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Transfusion related acute lung injury (TRALI) or Noncardiogenic pulomary oedema.5. Transfusion related acute lung injury (TRALI) or Noncardiogenic pulomary oedema.It is a rare reaction in which the recipient develops pulmonary oedema without a change in cardiac pressure.Pathogenesis The mechanisms postulated are a. Reaction between donor leucocyte antibodies and recipient leucocytes which from aggregates. The aggregates are trapped in the pulmonary circulation with change in vascular permeability. b. Activation of complement to C3a and C5a with release of histamine which produces leucocyte aggregates. Pulmonary leucostasis causes microvascular occlusion, capillary leakage and pulmonary oedema. c. Complement activated granulocytes produce oxygen radicals which damage pulmonary endothelial cells and lead to increased vascular permeability and oedema. Clinical features * Acute respiratory distress. * Fever with chills * Cyanosis * Hypotension X-ray chest pulmonary infiltrates in hilar region. Management 1. Stop the transfusion 2. Provide respiratory support. 3. Give steroids. Prevention Washed red cells may be used. Multiparous women and multitransfused patients should not be used as plasma donors, as their serum may have high titres of leucoagglutinating antibodies. Graft vs host disease (GVHD) GVHD is rare complication of transfusion occurring in severely immunosuppressed individuals such as patients on chemotherapy/irradiation. Patients with lymphopenia, bone marrow transplant recipients are at risk, as also neonates specially those who receive exchange transfusion. Pathogenesis The donor lymphocytes engraft and multiply in the recipient. The engrafted cells react with the host tissues to cause the clinical manifestations. The donor lymphocytes are not destroyed as the host is immunocompromised. Clinical features * Fever * Diffuse erythematous rash * Diarrhoea * Bone marrow suppression * Infection Prognosis The reaction is fatal in 90% cases. Prevention The use of irradiated blood and blood product can prevent GVHD. A radiation dose of 1500- 5000 rad for 10 minutes renders 85-95% of lymphocytes incapable of replication. Gamma irradiators are commercially available which can be used for irradiation of blood bags. Post transfusion purpura In this condition marked thrombocytopenia develops 5-10 days after transfusiàn. It is found more often in multiparous women. In some patients platelet specific alloantibody has been found (antiP1A1). The antibody destroys not only the transfused platelets but also the patient’s own platelets which are PJA1 negative. Thrombocytopenia is severe but self-limiting. Platelet transfusions are not beneficial and if treatment is required, therapeutic plasmapheresis is suggested. Intravenous immunoglobulins have a proven role in the management of these patients. Alloimmunization Blood transfusion exposes a patient to several foreign antigens. If the recipient does not possess these antigens, antibodies will be formed against them days, weeks or months after the transfusion. Ailoimmunization may occur to red cell, white cell or platelet antigens and to plasma proteins. Immunomodulation Transfusion of blood is associated with changes in immune function. The effect is apparent in multitransfused patients. There Is decreased lymphocyte responsiveness to phytohaemagglutinin and in mixed lymphocyte culture with pooled normal lymphocytes as stimulator cells. A reduced helper to suppressor ratio and decreased activity of NK cells is also observed. Tumour recurrence Transfusion of blood has a detrimental effect on the outcome of cancer surgery. The difference in tumour free survival in transfused and nontransfused patients is statistically significant and the rate of recurrence in the latter group is lower. Allograft recipients Transfusion increases the survival of allografts also by this immunosuppressi’e effect. Infection Transfusion is Implicated in decreasing resistance to infection with viruses and bacteria. There is a highly significant association of transfusion with an increased incidence of post-operative infections. In contrast, all these effects are not observed iwth the use of autologous blood.
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