Possible mechanisms underlying development of transfusion-related acute lung injury: roles of anti-major histocompatibility complex class II DR antibody

Integration of multiomics analysis to reveal the major pathways of vitamin A deficiency aggravates acute respiratory distress syndrome in neonatal rats

Acute respiratory distress syndrome (ARDS) is a major disease that threatens the life and health of neonates. Vitamin A (VA) can participate in early fetal lung development and affect lung immune function. Researches revealed that the serum VA level in premature infants with ARDS was lower than that in premature infants without ARDS of the same gestational age, and premature infants with VA deficiency (VAD) were more likely to develop ARDS. Moreover, the VA levels can be used as a predictor of the development and severity of neonatal ARDS. However, the critical question here is; Does ARDS develop due to VAD in these systemic diseases? Or does ARDS develop because these diseases cause VAD? We hypothesize that VAD may aggravate neonatal ARDS by affecting immunity, metabolism, barriers and other pathways. In this article, we used multiomics analysis to find that VAD may aggravate ARDS mainly through the Fc epsilon RI signaling pathway, the HIF-1 signaling pathway, glutathione metabolism, and valine, leucine and isoleucine degradation signaling pathways, which may provide the molecular pathogenic mechanism behind the pathology of VAD-aggravated ARDS and can also provide potential molecular targets for subsequent research on ARDS.

Comparison of the effects of autologous and non-autologous blood transfusions on the advantages, disadvantages, extubation time and bleeding after coronary bypass

Purpose

Blood transfusion; is considered an organ transplant. In coronary bypass surgery, large volumes of homologous blood transfusion may be required due to excessive bleeding. The large number of use of homologous blood transfusion in open heart surgery and the awareness of its various harmful effects have prompted researchers to conduct research on the use of autologous blood. With autologous transfusion, blood diseases, incompatibility, immunosuppression and organ damage can be prevented and the patient can be extubated earlier in the postoperative period.

Methods

Between January 2020 and January 2016, a total of 176 patients, 56 in the treatment group (with autologous blood transfusion) and 120 in the control group, whose information could be reached from hospital records were investigated retrospectively.

Results

No statistical difference was found between the mean intubation SO2 and PO2 values of the groups. On the contrary, considering the mean intubation times in the intensive care unit of both groups, the patients who underwent autologous blood transfusion were extubated at a statistically significant earlier time.

Conclusion

Autologous blood transfusion is a safe method in selected patients as well. Thanks to this method, patients are protected from complications associated with homologous blood transfusion. It is believed that performing autologous blood transfusion in selected patients undergoing open-heart surgery can decrease the number of postoperative transfusions, frequency of transfusion-related complications (especially in the lungs), and mean intubation times.

Antibodies to major histocompatibility complex class II antigens directly prime neutrophils and cause acute lung injury in a two-event in vivo rat model

BACKGROUND

Transfusion-related acute lung injury (TRALI) is a significant cause of mortality, especially after transfusions containing antibodies to major histocompatibility complex (MHC) class II antigens. We hypothesize that a first event induces both 1) polymorphonuclear neutrophils (PMNs) to express MHC class II antigens, and 2) activation of the pulmonary endothelium, leading to PMN sequestration, so that the infusion of specific MHC class II antibodies to these antigens causes PMN-mediated acute lung injury (ALI).

STUDY DESIGN AND METHODS

Rats were treated with saline (NS), endotoxin (lipopolysaccharide [LPS]), or cytokines (interferon-γ [IFNγ], macrophage colony-stimulating factor [MCSF], tumor necrosis factor-α [TNFα]); the PMNs were isolated; and the surface expression of the MHC class II antigen OX6 and priming by OX6 antibodies were measured by flow cytometry or priming assays.

RESULTS

A two-event model of ALI was completed with NS, LPS, or IFNγ/MCSF/TNFα (first events) and the infusion of OX6 (second event). Compared with NS incubation, rats treated with either LPS or IFNγ/MCSF/TNFα exhibited OX6 PMN surface expression, OX6 antibodies primed the formyl-methionyl-leucyl phenylalanine (fMLF)-activated respiratory burst, and PMN sequestration was increased. OX6 antibody infusion into LPS-incubated or IFNγ/MCSF/TNFα-incubated rats elicited ALI, the OX6 antibody was present on the PMNs, and PMN depletion abrogated ALI.

CONCLUSION

Proinflammatory first events induce PMN MHC class II surface expression, activation of the pulmonary endothelium, and PMN sequestration such that the infusion of cognate antibodies precipitates TRALI.

Histamine production by human neutrophils

Histamine is an important mediator in the development of allergic reactions. Only a small subset of human cell types is able to produce histamine. No previous studies have shown that human neutrophils are among them. The present work was undertaken to analyze whether human neutrophils produce histamine, and to determine what agonists are involved in histamine production by human neutrophils. The expression of histidine decarboxylase in human neutrophils was established by quantitative PCR, Western blotting, and flow cytometry analysis. The activity of the enzyme was determined by ELISA, which measured histamine in the culture supernatant of neutrophils stimulated with a set of classical agonists. Human neutrophils are bona fide histamine-producing cells. Neutrophils store ∼0.29 pg/cell and release ∼50% of the histamine content in an antigen-dependent manner and on stimulation with other neutrophil agonists. Basal expression of histidine decarboxylase, the rate-limiting enzyme in histamine production, is higher in neutrophils from patients with allergies than from healthy donors. Our results cannot be ascribed to cell contamination for several reasons. LPS failed to induce histamine release by basophils, whereas it induced histamine release by neutrophils; and we did not detect basophils, monocytes, or lymphocytes in our neutrophil preparations. Eosinophils, albeit detected, were only 0.001-0.004% of the final cell population, and they did not store or release histamine on antigen or LPS stimulation. Antigens to which patients with allergies were sensitized stimulated release of histamine from neutrophils. These observations represent a novel view of neutrophils as possible source of histamine in the allergic diseases.

Post transfusion lung injury in the neonatal population

OBJECTIVE

The objective of this study was to examine the changes in level of respiratory support following transfusion in neonates who require intermediate or intensive care.

STUDY DESIGN

Data on respiratory support were collected retrospectively from the medical record before, during and after transfusion. Neonatal post transfusion lung injury (NPTLI) was defined as an increase in the highest mean airway pressure (MAP) of ≥2 cm H(2)O or FiO(2) >0.15 in the 6-h after transfusion that persisted from 6 to 18 h post transfusion.

RESULT

A total of 373 (330 packed red blood cell) transfusions were given to 108 infants. NPTLI occurred following 31 (8.3%) transfusions in 23 patients. During the first 6 h after transfusion, FiO2 or MAP was increased in 47 transfusions (12.6%) and the changes persisted in 31 transfusions (7.8%). Infants who developed NPTLI were less mature (27.1±0.7 vs 31.0±0.5 weeks; P=0.005) and of lower birth weight (1001±110 vs1692±104 g; P=0.001). Infants who developed NPTLI were more likely to develop necrotizing enterocolitis (6/24 vs 4/85; P=0.002) and die within 24 h of transfusion (5/22 vs 3/85; P=0.003).

CONCLUSION

In neonates receiving intensive or intermediate care, blood transfusion was associated with need for increased respiratory support in a significant number of cases. Development of NPTLI was associated with poorer outcomes.

Recent advances in laboratory assays for nonhemolytic transfusion reactions

Nonhemolytic transfusion reactions (NHTRs) are the most common transfusion reactions and include transfusion-related acute lung injury (TRALI) and allergic and febrile reactions. White blood cell (WBC) antibodies (Abs) against human leukocyte antigen (HLA) and human neutrophil antigen (HNA) in blood components are frequently implicated in NHTRs, especially in TRALI. Recently, we established a five-cell-lineage immunofluorescence test, a modified granulocyte immunofluorescence test, and a panel of cell lines stably expressing HNAs for efficient detection of Abs against well-known HNA-1 to HNA-5, and also Abs against neutrophil antigens other than HNA-1 to HNA-5. Using these techniques, we found that most of the non-HLA WBC Abs detected in NHTR cases were against antigens other than HNA-1 to HNA-5. In addition, using our newly established neutrophil activation test, which assesses neutrophil activation elicited by immunologic stimuli such as WBC Abs and immune complex, we found that heparin-binding protein is a potential final effector molecule that induces NHTRs, including TRALI. More recently, we reported that the basophil activation test, which was originally developed to identify allergens in the field of allergic diseases, might be useful in transfusion medicine. In this review, we summarize these new techniques and other related tests.

The role of neutrophils in the pathogenesis of transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) is the major cause of transfusion related morbidity and mortality, world wide. Efforts to reduce or eliminate this serious complication of blood transfusion are hampered by an incomplete understanding of its pathogenesis. Currently, TRALI is thought to be mediated by donor alloantibodies directed against host leukocytes or the result of 2 distinct clinical events. For both proposed mechanisms, the neutrophil is the key effector cell. This article reviews TRALI pathophysiology, explores the role of the neutrophil, details practical information for appropriate diagnosis and promotes further studies into the pathogenesis of TRALI.

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.

Possible involvement of heparin-binding protein in transfusion-related acute lung injury

BACKGROUND

In antibody-mediated nonhemolytic transfusion reactions, transfusion-related acute lung injury (TRALI) tends to occur typically within 2 hours after a blood transfusion. White cell antibodies or immune complexes have been frequently shown to be associated with the syndrome, although the mechanisms by which they induce TRALI are poorly understood. The aim of this study was to characterize soluble mediators that are released from cells at an early stage after immune stimulation.

STUDY DESIGN AND METHODS

To explore the mechanism of TRALI, an in vitro whole-blood cell culture assay was established in which cells were stimulated by human antibodies and the activation of neutrophils was monitored by a cell surface marker (Mac-1) with flow cytometry and by measurement of the release of soluble factors, including perforin, interleukin-6, tumor necrosis factor-alpha, and heparin-binding protein (HBP) with enzyme-linked immunosorbent assays. In addition, the involvement of two neutrophil FcgammaRs (FcgammaRIIIb and FcgammaRIIa, also known as CD16 and CD32, respectively) was examined during antibody-induced cell activation with anti-FcgammaR blocking antibodies.

RESULTS

Substantial amounts of HBP were released within 30 minutes of stimulation by human antibodies, although other soluble mediators were not released within the same period. Furthermore, the release of HBP was mediated via signals through both FcgammaRIIIb and FcgammaRIIa.

CONCLUSION

HBP appears to be one of the primary effector molecules of antibody-mediated nonhemolytic transfusion reactions including TRALI.

Transfusion-Related Acute Lung Injury (TRALI): Current Clinical and Pathophysiologic Considerations

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.

Simultaneous five cell-lineage flow cytometric analysis system for detection of leucocyte antibodies

Although flow cytometric (FCM) analysis is one of the most widely used approaches to screen the presence of leucocyte antibodies, it has several drawbacks. First, neutrophils and, especially, monocytes exhibit high background reactivity. Second, to determine antibody specificity, it is often necessary to examine not only neutrophils and monocytes but also other lineage cells including T cells, B cells and platelets. Therefore, we attempted to establish an FCM analysis system in which four lineages of leucocytes and platelets are simultaneously tested with low background. FCM analysis was performed using ethylene diamine tetraacetic acid-anticoagulated whole blood as cell sample without any cell preparation. Discrimination of five cell lineages was carried out based on the differences in forward vs. side scatter distribution and in the expression of CD4, CD20 and CD14. When anti-HNA (human neutrophil antigen) 1b antiserum was applied to HNA 1b-positive blood samples, only neutrophils were unambiguously positive. When anti-Naka (anti-CD36) antiserum was applied, only platelets and monocytes were positive. The background reactivity of neutrophils and monocytes was low enough. When anti-human leucocyte antigen (HLA) class II antiserum was tested, only B-lymphocytes and monocytes were positive. When anti-HLA class I antiserum was tested, all the five-lineage cells were positive.

HLA class II antibodies in transfusion-related acute lung injury (TRALI). A case report

TRALI, a serious complication of blood transfusion, is underdiagnosed. Anti-granulocyte and anti-HLA class I molecules in donors or recipients and very recently, lipids in stored blood as well as anti-HLA class II have been associated with the syndrome. We present a TRALI case which occurred in a 56 year old woman after plasma transfusion. HLA class II antibodies were identified in the donor and were correlated with the recipients' HLA antigens. The presence of HLA class II antibodies without anti-HLA class I has been reported in very few cases and may facilitate the understanding of the pathogenesis of the syndrome.

Transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) is a life-threatening adverse event of transfusion, which has an increasing incidence in the United States and is the leading cause of transfusion-related death. TRALI and acute lung injury (ALI) share a common clinical definition except that TRALI is temporally- and mechanistically-related to transfusion of blood or blood components. A number of different models have been proposed to explain the pathogenesis. The first is an antibody-mediated event whereby transfusion of anti-HLA, class I or class II, or anti-granulocyte antibodies into patients whose leukocytes express the cognate antigens. The antibody:antigen interaction causes complement-mediated pulmonary sequestration and activation of neutrophils (PMNs) resulting in TRALI. The second is a two-event model: the first event is the clinical condition of the patient resulting in pulmonary endothelial activation and PMN sequestration, and the second event is the transfusion of a biologic response modifier (including anti-granulocyte antibodies, lipids, and CD40 ligand) that activates these adherent PMNs resulting in endothelial damage, capillary leak, and TRALI. These hypotheses are discussed with respect to animal models and human studies that provide the experimental and clinical relevance. The definition of TRALI, patient predisposition, treatment, prevention and reporting guidelines are also examined.

Understanding the Consequences of Transfusion-Related Acute Lung Injury

Although the blood supply has become safer with regard to transmission of infectious agents, attention should continue to focus on understanding and eliminating the other serious risks associated with transfusion. Transfusion-related acute lung injury (TRALI) is one such risk, only recently becoming recognized as an important and potentially preventable clinical syndrome. Strategies for prevention of TRALI, however, must rely on knowledge regarding its etiology and diagnosis, and significant gaps in our understanding of the syndrome currently exist. This review summarizes what is known and unknown about the incidence, severity, etiology, diagnosis, and prevention of TRALI and the potential consequences of these knowledge gaps.

Transfusion-related acute lung injury (TRALI)

A 50-year-old male presented for a Whipple's procedure to excise a pancreatic lesion. Massive transfusion of packed cells and fresh frozen plasma was required. Towards the end of the procedure, the patient developed sudden onset of frank pulmonary oedema and hypotension. A presumptive diagnosis of transfusion related lung injury was made after prompt investigations excluded circulatory overload or cardiogenic shock as the cause. This case report describes an increasingly common and life-threatening sequela of blood product transfusion, the management of which is complicated by the current lack of specific diagnostic tests.

Syndrome de détresse respiratoire aiguë post-transfusionnel : une pathologie méconnue

Transfusion related acute lung injury (TRALI) is a rare but potentially severe complication of blood transfusion, manifested by pulmonary oedema, fever and hypotension. The signs and symptoms are often attributed to other clinical aspects of a patient's condition, and therefore, TRALI may go unrecognised. It has been estimated to be the third cause of transfusion related mortality, so it should be better diagnosed. Cases are related to multiple blood units, such as white blood cells, red blood cells, fresh frozen plasma, platelets or intravenous immunoglobulins. Physiopathology of TRALI is poorly understood, and still controversial. It is often due to an immunological conflict between transfused plasma antibodies and recipients' blood cells. These antibodies are either HLA (class I or II) or granulocyte-specific. They appear to act as mediators, which result in granulocytes aggregation, activation and micro vascular pulmonary injury. Lipids or cytokines in blood units are also involved as TRALI priming agents. Diagnosis is based on antibody screening in blood components and on specific-antigen detection in the recipient. The screening of anti-HLA or anti-granulocytes is recommended as part of prevention for female donors who had been pregnant. Preventative measures should also include leucoreduction and measures to decrease the amount of priming agents in blood components. In this article, we summarise what is known about TRALI, and we focus attention on unanswered questions and controversial issues related to TRALI.

Transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) is a life-threatening adverse effect of transfusion that is occurring at increasing incidence in the United States and that, in the past 2 reporting years, has been the leading cause of transfusion-related death. TRALI and acute lung injury (ALI) share a common clinical definition except that TRALI is temporally and mechanistically related to the transfusion of blood/blood components. In prospective studies, 2 patient groups, 1 requiring cardiac surgery and 1 with hematologic malignancies and undergoing induction chemotherapy, were predisposed. Two different etiologies have been proposed. The first is a single antibody-mediated event involving the transfusion of anti-HLA class I and class II or antigranulocyte antibodies into patients whose leukocytes express the cognate antigens. The second is a 2-event model: the first event is the clinical condition of the patient resulting in pulmonary endothelial activation and neutrophil sequestration, and the second event is the transfusion of a biologic response modifier (including lipids or antibodies) that activates these adherent polymorphonuclear leukocytes (PMNs), resulting in endothelial damage, capillary leak, and TRALI. These hypotheses are discussed, as are the animal models and human studies that provide the experimental and clinical relevance. Prevention, treatment, and a proposed definition of TRALI, especially in the context of ALI, are also examined.

Flow-cytometric approach to the prompt laboratory diagnosis of TRALI: a case report

OBJECTIVES

Transfusion-related acute lung injury (TRALI) is a rare but serious complication which can occur after transfusion of blood components. In this report we describe our flow-cytometry approach to the laboratory diagnosis of a case of TRALI in a recipient of fresh frozen plasma containing human leukocyte antigen (HLA) class II antibodies.

METHODS

The post-transfusion reaction work-up included the direct and indirect Granulocyte Immunofluorescence Test (GIFT) on the recipient's neutrophils collected before and after the reaction and on the serum from the recipient and from all implicated donors; flow-cytometry bead-based screening and identification assay for HLA class I and II antibodies in donor sera and flow cytometry cross-matching on T and B patient's lymphocytes. Finally, we investigated the reactivity of one donor serum, containing HLA class II antibodies, with the patient's neutrophils activated in vitro to induce expression of HLA class II.

RESULTS

We found an increased level of IgG bound on patient's granulocytes collected after TRALI, in the absence of detectable granulocyte and HLA class I antibodies in the five implicated donors. One of them showed HLA-DR 1 and -DR 51 antibodies, which determined a positive cross-match with patient's B lymphocytes and in vitro activated granulocytes. Both HLA class II antigens were present in the recipient and absent in the donor.

CONCLUSIONS

In some pathological conditions, HLA class II antibodies can react with activated granulocytes expressing HLA-DR antigens, and activate TRALI reaction. HLA class II antibodies screening and flow cytometry cross-matching techniques should be added to the current diagnostic algorithm of TRALI.