Viability and in vitro properties of AS-1 red cells after gamma irradiation

Thresholds for Red Blood Cell Transfusion in Preterm Infants: Evidence to Practice

Rapid blood loss with circulatory shock is dangerous for the preterm infant as cardiac output and oxygen-carrying capacity are simultaneously imperilled. This requires prompt restoration of circulating blood volume with emergency transfusion. It is recommended that clinicians use both clinical and laboratory responses to guide transfusion requirements in this situation. For preterm infants with anemia of prematurity, it is recommended that clinicians use a restrictive algorithm from one of two recently published clinical trials. Transfusion outside these algorithms in very preterm infants is not evidence-based and is actively discouraged.

Blood donor, component, and recipient-specific factors associated with venous thromboembolism in transfused hospitalized adult patients: Data from the recipient epidemiology and donor evaluation Study-III (REDS-III)

OBJECTIVE

Growing evidence suggests multiple pathophysiological mechanisms linking red blood cells (RBC) transfusions to thrombosis. This study examined blood donor, component, and recipient factors which may be associated with thromboembolic outcomes following RBC transfusion.

METHODS

We utilized the Recipient Epidemiology Donor Evaluation Study-III (REDS-III) database on patients transfused in 12 hospitals between 2013-2016. Stratified Cox proportional hazards regression models with time-dependent exposures were used to examine associations of donor and component modification characteristics on venous thromboembolism (VTE) in patients transfused RBC units.

RESULTS

59,603 patients were transfused 229,500 RBC units during 79,298 hospitalizations with post-transfusion VTE occurring in 1869 (2.4%) of patients. In adjusted regression analyses, a per RBC-unit risk of VTE was present for gamma irradiation (HR = 1.03; 95% CI: 1.02-1.03), female donor sex (HR = 1.01; 95% CI: 1.00-1.01), storage duration greater than 5 weeks (HR = 1.01; 95% CI: 1.01-1.02), AS-1 storage solution (HR = 1.01; 95% CI: 1.00-1.01), and apheresis-derived collections (HR = 1.01; 95% CI: 1.01-1.02). Among recipient factors, male sex (HR = 1.03; 95% CI: 1.02-1.04), pre-transfusion hemoglobin level (HR = 0.94; 95% CI: 0.94-0.94), body mass index strata (HR = 1.11; 95% CI: 1.08-1.14), and principal diagnoses including malignancy (HR = 1.13; 95% CI: 1.10-1.16), cardiac arrest (HR = 1.38; 95% CI:1.07-1.77) and hip fracture (HR = 1.59; 95% CI:1.53-1.66) were associated with VTE in adjusted analyses.

DISCUSSION

We identified several donor, component, and recipient-specific factors associated with VTE in transfused hospitalized adult patients. In adjusted models, the dose-dependent associations of donor and component-specific factors with VTE were modest and unlikely to be clinically significant in the majority of transfused patients. Additional mechanistic and clinical studies linking blood donor and component factors with thrombotic outcomes are needed.

Donor genetic and non-genetic factors affecting red blood cell transfusion effectiveness

BACKGROUND

Red blood cell (RBC) transfusion effectiveness varies due to donor, component, and recipient factors. Prior studies identified characteristics associated with variation in hemoglobin increments following transfusion. We extended these observations, examining donor genetic and non-genetic factors affecting transfusion effectiveness.

METHODS

This is a multicenter retrospective study of 46,705 patients, and 102,043 evaluable RBC transfusions from 2013-2016 across 12 hospitals. Transfusion effectiveness was defined as hemoglobin, bilirubin, or creatinine increments following single RBC unit transfusion. Models incorporated a subset of donors with data on single nucleotide polymorphisms associated with osmotic and oxidative hemolysis in vitro. Mixed modelling accounting for repeated transfusion episodes identified predictors of transfusion effectiveness.

RESULTS

Blood donor (sex, Rh status, fingerstick hemoglobin, smoking), component (storage duration, gamma irradiation, leukoreduction, apheresis collection, storage solution), and recipient (sex, body mass index, race, age) characteristics were associated with hemoglobin and bilirubin but not creatinine increments following RBC transfusions. Increased storage duration was associated with increased bilirubin and decreased hemoglobin increments, suggestive of in vivo hemolysis following transfusion. Donor G6PD-deficiency and polymorphisms in SEC14L4, HBA2, and MYO9B genes were associated with decreased hemoglobin increments. Donor G6PD-deficiency and polymorphisms in SEC14L4 were associated with increased transfusion requirements in the subsequent 48 hours.

CONCLUSIONS

Donor genetic and other factors, such as RBC storage duration, affect transfusion effectiveness as defined by decreased hemoglobin or increased bilirubin increments. Addressing these factors will provide a precision medicine approach to improve patient outcomes, particularly for chronically-transfused RBC recipients, who would most benefit from more effective transfusion products.

Guideline development for prevention of transfusion-associated graft-versus-host disease: reduction of indications for irradiated blood components after prestorage leukodepletion of blood components

Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare, commonly fatal complication of transfusion preventable by irradiation of blood units. The revision of the Dutch transfusion guideline addressed the question whether irradiation is still necessary if blood components are prestorage leukodepleted. We searched for published cases of TA-GVHD following transfusion of prestorage leukodepleted blood and through contacting haemovigilance systems. Six presumed cases were found, dating from 1998 to 2013. Four out of six patients had received one or more non-irradiated units despite recognised indications for irradiated blood components. In the countries providing information, over 50 million prestorage leukodepleted, non-irradiated, non-pathogen-reduced cellular components were transfused in a 10-year period. Potential benefits of lifting indications for irradiation were considered. These include reduced irradiation costs (€ 1.5 million annually in the Netherlands) and less donor exposure for neonates. Findings were presented in an invitational expert meeting. Recommendations linked to human leukocyte antigen similarity between donor and recipient or intra-uterine transfusion were left unchanged. Indications linked to long-lasting deep T-cell suppression were defined with durations of 6 or 12 months after end of treatment (e.g. autologous or allogeneic stem cell transplantation). Need for continued alertness to TA-GVHD and haemovigilance reporting of erroneous non-irradiated transfusions was emphasised.

Impact of universal irradiation on chronic transfusion for sickle cell disease

BACKGROUND

Irradiation of blood products prevents transfusion-associated graft-versus-host disease, but most patients do not require this modification which could have an adverse impact on transfusion outcomes. We hypothesized that irradiation may increase transfusion requirements for patients with sickle cell disease (SCD) receiving chronic transfusion.

STUDY DESIGN AND METHODS

Our pediatric hospital implemented a new policy of universal blood product irradiation in May 2018. We conducted a retrospective chart review of patients with SCD receiving chronic red blood cell (RBC) transfusion throughout the year before and after institution of this policy. The primary outcome was the change in RBC transfusion volume per patient weight transfused during the pre- vs. post- universal irradiation period. Secondary outcomes were the change in median pretransfusion laboratory values.

RESULTS

Among 17 patients, 8 (47%) received more RBCs the year before irradiation and 9 (53%) received more the year after irradiation. Implementation of universal irradiation did not significantly increase transfusion volumes needed to clinically manage this population (median change +1.7 ml/kg/year, p = .54). Additionally, there were no significant changes in absolute reticulocyte count, hemoglobin, hemoglobin S%, white blood cell count, lactate dehydrogenase, total bilirubin, serum potassium, and ferritin during the two time periods.

CONCLUSION

In a cohort of patients with SCD receiving simple chronic transfusion, irradiation did not impact transfusion requirements or pertinent pretransfusion laboratory values. Irradiation does not appear to have clinically significant consequences for SCD chronic transfusion management.

Transfusion-associated hyperkalemia in pediatric population: Prevalence, risk factors, survival, infusion rate, and RBC unit features

BACKGROUND

Hyperkalemia is a rare life-threatening complication of red blood cell (RBC) transfusion. Stored RBCs leak intracellular potassium (K+) into the supernatant; irradiation potentiates the K+ leak. As the characteristics of patients and implicated RBCs have not been studied systematically, a multicenter study of transfusion-associated hyperkalemia (TAH) in the pediatric population was conducted through the AABB Pediatric Transfusion Medicine Subsection.

STUDY DESIGN

The medical records of patients <18 years old were retrospectively queried for hyperkalemia occurrence during or ≤12 h after the completion of RBC transfusion in a 1-year period. Collected data included patient demographics, diagnosis, medical history, timing of hyperkalemia and transfusion, mortality, and RBC unit characteristics.

RESULTS/FINDINGS

A total of 3777 patients received 19,649 RBC units during the study period in four facilities. TAH was found in 35 patients (0.93%) in 37 occurrences. The patient median age and weight were 1.28 years and 9.80 kg, respectively. All patients had multiple serious comorbidities. There were 79 RBC units transfused in the TAH events; 62% were irradiated, and the median age of the units was 10 days. The median total RBC volume transfused ≤12 h before TAH was 24% of patient estimated total blood volume, and the median infusion rate (IR) was19.6 ml/kg/h. Mortality rate within 1 day after the TAH event was 20%.

CONCLUSIONS

The prevalence of TAH in children was low; however, the 1-day mortality rate was 20%. Patients with multiple comorbidities may be at higher risk for TAH. The IR was higher for patients who had TAH than the IR threshold for safe transfusion.

Hypothermic storage of leukoreduced red blood cells for greater than 21 days is a safe alternative to irradiation

BACKGROUND

Irradiation of red blood cells (RBCs) inactivates residual donor T lymphocytes to prevent transfusion-associated graft-vs-host disease (TA-GVHD) but can have adverse effects on recipients and inventory management. Reported incidence of TA-GVHD is lower when leukoreduced RBCs and older blood products are transfused; therefore, the impact of leukoreduction and storage was evaluated as an alternative prevention strategy.

STUDY DESIGN AND METHODS

Effectiveness of leukoreduction filters on white blood cell (WBC) proliferation was evaluated by filtering buffy coat (BC) products and isolating residual WBCs. Additionally, leukoreduced RBCs were spiked with 5 × 10⁶ WBCs on Day 21 of hypothermic storage, then stored and processed on Days 7, 14, and 21 to obtain residual WBCs to investigate the impact of hypothermic storage on their viability and proliferative ability. Viability of residual WBCs was assessed by staining with annexin V and an antibody cocktail for flow cytometry analysis. Proliferative ability was assessed by placing carboxyfluorescein diacetate succinimidyl ester-labeled residual WBCs into culture for 6 days with phytohemagglutinin before flow cytometry assessment.

RESULTS

Filtration of BC units depleted WBCs, particularly T lymphocytes, to 0.001% ± 0.003% cells/unit, although proliferative activity remained consistent with prefiltration levels of WBCs. WBCs in stored RBCs remained viable even on Day 21 of storage; however, the proliferative activity decreased to 0.24% ± 0.41%.

CONCLUSIONS

Hypothermic storage of RBCs for 21 days or more is sufficient to inactivate T lymphocytes, which may help prevent TA-GVHD when irradiated RBCs are not available.

Effect of donor, component, and recipient characteristics on hemoglobin increments following red blood cell transfusion

Significant research has focused individually on blood donors, product preparation and storage, and optimal transfusion practice. To better understand the interplay between these factors on measures of red blood cell (RBC) transfusion efficacy, we conducted a linked analysis of blood donor and component data with patients who received single-unit RBC transfusions between 2008 and 2016. Hemoglobin levels before and after RBC transfusions and at 24- and 48-hour intervals after transfusion were analyzed. Generalized estimating equation linear regression models were fit to examine hemoglobin increments after RBC transfusion adjusting for donor and recipient demographic characteristics, collection method, additive solution, gamma irradiation, and storage duration. We linked data on 23 194 transfusion recipients who received one or more single-unit RBC transfusions (n = 38 019 units) to donor demographic and component characteristics. Donor and recipient sex, Rh-D status, collection method, gamma irradiation, recipient age and body mass index, and pretransfusion hemoglobin levels were significant predictors of hemoglobin increments in univariate and multivariable analyses (P < .01). For hemoglobin increments 24 hours after transfusion, the coefficient of determination for the generalized estimating equation models was 0.25, with an estimated correlation between actual and predicted values of 0.5. Collectively, blood donor demographic characteristics, collection and processing methods, and recipient characteristics accounted for significant variation in hemoglobin increments related to RBC transfusion. Multivariable modeling allows the prediction of changes in hemoglobin using donor-, component-, and patient-level characteristics. Accounting for these factors will be critical for future analyses of donor and component factors, including genetic polymorphisms, on posttransfusion increments and other patient outcomes.

Development, validation, and potential applications of biotinylated red blood cells for posttransfusion kinetics and other physiological studies: evidenced-based analysis and recommendations

The current reference method in the United States for measuring in vivo population red blood cell (RBC) kinetics utilizes chromium-51 (⁵¹ Cr) RBC labeling for determining RBC volume, 24-hour posttransfusion RBC recovery, and long-term RBC survival. Here we provide evidence supporting adoption of a method for kinetics that uses the biotin-labeled RBCs (BioRBCs) as a superior, versatile method for both regulatory and investigational purposes. RBC kinetic analysis using BioRBCs has important methodologic, analytical, and safety advantages over ⁵¹ Cr-labeled RBCs. We critically review recent advances in labeling human RBCs at multiple and progressively lower biotin label densities for concurrent, accurate, and sensitive determination of both autologous and allogeneic RBC population kinetics. BioRBC methods valid for RBC kinetic studies, including successful variations used by the authors, are presented along with pharmacokinetic modeling approaches for the accurate determination of RBC pharmacokinetic variables in health and disease. The advantages and limitations of the BioRBC method-including its capability of determining multiple BioRBC densities simultaneously in the same individual throughout the entire RBC life span-are presented and compared with the ⁵¹ Cr method. Finally, potential applications and limitations of kinetic BioRBC determinations are discussed.

Effect of red blood cell storage time on markers of hemolysis and inflammation in transfused very low birth weight infants

BackgroundProlonged storage of transfused red blood cells (RBCs) is associated with hemolysis in healthy adults and inflammation in animal models. We aimed to determine whether storage duration affects markers of hemolysis (e.g., serum bilirubin, iron, and non-transferrin-bound iron (NTBI)) and inflammation (e.g., interleukin (IL)-8 and monocyte chemoattractant protein (MCP)-1) in transfused very low birth weight (VLBW) infants.MethodsBlood samples from 23 independent transfusion events were collected by heel stick before and 2-6 h after transfusion.ResultsSerum iron, total bilirubin, NTBI, and MCP-1 levels were significantly increased after transfusion of RBCs (P<0.05 for each comparison). The storage age of transfused RBCs positively correlated with increases in NTBI following transfusion (P<0.001; R²=0.44). No associations between storage duration and changes in the other analytes were observed.ConclusionTransfusion of RBCs into VLBW infants is associated with increased markers of hemolysis and the inflammatory chemokine MCP-1. RBC-storage duration only correlated with increases in NTBI levels following transfusion. NTBI was only observed in healthy adults following 35 days of storage; however, this study suggests that VLBW infants are potentially more susceptible to produce this pathological form of iron, with increased levels observed after transfusion of only 20-day-old RBCs.

In premature infants there is no decrease in 24-hour posttransfusion allogeneic red blood cell recovery after 42 days of storage

BACKGROUND

Critically ill preterm very-low-birthweight (VLBW) neonates (birthweight ≤ 1.5 kg) frequently develop anemia that is treated with red blood cell (RBC) transfusions. Although RBCs transfused to adults demonstrate progressive decreases in posttransfusion 24-hour RBC recovery (PTR₂₄ ) during storage-to a mean of approximately 85% of the Food and Drug Administration-allowed 42-day storage-limited data in infants indicate no decrease in PTR₂₄ with storage.

STUDY DESIGN AND METHODS

We hypothesized that PTR₂₄ of allogeneic RBCs transfused to anemic VLBW newborns: 1) will be greater than PTR₂₄ of autologous RBCs transfused into healthy adults and 2) will not decrease with increasing storage duration. RBCs were stored at 4°C for not more than 42 days in AS-3 or AS-5. PTR₂₄ was determined in 46 VLBW neonates using biotin-labeled RBCs and in 76 healthy adults using ⁵¹ Cr-labeled RBCs. Linear mixed-model analysis was used to estimate slopes and intercepts of PTR₂₄ versus duration of RBC storage.

RESULTS

For VLBW newborns, the estimated slope of PTR₂₄ versus storage did not decrease with the duration of storage (p = 0.18) while for adults it did (p < 0.0001). These estimated slopes differed significantly in adults compared to newborns (p = 0.04). At the allowed 42-day storage limit, projected mean neonatal PTR₂₄ was 95.9%; for adults, it was 83.8% (p = 0.0002).

CONCLUSIONS

These data provide evidence that storage duration of allogeneic RBCs intended for neonates can be increased without affecting PTR₂₄ . This conclusion supports the practice of transfusing RBCs stored up to 42 days for small-volume neonatal transfusions to limit donor exposure.

Red blood cells derived from whole blood treated with riboflavin and ultraviolet light maintain adequate survival in vivo after 21 days of storage

BACKGROUND

Pathogen reduction (PR) of whole blood (WB) may increase blood safety when applied before component separation. This study evaluates the in vivo performance of red blood cells (RBCs) derived from WB treated with the riboflavin and ultraviolet (UV) light PR (Mirasol) system.

STUDY DESIGN AND METHODS

This was a prospective, two-center, single-blind, randomized, two-period, crossover clinical trial designed to evaluate autologous ⁵¹ Cr/^99m Tc-radiolabeled recovery and survival of RBCs derived from Mirasol-treated WB compared to untreated WB. RBCs were stored in AS-3 for 21 days at 1 to 6°C. In vitro RBC variables were characterized. Frequency and severity of treatment-emergent adverse event (TEAE) and neoantigenicity were determined.

RESULTS

Twenty-four healthy adult volunteers (n = 12 per site) were evaluated. The Mirasol 24-hr RBC recoveries were 82.5 ± 3.9% with one-sided 95% lower confidence limit of 80.9%, meeting US Food and Drug Administration acceptance criteria, albeit at lower level than controls (91.7 ± 6.8%, p < 0.001). Mean RBC survival and T₅₀ were reduced in the Mirasol group (61 and 23 days, respectively) versus controls (82 and 36 days, respectively; p < 0.001) with a mean area under the curve survival of treated RBCs of 83% of untreated controls. End-of-storage hemolysis in the Mirasol group was 0.22 ± 0.1% (control, 0.15 ± 0.1%; p < 0.001). No neoantigenicity or differences in TEAEs were found.

CONCLUSION

RBCs derived from Mirasol WB and stored for up to 21 days in AS-3 maintained acceptable cell quality and recovery, albeit modestly reduced compared with untreated RBCs. Mirasol WB may represent a valid single WB PR platform that allows manufacture of RBC for storage for up to 21 days.

Blood component preferences of transfusion services supporting infant transfusions: a University HealthSystem Consortium benchmarking study

BACKGROUND

The extent of acceptability of red blood cells (RBCs) containing additive solutions (ASs) for low-volume neonatal transfusions among hospitals is unknown. Also unknown is whether hospitals have policies that address the risk of hyperkalemia associated with prolonged storage either with or without irradiation for neonatal transfusions.

STUDY DESIGN AND METHODS

A benchmarking survey of University HealthSystem Consortium members included questions regarding the acceptability of RBC units containing ASs for low-volume neonatal transfusions, policies addressing the length of RBC storage in AS, and policies regarding storage periods after irradiation.

RESULTS

Twenty-eight of 47 respondents (60%) accept the use of at least one AS (AS-1, AS-3, or AS-5). Twenty-one (45%) accept the use of all three ASs for neonatal transfusions. Thirty-seven of 45 respondents (82%) do not have a policy requiring washing of RBCs used for low-volume transfusions beyond a specified number of days of storage or days after irradiation.

CONCLUSIONS

Although the majority of institutions will use ASs, a significant number of institutions will not. The reasons for these policies were not elicited. Most respondents did not have a policy requiring washing beyond a specified number of days of storage or days after irradiation. Since RBCs stored for prolonged periods of time after irradiation have increased plasma potassium, it is important to develop policies to prevent clinically significant posttransfusion hyperkalemia in at-risk patients when RBCs are irradiated and not used immediately. More work still needs to be done to resolve these fundamental precepts of neonatal transfusion.

Deterioration of red blood cell mechanical properties is reduced in anaerobic storage

BACKGROUND

Hypothermic storage of red blood cells (RBCs) results in progressive deterioration of the rheological properties of the cells, which may reduce the efficacy of RBC transfusions. Recent studies have suggested that storing RBC units under anaerobic conditions may reduce this storage-induced deterioration.

MATERIALS AND METHODS

The aim of this study was to compare the rheological properties of conventionally and anaerobically stored RBC and provide a measure of the relationship between oxidative damage to stored RBC and their ability to perfuse microvascular networks. Three different microfluidic devices were used to measure the ability of both types of stored RBC to perfuse artificial microvascular networks. Flow rates of the RBC passing through the entire network (bulk perfusion) and the individual capillaries (capillary perfusion) of the devices were measured on days 2, 21, 42, and 63 of storage.

RESULTS

The bulk perfusion rates for anaerobically stored RBC were significantly higher than for conventionally stored RBCs over the entire duration of storage for all devices (up to 10% on day 42; up to 14% on day 63). Capillary perfusion rates suggested that anaerobically stored RBC units contained significantly fewer non-deformable RBC capable of transiently plugging microfluidic device capillaries. The number of plugging events caused by these non-deformable RBC increased over the 63 days of hypothermic storage by nearly 16- to 21-fold for conventionally stored units, and by only about 3- to 6-fold for anaerobically stored units.

DISCUSSION

The perfusion measurements suggest that anaerobically stored RBC retain a greater ability to perfuse networks of artificial capillaries compared to conventionally (aerobically) stored RBC. It is likely that anaerobic storage confers this positive effect on the bulk mechanical properties of stored RBC by significantly reducing the number of non-deformable cells present in the overall population of relatively well-preserved RBC.

Risks associated with red blood cell transfusions: potential benefits from application of pathogen inactivation

BACKGROUND

Red blood cell (RBC) transfusion risks could be reduced if a robust technology for pathogen inactivation of RBC (PI-RBCs) were to be approved.

MATERIALS AND METHODS

Estimates of per-unit and per-patient aggregate infectious risks for conventional RBCs were calculated; the latter used patient diagnosis as a determinant of estimated lifetime exposure to RBC units. Existing in vitro data for the two technologies under development for producing PI-RBCs and the status of current clinical trials are reviewed.

RESULTS

Minimum and maximum per-unit risk were calculated as 0.0003% (1 in 323,000) and 0.12% (1 in 831), respectively. The minimum estimate is for known lower-risk pathogens while the maximal estimate also includes an emerging infectious agent (EIA) and endemic area Babesia risk. Minimum and maximum per-patient lifetime risks by diagnosis grouping were estimated as 1.5 and 3.3%, respectively, for stem cell transplantation (which includes additional risk for cytomegalovirus transmission); 1.2 and 3.7%, respectively, for myelodysplastic syndrome; and 0.2 and 44%, respectively, for hemoglobinopathy.

DISCUSSION

There is potential for PI technologies to reduce infectious RBC risk and to provide additional benefits (e.g., prevention of transfusion-associated graft-versus-host disease and possible reduction of alloimmunization) due to white blood cell inactivation. PI-RBCs should be viewed in the context of having a fully PI-treated blood supply, enabling a blood safety paradigm shift from reactive to proactive. Providing insurance against new EIAs. Further, when approved, the use of PI for all components may catalyze operational changes in blood donor screening, laboratory testing, and component manufacturing.

A systematic review of transfusion-associated graft-versus-host disease

Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare complication of blood transfusion. The clinicolaboratory features of TA-GVHD and the relative contributions of recipient and component factors remain poorly understood. We conducted a systematic review of TA-GVHD reports. The HLA relationship between donor and recipient was classified as D = 0 when no donor antigens were foreign to the recipient vs D ≥ 1 when ≥1 donor antigen disparity occurred. We identified 348 unique cases. Criteria for component irradiation were met in 48.9% of cases (34.5% immune-compromised, 14.4% related-donor), although nonirradiated components were transfused in the vast majority of these (97.6%). Components were typically whole blood and red cells. When reported, component storage duration was ≤10 days in 94%, and 23 (6.6%) were leukoreduced (10 bedside, 2 prestorage, and 11 unknown). Among 84 cases with HLA data available, the category of D = 0 was present in 60 patients (71%) at either HLA class I or II loci and was more common among recipients without traditional indications for component irradiation. These data challenge the historic emphasis on host immune defects in the pathogenesis of TA-GVHD. The dominant mechanism of TA-GVHD in both immunocompetent and compromised hosts is exposure to viable donor lymphocytes not recognized as foreign by, but able to respond against, the recipient.

Modern banking, collection, compatibility testing and storage of blood and blood components

The clinical practice of blood transfusion has changed considerably over the last few decades. The potential risk of transfusion transmissible diseases has directed efforts towards the production of safe and high quality blood. All transfusion services now operate in an environment of ever-increasing regulatory controls encompassing all aspects of blood collection, processing and storage. Stringent donor selection, identification of pathogens that can be transmitted through blood, and development of technologies that can enhance the quality of blood, have all led to a substantial reduction in potential risks and complications associated with blood transfusion. In this article, we will discuss the current standards required for the manufacture of blood, starting from blood collection, through processing and on to storage.

Serial assessment of biochemical changes in irradiated red blood cells

BACKGROUND

Transfusion associated graft vs host disease (TA-GVHD) is delayed effect of blood component therapy with a very high mortality rate. The use of irradiated blood components is the only proven method to prevent TA-GVHD in susceptible patients.

AIM

Our study was designed to analyze the quality of irradiated PRBCs in terms of their biochemical parameters during a storage period up to 28 days post irradiation.

METHODS

A total of 80 PRBC units were analyzed, 40 units each stored in CPDA-1 and additive solution-SAGM. The units were evaluated serially for the following biochemical parameters, plasma/ supernatant potassium, sodium, pH, glucose, lactate, plasma/supernatant hemoglobin and red cell ATP. We further evaluated the differences in these parameters between units irradiated on day 1 and day 7 of storage and stored these units up to 28 days and 35 days respectively. Ten units in each group were used as control. The assessment was done at weekly intervals from the day of irradiation.

RESULTS

Within each group of red cells, there was a rise in mean concentration of plasma potassium (K(+)) from day 1 to last day of storage. There was a highly significant difference (P<0.01) between irradiated and control units after first week of storage in both types of PRBCs. Irradiated CPDA-1 PRBC had significantly higher (K(+)) than irradiated SAGM PRBC. Intergroup comparison revealed significantly higher (P<0.05) mean hemoglobin in irradiated CPDA-1 PRBC as compared to SAGM PRBC. The mean pH was significantly higher (P<0.05) in irradiated CPDA-1 PRBC as compared to irradiated SAGM PRBC only on day 7 of storage. ATP levels significantly decreased in irradiated units as compared to control units. SAGM PRBCs had significantly higher (P<0.05) mean ATP concentration than CPDA-1PRBCs.

CONCLUSION

Our study demonstrates that SAGM-PRBCs show better stability after irradiation compared to CPDA-1 PRBCs. The limits of safety for CPDA-1 PRBCs appear to be two weeks after irradiation. SAGM-PRBCs on the other hand show acceptable limits of safety up to three weeks of irradiation. The shelf life of irradiated PRBCs may vary depending upon the storage solution and day of irradiation.

Blood banking/immunohematology: special relevance to pediatric patients

Blood banking/immunohematology is an area of laboratory medicine that involves the preparation of blood and blood components for transfusion as well as the selection and monitoring of those components following transfusion. The preparation, modification, and indications of both traditional and newer products are described in this review, along with special considerations for neonates, patients undergoing hematopoietic stem cell transplantation, those with sickle cell disease, and others. Immunohematological techniques are critical in the provision of blood and blood products and are briefly discussed.

Potassium changes associated with blood transfusion in pediatric patients

Storing packed red blood cells (pRBCs) increases the potassium concentration. This effect is characterized in citrate phosphate dextrose/citrate phosphate dextrose adenine units but not published for Adsol (AS-5) units. The change in whole-blood potassium concentration in pediatric patients during routine transfusion is also poorly characterized. In this study, pediatric patients undergoing transfusion had pre- and posttransfusion whole-blood potassium measurements. The pRBC unit transfused and the unit's segment were sampled, with potassium concentration measured. In addition, potassium concentration in AS-5 units was measured over 42 days of storage. Unit extracellular potassium increased in AS-5 units after day 7 at 0.83 mmol/L/d. The mean change in patient potassium concentration was 0.08 mmol/L (range, -0.5 to 0.5 mmol/L). No correlation with unit age or unit potassium concentration was identified with change in patient whole-blood potassium concentration. The lack of clinical effect on patient potassium does not support the use of "fresh" pRBC units with routine pediatric transfusion.

Population pharmacodynamic analysis of erythropoiesis in preterm infants for determining the anemia treatment potential of erythropoietin

A population pharmacokinetics/pharmacodynamic (PK/PD) model was developed to describe changes in erythropoiesis as a function of plasma erythropoietin (EPO) concentration over the first 30 days of life in preterm infants who developed severe anemia requiring red blood cell (RBC) transfusion. Several covariates were tested as possible factors influencing the responsiveness to EPO. Discarded blood samples in 27 ventilated preterm infants born at 24-29 wk of gestation were used to construct plasma EPO, hemoglobin (Hb), and RBC concentration-time profiles. The amount of Hb removed for laboratory testing and that transfused throughout the study period were recorded. A population PK/PD model accounting for the dynamic Hb changes experienced by these infants was simultaneously fitted to plasma EPO, Hb, and RBC concentrations. A covariate analysis suggested that the erythropoietic efficacy of EPO is increased for preterm infants at later gestational ages. The PD analysis showed a sevenfold difference in maximum Hb production rate dependent on gestational age and indicated that preterm infants, when stimulated by EPO, have the capacity to produce additional Hb that may result in a decrease in RBC transfusions. The present model has utility in clinical trial simulations investigating the treatment potential of erythropoietic stimulating agents in the treatment of anemia of prematurity.

Development of a riboflavin and ultraviolet light-based device to treat whole blood

BACKGROUND

In the United States, blood components are commonly used for patients in need of massive transfusion after blood loss. In combat situations, when severe traumatic injuries occur far from a hospital, fresh whole blood is a valuable transfusion therapy because components may not be available. The risk of infectious or immunological complications from fresh whole blood transfusions could be mitigated by a system that reduces pathogen loads and inactivates white blood cells (WBCs). Such a system is in development and utilizes riboflavin and ultraviolet light to provide pathogen reduction and WBC inactivation.

STUDY DESIGN AND METHODS

The system has been tested with in vitro and in vivo animal studies to evaluate WBC inactivation and pathogen reduction, and with in vitro studies to assess the function of the treated blood products.

RESULTS

Elimination of viable WBCs with the system is equivalent to gamma-irradiation. Results have been reported for reduction of Babesia microti, Trypanosoma cruzi, HIV, and bacteria, and preliminary results for Babesia divergens are available. Treated whole blood, platelets, and plasma maintain coagulation function. Treated red blood cell components exhibit low hemolysis and high adenosine triphosphate levels at the end of storage.

CONCLUSIONS

Treatment with riboflavin and ultraviolet light is a promising alternative to gamma-irradiation. Effectiveness of the system against a variety of pathogens has been established, and further studies are planned. The in vitro studies of function indicate that treated whole blood, as well as components from treated whole blood, will provide acceptable hemostasis and perform well in the next phase of in vivo studies.

Haemolysis and sublethal injury of RBCs after routine blood bank manipulations

OBJECTIVES

To determine the extent of RBC sublethal injury in male donor units as measured by both the mechanical fragility index (MFI) and percentage haemolysis after RBCs underwent leucoreduction (LR), irradiation (IRRAD), and washing.

BACKGROUND

RBCs frequently undergo post-collection processing to meet certain recipient's special needs. The extent of haemolysis and sublethal injury following these interventions has not been fully characterised.

METHODS

Eight to ten day old male, AS-5 RBCs underwent either LR, IRRAD or washing. A control group of male, AS-5 RBCs were unmanipulated. The MFI, percent haemolysis, and plasma free haemoglobin (PFHb) were measured immediately after manipulation and, for a series of irradiated RBCs, 28 days after irradiation (IRRAD28).

RESULTS

The MFI of the washed units was significantly higher than unmanipulated, LR, IRRAD, IRRAD28 units (P < 0·0001). The percent haemolysis was highest in the IRRAD28 units (1·4%) followed by the washed units (0·74%); the other three units demonstrated significantly less haemolysis (P < 0·0001). The largest mean total amount of PFHb per unit was found in the IRRAD28 units (500·5 mg/unit) followed by the washed units (149·8 mg/unit); the mean total amount of PFHb in the three other types of units was significantly less than that found in both the IRRAD28 and washed units (P at least < 0·001).

CONCLUSION

There is a significant quantity of PFHb in IRRAD28 RBC units, and potentially in washed allogeneic RBC units. Clinical correlation is required to determine if this quantity of PFHb and the transfusion of potentially fragile RBCs causes adverse events.

Red cell storage and prognosis

During storage of red blood cells (RBC), these cells develop storage lesions. The clinical relevance of these storage lesions is heavily discussed in literature. In this review, different aspects of the storage lesion are shown and how these potentially affect posttransfusion performance of the RBC. An overview of the conflicting literature on the clinical relevance of prolonged storage is given, summarizing the evidence on associations with mortality, length of stay, (postoperative) infections and organ failure. Subsequently, possible explanations are given for the conflicting results in the clinical studies and suggestions on how to proceed.

Evaluation of the properties of components prepared and stored after holding of whole blood units for 8 and 24 hours at ambient temperature

BACKGROUND

The capability of holding whole blood (WB) units at ambient temperature, overnight, should help in platelet (PLT) concentrate preparation logistics. We summarize the results of a study conducted in the early 1990s that compared, in particular, PLT and red blood cell (RBC) in vivo viability properties following storage after preparation after 8- and 24-hour WB hold periods.

STUDY DESIGN AND METHODS

Individuals donated units of WB on two occasions. Centrifugation at 20 to 24°C to separate PLTs and additive system RBC placement at 1 to 6°C was completed 8 hours after phlebotomy or after 24 hours in randomized order. Components were not leukoreduced. Studies including in vitro biochemical and hematologic analyses and autologous in vivo RBC and PLT evaluations were conducted at two sites.

RESULTS

RBC 24-hour in vivo (mean ± SD) recoveries (single-label approach), after 35 days of storage, were 79.2 ± 4.3 and 79.4 ± 3.9% (n = 9; p > 0.05), with WB holding periods of 8 and 24 hours, respectively. With 42 days of storage, recovery after a 24-hour hold was slightly less than with an 8-hour hold (72.9 ± 6.5% vs. 76.0 ± 5.4%; n = 17; p < 0.05). RBC 2,3-diphosphoglycerate acid levels were substantially less after the 24-hour hold compared to after the 8-hour hold (n = 18; p < 0.05). PLT recovery after 5 days of storage with 8- and 24-hour hold periods were similar, 51.1 ± 14.9 and 50.6 ± 17.7%, respectively (n = 18; p > 0.05). The PLT survival variable and in vitro properties reflecting storage quality also showed no significant difference.

CONCLUSION

RBC and PLT in vivo variables, and most in vitro variables, were not significantly different after storage with WB holding times of 8 and 24 hours except for a slight diminution of RBC recovery with the 24-hour hold after 42 days of storage.

In vivo viability of stored red blood cells derived from riboflavin plus ultraviolet light-treated whole blood

BACKGROUND

A novel system using ultraviolet (UV) light and riboflavin (Mirasol System, CaridianBCT Biotechnologies) to fragment nucleic acids has been developed to treat whole blood (WB), aiming at the reduction of potential pathogen load and white blood cell inactivation. We evaluated stored red blood cell (RBC) metabolic status and viability, in vitro and in vivo, of riboflavin/UV light-treated WB (IMPROVE study).

STUDY DESIGN AND METHODS

The study compared recovery and survival of RBCs obtained from nonleukoreduced WB treated using three different UV light energies (22, 33, or 44 J/mL(RBC)). After treatment, WB from 12 subjects was separated into components and tested at the beginning and end of component storage. After 42 days of storage, an aliquot of RBCs was radiolabeled and autologously reinfused into subjects for analysis of 24-hour recovery and survival of RBCs.

RESULTS

Eleven subjects completed the in vivo study. No device-related adverse events were observed. By Day 42 of storage, a significant change in the concentrations of sodium and potassium was observed. Five subjects had a 24-hour RBC recovery of 75% or more with no significant differences among the energy groups. RBC t(1/2) was 24 ± 9 days for the combined three groups. Significant correlations between 24-hour RBC recovery and survival, hemolysis, adenosine triphosphate (ATP), and CO(2) levels were observed.

CONCLUSIONS

This study shows that key RBC quality variables, hemolysis, and ATP concentration may be predictive of their 24-hour recovery and t(1/2) survival. These variables will now be used to assess modifications to the system including storage duration, storage temperature, and appropriate energy dose for treatment.

Clinical impact of blood storage lesions

Recent reports suggest that transfusion of old red blood cell (RBC) units (>2 weeks) was associated with increased risks of postoperative complications and higher mortality rate caught public attention (Yap et al., Ann Thorac Surg 2008; 86:554-559 and Koch et al., 2008; 358:1229-1239). This rekindled the decades old discussion regarding the impact of RBC aging and storage lesions in patient care. The objectives of this review are to provide readers with an overview of the process of banking RBC that may have an impact on its quality, the reported clinical impact of storage lesions, the consequences of transfusing new RBC units only to the nation's blood supply and potential solutions that may improve the feasibility of blood banks to issue new blood units only.

Gewinnung, Herstellung und Lagerung von Blut und Blutkomponenten

Blutspender leisten einen wertvollen Dienst für die Gemeinschaft: Die ständige Verfügbarkeit von Blutkomponenten ist zur unverzichtbaren Voraussetzung für viele Bereiche der Medizin geworden. Nicht nur die Gewinnung und Aufarbeitung von Blut und Blutbestandteilen zur Sicherstellung einer qualitativ wie quantitativ guten Versorgung, sondern auch die kompetente Betreuung der Spender ist eine der großen Aufgaben der Transfusionsmedizin.

International blood collection and storage: clinical use of blood products

Human blood transfusion is the process of transferring blood or blood-based products from an individual into the circulatory system of another. From the theory of circulation of blood to the early practice of blood transfusion, transfusion medicine has been an important concept for many centuries. The practicality of transfusion, however, only became a possibility during and shortly after the Second World War. Today, blood and its derivatives play a critical role in worldwide health care systems, with blood components having direct clinical indications. Over the past several years worldwide organizations including the World Health Organization (WHO) have made a number of substantial improvements to the regulation of the worlds blood supply. This continuous supply plays a critical role throughout health care systems worldwide, with procedures for blood collection, processing, and storage now complex, standardised processes. As the areas of clinical validation of different disease states from blood-derived sources (i.e., disease biomarkers) move towards validation stages, the importance of controlled- and standardised-protocols is imperative.

Effects of storage of red cells

SUMMARY

During storage, red blood cells intended for transfusion undergo progressive changes affecting survival and function. Some of these in vitro changes are partly restored in vivo after transfusion, and their clinical effects are largely unknown. We evaluated publications of clinical studies comparing storage times in connection with red blood cell transfusion using physiological or clinical outcomes. A few prospective randomised studies in humans investigated physiological outcomes or oxygen kinetics. Sixteen observational studies comparing clinical outcome yielded contradictory results regarding the effect of red cell storage on mortality, length of intensive care and hospital stay, infections, organ failure, and composite adverse effects. The use of different red blood cell products further obscures the issue. Available studies provide no evidence that longer stored red cells are more harmful than younger red cells. However, such an effect may occur under extreme clinical conditions of severe anaemia or septicaemia, but this can only be answered by randomised studies controlling for confounding factors.

Survival of red blood cells after transfusion: a comparison between red cells concentrates of different storage periods

BACKGROUND

The use of fresh red blood cells (RBCs) is recommended for critically ill patients and patients undergoing surgery, although there is no conclusive evidence that this is beneficial. In this follow-up study, the short-term and the long-term recovery of irradiated, leukoreduced RBCs transfused after either a short storage (SS) or a long storage (LS) period were compared. By consecutive transfusion of RBCs with a SS and LS period, a direct comparison of their survival within the same patient was possible.

STUDY DESIGN AND METHODS

Ten transfusion-requiring patients each received a SS RCCs (stored 0-10 days) and a LS RCCs (stored 25-35 days) consecutively. Short-term and long-term survival of the transfused RBCs was followed by flow cytometry using natural differences in RBC antigens between donors and patients. Posttransfusion recovery (PTR) was measured at several time points after transfusion.

RESULTS

The mean 24-hour PTR of SS RBCs is 86.4 +/- 17.8 percent and that of LS RBCs 73.5 +/- 13.7 percent. After the first 24 hours, the mean times to reach a PTR of 50 percent of the 24-hour PTR (T50) and mean potential life spans (mPLs) of the surviving SS and LS RBCs (41 and 116 days and 41 and 114 days, respectively) do not differ.

CONCLUSIONS

The mean 24-hour PTR of both SS and LS RBCs complies with the guidelines, even in a compromised patient population. The 24-hour PTR of SS RBCs, however, is significantly higher than that of LS RBCs. The remaining population of SS and LS RBCs has a nearly identical long-term survival. Therefore, depletion of the removal-prone RBCs before transfusion may be an efficient approach for product improvement.

Blood and blood component therapy in neonates

Blood component therapy is a very common intervention practiced in newborns; nearly 85% of extremely low birth weight (ELBW) babies get transfusions during their hospital stay. However, there are no set guidelines for transfusion of blood component therapy in newborns. This protocol includes available types of blood components, their methods of preparation, indications and side effects of transfusion, in relation to newborns.

Quality control of blood irradiation with a teletherapy unit: damage to stored red blood cells after cobalt-60 gamma irradiation

BACKGROUND

Previous publications have documented the damage caused to red blood cells (RBCs) irradiated with X-rays produced by a linear accelerator and with gamma rays derived from a 137Cs source. The biologic effects on RBCs of gamma rays from a 60Co source, however, have not been characterized.

STUDY DESIGN AND METHODS

This study investigated the effect of 3000 and 4000 cGy on the in vitro properties of RBCs preserved with preservative solution and irradiated with a cobalt teletherapy unit. A thermal device equipped with a data acquisition system was used to maintain and monitor the blood temperature during irradiation. The device was rotated at 2 r.p.m. in the irradiation beam by means of an automated system. The spatial distribution of the absorbed dose over the irradiated volume was obtained with phantom and thermoluminescent dosimeters (TLDs). Levels of Hb, K+, and Cl(-) were assessed by spectrophotometric techniques over a period of 45 days. The change in the topology of the RBC membrane was investigated by flow cytometry.

RESULTS

Irradiation caused significant changes in the extracellular levels of K+ and Hb and in the organizational structure of the phospholipid bilayer of the RBC membrane. Blood temperature ranged from 2 to 4 degrees C during irradiation. Rotation at 2 r.p.m. distributed the dose homogeneously (92%-104%) and did not damage the RBCs.

CONCLUSIONS

The method used to store the blood bags during irradiation guaranteed that all damage caused to the cells was exclusively due to the action of radiation at the doses applied. It was demonstrated that prolonged storage of 60Co-irradiated RBCs results in loss of membrane phospholipids asymmetry, exposing phosphatidylserine (PS) on the cells' surface with a time and dose dependence, which can reduce the in vivo recovery of these cells. A time- and dose-dependence effect on the extracellular K+ and plasma-free Hb levels was also observed. The magnitude of all these effects, however, seems not to be clinically important and can support the storage of irradiated RBC units for at last 28 days.