Length of storage and in vitro immunomodulation induced by prestorage leukoreduced red blood cells

BACKGROUND

The relationship between length of storage of red blood cell (RBC) units and biochemical changes has been well studied, but little is known about the progression of cellular immunomodulative properties in blood recipients. This study aims to quantify in vitro T-cell activation and cytokine release by white blood cells, after incubation with supernatants from leukoreduced RBCs.

STUDY DESIGN AND METHODS

Whole blood cultures were incubated with supernatant from five leukoreduced RBC units stored for 1, 6, 10, 15, 24, and 42 days. Supernatant-induced T-cell activation was evaluated by quantifying CD25 expression. Supernatant-induced cytokine production was determined by measuring interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-alpha levels.

RESULTS

No cytokines were detected in RBC supernatants even after 42 days of storage. However, IL-6 levels in whole blood culture increased significantly when incubated with supernatant from RBC units stored for 1, 6, and 15 days, by factors of 1.7 +/- 0.3, 1.7 +/- 0.3, and 1.4 +/- 0.3, respectively. TNF-alpha levels were significantly decreased on Days 24 and 42 of storage by factors of 0.50 +/- 0.42 and 0.33 +/- 0.21, respectively. IL-10 levels were significantly increased on Days 1 and 42 of storage by factors of 2.3 +/- 1.3 and 3.2 +/- 2.8, respectively. After an initial increase in IL-6 and TNF-alpha production, there was a significant linear decrease in their levels measured from units stored for longer times. No significant changes in CD25 expression were observed over time.

CONCLUSION

Although no cytokines were measured in the supernatants from leukoreduced RBCs, these supernatants exhibited variable immunomodulatory effects related to their length of storage.

Transfusion strategies for patients in pediatric intensive care units

BACKGROUND

The optimal hemoglobin threshold for erythrocyte transfusions in critically ill children is unknown. We hypothesized that a restrictive transfusion strategy of using packed red cells that were leukocyte-reduced before storage would be as safe as a liberal transfusion strategy, as judged by the outcome of multiple-organ dysfunction.

METHODS

In this noninferiority trial, we enrolled 637 stable, critically ill children who had hemoglobin concentrations below 9.5 g per deciliter within 7 days after admission to an intensive care unit. We randomly assigned 320 patients to a hemoglobin threshold of 7 g per deciliter for red-cell transfusion (restrictive-strategy group) and 317 patients to a threshold of 9.5 g per deciliter (liberal-strategy group).

RESULTS

Hemoglobin concentrations were maintained at a mean (+/-SD) level that was 2.1+/-0.2 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group (lowest average levels, 8.7+/-0.4 and 10.8+/-0.5 g per deciliter, respectively; P<0.001). Patients in the restrictive-strategy group received 44% fewer transfusions; 174 patients (54%) in that group did not receive any transfusions, as compared with 7 patients (2%) in the liberal-strategy group (P<0.001). New or progressive multiple-organ dysfunction syndrome (the primary outcome) developed in 38 patients in the restrictive-strategy group, as compared with 39 in the liberal-strategy group (12% in both groups) (absolute risk reduction with the restrictive strategy, 0.4%; 95% confidence interval, -4.6 to 5.4). There were 14 deaths in each group within 28 days after randomization. No significant differences were found in other outcomes, including adverse events.

CONCLUSIONS

In stable, critically ill children a hemoglobin threshold of 7 g per deciliter for red-cell transfusion can decrease transfusion requirements without increasing adverse outcomes. (Controlled-trials.com number, ISRCTN37246456 [controlled-trials.com].).

Survey on transfusion practices of pediatric intensivists

OBJECTIVE

To describe the red blood cell transfusion practices of pediatric intensivists.

DESIGN

Cross-sectional self-administered survey.

SETTING

Pediatric intensive care units.

PATIENTS

Academic pediatric intensivists.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Scenario-based survey among English- or French-speaking intensivists from Canada, France, Belgium, or Switzerland, working in tertiary-care pediatric intensive care units. Respondents were asked to report their decisions regarding transfusion practice with respect to four scenarios: cases of bronchiolitis, septic shock, trauma, and the postoperative care of a patient with Fallot's tetrad. The response rate was 71% (163 of 230). The overall baseline hemoglobin transfusion threshold that would have prompted intensivists to transfuse a patient ranged from 7 to 13 g/dL (70-130 g/L) within almost all scenarios. There was a significant difference between scenarios of the average baseline hemoglobin transfusion thresholds (p < .0001). A low Pao2, a high blood lactate concentration, a high Pediatric Risk of Mortality score, active gastric bleeding, emergency surgery, and age (2 wks) were important determinants of red blood cell transfusion, whereas none of the respondents' personal characteristics were. The average volume of packed red blood cells transfused in the four scenarios did not differ significantly.

CONCLUSIONS

This survey documented a significant variation in transfusion practice patterns among pediatric critical care practitioners with respect to the threshold hemoglobin concentration for red blood cell transfusion. The volume of packed red blood cells given was not adjusted to the hemoglobin concentration.

Detection of functional platelet-activating factor receptors on human tonsillar B lymphocytes

Although platelet-activating factor (PAF) receptors have been found on B lymphoblastoid cell lines, the action of PAF on freshly isolated human B cells has not been clearly demonstrated. Using a sensitive semiquantitative reverse-transcriptase PCR, we have found PAF receptor mRNA expressed by tonsillar B lymphocytes, but little in T lymphocytes. Examination of Percoll-fractionated tonsillar B cells indicated that the low density (primarily germinal center cells) and medium density fractions had approximately twofold more PAF receptor mRNA relative to the high density fraction. PAF (10-7 M) stimulated increases in intracellular Ca2+ that were consistently higher in the low and medium density B lymphocytes compared with high density cells. The PAF receptor antagonist Web 2170 inhibited this. Addition of PAF, but not lyso- or enantio-PAF, induced four- to sixfold greater synthesis of IgM and IgG in low and medium density cells compared with unstimulated controls, but had little effect on Ig production by high density cells. To investigate how PAF may influence Ig synthesis, PAF-stimulated B cells were examined for production of the Th2-type cytokines IL-4 and IL-13. PAF induced IL-4 and IL-13 mRNA expression in 17% of CD20+ cells, and IL-4 was detected in cell supernatants after 48-72 h of culture. Together, these data strongly suggest that functional PAF receptors are expressed on B cells in tonsils.

Detection of Functional Platelet-Activating Factor Receptors on Human Tonsillar B Lymphocytes

Although platelet-activating factor (PAF) receptors have been found on B lymphoblastoid cell lines, the action of PAF on freshly isolated human B cells has not been clearly demonstrated. Using a sensitive semiquantitative reverse-transcriptase PCR, we have found PAF receptor mRNA expressed by tonsillar B lymphocytes, but little in T lymphocytes. Examination of Percoll-fractionated tonsillar B cells indicated that the low density (primarily germinal center cells) and medium density fractions had approximately twofold more PAF receptor mRNA relative to the high density fraction. PAF (10−7 M) stimulated increases in intracellular Ca2+ that were consistently higher in the low and medium density B lymphocytes compared with high density cells. The PAF receptor antagonist Web 2170 inhibited this. Addition of PAF, but not lyso- or enantio-PAF, induced four- to sixfold greater synthesis of IgM and IgG in low and medium density cells compared with unstimulated controls, but had little effect on Ig production by high density cells. To investigate how PAF may influence Ig synthesis, PAF-stimulated B cells were examined for production of the Th2-type cytokines IL-4 and IL-13. PAF induced IL-4 and IL-13 mRNA expression in 17% of CD20+ cells, and IL-4 was detected in cell supernatants after 48–72 h of culture. Together, these data strongly suggest that functional PAF receptors are expressed on B cells in tonsils.

Characterization of B lymphocytes rescued from apoptosis by platelet-activating factor

B lymphocyte development is characterized by deletion via apoptosis of immature cells that are insufficiently stimulated. We have previously demonstrated that crosslinking of the B cell receptor (BCR) using anti-IgM antibodies (alphaIgM) (2 microg/ml) in Ramos B lymphoblastoid cells causes deletion of 30-40% of cells by apoptosis in 24 h. Addition of the potent lipid mediator platelet-activating factor (10(-7) M) to alphaIgM stimulated Ramos cells significantly decreases the number of apoptotic cells as measured by annexin V labeling. We have characterized the phenotype of Ramos cells that have not become apoptotic following BCR stimulation. In these cells, there is a significant decrease in the surface expression of the VLA-4 adhesion molecule (31% of control expression) and surface IgM expression (sIgM) (53% of control expression). Significantly fewer cells co-incubated with platelet-activating factor (PAF) underwent apoptosis, and the remaining cells maintained control levels of VLA-4 (104% of control expression) and sIgM expression (104% of control). All of these protective effects were inhibited by the specific PAF receptor antagonist, WEB 2170. The action of PAF on alphaIgM induced apoptosis was not inhibited by either cycloheximide or cytochalasin B, suggesting that de novo protein synthesis and F-actin polymerization were not implicated in the rescue of Ramos cells by PAF. In contrast, the ability of PAF to maintain sIgM and VLA-4 expression at control levels was inhibited by cycloheximide (7. 5 microg/ml). Cytochalasin B (5 microg/ml) had no effect on sIgM expression but blocked the decrease in VLA-4 expression mediated by alphaIgM. These data indicate that PAF's effect on rescuing and maintaining alphaIgM stimulated Ramos B cells is mediated via at least two pathways. Abrogation of apoptosis does not require de novo protein synthesis, while maintenance of sIgM and VLA-4 expression requires protein synthesis.

Intravenous immunoglobulin inhibits IgE production in human B lymphocytes

BACKGROUND

Intravenous immunoglobulin (IVIG) is commonly used as both an immune-enhancing and immune-modulating agent. Treatment with high doses of IVIG diminishes IgE secretion in patients with severe steroid-dependent asthma.

OBJECTIVE

We studied the action of IVIG on IgE production in highly purified B lymphocytes stimulated without additional T cells to determine the action of IVIG on B lymphocytes.

METHODS

Human B cells were purified from tonsils, and T lymphocytes were removed by E-rosetting. B cells were cultured with IL-4 (400 U/mL) and anti-CD40 antibodies (1 microg/mL¿, with or without additional IVIG. Cell proliferation was determined by 3[H]-thymidine uptake, and supernatant IgE was determined by ELISA. Cell cycle analysis was performed by flow cytometry, and IgE transcripts were measured by in situ hybridization.

RESULTS

IVIG (5 mg/mL) decreased B-cell proliferation in IL4/anti-CD40-stimulated B cells by an average of 74% (+/-6%). Addition of IVIG up to 48 hours after initiation of cell culture led to significant diminution of cell proliferation at 96 to 120 hours. This effect was dose dependent, with 10 mg/mL being the most effective and doses under 0.1 mg/mL having minimal effect. IVIG diminished the number of stimulated cells progressing in the cell cycle by 30%, and there was no difference in cell viability between IVIG-treated and IVIG-untreated cells. The production of IgE in culture by anti-CD40/IL4-stimulated B lymphocytes was curtailed by greater than 80% after addition of 5 mg/mL IVIG. This was associated with a decrease in IgE (epsilon) transcripts in IVIG-treated cultures.

CONCLUSION

These data indicate that diminution of IgE production in anti-CD40/IL-4-stimulated B cells by IVIG is due to inhibition of early events related to proliferation and progression in the cell cycle.

Platelet-activating factor abrogates apoptosis induced by cross-linking of the surface IgM receptor in a human B lymphoblastoid cell line

B lymphocyte development is characterized by deletion, via apoptosis, of immature cells that are stimulated via the B cell receptor in the absence of a second signal. We have investigated whether platelet-activating factor (PAF), a potent B lymphocyte activator, can provide a complementary signal with B cell receptor ligation to abrogate apoptosis. Cross-linking of the surface IgM on Ramos B lymphoblastoid cells using anti-IgM Abs (2 microg/ml) caused programmed cell death in 34 +/- 5.4% of the cells. Coincubation of PAF (10(-7)M) with alphaIgM led to a significant decrease in apoptotic cells as measured by DNA laddering and TUNEL assay (13.8 +/- 3%). The effect of PAF was dose dependent (10(-7)-10(-9) M) and was inhibited by the specific PAF receptor antagonist, WEB 2170. PAF protected cells from the effect of alphaIgM for up to 1 h after it was added. alphaIgM-induced programmed cell death in Ramos cells was blocked by catalase and, therefore, is caused in part by the production of toxic hydroxyl radicals from hydrogen peroxide. We investigated the action of PAF on markers of intracellular oxidation. H2O2 in low doses induced apoptosis, via production of OH. radicals. PAF inhibited H2O2-induced apoptosis in Ramos cells; it also attenuated H2O2- and alphaIgM-mediated increases in hydroxyl radical (OH.) as measured by the oxidation of 2',7'-dichlorofluorescein diacetate to 2',7'-dichlorofluorescein and blocked the depletion of reduced glutathione induced by alphaIgM. PAF maintained IgM secretion, which was greatly inhibited by incubation with alphaIgM alone. These data indicate that PAF potentially provides an important cosignal to surface IgM-stimulated Ramos cells by inhibiting apoptosis. This is in part due to the activity of PAF in the oxidant/ antioxidant pathway.

Platelet-activating factor abrogates apoptosis induced by cross-linking of the surface IgM receptor in a human B lymphoblastoid cell line

B lymphocyte development is characterized by deletion, via apoptosis, of immature cells that are stimulated via the B cell receptor in the absence of a second signal. We have investigated whether platelet-activating factor (PAF), a potent B lymphocyte activator, can provide a complementary signal with B cell receptor ligation to abrogate apoptosis. Cross-linking of the surface IgM on Ramos B lymphoblastoid cells using anti-IgM Abs (2 microg/ml) caused programmed cell death in 34 +/- 5.4% of the cells. Coincubation of PAF (10(-7)M) with alphaIgM led to a significant decrease in apoptotic cells as measured by DNA laddering and TUNEL assay (13.8 +/- 3%). The effect of PAF was dose dependent (10(-7)-10(-9) M) and was inhibited by the specific PAF receptor antagonist, WEB 2170. PAF protected cells from the effect of alphaIgM for up to 1 h after it was added. alphaIgM-induced programmed cell death in Ramos cells was blocked by catalase and, therefore, is caused in part by the production of toxic hydroxyl radicals from hydrogen peroxide. We investigated the action of PAF on markers of intracellular oxidation. H2O2 in low doses induced apoptosis, via production of OH. radicals. PAF inhibited H2O2-induced apoptosis in Ramos cells; it also attenuated H2O2- and alphaIgM-mediated increases in hydroxyl radical (OH.) as measured by the oxidation of 2',7'-dichlorofluorescein diacetate to 2',7'-dichlorofluorescein and blocked the depletion of reduced glutathione induced by alphaIgM. PAF maintained IgM secretion, which was greatly inhibited by incubation with alphaIgM alone. These data indicate that PAF potentially provides an important cosignal to surface IgM-stimulated Ramos cells by inhibiting apoptosis. This is in part due to the activity of PAF in the oxidant/ antioxidant pathway.