Background Antibody-mediated transfusion-related acute lung injury (TRALI) is an important cause of transfusion-associated morbidity and death. Preventive strategies are currently a matter of debate.Methods Specificities of leucocyte antibodies implicated in previous severe TRALI reactions were determined using standard techniques. Based on these results, a leucocyte antibody screening strategy for the testing of parous female donors was introduced.
ResultsOf 36 TRALI cases, 17, 12, four and three were due to human leucocyte antigen (HLA) class II, human neutrophil alloantigen (HNA), HLA class I, and mixtures of HLA class I and II antibodies, respectively. HNA-3a antibodies accounted for 10 of 12 HNA antibody-mediated reactions and 6 of 10 fatalities including one after transfusion of red blood cells. Investigation 5332 parous female donors showed leucocyte antibodies in 473 samples, resulting in an alloimmunization rate of 8·9%. Sixty-one per cent of these donors presented HLA class I, 19% class II, 12% HLA class I and II antibodies and 5% HNA antibodies. Additional HLA class I antibodies were found in 39% of HLA class II and in 17% of HNA antibodies containing sera. Our restrictive plasma strategy did not result in a shortage of plasma or platelets. No antibodymediated TRALI case was observed since introduction of the policy of plasma from male, nulliparous or tested multiparous donors.
ConclusionCompared to HLA class I antibodies, those directed against HLA class II and HNA-3a were of greater clinical relevance. Isolated HLA class I antibody screening was found to be insufficient for leucocyte antibody screening.
Data of the German Haemovigilance System were collected from 1997 to 2007 and assessed on the basis of pre-defined safety standards. Suspected cases of serious adverse reactions following transfusions reported to the Paul-Ehrlich-Institut were evaluated on the basis of national criteria, and the definitions of International Society of Blood Transfusion (ISBT) in compliance with defined causality criteria. The suspected cases were rated as confirmed and unconfirmed transfusion reactions. Assessment of causality took into consideration the clinical course of the adverse reaction and, if necessary, information about donation and manufacturing. Of the 5128 suspected serious adverse reactions, 1603 could be confirmed. Referring to the absolute figures, acute transfusion reactions (e.g. allergic reactions, hypotension and dyspnoea) were recorded most frequently, followed by transfusion-related acute lung injury (TRALI), haemolytic reactions, transfusion-related bacterial infections and virus infections. The majority of the 52 transfusion-related fatalities (14 each) were due to TRALI and acute transfusion reactions (mostly severe allergic reactions). Referred to the blood products administered, immune TRALI cases and TRALI-related fatal courses were most frequently reported after administration of fresh frozen plasma (FFP) (15/10(6) and 3.5/10(6) units, respectively), transfusion-related bacterial infections after administration of platelet concentrates (7/10(6) units), acute haemolytic transfusion reactions after administration of red blood cell concentrates (2.3/10(6)units) and acute transfusion reactions after administration of red blood cell or platelet concentrates (7.8/10(6) and 13/10(6) units, respectively). Despite the high safety standard required for blood products in Germany, there is still room for reducing the frequency of isolated cases of transfusion reactions by targeted action.
Haemovigilance data show the significance of female donors with a history of pregnancy for the development of antibody-mediated TRALI. Manufacturing of FFP from male plasma and female donor screening for WBC-Ab could represent preventive measures.
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