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Although the blood supply has become safer with regard to transmission of infectious agents, attention should continue to focus on understanding and eliminating the other serious risks associated with transfusion. Transfusion-related acute lung injury (TRALI) is one such risk, only recently becoming recognized as an important and potentially preventable clinical syndrome. Strategies for prevention of TRALI, however, must rely on knowledge regarding its etiology and diagnosis, and significant gaps in our understanding of the syndrome currently exist. This review summarizes what is known and unknown about the incidence, severity, etiology, diagnosis, and prevention of TRALI and the potential consequences of these knowledge gaps. (CHEST 2005; 128:5988-6048)
Key words: diagnosis; etiology; transfusion-related acute lung injury
Abbreviations: ALI = acute lung injury; FDA = Food and Drug Administration; FFP = fresh-frozen plasma; HLA = human leukocyte antigen; HNA = human neutrophil antigen; IL = interleukin; IVIG = IV immune globulin; TRALI = transfusion-related acute lung injury; WB-PLT = whole blood-derived platelet
Learning Objectives: 1. To review the incidence and current theories regarding the pathogenesis of transfusion-related acute lung injury. 2. To understand the rationale and consequences of donor deferrals as a means to prevent transfusion-related acute lung injury.
Transfusion-related acute lung injury (TRALI) is a well-characterized and serious adverse consequence of blood product transfusion.1 The reported incidence of TRALI indicates it is rare, although its overall occurrence is almost certainly more common than the oft-quoted estimate of one case in 5,000 U of blood transfused,2 and it is among the two leading causes of death resulting from transfusion.3 Cases of TRALI have gone unrecognized or misdiagnosed, since the symptoms can be confused with other transfusion-related events such as anaphylaxis, hemolysis, or circulatory overload, or with non-transfusion-related comorbidities such as cardiac failure.4,5 Suspected cases of TRALI may be insufficiently investigated,6 and mild or moderate cases may not be investigated or reported at all. Virtually all blood products have been implicated, and controversies exist as to whether the etiology of TRALI is mediated by antibodies, lipids, or a combination of both.7 Donor as well as recipient factors have been implicated in the pathogenesis of TRALI, but the relative importance of each is unknown. This lack of knowledge thwarts the clinician's ability to identify cases and to manage patients...