Delayed Hemolytic Transfusion Reaction (DHTR), anti- A and Anti-B, Bone Marrow Transplant

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Record number: 
Adverse Occurrence type: 
MPHO Type: 
Time to detection: 
6 days
Alerting signals, symptoms, evidence of occurrence: 
A 26-year-old, blood group O bone marrow transplant recipient experienced a severe, delayed hemolytic transfusion reaction 6 days following transplantation of marrow from his HLA-mixed lymphocyte culture - identical, blood group AB sister. He became acutely dyspneic. His hematocrit dropped to 18%; indirect hyperbilirubinemia and extensive agglutination on peripheral blood smear.
Demonstration of imputability or root cause: 
The direct antiglobulin test was positive for IgG and complement; anti-A and anti-B were eluted from his red cells. His peripheral blood smear demonstrated extensive agglutination resembling a mixed field reaction.
Imputability grade: 
3 Definite/Certain/Proven
Groups audience: 
Reference attachment: 
Suggest references: 
Warkentin, P. I., Yomtovian, R., Hurd, D., Brunning, R., Swanson, J., Kersey, J. H. and McCullough, J. (1983). Severe delayed hemolytic transfusion reaction complicating an ABO-incompatible bone marrow transplantation. Vox Sang 45(1):40-47.
Expert comments for publication: 
This case demonstrates that significant morbidity may be associated with major ABO-incompatible bone marrow transplantation, that the transfusion of incompatible red cells should be undertaken with extreme caution, and that efforts should be made to carry out pretransplant red cell removal from the infused bone marrow. Antibodies of the ABO system are clinically the most important in transfusion medicine for 2 main reasons: (1) almost all adults have anti-A or -B or both when the corresponding antigen is absent and (2) ABO antibodies cause acute intravascular hemolytic transfusion reactions.