1
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Known and Unknown Unknowns in Making Erythrocyte Transfusion Decisions. Anesthesiology 2021; 134:359-362. [PMID: 33475721 DOI: 10.1097/aln.0000000000003687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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2
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Peters AL, van de Weerdt EK, Prinsze F, de Korte D, Juffermans NP, Vlaar APJ. Donor characteristics do not influence transfusion-related acute lung injury incidence in a secondary analysis of two case-control studies. Transfus Clin Biol 2019; 26:10-17. [PMID: 30686333 DOI: 10.1016/j.tracli.2018.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 05/25/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To investigate the relation between donor characteristics and TRALI incidence. BACKGROUND Transfusion-related acute lung injury (TRALI) is a potentially fatal complication of transfusion. In pre-clinical studies and several clinical studies, TRALI has been related to loss of product quality during red blood cell (RBC) storage, called the "storage lesion". Donor characteristics, as for example age, genetics and life style choices influence this "storage lesion". We hypothesized that donor sex, age and blood type is related to TRALI incidence. METHODS/MATERIALS We performed a secondary analysis of two cohort studies, designed to identify TRALI risk factors by matching TRALI patients to transfused controls. We obtained donor sex, age and blood type from the Dutch Blood Bank Sanquin and investigated TRALI incidence in patients who were exposed to a certain donor characteristic. We used Kruskal-Wallis testing to compare the number of transfused products and Chi2 testing to compare proportions of TRALI patients and transfused control. RESULTS After implementation of the male-donor only plasma strategy, patients received more transfusion products from male donors. However, we did not detect a relation between TRALI incidence and donor sex. Both TRALI patients and transfused controls received mainly products from donors over 41 years old, but donor age did not influence TRALI risk. Donor blood type, the transfusion of blood type-compatible and blood type-matched products also had no influence on TRALI incidence. CONCLUSION We conclude that in two cohorts of TRALI patients, donor age, donor sex and donor blood type are unrelated to TRALI.
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Affiliation(s)
- A L Peters
- Laboratory of Experimental Intensive Care and Anesthesia, Academic Medical Center, Amsterdam, The Netherlands; Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands; Department Product and Process Development, Sanquin Blood Supply, Amsterdam, The Netherlands
| | - E K van de Weerdt
- Laboratory of Experimental Intensive Care and Anesthesia, Academic Medical Center, Amsterdam, The Netherlands; Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands; Department Product and Process Development, Sanquin Blood Supply, Amsterdam, The Netherlands.
| | - F Prinsze
- Department of Donor Studies, Sanquin Research, Amsterdam, The Netherlands
| | - D de Korte
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands; Department Product and Process Development, Sanquin Blood Supply, Amsterdam, The Netherlands
| | - N P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesia, Academic Medical Center, Amsterdam, The Netherlands; Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands; Department Product and Process Development, Sanquin Blood Supply, Amsterdam, The Netherlands
| | - A P J Vlaar
- Laboratory of Experimental Intensive Care and Anesthesia, Academic Medical Center, Amsterdam, The Netherlands; Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands; Department Product and Process Development, Sanquin Blood Supply, Amsterdam, The Netherlands
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3
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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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4
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Biagini S, Dale CS, Real JM, Moreira ES, Carvalho CRR, Schettino GPP, Wendel S, Azevedo LCP. Short-term effects of stored homologous red blood cell transfusion on cardiorespiratory function and inflammation: an experimental study in a hypovolemia model. ACTA ACUST UNITED AC 2017; 51:e6258. [PMID: 29185590 PMCID: PMC5685056 DOI: 10.1590/1414-431x20176258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 08/11/2017] [Indexed: 01/08/2023]
Abstract
The pathophysiological mechanisms associated with the effects of red blood cell (RBC) transfusion on cardiopulmonary function and inflammation are unclear. We developed an experimental model of homologous 14-days stored RBC transfusion in hypovolemic swine to evaluate the short-term effects of transfusion on cardiopulmonary system and inflammation. Sixteen healthy male anesthetized swine (68±3.3 kg) were submitted to controlled hemorrhage (25% of blood volume). Two units of non-filtered RBC from each animal were stored under blood bank conditions for 14 days. After 30 min of hypovolemia, the control group (n=8) received an infusion of lactated Ringer's solution (three times the removed volume). The transfusion group (n=8) received two units of homologous 14-days stored RBC and lactated Ringer's solution in a volume that was three times the difference between blood removed and blood transfusion infused. Both groups were followed up for 6 h after resuscitation with collection of hemodynamic and respiratory data. Cytokines and RNA expression were measured in plasma and lung tissue. Stored RBC transfusion significantly increased mixed oxygen venous saturation and arterial oxygen content. Transfusion was not associated with alterations on pulmonary function. Pulmonary concentrations of cytokines were not different between groups. Gene expression for lung cytokines demonstrated a 2-fold increase in mRNA level for inducible nitric oxide synthase and a 0.5-fold decrease in mRNA content for IL-21 in the transfused group. Thus, stored homologous RBC transfusion in a hypovolemia model improved cardiovascular parameters but did not induce significant effects on microcirculation, pulmonary inflammation and respiratory function up to 6 h after transfusion.
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Affiliation(s)
- S Biagini
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - C S Dale
- Laboratorio de Neuromodulação e Dor Experimental, Departamento de Anatomia, Universidade de São Paulo, São Paulo, SP, Brasil
| | - J M Real
- Associação TUCCA para Crianças e Adolescentes com Câncer, Departamento de Oncologia Pediátrica, Hospital Santa Marcelina, São Paulo, Brasil.,Centro de Investigação Translacional em Oncologia, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, SP, Brasil.,Hospital do Servidor Público Estadual de São Paulo (IAMSPE), São Paulo, SP, Brasil
| | - E S Moreira
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil.,Evidências - Kantar Health, São Paulo, SP, Brasil
| | - C R R Carvalho
- Departamento de Cardiopneumologia, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brasil
| | - G P P Schettino
- Departamento de Cardiopneumologia, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brasil.,Hospital Municipal da Vila Santa Catarina, Sociedade Beneficente Israelita Albert Einstein, São Paulo, SP, Brasil
| | - S Wendel
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil.,Banco de Sangue, Hospital Sirio-Libanes, São Paulo, SP, Brasil
| | - L C P Azevedo
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil.,Disciplina de Emergências Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
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5
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Peters AL, van Hezel ME, Klanderman RB, Tuip-de Boer AM, Wiersinga WJ, van der Spek AH, van Bruggen R, de Korte D, Juffermans NP, Vlaar APJ. Transfusion of 35-day-stored red blood cells does not alter lipopolysaccharide tolerance during human endotoxemia. Transfusion 2017; 57:1359-1368. [PMID: 28375559 DOI: 10.1111/trf.14087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/14/2016] [Accepted: 01/19/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transfusion-related immunomodulation (TRIM) encompasses immunosuppressive and proinflammatory effects induced by red blood cell (RBC) transfusion. Changes that occur during storage in the RBC product have been hypothesized to underlie TRIM, mediated by tolerance of toll-like receptors (TLR). We investigated whether transfusion of 35-day-stored autologous RBCs alters cytokine production in response to stimulation with lipopolysaccharide (LPS) or lipotheic acid (LTA), in a clinically relevant model of endotoxemia. STUDY DESIGN AND METHODS Eighteen volunteers received 2 ng/kg LPS intravenously, followed by normal saline or 2- or 35-day-stored autologous RBC transfusion. Before LPS, before transfusion, and 6 hours after transfusion blood was collected to measure cytokine gene expression. Whole blood was used for ex vivo stimulation with LPS and LTA, after which cytokine levels were measured with enzyme-linked immunosorbent assay. RESULTS In vivo LPS induced a biphasic response in cytokine mRNA with peak values 2 hours after LPS infusion. Storage time of RBC transfusion did not influence cytokine mRNA levels. In vivo infusion of LPS resulted in tolerance for ex vivo stimulation with LPS and LTA. However, transfusion of either fresh or stored RBCs did not further affect the capacity to produce cytokines after ex vivo stimulation. CONCLUSION In a clinically relevant model of human endotoxemia, autologous transfusion of 35-day-stored RBCs does not influence cytokine mRNA levels nor does it change the capacity of white blood cells in whole blood to produce cytokines after ex vivo stimulation with LPS or LTA.
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Affiliation(s)
- Anna L Peters
- Laboratory of Experimental Intensive Care and Anesthesia, Sanquin Blood Supply, Amsterdam, the Netherlands.,Department of Intensive Care, Sanquin Blood Supply, Amsterdam, the Netherlands
| | - Maike E van Hezel
- Laboratory of Experimental Intensive Care and Anesthesia, Sanquin Blood Supply, Amsterdam, the Netherlands.,Department of Intensive Care, Sanquin Blood Supply, Amsterdam, the Netherlands.,Department of Blood Cell Research, Sanquin Research, Amsterdam, the Netherlands
| | - Robert B Klanderman
- Laboratory of Experimental Intensive Care and Anesthesia, Sanquin Blood Supply, Amsterdam, the Netherlands.,Department of Intensive Care, Sanquin Blood Supply, Amsterdam, the Netherlands
| | - Anita M Tuip-de Boer
- Laboratory of Experimental Intensive Care and Anesthesia, Sanquin Blood Supply, Amsterdam, the Netherlands.,Department of Intensive Care, Sanquin Blood Supply, Amsterdam, the Netherlands
| | - W Joost Wiersinga
- Department of Medicine, Division of Infectious Diseases, Sanquin Blood Supply, Amsterdam, the Netherlands
| | - Anne H van der Spek
- Department of Endocrinology and Metabolism, Academic Medical Center, Amsterdam, the Netherlands
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin Research, Amsterdam, the Netherlands
| | - Dirk de Korte
- Department of Blood Cell Research, Sanquin Research, Amsterdam, the Netherlands.,Department of Product and Process Development, Sanquin Blood Supply, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesia, Sanquin Blood Supply, Amsterdam, the Netherlands.,Department of Intensive Care, Sanquin Blood Supply, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Laboratory of Experimental Intensive Care and Anesthesia, Sanquin Blood Supply, Amsterdam, the Netherlands.,Department of Intensive Care, Sanquin Blood Supply, Amsterdam, the Netherlands
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6
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Transfusion of 35-Day Stored RBCs in the Presence of Endotoxemia Does Not Result in Lung Injury in Humans*. Crit Care Med 2016; 44:e412-9. [DOI: 10.1097/ccm.0000000000001614] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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7
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Something Old, Something New…Something Else to Consider in Blood Utilization*. Crit Care Med 2016; 44:1259-60. [DOI: 10.1097/ccm.0000000000001686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Desmarets M, Bardiaux L, Benzenine E, Dussaucy A, Binda D, Tiberghien P, Quantin C, Monnet E. Effect of storage time and donor sex of transfused red blood cells on 1-year survival in patients undergoing cardiac surgery: an observational study. Transfusion 2016; 56:1213-22. [DOI: 10.1111/trf.13537] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 01/10/2016] [Accepted: 01/12/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Maxime Desmarets
- Centre d'Investigation Clinique, INSERM CIC 1431; University Hospital of Besançon; Besançon France
| | - Laurent Bardiaux
- Etablissement Français du Sang (EFS) Pyrénées Méditerranée; Toulouse, France
| | - Eric Benzenine
- Service de Biostatistiques et Informatique Médicale (DIM), University Hospital of Dijon; Dijon, France
| | - Alain Dussaucy
- Département d'Information Médicale; University Hospital of Besançon
| | - Delphine Binda
- Centre d'Investigation Clinique, INSERM CIC 1431; University Hospital of Besançon; Besançon France
| | - Pierre Tiberghien
- UMR 1098, INSERM, Université de Franche-Comté, Etablissement Français du Sang; Besançon, France
| | - Catherine Quantin
- Service de Biostatistiques et Informatique Médicale (DIM), University Hospital of Dijon; Dijon, France
- Centre d'Investigation Clinique, INSERM CIC 1432, University Hospital of Dijon
- UMR 1181, Biostatistiques, biomathématiques, pharmacoépidémiologie et maladies infectieuses (BP2PHI), INSERM Université de Bourgogne; Dijon France
| | - Elisabeth Monnet
- Centre d'Investigation Clinique, INSERM CIC 1431; University Hospital of Besançon; Besançon France
- EA 4266, Agents Pathogènes et Inflammation, Université de Franche-Comté; Besançon France
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9
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Abstract
BACKGROUND Transfusion-related acute lung injury incidence remains the leading cause of posttransfusion mortality. The etiology may be related to leukocyte antibodies or biologically active compounds in transfused plasma, injuring susceptible recipient's lungs. The authors have hypothesized that transfusion could have less severe effects that are not always appreciated clinically and have shown subtly decreased pulmonary oxygen gas transfer in healthy volunteers after transfusion of fresh and 21-day stored erythrocytes. In this study, the authors tested the same hypothesis in surgical patients. METHODS Ninety-one patients undergoing elective major spine surgery with anticipated need for erythrocyte transfusion were randomly allocated to receive their first transfusion of erythrocytes as cell salvage (CS), washed stored, or unwashed stored. Clinicians were not blinded to group assignment. Pulmonary gas transfer and mechanics were measured 5 min before and 30 min after erythrocyte transfusion. RESULTS The primary outcome variable, gas transfer, as assessed by change of PaO2/FIO2, with erythrocyte transfusion was not significant in any group (mean ± SD; CS: 9 ± 59; washed: 10 ± 26; and unwashed: 15 ± 1) and did not differ among groups (P = 0.92). Pulmonary dead space (VD/VT) decreased with CS transfusion (-0.01 ± 0.04; P = 0.034) but did not change with other erythrocytes; the change from before to after erythrocyte transfusion did not differ among groups (-0.01 to +0.01; P = 0.28). CONCLUSIONS The authors did not find impaired gas exchange as assessed by PaO2/FIO2 with transfused erythrocytes that did or did not contain nonautologous plasma. This clinical trial did not support the hypothesis of erythrocyte transfusion-induced gas exchange deficit that had been found in healthy volunteers.
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10
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Cortés-Puch I, Remy KE, Solomon SB, Sun J, Wang D, Al-Hamad M, Kelly SM, Sinchar D, Bellavia L, Kanias T, Popovsky MA, Kim-Shapiro DB, Klein HG, Natanson C. In a canine pneumonia model of exchange transfusion, altering the age but not the volume of older red blood cells markedly alters outcome. Transfusion 2015; 55:2564-75. [PMID: 26469998 PMCID: PMC4644122 DOI: 10.1111/trf.13275] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/29/2015] [Accepted: 06/30/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Massive exchange transfusion of 42-day-old red blood cells (RBCs) in a canine model of Staphylococcus aureus pneumonia resulted in in vivo hemolysis with increases in cell-free hemoglobin (CFH), transferrin-bound iron (TBI), non-transferrin-bound iron (NTBI), and mortality. We have previously shown that washing 42-day-old RBCs before transfusion significantly decreased NTBI levels and mortality, but washing 7-day-old RBCs increased mortality and CFH levels. We now report the results of altering volume, washing, and age of RBCs. STUDY DESIGN AND METHODS Two-year-old purpose-bred infected beagles were transfused with increasing volumes (5-10, 20-40, or 60-80 mL/kg) of either 42- or 7-day-old RBCs (n = 36) or 80 mL/kg of either unwashed or washed RBCs with increasing storage age (14, 21, 28, or 35 days; n = 40). RESULTS All volumes transfused (5-80 mL/kg) of 42-day-old RBCs resulted in alike (i.e., not significantly different) increases in TBI during transfusion as well as in CFH, lung injury, and mortality rates after transfusion. Transfusion of 80 mL/kg RBCs stored for 14, 21, 28, and 35 days resulted in increased CFH and NTBI in between levels found at 7 and 42 days of storage. However, washing RBCs of intermediate ages (14-35 days) does not alter NTBI and CFH levels or mortality rates. CONCLUSIONS Preclinical data suggest that any volume of 42-day-old blood potentially increases risks during established infection. In contrast, even massive volumes of 7-day-old blood result in minimal CFH and NTBI levels and risks. In contrast to the extremes of storage, washing blood stored for intermediate ages does not alter risks of transfusion or NTBI and CFH clearance.
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Affiliation(s)
- Irene Cortés-Puch
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Kenneth E. Remy
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Steven B. Solomon
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Dong Wang
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Mariam Al-Hamad
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Seth M. Kelly
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Derek Sinchar
- Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, 15213
| | - Landon Bellavia
- Department of Physics and the Translational Science Center, Wake Forest University, Winston-Salem, NC 27109
| | - Tamir Kanias
- Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, 15213
| | | | - Daniel B. Kim-Shapiro
- Department of Physics and the Translational Science Center, Wake Forest University, Winston-Salem, NC 27109
| | - Harvey G. Klein
- Department of Transfusion Medicine, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
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11
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Abstract
BACKGROUND Well-characterized biochemical, structural, and physiological changes occur when red blood cells (RBCs) are stored for a period of time and are collectively called the storage lesion. METHODS Key study results are summarized and contrasted and new data from recently completed randomized controlled trials will be discussed. RESULTS It is unclear whether in vitro changes to RBCs that occur during storage are clinically relevant. The clinical effects of RBC storage have been the focus of observational studies in recent years. However, these studies lack any consensus, possibly because of methodological limitations. CONCLUSIONS The clinical significance of storing RBCs is controversial, although new data from randomized controlled trials of neonates and patients undergoing cardiac surgery suggest that the duration of RBC storage is not associated with adverse clinical outcomes in these patient populations.
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Affiliation(s)
- Lirong Qu
- Department of Pathology, Institute for Transfusion Medicine, Pittsburgh, PA 15213, USA.
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12
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Patterson JA, Irving DO, Isbister JP, Morris JM, Mayson E, Roberts CL, Ford JB. Age of blood and adverse outcomes in a maternity population. Transfusion 2015; 55:2730-7. [PMID: 26177784 DOI: 10.1111/trf.13230] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/01/2015] [Accepted: 06/04/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND In recent times there has been debate around whether longer storage time of blood is associated with increased rates of adverse outcomes after transfusion. It is unclear whether results focused on cardiac or critically ill patients apply to a maternity population. This study investigates whether older blood is associated with increased morbidity and readmission in women undergoing obstetric transfusion. STUDY DESIGN AND METHODS Women giving birth in hospitals in New South Wales, Australia, between July 2006 and December 2010 were included in the study population if they had received between 1 and 4 red blood cell units during the birth admission. Information on women's characteristics, transfusions, and outcomes were obtained from five routinely collected data sets including blood collection, birth, and hospitalization data. Generalized propensity score methods were used to determine the effect of age of blood on rates of severe morbidity and readmission, independent of confounding factors. RESULTS Transfusion data were available for 2990 women, with a median age of blood transfused of 20 days (interquartile range, 14-27 days). There were no differences in the maximum age of blood transfused between women with and without severe morbidity (21 [14-28] days vs. 22 [15-30] days) and in women readmitted or not (22 [14-28] days vs. 22 [16-30] days). After potential confounding factors were considered, no relationship was found between the age of blood transfused and rates of severe morbidity and readmission. CONCLUSION Among women receiving low-volume transfusions during a birth admission, there was no evidence of increased rates of adverse outcomes after transfusion with older blood.
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Affiliation(s)
- Jillian A Patterson
- Clinical and Population Perinatal Health, Kolling Institute, University of Sydney, Sydney
| | - David O Irving
- Research and Development, Australian Red Cross Blood Service, Melbourne
| | - James P Isbister
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Jonathan M Morris
- Clinical and Population Perinatal Health, Kolling Institute, University of Sydney, Sydney
| | - Eleni Mayson
- Clinical and Population Perinatal Health, Kolling Institute, University of Sydney, Sydney
| | - Christine L Roberts
- Clinical and Population Perinatal Health, Kolling Institute, University of Sydney, Sydney
| | - Jane B Ford
- Clinical and Population Perinatal Health, Kolling Institute, University of Sydney, Sydney
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13
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Klein H, Natanson C, Flegel W. Transfusion of fresh vs. older red blood cells in the context of infection. ACTA ACUST UNITED AC 2015; 10:275-285. [PMID: 29805474 DOI: 10.1111/voxs.12109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The red blood cell (RBC) storage interval has been extended from less than a week to the current storage interval of 6-8 weeks. Regulatory criteria for extending storage rely upon a minimal degree of hemolysis and acceptable in vivo 24-h post transfusion recovery. Clinical studies of safety and efficacy have never been required. Concerns have arisen that RBC toward the end of storage develop a 'storage lesion' with previously unrecognized toxicity. Of the several mechanisms proposed, the bolus of iron delivered to macrophages as a result of hemolysis of stored RBC might pose a particular risk to patients with existing infections. We developed a canine model of pneumonia to compare the toxicity of stored RBC transfusion. We described increased mortality after transfusion of old RBC. We found that transfused older RBC increased mortality, in vivo hemolysis, circulating cell-free hemoglobin that scavenges nitric oxide, and elevations of non-transferrin bound and plasma labile iron. Disappearance of circulating iron correlated with increased mortality, worsening pulmonary function, and bacterial proliferation. Washing decreased the mortality associated with transfusing older RBC, but had the opposite effect on fresher blood. With low doses of bacteria, survival was unaffected by the age of blood, whereas high bacteria doses masked any effect of RBC age on mortality. Older RBC may have adverse effects, but the patient's clinical status, the age, volume and method of preparation of the RBC may be critical variables. Several mechanisms may account for this toxicity, but in the presence of bacterial infection, availability of iron likely plays a major role.
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Affiliation(s)
- H Klein
- CC/DTM, NIH, Bethesda, MD, USA
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14
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Orlov D, Karkouti K. The pathophysiology and consequences of red blood cell storage. Anaesthesia 2015; 70 Suppl 1:29-37, e9-12. [PMID: 25440392 DOI: 10.1111/anae.12891] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2014] [Indexed: 12/17/2022]
Abstract
Red cell transfusion therapy is a common treatment modality in contemporary medical practice. Although blood collection and administration is safer and more efficient than ever before, red cells undergo multiple metabolic and structural changes during storage that may compromise their functionality and viability following transfusion. The clinical relevance of these changes is a hotly debated topic that continues to be a matter of intense investigation. In the current review, we begin with an in-depth overview of the pathophysiological mechanisms underlying red cell storage, with a focus on altered metabolism, oxidative stress and red cell membrane damage. We proceed to review the current state of evidence on the clinical relevance and consequences of the red cell storage lesion, while discussing the strengths and limitations of clinical studies.
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Affiliation(s)
- D Orlov
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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15
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van der Meer PF, de Korte D. The Effect of Holding Times of Whole Blood and Its Components During Processing on In Vitro and In Vivo Quality. Transfus Med Rev 2015; 29:24-34. [DOI: 10.1016/j.tmrv.2014.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 10/14/2014] [Accepted: 10/17/2014] [Indexed: 11/25/2022]
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16
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Biagini S, Costa PA, Wendel S, Schettino G, Azevedo LCP. In vitro and in vivo validation of stored swine erythrocyte viability to establish an experimental model of homologous red blood cell transfusion: a pilot study. Rev Bras Ter Intensiva 2014; 26:287-91. [PMID: 25295823 PMCID: PMC4188465 DOI: 10.5935/0103-507x.20140040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Accepted: 06/04/2014] [Indexed: 01/20/2023] Open
Abstract
Objective To develop experimental models of erythrocyte transfusion, the first step is to
ensure the viability of the red blood cells transfused. In this pilot study, we
assessed the viability of transfused red blood cells with validation in vitro and
in vivo of homologous swine erythrocytes stored for 14 days. Methods Blood collected from one Agroceres® swine was stored in two red blood
cell units. In vivo validation was performed by labeling the red blood cells with
Na251CrO4 and recovering the viable
erythrocytes after 24 hours of infusion in one autologous and four homologous
animals. In vitro validation was performed at baseline and after 14 days in
sixteen red blood cell units by measuring hemoglobin, hematocrit, hemolysis index
and free hemoglobin. A post-mortem splenectomy was performed to evaluate the
splenic sequestration of erythrocytes, and the radioactivity of the supernatant
samples was counted to evaluate intravascular hemolysis. Results After 14 days of storage, the red blood cell units had lower volumes and
equivalent total concentrations of hemoglobin and hematocrit compared to human
standards. The free hemoglobin concentration increased from 31.0±9.3 to
112.4±31.4mg/dL (p<0.001), and the hemolysis index increased from 0.1±0.1 to
0.5±0.1% (p<0.001). However, these tests were within the acceptable range for
human standards. The percentage of radioactivity in supernatant samples was
similar at baseline and after 24 hours, thus excluding significant hemolysis. No
evidence of splenic sequestration of radioactive erythrocytes was found. Conclusion Swine red blood cells stored for 14 days are viable and can be used in
experimental studies of transfusion. These validation experiments are important to
aid investigators in establishing experimental models of transfusion.
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Affiliation(s)
- Silvana Biagini
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - Paulo Aguirre Costa
- Departamento de Medicina Nuclear, Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - Silvano Wendel
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - Guilherme Schettino
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil
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18
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The effect of the arterial catheter insertion technique on the success of radial artery cannulation: A prospective and randomized study. J Crit Care 2014; 29:475.e7-10. [DOI: 10.1016/j.jcrc.2014.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/18/2013] [Accepted: 01/06/2014] [Indexed: 11/20/2022]
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Abstract
PURPOSE OF REVIEW Possible adverse effects of prolonged storage of red blood cell concentrates (RBCs) are being formally assessed both by observational studies and in randomized controlled trials. New mechanisms have been put forth to explain earlier conflicting observations. This review summarizes ongoing investigations into clinical and basic science studies on RBC storage effects. RECENT FINDINGS Research into possible deleterious clinical effects of prolonged storage of RBCs has explored the contribution of various RBC production aspects (e.g. overnight hold, centrifugation speed, storage solution), seldom previously reported. Other studies investigated putative underlying mechanisms like free iron, inflammation, cytokines, and so on. Many publications include multiple analyses, like different cut-off values for 'old', or taking into account both oldest and average RBC storage time. Also, more studies correct for possible confounding effects to get a better estimate of associations. An alarming and ironic observation is that several studies found higher risks with fresh RBCs after correction for confounding. The results from the first large randomized controlled trials show no differences between old and fresh RBCs. SUMMARY We still do not know whether older red cells have adverse effects, and if so, what determines such clinical effects after transfusion of 'old' RBCs. RBC production factors, previously seldom reported, may play an important role and should be reported.
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20
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Flegel WA, Natanson C, Klein HG. Does prolonged storage of red blood cells cause harm? Br J Haematol 2014; 165:3-16. [PMID: 24460532 DOI: 10.1111/bjh.12747] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 12/13/2013] [Indexed: 12/18/2022]
Abstract
Red blood cells (RBCs) degrade progressively during the weeks of refrigerated storage. No universally accepted definition of 'fresh' or 'old' RBCs exists. While practices vary from country to country, preservative solutions permitting shelf life as long as 7 weeks have been licenced. Transfusion of stored RBCs, particularly those at the end of the approved shelf life, has been implicated in adverse clinical outcomes. The results of observational analyses, animal models and studies in volunteers have proved provocative, controversial and contradictory. A recently completed randomized controlled trial (RCT) in premature infants exemplifies the difficulties with moderately sized clinical studies. Several other RCTs are in progress. The effect of RBC storage may well vary according to the clinical setting. Resolution of the importance of the storage lesion may require large pragmatic clinical trials. In the meantime, institutions involved in blood collection and transfusion should explore strategies that assure blood availability, while limiting the use of the oldest RBCs currently approved by regulation.
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Affiliation(s)
- Willy A Flegel
- Department of Transfusion Medicine and Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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Adverse effects of hemorrhagic shock resuscitation with stored blood are ameliorated by inhaled nitric oxide in lambs*. Crit Care Med 2013; 41:2492-501. [PMID: 23887236 DOI: 10.1097/ccm.0b013e31828cf456] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Transfusion of stored RBCs is associated with increased morbidity and mortality in trauma patients. Plasma hemoglobin scavenges nitric oxide, which can cause vasoconstriction, induce inflammation, and activate platelets. We hypothesized that transfusion of RBCs stored for prolonged periods would induce adverse effects (pulmonary vasoconstriction, tissue injury, inflammation, and platelet activation) in lambs subjected to severe hemorrhagic shock and that concurrent inhalation of nitric oxide would prevent these adverse effects. DESIGN Animal study. SETTING Research laboratory at the Massachusetts General Hospital, Boston, MA. SUBJECTS Seventeen awake Polypay-breed lambs. INTERVENTIONS Lambs were subjected to 2 hours of hemorrhagic shock by acutely withdrawing 50% of their blood volume. Lambs were resuscitated with autologous RBCs stored for 2 hours or less (fresh) or 39 ± 2 (mean ± SD) days (stored). Stored RBCs were administered with or without breathing nitric oxide (80 ppm) during resuscitation and for 21 hours thereafter. MEASUREMENTS AND MAIN RESULTS We measured hemodynamic and oxygenation variables, markers of tissue injury and inflammation, plasma hemoglobin concentrations, and platelet activation. Peak pulmonary arterial pressure was higher after resuscitation with stored than with fresh RBCs (24 ± 4 vs 14 ± 2 mm Hg, p < 0.001) and correlated with peak plasma hemoglobin concentrations (R = 0.56, p = 0.003). At 21 hours after resuscitation, pulmonary myeloperoxidase activity was higher in lambs resuscitated with stored than with fresh RBCs (11 ± 2 vs 4 ± 1 U/g, p = 0.007). Furthermore, transfusion of stored RBCs increased plasma markers of tissue injury and sensitized platelets to adenosine diphosphate activation. Breathing nitric oxide prevented the pulmonary hypertension and attenuated the pulmonary myeloperoxidase activity, as well as tissue injury and sensitization of platelets to adenosine diphosphate. CONCLUSIONS Our data suggest that resuscitation of lambs from hemorrhagic shock with autologous stored RBCs induces pulmonary hypertension and inflammation, which can be ameliorated by breathing nitric oxide.
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Say NO to Old Blood*. Crit Care Med 2013; 41:2648-9. [DOI: 10.1097/ccm.0b013e318291cb05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Interactions of cardiopulmonary bypass and erythrocyte transfusion in the pathogenesis of pulmonary dysfunction in Swine. Anesthesiology 2013; 119:365-78. [PMID: 23619171 DOI: 10.1097/aln.0b013e31829419d3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Allogeneic erythrocyte transfusion in cardiac surgical patients is associated with a fourfold increase in pulmonary complications. Our understanding of the processes underlying these observations is poor and there is no experimental model of transfusion-related acute lung injury that shows homology to cardiac surgical patients. Our objective was to develop a novel swine recovery model to determine how two clinical risk factors, allogenic erythrocyte transfusion and cardiopulmonary bypass, interact in the genesis of postcardiac surgery acute lung injury. METHODS Thirty-six pigs were infused with allogeneic 14- or 42-day-old erythrocytes or they underwent cardiopulmonary bypass with or without transfusion of 42-day erythrocyte. Controls received saline. All pigs were recovered and assessed for pulmonary dysfunction, inflammation, and endothelial activation at 24 h. RESULTS Transfusion of stored allogeneic erythrocytes in pigs compared with sham caused pulmonary dysfunction characterized by reduced lung compliance (mean difference -3.36 [95% CI, -5.31 to -1.42] ml/cm H2O), an increase in protein levels in bronchoalveolar lavage fluid, histological lung injury inflammation, and endothelial activation. Transfusion of blood stored for up to 42 days resulted in greater protein levels in bronchoalveolar lavage fluid, macrophage infiltration, platelet activation, and depletion of T-lymphocytes in recipient lungs versus 14-day-old blood. Transfusion interacted with cardiopulmonary bypass to increase lung injury in the absence of platelet activation. CONCLUSIONS In this novel large animal model of allogeneic erythrocyte transfusion, pulmonary dysfunction occurs in the absence of any priming event, is increased when combined with other inflammatory stimuli, and is mediated by monocyte activation and T-lymphocyte depletion.
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Stark MJ, Keir AK, Andersen CC. Does non-transferrin bound iron contribute to transfusion related immune-modulation in preterms? Arch Dis Child Fetal Neonatal Ed 2013; 98:F424-9. [PMID: 23475935 DOI: 10.1136/archdischild-2012-303353] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE There is increasing awareness that allogeneic transfusion is potentially harmful in preterm neonates secondary to transfusion related immunomodulation (TRIM). Non-transferrin bound iron (NTBI) may contribute to TRIM by promoting oxidative damage and pro-inflammatory cytokine release. The current study aimed to determine if transfusion early in the neonatal period resulted in an increase in circulating NTBI, oxidative stress and immune activation. DESIGN Prospective observational study. SETTING One transfusion event was studied in infants ≤28 weeks gestation between 2 and 6 weeks postnatal age (n=33) admitted to a tertiary neonatal intensive care unit. METHODS Serum NTBI, inflammatory cytokines and malondialdehyde (MDA) were measured from the donor pack, prior to and at 2-4 and 24 h post-transfusion. RESULTS Median (range) age at transfusion was 17 (14-39) days with the pretransfusion haemoglobin level 9.6 (7.4-10.4) g/dl. NTBI was detectable in 18 (51%) of the transfusion packs. NTBI levels were higher after transfusion (p<0.01) returning to pretransfusion levels by 24 h. Post-transfusion NTBI level correlated with the age of transfused blood (p<0.001) and was positively correlated with plasma MDA (p=0.01) but not IL-1β, IL-6, IL8 or TNFα. CONCLUSIONS Circulating NTBI is transiently elevated following blood transfusion in preterm newborns. This increase was related to the age of blood transfused and correlated with increases in oxidative stress but not pro-inflammatory cytokines. While further studies are necessary to determine whether these transient effects influence clinical outcome, the current data do not support a significant role in the very preterm neonate for NTBI in TRIM.
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Affiliation(s)
- Michael J Stark
- Department of Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia.
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Lelubre C, Vincent JL. Relationship between red cell storage duration and outcomes in adults receiving red cell transfusions: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R66. [PMID: 23566599 PMCID: PMC3672637 DOI: 10.1186/cc12600] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 04/05/2013] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The duration of red blood cell (RBC) storage before transfusion may alter RBC function and supernatant and, therefore, influence the incidence of complications or even mortality. METHODS A MEDLINE search from 1983 to December 2012 was performed to identify studies reporting age of transfused RBCs and mortality or morbidity in adult patients. RESULTS Fifty-five studies were identified; most were single-center (93%) and retrospective (64%), with only a few, small randomized studies (eight studies, 14.5%). The numbers of subjects included ranged from eight to 364,037. Morbidity outcomes included hospital and intensive care unit (ICU) length of stay (LOS), infections, multiple organ failure, microcirculatory alterations, cancer recurrence, thrombosis, bleeding, vasospasm after subarachnoid hemorrhage, and cognitive dysfunction. Overall, half of the studies showed no deleterious effects of aged compared to fresh blood on any endpoint. Eleven of twenty-two (50%) studies reported no increased mortality, three of nine (33%) showed no increased LOS with older RBCs and eight of twelve (66%) studies showed no increased risks of organ failure. Ten of eighteen (55%) studies showed increased infections with transfusion of older RBCs. The considerable heterogeneity among studies and numerous methodological flaws precluded a formal meta-analysis. CONCLUSIONS In this systematic review, we could find no definitive argument to support the superiority of fresh over older RBCs for transfusion.
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Current World Literature. Curr Opin Anaesthesiol 2013; 26:244-52. [DOI: 10.1097/aco.0b013e32835f8a30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Blood storage and transfusion☆ Almacenamiento sanguíneo y transfusión. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1097/01819236-201341010-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Rivera Tocancipa D. Almacenamiento sanguíneo y transfusión. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rca.2012.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Kim HH, Lee DK, Park CY, Ju JK, Kim JC. Transfusion-Related Acute Lung Injury after Stored Packed Red Blood Cell Transfusion - A Case Report -. Korean J Crit Care Med 2013. [DOI: 10.4266/kjccm.2013.28.2.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ho-Hyun Kim
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Dong-Kyu Lee
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Chan-Yong Park
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Jae-Kyoon Ju
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Jung-Chul Kim
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
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Rivera Tocancipa D. Blood storage and transfusion. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rcae.2012.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Blood storage and transfusion☆ Almacenamiento sanguíneo y transfusión. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1097/01819236-201241010-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related mortality. To determine TRALI incidence by prospective, active surveillance and to identify risk factors by a case-control study, 2 academic medical centers enrolled 89 cases and 164 transfused controls. Recipient risk factors identified by multivariate analysis were higher IL-8 levels, liver surgery, chronic alcohol abuse, shock, higher peak airway pressure while being mechanically ventilated, current smoking, and positive fluid balance. Transfusion risk factors were receipt of plasma or whole blood from female donors (odds ratio = 4.5, 95% confidence interval [CI], 1.85-11.2, P = .001), volume of HLA class II antibody with normalized background ratio more than 27.5 (OR = 1.92/100 mL, 95% CI, 1.08-3.4, P = .03), and volume of anti-human neutrophil antigen positive by granulocyte immunofluoresence test (OR = 1.71/100 mL, 95% CI, 1.18-2.5, P = .004). Little or no risk was associated with older red blood cell units, noncognate or weak cognate class II antibody, or class I antibody. Reduced transfusion of plasma from female donors was concurrent with reduced TRALI incidence: 2.57 (95% CI, 1.72-3.86) in 2006 versus 0.81 (95% CI, 0.44-1.49) in 2009 per 10 000 transfused units (P = .002). The identified risk factors provide potential targets for reducing residual TRALI.
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