# Presentation: 816514

## Transfusion Related Acute Lung Injury (TRALI): Clinical and Laboratory Aspects

**David Stroncek, MD**
**Chief, Laboratory Services Section**
**Department of Transfusion Medicine**
**Clinical Center, NIH, Bethesda, Maryland **

## Disclaimer-1 

**The views expressed are those of the presenter and do not necessarily represent the position of the National Institutes of Health or the Department of Health and Human Services.**

## Disclaimer-2

**The views expressed are those of the presenter and do not necessarily represent the position of anyone else.**
**TRALI is controversial!**

## Overview

**Definition and clinical features**
**Pathophysiology**
**Female donors**
**Leukocyte antibodies**
**Leukocyte activating agents**
**Patient factors**
**Testing and TRALI**

## Transfusion Related Acute Lung Injury (TRALI): What is it? 

**Severe shortness of breath within 4 to 6 hours of a transfusion**
**No signs of fluid overload**
**Pulmonary infiltrates on chest x-ray**

## TRALI: NHLBI Working Group Definition

**TRALI**
**New ALI**
**Onset of symptoms or signs is within 6 hours after the transfusion of plasma containing blood components**
**ALI (Acute Lung Injury)**
**Acute onset**
**Chest x-ray: Bilateral infiltrates**
**Pulmonary artery occlusion pressure ****≤****18 mm Hg or lack of clinical evidence of left atrial hypertension**
**Hypoxemia: Ratio of PaO****2****/FiO2 ****≤****300mm Hg or O****2**** saturation of less ****≤****90% on room air**
**Clinical Diagnosis**

**Crit Care Med 2005;33:721-726**

## TRALI: Incidence and Products

**Incidence**
**From 1 in 1,000 to 1 in 10,000 units transfused**
**Products implicated**** **
**Fresh Frozen plasma, platelets, and red cell concentrates **
**More likely to be associated with FFP and platelets**
**SD plasma is not thought to cause TRALI**

**Sachs UJ et al. Transfusion 2005;45:1628-31**

## TRALI: Clinical Features

**Dyspnea and hypoxemia**
**Fever**
**Hypotension or hypertension**
**Chest x-ray: bilateral infiltrates, “white out**”

## TRALI: Treatment 

**Hypoxemia**
**Supplemental oxygen**
**Intubation and mechanical ventilation**
**Hypotension**
**Intravenous fluids  **
**Agents to increase blood pressure  **
**Corticosteroids**

**Moore SB. Critical Care Medicine 2006; 34: S114-117**

## TRALI: Clinical Course

**Symptoms generally resolve in 24 to 48 hours**
**Symptoms may resolve before diagnosis is made**
**Mortality 10% to 50%**
** **
**Moore SB. Critical Care Medicine 2006; 34: S114-117**
**Rana R et al. Transfusion 2006;46:1478-1483**

## Why the concern about female donors?

## A Prospective Study: Cardiopulmonary Reactions to Plasma for Multiparous Donors

**Palfi M, Berg S, Ernerudh J, Berlin G. Transfusion 2001;41:317-322**

**Multiparous = 3 or more births**

## Multiparous vs Control Plasma (n=100)

|  |  | Before | After | p |
| --- | --- | --- | --- | --- |
| 
PaO2:FiO2 
Ratio | Control | 32.7 ± 13.8 | 32.8 ± 12.8 | NS |
|  | Multip | 33.8  ± 12.8 | 31.1 ± 13.1 | <0.001 |
| Mean Arterial 
Pressure (mmHg) | Control | 78.6 ± 13.9 | 81.8 ± 14.9 | <0.01 |
|  | Multip | 81.2 ± 14.2 | 80.4 ± 14.5 | NS |

**Palfi et al. Transfusion 2001;41:317-322**

## Multiparous vs Control Plasma:Reactions

**TRALI**
**One case**
**Multiparous donor unit**
**Granulocyte antibodies; No HLA antibodies**
**Mild Reactions (4)**
**3 Pulmonary (multiparous units)**
**1 Fever only (control unit)**
**1 of 3 multiparous donors units had granulocyte, but no HLA antibodies**

## TRALI in ICU Patients

**Single Institution **
**Retrospective case-control study**
**All new cases of respiratory failure within 6 hr of a transfusion over 1 year**
**Number of patients studied: TRALI (n = 24), fluid overload (n = 25), and controls (n = 124) **
**TRALI patients were more likely to receive**
**Plasma-rich products**
**Larger volumes of plasma**
**Plasma from female donors**

**Rana R et al. Transfusion 2006;46:1478-1483**

##  What Causes TRALI? 

**Donor factors**
**Leukocyte antibodies**
**Product storage factors**
**Bioactive lipids**
**CD40L**
**Patients factors**

## 1957: Evidence that Leukoagglutinins Cause Transfusion Reactions

**One severe reaction**
**Infusion of 50 mL of blood with leukoagglutinins caused vomiting, diarrhea, chills, fever, hypotension, tachypnea, dyspnea, cyanosis and leukopenia within 45 minutes.**
**Symptoms resolved the next day, but a chest x-ray showed bilateral pulmonary infiltrates and a small pleural effusion. Two days the chest x-ray was normal.  **
**Two mild reactions**
**Infusion of 250 mL of plasma containing weak leukoagglutinins to two subjects cause mild reactions. **
**Brittingham TE. Vox Sang 1957; 2:242-248**

## Leukocyte Antigens Implicated in TRALI

**Human Neutrophil Antigens**
**HNA-1**
**HNA-2**
**HNA-3**
**Human Leukocyte Antigens**
**HLA Class I**
**HLA Class II**

## On the basis of case reports in the 1960’s and 1970’s the concept that leukoagglutinins causes pulmonary transfusion reactions takes hold

**...****both our cases suggest that the acute pulmonary edema was related to a leukoagglutinin, but such a relationship was not established.  (JS Thompson NEJM 1971:284:1120-1125)**
**...****both the responsible donors were multiparous, raising concern about the use of whole blood from multiparous donors... (JS Thompson NEJM 1971:284:1120-1125)**

## 1980’s: the term TRALI was first used and the idea that leukocyte antibodies cause TRALI becomes widely accepted

**1983 (Popovsky, Able, and Moore)**
**A series of 5 cases of pulmonary transfusions reactions**
**19 implicated donors**
**One donor for each case had an HLA antibody**
**TRALI defined **
**1985 (Popovsky and Moore)**
**36 cases**
**Leukocyte antibodies in 89%**
**HLA antibodies in 65%**

## Interpreting Antibody Test Results

**Incidence of leukocyte antibodies in blood donors**
**HLA Antibodies**
**4% to 7% of all donors**
**Up to 21% of females with 3 for more pregnancies**
**Neutrophil Antibodies**
**Less than 0.1% of donors**

**It is difficult to interpret the results of testing TRALI **
**implicated donors for HLA antibodies without **
**including a control group**

## Leukocyte Antibodies, TRALI, and Leukopenia

**Leukocyte antibody transfusion associated with leukopenia and TRALI**
**Anti-HNA-1b **
**Yomtovian et al. ****Lancet 1984;1:244-6**
**Anti-HLA class I and II, 3 cases**
**Nakagawa and Toy. ****Transfusion 2004;44:1689-94**
**Anti-HLA class I and II, 2 cases**
**Marques et al. ****Am J Hematol 2005;80:90-1**
**Leukocyte antibodies transfusions associated with leukopenia and transfusion reactions, but not TRALI**
**Anti-HNA-2a**
**Fadeyi et al. Transfusion. 2007;47:545-50**

## Look-Back Studies

| Antibody | # Donors | # Transf | All Reactions | Serious Reactions | Author |
| --- | --- | --- | --- | --- | --- |
| HNA-3a | 1 | 36 | 15 | 8 | Kopko et al |
| HNA-3a | 1 | 25 | 0 | 0 | Davoren et al |
| HNA-2a | 1 | 39 | 12 | 0 | Fadeyi et al |
| HLA Class I and II | 2 | 18 | 1 | 0 | Nicolle et al |
| HLA Class I and II | 1 | 6 | 0 | 0 | Fontaine et al |
| HLA Class I and II | 1 | 103 | 1 | 1 | Toy et al |
|  |  |  |  |  |  |

## Leukocyte Antibodies in Blood Donors

**Study Design**
**1043 donors**
**633 previously pregnant females**
**410 males**
**Tested for both HLA and neutrophil antibodies**
**Results**
**No neutrophils antibodies**
**No HLA antibodies in males**
**HLA antibodies in 62 (9.8%) of females**
**Look-back**
**211 components: 187 RBCs, 61 platelets, 48 FFP**
**1 case of TRALI (RBCs, multispecific HLA class I and class II)**

**Maslanka et al. Vox Sanguinis 2007:92:247-249**** **

## Animal Models of TRALI

| Antibody | Animal | PMNs |  | Complement | Authors |
| --- | --- | --- | --- | --- | --- |
|           Neutrophil Antibodies |  |  |  |  |  |
| HNA-3a | Rabbit | + | + |  | Seeger et al |
| HNA-2a | Rat | + | - |  | Sachs et al |
|           HLA Antibodies  |  |  |  |  |  |
| MHC Class I | Mouse | + | - |  | Looney et al |

## Bioactive Lipids

**Accumulate during the storage of cellular blood products (lysophosphatylcholine, L-PC)**
**Prime neutrophils: primed neutrophils have a greater response to activating agents **
**Enhance neutrophil-mediated lung injury in animal models**
**Prospective and retrospective studies have found greater levels of bioactive lipids in TRALI implicated units or post-transfusion sera from TRALI patients than controls**

**Silliman et al. Transfusion. 1997;37:719-26**
**Silliman et al. Blood. 2003;101:454-62**

## Soluble CD40L 

**Released by platelets**
**Levels increase in stored platelets**
**Primes neutrophils**
**Inhibition of CD40-CD40L system reduces acute lung injury in animal models**
**A case-control study found higher sCD40L levels in TRALI-implicated units than in control units**

**Khan et al. Blood. 2006;108:2455-62**** **

## Patient Factors

**TRALI is more common in**
**Surgery patients**
**Patients with hematological malignancies and cardiac disease**

**Moore. Crit Care Med 2006; 34: S114-S117**
**Silliman et al. Blood 2003; 101:454-462**

## Two-Hit TRALI Model

**Patient conditions ******** activation of pulmonary endothelium ******** sequestration of neutrophils ******** priming of neutrophils (adhesion)**
**Infusion of leukocyte antibody or biological response modifier ******** activates primed neutrophils ******** neutrophils damage pulmonary endothelium**

**CC Silliman. Crit Care Med 2006;34:S124-S131**

## Testing for TRALI-Associated Factors

## What and When to Test?

|  | What? | When? |
| --- | --- | --- |
| HLA antibodies | Donor Serum | At Donation |
| HNA Antibodies | Donor Serum | At Donation |
| Bioactive lipids |  Product | At Transfusion |
| CD40L  |  Product | At Transfusion |
|  |  |  |

## Type of Assays and Commercial Availability  

|  | Type | Commercial Kit Available?  |
| --- | --- | --- |
| HLA antibodies | Solid Phase | Yes |
| HNA Antibodies | Cellular | No |
| Bioactive lipids | Cellular | No |
| CD40L  | ELISA | Yes |

## HLA Class I and II Antibody Testing

**Antigen**
**Immune affinity chromatography**
**Recombinant technology**
**Solid phase assays**
**ELISA**
**Microbeads-flow cytometry**
**Microbeads-modified flow cytometry**
**Other**
**High throughput testing is possible**
**Most HLA antibodies containing products do not cause TRALI **

## HNA Antibody Testing

**Antigen**
**Intact neutrophils (short life span)**
**Assays**
**Agglutination**
**Immunoflourescence-flow cytometry**
**Monoclonal antibody capture**
**Mixed passive hemagglutination**
**Problems with solid phase**** **
**HNA-3a has not been characterized at a molecular level**
**No monoclonal antibody to HNA-3a**

## Bioactive Lipids

**Antigen**
**Intact neutrophils**
**Assay**
**Respiratory burst by stimulated neutrophils**
**Other**
**Threshold for causing TRALI is not known**

## CD40L 

**Assays**
**ELISA **
**Other**
**Available as a research assay**
**Threshold for causing TRALI is not known**

## Summary

**HLA antibodies**
**Testing donor samples is straight-forward**
**A positive result has a low predictive value of TRALI**
**HNA antibodies**
**Testing donors requires working with fresh neutrophils**
**A positive result has a higher predictive value for a transfusion reaction**
**Bioactive lipids**
**Testing donors requires working with fresh neutrophils**
**Testing products at the time of transfusion is challenging**
**CD40L **
**Testing is straight-forward**
**Testing products at the time of transfusion is challenging**

## Conclusions

**Donor, product, and patient factors have been implicated in TRALI**
**No single factor is highly predictive of TRALI**
**Testing for HLA antibodies and CD40L is feasible**
**Testing for neutrophil antibodies and bioactive lipids is possible but more difficult**

## Current Practices and Protocols: Department of Transfusion Medicine, Clinical Center, NIH

**Practices**
**Transfusion male plasma**
**Transfuse female AB apheresis plasma if negative for neutrophil antibodies**
**Defer TRALI implicated donors if an antibody to a characterized neutrophil antigen is identified**
**Protocol**
**Comparison of the incidence of transfusion reactions in recipients of platelet components with and without HLA antibodies**