Red Blood Cells Induce Necroptosis of Lung Endothelial Cells and Increase Susceptibility to Lung Inflammation

Abstract

Rationale: Red blood cell (RBC) transfusions are associated with increased risk of acute respiratory distress syndrome (ARDS) in the critically ill, yet the mechanisms for enhanced susceptibility to ARDS conferred by RBC transfusions remain unknown.Objectives: To determine the mechanisms of lung endothelial cell (EC) High Mobility Group Box 1 (HMGB1) release following exposure to RBCs and to determine whether RBC transfusion increases susceptibility to lung inflammation in vivo through release of the danger signal HMGB1.Methods: In vitro studies examining human lung EC viability and HMGB1 release following exposure to allogenic RBCs were conducted under static conditions and using a microengineered model of RBC perfusion. The plasma from transfused and nontransfused patients with severe sepsis was examined for markers of cellular injury. A murine model of RBC transfusion followed by LPS administration was used to determine the effects of RBC transfusion and HMGB1 release on LPS-induced lung inflammation.Measurements and Main Results: After incubation with RBCs, lung ECs underwent regulated necrotic cell death (necroptosis) and released the essential mediator of necroptosis, receptor-interacting serine/threonine-protein kinase 3 (RIP3), and HMGB1. RIP3 was detectable in the plasma of patients with severe sepsis, and was increased with blood transfusion and among nonsurvivors of sepsis. RBC transfusion sensitized mice to LPS-induced lung inflammation through release of the danger signal HMGB1.Conclusions: RBC transfusion enhances susceptibility to lung inflammation through release of HMGB1 and induces necroptosis of lung EC. Necroptosis and subsequent danger signal release is a novel mechanism of injury following transfusion that may account for the increased risk of ARDS in critically ill transfused patients.

Plasma Levels of Receptor Interacting Protein Kinase-3 (RIP3), an Essential Mediator of Necroptosis, are Associated with Acute Kidney Injury in Critically Ill Trauma Patients

“…In the current study, only plasma RIP3 levels at 48 hours, rather than on presentation, were associated with RBC transfusions, consistent with the hypothesis that transfusion augments necroptotic pathway activation and RIP3 release in humans. This relationship is mechanistically plausible: we have previously shown that RBC transfusion can cause necroptosis in endothelial cells, and that plasma RIP3 increases significantly in mice after RBC transfusion (18). Larger studies may further elucidate the potential contribution of necroptosis to mechanisms underlying the association of RBC transfusion with AKI.…”

“…We used a commercially available enzyme-linked immunosorbent assay (CUSABIO, Wuhan, China) to measure plasma RIP3 as previously described (18). Performing personnel were blind to each subject's AKI status.…”

“…Renal IRI from hemorrhage-related hypovolemic shock is common after major trauma (15). Red blood cell (RBC) transfusion is also a significant independent risk factor for AKI in this population, and we recently showed that banked human RBCs induce necroptosis in cultured human endothelial cells (16-18). Since cells undergoing necroptosis release RIP3, we reasoned that plasma concentrations of RIP3 might serve as a useful measure of necroptosis in humans.…”

Prolonged EVLP Using OCS Lung

“…21 In culture, Qing and colleagues showed that lung endothelial cells undergo necrotic cell death with prolonged RBC exposure. 22 In cardiac surgery, packed RBC transfusions have been linked to pulmonary dysfunction and decreased survival. 23,24 Lungs appear to be susceptible to packed RBC-induced injury in critically ill patients.…”

Serum levels of RIPK3 and troponin I as potential biomarkers for predicting impaired left ventricular function in patients with myocardial infarction with ST segment elevation and normal troponin I levels prior percutaneous coronary intervention

“…RIPK3 is not specific to the heart, so other reasons besides myocardial infarction for elevated levels of RIPK3 on Day 1 cannot be ruled out. Only a few studies of human pathology have examined levels of RIPK3 expression and their association with clinical outcomes (26,27). The current results suggest that the serum level of RIPK3 increased significantly 24 hours after the onset of symptoms.…”