Transfusion Related Acute Lung Injury (TRALI): Clinical and Laboratory Aspects

1. Transfusion Related Acute Lung Injury (TRALI): Clinical and Laboratory Aspects David Stroncek, MD Chief, Laboratory Services Section Department of Transfusion Medicine Clinical Center, NIH, Bethesda, Maryland

2. Disclaimer-1 The views expressed are those of the presenter and do not necessarily represent the position of the National Institutes of Health or the Department of Health and Human Services.

3. Disclaimer-2 The views expressed are those of the presenter and do not necessarily represent the position of anyone else. TRALI is controversial!

4. Overview Definition and clinical features Pathophysiology • Female donors • Leukocyte antibodies • Leukocyte activating agents • Patient factors Testing and TRALI

5. Transfusion Related Acute Lung Injury (TRALI): What is it? • Severe shortness of breath within 4 to 6 hours of a transfusion • No signs of fluid overload • Pulmonary infiltrates on chest x-ray

6. TRALI: NHLBI Working Group Definition TRALI • New ALI • Onset of symptoms or signs is within 6 hours after the transfusion of plasma containing blood components ALI (Acute Lung Injury) • Acute onset • Chest x-ray: Bilateral infiltrates • Pulmonary artery occlusion pressure ≤18 mm Hg or lack of clinical evidence of left atrial hypertension • Hypoxemia: Ratio of PaO2/FiO2 ≤300mm Hg or O2 saturation of less ≤90% on room air Clinical Diagnosis Crit Care Med 2005;33:721-726

7. TRALI: Incidence and Products Incidence • From 1 in 1,000 to 1 in 10,000 units transfused Products implicated • Fresh Frozen plasma, platelets, and red cell concentrates • More likely to be associated with FFP and platelets SD plasma is not thought to cause TRALI Sachs UJ et al. Transfusion 2005;45:1628-31

8. TRALI: Clinical Features • Dyspnea and hypoxemia • Fever • Hypotension or hypertension • Chest x-ray: bilateral infiltrates, “white out”

9. TRALI: Treatment Hypoxemia • Supplemental oxygen • Intubation and mechanical ventilation Hypotension • Intravenous fluids • Agents to increase blood pressure Corticosteroids Moore SB. Critical Care Medicine 2006; 34: S114-117

10. TRALI: Clinical Course • Symptoms generally resolve in 24 to 48 hours • Symptoms may resolve before diagnosis is made • Mortality 10% to 50% Moore SB. Critical Care Medicine 2006; 34: S114-117 Rana R et al. Transfusion 2006;46:1478-1483

11. Why the concern about female donors?

12. 100 ICU Patients 1 unit Donor Control Plasma 1 unit Multiparous Donor Plasma PaO2:FiO2 ratio BP, Heart rate Temp 1 unit Multiparous Donor Plasma 1 unit Control Donor Plasma PaO2:FiO2 ratio BP, Heart rate Temp End End A Prospective Study: Cardiopulmonary Reactions to Plasma for Multiparous Donors Multiparous = 3 or more births Palfi M, Berg S, Ernerudh J, Berlin G. Transfusion 2001;41:317-322

13. Multiparous vs Control Plasma (n=100) Palfi et al. Transfusion 2001;41:317-322

14. Multiparous vs Control Plasma:Reactions TRALI • One case • Multiparous donor unit • Granulocyte antibodies; No HLA antibodies Mild Reactions (4) • 3 Pulmonary (multiparous units) • 1 Fever only (control unit) • 1 of 3 multiparous donors units had granulocyte, but no HLA antibodies

15. TRALI in ICU Patients Single Institution Retrospective case-control study All new cases of respiratory failure within 6 hr of a transfusion over 1 year Number of patients studied: TRALI (n = 24), fluid overload (n = 25), and controls (n = 124) TRALI patients were more likely to receive • Plasma-rich products • Larger volumes of plasma • Plasma from female donors Rana R et al. Transfusion 2006;46:1478-1483

16. What Causes TRALI? Donor factors • Leukocyte antibodies Product storage factors • Bioactive lipids • CD40L Patients factors

17. 1957: Evidence that Leukoagglutinins Cause Transfusion Reactions One severe reaction • Infusion of 50 mL of blood with leukoagglutinins caused vomiting, diarrhea, chills, fever, hypotension, tachypnea, dyspnea, cyanosis and leukopenia within 45 minutes. • Symptoms resolved the next day, but a chest x-ray showed bilateral pulmonary infiltrates and a small pleural effusion. Two days the chest x-ray was normal. Two mild reactions • Infusion of 250 mL of plasma containing weak leukoagglutinins to two subjects cause mild reactions. Brittingham TE. Vox Sang 1957; 2:242-248

18. HLA antibodies Leukoagglutinins Neutrophil-specific antibodies Leukocyte Antigens Implicated in TRALI Human Neutrophil Antigens • HNA-1 • HNA-2 • HNA-3 Human Leukocyte Antigens • HLA Class I • HLA Class II

19. On the basis of case reports in the 1960’s and 1970’s the concept that leukoagglutinins causes pulmonary transfusion reactions takes hold …both our cases suggest that the acute pulmonary edema was related to a leukoagglutinin, but such a relationship was not established. (JS Thompson NEJM 1971:284:1120-1125) …both the responsible donors were multiparous, raising concern about the use of whole blood from multiparous donors… (JS Thompson NEJM 1971:284:1120-1125)

20. 1980’s: the term TRALI was first used and the idea that leukocyte antibodies cause TRALI becomes widely accepted 1983 (Popovsky, Able, and Moore) • A series of 5 cases of pulmonary transfusions reactions • 19 implicated donors • One donor for each case had an HLA antibody • TRALI defined 1985 (Popovsky and Moore) • 36 cases • Leukocyte antibodies in 89% • HLA antibodies in 65%

21. 2 RBCs 4 FFP 1 Platelet TRALI Interpreting Antibody Test Results • Incidence of leukocyte antibodies in blood donors • HLA Antibodies • 4% to 7% of all donors • Up to 21% of females with 3 for more pregnancies • Neutrophil Antibodies • Less than 0.1% of donors It is difficult to interpret the results of testing TRALI implicated donors for HLA antibodies without including a control group

22. Leukocyte Antibodies, TRALI, and Leukopenia Leukocyte antibody transfusion associated with leukopenia and TRALI • Anti-HNA-1b Yomtovian et al. Lancet 1984;1:244-6 • Anti-HLA class I and II, 3 cases Nakagawa and Toy. Transfusion 2004;44:1689-94 • Anti-HLA class I and II, 2 cases Marques et al. Am J Hematol 2005;80:90-1 Leukocyte antibodies transfusions associated with leukopenia and transfusion reactions, but not TRALI • Anti-HNA-2a Fadeyi et al. Transfusion. 2007;47:545-50

23. Look-Back Studies

24. Leukocyte Antibodies in Blood Donors Study Design • 1043 donors • 633 previously pregnant females • 410 males • Tested for both HLA and neutrophil antibodies Results • No neutrophils antibodies • No HLA antibodies in males • HLA antibodies in 62 (9.8%) of females Look-back • 211 components: 187 RBCs, 61 platelets, 48 FFP • 1 case of TRALI (RBCs, multispecific HLA class I and class II) Maslanka et al. Vox Sanguinis 2007:92:247-249

25. Animal Models of TRALI

26. Bioactive Lipids • Accumulate during the storage of cellular blood products (lysophosphatylcholine, L-PC) • Prime neutrophils: primed neutrophils have a greater response to activating agents • Enhance neutrophil-mediated lung injury in animal models • Prospective and retrospective studies have found greater levels of bioactive lipids in TRALI implicated units or post-transfusion sera from TRALI patients than controls Silliman et al. Transfusion. 1997;37:719-26 Silliman et al. Blood. 2003;101:454-62

27. Soluble CD40L • Released by platelets • Levels increase in stored platelets • Primes neutrophils • Inhibition of CD40-CD40L system reduces acute lung injury in animal models • A case-control study found higher sCD40L levels in TRALI-implicated units than in control units Khan et al. Blood. 2006;108:2455-62

28. Patient Factors TRALI is more common in • Surgery patients • Patients with hematological malignancies and cardiac disease Moore. Crit Care Med 2006; 34: S114-S117 Silliman et al. Blood 2003; 101:454-462

29. Two-Hit TRALI Model • Patient conditions  activation of pulmonary endothelium  sequestration of neutrophils  priming of neutrophils (adhesion) • Infusion of leukocyte antibody or biological response modifier  activates primed neutrophils  neutrophils damage pulmonary endothelium CC Silliman. Crit Care Med 2006;34:S124-S131

30. Testing for TRALI-Associated Factors

31. What and When to Test?

32. Type of Assays and Commercial Availability

33. HLA Class I and II Antibody Testing Antigen • Immune affinity chromatography • Recombinant technology Solid phase assays • ELISA • Microbeads-flow cytometry • Microbeads-modified flow cytometry Other • High throughput testing is possible • Most HLA antibodies containing products do not cause TRALI

34. HNA Antibody Testing Antigen • Intact neutrophils (short life span) Assays • Agglutination • Immunoflourescence-flow cytometry • Monoclonal antibody capture • Mixed passive hemagglutination Problems with solid phase • HNA-3a has not been characterized at a molecular level • No monoclonal antibody to HNA-3a

35. Bioactive Lipids Antigen • Intact neutrophils Assay • Respiratory burst by stimulated neutrophils Other • Threshold for causing TRALI is not known

36. CD40L Assays • ELISA Other • Available as a research assay • Threshold for causing TRALI is not known

37. Summary HLA antibodies • Testing donor samples is straight-forward • A positive result has a low predictive value of TRALI HNA antibodies • Testing donors requires working with fresh neutrophils • A positive result has a higher predictive value for a transfusion reaction Bioactive lipids • Testing donors requires working with fresh neutrophils • Testing products at the time of transfusion is challenging CD40L • Testing is straight-forward • Testing products at the time of transfusion is challenging

38. Conclusions • Donor, product, and patient factors have been implicated in TRALI • No single factor is highly predictive of TRALI • Testing for HLA antibodies and CD40L is feasible • Testing for neutrophil antibodies and bioactive lipids is possible but more difficult

39. Current Practices and Protocols: Department of Transfusion Medicine, Clinical Center, NIH Practices • Transfusion male plasma • Transfuse female AB apheresis plasma if negative for neutrophil antibodies • Defer TRALI implicated donors if an antibody to a characterized neutrophil antigen is identified Protocol • Comparison of the incidence of transfusion reactions in recipients of platelet components with and without HLA antibodies