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Transfusion-related Acute Lung Injury in the Critically Ill

Prospective Nested Case-Control Study

¹ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, ² Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, and ³ Division of Biostatistics, Department of Health Sciences Research, ⁴ Mayo Epidemiology and Translational Research in Intensive Care (METRIC), and ⁵ Department of Nursing, Mayo Clinic College of Medicine, Rochester, Minnesota

Correspondence and requests for reprints should be addressed to Ognjen Gajic, M.D., Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail: gajic.ognjen{at}mayo.edu

Rationale: Acute lung injury (ALI) that develops 6 hours after transfusion (TRALI) is the leading cause of transfusion-related mortality. Several transfusion characteristics have been postulated as risk factors for TRALI, but the evidence is limited to retrospective studies.

Objectives: To compare patient and transfusion risk factors between patients who do and do not develop ALI.

Methods: In this prospective cohort study, consecutive transfused critically ill patients were closely observed for development of ALI. Donor samples were collected from the transfusion bags. Risk factors were compared between patients who developed ALI after transfusion and transfused control patients, matched by age, sex, and admission diagnosis.

Measurements and Main Results: Seventy-four of 901 transfused patients developed ALI within 6 hours of transfusion (8%). Compared with transfused control subjects, patients with ALI were more likely to have sepsis (37 vs. 22%, P = 0.016) and a history of chronic alcohol abuse (37 vs. 18%, P = 0.006). When adjusted for patient characteristics, transfusion of plasma from female donors (odds ratio [OR], 5.09; 95% confidence interval [95% CI], 1.37–18.85) rather than male donors (OR, 1.60; 95% CI, 0.76 to 3.37), number of pregnancies among the donors (OR, 1.19; 95% CI, 1.05 to 1.34), number of donor units positive for anti-granulocyte antibodies (OR, 4.85; 95% CI, 1.32–17.86) and anti–HLA class II antibodies (OR, 3.08; 95% CI, 1.15–8.25), and concentration of lysophosphatidylcholine in the donor product (OR, 1.69; 95% CI, 1.10 to 2.59) were associated with the development of ALI.

Conclusions: Both patient and transfusion risk factors determine the probability of ALI after transfusion. Transfusion factors represent attractive targets for the prevention of ALI.

Key Words: fresh-frozen plasma • platelet transfusion • pulmonary edema • female • blood donors

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Transfusion-related acute lung injury is the leading cause of transfusion-related mortality and is believed to be widely underrecognized. Animal experiments and uncontrolled clinical studies suggest that specific transfusion factors play an important mechanistic role. What This Study Adds to the Field When a standardized definition was applied in a prospective cohort of critically ill patients, acute lung injury commonly occurred within 6 hours of transfusion. Plasma from alloimmunized donors predicted acute lung injury development, raising important implications for acute lung injury prevention.

 

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