Transfusion-Associated Circulatory

Overload and Transfusion-Related

Acute Lung Injury
A Review of Underreported Entities With Current Updates

AJCP / Review Article

Tayler A. van den Akker, MD,1 Zachary M.
Grimes, DO,1 and Mark T. Friedman, DO2
Overview

o
To review the new current diagnostic criteria of Transfusion Aassociated Circulatory
Overload (TACO) and Transfusion Related Acute Lung Injury (TRALI)
o
Although TACO and TRALI may closely mimic one another at presentation,
differentiation is of the utmost importance as the treatment and prevention differ
greatly.
o
With the new modifications and updated proposals for TACO and TRALI, this
journal provide an up-to-date review of the etiology, pathogenesis, and current
diagnostic criteria from the current literature to emphasize the importance of
reporting while providing aid in distinguishing these reactions in the clinical setting.
Transfusion-Associated Circulatory Overload
Development of acute respiratory distress in the form of pulmonary edema, which occurs in temporal association with a prior blood product transfusion.

The recent version (2018) defines TACO as a The revised 2018 criteria define TACO as the
new onset or exacerbation of respiratory onset of respiratory symptoms within 12 hours
symptoms within 6 hours of transfusion of blood product transfusion. The patient must
cessation. The symptoms must include three or have either acute/worsening respiratory compro-
more of the following: mise or acute/worsening pulmonary edema to
classify as having TACO.
(1) acute respiratory distress, manifested by
cough, dyspnea, orthopnea, and tachypnea;

(2) elevated brain natriuretic peptide (BNP);

(3) elevated central venous pressure;

(4) evidence of left heart failure;

(5) evidence of positive fluid balance; and/or

(6) radiographic evidence of pulmonary edema.

Transfusion-Associated Circulatory Overload

Pathogenesis: Risk Factors:

Circulatory overload manifests when increased History of heart failure (41%)
intravascular pressure forces fluid into the
pulmonary vasculature. This increased pressure Renal dysfunction (44%),
leads to transudate fluid extravasation into
interstitial spaces and alveoli, thus causing Age greater than 70 years (65%).
pulmonary edema.
Transfusion-Associated Circulatory Overload
Incidence: Mitigation Strategies:

1. Underreported and challenging to - Slower transfusion rates, one unit at a time

quantify.
- Washing with volume reduction of cellular blood
components
2. Passive reporting underestimates;
active reporting suggests incidence of 1
- Preemptive diuretics
in 9,000 to 13,000 transfusions.
- Advanced supervision
3. Incidence varies in low- and high-risk
populations (1%-12%).
Transfusion-Related Acute Lung Injury
Acute transfusion reaction during or following the transfusion of plasma, plasma-containing products (RBCs, platelets, cryoprecipitate), or products prepared from large pools of plasma (IV immunoglobulin).

2019 TRALI Definition: The nomenclature change sug-gested removal of

the “possible” TRALI terminology with the
1. Acute onset of hypoxemic introduction of two new TRALI categories: TRALI
respiratory distress during or within type I and TRALI type II.
6 hours of blood product
Additional imaging modalities, such as computed
transfusion. tomography (CT) scan or ultrasound, concurrently
with the traditional chest radiograph to identify
2. Hypoxemia defined as pulmonary edema
PaO2/FiO2 ≤ 300 mm Hg or O2
saturation < 90%.
3. Imaging evidence of bilateral
pulmonary edema with no evidence
of left atrial hypertension (LAH) or
LAH not main contributor.
Transfusion-Related Acute Lung Injury

Pathogenesis: Incidence:
- Immune-mediated (First hit and Two-hit 1. Incidence ranges from 1:1,200 to
hypothesis) 1:190,000; estimates narrowed to 1 in
57,000 to 64,000 transfusions.
- Non immune mediated
2. Challenges in incidence
determination due to underrecognition
and underreporting.
Transfusion-Related Acute Lung Injury

Mitigation Strategies:
1. Shifting toward nearly male-only plasma donations to reduce
anti-HNA/HLA antibodies.
2. Screening restrictions for apheresis-donated platelets to minimize TRALI
risk.
3. Use of pooled solvent detergent (S/D)-treated plasma to dilute antibodies.
4. Hypothesized use of platelet additive solution (PAS) to reduce TRALI risk.
5. Consideration of washed or fresh blood components for patients at risk of
nonimmune TRALI.
Conclusions
TRALI and TACO Overview:
TRALI and TACO are severe and
potentially fatal complications of blood
transfusions.
Recognition and Reporting Challenges:
1. Both conditions often go unrecognized and
underreported.
2. Lack of recognition leads to delayed
treatment and prevention measures.
Conclusions

Importance of Recognition:

- Refined definitions aim to enhance clinicians ability to identify and report transfusion reactions.

- Continued advancements in the understanding of pathogenesis, risk factors, clinical presentation, and distin-
guishing features are required to contribute to management improvements and prevention of these potentially
serious transfusion reactions.
THANK YOU