What is the treatment for an acute hemolytic transfusion (AHT) reaction?

Treatment of Acute Hemolytic Transfusion Reaction

Immediately stop the transfusion, maintain IV access with normal saline, and initiate aggressive supportive care to prevent renal failure and manage hemodynamic instability. 1, 2

Immediate Management Steps

Stop Transfusion and Initial Actions

• Discontinue the blood product immediately at the first sign of a transfusion reaction (tachycardia, hypotension, fever, rash, breathlessness, hemoglobinuria) 1
• Maintain IV access with normal saline to support renal perfusion and prevent acute kidney injury 2, 3
• Contact the transfusion laboratory immediately and return the blood product for investigation 1
• Double-check all documentation to identify potential administration errors 1

Supportive Care Priorities

Hemodynamic Support:

• Aggressive fluid resuscitation to maintain adequate blood pressure and renal perfusion 2, 4
• Monitor for and treat hypotension, which results from complement activation (C3a, C5a), histamine release, and kinin system activation 2, 4
• Address shock and circulatory collapse that may develop from systemic inflammatory response 2, 4

Renal Protection:

• Maintain high urine output (>100 mL/hour) through aggressive hydration to prevent acute tubular necrosis 2, 3
• Monitor for oliguria/anuria, as hemolysis-associated AKI can be severe and prolonged (requiring weeks to months for recovery) 3
• Consider diuretics if fluid overload develops, though renal replacement therapy may be necessary in severe cases 3

Management of Complications:

• Monitor for and treat disseminated intravascular coagulation (DIC), which develops from activation of the intrinsic clotting cascade and fibrinolysis 2, 4
• Address diffuse bleeding if it occurs secondary to DIC 2, 4
• Treat acute pulmonary edema if circulatory overload develops 3

Pharmacologic Interventions

Standard Acute Management

• Antihistamines may be administered for allergic symptoms 1
• Steroids may be given for severe reactions 1
• Intramuscular or intravenous epinephrine if the reaction is life-threatening or anaphylactic 1

Immunosuppressive Therapy for High-Risk Patients

For patients with sickle cell disease at high risk for acute hemolytic transfusion reaction (those with multiple alloantibodies or history of life-threatening reactions), consider prophylactic immunosuppression with IVIg, steroids, and/or rituximab before transfusion when compatible blood cannot be found 1

• IVIg: 0.4-1 g/kg/day for 3-5 days (up to total dose of 2 g/kg) 1, 5
• High-dose steroids: Methylprednisolone or prednisone 1-4 mg/kg/day 1, 5
• Rituximab: Primarily for prevention of additional alloantibody formation in patients requiring future transfusions 1, 5

Monitoring and Laboratory Evaluation

Essential monitoring includes:

• Serial hemoglobin/hematocrit measurements 2, 3
• Renal function tests (creatinine, BUN) to detect acute kidney injury 2, 3
• Lactate dehydrogenase (LDH) as marker of hemolysis 5, 2
• Direct antiglobulin test (DAT) and antibody screening 5, 2
• Coagulation studies to detect DIC 2, 4
• Urinalysis for hemoglobinuria 5, 2, 4

Critical Pitfalls to Avoid

Do not transfuse additional blood products during acute hemolysis unless life-threatening anemia is present, as this may exacerbate hemolysis and lead to a chronic protracted course or death 6

Prevention is paramount:

• Verify patient identification with four core identifiers (first name, last name, date of birth, patient ID number) before every transfusion 1
• Check compatibility label against patient identification at bedside 1
• Visually inspect blood products for discoloration, clots, or leakage 1
• For high-risk patients with sickle cell disease, use extended antigen matching (C/c, E/e, K, Jka/Jkb, Fya/Fyb, S/s) to prevent alloimmunization 1

Special Considerations for Severe Cases

In cases of hyperhemolytic transfusion reaction with severe anemia where transfusion was withheld and IVIG/steroids prescribed, anemia was corrected and hemolysis resolved without blood transfusion in all reported cases 6. This approach should be considered for serious, life-threatening reactions when the risk of further transfusion outweighs the benefit 6.