Transfusion medicine
Transfusion side effects
Metabolic effects of transfusion

Topic Completed: 1 September 2011

Revised: 5 April 2019

Copyright: 2002-2017,, Inc.

PubMed Search: Metabolic effects of transfusion [title]

Huy Phu Pham, M.D., M.P.H.
Page views in 2018: 340
Page views in 2019 to date: 159
Cite this page: Pham H. Metabolic effects of transfusion. website. Accessed July 24th, 2019.
Metabolic effects - general
  • Most often seen in neonates or in massive transfusion
  • Typically includes citrate toxicity, hyperkalemia, hypothermia
  • Due to preservatives, anticoagulants, other additives, biochemical changes in blood components during storage (Arch Pathol Lab Med 2007;131:708)
Citrate toxicity
  • Citrate is part of anticoagulant solution in pRBCs (CPDA-1 is citrate phosphate adenine anticoagulant preservative)
  • Metabolized primarily in liver to bicarbonate
  • May cause hypocalcemia (transiently decrease in patient’s ionized calcium), causing QT interval prolongation, decreased left ventricular function, hypotension, hypomagnesemia, cardiac arrhythmias
  • Risk factors: massive transfusion, hypothermia, liver failure, premature infant (cannot metabolize excess citrate)
  • Patients with renal failure may get metabolic alkalosis
  • May require slowing rate of transfusion or providing calcium / magnesium replacement
  • Prevent with continuous calcium gluconate infusion during large volume peripheral blood progenitor cell leukapheresis (Transfusion 2003;43:1615)
  • Transfusions to neonates may cause hypoglycemia unless continuous glucose infusion of 4 - 8 mg/kg/min
  • Transfusions may cause transient hyperglycemia due to glucose in preservative; this leads to insulin release and may cause hypoglycemia
  • Hypoglycemia more common with CPDA-1 red cells than AS-1 or AS-3, because CPD has lower glucose concentration
  • Most pRBCs are not currently stored in CPDA-1 solution
  • Transfusions usually not a factor in hyperglycemia in liver transplant patients (World J Gastroenterol 2005;11:2789)
  • Potassium accumulates in supernatant of whole blood and red cells during storage because ATP pump is impaired at this temperature
  • Leakage is accelerated by gamma irradiation of products
  • Total potassium in supernatant of most transfusions is clinically insignificant, but rapid infusion of large volumes (> 20 mL/kg) of stored or irradiated red cells may cause fatal hyperkalemia in infants, children and rarely adults
  • Increased susceptibility if patients have oliguric renal failure, hepatic failure or poor cardiac function
  • Case reports: ventricular fibrillation (Anaesth Intensive Care 2007;35:110)
  • Prevention: washing red cells or reducing volume of additive solution (Transfusion 2007;47:248, Eur J Cardiothorac Surg 2007;31:659), use of autotransfusion devices (Transfus Med 2007;17:89), potassium adsorption filter (Can J Anaesth 2004;51:639)
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