Transfusion related acute lung injury

Infobox_Disease
Name = Transfusion related acute lung injury


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In medicine, transfusion related acute lung injury (TRALI) is a serious blood transfusion complication characterized by the acute onset of non-cardiogenic pulmonary edema following transfusion of blood products. [Gajic O, Moore SB. Transfusion-related acute lung injury. Mayo Clin Proc. 2005 Jun;80(6):766-70. PMID 15945528.]

TRALI is the leading causes (around 50% of cases) of transfusion-related fatalities in the United States. [U.S. Food and Drug Administration, Center for Biologics Evaluation and Research. [http://www.fda.gov/cber/blood/fatal0506.pdf Fatalities Reported to FDA Following Blood Collection and Transfusion: Annual Summary for Fiscal Years 2005 and 2006] . Bethesda, Md: U.S. Food and Drug Administration.]

Definition

TRALI is defined as an acute lung injury that is temporally related to a blood transfusion; specifically, it must occur within the first six hours following a transfusion. [Toy P, Popovsky MA, Abraham E, Ambruso DR, Holness LG, Kopko PM, McFarland JG, Nathens AB, Silliman CC, Stroncek D; National Heart, Lung and Blood Institute Working Group on TRALI. Transfusion-related acute lung injury: definition and review. Crit Care Med. 2005 Apr;33(4):721-6. PMID 15818095.]

Differential diagnosis

*Acute respiratory distress syndrome

Etiology and Risk Factors

The etiology of TRALI is currently not fully understood. TRALI is thought to be immune mediated. [Dykes A, Smallwood D, Kotsimbos T, Street A. Transfusion-related acute lung injury (TRALI) in a patient with a single lung transplant. Br J Haematol. 2000 Jun;109(3):674-6. PMID 10886228.] Muller JY. [TRALI: from diagnosis to prevention] Transfus Clin Biol. 2005 Jun;12(2):95-102. PMID 15894508.] Antibodies directed toward Human Leukocyte Antigens (HLA) or Human Neutrophil Antigens (HNA) have been implicated. Women who are multiparous (have had more than one child) develop these antibodies through exposure to fetal blood; transfusion of blood components obtained from these donors is thought to carry a higher risk of inducing immune-mediated TRALI. Previous transfusion or transplantation can also lead to donor sensitization. To be at risk of TRALI via this mechanism, the blood recipient must express the specific HLA or neutrophil receptors to which the implicated donor has formed antibodies. A two-hit hypothesis has been suggested Fact|date=June 2008 wherein pre-existing pulmonary pathology (ie, the first-hit) leads to localization of neutrophils to the pulmonary microvasculature. The second hit occurs when the aforementioned antibodies are transfused and attach to and activate neutrophils, leading to release of cytokines and vasoactive substances that induce non-cardiac pulmonary edema.

A non-immune mechanism has been studied and proposed by Silliman, involving the accumulation of bioactive lipids in stored blood components (red cells, platelets, plasma) that possess neutrophil priming capabilities.

TRALI is typically associated with plasma products such as FFP, but can also occur in recipients of packed red blood cells due to the residual plasma present in the unit. The AABB (formerly the American Association of Blood Banks) recommended on 11/03/2006 in association bulletin 06-07 that blood banks use high plasma volume components from female donors for further manufacturing instead of transfusion due to the higher risk of TRALI.

Mortality & morbidity

The immune mediated form of TRALI occurs approximately once every 5000 transfusions and has a mortality of 6-9%. [Bux J. Transfusion-related acute lung injury (TRALI): a serious adverse event of blood transfusion. Vox Sang. 2005 Jul;89(1):1-10. PMID 15938734.]

Treatment

Treatment for TRALI is primarily supportive measures. Many patients with TRALI need mechanical ventilation. TRALI is associated with microvascular damage and not fluid overload, so diuretics are not recommended. There are tests that can be performed on apheresis platelet donors after donation but before transfusion to determine if the donor contains HLA antibodies thought to be involved with development of this disease. GTI Diagnostics, a company based in Waukesha, Wisconsin has an ELISA test that is capable of detecting HLA antibodies in plasma or serum.

References

ee also

*Flash pulmonary edema

External links

* [http://www.fda.gov/cber/ltr/trali101901.htm Transfusion Related Acute Lung Injury] - US Food and Drug Administration (FDA).
* [http://www.ashi-hla.org/publicationfiles/ASHI_Quarterly/28_2_2004/Neutrophil_Ag_Ab.pdf Neutrophil Antigens and Antibodies] - American Society of Histocompatibility and Immunogenetics.