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Febrile Nonhemolytic Transfusion Reactions
Febrile nonhemolytic transfusion reactions (FNHTRs) are common, occurring with 1–3% of transfusions. FNHTR manifests as fever and/or chills without hemolysis occurring in the patient during or within 4 hours of transfusion cessation. Diagnosis is made by excluding other causes of fever. Most common causes are passively transfused proinflammatory cytokines or recipient antibodies reacting with donor leukocytes. Most reactions are easily managed. FNHTRs are mitigated through prestorage leukoreduction.
Clinical Presentation
FNHTR is defined as occurring during or within 4 hours of cessation of transfusion, with fever (≥38°C and change of ≥1°C) from pretransfusion or chills/rigors. Fever may be absent due to antipyretic premedication. One-third of reactions are severe, resulting in rigors, temperature elevation of >2°C, dyspnea, headache, nausea, and vomiting.
Diagnosis
FNHTR is diagnosis of exclusion, as no specific tests are available. Differential diagnosis includes hemolysis, sepsis and TRALI, or fever due to medications or medical conditions. Hemolytic transfusion reaction is excluded thorough transfusion reaction workup, including clerical check, ABO confirmation of product and recipient, and serological workup. Transfusion-associated sepsis usually presents with high increase in fever and hypotension. Gram stain and culture of patient and unit support excluding septic transfusion reactions. TRALI typically presents with fever, dyspnea, and hypotension. Review of patient’s record can rule out fevers due to underlying disease or medications, such as beta-lactam antibiotics, procainamide, isoniazid, barbiturates, quinidine, and diphenylhydantoin.
Incidence
FNHTRs are the most common acute transfusion reactions. Prestorage leukocyte reduction has dramatically decreased its incidence to <0.2% for both RBCs and platelets, with higher incidence using active versus passive reporting. Certain patient populations are considered to be at a higher risk, including patients with hematologic diseases, who maybe HLA alloimmunized from frequent transfusions, or more sensitive to infused cytokines due to baseline inflammatory state.
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