Transfusion-related red blood cell alloantibodies: induction and consequences

Abstract

Blood transfusion is the most common procedure completed during a given hospitalization in the United States. Although often life-saving, transfusions are not risk-free. One sequela that occurs in a subset of red blood cell (RBC) transfusion recipients is the development of alloantibodies. It is estimated that only 30% of induced RBC alloantibodies are detected, given alloantibody induction and evanescence patterns, missed opportunities for alloantibody detection, and record fragmentation. Alloantibodies may be clinically significant in future transfusion scenarios, potentially resulting in acute or delayed hemolytic transfusion reactions or in difficulty locating compatible RBC units for future transfusion. Alloantibodies can also be clinically significant in future pregnancies, potentially resulting in hemolytic disease of the fetus and newborn. A better understanding of factors that impact RBC alloantibody formation may allow general or targeted preventative strategies to be developed. Animal and human studies suggest that blood donor, blood product, and transfusion recipient variables potentially influence which transfusion recipients will become alloimmunized, with genetic as well as innate/adaptive immune factors also playing a role. At present, judicious transfusion of RBCs is the primary strategy invoked in alloimmunization prevention. Other mitigation strategies include matching RBC antigens of blood donors to those of transfusion recipients or providing immunomodulatory therapies prior to blood product exposure in select recipients with a history of life-threatening alloimmunization. Multidisciplinary collaborations between providers with expertise in transfusion medicine, hematology, oncology, transplantation, obstetrics, and immunology, among other areas, are needed to better understand RBC alloimmunization and refine preventative strategies.

Figure 1.

Cartoon of an RBC with representative blood group antigens. Drawn by Elisabet Sjӧberg Webster, and reproduced with permission. GLOB, globoside.

Figure 2.

RBC alloantibody induction, evanescence, and anamnestic response. A model figure of events leading to a DHTR, with the typical time course of primary alloimmunization, antibody evanescence, and anamnestic response. The dashed line represents an example threshold of antibody detection by a transfusion service.

Figure 3.

Approximate RBC alloantibody prevalence by representative disease status. Alloimmunization rates by disease vary significantly by study; the data shown are approximately representative.

Figure 4.

Variables potentially impacting RBC alloantibody formation.