Transfusion-related acute lung injury

Development of lung injury during or within 6 hours of transfusion with respiratory distress, lung infiltrates, hypoxia, and fever.

Most occurrences take place during transfusion risk within the first 1-2 hours after it is completed.

Clinically associated with tachypnea, fever, dyspnea and cyanosis.

Chest x-ray findings include infiltrates with pulmonary edema.

TRALI previously was the leading cause of transfusion associated death, now it occurs in less than one in 10,000 transfused units.

Associated with red blood cells, fresh frozen plasma, platelets, anti-Hemophilic factor and hematopoietic progenitor cells.

The underlying cause is possibly leukocyte antibody.

When the antibody is transfused in large amounts or its strength is high, it can injure recipients lungs and cause ARDS, especially if the recipient already had inflammation or other patient risk factors.

The leukocyte antibodies that cause transfusion related to lung injury or granulocyte and HLA class II antibodies.

Pulmonary transfuion reactions associated with a mortality of 6-14%.

Estimated to cause 100 deaths per year in the U.S.

Pathophysiology related to white blood cell antibodies in the plasma component of transfusion product.

Neutrophils involved in transfusion related acute lung injury by endothelial activation which synthesizes chemokines and increases surface expression of adhesion molecules that cause polymorphonuclear adhesion and release of microbicidal agents that damage the endothelium, cause capillary leak and lung damage.

The TRALI rate has decreased as there has been a switch to plasma and whole blood from male dominant donors, meaning that most or all of the donors are male in the UK.

The risk of TRALI is highest when risk factors are present in both the transfusion or the patient.

Risks are increased if patients received transfusion from multiparous donors, and the risk is especially high if the patient receives large amounts of plasma containing strong anti-human leukocyte antigen (HLA) class II antibody and/or granulocyte antibody.

The presence of inflammation before transfusion, as indicated by elevated levels of Interleukin 8 increases risk.

Chronic alcohol abuse, smoking, higher peak airway pressure while mechanically ventilated, liver surgery, positive fluid balance are risk factors.

Differential diagnosis includes ARDS, transfusion associated circulatory overload, other  pulmonary syndromes, and transfusion associated bacterial infection.
TRALI is treated by supportive measures.
Mortality rate can be as high as 17-14.2%.

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