TRALI is Transfusion Related Acute Lung Injury, an acute immune response to transfused blood products that causes severe respiratory distress. It is the leading cause of transfusion-related deaths. TRALI can occur through immune or non-immune pathways that result in neutrophil activation and pulmonary edema. Symptoms include dyspnea, tachypnea, and hypoxemia. Treatment involves supportive care, discontinuing transfusion, oxygen supplementation, and mechanical ventilation if severe. Prevention includes using predominantly male plasma due to lower antibody levels in female donors.

1. CUTZONE(NOPRINTINGALLOWED)
CUTZONE(NOPRINTINGALLOWED)
TRALI
By:
Will
Engberg
UW
Hospital
and
Clinics
What
is
TRALI?
TRALI
is
short
for
Transfusion
Related
Acute
Lung
Injury.
As
the
name
suggests,
it
is
an
acute
immune
response
due
to
transfused
blood
products.
It
causes
severe
respiratory
distress
and
hypoxemia.
TRALI
is
considered
to
be
the
number
one
cause
of
transfusion-­‐associated
fataliBes,
now
surpassing
ABO
incompaBbility
and
bacterial
contaminaBon.
TRALI
has
a
6%
to
20%
fatality
rate.
TRALI
Pathogenesis
One
theory
for
the
TRALI
pathway
is
“immune
TRALI”.
AnBbodies
against
human
leukocyte
anBgen
(HLA)
or
human
neutrophil
anBgens
(HNA)
in
the
transfused
blood
component
react
with
recipient
leukocytes.
This
causes
aggregates
that
occlude
the
pulmonary
circulaBon.
Studies
have
shown
that
HLA
class
II
anBgens
and
HNA-­‐3a
anBgens
are
most
frequently
associated
with
severe
immune
TRALI.
Up
to
80%
of
TRALI
cases
react
in
this
manner.
The
other
pathway
is
known
as
“nonimmune
TRALI”.
Non-­‐
immune
TRALI
consists
of
a
“two-­‐hit”
event.
The
first
“hit”
consists
of
some
type
of
lung
trauma,
or
an
infecBous/
inflammatory
disease
in
the
paBent
that
affects
the
lungs.
This
results
with
the
priming
of
neutrophils.
The
second
“hit”
involves
transfusion
of
biologically
acBve
substances
accumulated
during
storage
of
the
blood
product.
Immune
and
Non-­‐immune
TRALI
both
lead
to
the
same
outcome,
which
is
an
influx
of
leukocytes
into
the
lungs,
followed
by
leukocyte
acBvaBon
and
release
of
cytotoxic
agents,
with
subsequent
endothelial
damage
and
capillary
permeability.
This
increased
capillary
permeability
leads
to
leakage
of
fluid
into
alveolar
spaces,
resulBng
in
pulmonary
edema
and
respiratory
distress.
The
picture
to
the
right
is
a
normal
chest
radiography
showing
adequately
aerated
lungs.
The
picture
to
the
le[
shows
a
classic
example
of
TRALI;
the
X-­‐ray
shows
pulmonary
edema
with
bilateral
infiltrates,
obtained
4
hours
a[er
iniBal
presentaBon
of
severe
respiratory
distress
during
transfusion
of
blood
products.
IniBal
Symptoms
• Dyspnea
• Tachypnea
• Fever
(Occasionally)
• Cyanosis
(Occasionally)
• Hypotension
(Occasionally)
Criteria
for
Diagnosis
• Onset
within
6
hours
of
transfusion
• PAO2/FiO2
<
300
mm
Hg
or
OxygenaBon
saturaBon
of
<
90%
room
air
• Chest
X-­‐ray
showing
bilateral
infiltrates
on
front
chest
radiography
• Pulmonary
artery
occlusion
pressure
<
18
mm
Hg
or
No
evidence
of
le[
atrial
hypertension
(FiO2
=
fracBon
of
inspired
oxygen;
PAO2
=
parBal
pressure
of
arterial
oxygen)
TRALI
vs
TACO
It
is
important
to
differenBate
TRALI
from
another
complicaBon
known
as
transfusion
associated
circulatory
overload
(TACO).
Both
present
with
severe
hypoxemia
and
chest
X-­‐ray
showing
pulmonary
edema.
Treatment
• SupporBve
therapy
• DisconBnue
transfusion
• Supplemental
Oxygen
• Mechanical
venBlaBon
in
severe
cases
PrevenBon
StarBng
around
2003,
countries
(for
example
the
United
Kingdom)
started
using
a
preventaBve
measure
called
“predominantly
male
plasma
policy”,
in
which
they
only
accept
male
plasma
donors.
This
is
because
women
are
more
likely
to
make
HLA/HNA
anBbodies
a[er
being
sensiBzed
through
pregnancy.
This
policy
has
significantly
decreased
the
number
of
TRALI
cases.
For
those
that
do
accept
female
plasma
and
platelet
donors,
HLA
anBbody
tesBng
has
been
implemented.
Sources
Arinsburg,
Suzanne
A.
"Conversion
to
Low
Transfusion-­‐
related
Acute
Lung
Injury
(TRALI)-­‐risk
Plasma
Significantly
Reduces
TRALI."
TRANSFUSION
53
(2012):
946-­‐52.
May
2012.
Web.
16
Feb.
2014.
Gandhi,
Manish
J.
"Lot-­‐to-­‐lot
Variability
in
HLA
AnBbody
Screening
Using
a
MulBplexed
Bead-­‐based
Assay."
TRANSFUSION
53
(2013):
1940-­‐946.
Sept.-­‐Oct.
2013.
Web.
16
Feb.
2014.
Harmening,
Denise.
Modern
Blood
Banking
&
Transfusion
Prac=ces.
Philadelphia:
F.A.
Davis,
2012.
Print.
Harris,
Shealynn,
MD.
"Department
of
Medicine."
TACO
vs.
TRALI:
Recogni=on,
Differen=a=on,
and
Inves=ga=on
of
Pulmonary
Transfusion
Reac=ons
(n.d.):
1-­‐41.
Web.
16
Feb.
2014.
www.fda.gov
Bloodjournal.hematologylibrary.org
imagebank.hematology.org
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