TRALI investigation

[Eagle Eye]

If you suspect a TRALI and donor unit is from young female(no transfusion or pregnancy history), what kind of additional testing you would perform?

In other words, either patient is negative for HLA and HNA antibodies and you are almost certain that patient had a TRALI, what other tests would you order? (Patient's sample is not available anymore).

[kate murphy]

If the donor has never been pregnant and has never had transfusions, how would she have developed antibodies? It seems that if this is the only unit given, then TRALI is not a likely diagnosis. I'd suggest looking at other causes for ARDS.

[Annabelle]

We had a discussion with our medical director while developing a policy for severe transfusion reaction investigations, and she mentioned that reactions that appear to be TRALI actually turn out to be TACO (transfusion associated circulatory overload). Not being a physician, I cannot elaborate on the details, but thought it may help.

[bmarotto]

There have been reported cases where TRALI resulted from leukocyte antibodies in the recipient reacting with donor leukocytes. So, TRALI can not be conclusively ruled out based on the donor(s) being male or nulliparous females. Here is a link to read more:

http://www.scbcinfo.org/publications/bulletin_v3_n1.htm

[MJDrew]

TRALI may also be caused by bioactive substances that may accumulate in stored products over time, such as CD40, which can prime PMNs and may be a cofactor in development of TRALI. Many of these are breakdown products from WBC membranes, such as bioactive lipids, or cytokines and other biological response modifiers from the cytosol that end up in the plasma and can also generate a TRALI reaction without any antibodies in a patient who has activated vascular endothelium in the lungs.

It's important to remember not all cases of TRALI are due to antibodies--this certainly explains the many "negative" HLA and/or PMN antibody workups we get back when investigating these cases. Most reported cases at my hospital are TACO--many times I can backtrack and check chest Xrays pre- and post-transfusion and an enlarged cardiac silhouette is reported post. This is TACO. If the pulmonary artery or central venous pressure is elevated, this is also TACO.

Another way to distinguish between TRALI & TACO may be to get a blood sample from the patient for BNP. This substance is elevated in cases of heart failure. TACO would cause heart failure just as volume overload from too much infused albumin, saline, etc.

[labgirl153]

Blood, 1 October 2006, Vol. 108, No. 7, pp. 2455-2462.

Recent paper on this topic in line with what several here have posted re: cytokines vs. HLA implication. The research seems to advocate leukoreduction to cut down on TRALI, but of course...that still leaves plasma as the main culprit.

[MJDrew]

The fact that at least some, if not many, of these reactions may occur via as yet unknown or underappreciated (!) mechanisms gives me some pause when I see blood collection centers implementing plans to either eliminate plasma donations from female donors, from female donors who have had babies, or all of the above! What about other mechanisms of TRALI?? What about platelets?

The reaction to this reminds me of the rush to LR everything so that we could have decreased length of hospital stay, decreased morbidity from all sorts of surgical procedures, etc. When RCTs came out later that largely refuted these hypotheses, the collective response seemed to be, "oh, well, we're already doing it, so we can't back down on it now." So it looks like we've found another "reason" for universal leukoreduction!

MJ:cool:

[labgirl153]

I agree MJ...the field of immunology is still young, even with all the tremendous advances and promising research. It's true...the call for universal leukoreduction was more hype than science. I will say however, that leukoreduction has substantially cut down on the number of febrile reactions to products that we blood bankers have to work up.

At my facility, leukoreduction is not automatic except where platelets are concerned. Because of our sizable onco population though, would like our blood center to arrive at a compromise and turn out half and half where leukoreduced products are concerned. This would save $$ by not going 100% leukoreduced, yet would still give my facility plenty of leukoreduced products without having to pall filter (an inferior alternative) at the bedside for our patients who are sensitive to non-reduced products and to some of our transplant patients.

When it comes to immunohematology my huge gripe for many years has been concern over the dearth of research in our specific field. Much of research is geared toward POC or the OR, versus updated protocols and antibody bench work-ups that might elucidate some of these sticky problems down the road. I do agree that passing sweeping reforms to ban women from donating plasma products is a tad premature since science really has no hard and fast answers at the moment. Fortunately, as you noted, TRALI is rarer than TACO and TACO is mostly avoidable.

[Eagle Eye]

Do you know a place where CD40 testing can be done? I agree with you that going only male donor plasma is not a solution. Blood centers can not afford to do the same with plateletpheresis so they are thinking to change plasma donor population.

I think we should give more attention to transfusion appropriatness to make sure we do not transfuse blood product unnecessarily.

[caj1018]

I think that there is strong evidence that TRALI has been associated with antibodies in plasma. Is it wise to ignore this and not try to switch to predominantly male plasma? The plasma from female donors would be used for manufacturing. It is true that there are not enough donors to switch to 100% male plasma plasma at this time, but maybe down the road males can be recruited to donate plasma via pheresis as they are for platelet products.

I attended a presentation on Hemovigilance by Dr. Benjamin and feel that his arguments to go in this direction are compelling.

[rcurrie]

Side note: I give a minimum of two lectures a month on transfusion reactions to nurses. These nurses come from all across the U.S. and Canada. I have been asking for a show of hands of those who have heard of TRALI before. I have yet to have a single nurse to admit to having the slightest idea what it is. There was an Associated Press story on TRALI that made our front page news. I was certain that my batting average for nurse TRALI knowledge was going to go down, but I have given a dozen lectures since then, and I am still batting 1.000.

BC

[Yanxia]

I have read an article which said a patient with TRALI had a positive antibody screening but negative cross-match with the donor blood(HLA and HNA).Then they use the flow-cytometry method can find the discompatiblility.

[rcurrie]

We have had some documented TRALI cases, and RBC serology was always negative. However, we were always able to find HLA incompatibility, either HLA antibody in the patient (1) or HLA antibody in the donor (3).

BC

[Yanxia]

We have had some documented TRALI cases, and RBC serology was always negative. However, we were always able to find HLA incompatibility, either HLA antibody in the patient (1) or HLA antibody in the donor (3).

BC

Sorry, my meaning is the HLA and HNA antibody screening and crossmatch used to test the incompatibility of HLA and HNA between the donor and recipient. Sometimes to use a more sensitive method will find something new, mybe can open a window of resolve for this difficult problem.

I have noted that the TRALI will have a lower blood pressure than normal and the TACO's blood pressure is higher than normal. So to distinguish them is not a difficult work.

[MJDrew]

My view from the bridge is that the exclusion of female plasma donors is fine if: 1) the blood center can manage to provide sufficient plasma inventory from male donors only, 2) some questions re: pregnancy or transfusion are asked of all donors (as applicable), as at least an initial screen, (it's unlikely that plasma from a female who has not been transfused or pregnant is any more likely to cause TRALI than that from an untransfused male), and 3) they very carefully inform their donors what's going on such that female donors don't get the idea that they aren't wanted or needed anymore. The press has already done a bangup job of screwing up this story! Losing female donors, especially repeat donors, unnecessarily is the last thing we need!

In addition, not all female donors who have been pregnant, or donors who have been transfused, are immunized! Another approach would be to simply perform HLA/HNA antibody testing on any donor who gave an affirmative answer to the history question and allow the donation if the results were negative.

My point is that although the UK trials pre- and post-exclusion of females donating plasma showed a drop in TRALI cases, we really know nothing about whether reporting criteria changed in that time frame, if caregiver education took place or not, or if fewer cases would have happpened even without such a ban. And we still are not addressing platelets. Because the risk is less? Because we can't without decimating the supply? Platelets may not be the leading cause of TRALI, but they also contain plasma. So how scientific is this thinking:confused: ?

Many, many transfusions from donors with antibodies (HLA or HNA) to patients with a "matching" antigen profile take place every year, yet the vast majority of these transfusions proceed with no reaction. There apparently needs to be the appropriate physiologic "setup" in the patient for this reaction to occur, and these conditions are not always met.

The bottom line is that we need to convince our patient care colleagues to stop transfusing so friggin' much plasma for questionable indications!! Every time I look into a "questionable" FFP transfusion I always make a point to inform the clinician that this component is the leading cause of TRALI. If they don't know about TRALI, they get he 2-minute spiel!

MJ :cool:

[Malcolm Needs ☆]

Hello All,

I'm sorry to come to this thread a little late (about three years late actually), but for those of you who are still interested in this subject, could I suggest that you try looking at a PowerPoint lecture I have posted on BBT that mat be of some interest?

This sounds extremely big-headed on my part, but the lecture was actually written by my Consultant, Dr. Nay Win, of NHSBT-Tooting Centre, and not by me (so I don't feel quite so guilty advertising it).

You go to References on the heading bar, then to Document Library, then User Submitted, then Educational Material, and go right to the bottom and click on the lecture.

This, as I say, may be of interest; on the other hand, it may not, but it could be worth a try!

:confused::confused:

[NedB]

What may resemble TRALI is the donor may have a high ABO titer, especially Anti-B. So, was the unit ABO incompatible to the Patient?

[Panda]

I can't seem to find the PPT [i'm new here].

I'm very interested in what your powerpoint has to offer in reference to a case study I'm currently working on.

Also I have a question, can TRALI be both immunologic and non-immunologic? If so, how?

[Malcolm Needs ☆]

I am in danger of being egocentric (more than normal) with this post, but there is a Powerpoint lecture and accompanying Word document on this subject in the library section. In this case, however, I'm not being too egocentric, as it was written by my Consultant Dr. Nay Win, and not by me (so I feel a bit better about recommending it). Note: it is, however, a bit old now.

[Panda]

In this case, however, I'm not being too egocentric, as it was written by my Consultant Dr. Nay Win, and not by me (so I feel a bit better about recommending it). Note: it is, however, a bit old now.

Any information would be great, no matter how old. It's always nice to do comparison studies with information