Study guide
7.9 Transfusion Medicine & Late Complications of Transplantation
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
7.9 Transfusion Medicine & Late Complications of Transplantation
Key Takeaways Explain This Topic AI
Indications for transfusion, complications of transfusions, allergic complications of transfusions, hematologic complications of HIV infection and late complications of bone marrow transplantation are separately enumerated blueprint topics.
A restrictive transfusion threshold of 7 g/dL is appropriate for most hemodynamically stable hospitalized patients.
Acute hemolytic transfusion reaction results from ABO incompatibility, usually a clerical error, and requires immediate cessation of the transfusion.
Transfusion-related acute lung injury produces hypoxemia with bilateral infiltrates and a normal filling pressure within six hours, whereas circulatory overload produces hypertension and elevated filling pressures.
Anaphylactic transfusion reaction in a patient with IgA deficiency requires washed or IgA-deficient blood products for future transfusions.
Last updated: August 2026
1. Indications for Transfusion
The governing principle in modern practice is restrictive transfusion , because liberal strategies have repeatedly failed to improve outcomes while increasing harm.
- Setting Threshold
- Most hospitalized, hemodynamically stable adults Hemoglobin 7 g/dL
- Cardiac surgery, or existing cardiovascular disease 7.5 to 8 g/dL
- Active bleeding with hemodynamic instability Transfuse based on clinical status, not a number
Transfuse one unit at a time and reassess. Ordering two units reflexively is a stewardship failure the exam consistently penalizes.
Platelets: transfuse prophylactically below 10,000 per microliter, below 20,000 with fever or sepsis, below 50,000 before most invasive procedures, and below 100,000 for neurosurgery or ocular surgery. Platelet transfusion is contraindicated in thrombotic thrombocytopenic purpura and heparin-induced thrombocytopenia , where it fuels microthrombosis.
Plasma is for bleeding with a documented coagulopathy or for urgent reversal, not for correcting a mildly abnormal INR before a low-risk procedure. Cryoprecipitate supplies fibrinogen and is used when fibrinogen falls below roughly 150 mg/dL in bleeding.
Irradiated products prevent transfusion-associated graft-versus-host disease and are required for hematopoietic cell transplant recipients, patients receiving purine analogues, and directed donations from relatives. Leukoreduction reduces febrile non-hemolytic reactions, cytomegalovirus transmission and alloimmunization, and is standard.
2. Transfusion Reactions
The blueprint lists complications of transfusions and, separately, allergic complications of transfusions including hemolytic reactions, transfusion-related acute lung injury and transfusion-related urticaria and anaphylaxis.
Reaction Timing Features Action
Acute hemolytic Minutes Fever, flank and back pain, hypotension, red urine , DIC Stop immediately ; fluids; report clerical error
Febrile non-hemolytic 1 to 6 hours Fever, chills; no hemolysis Stop, evaluate, antipyretics; use leukoreduced units
Allergic / urticarial Minutes to hours Hives only, no systemic features Pause; antihistamine; may resume if isolated urticaria resolves
Anaphylactic Minutes Hypotension, bronchospasm, angioedema Stop ; epinephrine; consider IgA deficiency
TRALI Within 6 hours Hypoxemia, bilateral infiltrates, normal filling pressures , often hypotension Stop; supportive ventilation
TACO Within 6 to 12 hours Hypoxemia, infiltrates, hypertension , elevated BNP and filling pressures Stop; diuresis
Delayed hemolytic 3 to 14 days Falling hemoglobin, rising bilirubin, positive direct antiglobulin test Supportive; identify the alloantibody
Septic Minutes to hours High fever, rigors, shock Stop; cultures; antibiotics
The two most heavily tested discriminations:
TRALI versus TACO. Both cause hypoxemia with bilateral infiltrates within hours of transfusion. TRALI is an inflammatory permeability injury — the patient is often hypotensive , filling pressures and BNP are normal, and treatment is supportive; diuresis is harmful. TACO is hydrostatic — the patient is hypertensive with elevated jugular venous pressure and BNP, and diuresis is the treatment. Blood pressure direction is the fastest bedside clue.
Anaphylaxis and IgA deficiency. An IgA-deficient recipient with anti-IgA antibodies can react anaphylactically to plasma-containing products. Future transfusions require washed red cells or products from IgA-deficient donors . This is the reason to check IgA levels after an unexplained anaphylactic transfusion reaction.
Transfusion-associated graft-versus-host disease is rare, nearly always fatal, and caused by viable donor lymphocytes in a susceptible host. It occurs 1 to 6 weeks after transfusion with fever, rash, diarrhea, hepatitis and pancytopenia — the pancytopenia distinguishes it from transplant-related graft-versus-host disease, in which the graft is the marrow. Irradiation of cellular products prevents it.
3. Iron Overload from Chronic Transfusion
Each unit of red cells contains roughly 200 to 250 mg of iron and the body has no excretory route. Chronically transfused patients — thalassemia, sickle cell disease, myelodysplastic syndrome — accumulate iron in the heart, liver and endocrine organs. Monitor ferritin , quantify with MRI T2 * for cardiac and hepatic iron, and use chelation with deferasirox or deferoxamine. Cardiac siderosis is the leading cause of death in transfusion-dependent thalassemia.
4. Late Complications of Hematopoietic Cell Transplantation
The blueprint restricts this topic to late complications only , which tells you the intended scope: the internist inherits these patients years after transplant.
Chronic graft-versus-host disease
The dominant late complication of allogeneic transplantation, typically beginning after day 100 and defined now by clinical features rather than by timing alone.
- Organ Manifestation
- Skin Lichenoid or sclerodermatous change , poikiloderma
- Mouth Lichenoid changes, ulceration, xerostomia
- Eyes Keratoconjunctivitis sicca
- Liver Cholestatic enzyme elevation
- Lung Bronchiolitis obliterans — a fixed obstructive defect that is the most feared pulmonary complication
- Gastrointestinal Esophageal webs, strictures, weight loss
- Musculoskeletal Fasciitis, joint contractures
Treatment is systemic corticosteroids with steroid-sparing agents. The consequence for the internist is functional asplenia and profound, prolonged immunodeficiency , since chronic graft-versus-host disease and its therapy suppress immune reconstitution for years.
Infection risk after transplantation
Patients with chronic graft-versus-host disease require antimicrobial prophylaxis against encapsulated organisms and Pneumocystis , and remain at risk for varicella-zoster reactivation, cytomegalovirus and invasive fungal infection.
Revaccination is mandatory , because transplantation erases pre-existing immunity. The childhood series is repeated on a defined schedule beginning several months after transplant. Live vaccines are deferred , typically to at least two years and only in the absence of active graft-versus-host disease and immunosuppression.
Other late complications
Secondary malignancy — therapy-related myelodysplastic syndrome and acute leukemia, and an elevated lifetime risk of solid tumors, particularly skin cancer (rigorous photoprotection and skin surveillance are warranted) and cancers of the oral cavity and thyroid
Endocrine — hypothyroidism, hypogonadism, infertility, growth hormone deficiency, adrenal insufficiency from prolonged steroid exposure
- Bone — osteoporosis and osteonecrosis
- Cataracts , particularly after total body irradiation
- Cardiovascular disease , accelerated by anthracycline exposure, irradiation and metabolic syndrome
- Iron overload from cumulative transfusion
Post-transplant lymphoproliferative disorder is Epstein-Barr virus-driven and presents with lymphadenopathy, fever and organ dysfunction; management begins with reduction of immunosuppression and rituximab.
5. Hematologic Complications of HIV Infection
A separately named blueprint subsection appearing under both Hematology and Infectious Disease.
Anemia is the most common hematologic abnormality and is multifactorial: anemia of chronic disease, direct marrow suppression, opportunistic infection, drug effect and nutritional deficiency.
Parvovirus B19 causes pure red cell aplasia in advanced HIV — profound anemia with a near-zero reticulocyte count and giant pronormoblasts on marrow examination. It responds to intravenous immunoglobulin, and untreated it persists because the host cannot clear the virus.
Immune thrombocytopenia is common and frequently improves with antiretroviral therapy alone, which is often the correct answer rather than immunosuppression.
Neutropenia from disease, opportunistic infection or drugs including zidovudine, ganciclovir and trimethoprim-sulfamethoxazole.
Thrombotic thrombocytopenic purpura occurs at increased frequency.
Malignancy — HIV-associated lymphoma, including primary central nervous system lymphoma and primary effusion lymphoma.
Effective antiretroviral therapy improves most HIV-associated cytopenias , which is the unifying management principle across this subsection.