TRALI Cases and Chapter Session Tanya Petraszko MD FRCPC CBS BC & Yukon January 2010
Dec 28, 2015
TRALICases and Chapter Session
Tanya Petraszko MD FRCPCCBS BC & YukonJanuary 2010
What is Transfusion-related Acute Lung Injury?
Sudden onset of “Acute Lung Injury” occurring within 6 hours of a transfusion
Acute Lung Injury Hypoxemia New bilateral chest X-ray infiltrates No evidence of volume overload
Canadian Consensus Conference Definition. Kleinman et al. Transfusion 2004;44:1774-89
Features of TRALI
SOB and abnormal CXR Fever, hypotension
onset is usually within the first 1-2 hours of transfusion, but may be delayed up to 6 hours
Normal CXR Patient’s CXR
TRALI Mortality
TRALI appears to be the most common cause of transfusion-related mortality
Reports to the FDA of transfusion-related deaths: TRALI > bacterial sepsis > acute hemolysis
Estimated rate of fatalities is 5 – 10%
Transfusion Related Fatalities Reported to FDA 2003-2005
Cause #cases (% of fatalities) TRALI 72 (32%) Bacterial sepsis 25 (11%) AHTR 23 (10%) Other 71 (32%) Not clearly tx related 34 (15%) Total 225 (100%)
Leading Cause of Adverse Transfusion Events reported to Health Canada
45
95
118 113 112
133
1017
30
48 42 46
0
20
40
60
80
100
120
140
2001 2002 2003 2004 2005 2006Nu
mb
er o
f A
dve
rse
Rea
ctio
ns
Total AR
TRALI
1 / 102
1 / 103
1 / 104
1 / 105
1 / 106
1984 1988 1992 1996 2000 2004
Tra
nsfu
sion
Ris
k pe
r U
nit
HCV
HIV
Evolution of Transfusion RisksHIV and HCV vs TRALI
Estimated TRALI fatality (?)
Estimated TRALI risk
Adapted from Goodnough L and Aubuchon J
WBC Antibody Hypothesis Antigen-Antibody reaction triggers TRALI
Activation
Lodged in pulmonary capillaries
Recipient WBC- Neutrophils- Lymphocytes- Monocytes
Donor-Anti-HNA-Anti-HLA I-Anti-HLA II
Release of substances causing pulmonary endothelial damage and capillary leak
Courtesy of Y. Lin
Clinical Correlation
Right, single lung transplant
10 weeks after transplant, transfused PRBCs for anemia
HLA B44 antibody in PRBC donor
HLA B44 antigen present in lung donor tissue only
Elegant clinical example of targeted endothelial injury from a blood transfusion
Dykes et al. Br J Haematol 2000.
What evidence is there for this
Many studies demonstrate HLA or leukoagglutinating alloantibodies in donors
Several examples of donor-recipient antigen/antibody concordance
Anti HLA class I and II implicated Anti-neutrophil antibodies implicated
Evidence for antibody theory ex vivo isolated rabbit lung model severe lung vascular leakage was
reproduced using a human anti-neutrophil antibody in the presence of cognate, human 5b-positive neutrophils
In contrast, no vascular leakage was noted in lungs perfused in the absence of either antibody, neutrophils, or a complement source.
No permeability increase occurred with the use of 5b-negative neutrophils
Seeger Blood. 76:1990.
Antibody theory animal models isolated perfused rat lungs perfused them with plasma containing anti HNA-2a mAb and
human neutrophils. If neutrophil expression of HNA-2a antigen was >70%, ALI
was manifest; if antigen expression was <30%, ALI was not manifest. However, if the lungs were primed with fMLP then lung
injury was induced in the group with < 30% antigen expression.
Thus, if there is no relevant first hit (priming with fMLP), TRALI may not be manifest even with cognate antibody unless the cognate antigen expression meets a certain threshold.
also demonstrated that anti-HNA 2a directly activates neutrophils in the absence of complement
Sachs Blood. 107(3): 2006.
Anti-neutrophil Antibodies (HNA-2a)
Sachs et al, Blood 2006.
+FMLP
Slide from Looney MD, UofC, SF
Non antibody mediated TRALI
15% of typical TRALI cases fail to demonstrate antibody
alternate hypothesis that some cases may be non-antibody mediated
Biologically active molecules contained in stored blood products lysophosphatidylcholines interleukins
What evidence is there for this Rats pre-treated with LPS developed acute lung injury
(ALI) when the lungs were perfused with plasma Rats did not get ALI with LPS alone
Rats pretreated also got ALI with lipids extracted from stored 42 day old human RBCs or platelets
Did NOT get ALI if given lipids from 5 day product thus plasma or lipids from fresh, human RBCs or
platelets did not cause lung injury.
Silliman CC J. Clin.Invest 101(7): 1998
Silliman CC Transfusion. 43: 2003
Two Event Model
Recipients of blood containing anti WBC antibodies don’t all get TRALI
perhaps two events required to manifest TRALI (as in ARDS) Predisposing clinical condition Infusion of biologically active mediators
First event results in activation of pulmonary endothelium with neutrophil priming
Second event results in activation of the neutrophils adherent to pulmonary endothelium and subsequent lung injury
Two event hypothesis
Silliman et al. Blood 2003;101:454-62Kleinman et al. Transfusion 2004;44:1774-89
1st event: Underlying clinical condition of patient (inflammation, infection, surgery)
Activation of pulmonary endothelium with increased adhesion molecules
2nd event: Transfusion of biologically active lipids or antibodies
Activation
Release of substances causing pulmonary endothelial damage and capillary leak
Evidence from animal models 2-event in vivo rat model first event
saline (NS) or endotoxin (LPS)
second event plasma from stored, human packed red blood cells
(PRBCs) or antibodies (OX18 and OX27) against rat MHC Class I
antigens NS treated rats did not develop TRALI
With plasma nor with antibody LPS treated rats developed ALI
With plasma and with antibody
Kelher Blood. 113(9):2009.
Neutrophil depleted rats had experiment
repeated and all failed to demonstrate ALI Confirmed that ALI is neutrophil dependent
also demonstrated that anti-MHC Class I localized to the neutrophil surface
They concluded that TRALI is the result of 2 events with the examples of the second event being plasma from stored blood and antibodies that prime neutrophils.
Case of recurrent TRALI52 year old female 4 months post allo BMT for myelofibrosis; transfusion dependent
2007-02-10 received 2 units red cells uneventfully as an outpatient. Discharged but became acutely SOB on way home,
returned to ER CXR showed bilateral new infiltrates Decreased sats, intubated and ventilated for 30 hours then
extubated and recovered.
Results of Investigation Recipient results: post- sample: Negative
Donor 1st unit negative Donor 2nd unit positive for anti HLA antibody
Crossmatch donor 2 with recipient positive
Case of recurrent TRALI52 year old female 4 months post allo BMT for myelofibrosis; transfusion dependent
2007-03-19 Had been discharged home receiving regular outpatient
transfusions 2x/week after transfusion of 2 units of RCC developed new onset
SOB, new CXR infiltrates and PO2<60. Required mechanical ventilation.
Results of Investigation Recipient results: pre-samples: positive anti HLA post-sample: positive anti HLA No crossmatch done
Donor 1st unit positive anti HLA antibody Donor 2nd unit positive anti HLA antibody
Two event model
In first TRALI event, implicated donor associated platelet unit did not cause TRALI in the recipient it was given to
That recipient was not primed or did not have cognate antigen….
Evidence from animal models in vivo mouse model BALB/c wild-type mice positive for MHC
Class I antigen were injected with MHC Class I mAb via the jugular vein and sacrificed at 2 hours.
Control mice were knock out mice negative for the antigen
Injection of MHC Class I mAb produced severe ALI in wild type mice with 50% mortality compared to controls negative for the cognate antigen.
Looney MRJ. Clin. Invest. 116:(2006)
0
20
40
60
80
100
120
140
0
20
40
60
80
100
120
140
160
180 BALB/K + MHC I mAb BALB/c + Isotype control mAb
BALB/c + MHC I mAb
Exc
ess
lun
g w
ate
r (µ
l)
EV
PE
(µ
l)
** **
0
20
40
60
80
100
15 30 45 60 75 90 105 120
Su
rviv
al (
%)
(Minutes)
**
PBS or Isotype control mAb
MHC I mAb
MHC I antibody produces severe ALI in mice
Evidence from animal models
• The MHC Class I mAb binds throughout the body and prominently in the lung microvasculature.
• The investigators demonstrated that this antibody also binds to neutrophils, but does not cause direct neutrophil activation.
Looney MRJ. Clin. Invest. 116:(2006)
Evidence from animal models Mice were also neutrophil depleted with GR-1 antibody
these mice were protected from lung injury. Thus the absence of circulating neutrophils renders the bound
antibody on lung tissue inert and unable to cause vascular permeability.
Using a knockout mouse it was further demonstrated that it was the Fc gamma receptor which was essential in responding to the antibody challenge.
The Fc gamma receptor knock out mice were fully protected from lung injury, however when wild type neutrophils were transfused back, the lung injury was restored.
Thus in this model, MHC Class I antibody binds to class I antigen on the endothelium then presents the Fc portion of the antibody to the neutrophil Neutrophil is then activated thru Fc gamma receptor engagement.
demonstrated a critical role for neutrophil Fc gamma receptors in mediating ALI.
Looney MRJ. Clin. Invest. 116:(2006)
Summary so far Clinical features of TRALI Leading cause of TR mortality Majority appear to be antibody
mediated Animal models support this
So….why don’t we always see TRALI when antibody and cognate ag are present?
Effect of environment on priming Mice were housed in specific-pathogen free
barrier conditions vs. non-barrier housing Repeated TRALI model
Barrier mice were protected from TRALI non barrier mice did develop ALI.
Barrier mice demonstrated lower levels of circulating neutrophils suggesting that this is the reason why they did not
respond to the second hit since this model is neutrophil dependent.
if barrier mice were primed with LPS prior to receiving anti-MHC Class I mAb, then they did develop ALI in a dose-dependent manner.
Looney. J Clin Invest. 119(11): 2009
Anti-neutrophil Antibodies (HNA-2a)
Sachs et al, Blood 2006.
+FMLP
Slide from Looney MD, UofC, SF
Role of neutrophils in ALI microfluidics model of the lung microcirculation. MHC Class I mAb is immunoadsorbed to the artificial
capillary bed, and the unbound antibody is removed by washing.
Next, Fc gamma receptor knockout neutrophils or wild-type neutrophils are perfused.
video demonstrates that Fc gamma receptor knockout neutrophils zip right through the capillaries as they cannot engage the bound antibody
wild-type neutrophils all get stuck as they engage the bound antibody through their Fc gamma receptor.
Effect of hematopoetic cells in priming hematopoietic chimeras TLR4 mice, which
are LPS unresponsive TLR4 mice reconstituted with TLR4 bone
marrow were protected in the two-event model of TRALI (LPS + MHC Class I mAb).
However, when TLR4 mice were reconstituted with wild-type bone marrow, lung injury was manifest
thus demonstrating that hematopoietic cells are the critical population that must be primed to produce lung injury.
Looney. J Clin Invest. 119(11): 2009
Conclusions from animal models Well developed animal models support the
two event hypothesis of TRALI. effective ‘second hits’ in TRALI
Neutrophil or MHC Class I antibodies or plasma or lipids from stored, human RBCs
Priming of hematopoietic cells is necessary in experimental TRALI and may be the ‘first hit’.
Common to all experimental models, neutrophils are the key effector cell in TRALI.
How can we prevent TRALI?
We have evidence that antibodies are responsible for TRALI in a primed host
How can we identify a primed host? Fresher product for the primed host?
How can we prevent TRALI? TRALI reduction strategies have focused on
donors with antibodies and specifically plasma containing products
Secondary – Measures taken to identify the cause of a reaction that has occurred and prevent it from happening again
Primary – Preventive measures taken to eliminate the risk before it happens in the first place
How can we prevent TRALI Secondary…defer implicated donors
Donors associated with a reported TRALI are investigated for anti HLA and anti neutrophil antibody and deferred if positive
Pilot 2001 – 2006, SOP 2006 Primary…avoid donors with anti HLA or anti
neutrophil antibody what have blood suppliers done and what
has the effect been Donor loss Reduction of TRALI
Which donors develop WBC antibodies?
WBC alloimmunization may occur following previous exposure to WBCs through pregnancy or transfusion 332 female plateletpheresis donors 17% had detectable anti-HLA antibody Frequency of HLA antibodies increased with
pregnancy:
0 pregnancies: 7.8%1-2 pregnancies: 14.6% 3 or more: 26.3%
Densmore et al. Transfusion 1999;39:103-6
Primary Prevention 2003 – UK changed component production
policy moving to predominantly male plasma for transfusion
2003 2004 2005
TRALI 36 23 23
Highly likely/probable
22 13 6
Chapman et al. Vox Sang 2006;91(Suppl 3):227
SHOT data 10 years hemovigilance in UK and impact of
preferential use of male donor plasma Risk of highly likely/probable TRALI due to
FFP decreased 15.5 per million units 1999-2004 3.2 per million units issued 2005-2006 (p=
0.0079) Risk of highly likely/probable TRALI due to
platelets decreased 14 per million to 5.8 per million
Chapman.Transfusion 2009;49:440-452
TRALI reduction measures CBS-predominantly male plasma
CBS moved to predominantly male plasma for transfusion Oct 2008
Female plasma diverted fractionation
Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 Q1
Total 6 6 6 16 14 21 35 19* 1
Tor 4 6 6 10 6 10 26 5 1
Edm 1 0 0 3 3 1 0 0* 0
TRA
LI p
ilot p
roje
ct C
CC
Janu
ary
(12h
rs)
TRA
LI C
CC
Apr
il (6
hou
rs)
BC
Edm
onto
n (M
arch
)
(Oct
ober
) m
ale
only
pla
sma
BC
Tor
onto
(Jan
uary
)
TRALI the CBS Experience – Definite and Possible
BC B
C &
Y (M
arch
)
SMH: GIFT, LIFT, LCT, X-Match when possible CBS:Luminex HLA
TRALI Reduction Measures – Platelet Apheresis
On July 20, 2009 CBS started asking all female platelet donors if they’d ever been pregnant
Any responding positively redirected to whole blood
Donor Loss YTD
June 2009 there were 2394 female apheresis platelet donors
By Nov 2009 only 300 active female apheresis platelet donors
32% of the remaining donors converted to whole blood or plasma (approx 765 donors)
Net loss of approx 1329 donors
BC&Y Platelet Imports and Issues (Doses)
0.0 K
2.0 K
4.0 K
6.0 K
8.0 K
10.0 K
12.0 K
14.0 K
16.0 K
18.0 K
20.0 K
Imp
ort
s an
d I
ssu
es
0.0%
2.5%
5.0%
7.5%
10.0%
12.5%
15.0%
17.5%
20.0%
22.5%
25.0%
% Im
po
rts
/ Iss
ue
Imports 650 1,335 2,344 3,642 2,559
Issues 12,829 14,318 15,599 17,412 17,719
% Imports/Issue 5% 9% 15% 21% 14%
2004/05 2005/06 2006/07 2007/08 2008/09
F2008/09 reversed the trend of large rises in the number of platelet imports.
TRALI – Platelet Apheresis In BC, LVPs allowed CBS to continue to meet
platelet demand with fewer imports
The number of platelet apheresis units collected since implementation of the TRALI reduction measures has not decreased, in fact increased with 38% growth
BC Yukon data National growth: 6% National data: LVP target 34.5% actual YTD
23.4%
Summary Primary Prevention
Reports of TRALI have decreased since shift to male plasma
Consistent with experience elsewhere Donor loss due to deferral of
previously pregnant females largely mitigated by collection of double platelets
Will there be enough snow for the Olympics??
Questions?