CBBS: Protocols for the detection and treatment of TRALI

Edward Snyder, MD (Director of Transfusion Service, Yale-New Haven Hospital) is drafting a national consensus algorithm for the detection and treatment of TRALI. This is to be presented at Dr. Morris Blajchman’s Consensus Symposium in early April in Canada. Dr. Snyder would like to know if colleagues have TRALI protocols that they would be willing to share with him as he develops the algorithm. All contributions are greatly appreciated and will be acknowledged in the presentation. Please email to edward.snyder@yale.edu or fax to 203.688.2748.

2. A physician in Australia suggests that colleagues might be interested in the discussion in the article entitled 'Investigating transfusion-related acute lung injury (TRALI)' by Fung YL et al of the Platelet and Granulocyte Immunobiology laboratory at the Australian Red Cross Blood Service in Brisbane, Queensland, Australia (Intern Med J. 2003 Jul;33(7):286-90).

3. Dr. Breanndan Moore, from the Mayo Clinic (attribution used with permission) reports that when he and Dr. Mark Popovsky first described 5 cases and coined the phrase TRALI in 1983 and subsequently reported a series in 1985, they thought they were defining an entity which included a set of clinical findings associated with the presence in donor (occasionally recipient) plasma of anti-HLA Class 1. Subsequently others, including Drs. Roslyn Yomtovian, Mary Clay and Jeff McCullough demonstrated the same clinical association with neutrophil-specific antibody. For many years the investigative protocol at Mayo Clinic has been as follows:

If none of the above testing identified a donor (or patient) antibody, the Mayo group did not designate the case as a TRALI since the definition of that entity required the detection of such antibodies.

The Mayo group is just now modifying their testing protocol to replace CDC testing with Luminex testing which they consider to be more sensitive and which also will allow them to detect anti-HLA Class 2, an important factor, as clearly demonstrated by the elegant studies of Patricia Kopko.

4. Editor's note: Colleagues may find the information within the new AABB booklet entitled "Guidelines for the Management of Transfusion Related Acute Lung Injury" to be germane to the present discussion.

ADDENDA Dec. 12, 2003

5. A colleague would like to submit the attached article by Dr. G. Kokkini of Athens which appeared in the April 2002 issue of TATM.

Kokkini presents different prevention measures and states that “recommendations and guidelines regarding the prevention of TRALI from authoritative organizations or committees or blood transfusion societies are needed.” Furthermore, the 5th Annual NATA Symposium that will be held in Atrhens, Greece, on March 18-19, 2004, will have a session dedicated to ARDS and TRALI. This session will include the following presentations

ARDS and ALI - Arthur Slutsky, Toronto, ON, Canada
Epidemiology and Clinical Picture of TRALI - Christopher C. Silliman, Denver, CO, USA
Pathogenesis of TRALI - Anneke Brand, Leiden, The Netherlands
Incidence/Prevalence of TRALI in Different Countries and Its Treatment - Jonathan P. Wallis, Newcastle upon Tyne, UK

ADDENDA Dec. 16, 2003

6. A colleague in Vienna reports that at the forthcoming 8th European Symposium on Platelet and Granulocyte Immunobiology, May 13-16, 2004, in Rust, Austria, TRALI will be a major subject, with half a day dedicated to its discussion. Speakers will include among others, Christopher Siliman from Denver, and Jürgen Bux from Berne.

ADDENDA Jan. 2, 2004

7. Editor's Note: A consensus conference on TRALI has just been announced by CBS/Hema-Quebec, to be held in Toronto on April 1-2, 2004.

ADDENDA Aug. 12, 2005

8. Editor's Note: The information at AABB Pulsepoints No. 707 Association Bulletin #05-09 Aug. 11, 2005: Transfusion-Related Acute Lung Injury is germane to this discussion.

ADDENDA Mar. 19, 2008

9. A colleague points out that there is a new Phase I accreditation requirement of the College of American Pathologists (CAP Inspection Checklist item TRM.42110 (effective 9/27/2007) that requires a plan to reduce the occurrence of TRALI and to track its frequency. The exact wording of the checklist item is as follows:

TRM.42110 - Is the laboratory developing a plan to reduce the risk of transfusion-related acute lung injury (TRALI)? NOTE: The laboratory should track the frequency of TRALI.

The complete checklist can be found HERE.

The inquiring colleague wonders how other transfusion services are planning to comply with this new accreditation item. Specifically, she would like to know if any transfusion service is including as part of the transfusion reaction investigation the looking up results of patients who have been tested for oxygen saturation, BNP, chest X-ray, etc., to screen for TRALI and/or Transfusion Associated Circulatory Overload (TACO)? Or are transfusion services merely "educating" the physicians in their facilities about the risks?

ADDENDA Mar. 30, 2008

10. A transfusion service medical director at an academic medical center located in Michigan reports that they work up patients who exhibit significant hypotension and/or SOB in association with transfusion for possible TRALI. As part of the workup they advise the clinician to test the patient for B-Type Natriuretic Peptides (BNP), O2 sat, CBC with WBC differential and a CXR or other studies if indicated. The laboratory can test a pre-transfusion CBC or a type & screen specimen for pre-transfusion BNP levels. The transfusion reaction investigation report includes a comparison of pre- and post-transfusion BNP levels, pre- and post-transfusion CBCs with WBC differentials, O2 sats, CXRs (if done), response to transfusion (change in Hgb, etc..), fluid balance in the previous 8 and 24 hrs, use of pressors or ACE inhibitors and a summary of any known prior reported reactions.