Transfusion-related acute lung injury

Role of extracellular adenosine in acute lung injury

Acute lung injury (ALI) is a lung disease characterized by pulmonary edema and severe hypoxia. The past decade hosted a search for endogenous mechanisms controlling lung inflammation and pulmonary edema during ALI. As such, recent evidence indicates extracellular adenosine in orchestrating the resolution of pulmonary edema and inflammation during ALI.

Mirasol Pathogen Reduction Technology treatment does not affect acute lung injury in a two-event in vivo model caused by stored blood components

INTRODUCTION

Mirasol Pathogen Reduction Technology (PRT) treatment uses riboflavin and UV light to inactivate pathogens in blood components. Neutrophil [polymorphonuclear cells (PMN)] priming activity accumulates during routine storage of cellular blood components, and this activity has been implicated in transfusion-related acute lung injury (TRALI). We hypothesize that PRT-treatment of blood components affects the priming activity generated during storage of packed RBCs (PRBCs) or platelet concentrates (PCs), which can elicit ALI in vivo.

METHODS

Plasma, PRBCs and PCs were isolated from healthy donor's whole blood or by apheresis. Half of a collected unit was treated with PRT treatment and the remainder was left as an unmodified control. Supernatant was collected during storage of PCs and PRBCs and assayed for PMN priming activity and used as the second event in a two-event in vivo model of TRALI.

RESULTS

PRT treatment did not induce priming activity in plasma or affect the priming activity generated during storage of PCs or PRBCs as compared with the unmodified controls. The supernatants from stored, but not fresh, PCs and PRBCs did cause ALI as the second event in a two-event animal model of TRALI, which was unaffected by PRT treatment. We conclude that the PRT treatment does not induce priming activity in plasma nor does it affect the priming activity generated during storage of PCs or PRBCs or their ability to cause ALI as the second event in a two-event in vivo model of TRALI. Moreover, the amount of priming activity in TRIMA-isolated PCs was significantly less than SPECTRA-isolated PCs.

Meta-analysis of clinical studies of the purported deleterious effects of "old" (versus "fresh") red blood cells: are we at equipoise?

BACKGROUND

A meta-analysis examined whether the available data support an adequate suspicion that transfusion of old red blood cells (RBCs) is associated with increased mortality, organ failure, infection, prolonged mechanical ventilation, and prolonged stay in the hospital or the intensive care unit. Such suspicion is required for intentionally exposing patients enrolled in randomized controlled trials (RCTs) to the known or probable--but rare--risks of old RBCs, to document (and prevent) purported common adverse effects of old RBCs.

STUDY DESIGN AND METHODS

Observational studies presenting adjusted results were eligible for analysis if the adequacy of the adjustment for confounding factors could be assessed. Three RCTs and 24 observational studies were retrieved. Medically and statistically homogeneous studies were integrated by fixed-effects methods. Otherwise homogeneous studies conducted in different clinical settings were integrated by random-effects methods.

RESULTS

Based on "as-treated" analysis, transfusion of old RBCs was associated with a significant reduction in mortality (summary odds ratio, 0.38; 95% confidence interval, 0.14-0.99; p < 0.05) across two small RCTs. Integration of adjusted findings on the same outcome, from observational studies conducted in the same setting, produced summary results that were either negative (in six analyses) or impossible to evaluate owing to uncontrolled confounding by the number of transfused RBCs (in two analyses).

CONCLUSION

The available data do not support an adequate suspicion that old RBCs may be associated with common adverse morbidity and/or mortality outcomes, so as to justify exposing experimental subjects to the other known or probable--but rare--risks of old RBCs.

Resuscitation and transfusion principles for traumatic hemorrhagic shock

The transfusion approach to massive hemorrhage has continually evolved since it began in the early 1900s. It started with fresh whole blood and currently consists of virtually exclusive use of component and crystalloid therapy. Recent US military experience has reinvigorated the debate on what the most optimal transfusion strategy is for patients with traumatic hemorrhagic shock. In this review we discuss recently described mechanisms that contribute to traumatic coagulopathy, which include increased anti-coagulation factors and hyperfibrinolysis. We also describe the concept of damage control resuscitation (DCR), an early and aggressive prevention and treatment of hemorrhagic shock for patients with severe life-threatening traumatic injuries. The central tenants of DCR include hypotensive resuscitation, rapid surgical control, prevention and treatment of acidosis, hypothermia, and hypocalcemia, avoidance of hemodilution, and hemostatic resuscitation with transfusion of red blood cells, plasma, and platelets in a 1:1:1 unit ratio and the appropriate use of coagulation factors such as rFVIIa and fibrinogen-containing products (fibrinogen concentrates, cryoprecipitate). Fresh whole blood is also part of DCR in locations where it is available. Additional concepts to DCR since its original description that can be considered are the preferential use of "fresh" RBCs, and when available thromboelastography to direct blood product and hemostatic adjunct (anti-fibrinolytics and coagulation factor) administration. Lastly we discuss the importance of an established massive transfusion protocol to rapidly employ DCR and hemostatic resuscitation principles. While the majority of recent trauma transfusion papers are supportive of these general concepts, there is no Level 1 or 2 data available. Taken together, the preponderance of data suggests that these concepts may significantly decrease mortality in massively transfused trauma patients.

Long-term survival and quality of life after transfusion-associated pulmonary edema in critically ill medical patients

BACKGROUND

Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) commonly complicate transfusion in critically ill patients. Prior outcome studies of TACO and TRALI have focused on short-term morbidity and mortality, but the long-term survival and quality of life (QOL) of these patients remain unknown.

METHODS

In a nested case-control study, we compared survival and QOL between critically ill medical patients who developed pulmonary edema after transfusion (TRALI or TACO) and medical critically ill transfused controls, matched by age, gender, and admission diagnostic group. QOL in survivors was assessed with a 36-item short form health survey 1 year after initial hospitalization.

RESULTS

Hospital, 1-year, and 2-year mortality among the 74 TRALI cases and 74 matched controls were 43.2% vs 24.3% (P = .020), 63.8% vs 46.4% (P = .037) and 74.3% vs 54.3% (P = .031), whereas among the 51 TACO cases and 51 matched controls these values were 7.8% vs 11.8% (P = .727), 38.0% vs 28.0% (P = .371), and 44.9% vs 38.8% (P = .512). When adjusted for age and baseline severity of illness in a Cox proportional hazard analysis, the development of TRALI remained associated with decreased survival (hazard ratio 1.86; 95% CI, 1.19-2.93; P = .006). Both TRALI (P = .006, P = .03) and TACO (P = .03, P = .049) were associated with prolonged ICU and hospital lengths of stay.

CONCLUSIONS

In critically ill medical patients, development of TRALI, but not TACO, is independently associated with decreased long-term survival.

[Transfusion-related acute lung injury]

The term Transfusion-Related Acute Lung Injury (TRALI) was coined in 1985. It is a relatively rare, life-threatening clinical syndrome characterized by acute respiratory failure and non-cardiogenic pulmonary edema during or following a blood transfusion. Although its true incidence is unknown, a rate 1 out of every 5000 transfusions has been quoted. TRALI has been the most common cause of transfusion-related fatalities during three years in the USA. Two different etiologies have been proposed. The first is a single antibody-mediated event involving the transfusion of anti-HLA or antigranulocyte antibodies into patients whose leukocytes express the cognate antigens. The second is a two-event model: the first event is related to the clinical condition of the patient (sepsis, trauma, etc.) resulting in pulmonary endothelial activation and neutrophil sequestration, and the second event is the transfusion of a biologic response modifier that activates these adherent polymorphonuclear leukocytes resulting in endothelial damage and capillary leak. The patient management is support as needed based on the severity of the clinical picture and strategies to prevent TRALI are focused on: donor-exclusion policies, product management strategies and avoidance of unnecessary transfusions.

Transfusion-related acute lung injury (TRALI): current concepts and misconceptions

Transfusion-related acute lung injury (TRALI) is the most common cause of serious morbidity and mortality due to hemotherapy. Although the pathogenesis has been related to the infusion of donor antibodies into the recipient, antibody negative TRALI has been reported. Changes in transfusion practices, especially the use of male-only plasma, have decreased the number of antibody-mediated cases and deaths; however, TRALI still occurs. The neutrophil appears to be the effector cell in TRALI and the pathophysiology is centered on neutrophil-mediated endothelial cell cytotoxicity resulting in capillary leak and ALI. This review will detail the pathophysiology of TRALI including recent pre-clinical data, provide insight into newer areas of research, and critically assess current practices to decrease it prevalence and to make transfusion safer.

The normal hematocrit cardiac trial revisited

The Normal Hematocrit Cardiac Trial (NHCT) was the first large, randomized study of patients receiving hemodialysis to examine the outcomes of treating anemia to a target hematocrit range of 42 +/- 3% versus maintaining partial correction in a range of 30 +/- 3%. The results of the NHCT and a meta-analysis adding eight subsequent trials of normalization of hematocrit/hemoglobin in chronic kidney disease (CKD) have demonstrated increased thrombovascular events and mortality associated with the higher targets. This article expands and clarifies the results of the NHCT, including data that were edited from the original publication, and highlights findings from more recent studies in the field. Paradoxically, none of the randomized trials has reported an association between higher attained hemoglobin concentration and mortality within randomized groups. Mean platelet count did not increase among the patients in the normal-hematocrit group in the NHCT or in two other large trials, CREATE and CHOIR. Exposure to high doses of erythropoietic stimulating agents and/or intravenous iron could be mediating complications in the CKD anemia-normalization studies, but post-hoc analyses to probe such potential associations have yielded conflicting results and are clearly hindered by the risk of confounding by indication. The mechanisms underlying the deleterious outcomes associated with efforts to correct renal anemia fully remain unproven.

Length of storage and in vitro immunomodulation induced by prestorage leukoreduced red blood cells

BACKGROUND

The relationship between length of storage of red blood cell (RBC) units and biochemical changes has been well studied, but little is known about the progression of cellular immunomodulative properties in blood recipients. This study aims to quantify in vitro T-cell activation and cytokine release by white blood cells, after incubation with supernatants from leukoreduced RBCs.

STUDY DESIGN AND METHODS

Whole blood cultures were incubated with supernatant from five leukoreduced RBC units stored for 1, 6, 10, 15, 24, and 42 days. Supernatant-induced T-cell activation was evaluated by quantifying CD25 expression. Supernatant-induced cytokine production was determined by measuring interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-alpha levels.

RESULTS

No cytokines were detected in RBC supernatants even after 42 days of storage. However, IL-6 levels in whole blood culture increased significantly when incubated with supernatant from RBC units stored for 1, 6, and 15 days, by factors of 1.7 +/- 0.3, 1.7 +/- 0.3, and 1.4 +/- 0.3, respectively. TNF-alpha levels were significantly decreased on Days 24 and 42 of storage by factors of 0.50 +/- 0.42 and 0.33 +/- 0.21, respectively. IL-10 levels were significantly increased on Days 1 and 42 of storage by factors of 2.3 +/- 1.3 and 3.2 +/- 2.8, respectively. After an initial increase in IL-6 and TNF-alpha production, there was a significant linear decrease in their levels measured from units stored for longer times. No significant changes in CD25 expression were observed over time.

CONCLUSION

Although no cytokines were measured in the supernatants from leukoreduced RBCs, these supernatants exhibited variable immunomodulatory effects related to their length of storage.

Antioxidants combined with NO donor enhance systemic inflammation in acute lung injury in rats

OBJECTIVES

Acute lung injury and acute respiratory distress syndrome (ALI, ARDS) are well-known complications of cardiac and major vascular surgery. ARDS is associated with high mortality and no effective treatment is available. Protective effects of antioxidants or nitric oxide (NO) in experimental studies were not confirmed in clinical trials, but the potential beneficial effects of their combination are poorly known. This study was designed to investigate whether concomitant administration of NO donor and antioxidants has synergic effects on lung protection in ALI.

DESIGN

ALI was induced in rats by intestinal ischemia-reperfusion. Superoxide dismutase and catalase were administered as antioxidants and arginine as NO donor. Lung wet-dry ratio, MPO activity, tissue-air ratio, airspace hemorrhage and serum TNF-alpha were used as parameters of lung injury and systemic inflammation.

RESULTS

Antioxidants and arginine significantly reduced lung damage when administered separately. However, concomitant administration of antioxidants and arginine abolished the protective effects and enhanced systemic inflammation.

CONCLUSIONS

Our data suggests that antioxidants and NO in combination should be avoided in clinical practice.

Transfusion-Related Acute Lung Injury — A Review

Transfusion-related acute lung injury (TRALI), a type of non-cardiogenic pulmonary oedema related to blood transfusion, is gaining prominence as a common adverse event related to blood transfusions in hospitals. Various mechanisms have been postulated to cause TRALI including both antibody-related and non-immune mechanisms. Although transfusion of all types of blood components have been implicated, by far the commonest product related to TRALI was, until recently, fresh frozen plasma, especially that obtained from female donors. However the use of male-only plasma donation in the UK has resulted in an increased observance of TRALI with platelet and red cell transfusions. The diagnosis of this condition is primarily one of exclusion of other causes of pulmonary oedema, with specialist laboratory tests performed to support the diagnosis. The management of TRALI is early diagnosis and good supportive care with, occasionally, ventilatory support. An increased awareness of this complication among intensive care physicians is desirable to prevent one of the commonest and most frequently under-recognised transfusion-related adverse events of the present day.

Animal models of transfusion-related acute lung injury

Currently, more than 50 years after its apparent early recognition in case reports, and more than 20 years after its name was coined to denote a distinct entity of pulmonary transfusion reactions, transfusion-related acute lung injury (TRALI) has emerged as a serious cause of transfusion-associated morbidity and the subject of an exponentially growing scientific literature. However, review articles, clinical case reports, and case series continue to dominate the published literature on the topic and experimental studies aimed at modeling and elucidating TRALI mechanisms are less frequent. This article reviews the current status of the known experimental models of TRALI, with particular emphasis on efforts to establish in vivo animal models of this important pulmonary transfusion reaction.

Heterotypic interactions enabled by polarized neutrophil microdomains mediate thromboinflammatory injury

Selectins and their ligands mediate leukocyte rolling, allowing interactions with chemokines that lead to integrin activation and arrest. Here we show that E-selectin is crucial for generating a secondary wave of activating signals, transduced specifically by E-selectin ligand-1, that induces polarized, activated alpha(M)beta(2) integrin clusters at the leading edge of crawling neutrophils, allowing capture of circulating erythrocytes or platelets. In a humanized mouse model of sickle cell disease, the capture of erythrocytes by alpha(M)beta(2) microdomains leads to acute lethal vascular occlusions. In a model of transfusion-related acute lung injury, polarized neutrophils capture circulating platelets, resulting in the generation of oxidative species that produce vascular damage and lung injury. Inactivation of E-selectin or alpha(M)beta(2) prevents tissue injury in both inflammatory models, suggesting broad implications of this paradigm in thromboinflammatory diseases. These results indicate that endothelial selectins can influence neutrophil behavior beyond its canonical rolling step through delayed, organ-damaging, polarized activation.

Influence of tissue perfusion on the outcome of surgical patients who need blood transfusion

PURPOSE

The aim this study was to evaluate the clinical outcome of patients needing intra-operative blood transfusion by tissue perfusion markers.

METHODS

A prospective single center cohort study. Adult patients needing blood transfusion during the intra-operative period were recruited.

RESULTS

This study included 61 patients. At the time of blood transfusion the hemoglobin level was 8.4+/-1.8 g/dL. Scv02 has been the best tissue perfusion marker to determine mortality, compared with hematemetric values and other tissue perfusion markers, with a cut-off point at ROC curve equal to 80% (AUC=0.75; sensitivity=80%; specificity=65.2%). Patients who received blood transfusion and had Scv02 <or=80% (N=29), in comparison to those with Scv02>80% (N=32), had lower mortality rates (12.5% vs. 47.1%; p=0.008) and lower incidence of postoperative complications (58.9% vs. 72.9%; p=0.06). Blood transfusion with a Scv02 <or=80% was also associated with reduced use of vasopressors (5.9% vs. 36.8%; p=0.009). Lower incidence of hypoperfusion (17.6% vs. 52.6%; p=0.009), and lower incidence of infection (23.5% vs. 52.6%; p=0.038) in the postoperative period.

CONCLUSIONS

In major surgeries, Scv02 appears to be an important variable to be taken into consideration to decide for or against blood transfusion, since blood transfusion with adequate perfusion, reflected by Scv02>80%, are associated with worse clinical outcomes.

Transfusion-related acute lung injury: current concepts for the clinician

The leading cause of transfusion-related morbidity and mortality in the United States is transfusion-related acute lung injury (TRALI). Diagnostic criteria for TRALI have recently been developed and primarily consist of hypoxia and bilateral pulmonary edema occurring during or within 6 h of a transfusion in the absence of cardiac failure or intravascular volume overload. The primary differential diagnosis is transfusion-associated circulatory overload and differentiation can be difficult. Treatment is supportive with oxygen and mechanical ventilation. Diuresis is not indicated and the role of steroids is unproven. Patients typically recover within a few days. All types of blood products have been associated with TRALI, however, the plasma-rich components, such as fresh frozen plasma and apheresis platelets, have been most frequently implicated. The pathogenesis of TRALI is not completely understood. Leukocyte antibodies in donor plasma have been implicated in most cases with antibodies directed at human leukocyte antigen (HLA) class I, HLA class II or neutrophil-specific antigens, particularly HNA-3a. Activation of pulmonary endothelium is important in the development of TRALI and may account for most cases being observed in surgical or intensive care unit patients. Transfused leukoagglutinating antibodies bind to recipients' neutrophils localized to pulmonary endothelium resulting in activation and release of oxidases and other damaging biologic response modifiers that cause capillary leak. In a minority of TRALI cases, no antibodies are identified and it is postulated that neutrophil priming factors in the transfused component can mediate TRALI in a patient with pulmonary endothelial activation, the so called "two hit" mechanism. Recognition of the role of anti-leukocyte antibodies has led to new strategies to reduce the risk of TRALI. Female blood donors with a previous pregnancy frequently have HLA antibodies with an overall prevalence of 24% and increasing prevalence related to the number of previous pregnancies. Since HLA antibodies have been implicated in TRALI, blood centers have adopted policies to produce plasma components primarily from male donors. Strategies to reduce the risk from apheresis platelets are problematic and are likely to involve testing female apheresis platelet donors for HLA antibodies. Much more research is needed to understand the blood component and patient risk factors for TRALI so that novel strategies for treatment and additional measures to reduce the risk of TRALI can be developed.

Screening of multiparous women to avoid transfusion-related acute lung injury: a single centre experience

The aim of this study was to investigate which approach for serological testing of multiparous donors might be feasible and effective to reduce the risk of transfusion-related acute lung injury (TRALI). TRALI is a serious adverse event of blood transfusion. Antibodies to granulocytes and human leucocyte antigens (HLAs) are frequently detected in sera of implicated donors. These donors are often multiparous women. A general deferral of female plasma or screening strategies for leucocyte antibodies has been proposed to increase blood safety. A prospective study was initiated in 2003. Until 2006, serum samples from all female donors reporting three or more pregnancies (n = 229) were screened for the presence of antibodies against granulocytes and HLAs by immunofluorescence and agglutination tests as well as by a commercial HLA enzyme immunoassay. In total, 40% of all multiparous women were reactive in one of the assays. Twenty-nine percent of the reactive sera contained antibodies to granulocytes but not to HLAs. During the observation period, three TRALI reactions occurred in our hospital, two of which would have been prevented if the screening program had been extended to all previously pregnant donors. We conclude from these data that, not unexpectedly, the number of previous pregnancies is not a reliable indicator for the likelihood of inducing TRALI. More importantly, screening strategies for antibodies that might induce TRALI should probably not be reduced to HLA antibody screening. This finding awaits further research.

The effect of storage on the accumulation of oxidative biomarkers in donated packed red blood cells

BACKGROUND

Transfusion-related acute lung injury (TRALI) is a life-threatening condition characterized by oxidative stress. Longer storage times of packed red blood cells (PRBC) and other blood products have been implicated with an increased risk in developing TRALI in transfused patients.

METHODS

A total of 10 units of blood containing PRBC stored in citrate-phosphate-dextrose buffer at 4 degrees C were included in the study. At Bonfils Blood Center (Denver, CO), samples were collected on storage day 1 and day 42. Samples were immediately centrifuged, and the supernatants were collected and stored at -80 degrees C until further analysis. Oxidation-reduction potential and protein oxidation were measured in both the day 1 and day 42 samples.

RESULTS

Oxidation-reduction potential significantly increased (p < 0.05) in the day 42 sample (98.1 mV +/- 21.9 SD) versus the day 1 sample (62.6 mV +/- 21.5 SD). The oxidation of human serum albumin increased by 63.6% during the storage time. Other serum proteins such as apolipoprotein A1 and transthyretin demonstrated similar increases in oxidation. Also, proteins with a cleaved C-terminal amino acid were observed indicating the presence of carboxypeptidase activity, a marker of inflammation.

CONCLUSIONS

The presence of an oxidative environment in transfused PRBC increases with storage time. This could partially explain the increased risk of developing TRALI related to the transfusion of older blood products.

Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention

As the risks of allogeneic blood transfusion (ABT)-transmitted viruses were reduced to exceedingly low levels in the US, transfusion-related acute lung injury (TRALI), hemolytic transfusion reactions (HTRs), and transfusion-associated sepsis (TAS) emerged as the leading causes of ABT-related deaths. Since 2004, preventive measures for TRALI and TAS have been implemented, but their implementation remains incomplete. Infectious causes of ABT-related deaths currently account for less than 15% of all transfusion-related mortality, but the possibility remains that a new transfusion-transmitted agent causing a fatal infectious disease may emerge in the future. Aside from these established complications of ABT, randomized controlled trials comparing recipients of non-white blood cell (WBC)-reduced versus WBC-reduced blood components in cardiac surgery have documented increased mortality in association with the use of non-WBC-reduced ABT. ABT-related mortality can thus be further reduced by universally applying the policies of avoiding prospective donors alloimmunized to WBC antigens from donating plasma products, adopting strategies to prevent HTRs, WBC-reducing components transfused to patients undergoing cardiac surgery, reducing exposure to allogeneic donors through conservative transfusion guidelines and avoidance of product pooling, and implementing pathogen-reduction technologies to address the residual risk of TAS as well as the potential risk of the next transfusion-transmitted agent to emerge in the foreseeable future.

Transfusion-related acute lung injury: a rare and life-threatening complication of a common procedure

Transfusion-related acute lung injury (TRALI) has emerged as one of the leading causes of transfusion-related morbidity and mortality and is undoubtedly under diagnosed. It is a serious pulmonary syndrome that can lead to death if not recognised and treated promptly. The diagnosis of TRALI is based primarily upon clinical signs and symptoms and is, in part, a diagnosis of exclusion.

Risks and predictors of blood transfusion in pediatric patients undergoing open heart operations

BACKGROUND

Blood transfusion in adults is associated with increased mortality and morbidity after cardiac operations. The aim of this study was to identify the main predictors of blood transfusion and explore the relationship between blood transfusion and adverse outcomes in a pediatric population.

METHODS

We retrospectively analyzed a prospectively collected database (January 2002 to December 2003) of 657 consecutive pediatric patients undergoing open heart procedures in a tertiary pediatric cardiac center. Risk models were calculated for each blood product and for the total amount of blood transfused during the operation and in the first 24 hours. Postoperative adverse events were investigated after propensity score adjustment.

RESULTS

During the postoperative period, 30 patients (4.6%) died, 80 (12.2%) sustained nonvascular pulmonary complications, and 113 (17.2%) had infection. The risk model for the total amount of blood transfusion included weight, preoperative creatinine clearance, preoperative mechanical ventilation, duration of operation and cross-clamp, surgeon, delayed chest closure, inotropic dose, and nitric oxide administration. Univariate analyses demonstrated significant associations between blood transfusion and occurrence of every complication except of neurologic events. After adjustment for propensity score and disease severity, the total amount of blood transfusion was independently associated with an increased risk for infections (odds ratio, 1.01; 95% confidence interval, 1.002 to 1.02; p = 0.01). Transfusion of platelets was associated with lower incidence of nonvascular pulmonary complications (odds ratio, 0.89; 95% confidence interval, 0.79 to 0.99; p = 0.049).

CONCLUSIONS

The amount of blood transfusion is independently associated with infections but not with mortality.

Plasma from stored packed red blood cells and MHC class I antibodies causes acute lung injury in a 2-event in vivo rat model

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion death. We hypothesize that TRALI requires 2 events: (1) the clinical condition of the patient and (2) the infusion of antibodies against MHC class I antigens or the plasma from stored blood. A 2-event rat model was developed with saline (NS) or endotoxin (LPS) as the first event and the infusion of plasma from packed red blood cells (PRBCs) or antibodies (OX18 and OX27) against MHC class I antigens as the second event. ALI was determined by Evans blue dye leak from the plasma to the bronchoalveolar lavage fluid (BALF), protein and CINC-1 concentrations in the BALF, and the lung histology. NS-treated rats did not evidence ALI with any second events, and LPS did not cause ALI. LPS-treated animals demonstrated ALI in response to plasma from stored PRBCs, both prestorage leukoreduced and unmodified, and to OX18 and OX27, all in a concentration-dependent fashion. ALI was neutrophil (PMN) dependent, and OX18/OX27 localized to the PMN surface in vivo and primed the oxidase of rat PMNs. We conclude that TRALI is the result of 2 events with the second events consisting of the plasma from stored blood and antibodies that prime PMNs.

Shock settico

Lo shock settico corrisponde all’associazione di un’infezione e di un’insufficienza emodinamica, eventualmente associata ad altri deficit viscerali. Le definizioni assimilano spesso lo shock settico alla sepsi grave, la cui insufficienza emodinamica è considerata reversibile. I fondamenti del trattamento si basano su misure che si devono applicare in tempi brevi: il trattamento specifico, che corrisponde alla lotta contro l’agente infettivo, e il trattamento sintomatico, in particolare mediante il ripristino di un’emodinamica efficace. L’aumento del numero delle infezioni gravi e degli shock settici nei paesi industrializzati è stato all’origine di sforzi considerevoli allo scopo di migliorarne la gestione. In particolare, il frutto delle riflessioni congiunte di diverse società scientifiche è stato formalizzato in raccomandazioni, riassunte in procedure. In effetti, la strategia che mira a un miglioramento delle pratiche sembra ridurre la mortalità legata alle infezioni. Alcuni ostacoli compromettono tuttavia il loro uso, dal riconoscimento del problema all’organizzazione delle cure.

Transfusion-related acute lung injury (TRALI) induced by donor-derived anti-HLA antibodies in aplastic anemia: possible priming effect of granulocyte-colony stimulating factor (G-CSF) on the recipient neutrophils

Transfusion-related acute lung injury (TRALI) is currently the leading cause of transfusion-related death. A 67-year-old man with severe aplastic anemia developed TRALI, consisting of acute respiratory insufficiency with severe hypoxia and diffuse pulmonary infiltration 2 hours after the transfusion of platelet concentrates. Although he required intensive respiratory support, he promptly recovered within 4 days. The presence of anti-HLA antibody (anti-HLA B52) in the donated blood product was demonstrated, and a lymphocytotoxicity test disclosed antibody-mediated cytotoxicity against the patient's cells. Furthermore, administration of granulocyte-colony stimulating factor was suggested to predispose the patient to TRALI by priming the neutrophils.

Fatal transfusion related acute lung injury following coronary artery by-pass surgery: a case report

Background

Transfusion related acute lung injury (TRALI) is a potentially fatal Acute Lung Injury following transfusion of blood components. Hypotheses implicate donor-derived anti-human leukocyte antigen or granulocyte antibodies reacting with recipients' leukocytes, releasing inflammatory mediators. Lack of agreement on underlying cellular and molecular mechanisms renders improving transfusion safety difficult and expensive.

Case Presentation

Literature search has not revealed any case of TRALI from Pakistan. We report the case of fatal TRALI in a 68 year old male who received blood products after coronary artery by-pass surgery.

Conclusion

This article aims to create awareness about this complication and suggests that post transfusion cardiopulmonary instability should alert to the possibility of TRALI.

Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma:packed red blood cells the answer?

BACKGROUND

Recent military experience suggests that immediate 1:1 fresh frozen plasma (FFP); red blood cells (RBC) for casualties requiring >10 units packed red blood cells (RBC) per 24 hours reduces mortality, but no clinical trials exist to address this issue. Consequently, we reviewed our massive transfusion practices during a 5-year period to test the hypothesis that 1:1 FFP:RBC within the first 6 hours reduces life threatening coagulopathy.

METHODS

We queried our level I trauma center's prospective registry from 2001 to 2006 for patients undergoing massive transfusion. Logistic regression was used to evaluate the independent effect of FFP:RBC in 133 patients who received >10 units RBC in 6 hours on (1) Coagulopathy (international normalized ratio [INR] >1.5 at 6 hours), controlling for our previously described risk factors predictive of coagulopathy, as well as RBC, FFP, and platelet administration (2) Death (controlling for all variables plus age, crystalloids per 24 hours, INR >1.5 at 6 hours).

RESULTS

Overall mortality was 56%; 50% died from acute blood loss in the operating room. Over 80% of the RBC transfusions were completed in the first 6 hours: (Median RBC: 18 units) Median FFP:RBC survivors, 1:2, nonsurvivors: 1:4. (p < 0.001) INR >1.5 at 6 hours occurred in 30 (23%); 81% died. Regarding mortality, logistic regression showed significant variables (p < 0.05) included: RBC per 6 hours (OR = 1.248, 95%CI: 1.957-53.255), INR at 6 hours >1.5 (OR = 10.208, 95% CI: 1.957-53.255), ED temperature <34 degrees C (OR = 15.491, 95% CI 1.376-174.396), and age >55 years (OR = 40.531, CI 5.315-309.077). The adjusted OR for FFP:RBC ratio including the quadratic term was found to follow a U-shaped association (quadratic term estimate 0.6737 +/- 0.0345, p = 0.0189).

CONCLUSION

Although our data suggest that 1:1 FFP:RBC reduced coagulopathy, this did not translate into a survival benefit. Our findings indicate that the relationship between coagulopathy and mortality is more complex, and further clinical investigation is necessary before recommending routine 1:1 in the exsanguinating trauma patient.

Endothelial pathomechanisms in acute lung injury

Acute lung injury (ALI) and its most severe extreme the acute respiratory distress syndrome (ARDS) refer to increased-permeability pulmonary edema caused by a variety of pulmonary or systemic insults. ALI and in particular ARDS, are usually accompanied by refractory hypoxemia and the need for mechanical ventilation. In most cases, an exaggerated inflammatory and pro-thrombotic reaction to an initial stimulus, such as systemic infection, elicits disruption of the alveolo-capillary membrane and vascular fluid leak. The pulmonary endothelium is a major metabolic organ promoting adequate pulmonary and systemic vascular homeostasis, and a main target of circulating cells and humoral mediators under injury; pulmonary endothelium is therefore critically involved in the pathogenesis of ALI. In this review we will discuss mechanisms of pulmonary endothelial dysfunction and edema generation in the lung with special emphasis on the interplay between the endothelium, the immune and hemostatic systems, and highlight how these principles apply in the context of defined disorders and specific insults implicated in ALI pathogenesis.

Endothelial permeability is increased by the supernatant of peripheral blood mononuclear cells stimulated with HLA Class II antibody

BACKGROUND

The generation of inflammatory mediators from monocytes activated by HLA Class II antibodies is thought to play important roles in the etiology of nonhemolytic transfusion reactions. Increased permeability of endothelial cells contributes to the pathogenesis of rash, urticaria, angioedema, and pulmonary edema, which are symptoms of transfusion reactions.

STUDY DESIGN AND METHODS

We investigated whether inflammatory mediators released from monocytes upon stimulation by HLA Class II antibodies could increase endothelial permeability. Human endothelial cell monolayers were incubated with cell-free supernatants of peripheral blood mononuclear cells (PBMNCs) stimulated with HLA Class II antibody-containing plasma (anti-HLA-DR plasma), which has been implicated in severe nonhemolytic transfusion reactions. The permeability of endothelial cells to dextran was measured.

RESULTS

The supernatants of PBMNCs stimulated with the anti-HLA-DR plasma in corresponding antigen-antibody combinations were able to increase endothelial permeability. At least 3 hours of exposure of PBMNCs to anti-HLA-DR plasma was required to produce a supernatant that could induce a significant increase in permeability. Simultaneous addition of tumor necrosis factor alpha (TNF-alpha) and interleukin 1 beta (IL-1 beta) neutralizing antibodies to the activated PBMNC supernatant significantly reduced the increase in permeability. Treatment of the endothelial cells with an inhibitor of nuclear factor kappaB (NF-kappaB), but not inhibitors of apoptosis, significantly prevented the increase in permeability.

CONCLUSION

Both TNF-alpha and IL-1 beta, generated from PBMNCs by anti-HLA-DR plasma in a corresponding antigen-antibody-dependent manner, led to an increase in endothelial permeability. The activation of monocytes by the HLA-DR antibodies and the resultant inflammatory mediators could contribute to the pathogenesis of rash, urticaria, angioedema, and pulmonary edema after transfusion.

Effects of leukoreduced blood on acute lung injury after trauma: a randomized controlled trial

OBJECTIVE

The requirement for a blood transfusion after trauma is associated with an increased risk of acute lung injury. Residual leukocytes contaminating red cells are potential mediators of this syndrome. The goal of this trial was to test our hypothesis that prestorage leukoreduction of blood would reduce rates of posttraumatic lung injury.

DESIGN

Double blind, randomized, controlled clinical trial.

SETTING

University-affiliated level I trauma center in King County, Seattle, WA.

PATIENTS

Two hundred sixty-eight injured patients requiring red blood cell transfusion within 24 hrs of injury.

INTERVENTIONS

Prestorage leukoreduced vs. standard allogeneic blood transfusions.

MEASUREMENTS AND MAIN RESULTS

We compared the incidence of acute lung injury and acute respiratory distress syndrome at early (< or = 72 hrs) and late (> 72 hrs) time points after injury. In a subset, we compared plasma levels of surfactant protein-D and von Willebrand factor antigen between intervention arms. Rates of acute lung injury (relative risk [RR] 1.06, 95% confidence interval [CI] .69-1.640) and acute respiratory distress syndrome (RR .96, 95% CI 0.48-1.91) were not statistically different between intervention arms early after injury. Similarly, no statistically significant effect of leukoreduced transfusion on rates of acute lung injury (RR .88, 95% CI .54-1.44) or acute respiratory distress syndrome (RR .95, 95% CI .58-1.57) was observed to occur late after injury. There was no significant difference in the number of ventilator-free days or in other ventilator parameters between intervention arms. No statistically significant effect of leukoreduced blood on plasma levels of surfactant protein-D or von Willebrand factor antigen was identified.

CONCLUSIONS

Prestorage leukoreduction had no effect on the incidence or timing of lung injury or on plasma measures of systemic alveolar and endothelial inflammation in a population of trauma patients requiring transfusion. The relationship between transfusion and lung injury is not obviously explained by mechanistic pathways involving the presence of transfused leukocytes.

Transfusion-related acute lung injury (TRALI): a report of two pediatric cases

Transfusion-related acute lung injury (TRALI) is a life-threatening adverse effect of transfusion that should be considered in the differential diagnosis of all patients who develop respiratory distress during or within 6 h of transfusion. Two children with TRALI are presented and the diagnosis, pathophysiology, treatment, and need for understanding and recognition to reduce morbidity and mortality are discussed.

Red blood cell transfusions and the risk of acute respiratory distress syndrome among the critically ill: a cohort study

INTRODUCTION

Recent data indicate that transfusion of packed red blood cells (pRBCs) may increase the risk for the development of acute respiratory distress syndrome (ARDS) in critically ill patients. Uncertainty remains regarding the strength of this relationship.

METHODS

To quantify the association between transfusions and intensive care unit (ICU)-onset ARDS, we performed a cohort study within Crit, a multicenter, prospective, observational study of transfusion practice in the ICU which enrolled 4,892 critically ill patients in 284 ICUs in the United States. Diagnostic criteria for ARDS were prospectively defined, and we focused on subjects without ARDS at admission. The development of ARDS in the ICU served as the primary endpoint.

RESULTS

Among the 4,730 patients without ARDS at admission, 246 (5.2%) developed ARDS in the ICU. At baseline, ARDS cases were younger, more likely to be in a surgical ICU, and more likely to be admitted with pneumonia or sepsis than controls without ARDS. Cases also were more likely to have a serum creatinine of greater than 2.0 mg/dl (23% versus 18%) and a serum albumin of less than or equal to 2.3 g/dl (54% versus 30%) and were more severely ill upon ICU admission as measured by either the APACHE II (Acute Physiology and Chronic Health Evaluation II) or SOFA (Sequential Organ Failure Assessment) score (p < 0.05 for all). Sixty-seven percent and 42% of cases and controls, respectively, had exposure to pRBC transfusions (p < 0.05), and the unadjusted odds ratio (OR) of developing ARDS in transfused patients was 2.74 (95% confidence interval [CI], 2.09 to 3.59; p < 0.0001) compared to those never transfused. After age, baseline severity of illness, admitting diagnosis, and process-of-care factors were adjusted for, the independent relationship between pRBC transfusions and ICU-onset ARDS remained significant (adjusted OR, 2.80; 95% CI, 1.90 to 4.12; p < 0.0001).

CONCLUSION

Development of ARDS after ICU admission is common, occurring in approximately 5% of critically ill patients. Transfusion of pRBCs is independently associated with the development of ARDS in the ICU.

Diagnosis and treatment of severe sepsis

The burden of infection in industrialized countries has prompted considerable effort to improve the outcomes of patients with sepsis. This has been formalized through the Surviving Sepsis Campaign 'bundles', derived from the recommendations of 11 professional societies, which have promoted global improvement in those practices whose primary goal it is to reduce sepsis-related death. However, difficulties remain in implementing all of the procedures recommended by the experts, despite the apparent pragmatism of those procedures. We summarize the main proposals made by the Surviving Sepsis Campaign and focus on the difficulties associated with making a proper diagnosis and supplying adequate treatment promptly to septic patients.

Transfusion-Related Acute Lung Injury: Incidence, Pathogenesis and the Role of Multicomponent Apheresis in Its Prevention

SUMMARY: Although transfusion-related acute lung injury (TRALI) is now appreciated as the most common cause of death from transfusion, its incidence remains unknown. The most frequently cited figure is 1:5,000 plasma-containing components. Certain patient groups may be at significantly higher risk. TRALI is both underdiagnosed and un-derreported. It is misdiagnosed as transfusion-associated circulatory overload. Several mechanisms have been proposed for its pathogenesis-leukocyte antibodies and the 2-hit model. These may overlap, and both involve transfusion of leukocyte antibodies. Passive transfusion of leukocyte antibodies is strongly associated with TRALI; these are identified in 60-85% of cases. Multiparous blood donors are the most frequent source of these antibody-containing components. The antibodies are HLA class I and II and/or granulocyte-specific. In 50% of cases the antibody corresponds to an epitope in the patient. HLA class I antibodies have been shown to prime and activate neutrophils. Clinical reports and animal models link HNA-3a antibodies with severe lung injury. A number of TRALI prevention and risk mitigation strategies have been proposed. In the UK and the USA, these strategies have centered upon excluding 'high risk' (HLA/HNA antibody containing) plasma from fresh frozen plasma and platelet products. Multicomponent apheresis collection of platelets, plasma and red blood cells is a means of accomplishing this objective.

Transfusion-Related Acute Lung Injury

Transfusion-related acute lung injury (TRALI) refers to a clinical syndrome of acute lung injury that occurs in a temporal relationship with the transfusion of blood products. Because of the difficulty in making its diagnosis, TRALI is often underreported. Three not necessarily mutually exclusive hypotheses have been described to explain its etiogenesis: antibody mediated, non-antibody mediated, and two hit mechanisms. Treatment is primarily supportive and includes supplemental oxygen. Diuretics are generally not indicated, as hypovolemia should be avoided. Compared with many other forms of acute lung injury, including the acute respiratory distress syndrome, TRALI is generally transient, reverses spontaneously, and carries a better prognosis. A variety of prevention strategies have been proposed, ranging from restrictive transfusion strategies to using plasma derived only from males.

Comparison of acute non-haemolytic transfusion reactions in female and male patients receiving female or male blood components

To study the relationship between antibodies detected in patients’ and/or donors’ sera and the clinical features of acute non-haemolytic transfusion reactions (ANHTRs), and to determine any gender-related difference. ANHTRs range from urticaria to transfusion-related acute lung injury (TRALI). Antibodies to human leukocyte antigen (HLA), granulocytes, platelets, and/or plasma proteins are implicated in some of the ANHTRs. A higher antibody positivity is expected for females than for males. A comparative study of ANHTRs for antibody positivity and their clinical features between females and males for both patients and donors is helpful for characterizing ANHTRs including TRALI more clearly, but such studies are few and outdated. Two hundred and twenty-three ANHTR cases reported by 45 hospitals between October 2000 and July 2005 were analysed. The patients and 196 donors of suspect blood products were screened for antibodies to HLA Class I, HLA Class II, granulocytes, and platelets. The patients were also screened for anti-plasma protein antibodies. The types and severity of ANHTR did not differ significantly between female and male patients. The frequency of the anti-HLA antibodies, but not that of the non-HLA antibodies, was significantly higher in females. Non-HLA antibodies were significantly associated with severe reactions in females. All the TRALI cases had predisposing risk factors for acute lung injury, and 60% of the cases showed anti-leucocyte antibodies. Although the anti-HLA antibodies were detected more frequently in females than males, no significant association of ANHTRs including TRALI with gender, not only for patients, but also for donors, could be shown in this study.