Transfusion-associated graft-versus-host disease,transfusion-associated hyperkalemia,and potassium filtration: advancing safety and sufficiency of the blood supply

Irradiation of cellular blood components is well established as a countermeasure against transfusion-associated graft-versus-host disease (TA-GVHD). Unintended consequences of ionizing radiation are also well established. The red cell “storage lesion” – a progression of metabolic, functional, and morphological changes – may be exacerbated by irradiation rates and doses typically used for TA-GVHD prophylaxis. With or without irradiation, a storage lesion change of clinical concern is the accelerated egress of intracellular potassium. ATP depletion during storage limits the activity of the red cell membrane’s sodium-potassium pump (Na,K-ATPase), which normally maintains intracellular potassium (K+) at levels 30–40 times higher than the extracellular milieu. The natural diffusion of potassium down this concentration gradient proceeds faster if the cell membrane is damaged, and oxidative damage to cellular membranes and membrane proteins – including Na,K-ATPase – is an effect of ionizing radiation.Preventing transfusion-related hyperkalemia is a reason for limiting the shelf life of irradiated red cells. In the absence of specific measurements to assess storage lesion in a particular unit of blood, and in the absence of specific interventions at the time of transfusion to mitigate effects of storage lesion, it is consistent with the precautionary principle to put conservative limits on a blood component’s shelf life. On the other hand, both the safety and sufficiency of a nation’s blood supply might be improved by interventions that benefit specific recipients when they are transfused, and benefit future patients by extending the allowable shelf life of blood components. Potassium filtration of irradiated red blood cell components is one such intervention.     

The critical role of blood from HLA-homozygous donors in fatal transfusion-associated graft-versus-host disease in immunocompetent patients

Fatal transfusion-associated graft-versus-host disease developed in a 69-year-old woman with colon cancer who underwent elective hemicolectomy. During the perioperative period, she was transfused with 4 units of nonirradiated fresh whole blood less than 6 hours after the blood was donated by family members. She was immunocompetent and was not treated with any immunosuppressive agents such as corticosteroids, chemotherapy, or irradiation therapy. The implicated donor was thought to be her daughter, who was homozygous for an HLA haplotype that was shared with the recipient: A24, Bw52, CBL, DR2. This is the most common haplotype in the Japanese population. This case and others in the Japanese literature indicate that the transfusion of fresh, nonirradiated blood that contains immunocompetent lymphocytes and peripheral hematopoietic precursor cells from HLA-homozygous donors can be lethal to the recipient.     

Diagnosis of transfusion-associated graft-versus-host disease by genetic fingerprinting and polymerase chain reaction

A patient with Hodgkin's disease (clinical stage IIIB) received chemotherapy and total nodal irradiation. After the transfusion of filtered packed red cells, this patient developed transfusion-associated graft-versus-host disease (TA-GVHD). The genetic fingerprint of the patient's peripheral blood lymphocytes (PBLs) differed completely from that of her other body tissues. Normally, after transfusion, only the patient's own genetic fingerprints are observed in the PBLs, as exemplified in more than 10 control cases in which the transfused blood had not been filtered before transfusion. No signal bands corresponding to those of the blood donor could be demonstrated in samples of the patient's tissue DNA. Moreover, chimerism was detected in the hybridization pattern of the patient's PBLs on the ninth day after the onset of symptoms. Polymorphic simple repeats in the HLA-DRB gene after amplification by polymerase chain reaction were also investigated, which confirmed the fingerprinting results. The advantages of these methods for the diagnosis of TA-GVHD include the rapid and unequivocal diagnosis as well as the fact that there is no need for the relatives to be HLA typed.     

滤除白细胞对全血保存质量的影响

目的 考察滤除白细胞对全血保存质量和功能的影响.方法 1袋(2 U=400 mL)新鲜全血均分为滤除白细胞全血(简称滤白)组:按照去白滤器的使用说明书操作,在采血＜6h过滤制备去白细胞全血;对照组:不滤除白细胞.过滤及未过滤的全血均采用无菌方式分别分为6小袋[(30～40) mL/袋],(4±2)℃常规保存,分别于保存1、7、14、21、28、35 d各取1小袋,检测血常规、pH、游离血红蛋白(FHb)、氧亲和力(P50)、ATP、2,3-二磷酸甘油酸(2,3-DPG)、电解质、红细胞膜表面PS、CD47表达、葡萄糖、乳酸等指标,比较过滤与未过滤全血质量的差异.结果 实验组1U全血过滤后剩余白细胞数为(0.32±0.05)×106个;滤白组和对照组比较,保存35 d时血红蛋白(Hb) (g/L)为149.00±11.53 vs 137.20±3.96、MCV(fL)为98.90±3.23vs 98.96±2.10、pH为6.78±0.02vs6.75±0.02、P50(mmHg)为15.36±0.63vs15.18±0.22、ATP(μmol/gHb)为3.57±0.15vs3.61±1.02、2,3-DPG (mmol/L)为0.13±0.09 vs 0.22±0.2、PS阳性率(％)为0.96±0.08vs1.19±0.03、CD47阳性率(％)为47.65±3.92vs48.37±4.35(P ＞0.05),溶血率(％)为0.08±0.02vs0.12±0.03(P ＜0.05);保存28 d时乳酸(mmoL/L)为15.76±0.19vs18.73 ±0.97、葡萄糖(mmol/L)为20.21±0.55vs18.57±0.46(P ＜0.05).结论 全血离体保存期间会发生一系列质量和功能的变化,滤除白细胞全血的溶血率、乳酸、葡萄糖等指标略优于未过滤的全血,二者的携释氧功能及其他生理生化指标均无明显差异,说明滤除白细胞未对全血保存期间的质量产生不良影响,并可能有利于血液保存.     

Identification of HLA class II antigens as the targets of effector clones which may cause transfusion-associated graft-versus-host disease

We established T cell clones, which were considered to be the possible cause of transfusion-associated graft-versus-host disease (TA-GVHD), from the peripheral blood lymphocytes (PBLs) of two patients. In both cases, several CD4⁺ cytotoxic T-cell (CTL) clones were established. In case I, the target antigen of the established CD4⁺ clones was a DRB1*0403-related antigen serologically typed as HLA DR4, which was one of the patient HLA antigens. In case II, the target of four out of five established CD4⁺ CTL was a DRB1*1302-related antigen. One CD4⁺ CTL clone showed cytotoxicity against cells carrying A*2402, B*4403, Cw*1403 and DPB1*0401. A monoclonal antibody (mAb) blocking study showed only anti-DP mAb inhibited the cytotoxicity of this clone. Thus, it might be considered that this clone recognizes HLA-DP with its binding peptides derived from either A*2402, B*4403, Cw*1403 or DRB1*1302. Our findings indicate that CD4⁺ CTLs may play important roles in the aetiology of TA-GVHD and that the antigens of patients recognized by donor-derived effector cells may not always recognize a single HLA antigen.     

Guest Editorial: Two hits and four factors affecting the development of,or resistance to,transfusion-associated graft-versus-host disease

Transfusion-associated graft-versus-host disease (TA-GVHD), a rare but usually fatal adverse effect of transfusion, is hypothesized here as a two-hit phenomenon: 1) predisposing “cytokine weather” irrespective of immunocompetence, plus 2) consequence of a (partial or total) one-way (donor to recipient) HLA match of viable donor T lymphocytes with proliferation potential. Since the introduction of irradiation, universal leukoreduction with third or later generation filters, and avoidance of transfusion from blood relatives, TA-GVHD has been successfully prevented in developed countries. However, potassium release from stored red blood cells is accelerated after irradiation, increasing the likelihood of hyperkalemia-associated mortality during rapid, and/or high-volume RBC transfusions, including exchange transfusions and extracorporeal circuit priming. Pathogen inactivation technologies may effectively prevent T lymphocyte replication, but have not yet been perfected for whole blood or red cell components. Protection against organ transplantation-associated GVHD (mainly from liver transplants) would likewise be improved by knowing and avoiding HLA one-way matched organ donors.     

The effects of leukodepletion on the generation and removal of microvesicles and prion protein in blood components

BACKGROUND: Universal leukodepletion (LD) has been implemented in the United Kingdom to reduce the risk of transfusion-transmitted variant Creutzfeldt-Jakob disease. If LD causes microvesiculation of blood cells, however, potentially infectious membrane-associated prion could reach the final products. STUDY DESIGN AND METHODS: We have measured microvesicles (MV) derived from red cells (RBC-MV), platelets (PLT-MV), and white blood cells (WBC-MV) and cellular prion protein (PrP(c)) in blood components produced by four whole-blood, five RBC, three PLT, and two plasma LD filters and three plateletpheresis techniques. RESULTS: RBC-MV and PLT-MV were either unaltered or reduced by all processes, with PLT-MV reduced 10-fold by RBC LD and greater than 300-fold by plasma LD. WBC-MV were reduced or unchanged by RBC and PLT LD and reduced by plasma LD. Whole-blood filtration appeared to increase MVs derived from granulocytes, but the load in the final components was comparable to that in processed RBCs in additive solution. PrP(c) was reduced by whole-blood, RBC, and plasma LD and unchanged by PLT techniques. There were differences between various filters and techniques, which were generally minor compared to the overall effects. CONCLUSION: These findings suggest no detrimental effects of LD processes in terms of generation of MVs or PrP(c) release.     

The impact of blood coagulability on atherosclerosis and cardiovascular disease

Summary. Although the link between blood coagulation and atherogenesis has been long postulated, only recently, and through the extensive work on transgenic mice, crossbred on an atherogenic background, has the direction of this interaction become visible. In general, hypercoagulability in mice tends to increase atherosclerosis, whereas hypocoagulability reduces the atherosclerotic burden, depending on the mouse model used. The information on a direct relationship between coagulation and atherosclerosis in humans, however, is not that clear. Almost all coagulation proteins, including tissue factor, are found in atherosclerotic lesions in humans. In addition to producing local fibrin, a matrix for cell growth, serine proteases such as thrombin may be very important in cell signaling processes, acting through the activation of protease‐activated receptors (PARs). Activation of PARs on vascular cells drives many complex processes involved in the development and progression of atherosclerosis, including inflammation, angiogenesis, and cell proliferation. Although current imaging techniques do not allow for a detailed analysis of atherosclerotic lesion phenotype, hypercoagulability, defined either by gene defects of coagulation proteins or elevated levels of circulating markers of activated coagulation, has been linked to atherosclerosis‐related ischemic arterial disease. New, high‐resolution imaging techniques and sensitive markers of activated coagulation are needed in order to study a causal contribution of hypercoagulability to the pathophysiology of atherosclerosis. Novel selective inhibitors of coagulation enzymes potentially have vascular effects, including inhibition of atherogenesis through attenuation of inflammatory pathways. Therefore, we propose that studying the long‐term vascular side effects of this novel class of oral anticoagulants should become a clinical research priority.     

The irradiation of blood and blood components to prevent graft-versus-host disease: Technical issues and guidelines

In recent years, there have been several advances in blood irradiation practice. These include a better definition of the most appropriate dose level that should be used when irradiating blood components. Commercial innovation has provided the tools for a quality assurance program to assess the dose that is delivered throughout the canister in a free-standing irradiator, and, through the use of radiationsensitive indicator labels, to confirm that the irradiation process has taken place. With the apparent increased use of linear-accelerators to irradiate blood components, appropriate quality assurance measures need to be developed. The maximum storage period for irradiated red cells should be shorter than for nonirradiated red cells if the treatment is performed early during the storage period because irradiation reduces the in vivo 24-hour red cell recovery parameter. The storage period for irradiated platelets does not need to be modified. Some questions are being raised regarding whether fresh-frozen plasma should be irradiated to inactivate a small number of immunocompetent progenitor cells that may be present.Table 4 summarizes the practices that should be followed in connection with the technical issues that have been addressed in this article. These guidelines follow the recommendations issued in July 1993 by the FDA in the United States. This article and Tables 1 and 2 contain additional guidelines.     

The impact of blood campaigns using mobile blood collection drives on blood supply management during the COVID-19 pandemic

Background and objectivesBlood transfusion is a lifesaving procedure for transfusion-dependent patients. Therefore, maintaining blood supply is extremely crucial. The coronavirus disease 2019 (COVID-19) pandemic has negatively affected blood supply by affecting donor attendance. This study aimed to investigate blood supply and demand during the pandemic and demonstrate the positive impact of blood donation campaigns through mobile blood drives.Materials and methodsA cross-sectional study was conducted based on data of the blood bank at Prince Muhammad bin Nasser Hospital (PMBNH) in southwestern Saudi Arabia. Data on the attendance of blood donors at PMBNH were retrieved and retrospectively reviewed to assess the impact of mobile blood drives during the COVID-19 pandemic.ResultsBlood supply and donor attendance during the COVID-19 pandemic dropped by 17.32 %. However, blood supply increased between March and May 2020 due to national blood donation campaigns conducted through mobile blood drives. The drop in blood supply after 3 months of mobile blood drives significantly decreased to 0.17 % (P < 0.01). This means the blood supply was increased as follows; (March 2020 = 32.67 %, April 2020 = 45.54 %, and May 2020 = 19.47 %). On the other hand, blood demand decreased by 12.83 %.ConclusionThis study demonstrated the significant impact of establishing blood donation campaigns through mobile blood drives. Our results showed that the strategy can contribute to sufficient blood units to patients during pandemics and emergencies.