Influence of prestorage leucocyte depletion and storage time on rheologic properties of erythrocyte concentrates

Effect of leukoreduction on the omics phenotypes of canine packed red blood cells during refrigerated storage

BACKGROUND

Red blood cell (RBC) storage promotes biochemical and morphological alterations, collectively referred to as storage lesions (SLs). Studies in humans have identified leukoreduction (LR) as a critical processing step that mitigates SLs. To date no study has evaluated the impact of LR on metabolic SLs in canine blood units using omics technologies.

OBJECTIVE

Compare the lipid and metabolic profiles of canine packed RBC (pRBC) units as a function of LR in fresh and stored refrigerated (up to 42 days) units.

ANIMALS

Packed RBC units were obtained from 8 donor dogs enrolled at 2 different Italian veterinary blood banks.

STUDY DESIGN AND METHODS

Observational study. A volume of 450 mL of whole blood was collected using Citrate-Phosphate-Dextrose-Saline-Adenine-Glucose-Mannitol (CPD-SAGM) transfusion bags with a LR filter to produce 2 pRBC units for each donor, without (nLR-pRBC) and with (LR-pRBC) LR. Units were stored in the blood bank at 4 ± 2°C. Sterile weekly samples were obtained from each unit for omics analyses.

RESULTS

A significant effect of LR on fresh and stored RBC metabolic phenotypes was observed. The nLR-pRBC were characterized by higher concentrations of free short and medium-chain fatty acids, carboxylic acids (pyruvate, lactate), and amino acids (arginine, cystine). The LR-pRBC had higher concentrations of glycolytic metabolites, high energy phosphate compounds (adenosine triphosphate [ATP]), and antioxidant metabolites (pentose phosphate, total glutathione).

CONCLUSION AND CLINICAL IMPORTANCE

Leukoreduction decreases the metabolic SLs of canine pRBC by preserving energy metabolism and preventing oxidative lesions.

An Evaluation of Morphological Changes and Deformability of Suspended Red Blood Cells Prepared Using Whole Blood with Different Hemoglobin Levels of Tibetans

Background

The hypoxic environment stimulates the human body to increase the levels of hemoglobin (HGB) and hematocrit and the number of red blood cells. Such enhancements have individual differences, leading to a wide range of HGB in Tibetans' whole blood (WB).

Study Design

WB of male Tibetans was divided into 3 groups according to different HGB (i.e., A: >120 but ≤185 g/L, B: >185 but ≤210 g/L, and C: >210 g/L). Suspended red blood cells (SRBC) processed by collected WB and stored in standard conditions were examined aseptically on days 1, 14, 21, and 35 after storage. The routine biochemical indexes, deformability, cell morphology, and membrane proteins were tested.

Results

Mean corpuscular volume, adenosine triphosphate, pH, and deformability were not different in group A vs. those in storage (p > 0.05). The increased rate of irreversible morphology of red blood cells was different among the 3 groups, but there was no difference in the percentage of red blood cells with an irreversible morphology after 35 days of storage. Group C performed better in terms of osmotic fragility and showed a lower rigid index than group A. Furthermore, SDS-PAGE revealed similar cross-linking degrees of cell membrane protein but the band 3 protein of group C seemed to experience weaker clustering than that of group A as detected by Western Blot analysis after 35 days of storage.

Conclusions

There was no difference in deformability or morphological changes in the 3 groups over the 35 days of storage. High HGB levels of plateau SRBC did not accelerate the RBC change from a biconcave disc into a spherical shape and it did not cause a reduction in deformability during 35 days of preservation in bank conditions.

Effect of Leukoreduction on Hematobiochemical Parameters and Storage Hemolysis in Canine Whole Blood Units

Simple Summary

During the storage of blood units, cells undergo many changes, defined as storage lesions; these are biochemical, morphological and immunological modifications and seem to be responsible for adverse post-transfusion effects in recipients. The pre-storage leukoreduction seems to reduce them. The aims of this study are both to evaluate the human filter effectiveness and the effect of pre-storage leukoreduction in stored canine whole blood units. We tested whole blood units, leukoreduced and not, obtained from seven enrolled subjects, until the 42nd day. The white blood cell (WBC) and platelet (PLT) counts are reported to express the leukoreduction effectiveness. As indicators of storage-induced hemolysis, the lactate dehydrogenase activity (LDH) and sodium, potassium, and chlorine electrolytes were measured in plasma, and the red blood cell (RBC) count, hemoglobin concentration (Hgb), and hematocrit (Hct) were obtained with the complete blood count (CBC). The mean corpuscular volume (MCV) values and morphological index obtained from blood smear evaluation were used as indices of morphological changes. We observed that the leukoreduction filter for human use is equally effective on canine whole blood and that leukoreduction has a partially protective role to prevent some storage lesions.

Abstract

Storage lesions (SLs) occur when the red blood cell quality is altered during the preservation of blood units. Pre-storage leukoreduction would limit the number of SLs. The aims of this study were to evaluate the effectiveness of a leukoreduction filter for human use and the effect of pre-storage leukoreduction on some ematobiochemical parameters in stored canine whole blood. Seven canine blood units were tested. Each one was divided into two units—one leukoreduced (LRWB) and one non-leukoreduced (nLRWB). On each unit, we determined the complete blood count (CBC), lactate-dehydrogenase (LDH), electrolytes (Na⁺, K⁺, Cl⁻), morphological index (MI) and hemolysis, on storage days 0, 7, 14, 21, 28, 35, and 42. Leukoreduction allowed a 98.30% recovery of the RBC count, retaining 99.69% and 94.91% of WBCs and PLTs, respectively. We detected a significant increase of LDH and MI with strongly higher values in nLRWB compared to LRWB. A progressive increase in electrolytes and LDH concentrations was observed as indices of stored hemolysis. LDH showed significantly lower values in LRWB units compared to nLRWB, suggesting its release from leukocytes. In the majority of units, hemolysis reached 1% on the 42nd day of storage. We assert the human leukoreduction filter effectiveness on canine whole blood, and we recommend using nLRWB before day 14, especially for critically ill patients. The difference of the basal hemolysis (day 0) percentages observed between subjects suggests that more studies should be performed to confirm a possible inter-individual donor biological variability of RBC membrane resistance, as happens in humans.

Effects of leukoreduction on storage lesions in whole blood and blood components of dogs

Background

Leukoreduction is a routine procedure in human transfusion medicine but is uncommon in veterinary.

Objectives

To evaluate the effect of leukoreduction on the quality of canine whole blood (WB) and blood products during storage.

Animals

Ten canine blood donors.

Methods

This is a case series study. An amount of 450 mL of blood was collected from each dog. Five WB and 5 packed red blood cells (pRBC) bags were divided into 2 units each: leukoreduced (LR) and non‐leukoreduced (nLR). RBC count, erythrocytes' mean osmotic fragility (MOF), 2,3‐diphosphoglycerate (2,3‐DPG), adenosine triphosphate (ATP), percentage of hemolysis, potassium (K), lactate, glucose, and cytokines were measured weekly from day of donation (T0) to day 35 (T35); pH, coagulation times, and clotting factors were evaluated at T0 and T35 from WB and in fresh frozen plasma after 1 year of storage.

Results

Leukoreduction showed positive effects on lactate (T35: LR WB 14.42 mmol/L SD 2.71, nLR WB 22.42 mmol/L SD 1.86, LR pRBC 20.88 mmol/L SD 2.65, nLR pRBC 36.81 mmol/L SD 2.34; P < .0001), pH (T35: LR WB 6.88 SD 0.16, nLR WB 6.69 SD 0.20, P = .02; LR pRBC 6.57 SD 0.23, nLR pRBC 6.22 SD 0.11; P < .001), and K (LR pRBC 4.08 mmol/L SD 0.88, nLR pRBC 5.48 mmol/L SD 0.90; P < .001). Increasing values of IL8 were observed in nLR units during storage (T0: 4167 ± 11 888 pg/mL; T35: 6367 ± 11 612 pg/mL).

Conclusion and Clinical Importance

LR blood units are recommended to critically ill dogs with marked inflammatory conditions.

Hematological, biochemical and microbiological evaluation of feline whole blood units collected using an open system and stored for 35 days

Despite the increasing availability of feline blood, which is collected and stored for transfusion purposes, few studies have assessed the effect of storage on feline whole blood (WB) units. The purpose of this study was to investigate selected hematologic and biochemical changes during storage of feline WB units and to determine when they occurred. Data from a quality control program for WB units was used in this study. Twelve feline WB units, collected using an open system, were sampled every 7 days from the point of collection to the end of storage at 35 days (D0, D7, D14, D21, D28, and D35). Measurements at each time point were: (1) hematologic parameters; (2) percentage hemolysis; (3) morphologic index scored at 0-3, based on echinocyte transformation of the erythrocytes; and (4) selected biochemical parameters. Aerobic and anaerobic culture was performed at D0 and D35. Results were compared statistically to D0 (statistical significance set at <0.01). Storage did not result in statistically significant changes in measured hematological parameters. There were statistically significant increases in percentage hemolysis and morphologic index, starting from D21 (P=0.000 and P=0.004, respectively). Glucose decreased significantly from D21 (P=0.003); potassium increased significantly from D7 (P=0.001); and sodium increased significantly, starting from D28 (P=0.009). Bacteria were not isolated. Blood in feline WB units collected using an open system underwent some significant storage changes that were time-dependent. As these changes could affect the quality and the utility of stored WB used in feline transfusion medicine, further study is required to determine their clinical importance.

Haematological and morphological evaluation of feline whole blood units collected for transfusion purposes

OBJECTIVES

Despite the increasing availability of feline blood collected and stored for transfusion purposes, few studies have been performed on feline blood units. The aim of this prospective in vitro study was to evaluate haematological and morphological changes in feline blood cells in whole blood units between collection and end of storage.

METHODS

Haematological examination (red blood cells [RBCs], haemoglobin, haematocrit, red cell distribution width, mean cell volume, mean cell haemoglobin concentration, mean cell haemoglobin, white blood cells [WBCs] and platelet [PLT] count) was performed on 40 non-leukoreduced feline whole blood units at the time of collection (day[D]0) and after storage (D35). The blood was collected into citrate-phosphate-dextrose-adenine anticoagulant-preservative solution using an open system in a veterinary blood bank and stored for 35 days at 4 ± 2°C. Twenty of these feline whole blood units were also analysed for blood cell morphology (normal RBCs, macrocytes, echinocytes, spherocytes, schistocytes, lysed RBCs, RBCs with Heinz bodies and recognisable WBC and PLT count). Differences between the two examination times were statistically analysed.

RESULTS

There was a statistically significant decrease in WBC and PLT counts after storage at D35 (P <0.0001 for both). The most significant cellular morphological changes after storage were an increase in echinocyte count (P = 0.0001), and lysed RBCs (P <0.0001), and a decrease in normal RBCs (P <0.0001). Recognisable WBCs - mainly lymphocytes - were present at the end of storage.

CONCLUSIONS AND RELEVANCE

This study showed that significant morphological changes occur in RBCs in feline blood units during storage for 35 days. In vivo studies are required to establish if these changes could affect the ability of stored RBCs to circulate and provide adequate oxygen delivery after transfusion.

The effects of freezing on long-term storage of canine erythrocytes

Human medicine studies have so far demonstrated that erythrocytes may be preserved and stored at low temperatures for decades retaining their metabolic and biochemical properties. However, detailed studies regarding this problem are not yet available in veterinary medicine. Therefore, the objective of the current study was to investigate time-dependent effects of long-term frozen storage of canine red blood cells.

Twelve healthy adult dogs meeting the criteria for blood transfusion were used in the study. Whole blood samples (450 ± 45 ml) collected from each dog were centrifuged by a cryogenic microcentrifuge and packed RBC suspensions were obtained. The samples were prewashed three times in 0.9% NaCl solution and were allocated into three groups to be evaluated at three different time points (day 0 and month 4 and 6). The samples to be frozen were subjected to glycerolization and then stored at −80°C for 4 and 6-month periods. At the end of this period the packed RBC samples were thawed, centrifuged and then washed in a consecutive series of dextrose solutions. 2,3-Diphosphoglycerate (2,3-DPG), Adenosin triphosphate (ATP), supernatant hemoglobin (SupHb), sodium (Na+) and potassium (K+) levels, residual glycerol concentrations and hemograms were evaluated and compared. Sterility tests were performed on all samples for bacterial contamination. A statistically significant decrease was noted in potassium levels, which was the natural outcome of deglycerolization process. No significant change was observed in terms of other parameters due based on different time points. In conclusion, long-term frozen storage had no negative effect on the quality parameters of canine erythrocytes.

Protocols for massive blood transfusion: when and why, and potential complications

PURPOSE

An update paper on massive bleeding after major trauma. A review of protocols to address massive bleeding, and its possible complications, including coagulation abnormalities, complications related to blood storage, immunosuppression and infection, lung injury associated with transfusion, and hypothermia is carried out.

METHODS

Literature review and discussion with authors' experience.

RESULTS

Massive bleeding is an acute life-threatening complication of major trauma, and consequently its prompt diagnosis and treatment is of overwhelming importance. Treatment requires rapid surgical management together with the massive infusion of colloid and blood.

CONCLUSIONS

Since massive transfusion provokes further problems in patients who are already severely traumatized and anaemic, once this course of action has been decided upon, a profound knowledge of its potential complications, careful monitoring and proper follow-up are all essential. To diagnose this bleeding, most authors favour, as the main first choice tool, a full-body CT scan (head to pelvis), in non-critical severe trauma cases. In addition, focused abdominal sonography for trauma (FAST, an acronym that highlights the necessity of rapid performance) is a very important diagnostic test for abdominal and thoracic bleeding. Furthermore, urgent surgical intervention should be undertaken for patients with significant free intraabdominal fluid and haemodynamic instability. Although the clinical situation and the blood haemoglobin concentration are the key factors considered in this rapid decision-making context, laboratory markers should not be based on a single haematocrit value, as its sensitivity to significant bleeding may be very low. Serum lactate and base deficit are very sensitive markers for detecting and monitoring the extent of bleeding and shock, in conjunction with repeated combined measurements of prothrombin time, activated partial thromboplastin time, fibrinogen and platelets.

Adaption to High Altitude: An Evaluation of the Storage Quality of Suspended Red Blood Cells Prepared from the Whole Blood of Tibetan Plateau Migrants

Hypoxia has been reported to cause the significant enhancement of hemoglobin (Hb) and hematocrit (Hct), which stabilizes at relatively high levels after an individual ascends to a high altitude. However, the quality of the suspended red blood cells (SRBCs) obtained from individuals at high altitudes such as Tibetan plateau migrants after storage has not been studied. In this study, we compared the storage quality of SRBCs prepared from Tibetan plateau and Deyang lowland populations by adding a normal volume of mannitol-adenine-phosphate (MAP), which is a common additive solution used in blood storage in Asian countries. The storage cell characteristics were examined on days1, 7, 14 and 35.We found higher Hct and Hb levels and viscosity in the high altitude samples. The metabolic rates, including those for electrolytes and lactate, were higher in plateau SRBCs than in lowland SRBCs; these findings were consistent with the higher osmotic fragility and hemolysis of plateau SRBCs throughout the entire storage period. In addition, the reduction rates of 2,3-diphosphoglycerate (2,3-DPG) and oxygen tension to attain 50% oxygen saturation of Hb (P50) in plateau SRBCs were higher than those in lowland SRBCs, and the oxygen delivering capacity in plateau SRBCs was weaker than that in lowland SRBCs. We concluded that the storage quality of plateau SRBCs was inferior to that of lowland SRBCs when using the same concentration of MAP. We suggested that the optimal formula, including the MAP concentration or even a new additive solution, to store the plateau SRBCs must be assessed and regulated.

Washing stored red blood cells in an albumin solution improves their morphologic and hemorheologic properties

BACKGROUND

Prolonged storage of red blood cells (RBCs) leads to storage lesions, which may impair clinical outcomes after transfusion. A hallmark of storage lesions is progressive echinocytic shape transformation, which can be partially reversed by washing in albumin solutions. Here we have investigated the impact of this shape recovery on biorheologic variables.

STUDY DESIGN AND METHODS

RBCs stored hypothermically for 6 to 7 weeks were washed in a 1% human serum albumin (HSA) solution. RBC deformability was measured with osmotic gradient ektacytometry. The viscosity of RBC suspensions was measured with a Couette-type viscometer. The flow behavior of RBCs suspended at 40% hematocrit was tested with an artificial microvascular network (AMVN).

RESULTS

Washing in 1% albumin reduced higher degrees of echinocytes and increased the frequency of discocytes, thereby shifting the morphologic index toward discocytosis. Washing also reduced RBC swelling. This shape recovery was not seen after washing in saline, buffer, or plasma. RBC shape normalization did not improve cell deformability measured by ektacytometry, but it tended to decrease suspension viscosities at low shear rates and improved the perfusion of an AMVN.

CONCLUSIONS

Washing of stored RBCs in a 1% HSA solution specifically reduces echinocytosis, and this shape recovery has a beneficial effect on microvascular perfusion in vitro. Washing in 1% albumin may represent a new approach to improving the quality of stored RBCs and thus potentially reducing the likelihood of adverse clinical outcomes associated with transfusion of blood stored for longer periods of time.

Red cell distribution width is associated with hospital mortality in unselected critically ill patients

BACKGROUND AND OBJECTIVES

Red cell distribution width (RDW) is a variability of red cell sizes and has been associated with outcomes in many clinical settings. Its prognostic value in intensive care unit (ICU) has been reported but requires confirmation. The study aimed to investigate the role of RDW in predicting hospital mortality in critically ill patients.

METHODS

This is a retrospective study conducted in a 24-bed ICU of a tertiary teaching hospital. Data on demographic characteristics and laboratory measurements were collected from medical information database. Baseline variables were compared between survivors and nonsurvivors. The primary endpoint was hospital mortality; and ICU length of stays (LOS) were compared between patients with RDW >14.8% and ≤14.8%. The predictive value of RDW was also measured using receiver operating characteristic (ROC) curves. Two-sided P<0.05 was considered to be statistically significant.

RESULTS

A total of 1,539 patients were enrolled during study period, including 1,084 survivors and 455 nonsurvivors. In univariate analysis, variables such as age, sex, primary diagnosis, C-reactive protein (CRP), RDW and albumin were significantly associated with hospital mortality. RDW remained significantly associated with mortality after adjustment for sex, age, Charlson index albumin and CRP, with an odds ratio of 1.1 (95% CI: 1.03-1.16). Diagnostic performance of RDW in predicting mortality appeared to be suboptimal (AU-ROC: 0.62). Changes in RDW during a short follow up period were not associated with mortality.

CONCLUSIONS

RDW measured on ICU entry is associated with hospital mortality. Patients with higher RDW will have longer LOS in ICU. Repeated measurements of RDW provide no additional prognostic value in critically ill patients.

Complications of massive transfusion

Massive transfusion (MT) is a lifesaving treatment of hemorrhagic shock, but can be associated with significant complications. The lethal triad of acidosis, hypothermia, and coagulopathy associated with MT is associated with a high mortality rate. Other complications include hypothermia, acid/base derangements, electrolyte abnormalities (hypocalcemia, hypomagnesemia, hypokalemia, hyperkalemia), citrate toxicity, and transfusion-associated acute lung injury. Blood transfusion in trauma, surgery, and critical care has been identified as an independent predictor of multiple organ failure, systemic inflammatory response syndrome, increased infection, and increased mortality in multiple studies. Once definitive control of hemorrhage has been established, a restrictive approach to blood transfusion should be implemented to minimize further complications.

Is red blood cell rheology preserved during routine blood bank storage?

BACKGROUND

Red blood cell (RBC) units stored for more than 2 weeks at 4 degrees C are currently considered of impaired quality. This opinion has primarily been based on altered RBC rheologic properties (i.e., enhanced aggregability, reduced deformability, and elevated endothelial cell interaction), during prolonged storage of nonleukoreduced RBC units. In this study, the rheologic properties and cell variables of leukoreduced RBC units, during routine blood bank storage in saline-adenine-glucose-mannitol, were investigated.

STUDY DESIGN AND METHODS

Ten leukoreduced RBC units were stored at the blood bank for 7 weeks at 4 degrees C. RBCs were tested weekly for aggregability, deformability, and other relevant variables.

RESULTS

RBC aggregability was significantly reduced after the first week of storage but recovered during the following weeks. After 7 weeks aggregability was slightly, but significantly, reduced (46.9 + or - 2.4-44.3 + or - 2.2 aggregation index). During storage the osmotic fragility was not significantly enhanced (0.47 + or - 0.01% phosphate-buffered saline) and the deformability at shear stress of 3.9 Pa was not significantly reduced (0.36 + or - 0.01 elongation index [EI]). The deformability at 50 Pa was reduced (0.58 + or - 0.01-0.54 + or - 0.01 EI) but remained within reference values (0.53 + or - 0.04). During 5 weeks of storage, adenosine triphosphate was reduced by 54% whereas mean cell volume, pH, and mean cell hemoglobin concentration were minimally affected.

CONCLUSIONS

RBC biochemical and physical alterations during storage minimally affected the RBC ability to aggregate and deform, even after prolonged storage. The rheologic properties of leukoreduced RBC units were well preserved during 7 weeks of routine blood bank storage.

Transfusion of stored red blood cells adhere in the rat microvasculature

BACKGROUND

Ex vivo storage of red blood cells (RBCS) for transfusions is associated with a "storage lesion," which decreases RBC deformability and increases RBC adhesiveness to vascular endothelium. This may impair microcirculatory flow with deleterious effects on oxygen delivery after transfusion. Previous studies have shown that human RBCs adhere to endothelial monolayers in vitro with prolonged storage and is reduced by prestorage leukoreduction (LR). The objective of this study was to determine whether duration of RBC storage and LR influence RBC adhesion in vivo in capillaries.

STUDY DESIGN AND METHODS

Rat RBCs were collected and stored in CPDA-1 under standard blood bank conditions. Three RBC products were compared: 1) fresh RBCs, less than 24 hours of storage (n = 6); 2) non leukoreduced (NLR) RBCs stored for 7 days (n = 6); and 3) prestorage LR RBCs stored for 7 days (n = 6). RBCs were labeled with fluorescein isothiocyanate (FITC) 24 hours before transfusion and reinjected in an isovolemic manner into healthy rats. The FITC-labeled RBCs were visualized in the extensor digitorum longus muscle using intravital video microscopy (20 x magnification). The number of RBCs adherent in capillaries was counted 1 hour after transfusion in 10 random fields and the median values were compared with one-way analysis of variance.

RESULTS

Stored RBCs showed increased levels of adherence in capillaries compared to their fresh counterparts (p < 0.05). Prestorage LR decreased RBC adherence to levels equivalent to those of fresh RBCs (p < 0.05 for stored LR vs. stored NLR).

CONCLUSION

Rat RBCs stored under conditions that closely mimicked clinical transfusion adhere in capillaries. The decreased RBC adherence with LR suggest a direct effect of white blood cells or their byproducts on RBC deformability and/or adhesiveness to microvascular endothelium. Further study will examine the mechanism of adherence and the impact it has on microcirculatory flow and oxygen delivery in the critically ill host.

An update on solutions for red cell storage

Anticoagulant and nutrient solutions allow red blood cells to be stored and transported, enabling modern blood banking. The development of these solutions has been slow, covering 90 years, and the reasons for past formulations are best understood in a historical context. Modern red cell storage solutions work well for blood banks, allowing 5-7-week storage, which means more than 90% of collected units find a recipient. Improved scientific understanding of the red cell storage lesion has shown a way to make even better storage solutions, which maintain red cell metabolism and reduce membrane loss.

Effects of storage on efficacy of red cell transfusion: When is it not safe?

OBJECTIVE

To review the literature on red blood cell storage and its relationship to the efficacy of transfusion.

RESULTS

Well-documented changes occur to the red blood cell product during ex vivo storage. These changes include a reduction in red blood cell deformability, altered red blood cell adhesiveness and aggregability, and a reduction in 2,3-diphosphoglycerate and ATP. Bioactive compounds with proinflammatory effects also accumulate in the storage medium. These changes reduce posttransfusion viability of red blood cells. The clinical effects beyond posttransfusion viability are uncertain, but a growing body of evidence suggests that the storage lesion may reduce tissue oxygen availability, have proinflammatory and immunomodulatory effects, and influence morbidity and mortality. There are no published randomized, control trials examining the effect of storage duration on morbidity and mortality. Leukoreduction improves the quality of stored red blood cell products and in some studies has been shown to reduce morbidity and mortality.

CONCLUSION

Although storage duration influences the quality of red blood cell product, there is currently insufficient evidence to advocate shorter storage periods for red blood cell products.