Kawamoto et al.

BMC Anesthesiology (2019) 19:83

https://doi.org/10.1186/s12871-019-0752-4

CASE REPORT Open Access

Hemolytic reaction in the washed salvaged

blood of a patient with paroxysmal
nocturnal hemoglobinuria
Yuko Kawamoto1, Tasuku Nishihara1* , Aisa Watanabe1, Kazuo Nakanishi2, Taisuke Hamada1, Amane Konishi1,
Naoki Abe1, Sakiko Kitamura1, Keizo Ikemune1, Yuichiro Toda3 and Toshihiro Yorozuya1

Abstract
Background: In patients with paroxysmal nocturnal hemoglobinuria (PNH), the membrane-attack complex (MAC)
formed on red blood cells (RBCs) causes hemolysis due to the patient’s own activated complement system by an
infection, inflammation, or surgical stress. The efficacy of transfusion therapy for patients with PNH has been documented,
but no studies have focused on the perioperative use of salvaged autologous blood in patients with PNH.
Case presentation: A 71-year-old man underwent total hip replacement surgery. An autologous blood salvage device
was put in place due to the large bleeding volume and the existence of an irregular antibody. The potassium
concentration in the transfer bag of salvaged RBCs after the wash process was high at 6.2 mmol/L, although the
washing generally removes > 90% of the potassium from the blood. This may have been caused by continued
hemolysis even after the wash process. Once activated, the complement in patients with PNH forms the MAC on
the RBCs, and the hemolytic reaction may not be stopped even with RBC washing.
Conclusions: Packed RBCs, instead of salvaged autologous RBCs, should be used for transfusions in patients with
PNH. The use of salvaged autologous RBCs in patients with PNH should be limited to critical situations, such as
massive bleeding. Physicians should note that the hemolytic reaction may be present inside the transfer bag
even after the wash process.
Keywords: Paroxysmal nocturnal hemoglobinuria, Blood salvage device, Autologous blood transfusion, Complement,
Hemolysis, Hyperkalemia, Potassium

Background are deficient. Therefore, red blood cells (RBCs) are

Paroxysmal nocturnal hemoglobinuria (PNH; OMIM destroyed by the membrane-attack complex (MAC)
300818) is a rare disease, which is caused by a mutation formed by the body’s own activated complement system.
in the PIGA gene on chromosome Xp22 [1]. Rare The use of transfusion therapy for patients with PNH
Disease Database of National Organization for Rare has been well studied. Washed RBCs lacking white blood
Disorders reports that the estimated prevalence is 0.5– cells and complement components were used in the
1.5 per million people in the general population. The past, but the practice of washing the RBCs was deemed
mutation in the PIGA gene causes the deficit or lack of unnecessary and packed RBCs are usable without any
glycosylphosphatidylinositol (GPI)-anchored proteins, problem for patients with PNH [2]. However, no reports
and as a result, GPI-anchored type factors regulating the have focused on the use of perioperative salvaged autolo-
complement system on the membrane of red blood cell gous RBCs for patients with PNH. In here, we describe a
[CD55 or decay-accelerating factor (DAF) and CD59] case involving the use of salvaged autologous RBCs in a
patient with PNH.

* Correspondence: [email protected]
1
Department of Anesthesia and Perioperative Medicine, Ehime University
Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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Kawamoto et al. BMC Anesthesiology (2019) 19:83 Page 2 of 4

Case presentation The amount of bleeding during the operation was 1900 ml,
A 71-year-old man was scheduled to undergo total hip and the infusion volume during the operation was 2400 ml
replacement surgery under general anesthesia to fix of crystalloids, 6 units of packed RBCs, and 280 ml of
malunion of the right hip joint. Two months before the salvaged autologous RBCs. The duration of surgery and
scheduled procedure, he had undergone left bipolar hip anesthesia was 140 and 215 min, respectively. Postopera-
arthroplasty and right acetabular fracture fixation due to tively, the patient was transferred to the intensive care unit
bilateral acetabular cartridge fractures. After the frac- (ICU).
tures, the patient had been prescribed oral polystyrene
sulfonate calcium because of hyperkalemia. He was diag- Postoperative course
nosed to have PNH at the age of 60, and the oral admin- Figure 1b indicates the patient’s progress after the oper-
istration of prednisolone was initiated. The therapy with ation. Glucose-insulin therapy was continued until the
eculizumab was not initiated. postoperative day (POD) 1. The patient left the ICU and
restarted the oral intake of polystyrene sulfonate calcium at
Preoperative examination POD 3 because the K+ increased again. At POD 18, the pa-
The preoperative blood examination showed pancyto- tient was transferred to another hospital for rehabilitation.
penia [white blood cells, 2.100/μl; hemoglobin (Hb),
12.7 g/dl; and platelets, 100 × 103/μl]. We suspected a Discussion and conclusion
hemolytic reaction due to the presence of a slightly in- In normal blood, hemolytic reactions do not occur in
creased aspartate aminotransferase, although bilirubin the absence of antigen-antibody reactions, but the
and lactase dehydrogenase level were within the normal hemolytic reactions in patients with PNH are independ-
limits. The hyperkalemia improved with the polystyrene ent of antigen-antibody reactions. In patients with PNH,
sulfonate calcium. The irregular antibody screening was RBCs are destroyed by an activated complement system
positive. Therefore, 6 units of packed RBCs and a blood due to the deficit of membrane proteins DAF and CD59,
salvage device (electa™; Sorin Group Italia, Italy) were which inhibit the formation of the MAC.
prepared. No other abnormal results in the cardiac, liver, Transfusions in patients with PNH used to be per-
or renal functions were observed. formed with saline washed RBCs to reduce the risk of
leukocyte sensitization, antibody production against
Intraoperative findings human leukocyte antigens, and reactions which may
Figure 1a depicts the intraoperative progress course. The activate complement system [3]. However, a review on
Hb and potassium (K+) levels after the anesthesia induction the subject concluded that the use of washed RBCs is
were 11.5 g/dL and 4.6 mmol/L, respectively. An hour after not necessary and group-specific fresh blood and blood
the operation started, the same levels became 9.6 g/dL and products should be used instead [2, 4]. For our patient,
5.4 mmol/L, respectively, due to unexpected bleeding and we prepared 6 units of packed RBCs and an autologous
presumably intravascular hemolysis. We initiated blood blood salvage device because of the positive irregular
salvage procedures and started transfusion of 2 units of pre- antibody screening result. Autologous blood transfusion
pared packed RBCs using a potassium adsorption filter. can avoid risks or side effects associated with blood
After that, 190 ml of the first salvaged autologous RBCs transfusions. Moreover, the autologous blood salvage
were re-infused. Blood examination results to check K+ device can eliminate over 90% of plasma components [5]
concentration levels in the transfer bag showed a high level presumably including complement factors, which (in
of 6.2 mmol/L in the salvaged RBCs. Because the patient’s theory) would be an added advantage for patients with
Hb became 7.6 g/dL due to continuous bleeding, we trans- PNH, although the RBCs themselves are still vulnerable.
fused two more units of packed RBCs and re-infused 90 ml In the past, over 90% of the K+ in salvaged blood was
of the second salvaged autologous RBCs using a potassium shown to be removed by the wash process [the washed
adsorption filter. The value of K+ in the transfer bag of the RBCs were left with 1–2 mmol/L of (K+)] [6], but in
second salvaged autologous RBCs batch was also high at our case, the K+ concentration in the transfer bag was
6.0 mmol/L. The patient’s Hb level recovered to 10.5 g/dL > 6 mmol/L. This fact indicates that the salvaged blood
after the RBC transfusion. However, the hyperkalemia pro- of patients with PNH continued to be lysed even after
gressed to 6.8 mmol/L of K+, and we administered 850 mg the wash process. Physical stresses, such as infections
of calcium gluconate and initiated glucose-insulin therapy. and surgery, can cause complement activation [7]. In
Although the operation was close to being finished, we addition, the unwashed salvaged blood contains in-
transfused two more units of packed RBCs anticipating the creased levels of proinflammatory cytokines, such as
possibility of intravascular hemolysis after the operation. interleukin-1β, 6, and 8, and activated complement
The surgery was performed without complications. The components compared to the circulatory blood [8, 9].
value of K+ at the end of the operation was 4.9 mmol/L. We suspect the hemolysis in our patient was caused by

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Kawamoto et al. BMC Anesthesiology (2019) 19:83 Page 3 of 4

Fig. 1 a Intraoperative progress. b Postoperative progress

surgical stress or surgical inflammation as the K+ con- inhibits C5, resulting in the inhibition of MAC formation
centration increased gradually during the operation. and the effect of eculizumab is remarkable [1, 10, 11].
The attack to the RBCs by the activated complement Although further reports are needed, if eculizumab had
may have proceeded also in the reservoir of blood been used in the present case, the results might have been
salvage device. The level of activated proinflammatory different.
cytokines and activated complement in the salvaged Based on our experience, packed RBCs using a potas-
blood is reduced by the wash [8]; however, once the sium adsorption filter, if available, should be preferred to
complement in the patients with PNH becomes acti- autologous blood in case of perioperative transfusion in
vated and starts forming MAC on the RBCs during the patients with PNH. Kathirvel S et al. has mentioned that
processes of the operation and blood salvage, the in general unwashed RBCs can be used without prob-
hemolytic reaction may not be stopped even with the lems, but for large blood transfusion volumes, the RBCs
washing procedure. That is, the MAC on the mem- may need to be washed [12]. Some anesthesiologists
brane of RBCs does not get washed off. Recently, eculi- may consider the use of washed autologous RBCs under
zumab, a monoclonal antibody to the complement some situations, such as massive hemorrhage or exist-
component 5 (C5), is widely used in PNH therapy. ence of irregular antibodies; however, a pitfall lurks in
However, not all the patients with PNH are adminis- the autologous RBCs of the patients with PNH. The
tered eculizumab because of several reasons such as in- washed autologous RBCs may transiently guarantee oxy-
dication, insurance, and patients’ choice. Eculizumab gen transport to the tissues, but the salvaged RBCs in

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Kawamoto et al. BMC Anesthesiology (2019) 19:83 Page 4 of 4

patients with PNH will become the target of the comple- 6. Serrick CJ, Scholz M, Melo A, Singh O, Noel D. Quality of red blood cells
ment and will get lysed again after the transfusion. using autotransfusion devices: a comparative analysis. J Extra Corpor
Technol. 2003;35:28–34.
Conclusively, packed RBCs instead of salvaged autolo- 7. Lewis RE Jr, Cruse JM, Richey JV. Effects of anesthesia and operation on the
gous RBCs should be used for transfusions in patients classical pathway of complement activation. Clin Immunol Immunopathol.
with PNH. The use of salvaged autologous RBCs in pa- 1982;23:666–71.
8. Tylman M, Bengtson JP, Bengtsson A. Activation of the complement system
tients with PNH should be limited to critical situations by different autologous transfusion devices: an in vitro study. Transfusion.
such as massive bleeding and physicians should keep in 2003;43:395–9.
mind that the hemolytic reaction may be present inside 9. Sieunarine K, Wetherall J, Lawrence-Brown MM, Goodman MA, Prendergast
FJ, Hellings M. Levels of complement factor C3 and its activated product,
the transfer bag even after the wash process. C3a, in operatively salvaged blood. Aust N Z J Surg. 1991;61:302–5.
10. Luzzatto L, Risitano AM, Notaro R. Paroxysmal nocturnal hemoglobinuria
Abbreviations and eculizumab. Haematologica. 2010;95:523–6.
PNH: Paroxysmal nocturnal hemoglobinuria; GPI: Glycosylphosphatidylinositol; 11. Parker C. Eculizumab for paroxysmal nocturnal haemoglobinuria. Lancet.
DAF: Decay-accelerating factor; RBCs: Red blood cells; MAC: Membrane-attack 2009;373:759–67.
complex; K+: Potassium; ICU: Intensive care unit; POD: Postoperative day 12. Kathirvel S, Prakash A, Lokesh BN, Sujatha P. The anesthetic management of
a patient with paroxysmal nocturnal hemoglobinuria. Anesth Analg. 2000;
Acknowledgments 91:1029–31 table of contents.
The authors would like to thank Enago (www.enago.jp) for the English
language review.

Funding
This case report was not supported by any funding.

Availability of data and materials

All data generated or analysed during this study are included in this
published article.

Authors’ contributions
YK was the main anesthesiologist of this case and wrote the manuscript
draft. TN coordinated and completed the manuscript. AW was the second
anesthesiologist for this case. KN and AK directed anesthesia management in
this case. TH, NA, SK, and KI supported perioperative management. YT and
TY edited manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable.

Consent for publication

The authors obtained informed consent from the patient regarding the
publication of this case report and the use of related data by written form.

Competing interests
The authors declare that they have no competing interests.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.

Author details
1
Department of Anesthesia and Perioperative Medicine, Ehime University
Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan.
2
Department of Anesthesiology, Ehime Prefectural Imabari Hospital, Imabari,
Ehime, Japan. 3Department of Anesthesiology and Intensive Care Medicine,
Kawasaki Medical School, Kurashiki, Okayama, Japan.

Received: 7 January 2019 Accepted: 9 May 2019

References
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4. Rosse WF. Transfusion in paroxysmal nocturnal hemoglobinuria. To wash or
not to wash? Transfusion. 1989;29:663–4.
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