Transfusion-related acute lung injury (TRALI): Current concepts and misconceptions

Abstract

Summary Transfusion-related acute lung injury (TRALI) is the most common cause of serious morbidity and mortality due to hemotherapy. Although the pathogenesis has been related to the infusion of donor antibodies into the recipient, antibody negative TRALI has been reported. Changes in transfusion practices, especially the use of male-only plasma, have decreased the number of antibody-mediated cases and deaths; however, TRALI still occurs. The neutrophil appears to be the effector cell in TRALI and the pathophysiology is centered on neutrophil-mediated endothelial cell cytotoxicity resulting in capillary leak and ALI. This review will detail the pathophysiology of TRALI including recent pre-clinical data, provide insight into newer areas of research, and critically assess current practices to decrease it prevalence and to make transfusion safer.

Experimental prestorage filtration removes antibodies and decreases lipids in RBC supernatants mitigating TRALI in vivo

“…TRALI in a susceptible host has been related to the infusion of donor antibodies against the HLA antigens of the recipient, which may reside on either the recipient's leukocytes or endothelial cells, or the infusion of lipids or sCD40L. [21][22][23] These antibodies, lipids, or sCD40L activate neutrophils (PMNs), allowing for PMN-mediated endothelial damage, capillary leak, and acute lung injury (ALI). [6][7][8]13,24 We hypothesize that a prestorage filter that removes antibodies, leukocytes, and platelets and decreases lipid bioactivity would significantly decrease the presence of donor HLA antibodies and the accumulation of biologically active lipids and sCD40L and would abrogate TRALI in a 2-event animal model.…”

Selected Arterial Blood Gasometry Parameters as Indicators of Blood Transfusion Effectiveness in Foals with Haemolytic Disease

“…In addition to anaphylactic shock, acute haemolytic transfusion reaction and disseminated intravascular coagulation, blood transfusion may also lead to pulmonary oedema, referred to as transfusionrelated acute lung injury (TRALI) in human medicine (4,13). The resulting impaired function of the blood-air barrier inhibits gas exchange in the lungs, leading to hypoxia and hypercapnia, and may obliterate the anticipated effects of blood transfusion despite an increase in the recipient's RBC counts (6,12).…”

Mortality after red blood cell transfusions from previously pregnant donors: complexities in the interpretation of large data

“…In the recent past, restrictive blood transfusion policies have improved patient outcomes with the added benefit of driving down medical costs (1). Other policies and advances in cell preservation technology such as ABO and Rh matching, leukoreduction and limitations in the age of storage (to the age of RBC viability) of blood products have decreased recipient morbidity and mortality (1)(2)(3). However, the concept that RBC donor female gender and parity may influence recipient mortality has been a subject of much debate in the blood banking community and differing conclusions are reported in several large retrospective studies (4,5).…”

“…The evidence linking female-derived plasma and poor patient outcomes is far more robust and various gender dependent differences have been identified in donated plasma (3,12). Infusion of female donor-derived anti-HLA or anti-neutrophil antibodies has been well documented to play roles in the etiology of TRALI (3,12).…”

“…Infusion of female donor-derived anti-HLA or anti-neutrophil antibodies has been well documented to play roles in the etiology of TRALI (3,12). Furthermore, male-only donor-derived plasma programs have significantly reduced the incidence of TRALI (12).…”