What are the contraindications to blood transfusions?

From the Guidelines

Blood transfusions are contraindicated in several specific situations, including patient refusal, hemolytic transfusion reactions from previous transfusions, and autoimmune hemolytic anemia where compatible blood cannot be found, as well as relative contraindications such as cardiac failure or pulmonary edema where volume overload is a concern, IgA deficiency, and cases where the risks outweigh potential benefits 1. The decision to transfuse should always balance the potential benefits against risks including infections, transfusion reactions, and alloimmunization. Some key points to consider include:

• Patient refusal, such as for religious reasons like Jehovah's Witnesses, is an absolute contraindication to blood transfusion.
• Hemolytic transfusion reactions from previous transfusions and autoimmune hemolytic anemia where compatible blood cannot be found are also absolute contraindications.
• Relative contraindications include cardiac failure or pulmonary edema where volume overload is a concern, IgA deficiency which can cause anaphylactic reactions, and cases where the risks outweigh potential benefits.
• Transfusion-associated circulatory overload (TACO) is a particular concern in patients with heart failure or renal failure.
• Febrile non-hemolytic reactions, while common, are not absolute contraindications but may require premedication with antipyretics.
• Patients with certain conditions like sickle cell disease may require special blood products (leukocyte-reduced, antigen-matched) 1. In emergency situations with life-threatening hemorrhage, some contraindications may be overridden when the immediate risk of death from blood loss exceeds transfusion risks. It is essential to weigh the potential benefits and harms associated with transfusion versus the effect of ongoing life-threatening anemia and to consider the respective mechanisms of action for choice of therapy 1. A shared decision-making process is critical in these situations. The most recent and highest quality study, published in 2020, provides guidelines for transfusion support in sickle cell disease, emphasizing the importance of balancing the potential benefits and risks of transfusion 1.

From the FDA Drug Label

Epogen is not indicated for use: In patients with cancer receiving hormonal agents, biologic products, or radiotherapy, unless also receiving concomitant myelosuppressive chemotherapy. In patients with cancer receiving myelosuppressive chemotherapy when the anticipated outcome is cure In patients with cancer receiving myelosuppressive chemotherapy in whom the anemia can be managed by transfusion. In patients scheduled for surgery who are willing to donate autologous blood. In patients undergoing cardiac or vascular surgery. As a substitute for RBC transfusions in patients who require immediate correction of anemia.

The contraindications to blood transfusions are not directly stated in the provided drug label. However, the label does provide information on the limitations of use for Epogen, which includes situations where RBC transfusions may be preferred or required, such as:

• Patients who require immediate correction of anemia
• Patients with cancer receiving myelosuppressive chemotherapy when the anticipated outcome is cure
• Patients with cancer receiving myelosuppressive chemotherapy in whom the anemia can be managed by transfusion
• Patients scheduled for surgery who are willing to donate autologous blood
• Patients undergoing cardiac or vascular surgery 2

From the Research

Contraindications to Blood Transfusions

• Contraindications to blood transfusions are not explicitly stated in the provided studies, but potential risks and adverse reactions are discussed 3, 4.
• Adverse reactions to blood transfusions can be acute or delayed, and may include hemolytic transfusion reactions, febrile nonhemolytic transfusion reactions, allergic and anaphylactic reactions, and transfusion-related acute lung injury 4.
• Anaphylactic reactions to immunoglobulin infusions in immunodeficient patients with undetectable IgA have been attributed to IgG or IgE anti-IgA antibodies, but the role of these antibodies in causing anaphylaxis is still controversial 5.
• IgA anaphylactic transfusion reactions are rare, estimated to occur in 1 in 20,000 to 47,000 transfusions, and are diagnosed by detecting IgA antibodies in the patient's serum 6, 7.
• The presence of IgA antibodies does not necessarily predict the risk of an anaphylactic transfusion reaction, and additional research is needed to define a more specific marker to identify those at risk 7.

Specific Contraindications

• IgA deficiency with anti-IgA antibodies may be a contraindication to blood transfusions containing IgA, as it can increase the risk of anaphylactic reactions 6, 7.
• A history of anaphylactic transfusion reactions may be a contraindication to future blood transfusions, depending on the underlying cause of the reaction 4, 7.