Reducing noninfectious risks of blood transfusion

Abstract

As screening for transfusion-associated infections has improved, noninfectious complications of transfusion now cause the majority of morbidity and mortality associated with transfusion in the United States. For example, transfusion-related acute lung injury, transfusion-associated circulatory overload, and hemolytic transfusion-reactions are the first, second, and third leading causes of death from transfusion, respectively. These complications and others are reviewed, and several controversial methods for prevention of noninfectious complications of transfusion are discussed, including universal leukoreduction of erythrocyte units, use of male-only plasma, and restriction of erythrocyte storage age.

Figure 1

Approach to distinguishing TRALI from TACO. BNP, B-type natriuretic peptide; BP, blood pressure; ECG, electrocardiogram; TACO, transfusion-associated circulatory overload; ALI, acute lung injury; TRALI, transfusion-related acute lung injury. modified from Gajic et al.

Figure 2

Schematic of the pathogenesis of TRALI. Neutrophils are activated by a “first hit” which is commonly surgery, trauma, or sepsis (not shown). The “second hit” is transfusion, which may introduce anti-HLA, anti-neutrophil antibodies, or other biologic response modifiers such as lyso-PC, a lipid product of cell membrane breakdown. The resulting injury results in protein leak, pulmonary edema, and release of factors which amplify the inflammatory response. lyso-PC, lysophosphatidylcholine; PMN, neutrophil; Anti-HLAAb; anti human leukocyte antigen antibody; MMP, matrix metalloproteinase; TNF, tumor necrosis factor.

Figure 3

Influence of universal leukoreduction on mortality, infection, fever, and antibiotic use, re-printed from Hebert et al. CI, confidence interval; OR, odds ratio.

Figure 4

(A) Total reported adverse events vs. reports of TRALI to the SHOT Program 1996–2009. Use of male-only plasma was initiated in 2003. (grey bars, TRALI reports; black bars, total adverse events) (B) Components implicated in TRALI 2002–2008. TRALI events associated with FFP and platelets fell after the transition to male only plasma was initiated in 2003. (grey bars, number of cases with FFP or Platelets implicated; black bars, number of cases with red cell units implicated). FFP, fresh frozen plasma; TRALI, transfusion-related acute lung injury; SHOT, Serious Hazards of Transfusion. adapted from: Annual Report 2008. Serious Hazards of Transfusion, 2008, accessed 12/14/10 from: http://www.shotuk.org/shot-reports/

Figure 5

Change in stored red blood cell characteristics over time. RBC 2,3-DPG (A), potassium (B), pH (C), lactate (D), pO2 (E), SO2 (F), cell-free hemoglobin in storage medium (G), and RBC surface phosphatidyl serine (PS) expression (H) as a function of storage time. Data are median with 25th and 75th percentiles. P values represent significance for change over time. RBC 2,3-DPG, red blood cell 2,3-diphosphoglycerate; pO₂, partial pressure of oxygen; HbSO₂, percent of hemoglobin saturated with oxygen; Free Hb, free hemoglobin; RBC Surface PS Expression, red blood cell surface phosphatidyl serine expression. re-printed from Bennett-Guerrero et al, Copyright 2007 National Academy of Sciences, U.S.A.