Transfusion-related acute lung injury (TRALI): Current understanding, challenges, and future directions

Transfusion-related acute lung injury (TRALI) remains one of the most serious yet often overlooked complications of blood transfusion, contributing to significant morbidity and mortality worldwide. It manifests as acute respiratory distress and non-cardiogenic pulmonary edema within 6 hours of transfusion, requiring immediate recognition and intervention. However, diagnosing TRALI is complex, as its clinical presentation overlaps with other causes of acute lung injury, and its underlying mechanisms remain incompletely understood. This review examines the global burden of TRALI, shedding light on underreporting issues, particularly in resource-limited settings where surveillance systems are inadequate. It explores both antibody-dependent and antibody-independent pathways, focusing on neutrophil activation, inflammatory mediators, and donor-specific factors that drive TRALI pathogenesis. While leukoreduction and improved donor selection have contributed to risk reduction, challenges persist, including the absence of standardized diagnostic criteria, gaps in data from low-income regions, and a lack of reliable biomarkers for early detection. Despite advances in understanding TRALI, more research is needed to refine diagnostic tools, enhance blood product safety, and develop targeted preventive strategies. By addressing these gaps, we can improve transfusion safety and patient outcomes on a global scale, ensuring that life-saving transfusions do not come with life-threatening risks.