What is the morbidity and mortality of transfusion reactions?

Updated: Jan 12, 2021
  • Author: S Gerald Sandler, MD, FCAP, FACP; Chief Editor: Emmanuel C Besa, MD  more...
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Complications include the following:

  • TRALI: Although uncommon, TRALI was the most frequent cause of acute transfusion fatality reported to the US Food and Drug Administration (FDA) from fiscal years 2008 through 2012, accounting for 37% of deaths. [41] Early and intensive pulmonary support reduces the risk of a fatal outcome. No long-term morbidity has been described in survivors.

  • Circulatory (volume) overload: Outcome varies with the overall clinical status of the patient. No long-term sequelae occur.

  • In a meta-analysis of health care–associated infection after RBC transfusion, the risk of serious infections was 11.8% with restrictive transfusion thresholds (ie, hemoglobin of < 7.0 g/dL) and 16.9% when liberal thresholds were used. Such infections included pneumonia, mediastinitis, wound infection, and sepsis. [42]

  • Bacterial contamination/endotoxemia is potentially fatal and may be caused by gram-positive or gram-negative bacteria. Early diagnosis, initiation of broad-spectrum antibiotics, and other intensive supportive measures may reverse the outcome of an otherwise fatal complication of transfusion. Based on the frequency of sepsis and positive cultures of platelet units, the mortality rate is estimated to be approximately 1 in 50,000 platelet units. [35, 43]

  • Acute hemolytic reactions (antibody mediated): Most severe and fatal reactions result from inadvertent transfusion of group AB or group A red cells to a group O recipient. Renal failure and disseminated intravascular coagulation (DIC) are potential complications for patients who survive the initial acute reaction. Mortality increases directly with the volume of incompatible blood that was transfused.

  • Acute hemolytic reactions (non–antibody-mediated) are typically benign; these include mechanical hemolysis of serologically compatible RBCs due to freezing, pressure infusion pumps, and osmotic hemolysis. [44] Transfusion of serologically compatible but hemolyzed red cells results in acute hemoglobinemia and hemoglobinuria. Rarely, short- or long-term complications occur.

  • Nonhemolytic febrile reactions are discomforting but typically benign. Occasionally, patients may have rigors, nausea, vomiting, and considerable distress. Patients who develop fever associated with a blood transfusion must be monitored carefully until the possibility of bacterial contamination of the blood product is excluded.

  • Allergic reactions are typically benign but bothersome to recipients. Occasionally, allergic reactions may progress from pruritus and hives to bronchospasm and a generalized reaction, but such events are uncommon.

  • Anaphylactic reactions are potentially, but rarely, fatal. The only fatal case of anti–IgA-related anaphylaxis identified in the medical literature by the authors involved a patient with an anti–IgA/IgA reaction who died of a myocardial infarction. [45] Patients experiencing an acute attack of angioedema due to C1-inhibitor deficiency may have severe abdominal or subcutaneous attacks or laryngeal edema requiring emergency treatment. [46] The mortality rate for anaphylaxis is estimated to be approximately 1 per year. [20]

  • Alloimmunization to RBC blood group antigens may be considered a complication of RBC transfusions, because such patients may be at risk of delays in the future if they require urgent transfusion of compatible RBCs. [47] Alloimmunization to RBC blood group antigens may also delay solid-organ transplantation if a significant number of serologically compatible RBCs are required. [48]

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