Transfusion-related acute lung injury: TRALI pulmonary leukoagglutinin reactions

1. Transfusion-related acute lung injury: TRALI (pulmonary leukoagglutinin reactions) 2007/07/09 Ri???

2. Introduction TRALI: poorly understood, life-threatening complication of blood perfusion, complicated by acute lung injury (ALI), progress to acute respiratory distress syndrome (ARDS) Finally definition: new ALI occurring during or within six hours after transfusion

3. Pathophysiology ALI Increased pulmonary microvascular permeability Increased protein in the edema fluid TRALI Leukocyte antibodies Biologically active substance Lipids and cytokines Neutrophil priming activity

4. Leukocyte Antibodies Neutrophil in pulmonary capillary ? pulmonar damage & capillary leak Antibody to donor leukocyte Ab to HLA I, II, granulocyte, monocyte, IgA Transient leukopenia Biologically Active Substance Patients condition Sepsis, surgery Active substance Lipid & cytokines Ab: 3.6% of TRALI reaction

5. Epidemiology FDA(2004):the leading cause of transfusion-related death in the United States Mortality rate:5-8% Incidence: not well established Underrecognition and underreporting All plasma-containing blood and blood compartments 1/5,000 blood & blood component 1/2,000 plasma-containing component 1/7,900 units of FFP 1/432 units of whole blood derived platelets

6. Risk Factors No definite risk factors for TRALI Implicated in some, not all: prolonged storage of transfused products administration of fresh FFP an underlying condition such as recent surgery cytokine treatment Thrombocytopenia massive blood transfusion active infection Dose not correlate with the volume of plasma infused or the titer of the anti-leukocyte antibody

7. Clinical Presentation Sudden onset, within 6 hours, but usually begin within 1~2 hours, of respiratory distress after transfusion

8. Clinical Presentation CXR: bilateral patchy alveolar infiltrates, classically with a normal cardiac silhouette and without effusions, consistent with ARDS Resolution rapidly, even when initial hypoxemia is severe Most can be extubated within 48 hours CXR return to normal within four days, although hypoxemia and pulmonary infiltrates persist up to seven days in a minority of patients

9. Diagnosis

10. Risk factors for ALI

11. Multiple transfusion Definition of multiple transfusion >10 units red cells or whole blood within 12 hrs ?15 units of blood within 24 hrs ?8 units RBC within 24 hrs Blood bank: massive transfusion One or more blood volumes within 24 hours 24-36% develop ALI Some of these ALI cases associated with massive transfusion could have been TRALI

12. D/D: think more before TRALI Underlying pulmonary disease Underlying cardiac disease such as CHF Transfusion- associated cardiac overload (TACO) Severe allergic or anaphylactic reactions All risk factors for acute lung injury

13. LAB Diagnosis The finding of granulocyte, leukoagglutinating, or lymphocytotoxic antibodies in serum from either the donor or the recipient is strong support for the diagnosis of TRALI ->if negative, cannot be excluded Decline in C3 or C5a levels 12 to 36 hours after the onset of symptoms, followed by a significant rise four to seven days later ->if negative, cannot be excluded

14. Treatment Supportive: oxygen, ventilator Diuretic: when pulmonary edema develops Steroid??

15. Subsequent use of blood products The recipient No further plasma-containing blood products from the implicated donor No increased risk for recurrent episodes following transfusions from other donors The donor Investigation

16. Prevention Producing FFP only from male donors Screening previously-pregnant and previously-transfused apheresis donors for HLA antibodies Improving tests for the detection of white blood cell antibodies

17. Definition limitation Only identify new, severe case of hypoxemia Already has ALI PaO2/FiO2 > 300 or SpO2 > 90% in room air TRALI with ALI risk factor Expert assessment Other risk factor: major surgery No definite laboratory data in definition Traditional 6-hr limit may not capture cases that develop later

18. Summary-take home massage! Acute lung injury after transfusion Leukocyte antibodies and neutrophil priming agents. Nurse Aware of the signs and symptoms of TRALI when transfusion Pulse oximetry Physician Criteria Report cases of TRALI to blood bank Blood bank Quarantine other blood units from a suspect donor Investigate implicated donors per local policy Report fatal cases to the FDA, and report nonfatal cases to MedWatch

19. Thanks for your attention!