Leucocyte and platelet-derived bioactive substances in stored blood: effect of prestorage leucocyte filtration

Re-introducing whole blood for transfusion: considerations for blood providers

Whole blood is the original blood preparation but disappeared from the blood bank inventories in the 1980s following the advent of component therapy. In the early 2000s, both military and civilian practice called for changes in the transfusion support for massive haemorrhage. The 'clear fluid' policy was abandoned and replaced by early balanced transfusion of platelets, plasma and red cells. Whole blood is an attractive alternative to multi-component therapy, which offers reduced hemodilution, lower donor exposure and simplified logistics. However, the potential for wider re-introduction of whole blood requires re-evaluation of haemolysins, storage conditions and shelf-life, the need for leucocyte depletion/ pathogen reduction and inventory management for blood providers. This review addresses these questions and calls for research to define the optimal whole blood product and the indications for its use.

Small Animal Transfusion Medicine

Transfusion medicine can be a lifesaving intervention. Component therapy has expanded the availability and blood products available. Patient safety and minimizing risk is important and can be accomplished through proper donor screening, collection, storage, compatibility testing, administration, and monitoring. The pros and cons of available products must be considered and tailored to each individual patient. Recent discoveries include new antigens and blood types, microbial effects on blood type, and the association between blood type and disease prevalence.

Leucoreduction helps to preserve activity of antioxidant barrier enzymes in stored red blood cell concentrates

BACKGROUND

Oxidoreductive imbalance is a major cause of excessive haemolysis in in vitro conditions. Leucocytes and blood platelets present in red blood cell concentrates (RBCs) are one of the sources of free radicals, which have a significant effect on the status of stored erythrocytes. The study objective was to assess the effect of leucoreduction on the intensity of lipid peroxidation and the activity of antioxidant barrier enzymes in RBC.

STUDY DESIGN AND METHODS

Red blood cell concentrates units obtained from 10 whole-blood units were split into two equal units, one of which was leucoreduced on the day of donation. Both units were stored for 35 days. The following markers of oxidoreductive balance were measured on day 0 (donation day) and on storage days 7, 14, 21 and 35: concentration of malondialdehyde (MDA) and activities of antioxidant barrier components, that is superoxide dismutase, glutathione peroxidase and glutathione reductase.

RESULTS

Lipid peroxidation in leucodepleted units (LRBC) was slower than that in non-leucodepleted ones. The analysis of LRBC revealed statistically significant decrease in concentrations of MDA. The activities of superoxide dismutase, glutathione peroxidase and glutathione reductase were higher throughout the storage period as compared to non-leucoreduced RBC. Statistically significant differences between RBC and LRBC units were noted throughout the storage in the activity of lactate dehydrogenase, and concentrations of K(+) ions and free haemoglobin.

CONCLUSIONS

Leucoreduction of RBC before storage helps to preserve the activity of antioxidant barrier enzymes in stored RBCs and significantly improves the quality of stored red blood cell components.

The ribosome-related protein, SBDS, is critical for normal erythropoiesis

Although anemia is common in Shwachman- Diamond syndrome (SDS), the underlying mechanism remains unclear. We asked whether SBDS, which is mutated in most SDS patients, is critical for erythroid development. We found that SBDS expression is high early during erythroid differentiation. Inhibition of SBDS in CD34(+) hematopoietic stem cells and early progenitors (HSC/Ps) and K562 cells led to slow cell expansion during erythroid differentiation. Induction of erythroid differentiation resulted in markedly accelerated apoptosis in the knockdown cells; however, proliferation was only mildly reduced. The percentage of cells entering differentiation was not reduced. Differentiation also increased the oxidative stress in SBDS-knockdown K562 cells, and antioxidants enhanced the expansion capability of differentiating SBDS-knockdown K562 cells and colony production of SDS patient HSC/Ps. Erythroid differentiation also resulted in reduction of all ribosomal subunits and global translation. Furthermore, stimulation of global translation with leucine improved the erythroid cell expansion of SBDS-knockdown cells and colony production of SDS patient HSC/Ps. Leucine did not reduce the oxidative stress in SBDS-deficient K562 cells. These results demonstrate that SBDS is critical for normal erythropoiesis. Erythropoietic failure caused by SBDS deficiency is at least in part related to elevated ROS levels and translation insufficiency because antioxidants and leucine improved cell expansion.

Packed blood cells stored in AS-5 become proinflammatory during storage

BACKGROUND

Studies have shown that packed blood cells (PBCs) stored in AS-1 (Adsol, Baxter) and AS-3 (Nutricel, Medsep Corp.) accumulate proinflammatory substances, which may contribute to increased complications from allogeneic blood transfusion. This study assessed whether supernates from PBCs stored in AS-5 (Optisol, Terumo Corp.) prime neutrophils (PMNs), activate platelets (PLTs), and accumulate proinflammatory cytokines and PMN granule constituents.

STUDY DESIGN AND METHODS

PBC units were prepared in AS-5 from nonleukoreduced (NLR) and leukoreduced (LR) whole-blood units and stored at 4 degrees C. Supernates from samples of PBCs collected at various storage times were analyzed by multiplex enzyme-linked immunosorbent assay for proinflammatory cytokines and myeloperoxidase (MPO) and were incubated with type-matched blood, which was assessed by flow cytometry for expression of CD11b on PMNs, CD62P on PLTs, and formation of PMN-PLT aggregates.

RESULTS

Supernates from NLR PBCs stored for at least 14 days elevated CD11b expression on PMNs and the number of PMN-PLT aggregates compared to supernates from collection day PBCs. The magnitude of these effects correlated with storage age. Supernates from LR PBCs did not elicit these responses. Expression of CD62P on PLTs was not affected by supernates from either NLR or LR PBCs. Levels of interleukin (IL)-1beta, IL-6, IL-8, IL-18, NAP-2, MCP-1, RANTES, and MPO were elevated in supernates from 28- and 42-day NLR units. Tumor necrosis factor alpha and MIP-1alpha did not increase, and cytokine levels in LR PBC units did not increase.

CONCLUSION

Units of NLR PBCs stored in AS-5 become increasingly proinflammatory as a function of storage time. Leukoreduction prevents this change.

Stored packed red blood cell transfusion up-regulates inflammatory gene expression in circulating leukocytes

SUMMARY BACKGROUND DATA

The transfusion of more than 6 units of packed red blood cells (PRBCs) within the first 12 hours of injury is the strongest independent predictor of multiple organ failure (MOF). This suggests that stored blood contains bioactive factors that may modify the immunoinflammatory response.

METHODS

To simulate postinjury major transfusions ex vivo, we obtained whole blood from 4 healthy adults and divided it into four 7-mL groups (I-IV). Group I was not diluted. Group II had 7 mL of 0.9% sterile saline (SS) added. Group III received 3.5 mL each of leuko-reduced stored PRBC and SS (simulating a major transfusion). Group IV received 3.5 mL each of SS and a hemoglobin-based oxygen carrier (PolyHeme) to evaluate the effects of hemoglobin alone. The hemoglobin content in groups III and IV was measured to be equal. Total leukocyte RNA was purified, and its gene array profiles were obtained.

RESULTS

Of the 56,475 oligonucleotide probe sets interrogated, 415 were statistically different (P < 0.001). Fourteen of the 415 probe sets were inflammatory-related. The PRBC group had a significantly different expression profile compared with the others and included up-regulation of the interleukin-8, toll-like receptor 4, cryropyrin, prostaglandin-endoperoxide synthase-2, and heparinase genes.

CONCLUSIONS

PRBCs activate inflammatory genes in circulating leukocytes, which may be central to the pathogenesis of the adverse inflammatory responses that lead to postinjury MOF.

Red blood cell age determines the impact of storage and leukocyte burden on cell adhesion molecules, glycophorin A and the release of annexin V

The influence of the age of the red blood cell (RBC) within its 120-day lifecycle at the time of blood donation on the RBC storage lesion is not well understood. Expression of cell adhesion molecules (CAMs) (CD44, CD47, CD58 and CD147), glycophorin A (GPA) and phosphatidylserine (PS) on young and old RBCs density separated prior to storage of the RBC concentrate was determined by flow cytometry. Older RBCs showed significantly reduced expression of GPA throughout storage and CD44 and CD147 from Day 28 onwards compared to young RBCs. Storage in the presence of leukocytes caused a significant decline in the expression of CD44, CD58, CD147 and GPA, whereas RBCs that were pre-storage leukocyte depleted maintained a relatively consistent level of expression throughout storage. PS was not detected at the external RBC membrane of young or old RBCs during storage. Increased levels of annexin V were detected in the supernatant of RBCs stored in the presence of leukocytes, with significantly greater supernatant levels found for old RBCs compared to young RBCs. These findings provide new insight into the RBC storage lesion and indicate that RBC age at the time of donation impacts upon the quality of stored RBC concentrates.

Targeted resuscitation strategies after injury

PURPOSE OF REVIEW

The management of the traumatically injured patient has evolved during the past half century despite continually high morbidity and mortality rates. The management of the trauma victim requires timely intervention and damage control in an attempt to maintain normal hemodynamic parameters and adequate systemic perfusion. There is a fine balance between oxygen delivery and consumption, and when this is perturbed, oxygen debt may ensue. The presence of ongoing oxygen debt is rather deleterious, resulting in an inflammatory cascade that can lead to multisystem organ dysfunction. The rapid identification and restoration of oxygen debt are central to the resuscitation of the critically ill patient, be it the result of sepsis or trauma.

RECENT FINDINGS

Resuscitation end points have evolved that allow the physician to more rapidly identify a perturbation between oxygen delivery and consumption. Moreover, end points allow uniformity in gauging the adequacy of resuscitation: preventing under- and overresuscitation and serving as a basis to compare outcome measures in resuscitation trials. Recent technologic advances have allowed a greater wealth of clinical data that can be obtained via less invasive means. Examples of this include esophageal Doppler monitoring, sublingual capnography, orthogonal polarization spectral imaging, and lithium dilution cardiac output determinations. These devices can be used in concert with more traditional resuscitation end points (ie, lactate and base deficit) to maximize oxygen delivery and correct tissue dysoxia. In addition, the management of hemorrhagic shock is continuing to evolve and challenge the dogmatic practices of normotensive resuscitation.

SUMMARY

This review addresses (1) resuscitation end points to optimize cardiac function, (2) resuscitation end points to assess the microcirculation, (3) recent developments in the management of hypotensive hemorrhagic shock, and (4) the translation of early goal-directed therapy from septic shock to use in trauma. Past findings are reflected on and direction for future investigation and clinical practice based on recent clinical advances is provided.

Supernatant from stored red blood cell primes inflammatory cells: influence of prestorage white cell reduction

BACKGROUND

The contribution of RBC transfusion to adverse patient outcomes is controversial. There is conflicting clinical data and limited biologic data that provide an underpinning biologic rationale for any adverse impacts from RBC transfusion. This study used in-vitro measures of PMN stimulation to determine the ability of supernatant from RBCs to stimulate allogeneic WBCs and to determine the influence of residual donor WBCs and storage time on the proinflammatory potential of RBCs.

STUDY DESIGN AND METHODS

Three types of RBCs were assessed: standard non-WBC-reduced RBCs (S-RBCs), buffy coat-poor RBCs (BCP-RBCs), and prestorage WBC-filtered RBC (LF-RBCs). Supernatant was collected weekly up to Day 42 of storage. PMN priming by supernatant from RBCs was determined by three methods: induction of CD11b expression on PMNs, induction of IL-8 release from PMNs, and the chemotactic effect of supernatant on PMNs.

RESULTS

Supernatant from S-RBCs induced the expression of CD11b on PMNs, primed PMNs to release IL-8, and was chemotactic for PMNs. The magnitude of this PMN-priming progressively amplified with storage time. In contrast, supernatant from BCP-RBCs or LF-RBCs did not significantly prime PMNs. The PMN-priming effect of supernatant from RBCs correlated more closely with the level of MNCs in the RBCs than PMN content.

CONCLUSION

Supernatant from stored S-RBCs prime unstimulated allogeneic PMNs in vitro. Prestorage buffy-coat WBC reduction was as effective as WBC depletion in abrogating this proinflammatory response elicited by supernatants from RBCs. The clinical consequences, if any, of these findings for transfusion recipients are unknown.

Humoral immune response to autologous blood transfusion in hip surgery: whole blood versus packed red cells and plasma

BACKGROUND AND OBJECTIVES

The immune response to the transfused autologous buffy coat content in whole blood has, to date, not been studied in detail.

SUBJECTS AND METHODS

Patients undergoing hip arthroplasty were studied according to whether they received autologous whole blood (WB) (n = 30), autologous fresh-frozen plasma and buffy coat-poor red cells (RC) (n = 40), or no transfusion (NT) (n = 27). Plasma levels of tumour necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and complement SC5b-9 were analysed by enzyme-linked immunosorbent assay (ELISA) 7 days after surgery.

RESULTS

There were no significant between-group differences regarding the time course of TNF-alpha, IL-6 and complement SC5b-9 plasma level changes, the infection rate, or the length of hospital stay.

CONCLUSION

In comparison to the impact of surgery on cytokine and complement levels, the transfusion of autologous buffy coat is not relevant.

Reduction of bioactive substances in stored donor blood: prestorage versus bedside leucofiltration

Leucocyte filtration has been suggested to improve transfusion products. We studied the effect of prestorage versus bedside leucofiltration on reduction of bioactive substances and leucocyte content in donor blood. Forty-five units of whole blood from healthy blood donors were studied. Of these units, 9 were stored under standard conditions for 35 d, 9 were leucofiltered after donation and then stored for 35 d, and 3x9 units were stored for 7, 21 and 35 d, respectively, before leucofiltration. Samples were collected from blood units immediately after donation, and before and after leucofiltration, and analysed by ELISA and RIA methods for extracellular content of myeloperoxidase (MPO), eosinophil cationic protein (ECP), histamine (HIS) and plasminogen activator inhibitor-1 (PAI-1). Leucocyte content was counted in all samples. In non-filtered blood extracellular MPO, ECP, HIS and PAI-1 were accumulated in a storage time-dependent manner, while prestorage leucofiltration prevented this accumulation. Leucofiltration after storage for 7, 21 or 35 d did not significantly reduce the accumulated bioactive substances, which were similar to levels in non-filtered blood stored for the same period of time. Prestorage and bedside leucofiltration on day 7 reduced the leucocyte content to less than 0.5x10(6)/L, whereas the median content in blood stored for 21 or 35 d was only reduced to 32.0 and 52.2x10(6)/L, respectively. Prestorage leucofiltration may thus be advantageous to bedside leucofiltration.

Prestorage and bedside leucofiltration of whole blood modulates storage-time-dependent suppression of in vitro TNFalpha release

Immunosuppression after transfusion may be related to the content of leucocytes in the transfused blood. Therefore we studied the effects of prestorage and bedside leucodepletion by filtration on the suppression by whole blood of in vitro stimulated tumour necrosis factor alpha (TNFalpha) release. Nine units of whole blood were leucofiltered prestorage and stored for 35 d. 27 units, 3 x 9, were stored and leucofiltered at the bedside after 7, 21 and 35 d. Supernatants were collected from all units during storage and added to a whole blood assay of E. coli-LPS-stimulated TNFalpha release. The effects of storage were assessed and compared with supernatants collected immediately after donation as reference. TNFalpha release was storage time dependently suppressed to: 81%, 74% and 57% by supernatants from non-filtered blood stored for 7, 21 and 35 d, respectively. Prestorage leucofiltration almost eliminated this effect, but we still observed a storage-time-dependent suppression by bedside-leucofiltered blood to 88%, 78% and 65%, respectively. Prestorage leucofiltration appeared to reduce storage-time-dependent suppression of in vitro stimulated TNFalpha release induced by plasma from whole blood compared with non-filtered and bedside-leucofiltered whole blood.

Prestorage leukocyte filtration may reduce leukocyte-derived bioactive substance accumulation in patients operated for burn trauma

Adverse effects of perioperative blood transfusion appear to be storage-time-dependent and may be related to extracellular accumulation of bioactive substances in blood products. In this study the clinical effects of leukofiltered and non-filtered blood products in patients undergoing surgery for burn trauma are investigated. 24 consecutive patients were randomly selected to receive transfusion with non-filtered blood components (group A, n = 12) or similar products, which were prestorage leukofiltered (group B, n = 12). The burn injury was scored using the Bull and Fischer index of age and burn surface area. Histamine, interleukin-6 (IL-6), plasminogen activator inhibitor-1 (PAI-1), eosinophil cationic protein (ECP) and myeloperoxidase (MPO) were analysed in plasma or serum collected from all patients 30 min before skin incision, at skin incision and 5, 10 and 30 min and thereafter every 30 min after skin incision until the grafts were secured by wrapping. Samples were also taken 8 h after skin incision and in the morning of postoperative days 1-5. The amount of blood products transfused from admission until day 5 postoperatively was recorded. All patients were followed until discharge or death. The Bull and Fischer index was comparable in the two groups. Prestorage leukofiltration reduced the amount of blood products required for transfusion significantly (p < 0.05) compared with non-filtered products. The levels of the various bioactive substances changed during and after the operation. In particular, ECP and MPO levels increased significantly (p < 0.05) in group A patients compared with unchanged (ECP) or decreased (MPO) levels in group B patients. IL-6 analyses showed, that the trauma had more severe impact on group B patients than on group A patients. Nevertheless, 4 patients died in group A and 2 in group B; all with a Bull and Fischer index between 1.0 and 2.0. Prestorage leukocyte filtration may reduce transfusion related accumulation of various bioactive substances and the requirement for blood in burn trauma patients.

Effect of heating on extracellular bioactive substances in stored human blood: in vitro study

BACKGROUND

We have previously shown extracellular accumulation of various leukocyte and platelet-derived bioactive substances in human blood during storage. Release of bioactive substances may be temperature-dependent, and we studied the effect of heating during in vitro transfusion on bioactive substance accumulation in stored human blood.

METHODS

Eight units of whole blood and eight units of prestorage leukofiltered whole blood were stored at 4 degrees C for 7 days. Subsequently, the blood from all 16 units was transfused via a blood-heating device, which increased the blood temperature to 37 degrees C at outlet. Samples for enzyme-linked immunosorbent assay or radioimmunoassay analyses of histamine, myeloperoxidase (MPO), eosinophil cationic protein (ECP), and plasminogen activator inhibitor-1 (PAI-1) were drawn from the units at donation, after 7 days of storage just before transfusion, and during the in vitro transfusion.

RESULTS

Extracellular concentrations of histamine, MPO, ECP, and PAI-1 were significantly (p < 0.05) increased in nonfiltered whole blood stored for 7 days compared with concentrations in fresh donated blood and in prestorage leukofiltered whole blood stored for 7 days. Heating reduced histamine, MPO, and ECP concentrations significantly (p < 0.05) in nonfiltered whole blood, whereas PAI-1 concentrations increased significantly (p < 0.05). Finally, there was no difference in concentrations of histamine, MPO, ECP, and PAI-1 in samples collected before and after heating of leukofiltered whole blood.

CONCLUSIONS

Heating reduces accumulation of extracellular leukocyte-derived bioactive substances in whole blood, whereas it increases platelet-derived substances. Prestorage leukofiltration, however, reduces the obligatory extracellular accumulation of leukocyte and platelet-derived bioactive substances, which in addition is unchanged by heating.