This document discusses transfusion-related acute lung injury (TRALI), a pulmonary complication that can occur after blood transfusion. TRALI is the leading cause of transfusion-related mortality. It involves the acute onset of respiratory distress within 6 hours of transfusion due to pulmonary edema. While the exact mechanisms are unclear, it is proposed to occur through either antibody-mediated activation of neutrophils or non-immune lipid accumulation during blood product storage. The prognosis is generally good with supportive care, though 5-10% of cases are fatal. Recent studies have challenged the idea that plasma from male donors is safer, finding no difference in reaction severity between male and female plasma recipients. Further research is still needed to better understand and prevent TR

4.  The plasma of multiparous women is
expected to possess more antibodies, on
average, than men due to the increased
exposure to additional antigens during
childbirth.
 Therefore, plasma donated by females is
more likely to cause immune-mediated
transfusion reactions.

6.  Purpose:
› evaluate the relationship between donor/recipient Ab’s and ANHTR’s.
 M&M:
› 223 ANHTR pts and 196 of their donors
› screened for antibodies to HLA Classes I & II as well as granulocytes
and platelets.
 Results:
› No difference in the types and severity of ANHTR’s.
› Frequency of only anti-HLA Ab’s was higher in females.
› Non-HLA Ab’s were associated with more severe reactions.
 Discussion:
› 5 TRALI’s were observed
 All 5 had concomitant lung disease.
 The 5 patients had received blood from 2 male donors with anti-
granulocyte antibodies!

11.  First described in 1985, Transfusion-Related
Acute Lung Injury has since become the
most common serious transfusion reaction in
the United States.
 It’s estimated to occur in 1 in 5000
transfused units.

12.  TRALI is characterized by the acute (less
than 6 hrs*) onset of bilateral non-
cardiogenic pulmonary edema/respiratory
failure with resultant hypoxemia after
blood/blood product transfusion.
 Fever, tachycardia, hypotension, cyanosis
and characteristic CXR findings are common
as well.

13.  Currently there are two proposed
mechanisms:
1. Immune-Mediated
2. Non-Immune-Mediated

14. Alloantibodies
(anti-HLA and
anti-HNA) in
donor* plasma
activate
compliment** in
the pulmonary
microvasculature
Sequestration
and activation of
neutrophils with
release of
cytokines and
oxygen-readctive
substances.
Pulmonary
endothelial
damage and
capillary leakage.
Pulmonary
edema and
respiratory
failure.

16.  As blood products are stored, degradation
occurs.
 Degradation results in the accumulation of
free lipids/lipopolysaccharides.
 Infusion of these products has been shown
to activate neutrophils adherent to lung
vasculature and cause the same end result
as immune-mediated TRALI’s.

17.  Currently, the thought is that the two
processes are not mutually exclusive, and
may, in fact, work synergistically.
 It is also of note, that recent studies have
also determined that previous injury,
particularly lung injury, is highly correlated
with TRALI occurrence.

18. http://www.mayoclinicproceedings.com/inside.asp?AID=936&UID=

19. http://www.frca.co.uk/article.aspx?articleid=100902

21.  Supportive.
 Mild TRALI cases may be treated with O2
via NC alone.
 More serious cases may require intubation
and mechanical ventillation.
 Treat hypotension with pressors.
 Avoid diuretic administration.
 STX and surfactant have not been found to
be beneficial.

23.  Prognosis is much better than ARDS.
 Within 96 hours most patients show clinical
improvement was well as resolution of
infiltrates on CXR.
 A minority of patients may experience
persistent hypoxemia for up to 7 days.
 Approximately 5-10% of reported TRALI’s
are fatal.

24.  We had a reported TRALI event:
› Hx: 68 year-old female with severe pancytopenia
secondary to MDS was admitted to AMC for
chemo/line placement. Pt was given platelets
prior to procedure and within 15 minutes, the pt
developed severe dyspnea and hypoxia. The
transfusion was immediately discontinued and an
ABG and CXR were ordered.

25.  ABG showed severely decrease PO2.
 CXR was read as negative.
 Culture of platelet bag grew gram positive
rods (PCR: staphylococcus epidermis).

27.  Observation and supportive care with
oxygen supplementation.
 Despite the bacterial contamination of the
unit, the patient’s symptoms were deemed
more compatible with TRALI than sepsis.
 Case report submitted to the Red Cross.

29.  While TRALI is not fully understood at this point,
it is extremely important for clinicians to be
aware of it’s presentation as it has become the
most common serious transfusion reaction in
the United States.
 In an effort to reduce the probability of having a
ANFHTR, it has been postulated that using
male-only plasma may reduce such a risk.
 However, more recent studies have shown that
this may, in fact, not be true.

30.  There is still no diagnostic test to diagnose
TRALI.
 Some suggested methods of reducing TRALI
incidence include:
› Filtration/leukoreduction of all blood products.
› Reduced storage time of products
 PRBC’s to less than 14 days.
 PLT’s to less than 2 days.
 The key is surveillance and awareness.

31. Anderson, B. Ban on female plasma donors possible: Valley joins nation in reaction
to study on plasma risk. Fresno Bee. December 29, 2006.
Associated Press. Blood blanks may soon only take male plasma. January 22, 2007.
Berry, I. Blood bank to change plasma policy. Chattanooga Times. January 24, 2007.
Fabron A, Lopes L, Brodin J. Transfusion-related actue lung injury. J Bras Pneumol.
2007.
Gajic O, Moore B. Transfusion-Related Acute Lung Injury. May Clinic Proc. June
2005.
Imoto S, Araki N, Shimada E, Nishimura K, Nose, Y, Bouike Y, Hasimoto M, Mito H,
Okazaki H. Comparison of acute non-hemolytic transfusion reactions in female and
male patients receiving female or male blood components. Transfusion Medicine.
September 2006.