Monitoring Research Of Adverse Transfusion Reactions And The Study On Pathogenesis Mechanism And Intervention Of Transfusion-related Acute Lung Injury

BackgroundBlood transfusion is one of the most common procedures for patients in hospital.It is a lifesaving therapy associated with substantial risks and cost because the adverse transfusion reactions(ATR)may occur during the transfusion process.The occurrence of ATRs always cause discomfort in patients and the most serious reactions can be fatal,threatening confidence in and burdening the health-care system.As a very populous country,China uses a large number of blood components every year while the transfusion reactions had not been well studied over the years.Most Chinese hospitals rely on institutional offline Transfusion Reaction Reporting Form(TRRF)to report patients’transfusion reactions.It’s difficult to compare the reported ATR results between the institutions because the classification and the diagnostic criteria of transfusion reactions in these hospitials are different without the standardization.The reported rate of transfusion reactions in different hospitals can be variable due to different reporting practices and the real condition of transfusion reactions in China is less known.In this study,we carried out a retrospective analysis of offline reported transfusion reactions in different Chinese hospitals to acquire a better understanding of previous ATRs reporting condition.And then,we conducted an in-depth research of ATRs based on the standardized diagnostic criteria and the unified reporting process through an online ATRs reporting system.In addition,the mechanism study of ATRs is also an important part,which is of great significance for better prevention,diagnosis and management of ATRs,especially the serious ATR types.Transfusion-related acute lung injury(TRALI)is one of the major causes of transfusion-related death.The pathological mechanism of TRALI is relatively complex while the development of TRALI involves a series of biological processes,including inflammatory cells infiltration,oxidative stress,alveolar capillary barrier damage,alveolar capillary permeability changes,cell apoptosis and so on.There are numerous signaling molecules and signaling pathways participated in TRALI and the specific mechanism are still less known.Mammalian target of rapamycin(mTOR)signaling pathway is one of the important participants in inflammatory responses,which always play an important role in different types of acute lung injury.In this study,we focus on TRALI and explore the changes of mTOR signaling pathways in TRALI development and explore the preventive intervention effect of rapamycin on TRALI mice.TRALI is an important type of acute lung injury,the study on mTOR will be of great significance to explore the mechanism of TRALI and the functional role of mTOR signaling pathway in inflammatory response.Objective1 To better understand the ATRs’ condition in Chinese hospitals and standardize the diagnostic criteria of ATRs tentatively.2 To explore a good way of ATRs monitoring which is suitable for the actual situation of Chinese medical system,providing experience and data support for future establishment of national hemovigilance system in China.3 To explore the changes of mTOR signaling pathways in TRALI development and the preventive intervention effect of rapamycin on TRALI mice,giving a further exposition of the pathophysiological mechanism of TRALI.Methods1 The monitoring research of adverse transfusion reactions1.1 Multi-center retrospective study1.1.1 Collect Transfusion Reaction Report Form(TRRF)of ATRs from different hospitals of Sichuan,China.In TRRF study,we investigated the transfusion reactions based on the hospital’s reporting results and the analysis fully in accordance with the information in TRRF.1.1.2 Collect Patient Medical Records(PMR)of ATRs from different hospitals of Sichuan,China.In PMR study,the reported cases were reviewed again according to patients’vital signs,clinical symptoms and related laboratory tests.1.2 Multi-center online monitoring study1.2.1 Standardize the diagnostic criteria and the reporting process of ATRs based on the results of ATRs multi-center retrospective study.1.2.2 Establish a multi-center online reporting system of ATRs with the standardized diagnostic criteria and then recruit participating hospitals on a national scale.1.2.3 Collect the ATRs data from participating facilities through the established ATRs online reporting system and then conduct an in-depth data analysis from many aspects.2 The Study on Pathogenesis Mechanism and Intervention of Transfusion-related Acute Lung Injury.2.1 The establishment of a TRALI animal model on mouseThe eight-week-old BALB/c mice were selected to establish a TRALI model by "TwoHit" method.(1)First Hit:the mice were intraperitoneal injected with a low dose of LPS at 0.1mg/kg one day before the experiment;(2)Second Hit:2mg/kg of MHC-I mAb was administered to mouse via tail vein 24h after LPS injection;(3)Observe the vital signs of mouse closely after the ’Second Hit’ process.If the mouse shows abnormal signs of acute lung injury,such as hypoxia,pulmonary edema and so on,indicating the TRALI model is established successfully.2.2 Proteomics and phosphorylated proteomics analysisThe lung tissue samples of TRALI mouse and normal mouse were prepared for 4Dlabel Free quantitative proteomics and phosphorylated proteomics analysis.The changes of mTOR related signaling pathways and other immune and inflammatory signaling molecules in the lung tissues of the two groups were explored through biological analysis.2.3 Preventive intervention study of rapamycin on TRALI mouseEight-week-old BALB/c mice were selected and divided into 4 groups randomly.Corresponding treatment was given according to the following experimental steps.(1)Normal control group:no treatment;(2)LPS group:only a low-dose LPS intraperitoneal injection was performed;(3)TRALI group:establish the TRALI model by "Two-Hit" method;(4)PAPA group:the prophylactic intraperitoneal injection of rapamycin was given for 5 days at a concentration of 5mg/kg,before the TRALI model was established.Results1 The monitoring research of adverse transfusion reactions1.1 Multi-center retrospective study(1)1836 TRRFs were collected in TRRF study.The major types of reported transfusion reactions were only allergic reactions,febrile reactions and other.Some transfusion reactions types information,blood components data,age information,sex record and department information were missing in TRRF.(2)912 reported cases were collected through PMR.There were some AHTRs,hypotensive transfusion reactions and TADs except allergic reactions and FNHTRs.The information integrity was greatly improved compared with TRRF study in this part.The traditional offline reporting method may easy lead to data missing or transfusion reaction misreporting.Improvement is urgently needed to solve theses problems.1.2 Multi-center online monitoring study1.2.1 The ATRs were classified into the following reaction types according to the standardized criteria:transfusion-associated circulatory overload(TACO),transfusionassociated acute lung injury(TRALI),transfusion-associated dyspnea(TAD),allergic reaction,hypotensive transfusion reaction,febrile non-hemolytic transfusion reaction(FNHTR),acute hemolytic transfusion reaction(AHTR),delayed hemolytic transfusion reaction(DHTR),delayed serologic transfusion reaction(DSTR),transfusion-associated graft vs.host disease(TAGVHD),post-transfusion purpura(PTP),transfusion-transmitted infection(TTI),and Other/Unknown.And the ATRs are evaluated again from "case definition","severity" and "imputability".1.2.2 The establishment of ATRs online reporting system:An online reporting system for ATRs was successfully established and 87 participating units were recruited during the styudy period.From 2018 to 2020,a total of 3,061 cases of ATRs were collected through the online reporting system and an in-depth data analysis was conducted.The analysis results showed that the standardization of ATRs diagnostic criteria and the unification of the reporting process was significantly improving the reporting data data quality.Some of the previously missed and misreported ATRs were successfully identified.2 The Study on Pathogenesis Mechanism and Intervention of Transfusion-related Acute Lung Injury2.1 Proteomics and phosphorylated proteomics analysis2.1.1 A total of 347 significantly different proteins and 344 significantly different phosphorylation sites were screened out.These significantly differentiated proteins and phosphorylated modified proteins are mainly involved in biological processes such as protein cascade activation,complement activation,coagulation and hemostasis,immune defense,immune response,inflammatory reaction and so on.2.1.2 Bioinformatics analysis showed that the complement and coagulation cascade signaling pathway,chemokine signaling pathway,cytokine and cytokine receptor signaling pathway,EGFR signaling pathway,PI3K-Akt signaling pathway,MAPK signaling pathway,mTOR signaling pathway,Ras signaling pathway and neutrophil external traprelated signaling pathway showed significant changes in TRALI mice.The mTOR signaling pathway,which is the focus of this study,was significantly upregulated and activated in TRALI model.2.2 Preventive intervention study of rapamycin on TRALI mouse2.2.1 The mTOR signaling pathway was significantly activated in TRALI mouse model,and the activation of this signaling pathway could be inhibited by rapamycin prophylactic administration2.2.2 Prophylactic rapamycin administration had a certain anti-inflammatory effect on TRALI mice,which could alleviate the severity of lung injury in mice to a certain extent.Conclusion1 The traditional offline reporting method may easy lead to data missing or transfusion reaction misreporting.Improvement is urgently needed to solve these problems.2 A unified diagnostic criteria of transfusion reactions and the standardized of the reaction reporting process can make a great contribution in the aspect of online reported transfusion reaction data accuracy.The establishment of hemovigilance system may be the final way to improve the ATRs reporting situation.3 The mTOR signal pathway is activated when TRALI occurs.The prophylactic use of rapamycin can reduce the severity of lung injury in mice,and the mTOR receptor may be a potential target for the preventive treatment of TRALI.