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

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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

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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.

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Disclaimer-2

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

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Overview

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

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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

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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 PaO2/FiO2 300mm Hg or O2
  saturation of less 90 on room air
• Clinical Diagnosis

Crit Care Med 200533721-726
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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 2005451628-31
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TRALI Clinical Features

• Dyspnea and hypoxemia
• Fever
• Hypotension or hypertension
• Chest x-ray bilateral infiltrates, white out

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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
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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 2006461478-1483

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Why the concern about female donors?
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A Prospective Study Cardiopulmonary Reactions to
Plasma for Multiparous Donors
Multiparous 3 or more births
Palfi M, Berg S, Ernerudh J, Berlin G.
Transfusion 200141317-322
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Multiparous vs Control Plasma (n100)
Before After p
PaO2FiO2 Ratio Control 32.7 13.8 32.8 12.8 NS
PaO2FiO2 Ratio Multip 33.8 12.8 31.1 13.1 lt0.001
Mean Arterial Pressure (mmHg) Control 78.6 13.9 81.8 14.9 lt0.01
Mean Arterial Pressure (mmHg) Multip 81.2 14.2 80.4 14.5 NS
Palfi et al. Transfusion 200141317-322
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Multiparous vs Control PlasmaReactions

• 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

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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 2006461478-1483
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What Causes TRALI?

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

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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 2242-248

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Leukocyte Antigens Implicated in TRALI

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

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On the basis of case reports in the 1960s and
1970s 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 19712841120-1125)
• both the responsible donors were multiparous,
  raising concern about the use of whole blood from
  multiparous donors (JS Thompson NEJM
  19712841120-1125)

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1980s 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

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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
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Leukocyte Antibodies, TRALI, and Leukopenia

• Leukocyte antibody transfusion associated with
  leukopenia and TRALI
• Anti-HNA-1b
• Yomtovian et al. Lancet 19841244-6
• Anti-HLA class I and II, 3 cases
• Nakagawa and Toy. Transfusion 2004441689-94
• Anti-HLA class I and II, 2 cases
• Marques et al. Am J Hematol 20058090-1
• Leukocyte antibodies transfusions associated with
  leukopenia and transfusion reactions, but not
  TRALI
• Anti-HNA-2a
• Fadeyi et al. Transfusion. 200747545-50

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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

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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 200792247-249
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Animal Models of TRALI
Antibody Animal PMNs PMNs Complement Authors
Neutrophil Antibodies Neutrophil Antibodies Neutrophil Antibodies Neutrophil Antibodies Neutrophil Antibodies
HNA-3a Rabbit Seeger et al
HNA-2a Rat - - Sachs et al
HLA Antibodies HLA Antibodies HLA Antibodies HLA Antibodies HLA Antibodies
MHC Class I Mouse - - Looney et al
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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. 199737719-26
Silliman et al. Blood. 2003101454-62
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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. 20061082455-62
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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 101454-462
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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 200634S124-S131
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Testing for TRALI-Associated Factors
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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

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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
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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

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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

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Bioactive Lipids

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

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CD40L

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

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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

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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

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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