输血相关急性肺损伤：临床新观点  

作　　者：Darrell J. Triulzi, MD 李立晶(译) 岳云(校) 

机构地区：[1]Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh Medical Center, Institute for Transfusion Medicine, Pittsburgh, Pennsylvania [2]不详

出　　处：《麻醉与镇痛》2010年第3期12-19,共8页Anesthesia & Analgesia

摘　　要：在美国，输血相关急性肺损伤（TRALI）在输血相关致病率和死亡率统计中成为首要原因。TRALI的诊断标准近年来有所改进，主要包括发生于输血过程中或输血后6小时内出现的缺氧和双侧肺水肿，而患者本身无心衰或血管内容量超负荷。输血相关循环超负荷是主要的鉴别诊断，并且鉴别有一定困难。治疗需要氧气和机械通气的辅助，不需要使用利尿剂，激素的效果也没有得到证实。患者通常在几天内可以恢复。各种血液制品都会；l起TRALI，但是血浆成分丰富的制品，如新鲜冰冻血浆和浓缩血小板是最常见的诱因。TRALI的发病机制尚不完全清楚。捐献者血浆中的白细胞抗体几乎存在于所有病例中，这些抗体针对I型人类白细胞抗原（HLAI）、HLAⅡ或中性粒细胞特异性抗原，特别是HNA-3a。在外科和ICU患者中常可观察到，激活肺内皮细胞在TRALI的病情发展中有重要作用。输入的白细胞凝集抗体与受血者的中性粒细胞结合，聚集在肺内皮组织局部，激活和释放氧化酶，发生其他有害生物反应导致血管变得脆弱。在少数TRALI病例中，没有发现抗体，推测输入血中的中性粒细胞刺激因子可以在肺内皮细胞已经激活的患者中引起TRALI，这被称为“双重打击”机制。了解抗白细胞抗体的作用，使医生有新的办法降低TRALI的发生危险。曾经妊娠过的女性捐赠者有24％的人血液中通常会存在HLA抗体，并且随着妊娠次数的增加存在抗体的可能性也增大。随着在TRALI中发现HLA抗体，血液中心采取了尽量从男性捐赠者血液中提取血浆成分的方法。输入浓缩血小板时怎样降低发病风险尚存在疑问，并且可能需要对女性捐赠者进行血小板HLA抗体检测。我们需要更多有关血液成分和TRALI致病危险因素的研究，从而制定新的治疗方案，以便有更多方法减少TRALI的发生。The leading cause of transfusion-related morbidity and mortality in the United States is transfusion-related acute lung injury （TRALI）. Diagnostic criteria for TRALI have recently been developed and primarily consist of hypoxia and bilateral pulmonary edema occurring during or within 6 h of a transfusion in the absence of cardiac failure or intravascttlar volume overload. The primary differential diagnosis is transfusion-associated circulatory overload and differentiation can be difficult. Treatment is supportive with oxygen and mechanical ventilation. Diuresis is not indicated and the role of steroids is unproven. Patients typically recover within a few days. All types of blood products have been associated with TRALI, however, the plasma-rich components, such as fresh frozen plasma and apheresis platelets, have been most frequently implicated. The pathogenesis of TRALI is not completely understood. Leukocyte antibodies in donor plasma have been implicated in most cases with antibodies directed at human leukocyte antigen （HLA） class I, HLA class Ⅱ or neutrophil-specific antigens, particularly HNA-3a. Activation of pulmonary endothelium is important in the development of TRALI and may acount for most cases being observed in surgical or intensive care unit patients. Transfused leukoagglutinating antibodies bind to recipients＇ neutrophils localized to pulmonary endothelium resulting in activation and release of oxidases and other damaging biologic response modifiers that cause capillary leak. In a minority of TRALI cases, no antibodies are identified and it is postulated that neutrophil priming factors in the transfused component can mediate TRALI in a patient with pulmonary endothelial activation, the so called ＂two hit＂ mechanism. Recognition of the role of anti-leukocyte antibodies has led to new strategies to reduce the risk of TRALI. Female blood donors with a previous pregnancy frequently have HLA antibodies with an overall prevalence of 24% and increasing prevalence related to the number of p

关 键 词：输血相关急性肺损伤 TRALI 白细胞抗体 ICU患者 HLA抗体 浓缩血小板 中性粒细胞 人类白细胞抗原 

分 类 号：R361.3[医药卫生—病理学]