weakly positive with

anti-complement only After a further 5 days, the Hb was 89 g/l,

the reticulocyte count was 17% but the haemoglobinuria had

ceased Eight weeks after delivery, anti-C was detectable in

the plasma for the first time (Patten et al 1982)

Immuniza-tion to C during pregnancy may have played some role in this

immune response (Mollison and Newland 1976).

Early descriptions of delayed haemolytic

transfusion reactions in humans

The case described by Boorman and co-workers (1946)

as a ‘delayed blood-transfusion-incompatibility

reaction’ seems to be the first account of a DHTR in

humans The patient was a young woman with

pul-monary tuberculosis and haemolytic anaemia; her

blood group was A2 She was given a transfusion of

group O blood and, between 4 and 7 days afterward,

8 units of group A blood At least 7 units were

sub-sequently shown to be A1 One week after the last

transfusion she became severely jaundiced and

anti-A1, which had not previously been detected in her

serum, was demonstrable (titre 32 at 37°C); some

20% of the group O transfused cells were still present

in the circulation, but there were no circulating A1cells.Other early descriptions of DHTR in humansinclude: (1) haemoglobinuria developing 8 days aftertransfusion shown to be due to anti-K [Collins, quoted

by Young (1954)]; (2) accelerated destruction of

Rh D-positive red cells starting on about the fourth day after transfusion (Mollison and Cutbush 1955;Fig 11.4); and (3) jaundice and oliguria developing

10 days after the first of a series of transfusions, shown

to be due to anti-k (Fudenberg and Allen 1957)

Clinical features of delayed haemolytictransfusion reactions

The most constant features are fever and a fall

in Hb concentration (Pineda et al 1978a) Other

features that are often observed are jaundice andhaemoglobinuria

Jaundice

Jaundice does not appear before day 5 after fusion In nine reported cases in which adequate datawere provided, jaundice was first noted at a mean of6.9 days after transfusion (see fourth edition, p 619).Jaundice may occur as late as 10 days after transfusion

Fig 11.4 Delayed haemolytic reaction

due to anti-D The patient was transfused with 1 unit of D-positive blood on day 0 before it was realized that her serum contained a trace of anti-D There were no signs of red cell destruction and 3 days later when a test dose of 1 ml of D-positive red cells was given, only 10% of the cells were destroyed within 24 h However, between days 4 and 5 almost all the remaining labelled cells and presumably also the transfused red cells were destroyed; the anti-D titre started to increase on day 3 and reached 1000 on day 9 (data from Mollison and Cutbush 1955).

Haemoglobinuria is not uncommon in patients with

DHTRs, and may occur in association with antibodies

of many different specificities: anti-Jka(Rauner and

Tanaka 1967); anti-Jkb(Kurtides et al 1966; Holland

and Wallerstein 1968); anti-C (or Ce), in five cases

described by Pickles and colleagues (1978); anti-c

(Roy and Lotto 1962); anti-c plus anti-M (Croucher

et al 1967); anti-U (Meltz et al 1971; Rothman et al

1976); anti-HI, -Jkb, -S and -Fyb(Giblett et al 1965);

anti-E, -K, -S and -Fya (Moncrieff and Thompson

1975); and anti-c, -E and -Jkb(Joseph et al 1964) In

these 15 cases the mean interval between transfusion

and haemoglobinuria was 7.9 days

The association of anti-C (or -Ce) with

haemo-globinuria is surprising Apart from the five cases

mentioned in the preceding paragraph, in all of

which the antibody titre was relatively low, at least

three cases have been encountered at the Puget

Sound Blood Center, all characterized by intravascular

haemolysis associated with anti-C reacting weakly

in vitro (ER Giblett, personal communication,

1981)

DHTRs in patients with sickle cell disease frequently

present with haemoglobinuria An 11-year

retro-spective chart review of paediatric patients with a

dis-charge diagnosis of sickle cell disease and transfusion

reaction found seven patients who developed nine

episodes of DHTR occurring 6 –10 days after

trans-fusion (Talano et al 2003) Each presented with fever

and haemoglobinuria All but one patient experienced

pain initially ascribed to vaso-occlusive crisis The DAT

was positive in only two out of the nine episodes

The presenting Hb was lower than pretransfusion

levels in eight out of the nine events Severe

com-plications observed after the onset of DHTR included

acute chest syndrome (3), pancreatitis (1), congestive

heart failure (1), and acute renal failure (1) It is

particularly important to consider this possibility in

patients with apparent exacerbations of sickle cell

syndromes within 10 days of transfusion, and to avoid

additional transfusions when possible When

trans-fusion is necessary, red cells typed to avoid a variety

of antigens known to provoke these reactions should

be provided if the patient’s extended phenotype is

not available to assist with blood selection (Diamond

et al 1980).

Renal failure

DHTRs are only occasionally followed by renal ure Moreover, when this complication does occur it isusually difficult to know what role, if any, has beenplayed by the transfusion reaction, as the patients concerned often have concomitant failure of other systems Although renal failure occurred in the casereported by Meltz and co-workers (1971) associatedwith anti-U, there was little evidence that the renaldamage was due to intravascular lysis In a casereported by Holland and Wallerstein (1968) due toanti-Jkb, oliguria and uraemia developed about 2 weeksafter the transfusion of 3 units of Jk(b+) blood; anadditional unit of Jk(b+) blood was transfused at aboutthe time of onset of oliguria Renal failure has beenreported in sickle cell patients with DHTR (Talano

fail-et al 2003), but this is often in the sfail-etting of

general-ized sickling in patients with underlying renal disease.Although renal failure was noted in 4 out of 23

DHTRs reported from the Mayo Clinic (Pineda et al.

1978a), all of the patients had serious underlying ease; in a later series from the same institution, not asingle case of renal failure was reported in 37 patients

jaun-When signs of red cell destruction develop within

24 – 48 h of transfusion, the patient has usually beentransfused during the development of a secondaryresponse to a transfusion given some days previously

A case described by Lundberg and McGinniss (1975)

of an A2B patient who developed anti-A1 is a goodexample The patient had been sensitized by an initialtransfusion of A1-positive blood and received a secondtransfusion of A1-positive blood 6 weeks later A third transfusion of A1-positive blood, given 5 daysafter the second, was followed within 48 h by signs ofred cell destruction, most likely because a secondaryresponse to the second transfusion was developing.Anti-A1was not detected in the compatibility test atthe time of the second transfusion, but was active at37°C 4 days later

In one exceptional case, signs of red cell destruction

did not develop until about 3 weeks after a 6-unit

transfusion given during a splenectomy Anti-Fybwas

detected in the patient’s serum The late onset of red

cell destruction might have been related to an altered

immune response associated with the splenectomy

(Boyland et al 1982).

In DHTR, incompatible cells are not usually found

in the recipient’s circulation more than about 2 weeks

after the transfusion, although in the case illustrated

in Fig 11.5 incompatible cells could still be detected

3 weeks after transfusion

Occasionally, signs of an IHTR and of a delayed

reaction are combined, such as when the recipient has

a relatively low-titre antibody, so that there are only

very mild signs of red cell destruction at the time of

transfusion and further signs of destruction develop a

few days later as the antibody reappears in the tion An example of such a reaction is shown in Fig 11.6

circula-Haematological and serological features ofdelayed haemolytic transfusion reactions

Haematological findings

The regular occurrence of anaemia has already beendescribed

Spherocytosis is often noted in blood films taken

from patients during DHTR and may be the first indication that red cell destruction is occurring Whenlarge amounts of blood have been transfused, themajority of the red cells in the patient’s blood may beinvolved in a subsequent DHTR, and a picture closely

resembling AIHA may develop (Croucher et al 1967).

0 0

Fig 11.5 Slow destruction of transfused red cells in a

delayed haemolytic transfusion reaction due to anti-Jk a

The direct antiglobulin test (DAT) became weakly positive

6 days after an uneventful transfusion, but no alloantibodies

could be detected in the plasma On the same day that a

dose of 51 Cr-labelled red cells was injected, anti-Jk a was

detected in the plasma Although the titre of anti-Jk a rose

to 64 on day 9 and to 128 by day 12, the labelled red cells,

and presumably the transfused red cells, were eliminated slowly, over a period of 3 weeks after the original transfusion It may be relevant that the patient’s spleen had been removed at the time of the original transfusion The maximum rate of red cell destruction occurred between days

8 and 10 when mild haemoglobinaemia and a fall in plasma haptoglobin (Hp) were observed (from (Mollison and Newlands 1976).

The patient had had two pregnancies and a blood transfusion

between 16 and 18 years previously On the present occasion

she had been transfused with 9 units of blood in 6 days

because of severe bleeding from fibroids On day 6 she

under-went a hysterectomy but, although the bleeding stopped, her

Hb concentration continued to fall From day 7 onwards, and

up to about day 20, spherocytes were present on her

peri-pheral blood films Jaundice was noticed on day 9 and began

to fade by day 13 Her urine contained ‘blood’ on day 10 On

the same day her Hb concentration was found to have fallen

to 62 g/l, the reticulocyte count was 13%, the serum bilirubin

concentration 4.5 mg/dl, and the Hp concentration was nil.

The DAT was strongly positive A minor degree of red cell

autoagglutination was observed and the serum reacted with

all 30 samples tested Based on the findings, the diagnosis of

AIHA seemed possible However, a sample composed largely

of the recipient’s own red cells was obtained by differential

centrifugation and these cells were found to have a negative

DAT and did not react with the patient’s own serum The

patient’s serum was found to contain the alloantibodies

anti-Fy a , anti-Ce and anti-e.

Serological findings Positive direct antiglobulin test Characteristically,

the DAT becomes positive a few days after transfusionand remains positive until the incompatible transfusedred cells have been eliminated (but see below) By mak-ing an eluate from the red cells it may be possible toidentify the alloantibody responsible for the reaction

at a time when antibody can be detected only withdifficulty in the patient’s plasma

Antibody in plasma It is typical of DHTRs that even

when antibody has been present in the recipient’splasma immediately before transfusion, no free anti-body is found for several days after transfusion.Typically, antibody becomes detectable between about

4 and 7 days after transfusion and reaches a peak valuebetween 10 and 15 days after transfusion

1000

10 100

1 0

Fig 11.6 Mild immediate haemolytic reaction combined

with a delayed haemolytic reaction following the transfusion

of 7.5 units of group A blood to a group O subject whose

plasma contained a relatively low-titre anti-A (32) The

only sign of immediate red cell destruction was transient

haemoglobinaemia During the following 3 days, no anti-A

could be detected in the plasma although appreciable

destruction of group A red cells occurred from day 2

onwards and the serum bilirubin concentration reached

a peak on day 4 Following the reappearance of anti-A, red cell destruction accelerated and was complete by day 7 Estimates of the survival of group A red cells were made by the differential agglutination/ 51 Cr method referred to on

p 347 As indicated, the direct antiglobulin test (DAT) turned negative by day 6 However, the results shown refer

to tests with anti-IgG With anti-C3d the test was still positive on day 11 (sixth edition 1979, p 579, supplemented by unpublished data).

A negative patient was transfused with 6 units of

positive blood during vascular surgery because insufficient

D-negative blood was available and because no anti-D had been

detected in his serum before transfusion A routine blood film

5 days after transfusion showed striking microspherocytosis,

which led to the discovery that the DAT was strongly positive

and that potent anti-D was present in the serum Retesting of

the pretransfusion sample of serum showed a very low

con-centration of anti-D, estimated at 0.004 µg/ml; subsequent

estimates were as follows: day 6, 90 µg/ml; day 9, 500 µg/ml;

and day 12, 460 µg/ml.

In a case reported by Beard and co-workers

(1971), the anti-D concentration was higher on day 14

(162 µg/ml) than on day 8 (95 µg/ml)

Some other serological findings in delayed

haemolytic transfusion reactions

Persistent direct antiglobulin reactions following

delayed haemolytic transfusion reaction. Some

DHTRs are first diagnosed when the recipient requires

a further blood transfusion and routine tests show that

the previously negative DAT has turned positive As

the amount of the induced antibody increases in the

recipient’s plasma, the surviving incompatible red cells

become coated with a sufficient amount of antibody to

yield a positive DAT and the test will remain positive

until the incompatible cells have been cleared from the

circulation In practice, the situation is even more

com-plex, because the DAT may remain positive after all

transfused cells have been cleared from the circulation

In one series of DHTR, the DAT was found to be

positive with anti-C3d 11 days or more after the

last transfusion in at least 21 out of 26 cases The

DAT often remained positive for at least 3 months

In a minority of cases the red cells reacted with

anti-IgG as well as with anti-C3d (Salama and

Mueller-Eckhardt 1984) In another series mainly delayed

serological transfusion reactions (‘DSTR’: see below),

the DAT also remained positive for long periods after

transfusion – for at least 25 days in 13 out of 15 cases

In this series, the red cells reacted with anti-IgG in 12

out of 15 cases, with anti-complement as well in five

and with anti-complement alone in one (Ness et al.

1990) In both the foregoing series, in a minority

of cases, alloantibody apparently having the same

specificity as that in the serum could be eluted from

circulating red cells many weeks after transfusion

These findings await explanation, although the

pos-sibility that they represent concurrently producedautoantibodies that either bind alloantibody or mimicalloantibody has substantial supportive evidence

(Weber et al 1979).

Development of warm autoantibodies in association with alloimmunization and delayed haemolytic transfusion reaction

Although alloimmunization to erythrocyte antigens

is a recognized complication of heavily transfusedpatients, the frequency of concurrent autoantibodyformation is an important but less well-appreciatedoccurrence Dameshek and Levine (1943) first describedthis phenomenon more than 60 years ago in a casereport of an alloimmunized patient who developed

an autoantibody that resulted in a severe haemolyticepisode The clinical spectrum of these autoanti-bodies ranges from asymptomatic serological detec-tion to severe life-threatening haemolysis Chaplin and Zarkowsky (1981) described four patients withsickle cell anaemia who suffered severe autoimmunehaemolysis after red blood cell transfusion All fourhad previously been alloimmunized These patientswere treated with glucocorticosteroids with good clinical responses and the eventual reversion of theirDAT results to negative In a retrospective review,Castellino and colleagues (1999) described a series

of 184 children with sickle cell anaemia, 14 (7.6%) ofwhom appeared to have transfusion-associated IgGwarm-reactive red blood cell autoantibodies Four

of the 14 patients with autoantibodies developed clinically significant haemolysis

Although most of the reported patients have beentransfused for sickle cell disease, in a recent series,three of four patients had different disorders In onecase, the autoantibody found on routine screening had

no clinical significance In another case, the body made accurate blood typing and subsequenttransfusion exceedingly difficult Two patients experi-enced haemolysis as a consequence of the autoanti-

autoanti-body (Zumberg et al 2001) A typical patient is

described below:

A 64-year-old woman with a history of stage IIB matory carcinoma of the right breast underwent high-dose chemotherapy and autologous peripheral blood progenitor cell transplantation Her blood type was A, Rh positive, and results of serum antibody screen were negative on eight

inflam-separate occasions During the 5-month treatment interval

prior to the autologous stem cell transplantation, she had

received 8 units of group A-compatible red blood cells

with-out incident The post-transplantation course was complicated

by neutropenic fever, requiring intravenous antibiotics, and

herpetic oesophagitis was treated successfully with

famci-clovir She received an additional 6 units of red blood cells

and 43 units of platelets, all gamma irradiated during the

peritransplantation period A DAT performed 6 days after

transplantation was negative.

Ten weeks after discharge, the patient developed a

low-grade fever nausea and mild diarrhoea Her PCV had fallen

from 0.34 to 0.28 Serological screening revealed anti-E and a

weakly positive DAT with polyspecific antihuman globulin

and anti-C3b-C3d reagents The patient received 2 units of

E-negative compatible red blood cells Two weeks later, the

PCV had fallen to 0.17, the lactate dehydrogenase level had

risen to 542 units/l (normal range 113 –226 units/l), and the

bilirubin level had risen to 44 µmol/l (2.6 mg/dl) (normal

range, 1.7–17 µmol/l (0.1–1.0 mg/dl) There was brisk

haemolysis, with spherocytes on the blood film During the

next 2 weeks, serological studies confirmed the presence of an

anti-E, a positive DAT with anti-IgG and anti-complement

reagents, a panagglutinin in the eluate prepared from the

coated red blood cells and serum reactivity consistent with

a warm-reactive autoantibody No other alloantibodies

were identified The patient required 15 additional

com-patible red blood cell transfusions for the management of

her haemolysis The possibility of drug-associated antibodies

was investigated and eliminated She was eventually treated

with a short course of high-dose methylprednisolone sodium

succinate, with resolution of autoimmune haemolysis over

the next 2 weeks.

The mechanism of the allo/autoimmune response is

unknown It has been proposed that passively acquired

erythrocyte alloantibodies bound to recipient

antigen-positive red blood cells lead to a conformational

change in surface antigen epitopes These changes

may increase the chance that the recipient red blood

cells will be recognized as foreign by normal immune

surveillance cells and lead to the subsequent formation

of an autoantibody (Castellino et al 1999).

The importance of recognizing this syndrome lies in

the approach to treatment, which may favour

corticos-teroids and recombinant erythropoietin over additional

transfusion

Development of cold autoagglutinins After repeated

transfusion of rabbits, cold autoagglutinins may

develop It seems that, in humans also, potent cold

autoagglutinins may sometimes develop in associationwith alloimmunization

In a case described by Giblett and co-workers (1965), a 15-year-old boy with thalassaemia major who had received several previous transfusions was again transfused without immediate ill-effect, but 7 days later complained of back pain and passed red urine During the following days, his liver enlarged rapidly, his PCV fell precipitously and methaemo- globinaemia was detectable; during a 3-day period his DAT was positive and a potent cold agglutinin of specificity ‘pseudo- anti-IH’ appeared in his serum The authors concluded that the episode of red cell destruction was probably not due to this agglutinin but to other antibodies such as anti-S and anti-Fy b that later became detectable in the patient’s plasma.

A similar case was encountered by GN Smith (personal communication) In a child aged 11 years with thalassaemia major, the transfusion of 2 units of blood produced an initially satisfactory response but 6 days after transfusion severe anaemia (Hb 3 g/dl) and jaundice developed Anti-E, anti-Fy b and anti-

Jk b were found in the serum together with a potent cold autoagglutinin of a specificity related to H Although the autoagglutinin was active up to a temperature of about 30°C

in vitro and was associated with a positive DAT (complement

only) its contribution to the haemolytic process is uncertain.

Are the recipient’s own red cells destroyed at an accelerated rate in some delayed haemolytic transfusion reaction?

The finding, referred to above, that following a DHTRthe recipient’s red cells may develop a positive DATthat persists for at least many weeks does not implyeither that an autoantibody is involved or that the cells are undergoing accelerated destruction

In a case described by Polesky and Bove (1964), there was good evidence of accelerated destruction of the patient’s own red cells following a haemolytic transfusion reaction due to anti-Jk a By a fortunate chance, the patient’s own red cells had been labelled with 51 Cr for a red cell survival study and had been shown to be surviving normally for 1 week before the incompatible transfusion was given After the haemolytic reaction due to anti-Jk a , there was a rapid and substantial increase in the rate of destruction of the patient’s own red cells It has been suggested that the phenomenon of reactive lysis, the lysis of ‘bystander’ cells by C5b6 released from cells undergoing lysis by the membrane attack complex

of complement, may explain the destruction of some of the recipient’s red cells in haemolytic transfusion reactions

(Greene et al 1993).

Although little evidence supports this hypothesis,

the phenomenon might account for red cell

destruc-tion in patients of groups A or B grafted with group O

bone marrow, in whom transfused group O cells may

be haemolysed (Gajewski et al 1992).

Alloantibodies involved in delayed haemolytic

transfusion reactions

In estimating the relative frequency with which

dif-ferent antibodies are involved, reviews of individual

case reports are misleading because of the propensity

to publish unusual cases The best estimates can be

obtained by analysing experience from particular

cen-tres over a relatively long period Three such series are

available for analysis: (1) Mayo Clinic, 1964 –73, 23

cases (Pineda et al 1978b); (2) Mayo Clinic, 1974 –77,

37 cases (Moore et al 1980); and (3) Toronto General

Hospital 1974–78, 40 cases (Croucher 1979)

In each series there were cases in which more than

one alloantibody was found in the patient’s serum In

the following analysis, the published figures for the

number of such cases have been revised slightly as

fol-lows: first, when both alloantibodies belonged to the

same blood group system, for example c and

anti-E, the patient has been regarded as having only a single

antibody; second, when one of the alloantibodies was

known to be a common cause of a DHTR, such as

anti-Jka, and the second alloantibody was a cold agglutinin

such as anti-P1, which hardly ever causes a DHTR,

the case has again been regarded as having only one

specificity, i.e anti-Jka in this example With these

minor revisions the figures for the 100 cases were as

follows: one alloantibody, 90 cases; two

alloanti-bodies, 10 cases; of the cases in which only one antibody

was found the specificities of the antibodies were as

follows: Rh system, 31 (34.4%); Jk system, 27 (30%);

Fy system, 13 (14.4%); Kell system, 12 (13.3%);

MNSs system, 4 (4.4%); and others, 3 (3.3%) Among

the 10 cases in which more than one specificity was

found, the specificities were as follows: Rh, 8; Kell, 6;

Jk 3; Fy, 2; and S, 1 In Chapter 3 (Table 3.6) these

figures are compared with the relative frequencies with

which the different red cell alloantibodies are found

in random transfusion recipients and in patients who

have had haemolytic transfusion reactions

Further details of the figures given above are as

fol-lows: of the 90 cases in which only one antibody was

involved, Rh system: anti-D or -D, -E, 3; -c, 5; -c, -E, 6; -E, 12; -C or -Cw, 3; -C, -E, 1; -e, 1; Jk system: 27 (-Jka,24; -Jkb, 23); Fy system: 13 (all -Fya); Kell system:

12 (all anti-K); MNSs system: 4 (-M, 2; -S, 1; -s, 1);anti-A1, 1; anti-Lea, -Leb(see comment below), 1; andunidentified, 1

As expected, anti-D is involved relatively quently, that is when, owing to a shortage of D-negative blood, D-positive blood is transfused to a D-negative subject whose plasma lacks detectable anti-D but who has been sensitized in the past by eitherprevious transfusion or previous pregnancy

infre-Antibodies not mentioned in the above list but mentioned earlier in the chapter include anti-A, -B, -k,-Fyband -U Others that have been implicated include

anti-ce(f) (O’Reilly et al 1985), anti-N (Ballas et al.

1985), anti-Lub(Greenwalt and Sasaki 1957), anti-Dib

(Thompson et al 1967), anti-Dob (Moheng et al.

1985) and anti-Cob(Squires et al 1985).

Cold alloantibodies have only very rarely beeninvolved: anti-A1 in five published cases (Boorman

et al 1946; Salmon et al 1959; Perkins et al 1964; Lundberg and McGinniss 1975; Pineda et al 1978a);

anti-P1in one (Dinapoli et al 1977); and anti-M in one (Alperin et al 1983).

Lewis antibodies have been believed to be

respons-ible for a DHTR in two cases (Pineda et al 1978b; Weir et al 1987), but neither case is entirely convinc-

ing The fact that transfused red cells rapidly assumethe Lewis phenotype of the recipient makes it unlikelythat Lewis antibodies can cause DHTR For an ex-ample of a case in which, following the transfusion

of Le(a+) red cells to an Le(a–b–) subject, a powerful secondary response failed to produce a DHTR, seeChapter 10

DHTR associated with ABO-incompatible bone marrow transplantation

In the first case to be reported, a patient of group O was prepared for a transplant of bone marrow from a group AB donor by a plasma exchange of 11 l, which reduced the anti-A and anti-B titres of the plasma to low levels Four units of group AB cells were then transfused without reaction, followed by the bone marrow The total volume of AB cells transfused, including those in the transplanted marrow, was estimated at 1625 ml On the sixth day after transplantation the patient became acutely dyspnoeic and was found to have

a PCV of 0.18, a positive DAT and hyperbilirubinaemia

with extensive agglutination of red cells on a blood smear.

Anti-A and anti-B were eluted from circulating red cells The

patient was given group O red cells and corticosteroids and

recovered rapidly (Warkentin et al 1983).

Frequency of delayed haemolytic transfusion

reactions

In three successive series from the Mayo Clinic over

the period 1964–80, the frequency with which DHTRs

were diagnosed, in relation to the numbers of units

of blood transfused, increased as follows: 1964 –73,

1 per 11 650; 1974 –77, 1 per 4000; and 1978–80,

1 per 1500 The increase was attributed to a number of

factors, including the introduction of more sensitive

methods of antibody detection and a greater

aware-ness of the syndrome, leading to an increasing

tend-ency to include asymptomatic cases (Taswell et al.

1981) This latter point raises the question of the

criteria for diagnosis

The definition of a DHTR is accelerated destruction

of transfused red cells after an interval, during which

the recipient mounts an immune response to an

anti-gen carried by the transfused cells The problem is that,

whereas it is relatively easy to demonstrate that a ‘new’

antibody has been produced following transfusion,

it may be difficult to diagnose accelerated destruction

of transfused red cells The usual clinical criteria of

increased destruction, fever and progressive anaemia,

sometimes accompanied by jaundice or

haemoglobin-uria, have been discussed above, but the absence of all

of these signs clearly does not exclude relatively minor

increases in the rate of destruction An example of a

subclinical DHTR is given in Fig 11.5

Concept of delayed serological transfusion

reaction

The term DSTR has been used to describe an anamnestic

response following a transfusion but with no signs

of haemolysis (Ness et al 1990) The concept is not

entirely satisfactory because there are bound to be

dif-ferences in the assiduity with which signs of

destruc-tion are sought For example, one observer might be

satisfied to look for jaundice, whereas another would

make daily estimations of serum bilirubin

concentra-tion Furthermore, accelerated destruction of red cells

may be silent, detectable only by direct measurement

of red cell survival (Fig 11.5) Despite the absence of

a clear-cut distinction from a DHTR, the concept of

a DSTR is a useful one, as it recognizes the fact thatanamnestic responses without overt signs or symp-toms of haemolysis are common

Frequency of delayed haemolytic transfusion reaction and delayed serological transfusion reaction

Between 1980 and 1992 more than half a million units

of blood or red cells were transfused at the MayoClinic Diagnoses of DHTR vs DSTR were madewhile the patient was hospitalized or shortly after dis-charge The frequency of DHTR was 1 in 5405 unitsand that of DSTR 1 in 2990 units (combined frequency

1 in 1899 units) Anti-Jka and anti-Fya were morelikely to be associated with a DHTR than a DSTR, butthe converse was true for antibodies belonging to the

Rh and Kell systems (Vamvakas et al 1995) In a much

smaller series (about 50 000 units transfused to about

10 000 patients), the frequency of DSTR was similar (1 per 3000 units) but that of DHTR was less than one

per 10 000 units (Pinkerton et al 1992).

In a prospective study, 530 patients, 183 of whomhad been pregnant or had been transfused previously,were tested 1 week after they had undergone cardiacsurgery involving transfusion, most commonly of 2– 6units Of the 530, 2% developed new antibodies butnot one developed a positive DAT or signs of red cell

destruction (Hewitt et al 1988).

A high incidence of DHTR was reported in a smallseries of patients undergoing partial exchange trans-fusion in sickle cell disease Of 18 patients, three

developed a DHTR (Diamond et al 1980) Similarly,

in a series of 107 patients with sickle cell disease whoreceived regular transfusions, 14 developed a DHTR

(Vichinsky et al 1990) This is much higher than the

combined frequency of DSTR and DHTR (9%) in

other series (Aygun et al 2002).

Mortality associated with delayed haemolytictransfusion reactions

When patients die during the course of a DHTR, it isusually difficult to implicate the transfusion reaction as

a cause of death The series of Pineda and co-workers