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Gottschall J, Triulzi D, Kakaiya R, Carrick D, Roback JD, Carey P, Kleinman S. Human neutrophil antibodies in a blood donor population: a lookback study. Vox Sang 2013; 104:166-70. [PMID: 22998453 PMCID: PMC4133116 DOI: 10.1111/j.1423-0410.2012.01651.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Human neutrophil antibodies (HNA) have been associated with severe transfusion-related acute lung injury (TRALI). We identified HNA antibodies in a blood donor population and performed an observational lookback on patients who received products from these donors to determine whether TRALI was associated with these transfusions. MATERIALS AND METHODS Human neutrophil antibodies were determined in 1171 blood donors (388 non-transfused males, 390 human leucocyte antigen (HLA) antibody-negative females and 393 HLA antibody-positive females) for IgG and IgM antibodies using a flow cytometric assay. Selected positive samples had a monoclonal antibody immobilization of granulocyte antigen (MAIGA) and neutrophil genotyping performed to confirm specificity. Lookback was performed on patients receiving blood from donors with positive samples by extracting recipient data from hospital medical records. An expert panel of three pulmonary critical care physicians reviewed the summarized data and assigned a diagnosis of TRALI, possible TRALI, cannot distinguish between TRALI and TACO, TACO and other. RESULTS Eight donors had HNA antibodies of which five contributed to this lookback (3-HNA-specific antibodies, 2-HNA non-specific antibodies). Seventy-six blood products were transfused from these donors into individual patients. One patient developed TRALI that was associated with a donor with a non-specific HNA antibody as well as class-I and class-II HLA antibodies. CONCLUSION The incidence of TRALI in this lookback was low and combined with low frequency of HNA antibodies in the donor population suggests not screening donors for HNA antibodies at this time is acceptable.
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Affiliation(s)
- J Gottschall
- BloodCenter of Wisconsin, Medical College of Wisconsin, Milwaukee, WI 53233, USA.
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2
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Abstract
Plasma utilization has increased over the past two decades, and there is a growing concern that many plasma transfusions are inappropriate. Plasma transfusion is not without risk, and certain complications are more likely with plasma than other blood components. Clinical and laboratory investigations of the patients suffering reactions after infusion of fresh-frozen plasma (FFP) define the etiology and pathogenesis of the panoply of adverse effects. We review here the pathogenesis, diagnosis, and management of the risks associated with plasma transfusion. Risks commonly associated with FFP include: 1) transfusion-related acute lung injury, 2) transfusion-associated circulatory overload, and 3) allergic and/or anaphylactic reactions. Other less common risks include 1) transmission of infections, 2) febrile nonhemolytic transfusion reactions, 3) red blood cell alloimmunization, and 4) hemolytic transfusion reactions. The effects of pathogen inactivation or reduction methods on these risks are also discussed. Fortunately, a majority of the adverse effects are not lethal and are adequately treated in clinical practice.
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Affiliation(s)
- Suchitra Pandey
- Department of Laboratory Medicine, University of California, San Francisco, California 94143, USA
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3
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Lucas G, Win N, Calvert A, Green A, Griffin E, Bendukidze N, Hopkins M, Browne T, Poles A, Chapman C, Massey E. Reducing the incidence of TRALI in the UK: the results of screening for donor leucocyte antibodies and the development of national guidelines. Vox Sang 2011; 103:10-7. [DOI: 10.1111/j.1423-0410.2011.01570.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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4
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Kleinman SH, Triulzi DJ, Murphy EL, Carey PM, Gottschall JL, Roback JD, Carrick D, Mathew S, Wright DJ, Cable R, Ness P, Gajic O, Hubmayr RD, Looney MR, Kakaiya RM. The Leukocyte Antibody Prevalence Study-II (LAPS-II): a retrospective cohort study of transfusion-related acute lung injury in recipients of high-plasma-volume human leukocyte antigen antibody-positive or -negative components. Transfusion 2011; 51:2078-91. [PMID: 21446938 PMCID: PMC3606005 DOI: 10.1111/j.1537-2995.2011.03120.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND We used a multicenter retrospective cohort study design to evaluate whether human leukocyte antigen (HLA) antibody donor screening would reduce the risk of transfusion-related acute lung injury (TRALI) or possible TRALI. STUDY DESIGN AND METHODS In the Leukocyte Antibody Prevalence Study-II (LAPS-II), we evaluated pulmonary outcomes in recipients of 2596 plasma-rich blood components (transfusable plasma and plateletpheresis) sent to participating hospitals; half of the components were collected from anti-HLA-positive donors (study arm) and half from anti-HLA-negative donors (control arm) matched by sex, parity, and blood center. A staged medical record review process was used. Final recipient diagnosis was based on case review by a blinded expert panel of pulmonary or critical care physicians. RESULTS TRALI incidence was 0.59% (seven cases) in study arm recipients versus 0.16% (two cases) in control arm recipients for an odds ratio (OR) of 3.6 (95% confidence interval [CI], 0.7-17.4; p = 0.10). For possible TRALI cases (nine study arm, eight control arm), the OR was 1.2 (95% CI, 0.4-3.0; p = 0.81), and for TRALI and possible TRALI aggregated together, it was 1.7 (95% CI, 0.7-3.7; p = 0.24). Transfusion-associated circulatory overload incidence was identical in the two arms (1.17 and 1.22%, respectively; OR, 1.0; p = 1.0). CONCLUSIONS TRALI incidence in recipients of anti-HLA-positive components was relatively low for a lookback study (1 in 170) and was higher than in the control arm, but did not reach significance. Based on this trend, the data are consistent with the likelihood that TRALI risk is decreased by selecting high-volume plasma components for transfusion from donors at low risk of having HLA antibodies.
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5
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Abstract
Transfusion-related acute lung injury (TRALI) is defined clinically as acute lung injury occurring within six hours of the transfusion of any blood product. It is the leading cause of transfusion-related death in the United States, but under-recognition and diagnostic uncertainty have limited clinical research to smaller case control studies. In this review we discuss the contribution of experimental models to the understanding of TRALI pathophysiology and potential therapeutic approaches. Experimental models suggest that TRALI occurs when a host, with a primed immune system, is exposed to an activating agent such as anti-leukocyte antibody or a biologic response modifier such as lysophosphatidylcholines. Recent work has suggested a critical role for platelets in antibody-based experimental models and identified potential therapeutic strategies for TRALI.
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Affiliation(s)
- Brian M Gilliss
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA
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6
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Hashimoto S, Nakajima F, Kamada H, Kawamura K, Satake M, Tadokoro K, Okazaki H. Relationship of donor HLA antibody strength to the development of transfusion-related acute lung injury. Transfusion 2010; 50:2582-91. [DOI: 10.1111/j.1537-2995.2010.02779.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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7
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Chapman CE, Stainsby D, Jones H, Love E, Massey E, Win N, Navarrete C, Lucas G, Soni N, Morgan C, Choo L, Cohen H, Williamson LM. Ten years of hemovigilance reports of transfusion-related acute lung injury in the United Kingdom and the impact of preferential use of male donor plasma. Transfusion 2009; 49:440-52. [DOI: 10.1111/j.1537-2995.2008.01948.x] [Citation(s) in RCA: 232] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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8
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Norris PJ, Lee JH, Carrick DM, Gottschall JL, Lebedeva M, de Castro BR, Kleinman SH, Busch MP. Long-term in vitro reactivity for human leukocyte antigen antibodies and comparison of detection using serum versus plasma. Transfusion 2009; 49:243-51. [PMID: 18980615 PMCID: PMC3058293 DOI: 10.1111/j.1537-2995.2008.01955.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Human leukocyte antigen (HLA) antibodies are a possible cause of transfusion-related acute lung injury (TRALI), and fluorescent bead assays are often used for antibody detection. Serum is the manufacturer's recommended sample, but plasma may be easier to obtain for studies of HLA antibody prevalence and TRALI case investigations. STUDY DESIGN AND METHODS Specimens were obtained from 44 multiparous females positive for the presence of HLA antibodies by lymphocytotoxicity testing at least 13 years prior and from 1000 contemporary blood donors. Screening tests were performed using a multiplex bead-based assay. In addition to comparing results obtained with paired plasma and serum samples, the effects of storage at 4 degrees C for 1 week and of multiple freeze-thaw cycles were evaluated. RESULTS Of 42 evaluable subjects with HLA antibodies documented more than 13 years earlier, only 1 showed loss of detectable antibodies, with 39 (93%) positive in the screening assay for HLA Class I and 24 (57%) positive in the screening assay for HLA Class II antibodies. In 968 evaluable contemporary donors, 291 screened positive for the presence of HLA Class I and 206 for HLA Class II antibodies using a low assay cutoff. Screening test concordance using paired plasma and serum samples was high, particularly for subjects with higher-level antibodies. Refrigeration of samples for 1 week did not significantly affect assay results, while repeated freeze-thaw cycles caused a decrement in signal level. CONCLUSION Serum and plasma samples gave concordant results in the majority of cases, particularly for specimens with higher-level antibodies. High-level HLA antibodies were present in most individuals for more than 13 years.
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Affiliation(s)
- Philip J Norris
- Blood Systems Research Institute, University of California, San Francisco, USA.
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9
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Eder AF, Benjamin RJ. TRALI risk reduction: Donor and component management strategies. J Clin Apher 2009; 24:122-9. [DOI: 10.1002/jca.20198] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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10
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Heuft HG, Hitzler W. The Pathogenetic Background of Transfusion-Associated Acute Lung Injury Cannot Be Confined to the Passive Transfer of Donor Leucocyte Antibodies to Transfusion Recipients. Transfus Med Hemother 2008; 35:70-72. [PMID: 21512629 PMCID: PMC3076336 DOI: 10.1159/000121376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Hans-Gert Heuft
- Institute for Transfusion Medicine, Hanover Medical School, Germany
| | - Walter Hitzler
- Transfusion Centre, Clinics of Johnannes Gutenberg University Mainz, Germany
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11
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12
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Kleinman S, Gajic O, Nunes E. Promoting Recognition and Prevention of Transfusion-Related Acute Lung Injury. Crit Care Nurse 2007. [DOI: 10.4037/ccn2007.27.4.49] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Steven Kleinman
- Steven Kleinman is senior medical advisor to AABB (formerly the American Association of Blood Banks) and serves as chair of the AABB TRALI Task Force
| | - Ognjen Gajic
- Ognjen Gajic is an assistant professor of medicine and the director of the Mayo Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic College of Medicine in Rochester, Minnesota
| | - Eduardo Nunes
- Eduardo Nunes is director of standards and international affairs at the AABB in Bethesda, Maryland
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13
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Sheppard CA, Lögdberg LE, Zimring JC, Hillyer CD. Transfusion-related Acute Lung Injury. Hematol Oncol Clin North Am 2007; 21:163-76. [PMID: 17258125 DOI: 10.1016/j.hoc.2006.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
With the success of reducing the risk of transfusion-transmitted infectious diseases, noninfectious serious hazards of transfusion have come to the forefront with respect to transfusion safety. Transfusion-related acute lung injury has emerged as a dominant noninfectious serious hazard of transfusion. Improved understanding of its pathophysiology is needed to improve clinical strategies to deal with the risk. Such understanding, in turn, will depend on the continued progress in development of good model systems, in vitro and in vivo, for experimental studies. As the pathologic mechanisms are elucidated, a universal definition and strategies for the prevention and/or mitigation may become more tangible. This article reviews the clinical manifestations, evolving definition, incidence, pathophysiology, animal modeling, and donor screening and deferral algorithms as they relate to transfusion-related acute lung injury.
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Affiliation(s)
- Chelsea A Sheppard
- Department of Pathology and Laboratory Medicine, Room D-655, Emory University School of Medicine, 1364 Clifton Road N.E., Atlanta, GA 30322, USA
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14
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Abstract
Transfusion-related acute lung injury (TRALI) is a serious and potentially fatal complication of transfusion of blood and blood components. TRALI is under-diagnosed and under-reported because of a lack of awareness. A number of models have been proposed to explain the pathogenesis of TRALI: an antibody mediated model; a two-event biologically active mediator model; and a combined model. TRALI can occur with any type of blood product and can occur with as little as one unit. Its presentation is similar to other forms of acute lung injury and management is predominantly supportive. The main strategy in combating TRALI is prevention both through manipulation of the donor pool and through clinical strategies directed at reducing transfusion of blood products including, but not limited to, evidence-based lower transfusion thresholds. This article presents a review of TRALI and addresses the definition, pathology, pathogenesis, clinical manifestations, treatment and prevention of the syndrome.
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Affiliation(s)
- N A Barrett
- Intensive Therapy Unit, University of Sydney at The Royal North Shore Hospital, St Leonards, NSW 2065, Australia
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15
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Swanson K, Dwyre DM, Krochmal J, Raife TJ. Transfusion-Related Acute Lung Injury (TRALI): Current Clinical and Pathophysiologic Considerations. Lung 2006; 184:177-85. [PMID: 16902843 DOI: 10.1007/s00408-005-2578-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2006] [Indexed: 11/25/2022]
Abstract
Transfusion-related acute lung injury (TRALI) is a rare transfusion reaction presenting as respiratory distress during or after transfusion of blood products. TRALI varies in severity, and mortality is not uncommon. TRALI reactions have equal gender distributions and can occur in all age groups. All blood products, except albumin, have been implicated in TRALI reactions. TRALI presents as acute respiratory compromise occurring in temporal proximity to a transfusion of a blood product. Other causes of acute lung injury should be excluded in order to definitively diagnose TRALI. Clinically and pathologically, TRALI mimics acute respiratory distress syndrome (ARDS), with neutrophil-derived inflammatory chemokines and cytokines believed to be involved in the pathogenesis of both entities. Anti-HLA and anti-neutrophil antibodies have been implicated in some cases of TRALI. Treatment for TRALI is supportive; prevention is important. It is suspected that TRALI is both underdiagnosed and underreported. One of the difficulties in the evaluation of potential TRALI reactions is, until recently, the lack of diagnostic criteria. A group of transfusion medicine experts, the American-European Consensus Conference (AECC), recently met and developed diagnostic criteria of TRALI, as well as recommendations for management of donors to prevent future TRALI reactions. In light of the AECC consensus recommendations, we report an incident of TRALI in an oncology patient as an example of the potential severity of the lung disease and the clinical and laboratory evaluation of the patient. We also review the literature on this important complication of blood transfusion that internists may encounter.
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Affiliation(s)
- Kelly Swanson
- Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa city, IA, 52242, USA
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16
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Mair DC, Hirschler N, Eastlund T. Blood donor and component management strategies to prevent transfusion-related acute lung injury (TRALI). Crit Care Med 2006; 34:S137-43. [PMID: 16617258 DOI: 10.1097/01.ccm.0000214291.93884.bb] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Discuss the pros and cons of using donor and blood product-management strategies to prevent transfusion-related acute lung injury (TRALI). DATA SOURCE A review of the literature was performed. RESULTS Despite therapeutic advances in pulmonary and critical care medicine, TRALI is now considered to be one of the leading causes of transfusion-associated mortality, and thus determining how to prevent TRALI is extremely important. Donor and product-management strategies to prevent this life-threatening condition have been suggested, but because of gaps in our understanding of TRALI, blood-bankers do not know how beneficial these interventions will be, nor the amount of potential harm-such as decreasing the availability of blood-that could arise if they were implemented. This article discusses the advantages and disadvantages of the various preventive measures that have been described in the literature. CONCLUSIONS Preventing TRALI poses a difficult challenge for blood-banking experts, because it is unknown which measures will be effective in decreasing the incidence of TRALI and which could have significant drawbacks. Only additional research into TRALI prevention will provide the answers on how to best protect patients from this potentially fatal reaction.
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Affiliation(s)
- D C Mair
- American Red Cross-North Central Blood Services, St. Paul, MN, USA
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17
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Abstract
PURPOSE OF REVIEW Transfusion-related acute lung injury is an uncommon complication of blood transfusion typically manifested by shortness of breath, fever, and hypotension. Transfusion-related acute lung injury is an important cause of transfusion-related morbidity and mortality. RECENT FINDINGS Much about the pathogenesis, treatment, and prevention of transfusion-related acute lung injury is poorly understood or is controversial. There is increasing recognition that transfusion-related acute lung injury is an important clinical syndrome, causing most transfusion-related deaths. SUMMARY In this report, what is known about transfusion-related acute lung injury is summarized with particular emphasis on recent studies. Some of the areas in which knowledge and/or consensus are currently lacking are identified.
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Affiliation(s)
- Kathryn E Webert
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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18
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Abstract
BACKGROUND AND OBJECTIVE Transfusion of blood components can trigger immunological reactions which may result in a transfusion-related acute lung injury (TRALI). The reported incidence is low; however, there is increasing evidence that the true incidence of this complication may be much higher. One reason for underdiagnosing TRALI could be a deficiency of knowledge about this complication. Therefore, we studied the level of knowledge concerning TRALI among clinicians working on intensive care units (ICU) of an university teaching hospital. METHODS A total of 65 clinicians were asked to complete a confidential questionnaire designed to evaluate their knowledge about incidence, pathophysiology, clinical symptoms, therapy and outcome of TRALI. This questionnaire consisted of 13 questions which could be assessed by 'yes', 'no' or 'do not know'. RESULTS Only 42 +/- 18% (mean +/- SD) of all answers were correct, while 33 +/- 17% were wrong and 25 +/- 8% unanswered ('do not know'). The 95% confidence interval for the correct answers was 30.8-53.8% implying that there was no significant difference compared to the probability of arbitrary guessing (33.3%). CONCLUSIONS Our survey uncovered a marked deficit of knowledge about TRALI suggesting that the low reported incidence of this complication may be in part due to a lack of awareness for TRALI. We conclude that training programmes for clinicians should alert them to the symptoms, diagnosis and treatment options of TRALI.
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Affiliation(s)
- R Kram
- University Hospital Düsseldorf, Department of Anaesthesiology, Düsseldorf, Germany
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19
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Win N, Amess P, Needs M, Hewitt PE. Use of red cells preserved in extended storage media for exchange transfusion in anti-k haemolytic disease of the newborn. Transfus Med 2005; 15:157-60. [PMID: 15859984 DOI: 10.1111/j.0958-7578.2005.00566.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Anti-k is a Kell-related antibody. There is little correlation between the maternal antibody titre and the severity of haemolytic disease of the foetus and newborn, and anaemia is usually associated with low bilirubin levels. Severe erythroblastosis has been reported with a low titre anti-k (IAT 8-16). We report a case of severe haemolytic disease of the newborn (HDN) due to anti-k. HDN was associated with a normal bilirubin level and reticulocytopenia. The foetus was monitored by ultrasound, and delivery by elective caesarean section (CS) was planned. The mother was admitted 1 week before the expected date of delivery, and the infant was delivered by urgent CS. The infant required exchange transfusion. As suitable plasma-reduced (k antigen(-)) red cell units were not readily available, k- SAGM red cell units (preserved in extended storage media: SAGM sodium chloride, adenine, glucose and mannitol) were provided. The post-transfusion Hb remained stable, and the infant did not require further transfusion support. Our findings (reticulocytopenia and normal bilirubin levels) support the hypothesis that the pathogenesis of anaemia and haemolysis in anti-k HDN may be similar to that in anti-K (suppression of erythropoesis and immune destruction of K+ erythroid progenitor cells by macrophages in the foetal liver). The ideal product for exchange transfusion is plasma-reduced RBC, less than 5-days old. We provided a 4-day-old SAGM red cell unit for exchange transfusion in a term infant, and this was uneventful. Caution should be taken, however, and renal function and electrolyte levels should be monitored closely. More information is required regarding the safety of SAGM units for exchange transfusion.
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Affiliation(s)
- N Win
- Red Cell Immunohaematology, National Blood Service, Tooting Centre, London, UK.
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20
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Kleinman S, Caulfield T, Chan P, Davenport R, McFarland J, McPhedran S, Meade M, Morrison D, Pinsent T, Robillard P, Slinger P. Toward an understanding of transfusion-related acute lung injury: statement of a consensus panel. Transfusion 2004; 44:1774-89. [PMID: 15584994 DOI: 10.1111/j.0041-1132.2004.04347.x] [Citation(s) in RCA: 471] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Steven Kleinman
- Kleinman Biomedical Research, Victoria, British Columbia, Canada
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21
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Toy P, Hollis-Perry KM, Jun J, Nakagawa M. Recipients of blood from a donor with multiple HLA antibodies: a lookback study of transfusion-related acute lung injury. Transfusion 2004; 44:1683-8. [PMID: 15584980 DOI: 10.1111/j.0041-1132.2004.04193.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The effects of transfusion of HLA antibodies to patients with corresponding antigens are not well known. STUDY DESIGN AND METHODS Records of patients who received blood from previous donations of a donor implicated in a case of transfusion-related acute lung injury (TRALI) were examined. The donor had multiple HLA antibodies reactive with 96 percent of HLA Class I antigens and 88 percent of HLA Class II antigens. RESULTS Among 103 patients (40 with a pretransfusion white blood cell [WBC] count of >/=3.5 x 10(9)/L), 1 patient met criteria for TRALI and had clinical evidence for diffuse alveolar hemorrhage. Among the subset of 55 patients (17 with a pretransfusion WBC count of 3.5 x 10(9)/L) with known HLA types, none developed TRALI even though 54 (98%) had one to five corresponding HLA antigens. In a subgroup of patients four of 62 patients with chest radiographs, developed new or worse bilateral infiltrates with implicated but not control units (p = 0.0625). CONCLUSION Transfusion of HLA antibodies from this donor to nonneutropenic patients did not cause TRALI, but there was a trend of an association with new or worse bilateral pulmonary infiltrates. Further research is needed to determine why transfusion of HLA antibodies to recipients with corresponding antigens causes TRALI in some cases and not in others.
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Affiliation(s)
- Pearl Toy
- Blood Bank, Department of Laboratory Medicine, University of California at San Francisco, San Francisco, California 94143-0100, USA.
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22
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Abstract
Transfusion-related acute lung injury (TRALI) is an underreported complication of transfusion therapy, and it is the third most common cause of transfusion-associated death. TRALI is defined as noncardiogenic pulmonary edema temporally related to transfusion therapy. The diagnosis of TRALI relies on excluding other diagnoses such as sepsis, volume overload, and cardiogenic pulmonary edema. Supportive diagnostic evidence includes identifying neutrophil or human leukocyte antigen (HLA) antibodies in the donor or recipient plasma. All plasma-containing blood products have been implicated in TRALI, with the majority of cases linked to whole blood, packed RBCs, platelets, and fresh-frozen plasma. The pathogenesis of TRALI may be explained by a "two-hit" hypothesis, with the first "hit" being a predisposing inflammatory condition commonly present in the operating room or ICU. The second hit may involve the passive transfer of neutrophil or HLA antibodies from the donor or the transfusion of biologically active lipids from older, cellular blood products. Treatment is supportive, with a prognosis substantially better than most causes of clinical acute lung injury.
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Affiliation(s)
- Mark R Looney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, 94143-0130, USA.
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23
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Abstract
Transfusion-related acute lung injury (TRALI) is an uncommon complication of allogeneic blood transfusion manifested typically by shortness of breath, fever, and hypotension. It has been estimated to occur in 0.04% to 0.16% per patient transfused. TRALI has been identified as an important cause of transfusion-related morbidity and mortality. Despite the increasing recognition that TRALI represents an important clinical syndrome, much about the pathogenesis, treatment, and prevention of TRALI is poorly understood or is controversial. In this report, what is known about TRALI is summarized and some of the areas in which knowledge and/or consensus are currently lacking are identified.
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Affiliation(s)
- Kathryn E Webert
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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24
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Abstract
BACKGROUND TRALI is a serious adverse effect of blood transfusion. There is evidence that the condition is underrecognized and underreported. STUDY DESIGN AND METHODS This study was an observational study carried out in a single hospital. RESULTS Eleven cases of TRALI were recognized over 12 years. In 10 cases the implicated donor unit was FFP and in 1 case uncertain. All implicated donors were parous women. In 4 cases the presumed causative antibodies were to an HLA class II antigen only. Specific anti-neutrophil antibodies, possibly causative, were detected in 1 case only. Ten of the 11 cases required mechanical ventilatory support. Five persons died as a result of the TRALI. The observed incidence of TRALI caused by FFP is 1 in 7900 units transfused. CONCLUSION TRALI is the most common serious adverse effect of blood transfusion in our hospital. Antibodies to HLA class II antigens should be looked for routinely when investigating a possible case of TRALI.
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Affiliation(s)
- Jonathan P Wallis
- Department of Hematology, Freeman Hospital, and the National Blood Service, Newcastle upon Tyne, UK.
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