TRALI

Transfusion related acute lung injury (TRALI)

Updated: 07/28/2025

© Jun Wang, MD, PhD

 

General features

  • Definition

o   New acute lung injury within 6 hours of transfusion

o   Lung injuries results in hypoxemia (PaO2≤300mmHg, or O2 saturation <90%) and bilateral infiltrates

o   No other risk factors for pulmonary edema

o   No pre-existing acute lung injury

  • Most common cause of death associated with transfusion
  • Commonly associated with platelets/plasma transfusion

Clinical presentations

  • Sudden onset, within up to 6 hours of initiation of transfusion
  • Most cases occur within minutes after transfusion started
  • Fever and chill
  • Cyanosis
  • Bilateral lung infiltrates on image studies
  • Transient hypertension followed by hypotension
  • Tachypnea, tachycardia, etc

Key pathogenesis

  • Most common: Donor antibodies against recipient neutrophils (anti-HLA or anti-neutrophil)
  • Less common: Recipient antibodies against donor WBC
  • Antibody-neutrophil complexes deposit in pulmonary vessels
  • Neutrophils activated by antibody binding
  • Activated neutrophils produce oxygen radicals and anti-bacterial enzymes, resulting in pulmonary endothelial injury

Laboratory findings

  • Clinical diagnosis, no lab test is needed
  • Anti-HLA and anti-neutrophil 

Management

  • Stop transfusion
  • Supportive management: oxygen, intubation, etc
  • Prevention: anti-HLA and anti-neutrophil tests

 

 

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