The mystery of transfusion-related acute lung injury

A possible case of recipient anti-neutrophil and anti-human leukocyte antigen antibody-mediated fatal reverse transfusion-related acute lung injury

BACKGROUND

Transfusion-related acute lung injury (TRALI) is a transfusion complication often mediated by recipient exposure to plasma from donors with human leukocyte antigen (HLA) and human neutrophil antigen (HNA) antibodies. Recipient anti-donor HLA or HNA antibodies have rarely been implicated.

STUDY DESIGN AND METHODS

Herein, we describe a case of fatal TRALI mediated by recipient anti-HLA and anti-HNA antibodies. Cognate antibody-antigen match was confirmed with serologic and molecular assays.

RESULTS

A 69-year-old G5P5 female with no prior transfusion history and metastatic cholangiocarcinoma with thromboembolic complications presented with heart failure and dyspnea. She was transfused 15 ml of a unit of Fy^a -negative red blood cells and subsequently developed acute onset dyspnea, hypoxemia, hypotension, and fever. Clinical investigations revealed bilateral infiltrates on chest X-ray and cognate recipient HLA and HNA antibodies to donor antigens. The patient died of acute respiratory failure within 24 h of transfusion. In total, the patient had Fy^a , HLA Class I, HNA, and human platelet antigen (HPA) alloantibodies. The 63-year-old female donor had detectable HLA class II antibodies (recipient class II genotype unavailable).

CONCLUSION

The pathophysiology of TRALI has traditionally been ascribed to underlying conditions that put the recipient at risk in combination with donor biological response modifiers. This case illustrates alternative pathogenic mediators including alloantibodies to donor HLA and HNA. Additional studies to determine the contribution and frequency of recipient alloantibodies in TRALI may inform future mitigation strategies to further reduce the incidence of TRALI, particularly in female transfusion recipients.

Transfusion-related Acute Lung Injury in the Perioperative Patient

Transfusion-related acute lung injury is a leading cause of death associated with the use of blood products. Transfusion-related acute lung injury is a diagnosis of exclusion which can be difficult to identify during surgery amid the various physiologic and pathophysiologic changes associated with the perioperative period. As anesthesiologists supervise delivery of a large portion of inpatient prescribed blood products, and since the incidence of transfusion-related acute lung injury in the perioperative patient is higher than in nonsurgical patients, anesthesiologists need to consider transfusion-related acute lung injury in the perioperative setting, identify at-risk patients, recognize early signs of transfusion-related acute lung injury, and have established strategies for its prevention and treatment.

Effect of premedication and other factors on the occurrence of acute transfusion reactions in dogs

OBJECTIVE

To evaluate the effect of premedication on transfusion reactions (TRs) within 24 hours after blood product transfusions in dogs.

DESIGN

Retrospective study between 2008 and 2011.

SETTING

Private veterinary referral hospital.

ANIMALS

Nine hundred and thirty-five transfusion events in 558 dogs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Medical records of dogs receiving blood product transfusions were reviewed. Information collected included signalment, weight, transfusion product type, reason for transfusion, first or subsequent transfusion, whether an acute reaction occurred, type of reaction, whether the reaction was treated, premedication prior to the transfusion and the premedication used, other medications the animal was given, whether the animal had an immune-mediated process, and whether the transfusion was administered in the perioperative period. A total of 144 (15%) acute TRs were documented in 136 dogs. The most common TRs were fever alone (77/144 [53%]) and vomiting alone (26/144 [18%]). Six dogs died due to the TR (4%). TR was not associated with age (P = 0.257), sex (P = 0.754), weight (P = 0.829), or premedication (P = 0.312). The type of blood product transfused (P < 0.001) was significantly associated with TRs, with packed RBCs most likely associated with a TR, and plasma least likely. Immune disease (P = 0.015) was significantly associated with occurrence of a TR. Significantly fewer reactions were documented following transfusions given in the perioperative period (P = 0.023).

CONCLUSIONS

While most TRs were mild, there were some serious reactions observed including hemolysis, dyspnea, and 6 deaths. Immune-mediated disease was associated with development of a TR, while transfusion during the perioperative period was associated with lower likelihood of reaction. Packed RBC transfusions were associated with development of acute TRs. Overall occurrence of TR was not significantly altered with premedication; however, when evaluated alone, antihistamines decreased the incidence of acute allergic reactions.