Lesión pulmonar aguda producida por transfusión (TRALI): Reporte de caso / Transfusion-induced acute lung injury (TRALI): Case report

Introducción: La lesión pulmonar aguda (TRALI) y la sobrecarga circulatoria (TACO) son las principales causas de morbilidad y mortalidad relacionadas con la transfusión. La TRALI se presenta durante o después de las transfusiones de plasma y sus derivados, o por inmunoglobulinas en alta concentración intravenosa; se asocia a procesos sépticos, cirugías y transfusiones masivas. La TACO es la exacerbación de manifestaciones respiratorias en las primeras 6 horas postransfusión. Reporte caso: Paciente de sexo masculino de 38 días de vida, ingresó al servicio de urgencias con un cuadro clínico de 8 días de evolución, caracterizado por dificultad respiratoria dado por retracciones subcostales y aleteo nasal sin otro síntoma asociado, con antecedentes de importancia de prematuridad y bajo peso al nacer. El reporte de hemograma arrojó cifras compatibles con anemia severa, por lo que requirió transfusión de glóbulos rojos empaquetados desleucocitados. El paciente presentó un cuadro respiratorio alterado en un periodo menor a 6 horas, por lo que se descartaron causas infecciosas y finalmente se consideró cuadro compatible con TRALI. Conclusiones: Se debe considerar una lesión pulmonar aguda relacionada con una transfusión de sangre si se produce una insuficiencia respiratoria aguda durante o inmediatamente después de la infusión de hemoderivados que contienen plasma.

Introduction: Acute lung injury (TRALI) and circulatory overload (TACO) are the main causes of transfusion-related morbidity and mortality. TRALI occurs during or after transfusions of plasma or its derivatives, or by immunoglobulins in high intravenous concentration; it is associated with septic processes, surgeries, and massive transfusions. TACO is the exacerbation of respiratory manifestations in the first 6 hours post transfusion. Case report: A 38-day-old male was admitted to the emergency department with clinical symptoms experienced over the course of 8 days and characterized by respiratory distress due to subcostal retractions and nasal flaring with no other associated symptoms. Important antecedents included prematurity and low birth weight. The hemogram report showed figures compatible with anemia, which benefited from transfusion of packed red blood cells without leukocytes. In a period of less than 6 hours, the patient presented altered respiratory symptoms, practitioners ruled out infectious causes and finally considered clinical signs compatible with TRALI. Conclusion: Acute lung injury related to blood transfusion should be considered if acute respiratory failure occurs during or immediately after infusion of plasma-containing blood products.

Lesión pulmonar aguda extrema producida por transfusión en el perioperatorio de cirugía cardíaca: Presentación de un caso / Extreme Transfusion-Related Acute Lung Injury in the Perioperative Period of Cardiac Surgery: Case Report

RESUMEN La lesión pulmonar aguda producida por transfusión (TRALI, por sus siglas en inglés) es un síndrome clínico relativamente raro, que puede constituir una amenaza para la vida y que se caracteriza por insuficiencia respiratoria aguda, edema pulmonar no cardiogénico e hipotensión arterial durante o en el transcurso de 6 horas después de una transfusión de productos hemáticos. Aunque su verdadera incidencia es desconocida, se le ha atribuido 1 caso por cada 5000 transfusiones de cualquier producto hemático y ha sido una de las causas más frecuentes de muerte relacionada con la transfusión. Se presenta un caso de TRALI en el perioperatorio de una cirugía cardíaca con manifestaciones clínicas extremas, cuyo abordaje terapéutico fue extremadamente difícil para el equipo médico-quirúrgico, debido al contexto clínico en el que se presentó: cirugía cardíaca con circulación extracorpórea por diagnóstico de endocarditis infecciosa, lesión pulmonar previa y antecedente de otro tipo de reacción postransfusional.

ABSTRACT Transfusion-Related Acute Lung Injury (TRALI) is a relatively unusual, life-threatening clinical syndrome, characterized by acute respiratory failure, hypotension, and non-cardiogenic pulmonary edema during or within 6 hours after a blood product transfusion. Although its true incidence is unknown, it has been attributed one case per 5.000 transfusions of any blood product and has been one of the most frequent causes of transfusion-related death. We present a case of TRALI in the perioperative period of cardiac surgery with extreme clinical manifestations, whose therapeutic approach was extremely difficult for the medical-surgical team, due to its complex clinical setting: cardiac surgery with cardiopulmonary bypass due to diagnosis of infective endocarditis, previous lung injury and history of other post-transfusion reaction.

Transfusion-related acute lung injury associated to intravenous immunoglobulin infusion in a pediatric patient / Lesão pulmonar aguda relacionada à transfusão associada com infusão de imunoglobulina intravenosa em paciente pediátrico

ABSTRACT Case report of a patient with an immunodeficiency who demands regular replacement of intravenous immunoglobulin. She presented an episode of transfusion-related acute lung injury shortly after using an immunoglobulin product different than the one she usually received. The patient evolved with respiratory changes (hypoxia, dyspnea, change in pulmonary auscultation) minutes after the end of the infusion, and received non-invasive respiratory support. She was discharged after 36 hours with good outcome. The patient achieved full recovery, showing no further reactions in subsequent immunoglobulin infusions (no longer receiving the product that was used when she had the episode of transfusion-related acute lung injury). Although rare, this reaction is potentially serious and has no specific treatment other than supportive therapy. The literature is scarce regarding the risk of recurrence. The decision on whether to proceed with immunoglobulin therapy after this adverse effect should be analyzed individually, assessing the possible risks and benefits for the patient.

RESUMO Relato de caso de paciente com imunodeficiência que necessitava de reposição regular de imunoglobulina endovenosa. Ela apresentou um episódio de lesão pulmonar aguda relacionada à transfusão após uso de produto de imunoglobulina diferente daquele que recebia habitualmente. Evoluiu com alterações respiratórias (hipóxia, dispneia e alteração de ausculta pulmonar) minutos após o fim da infusão, necessitando de suporte respiratório não invasivo. A paciente recebeu alta hospitalar após 36 horas, com boa evolução. Obteve recuperação total dos sintomas, sem mais reações nas infusões subsequentes de imunoglobulina (sendo optado por não mais prescrever o produto que foi usado quando ocorreu o episódio de lesão pulmonar aguda relacionada à transfusão). Apesar de rara, essa reação é potencialmente grave, não possui tratamento específico além de terapia de suporte, e há pouca informação na literatura sobre o risco de recorrência. A decisão sobre o seguimento da terapia com imunoglobulina após esse efeito adverso deve ser analisada individualmente, avaliando os possíveis riscos e benefícios para o paciente.

Five year review of open radical nephrectomies at a regional hospital in South Africa: room for improvement

Background:To review the presentation and outcomes of patients undergoing open radical nephrectomy (ORN) for renal cell carcinoma (RCC) at a regional hospital in KwaZulu-Natal, South Africa.Methods:A retrospective chart review was performed of patients having undergone nephrectomy at St Aidan's hospital between 2010 and 2015, focusing on those with RCC. Demographic, operative, histopathology and outcomes data were collected.Results:Fifty-two patients (51%) had ORN for suspected malignant disease. Forty-one RCCs were found including one incidental finding at simple nephrectomy. Data was insufficient to assess risk factors for RCC. HIV positive patients tended to present earlier (45 vs. 53 years). The mean tumour size was 10 cm and organ confined disease was present in 73.2% of patients. Only 11 patients (26.8%) had pT1 disease. The high-grade complication rate was 9.8%, in-hospital mortality rate 4.9% and transfusion rate 51.2%. The median operating time was 1h 50min and length of hospital stay 13 days.Conclusions:Open radical nephrectomy is the standard surgical treatment for RCC at regional level in South Africa. Patients tend to present at a younger age, particularly if HIV positive, and with large tumours. Further research into risk factors for RCC in the South African population is needed. There are high complication and transfusion rates in patients undergoing ORN. Review of accessibility of blood at St Aidan's hospital and revision of the transfusion protocol is suggested. A follow-up study to assess the feasibility and cost-effectiveness of laparoscopic nephrectomy in the resource-constrained South African environment is necessary

Lesão pulmonar aguda relacionada à transfusão (TRALI): revisão da literatura / Transfusion-related acute lung injury (TRALI) literature review

Introdução: Desde a introdução da transfusão de sangue, os riscos, incluindo infecções e incompatibilidade sanguínea, têm sua incidência diminuída devido à maior qualidade do ato transfusional. Enquanto a frequência de complicações tem diminuído, a lesão pulmonar aguda relacionada à transfusão (TRALI) tem sido a maior causa de morbimortalidade associada à transfusão sanguínea, embora seja subdiagnosticada. Objetivos: Revisão da abordagem dessa síndrome, ressaltando características clínico-epidemiológicas que auxiliam na suspeita, no raciocínio clínico e no diagnóstico. Métodos: Consistiu na pesquisa de publicações que contemplassem os aspectos de TRALI, desde 1957 até 2016. A pesquisa iniciou-se pelo acesso ao Pubmed, ao Ministério da Saúde, à Agência Nacional de Vigilância Sanitária (Anvisa) e à base de dados SciELO. A estratégia de busca utilizou as palavras-chave "lesão pulmonar aguda relacionada à transfusão", "TRALI", "injúria pulmonar e transfusão" com diferentes combinações e correspondentes em inglês. Avaliaram-se 11 documentos, sendo 9 artigos científicos, uma publicação do Ministério da Saúde e uma da Anvisa. Discussão: TRALI é uma síndrome complexa que, por sua morbimortalidade, é uma das complicações graves relacionadas ao ato transfusional. A compreensão de epidemiologia e fisiopatologia é útil no aprimoramento da abordagem dos pacientes transfundidos. A despeito do crescente conhecimento científico, muito sobre patogênese, tratamento e prevenção é controverso e incompreendido. Conclusão: Medidas ideais para redução da morbimortalidade abordam a alta suspeição clínica e a intervenção precoce. Para isso, é necessária a difusão do conhecimento sobre TRALI como um diagnóstico diferencial em pacientes com desconforto respiratório agudo durante ou após o ato transfusional. (AU)

Introduction: Since the introduction of blood transfusion, the risks, including infections and blood incompatibility, are diminished because of the higher quality of the transfusion. While the frequency of complications has decreased, acute transfusion-related lung injury (TRALI) has been the major cause of morbidity and mortality associated with blood transfusion, although it is underdiagnosed. Objectives: Review of the approach of this syndrome, highlighting clinical and epidemiological characteristics that aid in suspicion, clinical reasoning and diagnosis. Methods: It consisted in the research of publications that contemplated the aspects of TRALI, from 1957 to 2016. The research began by access to Pubmed, to the Ministry of Health, to the National Agency of Sanitary Surveillance (Anvisa) and to the SciELO database. The search strategy used the keywords "acute lung injury related to transfusion", "TRALI", "pulmonary injury and transfusion" with different combinations and corresponding in English. Eleven documents were evaluated, being 9 scientific articles, a publication of the Ministry of Health and one of Anvisa. Discussion: TRALI is a complex syndrome that, due to its morbidity and mortality, is one of the serious complications related to the transfusion. Understanding of epidemiology and pathophysiology is useful in enhancing the approach of transfused patients. Despite growing scientific knowledge, much about pathogenesis, treatment and prevention is controversial and misunderstood. Conclusion: Ideal measures to reduce morbidity and mortality address high clinical suspicion and early intervention. For this, it is necessary to disseminate the knowledge about TRALI as a differential diagnosis in patients with acute respiratory distress during or after the transfusion. (Au)

Lesión pulmonar aguda secundaria a transfusión (TRALI): reporte de un caso y revisión de la bibliografía / Acute lung injury secondary to transfusion (TRALI): report of a case and review of the bibliography

La lesión pulmonar aguda producida por transfusión (TRALI) es un grave síndrome clínico que se presenta con hipoxemia aguda y edema pulmonar no cardiogénico dentro de las 6 h de una transfusión con productos sanguíneos. La incidencia reportada oscila entre 1 caso cada 5000-100.000 transfusiones. Se han propuesto dos teorías sobre su fisiopatología: inmunomediada y no inmune. El diagnóstico es clínico y el tratamiento, de sostén. La tasa de mortalidad puede llegar al 10%, y la morbilidad es alta. Presentamos un paciente que, durante el posoperatorio inmediato de una artrodesis posterior instrumentada por escoliosis, evoluciona con hipoxemia resistente. En la cirugía, requirió múltiples transfusiones con hemoderivados por sangrado activo, por lo que se arriba al diagnóstico de TRALI. Requirió asistencia respiratoria mecánica con altos parámetros por 72 h y sostén hemodinámico por bajo gasto cardíaco. La evolución fue favorable y recibió el alta hospitalaria a los 11 días, sin complicaciones(AU)

Transfusion-related acute lung injury (TRALI) is a serious clinical syndrome that occurs with acute hypoxemia and non-cardiogenic pulmonary edema within 6 hours of a transfusion with blood products. The reported incidence ranges from 1 case per 5,000-100,000 transfusions. Two theories have been proposed about its pathophysiology, an immune-mediated one and a non-immune one. The diagnosis is clinical, and the treatment is supportive. Mortality may reach 10%, with high morbidity. We report a patient who in the immediate postoperative period of posterior instrumented arthrodesis for scoliosis developed refractory hypoxemia. During surgery, he required multiple blood products transfusions due to active bleeding, so we diagnosed TRALI. The patient required mechanical ventilation with high parameters during 72 hours and hemodynamic support for low cardiac output. The outcome was favorable and he was discharged at day 11 without complications. (AU)

TRALI, una amenaza enmascarada: biología y fisiopatología / TRALI, a masked menace: biology and pathophysiology

El daño pulmonar agudo ocasionado por la transfusión o TRALI (por sus siglas en inglés), definido como la aparición de un distrés respiratorio agudo en un paciente recién transfundido, pasó de ser considerado una complicación infrecuente de la terapia transfusional a ser actualmente la principal causa de mortalidad por transfusión, según sistemas de hemovigilancia de Europa y Norteamérica. Su desarrollo en forma clínicamente reconocible se atribuye a la interacción entre factores dependientes de la unidad transfundida (tipo de componente, presencia de sustancias biológicamente activas, etc.) y el estado de las respuestas celulares en el receptor. La heterogeneidad en cuanto al cuadro clínico de los pacientes afectados,la variación en el volumen infundido, el tipo de componente implicado y el tiempo desde el inicio de la transfusión hasta la aparición de los síntomas, ha hecho evolucionar la explicación a la génesis de este evento adverso, en el afán de incluir los casos sin explicación mediante las distintas hipótesis. Dos interesantes acercamientos patogénicos resultan la teoría de dos golpes y el modelo basado en el umbral que impone la relación entre los distintos factores de riesgo. La naturaleza multicausal del TRALI y el sinnúmero de variables que pueden influir en su aparición y reconocimiento, continúan haciendo de este un reto médico importante en el contexto de la medicina transfusional, donde su mejor enfoque terapéutico sigue siendo el preventivo(AU)

Transfusion-related acute lung injury (TRALI) defined as the onset of an acute respiratory distress in a recently transfused patient, has passed from been considered a rare complication of transfusion therapy to be the leading cause of transfusion-associated death, as reported by hemovigilance systems in Europe and America. In a previous paper definition, epidemiology and some clinical aspects of TRALI are reviewed. Now we focused our efforts in reviewing the incompletely understood world of its pathogenesis. Clinically recognizable TRALI´s development depends on the interaction between risk factors from both the transfused component unit (as the kind of component and substances within it) and receiver patient´s cellular response. Heterogeneity of clinical features, transfused volumes, component type and time elapsed from the beginning of transfusion to the onset of symptoms have pushed the explanations for its genesis to evolve in an effort to include as much cases as the different hypotheses allowed. Two interesting approaches to TRALI´s pathogenesis are the two hit; theory and the threshold; model imposed by risk factors interactions. The large diversity of variables and causes which can influence its onset and clinical recognition continue to make it a real challenge for clinicians, mainly within transfusion medicine, where the best therapeutic approach available is prevention(AU)