Transfusion-Related Acute Lung Injury (TRALI): Current Clinical and Pathophysiologic Considerations

Abstract

Transfusion-related acute lung injury (TRALI) is a rare transfusion reaction presenting as respiratory distress during or after transfusion of blood products. TRALI varies in severity, and mortality is not uncommon. TRALI reactions have equal gender distributions and can occur in all age groups. All blood products, except albumin, have been implicated in TRALI reactions. TRALI presents as acute respiratory compromise occurring in temporal proximity to a transfusion of a blood product. Other causes of acute lung injury should be excluded in order to definitively diagnose TRALI. Clinically and pathologically, TRALI mimics acute respiratory distress syndrome (ARDS), with neutrophil-derived inflammatory chemokines and cytokines believed to be involved in the pathogenesis of both entities. Anti-HLA and anti-neutrophil antibodies have been implicated in some cases of TRALI. Treatment for TRALI is supportive; prevention is important. It is suspected that TRALI is both underdiagnosed and underreported. One of the difficulties in the evaluation of potential TRALI reactions is, until recently, the lack of diagnostic criteria. A group of transfusion medicine experts, the American-European Consensus Conference (AECC), recently met and developed diagnostic criteria of TRALI, as well as recommendations for management of donors to prevent future TRALI reactions. In light of the AECC consensus recommendations, we report an incident of TRALI in an oncology patient as an example of the potential severity of the lung disease and the clinical and laboratory evaluation of the patient. We also review the literature on this important complication of blood transfusion that internists may encounter.

Transfusion-related acute lung injury: A dangerous and underdiagnosed noncardiogenic pulmonary edema

“…Two mechanisms which lead to the development of the syndrome are distinguished as refl ected in the following classifi cation: -immune-mediated TRALI, predominantly caused by anti-HLA (human leukocyte antigen) antibodies class I, II and/or less frequent antibodies directed against specifi c antigens of granulocytes -HNA (human neutrophil antigen), present in the serum of the recipient or donor, which react with the donor's or recipient's leukocytes respectively [4,5,7,[12][13][14][15]. -non-immune-mediated TRALI, which may be attributed to transfusion of biologically active compounds accumulated in stored blood components such as bioactive lipids, proinfl ammatory cytokines or platelet microparticles with high procoagulant activity.…”

“…-non-immune-mediated TRALI, which may be attributed to transfusion of biologically active compounds accumulated in stored blood components such as bioactive lipids, proinfl ammatory cytokines or platelet microparticles with high procoagulant activity. A high potassium level is considered an additional risk factor [4,[13][14][15][16][17][18][19][20]. Leukocyte antibodies are currently believed to be crucial for TRALI development.…”

“…During the conference in Toronto in 2004, a panel of experts from the National Institute of Health fi nally established a clinical defi nition of TRALI based on ALI temporally associated with transfusion and characterized by dyspnea, hypoxemia and bilateral infi ltrates on a chest X-ray [3]. This life--threatening reaction may be caused by any blood component that contains plasma [4,5]. TRALI was most frequently observed following transfusions of whole blood, red blood cell concentrates, fresh frozen plasma and platelet concentrates [5,6].…”

“…In some reports the volume of plasma suffi cient to induce TRALI is estimated at 10-15 mL [7,8]. The complication affects all age groups and occurs with the same frequency in both men and women [4]. According to the Food and Drug Administration statistics TRALI is responsible for 43% of transfusion--related deaths reported in 2007-2011 and it is the leading cause of mortality associated with this procedure [9,10].…”

“…According to the Food and Drug Administration statistics TRALI is responsible for 43% of transfusion--related deaths reported in 2007-2011 and it is the leading cause of mortality associated with this procedure [9,10]. TRALI risk is estimated at approximately 0.02% per unit of blood component or 0.16% per recipient [4,11,12]. Shaz et al [13] estimate the incidence of this syndrome at 1/260 000 transfusions.…”