Acute renal failure from hemolytic transfusion reactions
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Acute renal failure from hemolytic transfusion reactions. Brad Weaver, MD 9/25/07. Acute hemolytic transfusion reaction. ABO incompatability is the major cause of death from transfusion

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Acute renal failure from hemolytic transfusion reactions

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Acute renal failure from hemolytic transfusion reactions

Brad Weaver, MD

9/25/07


Acute hemolytic transfusion reaction

  • ABO incompatability is the major cause of death from transfusion

  • 125 deaths reported to FDA due to ABO incompatable transfusion from 1976 to 1985. Sazama et al. Transfusion 1990 Sep;30(7):583-90.

  • IgM anti-A and anti-B fix complement  rapid intravascular hemolysis

    • Acute renal failure from ATN

    • DIC

    • Shock

    • Hyperkalemia

  • Renal failure can be caused by direct toxicity of hemoglobin and by renal ischemia from shock


Hemoglobinuria

Alpha-Beta dimers MW 34,000 -- small enough to be filtered by glomerulus


Proposed mechanisms of renal injury

1. Obstruction of tubules with heme pigment casts

2. Oxidative damage to proximal tubule by released free iron

Low FENa characteristic


Prevention of ARF

  • Volume repletion

  • Alkalinization of urine

  • Mannitol diuresis


Alkalinization of urine and mannitol

  • Hemoglobin less likely to precipitate with Tamm-Horsfall protein in alkaline urine

  • Alkalinization stabilizes reactive iron species

  • Mannitol acts as an osmotic diuretic, dilates renal vasculature, and is an antioxidant


A retrospective seriesBrown et al. J Trauma 56(6) 2004

  • Series of 382 patients with serum CK concentration >5000 U/L, 154 (40 percent) were treated with bicarbonate and mannitol

  • No statistically significant difference in the incidence of:

    • renal failure as defined by Cr >2.0 (22 versus 18 percent)

    • dialysis (7 versus 6 percent)

    • death (15 versus 18 percent)


A case reportAmyot et al. Intensive Care Med. 25. 1999

  • A 30yo man with myoglobin-induced renal failure was treated with CVVH for 33h

  • Blood flow 150 mL/min, ultrafiltration rate 2 to 3L/h

  • Serum myoglobin (MW 17,000) concentration decreased from 92,000 ug/L to 28,600 ug/L after 18h

  • Required HD for 25 days and eventually recovered normal renal function


Preventing hemolysis – recombinant complement receptor 1 Yazdanbakhsh et al. Blood 101 (12) 2003

  • Complement receptor 1 (CR1) – transmembrane protein that inhibits C3 and C5 convertases and cofactor for serum protease 1

  • Mouse study: recombinant soluble form of CR1 inhibited complement activation in mice with pre-existing anti-A transfused with human group A RBCs

  • RBC survival increased by 50%


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