Fresh Red Blood Cell Transfusion and Short-Term Pulmonary, Immunologic, and Coagulation Status

Abstract

Rationale: Transfusion-related pulmonary complications are leading causes of morbidity and mortality attributed to transfusion. Observational studies suggest an important role for red blood cell (RBC) storage duration in these adverse outcomes. Objectives: To evaluate the impact of RBC storage duration on shortterm pulmonary function as well as immunologic and coagulation status in mechanically ventilated patients receiving RBC transfusion. Methods: This is a double-blind, randomized, clinical trial comparing fresh (<5 d of storage) versus standard issue single-unit RBC transfusion in adult intubated and mechanically ventilated patients. The primary outcome is the change in pulmonary gas exchange as assessed by the partial pressure of arterial oxygen to fraction of inspired oxygen concentration ratio ( Since the first successful attempt at blood storage almost a century ago, advances in extracorporeal red blood cell (RBC) preservation have incrementally prolonged the viability of stored RBCs. With contemporary preservative solutions, the accepted duration of RBC storage has now been extended to 42 days (1). In the past two decades, there has been increased interest in the time-dependent changes in RBC quantity and quality during this storage period. The various changes that occur within both the RBC and storage media during ex vivo preservation have been collectively termed the RBC "storage lesion." Importantly, alterations that occur during the RBC storage process are believed potentially responsible for many of the adverse effects associated with blood product administration (2). Among these concerns is a potentially increased risk of transfusion-related acute lung injury (TRALI) (3-6) as well as risk-adjusted mortality (7-10). Multiple publications have suggested that these associations become more significant with increased duration of RBC storage (8,(11)(12)(13). In a database analysis, Koch and colleagues found an association of RBC storage duration with mortality in patients undergoing cardiac surgery (8). This association was largely driven by an increased rate of respiratory complications. However, the observational nature of this investigation and concerns over residual confounding preclude definitive statements regarding causality. Moreover, evidence to the contrary exists as well (14-17), and the impact of RBC storage duration on development of transfusion-related complications remains a matter of debate (18,19).While the majority of TRALI cases are believed to be the result of an interaction between donor anti-HLA or anti-leukocyte antibodies and the cognate antigen on recipient leukocytes (20), a second "two-hit" model for TRALI has also been described (21). This model suggests that in a "primed" host, infusion of Author Contributions: D.J.K. contributed to the acquisition of data, and analysis and interpretation of the study results. R.K. contributed to the study design and procedures and the acquisition of the data. R.B.W. contributed to the study conception and design as well as the interpretati...

Transfusion of fresher vs older red blood cells in hospitalized patients: a systematic review and meta-analysis

“…Of the 16 trials included in the recent Cochrane review, 25 we judged 6 to be ineligible 36-41 because they did not report the outcomes examined in this review, leaving a total of 12 eligible studies. 26,27,37,[42][43][44][45][46][47][48][49][50] Agreement (k) for the title and abstract screening was 0.73, and for the completed full-text screening 0.71. Inter-rater agreement on individual domains of the risk of bias tool ranged from 0.51 to 0.69.…”

“…Evidence from 12 randomized controlled trials 26,27,37,[42][43][44][45][46][47][48][49][50] that included patients with varying ages and experiencing a range of medical and surgical conditions found no benefit when fresher RBCs were transfused as opposed to older/standard-issue RBCs for either mortality ( Figure 3 and Table 2) or adverse events ( Figure 4 and Table 2). Results suggested that, if anything, fresher RBCs might lead to an increase rather than a decrease in nosocomial infections ( Figure 5 and Table 2).…”

Storage of Red Blood Cells and Transfusion-Related Acute Lung Injury

“…Despite these numerous studies which suggest that the use of fresher blood for transfusions could be potentially beneficial, a randomized control trial did not find a difference in outcome between the use of a single unit of fresh blood and a single unit of stored blood when assessing pulmonary, inflammatory and coagulation markers [33].…”

“…The quality and efficacy of RBC storage may have significant impact on the occurrence and pathogenesis of TRALI [33,34]. The current standard of duration of storage of red blood cells (RBCs) by the American Association of Blood Banks is a maximum of 6 weeks (42 days) of storage [35].…”

“…Although the relationship between storage duration of RBCs and potential incidence of TRALI was not always found [15,19,33,41] a meta-analysis examining 21 studies (primarily in the field of cardiac surgery and trauma) demonstrated that mortality increased with transfusion of older RBC units compared to units stored for shorter periods (a time period closer to 21 days was set as a cut-off point between fresh and older blood, unless mentioned otherwise) [2]. In trauma patients, the risk for development of ARDS was significantly increased in patients who received transfusion of leukoreduced RBCs stored for longer than 14 days, and transfusion of red cells older that 28 days has also been associated with deep vein thrombosis and multiple organ [19,25].…”