Patiënt gerelateerde risicofactoren voor TRALI Nicole Juffermans, intensivist Academisch Medisch Centrum Agenda • • • • TRALI definition TRALI incidence TRALI host factors Implications for management and prevention? Transfusion-Related Acute Lung Injury: concensus criteria • • • • • 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 • • • • • • 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 • • • • 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 • • • • 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
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