Transfusion of Autologous, Hydroxyethyl Starch-Cryopreserved Red Blood Cells

Is post-hypertonic lysis of human red blood cells caused by excessive cell volume regulation?

Human red blood cells (RBC) exposed to hypertonic media are subject to post-hypertonic lysis - an injury that only develops during resuspension to an isotonic medium. The nature of post-hypertonic lysis was previously hypothesized to be osmotic when cation leaks were observed, and salt loading was suggested as a cause of the cell swelling upon resuspension in an isotonic medium. However, it was problematic to account for the salt loading since the plasma membrane of human RBCs was considered impermeable to cations. In this study, the hypertonicity-related behavior of human RBCs is revisited within the framework of modern cell physiology, considering current knowledge on membrane ion transport mechanisms - an account still missing. It is recognized here that the hypertonic behavior of human RBCs is consistent with the acute regulatory volume increase (RVI) response - a healthy physiological reaction initiated by cells to regulate their volume by salt accumulation. It is shown by reviewing the published studies that human RBCs can increase cation conductance considerably by activating cell volume-regulated ion transport pathways inactive under normal isotonic conditions and thus facilitate salt loading. A simplified physiological model accounting for transmembrane ion fluxes and membrane voltage predicts the isotonic cell swelling associated with increased cation conductance, eventually reaching hemolytic volume. The proposed involvement of cell volume regulation mechanisms shows the potential to explain the complex nature of the osmotic response of human RBCs and other cells. Cryobiological implications, including mechanisms of cryoprotection, are discussed.

A novel exopolysaccharide (p-CY01) from the Antarctic bacterium Pseudoalteromonas sp. strain CY01 cryopreserves human red blood cells

Cryopreservation of human red blood cells (RBCs) is vital for regenerative medicine and organ transplantation, but current cryoprotectants (CPAs) like glycerol and hydroxyethyl starch (HES) have limitations. Glycerol requires post-thaw washing due to cell membrane penetration, while HES causes high viscosity. To address these issues, we explored exopolysaccharides (EPS) from Antarctic Pseudoalteromonas sp. strain CY01 as a non-penetrating CPA for RBC cryopreservation. The EPS, p-CY01, consisted mainly of repeating (1-4) glucose and (1-6) galactose linkages with a molecular mass of 1.1 × 107 Da. Through mild acid hydrolysis, we obtained low molecular weight p-CY01 (p-CY01 LM) with a molecular weight of 2.7 × 105 Da, offering reduced viscosity, improved solubility, and cryoprotective properties. Notably, combining low concentrations of penetrating CPAs (>1% glycerol and dimethyl sulfoxide) with 2.5% (w/v) p-CY01 LM demonstrated significant cryoprotective effects. These findings highlight the potential of p-CY01 LM as a highly effective CPA for human RBC cryopreservation, replacing HES and glycerol and enabling the long-term storage of biological materials.

Nationwide analysis of cryopreserved packed red blood cell transfusion in civilian trauma

BACKGROUND

Liquid packed red blood cells (LPRBCs) have a limited shelf life and worsening quality with age. Cryopreserved packed red blood cells (CPRBCs) can be stored up to 10 years with no quality deterioration. The effect of CPRBCs on outcomes in civilian trauma is less explored. This study aims to evaluate the safety and efficacy of CPRBCs in civilian trauma patients.

METHODS

We analyzed the (2015-2016) Trauma Quality Improvement Program, including adult (age, ≥18 years) patients who received a RBC transfusion within 4 hours of admission. Patients were stratified, those who received LPRBC and those who received CPRBC. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were major complications. Propensity matching was performed adjusting for demographics, vitals, blood components, injury parameters, comorbidities, and center parameters.

RESULTS

A total of 39,975 patients were identified, and a matched cohort of 483 was obtained. A total of 161 received CPRBC (CPRBC, 2 [2-4]; plasma, 2 [0-5]; platelets, 1 [0-2]) and 322 received LPRBC (LPRBC, 3 [2-6]; plasma, 3 [0-6]; platelets, 1 [0-2]). The mean age was 43 ± 22 years, 62% were men, Injury Severity Score was 18 (12-27), and 65% had a blunt injury. Patients who received CPRBC had similar 24-hour mortality (1.8% vs. 2.3%; p = 0.82) and in-hospital mortality (4.9% vs. 5.2%; p = 0.88). No difference was found in terms of complications (15.3% vs. 17.2%; p = 0.21) between the two groups.

CONCLUSION

Transfusion of CPRBCs may be as safe and effective as transfusion of LPRBCs in moderately injured trauma patients. Cryopreservation has the potential to expand our transfusion armamentarium in diverse settings, such as periods of increased usage, disaster scenarios, and rural areas.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Cryopreservation of feline red blood cells in liquid nitrogen using glycerol and hydroxyethyl starch

OBJECTIVES

The objective of this study was to evaluate the techniques and short-term effects of cryopreservation of feline red blood cells (RBCs) in liquid nitrogen using glycerol or hydroxyethyl starch (HES) as a cryoprotectant.

METHODS

Feline RBCs were manually mixed with either 20% glycerol or 12.5% HES and frozen for 24 h in liquid nitrogen. The samples were thawed and glycerolized samples were manually washed. Success of the freeze/thaw process was determined by recovery rate of RBCs and evaluation of morphological changes using scanning electron microscopy (SEM). A unit of canine packed RBCs was also subjected to the same methodology to evaluate the cryopreservation handling technique.

RESULTS

Feline RBCs preserved with 20% glycerol had a high recovery rate (94.23 ± 1.25%) immediately after thawing. However, the majority of the cells were lost during the washing process, with a final packed cell volume of <1%. A recovery rate was unable to be assessed for samples preserved with HES owing to the high viscosity of the mixture. SEM revealed significant morphological changes after glycerol was added to the feline RBCs. Although these morphological changes were partially reversed after thawing, the majority of the RBCs were lost during the washing process. Minimal morphological changes were noted in the HES sample. Similar results were noted with the canine RBCs.

CONCLUSIONS AND RELEVANCE

The described manual technique for cryopreservation using glycerol was not able to successfully preserve feline or canine RBCs. In the present study, it was difficult to make conclusions about the efficacy of HES. Further studies evaluating HES as a cryoprotectant are warranted.

Effect of different freezing rates during cryopreservation of rat mesenchymal stem cells using combinations of hydroxyethyl starch and dimethylsulfoxide

Background

Mesenchymal stem cells (MSCs) are increasingly used as therapeutic agents as well as research tools in regenerative medicine. Development of technologies which allow storing and banking of MSC with minimal loss of cell viability, differentiation capacity, and function is required for clinical and research applications. Cryopreservation is the most effective way to preserve cells long term, but it involves potentially cytotoxic compounds and processing steps. Here, we investigate the effect of decreasing dimethyl sulfoxide (DMSO) concentrations in cryosolution by substituting with hydroxyethyl starch (HES) of different molecular weights using different freezing rates. Post-thaw viability, phenotype and osteogenic differentiation capacity of MSCs were analysed.

Results

The study confirms that, for rat MSC, cryopreservation effects need to be assessed some time after, rather than immediately after thawing. MSCs cryopreserved with HES maintain their characteristic cell surface marker expression as well as the osteogenic, adipogenic and chondrogenic differentiation potential. HES alone does not provide sufficient cryoprotection for rat MSCs, but provides good cryoprotection in combination with DMSO, permitting the DMSO content to be reduced to 5%. There are indications that such a combination would seem useful not just for the clinical disadvantages of DMSO but also based on a tendency for reduced osteogenic differentiation capacity of rat MSC cryopreserved with high DMSO concentration. HES molecular weight appears to play only a minor role in its capacity to act as a cryopreservation solution for MSC. The use of a ‘straight freeze’ protocol is no less effective in maintaining post-thaw viability of MSC compared to controlled rate freezing methods.

Conclusion

A 5% DMSO / 5% HES solution cryopreservation solution using a ‘straight freeze’ approach can be recommended for rat MSC.

Enhanced central organ oxygenation after application of bovine cell-free hemoglobin HBOC-201

PURPOSE

While the effects of dilutional anemia or isovolemic hemodilution (IHD) on the oxygen extraction and tissue oxygenation in peripheral organs after application of hemoglobin-based oxygen carriers like HBOC-201 have been studied intensively, little is known about tissue oxygenation properties of hemoglobin solutions in central organs like the liver.

METHODS

Twelve Foxhounds were anesthetized and then randomized to either a control group without hemodilution (Group 1) or underwent first step isovolemic hemodilution (pulmonary artery occlusion pressure constant) with Ringer's solution (Group 2) to a hematocrit of 25% with second step infusion of HBOC-201 until a hemoglobin concentration of +0.6 g.dL(-1) was reached. Tissue oxygen tensions (tpO2) were measured in the gastrocnemius muscle using a polarographic needle probe, and in the liver using a flexible polarographic electrode.

RESULTS

While arterial oxygen content and oxygen delivery decreased with hemodilution in Group 2, global liver and muscle oxygen extraction ratio increased after hemodilution and additional application of HBOC-201. Hemodilution and application of HBOC-201 provided augmentation of the mean liver tpO2 (baseline: 48 +/- 9, 20 min: 53 +/- 10, 60 min: 67 +/- 11*, 100 min: 68 +/- 7*; *P < 0.05 vs baseline and Group 1), while oxygen tensions in Group 1 remained unchanged. Oxygen tension in the skeletal muscle increased after hemodilution and additionally after application of HBOC-201 in comparison to baseline and to the control group (P < 0.05).

CONCLUSION

In the present animal model, IHD with Ringer's solution and additional application of HBOC-201 increased oxygen extraction and tpO(2) in the liver and skeletal muscle, in parallel and in comparison with baseline values and a control group.

Biopreservation of red blood cells: past, present, and future

Preservation and long-term storage of red blood cells (RBCs) is needed to ensure a readily available, safe blood supply for transfusion medicine. Effective preservation procedures are required at various steps in the production of a RBC product including testing, inventory, quality control, and product distribution. Biopreservation is the process of maintaining the integrity and functionality of cells held outside the native environment for extended storage times. The biopreservation of RBCs for clinical use can be categorized based on the techniques used to achieve biologic stability and ensure a viable state after long-term storage. This paper will review the history, science, current practices, and emerging technologies of current RBC biopreservation approaches: hypothermic storage, cryopreservation, and lyophilization.

Red cell freezing and its impact on the supply chain

Red blood cells (RBC) can be frozen in glycerol solutions and stored for many years. Thawed RBC must have the glycerol removed, but the recovered cells have normal survival in humans. Freezing has been used to store RBC of rare phenotypes for more than 40 years. In the 1960s and 1970s, when medical technology and blood use were expanding rapidly and liquid whole blood and RBC storage were limited to 3 weeks, many attempts were made to expand the use of frozen RBC for meeting the needs for a stable blood supply and to have RBC reserves for emergencies. These attempts have largely been abandoned because of the cost of freezing, storing and processing, better management of the larger and longer lived RBC inventory, concerns about the safety of stored RBC that have not received the most up-to-date testing and the losses associated with the short shelf life of thawed RBC. New automated frozen RBC processing systems will potentially allow extending the outdate of thawed RBC to 2 weeks, but will not materially effect the costs or losses associated with the use of frozen RBC. RBC freezing will have little effect on the logistics of blood supply.

A Comparative Study of the Effects of Glycerol and Hydroxyethyl Starch in Canine Red Blood Cell Cryopreservation

Hydroxyethyl starch (HES) is a nonpenetrating extracellular cryoprotectant. In contrast to glycerol, it does not require labor-intensive removal from thawed red blood cells (RBCs) prior to transfusion. In this study, we compared glycerol and HES, and assessed HES as a substitute for glycerol in cryopreserved canine RBCs. The RBCs were preserved for 2 months in liquid nitrogen using a 20% (w/v) glycerol solution, and variable concentrations of HES solution. We evaluated the two cryoprotectants by the percentage of post-thaw hemolysis from the total free hemoglobin, saline stability, osmotic fragility, and by observing the erythrocyte morphology using a scanning electron microscope after thawing. The optimal concentration of HES was 12.5% (w/v) for the cryopreservation of canine RBCs. The thaw hemolysis, saline stability, and osmotic fragility index were 25.6 +/- 4.7%, 87.8 +/- 6.9%, and 0.445 +/- 0.024% NaCl respectively. These parameters resemble the results of RBCs frozen in a 20% (w/v) glycerol solution, which are 24.7 +/- 5.2%, 99.2 +/- 0.1%, and 0.485 +/- 0.023% NaCl respectively. From a morphological point of view, 12.5% (w/v) HES showed the best cryoprotection of RBCs compared to the other concentrations of HES. These results suggest that HES could be a possible substitute for glycerol for the cryopreservation of canine RBCs.

Biochemical stabilization enhances red blood cell recovery and stability following cryopreservation

Glycerolized red blood cells (RBC) are approved for long-term cryopreservation. However, the need to remove the glycerol cryoprotectant prior to transfusion has limited the usefulness of this cryopreservation method. This report describes using non-cryoprotectant biochemical stabilization techniques to substitute for the standard glycerol cryoprotectant. The glycerolized RBC method was compared to a newly developed LC-V method that combines transfusable cryoprotectants (hydroxyethyl starch and dextran) and specific non-cryoprotectant biochemical stabilizers (nicotinamide, nifedipine, and flurbiprofen). Results demonstrate that the biochemical stabilizers significantly reduce cryopreservation-induced hemolysis compared to cryopreservation in their absence and that thaw hemolysis levels approach those of standard 40% (w/v) glycerolized RBC (3.1+/-0.2% for 40% glycerol compared to 8.7+/-0.9% for the LC-V protocol). Furthermore, LC-V cryopreserved RBC exhibit a significantly enhanced post-thaw stability compared to glycerolized RBC as determined by osmotic fragility index (0.557+/-0.034 for 40% glycerol compared to 0.478+/-0.016 for the LC-V protocol). Analysis of biochemically stabilized RBC proteins revealed a transient translocation of carbonic anhydrase to the membrane fraction. However, the enhanced RBC recovery and stability could not be attributed to this event. Finally, DSC analysis demonstrated that the biochemical stabilizers of the LC-V process were not functioning as surrogate cryoprotectants in that they did not affect the quantity or quality of ice formed. Overall, this work demonstrates that cryopreservation-induced RBC damage may be corrected or prevented through specific biochemical stabilization and represents a significant step toward a directly transfusable cryopreserved RBC product.

Effects of high-molecular-weight cryoprotectants on platelets and the coagulation system

The objective of this study is to examine the effects of the most widely used high-molecular-weight cryoprotectants on the coagulation system. Dextran, hydryoxyethyl starch (HES), polyvinyl pyrrolidone (PVP), polyethylene glycol (PEG), and albumin were added at different concentrations in the range between 0.01-1% (w/v) to solvent/detergent-treated plasma. Using a STA/STA Compact coagulation analyzer the following clotting tests were performed: prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), Factor V, and Factor VIII percentage of activity. PVP and PEG caused a significant increase in APTT, a decrease in Factor VIII percentage of activity, and a slight decrease in TT, while PT and Factor V percentage of activity remained unchanged. Dextran, HES, and albumin did not effect the clotting tests. The effect of high-molecular-weight cryoprotectants on platelets was assessed by platelet-induced clot retraction (PICR) and aggregation with thrombin and agglutination with ristocetin. Platelet aggregation and agglutination were unaffected by all cryoprotectants tested; however, PICR was significantly reduced in the presence of PVP or PEG. Possible mechanisms by which PVP and PEG interfere with the coagulation system are discussed. We also raise issues concerning the development of one-step blood cryopreservation techniques which do not require cryoprotectant removal prior to transfusion.