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Crawford T, Andersen C, Marks DC, Robertson SA, Stark M. Does donor sex influence the potential for transfusion with washed packed red blood cells to limit transfusion-related immune responses in preterm newborns? Arch Dis Child Fetal Neonatal Ed 2023; 108:471-477. [PMID: 36690436 DOI: 10.1136/archdischild-2022-324531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 01/06/2023] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate the association of donor sex with transfusion-associated recipient immune responses in preterm newborns receiving unwashed and washed blood. DESIGN A cohort study using data collected during the Effect of Washed versus Unwashed Packed Red Blood Cell Transfusion on Immune Responses in the Extremely Preterm Newborn randomised trial. SETTING Participants were recruited from two South Australian hospitals between September 2015 and December 2020. PATIENTS Preterm newborns (<29 weeks). INTERVENTIONS Transfusion with unwashed and washed packed red blood cells (PRBCs) from either exclusively male or any female donor for the first three transfusions. MAIN OUTCOMES MEASURES The primary outcome was the change from baseline in post-transfusion plasma cytokine concentrations, specifically interferon gamma, interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12, IL-17A and tumour necrosis factor (TNF). RESULTS In total, 153 newborns were evaluated. By the third transfusion, the magnitude of pretransfusion to post-transfusion change in cytokines between the groups differed for IL-6 (p=0.003), IL-12 (p=0.008), IL-17A (p=0.003) and TNF (p=0.007). On post hoc comparison, compared with the unwashed-any female donor group, IL-6 (p<0.05), IL-12 (p<0.05) and IL-17A (p<0.01) were lower in the washed-exclusively male donor group, and IL-6 (p<0.01), IL-12 (p<0.05) and TNF (p<0.01) were lower in the washed-any female donor group. CONCLUSION These findings suggest that transfusion with unwashed PRBCs from female donors is associated with an increased recipient immune response, an effect that can be ameliorated with pretransfusion washing. Larger randomised controlled studies confirming this mechanistic link between donor sex and transfusion-associated morbidity are warranted. TRIAL REGISTRATION NUMBER ACTRN12613000237785.
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Affiliation(s)
- Tara Crawford
- Neonatal Medicine, Women's and Children's Hospital Adelaide, North Adelaide, South Australia, Australia
- The University of Adelaide Robinson Research Institute, North Adelaide, South Australia, Australia
| | - Chad Andersen
- Neonatal Medicine, Women's and Children's Hospital Adelaide, North Adelaide, South Australia, Australia
- The University of Adelaide Robinson Research Institute, North Adelaide, South Australia, Australia
| | - Denese C Marks
- Product Development and Storage, Australian Red Cross Blood Service New South Wales and Australian Capital Territory, Alexandria, New South Wales, Australia
| | - Sarah A Robertson
- The University of Adelaide Robinson Research Institute, North Adelaide, South Australia, Australia
| | - Michael Stark
- Neonatal Medicine, Women's and Children's Hospital Adelaide, North Adelaide, South Australia, Australia
- The University of Adelaide Robinson Research Institute, North Adelaide, South Australia, Australia
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Pandey S, Mahato M, Srinath P, Bhutani U, Goap TJ, Ravipati P, Vemula PK. Intermittent scavenging of storage lesion from stored red blood cells by electrospun nanofibrous sheets enhances their quality and shelf-life. Nat Commun 2022; 13:7394. [PMID: 36450757 PMCID: PMC9712616 DOI: 10.1038/s41467-022-35269-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022] Open
Abstract
Transfusion of healthy red blood cells (RBCs) is a lifesaving process. However, upon storing RBCs, a wide range of damage-associate molecular patterns (DAMPs), such as cell-free DNA, nucleosomes, free-hemoglobin, and poly-unsaturated-fatty-acids are generated. DAMPs can further damage RBCs; thus, the quality of stored RBCs declines during the storage and limits their shelf-life. Since these DAMPs consist of either positive or negative charged species, we developed taurine and acridine containing electrospun-nanofibrous-sheets (Tau-AcrNFS), featuring anionic, cationic charges and an DNA intercalating group on their surfaces. We show that Tau-AcrNFS are efficient in scavenging DAMPs from stored human and mice RBCs ex vivo. We find that intermittent scavenging of DAMPs by Tau-AcrNFS during the storage reduces the loss of RBC membrane integrity and reduces discocytes-to-spheroechinocytes transformation in stored-old-RBCs. We perform RBC-transfusion studies in mice to reveal that intermittent removal of DAMPs enhances the quality of stored-old-RBCs equivalent to freshly collected RBCs, and increases their shelf-life by ~22%. Such prophylactic technology may lead to the development of novel blood bags or medical device, and may therefore impact healthcare by reducing transfusion-related adverse effects.
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Affiliation(s)
- Subhashini Pandey
- grid.475408.a0000 0004 4905 7710Institute for Stem Cell Science and Regenerative Medicine (inStem), GKVK Post, Bellary Road, Bangalore, 560065 Karnataka India ,grid.502290.c0000 0004 7649 3040The University of Trans-Disciplinary Health Sciences and Technology, Attur (post), Yelahanka, Bangalore, 560064 Karnataka India
| | - Manohar Mahato
- grid.475408.a0000 0004 4905 7710Institute for Stem Cell Science and Regenerative Medicine (inStem), GKVK Post, Bellary Road, Bangalore, 560065 Karnataka India
| | - Preethem Srinath
- grid.475408.a0000 0004 4905 7710Institute for Stem Cell Science and Regenerative Medicine (inStem), GKVK Post, Bellary Road, Bangalore, 560065 Karnataka India
| | - Utkarsh Bhutani
- grid.475408.a0000 0004 4905 7710Institute for Stem Cell Science and Regenerative Medicine (inStem), GKVK Post, Bellary Road, Bangalore, 560065 Karnataka India
| | - Tanu Jain Goap
- grid.475408.a0000 0004 4905 7710Institute for Stem Cell Science and Regenerative Medicine (inStem), GKVK Post, Bellary Road, Bangalore, 560065 Karnataka India ,grid.502290.c0000 0004 7649 3040The University of Trans-Disciplinary Health Sciences and Technology, Attur (post), Yelahanka, Bangalore, 560064 Karnataka India
| | - Priusha Ravipati
- grid.475408.a0000 0004 4905 7710Institute for Stem Cell Science and Regenerative Medicine (inStem), GKVK Post, Bellary Road, Bangalore, 560065 Karnataka India
| | - Praveen Kumar Vemula
- grid.475408.a0000 0004 4905 7710Institute for Stem Cell Science and Regenerative Medicine (inStem), GKVK Post, Bellary Road, Bangalore, 560065 Karnataka India
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3
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Baker SA, Wong LK, Wieland R, Bulterys P, Allard L, Nguyen L, Quach T, Nguyen A, Chaesuh E, Cheng P, Bowen R, Virk M. Validated transport conditions maintain the quality of washed red blood cells. Transfusion 2022; 62:1860-1870. [DOI: 10.1111/trf.17062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/07/2022] [Accepted: 07/15/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Steven Andrew Baker
- Division of Transfusion Medicine, Department of Pathology Stanford University Stanford California USA
- Transfusion Medicine Section, Department of Pathology University of Utah Salt Lake City Utah USA
| | - Lisa Kanata Wong
- Division of Transfusion Medicine, Department of Pathology Stanford University Stanford California USA
| | - Rebekah Wieland
- Department of Pathology Stanford University Stanford California USA
| | - Philip Bulterys
- Department of Pathology Stanford University Stanford California USA
| | - Libby Allard
- Department of Pathology Stanford University Stanford California USA
| | - Lang Nguyen
- Division of Transfusion Medicine, Department of Pathology Stanford University Stanford California USA
| | - Thinh Quach
- Division of Transfusion Medicine, Department of Pathology Stanford University Stanford California USA
| | - AnhThu Nguyen
- Division of Transfusion Medicine, Department of Pathology Stanford University Stanford California USA
| | - Eunkyong Chaesuh
- Division of Clinical Chemistry, Department of Pathology Stanford University Stanford California USA
| | - Phil Cheng
- Division of Clinical Chemistry, Department of Pathology Stanford University Stanford California USA
| | - Raffick Bowen
- Division of Clinical Chemistry, Department of Pathology Stanford University Stanford California USA
| | - Mrigender Virk
- Division of Transfusion Medicine, Department of Pathology Stanford University Stanford California USA
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4
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Lu S, Allyn M, Weigand M, Chalmers JJ, Palmer AF. Tangential flow filtration facilitated washing of human red blood cells: A proof-of-concept study. Vox Sang 2022; 117:803-811. [PMID: 35262216 DOI: 10.1111/vox.13259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 01/14/2022] [Accepted: 01/27/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Red blood cell (RBC) units in hypothermic storage degrade over time, commonly known as the RBC storage lesion. These older RBC units can cause adverse clinical effects when transfused, as older RBCs in the unit lyse and release cell-free haemoglobin (Hb), a potent vasodilator that can elicit vasoconstriction, systemic hypertension and oxidative tissue injury after transfusion. In this study, we examined a novel method of washing ex vivo stored single RBC units to remove accumulated cellular waste, specifically cell-free Hb, using tangential flow filtration (TFF) driven by a centrifugal pump. MATERIALS AND METHODS The TFF RBC washing system was run under hypothermic conditions at 4°C, at a constant system volume with 0.9 wt% saline as the wash solution. The RBC washing process was conducted on 10 separate RBC units. For this proof-of-concept study, RBC units were expired at the time of washing (60-70 days old). Cell-free Hb was quantified by UV-visible absorbance spectroscopy and analysed via the Winterbourn equations. Pre- and post-wash RBC samples were analysed by Hemox Analyser, Coulter counter and Brookfield rheometer. The RBC volume fraction in solution was measured throughout the wash process by standard haematocrit (HCT) analysis. RESULTS No substantial decrease in the HCT was observed during the TFF RBC washing process. However, there was a significant decrease in RBC concentration in the first half of the TFF RBC wash process, with no significant change in RBC concentration during the second half of the TFF cell wash process with an 87% overall cell recovery compared with the total number of cells before initiation of cell washing. Utilization of the extinction coefficients and characteristic peaks of each Hb species potentially present in solution was quantified by Winterbourn analysis on retentate and permeate samples for each diacycle to quantify Hb concentration during the washing process. Significant cell-free Hb reduction was observed within the first four diacycles with a starting cell-free Hb concentration in the RBC unit of 0.105 mM, which plateaus to a constant Hb concentration of 0.01 mM or a total extracellular Hb mass of 0.2 g in the resultant washed unit. The oxygen equilibrium curve showed a significant decrease in P50 between the initial and final RBC sample cell wash with an initial P50 of 15.6 ± 1.8 mm Hg and a final P50 of 14 ± 1.62 mm Hg. Cooperativity increased after washing from an initial Hill coefficient of 2.37 ± 0.19 compared with a final value of 2.52 ± 0.12. CONCLUSION Overall, this study investigated the proof-of-concept use of TFF for washing single RBC units with an emphasis on the removal of cell-free Hb from the unit. Compared with traditional cell washing procedures, the designed system was able to more efficiently remove extracellular Hb but resulted in longer wash times. For a more complete investigation of the TFF RBC washing process, further work should be done to investigate the effects of RBC unit storage after washing. The designed system is lightweight and transportable with the ability to maintain sterility between uses, providing a potential option for bedside ex vivo transfusion in clinical applications.
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Affiliation(s)
- Shuwei Lu
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Megan Allyn
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Mitchell Weigand
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Jeffrey J Chalmers
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Andre F Palmer
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio, USA
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5
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Smith NK, Kim SJ, Simmons Q, Lin HM, Romano D, Boydston E, DeMaria S, Zerillo J. The Optimal Cell Salvage Settings to Maximize Hematocrit and Minimize Potassium Using the Cobe BRAT2 Autologous Blood Recovery Unit. J Cardiothorac Vasc Anesth 2021; 36:1893-1900. [PMID: 34446326 DOI: 10.1053/j.jvca.2021.07.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/16/2021] [Accepted: 07/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The objective was to determine the optimal cell saver device settings (infusion rate and wash rate) at which hematocrit is preserved and potassium and lactate are removed from banked red blood cells (RBC). DESIGN Red cells were washed using the Cobe BRAT 2 Autologous Blood Recovery Unit and sampled for electrolyte composition and hematocrit pre- and postwash. SETTING This was a single-center study. INTERVENTIONS Red cells were washed using six infusion rates (100-1,000 mL/min) and six wash rates (100-1,000 mL/min) for a total of 36 combinations. Hematocrit, potassium, glucose, and lactate were evaluated before and after washing. MEASUREMENTS AND MAIN RESULTS At wash rates ≤400 mL/min, hematocrit increased independent of infusion rate. At wash rates ≥400 mL/min, slower infusion rates were associated with higher hematocrit compared to faster infusion rates (p < 0.0001 for a wash rate 400-800 mL/min, p < 0.0005 for a wash rate 1,000 mL/min). Maximal wash speeds were associated with decreasing hematocrit. Infusion and wash rate were both independent predictors of potassium change; slower rates were associated with a larger decrease in potassium. Glucose decreased proportionally as infusion and wash rate decreased. Lactate did not show an association with either infusion or wash rate. CONCLUSION Red-cell washing produces higher hematocrit and lower potassium as infusion rate and wash rate decrease. A 340-mL unit of RBC can be processed in 4.26 minutes without loss of hematocrit or an increase in potassium when both infusion and wash rates are set to 400 mL/min.
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Affiliation(s)
- Natalie K Smith
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Sang J Kim
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York
| | - Qasim Simmons
- Cardiovascular Perfusion Services, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Diana Romano
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elaine Boydston
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at, UCLA, Los Angeles, CA
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeron Zerillo
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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6
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Bedside Allogeneic Erythrocyte Washing with a Cell Saver to Remove Cytokines, Chemokines, and Cell-derived Microvesicles. Anesthesiology 2021; 134:395-404. [PMID: 33503656 DOI: 10.1097/aln.0000000000003689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Removal of cytokines, chemokines, and microvesicles from the supernatant of allogeneic erythrocytes may help mitigate adverse transfusion reactions. Blood bank-based washing procedures present logistical difficulties; therefore, we tested the hypothesis that on-demand bedside washing of allogeneic erythrocyte units is capable of removing soluble factors and is feasible in a clinical setting. METHODS There were in vitro and prospective, observation cohort components to this a priori planned substudy evaluating bedside allogeneic erythrocyte washing, with a cell saver, during cardiac surgery. Laboratory data were collected from the first 75 washed units given to a subset of patients nested in the intervention arm of a parent clinical trial. Paired pre- and postwash samples from the blood unit bags were centrifuged. The supernatant was aspirated and frozen at -70°C, then batch-tested for cell-derived microvesicles, soluble CD40 ligand, chemokine ligand 5, and neutral lipids (all previously associated with transfusion reactions) and cell-free hemoglobin (possibly increased by washing). From the entire cohort randomized to the intervention arm of the trial, bedside washing was defined as feasible if at least 75% of prescribed units were washed per protocol. RESULTS Paired data were available for 74 units. Washing reduced soluble CD40 ligand (median [interquartile range]; from 143 [1 to 338] ng/ml to zero), chemokine ligand 5 (from 1,314 [715 to 2,551] to 305 [179 to 488] ng/ml), and microvesicle numbers (from 6.90 [4.10 to 20.0] to 0.83 [0.33 to 2.80] × 106), while cell-free hemoglobin concentration increased from 72.6 (53.6 to 171.6) mg/dl to 210.5 (126.6 to 479.6) mg/dl (P < 0.0001 for each). There was no effect on neutral lipids. Bedside washing was determined as feasible for 80 of 81 patients (99%); overall, 293 of 314 (93%) units were washed per protocol. CONCLUSIONS Bedside erythrocyte washing was clinically feasible and greatly reduced concentrations of soluble factors thought to be associated with transfusion-related adverse reactions, increasing concentrations of cell-free hemoglobin while maintaining acceptable (less than 0.8%) hemolysis. EDITOR’S PERSPECTIVE
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7
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Pulliam KE, Joseph B, Makley AT, Caldwell CC, Lentsch AB, Goodman MD, Pritts TA. Washing packed red blood cells decreases red blood cell storage lesion formation. Surgery 2020; 169:666-670. [PMID: 32847673 DOI: 10.1016/j.surg.2020.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/29/2020] [Accepted: 07/09/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transfusion of blood products is the ideal resuscitative strategy after hemorrhage. Unfortunately, older packed red blood cells have been associated with increased morbidity and mortality after massive transfusion. These packed red blood cells accumulate biochemical and structural changes known as the red blood cell storage lesions. The effect of washing on the formation of red blood cell storage lesions is unknown. We hypothesized that washing packed red blood cells during storage would decrease the development of the red blood cell storage lesions. METHODS Blood from 8- to 10-week-old male mice donors was stored as packed red blood cells for 14 days. A subset of packed red blood cells were washed with phosphate-buffered saline on storage day 7 and resuspended in AS-1 solution for an additional 7 days as washed packed red blood cells. Subsequently, the packed red blood cells were analyzed for microvesicle release, band-3 erythrocyte membrane integrity protein (Band-3), expression of phosphatidylserine, cell viability (calcein), accumulation of cell-free hemoglobin, and osmotic fragility. RESULTS In the washed packed red blood cells group, there was less microvesicle accumulation, greater Band-3 expression, less phosphatidylserine expression, a decrease in cell-free hemoglobin accumulation, and a decrease in osmotic fragility, but no differences in red blood cells viability. CONCLUSION Washing packed red blood cells during storage decreases the accumulation of red blood cell storage lesions. This strategy may lessen the sequelae associated with transfusion of older packed red blood cells.
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Affiliation(s)
- Kasiemobi E Pulliam
- Department of Surgery, Section of General Surgery, University of Cincinnati, OH
| | - Bernadin Joseph
- Department of Surgery, Section of General Surgery, University of Cincinnati, OH
| | - Amy T Makley
- Department of Surgery, Section of General Surgery, University of Cincinnati, OH
| | - Charles C Caldwell
- Department of Surgery, Section of General Surgery, University of Cincinnati, OH
| | - Alex B Lentsch
- Department of Surgery, Section of General Surgery, University of Cincinnati, OH
| | - Michael D Goodman
- Department of Surgery, Section of General Surgery, University of Cincinnati, OH
| | - Timothy A Pritts
- Department of Surgery, Section of General Surgery, University of Cincinnati, OH.
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8
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Cardigan R, New HV, Tinegate H, Thomas S. Washed red cells: theory and practice. Vox Sang 2020; 115:606-616. [DOI: 10.1111/vox.12971] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 05/27/2020] [Accepted: 06/09/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Rebecca Cardigan
- Department of Haematology NHS Blood & Transplant University of Cambridge Cambridge UK
| | - Helen V. New
- Department of Haematology NHS Blood & Transplant Imperial College London London UK
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9
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Lopez Domowicz DA, Welsby I, Esther CR, Zhu H, Marek RD, Lee G, Shah N, Poisson JL, McMahon TJ. Effects of repleting organic phosphates in banked erythrocytes on plasma metabolites and vasoactive mediators after red cell exchange transfusion in sickle cell disease. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:200-207. [PMID: 32203007 PMCID: PMC7250688 DOI: 10.2450/2020.0237-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/20/2019] [Indexed: 04/14/2023]
Abstract
BACKGROUND Red blood cell (RBC) exchange (RCE) transfusion therapy is indicated for certain patients with sickle cell disease (SCD). Although beneficial, this therapy is costly and inconvenient to patients, who may require it monthly or more often. Identification of blood and plasma biomarkers that could improve or help individualise RCE therapy is of interest. Here we examined relevant blood and plasma metabolites and biomarkers of vasoactivity and RBC fragility in a pilot study of SCD patients undergoing RCE using either standard RBC units or RBC units treated with a US Food and Drug Administration (FDA)-approved additive solution containing phosphate, inosine, pyruvate, and adenine ("PIPA"). MATERIALS AND METHODS In this prospective, single-blind, cross-over pilot clinical trial, patients were randomised to receive either standard RBC exchange or PIPA-treated RBC exchange transfusion with each RCE session over a 6-month treatment period. Pre- and post-transfusion blood samples were obtained and analysed for RBC O2 affinity, ATP, purine metabolites, RBC microparticles, and cell free haemoglobin. RESULTS Red blood cell O2 affinity was maintained after PIPA-RCE in contrast to standard RCE, after which P50 fell (net O2 affinity rose). Plasma ATP did not change significantly after RCE using either of the RBC unit types. Exchange transfusion with PIPA-treated RBC units led to modest increases in plasma inosine and hypoxanthine. Plasma cell free haemoglobin fell after either standard or PIPA-treated RBC exchange transfusion (novel findings), and to a similar extent. RBC-derived microparticles in the plasma fell significantly and similarly after both standard and PIPA-treated RCE transfusion. DISCUSSION In summary, treatment of RBCs with PIPA prior to RCE elicited favourable or neutral changes in key metabolic and vascular biomarkers. Further study of its efficacy and safety is recommended and could ultimately serve to improve outcomes in chronically transfused SCD patients.
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Affiliation(s)
| | - Ian Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States of America
| | - Charles R. Esther
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Hongmei Zhu
- Department of Medicine, Duke University Medical Center, Durham, NC, United States of America
| | - Robert D. Marek
- Department of Medicine, Duke University Medical Center, Durham, NC, United States of America
| | - Grace Lee
- Department of Medicine, Duke University Medical Center, Durham, NC, United States of America
| | - Nirmish Shah
- Department of Pediatrics, Duke University Medical Center, Durham, NC, United States of America
- Department of Medicine, Duke University Medical Center, Durham, NC, United States of America
| | - Jessica L. Poisson
- Department of Pathology, Duke University Medical Center, Durham, NC, United States of America
| | - Tim J. McMahon
- Department of Medicine, Duke University Medical Center, Durham, NC, United States of America
- Durham Vetern Affairs Health Care System, Durham, NC, United States of America
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10
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McMahon TJ. Red Blood Cell Deformability, Vasoactive Mediators, and Adhesion. Front Physiol 2019; 10:1417. [PMID: 31803068 PMCID: PMC6873820 DOI: 10.3389/fphys.2019.01417] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 11/01/2019] [Indexed: 01/16/2023] Open
Abstract
Healthy red blood cells (RBCs) deform readily in response to shear stress in the circulation, facilitating their efficient passage through capillaries. RBCs also export vasoactive mediators in response to deformation and other physiological and pathological stimuli. Deoxygenation of RBC hemoglobin leads to the export of vasodilator and antiadhesive S-nitrosothiols (SNOs) and adenosine triphosphate (ATP) in parallel with oxygen transport in the respiratory cycle. Together, these mediated responses to shear stress and oxygen offloading promote the efficient flow of blood cells and in turn optimize oxygen delivery. In diseases including sickle cell anemia and conditions including conventional blood banking, these adaptive functions may be compromised as a result, for example, of limited RBC deformability, impaired mediator formation, or dysfunctional mediator export. Ongoing work, including single cell approaches, is examining relevant mechanisms and remedies in health and disease.
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Affiliation(s)
- Timothy J McMahon
- Durham VA Medical Center, Duke University, Durham, NC, United States
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11
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Development of Zinc Chelating Resin Polymer Beads for the Removal of Cell-Free Hemoglobin. Ann Biomed Eng 2019; 47:1470-1478. [PMID: 30919138 DOI: 10.1007/s10439-019-02249-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/14/2019] [Indexed: 10/27/2022]
Abstract
Red blood cell (RBC) hemolysis is one of the most common storage lesions in packed RBCs (pRBC). Older units of pRBCs, especially those > 21 days old, have increasing levels of hemolysis leading to increased oxidative stress and premature platelet activation. This effect can mostly be attributed to the increase of cell-free hemoglobin (Hb). Therefore, removal of cell-free Hb from pRBCs prior to transfusion could mitigate these deleterious effects. We propose a new method for the removal of Hb from pRBCs using zinc beads. Prepared Hb solutions and pRBCs were treated with zinc beads using two different protocols. UV-Vis spectrophotometry was used to determine Hb concentrations, before and after treatment. Experiments were run in triplicate and paired t tests were used to determine significant differences between groups. Zinc beads removed on average 94% of cell-free Hb within 15 min and 78% Hb from pRBCs (p < 0.0001), demonstrating a maximum binding capacity ~ 66.2 ± 0.7 mg Hb/mL beads. No differences in RBC morphology or deformability were observed after treatment. This study demonstrates the feasibility of using zinc beads for the rapid and targeted removal of Hb from pRBC units. Further investigation is needed to scale this method for large volume removal.
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12
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Lu M, Lezzar DL, Vörös E, Shevkoplyas SS. Traditional and emerging technologies for washing and volume reducing blood products. J Blood Med 2019; 10:37-46. [PMID: 30655711 PMCID: PMC6322496 DOI: 10.2147/jbm.s166316] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Millions of blood components including red blood cells, platelets, and granulocytes are transfused each year in the United States. The transfusion of these blood products may be associated with adverse clinical outcomes in some patients due to residual proteins and other contaminants that accumulate in blood units during processing and storage. Blood products are, therefore, often washed in normal saline or other media to remove the contaminants and improve the quality of blood cells before transfusion. While there are numerous methods for washing and volume reducing blood components, a vast majority utilize centrifugation-based processing, such as manual centrifugation, open and closed cell processing systems, and cell salvage/autotransfusion devices. Although these technologies are widely employed with a relatively low risk to the average patient, there is evidence that centrifugation-based processing may be inadequate when transfusing to immunocompromised patients, neonatal and infant patients, or patients susceptible to transfusion-related allergic reactions. Cell separation and volume reduction techniques that employ centrifugation have been shown to damage blood cells, contributing to these adverse outcomes. The limitations and disadvantages of centrifugation-based processing have spurred the development of novel centrifugation-free methods for washing and volume reducing blood components, thereby causing significantly less damage to the cells. Some of these emerging technologies are already transforming niche applications, poised to enter mainstream blood cell processing in the not too distant future.
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Affiliation(s)
- Madeleine Lu
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204-5060, USA,
| | - Dalia L Lezzar
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204-5060, USA,
| | - Eszter Vörös
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204-5060, USA,
| | - Sergey S Shevkoplyas
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204-5060, USA,
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13
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Yoon U, Gerney G, Hsu G, Elia E, Kang Y. Exchange Autotransfusion for Rapid Correction of Hyperkalemia During Liver Transplantation: A Case Report. A A Pract 2019; 12:15-18. [PMID: 29985842 DOI: 10.1213/xaa.0000000000000831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 46-year-old woman with alcoholic cirrhosis and hepatorenal syndrome requiring hemodialysis presented with hyperkalemia (5.5 mEq/L) immediately before liver transplantation. For correction of hyperkalemia, an exchange transfusion began by removing her blood into an autotransfusion system to wash out noncellular components while maintaining normovolemia. Additionally, she received washed homologous red blood cells, insulin, and glucose to minimize or reduce the degree of hyperkalemia. Serum potassium level decreased to 4.0 mEq/L within 3 hours and was 5.0 mEq/L 30 seconds after reperfusion of the grafted liver. Postreperfusion syndrome was not observed. In summary, exchange transfusion was used successfully for rapid correction of hyperkalemia, showing the value of its application in liver transplantation.
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Affiliation(s)
- Uzung Yoon
- From the Department of Anesthesiology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
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14
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Wozniak MJ, Sullo N, Qureshi S, Dott W, Cardigan R, Wiltshire M, Morris T, Nath M, Bittar N, Bhudia SK, Kumar T, Goodall AH, Murphy GJ. Randomized trial of red cell washing for the prevention of transfusion-associated organ injury in cardiac surgery. Br J Anaesth 2018; 118:689-698. [PMID: 28475670 PMCID: PMC5430295 DOI: 10.1093/bja/aex083] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2017] [Indexed: 12/18/2022] Open
Abstract
Background. Experimental studies suggest that mechanical cell washing to remove pro-inflammatory components that accumulate in the supernatant of stored donor red blood cells (RBCs) might reduce inflammation and organ injury in transfused patients. Methods. Cardiac surgery patients at increased risk of large-volume RBC transfusion were eligible. Participants were randomized to receive either mechanically washed allogenic RBCs or standard care RBCs. The primary outcome was serum interleukin-8 measured at baseline and at four postsurgery time points. A mechanism substudy evaluated the effects of washing on stored RBCs in vitro and on markers of platelet, leucocyte, and endothelial activation in trial subjects. Results. Sixty adult cardiac surgery patients at three UK cardiac centres were enrolled between September 2013 and March 2015. Subjects received a median of 3.5 (interquartile range 2–5.5) RBC units, stored for a mean of 21 (sd 5.2) days, within 48 h of surgery. Mechanical washing reduced concentrations of RBC-derived microvesicles but increased cell-free haemoglobin concentrations in RBC supernatant relative to standard care RBC supernatant. There was no difference between groups with respect to perioperative serum interleukin-8 values [adjusted mean difference 0.239 (95% confidence intervals −0.231, 0.709), P=0.318] or concentrations of plasma RBC microvesicles, platelet and leucocyte activation, plasma cell-free haemoglobin, endothelial activation, or biomarkers of heart, lung, or kidney injury. Conclusions. These results do not support a hypothesis that allogenic red blood cell washing has clinical benefits in cardiac surgery. Clinical trial registration. ISRCTN 27076315.
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Affiliation(s)
- M J Wozniak
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
| | - N Sullo
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
| | - S Qureshi
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
| | - W Dott
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
| | - R Cardigan
- National Health Service Blood and Transplant, Cambridge CB2 0PT, UK
| | - M Wiltshire
- National Health Service Blood and Transplant, Cambridge CB2 0PT, UK
| | - T Morris
- Leicester Clinical Trials Unit, Leicester Diabetes Centre, Leicester General Hospital, Leicester LE5 4PW, UK
| | - M Nath
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
| | - N Bittar
- Blackpool Victoria Hospital NHS Trust, Blackpool, Lancashire FY3 8NR, UK
| | - S K Bhudia
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - T Kumar
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
| | - A H Goodall
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
| | - G J Murphy
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
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15
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Vörös E, Lu M, Lezzar D, Shevkoplyas SS. Centrifugation-free washing reduces buildup of potassium and free hemoglobin in washed red blood cells after the procedure. Am J Hematol 2018; 93:E389-E391. [PMID: 30184257 DOI: 10.1002/ajh.25277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 08/31/2018] [Accepted: 09/02/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Eszter Vörös
- Department of Biomedical Engineering; University of Houston; Houston Texas
| | - Madeleine Lu
- Department of Biomedical Engineering; University of Houston; Houston Texas
| | - Dalia Lezzar
- Department of Biomedical Engineering; University of Houston; Houston Texas
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16
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Roubinian N. TACO and TRALI: biology, risk factors, and prevention strategies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:585-594. [PMID: 30570487 PMCID: PMC6324877 DOI: 10.1182/asheducation-2018.1.585] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are the leading causes of transfusion-related morbidity and mortality. These adverse events are characterized by acute pulmonary edema within 6 hours of a blood transfusion and have historically been difficult to study due to underrecognition and nonspecific diagnostic criteria. However, in the past decade, in vivo models and clinical studies utilizing active surveillance have advanced our understanding of their epidemiology and pathogenesis. With the adoption of mitigation strategies and patient blood management, the incidence of TRALI and TACO has decreased. Continued research to prevent and treat these severe cardiopulmonary events is focused on both the blood component and the transfusion recipient.
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Affiliation(s)
- Nareg Roubinian
- Blood Systems Research Institute, San Francisco, CA; Kaiser Permanente Northern California Medical Center and Division of Research, Oakland, CA; and Department of Laboratory Medicine, University of California, San Francisco, CA
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17
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Wirtz MR, Jurgens J, Zuurbier CJ, Roelofs JJTH, Spinella PC, Muszynski JA, Carel Goslings J, Juffermans NP. Washing or filtering of blood products does not improve outcome in a rat model of trauma and multiple transfusion. Transfusion 2018; 59:134-145. [PMID: 30461025 PMCID: PMC7379301 DOI: 10.1111/trf.15039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/04/2018] [Accepted: 09/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transfusion is associated with organ failure and nosocomial infection in trauma patients, which may be mediated by soluble bioactive substances in blood products, including extracellular vesicles (EVs). We hypothesize that removing EVs, by washing or filtering of blood products, reduces organ failure and improves host immune response. MATERIALS AND METHODS Blood products were prepared from syngeneic rat blood. EVs were removed from RBCs and platelets by washing. Plasma was filtered through a 0.22‐μm filter. Rats were traumatized by crush injury to the intestines and liver, and a femur was fractured. Rats were hemorrhaged until a mean arterial pressure of 40 mm Hg and randomized to receive resuscitation with standard or washed/filtered blood products, in a 1:1:1 ratio. Sham controls were not resuscitated. Ex vivo whole blood stimulation tests were performed and histopathology was done. RESULTS Washing of blood products improved quality metrics compared to standard products. Also, EV levels reduced by 12% to 77%. The coagulation status, as assessed by thromboelastometry, was deranged in both groups and normalized during transfusion, without significant differences. Use of washed/filtered products did not reduce organ failure, as assessed by histopathologic score and biochemical measurements. Immune response ex vivo was decreased following transfusion compared to sham but did not differ between transfusion groups. CONCLUSION Filtering or washing of blood products improved biochemical properties and reduced EV counts, while maintaining coagulation abilities. However, in this trauma and transfusion model, the use of optimized blood components did not attenuate organ injury or immune suppression.
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Affiliation(s)
- Mathijs R Wirtz
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Trauma Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jordy Jurgens
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Coert J Zuurbier
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Philip C Spinella
- Department of Pediatrics, Division of Critical Care, Washington University in St Louis, St Louis, Missouri
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - J Carel Goslings
- Department of Trauma Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
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18
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A portable system for processing donated whole blood into high quality components without centrifugation. PLoS One 2018; 13:e0190827. [PMID: 29346441 PMCID: PMC5773086 DOI: 10.1371/journal.pone.0190827] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 12/20/2017] [Indexed: 02/04/2023] Open
Abstract
Background The use of centrifugation-based approaches for processing donated blood into components is routine in the industrialized world, as disparate storage conditions require the rapid separation of ‘whole blood’ into distinct red blood cell (RBC), platelet, and plasma products. However, the logistical complications and potential cellular damage associated with centrifugation/apheresis manufacturing of blood products are well documented. The objective of this study was to evaluate a proof-of-concept system for whole blood processing, which does not employ electromechanical parts, is easily portable, and can be operated immediately after donation with minimal human labor. Methods and findings In a split-unit study (n = 6), full (~500mL) units of freshly-donated whole blood were divided, with one half processed by conventional centrifugation techniques and the other with the new blood separation system. Each of these processes took 2–3 hours to complete and were performed in parallel. Blood products generated by the two approaches were compared using an extensive panel of cellular and plasma quality metrics. Comparison of nearly all RBC parameters showed no significant differences between the two approaches, although the portable system generated RBC units with a slight but statistically significant improvement in 2,3-diphosphoglyceric acid concentration (p < 0.05). More notably, several markers of platelet damage were significantly and meaningfully higher in products generated with conventional centrifugation: the increase in platelet activation (assessed via P-selectin expression in platelets before and after blood processing) was nearly 4-fold higher for platelet units produced via centrifugation, and the release of pro-inflammatory mediators (soluble CD40-ligand, thromboxane B2) was significantly higher for centrifuged platelets as well (p < 0.01). Conclusion This study demonstrated that a simple, passive system for separating donated blood into components may be a viable alternative to centrifugation—particularly for applications in remote or resource-limited settings, or for patients requiring highly functional platelet product.
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19
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Murphy GJ, Mumford AD, Rogers CA, Wordsworth S, Stokes EA, Verheyden V, Kumar T, Harris J, Clayton G, Ellis L, Plummer Z, Dott W, Serraino F, Wozniak M, Morris T, Nath M, Sterne JA, Angelini GD, Reeves BC. Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundAnaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.Methods and resultsWorkstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.LimitationsExisting studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.ConclusionsA systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.Study registrationCurrent Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Veerle Verheyden
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gemma Clayton
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lucy Ellis
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Zoe Plummer
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - William Dott
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Filiberto Serraino
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Mintu Nath
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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20
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Sikorski RA, Rizkalla NA, Yang WW, Frank SM. Autologous blood salvage in the era of patient blood management. Vox Sang 2017; 112:499-510. [DOI: 10.1111/vox.12527] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 04/01/2017] [Accepted: 04/06/2017] [Indexed: 12/11/2022]
Affiliation(s)
- R. A. Sikorski
- Department of Anesthesiology/Critical Care Medicine; The Johns Hopkins Medical Institutions; Baltimore MA USA
| | - N. A. Rizkalla
- Department of Anesthesiology/Critical Care Medicine; The Johns Hopkins Medical Institutions; Baltimore MA USA
| | - W. W. Yang
- Department of Anesthesiology/Critical Care Medicine; The Johns Hopkins Medical Institutions; Baltimore MA USA
| | - S. M. Frank
- Department of Anesthesiology/Critical Care Medicine; Johns Hopkins Health System Blood Management Program; The Johns Hopkins Medical Institutions; MA USA
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21
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Washing in hypotonic saline reduces the fraction of irreversibly-damaged cells in stored blood: a proof-of-concept study. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 15:463-471. [PMID: 28686152 DOI: 10.2450/2017.0013-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 01/23/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND During hypothermic storage, a substantial fraction of red blood cells (RBCs) transforms from flexible discocytes to rigid sphero-echinocytes and spherocytes. Infusion of these irreversibly-damaged cells into the recipient during transfusion serves no therapeutic purpose and may contribute to adverse outcomes in some patients. In this proof-of-concept study we describe the use of hypotonic washing for selective removal of the irreversibly-damaged cells from stored blood. MATERIALS AND METHODS Stored RBCs were mixed with saline of various concentrations to identify optimal concentration for inducing osmotic swelling and selective bursting of spherical cells (sphero-echinocytes, spherocytes), while minimising indiscriminate lysis of other RBCs. Effectiveness of optimal treatment was assessed by measuring morphology, rheological properties, and surface phosphatidylserine (PS) exposure for cells from several RBCs units (n=5, CPD>AS-1, leucoreduced, 6 weeks storage duration) washed in hypotonic vs isotonic saline. RESULTS Washing in mildly hypotonic saline (0.585 g/dL, osmolality: 221.7±2.3 mmol/kg) reduced the fraction of spherical cells 3-fold from 9.5±3.4% to 3.2±2.8%, while cutting PS exposure in half from 1.48±0.86% to 0.59±0.29%. Isotonic washing had no effect on PS exposure or the fraction of spherical cells. Both isotonic and hypotonic washing increased the fraction of well-preserved cells (discocytes, echinocytes 1) substantially, and improved the ability of stored RBCs to perfuse an artificial microvascular network by approximately 25%, as compared with the initial sample. DISCUSSION This study demonstrated that washing in hypotonic saline could selectively remove a significant fraction of the spherical and PS-exposing cells from stored blood, while significantly improving the rheological properties of remaining well-preserved RBCs. Further studies are needed to access the potential effect from hypotonic washing on transfusion outcomes.
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22
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Murphy GJ, Verheyden V, Wozniak M, Sullo N, Dott W, Bhudia S, Bittar N, Morris T, Ring A, Tebbatt A, Kumar T. Trial protocol for a randomised controlled trial of red cell washing for the attenuation of transfusion-associated organ injury in cardiac surgery: the REDWASH trial. Open Heart 2016; 3:e000344. [PMID: 26977309 PMCID: PMC4785436 DOI: 10.1136/openhrt-2015-000344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/11/2015] [Accepted: 01/11/2016] [Indexed: 11/29/2022] Open
Abstract
Introduction It has been suggested that removal of proinflammatory substances that accumulate in stored donor red cells by mechanical cell washing may attenuate inflammation and organ injury in transfused cardiac surgery patients. This trial will test the hypotheses that the severity of the postoperative inflammatory response will be less and postoperative recovery faster if patients undergoing cardiac surgery receive washed red cells compared with standard care (unwashed red cells). Methods and analysis Adult (≥16 years) cardiac surgery patients identified at being at increased risk for receiving large volume red cell transfusions at 1 of 3 UK cardiac centres will be randomly allocated in a 1:1 ratio to either red cell washing or standard care. The primary outcome is serum interleukin-8 measured at 5 postsurgery time points up to 96 h. Secondary outcomes will include measures of inflammation, organ injury and volumes of blood transfused and cost-effectiveness. Allocation concealment, internet-based randomisation stratified by operation type and recruiting centre, and blinding of outcome assessors will reduce the risk of bias. The trial will test the superiority of red cell washing versus standard care. A sample size of 170 patients was chosen in order to detect a small-to-moderate target difference, with 80% power and 5% significance (2-tailed). Ethics and dissemination The trial protocol was approved by a UK ethics committee (reference 12/EM/0475). The trial findings will be disseminated in scientific journals and meetings. Trial registration number ISRCTN 27076315.
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Affiliation(s)
- G J Murphy
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
| | - V Verheyden
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
| | - M Wozniak
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
| | - N Sullo
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
| | - W Dott
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
| | - S Bhudia
- University Hospitals Coventry and Warwickshire NHS Trust , Coventry , UK
| | - N Bittar
- Blackpool Victoria Hospital NHS Trust , Blackpool , UK
| | - T Morris
- Leicester Clinical Trials Unit , Leicester Diabetes Centre, Leicester General Hospital , Leicester , UK
| | - A Ring
- Leicester Clinical Trials Unit , Leicester Diabetes Centre, Leicester General Hospital , Leicester , UK
| | - A Tebbatt
- Department of Clinical Perfusion , University Hospital Leicester NHS Trust, Glenfield Hospital , Leicester , UK
| | - T Kumar
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
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Delobel J, Garraud O, Barelli S, Lefrère JJ, Prudent M, Lion N, Tissot JD. Storage lesion: History and perspectives. World J Hematol 2015; 4:54-68. [DOI: 10.5315/wjh.v4.i4.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/01/2015] [Accepted: 10/19/2015] [Indexed: 02/05/2023] Open
Abstract
Red blood cell concentrates (RBCCs) are the major labile blood component transfused worldwide to rescue severe anemia symptoms. RBCCs are frequently stored in additive solutions at 4 °C for up to 42 d, which induces cellular lesion and alters red blood cell metabolism, protein content, and rheological properties. There exists a hot debate surrounding the impact of storage lesion, with some uncertainty regarding how RBCC age may impact transfusion-related adverse clinical outcomes. Several studies show a tendency for poorer outcomes to occur in patients receiving older blood products; however, no clear significant association has yet been demonstrated. Some age-related RBCC alterations prove reversible, while other changes are irreversible following protein oxidation. It is likely that any irreversible damage affects the blood component quality and thus the transfusion efficiency. The present paper aims to promote a better understanding of the occurrence of red blood cell storage lesion, with particular focus on biochemical changes and microvesiculation, through a discussion of the historical advancement of blood transfusion processes.
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Acker JP, Hansen AL, Yi QL, Sondi N, Cserti-Gazdewich C, Pendergrast J, Hannach B. Introduction of a closed-system cell processor for red blood cell washing: postimplementation monitoring of safety and efficacy. Transfusion 2015; 56:49-57. [DOI: 10.1111/trf.13341] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 07/21/2015] [Accepted: 07/23/2015] [Indexed: 01/04/2023]
Affiliation(s)
- Jason P. Acker
- Centre for Innovation; Canadian Blood Services
- Department of Laboratory Medicine and Pathology; University of Alberta; Edmonton Alberta, Canada
| | | | - Qi-Long Yi
- Canadian Blood Services; Ottawa Ontario, Canada; and
| | | | | | - Jacob Pendergrast
- University Health Network
- Department of Laboratory Medicine and Pathobiology; University of Toronto
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25
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Stapley R, Rodriguez C, Oh JY, Honavar J, Brandon A, Wagener BM, Marques MB, Weinberg JA, Kerby JD, Pittet JF, Patel RP. Red blood cell washing, nitrite therapy, and antiheme therapies prevent stored red blood cell toxicity after trauma-hemorrhage. Free Radic Biol Med 2015; 85:207-18. [PMID: 25933588 PMCID: PMC4508223 DOI: 10.1016/j.freeradbiomed.2015.04.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 04/02/2015] [Accepted: 04/20/2015] [Indexed: 12/29/2022]
Abstract
Transfusion of stored red blood cells (RBCs) is associated with increased morbidity and mortality in trauma patients. Pro-oxidant, pro-inflammatory, and nitric oxide (NO) scavenging properties of stored RBCs are thought to underlie this association. In this study we determined the effects of RBC washing and nitrite and antiheme therapy on stored RBC-dependent toxicity in the setting of trauma-induced hemorrhage. A murine (C57BL/6) model of trauma-hemorrhage and resuscitation with 1 or 3 units of RBCs stored for 0-10 days was used. Tested variables included washing RBCs to remove lower MW components that scavenge NO, NO-repletion therapy using nitrite, or mitigation of free heme toxicity by heme scavenging or preventing TLR4 activation. Stored RBC toxicity was determined by assessment of acute lung injury indices (airway edema and inflammation) and survival. Transfusion with 5 day RBCs increased acute lung injury indexed by BAL protein and neutrophil accumulation. Washing 5 day RBCs prior to transfusion did not decrease this injury, whereas nitrite therapy did. Transfusion with 10 day RBCs elicited a more severe injury resulting in ~90% lethality, compared to <15% with 5 day RBCs. Both washing and nitrite therapy significantly protected against 10 day RBC-induced lethality, suggesting that washing may be protective when the injury stimulus is more severe. Finally, a spectral deconvolution assay was developed to simultaneously measure free heme and hemoglobin in stored RBC supernatants, which demonstrated significant increases of both in stored human and mouse RBCs. Transfusion with free heme partially recapitulated the toxicity mediated by stored RBCs. Furthermore, inhibition of TLR4 signaling, which is stimulated by heme, using TAK-242, or hemopexin-dependent sequestration of free heme significantly protected against both 5 day and 10 day mouse RBC-dependent toxicity. These data suggest that RBC washing, nitrite therapy, and/or antiheme and TLR4 strategies may prevent stored RBC toxicities.
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Affiliation(s)
- Ryan Stapley
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Cilina Rodriguez
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Joo-Yeun Oh
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Jaideep Honavar
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Angela Brandon
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Brant M Wagener
- Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Jordan A Weinberg
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeffrey D Kerby
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Jean-Francois Pittet
- Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; Center for Free Radical Biology and Pulmonary Injury Repair Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Rakesh P Patel
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; Center for Free Radical Biology and Pulmonary Injury Repair Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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26
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Peters AL, Van Stein D, Vlaar APJ. Antibody-mediated transfusion-related acute lung injury; from discovery to prevention. Br J Haematol 2015; 170:597-614. [PMID: 25921271 DOI: 10.1111/bjh.13459] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Transfusion-related acute lung injury (TRALI), a syndrome of respiratory distress caused by blood transfusion, is the leading cause of transfusion-related mortality. The majority of TRALI cases have been related to passive infusion of human leucocyte antigen (HLA) and human neutrophil antigen (HNA) antibodies in donor blood. In vitro, ex vivo and in vivo animal models have provided insight in TRALI pathogenesis. The various classes of antibodies implicated in TRALI appear to have different pathophysiological mechanisms for the induction of TRALI involving endothelial cells, neutrophils, monocytes and, as very recently has been discovered, lymphocytes. The HLA and HNA-antibodies are found mainly in blood from multiparous women as they have become sensitized during pregnancy. The incidence of TRALI has decreased rapidly following the introduction of a male-only strategy for plasma donation. This review focuses on pre-clinical and clinical studies investigating the pathophysiology of antibody-mediated TRALI.
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Affiliation(s)
- Anna L Peters
- Laboratory of Experimental Intensive Care and Anaesthesia/Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands
| | - Danielle Van Stein
- Department of Internal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Alexander P J Vlaar
- Laboratory of Experimental Intensive Care and Anaesthesia/Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands
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