Acute hemolytic transfusion reaction

Acute hemolytic transfusion reaction

Updated: 07/25/2025

© Jun Wang, MD, PhD

 

General features

  • AKA immediate hemolytic transfusion reaction 
  • Intravascular or extravascular hemolysis
  • Most commonly due to clerical error
  • Commonly associated with anti-A, anti-Kell, anti-JKa and anti-Fya
  • Most severe if ABO-related

Clinical presentations

  • Manifestations start during transfusion
  • Severe cases occur within the first 15 minutes 
  • Fever and chill
  • Back or infusion site pain
  • Hypotension/shock
  • Bleeding if disseminated intravascular coagulation (DIC)
  • Organ failures, commonly acute renal failure

Key pathogenesis

  • Immune mediated hemolysis
  • Coagulation and inflammation caused by circulating free hemoglobin
  • Organ dysfunctions/injury due to DIC or inflammation

Laboratory findings

  • Evidence of hemolysis: hemoglobinemia, hemoglobinuria, elevated bilirubin and LDH, etc
  • Positive DAT
  • Schistocytosis or spherocytosis
  • Evidence of DIC: thrombocytopenia, prolong PT, aPTT, elevated D-dimer/FDP, decreased fibrinogen, etc

Management

  • Stop transfusion
  • Clerical check
  • Repeat ABO and Rh typing 
  • Hydration and diuresis
  • Management of complications: DIC, renal failure, hypotension, shock, etc

 

 

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