syuketsu.jstmct.or.jp/wp-content/uploads/2015/03/052010026.pdf · 表2 (和訳)traliとpossible...

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TRANSFUSION-RELATED ACUTE LUNG INJURY

Hitoshi OkazakiJapanese Red Cross Society, Blood Service Headquarters, Central Blood Institute

non-hemolytic transfusion reaction, acute lung injury, diagnostic criteriaKey wordsÝ

Japanese Journal of Transfusion Medicine, Vol. 52. No. 1 52̈ 1�Ý26Þ35, 2006

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�3(�wxw&�'��"&r&� 2001'^2003'� 3'���\���<�e��-a&TRALI�#(�yz�-���&r FDA{������<�e��n|�}&'("TRALI�� ��~e���<5��M��-�"3'�&� TRALI�3�e�)� 49)&"TRALI�*e�a��� e����-TRALI�)�a-(�������+���19���r&���� SHOT@Serious Hazards ofTransfusion�����3�� 2004'�� 23)�TRALI�����"17)� possible�����"p� 3)�e�!�20��HJ��&� 2003'�� 15)� TRALI��)�p� 3)�e�!�21��,-���,�{�$s%�����f��.�&"TRALI��d���)�1997'3(����� l��!o���3p�-��� ���Z�("��&�'��30)/�����'��'������C-[�fg8�%!��w&��)8�0�!C���"1997'a� 2004'w&� TRALI� 99)"

possible TRALI� 27)[���"e��� 10�`&'���GM��t81� TRALI��)���9�$s%��)82��3!}��"TRALI8��!C�)�yz�-�C�GM��4���5���t�!B����"9�$s%8��!C�GM&� 10�`&'("6���!B��C�bc����5���t����TRALI��)�9�$s%��)�&��!B��-�&"bc��5���t� TRALI{�<7�k���Z(�!C���m�8&��9&'��": ¡5¢�3( TRALI������!C���� '("<7�;+&Z-22��

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("E�TU"���TU"�¥=¦�<"�§>TU&������6�����"?¨©ª«¬�23�24�~P¬­®¯L°±M²25�&����� ������@A���&���CTRALI��� '�26�27��

TRALI�� �������TRALI�¬�P���8B��5�³b5�

�'��¤�"-a& C´-���kµ¶!����·+����D¸¹º�bc28�"»¼½¾��bc29�̂ 31�"¿¸½¾��bc32�"#� TRALI8��!Cbc� p#����)33�-Y�'��

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F?¨Â�ÃÄ�3� �&'��?¨Â�ÃÄ�3� ��Å�a��y�tG

Æ�HÇÈ8ÉZ��!��pÊË&'���GMIJ��5���t !��bc� � �Ì���5���t�yz�-("��Í�"bc5�� !��TUK�Π!�5����ÏÐs%�3("5���Ñ%Ò���("t�Ñ%Ò"HLV�Ó{�MN�3Ô��ÕÈ"�ÓO$%�PÖ-Y8×�!"FDy%�HØÙ8��5�pË@�tË�&'

,-��ÂÚÛÜ Q52Ý Q 1Þ 27

��Popovsky�� 1985�� 36�� TRALI�

�� ������� 89��� ������������� ��� �11��� !���"� HLA class I���#$"��%&'()��*+��,�-./01�23�)45.�678)�� HLA class I���9�*� TRALI:��; �� 1970�<=>�?>34�@36��� !����9��ABC.�� HNA-1aDNA-1��HNA-1bDNA-2��HNA-2aDNB-1��NB-2,HNA-3aD5b����=� TRALI�'(� �17�29�37�@39��1999�� Kopko��� HLA class II���=� TRALI�E:�����FGH .� HLA class II���=� TRALI��6'(� �36�40�@44��IJK����� �'() TRALI�,�-A'(� �8�26�31�34��'��L�DMonocyte��M*���A TRALI:�.� �'(� �45�@47��C)� IgA���9�A'(� �48��NOPQ 10RF�IJ.� HLA-B44���1��S���'(�HLA class IDB44��23�)PQO�T�TRALI�E:�)" �A?>���UVW�XY"���Z[.A TRALI�\]�^_1�`a�� �49��C)�bcVd����7�����e5)IJ������Sf��#��Z[�=��ghi��jk�=> TRALI�\]�)^_1�?��A'(� �27�50�51��]�=���glmno�A�p6�#��Z[�948� �"qr'(�s�tu'(� 6 ����$"68� �^_1A?��Grim-minger��.�� 5b��D� HNA-3a����� ��"Ovw�xyzXY"�{|�. Leukotriene C46}�x~�1���*������'(�]"�� ��� �52��C)�Nishimura��� HLA-class II��"^ 1HLA�#�=>jk'(� immune complex��"O�X�xyzXY"�{|�.yzXY����\]*]"�`�� �53��'��Kopko��� 5b����� priming�9��� �]"�`�� �54��]�=�� �;7������(� ���E:��X6no�

9���8�>"�)����� 6 �E:�C(.?�]"=>��������6

767��.?���2001�� Palfi��=����� prospective randomized controlled trial��6'()�105c� ICUIJ�M�"��2����Vd� FFP���"*�IJ��3�Vd��������7�� FFP" ¡�¢�£� FFP��(¤( 4¥f�f¦�?5§��)�¨©.�ª�� ¡�¢�£� FFP�A�¨©.�ª�����7�� FFP�§���«¬��­��®�P�F ratio�¯°"�±²�)"]³�5c���´µ��T�(���� 4c��������� FFP���'()F�8)�1c�IJ. TRALI�E:��]�,�-A���7�� FFP�§�F.?>�� !�����1.?8)�¶·m�� P�F ratio�� �����7�� FFP§�F� ¡�¢�£� FFP§�F=>�¸�¹º�� )55���������S!�� HLA���9���»¼�©�½8�¾�6�¿��?�]"�'(��>�ÀÁ���ÂÃ�ÄÅ� ��SÆ¡Ç���A'(� �56�57�������VW.� TRALI�#$"68)"

È��(������S�=��É�´µ���ÊË*� look-back study�Ì4(� ��TRALIE:�.������ HLA class I���� HLA class II���� !����Í��� )Îi���������É�´µ�Ï�9�����Ð+��>�TRALIE:�Ñt'()" �A?(Ò�Ñt.�678)" �A?>�p.?�58�@62��]�]"������������ÓÔ� TRALIE:�ÕÖ×Ø.�6 ]"�`a�� ���glmno�=�v�ÙÚ£Aµk'(��

>�Seeger��=� ex vivo� rabbit lung�� )� 5b��D� HNA-3a���" 5b�1������ )U.� rabbit plasma�ÓÔº�OÛÜÙÚ£�µk�� �63��C) Bux�� ratlung�� �mouse monoclonal� HNA-2a��" HNA-2a�1� 70�Vd�������*�]"�=>OÛÜ�ÝÅ'Þ� �64��Susskind

28 Japanese Journal of Transfusion Medicine, Vol. 52. No. 1

�� BALB�c mouse����mouse MHC class ImAb� injection�� TRALI������� ���65������ TRALI������������

��������� �!��"���#$%���& HLA&��&�'&��()*� ���+�,-�.�/0��1��23��4���� TRALI��5��6���7�%����8%�&�9:�()*�; TRALI��5<�8��=>��?�&�@�AB<�;��CD�%�45�46��E��FG������ TRALI��5<�

6�;�7�%�?�FH���'���I�J4�%�&��43��E3����;K��FG����LMN�OP� TRALI�KQ�%���66�R68����ST�UV���;���Silliman��W

XYZ��[��\�%����9��TRALI5���]���� *�^�_�D`�Ja5��b�cd�ef�gfh� ��������i5�j���kl����m�%�n�op��q�r �K���s@�K�69��8�t@�!"uvX�����#��%�w�'E���x$kl� LPS �y� rat�%�&'<��%z{�|}���s;��K��#��%��~kl�� lysophosphatidylcholine_lyso-PC���n�"p�K���%���70�71��In vitro�uvX���%(���)*�+�

�����'���,-/0���%���z{�� LPS� lyso-PC�����'�n����%��)*�+�n�����<������72����ST�UV�AB<��������Silli-

man�� 90�� TRALI�P����7�K��4.G�OP���� 90�� TRALI5���m��?�+�/0� 1�1,120�K3��&��'&���1� 25��K�2����3�}��� 3.6��<��23�73��8���ST�UV��<�45�56;�b

�7�%���74��TRALI���

Dry�� 1999.��7�� TRALI�8��

��%���|8�� 2�G��9��?��1� TRALI�%�:�����D����CD�%�75��O;� ALI�ARDS��<=� DAD_Diffuse Alveolar Damage���%�����!���������%z{;�$3��<�����2>�����D�%��8��?���8��7��%(����&�'��@���%�%+ *�+�¡{�%+A¢�£�"�BC���%����

TRALI�������8��s��7�D�;¤¥�5��7�88

�b��2�ED�}�?3¦�2�§E3�}������bE�¨F©ª�GO�%�?�«�¬­�®¯*��+�¨F©ª�E°E°�K�±� TRALI�±� TRALI�����2�HF�}«�I�JK� �L3�M²��<�8���}���s�^³�K3��+�� " 2004. � 4´ � Consensus Conference�µ�%�TRALI�¨F©ª¶��\��2004.� 12´�¨F©ª�·¸¶� Transfusion�¹º�%�76��8�¨F©ª¶� 1994.��\�%� The American-European Consensus Con-ference on ARDS� ALI�ARDS�¨F©ª�©»��;��K�¼½¾T����TNO��3¦��)�§�;��K�77�78���2��P���¿ �HQ©ª�R$«�SÀ��¨F©ª�K��"��Áy TRALI����ÂP�%����P%ÃÄ�ÅT�U ��3���ÆV��K��7 1�2�+�¨F©ª¶_Ç6?�ÈWX���=<��8�¨F©ª�� TRALI_�¨��� possible TRALI_ÆV����N:�¨F<�8���3�?���ÉÊ� ALI�ËÌ]F� *Y��q<�ÍÎ���TRALI�ÆV�������¨���ÏZ��ÂÐ<��s��%����[Y%�£ÑÒ���y 6�GÉ)��5���É\� ALI��q�]Ó�ÔÕE%����"���ÉÊ�Ç]�?8� ALI�P��2�Ö��]Ó�}������2�1^�%��National Heart , Lung and Blood InstituteWorking Group on TRALI�; TRALI�P��Q×������ØÙI��K�79��

_`��TÚÛÜ a52Ý a 1Þ 29

表1 Recommended criteria for TRALI and possible TRALI

1.TRALI criteriaa.ALI堰.Acute onset奄.Hypoxemia

Research setting:PaO2/FiO2≦300 or SpO2<90% on room airNonresearch setting:PaO2/FiO2≦300 or SpO2<90% on room air or other clinical evidence of hypoxemia

宴.Bilateral infiltrates on frontal chest radiograph延.No evidence of left atrial hypertension(i.e., circulatory overload)b.No preexisting ALI before transfusionc.During or within 6 hr of transfusiond.No temporal relationship to an alternative risk factor for ALI

2.Possible TRALIa.ALIb.No preexisting ALI before transfusionc.During or within 6 hr of transfusiond.A clear temporal relationship to an alternative risk factor for ALI

Risk factors for ALI Direct lung injury Indirect lung injury  Aspiration Severe sepsisPneumonia ShockToxic inhalation Multiple traumaLung contusion Burn injuryNear drowning Acute pancreatitis Cardiopulmonary bypass Drug overdose

(Kleinman S, et al. Transfusion 2004;44:1774-89) 76

���������� ���������������������� ��!�"#$�%�&!��'�(TACO)Transfusion as-sociated circulatory overload*��TRALI�+�$��,-./�012��'�80*(34�5&6�����789��)����*���-./'��:6;<�=>��?6&�%? @AB�CDE��&��FGHIJK LMN�OPQRS�TUVWXYZ�CDE� TACO� 2000[% 2003[� 4[\ 217]HIJK�TRALI�HI^ 20]�_`$��a 10b�cd5,6&����e%�81*(TACO�5&6fghi�jkl�5,� @�TRALI�����12'�(0mnopqjrostp�uv,��,�wK��x���yz���$�6�{]uv,�e|�

�}�w�~����:6 BNP)B-natriureticpeptide*� �m����$��DLD��/:6���:�!�$�yz��JK6&�82*(�������j%��������:��������6�� ���yz�K65x���J����$�,����K�32*(

TRALI���������� ���JK ��� ���¡��ALI�

ARDS���� ���¡�:6:¢:¢&eK6&��!��DLD����!��£¤�¥JK65�¦�'}§¨©ª���'��&!��'�(!�«��¬j����­$��x®&� !$�%¯�°�JK6&�(TRALI��[±²5���³����� �´µ�w�§§¶/:6·&% !%���¸µ�5��¹º»@������J��¼2��

30 Japanese Journal of Transfusion Medicine, Vol. 52. No. 1

表2 (和訳)TRALIとpossible TRALIの診断指針の推奨案

1.TRALIの診断基準a.ALI(急性肺障害)

堰.急性発症奄.低酸素血症

研究目的の場合PaO2/FiO2≦300またはSpO2<90%(room air)研究目的でない場合PaO2/FiO2≦300またはSpO2<90%(room air)またはその他の低酸素血症の臨床症状

宴.胸部正面X線上両側肺野の浸潤影 延.左房圧上昇(循環過負荷)の証拠がない

b.輸血以前にALIがないc.輸血中もしくは輸血後6時間以内に発症d.時間的に関係のある輸血以外のALIの危険因子*がない

2.Possible TRALIの診断基準a.ALI(急性肺障害)b.輸血以前にALIがないc.輸血中もしくは輸血後6時間以内に発症d.時間的に関係のある輸血以外のALIの危険因子*が存在する

*ALIの危険因子直接的肺障害 間接的肺障害  誤嚥 重症敗血症肺炎 ショック有害物吸入 多発外傷肺挫傷 火傷溺水 急性膵炎 心肺バイパス 薬物過剰投与

���������� ���� TRALI��������������83����� !"#����$�%&'�()�*+,-���./�01234�56��789:;<=>�?��0@AB�CDEFDGHI�J$6����/./�34K TRALILMN����/OPQ�?�����ALI�*����L�60�RB�ST��-�UQ�VW&'�XY�?+�-��34��Z[�.-\]��./�^_TRALILMN�,��`L�a�bcd�?��`�6�bc����*ef�gh�34Kijkl��+�m��MN"#�noKpqlr�6���

TRALI����std� TRALIKgh�uv�,�wx*�

���y���z{|Ky�}~��$�[�o�K�}��[����6��Q�[��� �

a���������-�h����Kh�����L`��?�����*�� TRALIK�`����[����Q��[��[�*Z[�*����`LL�������[���*����� ��}¡������look-back study�¢£�¤~./� TRALIK�`��¥8>�[��'4 TRALIK�`~¦§�*��`L���~¨����[����OP�?�L�/()���`LKpq�L�std�©ª��[�«§K� ~�`L��¬£­�a/�*¥8>®>¯�°y�bc��$�±k�²³��§�r�6���?�/56�84��

TRALI���©´­�µ¶*�} Supportive careK"�L

~��·¸¶x¹PaO2º60 Torr�SpO2º90»K¼���½¾�����¿À�.ÁÂÃVWÀÄ�½¾���`L����VWÀÄ�wx* ARDS

��Z[ÅÆÇÈ É52Ê É 1Ë 31

��������PEEP�Small tidal volume�Permissive hypercapnia� � strategy������������������������ !"�#$%&'()*����+�85,-88,./01*'��23456�7829:;<=>� �?�@AB*�C���DE��*���FG$*')7HIJ2�K�*BL��MN>�O(F�PQ�RS@TUVW��)X�YZ[*�\]^_�`a��89,90,bcde��fgh#$ ALI�ARDS^1�)X�i5685J�j�@A)��kl'�mG)�

����no TRALI�p��qr')��^_s��

tu'��#��v���wxy�z{|g}~��# TRALI�@�������~��������OO���������^_�)X��:�:���� ����wx���'��$�K��@��������#�DE����������A

� �

1,Shimada E, Tadokoro K, Watanabe Y, et al�Ana-phylactic transfusion reactions in haptoglobin-deficient patients with IgE and IgG haptoglobinantibodies. Transfusion, 42�766�773, 2002.

2,Barnard RD�Indiscriminate transfusion�a cri-tique of case reports illustrating hypersensitivityreactions. N Y State J Med, 51�2399�2402, 1951.

3,Philipps E, Fleischner FG�Pulomonary edema inthe course of a blood transfusion without over-loading the circulation. Dis Chest, 50�619�623,1966.

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