Transfusion‐associated hyperkalemia in pediatric population: Prevalence, risk factors, survival, infusion rate, and RBC unit features

Abstract

Background Hyperkalemia is a rare life‐threatening complication of red blood cell (RBC) transfusion. Stored RBCs leak intracellular potassium (K+) into the supernatant; irradiation potentiates the K+ leak. As the characteristics of patients and implicated RBCs have not been studied systematically, a multicenter study of transfusion‐associated hyperkalemia (TAH) in the pediatric population was conducted through the AABB Pediatric Transfusion Medicine Subsection. Study Design The medical records of patients <18 years old were retrospectively queried for hyperkalemia occurrence during or ≤12 h after the completion of RBC transfusion in a 1‐year period. Collected data included patient demographics, diagnosis, medical history, timing of hyperkalemia and transfusion, mortality, and RBC unit characteristics. Results/Findings A total of 3777 patients received 19,649 RBC units during the study period in four facilities. TAH was found in 35 patients (0.93%) in 37 occurrences. The patient median age and weight were 1.28 years and 9.80 kg, respectively. All patients had multiple serious comorbidities. There were 79 RBC units transfused in the TAH events; 62% were irradiated, and the median age of the units was 10 days. The median total RBC volume transfused ≤12 h before TAH was 24% of patient estimated total blood volume, and the median infusion rate (IR) was19.6 ml/kg/h. Mortality rate within 1 day after the TAH event was 20%. Conclusions The prevalence of TAH in children was low; however, the 1‐day mortality rate was 20%. Patients with multiple comorbidities may be at higher risk for TAH. The IR was higher for patients who had TAH than the IR threshold for safe transfusion.

X‐ and gamma‐irradiation have similar effects on the in vitro quality of stored red cell components

“…11,13,15 While post-irradiation concentrations of potassium are generally well-tolerated, high supernatant potassium leading to hyperkalemia and cardiac arrest in both adult and pediatric recipients is still of concern, particularly in rapid, large volume red cell transfusions where other co-morbidities reduce the capacity of normal potassium homeostasis mechanisms. [16][17][18][19] Recently published guidelines note that the incidence of TA-GVHD is extremely low even in multiple transfused preterm infants, and that routine irradiation of red cells for transfusion to preterm or term infants (other than for neonatal exchange transfusion) is not required unless there has been a previous IUT. 6 Early gamma-irradiation followed by storage in SAG-M has previously been shown to increase red cell microparticle release.…”

Transfusion-Associated Hyperkalemic Cardiac Arrest in Neonatal, Infant, and Pediatric Patients

“…TAHCA is not unique to neonatal and pediatric populations (61,71), but these patients have increased susceptibility due to their unique physiology. There is a 20% 1-day mortality rate in pediatric patients who experience TAHCA (7), and hyperkalemia after transfusion is the second most common cause of perioperative cardiac arrest in neonates, infants, and children (74). Potential strategies to mitigate the risk of TAHCA include the use of fresh RBCs for pediatric cardiac surgery and ECMO, limiting the duration of storage post-irradiation, washing RBCs and/or pre-bypass filtration to remove extracellular K + , slower rates of transfusion, and the use of specialized pre-transfusion filters to reduce [K + ] (42,81,87,93,101,102,104).…”

“…Neonatal and pediatric patients are physiologically different from adults, and as such, transfusion indications and clinical management can present unique challenges (4,5). For example, younger patients are more susceptible to electrolyte and metabolic consequences of transfusions (e.g., hyperkalemia, hypocalcemia), since the amount of blood given during surgery or massive transfusion can equal the total blood volume of a neonate, and the glomerular filtration rate of newborns does not reach maturity until near the first year of life (4,6,7). Moreover, many children's hospitals follow a dedicated donor strategy, wherein a single-donor unit is split into multiple pediatric packs for use in a designated patient (8)(9)(10), up to the date of expiration.…”

Irradiated red blood cells: Can all sins be washed away?

“…We read with interest the study on transfusion-associated hyperkalemia (TAH) by Yamada et al 1 and the editorial by Romon and Cortes. 2 We thank the authors for their letter to increase awareness of TAH.…”