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TACO vs. TRALI:Recognition, Differentiation, and Investigation
ofPulmonary Transfusion Reactions
Shealynn Harris, M.D.
Assistant Medical DirectorAmerican Red Cross Blood Services
Southern Region
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Case Presentation
74 year-old female with GI bleed Transfused
1 unit Apheresis Platelets
4 units RCs
!urin" transfusion
!iffi#ulty breathin"
$ypo%ia
In#reased respiratory rate
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Considerations&
Transfusion Rea#tion
Pulmonary Transfusion Reacion
Transfusion-asso#iated #ir#ulatory o'erload
(TAC)*
Transfusion-related a#ute lun" in+ury (TRA,I*
Transfusion Reacion !ih Pulmonary
Sym"oms
Aller"i# (anaphyla%is*
epti# Transfusion Rea#tion
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)ther Considerations
Myocar#ial infarcion
Acue res"iraory #isress
syn#rome $ARDS%
Se"sis
Dru& reacion
Pneumonia
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Challen&es in Characeri'in&
Pulmonary Sym"oms
Associae# !ih Transfusion
Re#o"ni.in" a transfusion rea#tion
!ifferentiatin" between possible etiolo"ies
Criteria for dia"nosis !ia"nosti# tools
Contributin" fa#tors (e/"/0 underlyin" disease*
)btainin" #omplete #lini#al and laboratory
information
In'esti"atin" donors and understandin" results
of in'esti"ation
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Case Presentation
74 year-old female with GI bleed Transfused
1 unit Apheresis Platelets
4 units RCs
!urin" transfusion
!iffi#ulty breathin"
$ypo%ia
In#reased respiratory rate
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Pre(Transfusion
op2o P30 $olland P/ Br J Haematol/ 1555618&9::-9:5/
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Pos(Transfusion
op2o P30 $olland P/ Br J Haematol/ 1555618&9::-9:5/
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Transfusion(Associae#
Pulmonary )#ema:
TACO vs TRALI
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Pulmonary ;dema
A*normal accumulaion of flui# in he lun&
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Pulmonary ;dema
Car#io&enic $hy#rosaic%
TAC)
3yo#ardial Infar#tion
+on(car#io&enic $"ermea*iliy%
TRA,I
AR!
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Transfusion-Asso#iated
Cir#ulatory )'erload (TAC)*
olume o'erloadtemporally asso#iated withtransfusion
Si&ns an# Sym"oms hortness of breath In#reased respiratory rate
$ypo%emia
In#reased left atrial
pressure
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Transfusion-Asso#iated
Cir#ulatory )'erload (TAC)*
Inci#ence
)'erall& /1= - 1=
;lderly& up to >=
Criti#al Care& := - 11=
Moraliy
;stimated 8 - 18=
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Transfusion-Asso#iated
Cir#ulatory )'erload (TAC)*
Treamen
)%y"en
Possible intubation and me#hani#al 'entilation
!iuresis to redu#e 'olume
Also consi#er Myocar#ial Infarcion
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Transfusion-Related
A#ute ,un" In+ury (TRA,I*
,ea2a"e of fluid into
al'eolar spa#e due to
diffuse al'eolar #apillary
dama"e? Si&ns an# Sym"oms
hortness of breath
In#reased respiratory rate
$ypo%emia
$ypotension
)##asionally fe'er
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Transfusion-Related
A#ute ,un" In+ury (TRA,I*
Inci#ence
)'erall& /1@= per patient
Criti#al Care& />= per unit transfused
Tertiary Care& /4= per unit transfused
Moraliy
;stimated 8= - 1=
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Transfusion-Related
A#ute ,un" In+ury (TRA,I*
Treamen
)%y"en
Possible intubation and me#hani#al 'entilation
Possible fluids to treat hypotension
Also consi#er ARDS
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Transfusion-Related
A#ute ,un" In+ury (TRA,I*
$,I !efinition
BTRALI is #efine# as ne! acue lun&
inury occurrin& #urin& or !ihin -hrs afer a ransfusion, !ih a
clear em"oral relaionshi" o he
ransfusion/D
Crit Care 3ed/ :8 Apr699(4*&7:1-@/
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Transfusion-Related
A#ute ,un" In+ury (TRA,I*Canadian TRA,I Consensus Conferen#e !efinition
TRA,I
ew o##urren#e of a#ute onset a#ute lun" in+ury (withhypo%emia and bilateral infiltrates on #hest %-ray butno e'iden#e of left atrial hypertension
ot pree%istin" ET
;mer"in" durin" or within @ hours of the end of
transfusion A!
$a'in" no temporal relationship to an alternati'e
a#ute lun" in+ury ris2 fa#tor
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Transfusion-Related
A#ute ,un" In+ury (TRA,I*
Canadian TRA,I Consensus Conferen#e !efinition
Possible TRA,I
Cases in whi#h there was a temporal asso#iation withan alternati'e ris2 fa#tor
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TRALI is a Dia&nosis of
)clusion/e mus rule ou all oher
"ossi*le eiolo&ies *eforeren#erin& a #ia&nosis of TRALI
TAC) TRA,I
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TAC) 's/ TRA,I
!ia"nosti# Tools& Chest F-ray Pros&
Identify pulmonary edema
Identify pleural effusions (more #onsistent
with TAC)*
ee e'iden#e of other pulmonary disease
Cons& !oes not show spe#ifi# me#hanism of
edema
Radiolo"y reports are often 'a"ue
u""ested to measure 'as#ularpedi#le width and #ardiothora#i# ratioto impro'e spe#ifi#ity (ne'er seen this*
TAC) 's TRA,I
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TAC) 's/ TRA,I
!ia"nosti# Tools&
Pulmonary Artery )##lusion Pressure Insertion of #atheter into
pulmonary artery tomeasure ba#2 pressurefrom heart
Pros !efiniti'e measurement Cons
In'asi'e
In#reased morbidity andmortality www/emedi#ine/#om
Interobser'er 'ariability
,a#2s sensiti'ity andspe#ifi#ity
TAC) 's TRA,I
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cmed%5Cimages%5CLarge%5C32033203swan_ganz_catheter.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cmed%5Cimages%5CLarge%5C32033203swan_ganz_catheter.jpg&template=izoom27/26/2019 Taco vs Trali
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TAC) 's/ TRA,I
!ia"nosti# Tools& Pulmonary ;dema luid
Protein Con#entration mall #atheter inserted into the al'eoli to
measure lun" fluid protein #on#entration lood sample to measure plasma protein
#on#entration
Cal#ulate ratio pulmonary edemaHplasma protein#on#entration
Pros& ensiti'e measurement
Cons& 3ostly used in resear#h ot 'ery feasible in #lini#al settin"
3ust sample as soon as patient is intubated (diffi#ulttimin"*
TAC) TRA,I
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TAC) 's/ TRA,I
!ia"nosti# Tools&;#ho#ardio"raphy ound wa'es used to measure
heart fun#tion
Pros
ot in'asi'e ensiti'e and spe#ifi# for measurin" left
heart fun#tion (e+e#tion fra#tion*
Cons
ormal test !); )T rule out #ardio"eni#
pulmonary edema
TAC) s TRA,I
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TAC) 's/ TRA,I
-type atriureti# Peptide (P* $ormone released from heart with 'olume e%pansion in
'entri#les from pressure o'erload
P :8 p"Hm, more #onsistent with TRA,I
Pros&
;asy to measure ensiti'e and spe#ifi# indi#ator of #ardio"eni# pulmonary
symptoms
Pre-transfusion to post-transfusion ratio has relati'ely "ood sens
and spe#
Can be used to rule out TAC) Cons&
iolo"i#al 'ariability
Jho measures P before transfusionK
ew onset hypo%emia& Pa):HI): 9 or Arterial )%y"en aturation 5= on
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y y"room air
Chest %-ray& new or worsenin" bilateral infiltrates #onsistent with pulmonary edema
ymptoms started within @h of transfusion
;demaHplasma protein #on#entration L/@8
Pulmonary artery o##lusion pressure 1> mm$"
P :8 or preHpost transfusion P ratio 1/8
Absen#e of rapid impro'ement with 'olume redu#tion (diureti#s*
Two of the followin"&
?ystoli# e+e#tion fra#tion L48 and no se'er 'al'ular heart
disease ?ystoli# P 1@
?as#ular Pedi#le Jidth @8 mm and Cardio-thora#i# ratio /88
+O 0)S
CARDIO1)+IC +O+(CARDIO1)+IC
P2LMO+AR0 )D)MA P2LMO+AR0 )D)MA
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CARDIO1)+IC
P2LMO+AR0 )D)MA
ew ;CG is#hemi# #han"es )R
ew Troponin T L /8
0)S +O
Car#iac TACO
Ischemia
+O+(CARDIO1)+IC
P2LMO+AR0 )D)MA
Clear temporal relationship to
another A,I ris2 fa#tor (sepsis0
aspiration*
+O 0)S
TRALI Possi*le
TRALI
Gajic O et al. Crit Care Med 2006;34(5) Suppl: 109-113.
TRALI TACO
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TRALI TACO
Dyspnea M; M;
Arterial blood gas $ypo%emia $ypo%emia
Blood Pressure ,ow to ormal ormal to $i"h
Temperature ormal to ;le'ated ormal
Chest X-ray Jhite out/ ormal heart Jhite out/ ormal tosi.e/ o 'as#ular in#reased heart si.e/#on"estion/ as#ular #on"estion/
Pleural effusions/
BNP ,ow (:8 p"Hm,* $i"h
Pulm artery occlusion ,ow to ormal $i"hpressureEchocardiogram ormal heart fun#tion Abnormal heart
fun#tionesponse to Jorsens Impro'esDiuretics
eponse to !luids Impro'es Jorsens
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/ha a*ou Tesin& for Donor
Leu3ocye Ani*o#ies4
Ani(HLA
Ani(1ranulocye $ani(H+A%
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TRA,I and ,eu2o#yte Antibodies
Patho"enesis of TRA,I is not #lear
ew #ontrolled e%perimental studies ofTRA,I
,a#2 of in 'i'o animal model Two $ypotheses
!onor leu2o#yte antibodies bind to re#ipient
neutrophils whi#h #ause a#ute lun" in+ury ioa#ti'e lipids in stored blood BprimeD
neutrophils whi#h #ause a#ute lun" in+ury
Popo's2y et al Trans#usion6 15>8 :8&879 877
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Popo's2y et al" Trans#usion6 15>8/ :8&879-877/
Test n =
Granulo#yte antibodies
Patient : @
Donor 9: >5
,ympho#ytoto%i# :@ 7:antibodies (donor*
$,A-spe#ifi# antibodies 11N @8
$,A-anti"en 1N 85(patient*Hantibody#orresponden#e
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!ensmore et al"Pre'alen#e of $,A sensiti.ation in female
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apheresis donors/ Trans#usion"1555695&19-1@/
Pre&nancies +um*er +um*er Percena&e
Tese# Sensii'e# of /omen
Sensii'e#
19 > 7/>
1 99 8 18/:: 7 1 14/9
9 8> 18 :8/5
4 99 1 9/9
L8 :7 @ ::/:
All women 9:4 84 1@/@
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E $)T !ata
TRA,I ris2 is 8 to 7 fold "reater in#omponents #ontainin" hi"h 'olume
of plasma
3a+ority of TRA,I #ases in'ol'edleu2o#yte-antibody positi'e female donors
)#t :9& E mo'ed to male-only plasma
i"nifi#ant redu#tion in TRA,I #ases in Esin#e
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ARC !ata
TRA,I reports :9-:8 (n O 88*
9> #ases of probable TRA,I
:4 related to plasma transfusion
78= #ases in'ol'ed plasma from
leu2o#yte-antibody positi'e female donors
;der A et al/ Transfusion :7 in press/
TRA,I& In i'o 3ouse 3odel
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TRA,I& In i'o 3ouse 3odel
heppard CA et al/ $ematol )n#ol Clin Am :76:7&1@9-17@/
ray RA0 $arris 0
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for transplant patients& $,A antibodies in blood #omponents/
$um Immunol :46@8(9*&:4-4/
Class I Class II Class I 5 ToalCom"onens $n% n $6% n $6% Class II n $6%
n $6%
R7Cs $89-% 7 (7* > (>* 9 (9* 1> (17*
Cryo $--% 9 (8* 9 (8* 1 (18* 1@ (:4*
Pls $;% 7 (1:* 8 (5* 1 (:* 19 (::*
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Challen"es
o #lear test for TRA,I
,eu2o#yte antibody positi'e donor !); )T
eual TRA,I dia"nosis
In#iden#e of $,A antibodies in donors is 'eryhi"h relati'e to number of TRA,I #ases
3any TRA,I #ases are not asso#iated with
leu2o#yte antibodies
3assi'e transfusion& odds are hi"h that at least
one donor will be positi'e
C P t ti
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Case Presentation
74 year-old female with GI bleed Transfused
1 unit Apheresis Platelets
4 units RCs !urin" transfusion
!iffi#ulty breathin"
$ypo%ia In#reased respiratory rate
In'esti"ation of Pulmonary
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In'esti"ation of Pulmonary
Transfusion Rea#tions Rule out ;;RMT$IG before dia"nosin"
TRA,I
Clini#al Presentation& eed as mu#h informationas possible
Timeline of ;'ents& Temporal relationship oftransfusion to symptoms
!ia"nosti# tudies& Chest %-ray0 P0;#ho#ardio"ram0 lood #ultures
!onor Testin"& only if hi"hly suspi#ious forTRA,I 3ale donor& no testin" unless transfusion h%
emale donor& if test positi'e0 then defer
$,A #rossmat#h positi'e& more supporti'e of TRA,I
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ummary
e'eral etiolo"ies to #onsider with pulmonarysymptoms durin" transfusion
Pulmonary edema within @ hrs of transfusion
#onsider TAC) and TRA,I Consider #lini#al presentation and all dia"nosti#
studies
o spe#ifi# dia"nosti# study
TRA,I is a !IAG)I ) ;FC,EI)
TRA,I is not dia"nosed by positi'e leu2o#yte
antibody test alone