Transfusion-related acute lung injury

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Background

  • Abbreviation: TRALI

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
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