Transfusion-Related Acute Lung Injury: Current Concepts for the Clinician

Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh Medical Center, Institute for Transfusion Medicine, 3636 Blvd of the Allies, Pittsburgh, PA 15213, USA.
Anesthesia and analgesia (Impact Factor: 3.47). 04/2009; 108(3):770-6. DOI: 10.1213/ane.0b013e31819029b2
Source: PubMed


The leading cause of transfusion-related morbidity and mortality in the United States is transfusion-related acute lung injury (TRALI). Diagnostic criteria for TRALI have recently been developed and primarily consist of hypoxia and bilateral pulmonary edema occurring during or within 6 h of a transfusion in the absence of cardiac failure or intravascular volume overload. The primary differential diagnosis is transfusion-associated circulatory overload and differentiation can be difficult. Treatment is supportive with oxygen and mechanical ventilation. Diuresis is not indicated and the role of steroids is unproven. Patients typically recover within a few days. All types of blood products have been associated with TRALI, however, the plasma-rich components, such as fresh frozen plasma and apheresis platelets, have been most frequently implicated. The pathogenesis of TRALI is not completely understood. Leukocyte antibodies in donor plasma have been implicated in most cases with antibodies directed at human leukocyte antigen (HLA) class I, HLA class II or neutrophil-specific antigens, particularly HNA-3a. Activation of pulmonary endothelium is important in the development of TRALI and may account for most cases being observed in surgical or intensive care unit patients. Transfused leukoagglutinating antibodies bind to recipients' neutrophils localized to pulmonary endothelium resulting in activation and release of oxidases and other damaging biologic response modifiers that cause capillary leak. In a minority of TRALI cases, no antibodies are identified and it is postulated that neutrophil priming factors in the transfused component can mediate TRALI in a patient with pulmonary endothelial activation, the so called "two hit" mechanism. Recognition of the role of anti-leukocyte antibodies has led to new strategies to reduce the risk of TRALI. Female blood donors with a previous pregnancy frequently have HLA antibodies with an overall prevalence of 24% and increasing prevalence related to the number of previous pregnancies. Since HLA antibodies have been implicated in TRALI, blood centers have adopted policies to produce plasma components primarily from male donors. Strategies to reduce the risk from apheresis platelets are problematic and are likely to involve testing female apheresis platelet donors for HLA antibodies. Much more research is needed to understand the blood component and patient risk factors for TRALI so that novel strategies for treatment and additional measures to reduce the risk of TRALI can be developed.

    • "Such investigation may take days and hence are not useful in acute clinical setting. Moreover, the mere demonstration of HLA and neutrophil antibody does not absolutely confirms the diagnosis of TRALI as not all donor antibodies result in TRALI.[12] Therefore, in our case, “possible TRALI” should be a better diagnosis.[12] "
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    ABSTRACT: Transfusion associated circulatory overload (TACO) and transfusion related acute lung injury (TRALI) are two dissimilar pathological conditions associated with transfusion of blood products where the time course of the events and clinical presentation overlap leading to uncertainty in establishing the diagnosis and initiating the treatment, which otherwise differs. We encountered a case where a patient of post-partum hemorrhage developed TACO in the immediate post-operative period due to aggressive resuscitative attempts with blood products. The patient's condition was appropriately diagnosed and was managed according to the clinical scenario, and the condition abated. Subsequently, on the third post-operative day the patient again required blood product transfusions following which the patient developed TRALI, the diagnosis of which was also established and adequate treatment strategy was undertaken.
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    • "The theory of multiple insults leading to the clinical syndrome of ALI/ARDS is logical and stems from experiences at the bedside (Lang and Hickman-Davis, 2005). The most notable example of a " two-hit " phenomenon is transfusion-related acute lung injury (Looney et al., 2006; Looney et al., 2009; Triulzi, 2009). "
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    • "PE resulting from transfusion can be difficult to detect and may result in severe complications, such as transfusion-related acute lung injury (TRALI) [11] and transfusion-associated circulatory overload (TACO). Classification of the two is not easy, as the adverse effects of transfusion in TACO have not been established and reports of it occurring are equivocal and range from below 1% up to 8% [12]. "
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