AABB Issues Transfusion Related Acute Lung Injury (TRALI) Bulletin #06-07

Recently, the AABB board of directors convened the AABB TRALI Working Group and charged it with exploring the effects on blood safety and availability of potential intervention strategies to reduce the incidence of TRALI; and reporting or recommending to the board any guidance or communication to AABB membership.

Based on the Working Group's recommendations, AABB issued Association Bulletin #06-07 on Nov. 3, 2006. The complete text of this bulletin can be found on the AABB Web site (Members Area) or Bonfils Blood Center can provide copies upon request. The synopsis of the bulletin as well as Bonfils' role in TRALI research follows.

Background

Pulmonary reactions, which include dyspnea of unknown etiology, transfusion-associated circulatory overload and TRALI are still among the most frequent adverse consequences of blood transfusion; the contribution that each of these symptoms makes to post-transfusion pulmonary complications is unknown 1. Although much about TRALI is still not completely understood, an advance has occurred with the standardization of the definition of TRALI, as set forth by the National Heart, Lung and Blood Institute working group and the Canadian TRALI Consensus Conference Panel. Both of these definitions are based solely on clinical and radiological parameters.^2,3 

In spite of the relatively straightforward criteria, the diagnosis of TRALI is still problematic in some cases because of the difficulty in ruling out left arterial hypertension and/or acute lung injury (ALI) resulting from other causes when other risk factors for ALI are present in a transfused patient.

Products typically implicated in TRALI are whole blood, packed red blood cells, fresh frozen plasma, cryoprecipitate, platelet concentrates, apheresis platelets and rarely IGIV. The etiology of TRALI may be attributable to the presence of anti-HLA and/or anti-granulocyte antibodies in the plasma of multiparous females or donors who have received previous transfusions. Only about half of TRALI cases have identifiable antibodies in the donors or recipients. Other causes in cell containing components such as lipids, chemokines and cytokines, have been identified and are clearly responsible for lung injury.⁴

Information about the frequency of TRALI-related deaths was previously provided in Association Bulletin #05-09. Since the publication of that bulletin, new data has been accumulated. TRALI was the most frequent cause of transfusion-related death reported to the Food and Drug Administration (FDA) between October 2003 through September 2005. Additional data about TRALI related deaths can be found in the #06-07 Association Bulletin.

Action

AABB's TRALI Working Group recommended and the AABB board has adopted the following recommendations to reduce the incidence of TRALI:

• Blood collecting facilities should implement interventions to minimize the preparation of high plasma-volume components from donors known to be leukocyte-alloimmunized or at increased risk of leukocyte alloimmunization.
• Blood transfusion facilities should work towards implementing appropriate evidence-based hemotherapy practices in order to minimize unnecessary transfusion. 
• Blood collection and transfusion facilities should monitor the incidence of reported TRALI and TRALI-related mortality.

AABB also recommended that blood collection and transfusion facilities begin implementation of these TRALI risk reduction measures for all high plasma-volume components as soon as possible according to the following schedule:

• Complete full implementation of the measures relating to plasma components and whole blood by November 2007.
• Complete full implementation of measures relating to platelet components as soon as possible, but no later than November 2008.

"No specific interventions (other than working towards implementing evidence-based hemotherapy practices) are recommended at this time for lower plasma-volume components, because the per unit risk attributed to antibody-mediated TRALI from these components has been documented to be significantly lower," AABB said.

Bonfils' Role

Bonfils Blood Center is currently evaluating the most recent Association Bulletin and will formulate a plan based on the timelines suggested above. We will keep our hospital partners fully informed as we take steps to implement these suggested measures.

1. Andrzejewski C, Popovsky, MA. Transfusion-associated adverse pulmonary sequelae :  Widening our perspective. Transfusion 2005;45:1048-50.
2. Kleinman S, Caulfield T, Chan P, et al. Toward an understanding of transfusion related acute lung injury:  Statement of a consensus panel. Transfusion 2004;44:1774-89.
3. Toy P, Popovsky MA, Abraham E, et al. Transfusion-related acute lung injury :  Definition and review. Critical Care Medicine 2005;33:721-6.
4. Silliman CC,  Ambruso DR, Boshkov LL. Transfusion Related Acute Lung Injury. Blood 2005; 105:2266-2273
   

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