Storage Of Blood Components Research Articles

Conventional blood banking and blood component storage regulation: opportunities for improvement.

Blood banking is a medical logistic activity. It attempts to bring the potentially life-saving benefits of transfusion to the patients who need them by making blood components available, safe, effective and cheap1. Blood banks try to maximize delivering getting blood from the right donors to the right patients in a timely manner. The easiest way to assure the timely availability of blood is to have an appropriate inventory on the shelf at all times. Standards for blood banking have evolved in response to problems observed in the past2. Donors need to be free of syphilis, hepatitis, and human immunodeficiency virus (HIV) and from a host of other diseases as well. Methods for cleaning the arms of donors should work. Blood bags should contain the appropriate solutions and be sterile. Systems for the identification of donors and patients, for the determination of antigens on their blood cells and the antibodies in their sera, and for the procedures and processes used to gather and maintain this information should be robust. Regulatory agencies, like the United States (U.S.) Food and Drug Administration (FDA), are charged to assure that blood products are safe and effective3. They attempt to assure safety by enforcing the standards noted above. They attempt to assure effectiveness by demanding demonstrations that a reasonable fraction of red cells, platelets and plasma proteins survive after storage before licensing new blood storage systems or blood modifying products like leukocyte reduction filters4,5. Yet the reasonable fraction for red cells is 75%, for platelets is 67%, and for plasma proteins is 80%. Standards, such as insisting that every unit of blood be tested for HIV, work only if the licensed tests detect the circulating viruses, a moving target. Better understanding of the basic biology and better tests on which to base better standards are needed. If we understood the changes that occur with the storage of red cells, platelets and plasma better, we could both design better storage systems and regulate storage more effectively. If we knew more about the viruses and bacteria and the cytokines and blood breakdown products that threaten blood safety we could institute controls to further improve blood safety. This paper will explore some specific examples.

Damage Control Resuscitation with Fresh Blood Products Attenuates the Systemic Inflammatory Response Following Hemorrhagic Shock

Introduction: Hemorrhagic shock initiates a dysfunctional inflammatory response that clinically leads to increased morbidity and mortality. Damage control resuscitation used to treat severe hemorrhage routinely utilizes stored packed red blood cells (pRBCs) and plasma. Stored pRBCs undergo structural and functional changes over time, but the effect of storage age on inflammation following transfusion is unknown. We hypothesized that the transfusion of fresh blood products attenuates inflammation following hemorrhagic shock as compared to stored blood components.

Storage of Blood Components Does Not Decrease Haemostatic Potential: In vitro Assessment of Fresh versus Stored Blood Components Using Thromboelastography

Background: Major surgery and severe trauma typically lead to massive blood loss requiring rapid transfusion of large amounts of blood products. It has been suggested that fresh, unrefrigerated whole blood provides a haemostatic advantage in this setting. The aim of the current study was to compare the clot formation parameters of fresh, unrefrigerated whole blood and whole blood reconstituted from components stored for varying periods of time, using rotational thromboelastography (ROTEM®). Methods: Fresh whole blood and reconstituted whole blood using combinations of nonleucoreduced red cell units (stored for 7, 14, 21, 28, or 35 days), platelet concentrates (stored for 1, 3 or 5 days), and fresh frozen plasma (stored for 6 months) were analysed using ROTEM. Measurements of the clotting time (CT), clot formation time (CFT), and maximal clot firmness (MCF) were compared between units of fresh whole blood and reconstituted whole blood samples. Results: There was no difference in the haemostatic parameters measured of fresh whole blood and reconstituted whole blood using red cell units stored for less than 21 days. ROTEM demonstrated that the CT and CFT were significantly shorter for reconstituted whole blood samples using red cells stored for longer than 21 days when compared to fresh whole blood and to reconstituted whole blood samples using red cell units stored for less than 21 days. The CT was inversely correlated to the duration of platelet storage. The MCF was unchanged regardless of duration of blood product storage. Conclusion: Fresh unrefrigerated whole blood and blood products stored for short duration (less than 21 days) were not superior to those stored for longer durations.

Transfusion-related acute lung injury

Sir, Transfusion-related acute lung injury (TRALI) is an uncommon, probably underrecognized complication of transfusion of plasma-containing blood components, which is characterized by acute respiratory distress. It is a clinical diagnosis and may be diagnosed when acute lung injury (ALI) occurs during or within six hours of transfusion in a patient without pre-existing ALI, in the absence of temporally related alternative risk factors for ALI (e.g., sepsis, shock, cardiac failure, etc.).[1] This communication discusses a case of TRALI in a middle-aged woman. A 52-year-old female patient with a diagnosis of inoperable carcinoma of the uterine cervix, received whole blood transfusion, in view of severe anemia. Before blood transfusion, she was alert, oriented, with no cardiorespiratory abnormality on clinicoradiological evaluation. Her vital parameters were normal and total leukocyte count was 8700/mm3 with normal blood biochemistry. After receiving approximately 200 ml of blood for over two hours, she complained of breathlessness, which progressively increased over the next 20 minutes. On examination she was febrile, tachypneic (respiratory rate 32/minute), slightly cyanotic, with a pulse rate of 120/minute, blood pressure 90/60 mmHg, and SpO2 68%. The jugular venous pressure (JVP) was normal and chest auscultation revealed bilateral basal fine inspiratory crackles with normal breath sounds. Sinus tachycardia was noted on an electrocardiogram (ECG). An urgent X-ray chest showed bilateral patchy infiltrates in the mid- and lower zones with normal heart size, suggestive of noncardiogenic pulmonary edema. Echocardiography also ruled out cardiogenic dysfunction. Hematological investigations at this stage showed a total leukocyte count of 3200/mm3, with no evidence of any hemolytic process. In the absence of other mechanisms to explain ALI, a diagnosis of TRALI was made. The blood transfusion was stopped immediately and she was managed with oxygen therapy and intravenous fluids that resulted in a gradual improvement of dyspnea and oxygen saturation. She became completely chest asymptomatic after three days, with a normal chest X-ray. The reported incidence of TRALI in medical literature is one in 5000 transfusions and this may actually be much higher as TRALI is usually an underrecognized and underreported entity.[2] TRALI has been associated with antibodies to WBCs in transfused blood components. Less frequently, it has been associated with leukocyte antibodies in the transfusion recipient. It has also been linked to the infusion of biologically-active lipids in stored cellular blood components.[3] A mild form of TRALI can present with dyspnea and fever, while more severe forms can have severe respiratory distress that can quickly progress to respiratory failure. Other features include hypotension, frothy endotracheal secretions, and so on. Transient leucopenia, as noted in our patient, is occasionally observed and is believed to be due to the sequestration of leukocytes in pulmonary circulation. It is important to distinguish TRALI from volume overload, as the treatment of the two conditions is markedly different. Diuretics are contraindicated in TRALI and there is no role for steroids also. Severe forms of TRALI may require mechanical ventilation.[3] Suspected cases of TRALI should be reported to the blood bank, to permit evaluation and deferral of high-risk donors, especially multiparous females. TRALI can be best prevented by avoiding unnecessary blood-product transfusions in selected populations.

Mirasol Pathogen Reduction Technology®treatment does not affect acute lung injury in a two-event in vivo model caused by stored blood components

Mirasol Pathogen Reduction Technology (PRT) treatment uses riboflavin and UV light to inactivate pathogens in blood components. Neutrophil [polymorphonuclear cells (PMN)] priming activity accumulates during routine storage of cellular blood components, and this activity has been implicated in transfusion-related acute lung injury (TRALI). We hypothesize that PRT-treatment of blood components affects the priming activity generated during storage of packed RBCs (PRBCs) or platelet concentrates (PCs), which can elicit ALI in vivo. Plasma, PRBCs and PCs were isolated from healthy donor's whole blood or by apheresis. Half of a collected unit was treated with PRT treatment and the remainder was left as an unmodified control. Supernatant was collected during storage of PCs and PRBCs and assayed for PMN priming activity and used as the second event in a two-event in vivo model of TRALI. PRT treatment did not induce priming activity in plasma or affect the priming activity generated during storage of PCs or PRBCs as compared with the unmodified controls. The supernatants from stored, but not fresh, PCs and PRBCs did cause ALI as the second event in a two-event animal model of TRALI, which was unaffected by PRT treatment. We conclude that the PRT treatment does not induce priming activity in plasma nor does it affect the priming activity generated during storage of PCs or PRBCs or their ability to cause ALI as the second event in a two-event in vivo model of TRALI. Moreover, the amount of priming activity in TRIMA-isolated PCs was significantly less than SPECTRA-isolated PCs.

Red cell storage

Blood component storage allows the donor and recipient to be separated in time and space. This separation converts transfusion from a desperate clinical act into a planned, orderly healthcare logistic activity with concomitant increases in both blood product availability and safety. However, storage has the potential to reduce the efficacy of transfused blood components by reducing their flow, functional capacity, and survival. Storage time also allows the accumulation of leaked potassium from red cells and the growth of contaminating bacteria. Many different aspects of the red cell storage lesion have been described, including changes in metabolism, shape, and rheology changes, loss of membrane carbohydrates, lipids and proteins, and alterations in secretion, oxygen delivery, and adhesion. What has been harder to show is that these known changes have significant clinical effects. Therefore, regulatory decisions about product storage have been conservative, and largely based on historic patterns of use. The increasing power of proteomics and metabolomics offers the potential of deeper understanding of blood function and storage and of better clinical products in the future.

Warm fresh whole blood transfusion for severe hemorrhage: U.S. military and potential civilian applications

The objective of this study was to review the history and current literature regarding the benefits and risks of warm fresh whole blood transfusion to include recent U.S. Army research from Afghanistan and Iraq. We also discuss current indications for its use as well as potential civilian applications for large-scale disasters. The use of warm fresh whole blood currently only persists in emergency life-threatening scenarios when tested stored blood components are not available. Recent combat operations in Afghanistan and Iraq have redirected attention on the benefits and risks of warm fresh whole blood for life-threatening injuries in casualties. Between March 2003 and July 2007, over 6000 units of warm fresh whole blood have been transfused in Afghanistan and Iraq by U.S. medical providers to patients with life-threatening traumatic injuries with hemorrhage. Preliminary results in approximately 500 patients with massive transfusion indicate that the amount of fresh warm whole blood transfused is independently associated with improved 48-hr and 30-day survival and the amount of stored red blood cells is independently associated with decreased 48-hr and 30-day survival for patients with traumatic injuries that require massive transfusion. Risks of warm fresh whole blood transfusion include the transmission of infectious agents and the potential for microchimerism. For patients with life-threatening hemorrhage at risk for massive transfusion, if complete component therapy is not available or not adequately correcting coagulopathy, the risk:benefit ratio of warm fresh whole blood transfusion favors its use. In addition, recent evidence suggests that there is potential for warm fresh whole blood to be more efficacious than stored component therapy that includes stored red blood cells in critically ill patients requiring massive transfusion. Efforts must continue to improve the safety of warm fresh whole blood transfusion for patients when it is required in emergency situations. U.S. civilian disaster agencies are preparing guidelines for its use in massive casualty scenarios and prospective, randomized trials are about to start to determine whether stored warm fresh (<24 hrs) whole blood improves outcomes compared with standard stored component therapy.

Tranfusion reactions in newborns

The transfusion of blood components is a safe and life-saving procedure. However, it may lead to an adverse outcome. Some of the more frequent acute immunologic transfusion reactions that are seen in older children and adults, such as febrile or allergic reactions, are rarely reported in the newborn. When these reactions do occur, they are usually the result of passively acquired antibodies infused into a relatively small plasma volume, rather than of antibodies produced by the infant. Newborns, on the other hand, may be more vulnerable to metabolic or physiologic complications as a result of the immature nature of their organ systems. The immature development of several organ systems in the premature infant has led to many concerns relating to the infant's ability to efficiently metabolize various compounds present in the anticoagulants and preservatives used for the storage of blood components. The risks for transfusion-related infection from screened donations for hepatitis B virus, hepatitis C virus and human immunodeficiency virus are today very low. Unfortunately, the potential still exists for previously unknown microorganisms to be transmitted via transfusion. All transfusions should be carefully monitored, and adverse reactions to blood components should be appropriately investigated. The decision to transfuse a patient, whether the patient is a newborn, an older child, or an adult, requires considering both the risks and the intended benefits of the transfusion

Transfusion medicine in the era of proteomics

Blood components (BCs) are highly complex mixtures of plasma proteins and cells. At present, BC and blood derivatives (BDs) quality control is mainly focused on standardized quantitative assessment, providing relatively limited information about products. Unfortunately, during the production, inactivation, and storage processes there is the risk of changes in their integrity, especially at the protein level, which could cause negative effects on transfusion. It is therefore a major challenge to identify significant alterations of these products, and, in this context, proteomics can play a potentially relevant role in transfusion medicine (TM) to assess the protein composition of blood-derived therapeutics, particularly for identifying modified proteins. It can provide comprehensive information about changes occurring during processing and storage of BCs and BDs and can be applied to assess or improve them, therefore potentially enabling a global assessment of processing, inactivation and storage methods, as well as of possible contaminants and neoantigens that may influence the immunogenic capacity of blood-derived therapeutics. Thus, proteomics could become a relevant part of quality-control process to verify the identity, purity, safety, and potency of various blood therapeutics. A more detailed understanding of the proteins found in blood and blood products, and the identification of their interactions, may also yield important information for the design of new small molecule therapeutics and also for future improvements in TM. Proteomics, together with genomics in the near future, will presumably have an impact on disease diagnosis and prognosis as well as on further advances in the production, pathogen inactivation and storage processes of blood-based therapeutics.

Re-transfusion of salvaged washed red cells improves clot formation in pigs as measured by rotational thrombelastometry (ROTEM®)

Patients exhibiting considerable blood loss are prone to develop dilutional coagulopathy following volume supply. In such patients, in addition to transfusing stored blood components, cell saver systems are used to minimize allogeneic transfusion. Since red cell transfusion might influence the haemostatic system by further dilution, we investigated the effects of re-transfusion of salvaged washed red blood cells on the haemostatic process in an animal model of controlled haemorrhage using rotational thrombelastometry (ROTEM; Pentapharm Co., Munich, Germany). Anaesthetized pigs (n = 20) developed coagulopathy following haemorrhagic shock (withdrawal of 66% of estimated blood volume) and volume resuscitation with 6% hydroxyethyl starch 130/0.4. The shed blood was processed in a Cellsaver device (CATS; Fresenius AG, Bad Homburg, Germany), and the resulting salvaged red blood cells were re-transfused. ROTEM assays were performed at baseline, after blood loss, after volume resuscitation and following re-transfusion of salvaged red blood cells. As compared with baseline, blood loss and subsequent volume resuscitation resulted in significantly increased median values of clotting time (CT: 47.0, 5 .3 and 103.5 s), and clot formation time (CFT: 36.0, 40.0 and 186.0 s), whiggle maximum clot firmness decreased (MCF: 72.0, 68.5 and 39.5 mm). After re-transfusion of salvaged red blood cells (805 +/- 175 mL) all these parameters improved (CT: 80.5 s; P = 0.05, CFT: 144.0 s; P = 0.0008, MCF: 42.0 mm; P = 0.0019) although baseline values were not reached. In the case of extreme isovolaemic haemodilution, increasing the circulating red cell mass by re-transfusing salvaged red blood cells did not worsen the findings of dilutional coagulopathy but interestingly, at least partially, improves the clot formation process.

Lesão pulmonar aguda associada à transfusão

Transfusion-related acute lung injury (TRALI) is a serious clinical syndrome associated with the transfusion of plasma-containing blood components. Recently, TRALI has come to be recognized as the leading cause of transfusion-related death in the United States and United Kingdom. This complication typically presents as shortness of breath, hypoxemia, hypotension, fever and noncardiogeneic pulmonary edema, all occurring during or within 6 h after transfusion. Although the mechanism of TRALI has not been fully elucidated, it has been associated with human leukocyte antigen antibodies (class I, class II or neutrophil alloantigens) and with biologically active mediators in stored cellular blood components. Most of the donors implicated in cases of TRALI are multiparous women. Rarely diagnosed, TRALI can be confused with other causes of acute respiratory failure. Greater knowledge regarding TRALI on the part of clinicians could be crucial in preventing and treating this severe complication of blood transfusion.

The pathogenesis of transfusion‐related acute lung injury (TRALI)

In recent years, transfusion-related acute lung injury (TRALI) has developed from an almost unknown transfusion reaction to the most common cause of transfusion-related major morbidities and fatalities. A clinical definition of TRALI was established in 2004, based on acute respiratory distress, non-cardiogenic lung oedema temporal association with transfusion and hypoxaemia. Histological findings reveal lung oedema, capillary leucostasis and neutrophil extravasation. However, the pathogenesis of TRALI remains controversial. Leucocyte antibodies, present in fresh frozen plasma and platelet concentrates from multiparous donors, and neutrophil priming agents released in stored cellular blood components have been considered to be causative. As neutrophils and endothelial cells are pivotal in the pathogenesis of TRALI, a threshold model was established to try to unify the various reported findings on pathogenesis. This model comprises the priming of neutrophils and/or endothelium by the patient's co-morbidity, neutrophil and/or endothelial cell activation by the transfused blood component, and the severity of the TRALI reaction.

Vasoactive mediators and hypotensive transfusion reactions

Vasoactive mediators and hypotensive transfusion reactions

Soluble CD40 ligand accumulates in stored blood components, primes neutrophils through CD40, and is a potential cofactor in the development of transfusion-related acute lung injury

AbstractTransfusion-related acute lung injury (TRALI) is a form of posttransfusion acute pulmonary insufficiency that has been linked to the infusion of biologic response modifiers (BRMs), including antileukocyte antibodies and lipids. Soluble CD40 ligand (sCD40L) is a platelet-derived proinflammatory mediator that accumulates during platelet storage. We hypothesized that human polymorpho-nuclear leukocytes (PMNs) express CD40, CD40 ligation rapidly primes PMNs, and sCD40L induces PMN-mediated cytotoxicity of human pulmonary microvascular endothelial cells (HMVECs). Levels of sCD40L were measured in blood components and in platelet concentrates (PCs) implicated in TRALI or control PCs that did not elicit a transfusion reaction. All blood components contained higher levels of sCD40L than fresh plasma, with apheresis PCs evidencing the highest concentration of sCD40L followed by PCs from whole blood, whole blood, and packed red blood cells (PRBCs). PCs implicated in TRALI reactions contained significantly higher sCD40L levels than control PCs. PMNs express functional CD40 on the plasma membrane, and recombinant sCD40L (10 ng/mL-1 μg/mL) rapidly (5 minutes) primed the PMN oxidase. Soluble CD40L promoted PMN-mediated cytotoxicity of HMVECs as the second event in a 2-event in vitro model of TRALI. We concluded that sCD40L, which accumulates during blood component storage, has the capacity to activate adherent PMNs, causing endothelial damage and possibly TRALI in predisposed patients.

Temperature-Sensitive Labels for Containers of RBCs

Temperature-sensitive labels are adhesive tags that display color changes at preset temperatures. There have been no studies of the suitability of this technology for measuring the temperature of blood components during transportation and storage. We used a digital thermometer to measure temperature in different locations inside containers of RBC as they were allowed to warm to ambient temperatures following removal from refrigeration. We compared these temperature readings with those of 3 temperature-sensitive labels. These labels are marketed to alert transfusion services if the temperature of blood bags exceeds 10 degrees C, which is the maximum permissible by Food and Drug Administration and American Association of Blood Banks requirements for transporting RBCs. The contents of refrigerated RBC units changed from one homogeneous temperature to a range of temperatures when containers were allowed to warm (undisturbed) to ambient temperatures. Color changes of all 3 temperature-sensitive labels correlated more with core compared with surface temperatures of RBCs units. These devices add an additional dimension of safety to the conventional 30-minute rule, which limits storage of blood components at ambient temperature to 30 minutes.

Temperature-Sensitive Labels for Containers of RBCs

Temperature-sensitive labels are adhesive tags that display color changes at preset temperatures. There have been no studies of the suitability of this technology for measuring the temperature of blood components during transportation and storage. We used a digital thermometer to measure temperature in different locations inside containers of RBCs as they were allowed to warm to ambient temperatures following removal from refrigeration. We compared these temperature readings with those of 3 temperature-sensitive labels. These labels are marketed to alert transfusion services if the temperature of blood bags exceeds 10°C, which is the maximum permissible by Food and Drug Administration and American Association of Blood Banks requirements for transporting RBCs. The contents of refrigerated RBC units changed from one homogeneous temperature to a range of temperatures when containers were allowed to warm (undisturbed) to ambient temperatures. Color changes of all 3 temperature-sensitive labels correlated more with core compared with surface temperatures of RBC units. These devices add an additional dimension of safety to the conventional 30-minute rule, which limits storage of blood components at ambient temperature to 30 minutes.

Transfusion‐related acute lung injury and transfusion‐associated circulatory overload

Pulmonary complications of transfusion were once believed to be infrequent and relatively unimportant in terms of morbidity. Transfusion‐related acute lung injury (TRALI) and transfusion‐associated circulatory overload (TACO) are now appreciated as being relatively common and clinically important. TRALI is one of the two most frequent causes of transfusion‐associated death and patients with TACO have longer hospitalizations and increased morbidity. Both entities are diagnosed primarily on clinical grounds but laboratory tests are available which can confirm or supplement the clinical impression. The high‐risk patient for TRALI has not been identified but in TACO, very young or older patients who are transfused too rapidly or with too much volume are the most vulnerable. The mechanism of TRALI is incompletely understood but antibodies in stored blood components certainly play an important role. In TACO, the problem is primarily a mechanical issue. Prompt recognition is the key to successful treatment for both entities.

Transforming growth factor‐β1, Th1 responses, and autoimmune liver disease

Transforming growth factor-beta1 (TGF-beta1) is released during the storage of blood components, particularly platelet concentrates, and transfusion recipients are exposed to high levels of TGF-beta1. Because TGF-beta1 is one of the most potent immunosuppressive cytokines known, understanding the immunobiologic functions of TGF-beta1 may be relevant for understanding the immunobiologic effects of transfusion. Our laboratory studies the biologic effects of TGF-beta1 in the immune system. Mice deficient in TGF-beta1 spontaneously develop autoimmunity, confirming the important role of this cytokinean an immune regulator. A few years ago, my laboratory made the observation that genetic background strongly affects the phenotype of TGF-beta1-/- mice. TGF-beta1-/- mice on the BALB/c background rapidly develop an aggressive T-cell-mediated hepatitis, whereas TGF-beta1-/- mice on the 129/CF-1 background do not. In this review, I summarize findings published or in press from our laboratory on disease pathogenesis in TGF-beta1-/- mice and then discuss some of the exciting (as-yet-unpublished) directions our laboratory is currently taking.

保存前白血球除去に用いる全血用白血球除去フィルター付きクローズドバッグシステムの性能評価

In order to avoid a wide variety of side effects associated with blood transfusion such as nonhemolytic febrile transfusion reactions (NHFTR), HLA-sensitization and Cytomegalovirus infection. Leukocyte filters have come into wide use in bedside blood transfusion in Japan. During the storage of blood components, however, residual leukocytes disintegrate and release various biologically active substances, which constitute one of the causes of transfusion-related adverse events. Therefore, removal of leukocytes immediately or at an early stage after blood collection is expected to decrease the incidence of transfusion-related side effects by controlling the deterioration of blood cells or preventing the accumulation of cytokines.The WBF2 closed-bag system is a blood collection-component separation system designed for the removal of leukocytes from whole blood and the preparation of blood components by centrifugation. In the present study, we evaluated the usefulness of the system in the preparation of leukocyte-reduced RC-MAP and FFP using WBF2, and compared the quality of these preparations with those by conventional post-storage leukoreduction or non-leukoreduction. The WBF2 system yielded red cell components with superior red cell recovery and lower accumulation of some cytokines, demonstrating its suitability for use in a blood center program. It was also noted that there was almost no macroaggregation in red cell components prepared by prestorage leukoreduction.

Review: transfusion-related acute lung injury: pathophysiology, laboratory investigation, and donor management

Abstract Transfusion-related acute lung injury (TRALI) is a serious clinical syndrome that is temporally associated with the transfusion of plasma-containing blood components. The syndrome typically occurs within 6 hours of transfusion. Approximately 80 percent of cases will resolve within 96 hours with supportive care. The syndrome has been associated with antibodies to WBC antigens and generation of biologically active mediators in stored cellular blood components. Appropriate laboratory investigation of TRALI can be crucial in confirmation of the clinical diagnosis, as well as in decisions regarding donor management.