Pharmacological interventions for the prevention of allergic and febrile non-haemolytic transfusion reactions

Evaluation of leukocyte depletion of packed red blood cell units and impact on clinically observed transfusion reactions

Introduction

The aim of this retrospective study was to determine whether there is an association between leukoreduction of packed red blood cell (pRBC) units and reduction of clinically observed transfusion reactions (TR), particularly febrile non-haemolytic transfusion reactions (FNHTR), and better outcomes in dogs. Secondary aims were to evaluate the effects of other factors suspected to influence transfusion reaction frequency or survival, including crossmatching, use of immunosuppressive drugs, and age and number of the blood products being administered.

Materials and methods

Medical data on dogs transfused with leukocyte-reduced (LR) and non-leukocyte-reduced (N-LR) pRBC units at the Animal Hospital Zürich, University of Zürich, Switzerland between January 1, 2007, and December 17, 2018 were searched. Before 2014, only N-LR blood were transfused. After 2014, both LR and N-LR blood were available.

Results

A total of 339 canine patients were transfused with 413 pRBC units; 30.5% (126/413) were LR units and 69.5% (287/413) were N-LR. Data collected from medical records was analyzed using univariate and multivariate logistic regression. In the present study, TR occurred in 19.8% of pRBC units (25/126) with LR and in 17.7% (51/287) of pRBC with N-LR; p > 0.05. FNHTR occurred in 6.3% of pRBC units (8/126) with LR and in 4.5% (13/287) of those with N-LR; p > 0.05. There was no correlation between the occurrence of TR and discharge from hospital (p > 0.05). Crossmatching, immunosuppressive therapy, and age of the blood product were not associated with the frequency of TR; p > 0.05 for all. The duration of survival days was not related to the number of transfusions dogs received.

Discussion

In the present study, the leukocyte-depletion of transfused pRBC units was not associated with fewer TR nor to fewer FNHTR compared to N-LR units. Discharge of dogs from hospital was not dependent on the occurrence of TR.

Research progress on febrile non-hemolytic transfusion reaction: a narrative review

Background and Objective

About 1% of patients who receive blood transfusions will develop transfusion reactions. Febrile non-hemolytic transfusion reaction (FNHTR) is the most common type of transfusion reaction. It not only leads to misdiagnosis and delayed treatment, but also incurs a huge economic burden. This article reviews FNHTR systematically, aiming to make clinicians have a more comprehensive understanding of FNHTR and reduce the occurrence of this side effect.

Methods

A comprehensive search of the PubMed, Embase, and Cochrane Library databases was performed. Medical Subject Headings (MeSH) included Blood Transfusion, Transfusion Reaction, and Febrile Non-Hemolytic Transfusion Reaction. The searches and literature screening were performed by 2 researchers; any differences of opinion or results were resolved through negotiation.

Key Content and Findings

The pathophysiological mechanisms of FNHTR mainly included immune and non-immune pathways. The former was associated with antibodies against human leukocyte antigen (HLA) produced in transfused patients, while the latter was associated with cytokines released from blood products during storage. Women with a reproductive history and those patients with multiple blood transfusions were more likely to experience FNHTR. Primary hematologic disease, malignant disease, and transfusion with over 6 units of leukocyte-depleted packed red blood cells were independent risk factors for the development of FNHTR. FNHTR could be diagnosed by accompaniment of the fever symptom (body temperature ≥38 ℃, maybe an increase of body temperature of more than 1 ℃ compared with that before blood transfusion) during or within 4 hours after transfusion, or the presence of chills, shakes, headache, and nausea, among other symptoms. FNHTR should be mainly differentiated from other types of transfusion reactions with similar symptoms. Prophylactic strategies for the routine use of antipyretic drugs before transfusion remain controversial. Removal of leukocyte components from blood could reduce the incidence of FNHTR significantly.

Conclusions

The pathogenesis of FNHTR is mainly associated with anti-HLA antibodies and cytokines released from blood products during storage. Specific markers and effective detection methods for FNHTR are still lacking. Treatment for FNHTR is currently limited to antipyretic drugs, sedation, and other symptomatic treatment measures. More studies are warranted to focus on the pathological mechanism of FNHTR.

Adverse transfusion reactions and what we can do

INTRODUCTION

Transfusions of blood and blood components have inherent risks and the ensuing adverse reactions. It is very important to understand the adverse reactions of blood transfusion comprehensively for ensuring the safety of any future transfusions.

AREAS COVERED

According to the time of onset, adverse reactions of blood transfusion are divided into immediate and delayed transfusion reactions. In acute transfusion reactions, timely identification and immediate cessation of transfusion is critical. Vigilance is required to distinguish delayed responses or reactions that present non-specific signs and symptoms. In this review, we present the progress of mechanism, clinical characteristics and management of commonly encountered transfusion reactions.

EXPERT OPINION

The incidence of many transfusion-related adverse events is decreasing, but threats to transfusion safety are always emerging. It is particularly important for clinicians and blood transfusion staff to recognize the causes, symptoms and treatment methods of adverse blood transfusion reactions to improve the safety. In the future, at-risk patients will be better identified and can benefit from more closely matched blood components.

Educational Case: Febrile Nonhemolytic Transfusion Reaction

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.1.

Shifting ground and gaps in transfusion support of patients with hematological malignancies

The transfusion support of hematological malignancies considers 2 dimensions: the quantity of what we order (in terms of triggers, doses, targets, and intervals), and the special qualities thereof (with respect to depths of matching and appropriate product modifications). Meanwhile, transfusion-related enhancements in the quantity and quality of life may not be dose dependent but rather tempered by unintended patient harms and system strains from overexposure. Evidence and guidelines concur in endorsing clinically noninferior conservative red blood cell (RBC) transfusion care strategies (eg, triggering at hemoglobin <7-8 g/dL and in single-unit doses for stable, nonbleeding inpatients). However, the unique subpopulation of patients with hematological malignancies who are increasingly managed on an outpatient basis, and striving at least as much for quality of life as quantity of life, is left on the edges of these recommendations, with more questions than answers. If a sufficiently specific future wave of evidence can satisfy the concerns (and contest the assumptions) of the remaining proponents of liberalism, and if conservatism is broadly adopted, savings may be potentially immense. These savings can then be reinvested to address other gaps and inconsistencies in RBC transfusion care, such as the best achievable degrees of prophylactic antigen matching that can minimize alloimmunization-related service delays and reactions.

Efficacy of Oral Acetaminophen and Intravenous Chlorpheniramine Maleate versus Placebo to Prevent Red Cell Transfusion Reactions in Children and Adolescent with Thalassemia: A Prospective, Randomized, Double-Blind Controlled Trial

Background

Thalassemia is a common congenital hemolytic disorder. In severe cases, regular blood transfusion is essentially required. The role of premedications to prevent transfusion reactions is varied among institutions with no standard guideline.

Objective

To prospectively compare the risk of transfusion reactions in thalassemia patients premedicated with acetaminophen and chlorpheniramine maleate (CPM) versus placebo prior to blood transfusion.

Material and Method

A randomized, double-blinded, placebo-controlled transfusion reaction study of 147 eligible patients was analyzed. All administered red blood cell (RBC) products were leukoreduced blood products. Patients were monitored and followed for the development of transfusion reactions for 24 hours after RBC transfusion.

Results

A total of 73 patients randomized to receive active drugs consisting of acetaminophen and CPM were compared to 74 patients receiving placebo. The overall incidences of febrile reaction and urticarial rash were 6.9% and 22% in the patients randomized to receive active drugs comparing with 9.5% and 35.2% in the patients receiving placebo with no significant differences between two groups. However, delayed development of urticarial rash at 4-24 hours after RBC transfusion was significantly higher in female and patients receiving placebo.

Conclusion

Administration of premedications in thalassemia patients receiving RBC transfusion without a history of transfusion reactions does not decrease the overall risk of transfusion reactions. However, the use of CPM might be beneficial to prevent delayed urticarial rash in those patients especially in females (Thai Clinical Trial Registry (TCTR) study ID: 20140526001).

Recommendations on Selection and Processing of RBC Components for Pediatric Patients From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative

OBJECTIVES

To present the recommendations and supporting literature for selection and processing of RBC products in critically ill children developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

DESIGN

Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children METHODS:: The panel of 38 experts developed evidence-based, and when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The RBC processing subgroup included five experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.

RESULTS

Five recommendations reached agreement (> 80%). Irradiated cellular products are recommended for children at risk of transfusion-associated graft versus host disease due to severe congenital or acquired causes of immune deficiency or when the blood donor is a blood relative. Washed cellular blood components and avoidance of other plasma-containing products are recommended for critically ill children with history of severe allergic reactions or anaphylaxis to blood transfusions, although patient factors appear to be important in the pathogenesis of reactions. For children with history of severe allergic transfusion reactions, evaluation for allergic stigmata prior to transfusion is recommended. In children with severe immunoglobulin A deficiency with evidence of antiimmunoglobulin A antibodies and/or a history of a severe transfusion reaction, immunoglobulin A-deficient blood components obtained either from an immunoglobulin A-deficient donor and/or washed cellular components is recommended.

CONCLUSIONS

The Transfusion and Anemia Expertise Initiative consensus conference developed recommendations for selection and processing of RBC units for critically ill children. Recommendations in this area are largely based on pediatric and adult case report data.

Adverse Reactions to Transfusion of Blood Products and Best Practices for Prevention

Transfusion, a common practice in critical care, is not without complication. Acute adverse reactions to transfusion occur within 24 hours and include acute hemolytic transfusion reaction, febrile nonhemolytic transfusion reaction, allergic and anaphylactic reactions, and transfusion-related acute lung injury, transfusion-related infection or sepsis, and transfusion-associated circulatory overload. Delayed transfusion adverse reactions develop 48 hours or more after transfusion and include erythrocyte and platelet alloimmunization, delayed hemolytic transfusion reactions, posttransfusion purpura, transfusion-related immunomodulation, transfusion-associated graft versus host disease, and, with long-term transfusion, iron overload. Clinical strategies may reduce the likelihood of reactions and improve patient outcomes.

Transfusion reactions: prevention, diagnosis, and treatment

Blood transfusion is one of the most common procedures in patients in hospital so it is imperative that clinicians are knowledgeable about appropriate blood product administration, as well as the signs, symptoms, and management of transfusion reactions. In this Review, we, an international panel, provide a synopsis of the pathophysiology, treatment, and management of each diagnostic category of transfusion reaction using evidence-based recommendations whenever available.

Transfusion as an Inflammation Hit: Knowns and Unknowns

Transfusion of blood cell components is frequent in the therapeutic arsenal; it is globally safe or even very safe. At present, residual clinical manifestations are principally inflammatory in nature. If some rare clinical hazards manifest as acute inflammation symptoms of various origin, most of them linked with conflicting and undesirable biological material accompanying the therapeutic component (infectious pathogen, pathogenic antibody, unwanted antigen, or allergen), the general feature is subtler and less visible, and essentially consists of alloimmunization or febrile non-hemolytic transfusion reaction. The present essay aims to present updates in hematology and immunology that help understand how, when, and why subclinical inflammation underlies alloimmunization and circumstances characteristic of red blood cells and – even more frequently – platelets that contribute inflammatory mediators. Modern transfusion medicine makes sustained efforts to limit such inflammatory hazards; efforts can be successful only if one has a clear view of each element’s role.

Leukoreduction for the prevention of adverse reactions from allogeneic blood transfusion

BACKGROUND

A blood transfusion is an acute intervention, implemented to solve life and health-threatening conditions on a short-term basis. However, blood transfusions have adverse events, some of them potentially related to immune modulation or to a direct transmission of infectious agents (e.g. cytomegalovirus). Leukoreduction is a process in which the white blood cells are intentionally reduced in packed red blood cells (PRBCs) in order to reduce the risk of adverse reactions. The potential benefits of leukoreduced PRBCs in all types of transfused patients for decreasing infectious and non-infectious complications remain unclear.

OBJECTIVES

To determine the clinical effectiveness of leukoreduction of packed red blood cells for preventing adverse reactions following allogeneic blood transfusion.

SEARCH METHODS

We ran the most recent search on 10th November 2015. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), MEDLINE (OvidSP), Embase(OvidSP), CINAHL Plus (EBSCO), LILACS (BIREME), and clinical trials registers. In addition, we checked the reference lists of all relevant trials and reviews identified in the literature searches.

SELECTION CRITERIA

Randomised clinical trials including patients of all ages requiring PRBC allogeneic transfusion. Any study was eligible for inclusion, regardless of the length of participant follow-up or country where the study was performed. The primary outcome was transfusion-related acute lung injury (TRALI). Secondary outcomes were death from any cause, infection from any cause, non-infectious complications and any other adverse event.

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed study selection, 'Risk of bias' assessments and data extraction. We estimated pooled relative risk for dichotomous outcomes, and we measured statistical heterogeneity using I² statistic. The random-effects model was used to synthesise results. We conducted a trial sequential analysis to assess the risk of random errors in cumulative meta-analyses.

MAIN RESULTS

Thirteen studies, most including adult patients, met the eligibility criteria. We found no clear evidence of an effect of leukoreduced PRBC versus non-leukoreduced PRBC in patients that were randomised to receive transfusion for the following outcomes: TRALI: RR 0.96, 95% CI 0.67 to 1.36, P = 0.80 from one trial reporting data on 1864 trauma patients. The accrued information of 1864 participants constituted only 28.5% of the diversity-adjusted required information size (DARIS) of 6548 participants. The quality of evidence was low. Death from any cause: RR 0.81, 95% CI 0.58 to 1.12, I² statistic = 63%, P = 0.20 from nine trials reporting data on 6485 cardiovascular surgical patients, gastro-oncology surgical patients, trauma patients and HIV infected patients. The accrued information of 6485 participants constituted only 55.3% of the DARIS of 11,735 participants. The quality of evidence was very low. Infection from any cause: RR 0.80, 95% CI 0.62 to 1.03, I² statistic = 84%, P = 0.08 from 10 trials reporting data on 6709 cardiovascular surgical patients, gastro-oncology surgical patients, trauma patients and HIV infected patients. The accrued information of 6709 participants constituted only 60.6% of the DARIS of 11,062 participants. The quality of evidence was very low. Adverse events: The only adverse event reported as an adverse event was fever (RR 0.81, 95% CI 0.64 to 1.02; I² statistic= 0%, P = 0.07). Fever was reported in two trials on 634 cardiovascular surgical and gastro-oncology surgical patients. The accrued information of 634 participants constituted only 84.4% of the DARIS of 751 participants. The quality of evidence was low. Incidence of other non-infectious complications: This outcome was not assessed in any included trial.

AUTHORS' CONCLUSIONS

There is no clear evidence for supporting or rejecting the routine use of leukoreduction in all patients requiring PRBC transfusion for preventing TRALI, death, infection, non-infectious complications and other adverse events. As the quality of evidence is very low to low, more evidence is needed before a definitive conclusion can be drawn.

Transfusion-related adverse events in the Platelet Dose study

BACKGROUND

How platelet (PLT) product characteristics such as dose, source (whole blood derived [WBD] vs. apheresis), storage duration, and ABO matching status affect the risks of transfusion-related adverse events (TRAEs) is unclear. Similarly, more information is needed to define how recipient characteristics affect the frequency of TRAEs after PLT transfusion.

STUDY DESIGN AND METHODS

In the multicenter Platelet Dose ("PLADO") study, pediatric and adult hematology-oncology patients with hypoproliferative thrombocytopenia were randomized to receive low-dose (LD), medium-dose (MD), or high-dose (HD) PLT prophylaxis for a pretransfusion PLT count of not more than 10 × 10(9) /L. All PLT units (apheresis or WBD) were leukoreduced. Post hoc analyses of PLADO data were performed using multipredictor models.

RESULTS

A total of 5034 PLT transfusions to 1102 patients were analyzed. A TRAE occurred with 501 PLT transfusions (10.0%). The most common TRAEs were fever (6.6% of transfusions), allergic or hypersensitivity reactions (1.9%), and sinus tachycardia (1.8%). Patients assigned HD PLTs were more likely than LD or MD patients to experience any TRAE (odds ratio for HD vs. MD, 1.50; 95% confidence interval, 1.10-2.05; three-group comparison p = 0.02). PLT source and ABO matching status were not significantly related to overall TRAE risk. Compared to a patient's first PLT transfusion, subsequent PLT transfusions were less likely to have a TRAE reported, primarily due to a lower risk of allergic or hypersensitivity reactions.

CONCLUSION

The most important PLT unit characteristic associated with TRAEs was PLT dose per transfusion. HD PLTs may increase the risk of TRAEs, and LD PLTs may reduce the risk.

Transfusion and component characteristics are not associated with allergic transfusion reactions to apheresis platelets

BACKGROUND

Transfusion-related characteristics have been hypothesized to cause allergic transfusion reactions (ATRs) but they have not been thoroughly studied. The primary objective of this study is to evaluate the associations of infusion rate, infusion volume, ABO mismatching, component age, and pretransfusion medication with the incidence and severity of ATRs. A secondary objective is to compare the risk of these attributes relative to the previously reported risk factor for aeroallergen sensitization in transfusion recipients, as measured by an aeroallergen-specific immunoglobulin (Ig)E antibody screen.

STUDY DESIGN AND METHODS

Clinical and transfusion-related data were collected on subjects with reported ATRs and uneventful (control) apheresis platelet (PLT) transfusions over a combined 21-month period at two academic medical centers. Control transfusions were selected as the next uneventful transfusion after an ATR was reported. Logistic regression, Mann-Whitney, and t tests were used to assess associations with ATRs. Previously reported aeroallergen-specific IgE screening data were incorporated into a multivariable logistic regression.

RESULTS

A total of 143 ATRs and 61 control transfusions were evaluated among 168 subjects, ages 2 to 86 years. Infusion rate, infusion volume, ABO mismatching, component age, and pretransfusion medication showed no significant association with ATRs (p > 0.05). Neither infusion rate nor infusion volume increased the risk of anaphylaxis versus mucocutaneous-only ATRs. Aeroallergen sensitization has previously been associated with ATRs. After transfusion-related covariates were controlled for, aeroallergen sensitization remained significantly associated with ATRs (odds ratio, 2.68; 95% confidence interval, 1.26-5.69).

CONCLUSIONS

Transfusion- and component-specific attributes are not associated with ATRs. An allergic predisposition in transfusion recipients is associated most strongly with ATR risk.

The prevention of adverse reactions to transfusions in patients with haemoglobinopathies: a proposed algorithm

BACKGROUND

Transfusion therapy remains the main treatment for patients with severe haemoglobinopathies, but can cause adverse reactions which may be classified as immediate or delayed. The use of targeted prevention with drugs and treatments of blood components in selected patients can contribute to reducing the development of some reactions.The aim of our study was to develop an algorithm capable of guiding behaviours to adopt in order to reduce the incidence of immediate transfusion reactions.

MATERIALS AND METHODS

Immediate transfusion reactions occurring over a 7-year period in 81 patients with transfusion-dependent haemoglobinopathies were recorded. The patients received transfusions with red cell concentrates that had been filtered prestorage. Various measures were undertaken to prevent transfusion reactions: leucoreduction, washing the red blood cells, prophylactic administration of an antihistamine (loratidine 10 mg tablet) or an antipyretic (paracetamol 500 mg tablet).

RESULTS

Over the study period 20,668 red cell concentrates were transfused and 64 adverse transfusion reactions were recorded in 36 patients. The mean incidence of reactions in the 7 years of observation was 3.1‰. Over the years the incidence gradually decreased from 6.8‰ in 2004 to 0.9‰ in 2010.

DISCUSSION

Preventive measures are not required for patients who have an occasional reaction, because the probability that such a type of reaction recurs is very low. In contrast, the targeted use of drugs such as loratidine or paracetamol, sometimes combined with washing and/or double filtration of red blood cells, can reduce the rate of recurrent (allergic) reactions to about 0.9‰. The system for detecting adverse reactions and training staff involved in transfusion therapy are critical points for reliable collection of data and standardisation of the detection system is recommended for those wanting to monitor the incidence of all adverse reactions, including minor ones.

Recovery, safety, and tolerability of a solvent/detergent-treated and prion-safeguarded transfusion plasma in a randomized, crossover, clinical trial in healthy volunteers

BACKGROUND

Octaplas LG is a prion-depleted version of a previous generation product called Octaplas S/D. We compared the recovery, safety, and tolerability of these two pharmaceutical-grade plasmas.

STUDY DESIGN AND METHODS

In this comparative, block-randomized, open-label, active-controlled, crossover Phase I trial, 60 healthy adult volunteers received single transfusions of 1200 mL of parent product (in Period 1) and of the LG plasma product (in Period 2) or vice versa. In both periods, plasmapheresis (600 mL) preceded the transfusion. Blood samples were drawn before and after apheresis and 15 minutes, 2 hours, 24 hours, and 7 days after end of plasma transfusion, to assess recovery, safety, and tolerability. The primary efficacy endpoints were the changes in coagulation factors and hemostatic variables compared to baseline; their relative recovery was computed in the per-protocol analysis (n = 43). Safety and tolerability were assessed (n = 60).

RESULTS

Variations in coagulation factors and hemostatic variables over time were similar between the two treatments and within normal range; 90% confidence intervals for the derived recovery data were within predefined limits of equivalence. Both products were well tolerated. The advanced manufacturing process also significantly increased plasmin inhibitor concentrations after transfusion in vivo.

CONCLUSION

The LG plasma product was bioequivalent to its predecessor with respect to recovery of clotting factors and demonstrated comparable safety and tolerability in healthy volunteers. Both products compensated well for the loss of clotting factors after apheresis (NCT01063595).

Scratching the surface of allergic transfusion reactions

Allergic transfusion reactions (ATRs) are a spectrum of hypersensitivity reactions that are the most common adverse reaction to platelets and plasma, occurring in up to 2% of transfusions. Despite the ubiquity of these reactions, little is known about their mechanism. In a small subset of severe reactions, specific antibody has been implicated as causal, although this mechanism does not explain all ATRs. Evidence suggests that donor, product, and recipient factors are involved, and it is possible that many ATRs are multifactorial. Further understanding of the mechanisms of ATRs is necessary so that rationally designed and cost-effective prevention measures can be developed.

Reducing noninfectious risks of blood transfusion

As screening for transfusion-associated infections has improved, noninfectious complications of transfusion now cause the majority of morbidity and mortality associated with transfusion in the United States. For example, transfusion-related acute lung injury, transfusion-associated circulatory overload, and hemolytic transfusion-reactions are the first, second, and third leading causes of death from transfusion, respectively. These complications and others are reviewed, and several controversial methods for prevention of noninfectious complications of transfusion are discussed, including universal leukoreduction of erythrocyte units, use of male-only plasma, and restriction of erythrocyte storage age.