Chapter 109: Transfusion Biology and Therapy

Antigens systems important in transfusion medicine comprise red blood cell (RBC), platelet, neutrophil, and the widely distributed human leukocytes (HLA) antigens.

The study of RBC antigens and antibodies forms the foundation of transfusion medicine. Serologic studies initially characterized these antigens, but now the molecular composition and structure of many are known. Antigens, either carbohydrate or protein, are assigned to a blood group system based on the structure and similarity of the determinant epitopes. Other cellular blood elements such as platelets and plasma proteins are also antigenic and can result in alloimmunization, the production of antibodies directed against antigenic determinants of another individual. These antibodies, called alloantibodies, can comprise anti-RBC Abs, anti-human platelet antigens (HPA) Abs, as well as anti-human leukocytes antigens (HLA) Ab.

Antibodies directed against RBC antigens may result from “natural” exposure, particularly to carbohydrates that mimic some blood group antigens that are present in the environment, particularly saprophyte bacteria. Those antibodies that occur via natural stimuli are usually produced by a T cell–independent response (thus, generating no immune memory) and are mainly IgM isotype. Autoantibodies (antibodies against autologous blood group antigens) arise spontaneously or as the result of infectious sequelae (e.g., from Mycoplasma pneumoniae) and are also often IgM. These antibodies are often clinically insignificant due to their low affinity for antigen at body temperature. However, IgM antibodies can activate the complement cascade and result in hemolysis. Autoantibodies can also arise in an autoimmune setting with most often an IgG isotype. Antibodies that result from allogeneic exposure, such as transfusion or pregnancy, are usually IgG. IgG antibodies commonly bind to antigen at warmer temperatures and may hemolyze RBCs. Unlike IgM antibodies, IgG antibodies can cross the placenta and bind fetal erythrocytes bearing the corresponding antigen, resulting in hemolytic disease of the newborn, or hydrops fetalis. The same holds true for IgG directed against HPA antigens on platelets that can lead to fetal or neonatal immunization and result in intracranial hemorrhage.

Recipient alloimmunization to leukocytes, platelets, and plasma proteins may also result in transfusion complications such as fevers and urticaria as well as platelet transfusion refractoriness, but generally does not cause hemolysis. Such an alloimmunization in the blood donor may also result in a severe lung disorder called transfusion-related acute lung injury (TRALI). Assay for these non-hemolytic alloantibodies is not routinely performed; however, they may be detected using special assays.

The first blood group antigen system, recognized in 1900, was ABO, the most important in transfusion medicine. The major blood groups of this system are A, B, AB, and O. O type RBCs lack A or B antigens. These antigens are carbohydrates attached to a precursor backbone, may be found on the cellular membrane either as glycosphingolipids or glycoproteins, and are secreted into plasma and body fluids as glycoproteins. H substance is the immediate precursor on which the A and B antigens are added. This H substance is formed by the addition of fucose to the glycolipid or glycoprotein backbone. The subsequent addition of N-acetylgalactosamine creates the A antigen, while the addition of galactose produces the B antigen.

The genes that determine the A and B phenotypes are found on chromosome 9q and are expressed in a Mendelian codominant manner. The gene products are glycosyl transferases, which confer the enzymatic capability of attaching the specific antigenic carbohydrate. Individuals who lack the “A” and “B” transferases are phenotypically type “O,” while those who inherit both transferases are type “AB.” Rare individuals lack the H gene, which codes for fucose transferase, and cannot form H substance. These individuals are homozygous for the silent h allele (hh) and have Bombay phenotype (O_h).

The ABO blood group system is important because essentially all individuals produce antibodies to the ABH carbohydrate antigen that they lack. The “naturally” occurring anti-A and anti-B antibodies are termed isoagglutinins. Thus, type A individuals produce anti-B, while type B individuals make anti-A. Neither isoagglutinin is found in type AB individuals, while type O individuals produce both anti-A and anti-B. Thus, persons with type AB are considered “universal recipients” with regard to RBC transfusion because they do not have antibodies against any ABO phenotype, while persons with type O blood can donate to essentially all recipients because their cells are not recognized by any ABO isoagglutinins. The rare individuals with Bombay phenotype produce antibodies to H substance (which is present on all red cells except those of hh phenotype) as well as to both A and B antigens and are therefore compatible only with other hh donors.

In most people (80%), A, B, and H antigens are secreted by the cells and are present in the circulation as well as in various secretions such as saliva (Se phenotype). Others, called “nonsecretors” do not secrete A, B, and H antigens (se phenotype). ABO and Se/se systems influence the susceptibility to a variety of diseases. For example, malaria is less severe in O than non O patients. Conversely, group O is associated with enhanced susceptibility to Helicobacter pylori (and gastric ulcer) as well as to cholera bacillus or to norovirus. Furthermore, group O individuals exhibit a lesser procoagulation phenotype when compared to non O individuals.

The Rh system is the second most important blood group system in pretransfusion testing. The Rh antigens are found on a 30- to 32-kDa RBC membrane protein that has no defined function. Although >40 different antigens in the Rh system have been described, five determinants account for the vast majority of phenotypes. The two RH genes are located on chromosome 1. The RHD gene codes for the RhD protein. The RHCE gene codes for RhCE proteins expressing C and/or c, and E and/or e antigens. The presence of the D antigen confers Rh “positivity,” while persons who lack the D antigen are Rh negative. Two allelic antigen pairs, E/e and C/c, are also found on the Rh protein. These two Rh genes, RHD and RHCE, determine eight main haplotypes (DCe, DcE, Dce, DCE, dce, dCe, dcE, and dCE) whose frequencies differ among different populations. The high diversity of the RH antigens includes weak or partial expression. Identifying individuals (especially young female of childbearing potential and multi-transfused patients) with a weak or RhD antigen is important to adequately select RhD positive or negative RBC. Molecular biology is now routinely applied to resolve such situations.

The D antigen is a potent alloantigen. About 15% of individuals lack this antigen. Exposure of these Rh-negative people to even small amounts of Rh-positive cells, by either transfusion or pregnancy, can result in the production of anti-D alloantibody.

Thirty-six RBC group systems, six collections (related set of antigens not sufficiently distinct from existing systems to qualify as systems) and two series (low frequency [“private”] and high frequency [“public”] individual antigens) are presently recognized, composed of more than 350 antigens. The presence or absence of certain antigens has been associated with various diseases and anomalies; antigens also act as receptors for infectious agents. Alloantibodies of importance in routine clinical practice are listed in Table 109-1.

Antibodies to Lewis system carbohydrate antigens are the most common cause of incompatibility during pretransfusion screening. The Lewis gene product is a fucosyl transferase and maps to chromosome 19. The antigen is not an integral membrane structure but is adsorbed to the RBC membrane from the plasma. Antibodies to Lewis antigens are usually IgM and cannot cross the placenta. Lewis antigens may be adsorbed onto tumor cells and may be targets of therapy.

I system antigens are also oligosaccharides related to H, A, B, and Le. I and i are not allelic pairs but are carbohydrate antigens that differ only in the extent of branching. The i antigen is an unbranched chain that is converted by the I gene product, a glycosyltransferase, into a branched chain. The branching process affects all the ABH antigens, which become progressively more branched in the first 2 years of life. Some patients with cold agglutinin disease or lymphomas can produce anti-I autoantibodies that cause RBC destruction. Occasional patients with mononucleosis or Mycoplasma pneumonia may develop cold agglutinins of either anti-I or anti-i specificity. Most adults lack i expression; thus, finding a donor for patients with anti-i is not difficult. Even though most adults express I antigen, binding is generally low at body temperature. Thus, administration of warm blood prevents isoagglutination.

The P system is another group of carbohydrate antigens controlled by specific glycosyltransferases. The very rare individuals lacking the P antigen produce an anti-P antibody. Finding a compatible donor for such individuals is difficult. P antigen is also the target of auto-antibodies in diseases such as syphilis and viral diseases in children, and can result in paroxysmal cold hemoglobinuria. In the latter case, an autoantibody to P binds to RBCs in the cold and fixes complement upon warming. Antibodies with these biphasic properties are called Donath-Landsteiner antibodies. The P antigen is the cellular receptor of parvovirus B19 and also may be a receptor for Escherichia coli binding to urothelial cells.

The MNS system is regulated by genes on chromosome 4. M and N are determinants on glycophorin A, an RBC membrane protein, and S and s are determinants on glycophorin B. Anti-S and anti-s IgG antibodies may develop after pregnancy or transfusion and lead to hemolysis. Glycophorin B expresses a public antigen named U. Anti-U antibodies can occur in the rare individuals lacking the U antigen. Such occurrence is problematic; virtually every donor is incompatible because nearly all persons express U.

The Kell protein is very large (720 amino acids), and its secondary structure contains many different antigenic epitopes. The immunogenicity of Kell is third behind the ABO and Rh systems. The Kell protein is linked to another blood group protein termed Kx. The rare absence of this protein (controlled by a gene on X) is associated with weak KEL antigen, acanthocytosis, shortened RBC survival, and a progressive form of muscular dystrophy that includes cardiac defects. This rare condition is called the McLeod phenotype. The K_x gene is linked to the 91-kDa component of the NADPH-oxidase on the X chromosome, deletion or mutation of which accounts for about 60% of cases of chronic granulomatous disease. Such individuals can produce an anti-Kx antibody that makes finding a compatible blood product difficult.

The Duffy antigens are codominant alleles, Fy^a and Fy^b, that also serve as receptors for Plasmodium vivax. More than 70% of persons in sub-Saharan Africa lack these antigens, probably from selective influences of malaria infection on the population. For unknown reasons, the lack of the Duffy antigen receptor for cytokines (DARC) is associated with mild neutropenia.

The Kidd antigens, Jk^a and Jk^b, may elicit antibodies transiently. A delayed hemolytic transfusion reaction (DHTR) that occurs with blood tested as compatible is often related to delayed appearance of anti-Jk^a.

Pretransfusion testing of a potential recipient consists of the “type and screen.” The “forward type” determines the ABO and Rh phenotype of the recipient’s RBC by using antisera directed against the A, B, and D antigens. The “reverse type” detects isoagglutinins in the patient’s serum and should correlate with the ABO phenotype, or forward type. Additional typing for other main Rh antigens (CcEe), the K antigen, and more rarely Duffy, Kidd and Ss antigens, can be required depending on the clinical setting. Molecular typing is increasingly used to predict the RBC phenotype and facilitate the selection of a compatible blood component.

The alloantibody screen identifies antibodies directed against other RBC antigens. The alloantibody screen is performed by mixing patient serum with type O RBCs that contain the major antigens of most blood group systems and whose extended phenotype is known. The specificity of the alloantibody is identified by correlating the presence or absence of antigen with the results of the agglutination. Special attention should be given to patients receiving monoclonal antibody treatment that may bind to RBC (such as anti-CD38 treatment for myeloma) and therefore interfere with alloantibody screening.

Cross-matching is ordered when there is a high probability that the patient will require a packed RBC (PRBC) transfusion. In the setting of a systematic alloantibody screen, such a crossmatch can be restricted to alloimmunized patients as well as patients at high risk of alloimmunization (prior pregnancies, transfusions). Blood selected for cross-matching must be ABO compatible and lack antigens for which the patient has alloantibodies. Nonreactive cross-matching confirms the absence of any major incompatibility and reserves that unit for the patient.

In the case of Rh (D) -negative patients, every attempt must be made to provide Rh-negative blood components to prevent alloimmunization to the D antigen. In an emergency, Rh-positive blood can be safely transfused to an Rh-negative patient who lacks anti-D; however, the recipient is likely to become alloimmunized and produce anti-D. Rh-negative women of childbearing age who are transfused with products containing Rh-positive RBCs should receive passive immunization with anti-D (RhoGam or WinRho) to reduce or prevent sensitization.

Blood products intended for transfusion are routinely collected as whole blood (450 mL) in various anticoagulants. Most donated blood is processed into components: PRBCs, platelets, and fresh-frozen plasma (FFP) or cryoprecipitate (Table 109-2). Whole blood can be first separated into PRBCs and platelet-rich plasma by slow centrifugation. The platelet-rich plasma is then centrifuged at high speed to yield one unit of random donor (RD) platelets (subsequently pooled) and one unit of FFP. Alternatively, whole blood can undergo high speed centrifugation to separate a PRBC, a FFP and a “buffy-coat” containing leukocytes and platelets. The buffy coat then undergoes pooling and is centrifuged at low speed to produce pooled platelets. The leukocyte level of blood products can be lowered by an additional filtration step after which they are referred to as leukoreduced (or leukodepleted) (<1 to 5 × 10⁶ leukocytes per product). Cryoprecipitate is produced by thawing FFP to precipitate the plasma proteins, then separated by centrifugation.

Apheresis technology is used for the collection of multiple units of platelets from a single donor. These single-donor apheresis platelets (SDAP) contain the equivalent of at least five units of RD platelets and before eventual leukoreduced, have fewer contaminating leukocytes than pooled RD platelets.

Plasma as well as RBCs and granulocytes may also be collected by apheresis. Plasma-derived products such as albumin, intravenous immunoglobulin, antithrombin, and coagulation factor concentrates are prepared from pooled plasma from many donors. Plasma fractionation includes steps that eliminate infectious agents.

Whole blood provides both oxygen-carrying capacity and volume expansion. It is the ideal component for patients who have sustained acute hemorrhage of ≥25% total blood volume loss. Whole blood is stored at 4°C to maintain erythrocyte viability, but platelet dysfunction and degradation of some coagulation factors occur. In addition, 2,3-bisphosphoglycerate levels fall over time, leading to an increase in the oxygen affinity of the hemoglobin and a decreased capacity to deliver oxygen to the tissues, a problem with all red cell storage. Fresh whole blood avoids these problems, but it is typically used only in emergency settings (i.e., military). Whole blood is not readily available, since it is routinely processed into components.

This product increases oxygen-carrying capacity in the anemic patient. PRBC are stored in additive solution up to 35–42 days at 4°C. Adequate oxygenation can be maintained with a hemoglobin content of 70 g/L in the normovolemic patient without cardiac disease; however, comorbid factors may necessitate transfusion at a higher threshold. The decision to transfuse should be guided by the clinical situation and not by an arbitrary laboratory value. In the critical care setting, liberal use of transfusions to maintain near-normal levels of hemoglobin has not proven advantageous. In most patients requiring transfusion, levels of hemoglobin of 80 g/L are sufficient to keep oxygen supply from being critically low.

PRBCs may be modified to prevent certain adverse reactions. The majority of cellular blood products are now leukocyte-reduced and universal prestorage leukocyte reduction has been recommended. Prestorage filtration appears superior to bedside filtration as smaller amounts of cytokines are generated in the stored product. These PRBC units contain <1 to 5.10⁶ donor leukocytes, and their use lowers the incidence of posttransfusion fever and chills, cytomegalovirus (CMV) infections, and alloimmunization. Other theoretical benefits include less immunosuppression in the recipient and lower risk of infections with intracellular pathogens (in addition to CMV). Plasma, which may cause allergic reactions, can be removed from cellular blood components by washing. Patients with hemoglobinopathies such as sickle cell disease may undergo RBC exchange, an apheresis procedure by which sickled RBCs are replaced by donor RBCs.

Thrombocytopenia is a risk factor for hemorrhage, and platelet transfusion reduces the incidence of bleeding. Platelets are stored in plasma or in additive solution up to 5–7 days at 20–24°C and under permanent motion. The threshold for prophylactic platelet transfusion is 10,000/μL. In patients without fever or infections, a threshold of 5000/μL may be sufficient to prevent spontaneous hemorrhage. For invasive procedures, 50,000/μL platelets is the usual target level.

Platelets are given either as pools of 4 to 6 prepared RDs or as SDAPs from a single donor. In an unsensitized patient without increased platelet consumption (splenomegaly, fever, disseminated intravascular coagulation [DIC]), two units of transfused RD per square-meter body surface area (BSA) is anticipated to increase the platelet count by ~10,000/uL. Patients who have received multiple transfusions may be alloimmunized to many HLA- and platelet-specific antigens and have little or no increase in their posttransfusion platelet counts. Patients who may require multiple transfusions are best served by receiving leukocyte-reduced components to lower the risk of alloimmunization.

Refractoriness to platelet transfusion may be evaluated using the corrected count increment (CCI):

where BSA is body surface area measured in square meters. The platelet count performed 1 h after the transfusion is acceptable if the CCI is 10 × 10⁹/mL, and after 18–24 h an increment of 7.5 × 10⁹/mL is expected. Patients who have suboptimal responses are likely to have received multiple transfusions and have antibodies directed against class I HLA antigens. Refractoriness can be investigated by detecting anti-HLA antibodies in the recipient’s serum. Patients who are sensitized will often react with 100% of the lymphocytes used for the HLA-antibody screen, and HLA-matched SDAPs should be considered for those patients who require transfusion. Although ABO-identical HLA-matched SDAPs provide the best chance for increasing the platelet count, locating these products is difficult. Platelet cross-matching is available in some centers. Additional clinical causes for a low platelet CCI include fever, bleeding, splenomegaly, DIC, or medications in the recipient.

FFP contains stable coagulation factors and plasma proteins: fibrinogen, antithrombin, albumin, as well as proteins C and S. Indications for FFP include correction of coagulopathies, including the rapid reversal of warfarin; supplying deficient plasma proteins; and treatment of auto-antibody-mediated thrombotic thrombocytopenic purpura (TTP). In the latter case, therapeutic plasma exchange allows both the removal of the autoantibody and the supplementation of the depleted enzyme (ADAMTS13). Other auto-immune diseases such as Guillain-Barré syndrome and myasthenia gravis may benefit from plasma exchange. FFP should not be routinely used to expand blood volume. FFP is an acellular component and does not transmit intracellular infections, e.g., CMV. In addition to FFP, pre-thawed or never frozen plasma as well as freeze-dried plasma are increasingly used to insure immediate availability when required. Patients who are IgA-deficient and require plasma support should receive FFP from IgA-deficient donors to prevent anaphylaxis (see below).

Cryoprecipitate is a source of fibrinogen, factor VIII, and von Willebrand factor (vWF). It is ideal for supplying fibrinogen to the volume-sensitive patient. When factor VIII concentrates are not available, cryoprecipitate may be used since each unit contains ~80 units of factor VIII. Cryoprecipitate may also supply vWF to patients with dysfunctional (type II) or absent (type III) von Willebrand disease.

Plasma from thousands of donors may be pooled to derive specific protein concentrates, including albumin, intravenous immunoglobulin, antithrombin, and coagulation factors. In addition, donors who have high-titer antibodies to specific agents or antigens provide hyperimmune globulins, such as anti-D (RhoGam, WinRho), and antisera to hepatitis B virus (HBV), varicella-zoster virus, CMV, and other infectious agents.

Adverse reactions to transfused blood components occur despite multiple tests, inspections, and checks. Fortunately, the most common reactions are not life threatening, although serious reactions can present with mild symptoms and signs. Some reactions can be reduced or prevented by modified (filtered, washed, or irradiated) blood components. Blood product pathogen reduction is an option for platelets and plasma, and underway for whole blood and PRBC. When an adverse reaction is suspected, the transfusion should be stopped and reported to the blood bank for investigation.

Transfusion reactions may result from immune and nonimmune mechanisms. Immune-mediated reactions are often due to preformed donor or recipient antibody; however, cellular elements may also cause adverse effects. Nonimmune causes of reactions are due to the chemical and physical properties of the stored blood component and its additives.

Transfusion-transmitted viral infections are increasingly rare due to improved screening and testing. As the risk of viral infection is reduced, the relative risk of other reactions increases, such as hemolytic transfusion reactions and sepsis from bacterially contaminated components. However, one must remain concerned by novel or previously unidentified viral risks. Pretransfusion quality assurance improvements further increase the safety of transfusion therapy. Infections, like any adverse transfusion reaction, must be brought to the attention of the blood bank for appropriate actions (Table 109-3).

Acute Hemolytic Transfusion Reactions

Immune-mediated hemolysis occurs when the recipient has preformed antibodies that lyse donor erythrocytes. The anti-A or anti-B antibodies are responsible for the majority of these reactions. However, alloantibodies directed against other RBC antigens, i.e., Rh, Kell, and Duffy, are responsible for fatal hemolytic transfusion reactions as well.

Acute hemolytic reactions may present with hypotension, tachypnea, tachycardia, fever, chills, hemoglobinemia, hemoglobinuria, chest and/or flank pain, and discomfort at the infusion site. Monitoring the patient’s vital signs before and during the transfusion is important to identify reactions promptly. When acute hemolysis is suspected, the transfusion must be stopped immediately, intravenous access maintained, and the reaction reported to the blood bank. A correctly labeled posttransfusion blood sample and any untransfused blood should be sent to the blood bank for analysis. The laboratory evaluation for hemolysis includes the measurement of serum haptoglobin, lactate dehydrogenase (LDH), and indirect bilirubin levels.

The immune complexes that result in RBC lysis can cause renal dysfunction and failure. Diuresis should be induced with intravenous fluids and furosemide or mannitol. Tissue factor released from the lysed erythrocytes may initiate DIC. Coagulation studies including prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, and platelet count should be monitored in patients with hemolytic reactions.

Errors at the patient’s bedside, such as mislabeling the sample or transfusing the wrong patient, are responsible for the majority of these reactions. The blood bank investigation of these reactions includes examination of the pre- and posttransfusion samples for hemolysis and repeat typing of the patient samples; direct antiglobulin test (DAT), sometimes called the direct Coombs test, of the posttransfusion sample; repeating the cross-matching of the blood component; and checking all clerical records for errors. DAT detects the presence of antibody or complement bound to RBCs in vivo (Fig. 109-1).

Delayed Hemolytic and Serologic Transfusion Reactions

DHTRs are not completely preventable. These reactions occur in patients previously sensitized to RBC alloantigens who have a negative alloantibody screen due to low antibody levels. When the patient is transfused with antigen-positive blood, an anamnestic response results in the early production of alloantibody that binds donor RBCs. The alloantibody is detectable 1–2 weeks following the transfusion, and the posttransfusion DAT may become positive due to circulating donor RBCs coated with antibody or complement. The transfused, alloantibody-coated erythrocytes are cleared by the reticuloendothelial system. These reactions are detected most commonly in the blood bank when a subsequent patient sample reveals a positive alloantibody screen or a new alloantibody in a recently transfused recipient.

No specific therapy is usually required, although additional RBC transfusions may be necessary. Delayed serologic transfusion reactions are similar to DHTR, as the DAT is positive and alloantibody is detected; however, RBC clearance is not increased.

Febrile Nonhemolytic Transfusion Reaction

The most frequent reaction associated with the transfusion of cellular blood components is a febrile nonhemolytic transfusion reaction (FNHTR). These reactions are characterized by chills and rigors and a ≥1°C rise in temperature. FNHTR is diagnosed when other causes of fever in the transfused patient are ruled out. Antibodies directed against donor leukocyte and HLA antigens may mediate these reactions; thus, multiply transfused patients and multiparous women are felt to be at increased risk. Although anti-HLA antibodies may be demonstrated in the recipient’s serum, investigation is not routinely done because of the mild nature of most FNHTRs. The use of leukocyte-reduced blood products may prevent or delay sensitization to leukocyte antigens and thereby reduce the incidence of these febrile episodes. Cytokines released from leukocytes within stored blood components may mediate FNHTR; thus, leukoreduction before storage may prevent these reactions. Likewise, cytokines and chemokines released from platelets components, released during storage may also mediate FNHTR.

Allergic Reactions

Urticarial reactions are related to plasma proteins found in transfused components. Mild reactions may be treated symptomatically by temporarily stopping the transfusion and administering antihistamines (diphenhydramine, 50 mg orally or intramuscularly). The transfusion may be completed after the signs and/or symptoms resolve. Patients with a history of allergic transfusion reaction may be premedicated with an antihistamine. Cellular components can be washed to remove residual plasma for the extremely sensitized patient. Most of the allergic presentation may not depend on preformed antibodies and may be attributable to biological response modifiers triggering histamine and serotonin release from platelets and leukocytes.

Anaphylactic Reaction

This severe allergic reaction presents after transfusion of only a few milliliters of the blood component. Symptoms and signs include difficulty breathing, coughing, nausea and vomiting, hypotension, bronchospasm, loss of consciousness, respiratory arrest, and shock. Treatment includes stopping the transfusion, maintaining vascular access, and administering epinephrine (0.5–1 mL of 1:1000 dilution subcutaneously). Glucocorticoids may be required in severe cases.

Patients who are IgA-deficient, <1% of the population, may be sensitized to this Ig class and are at risk for anaphylactic reactions associated with plasma transfusion. Individuals with severe IgA deficiency should therefore receive only IgA-deficient plasma and washed cellular blood components. Patients who have anaphylactic or repeated allergic reactions to blood components should be tested for IgA deficiency. Of note, the importance of the allergic risk associated with IgA deficiency may be overestimated and is currently debated.

Graft-Versus-Host Disease

Graft-versus-host disease (GVHD) is a frequent complication of allogeneic stem cell transplantation, in which lymphocytes from the donor attack and cannot be eliminated by an immunodeficient host. Transfusion-related GVHD is mediated by donor T lymphocytes that recognize host HLA antigens as foreign and mount an immune response, which is manifested clinically by the development of fever, a characteristic cutaneous eruption, diarrhea, and liver function abnormalities. GVHD can also occur when blood components that contain viable T lymphocytes are transfused to immunodeficient recipients or to immunocompetent recipients who share HLA antigens with the donor (e.g., a family donor). In addition to the aforementioned clinical features of GVHD, transfusion-associated GVHD (TA-GVHD) is characterized by marrow aplasia and pancytopenia. TA-GVHD is highly resistant to treatment with immunosuppressive therapies, including glucocorticoids, cyclosporine, antithymocyte globulin, and ablative therapy followed by allogeneic bone marrow transplantation. Clinical manifestations appear at 8–10 days, and death occurs at 3–4 weeks posttransfusion.

TA-GVHD can be prevented by irradiation of cellular components (minimum of 2500 cGy) before transfusion to patients at risk. Recently, pathogen inactivation technologies have shown to prevent TA-GVHD as well. Patients at risk for TA-GVHD include fetuses receiving intrauterine transfusions, selected immunocompetent (e.g., lymphoma patients) or immunocompromised recipients, recipients of donor units known to be from a blood relative, and recipients who have undergone marrow transplantation. Directed donations by family members should be discouraged (they are not less likely to transmit infection); lacking other options, the blood products from family members should always be irradiated.

Transfusion-Related Acute Lung Injury

TRALI is among the most common cause of transfusion related fatalities. The recipient develops symptoms of hypoxia (PaO2/FiO2 < 300 mmHg) and signs of noncardiogenic pulmonary edema, including bilateral interstitial infiltrates on chest x-ray, either during or within 6 h of transfusion. Treatment is supportive, and patients usually recover without sequelae. TRALI usually results from the transfusion of donor plasma that contains high-titer anti-HLA class II antibodies that bind recipient leukocytes. Anti-HLA class I and anti-human neutrophil antigen (HNA) antibodies can be involved as well. The leukocytes aggregate in the pulmonary vasculature and release mediators that increase capillary permeability. Testing the donor’s plasma for anti-HLA antibodies can support this diagnosis. The implicated donors are frequently multiparous women. The transfusion of plasma and platelets from male and nulliparous women donors reduces the risk of TRALI. Recipient factors that are associated with increased risk of TRALI include smoking, chronic alcohol use, shock, liver surgery (transplantation), mechanical ventilation with >30 cm H₂0 pressure support and positive fluid balance.

Posttransfusion Purpura

This reaction presents as thrombocytopenia 7–10 days after platelet transfusion and occurs predominantly in women. Platelet-specific antibodies are found in the recipient’s serum, and the most frequently recognized antigen is HPA-1a found on the platelet glycoprotein IIIa receptor. The delayed thrombocytopenia is due to the production of antibodies that react to both donor and recipient platelets. Additional platelet transfusions can worsen the thrombocytopenia and should be avoided. Treatment with intravenous immunoglobulin may neutralize the effector antibodies, or plasmapheresis can be used to remove the antibodies.

Alloimmunization

A recipient may become alloimmunized to a number of antigens on cellular blood elements and plasma proteins. Alloantibodies to RBC antigens are detected during pretransfusion testing, and their presence may delay finding antigen-negative cross-match-compatible products for transfusion. Women of childbearing age who are sensitized to certain RBC antigens (i.e., D, c, E, Kell, or Duffy) are at risk for bearing a fetus with hemolytic disease of the newborn. Matching for RBC antigen is the only pretransfusion selection test to prevent RBC alloimmunization.

Alloimmunization to antigens on leukocytes and platelets can result in refractoriness to platelet transfusions. Once alloimmunization has developed, HLA-compatible platelets from donors who share similar antigens with the recipient may be difficult to find. Hence, prudent transfusion practice is directed at preventing sensitization through the use of leukocyte-reduced cellular components, as well as limiting antigenic exposure by the judicious use of transfusions and use of SDAPs.

Fluid Overload

Blood components are excellent volume expanders, and transfusion may quickly lead to transfusion-associated circulatory overload (TACO). Dyspnea with O₂% <90 on room air, bilateral infiltrates on CXR with systolic hypertension are found with TACO. Brain natriuretic peptide (BNP) is often elevated (>1.5) that of pre-transfusion levels. Monitoring the rate and volume of the transfusion and using a diuretic can minimize this problem.

Hypothermia

Refrigerated (4°C) or frozen (−18°C or below) blood components can result in hypothermia when rapidly infused. Cardiac dysrhythmias can result from exposing the sinoatrial node to cold fluid. Use of an in-line warmer will prevent this complication.

Electrolyte Toxicity

RBC leakage during storage increases the concentration of potassium in the unit. Neonates and patients in renal failure are at risk for hyperkalemia. Preventive measures, such as using fresh or washed RBCs, are warranted for neonatal transfusions because this complication can be fatal.

Citrate, commonly used to anticoagulate blood components, chelates calcium and thereby inhibits the coagulation cascade. Hypocalcemia, manifested by circumoral numbness and/or tingling sensation of the fingers and toes, may result from multiple rapid transfusions. Because citrate is quickly metabolized to bicarbonate, calcium infusion is seldom required in this setting. If calcium or any other intravenous infusion is necessary, it must be given through a separate line.

Iron Overload

Each unit of RBCs contains 200–250 mg of iron. Symptoms and signs of iron overload affecting endocrine, hepatic, and cardiac function are common after 100 units of RBCs have been transfused (total-body iron load of 20 g). Preventing this complication by using alternative therapies (e.g., erythropoietin) and judicious transfusion is preferable and cost effective. Chelating agents, such as deferoxamine and deferasirox, are available, but the response though is often suboptimal.

Hypotensive Reactions

Transient hypotension may be noted among transfused patients who take angiotensin-converting enzyme (ACE) inhibitors. Since blood products contain bradykinin that is normally degraded by ACE, patients on ACE inhibitors may have increased bradykinin levels that cause hypotension in the recipient. The blood pressure typically returns to normal without intervention.

Immunomodulation

Transfusion of allogeneic blood is immunosuppressive. Multiply transfused renal transplant recipients are less likely to reject the graft, and transfusion may result in poorer outcomes in cancer patients and increase the risk of infections. Transfusion-related immunomodulation is thought to be mediated by transfused leukocytes. Leukocyte-depleted cellular products may cause less immunosuppression, though controlled data are unlikely to be obtained as the blood supply becomes universally leukocyte-depleted.

The blood supply is initially screened by selecting healthy donors without high-risk lifestyles, medical conditions, or exposure to transmissible pathogens, such as intravenous drug use or visiting malaria endemic areas. Multiple tests performed on donated blood to detect the presence of infectious agents using nucleic acid amplification testing (NAT) or evidence of prior infections by testing for antibodies to pathogens and sterility of platelet products further reduce the risk of transfusion-acquired infections. Pathogen reduction of platelets and plasma offer an additional mean to reduce such risk.

Viral Infections

HEPATITIS C VIRUS

Blood donations are tested for antibodies to HCV and HCV RNA. The risk of acquiring HCV through transfusion is now calculated to be 0,1 to 1 in 1,000,000 units. Infection with HCV may be asymptomatic or lead to chronic active hepatitis, cirrhosis, and liver failure.

HUMAN IMMUNODEFICIENCY VIRUS TYPE 1

Donated blood is tested for antibodies to HIV-1, HIV-1 p24 antigen, and HIV RNA using NAT. The risk of HIV-1 infection per transfusion episode is 0,1 to 1 in 1 million. Antibodies to HIV-2 are also measured in donated blood. No cases of HIV-2 infection in blood donors have been reported in the United States since 1992.

HEPATITIS B VIRUS

Donated blood is screened for HBV using assays for hepatitis B surface antigen (HbsAg) most combined with NAT testing. The risk of transfusion-associated HBV infection is several times greater than for HCV. Vaccination of individuals who require long-term transfusion therapy can prevent this complication.

OTHER HEPATITIS VIRUSES

Hepatitis A virus is rarely transmitted by transfusion; infection is typically asymptomatic and does not lead to chronic disease. Hepatitis E (HEV) can be transmitted by transfusion and may lead to chronic disease. Routine HEV RNA testing has been introduced in several European countries starting in 2015. West Nile virus (WNV) Transfusion-transmitted WNV infections were documented in 2002. This RNA virus can be detected using NAT; routine screening began in 2003. WNV infections range in severity from asymptomatic to fatal, with the older population at greater risk.

CYTOMEGALOVIRUS

This ubiquitous virus infects ≥50% of the general population and is transmitted by the infected “passenger” leukocytes found in transfused PRBCs or platelet components. Cellular components that are leukocyte-reduced have a decreased risk of transmitting CMV, regardless of the serologic status of the donor. Groups at risk for CMV infections include immunosuppressed patients, CMV-seronegative transplant recipients, and neonates; these patients should receive leukocyte-depleted components or CMV seronegative products.

HUMAN T LYMPHOTROPIC VIRUS (HTLV) TYPE I

Assays to detect HTLV-I and -II are used to screen all donated blood. HTLV-I is associated with adult T cell leukemia/lymphoma and tropical spastic paraparesis in a small percentage of infected persons (Chap. 196). The risk of transfusion-mediated HTLV-1 infection is further mitigated by blood product leukoreduction. HTLV-II is not clearly associated with any disease.

PARVOVIRUS B-19

Blood components and pooled plasma products can transmit this virus, the etiologic agent of erythema infectiosum, or fifth disease, in children. Parvovirus B-19 shows tropism for erythroid precursors and inhibits both erythrocyte production and maturation. Pure red cell aplasia, presenting either as acute aplastic crisis or chronic anemia with shortened RBC survival, may occur in individuals with an underlying hematologic disease, such as sickle cell disease or thalassemia (Chap. 94). The fetus of a seronegative woman is at risk for developing hydrops from this virus.

Bacterial Contamination

The relative risk of transfusion-transmitted bacterial infection has increased as the absolute risk of viral infections has dramatically decreased.

Most bacteria do not grow well at cold temperatures; thus, PRBCs and FFP are not common sources of bacterial contamination. However, some gram-negative bacteria can grow at 1° to 6°C. Yersinia, Pseudomonas, Serratia, Acinetobacter, and Escherichia species have all been implicated in infections related to PRBC transfusion. Platelet concentrates, which are stored at room temperature, are more likely to contain skin contaminants such as gram-positive organisms, including coagulase-negative staphylococci. It is estimated that 1 in 1000–2000 platelet components is contaminated with bacteria. The risk of death due to transfusion-associated sepsis is estimated to be in the order of 1 in 200,000–400,000 platelets products. Since 2004, blood banks have instituted methods to detect contaminated platelet components. Pathogen-reduced platelets have been available and offer an alternative to prevent transfusion-transmitted bacterial infection.

Recipients of transfusion contaminated with bacteria may develop fever and chills, which can progress to septic shock and DIC. These reactions may occur abruptly, within minutes of initiating the transfusion, or after several hours. The onset of symptoms and signs is often sudden and fulminant, which distinguishes bacterial contamination from an FNHTR. The reactions, particularly those related to gram-negative contaminants, are the result of infused endotoxins formed within the contaminated stored component.

When these reactions are suspected, the transfusion must be stopped immediately. Therapy is directed at reversing any signs of shock, and broad-spectrum antibiotics should be given. The blood bank should be notified to identify any clerical or serologic error. The blood component bag should be sent for culture and Gram stain.

Other Infectious Agents

Various parasites, including those causing malaria, babesiosis, and Chagas disease, can be transmitted by blood transfusion. Geographic migration and travel of donors shift the incidence of these infections. Other agents implicated in transfusion transmission include dengue, zika virus, variant Creutzfeldt-Jakob disease, Anaplasma phagocytophilum, and yellow fever vaccine virus and the list will grow. Tests for some pathogens are available, such as Trypanosoma cruzi, but not universally required while others are being developed (Babesia microti). These infections should be considered in the transfused patient in the appropriate clinical setting.

Alternatives to allogeneic blood transfusions that avoid homologous donor exposures with attendant immunologic and infectious risks remain attractive. Autologous blood remains an option when transfusion is anticipated. However, the cost-benefit ratio of autologous transfusion remains high. No transfusion is a zero-risk event; clerical errors and bacterial contamination remain potential complications even with autologous transfusions. Additional methods of autologous transfusion in the surgical patient include preoperative hemodilution, recovery of shed blood from sterile surgical sites, and postoperative drainage collection. Directed or designated donation from friends and family of the potential recipient has not been safer than volunteer donor component transfusions. Such directed donations may in fact place the recipient at higher risk for complications such as GVHD and alloimmunization.

Granulocyte and granulocyte-macrophage colony-stimulating factors are clinically useful to hasten leukocyte recovery in patients with leukopenia related to high-dose chemotherapy. Erythropoietin stimulates erythrocyte production in patients with anemia of chronic renal failure and other conditions, thus avoiding or reducing the need for transfusion. This hormone can also stimulate erythropoiesis in the autologous donor to enable additional donation.

Gene therapy approaches in patients with sickle cell or major thalassemia offers the potential of dramatically reducing their transfusion needs. Stem cell-derived blood cells such as RBCs or platelets may in the future become a suitable alternative to very rare blood donors.

Lastly, optimizing the use of blood products through patient blood management programs can improve the therapeutic index of transfusion medicine.

ACKNOWLEDGMENT

We are pleased to acknowledge the assistance of Olivier Garaud, MD, PhD, and Jacques Chiaroni, MD, PhD, in the preparation of this chapter.