Patiënt gerelateerde risicofactoren
voor TRALI
Nicole Juffermans, intensivist
Academisch Medisch Centrum
Agenda
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TRALI definition
TRALI incidence
TRALI host factors
Implications for management and
prevention?
Transfusion-Related Acute Lung Injury:
concensus criteria
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Acute onset
Hypoxemia
(PaO2/FiO2 < 300)
Bilateral interstitial
pulmonary changes
No circulatory overload
(PAOP < 18 mmHg)
Transfusion < 6 hrs
TRALI is a clinical syndrome
Problem:
TRALI definitions: consensus criteria
• Clinical picture compatible with definition:
Suspected TRALI
• When another ALI risk factor is present:
Possible TRALI
TRALI:
part of the ALI/ ARDS spectrum,
but also with distinct entities…
TRALI: two hit hypothesis
LysoPCs
Antibodies
“First Hit”: priming neutrophils
IL-8
“Second Hit”: Transfusion
O-2
P-selectin
Capillair
PAF
L-selectin
E-selectin
CD18
Pulmonary edema
TRALI: threshold model
Bux, Br J Haematol 2007
Agenda
• TRALI definition A ‘multiple hit’ clinical
syndrome. Transfusion factors and patient
factors play a role
• TRALI incidence
• TRALI host factors
• Implications for management and
prevention?
Agenda
• TRALI definition A ‘multiple hit’ clinical
syndrome. Transfusion factors and patient
factors play a role
• TRALI incidence
• TRALI host factors
• Implications for management and
prevention?
Not recognized by clinicians
Not meeting the consensus criteria
Report!
TRALI?
fullfilling criteria
TRALI: “imputability”
Donor: anti HLA Abs, Crossmatch +
No anti HLA Abs, Crossmatch –
2nd involvement: HLA abs, luminex +
Incidence of TRALI
1.12
Incidence per blood product
1.2
1.0
0.9
0.8
Hospital patients ICU patients
0.6
0.32
0.4
0.19
0.2
0.02
0.076
0.02
Silliman
Toy
Rana
Gajic
AMC
2003
2012
2006
2007
2008
0.0
Popovsky
1983
Clark
1994
consensus criteria
TRALI: two hit hypothesis
LysoPCs
Antibodies
“First Hit”: priming neutrophils
IL-8
“Second Hit”: Transfusion
O-2
P-selectin
Capillair
PAF
L-selectin
E-selectin
CD18
Pulmonary edema
Agenda
• TRALI definition
• TRALI incidence: A relevant problem on
the ICU
• TRALI host factors
• Implications for management and
prevention?
Agenda
• TRALI definition
• TRALI incidence: A relevant problem on
the ICU
• TRALI host factors
• Implications for management and
prevention?
TRALI in general hospital population
0.02% per product
TRALI risk factors
in general population
Risk factors for TRALI
in the critically ill at the AMC
Patient-related risk factors
TRALI vs Transfused controls
Variable
OR (95%)
P value
APACHE II
1.1 (1.0-1.1)
0.002
13.1 (2.7-63.8)
0.001
Sepsis
2.5 (1.2-5.2)
0.02
Mechanical ventilation
3.0 (1.3-7.1)
0.01
Massive transfusion
4.5 (2.1-9.8)
0.001
17.6 (1.8-168.5)
0.01
Hematologic malignancy
Emergency CABG
Transfusion-related risk factors
8% of transfused patients
or 1.1% per product
Risk factors for TRALI
TRALI in cardiac surgery patients
Cardiopulmonary
bypass?
“First Hit”: priming neutrophils
IL-8
LysoPCs
Antibodies
Deflation of lungs
during surgery?
“Second Hit”: Transfusion
O-2
P-selectin
Capillair
PAF
L-selectin
E-selectin
CD18
Pulmonary edema
1 patient
reported to Blood Bank
2.4% of patients
or 0.6% per product
Risk factors for TRALI:
multivariate analysis
TRALI in ICU patients with GI bleeding
“First Hit”: priming neutrophils
IL-8
“Second Hit”: Transfusion
O-2
P-selectin
Capillair
PAF
L-selectin
E-selectin
CD18
Pulmonary edema
9.8% of patients
Risk factors for TRALI
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Sepsis
Aspiration
Cardio pulmonary bypass time
Liver disease
Hematologic malignancy
Mechanical ventilation
• FFP
• anti HLA-II Abs
• anti HNA Abs
Outcome of TRALI in ICU
in the critically ill:
41% mortality vs 23% in transfused controls
in cardiac surgery:
13% mortality vs 3% in transfused controls
in GI bleeding:
91% mortality vs 20% in transfused controls
TRALI, not TACO, is associated with
increased mortality in ICU patients
Agenda
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TRALI definition
TRALI incidence
TRALI host factors
Implications for management and
prevention?
TRALI is not a diagnosis ‘per exclusion’
Excluding female plasma donors
reduces TRALI at Mayo clinics
NB: possible TRALI excluded
Excluding female plasma donors reduces
possible TRALI in ICU patients
Period
TRALI
cases
Incidence per
product
Transfused
June - Oct
2006
17
1,05 %
49%
June - Oct
2007
6
0,65 %
43%
RR 2.8 [95%CI 1.1 to 7.0] p<0.03
Blood storage time:
a pulmonary hit?
• Rat model
• Transfusion of rat RBCs stored for 14 days
Control
Stored RBCs cause
lung inflammation
RBCs day 0
RBCs day 14
Aged RBCs cause pulmonary inflammation,
but not after washing of cells
Supernatant was
causative
Storage time: not a risk factor for TRALI
Other methods
to reduce ‘storage lesion’
Agenda
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TRALI definition
TRALI incidence
TRALI host factors
Implications for management and
prevention? Report TRALI. Exclusion of
female donors for plasma seems effective.
• Exclusion of female donors for RBC?
Washing? Reduce cytokines?
Thank you