From the Guidelines
Acute hemolytic transfusion reactions require immediate intervention, and the first step is to stop the transfusion immediately and maintain IV access with normal saline. The treatment approach should prioritize supportive care and management of symptoms, as outlined in the American Society of Hematology 2020 guidelines for sickle cell disease: transfusion support 1. Key interventions include:
- Notifying the blood bank and sending the blood product bag for testing
- Monitoring vital signs frequently and providing supportive care based on symptoms
- Managing hypotension with IV fluids and vasopressors if needed
- Treating respiratory distress with oxygen and possibly mechanical ventilation
- Administering antipyretics like acetaminophen (650-1000 mg) for fever
- Maintaining adequate hydration with IV fluids (typically normal saline at 1-2 mL/kg/hr) and considering diuretics like furosemide (20-40 mg IV) to maintain urine output above 100 mL/hour if the patient is not hypotensive
- Monitoring for and treating DIC if it develops
- Laboratory monitoring should include CBC, coagulation studies, renal function tests, urinalysis, and serial hemoglobin levels
In cases of life-threatening anemia, consideration should be given to transfusion with extended matched red cells that also lack the offending antigen, as well as the use of immunosuppressive therapies such as IVIg, high-dose steroids, eculizumab, and/or rituximab 1. The choice of therapy should be individualized and based on a shared decision-making process between the hematologist, transfusion medicine specialist, and the patient. It is essential to weigh the potential benefits and harms associated with transfusion versus the effect of ongoing life-threatening anemia 1.
From the Research
Treatment for Acute Hemolytic Transfusion Reaction (AHTR)
The treatment for AHTR is mostly supportive measures, with the goal of managing the symptoms and preventing further complications 2. Some of the key aspects of treatment include:
- Discontinuation of the transfusion immediately upon suspicion of an AHTR
- Monitoring of vital signs and laboratory parameters, such as hemoglobin, hematocrit, and renal function
- Supportive care, such as fluid resuscitation, oxygen therapy, and blood pressure management
- Management of disseminated intravascular coagulation (DIC) and acute renal failure, if present
Role of Plasma Exchange in AHTR
Plasma exchange (PE) has been used as a treatment for AHTR, particularly in severe cases 2, 3. The decision to perform PE should be made on a case-by-case basis, taking into account the severity of the reaction, the presence of comorbidities, and the patient's overall clinical status. Some studies suggest that PE may be beneficial in patients with AHTR, particularly those with cardiac and renal comorbidities, large volume erythrocyte transfusion, negative direct antiglobulin test (DAT), and macroscopic hemoglobinuria 2.
Use of Ruxolitinib in AHTR
Ruxolitinib, a Janus kinase inhibitor, has been used as a part of therapy in a patient with severe AHTR 3. The patient showed significant improvement in clinical status after initiation of ruxolitinib, suggesting that it may be a life-saving treatment option in patients with severe AHTR.
Prevention of AHTR
Prevention of AHTR is crucial, and careful monitoring of the patient during transfusion, as well as strict adherence to blood transfusion protocols, can help minimize the risk of AHTR 4, 5. Nursing staff play a critical role in recognizing symptoms of a transfusion reaction and initiating prompt treatment.