Immune complications

Red cell alloimmunization

Red cell transfusion leads to red cell antibody formation in some patients, particularly certain populations such as those receiving multiple transfusions or with sickle cell disease. Phenotyped red cells are then required. Occasionally, delayed hemolytic transfusion reactions occur when antibodies in the recipient's serum are below the threshold for detection.

Human leukocyte antigen (HLA) alloimmunization

Patients may develop HLA antibodies to antigens on white cells present as contaminants in red cell preparations. HLA antibodies can cause non-hemolytic febrile transfusion reactions or reduced survival of transplanted organs, or the patient may become refractory to platelet transfusions.

Allergic reactions

Rarely, hypersensitivity to plasma proteins causes urticaria or even anaphylaxis; this is less likely when using red cell concentrates rather than whole blood as most of the donor plasma has been removed.

Transfusion-associated graft versus host disease

This may occur in severely immunodeficient patients or in patients receiving blood from a first-degree relative. It can be prevented by irradiation of red cells (or platelets) to destroy donor leukocytes.

Transfusion-related acute lung injury

If leukocyte antibodies are present in the donor unit of red cells (or platelets or fresh frozen plasma), they can interact with leukocyte antigens present on the recipient's white cells. A severe and potentially fatal reaction follows, with fever, dyspnea, and hypotension. A chest radiograph typically shows numerous perihilar nodules and infiltration of the lower lung fields without cardiac enlargement. Leukodepletion is not effective in preventing transfusion-related acute lung injury as it cannot remove antibodies present in the donor's blood. Implicated donors should be removed from the donor panel.

Immune modulation

Currently, there is much debate about possible immune-modulating effects of blood transfusion which may have additional effects on the recovery of a critically ill patient.

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