D1.436 - Transfusion-Related Acute Lung Injury (TRALI) following plasma transfusion: A case report

Introduction Sudden acute respiratory distress after transfusion is the hallmark of an uncommon but dangerous disease known as transfusion-related acute lung injury (TRALI). In the absence of temporally associated risk factors for acute respiratory distress syndrome, it is defined as new, acute respiratory distress that occurs during or within 6 hours of the administration of blood components (such as red blood cells, plasma, or platelets) or blood products (such as plasma protein product).

Aim of the paper To report a patient with end-stage liver disease who experienced TRALI following plasma transfusion, and to review the clinical characteristics, pathogenesis, treatment, and results of such an incident.

Case report A 51-year-old woman with a history of liver cirrhosis presented with abdominal pain, dizziness, weakness, severe epistaxis, and hemoptysis. Laboratory investigations revealed severe anemia (Hb 67 g/L), hypoalbuminemia (19.0 g/L), and hypoprothrombinemia (29.1%). She was admitted to our hospital and received a red blood cell transfusion without any adverse events. Within the next 48 hours, she was transfused with fresh frozen plasma (FFP). Approximately 2 hours after FFP administration, the patient developed acute respiratory distress, requiring urgent endotracheal intubation and initiation of positive pressure mechanical ventilation. She rapidly progressed to acute respiratory distress syndrome, which subsequently evolved into multiple organ dysfunction syndrome. Despite intensive care management, the patient died on day 7 following the transfusion. The diagnosis of TRALI was established based on clinical and radiographic criteria.

Conclusions The development of post-transfusion pulmonary edema in the absence of cardiovascular overload should raise suspicion for TRALI, particularly in predisposing clinical settings, such as sepsis, mechanical ventilation, cardiovascular surgery, or end-stage liver disease. TRALI is primarily attributed to the transfusion of anti-leukocyte antibodies or biological response modifiers (BRMs). The 2019 classification differentiates TRALI type I (no risk factors) from TRALI type II (pre-existing or concurrent risk factors for ARDS). Its diagnosis remains challenging due to the absence of pathognomonic laboratory tests and is therefore based predominantly on clinical presentation and radiographic findings. TRALI is associated with significant mortality, and most affected patients require ventilatory support.