Removal of Plasmodium falciparum–infected red blood cells from whole blood by leukoreduction filters

Abstract

There has been an unexplained decrease in the incidence of transfusion-transmitted malaria in recent years. The decrease in incidence has paralleled the increasing use of leukoreduction filters. Malaria-infected red blood cells (RBCs) share surface characteristics of hemoglobin S-containing cells. Because units collected from donors with sickle trait do not filter optimally due to adherence of RBCs to the filters, the possibility that malaria-infected RBCs may also adhere to filters was investigated. Malaria-infected whole blood or calcium ionophore (A25187)-treated and control RBCs were filtered with leukoreduction filters. Quantitation of malaria-infected RBCs before and after filtration was performed by flow cytometry to determine the presence of DNA within RBCs, indicating malaria infection. Annexin V binding was also determined before and after filtration of RBCs treated with A25187. Immediately after filtration, filters were fixed and examined by scanning and transmission electron microscopy. There were at least three configurations of adherence of malaria-infected RBCs demonstrated within the filters. The first was direct adherence of infected RBCs to filter fibers; the second involved adherence of malaria-infected RBCs to platelets, which were adherent to filter fibers; and the third was adherence of infected RBCs to other RBCs. Filtration also resulted in preferential removal of phosphatidylserine (PS)-expressing cells as seen by the reduction of annexin V binding after filtration. This was further confirmed by electron micrographic examination of the filters in which untreated RBCs sit within the filter resting on top of filter fibers; however, calcium ionophore-treated RBCs are seen to cling tightly to the fibers. PS expression by RBCs leads to their adherence within leukoreduction filters. Malaria-infected RBCs are retained via more than one mechanism. The efficiency of removal requires further study.