How much residual plasma may cause TRALI?

Abstract

Although passive infusion of plasma-rich components containing white blood cell (WBC) antibodies are responsible for majority of the reported transfusion-related acute lung injury (TRALI) cases, the minimum volume of residual plasma, which might trigger TRALI, is not known. We report three cases of TRALI where the implicated donor component contained between 10 and 20 mL of residual plasma. Two cases were related to transfusion of red blood cells prepared in optimal additive solution, and the other was related to transfusion of pooled buffy coat platelets. In the latter case, WBC antibodies that matched the patient's human leucocyte antigen (HLA) antigens were only found in one buffy coat donor (female) who contributed a buffy coat for pooled platelets preparation. Plasma prepared from pooling platelets was collected from a male donor. Laboratory investigation confirmed that in all three cases, the donors' serum contained three to four different HLA class 1-specific and class 11-specific antibodies that matched with the patient's HLA type. Our cases suggest that the residual plasma volume as small as 10-20 mL containing donor derived WBC antibodies may cause TRALI. The risk of TRALI remains, despite providing pooled platelets suspended in male donor plasma. The significance of multiple HLA antigen/antibody matching between donor and recipient in immune TRALI warrants further study.

The incidence, risk factors, and outcome of transfusion-related acute lung injury in a cohort of cardiac surgery patients: a prospective nested case-control study

“…Furthermore, plasma volumes in RBCs units as small as 10 to 20 mL containing donor-derived antibodies are sufficient to cause TRALI. 50 Our results suggest that either exclusion of all female donor blood for preparation of all blood products or exclusion of those tested positive for the presence of antibodies may reduce TRALI incidence. A policy of screening and excluding donors based on a certain cut-off titer of HLA/HNA antibodies 51 may not reduce TRALI incidence in patients with a priming condition, as experimental data suggest that the presence of a "first event" requires a lower titer of HLA/HNA antibodies for the onset of TRALI.…”

Determining the Volume of Additive Solution and Residual Plasma in Whole Blood Filtered and Buffy Coat Processed Red Cell Concentrates

“…Transfusion of plasma is associated with transfusion-related acute lung injury (TRALI) [6], the leading cause of transfusion-related deaths in North America. It has been suggested that larger volumes of residual plasma in RCCs could be associated with an increased risk of TRALI [1,7]. In addition to clinical outcomes, there is also interest in how residual plasma influences in vitro RCC quality during storage.…”

Fatal peri-operative hyperacute graft rejection during heart transplantation related to infusion of red blood cell concentrate

“…Thus, TRALI is most often caused by the FFP, 9 but has also been described after RBC transfusions. 10 -12 Win et al 13 showed that residual plasma volume, as little as 10 to 20 ml, may induce TRALI. In our study, the imputative RBC concentrate contained about 10 ml of residual plasma, with very high levels of HLA antibodies, specific to graft antigens.…”