Transfusion-related acute lung injury: incidence and risk factors

Abstract

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related mortality. To determine TRALI incidence by prospective, active surveillance and to identify risk factors by a case-control study, 2 academic medical centers enrolled 89 cases and 164 transfused controls. Recipient risk factors identified by multivariate analysis were higher IL-8 levels, liver surgery, chronic alcohol abuse, shock, higher peak airway pressure while being mechanically ventilated, current smoking, and positive fluid balance. Transfusion risk factors were receipt of plasma or whole blood from female donors (odds ratio = 4.5, 95% confidence interval [CI], 1.85-11.2, P = .001), volume of HLA class II antibody with normalized background ratio more than 27.5 (OR = 1.92/100 mL, 95% CI, 1.08-3.4, P = .03), and volume of anti-human neutrophil antigen positive by granulocyte immunofluoresence test (OR = 1.71/100 mL, 95% CI, 1.18-2.5, P = .004). Little or no risk was associated with older red blood cell units, noncognate or weak cognate class II antibody, or class I antibody. Reduced transfusion of plasma from female donors was concurrent with reduced TRALI incidence: 2.57 (95% CI, 1.72-3.86) in 2006 versus 0.81 (95% CI, 0.44-1.49) in 2009 per 10 000 transfused units (P = .002). The identified risk factors provide potential targets for reducing residual TRALI.

Figures

Figure 1

Enrollment of TRALI cases and controls at 2 academic centers (2006-2009). All RBC and platelet units (all collected by apheresis) were leuko-reduced. To determine risk factors, 89 TRALI cases and 164 controls that occurred during the case-control study period from March 1, 2006 to August 31, 2009 were included. DAH indicates diffuse alveolar hemorrhage; ILD, interstitial lung disease; CVP, central venous pressure; and TACO, transfusion associated circulatory overload.

Figure 2

TRALI incidence by year at 2 academic medical centers (2006-2009). Reduction of high-risk plasma was implemented from 2007 to 2008. In 2006, neither center had started TRALI mitigation. In 2009, both centers had completed TRALI mitigation. The annual TRALI incidence decreased from 2.57 (95% CI, 1.72-3.86) per 10 000 units transfused (23 cases/89 321 units) in 2006 to 0.81 (95% CI, 0.44-1.49) per 10 000 units transfused (10 cases/123 731 units) in 2009. *P = .002. There was an estimated 35% reduction in TRALI per year by trend analysis (95% CI, 21%-47%, P < .0001).