Current issues related to the quality of stored RBCs

Recent advances on the development of a universal blood type

Blood transfusion is the most common form of tissue transplant, and correct blood type matching is decisive for the success of this procedure. However, the availability of different blood types depends on each population, leading to a shortage of blood units from uncommon types. Then, it represents a problem for patients who need a blood transfusion because the supply for their blood type is scarce. Fortunately, researchers have been developing different techniques to engineer universal red blood cells (RBC) that could be transplanted to any human being independent of its blood type. This paper details the main features of blood transfusion and red blood cells maintenance and the two more recent procedures used to produce universal RBCs, the Enzymatically Converted Group O (ECO) and the antigen masking methods.

Stabilization of Lipid Membranes through Partitioning of the Blood Bag Plasticizer Di-2-ethylhexyl phthalate (DEHP)

The safe storage of blood is of fundamental importance to health care systems all over the world. Currently, plastic bags are used for the collection and storage of donated blood and are typically made of poly(vinyl chloride) (PVC) plasticized with di-2-ethylhexyl phthalate (DEHP). DEHP is known to migrate into packed red blood cells (RBC) and has been found to extend their shelf life. It has been speculated that DEHP incorporates itself into the RBC membrane and alters membrane properties, thereby reducing susceptibility to hemolysis and morphological deterioration. Here, we used high-resolution X-ray diffraction and molecular dynamics (MD) simulations to study the interaction between DEHP and model POPC lipid membranes at high (9 mol %) and low (1 mol %) concentrations of DEHP. At both concentrations, DEHP was found to spontaneously partition into the bilayer. At high concentrations, DEHP molecules were found to aggregate in the aqueous phase before inserting as clusters into the membrane. The presence of DEHP in the bilayers resulted in subtle, yet statistically significant, alterations in several membrane properties in both the X-ray diffraction experiments and MD simulations. DEHP led to (1) an increase of membrane width and (2) an increase in the area per lipid. It was also found to (3) increase the deuterium order parameter, however, (4) decrease membrane orientation, indicating the formation of thicker, stiffer membranes with increased local curvature. The observed effects of DEHP on lipid bilayers may help to better understand its effect on RBC membranes in increasing the longevity of stored blood by improving membrane stability.

Objective assessment of stored blood quality by deep learning

Stored red blood cells (RBCs) are needed for life-saving blood transfusions, but they undergo continuous degradation. RBC storage lesions are often assessed by microscopic examination or biochemical and biophysical assays, which are complex, time-consuming, and destructive to fragile cells. Here we demonstrate the use of label-free imaging flow cytometry and deep learning to characterize RBC lesions. Using brightfield images, a trained neural network achieved 76.7% agreement with experts in classifying seven clinically relevant RBC morphologies associated with storage lesions, comparable to 82.5% agreement between different experts. Given that human observation and classification may not optimally discern RBC quality, we went further and eliminated subjective human annotation in the training step by training a weakly supervised neural network using only storage duration times. The feature space extracted by this network revealed a chronological progression of morphological changes that better predicted blood quality, as measured by physiological hemolytic assay readouts, than the conventional expert-assessed morphology classification system. With further training and clinical testing across multiple sites, protocols, and instruments, deep learning and label-free imaging flow cytometry might be used to routinely and objectively assess RBC storage lesions. This would automate a complex protocol, minimize laboratory sample handling and preparation, and reduce the impact of procedural errors and discrepancies between facilities and blood donors. The chronology-based machine-learning approach may also improve upon humans' assessment of morphological changes in other biomedically important progressions, such as differentiation and metastasis.

Modelling of Red Blood Cell Morphological and Deformability Changes during In-Vitro Storage

Storage lesion is a critical issue facing transfusion treatments, and it adversely affects the quality and viability of stored red blood cells (RBCs). RBC deformability is a key indicator of cell health. Deformability measurements of each RBC unit are a key challenge in transfusion medicine research and clinical haematology. In this paper, a numerical study, inspired from the previous research for RBC deformability and morphology predictions, is conducted for the first time, to investigate the deformability and morphology characteristics of RBCs undergoing storage lesion. This study investigates the evolution of the cell shape factor, elongation index and membrane spicule details, where applicable, of discocyte, echinocyte I, echinocyte II, echinocyte III and sphero-echinocyte morphologies during 42 days of in-vitro storage at 4 °C in saline-adenine-glucose-mannitol (SAGM). Computer simulations were performed to investigate the influence of storage lesion-induced membrane structural defects on cell deformability and its recoverability during optical tweezers stretching deformations. The predicted morphology and deformability indicate decreasing quality and viability of stored RBCs undergoing storage lesion. The loss of membrane structural integrity due to the storage lesion further degrades the cell deformability and recoverability during mechanical deformations. This numerical approach provides a potential framework to study the RBC deformation characteristics under varying pathophysiological conditions for better diagnostics and treatments.

Interactions of amphiphiles with plasticisers used in polymers: Understanding the basis of health and environmental challenges

Plasticisers are widely used to provide desirable mechanical properties of many polymeric materials. These small molecule additives are also known to leach from the finished products, and this not only may modify the physical properties but the distribution of these materials in the environment and in the human body can cause long-term health concerns and environmental challenges. Many of these plasticisers are esters of polyvalent acids and phthalic acid has previously been predominant but various alternatives are now being more widely explored. The eventual distribution of these compounds depends not just on solubility in aqueous media and on vapour pressure but also on their interaction with other materials, particularly lipids and amphiphiles. This review provides an overview of both the basic physical data (solubility, partition coefficients, surface tension, vapour pressure) that is available in the literature and summarises what has been learnt about the molecular interactions of various plasticisers with surfactants and lipids.

Hemolysis risk after packed red blood cells transfusion with infusion pumps

OBJECTIVE

To evaluate the hemolysis biomarkers of packed red blood cells transfused by two different linear peristaltic infusion pumps at two infusion rates.

METHOD

An experimental and randomized study was designed simulating the clinical practice of transfusion. Two linear peristaltic infusion pumps from different manufactures were studied in triplicate at 100 mL/h and 300mL/h infusion rates. The chosen hemolysis biomarkers were total hemoglobin, free hemoglobin, hematocrit, potassium and degree of hemolysis. They were analyzed before and after each infusion.

RESULTS

Potassium showed statistically significant variations in all scenarios of the experiment (P<0.010). In a separated analysis, potassium increased mainly at 300mL/h rate (P=0.021) and free hemoglobin had significant variation when comparing infusion pumps from different manufacturers (P=0.026). Although hematocrit, total hemoglobin and degree of hemolysis had increased after infusion, no statistically significance variations were identified.

CONCLUSIONS

Hemolysis risk induced by a linear peristaltic infusion pump was identified by an increase in free hemoglobin and potassium markers. As the potassium biomarker is often increased in aged packed red blood cells, we do not recommend using them in this scenario. Additional studies should be performed about other markers and using larger samples in order to reinforce the transfusion practice in nursing.

Preservative solution that stabilizes erythrocyte morphology and leukocyte viability under ambient conditions

The deterioration of whole blood ex vivo represents a logistical hurdle in clinical and research settings. Here, a cocktail preservative is described that stabilizes leukocyte viability and erythrocyte morphology in whole blood under ambient storage. Neutrophil biostabilization was explored using a sophisticated microfluidic assay to examine the effectiveness of caspase inhibition to stabilize purified neutrophils. Following 72 h ambient storage, neutrophils remained fully functional to migrate towards chemical cues and maintained their ability to undergo NETosis after stimulation. Furthermore, stored neutrophils exhibited improved CD45 biomarker retention and reduced apoptosis and mortality compared to untreated controls. To stabilize erythrocyte morphology, a preservative solution was formulated using Taguchi methods of experimental design, and combined with the caspase inhibitor to form a whole blood cocktail solution, CS_WB. CS_WB was evaluated in blood from healthy donors and from women with metastatic breast cancer stored under ambient conditions for 72 h. CS_WB-treated samples showed a significant improvement in erythrocyte morphology compared to untreated controls. Leukocytes in CS_WB-treated blood exhibited significantly higher viability and CD45 biomarker retention compared to untreated controls. This 72 h shelf life under ambient conditions represents an opportunity to transport isolates or simply ease experimental timelines where blood degradation is problematic.

Biochemical assessment of red blood cells during storage by (1)H nuclear magnetic resonance spectroscopy. Identification of a biomarker of their level of protection against oxidative stress

BACKGROUND

Blood transfusion is an established therapeutic practice. The characteristics of blood components at different storage times are expected to affect the efficacy of transfusion therapy. Metabolic profiling by nuclear magnetic resonance (NMR) spectroscopy requires little or no sample treatment and allows identification of more than 50 soluble metabolites in a single experiment. The aim of this study was to assess the metabolic behaviour of red blood cells during 42 days of storage in blood bank conditions.

MATERIALS AND METHODS

Red blood cells (RBC), collected from eight healthy male donors, aged 25-50 years, were prepared as prestorage leukoreduced erythrocyte concentrates and stored under standard blood bank conditions. Samples taken at various storage times were separated in two fractions: the supernatant, recovered after centrifugation, and the red blood cell lysate obtained after protein depletion by ultrafiltration. The metabolic profile of the red blood cells was determined from analysis of (1)H-NMR spectra.

RESULTS

The red blood cell supernatant was studied to track the consumption of the preservative additives and to detect and quantify up to 30 metabolites excreted by the erythrocytes. The NMR spectra of the RBC lysate provided complementary information on some biochemical pathways and set the basis for building a time-dependent red blood cell metabolic profile.

DISCUSSION

We proved the analytical power of (1)H-NMR spectroscopy to study red blood cell metabolism under blood bank conditions. A potential biomarker able to provide information on the level of cellular oxidative stress protection was identified. Our data support the hypothesis that a more detailed knowledge of metabolic modifications during storage opens the way to the development of new and more effective protocols for red blood cell conservation and patient-oriented transfusion therapy.

Red blood cell in vitro quality and function is maintained after S-303 pathogen inactivation treatment

BACKGROUND

Over the past decade there has been a growth in the development of pathogen reduction technologies to protect the blood supply from emerging pathogens. This development has proven to be difficult for red blood cells (RBCs). However the S-303 system has been shown to effectively inactivate a broad spectrum of pathogens, while maintaining RBC quality.

STUDY DESIGN AND METHODS

A paired three-arm study was performed to compare the in vitro quality of S-303-treated RBCs with RBCs stored at room temperature (RT) for the duration of the treatment (18-20 hr) and control RBCs stored at 2 to 6°C. Products were sampled weekly over 42 days of storage (n = 10) and tested using an array of in vitro assays to measure quality, metabolism, and functional variables.

RESULTS

During S-303 treatment there was a slight loss of RBCs and hemoglobin (Hb < 5 g). Hemolysis, glucose consumption, and potassium release were similar in all groups during the 42 days of storage. S-303-treated RBCs had a significantly lower lactate concentration and pH compared to the paired controls. The S-303-treated RBCs had significantly higher adenosine triphosphate than the RT and control RBCs. There was a significant loss of 2,3-diphosphoglycerate in the S-303-treated products, which was also observed in the RT RBCs. Flow cytometry analysis demonstrated similar RBC size, morphology, expression of CD47, and glycophorin A in all groups.

CONCLUSION

RBCs treated with S-303 for pathogen reduction had similar in vitro properties to the paired controls and were within transfusion guidelines.

Storage of red blood cells affects membrane composition, microvesiculation, and in vitro quality

BACKGROUND

During storage detrimental biochemical and biomechanical changes occur within a red blood cell (RBC). RBC microparticles (RMPs) produced during storage have been identified as biomarkers of RBC quality, being potentially immunogenic and inhibitory to nitric oxide regulation.

STUDY DESIGN AND METHODS

In this study, microvesiculation and changes in the composition of the RBC membrane were investigated throughout 49 days of storage and were correlated with in vitro assays examining membrane quality. Leukoreduced RBC units produced using the buffy coat method were collected and stored at 1 to 6°C and were tested weekly for hemolysis, osmotic fragility, deformability, ATP, hematologic indices, and morphology. Microvesiculation was assessed using multicolor flow cytometry. High-performance liquid chromatography and mass spectrometry were used to determine the composition and quantity of phospholipids (PLs) and cholesterol (C) on Days 2 and 43.

RESULTS

The assessment of RBCs throughout storage revealed significant increases in percent hemolysis, while significant decreases in ATP concentrations, and the mean corpuscular hemoglobin concentration were observed. Flow cytometry analysis revealed a significant increase in the mean number of microparticles per microliter during storage. Throughout storage, significant decreases were identified in the amount of PLs and total lipids within the RBC membrane. No significant change in the amount of C in the RBC membrane was identified.

CONCLUSION

Significant changes to the RBC membrane occur during storage. The length of storage will influence RMP generation, osmotic fragility, hemolysis, and changes in deformability. These changes in RBC in vitro quality may contribute to transfusion reactions and negative posttransfusion outcomes.

Effect of irradiation and/or leucocyte filtration on RBC storage lesions

Red blood cell (RBC) storage lesions have been shown to be associated with some adverse reactions; numerous studies have focused on the lesions caused by storage, and few data on the RBC storage lesions caused by prestorage treatments of leucocyte filtration and irradiation. In this study, we examined the changes related with the RBC storage lesions, including 2,3-diphosphatidylglyceric acid (2,3-DPG), pH, free hemoglobin (Hb), supernatant free K⁺ and Na⁺ concentration, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH). Along with the increasing storage time, decreases in 2, 3-DPG levels, pH and Na⁺ concentration, increases in K⁺ and free Hb concentrations, and significant morphological changes in RBC in all groups were found. The changes in the groups of irradiation, leucocyte filtration and the combined irradiation and leucocyte filtration were more significant than those in the untreated group. Meanwhile, the MCV levels of the three treated groups were significantly lower than those in the untreated group, while the MCH variations were significantly higher. Our results suggest that irradiation and leucocyte filtration before storage may aggravate blood storage lesions.

Emerging Role for Use of Liposomes in the Biopreservation of Red Blood Cells

SUMMARY: Biopreservation is the process of maintaining the integrity and functionality of cells held outside the native environment for extended storage times. The development of red blood cell (RBC) biopreservation techniques that maintain in vitro RBC viability and function represents the foundation of modern blood banking. The biopreservation of RBCs for clinical use can be categorized based on the techniques used to achieve biologic stability, including hypothermic storage and cryopreservation. This review will examine the emerging role of liposomes in the RBC biopreservation, including the incorporation of liposomes into RBC membranes as an effective approach for minimizing RBC hypothermic storage membrane lesion and use of liposomes as a permeabilization strategy for the intracellular accumulation of novel intracellular cryoprotectants. Integration of current biopreservation research with blood banking practices offers enormous potential for future improvements of safety and efficacy of RBC transfusion.

Stored red blood cells: a changing universe waiting for its map(s)

The availability of stored red blood cells (RBCs) for transfusion remains an important aspect of the treatment of polytrauma, acute anemia or major bleedings. RBCs are prepared by blood banks from whole blood donations and stored in the cold in additive solutions for typically six weeks. These far from physiological storage conditions result in the so-called red cell storage lesion that is of importance both to blood bankers and to clinical practitioners. Here we review the current state of knowledge about the red cell storage lesion from a proteomic perspective. In particular, we describe the current models accounting for RBC aging and response to lethal stresses, review the published proteomic studies carried out to uncover the molecular basis of the RBC storage lesion, and conclude by suggesting a few possible proteomic studies that would provide further knowledge of the molecular alterations carried by RBCs stored in the cold for six weeks.

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.

Age of transfused red cells and early outcomes after cardiac surgery

BACKGROUND

Red blood cells (RBC) undergo many changes during storage. Such changes are associated with reduced oxygen-carrying capacity and transfusion-related inflammatory reactions. The clinical significance of these changes in the cardiac surgical setting is unclear. This observational cohort study investigates the association between age of transfused RBC and early outcomes after cardiac surgery.

METHODS

The cardiac surgery database at St. Vincent's Hospital Melbourne was cross-referenced with the Blood Transfusion Services database. In all, 670 consecutive patients who had nonemergency coronary artery bypass grafting or aortic valve replacement, or both, between June 2001 and June 2007 and had at least 2 RBC units transfused were studied. The storage variables studied were mean age of RBC, age of oldest RBC unit transfused, and transfusion of RBC stored longer than 30 days. Age of transfused blood was analyzed using logistic and linear regression analysis to determine an independent association with clinical outcomes: postoperative early mortality, renal failure, pneumonia, intensive care unit stay, and ventilation hours. Patient preoperative risk profile (EuroSCORE) and total number of RBC units transfused were adjusted for.

RESULTS

The storage age of RBC was not independently associated with any of the endpoints studied. The total quantity of RBC transfused was significantly associated with all studied endpoints.

CONCLUSIONS

Under current transfusion practice, the age of transfused RBC is not associated with early mortality and morbidity after cardiac surgery.

Cardiac arrests associated with hyperkalemia during red blood cell transfusion: a case series

BACKGROUND

Transfusion-associated hyperkalemic cardiac arrest is a serious complication of rapid red blood cell (RBC) administration. We examined the clinical scenarios and outcomes of patients who developed hyperkalemia and cardiac arrest during rapid RBC transfusion.

METHODS

We retrospectively reviewed the Mayo Clinic Anesthesia Database between November 1, 1988, and December 31, 2006, for all patients who developed intraoperative transfusion-associated hyperkalemic cardiac arrest.

RESULTS

We identified 16 patients with transfusion-associated hyperkalemic cardiac arrest, 11 adult and 5 pediatric. The majority of patients underwent three types of surgery: cancer, major vascular, and trauma. The mean serum potassium concentration measured during cardiac arrest was 7.2 +/- 1.4 mEq/L (range, 5.9-9.2 mEq/L). The number of RBC units administered before cardiac arrest ranged between 1 (in a 2.7 kg neonate) and 54. Nearly all patients were acidotic, hyperglycemic, hypocalcemic, and hypothermic at the time of arrest. Fourteen (87.5%) patients received RBC via central venous access. Commercial rapid infusion devices (pumps) were used in 8 of 11 (72.7%) of the adult patients, but RBC units were rapidly administered (pressure bags, syringe pumped) in all remaining patients. Mean resuscitation duration was 32 min (range, 2-127 min). The in-hospital survival rate was 12.5%.

CONCLUSION

The pathogenesis of transfusion-associated hyperkalemic cardiac arrest is multifactorial and potassium increase from RBC administration is complicated by low cardiac output, acidosis, hyperglycemia, hypocalcemia, and hypothermia. Large transfusion of banked RBCs and conditions associated with massive hemorrhage should raise awareness of the potential for hyperkalemia and trigger preventative measures.

Viability of AS-3 and SAG-M red cells stored in plastic syringes for pediatric transfusion

BACKGROUND

Pediatric patients may require small-volume transfusions necessitating splitting of red cell (RBC) units. This process usually involves temporary storage of aliquots in pediatric blood bags or, in some cases, plastic syringes, until they are transfused. While many studies have been published on the efficacy of storage in blood bags, there is little evidence to show that RBCs are safe and effective for transfusion after separation into plastic syringe aliquots.

STUDY DESIGN AND METHODS

Donor RBC units, stored in either SAG-M (n = 10) or AS-3 additive (n = 11), were split into transfer bags and plastic syringes and stored at either 4 degrees C or room temperature (RT). Half of the aliquots were also irradiated at 25 Gy. RBCs were monitored after 0, 4, and 24 hours of storage with the following variables to assess cellular function and viability: adenosine triphosphate, percent hemolysis, hematocrit, pH, lactate dehydrogenase, extracellular potassium, sodium, and RBC indices.

RESULTS

There was no difference found between irradiated and nonirradiated aliquots or aliquots stored in the refrigerator versus those stored at RT. Significant differences between aliquots stored in approved transfer bags and those stored in syringes were not identified.

CONCLUSIONS

Irradiation and storage of aliquoted RBCs demonstrated expected but not significant changes in the in vitro variables. Storage for up to 24 hours in syringes does not have a greater detrimental effect on RBCs than storage in transfer bags, making products stored in either container safe for transfusion to pediatric patients.

Effects of γ-irradiation on the membrane ATPases of human erythrocytes from transfusional blood concentrates

Irradiation of blood derivatives is employed in blood banks to avoid transfusion-associated graft-vs-host disease. As irradiation can damage membranes and membrane proteins by generation of reactive oxygen species, we investigated whether the membrane permeability, Na(+),K(+)-ATPase, and Ca(2+)-ATPase from red blood cell plasma membranes were altered by gamma-irradiation. Whole blood was collected from healthy donors and concentrated to 90% cell fraction. Within 24 h of collection, blood concentrates were irradiated with 25 Gy of gamma-radiation. At days 1, 7, 14, and 28 post-irradiation, fractions were removed and centrifuged. Na(+),K(+)-ATPase and Ca(2+)-ATPase activities from ghost membranes were assessed by gamma-(32)P-ATP hydrolysis. The Na(+),K(+)-ATPase was not immediately affected by irradiation, but it was inhibited by 40% by day 14 and until day 28. The Ca(2+)-ATPase was unaltered by irradiation. The rate and the maximal (45)Ca(2+) uptake from re-sealed inside-out vesicles were reduced, and the passive efflux of (45)Ca(2+) was increased. Thus, irradiation of blood concentrates increased the plasma membrane permeability to monovalent and divalent cations and would change ion homeostasis and cell function. We recommend the use of irradiated blood within a period shorter than 14 days after irradiation.

Red blood cell (RBC) age at collection and storage influences RBC membrane-associated carbohydrates and lectin binding

BACKGROUND

Membrane-associated carbohydrate changes act as signals for removal of senescent and damaged red blood cells (RBCs) from the circulation and could play a role in the RBC storage lesion and RBC survival after transfusion. In this study, a panel of lectins was used to investigate the expression of carbohydrates on RBCs that had been separated before storage into young and old RBCs.

STUDY DESIGN AND METHODS

Leukodepleted RBCs were separated before storage into young and old RBCs (n = 9 paired units) by centrifugation and sampled at nominated time points during 42 days of storage. Changes to carbohydrate expression at the RBC membrane during storage were determined by flow cytometry with a panel of fluorescein-labeled lectins.

RESULTS

Old RBCs showed lower fluorescence intensity throughout storage, suggesting reduced binding of lectins compared to young RBCs. Progressively increased binding of lectins specific for galactose and N-acetylglucosamine residues was observed during storage of young and old RBCs.

CONCLUSION

Changes to lectin binding during storage of RBCs suggest that significant changes occur to the carbohydrate structures at the RBC membrane. These findings provide further insight into the mechanisms of the RBC storage lesion and potential influence on RBC survival after transfusion.

Proteomics and transfusion medicine: Future perspectives

Limited number of important discoveries have greatly contributed to the progresses achieved in the blood transfusion; ABO histo-blood groups, citrate as anticoagulant, fractionation of plasma proteins, plastic bags and apheresis machines. Three major types of blood products are transfused to patients: red cell concentrates, platelet concentrates and fresh frozen plasma. Several parameters of these products change during storage process and they have been well studied over the years. However, several aspects have completely been ignored; in particular those related to peptide and protein changes. This review presents what has been done using proteomic tools and the potentials of proteomics for transfusion medicine.