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Age of blood and recipient factors determine the severity of transfusion-related acute lung injury (TRALI)

John-Paul Tung123*, John F Fraser234, Maria Nataatmadja23, Kathryn I Colebourne34, Adrian G Barnett35, Kristen M Glenister6, Anna Y Zhou6, Peter Wood27, Christopher C Silliman1089 and Yoke L Fung11123

Author Affiliations

1 Research and Development, Australian Red Cross Blood Service, 44 Musk Avenue, Kelvin Grove, Brisbane, QLD 4059, Australia

2 The School of Medicine, The University of Queensland, 288 Herston Road, Herston, Brisbane, QLD, Australia

3 The Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD 4059, Australia

4 The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD 4032, Australia

5 Institute of Health and Biomedical Innovation and School of Public Health, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Brisbane, QLD 4059, Australia

6 Research and Development, Australian Red Cross Blood Service, Corner Balston and Kavanagh Streets, Southbank, Melbourne, VIC 3006, Australia

7 Haematology Department, The Princess Alexandra Hospital, 199 Ipswich Road, Wooloongabba, Brisbane, QLD 4102, Australia

8 Research Department, Bonfils Blood Center, 717 Yosemite Street, Denver, CO 80230, USA

9 The Department of Pediatrics, School of Medicine, University of Colorado Denver, 12700 East 19th Avenue, Aurora, CO 80045, USA

10 The Department of Surgery, School of Medicine, University of Colorado Denver, 12700 East 19th Avenue, Aurora, CO 80045, USA

11 Cardiac Surgery Research Unit, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD 4059, Australia

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Critical Care 2012, 16:R19  doi:10.1186/cc11178

Published: 1 February 2012

Abstract

Introduction

Critical care patients frequently receive blood transfusions. Some reports show an association between aged or stored blood and increased morbidity and mortality, including the development of transfusion-related acute lung injury (TRALI). However, the existence of conflicting data endorses the need for research to either reject this association, or to confirm it and elucidate the underlying mechanisms.

Methods

Twenty-eight sheep were randomised into two groups, receiving saline or lipopolysaccharide (LPS). Sheep were further randomised to also receive transfusion of pooled and heat-inactivated supernatant from fresh (Day 1) or stored (Day 42) non-leucoreduced human packed red blood cells (PRBC) or an infusion of saline. TRALI was defined by hypoxaemia during or within two hours of transfusion and histological evidence of pulmonary oedema. Regression modelling compared physiology between groups, and to a previous study, using stored platelet concentrates (PLT). Samples of the transfused blood products also underwent cytokine array and biochemical analyses, and their neutrophil priming ability was measured in vitro.

Results

TRALI did not develop in sheep that first received saline-infusion. In contrast, 80% of sheep that first received LPS-infusion developed TRALI following transfusion with "stored PRBC." The decreased mean arterial pressure and cardiac output as well as increased central venous pressure and body temperature were more severe for TRALI induced by "stored PRBC" than by "stored PLT." Storage-related accumulation of several factors was demonstrated in both "stored PRBC" and "stored PLT", and was associated with increased in vitro neutrophil priming. Concentrations of several factors were higher in the "stored PRBC" than in the "stored PLT," however, there was no difference to neutrophil priming in vitro.

Conclusions

In this in vivo ovine model, both recipient and blood product factors contributed to the development of TRALI. Sick (LPS infused) sheep rather than healthy (saline infused) sheep predominantly developed TRALI when transfused with supernatant from stored but not fresh PRBC. "Stored PRBC" induced a more severe injury than "stored PLT" and had a different storage lesion profile, suggesting that these outcomes may be associated with storage lesion factors unique to each blood product type. Therefore, the transfusion of fresh rather than stored PRBC may minimise the risk of TRALI.