Transfusion‑related acute lung injury (TRALI)

Notes

1. QLD data is unavailable for 2012–13.
2. Sex and facility location data is unavailable for NSW.
3. Time of transfusion data is unavailable for NSW and SA.
4. Data is unavailable for WA.
5. Uncategorised refers to those reports where no data was provided.

TRALI is a serious transfusion-associated adverse event leading to pulmonary oedema and respiratory distress. From 2011–12 to 2012–13, there were five suspected cases of TRALI reported to the National Haemovigilance Program, accounting for 0.5% of all reports (1,044). The number of cases reporting life threatening severity dropped from two in 2008–09 to zero in 2011–12 and 2012–13.

TRALI is the common cause of mortality and morbidity in patients who receive blood components, particularly plasma‑containing components. Female donors were implicated in these cases. Countries such as Australia, the UK and New Zealand Blood Service have introduced risk reduction strategies to reduce the TRALI cases.

• From July 2007, the Blood Service commenced deferring blood donors implicated in confirmed TRALI cases, suspending pooled platelets in platelet additive solution and introducing male-only plasma. The supply of 100% male plasma was achieved in 2012. With current levels of TRALI reporting it is impossible to comment on any potential impact of this policy on the incidence of TRALI in Australia.
• All UK Blood Services moved to 100% FFP from male donors, suspension of platelet pools and preferably recruitment of male apheresis platelet donors. The newly recruited female platelet donors are screened for HLA or human neutrophil antigen (HNA) antibodies and rested after pregnancies. With the introduction of these strategies, the number of TRALI cases has decreased from a peak of 36 suspected cases (seven deaths) in 2003 to 11 suspected cases (no deaths) in 2012.^[29]
• The New Zealand Blood Service has reduced the risk of TRALI through implementing clinical FFP from only male donors in 2008, HLA antibody screening of female plateletpheresis donors in July 2012, and extending the male only policy to include cryoprecipitate and cryodepleted plasma by the end of 2013.^[30] The number of TRALI cases has decreased from 10 in 2005 to 2 in 2012.

Clinical recommendation

The ANZSBT Guidelines for the Administration of Blood Products identify that TRALI can occur unpredictably and progress rapidly, therefore further indicating the need for close observation throughout the transfusion. TRALIs must be reported to the institution's incident reporting system and reviewed by the hospital transfusion committee or other defined governance committee.

The Blood Service provides guidance on the recognition, investigation and management of TRALI.^[31]

• When to suspect this adverse reaction?
  

  Acute onset of fever, chills, dyspnoea, tachypnoea, tachycardia, hypotension, hypoxaemia and noncardiogenic bilateral pulmonary oedema leading to respiratory failure during or within 6 hours of transfusion.

  TRALI has been implicated in transfusion of unfractionated plasma-containing components (red cells, platelets and plasma).

  Its incidence is variably reported between 1:1,200 to 1:190,000 transfusions with estimates around 1:10,000 most commonly reported.

• Usual causes?
  

  The most widely held pathogenesis theory is that HLA or HNA antibodies found in the donor's plasma are directed against the recipient's leucocyte antigen.

  The antigen-antibody reaction activates neutrophils in the lung microcirculation, releasing oxidases and proteases that damage blood vessels and make them leak. Biological response modifiers, such as biologically active lipids can accumulate in some cellular components during storage and may also induce TRALI in susceptible patients.

• Investigation
  

  TRALI has many clinical features in common with fluid overload or cardiogenic pulmonary oedema and careful clinical assessment is required.

  Acute haemolytic reaction or transfusion associated sepsis may have similar initial clinical findings. DAT, blood count and repeat ABO grouping may be indicated.

  Once TRALI is clinically suspected, test the donor and recipient serum for HLA and HNA antibodies and perform an HLA type on the recipient as demonstration of these antibodies supports diagnosis. TRALI testing is specialised and contact with the Blood Service is necessary.

  Chest X-ray will show bilateral interstitial infiltrates.

• What to do?
  

  Stop transfusion immediately and follow other steps for managing suspected transfusion reactions.

  Provide cardiovascular and airway support. Administer supplemental oxygen and employ ventilation as necessary. Diuretics are not beneficial.

  This may become a medical emergency; support blood pressure and maintain an open airway.

  Notify your Transfusion Service Provider to contact the Blood Service so related components from the same donor can be quarantined and tested to prevent TRALI in other recipients.