Transfusion related acute lung injury-TRALI: a review

Javier Alcazar-Castro, Alejandro Zarate-Aspiros, Elias Andrade-Cuellar, Brenda Alvarez-Perez, Alan I. Valderrama-Treviño, Juan J. Granados-Romero, Rodrigo Banegas-Ruiz, Baltazar Barrera-Mera, Cristopher Alvarado-Rodriguez, Karen Uriarte-Ruiz


Acute pulmonary damage caused by transfusion is characterized by the sudden onset of respiratory distress in newly transfused patients within 6 hours after the transfusion, bilateral infiltrative changes in chest X-ray, PaO2/FIO2 <300 mmHg, absence of other risk factors for acute lung injury and absence of signs suggesting cardiogenic origin of pulmonary edema. Being one of the most serious complications of blood transfusion, plasma is the most involved factor, although all blood components can cause it, and is caused by antigen reactions/leukocyte antibody and lipid activity with ability to modify the biological response on primitive leukocytes. The diagnosis is based on the integration of clinical, radiological and gasometric elements, ruling out the rest of the possible causes of acute lung injury. Its differential diagnosis should include hemodynamic overload, anaphylactic reaction, bacterial contamination of transfused blood products and transfusion hemolytic reaction. The treatment is supportive measures based on the needs and does not differ from the treatment of acute lung injury secondary to other etiologies, severe cases require endotracheal intubation and mechanical ventilation while the non-severe can be managed with oxygen therapy.


Blood products, Pulmonary injury, Plasma, Risk factor, Respiratory insufficiency, Transfusion

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Frazier, S, Higgins, J, Bugajski A, Jones AR, Brown MR. Adverse reactions to transfusion of blood products and best practices for prevention. Crit Care Nurs Clin North Am. 2017;29(3):271-90.

Mitra B, O’Reilly G, Cameron PA, Zatta A, Gruen RL. Effectiveness of massive transfusion protocols on mortality in trauma: a systematic review and meta-analysis. ANZ J Surg. 2013;83(12):918-23.

Cantle PM, Cotton BA. Prediction of massive transfusion in trauma. Crit Care Clin. 2017;33(1):71-84.

McDaniel L, Etchill EW, Raval JS, Neal MD, State of the art: massive transfusion. Transfus. 2014;24(3):138-44.

Liu J, Khitrov MY, Gates JD, Odom SR, Havens JM, et al. Automated analysis of vital signs to identify patients with substantial bleeding before hospital arrival: a feasibility study. Shock. 2015;23(5):429-36.

Johansson PI, Stensballe J, Hemostatic resuscitation for massive bleeding: the paradigm of plasma and platelets. review current literature. Transfusion. 2010;50(3):701-10.

Neal MD, Marsh A, Marino R, Kautza B, Raval JS, Forsythe RM, et al. Massive transfusion: an evidence-based review of recent developments, Arch Surg. 2012;147(6):563-71.

Añóna J, García de Lorenzo A, Quintana M, Gonzalez E, Bruscas MJ. Lesión pulmonar aguda producida por transfusión Transfusion-related acute lung injury. Med Intensive. 2010;34(2):139-49.

Benjamin RJ. Tracking TRALI in target populations. Blood. 2011;117(16):4163-4.

Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma.2007;63:805-13.

Callcut RA, Cotton BA, Muskat P, Fox EE, Wade CE, Holcomb JB, et al. Defining when to initiate massive transfusion [mt]: A validation study of individual massive transfusion triggers in prommtt patients. The J Trauma Acute Care Surg. 2013 Jan;74(1):59.

Triulzi DJ. Transfusion-related acute lung injury: current concepts for the clinician. J Anest Analg. 2009;108(3):770-6.

Wallis JP. Transfusion-related acute lung injury (TRALI): presentation, epidemiology and treatment. Intensive Care Med. 2007;3(1):12-6.

Win N, Montgomery J, Sage D, Street M, Duncan J, Lucas G, Recurrent transfusion-related acute lung injury. Transfusion. 2001;41(11):1421-5.

Jürgen Bux, Sachs UJ. The pathogenesis of transfusion‐related acute lung injury (TRALI). British J Hematology. 2007;136(6):788-99.

Oldman M, Webert KE, Arnold DM, Freedman J, Hannon J, Blajchman Ma, et al. Proceedings of a consensus conference: towards and understanding of TRALI. Transfus Med Rev. 2005;19(1):2-31.

Kleinman SH, Triulzi DJ, Murphy EL, Carey PM, Gottschall JL, et al. The Leukocyte Antibody Prevalence Study-II (LAPS-II): a retrospective cohort study of transfusion-related acute lung injury in recipients of high-plasma-volume human leukocyte antigen antibody-positive or -negative components. Transfusion. 2011;51(10):2078-91.

Dykes A, Smallwood D, Kotsimbos T, Street A, Transfusion-related acute lung injury (Trali) in a patient with a single lung transplant. Br J Haematol. 2000;109(3):674-6.

Vlaar AP, Juffermans NP. Transfusion-related acute lung injury: a clinical review. The Lancet J. 2013;382(9896):984-94.

Haemovigilance., 2018. Available at: Accessed on 19 September 2018.

Toy P, Popovsky MA, Abraham E, Ambruso DR, Holness LG, Kopko PM, et al. National Heart, Lung and Blood Institute Working Group on TRALI. Transfusion-related acute lung injury: definition and review. Crit Care Med. 2005;33(4):721-6.