• John W Semple, Mark J McVey, Michael Kim, Johan Rebetz, Wolfgang M Kuebler, and Rick Kapur.
• Departments of Anesthesia and Physiology, University of Toronto, Toronto, ON, Canada.
• Crit. Care Med. 2018 May 1; 46 (5): e452-e458.

ObjectivesTransfusion-related acute lung injury is characterized by the onset of respiratory distress and acute lung injury following blood transfusion, but its pathogenesis remains poorly understood. Generally, a two-hit model is presumed to underlie transfusion-related acute lung injury with the first hit being risk factors present in the transfused patient (such as inflammation), whereas the second hit is conveyed by factors in the transfused donor blood (such as antileukocyte antibodies). At least 80% of transfusion-related acute lung injury cases are related to the presence of donor antibodies such as antihuman leukocyte or antihuman neutrophil antibodies. The remaining cases may be related to nonantibody-mediated factors such as biolipids or components related to storage and ageing of the transfused blood cells. At present, transfusion-related acute lung injury is the leading cause of transfusion-related fatalities and no specific therapy is clinically available. In this article, we critically appraise and discuss recent preclinical (bench) insights related to transfusion-related acute lung injury pathogenesis and their therapeutic potential for future use at the patients' bedside in order to combat this devastating and possibly fatal complication of transfusion.Data SourcesWe searched the PubMed database (until August 22, 2017).Study SelectionUsing terms: "Transfusion-related acute lung injury," "TRALI," "TRALI and therapy," "TRALI pathogenesis."Data ExtractionEnglish-written articles focusing on transfusion-related acute lung injury pathogenesis, with potential therapeutic implications, were extracted.Data SynthesisWe have identified potential therapeutic approaches based on the literature.ConclusionsWe propose that the most promising therapeutic strategies to explore are interleukin-10 therapy, down-modulating C-reactive protein levels, targeting reactive oxygen species, or blocking the interleukin-8 receptors; all focused on the transfused recipient. In the long-run, it may perhaps also be advantageous to explore other strategies aimed at the transfused recipient or aimed toward the blood product, but these will require more validation and confirmation first.

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