Transfusion-related acute lung injury (TRALI): a retrospective review of reported cases in Queensland, Australia over 20 years.

BACKGROUND: Transfusion-related acute lung injury (TRALI) is a rare but potentially fatal transfusion reaction. An effective haemovigilance programme is important in implementing successful and targeted risk reduction strategies. We aim to provide a summary of TRALI cases referred for investigation in Queensland (QLD) Australia from 1999 to 2019, describing the epidemiological and laboratory features of local TRALI cases. MATERIALS AND METHODS: A retrospective audit evaluated all cases reported to the QLD Australian Red Cross Lifeblood over the 20-year study period. Cases were categorised according to the 2004 Canadian consensus criteria. RESULTS: Of the 91 cases referred for investigation, expert review confirmed 30 of TRALI and 18 of possible TRALI. A total of 238 donors and 110 blood products were assessed in confirmed cases. TRALI affected patients of all ages. Most patients had underlying haematological malignancies (25%), surgery (15%) or liver disease (13%). TRALI incidence was measured at 1 in 130,000 per issued product in QLD. Red cells were transfused in 32 cases, platelets in 18 and plasma products in 21, with 16 cases involving multiple products. Following laboratory assessment, 23% of cases had findings supportive of antibody mediated TRALI and 21% as likely non-antibody mediated. Possible TRALI was identified in 37.5% of cases of which 25% were antibody mediated and 12.5% non-antibody mediated. Nine (18.5%) cases were uncategorised due to insufficient immunologic investigations. DISCUSSION: Rates of TRALI incidence measured are lower than those seen in many international studies. A reduction in confirmed cases has been noted over recent years, supporting the implementation of risk-reduction strategies. We report a relatively higher proportion of non-antibody mediated TRALI and possible TRALI cases in more recent years, suggesting the need to further understand the role of product age and biological risk modifiers.

Clinical practices and outcomes of RhD immunoglobulin prophylaxis following large-volume fetomaternal haemorrhage in Queensland, Australia.

BACKGROUND: Guidelines for laboratory assessment of fetomaternal haemorrhage (FMH) was published by the Australian and New Zealand Society of Blood Transfusion (ANZSBT) in 2002. However, data on adherence by practitioners and clinical outcomes are lacking. AIMS: The primary objective is to examine the follow-up testing and dosing of additional RhD immunoglobulin in RhD negative women who experienced large-volume FMH for whom additional intravenous RhD immunoglobulin was requested in Queensland, Australia. The secondary objectives are to examine the rate and risk factors of RhD alloimmunisation in these women. MATERIALS AND METHODS: RhD negative women with FMH >6 mL for whom additional dose(s) of intravenous RhD immunoglobulin was requested through Australian Red Cross Lifeblood from February 2007 to February 2018 were identified. For each patient, the volume of FMH, methods and timing of FMH quantitation, dose of RhD immunoglobulin, maternal and cord blood groups were analysed against the corresponding antibody screen and identification. RESULTS: Following FMH >6 mL, only 15% and 11.5% of cases adhered to current ANZSBT guideline on follow-up testing and supplemental RhD immunoglobulin dosing respectively. Despite the provision of single supplemental RhD immunoglobulin at a ratio of 100 IU to 1 mL fetal red cells, the rate of RhD alloimmunisation in RhD negative women with RhD positive fetus or fetus of unknown RhD status following FMH >6 mL is at least 4%. CONCLUSIONS: Poor compliance with guidelines for follow-up and management of large-volume FMH may contribute to increased risk of RhD alloimmunisation. Further analysis of data is warranted.

Pretransplant platelet transfusion refractoriness is not associated with platelet nonengraftment in T-replete hematopoietic progenitor cell transplantation for hematologic malignancies.

BACKGROUND: Cellular engraftment after allogeneic hematopoietic progenitor cell transplantation (HPCT) can be affected by pre-HPCT antibodies against donor human leukocyte antigen (HLA; donor-specific antibodies [DSAs]), which are commonly acquired by either pregnancy or transfusion. Issues regarding high assay sensitivity and variable interpretation limit routine screening for DSAs. Platelet (PLT) transfusion refractoriness (PTR) is relatively common in patients with hematologic malignancies, and anti-HLA alloantibodies can be identified in up to 20% of cases. For patients with PTR undergoing subsequent allogeneic HPCT, however, the effect if any on subsequent PLT nonengraftment is unknown. STUDY DESIGN AND METHODS: We conducted a retrospective study of 480 adults who underwent T-replete HPCT for hematologic malignancy and compared the posttransplantation clinical outcomes between patients who were PTR before HPCT and those who were not. RESULTS: Multivariate analysis demonstrated that PTR was not directly associated with PLT nonengraftment or graft failure, but did predict for early intensive care unit admission, which was the only variable associated with these outcomes (p < 0.0001). CONCLUSION: Our findings suggest that PTR before HPCT identifies patients at higher risk of early clinical rather than immunologic complications.

Surgery for hemophilia in developing countries.

Surgical interventions in patients with hemophilia (PWH) in the developing world are difficult in the setting of limited availability of factor concentrates. Although the adequacy of international guidelines for factor concentrate prophylaxis for PWH undergoing surgery has been established, frequently it is not practical in the developing world. These recommendations were not established based on large clinical trials and fail to define the safe lower limit of factor concentrate prophylaxis for surgery. The need to define these lower limits is essential in the developing world so that the limited resources may be used optimally for the cohort of PWH. There are limited data from the developing world with regard to PWH undergoing surgical procedures. In this article, we outline experience from our institution, a tertiary referral center for hemophilia care in India. We trace the basis on which our current factor concentrate prophylaxis regimen (which is lower than that recommended internationally) was established. In our experience our low-dose protocols are effective, reduce factor consumption by one third, and are not associated with a significantly increased risk of delayed hemorrhage. We hope that this experience will form a framework on which guidelines can be established for developing countries.