1. 輸血後疑似TRALI案例報告
台中榮民總醫院病理檢驗部 血庫
謝獻旭

3. Case Presentation (1) MER case Chief complaint Present illness
Admission Date 99/03/19
Age 54 year(s) old
Female
Chief complaint
Acute onset of persistent Gum bleeding for 4-5 days
Present illness
Increased episodes of common cold in recent months
Fatique, weakness, sorethroat, and poor appetite developed
she noted that she has ecchymosis easily after trauma.(搥背後會有瘀青) for weeks
In recent one week, sudden onset of persistent gum bleeding was noted
Past history
Hypertension under regular medication
HBV carrier

4. Lab. Data (1) CBC: Other’s DIC profiles (+)
leukocytosis(WBC=15100/cumm),
anemia(Hb=7.7 g/dl), and
thrombocytopenia(plt=10000/cumm)
DC：Blast: 2%, promyelocyte: 69%,
myelocyte: 4%, meta.: 1%, band: 2%,
segment: 8%, lymphocyte: 13%, monocyte: 1%
Other’s DIC profiles (+)
Prothrombin time : ( C: 10.3 SEC P: SEC) INR: R ( );
APTT : ( C: 27.4 SEC P: SEC) ( )
D-Dimer : ug/L D.D.U ( < 324 ug/L D.D.U)
Fibrinogen < 100

5. Lab. Data (2) CRP: 12.16 mg/dL ( < 0.3 mg/dL)
LDH: U/l ( )
BM aspiration & biopsy: acute promyelocytic leukemia
Flow cytometry: CD33(+); HLDR (-)
Meta-phase cytogenetic data: t(15;17)

6. Hospital Course
Diagnosis: Acute promyelocytic leukemia (FAB classification: M3)
Initial treatment:
All-trans-retinoid acid (ATRA)(dose :45mg/m2 /day)
Blood transfusion: 2 Unit packed RBC
8 Units FFP + 1 unit Plateletpheresis
After blood transfusion she suffered from acute onset of dyspnea hypoxia and hypotension
Transfer to ICU

7. CXR Before Transfusion After Transfusion
Chest X ray looks like ARDS(Acute Respiratory Distress Syndrome )

8. TRALI Definition New ALI：
Acute onset
Hypoxia O2sat≦90％ on room air
Bilateral infiltrates on frontal chest radiograph
No evidence of atrial hypertension
Onset of symptoms within 6 hours of transfusion
No preexisting ALI before transfusion

9. TRALI:What are the triggers?

10. Leukocyte Antigens Implicated in TRALI
Leukoagglutinins
HLA antibodies
Neutrophil-specific
antibodies
Human Neutrophil Antigens
HNA-1 (1a, 1b, 1c)
HNA-2
HNA-3 (3a,2009)
HNA-4 (2009)
HNA-5 (2009)
Human Leukocyte Antigens
HLA Class I
HLA Class II

11. Bioactive Lipids
Accumulate during the storage of cellular blood products (lysophosphatidylcholine, L-PC)
Prime neutrophils: primed neutrophils have a greater response to activating agents
Enhance neutrophil-mediated lung injury in animal models
Prospective and retrospective studies have found greater levels of bioactive lipids in TRALI implicated units or post-transfusion sera from TRALI patients than controls
Silliman et al. Transfusion. 1997;37:719-26
Silliman et al. Blood. 2003;101:454-62

12. Levels increase in stored platelets Primes neutrophils
Soluble CD40L
Released by platelets
Levels increase in stored platelets
Primes neutrophils
Inhibition of CD40-CD40L system reduces acute lung injury in animal models
A case-control study found higher sCD40L levels in TRALI-implicated units than in control units
Khan et al. Blood. 2006;108:

13. Clinical Management Stop the transfusion Respiratory Support
Supplemental oxygen
Mechanical ventilation
Pressor agents
Rule out of other causes of respiratory distress
No evidence of role for diuretics or steroid

14. TRALI: Clinical Course
Symptoms generally resolve in 24 to 48 hours
Symptoms may resolve before diagnosis is made
Mortality 10% to 50%
Moore SB. Critical Care Medicine 2006; 34: S
Rana R et al. Transfusion 2006;46:

15. Patient Factors TRALI is more common in Surgery patients
Patients with hematological malignancies and cardiac disease
Moore. Crit Care Med 2006; 34: S114-S117
Silliman et al. Blood 2003; 101:

16. TRALI:Most Frequently Implicated Blood Product
Red Blood Cells
Fresh Frozen Plasma
Platelet Concentrates
Apheresis Platelets

17. SHOT Annual Report 2009

18. SHOT Annual Report 2009

19. There is no diagnostic test for TRALI and it is easily confused with other causes of acute lung injury, circulatory overload or infection

20. TRALI (Transfusion-Related Acute Lung Injury )
TACO (Transfusion-Associated Circulatory Overload )

21. TACO (Transfusion-Associated Circulatory Overload )
在短時間內輸血量超過病人生理之耐受量
易發生於：
慢性貧血而血液體積正常者
老年者
心臟功能不佳者
Acute respiratory distress
Acute or worsening pulmonary edema
Evidence of positive fluid balance.
Tachycardia
Increased blood pressure

22. TRALI (Transfusion-Related Acute Lung Injury )
TACO (Transfusion-Associated Circulatory Overload )
ATRA syndrome

23. 臨床發現以all-trans-retinoic acid (簡稱ATRA) 治療APL可達高緩解率，並可減少出血性併發症。
All-trans-retinoid acid (ATRA)
臨床發現以all-trans-retinoic acid (簡稱ATRA)
治療APL可達高緩解率，並可減少出血性併發症。
2 doses of ATRA
2 doses of ATRA
2 doses of ATRA

24. ATRA syndrome is an unpredictable but frequent complication of the use of ATRA to treat APL. Prominent respiratory distress with concurrent symptoms that are often less immediately appreciable, may lead to the misdiagnosis
JASON P. et al Psychosomatics :

25. Diagnosis of ATRA syndrome
association of at least three of the following signs
weight gain
fever
respiratory distress
lung infiltrates
pleural or pericardial effusion
hypotension
renal failure
S de Botton et al Leukemia (2003) 17, 339–342.

26. CXR (after steroid treatment)
99/03/22
99/03/23
99/03/26

27. TRALI (Transfusion-Related Acute Lung Injury )
TACO (Transfusion-Associated Circulatory Overload )
ATRA syndrome
Atypical pneumonia

28. Discussion TRALI => Steroid +通報捐血中心 TACO => Diuretics + ICU
ATRA syndrome => Steroid + DC drug
Atypical pneumonia=> Antibiotics

29. Thank You!!