Recognition of Transfusion-Related Acute Lung Injury in a Patient With End-Stage Liver Disease and Sepsis.

A man in his 40s with history of decompensated cirrhosis presented with acute leg pain. On presentation, he was febrile, tachycardic, and jaundiced. Laboratory findings included leukocytosis with bandemia, anemia, elevated creatinine, hyponatremia, lactic acidosis, hyperbilirubinemia, and elevated INR. His model for end-stage liver disease-sodium (MELD-Na) score was 32. Diagnostic paracentesis did not suggest spontaneous bacterial peritonitis, but blood cultures revealed Escherichia coli. He received intravenous fluids, broad-spectrum antibiotics, and packed RBC. He became acutely dyspneic, 1 h into the transfusion. Over the next 36 h, he developed worsening hypoxia with infiltrates on serial chest x-rays despite adequate diuresis. He required intubation for respiratory failure and his hospital course was complicated by hepatic encephalopathy. Ultimately, he was discharged on hospital Day 18 and was retrospectively diagnosed with transfusion-related acute lung injury (TRALI) Type II. This case focuses on management of TRALI in sepsis and highlights the elevated risk of transfusion-associated reactions in liver failure patients and its mortality and morbidity.