Transfusion-associated acute pulmonary insufficiency
| Classification according to ICD-10 | |
|---|---|
| T80.8 | Other complications following infusion, transfusion, or injection for therapeutic purposes |
| ICD-10 online (WHO version 2019) | |
The transfusion-related acute lung injury ( transfusion-related acute lung injury , TRALI; outdated: transfusion associated nichtkardiogenes pulmonary edema) is an acute disease of the lungs , according to a transfusion of blood products occurs and is one of the most serious transfusion side effects.
TRALI is defined as acute shortness of breath that occurs within six hours of a blood transfusion, with pulmonary infiltrates ( pulmonary edema ) on the chest x-ray and no evidence of heart failure due to volume overload as the cause.
The frequency in Germany for erythrocyte concentrates (after the introduction of leukocyte depletion ) is given as below 1: 1,000,000, for therapeutic single plasma and platelet concentrates it is 1–10: 100,000 (guidelines for hemotherapy of the German Medical Association 2010). The mortality rate is around 10%. or up to 25% (cross-sectional guidelines for blood component therapy of the German Medical Association 2008). TRALI was first described in 1951.
causes
Antibodies that are directed against white blood cells ( granulocytes ) of the recipient and are mainly transfused with fresh plasma (FFP) and platelet concentrates are held responsible as the main cause of TRALI. The antibodies bind to human leukocyte antigens (HLA) class I and human neutrophil antigens (HNA) of the granulocytes. These then agglutinate, are activated and can no longer pass through the pulmonary capillaries. The release of oxygen radicals and enzymes increases the permeability of the pulmonary vessels, blood plasma escapes and forms pulmonary edema .
Biologically active lipids ( phosphatidylcholines ) are also known as antibody-independent trigger mechanisms , which are transferred with blood and can also activate granulocytes. The clinical course of this so-called non - immunogenic TRALI is usually milder.
clinic
TRALI typically manifests itself as acute shortness of breath ( dyspnoea ), often accompanied by a drop in blood pressure ( hypotension ) and fever . In the chest x-ray (chest x-ray ), significant infiltrates can occur as a result of the pulmonary edema , which are often in discrepancy with the clinical picture. Often there is also a drop in leukocytes in the blood count .
A differentiation from acute lung failure ( ARDS ) of other causes is usually not possible on the basis of the clinical picture.
Diagnosis
The diagnosis is based on the clinical picture in connection with a transfusion and the chest x-ray. In the most important differential diagnosis , cardiogenic pulmonary edema due to an overload of the circulatory system due to the transfusion volume ( transfusion-associated circulatory overload , TACO), the left ventricular pump function is often restricted ( echocardiography ), the heart silhouette is changed (chest x-ray) and the brain natriuretic peptides are increased .
The administered canned food is immunologically tested for HNA and HLA antibodies.
therapy
The patients receive oxygen for treatment . The indication for intubation and ventilation is made early; these can be decisive for the course. The benefit of corticosteroids has not been established, but the administration is still partially practiced. Further (if necessary intensive care ) therapy is symptomatic. Recovery is rapid in most cases.
Prevention
The transfusion of products from donors whose blood products could be identified as the trigger is subsequently dispensed with.
Most TRALI cases are caused by FFP transfusions from donors who have been sensitized to leukocyte antigens in several pregnancies and have produced appropriate antibodies. The use of blood products by women without previous pregnancies or only by men, which in practice only takes place to a limited extent due to the scarcity of blood reserves, therefore reduces the risk.
Routine testing of all donors for the corresponding antibodies is not required and is usually not carried out for economic reasons.
literature
- A. Reil, J. Bux: Transfusion-Associated Acute Lung Insufficiency: An Underestimated Side Effect of Blood Transfusions. In: Dtsch Arztebl. 2007; 104 (15), pp. A-1018-A-1023. ( PDF, 203 kB )
- Guidelines for the collection of blood and blood components and for the use of blood products (hemotherapy), drawn up by the German Medical Association in accordance with the Transfusion Act in agreement with the Paul Ehrlich Institute. 2010 [1]
- Cross-sectional guidelines (BÄK) for therapy with blood components and plasma derivatives. (PDF; 1.5 MB) 4th, revised and updated edition 2014. Board of the German Medical Association , accessed on July 4, 2016 .
- DJ Triulzi: Transfusion-related acute lung injury: an update. In: Hematology Am Soc Hematol Educ Program. 2006, pp. 497-501. Review. PMID 17124105
- CC Silliman, DR Ambruso, LK Boshkov: Transfusion-related acute lung injury. In: Blood. 2005 Mar 15; 105 (6), pp. 2266-2273. Review. PMID 15572582
- P. Toy, O. Gajic: Transfusion-related acute lung injury. In: Anesth Analg. 2004 Dec; 99 (6), pp. 1623-1624. Review. PMID 15562043
- MR Looney, MA Gropper, MA Matthay: Transfusion-related acute lung injury: a review. In: Chest. 2004 Jul; 126 (1), pp. 249-258. Review. PMID 15249468
Individual evidence
- ↑ European Haemovigilance Network (EHN): Definitions of Adverse Transfusion Events. http://www.ehn-org.net/
- ↑ a b c d e f A. Reil, J. Bux: Transfusion-associated acute pulmonary insufficiency: an underestimated side effect of blood transfusions. In: Dtsch Arztebl. 2007; 104 (15), pp. A-1018-A-1023.
- ↑ RD Barnard: Indiscriminate transfusion: a critique of case reports illustrating hypersensitivity reactions. In: NY State J Med. 1951 Oct 15; 51 (20), pp. 2399-2402. PMID 14882557 .
