Transfusion-related acute lung injury: a review. Chest

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. ( CHEST 2004; 126:249 -258) Key words: ARDS; lung injury; pulmonary edema; transfusion; transfusion-related acute lung injury Abbreviations: ALI ϭ acute lung injury; FDA ϭ Food and Drug Administration; Fio 2 ϭ fraction of inspired oxygen; HLA ϭ human leukocyte antigen; PRBC ϭ packed RBC; TRALI ϭ transfusion-related acute lung injury T ransfusion-related acute lung injury (TRALI) was first coined by Popovsky et al 1 in 1983 to refer to noncardiogenic pulmonary edema complicating transfusion therapy. The syndrome had previously been referred to as pulmonary hypersensitivity reaction, 2,3 allergic pulmonary edema, 4 noncardiogenic pulmonary edema, 5-7 and pulmonary leukoagglutinin reaction. 8 Barnard 9 in 1951 described the first case of fatal pulmonary edema accompanying transfusion therapy. Brittingham 10 in 1957 was the first to initially shed light on the pathogenesis of TRALI. He transfused a strong leukoagglutinin to a volunteer who developed bilateral pulmonary infiltrates. This review will summarize the clinical features of TRALI and highlight potential mechanisms that may precipitate acute lung injury (ALI) and the ARDS. Definition and Clinical Presentation TRALI is defined as noncardiogenic pulmonary edema temporally related to the transfusion of blood products. The development of TRALI has been associated with all plasma-containing blood products, but most commonly involves whole blood, packed RBCs (PRBCs), fresh-frozen plasma, and platelets. TRALI has also occurred after the transfusion of cryoprecipitate and IV Ig. 11