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Zhao D, Zhang X, Feng Y, Bian Y, Fu Z, Wu Y, Ma Y, Li C, Wang J, Dai J, Fu Y, Lin S, Hu J. Taurine Alleviates LPS-Induced Acute Lung Injury by Suppressing TLR-4/NF-κB Pathway. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1370:63-72. [DOI: 10.1007/978-3-030-93337-1_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Tung JP, Chiaretti S, Dean MM, Sultana AJ, Reade MC, Fung YL. Transfusion-related acute lung injury (TRALI): Potential pathways of development, strategies for prevention and treatment, and future research directions. Blood Rev 2022; 53:100926. [DOI: 10.1016/j.blre.2021.100926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/01/2021] [Accepted: 12/30/2021] [Indexed: 02/08/2023]
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Neutrophil Adaptations upon Recruitment to the Lung: New Concepts and Implications for Homeostasis and Disease. Int J Mol Sci 2020; 21:ijms21030851. [PMID: 32013006 PMCID: PMC7038180 DOI: 10.3390/ijms21030851] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 12/14/2022] Open
Abstract
Neutrophils have a prominent role in all human immune responses against any type of pathogen or stimulus. The lungs are a major neutrophil reservoir and neutrophilic inflammation is a primary response to both infectious and non-infectious challenges. While neutrophils are well known for their essential role in clearance of bacteria, they are also equipped with specific mechanisms to counter viruses and fungi. When these defense mechanisms become aberrantly activated in the absence of infection, this commonly results in debilitating chronic lung inflammation. Clearance of bacteria by phagocytosis is the hallmark role of neutrophils and has been studied extensively. New studies on neutrophil biology have revealed that this leukocyte subset is highly adaptable and fulfills diverse roles. Of special interest is how these adaptations can impact the outcome of an immune response in the lungs due to their potent capacity for clearing infection and causing damage to host tissue. The adaptability of neutrophils and their propensity to influence the outcome of immune responses implicates them as a much-needed target of future immunomodulatory therapies. This review highlights the recent advances elucidating the mechanisms of neutrophilic inflammation, with a focus on the lung environment due to the immense and growing public health burden of chronic lung diseases such as cystic fibrosis (CF) and chronic obstructive pulmonary disease (COPD), and acute lung inflammatory diseases such as transfusion-related acute lung injury (TRALI).
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Rosenfeld DM, Smith ML, Seamans DP, Giorgakis E, Gaitan BD, Khurmi N, Aqel BA, Reddy KS. Fatal diffuse pulmonary fat microemboli following reperfusion in liver transplantation with the use of marginal steatotic allografts. Am J Transplant 2019; 19:2640-2645. [PMID: 31012531 DOI: 10.1111/ajt.15399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/29/2019] [Accepted: 04/18/2019] [Indexed: 01/25/2023]
Abstract
Organ shortage is a major cause of delayed liver transplantation and increased waitlist time. The level of donor steatosis is a significant determinant in organ selection. Scarcity of organs has led some programs to expand their acceptable criteria for the percentage of steatosis. We report two cases of liver transplantation of steatotic donor organs that resulted in mortality within hours from transplantation. Postmortem analysis showed evidence of diffuse pulmonary fat microemboli likely originating from the donor organ, with marked preservation reperfusion injury. The mechanism of diffuse fat microemboli in this setting and possible relationship to other perioperative syndromes (transfusion-related lung injury, acute kidney injury, and postreperfusion syndrome) is discussed.
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Affiliation(s)
- David M Rosenfeld
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Maxwell L Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Phoenix, Arizona
| | - David P Seamans
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Emmanouil Giorgakis
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Brantley D Gaitan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Narjeet Khurmi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Bashar A Aqel
- Department of Medicine, Division of Transplant Hepatology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Kunam S Reddy
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona
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Transfusion-associated circulatory overload and transfusion-related acute lung injury. Blood 2019; 133:1840-1853. [PMID: 30808638 DOI: 10.1182/blood-2018-10-860809] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 12/10/2018] [Indexed: 01/18/2023] Open
Abstract
Transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) are syndromes of acute respiratory distress that occur within 6 hours of blood transfusion. TACO and TRALI are the leading causes of transfusion-related fatalities, and specific therapies are unavailable. Diagnostically, it remains very challenging to distinguish TACO and TRALI from underlying causes of lung injury and/or fluid overload as well as from each other. TACO is characterized by pulmonary hydrostatic (cardiogenic) edema, whereas TRALI presents as pulmonary permeability edema (noncardiogenic). The pathophysiology of both syndromes is complex and incompletely understood. A 2-hit model is generally assumed to underlie TACO and TRALI disease pathology, where the first hit represents the clinical condition of the patient and the second hit is conveyed by the transfusion product. In TACO, cardiac or renal impairment and positive fluid balance appear first hits, whereas suboptimal fluid management or other components in the transfused product may enable the second hit. Remarkably, other factors beyond volume play a role in TACO. In TRALI, the first hit can, for example, be represented by inflammation, whereas the second hit is assumed to be caused by antileukocyte antibodies or biological response modifiers (eg, lipids). In this review, we provide an up-to-date overview of TACO and TRALI regarding clinical definitions, diagnostic strategies, pathophysiological mechanisms, and potential therapies. More research is required to better understand TACO and TRALI pathophysiology, and more biomarker studies are warranted. Collectively, this may result in improved diagnostics and development of therapeutic approaches for these life-threatening transfusion reactions.
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Rebetz J, Semple JW, Kapur R. The Pathogenic Involvement of Neutrophils in Acute Respiratory Distress Syndrome and Transfusion-Related Acute Lung Injury. Transfus Med Hemother 2018; 45:290-298. [PMID: 30498407 PMCID: PMC6257140 DOI: 10.1159/000492950] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/16/2018] [Indexed: 12/19/2022] Open
Abstract
The acute respiratory distress syndrome (ARDS) is a serious and common complication of multiple medical and surgical interventions, with sepsis, pneumonia, and aspiration of gastric contents being common risk factors. ARDS develops within 1 week of a known clinical insult or presents with new/worsening respiratory symptoms if the clinical insult is unknown. Approximately 40% of the ARDS cases have a fatal outcome. Transfusion-related acute lung injury (TRALI), on the other hand, is characterized by the occurrence of respiratory distress and acute lung injury, which presents within 6 h after administration of a blood transfusion. In contrast to ARDS, acute lung injury in TRALI is not attributable to another risk factor for acute lung injury. 'Possible TRALI', however, may have a clear temporal relationship to an alternative risk factor for acute lung injury. Risk factors for TRALI include chronic alcohol abuse and systemic inflammation. TRALI is the leading cause of transfusion-related fatalities. There are no specific therapies available for ARDS or TRALI as both have a complex and incompletely understood pathogenesis. Neutrophils (polymorphonuclear leukocytes; PMNs) have been suggested to be key effector cells in the pathogenesis of both syndromes. In the present paper, we summarize the literature with regard to PMN involvement in the pathogenesis of both ARDS and TRALI based on both human data as well as on animal models. The evidence generally supports a strong role for PMNs in both ARDS and TRALI. More research is required to shed light on the pathogenesis of these respiratory syndromes and to more thoroughly establish the nature of the PMN involvement, especially considering the heterogeneous etiologies of ARDS.
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Affiliation(s)
| | - John W. Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
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Affiliation(s)
- Y. L. Fung
- School of Health & Sports Sciences; University of Sunshine Coast; Sunshine Coast QLD Australia
| | - J.P. Tung
- Research and Development; Australian Red Cross Blood Service; Kelvin Grove QLD Australia
- Critical Care Research Group; University of Queensland and The Prince Charles Hospital; Brisbane QLD Australia
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Correger E, Villanueva J, Cardinal-Fernández P, Rios F. In reply to "Acute respiratory distress secondary to blood transfusion". Med Intensiva 2017; 41:445-446. [PMID: 28408100 DOI: 10.1016/j.medin.2017.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 02/27/2017] [Indexed: 11/29/2022]
Affiliation(s)
- E Correger
- Unidad de Cuidados Intensivos, Hospital Español de Buenos Aires-Hospital de Alta complejidad en red "El Cruce", Dr. Néstor Carlos Kirchner, Buenos Aires, Argentina
| | - J Villanueva
- Unidad de Cuidados Intensivos, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - P Cardinal-Fernández
- Servicio de Emergencia, Hospital Universitario HM Sanchinarro, Madrid, Spain; Fundación de investigación HM Hospitales, Madrid, Spain.
| | - F Rios
- Unidad de Cuidados Intensivos, Hospital Nacional Profesor Alejando Posadas, Buenos Aires, Argentina
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Juffermans NP, Vlaar AP. Transfusion and Acute Respiratory Distress Syndrome: Pathogenesis and Potential Mechanisms. Respir Med 2017. [DOI: 10.1007/978-3-319-41912-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- A. L. Peters
- Laboratory of Experimental Intensive Care and Anesthesiology/Department of Intensive Care; Academic Medical Centre; Amsterdam The Netherlands
| | - A. P. J. Vlaar
- Laboratory of Experimental Intensive Care and Anesthesiology/Department of Intensive Care; Academic Medical Centre; Amsterdam The Netherlands
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12
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McGuire AR, DeJoseph ME, Gill JR. An approach to iatrogenic deaths. Forensic Sci Med Pathol 2016; 12:68-80. [DOI: 10.1007/s12024-016-9745-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2016] [Indexed: 12/19/2022]
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Berthold T, Glaubitz M, Muschter S, Groß S, Palankar R, Reil A, Helm CA, Bakchoul T, Schwertz H, Bux J, Greinacher A, Delcea M. Human neutrophil antigen-3a antibodies induce neutrophil stiffening and conformational activation of CD11b without shedding of L-selectin. Transfusion 2015; 55:2939-48. [DOI: 10.1111/trf.13299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 05/27/2015] [Accepted: 06/29/2015] [Indexed: 02/05/2023]
Affiliation(s)
- Tom Berthold
- Institute for Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| | - Michael Glaubitz
- Nanostructure Group, ZIK HIKE-Center for Innovation Competence, Humoral Immune Reactions in Cardiovascular Diseases; Ernst-Moritz-Arndt-University Greifswald; Greifswald Germany
| | - Stefan Muschter
- Institute for Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| | - Stefan Groß
- Department of Cardiology; Universitätsmedizin Greifswald; Greifswald Germany
- DZHK-German Centre for Cardiovascular Research; Greifswald Germany
| | - Raghavendra Palankar
- Nanostructure Group, ZIK HIKE-Center for Innovation Competence, Humoral Immune Reactions in Cardiovascular Diseases; Ernst-Moritz-Arndt-University Greifswald; Greifswald Germany
| | | | | | - Tamam Bakchoul
- Institute for Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| | - Hansjörg Schwertz
- Institute for Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
- Lichtenberg-Professor for Experimental Hemostasis; Universitätsmedizin Greifswald
- Program in Molecular Medicine; University of Utah; Salt Lake City Utah
- Department of Surgery; University of Utah; Salt Lake City Utah
| | | | - Andreas Greinacher
- Institute for Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| | - Mihaela Delcea
- Nanostructure Group, ZIK HIKE-Center for Innovation Competence, Humoral Immune Reactions in Cardiovascular Diseases; Ernst-Moritz-Arndt-University Greifswald; Greifswald Germany
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Bayat B, Tjahjono Y, Berghöfer H, Werth S, Deckmyn H, De Meyer SF, Sachs UJ, Santoso S. Choline Transporter-Like Protein-2: New von Willebrand Factor-Binding Partner Involved in Antibody-Mediated Neutrophil Activation and Transfusion-Related Acute Lung Injury. Arterioscler Thromb Vasc Biol 2015; 35:1616-22. [PMID: 25931511 DOI: 10.1161/atvbaha.115.305259] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 03/30/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVE In contrast to other antibodies involved in transfusion-related acute lung injury, anti-HNA-3a antibodies are incapable of inducing direct neutrophil activation and seem to interact with endothelial cells (ECs) primarily. In animal studies, anti-HNA-3a-mediated transfusion-related acute lung injury could be precipitated in the absence of neutrophils, but was stronger when neutrophils were present. In a different context the target protein of these antibodies, choline transporter-like protein-2 (CTL-2), was reported to interact with a protein of the inner ear carrying 2 von Willebrand factor (VWF) A-domains. These observations prompted us to investigate whether VWF might be involved in anti-HNA-3a-mediated neutrophil activation, and whether signaling via CD11b/CD18 is involved, as in various other experimental settings. APPROACH AND RESULTS Cell adhesion demonstrated specific binding of CTL-2 to VWF. Immunoprecipitation analysis of CTL-2/CD11b/CD18 coexpressing cells indicated that anti-HNA-3a colocalizes CTL-2 and CD11b/CD18 when VWF is present. Functional studies revealed that anti-HNA-3a-mediated neutrophil agglutination is an active, protein kinase C-dependent and partially Fc-dependent process. Agglutination and the production of reactive oxygen species seem to require the formation of a trimolecular complex between the target antigen (CTL-2), CD11b/CD18 and VWF. In line with these observations, anti-HNA-3a induced less severe transfusion-related acute lung injury and less neutrophil recruitment to the alveolar space in VWF knockout mice. CONCLUSIONS We introduce CTL-2 as a new binding partner for VWF. Interaction of neutrophils with VWF via CTL-2 allows anti-HNA-3a to induce signal transduction via CD11b/CD18, which leads to neutrophil activation and agglutination. In transfusion-related acute lung injury, this mechanism may further aggravate endothelial leakage.
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Affiliation(s)
- Behnaz Bayat
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (B.B., Y.T., H.B., S.W., U.J.S., S.S.); and Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (H.D., S.F.D.M.)
| | - Yudy Tjahjono
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (B.B., Y.T., H.B., S.W., U.J.S., S.S.); and Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (H.D., S.F.D.M.)
| | - Heike Berghöfer
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (B.B., Y.T., H.B., S.W., U.J.S., S.S.); and Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (H.D., S.F.D.M.)
| | - Silke Werth
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (B.B., Y.T., H.B., S.W., U.J.S., S.S.); and Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (H.D., S.F.D.M.)
| | - Hans Deckmyn
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (B.B., Y.T., H.B., S.W., U.J.S., S.S.); and Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (H.D., S.F.D.M.)
| | - Simon F De Meyer
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (B.B., Y.T., H.B., S.W., U.J.S., S.S.); and Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (H.D., S.F.D.M.)
| | - Ulrich J Sachs
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (B.B., Y.T., H.B., S.W., U.J.S., S.S.); and Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (H.D., S.F.D.M.)
| | - Sentot Santoso
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (B.B., Y.T., H.B., S.W., U.J.S., S.S.); and Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (H.D., S.F.D.M.).
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Peters AL, Van Stein D, Vlaar APJ. Antibody-mediated transfusion-related acute lung injury; from discovery to prevention. Br J Haematol 2015; 170:597-614. [PMID: 25921271 DOI: 10.1111/bjh.13459] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Transfusion-related acute lung injury (TRALI), a syndrome of respiratory distress caused by blood transfusion, is the leading cause of transfusion-related mortality. The majority of TRALI cases have been related to passive infusion of human leucocyte antigen (HLA) and human neutrophil antigen (HNA) antibodies in donor blood. In vitro, ex vivo and in vivo animal models have provided insight in TRALI pathogenesis. The various classes of antibodies implicated in TRALI appear to have different pathophysiological mechanisms for the induction of TRALI involving endothelial cells, neutrophils, monocytes and, as very recently has been discovered, lymphocytes. The HLA and HNA-antibodies are found mainly in blood from multiparous women as they have become sensitized during pregnancy. The incidence of TRALI has decreased rapidly following the introduction of a male-only strategy for plasma donation. This review focuses on pre-clinical and clinical studies investigating the pathophysiology of antibody-mediated TRALI.
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Affiliation(s)
- Anna L Peters
- Laboratory of Experimental Intensive Care and Anaesthesia/Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands
| | - Danielle Van Stein
- Department of Internal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Alexander P J Vlaar
- Laboratory of Experimental Intensive Care and Anaesthesia/Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands
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Pathogenesis of non-antibody mediated transfusion-related acute lung injury from bench to bedside. Blood Rev 2015; 29:51-61. [DOI: 10.1016/j.blre.2014.09.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 09/02/2014] [Indexed: 12/11/2022]
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Panackal AA, Bennett JE, Williamson PR. Treatment options in Invasive Aspergillosis. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2014; 6:309-325. [PMID: 25328449 DOI: 10.1007/s40506-014-0016-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mackenzie I, Tunnicliffe B, Clasper J, Mahoney P, Kirkman E. What the Intensive Care Doctor Needs to Know about Blast-Related Lung Injury. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400407] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Explosions are currently the primary cause of military combat injuries. A minority of civilian trauma is also caused by explosions. People hurt by explosion are likely to present with complex injuries. The aim of the article is to explain the mechanism underlying these injuries and the associated physiology to help the intensive care clinician manage these casualties properly. The generic term ‘blast injury’ is applied to a collection of injuries caused by explosion. Components of blast injuries have precise definitions relating to the elements of the explosion that caused the injuries: primary blast injury is due to a shock wave, secondary blast injury is caused by fragments and debris colliding with the victim and tertiary blast injury is due to the casualty being thrown against solid objects. Primary blast injury results in damage principally in gas-containing organs, eg the lungs (blast lung) and can lead to impaired pulmonary gas transfer and hypoxaemia. Secondary blast injuries are often penetrating and can lead to haemorrhage while tertiary blast injuries are often blunt and involve substantial tissue damage. Survivors of explosions in confined spaces are more likely to exhibit primary blast injury than those injured in open spaces. The current military approach to immediate management is to apply the C ABC principle (arrest catastrophic haemorrhage first and then deal with airway, breathing and circulation) to achieve Damage Control Resuscitation. Early administration of blood products (plasma as well as red cells) is advocated for those suffering significant haemorrhage. Initial resuscitation is hypotensive to minimise risk of dislodging nascent clots. However, if evacuation is protracted (longer than one hour) then consideration should be given to improving blood flow / oxygen delivery by adopting a revised normotensive blood pressure target to reverse the deleterious consequences of the hypotensive shock state. Animal studies have shown that titrating FiO2 to a target SaO2 of 95% can improve survival and ‘buy time’ during hypotensive resuscitation. Ventilator strategies should use a lung-protective approach with permissive hypercapnia if necessary. Blast casualties are often a challenging group of patients needing expert, tailored, care. Outcome can be good especially in young, otherwise fit, casualties with more than 96% surviving to ICU discharge, although this figure may be lower with a mixed civilian group.
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Affiliation(s)
- Iain Mackenzie
- Consultant in Intensive Care Medicine, Queen Elizabeth Hospital, Birmingham
| | - Bill Tunnicliffe
- Consultant in Intensive Care Medicine, Queen Elizabeth Hospital, Birmingham
| | - Jon Clasper
- Defence Professor Trauma and Orthopaedics, Royal Centre for Defence Medicine
| | - Peter Mahoney
- Defence Professor of Anaesthesia and Intensive Care, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham
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Van Ness M, Jensen H, Adamson GN, Kysar PE, Holland P. Neutrophils contain cholesterol crystals in transfusion-related acute lung injury (TRALI). Am J Clin Pathol 2013; 140:170-6. [PMID: 23897251 DOI: 10.1309/ajcpgkojv15avznt] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES Intracellular components of transfusion-related acute lung injury (TRALI) were investigated by transmission electron microscopy. METHODS The lungs from 2 fatal TRALI cases and 2 controls, previously studied by scanning electron microscopy, were studied by transmission electron microscopy. Morphologic data by light and phase microscopy, along with scanning and transmission electron microscopic observations, were collated. RESULTS The 2 fatal TRALI cases exhibited dense laminated material within capillaries and postcapillary venules, similar to material identified within their neutrophils when viewed by transmission electron microscopy. This material polarized light and is presumed to be cholesterol crystals. CONCLUSIONS The damage to the pulmonary vascular endothelium in TRALI is related to formation of cholesterol crystals originating within neutrophils.
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Affiliation(s)
- Michael Van Ness
- Department of Pathology and Laboratory Medicine, University of California Davis Health System, Sacramento, CA
| | - Hanne Jensen
- Department of Pathology and Laboratory Medicine, University of California Davis Health System, Sacramento, CA
| | - Grete N. Adamson
- Department of Pathology and Laboratory Medicine, University of California Davis Health System, Sacramento, CA
| | - Patricia E. Kysar
- Department of Pathology and Laboratory Medicine, University of California Davis Health System, Sacramento, CA
| | - Paul Holland
- Department of Pathology and Laboratory Medicine, University of California Davis Health System, Sacramento, CA
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Juffermans NP. Transfusion-related acute lung injury: emerging importance of host factors and implications for management. Expert Rev Hematol 2011; 3:459-67. [PMID: 21083036 DOI: 10.1586/ehm.10.41] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Recent insights from models of transfusion-related acute lung injury (TRALI), and from clinical reports, reveal that host factors are important in TRALI pathogenesis. Predisposing factors with lung neutrophil-priming capacity, such as sepsis and mechanical ventilation, increase susceptibility for a TRALI reaction, and can aggravate the course of disease. These findings may explain the higher incidence of TRALI in the critically ill compared with general hospital populations. The emerging importance of host factors may have implications for TRALI management. Suspected TRALI cases in which another acute lung injury risk factor is present (termed 'possible TRALI' in the consensus definition) should be reported to the blood bank, including patients suffering from an underlying condition. In reporting of TRALI cases, use of the international TRALI consensus definition should be used, rather then national TRALI scoring systems, to ensure a uniform approach, which may decrease variance in estimations of incidence. In terms of treatment of TRALI patients, there is a rationale to apply therapeutic strategies, which have proven to be beneficial in acute lung injury.
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Affiliation(s)
- Nicole P Juffermans
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, Room G3-206, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Abstract
Over the past 60 years, the transfusion medicine community has attained significant knowledge regarding transfusion-related acute lung injury (TRALI) through the bedside to bench and back to the bedside model. First, at the bedside, TRALI causes hypoxia and noncardiogenic pulmonary edema, typically within 6 hours of transfusion. Second, bedside studies showed a higher incidence in plasma and platelet products than in red blood cell products (the fatal TRALI incidence for plasma is 1:2-300 000 products; platelet, 1:3-400 000; red blood cells, 1:25 002 000), as well as an association with donor leukocyte antibodies (∼ 80% of cases). Third, at the bench, antibody-dependent and antibody-independent mechanisms have been described, requiring neutrophil and pulmonary endothelial cell activation. Antibodies, as well as alternate substances in blood products, result in neutrophil activation, which, in a susceptible patient, result in TRALI (2-hit hypothesis). Fourth, back to the bedside, policy changes based on results of these studies, such as minimizing use of plasma and platelet products from donors with leukocyte antibodies, have decreased the incidence of TRALI. Thus, steps to mitigate TRALI are in place, but a complete mechanistic understanding of the pathogenesis of TRALI and of which patients are at highest risk remains to be elucidated.
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Lee JH, Kang ES, Kim DW. Two cases of transfusion-related acute lung injury triggered by HLA and anti-HLA antibody reaction. J Korean Med Sci 2010; 25:1398-403. [PMID: 20808691 PMCID: PMC2923780 DOI: 10.3346/jkms.2010.25.9.1398] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 11/23/2009] [Indexed: 11/20/2022] Open
Abstract
Transfusion-related acute lung injury (TRALI) is a serious adverse transfusion reaction that is presented as acute hypoxemia and non-cardiogenic pulmonary edema, which develops during or within 6 hr of transfusion. Major pathogenesis of TRALI is known to be related with anti-HLA class I, anti-HLA class II, or anti-HNA in donor's plasma. However, anti-HLA or anti-HNA in recipient against transfused donor's leukocyte antigens also cause TRALI in minor pathogenesis and which comprises about 10% of TRALI. Published reports of TRALI are relatively rare in Korea. In our cases, both patients presented with dyspnea and hypoxemia during transfusion of packed red blood cells and showed findings of bilateral pulmonary infiltrations at chest radiography. Findings of patients' anti-HLA antibodies and recipients' HLA concordance indicate that minor pathogenesis may be not as infrequent as we'd expected before. In addition, second case showed that anti-HLA class II antibodies could be responsible for immunopathogenic mechanisms, alone.
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Affiliation(s)
- Ji Hyun Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Suk Kang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dae-Won Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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23
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Beasley MB. The pathologist's approach to acute lung injury. Arch Pathol Lab Med 2010; 134:719-27. [PMID: 20441502 DOI: 10.5858/134.5.719] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Acute lung injury and acute respiratory distress syndrome are significant causes of pulmonary morbidity and are frequently fatal. These 2 entities have precise definitions from a clinical standpoint. Histologically, cases from patients with clinical acute lung injury typically exhibit diffuse alveolar damage, but other histologic patterns may occasionally be encountered such as acute fibrinous and organizing pneumonia, acute eosinophilic pneumonia, and diffuse hemorrhage with capillaritis. OBJECTIVE To review the diagnostic criteria for various histologic patterns associated with a clinical presentation of acute lung injury and to provide diagnostic aids and discuss the differential diagnosis. DATA SOURCES The review is drawn from pertinent peer-reviewed literature and the author's personal experience. CONCLUSIONS Acute lung injury remains a significant cause of morbidity and mortality. The pathologist should be aware of histologic patterns of lung disease other than diffuse alveolar damage, which are associated with a clinical presentation of acute lung injury. Identification of these alternative histologic findings, as well as identification of potential etiologic agents, especially infection, may impact patient treatment and disease outcome.
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Affiliation(s)
- Mary Beth Beasley
- Department of Pathology, The Mount Sinai Medical Center, New York, New York 10029, USA.
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Jensen HM, Galante JM, Kysar PE, Tolstikov VV, Reddy KJ, Holland PV. TRALI is due to pulmonary venule damage from leucocytes with cholesterol crystal formation. Vox Sang 2009; 98:130-7. [PMID: 19708890 DOI: 10.1111/j.1423-0410.2009.01235.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There are two presumed mechanisms for the pulmonary oedema in transfusion-related acute lung injury (TRALI). One is antibodies to leucocytes while the other is biologically active lipids. We evaluated the vascular injury due to the former. METHODS The pulmonary vasculature was studied by light microscopy (LM) and scanning electron microscopy (SEM) in three fatal cases of TRALI and compared with that of two autopsied control patients. Lung tissue from two of the TRALI cases and both controls was studied by gas chromatography-mass spectroscopy (GC-MS) to identify crystals present in the former. RESULTS All three TRALI cases exhibited massive pulmonary oedema by weight and light microscopy and extensive defects by SEM in the endothelium of venules of the lungs. Such endothelial defects were absent in controls. Thrombi, composed of crystals, were present in venules and small veins diffusely throughout the lungs in Case 1. Similar crystals were identified in Case 2. The crystals in the lung vessels were identified morphologically as cholesterol and were proximate to the cytoplasmic defects of the endothelial surfaces. By GC-MS, there were markedly elevated levels of cholesterol and fatty acids in the two TRALI lungs tested compared with the lungs of the two controls. CONCLUSIONS Pulmonary damage in TRALI is related to formation of cholesterol crystals that appear to pierce endothelial membranes of venules. The endothelial defects lead to plasma extravasation into the alveoli causing TRALI.
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Affiliation(s)
- H M Jensen
- Department of Pathology and Laboratory Medicine, Davis Medical Center, University of California, Sacramento, CA, USA
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Fowler RA, Adhikari NKJ, Scales DC, Lee WL, Rubenfeld GD. Update in critical care 2008. Am J Respir Crit Care Med 2009; 179:743-58. [PMID: 19383928 DOI: 10.1164/rccm.200902-0207up] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Robert A Fowler
- University of Toronto, Department of Medicine, Sunnybrook Health Sciences Centre, Chief, Program in Trauma, Emergency, and Critical Care, Toronto, ON, M4V 1E5 Canada
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