Red blood cell (RBC) transfusion is a critical, life-saving treatment for severe anaemia caused by disease or chemotherapy, or by blood loss due to trauma or major surgery. For several decades RBC components have been prepared as concentrates suspended in nutrient additive solution, which preserves and extends the shelf-life of the RBC component, allowing up to 6–7 weeks of refrigerated storage1. Nevertheless, during storage RBCs undergo a complex and progressive accumulation of physicochemical changes, collectively referred to as the RBC storage lesion2,3. Recent clinical studies have identified RBC transfusion as an independent risk factor for increased morbidities and mortalities in certain groups of patients, including trauma, cardiac surgery and the critically-ill (reviewed in4–6). Additionally, some of these studies have identified that older stored RBCs are more strongly implicated in poorer outcomes compared to fresher RBCs6. In order to address these concerns, there is renewed interest to better understand the RBC storage lesion and to find ways to ameliorate the deleterious effects of storage, thereby improving the quality, efficacy and safety of RBC components for all transfusion recipients. While increased research effort is being directed to better understand the effects of storage on RBCs and the potential impact on transfusion outcomes7, slower progress is being made in finding ways to deter the detrimental effects of the RBC storage lesion. This perspectives paper will focus on this latter aspect and will provide a brief overview of the currently licensed RBC additive solutions, new experimental additive solutions, some of the challenges for progressing the development of RBC storage systems and where the application of “omics” analyses could benefit the advancement of RBC storage systems.

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