|Year : 2012 | Volume
| Issue : 1 | Page : 27-32
Pattern of acute blood transfusion reactions in Kano, North-Western Nigeria
Baffa A Gwaram1, Musa M Borodo1, Abdulhamid I Dutse1, Aisha Kuliya-Gwarzo2
1 Department of Medicine, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Hematology and Blood Transfusion, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||10-Oct-2012|
Baffa A Gwaram
Department of Medicine, Bayero University Kano/Aminu Kano Teaching Hospital, PMB 3452, Kano
Source of Support: None, Conflict of Interest: None
Background : Advancement in transfusion medicine has led to the use of large quantities of blood and blood components in modern clinical practice. The purpose of this study is to determine the pattern of acute blood transfusion reactions among adults in North-Western Nigeria. Materials and Methods: This was a descriptive observational study over a 3-month period that evaluated 302 blood transfusions in 180 consenting recipients in Aminu Kano Teaching Hospital. Data was analyzed using descriptive and inferential statistics, and P-values of ≤ 0.05 were regarded as significant. Results: The mean age of the recipients was 37.2 ± 13.7 (95% CI: 35.2 - 39.2) years. The incidence of acute transfusion reaction (ATRs) was 3.6%, out of which 3.3% were febrile non-hemolytic transfusion reaction (FNHTR) and 0.3% were acute allergic reaction (AAR). All the recipients that reacted presented clinically with fever and more than 90% of them had associated chills and/or rigors. There was a significant relationship between ATRs and history of previous transfusion (χ2 = 4.12; P = 0.04) and stored blood of more than 3 days (χ2 = 5.20; P = 0.02). Conclusion: Patients with previous history of transfusion should be monitored closely as they have a higher risk of developing transfusion reaction, and transfusion of blood stored for more than 3 days should as much as possible be avoided, especially in patients that have a potential risk of transfusion reaction.
Keywords: Acute blood transfusion reaction, age of stored blood, previous transfusion
|How to cite this article:|
Gwaram BA, Borodo MM, Dutse AI, Kuliya-Gwarzo A. Pattern of acute blood transfusion reactions in Kano, North-Western Nigeria. Niger J Basic Clin Sci 2012;9:27-32
|How to cite this URL:|
Gwaram BA, Borodo MM, Dutse AI, Kuliya-Gwarzo A. Pattern of acute blood transfusion reactions in Kano, North-Western Nigeria. Niger J Basic Clin Sci [serial online] 2012 [cited 2022 Dec 9];9:27-32. Available from: https://www.njbcs.net/text.asp?2012/9/1/27/102110
| Introduction|| |
Despite the increasing public awareness on the risks and complications of blood transfusion that has resulted in a more stringent approach to donation, testing, and preparation of blood and its components, blood transfusion is still associated with significant complications. The frequency of the complications, however, varies inversely with the care exercised in the preparation for and supervision of the transfusion.  Approximately 20% of all transfusions may lead to some type of adverse reaction or the other.  Complications associated with blood transfusion therapy may be classified based on time of onset as acute and late transfusion reactions , or based on etiology as immunological and non-immunological. 
Early onset transfusion reactions are usually acute reactions that occur during transfusion or anytime within 24 hours following transfusion of the blood or blood components, while late reactions occur from 24 hours to 2 weeks following the transfusion. 
Reported incidences of acute transfusion reaction (ATR) differ significantly. While incidence of 0.2%  and 0.34%  are reported in Europe and South America, respectively, the incidence of acute immune-mediated transfusion reactions is reported to be 11.8% in North East Nigeria, out of which 0.01% was due to Acute hemolytic transfusion reaction (AHTR), 9.8% due to febrile non-hemolytic transfusion reaction (FNHTR) and 2% attributed to allergic transfusion reactions.  Similarly, the incidence of ATR in Ile- Ife  was found to be 8.7%, out of which FNHTR constituted 65% of the reactions. Acute transfusion reactions (ATRs) in practice are associated with an immune response to antigens on red cells, white cells, or platelets and plasma proteins; they could also be due to bacterial contamination of blood or blood components.  The rate of reaction with whole blood transfusion was about two and a half times greater than with packed red blood cells,  and there is also a significant relationship between reactions and increased storage time of blood components. , Most types of reactions occur when patients require more than one unit or large volumes of blood.  It has also been reported that FNHTRs associated with red cell transfusions occurred more in patients who have had previous pregnancies and/or previous blood transfusions. ,
Manifestations of the type of ATR may vary with the blood product transfused, the clinical condition, and past medical history of the recipient and may present clinically as acute febrile reactions, acute allergic reactions, or dyspneic transfusion reactions. 
While the majority of ATRs are transient and do not result in lasting sequelae, similarities in the presenting features among the various types of reactions make it impossible to differentiate a relatively benign event from the early stages of severe life-threatening transfusion reaction. This calls for vigilance before, during, and after transfusion so that ATRs are identified early in order to reduce morbidity and mortality.
Generally there is inadequate data on ATRs in Nigeria, and there has never been a study of this nature in this center. The objectives of this study are to determine the incidence, types, clinical presentation, and risk factors associated with acute blood transfusion reactions in Aminu Kano Teaching Hospital. Approval for the study was obtained from the hospital ethical committee.
| Materials and Methods|| |
The study was carried out at Aminu Kano Teaching Hospital (AKTH), located in Kano State, North-Western Nigeria over a 3-month period from February to May 2007. AKTH serves the cosmopolitan city of Kano and gets referrals from neighboring states like Jigawa, Katsina, Zamfara, Kebbi, Bauchi, and parts of Kaduna and Sokoto. The annual transfusion utilization in AKTH is about 3000 units.
All adult patients on admission in the hospital who required blood transfusion and had established diagnosis and consented were included in the study. However, those requiring blood transfusion intra-operatively, less than 24 hrs post-operatively, or while undergoing hemodialysis were excluded.
Each consenting blood transfusion recipient who met the inclusion criteria was administered a questionnaire to obtain bio-data, relevant social, and past medical history including transfusion history. A general physical examination was also carried out on each of them before commencing the transfusion.
During transfusion, vital signs were monitored half an hour after the commencement of the transfusion and then subsequently hourly to the end of the transfusion. At the same time, patients were observed for features of transfusion reaction, which included chills/rigors, itching, urticaria, nausea, vomiting, and dyspnea. The monitoring was continued 4 hourly up to 24 hours after transfusion. Data on the date of blood donation, blood group of donor blood, type of donation, and type of blood component were also recorded.
Blood and urine samples were collected from each patient before and after transfusion, which were used to investigate for ATR in suspected cases. Investigations performed were based on standard operating procedure (SOP) as described by Dacie and Lewis. 
All the patients had pre-transfusion packed cell volume (PCV) and urinalysis done, and the post-transfusion urine sample was visually checked for hemoglobinuria in addition to urinalysis.
Subjects suspected to have ATR clinically or from screening of urine samples had the donor blood sample sent for microscopy and culture, regrouping, crossmatch, and direct Coombs' test while the recipient's blood was tested for plasma hemoglobin and unconjugated bilirubin levels, malaria parasite and was screened for disseminated intravascular coagulation (platelet count, prothrombin time and activated partial thromboplastin time).
The management given to the blood recipients who reacted was the same. All the patients were managed with exposure, tepid sponging, intravenous chlorpheniramine 10 mg, and intramuscular paracetamol 30 mg. Four (40%) patients among those that had FNHTR were also given additional I.V hydrocortisone 100 mg statim. The patient who had AAR was also given additional repeated IV hydrocortisone 100 mg 8 hourly for 24 hrs.
| Results|| |
A total of 180 blood recipients participated in this study, out of which 94 (52.2%) were males and 86 (47.8%) were females with the male: female ratio being 1.1:1. The average age of the blood recipients was 37.2 ± 13.7 (95% CI: 35.2 - 39.2) years. [Figure 1] shows the age and sex distribution. Fifty-five (30.6%) recipients were within the 18 - 27 year age group, out of which 35 were females and 20 were males. However, in the 28 - 37 year age group, there were 28 males and 23 females. Only 1 male was in the 68 - 77 year age group.
Among the female blood recipients, decreasing number of transfusions with increasing age was observed. One hundred and fifty four (74.4%) recipients were Hausa by tribe, 10 (5.6%) Yoruba, 9 (5.0%) Fulani, and 8 (4.4%) Igbos. Nineteen (10.6%) recipients belong to other tribes.
A total of 302 consecutive transfusions of various blood components were observed, 288 (95.4%) were whole blood transfusions, 12 (4.0%) were packed cells; one unit (0.3%) was platelet concentrate and 1 (0.3%) other unit was cryoprecipitate.
As shown in [Figure 2], the commonest diagnosis among the recipients was HIV/AIDS with 29 (16.1%) cases. Malignancies accounted for 28 (15.6%) cases, while chronic renal failure and various obstetrics and gynecology (O and G) cases accounted for 26 (14.4%) cases each. Other diagnoses included sickle cell anemia (SCA) with 7 (5.0%) cases, tuberculosis (TB), road traffic accidents (RTA) and those lumped up under medical and surgical cases.
Eleven transfusions ended up with adverse transfusion reactions. Hence, the overall incidence of acute transfusion reactions was 3.6%. Ten reactions out of the 11 were FNHTR, thereby giving an incidence of 3.3% while only 1 case was AAR, giving an incidence rate of 0.3%. All the reactions noticed were in subjects transfused with whole blood, out of whom 4 were males and 7 were females. All the 7 (63.6%) reactions observed in women occurred in those having 2 or more previous pregnancies. The mean storage time of the blood before transfusion was 7.5 ± 6.4 days. The patient that had AAR was transfused with blood stored for 7 days.
A statistically significant difference in reaction between subjects transfused with blood stored for less than 3 days and those transfused with blood stored for 3 days and above was observed (P = 0.02) [Table 1].
Among the subjects that reacted, 3 had no history of previous blood transfusion (including AAR) while 8 had previous transfusion of blood or blood component. As shown in [Table 2], a statistically significant relationship between reaction and previous transfusion was observed (P = 0.04).
All the subjects that had transfusion reaction presented with fever with an average highest temperature of 39.3 ± 0.6 (95% CI: 38.9 - 39.7°C). Associated with fever in the FNHTR group was rigor in 2 (18.2%) and chills in 5 (45.5%) subjects, while 3 (27.3%) subjects had associated chills and rigors. The single episode of acute allergic reaction presented with facial swelling, rashes and itching in addition to the fever. No associated hypotension or dyspnea was observed among the recipients that had fever. All the cases experienced the clinical signs and symptoms during transfusion with an average time of appearance of the fever and chills and/or rigors of 1.37 ± 1.01 hrs after commencement of the transfusion. All the transfusions in question were suspended for laboratory investigations to be carried out but were later recommenced and monitored to their completion after the investigations, except the one due to AAR.
Twelve recipients were investigated for acute blood transfusion reaction, and at the end, 11 were concluded to have reacted to the blood component they were transfused with, while the remaining one had malaria.
There were no gross differences between the pre and 24 hrs post-transfusion urinalysis results obtained among the recipients. However, as shown in [Table 3], two urine samples were thought to have hemoglobinuria visually, and when the samples were further centrifuged and stained for the presence of hemosiderin, they were positive. These were the subjects with burns and SCA. Similarly, they had high pre- and post-transfusion plasma hemoglobin levels (17.70 mg/dl; 19.30 mg/dl and 5.82 mg/dl; 6.52 mg/ dl, respectively). They also expectedly had high pre- and post-transfusion indirect bilirubin levels (17.1 umol/l; 18:8 umol/l and 14.1 umol/l; 14.3 umol/l, respectively). This showed that the subjects were hemolyzing as a result of their pre- transfusion conditions and not as a result of ATR. The remaining 9 subjects that reacted had normal levels of plasma hemoglobin and indirect bilirubin. The table also shows that only two subjects investigated were positive for malaria parasite, the one that had AAR and the one diagnosed to have malaria.
Screening for DIC was not suggestive, and blood cultures of the donor blood yielded no growth in the cases investigated. Direct Coombs' Test, regrouping and crossmatch done at room temperature 37°C revealed that all the subjects were transfused with compatible donor blood components.
| Discussion|| |
The incidence of acute blood transfusion reactions in this study (3.6%) is lower than reports from elsewhere in Nigeria , and other parts of the world. , The low incidence of 0.2% reported from Europe was attributed to under-reporting and use of leucodepleted blood components. In the present study, whole blood (not leucodepleted) was the predominantly used type, which might have contributed to the higher incidence seen compared to Europe. The nature of donation was mostly family replacement from Hausa donors with fewer tendencies to tribal or racial diversity, hence minimal antigenic differences between donors and recipients may have reduced blood transfusion reactions compared to the other Nigerian study areas that has a donor pool from different parts of Nigeria and may have experienced more inter-tribal diversity between donors and recipients. This may explain the higher incidence rate of ATR in Ile-Ife  and Maiduguri  compared to Kano.
The types of reactions observed in this study were FNHTR and AAR. Febrile reactions were the commonest observed, and this is in agreement with earlier reports that febrile reactions are generally the commonest reactions to blood transfusion. ,, The incidence of AAR in this study was 0.3%, which is similar to that reported by Domen.  Acute allergic reactions are also said to be the second commonest type of reactions associated with blood component therapy.  This is in agreement with the findings in this study where the second most common type of reaction observed was AAR.
All the recipients that reacted had fever, with associated rigor in 2 (18.2%) cases and chills in 5 (45.5%) cases, while 3 (27.3%) cases had associated chills and rigors. They were concluded to have FNHTR based on the recognition of the most frequent expressions of FNHTR  and the absence of malaria parasite in their peripheral blood films. The patient that had AAR had facial swelling, rashes, and itching associated with fever. This is consistent with the clinical presentation of AAR documented by other researchers. , No episode of difficulty in breathing or hypotension that will suggest dyspneic transfusion reaction was observed.
In this study, a statistically significant relationship was obtained between acute transfusion reaction and previous transfusion, which is similar to earlier reports from Maiduguri and Ife. , Also, a statistical significance was observed between the age of stored blood components and transfusion reaction. This is in agreement with studies that reported that the longer the storage time of blood component, the more likelihood of transfusion reaction. , Also, studies have revealed that the dominant factor determining risk of febrile reaction was not white cell contamination but the age of the stored product. ,, The storage changes responsible for this are the release of cytokines, especially in stored platelets.
Acute hemolytic transfusion reaction from ABO incompatibility (that is commonly due to clerical error)  with a reported incidence of 0.01% in Nigeria  was not recorded in this study. Also, no episode of transfusion related acute lung injury (TRALI) was seen although it is rare with an incidence of 0.02%. 
The use of premedication with anti-pyretics as a management modality for FNHTR has remained controversial;  however, the result in this study showed that most instances of transfusion complicated by FNHTR were safely completed using exposure and tepid sponging with anti-pyretic cover coupled with slower transfusion rate. Only one unit of blood was wasted as a result of AAR.
| Conclusions|| |
Acute blood transfusion reaction was not uncommon in the population studied and occurs in both females and males alike with an incidence rate of 3.6%. FNHTR was the commonest reaction observed with an incidence of 3.3% while AAR presented with an incidence of 0.3%. A statistically significant relationship was established between ATRs and previous transfusion and also with the age of stored blood.
Fever and chills were the commonest clinical presentations; as such, any increase in pre-transfusion temperature or development of fever during transfusion must be taken seriously.
It is recommended from this study that type of blood component transfused should be appropriate to the clinical situation and whole blood therapy should be avoided or restricted to specific situations. Also, patients with previous history of transfusion should be monitored closely as they have a higher risk of developing transfusion reaction and also transfusion of blood stored for more than 3 days should as much as possible be avoided, especially in patients that have a potential risk of transfusion reaction. Bedside blood filters that have been shown to decrease the incidence of FNHTR should be provided in order to achieve meaningful reduction in the rate of blood transfusion reactions. Establishing a haemovigilance system of monitoring, collating, and analyzing data on adverse effects of blood transfusion both locally and nationally will help in reducing the incidence of acute transfusion reactions.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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