erythrocyte aging and it's potential clinical consequences ioannina 2010

VMJ Novotny, Ioannina 2010


ERYTHROCYTE AGING & IT’S POTENTIAL CLINICAL CONSEQUENCES


Red cell transfusions:

Maintenance/restoration tissue oxygenation

• US:14.000.000 units/year

• NL:560.000 units/year

• Inhabitants 16.400.000

• Hospitals: 107

• University Hospitals 8

• HIC centre 12

• All cellular blood products leukocyte depleted


The RBC unit transfused in NL

• Whole blood 500ml (CPD)

• Buffy coat removed

• Prestorage leukocyte depletion

• Storage medium: SAGM

• Storage time max 35 days

• Volume: 270- 340 ml

• Hb 10.3-12.7 mmol/l

• Hb 2.7-4.3 mmol

• RBC 5.23-7.12 x 1012/l

• Relation donor haemoglobin?

• Variation blood volume patiënt:

Impact transfusion frequency?


Transfusion dependent adult patients

• Haemato-oncological

•Acute leukemia

•Lymphoma

•Myeloma

•Myelodysplastic syndromes

• Non Haemato-oncological

•Aplastic anaemia

•haemoglobinopathy

Long term

transfusion dependent

Chemotherapy

SCT


Transfusion dependent patients The Netherlands

• MDS estimated 1200/2400 patients

• Each patiënt 2 RBC units/2 weeks 52/year

• Total 1200 x 52 62.400/year

• Haemoglobinopathy 400/800

• Each patiënt 2 RBC units/2 weeks 52/year

• Total 400 x 52 20.800/year

• > 80.000 RBC units transfused yearly

• ca. 15% RBC units


Klein HG et al Lancet 2007 aug 4

Side effects


Other side effects of RBC transfusion

RBC side effects:

• Iron overload

• erythrocyte alloimmunisation

• erythrocyte autoimmunisation

• Endothelial damage

• Impaired microcirculation

• (Pro)inflammatory

• immunomodulatory

Controversial data

• Leukocyte depletion versus non-leukocyte depleted

• Length of storage variable

• Number of units variable

• The most clincal compromised patients transfused

• How to decide?

• What about storage?

Zimrin and Hess Vox Sang 2009

Vamkamas Transfusion 2010



BAND 3 OCCUPIES A CENTRAL POSITION IN REGULATION OF ERYTHROCYTE AGING: TRANSPORT, CELL SHAPE, AND SENESCENT CELL ANTIGEN

• Physiological aging

• band 3

• Senescent cell antigens

• IgG to SCA’s

• Depletion RBC

• Physiological automimmunity


A NEW ASPECT OF ERYTHROCYTE AGING:VESICLE FORMATION

Vesicles from plasma:• <300 nm AND >800 nm• right –side-out and inside-out • Haemoglobin composition of old erythrocytes

Werre et al. (2004) Cell Mol Biol 50, 139-146 (review)

VESICLES ARE RAPIDLY REMOVEDBY KUPFFER CELLS IN THE LIVER

(THROUGH PS EXPOSURE?)

Willekens et al (2005) Blood 105, 2141-2145


RBC changes during storage

• ATP

• 2,3 DPG - Oxygen delivery - Restoration 24- 72 hours

• pH

• K

• Hb supernatant

• Phosphatidylserine expression

• Vesicle formation (membrane loss)

Erythrocyte changes from donor to RBC unit


•Band 3 degeneration

•Vesiculation

•PS exposure: seen early after processing

“autoantigen” band 3 expression increases during storage

S. Dinkla

AutoA

b 6

wee

k old

RBC

TX100

AutoA

b 3

wee

k old

RBC

TX100

• Matched RBCs and identical plasma were used

• Shown with plasma of 2 different AIHA patients

250

150

100

50

37

25

Antonelou et al. Transfusion 2010


RBC survival Luten et al 2008

• Non –radioactive survival method; discriminating red cell antigens

• Short storage 5 + 3 (3-10 days) loss 20-25 %

• Long storage 30 + 10 (25-35 days) loss 25-30 %


Other side effects of RBC transfusion

RBC side effects:

• Iron overload



• Endothelial damage

• Impaired microcirculation

• (Pro)inflammatory



Side effects RBC transfusion

• 1 unit RBC 200 mg Fe

• Normal diet

adsorbed 1-1.5 mg

• Iron overload/organ damage

• Liver, heart, endocrine organs

• Iron chelation compliance results

Deferoxamine fair cardiac +

Deferiprone excellent cardiac +

Deferasirox excellent experience +

Barton C. drugs 2007


Side effects transfusion 2

• Alloimmunisation 1:100

• Inflammation is promoting

• Autoimmunisation 10%Young et al 2004

• Sometimes serious haemolysis

• Relation storage lesion?

• Stored RBC/immune response patiënt?


RBC age and expression cell adhesion molecules

• CD44,CD47, CD58,CD147, GPA (function?)

• Storage CD 44 CD 47 (self-discrimination antigen)

Annexin V

Effect related to:

•RBC storage

•Leukocyte depletionSparrow et al 2005

RBC allo/autoimmunisation?


Side effect RBC transfusion 3

• Transfusion related immune modulation:

Infection rate Allograft survival

• Cytokine levels

• (anti-inflammatory) IL-10

• (proinflammatory) TNF

• Humoral activity

• Cellular immunity

• Twomley KM et al J Throm Thrombolysis 2006

• Karam et al. Transfusion 2009

•RBC storage

•Leukocyte depletion

•effect supernatant

Stored Red Blood Cell Transfusion Induces Regulatory T CellsJoel M Baumgartner, MD, Christopher C Silliman, MD, PhD, Ernest E Moore, MD, FACS, Anirban Banerjee, PhD, Martin D McCarter, MD, FACS

J Am Coll SurgVol. 208, No. 1, January 2009


Leukocyte depleted


RBC and inflammation

Inflammation:

• RBC storage upregulation inflammatory genes

(Toll like receptors etc.)

Escobar GA et al Ann surgery 2007

• Consequences haemato-oncologic patiënt?

•Fever/infection

•therapy related endothelial damage

•Bleeding risk

•RBC storage

•Leukocyte depletion


Endothelial damageprothrombotic statesmicrocirculation

• damaged/old RBC’s:

• ADP release > platelet activation

• Release haem > hyperperoxidase >

endothelial damage

• RBC Nitric oxide

• Nitric oxide flowregulator > microcirculation

• protection platelet activation > platelet activation

• RBC Vesiculation > thrombin generation Sweeney et al. 2009


The multitransfused patient exposed to seferal risks

RBC side effects:

• iron overload



• endothelial damage

• impaired microcirculation

• (pro)inflammatory



Understanding the RBC during storage and after transfusion: our challenge

•20-30% transfused RBC’s lost < 24 hrs

Mechanism?

Prevention?

•RBC interaction with the patiënt

•Storage or the red cell????

Understanding the erythrocyte!!!


ERYTHROCYTE AGING & IT’S POTENTIAL CLINICAL CONSEQUENCES

• Giel Bosman1

• Nicole Blijlevens2

• Sip Dinkla1

• Irma Joosten3

• Vĕra Novotný2

• Jan Werre1

• Frans Willekens4

1.Radboud University Medical Center Nijmegen, Dept of biochemistry

2. Radboud University Medical Center Nijmegen, Dept of haematology

3. Radboud University Medical Center Nijmegen, Dept laboratory medical immunology

4..Rijnstate ziekenhuis Arnhem, Dept of clinical chemistry

Salomao et al. 2008

erythrocyte aging and it's potential clinical consequences ioannina 2010

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