Title: RBC storage lesions: What they are, and how we can minimize them
1RBC storage lesionsWhat they are, and how we
can minimize them
- Tatsuro Yoshida PhD
- New Health Sciences Inc. Bethesda MD
- Biomedical Engineering, Boston University
- Boston MA
2Storage lesions
- What are they?
- How are they related?
- What are the consequences?
- What can we do about them?
- Prevention
- Reversal
- Targets for ideal refrigerated RBC storage.
Recent review literatures 1-3
3Refrigerated RBC storage altered parameters
Biochemical Metabolic
Biomechanical
Oxidative
SNO-Hb ?
4Refrigerated RBC storage altered parameters
Biochemical Metabolic
Biomechanical
Oxidative
SNO-Hb ?
5Refrigerated RBC storage altered parameters
Biochemical Metabolic
Biomechanical
Oxidative
SNO-Hb ?
6Refrigerated RBC storage altered parameters
Biochemical Metabolic
Biomechanical
Oxidative
SNO-Hb ?
7Storage lesions of metabolic origin
Biochemical Metabolic
Biomechanical
Oxidative
SNO-Hb ?
8Storage lesions of metabolic origin
References 4,5
9Consequences of ATP depletion
References 4,5
10Consequences of ATP depletion (2)
References 4,5
11Storage lesion loss of vasoregulation
- Hemolysis gradual increase
- NO scavenger--vasoconstriction
- ATP release gradual decrease
- Loss of ATP mediated vasodilation
- Loss of NO delivery by RBC fast
- Impaired vasoregulation
12Regulation of microvascular perfusion mediated by
ATP
References 4,5
13Consequence of 2,3-DPG depletion
Release DPG from Hb
References 4,5
Reduced oxygen delivery capacity
14Consequences of depleted 2,3-DPGreduction in
tissue oxygen delivery
From Bunn Forget 1986 7
152,3-DPG and hemoglobin
Release DPG from Hb
Modified figure from Perutz, Nature 228734,1970
References 4,5
Reduced oxygen delivery capacity
16Loss of NO-linked vasoregulation by RBC
- Studies Stored blood lacks nitric oxide
Associated Press October 8, 2007 080620 PM PST - Vasodiatory activity of RBC is lost 3 hrs after
blood collection - Bennett-Guerrero E, Veldman TH, Doctor A, et al.
Evolution of adverse changes in stored RBCs.
Proceedings of the National Academy of Sciences
2007104(43)17063-68.
17RBC is a carrier of NO for vasoregulation
Regulation of microvascular perfusion mediated
by Hemoglobin NO
SNO
SNO---biologically active S-nirtrosothiol
References 27,28
18Hemoglobin and nitric oxide
NO
(Hb)3Hb-NO
(Hb)4
T-State
O2
RSNO
(HbO2)4-SNO
(Hb)4-SNO
R-State
O2
LUNG
19Loss of NO-linked RBC mediated vasoregulation
- Immediately after transfusion, RBCs may not only
fail to increase peripheral blood flow, but may
also function as NO sink
20Loss of NO-linked RBC mediated vasoregulation
- Immediately after transfusion, RBCs may not only
fail to increase peripheral blood flow, but may
also function as NO sink - How serious is this effect in relation to other
storage lesions? - Is it reversible in vivo---most likely
- How fast can it recover in vivo??
21Storage lesions linked to oxidative damage
Biochemical Metabolic
Biomechanical
Oxidative
SNO-Hb ?
22Oxidative damage pathway
References 8-11
23Storage lesions linked to oxidative damage
SNO-Hb ?
References 8-11
24Consequences oxidative damage
References 12,13
25Damage pathways
Biochemical / Metabolic alterations
Oxidative Damage
Bio-mechanical changes Hemolysis Post-transfusion
removal TRALI
26Reduction or delaying development of storage
lesions
27RBC metabolic pathways
26
28Prevention of metabolic storage
lesionsEmbden-Meyerhof pathway ATP and 23DPG
Metabolic modulation 14-15
29Prevention of metabolic storage lesions
manipulations with additive solution
Review Hess 2006 16
30Prevention of metabolic storage lesions
storage under anaerobic condition
References 17-19
31Reduction or delaying development of storage
lesions
32Reduction of oxidative damageRBC redox system
33Reduction of oxidative damage metabolic
manipulations
- GSH precursors 20
- L-carnitine (protection of RBC membrane 21)
- Anti-oxidant / free radical
- scavenger in storage solution
- Mannitol, N-acetylcysteine
- tirilazad mesylate, etc
- 11,22,23
34Reduction of oxidative damage storage under
anaerobic condition
- Store RBC without oxygen
- Stop hydroxyl radical-mediated peroxidation
cycles - Prevent hemoglobin denaturation
Reference 19
35Reversal of storage lesions
36Reversibility of storage lesions
?
SNO-Hb
37Rejuvenation
- Post-storage metabolic manipulations
- Mixture of pyruvate, inosine, Pi, adenine, PEP
etc - Rejuvesol (Cytosol Laboratory Inc)
- 37C incubation followed by cell washing 24
- Experimental
- PEP references in 25
38RBC metabolic pathways
26
39Rejuvenation by PIPA (Rejuvesol)
40Rejuvenation by PIPA
Rejuvenation by PIPA (Rejuvesol)
41Rejuvenation by PIPA
Rejuvenation by PIPA (Rejuvesol)
42Rejuvenation with PEP
Reference 25
43Result of rejuvenation
- Restored ATP
- Elevated 2,3-DPG
- Increased 24-hr recovery rate
- Rejuvesol is approved by FDA, but RBC must be
washed
44Result of rejuvenation
- Restored ATP
- Elevated 2,3-DPG
- Increased 24-hr recovery rate
- Rejuvesol is approved by FDA, but RBC must be
washed - Rejuvesol can be added during storage
- High levels of ATP and 2,3DPG throughout extended
storage period - Prevent PS accumulation on RBC surface
- Increased 24-hr recovery rate
45Goals for improved RBC storage
46Reduced toxicity
- Reduce hemolysis
- Reduce dead-on-arrival RBC
- Iron toxicity
- Vasoconstriction via NO scavenging
- Maintain deformability / prevent aggregation
- Prevent capillary blockage
47Increase 24-hr recovery rate and / or extend
shelf-life
- Maintenance of high ATP
- Minimize oxidative damage
- Maintain below threshold parameters causing
removal after transfusion to provide sufficient
time for recovery in body after transfusion
48Targets for ideal refrigerated RBC storage
Reduced toxicity
- Reduce hemolysis
- Reduce dead-on-arrival RBC
- Iron toxicity
- Vasoconstriction via NO scavenging
- Maintain deformability / prevent aggregation
- Prevent capillary blockage
- Prevent release, and/or remove bio-active
substances - Prevention of TRALI
- Leukoreduction, irradiation, pathogen-reduction,
etc.
49Higher functionality for efficient
tissue oxygenation
- Maintain high levels of
- 2,3-DPG oxygen release
- SNO-Hb regulation of vascular perfusion
- ATP regulation of vascular perfusion
- Deformability capillary perfusion
50Selected recent reviews
- Storage lesion
- Ho J, Sibbald WJ, Chin-Yee IH. Effects of storage
on efficacy of red cell transfusion when is it
not safe? Crit Care Med 200331(12
Suppl)S687-97. - Chin-Yee I, Arya N, d'Almeida MS. The red cell
storage lesion and its implication for
transfusion. Transfus Sci 199718(3)447-58. - Clinical consequences of transfusion (not covered
in this talk) - Tinmouth A, Fergusson D, Yee IC, Hebert PC.
Clinical consequences of red cell storage in the
critically ill. Transfusion 200646(11)2014-27. - Solheim BG, Flesland O, Seghatchian J, Brosstad
F. Clinical implications of red blood cell and
platelet storage lesions an overview. Transfus
Apher Sci 200431(3)185-9. - Vincent JL, Baron JF, Reinhart K, et al. Anemia
and blood transfusion in critically ill patients.
Jama 2002288(12)1499-507. - Spiess BD. Blood transfusion the silent
epidemic. Ann Thorac Surg 200172(5)S1832-7. - Additive solutions
- Hess JR. An update on solutions for red cell
storage. Vox Sang 200691(1)13-9. - Vasoregulatory function of stored RBC
- Bennett-Guerrero E, Veldman TH, Doctor A, et al.
Evolution of adverse changes in stored. RBCs.
Proceedings of the National Academy of Sciences
2007104(43)17063-68.
51References (1)
- 1. Tinmouth A, Fergusson D, Yee IC, Hebert PC.
Clinical consequences of red cell storage in the
critically ill. Transfusion 200646(11)2014-27. - 2. Ho J, Sibbald WJ, Chin-Yee IH. Effects of
storage on efficacy of red cell transfusion when
is it not safe? Crit Care Med 200331(12
Suppl)S687-97. - 3. Chin-Yee I, Arya N, d'Almeida MS. The red cell
storage lesion and its implication for
transfusion. Transfus Sci 199718(3)447-58. - 4. Ellsworth ML, Forrester T, Ellis CG, Dietrich
HH. The erythrocyte as a regulator of vascular
tone. Am J Physiol 1995269(6 Pt 2)H2155-61. - 5. Sprague RS, Ellsworth ML, Stephenson AH,
Lonigro AJ. ATP the red blood cell link to NO
and local control of the pulmonary circulation.
Am J Physiol 1996271(6 Pt 2)H2717-22. - 6. Burnstock G, Kennedy C. A dual function for
adenosine 5'-triphosphate in the regulation of
vascular tone. Excitatory cotransmitter with
noradrenaline from perivascular nerves and
locally released inhibitory intravascular agent.
Circ Res 198658(3)319-30. - 7. Bunn H, Foget B. Hemoglobin Molecular
genetics and clinical aspects. Philadelphia, PA
WB Sanders, 1986. - 8. Wolfe LC, Byrne AM, Lux SE. Molecular defect
in the membrane skeleton of blood bank-stored red
cells. Abnormal spectrin-protein 4.1-actin
complex formation. J Clin Invest
198678(6)1681-6. - 9. Wolfe LC. Oxidative injuries to the red cell
membrane during conventional blood preservation.
Semin Hematol 198926(4)307-12. - 10.Beppu M, Mizukami A, Nagoya M, Kikugawa K.
Binding of anti-band 3 autoantibody to
oxidatively damaged erythrocytes. Formation of
senescent antigen on erythrocyte surface by an
oxidative mechanism. J Biol Chem
1990265(6)3226-33.
52References (2)
- 11. Knight JA, Searles DA. The effects of various
antioxidants on lipid peroxidation in stored
whole blood. Ann Clin Lab Sci 199424(4)294-301. - 12. Silliman CC, Voelkel NF, Allard JD, et al.
Plasma and lipids from stored packed red blood
cells cause acute lung injury in an animal model.
J Clin Invest 1998101(7)1458-67. - 13. Boas FE, Forman L, Beutler E.
Phosphatidylserine exposure and red cell
viability in red cell aging and in hemolytic
anemia. Proc Natl Acad Sci U S A
199895(6)3077-81. - 14. Messana I, Ferroni L, Misiti F, et al. Blood
bank conditions and RBCs the progressive loss of
metabolic modulation. Transfusion
200040(3)353-60. - 15. Messana I, Orlando M, Cassiano L, et al.
Human erythrocyte metabolism is modulated by the
O2-linked transition of hemoglobin. FEBS Lett
1996390(1)25-8. - 16. Hess JR. An update on solutions for red cell
storage. Vox Sang 200691(1)13-9. - 17. Asakura T, Sato Y, Minakami S, Yoshikawa H.
Effect of deoxygenation of intracellular
hemoglobin on red cell glycolysis. J Biochem
(Tokyo) 196659(5)524-6. - 18. Hamasaki N, Rose ZB. The binding of
phosphorylated red cell metabolites to human
hemoglobin A. J Biol Chem 1974249(24)7896-901. - 19. Yoshida T, Aubuchon JP, Tryzelaar L, et al.
Extended storage of red blood cells under
anaerobic conditions. Vox Sang 200792(1)22-31. - 20. Dumaswala UJ, Zhuo L, Mahajan S, et al.
Glutathione protects chemokine-scavenging and
antioxidative defense functions in human RBCs. Am
J Physiol Cell Physiol 2001280(4)C867-73.
53References (3)
- 21. Arduini A, Holme S, Sweeney JD, et al.
Addition of L-carnitine to additive
solution-suspended red cells stored at 4 degrees
C reduces in vitro hemolysis and improves in vivo
viability. Transfusion 199737(2)166-74. - 22. Epps DE, Knechtel TJ, Bacznskyj O, et al.
Tirilazad mesylate protects stored erythrocytes
against osmotic fragility. Chem Phys Lipids
199474(2)163-74. - 23. Racek J, Herynkova R, Holecek V, et al.
Influence of antioxidants on the quality of
stored blood. Vox Sang 199772(1)16-9. - 24. Valeri CR. Use of rejuvenation solutions in
blood preservation. Crit Rev Clin Lab Sci
198217(4)299-374. - 25. Hamasaki N, Yamamoto M. Red blood cell
function and blood storage. Vox Sang
200079(4)191-7. - 26. Tanaka KR, Zerez CR. Red cell
enzymopathies of the glycolytic pathway. Semin
Hematol 199027(2)165-85. - 27. Reynolds JD, Ahearn GS, Angelo M,
et al. S-nitrosohemoglobin deficiency A
mechanism for loss of physiological activity
in banked blood. Proceedings of the National
Academy of Sciences 2007
104(43)17058-62. - 28. Bennett-Guerrero E, Veldman TH,
Doctor A, et al. Evolution of adverse changes in
stored RBCs. Proceedings of the
National Academy of Sciences 2007104(43)17063-68
.