Transfusionsassoziierte akute Lungeninsuffizienz (TRALI)

 

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Zusammenfassung

Die transfusionsassoziierte akute Lungeninsuffizienz (TRALI) wird hauptsächlich durch Transfusionen von frisch gefrorenem Plasma oder Thrombozytenkonzentraten verursacht und tritt definitionsgemäß innerhalb von 6 Stunden nach Transfusion mit akuter Atemnot, Hypoxämie und röntgenologisch nachweisbaren bilateralen Thoraxinfiltraten auf. Ursache sind meistens leukozytäre Antikörper im Plasma des Blutspenders (immunogene TRALI). Aber auch antikörperunabhängige Substanzen wie biologisch aktive Lipide, die vorwiegend bei der Lagerung von Thrombozyten- und Erythrozytenkonzentraten entstehen, können neutrophile Granulozyten aktivieren und eine nichtimmunogene TRALI auslösen. Pathophysiologisch setzen die Granulozyten in den Kapillaren der Lungenstrombahn Sauerstoffradikale und Enzyme frei, die die Endothelzellen schädigen und zum Lungenödem führen. Therapeutisch kann nasale Sauerstoffgabe ausreichen. In schweren Fällen sind mechanische Beatmung, invasive hämodynamische Überwachung und Flüssigkeitszufuhr erforderlich. Diuretika sind zu vermeiden. Die Gabe von Glukokortikoiden ist umstritten. Da antikörperbedingte TRALI-Reaktionen hauptsächlich nach Transfusion von frisch gefrorenem Plasma auftraten, das von Frauen gewonnen wurde, die sich im Verlauf von Schwangerschaften gegen leukozytäre Antigene immunisiert haben, wird in Deutschland seit 2009 nur Plasma von Spenderinnen ohne Schwangerschaften in der Anamnese oder nach negativer Testung auf Antikörper gegen HLA-Klasse I, II und HNA eingesetzt mit der Folge, dass seitdem kein TRALI-bedingter Todesfall mehr registriert wurde.

Abstract

Transfusion-related acute lung injury (TRALI) is primarily caused by transfusion of fresh frozen plasma or platelet concentrates and occurs by definition within 6 hours after transfusion with acute shortness of breath, hypoxemia and radiographically detectable bilateral infiltrates of the lung. Mostly leucocyte antibodies in the plasma of the blood donor (immunogenic TRALI) are responsible. Apart from antibodies, other substances such as biologically active lipids, mainly arising from the storage of platelet and red blood cell concentrates, can activate neutrophilic granulocytes and trigger a non-immunogenic TRALI. Pathophysiologically, granulocytes in the capillaries of the lung vessels release oxygen radicals and enzymes which damage the endothelial cells and cause pulmonary edema. Therapeutically, nasal oxygen administration may be sufficient. In severe cases, mechanical ventilation, invasive hemodynamic monitoring and fluid intake are required. Diuretics should be avoided. The administration of glucocorticoids is controversial. Antibody-related TRALI reactions occurred mainly after transfusion of fresh frozen plasma, which had been obtained from womenimmunized during pregnancy against leukocyte antigens. Therefore, in Germany, since 2009 only plasma from female donors without a history of prior or current pregnancy or negative testing for antibodies against HLA I, II or HNA has been used with the result that since then no TRALI-related death has been registered.

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