1
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Wood B, Johnson L, Hyland RA, Marks DC. Maximising platelet availability by delaying cold storage. Vox Sang 2018; 113:403-411. [PMID: 29633290 DOI: 10.1111/vox.12649] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/28/2018] [Accepted: 03/04/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Cold-stored platelets may be an alternative to conventional room temperature (RT) storage. However, cold-stored platelets are cleared more rapidly from circulation, reducing their suitability for prophylactic transfusion. To minimise wastage, it may be beneficial to store platelets conventionally until near expiry (4 days) for prophylactic use, transferring them to refrigerated storage to facilitate an extended shelf life, reserving the platelets for the treatment of acute bleeding. MATERIALS AND METHODS Two ABO-matched buffy-coat-derived platelets (30% plasma/70% SSP+) were pooled and split to produce matched pairs (n = 8 pairs). One unit was stored at 2-6°C without agitation (day 1 postcollection; cold); the second unit was stored at 20-24°C with constant agitation until day 4 then stored at 2-6°C thereafter (delayed-cold). All units were tested for in vitro quality periodically over 21 days. RESULTS During storage, cold and delayed-cold platelets maintained a similar platelet count. While pH and HSR were significantly higher in delayed-cold platelets, other metabolic markers, including lactate production and glucose consumption, did not differ significantly. Furthermore, surface expression of phosphatidylserine and CD62P, release of soluble CD62P and microparticles were not significantly different, suggesting similar activation profiles. Aggregation responses of delayed-cold platelets followed the same trend as cold platelets once transferred to cold storage, gradually declining over the storage period. CONCLUSION The metabolic and activation profile of delayed-cold platelets was similar to cold-stored platelets. These data suggest that transferring platelets to refrigerated storage when near expiry may be a viable option for maximising platelet inventories.
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Affiliation(s)
- B Wood
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - L Johnson
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - R A Hyland
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - D C Marks
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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2
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Waters L, Cameron M, Padula MP, Marks DC, Johnson L. Refrigeration, cryopreservation and pathogen inactivation: an updated perspective on platelet storage conditions. Vox Sang 2018; 113:317-328. [PMID: 29441601 DOI: 10.1111/vox.12640] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/28/2017] [Accepted: 01/15/2018] [Indexed: 01/08/2023]
Abstract
Conventional storage of platelet concentrates limits their shelf life to between 5 and 7 days due to the risk of bacterial proliferation and the development of the platelet storage lesion. Cold storage and cryopreservation of platelets may facilitate extension of the shelf life to weeks and years, and may also provide the benefit of being more haemostatically effective than conventionally stored platelets. Further, treatment of platelet concentrates with pathogen inactivation systems reduces bacterial contamination and provides a safeguard against the risk of emerging and re-emerging pathogens. While each of these alternative storage techniques is gaining traction individually, little work has been done to examine the effect of combining treatments in an effort to further improve product safety and minimize wastage. This review aims to discuss the benefits of alternative storage techniques and how they may be combined to alleviate the problems associated with conventional platelet storage.
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Affiliation(s)
- L Waters
- Research & Development, Australian Red Cross Blood Service, Alexandria, NSW, Australia.,School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia
| | - M Cameron
- Research & Development, Australian Red Cross Blood Service, Alexandria, NSW, Australia.,School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia
| | - M P Padula
- School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia
| | - D C Marks
- Research & Development, Australian Red Cross Blood Service, Alexandria, NSW, Australia
| | - L Johnson
- Research & Development, Australian Red Cross Blood Service, Alexandria, NSW, Australia
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3
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Affiliation(s)
- D. C. Marks
- Research and Development; Australian Red Cross Blood Service; Sydney NSW Australia
- Sydney Medical School; University of Sydney; Sydney NSW Australia
| | - L. Johnson
- Research and Development; Australian Red Cross Blood Service; Sydney NSW Australia
| | - M. C. Reade
- Faculty of Medicine; University of Queensland; Brisbane QLD Australia
- Joint Health Command; Australian Defence Force; Canberra ACT Australia
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4
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Strunk D, Lozano M, Marks DC, Loh YS, Gstraunthaler G, Schennach H, Rohde E, Laner-Plamberger S, Öller M, Nystedt J, Lotfi R, Rojewski M, Schrezenmeier H, Bieback K, Schäfer R, Bakchoul T, Waidmann M, Jonsdottir-Buch SM, Montazeri H, Sigurjonsson OE, Iudicone P, Fioravanti D, Pierelli L, Introna M, Capelli C, Falanga A, Takanashi M, Lόpez-Villar O, Burnouf T, Reems JA, Pierce J, Preslar AM, Schallmoser K. International Forum on GMP-grade human platelet lysate for cell propagation: summary. Vox Sang 2017; 113:80-87. [PMID: 29076169 DOI: 10.1111/vox.12593] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- D Strunk
- Institute of Experimental and Clinical Cell Therapy, Paracelsus Medical University, Salzburg, Austria
| | - M Lozano
- Hospital Clinic, Department of Hemotherapy and Hemostasis, Hospital Clínic University of Barcelona , Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - K Schallmoser
- Department of Blood Group Serology and Transfusion Medicine, Paracelsus Medical University Hospital Salzburg, Salzburg, Austria
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5
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Strunk D, Lozano M, Marks DC, Loh YS, Gstraunthaler G, Schennach H, Rohde E, Laner-Plamberger S, Öller M, Nystedt J, Lotfi R, Rojewski M, Schrezenmeier H, Bieback K, Schäfer R, Bakchoul T, Waidmann M, Jonsdottir-Buch SM, Montazeri H, Sigurjonsson OE, Iudicone P, Fioravanti D, Pierelli L, Introna M, Capelli C, Falanga A, Takanashi M, López-Villar O, Burnouf T, Reems JA, Pierce J, Preslar AM, Schallmoser K. International Forum on GMP-grade human platelet lysate for cell propagation. Vox Sang 2017; 113:e1-e25. [PMID: 29071726 DOI: 10.1111/vox.12594] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | | | - D C Marks
- Australian Red Cross Blood Service, Research and Development, 17 O'Riordan Street, Sydney, New South Wales, 2015, Australia
| | - Y S Loh
- Australian Red Cross Blood Service, Research and Development, 17 O'Riordan Street, Sydney, New South Wales, 2015, Australia
| | - G Gstraunthaler
- Division of Physiology, Medical University Innsbruck, Schöpfstr. 41, Innsbruck, A-6020, Austria
| | - H Schennach
- Central Institute of Blood Transfusion and Immunology, University Hospital Innsbruck, Anichstr. 35, Innsbruck, A-6020, Austria
| | - E Rohde
- Department of Blood Group Serology and Transfusion Medicine, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Lindhofstrasse 20-22, Salzburg, 5020, Austria
| | - S Laner-Plamberger
- Department of Blood Group Serology and Transfusion Medicine, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Lindhofstrasse 20-22, Salzburg, 5020, Austria
| | - M Öller
- Department of Blood Group Serology and Transfusion Medicine, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Lindhofstrasse 20-22, Salzburg, 5020, Austria
| | - J Nystedt
- Finnish Red Cross Blood Service, Advanced Cell Therapy Centre, Kivihaantie 7, FI-00310, Helsinki, Finland
| | - R Lotfi
- Institute for Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Service, Baden-Wuerttemberg-Hessen , University Hospital Ulm, University of Ulm, Helmholtzstr. 10, Ulm, 89081, Germany
| | - M Rojewski
- Institute for Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Service, Baden-Wuerttemberg-Hessen , University Hospital Ulm, University of Ulm, Helmholtzstr. 10, Ulm, 89081, Germany
| | - H Schrezenmeier
- Institute for Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Service, Baden-Wuerttemberg-Hessen , University Hospital Ulm, University of Ulm, Helmholtzstr. 10, Ulm, 89081, Germany
| | - K Bieback
- Institute of Transfusion Medicine and Immunology, Medical Faculty Mannheim, German Red Cross Blood Service Baden-Württemberg - Hessen, Heidelberg University, Friedrich-Ebert Str. 107, Mannheim, D-68167, Germany
| | - R Schäfer
- Institute for Transfusion Medicine and Immunohematology, German Red Cross Blood Donor Service Baden-Württemberg- Hessen gGmbH, Goethe-University Hospital, Sandhofstrasse 1, Frankfurt am Main, D-60528, Germany
| | - T Bakchoul
- Center for Clinical Transfusion Medicine, Otfried-Müller-Strasse 4/1, D-72076 , Tuebingen, Germany
| | - M Waidmann
- Center for Clinical Transfusion Medicine, Otfried-Müller-Strasse 4/1, D-72076 , Tuebingen, Germany
| | - S M Jonsdottir-Buch
- The Blood Bank, Landspitali University Hospital, Snorrabraut 60, 101, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, 101, Reykjavik, Iceland.,Platome Biotechnology, Alfaskeid 27, 220, Hafnarfjordur, Iceland
| | - H Montazeri
- The Blood Bank, Landspitali University Hospital, Snorrabraut 60, 101, Reykjavik, Iceland.,Platome Biotechnology, Alfaskeid 27, 220, Hafnarfjordur, Iceland
| | - O E Sigurjonsson
- The Blood Bank, Landspitali University Hospital, Snorrabraut 60, 101, Reykjavik, Iceland.,Platome Biotechnology, Alfaskeid 27, 220, Hafnarfjordur, Iceland.,School of Science and Engineering, University of Reykjavik, Menntavegur 1, 101, Reykjavik, Iceland
| | - P Iudicone
- San Camillo Forlanini Hospital, Circonvallazione Gianicolense 87, Rome, 00152, Italy
| | - D Fioravanti
- San Camillo Forlanini Hospital, Circonvallazione Gianicolense 87, Rome, 00152, Italy
| | - L Pierelli
- Department of Experimental Medicine, Sapienza University, Piazzale Aldo Moro 5, Rome, 00185, Italy
| | - M Introna
- QP USS Centro di Terapia Cellulare 'G. Lanzani', USC Ematologia, ASST Papa Giovanni XXIII, Via Garibaldi 11/13, Bergamo, 24124, Italy
| | - C Capelli
- USS Centro di Terapia Cellulare 'G. Lanzani', USC Ematologia, ASST Papa Giovanni XXIII, Via Garibaldi 11/13, Bergamo, 24124, Italy
| | - A Falanga
- Division of Immunohematology and Transfusion Medicine, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, 24127, Italy
| | - M Takanashi
- Japanese Red Cross Blood Service Headquarters, 1-2-1 Shiba-koen, Minato-ku, Tokyo, 105-0011, Japan
| | - O López-Villar
- Department of Hematology, University Hospital of Salamanca, P/San Vicente 58-182, Salamanca, 37007, Spain
| | - T Burnouf
- Graduate Institute of Biomedical Materials and Tissue Engineering, International PhD Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, 250 Wu-Shin Street, Taipei, 101, Taiwan
| | - J A Reems
- Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Utah Cell Therapy and Regenerative Medicine, 675 Arapeen, Suite 300, Salt Lake City, Utah, 84108, USA
| | - J Pierce
- Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Utah Cell Therapy and Regenerative Medicine, 675 Arapeen, Suite 300, Salt Lake City, Utah, 84108, USA
| | - A M Preslar
- Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Utah Cell Therapy and Regenerative Medicine, 675 Arapeen, Suite 300, Salt Lake City, Utah, 84108, USA
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6
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Cohn CS, Dumont LJ, Lozano M, Marks DC, Johnson L, Ismay S, Bondar N, T'Sas F, Yokoyama APH, Kutner JM, Acker JP, Bohonek M, Sailliol A, Martinaud C, Pogłód R, Antoniewicz-Papis J, Lachert E, Pun PBL, Lu J, Cid J, Guijarro F, Puig L, Gerber B, Alberio L, Schanz U, Buser A, Noorman F, Zoodsma M, van der Meer PF, de Korte D, Wagner S, O'Neill M. Vox Sanguinis International Forum on platelet cryopreservation: Summary. Vox Sang 2017; 112:684-688. [PMID: 28929502 DOI: 10.1111/vox.12533] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- C S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, D242 Mayo Building, MMC 609, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - L J Dumont
- Blood Systems Research Institute Denver, 717 Yosemite Street, Denver, CO, 80230, USA
| | - M Lozano
- Department of Hemotherapy and Hemostasis, University Clinic Hospital, University of Barcelona, 08036, Barcelona, Spain
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7
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Marks DC, van der Meer PF. Serum eye drops: a survey of international production methods. Vox Sang 2017; 112:310-317. [PMID: 28332214 DOI: 10.1111/vox.12502] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/24/2017] [Accepted: 01/25/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Serum eye drops (SEDs) are used to treat dry eye syndrome and non-healing corneal lesions when other treatments fail. Despite many clinical studies demonstrating the efficacy of both autologous and allogeneic SEDs, there is no internationally harmonized method for producing SEDs. MATERIALS AND METHODS A 40-question survey requesting information regarding donor selection, blood collection and processing, infectious disease screening, shelf life and regulatory requirements for the production of autologous and allogeneic SEDs was developed by the Biomedical Excellence for Safer Transfusion Collaborative. Survey data were collected into a database via a secure web interface and then downloaded into Excel for further analysis. RESULTS A total of 55 responses were received, with 21 responses from centres indicating they produce SEDs. Based on the responses, collection and processing practices differ widely, according to the size of the centre making the SEDs, and their ability to collect, process and test the blood. CONCLUSION Despite divergences in the methods for producing SEDs, the end result is a small-volume aliquot of serum that can be administered by a patient at home. If more centres move from producing autologous to allogeneic SEDs, this may provide an opportunity for production methods to become more standardized internationally.
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Affiliation(s)
- D C Marks
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - P F van der Meer
- Department of Product and Process Development, Sanquin Blood Supply, Amsterdam, The Netherlands
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8
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Loh YS, Tan S, Kwok M, Stark MJ, Marks DC. Reduction of biological response modifiers in the supernatant of washed paediatric red blood cells. Vox Sang 2016; 111:365-373. [PMID: 27864978 DOI: 10.1111/vox.12442] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 06/01/2016] [Accepted: 07/07/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Washing of red blood cells (RBC) can reduce unwanted biological response modifiers (BRMs) that can mediate transfusion complications in infants. The aim of this study was to examine the in vitro quality and the changes in BRMs following washing in paediatric RBC units. MATERIALS AND METHODS A pool and split design was used to prepare RBC (either 1 or 4 days old; n = 26 pairs). One unit was washed with 0·9% saline by centrifugation and then resuspended in SAG-M, while the other remained unwashed. Each RBC unit was divided to produce four units of paediatric-sized components. Samples were taken after 3 h and subsequently on days 1, 2, 7 and 14 post-wash. RESULTS Washing of RBC resulted in some red cell loss, with a minor increase in haemolysis. Washing effectively reduced supernatant potassium and IgA, as well as cytokines and complement proteins. RBC microparticles were significantly reduced in RBC washed at 1, but not 4 days post-collection. Incubation with supernatant from unwashed but not washed RBC led to endothelial cell activation, with increased cell surface expression of CD62E (E-selectin) and CD106 (VCAM). CONCLUSION Although washing affected some aspects of the in vitro quality of RBC, it effectively reduced the concentration and activity of BRMs in the supernatant of RBC. Such a reduction may be clinically beneficial in selected patient groups.
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Affiliation(s)
- Y S Loh
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - S Tan
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - M Kwok
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - M J Stark
- School of Paediatrics and Reproductive Health, The Robinson Institute, University of Adelaide, Adelaide, NSW, Australia
| | - D C Marks
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
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9
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Faddy HM, Fryk JJ, Watterson D, Young PR, Modhiran N, Muller DA, Keil SD, Goodrich RP, Marks DC. Riboflavin and ultraviolet light: impact on dengue virus infectivity. Vox Sang 2016; 111:235-241. [PMID: 27281512 DOI: 10.1111/vox.12414] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 04/01/2016] [Accepted: 04/01/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dengue viruses (DENV 1-4) are emerging across the world, and these viruses pose a risk to transfusion safety. Pathogen inactivation may be an alternative approach for managing the risk of DENV transfusion transmission. This study aimed to investigate the ability of riboflavin and UV light to inactivate DENV 1-4 in platelet concentrates. MATERIALS AND METHODS DENV 1-4 were spiked into buffy coat-derived platelet concentrates in additive solution (SSP+) before being treated with riboflavin and UV light. Infectious virus was quantified pre- and posttreatment, and the reduction in viral infectivity was calculated. RESULTS All four DENV serotypes were modestly reduced after treatment. The greatest amount of reduction in infectivity was observed for DENV-4 (1·81 log reduction) followed by DENV-3 (1·71 log reduction), DENV-2 (1·45 log reduction) and then DENV-1 (1·28 log reduction). CONCLUSION Our study demonstrates that DENV 1-4 titres are modestly reduced following treatment with riboflavin and UV light. With the increasing number of transfusion-transmitted cases of DENV around the globe, and the increasing incidence and geographical distribution of DENV, additional approaches for maintaining blood safety may be required in the future.
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Affiliation(s)
- H M Faddy
- Research and Development, Australian Red Cross Blood Service, Brisbane, Qld, Australia. .,School of Medicine, University of Queensland, Brisbane, Qld, Australia.
| | - J J Fryk
- Research and Development, Australian Red Cross Blood Service, Brisbane, Qld, Australia
| | - D Watterson
- Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Qld, Australia
| | - P R Young
- Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Qld, Australia
| | - N Modhiran
- Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Qld, Australia
| | - D A Muller
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, Qld, Australia
| | | | | | - D C Marks
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
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10
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Loh YS, Dean MM, Johnson L, Marks DC. Treatment of platelets with riboflavin and ultraviolet light mediates complement activation and suppresses monocyte interleukin-12 production in whole blood. Vox Sang 2015; 109:327-35. [DOI: 10.1111/vox.12283] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 03/03/2015] [Accepted: 03/17/2015] [Indexed: 01/07/2023]
Affiliation(s)
- Y. S. Loh
- Research and Development; Australian Red Cross Blood Service; Sydney NSW Australia
| | - M. M. Dean
- Research and Development; Australian Red Cross Blood Service; Brisbane QLD Australia
| | - L. Johnson
- Research and Development; Australian Red Cross Blood Service; Sydney NSW Australia
| | - D. C. Marks
- Research and Development; Australian Red Cross Blood Service; Sydney NSW Australia
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11
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Winter KM, Johnson L, Webb RG, Marks DC. Gamma-irradiation of deglycerolized red cells does not significantly affect in vitro quality. Vox Sang 2015; 109:231-8. [PMID: 25953334 DOI: 10.1111/vox.12282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/11/2015] [Accepted: 03/11/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Red cells frozen with glycerol may require gamma-irradiation after thawing and deglycerolization for transfusion to at-risk patients. Both freezing and irradiation are known to cause red cell damage. However, the effect of irradiation on the quality of deglycerolized red cells and the optimal shelf life of such a component is currently unknown. MATERIALS AND METHODS Red cells (<7 days) were pooled, split and glycerolized using an ACP-215 automated cell washer (n = 12 pairs) and frozen at -80°C. Red cells were thawed, deglycerolized and resuspended in SAG-M. One of each pair was gamma-irradiated, while the other served as a control. Products were stored at 2-6°C and sampled for in vitro testing immediately after irradiation, and at 24 and 48 h postirradiation. RESULTS Irradiation of deglycerolized red cells led to a >1·5-fold increase in extracellular potassium, compared to control units at 24 and 48 h postirradiation. Other parameters, including haemolysis, were not significantly affected by irradiation postdeglycerolization. CONCLUSION Deglycerolized, irradiated red cells had increased supernatant potassium, but remained of acceptable quality for 24 h postirradiation.
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Affiliation(s)
- K M Winter
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - L Johnson
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - R G Webb
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - D C Marks
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
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12
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Johnson L, Kwok M, Marks DC. Preparation of red blood cell concentrates and plasma units from whole blood held overnight using a hollow-fibre separation system. Transfus Med 2015; 25:13-9. [PMID: 25808374 DOI: 10.1111/tme.12192] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 02/22/2015] [Accepted: 03/10/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The ErySep system represents an alternative to centrifuge-based whole blood (WB) separation, using gravity and filtration through hollow-fibres (0·2 µm pore size) to produce red blood cell (RBC) and plasma components. The aim of this study was to characterise the quality of ErySep RBC and plasma units compared with standard products from WB held overnight. METHODS/MATERIALS Two ABO-compatible WB units (n = 24) were pooled and split to produce matched products. One of the WB units was separated into components using the ErySep system (ErySep; n = 12), whereas the other units were separated by centrifugation (control; n = 12). RBC units were stored at 2-6 °C and assessed for in vitro quality over 42 days of storage. Plasma was frozen at -30 °C and tested upon thawing. RESULTS Processing WB with the ErySep system took longer than controls. The ErySep RBC units were of an appropriate volume (307 ± 17 mL) and contained sufficient Hb (50 ± 2 g unit(-1) ). ErySep RBC components contained more microparticles relative to controls at expiry. The plasma volume, total protein, coagulation factor activity (fibrinogen, FV, FVIII) and number of microparticles was lower in the ErySep units compared with controls. CONCLUSION Following overnight hold of WB, the ErySep system was capable of producing RBC components that met specifications. However, the ErySep plasma components did not meet quality specifications.
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Affiliation(s)
- L Johnson
- Research and Development, Australian Red Cross Blood Service, Sydney, Australia
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13
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Winter KM, Johnson L, Kwok M, Reid S, Alarimi Z, Wong JKL, Dennington PM, Marks DC. Understanding the effects of gamma-irradiation on potassium levels in red cell concentrates stored in SAG-M for neonatal red cell transfusion. Vox Sang 2014; 108:141-50. [DOI: 10.1111/vox.12194] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 07/30/2014] [Accepted: 08/11/2014] [Indexed: 11/30/2022]
Affiliation(s)
- K. M. Winter
- Research and Development; Australian Red Cross Blood Service; Sydney NSW Australia
| | - L. Johnson
- Research and Development; Australian Red Cross Blood Service; Sydney NSW Australia
| | - M. Kwok
- Research and Development; Australian Red Cross Blood Service; Sydney NSW Australia
| | - S. Reid
- Research and Development; Australian Red Cross Blood Service; Sydney NSW Australia
| | - Z. Alarimi
- Medical, Transplantation and Quality Services; Australian Red Cross Blood Service; Sydney NSW Australia
| | - J. K. L. Wong
- Medical, Transplantation and Quality Services; Australian Red Cross Blood Service; Sydney NSW Australia
| | - P. M. Dennington
- Medical, Transplantation and Quality Services; Australian Red Cross Blood Service; Sydney NSW Australia
| | - D. C. Marks
- Research and Development; Australian Red Cross Blood Service; Sydney NSW Australia
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14
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Affiliation(s)
- D. C. Marks
- Research and Development; Australian Red Cross Blood Service; Sydney New South Wales Australia
| | - H. M. Faddy
- Research and Development; Australian Red Cross Blood Service; Brisbane Queensland Australia
| | - L. Johnson
- Research and Development; Australian Red Cross Blood Service; Sydney New South Wales Australia
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Reade MC, Marks DC, Johnson L, Irving DO, Holley AD. Frozen platelets for rural Australia: the CLIP trial. Anaesth Intensive Care 2013; 41:804-805. [PMID: 24180724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Johnson L, Winter KM, Kwok M, Reid S, Marks DC. Evaluation of the quality of blood components prepared using the Reveos automated blood processing system. Vox Sang 2013; 105:225-35. [DOI: 10.1111/vox.12051] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/05/2013] [Accepted: 04/07/2013] [Indexed: 01/03/2023]
Affiliation(s)
- L. Johnson
- Applied and Developmental Research; Research and Development; Australian Red Cross Blood Service; Sydney; Australia
| | - K. M. Winter
- Applied and Developmental Research; Research and Development; Australian Red Cross Blood Service; Sydney; Australia
| | - M. Kwok
- Applied and Developmental Research; Research and Development; Australian Red Cross Blood Service; Sydney; Australia
| | - S. Reid
- Applied and Developmental Research; Research and Development; Australian Red Cross Blood Service; Sydney; Australia
| | - D. C. Marks
- Applied and Developmental Research; Research and Development; Australian Red Cross Blood Service; Sydney; Australia
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Johnson L, Loh YS, Kwok M, Marks DC. In vitroassessment of buffy-coat derived platelet components suspended in SSP+ treated with the INTERCEPT Blood system. Transfus Med 2013; 23:121-9. [DOI: 10.1111/tme.12020] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 01/29/2013] [Accepted: 01/30/2013] [Indexed: 12/01/2022]
Affiliation(s)
- L. Johnson
- Research and Development; Australian Red Cross Blood Service; Sydney; Australia
| | - Y. S. Loh
- Research and Development; Australian Red Cross Blood Service; Sydney; Australia
| | - M. Kwok
- Research and Development; Australian Red Cross Blood Service; Sydney; Australia
| | - D. C. Marks
- Research and Development; Australian Red Cross Blood Service; Sydney; Australia
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Holley A, Marks DC, Johnson L, Reade MC, Badloe JF, Noorman F. Frozen blood products: clinically effective and potentially ideal for remote Australia. Anaesth Intensive Care 2013; 41:10-9. [PMID: 23362885 DOI: 10.1177/0310057x1304100104] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023]
Abstract
The development of effective cryopreservation techniques for both red blood cells and platelets, which maintain ex vivo biological activity, in combination with frozen plasma, provides for a unique blood banking strategy. This technology greatly enhances the storage life of these products. The rationale and potential advantages of using cryopreservation techniques for the provision of blood products to remote and military environments have been effectively demonstrated in several conflicts over the last decade. Current haemostatic resuscitation doctrine for the exsanguinating patient supports the use of red blood cells, platelets and frozen plasma early in the resuscitation. We believe an integrated fresh-frozen blood bank inventory could facilitate provision of blood products, not only in the military setting but also in regional Australia, by overcoming many logistic and geographical challenges. The processes involved in production and point of care thawing are sufficiently well developed and achievable to make this technology a viable option. The potential limitations of cryopreservation and subsequent product thawing need to be considered if such a strategy is to be developed. A substantial body of international experience using cryopreserved products in remote settings has already been accrued. This experience provides a template for the possible creation of an Australian integrated fresh-frozen blood bank inventory that could conceivably enhance the care of patients in both regional Australia and in the military setting.
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Affiliation(s)
- A Holley
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.
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Johnson L, Winter KM, Reid S, Hartkopf-Theis T, Marschner S, Goodrich RP, Marks DC. The effect of pathogen reduction technology (Mirasol) on platelet quality when treated in additive solution with low plasma carryover. Vox Sang 2011; 101:208-14. [DOI: 10.1111/j.1423-0410.2011.01477.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Johnson LN, Winter KM, Reid S, Hartkopf-Theis T, Marks DC. Cryopreservation of buffy-coat-derived platelet concentrates in dimethyl sulfoxide and platelet additive solution. Cryobiology 2011; 62:100-6. [PMID: 21241687 DOI: 10.1016/j.cryobiol.2011.01.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 01/06/2011] [Accepted: 01/10/2011] [Indexed: 10/18/2022]
Abstract
Platelets prepared in plasma can be frozen in 6% dimethyl sulfoxide (Me(2)SO) and stored for extended periods at -80°C. The aim of this study was to reduce the plasma present in the cryopreserved product, by substituting plasma with platelet additive solution (PAS; SSP+), whilst maintaining in vitro platelet quality. Buffy coat-derived pooled leukoreduced platelet concentrates were frozen in a mixture of SSP+, plasma and 6% Me(2)SO. The platelets were concentrated, to avoid post-thaw washing, and frozen at -80°C. The cryopreserved platelet units (n=9) were rapidly thawed at 37°C, reconstituted in 50% SSP+/plasma and stored at 22°C. Platelet recovery and quality were examined 1 and 24h post-thaw and compared to the pre-freeze samples. Upon thawing, platelet recovery ranged from 60% to 80%. However, there were differences between frozen and liquid-stored platelets, including a reduction in aggregation in response to ADP and collagen; increased CD62P expression; decreased viability; increased apoptosis and some loss of mitochondrial membrane integrity. Some recovery of these parameters was detected at 24h post-thaw, indicating an extended shelf-life may be possible. The data suggests that freezing platelets in 6% Me(2)SO and additive solution produces acceptable in vitro platelet quality.
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Affiliation(s)
- L N Johnson
- Research and Business Development, Australian Red Cross Blood Service, 153 Clarence Street, Sydney, NSW 2000, Australia.
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Reesink HW, Panzer S, McQuilten ZK, Wood EM, Marks DC, Wendel S, Trigo F, Biagini S, Olyntho S, Devine DV, Mumford I, Cazenave JP, Rasonglès P, Garraud O, Richard P, Schooneman F, Vezon G, Al Radwan R, Brand A, Hervig T, Castro E, Lozano M, Navarro L, Puig L, Almazán C, MacLennan S, Cardigan R, Franklin IM, Prowse C. Pathogen inactivation of platelet concentrates. Vox Sang 2010; 99:85-95. [PMID: 20230599 DOI: 10.1111/j.1423-0410.2010.01319.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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McMahon KA, Wilson NJ, Marks DC, Beecroft TL, Whitty GA, Hamilton JA, Csar XF. Colony-stimulating factor-1 (CSF-1) receptor-mediated macrophage differentiation in myeloid cells: a role for tyrosine 559-dependent protein phosphatase 2A (PP2A) activity. Biochem J 2001; 358:431-6. [PMID: 11513742 PMCID: PMC1222076 DOI: 10.1042/0264-6021:3580431] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
M1 myeloid cells transfected with the wild-type (WT) colony-stimulating factor-1 (CSF-1) receptor (CSF-1R; M1/WT cells) undergo CSF-1-dependent macrophage differentiation. By mutation studies, we have provided prior evidence that tyrosine 559 in the CSF-1R cytoplasmic domain governs the Src-dependent differentiation pathway. Further components of this pathway were then sought. We report that the extent of CSF-1-mediated tyrosine phosphorylation of protein phosphatase 2A (PP2A), and the associated loss of its activity were reduced in M1 cells transfected with the CSF-1R with a tyrosine-to-phenylalanine mutation at position 559 (M1/559 cells), compared with the corresponding responses in CSF-1-treated M1/WT cells. This evidence for an involvement of a reduction in PP2A activity in the differentiation process was supported by the restoration of the defect in the CSF-1-mediated differentiation of M1/559 cells by the addition of the PP2A inhibitor, okadaic acid. It was also found that the degree of activation of extracellular-signal-regulated kinase (ERK) activities by CSF-1 was reduced in M1/559 cells, suggesting their involvement in the differentiation process. These data suggest that PP2A and ERK form part of the Src-dependent signal-transduction cascade governing CSF-1-mediated macrophage differentiation in M1 cells.
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Affiliation(s)
- K A McMahon
- Arthritis and Inflammation Research Centre, University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Csar XF, Wilson NJ, McMahon KA, Marks DC, Beecroft TL, Ward AC, Whitty GA, Kanangasundarum V, Hamilton JA. Proteomic analysis of macrophage differentiation. p46/52(Shc) Tyrosine phosphorylation is required for CSF-1-mediated macrophage differentiation. J Biol Chem 2001; 276:26211-7. [PMID: 11290743 DOI: 10.1074/jbc.m100213200] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Macrophage colony stimulating factor (M-CSF or CSF-1) acts to regulate the development and function of cells of the macrophage lineage. Murine myeloid FDC-P1 cells transfected with the CSF-1 receptor (FD/WT) adopt a macrophage-like morphology when cultured in CSF-1. This process is abrogated in FDC-P1 cells transfected with the CSF-1 receptor with a tyrosine to phenyalanine substitution at position 807 (FD/807), suggesting that a molecular interaction critical to differentiation signaling is lost (Bourette, R. P., Myles, G. M., Carlberg, K., Chen, A. R., and Rohrschneider, L. R. (1995) Cell Growth Differ. 6, 631--645). A detailed examination of lysates of CSF-1-treated FD/807 cells by two-dimensional SDS-polyacrylamide gel electrophoresis (PAGE) revealed a number of proteins whose degree of tyrosine phosphorylation was modulated by the Y807F mutation. Included in this category were three phosphorylated proteins that co-migrated with p46/52(Shc). Immunoprecipitation, Western blotting, and in vitro binding studies suggest that they are indeed p46/52(Shc). A key regulator of differentiation in a number of cell systems, ERK was observed to exhibit an activity that correlated with the relative degree of differentiation induced by CSF-1 in the two cell types. Transfection of cells with a non-tyrosine-phosphorylatable form of p46/52(Shc) prevented the normally observed CSF-1-mediated macrophage differentiation as determined by adoption of macrophage-like morphology and expression of the monocyte/macrophage lineage cell surface marker, Mac-1. These results are the first to suggest that p46/52(Shc) may play a role in CSF-1-induced macrophage differentiation. Additionally, a number of proteins were identified by two-dimensional SDS-PAGE whose degree of tyrosine phosphorylation is also modulated by the Y807F substitution. This group of molecules may contain novel signaling molecules important in macrophage differentiation.
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Affiliation(s)
- X F Csar
- Arthritis and Inflammation Research Centre, University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia 3050.
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Marks DC, Csar XF, Wilson NJ, Novak U, Ward AC, Kanagasundarum V, Hoffmann BW, Hamilton JA. Expression of a Y559F mutant CSF-1 receptor in M1 myeloid cells: a role for Src kinases in CSF-1 receptor-mediated differentiation. Mol Cell Biol Res Commun 1999; 1:144-52. [PMID: 10356364 DOI: 10.1006/mcbr.1999.0123] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We have established two M1 myeloid cell lines, M1/WT cells overexpressing the wild-type CSF-1 receptor and M1/Y559F cells expressing a specific tyrosine mutant. M1/WT cells differentiated in response to CSF-1, with a reduction in their proliferative capacity. CSF-1-mediated differentiation was partially abrogated in the M1/Y559F cells, with a less marked reduction in proliferative capacity. The Src tyrosine kinases c-Src, c-Yes, c-Fyn, and c-Hck were tyrosine phosphorylated in the M1/WT cells in response to CSF-1 and bound to the WT CSF-1R through their SH2 domains. Binding of the Src kinases to the CSF-1 receptor was greatly reduced in the M1/Y559F cells. CSF-1-mediated activation of STAT3 was also abrogated in the M1/Y559F cell line. Treatment of M1/WT cells with the Src family inhibitor PP2 resulted in an inhibition of CSF-1-mediated differentiation, equivalent to that observed in the M1/Y559F cells. These data suggest that the reduced Src binding observed in the M1/Y559F cells may contribute to their reduced ability to differentiate.
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Affiliation(s)
- D C Marks
- Inflammation Research Centre, Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.
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Abstract
The development of drug resistance was studied in a series of haemopoietic cells to determine its relationship to cell lineage. Treatment of the U937 monocytic cell line with epirubicin (15 ng/ml) or vinblastine (8 ng/ml) induced drug-resistant sublines with cross-resistance to epirubicin (8- and 16-fold respectively), vinblastine (5- and 20-fold), paclitaxel (15- and 42-fold) and etoposide (19- and 13-fold). However, sublines were also 3-5-fold resistant to the alkylating agent chlorambucil, cis-platinum and methotrexate, demonstrating an extended multidrug resistance (MDR) phenotype. These cells over-expressed P-glycoprotein, but decreased drug accumulation was not restored in the presence of verapamil, suggesting that the P-glycoprotein was not functional. Similar drug treatment of the HL60 promyelocytic cell line also produced sublines exhibiting an extended MDR phenotype. The KG1a and the HEL cell lines expressed functional P-glycoprotein and were resistant to the drug concentrations used for treatment. Multidrug resistance as mediated by P-glycoprotein cannot explain the resistance of CML patients to chemotherapy, especially in blast crisis. The induction of an extended MDR phenotype specifically in myeloid cells in response to drug treatment may explain the resistance observed in the treatment of CMI.
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Affiliation(s)
- D C Marks
- Neurobiology Unit, University of Technology, Sydney, N.S.W., Australia
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Abstract
With the increasing use of inducers of cellular differentiation in the treatment of leukaemia, it is essential to understand the relationship between differentiation and the expression of the multidrug resistance. Using the K562 human leukaemia cell line and its multidrug resistant subline K562/E15B, differentiation was examined along two different pathways, megakaryocyte in response to treatment with 12-O-tetradecanoylphorbol-13-acetate (TPA), and erythroid in response to treatment with sodium butyrate, in the same cell line. P-glycoprotein expression was increased in the multidrug resistant K562/E15B subline, but not induced in the parental K562 cell line. However, both treatments conferred a different phenotype on the drug resistant subline. TPA treatment caused an increase in P-glycoprotein, increased drug resistance and decreased rhodamine-123 accumulation which was verapamil sensitive, demonstrating that TPA induced a fully functional P-glycoprotein. However, sodium butyrate treatment caused an increase in P-glycoprotein without increased drug resistance or without decreased rhodamine-123 accumulation suggesting that the P-glycoprotein induced by sodium butyrate was nonfunctional. These results stress the importance of examining not only the expression of P-glycoprotein in cells, but also the function of the P-glycoprotein induced.
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Affiliation(s)
- D C Marks
- Neurobiology Unit, University of Technology, Sydney, NSW, Australia
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Abstract
The relationship between differentiation and P-glycoprotein expression in response to chemotherapeutic drugs was studied in the K562 human leukaemia cell line by treatment with low, but clinically achievable levels of vinblastine and epirubicin. Resistant sublines were easily generated with the multidrug resistant phenotype being expressed in response to drug treatment as low as 1 ng/ml vinblastine and 10 ng/ml epirubicin. These sublines showed stable but heterogeneous expression of P-glycoprotein as revealed by immunocytochemistry, and confirmed by cloning. This heterogeneity was maintained over 18 months with intermittent drug treatment. While selection for resistance induced erythroid and myeloid differentiation, expression of P-glycoprotein was not correlated with the stem cell antigen CD34 or with specific markers of erythroid or myeloid differentiation.
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MESH Headings
- ATP Binding Cassette Transporter, Subfamily B, Member 1
- Antigens, Neoplasm/analysis
- Blotting, Western
- Carrier Proteins/analysis
- Carrier Proteins/drug effects
- Cell Differentiation/drug effects
- Drug Resistance
- Epirubicin/pharmacology
- Humans
- In Vitro Techniques
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/immunology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Membrane Glycoproteins/analysis
- Membrane Glycoproteins/drug effects
- Neoplasm Proteins/analysis
- Neoplasm Proteins/drug effects
- Tumor Cells, Cultured
- Verapamil/pharmacology
- Vinblastine/pharmacology
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Affiliation(s)
- D C Marks
- Neurobiology Unit, School of Biological and Biomedical Sciences, University of Technology, Sydney, N.S.W., Australia
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Abstract
The MTT cell viability assay is widely used in determining drug sensitivity profiles for patients with hematological malignancies and in primary screening of potential chemotherapeutic drugs. Because the multidrug resistance (MDR) phenotype is associated with these malignancies, and since many vital dyes are effluxed from MDR expressing cells, we have investigated whether the MDR phenotype interferes with the MTT assay. In CCRF-CEM and K562 human leukemic cell lines and drug-resistant sub-lines developed from them, comparison of the MTT assay with other cell viability assays showed significant variation in IC50 concentrations, although the resistance relative to the sensitive parent cell was correlated. Inclusion of verapamil, an inhibitor of drug efflux activity, had no effect on the MTT assay.
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Affiliation(s)
- D C Marks
- Neurobiology Unit, School of Biological and Biomedical Sciences, University of Technology, Sydney, Gore Hill, N.S.W., Australia
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