Transfusion-related acute lung injury: Difference between revisions

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==Epidemiology==
==Background==
===Epidemiology===
*Leading cause of transfusion related mortality in the US – 5-8% <ref>Fatalities Reported to FDA Following Blood Collection and Transfusion: Annual Summary for Fiscal Year 2011. Available at www.fda/gov/biologicsbloodvaccines/safetyavailability/reportaproblem/transfusiondonationfatalities/ucm302847.htm</ref><ref><Looney MR, et al. Transfusion-related acute lung injury: a review. Chest. 2004;126:249</ref>
*Leading cause of transfusion related mortality in the US – 5-8% <ref>Fatalities Reported to FDA Following Blood Collection and Transfusion: Annual Summary for Fiscal Year 2011. Available at www.fda/gov/biologicsbloodvaccines/safetyavailability/reportaproblem/transfusiondonationfatalities/ucm302847.htm</ref><ref><Looney MR, et al. Transfusion-related acute lung injury: a review. Chest. 2004;126:249</ref>
*Occurs at a rate of 0.04-0.1%, or 1/5000, transfused blood components <ref name="four">Silliman CC, et al. Transfusion-related acute lung injury: epidemiology and a prospective analysis of etiologic factors. Blood. 2003;101:454</ref><ref>Popovsky MA, et al. Diagnostic and pathogenietic considerations in transfusion-related acute lung injury. Transfusion. 1985;25:573</ref><ref>Wallis JP. Transfusion-related acute lung injury (TRALI) - under-diagnosed and under-reported. Br J Anaesth. 2003;90:573</ref><ref>Rana R, et al. Transfusion-related acute lung injury and pulmonary edema in critically ill patients: a retrospective study. Transfusion. 2006;46:1478</ref>
*Occurs at a rate of 0.04-0.1%, or 1/5000, transfused blood components <ref name="four">Silliman CC, et al. Transfusion-related acute lung injury: epidemiology and a prospective analysis of etiologic factors. Blood. 2003;101:454</ref><ref>Popovsky MA, et al. Diagnostic and pathogenietic considerations in transfusion-related acute lung injury. Transfusion. 1985;25:573</ref><ref>Wallis JP. Transfusion-related acute lung injury (TRALI) - under-diagnosed and under-reported. Br J Anaesth. 2003;90:573</ref><ref>Rana R, et al. Transfusion-related acute lung injury and pulmonary edema in critically ill patients: a retrospective study. Transfusion. 2006;46:1478</ref>
**Higher in critically ill
**Higher in critically ill


==Pathophysiology==
===Pathophysiology===
*Two-hit mechanism <ref name="four"></ref><ref>Sillman CC. The two-event model of transfusion-related acute lung injury. Crit Care Med. 2006;34:S124</ref><ref>Bux J, et al. The pathogenesis of transfusion-related acute lung injury (TRALI). Br J Haematol. 2007;136:788</ref>
*Two-hit mechanism <ref name="four"></ref><ref>Sillman CC. The two-event model of transfusion-related acute lung injury. Crit Care Med. 2006;34:S124</ref><ref>Bux J, et al. The pathogenesis of transfusion-related acute lung injury (TRALI). Br J Haematol. 2007;136:788</ref>
**'''Neutrophil sequestration and priming in lung microvasculature'''
**'''Neutrophil sequestration and priming in lung microvasculature'''
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****Leads to '''inflammatory pulmonary edema'''
****Leads to '''inflammatory pulmonary edema'''


==Risk factors==
===Risk factors===
*'''Recipient factors''' <ref>Vlaar AP, et al. Risk factors and outcome of transfusion-related acute lung injury in the critically ill: a nested case-control study. Crit Care Med. 2007;176:886</ref><ref>Gajic O, et al. Transfusion-related acute lung injury in the critically ill: prospective nested case-control study. Am J Respir Crit Care Med. 2007;176:886</ref><ref name="fifteen">Toy P, et al. Transfusion-related acute lung injury: incidence and risk factors. Blood. 2012;119:1757</ref><ref>Benson AB, et al. Transfusion-related acute lung injury in ICU patients admitted with gastrointestinal bleeding. Intensive Care Med. 2010;36:1710</ref>
*'''Recipient factors''' <ref>Vlaar AP, et al. Risk factors and outcome of transfusion-related acute lung injury in the critically ill: a nested case-control study. Crit Care Med. 2007;176:886</ref><ref>Gajic O, et al. Transfusion-related acute lung injury in the critically ill: prospective nested case-control study. Am J Respir Crit Care Med. 2007;176:886</ref><ref name="fifteen">Toy P, et al. Transfusion-related acute lung injury: incidence and risk factors. Blood. 2012;119:1757</ref><ref>Benson AB, et al. Transfusion-related acute lung injury in ICU patients admitted with gastrointestinal bleeding. Intensive Care Med. 2010;36:1710</ref>
**Liver disease
**Liver disease

Revision as of 17:41, 26 July 2016

Background

Epidemiology

  • Leading cause of transfusion related mortality in the US – 5-8% [1][2]
  • Occurs at a rate of 0.04-0.1%, or 1/5000, transfused blood components [3][4][5][6]
    • Higher in critically ill

Pathophysiology

  • Two-hit mechanism [3][7][8]
    • Neutrophil sequestration and priming in lung microvasculature
    • Recipient neutrophil activation by factor in the blood product (i.e. antibodies in blood component directed at recipient antigens, bioactive lipids, etc.)
      • Neutrophils release cytokines, reactive oxygen species, etc. that damage pulmonary capillary endothelium
        • Leads to inflammatory pulmonary edema

Risk factors

  • Recipient factors [9][10][11][12]
    • Liver disease
    • Hematologic malignancy
    • Alcohol abuse
    • High peak airway pressures on mechanical ventilation
    • Current smoking
    • Positive fluid balance
    • Massive transfusion
    • Critical illness
    • Sepsis
    • Shock
  • Blood component factors [11]
    • Plasma or whole blood from female donor
    • Volume of HLA class II antibody reactive to recipient HLA antigen
    • Volume of transfused anti-human neutrophil antigen antibody
    • Highest risk components (though can occur with any, including PRBC)
      • Plasma
      • Apheresis platelet concentrates
      • Whole blood

Clinical Features

  • Time Frame: abrupt to within 6 hours of transfusion initiation
  • ARDS-like symptoms

Differential Diagnosis

Transfusion Reaction Types

Acute allergic reaction

Evaluation

TRALI vs TACO

TRALI TACO
Onset Acute, within 6hrs Often more gradual
BP Low High
Temp Febrile Normal
JVD/pedal edema Unlikely Likely
CVP/PAWP Normal Elevated
BNP Normal Elevated
Resp Dyspneic Dyspneic
CXR B/l infiltrates B/l infiltrates

Management

  • Strop transfusion
  • Treat like ARDS
  • Avoid diuresis

Disposition

  • Bilateral pulmonary infiltrates due to noncardiogenic pulmonary edema within 6h of transfusion

See Also

External Links

References

  1. Fatalities Reported to FDA Following Blood Collection and Transfusion: Annual Summary for Fiscal Year 2011. Available at www.fda/gov/biologicsbloodvaccines/safetyavailability/reportaproblem/transfusiondonationfatalities/ucm302847.htm
  2. <Looney MR, et al. Transfusion-related acute lung injury: a review. Chest. 2004;126:249
  3. 3.0 3.1 Silliman CC, et al. Transfusion-related acute lung injury: epidemiology and a prospective analysis of etiologic factors. Blood. 2003;101:454
  4. Popovsky MA, et al. Diagnostic and pathogenietic considerations in transfusion-related acute lung injury. Transfusion. 1985;25:573
  5. Wallis JP. Transfusion-related acute lung injury (TRALI) - under-diagnosed and under-reported. Br J Anaesth. 2003;90:573
  6. Rana R, et al. Transfusion-related acute lung injury and pulmonary edema in critically ill patients: a retrospective study. Transfusion. 2006;46:1478
  7. Sillman CC. The two-event model of transfusion-related acute lung injury. Crit Care Med. 2006;34:S124
  8. Bux J, et al. The pathogenesis of transfusion-related acute lung injury (TRALI). Br J Haematol. 2007;136:788
  9. Vlaar AP, et al. Risk factors and outcome of transfusion-related acute lung injury in the critically ill: a nested case-control study. Crit Care Med. 2007;176:886
  10. Gajic O, et al. Transfusion-related acute lung injury in the critically ill: prospective nested case-control study. Am J Respir Crit Care Med. 2007;176:886
  11. 11.0 11.1 Toy P, et al. Transfusion-related acute lung injury: incidence and risk factors. Blood. 2012;119:1757
  12. Benson AB, et al. Transfusion-related acute lung injury in ICU patients admitted with gastrointestinal bleeding. Intensive Care Med. 2010;36:1710