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Abstract
Noncardiogenic pulmonary edema caused by
transfusion has been observed for almost 60 years.
Today, we know this entity as transfusion-related acute
lung injury (TRALI). TRALI is an uncommon but
potentially fatal adverse reaction to transfusion of
plasma-containing blood components. It is typified by
dyspnea, cough, hypoxemia, and pulmonary edema
within 6 hours of transfusion. Most commonly, it is
caused by donor HLA antibodies that react with
recipient antigens. It may also be caused by
biologically active compounds accumulated during
storage of blood products, which are capable of
priming neutrophils. Without a gold standard, the
diagnosis of TRALI relies on a high index of suspicion
and on excluding other types of transfusion reactions.
Although current definitions of TRALI depend on
symptoms, laboratory parameters can aid in the
diagnosis and frequently identify the causative donor
unit. As our understanding of TRALI deepens, risk
reduction or prevention may become possible.
Recently, a 72-year-old man with peripheral vascular disease was admitted to our institution with an occluded right
lower extremity arterial bypass graft and cellulitis of the right
foot. On the second hospital day, 2 U of fresh frozen plasma
(FFP) were ordered to correct an international normalized
ratio of 1.73 before surgery.
After transfusion of approximately 100 mL of the first
unit of FFP, the patient became acutely short of breath, hypoxemic, and hypotensive. The transfusion was stopped, and the
patient was given supplemental oxygen. A chest radiograph
taken shortly after the onset of symptoms revealed bilateral
pulmonary infiltrates. Intubation and mechanical ventilation
were required to maintain adequate oxygenation, and vasopressors were needed to maintain adequate perfusion. A CBC
count drawn approximately 1 hour after the onset of symptoms revealed a WBC count of 7,500/L (7.5 109/L), which
was markedly decreased from 10,560/L (10.6 109/L) earlier that day. During the ensuing hours, the patient became
anuric, and after several hours of maximal support, the family
decided against further resuscitative measures. Shortly thereafter, the patient became asystolic and was pronounced dead.
Autopsy revealed edematous lungs with a combined
weight of 2,780 g. Histologic examination revealed neutrophilic aggregates throughout the pulmonary, central nervous system, hepatic, and renal vasculature. Investigation of the
implicated unit of FFP revealed that it was from a multiparous
female donor with class I and II histocompatibility antibodies.
DOI: 10.1309/D3F7BXH466AE3G0P
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A New Disease
Numerous case reports of pulmonary reactions due to
transfusions were published after the initial description by
Lanman et al.1 Anaphylactoid,1 hypersensitivity,2,8 unknown
incompatibility,4 allergic,8,9 and noncardiogenic pulmonary
edema10 are some of the terms used to describe this pattern of
pulmonary deterioration following transfusion of blood products. In 1983, Popovsky et al11 recognized a pattern of acute
pulmonary compromise in a series of 5 patients and termed it
transfusion-related acute lung injury (TRALI). All patients
had received whole blood or packed RBCs (PRBCs). Analysis
of the recipient samples and donor units revealed lymphocytotoxic antibodies in the latter. HLA antibodies against recipient antigens were found in 3 of 5 cases.11 Based on the total
number of patients and units transfused during the observed
period, they estimated an incidence of TRALI of 0.02% per
unit transfused and 0.16% per recipient.11 Although rare,
TRALI has become the leading cause of transfusion-related
deaths reported to the US Food and Drug Administration
(FDA) since 2004 (J.C. Goldsmith, written communication,
May 4, 2007).
In an effort to confirm their initial findings, Popovsky and
Moore12 identified 36 patients with acute respiratory distress
occurring within 4 hours of transfusion from 22,292 patients
who had received 194,715 units. In 89% of the cases, granulocyte antibodies were detected in the serum of the donors.
Lymphocytotoxic antibodies were found in 72% of the cases.
The lack of antibodies in recipients pretransfusion serum led
the authors to believe that passive transfer of antibodies is
associated with the occurrence of TRALI and likely a factor in
its pathogenesis.12 A similar incidence of 0.02% per unit transfused and 0.16% per patient transfused was demonstrated in
this study. Of the 36 patients, 2 died, resulting in a 6% mortality risk.12 In the reports by Popovsky et al11 and Popovsky and
American Society for Clinical Pathology
recent surgery, massive transfusion, or cytokine administration) and hypothesized that 2 events are necessary to induce
TRALI.23 Thus, predisposing clinical factors would prime
neutrophils and are necessary but not sufficient to cause
TRALI. The second insult would be the transfusion or, more
specifically, biologically active lipids that accumulate during
storage of cellular components.23 Subsequently, Silliman et
al14,24 identified lysophosphatidylcholine as a component of
these biologically active lipids and showed that it can prime
neutrophils. In 2003, the same investigators prospectively
determined that the lipid-priming activity was higher in units
of whole blood platelets implicated in TRALI than in control
units.25 In a case report of recurrent TRALI, Win and colleagues26 also noted that biologically active lipids may have
had a role in the second TRALI event.
Silliman and colleagues27 reproduced TRALI with biologically active lipids in animal models. In keeping with the 2insult model, the authors first pretreated rats with endotoxin.
The rat lungs were then isolated, ventilated, and perfused with
saline, 5% fresh human plasma, plasma from stored blood
from the day of isolation, plasma from stored blood from the
day of outdate, lipid extracts from day of outdated plasma, or
purified lysophosphatidylcholine.27 Rat lungs pretreated with
endotoxin and perfused with day-of-outdate plasma developed
ALI. Significant pulmonary edema was also seen in the endotoxin-pretreated lungs perfused with lipid extracts from dayof-outdate plasma and lysophosphatidylcholine.27 A similar
study in rats with plasma from whole bloodderived and
apheresis platelets was done by Silliman et al.28 Again, plasma from both sources collected at day 5 induced ALI in endotoxin-pretreated rats, but plasma from day 0 did not.28
In a retrospective case control study, Khan et al29 identified the CD40 ligand (CD40L) as a cofactor in the development of TRALI. Soluble CD40L levels were 76% higher in
implicated platelet concentrates than in nonimplicated units.29
The highest levels were found in apheresis products. The
authors also found that CD40L accumulates during the storage of PRBCs and whole blood.29 Furthermore, CD40L
increased in the posttransfusion plasma of 8 of 12 patients
with TRALI compared with pretransfusion levels. These findings suggested an association among soluble CD40L in
platelet concentrates, activation of the innate immune system,
and development of TRALI.29
Differentiating TRALI
Because transfusions typically are given to sick patients,
it is important to consider all entities that might cause acute
respiratory distress. Transfusion-associated circulatory overload (TACO) is chief among these entities. Reports of the incidence of TACO vary from less than 1% to 11% in critically ill
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medical patients.30,31 Mortality from TACO has been estimated from 3.6%30 to 20%.31 Clinically, patients with TACO have
tachypnea, dyspnea, cyanosis, tachycardia, and hypertension.32 They also have signs of circulatory overload, such as
jugular venous distension and an elevated pulmonary artery
occlusion pressure.32 Such signs may be present before the
initiation of transfusion, and review of the patients intake and
output will likely add evidence for the diagnosis.33 TACO usually responds to diuresis and ventilatory support.34
Respiratory distress is a major symptom in anaphylactic
transfusion reactions as well. These typically include tachypnea, cyanosis, and wheezing.35 Hypotension is also frequently
a component.35 Theses symptoms typically arise from laryngeal and bronchial edema instead of interstitial pulmonary
involvement.35 Skin manifestations include urticaria, erythema, and edema of the face and trunk.35 Bacterial contamination
of transfused blood products should also be considered in a
patient with respiratory distress. Sepsis usually manifests as
hypotension, fever, and even circulatory collapse, often accompanied by respiratory distress.32 Culture of the blood bag is crucial in the evaluation. Finally, an acute hemolytic transfusion
reaction must also be considered and ruled out because the
signs and symptoms may include respiratory distress.
Table 1
Current Criteria for the Diagnosis of TRALI
American-European Consensus Conference Definition of ALI39
Acute onset
Bilateral pulmonary infiltrates evident on chest radiograph
Hypoxemia, defined as PaO2/FIO2 300
No evidence of left atrial hypertension (ie, no congestive heart
failure; or PAOP 18, if available)
National Heart, Lung, and Blood Institute Definition of TRALI40
No ALI before transfusion
Signs or symptoms of TRALI during or within 6 hours of transfusion
In patients with an alternative ALI risk factor, TRALI is still possible.
Massive transfusion should not exclude the possibility of TRALI.
European Haemovigilance Network Definition of TRALI37
Respiratory distress during or within 6 hours of transfusion
No signs of circulatory overload
Radiographic evidence of bilateral pulmonary infiltrates
ALI, acute lung injury; FIO2, fraction of inspired oxygen; PAOP, pulmonary artery
occlusion pressure; TRALI, transfusion-related ALI.
prompt reporting of all transfusion-related deaths and encourages voluntary reporting of complications of transfusions.
Complete assessment requires specimens from the recipient, all blood components transfused within the preceding 6
hours, and the corresponding donor(s). The AECC suggests
testing the donor(s) for HLA class I and II and HNA antibodies and determining their specificity, if positive.39 Donors
implicated in TRALI are those with antibodies specific for a
recipient antigen or causing a positive WBC crossmatch.39
Although neutrophil priming activity has also been postulated
in TRALI,14,21 the AECC recognized the lack of widespread
availability for testing and recommended it only for research
settings.39 Because numerous studies have found that the
implicated unit was from a multiparous woman,7,12,58 serologic investigation of cases in which multiple transfusions were
given in the preceding 6 hours should begin with units from
such donors.
Treating TRALI
Predicting TRALI
Although any blood component can cause TRALI, plasma-rich units are more likely to be the culprits.31 In addition,
Silliman et al25 found that patients with hematologic malignancies and those requiring coronary bypass surgery are at
particular risk.
Donor factors may also predict the possibility of developing TRALI. Since 1971, multiple previous pregnancies in the
donor have been considered a risk factor for inducing
TRALI.7 Densmore et al59 showed that the prevalence of HLA
sensitization is directly related to parity: 15% of women
reporting 1 to 2 pregnancies and 26% of women with 3 or
more. However, transfusion of HLA antibodies into patients
with corresponding antigens typically does not result in
TRALI.59,60 Palfi and colleagues58 conducted the first randomized, controlled trial of TRALI and multiparous donors.
They identified 100 critically ill patients who needed transfusion of 2 U of FFP and gave each one a unit from a nulliparous
and a unit from a multiparous donor. Patients were randomized to receive the nulliparous or the multiparous unit first, at
least 4 hours apart. Hemodynamics, cytokine levels, and
PaO2/fraction of inspired oxygen (FIO2) ratio were measured.
Although only 1 case of TRALI was diagnosed, a small but
statistically significant decrease in the PaO2/FIO2 ratio
occurred after transfusion of the multiparous units.58
Investigating TRALI
Although the diagnosis of TRALI relies on clinical symptoms and the exclusion of other causes, a thorough laboratory
investigation will help support the diagnosis. Any investigation into suspected TRALI should begin with immediate notification of the hospital transfusion service, which will ensure
proper evaluation and follow-up Table 2. The FDA requires
Preventing TRALI
Transfusion of any blood component poses a risk for
developing TRALI. Consistent, evidence-based transfusion
guidelines will likely decrease the number of transfusions
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Image 1 A complete autopsy was performed on a patient who died with the clinical diagnosis of transfusion-related acute
lung injury. The most significant finding was pulmonary edema (combined lung weight of 2,780 g) (A) with neutrophilic
aggregates in the pulmonary vasculature (B, H&E, 180).
Image 1 Also, marked congestion of most tissues, sludging of RBCs, and neutrophilic collections were found in the liver
sinusoids (C, H&E, 180), myocardium, glomeruli, and central nervous system.Several meningeal blood vessels of frontal
lobes and hippocampus contained RBCs and leukocytes (D, H&E, 50; E, H&E, 50), and pontine blood vessels had dense
neutrophilic aggregates (F, H&E, 180). Several small lacunar infarcts of the pons were noted (not shown).
might be taking.72 Administration of erythropoietin preoperatively has also been shown to decrease allogeneic transfusion requirements in certain populations.73 Intraoperatively,
reductions in transfusion rates of plasma and platelets are also
attainable. The use of antifibrinolytic drugs can decrease
transfusion requirements in a variety of surgical procedures,74
as can the avoidance of intraoperative hypothermia.75 The
retransfusion of postoperatively shed blood has also received
attention, and it is effective for reducing the number of allogeneic transfusions in total hip and knee arthroplasty.76
Despite maximal efforts to reduce the number of transfusions, patients will continue to require them for specific conditions. When transfusion of plasma is indicated, exclusion of
Table 2
Investigation of Suspected TRALI*
Discontinue transfusion
Notify hospital transfusion service
Repeat ABO typing and crossmatch
Obtain CBC count, levels of ABG, blood cultures, and chest radiograph
Return all component bags recently transfused
Test donor and recipient for HLA class I and II antibodies and human
neutrophil antigenspecific antibodies (antihuman globulin
complementdependent cytotoxicity or flow cytometry)
Determine specificity, if antibodies detected
Perform donor-recipient WBC crossmatch
Determine parity of donor(s)
Determine age of unit(s) transfused
Test for neutrophil-priming activity when available in research settings
ABG, arterial blood gases; TRALI, transfusion-related acute lung injury.
* Based, in part, on American-European Consensus Conference recommendations.39
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not impossible, in a clinical setting. Washing of cellular components reduces neutrophil priming activity and biologically
active substances80 but has negative effects on shelf life.81
Prestorage leukocyte reduction may reduce the risk of TRALI
by limiting complement-mediated processes, which have been
shown to be a contributor to TRALI in a rat model.20
What Is to Come?
We hope the near future will produce more answers
about the pathogenesis and prevention of TRALI. Large,
prospective studies of the incidence of TRALI might provide
more data about which patients are most at risk and which
donors are most likely associated with TRALI. From there,
various prevention strategies could be prospectively implemented to test their efficacy. In addition, donor management
could be honed to exclude donors whose blood is most likely to cause TRALI, while allowing others with less risk to
continue contributing to the already small donor pool.
Screening for HLA and HNA antibodies may eventually
become feasible, but cost and interpretation of results must be
taken into consideration before widespread implementation.
Finally, as Wallis82 suggested, the question of whether the
lungs are the only affected organ is still open. During the
autopsy of the patient who died of TRALI described in the
introduction, we identified microvascular neutrophil infiltration in various organs besides the lungs (Image 1) and Image
2. Although the pulmonary vasculature is the first capillary
bed encountered by transfusions, the effects of TRALI may
indeed be systemic, and further study to elucidate these
effects is warranted.
Image 2 Myeloperoxidase (MPO) stain confirmed that most of the cells in the microvasculature of the lungs and pons were
neutrophilic/MPO+ collections (A, 180; B, 100).
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Conclusion
TRALI is a rare but serious complication of transfusion
therapy. Since the first description, a great deal of insight has
been gained into its pathogenesis, yet many questions remain
unanswered. There is clear evidence that passively transfused
antibodies have a role in many cases of TRALI. However, the
case for a role for biologically active lipids as causative agents
continues to mount. Whether these 2 causes are separate entities or represent different points along the same continuum is
unknown. Rapid recognition when cases of TRALI occur
remains vital to the further understanding and proper treatment of this complication. Notification of the transfusion service is crucial to ensure that a proper investigation is carried out
and, if necessary, the case reported to regulatory authorities.
Perhaps with a broader and more detailed understanding into
the pathogenesis of TRALI, at-risk donors and recipients can
be identified and measures taken to lessen the recipients risk.
From the Departments of 1Anesthesiology and 2Pathology,
Division of Laboratory Medicine, University of Alabama at
Birmingham.
Address reprint requests to Dr Cherry: Dept of Anesthesiology,
JT 964; 619 19th St S, Birmingham, AL 35249-6810.
References
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