ORIGINAL RESEARCH Ten years of TRALI mitigation: measuring our progress Sarah Vossoughi , 1,2 Jed Gorlin, 3 Debra A. Kessler, 1 Christopher D. Hillyer, 1 Nancy L. Van Buren, 3 Alexandra Jimenez, 1 and Beth H. Shaz 1,2 BACKGROUND: Transfusion-related acute lung injury (TRALI) is a leading cause of transfusion-associated mortality for which multiple mitigation strategies have been implemented over the past decade. However, product-specific TRALI rates have not been reported longitudinally and may help refine additional mitigation strategies. STUDY DESIGN AND METHODS: This retrospective multicenter study included analysis of TRALI rates from 2007 through 2017. Numerators included definite or probable TRALI reports from five blood centers serving nine states in the United States. Denominators were components distributed from participating centers. Rates were calculated as per 100,000 components distributed (p < 0.05 significant). RESULTS: One hundred four TRALI cases were reported from 10,012,707 components distributed (TRALI rate of 1.04 per 100,000 components). The TRALI rate was 2.25 for female versus 1.08 for male donated components (p < .001). The TRALI rate declined from 2.88 in 2007 to 0.60 in 2017. From 2007 to 2013, there was a significantly higher TRALI rate associated with female versus male plasma (33.85 vs. 1.59; p < 0.001) and RBCs (1.97 vs. 1.15; p = 0.03). From 2014 through 2017, after implementation of mitigation strategies, a significantly higher TRALI rate only from female-donated plateletpheresis continued to be observed (2.98 vs. 0.75; p = 0.04). CONCLUSION: Although the TRALI rates have substantially decreased secondary to multiple strategies over the past decade, a residual risk remains, particularly with female-donated plateletpheresis products. Additional tools that may further mitigate TRALI incidence include the use of buffy coat pooled platelets suspended in male donor plasma or platelet additive solution due to the lower amounts of residual plasma. T ransfusion-related acute lung injury (TRALI) is one of the leading causes of transfusion-related mor- bidity, with 10% mortality and 70% to 90% of patients requiring mechanical ventilation. 1–3 The serious TRALI consequences, and lack of TRALI-specific treatments have resulted in a focused effort to decrease recipient risk of ever acquiring TRALI. Over the past decade, a number of mitigation steps have been implemented to decrease the TRALI rate. Yet most of the available data regarding the effectiveness of these strategies focus on the decreased rate from male donor–only plasma transfusions. 4,5 Less is known about the residual risk from platelets (PLTs) or red blood cells (RBCs) with other miti- gation strategies. 5 The aim of this study is to determine the cur- rent residual risk of various product types following TRALI mitigation strategies. The Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network’s hemovigilance manual on transfusion reactions and incident reporting contains a definition for TRALI based on the Canadian consensus con- ference and also includes imputability criteria. 6,7 TRALI is composed of two components: 1) the onset of an acute lung injury (ALI), and 2) the symptoms are caused by a blood prod- uct transfusion. 1 An ALI is defined as evidence of hypoxemia (whether from clinical symptoms or oxygen saturation monitor- ing), radiographic evidence of bilateral infiltrates due to pulmo- nary edema, and the absence of left atrial hypertension, implying no circulatory overload. 1,6 To be considered associated ABBREVIATIONS: ALI = acute lung injury; CDC = Centers for Disease Control and Prevention; HLA = human leukocyte antigen; PAS = platelet additive solution; TRALI = transfusion-related acute lung injury. From the 1 New York Blood Center, the 2 Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York; and the 3 Innovative Blood Resources, St. Paul, Minnesota. Address reprint requests to: Beth H. Shaz, MD, New York Blood Center, 310 East 67th Street, New York, NY 10065; e-mail: bshaz@nybc.org. Received for publication March 11, 2019; revision received May 6, 2019, and accepted May 7, 2019. doi:10.1111/trf.15387 © 2019 AABB TRANSFUSION 2019;9999;1–8 TRANSFUSION 1