Dengue Special Transfusion-related acute lung injury (TRALI)

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Transfusion of even one unit of a plasma-containing blood product sometimes causes acute lung injury/acute respiratory distress syndrome (ALI/ARDS).(1,2)

What can cause TRALI: Fresh frozen plasma, platelet, and packed red blood cell transfusions?

Definition: New ALI occurring during or within 6 hours after a transfusion.

Pathogenesis: A “two-event” hypothesis holds that recipient granulocytes are primed, either by transfused active substances or by virtue of the patient’s underlying clinical condition. Preformed anti-leukocyte antibodies contained in the transfusion product then “activate” these functionally hyperactive granulocytes.

Which donors: Anti-leukocyte antibodies are more likely to be found in blood donated by multiparous women due to sensitization to fetal antigens during pregnancy.

When to suspect: Whenever dyspnea, hypoxemia, and pulmonary infiltrates occur during or within 6 hours after transfusion of any plasma-containing blood product.

Differential diagnosis

  • Transfusion-associated circulatory overload
  • Hemolytic transfusion reaction
  • Anaphylaxis of IgA-containing products to a IgA deficiency recipient

Management: Supportive (mechanical ventilation, supplemental oxygen, diuretics when volume overload is present). Clinical improvement will occur spontaneously as lung injury resolves.

Action: Individuals who have developed TRALI should receive no further plasma-containing blood products from the implicated donor.

Prevention

  • Take plasma products only from male donors
  • Screen previously-pregnant and previously-transfused apheresis donors for HLA antibodies
  • Start testing for the detection of white blood cell antibodies

References

  1. Bux J, Sachs UJ. The pathogenesis of transfusion-related acute lung injury (TRALI). Br J Haematol 2007;136:788.
  2. Khan H, Belsher J, Yilmaz M, et al. Fresh-frozen plasma and platelet transfusions are associated with development of acute lung injury in critically ill medical patients. Chest 2007;131:1308.