Acute haemolysis after transfusion of uncross-matched red blood cell (RBC) transfusion

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Record number: 
Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
The authors identified 14 studies evaluating the frequency of acute HTR post-emergency transfusion of uncross-matched RBC units and the literature review found the frequency to be 2/3998 (0.06%, 95%CI, 0.01-0.21%).
Time to detection: 
The clinical complication started soon after the administration of three uncross-matched units of blood, two of which were incompatible with pre-exisiting RBC alloantibodies.
Alerting signals, symptoms, evidence of occurrence: 
A male stabbing victim received three units of uncross-matched RBC units complicated by acute intravascular HTR, disseminated intravascular coagulation (DIC) and renal failure. Acute HTR was shown by haemoglobinuria, free-plasma haemoglobin and methemalbumin, with anti-K and anti-Fya eluted from recipient cells; acute DIC featured severe hypofibrinogenemia, thrombocytopenia, elevated fibrin D-dimer and multiple bilateral infarcts.
Demonstration of imputability or root cause: 
The patient's pre-transfusion blood sample showed blood group A, RhD-negative, with a positive alloantibody screen and negative direct antiglobulin test (DAT). The patient's plasma contained anti-Fya (titre 512) and anti-K alloantibodies (titre 128). Phenotyping and serological cross-match of the three uncross-matched RBC units (two group 0, one group A) showed that two units (typed as Fya+/K+ and Fya+K-) were incompatible. Three days post-uncross-matched RBC transfusion, the DAT was positive (IgG and Complement). Elution studies revealed anti-Fya 3 days post-trauma, both anti-Fya and anti-K 6 days post-trauma and anti-Fya at 3 months post-trauma. Three months post-trauma the patient's anti-Fy and anti-K titres rose to 8192 and 2048, respectively.
Imputability grade: 
3 Definite/Certain/Proven
Groups audience: 
Suggest references: 
J. Fiorellino, A. L. Elahie, T. E. Warkentin. Acute haemolysis, DIC and renal failure after transfusion of uncross-matched blood during trauma resuscitation: illustrative case and literature review. Transfus Med. 2018 Feb 19. doi: 10.1111/tme.12513. [Epub ahead of print]
Expert comments for publication: 
The case presented is a rare example that illustrates the risk of a severe acute HTR related to the common clinical practice of using emergency-release uncross-matched blood. Although this experience should not argue against the use of such transfusions in an emergency-release fashion, clinicians should be attuned to the small but potentially serious risk (<1/1000) of an alloantibody-mediated acute HTR, with the potential for associated morbidity and mortality.