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Anaphylactic reactions are excluded by the presence of red plasma or urine, discordant pretransfusion and posttransfusion ABO blood types, or a positive direct antiglobulin (Coombs) test result. Demonstration of anti-IgA in a pretransfusion sample of the recipient's serum or plasma establishes the diagnosis.
Why is it that an Rh-negative person does not have a transfusion reaction on the first exposure to Rh-positive blood but does have a reaction on the second exposure? Because antibodies that cause the reaction are not naturally occurring. One has to be exposed to Rh in order to make antibodies to it.