Good bye

TRALI, Welcome
TACO
(apakah memang
benar??)

Teguh Triyono
RSUP Dr Sardjito/
Fakultas Kedokteran UGM

The risk of blood transfusion :

Immune / serologic reaction
Blood transmitted infections
TRALI
TACO
GvHD
Mistransfusion

Osterman & Arora.Emerg Med Clin N Am 32 (2014) 727738

TRALI

Transfusion-related
acute lung injury
(TRALI)

The most common cause of transfusionrelated death world-wide.

First described in the 1950s the clinical
term was not coined until 1985.
The initial reports of TRALI occurred in
relatively healthy patients with the first
large series reported on patients who required transfusion after recent surgery.

Prevalence and mortality

The prevalence commonly as 1/1333
1/5000 per unit transfused in North
America with lesser rates in Europe.
The mortality is 535%, with lower
mortality rates (510%) being more
common.
However, recent prospective data from
critically ill patients in the intensive
care units have documented TRALI
rates as high as 8%
Most patients recover within 72 h.
C.C. Silliman et al. / Blood Reviews 23 (2009) 245255

Clinical Hallmarks of TRALI

Dyspnea
Tachypnea
Hypoxemia
Bilateral pulmonary opacities on chest
radiograph
Edema fluid in the endotracheal tube of
intubated patients (severe TRALI)
Absence of evidence of volume overload or
cardiac dysfunction as the principal
cause of pulmonary edema.
Sayah et al. Crit Care Clin 28 (2012) 363372

A. Alam et al. / Transfusion and Apheresis Science 50 (2

Vlaar &Juffermans
www.thelancet.com. Vol382 September14,2013

Pathogenesis: The
two-hit model
The first hit is underlying patient factors,
resulting in adherence of primed neutrophils to
the pulmonary endothelium.
The second hit is caused by mediators in the
blood transfusion that activate the endothelial
cells and pulmonary neutrophils, resulting in
capillary leakage and subsequent pulmonary
oedema.
The second hit can be antibody-mediated or
non-antibody-mediated.
Vlaar &Juffermans
www.thelancet.com. Vol382 September14,2013

The two-hit model of TRALI

Vlaar &Juffermans
www.thelancet.com. Vol382 September14,2013

. Peters et al. / Blood Reviews 29 (2015) 5161

2 Forms of TRALI
1. Antibody/Immune mediated
2. Non-antibody mediated
16

Antibody Mediated TRALI

Middleburg et
al 2008
Transfusion

80% cases Ab
detected

Hassell et al
2010
Vox Sang

72% cases Ab
detected

Funk et al 2012 75% cases Ab

70-82%
detected
Vox Sang
17

Characteristics of Ab involved in TRALI

Reil A. 2008 Vox Sang
(36 TRALI cases)

Ab to HNA-3a & HLA II > HLA I

Toy P. 2012 Blood
(case-control study, 2 med centres, 89 cases and 164 transfused controls)

vol of HLA class II Ab (NR > 27.5)

vol of HNA Ab
Saw CL 2012 Transfusion
(Compared HLA Ab of TRALI vs non-TRALI donations)

Ab must have cognate Ag

Ab strength risk of TRALI

Anti-HNA-3a
Anti-HLA II
Strength of Ab

Other cells involved with TRALI

Platelets
Lymphocytes
Monocytes
Endothelial cells

HLA and HNA antibody

specificities detected in reported
TRALI cases: German vs UK
experience

20
Makar et al.Transfusion Medicine Reviews, Vol 26, No 4 (October),
2012: pp 305

Threshold model of antibodymediated transfusion-related acute

lung injury (TRALI)

Vlaar &Juffermans
www.thelancet.com. Vol382 September14,2013

Diagnosis and treatment

TRALI is a clinical diagnosis, and
while laboratory data may support
the diagnosis it is not required.
TRALI occurs within 6 h of
transfusion with the majority of cases
presenting during the transfusion or
within the first 2 h.

C.C. Silliman et al. / Blood Reviews 23 (2009) 245255

Diagnosis and treatment

TRALI is the insidious onset of acute
pulmonary insufficiency presenting as
tachypnea, cyanosis, and dyspnea
with acute hypoxemia, PaO2/FiO2
<300
mm
Hg,
and
decreased
pulmonary compliance, despite normal
cardiac function.
Radiographic
examination
reveals
diffuse, fluffy infiltrates consistent with
pulmonary edema

C.C. Silliman et al. / Blood Reviews 23 (2009) 245255

Four anteroposterior (AP) radiographs of the chest (A, B, C, and D)

of a patient who developed TRALI. (A) Pretransfusion chest
radiograph shows clear lungs. (B and C) approximately 5 and 40 h
after transfusion show developing confluent alveolar opacities
with perihilar predominance in the bilateral mid and lower lung
zones. AP radiograph 72 h after transfusion (D) shows partial
resolution of lung opacities.

arcano et al. / Clinical Imaging 37 (2013) 10201023

Diagnosis and treatment

The treatment for TRALI is supportive
and consists of aggressive respiratory
support with supplemental oxygen
and mechanical ventilation if required
at low enough pressure and tidal
volume to not induce barotrauma.

C.C. Silliman et al. / Blood Reviews 23 (2009) 245255

InvestigationofAbmediatedTRALI
Doesthepatienthave
PMNAbs?

Dothedonationshave
PMNAbs?

SCREENforHNA,HLACI&IIAb
Y

a sso c i
ation

ConfirmpatienthascognateAgtodonorAb?
ca t
i
l
p
im

ed

Do patients PMN reacts with donor samples?

Cross match using GIFT & GAT

Fung2007ISBTScienceSeries,Silliman2009BloodReviews

TACO

Vlaar &Juffermans
www.thelancet.com. Vol382 September14,2013

Diagnostic and treatment similarities and

differences between transfusion-related
circulatory overload (TACO) and
transfusion-related acute lung injury
(TRALI)

Osterman & Arora.Emerg Med Clin N Am 32 (2014) 727738

TACO (Clinical presentation):

Develop respiratory distress within 1
2 h of transfusion.
The at-risk recipient is generally
advanced in years or very young.
Cyanosis,
elevated blood pressure,
widened pulse pressure and
tachycardia are prominent features.
Headache is a non-specific but
frequent finding.
36% fatality rate.

MITIGATION OF T R
ALI

PROPOSED MITIGATION
STRATEGIES
Sex based mitigation: prospective
deferral of multiparous (3
pregnan- cies) women donors
Testing for HLA/ HNA antibodies
Blood processing: lekoreduction,
washing, freshblood

Makar et al.Transfusion Medicine Reviews, Vol 26, No 4 (October), 2012: pp 305

Muller et al. Transfusion.2015:55

Messages
TRALI is a complex clinical syndrome that
appears to require at least two clinical events
for its development.
TRALI is a clinical diagnosis and should be
made on clinical grounds although laboratory
test may be supportive.
Male-predominant plasma transfusion appears
effective to reduce TRALI and further work is
needed to include all cases and not just those
with donor antibodies.

Diagnostic and treatment similarities

between TRALI and TACO should be
considered.

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