Currently red blood cells can be stored for up to 42 days, though most transfusions involve blood that is about 18 days old. During the storage of donated blood at 1–6 °C, red blood cells undergo physical and biochemical changes that may decrease their oxygen carrying capacity. The level of 2, 3-DPG is less than10% of the normal value in red blood cell units stored longer than 14 days. Other biochemical changes include decreased glucose, decreased ATP, increased lactic acid, decreased pH and increased plasma potassium. The oxygen dissociation curve becomes left-shifted, resulting in an increased hemoglobin-oxygen affinity and subsequently less oxygen carried to tissues. Potentially, these changes could lead to microvascular occlusion, inflammation, febrile transfusion reactions and immunomodulation.

More than 50 observational studies have been carried out during the past 30 years trying to determine if this so-called storage lesion affects clinical outcomes of transfusion recipients. Results of these studies have been mixed with approximately 50% showing that blood stored for more than 2 or 3 weeks was associated with worse outcomes while the other half did not detect any significant difference.

Recently, 4 large randomized clinical trials have been published that investigated clinical outcomes of fresher versus older RBC transfusions in 3 different patient populations. The Age of Red Blood Cells in Premature Infants (ARIPI) trial was a randomized controlled trial involving 377 very low birth weight infants in a neonatal intensive care unit (Fergusson DA, et al. JAMA 2012;308:1443-51). One hundred and eighty eight infants were transfused with fresh RBCs, having a median storage duration of 5.1 days and 189 were transfused with RBCs stored for a median duration of 14.9 days. The primary outcome was a composite measure of neonatal morbidities including necrotizing enterocolitis, retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary dysplasia and death. The primary outcome was met in 52.7% of neonates receiving fresher RBCs and 52.9% of neonates receiving older blood.

Secondary outcomes included infection rate and positive cultures. The rate of suspected infection in the fresher red cell group was 77.7% (n = 146) compared with 77.2% (n = 146) in the older red cell group. Positive cultures were present in 67.5% (n = 127) in the fresher red cell group compared with 64.0% (n = 121) in the older red cell group.

The ARIPI trial concluded that the use of fresher red cells did not improve outcomes in premature, very-low-birth-weight infants requiring a transfusion compared to those receiving standard of care. A benefit of using older blood was a reduction of total donor exposures to the neonates (3.7 ± 2.7 donors versus 2.1 ± 1.6 donors).

The Tissue Oxygenation by Transfusion in Severe Anemia with Lactic Acidosis (TOTAL) study compared the outcomes of longer storage versus shorter storage RBC units in children presenting with elevated blood lactate levels due to severe anemia. Reduction in blood lactate concentration was used as a surrogate marker for oxygen delivery to tissues. The study involved 290 severely anemic children, aged 6 months to 5 years who mostly had malaria (81%) or sickle cell disease (13%). Hemoglobin levels were 5 g/dL or less and blood lactate levels were 5 mmol/L of higher. These children were randomized to receive transfusions of RBCs that were stored for 10 days or less or units stored for 25 to 35 days.

The primary outcome measure was the proportion of patients with blood lactate levels of 3 mmol/L or less at 8 hours. Secondary outcomes included blood lactate levels at 2, 4, 6, 8, and 24 hours , cerebral tissue oxygen saturation, and survival. For the primary outcome, 87 of 143 children (61%) receiving older RBCs and 83 of 143 children (58%) receiving younger RBCs had a lactate level of 3 mmol/L or lower at 8 hours. There was no difference in any of the secondary measures between the two groups. This trial demonstrated that transfusion of very old RBC was just as effective as fresh RBCs in improving tissue oxygenation in severely anemic children.

The Red Cell Storage Duration Study (RECESS) study was a randomized controlled trial conducted at 33 medical centers in the United States that evaluated the effect of red blood cell storage time in 1481 patients aged 12 years or older undergoing complex cardiac surgery between 2010 and 2014(Steiner ME, et al. N Engl J Med.2015;doi:10.1056/NEJMoa 1414219).Patients were randomized to receive either fresher units of leukocyte reduced red blood cells stored for 10 days or less or older units stored for 21 days or more. The primary outcome was the change in the multi-organ dysfunction score (MODS) through day 7. Higher scores indicated more serious organ dysfunction. Secondary end points included changes in MODS through day 28, serious adverse events and mortality at 28 days post surgery.

Of the 1096 evaluable patients who received transfusions within 96 hours following surgery, 538 patients received blood with a median of 4 units of fresher RBCs with a median storage duration of 7 days and 560 patients received a median of 3 units of older RBCs with a median storage duration of 28 days. The mean change in MODS was an increase of 8.5 points in the shorter-term storage group and 8.7 points in the longer-term storage group (95% CI for the difference, –0.6 to 0.3; P = .44).  This difference was not statistically significant.

Seven-day mortality rates were 4.4% in the shorter-term storage group and 5.3% in the longer-term storage group (P = .57). There was no difference between the groups in adverse events except that the longer-term storage group was more likely to have hyperbilirubinemia.

This randomized trial did not detect differences in MODS, serious adverse events or mortality at day 28 in patients who were transfused with leukocyte-reduced red blood cells that were stored for shorter or longer periods.

The Age of Transfused Blood in Critically Ill Patients (ABLE) study randomized 2430 patients admitted to intensive care units at 64 medical centers in Canada and Europe to receive fresher blood that was stored for an average duration of 6 days or standard-issue blood that was stored for an average duration of 22 days (Lacroix J, et al. N Engl J Med 2015.doi.10.1056/NEJMoa1500704).

At 90 days, 37% of patients who received fresh blood had died, compared with 35% in the standard-issue blood group (time-to-death hazard ratio=1.1, p=0.38). Mortality rates were essentially the same. The groups exhibited no differences in secondary outcomes including major illnesses; duration of respiratory, hemodynamic or renal support; length of hospital stay; and transfusion reactions. The authors concluded that fresh RBcs did not appear to be superior to standard issue RBCs in critically ill patients.  

Four large randomized trials in neonates, cardiac surgery patients and ICU patients have concluded that freshly donated blood is not better than older blood when it is transfused into severely ill patients.These studies support continuation of the current inventory management practice of issuing the oldest units first before they outdate.

Daratumumab (Darzalex, Janssen Biotech, Horsham, PA) is a human IgG1k monoclonal antibody that was approved by the Food and Drug Administration in November 2015 for the treatment of patients with multiple myeloma who have failed treatment with proteasome inhibitors, immunomodulators and alkylating agents. Daratumumab binds with high affinity to CD38, which is a transmembrane glycoprotein that is highly expressed on the surface of multiple myeloma cells. It is believed to induce rapid tumor cell death through multiple mechanisms including apoptosis, complement-dependent cytotoxicity, antibody-dependent cellular phagocytosis and antibody-dependent cellular cytotoxicity.

The cost per infusion is approximately $5,850 for a typical 176-pound (80 kilogram) patient. A course of treatment is estimated to cost $23,400 per month for the first two months, $11,700 per month for the next four months, and $5,850 per month for each month thereafter.

Daratumumab also binds to red blood cells and platelets because they weakly express CD38. It does not appear to cause hemolysis or thrombocytopenia. Plasma samples from patients treated with daratumumab consistently have a positive indirect antiglobulin test and less often, a positive direct antiglobulin test. This occurs because daratumumab binds to CD38 on reagent red blood cells causing panreactivity in vitro. Affected tests include antibody screen, antibody identification panels, and antihuman globulin crossmatches. Daratumumab does not interfere with ABO and Rh typing or with immediate spin crossmatches.

Coating of reagent red blood cells with anti-CD38 antibody interferes with the ability to detect alloantibodies in patient sera. Daratumumab may persist in plasma for up to 6 months after the last infusion. Daratumumab cannot be removed by adsorption because CD38 is too weakly expressed on red blood cells.

Patient's plasma is usually weakly to 1+ reactive with all panel red blood cells. DAT is positive for IgG only. The degree of reactivity can vary over time. Agglutination due to anti-CD38 may occur with all suspension media including saline, low ionic strength saline (LISS) and polyethylene glycol. Reactions are seen with all methods including tube, gel and solid phase.

In an article published in the June 2015 issue of Transfusion, five of five (100%) of treated patients had a positive antibody screen and three of five (60%) had a positive direct antiglobulin test.

If the transfusion service is unaware that a patient has received daratumumab therapy, these serologic reactions could cause delays in issuing red blood cells and result in failure to identify a clinically significant alloantibody. To avoid these problems, the hematology/oncology service needs to notify the transfusion service whenever a patient is scheduled to receive this drug. Before the first dose, a baseline type and screen and red blood cell phenotype or genotype should be performed.

After the first dose, antibody screen and identification should be performed using DTT treated reagent red blood cells. The extracellular domain of CD38 contains six disulfide bonds that are necessary to maintain its structural conformation. Treatment of reagent red blood cells with dithiothreitol (DTT) denatures CD38 and prevents daratumumab binding. DTT treatment of reagent red blood cells prior to addition of patient serum eliminates daratumumab interference and allows detection of alloantibodies with the exception of alloantibodies to Kell system antigens. Because DTT treatment destroys Kell system antigens, Kell negative units should be provided unless the patient is known to be K positive. Other antigens such as k, Yta, Doa and Dob are denatured by DTT. Therefore antibodies against these antigens are also not detected when DTT treated reagent cells are used. However, these antibodies occur very infrequently.

Another transfusion strategy is to perform extended genotyping on patients treated with daratumumab and provide matched units for common blood group antigens to  patients with daratumumab interference. This approach eliminates the need for DTT treatment of reagent red blood cells.

If an emergency transfusion is necessary, uncrossmatched ABO and RhD compatible red blood cells may be given.

References

Chapuy CL, et al. Resolving the daratumumab interference with blood compatibility testing. Transfusion 2015;55:1545-54.

Hannon JL and Clarke G. Transfusion management of patients receiving daratumumab therapy for advanced plasma cell myeloma. Transfusion 2015;55:2770.

Schmidt AE. et al. An alternative method to dithiothreitol treatment for antibody screening in patients receiving daratumumab. Transfusion 2015;55:2292-93.

AABB Association Bulletin #16-02, January 15, 2016.

Severe IgA deficiency occurs in approximately 1 in 900 blood donors in the United States and United Kingdom. Approximately 20 to 30% of IgA deficient individuals, who are otherwise healthy, form anti-IgA antibodies, while approximately 80% of IgA deficient individuals with autoimmune disease form anti-IgA antibodies. Anti-IgA is usually IgG but may be IgM or IgE. Anti-IgA can have broad or limited specificity. When anti-IgA antibody binds to IgA in transfused plasma, complement is activated and severe anaphylaxis can occur.

Since 1968, patients with IgA deficiency and anti-IgA antibodies have been thought to be at increased risk of having an anaphylactic transfusion reaction following exposure to blood components containing IgA. A Commentary in the January 2015 issue of Transfusion questions this association and concludes that the entity of IgA-related anaphylactic transfusion reaction has not been established by evidence-based medicine (S.G. Sandler et al. Transfusion 2015;55:199-204).

Approximately 1 in 1200 individuals is IgA deficient and has detectable anti-IgA antibody. This is a much higher frequency than the incidence of anaphylactic transfusion reactions which is approximately 1 per 50,000 RBC transfusions. Therefore, not all individuals with IgA deficiency and anti-IgA, who are transfused, experience anaphylactic reactions.

The American Red Cross National Reference Laboratory provided some of the first evidence that anti-IgA was not the cause of the majority of anaphylactic transfusion reactions. Only 61 of 359 (17%) patients who experienced an anaphylactic transfusion reaction were IgA deficient with coexisting anti-IgA. (Sandler et al. Blood 1994;84:2031-5). More recent, hemovigilance data from other countries has documented that only 3 of 229 patients with anaphylactic or severe allergic reactions had IgA deficiency with anti-IgA. From 2008 through 2012, 12 cases of transfusion related fatal anaphylaxis cases were reported to the Food and Drug Administration (FDA). IgA deficiency was ruled out in 11 of the cases. IgA levels were not measured in the remaining case.

Transfusion of blood components from donors, who were subsequently identified to be IgA deficient with anti-IgA, to recipients with normal IgA levels does not cause anaphylaxis (Winters JL et al. Transfusion 2004;44:382-5).

This controversy creates a dilemma for the transfusion service regarding management of patients with a history of a severe allergic or anaphylactic transfusion reaction and/or laboratory evidence of IgA deficiency with or without anti-IgA antibodies. In my opinion, it remains prudent to err on the safe side.

Patients with severe allergic reactions after a transfusion should have an IgA level measured on a pretransfusion sample. The presence of IgA eliminates IgA deficiency as the cause of anaphylaxis and conventional transfusion therapy can be recommended. If IgA is not detected, testing for anti-IgA antibodies should be pursued. Patients with IgA deficiency and anti-IgA antibodies need to receive blood components which lack IgA. Plasma must be obtained from IgA-deficient donors. Red blood cells and platelets must be washed to remove as much plasma as possible.

Anaphylactic reactions have been seen in some IgA-deficient patients without detectable anti-IgA antibody. These patients should be carefully monitored for severe allergic reactions, but it may not be necessary to restrict them to washed or IgA-deficient products without a carefully monitored trial of unmodified blood products. 

Granulocyte transfusions are usually ordered for patients with hematologic malignancies and absolute neutropenia who have a bacterial or fungal infection that is not responding to appropriate antimicrobial therapy. Recipients should meet the following criteria:

• Granulocyte count of <500/uL
• Clear evidence of a bacterial or fungal infection
• Inadequate response to definitive antimicrobial therapy

Most recipients have a hematologic malignancy being treated with aggressive chemotherapy and /or undergone hematopoietic stem cell transplant. Recipients not expected to recover marrow function generally should not be considered candidates for granulocyte transfusion.

Granulocyte transfusions may also be ordered for neonates with sepsis, who develop neutropenia from storage pool depletion.  Evidence for their efficacy in this setting is of low quality.

The Resolving Infection in Neutropenia with Granulocytes (RING) study was a 5-year (2008-2013) randomized controlled trial sponsored by the NHLBI Transfusion Medicine/Hemostasis Clinical Trials Network. Subjects with severe neutropenia (ANC< 500/mL) and bacterial and/or fungal infections were randomized to two groups. One group received standard antimicrobial therapy alone, while the second group received standard antimicrobial therapy in combination with daily granulocyte transfusions from donors stimulated with granulocyte colony stimulating factor (G-CSF) and dexamethasone.

The study's dose of granulocytes (40 x 10⁹ granulocytes/unit) was four times higher than the dose required by AABB Clinical Standards (10 x 10⁹ granulocytes/unit). Primary endpoints were overall survival and response to infection at 42 days. Investigators were unable to detect statistical differences in antimicrobial response rates or overall survival between arms. Post hoc secondary analyses suggested that higher doses were effective. The efficacy of granulocyte transfusion remains unknown.

Granulocytes are collected from a single donor by apheresis. The donor is stimulated the day before collection with an injection of granulocyte colony stimulating factor (G-CSF) and an oral dose of dexamethasone. Stimulation increases the yield of granulocytes collected to 4.0 x 10¹⁰ granulocytes or more. Collection by apheresis generally takes 2.5 to 3 hours; during which 7 to 10 liters of whole blood are processed. G-CSF stimulated donors often experience self-limited headache, arthralgia, bone pain, fatigue and difficulty sleeping.

Because of their short shelf life, granulocytes are usually issued before infectious disease testing is completed. For this reason, granulocytes are usually collected from apheresis platelet donors who have tested negative in the past 30 days.

Granulocytes are not licensed by the Food and Drug Administration (FDA). They should be stored at room temperature without agitation. The final volume including anticoagulants and residual plasma is 200 to 300 mL. Granulocytes contain between 20 and 50 mL of red blood cells. Therefore, they must be ABO and crossmatch compatible with the recipient. If the intended recipient has an alloantibody, the granulocyte must be collected from a donor, whose red blood cells are negative for the corresponding antigen.

Granulocytes must be irradiated to prevent transfusion-associated graft versus host disease. Patients who are CMV negative need to receive granulocytes from a CMV negative donor. If the recipient has HLA antibodies, granulocytes should be collected from a donor who is HLA compatible.

The typical life span of a granulocyte is approximately 8 hours. Granulocytes collected from G-CSF and steroid stimulated donors may have an increased life span up to 24 hours. AABB Standards indicate that granulocytes expire within 24 hours. Ideally, granulocytes should be given as soon as processing and irradiation have been completed. They should be transfused using a standard blood infusion set. Granulocytes should not be transfused through a leukocyte reduction filter or a microaggregate filter.

Granulocyte transfusions cause adverse reactions such as fever, chills and hives in up to 50% of recipients. More seriously, transfused granulocytes may be sequestered in pulmonary capillaries causing transfusion related acute lung injury (TRALI). Alloimmunization to HLA and HNA antigens can occur and complicate future transfusions.

Granulocyte transfusions are usually continued on a daily basis for five to seven days, until the recipient's granulocyte count recovers to >500/uL. Recipient's granulocyte count should be monitored before and after each transfusion. The decision to discontinue granulocyte transfusions is based on the recipient's granulocyte count and resolution of infection.

References

Price, TH et al. Efficacy of transfusion with granulocytes from G-CSF/dexamethosone-treated donors in neutropenic patients with infection. Blood. 2015. 126:2153-61.

Cancellas JA. Granulocyte transfusion: questions remain. Blood. 2015. 126:2082-3.

The National Healthcare Safety Network (NHSN) hemovigilance protocol defines transfusion associated dyspnea (TAD) as acute respiratory distress occurring within 24 hours of cessation of transfusion that does not meet the definitions of an allergic reaction, transfusion associated circulatory overload (TACO) and transfusion related acute lung injury (TRALI).

Hypotension is a rare complication of blood transfusion. The reported incidence has ranged from 0.04 to 1.3 cases per 10, 000 units issued. Hypotension reactions have been reported to occur with blood products that were leukocyte reduced using negatively charged leukocyte reduction filters. Negatively charged blood filters can activate the kallikrein-kinin system by binding coagulation factor XII. Activated factor XII cleaves prekallikrein to kallikrein, which in turn cleaves high molecular weight kininogen releasing bradykinin. Bradykinin binds to endotherlial cells, causing vasodilation and hypotension.

Normally, bradykinin is rapidly inactivated by angiotensin converting enzyme (ACE). Patients treated with ACE inhibitors are more prone to these reactions. Some patients appear to have an inherent defect in their ability to degrade kinins. Bradykinin binds to receptors on vascular endothelium, causing vasodilation.

Approximately one third of patients with hypotensive reactions have undergoine cardiac surgery. Cardiopulmonary bypass results in increased bradykinin generation and decreased degradation. Bypassing the lungs increases the concentration of bradykinin because the lungs are the major site of bradykinin metabolism. Other extracorporeal circuits such as ECMO and dialysis may also activate the coagulation contact system and interfere with bradykinin degradation.

Hypotensive reactions usually occur within 15 minutes of the start of transfusion. Less commonly they develop between 15 minutes after start and 1 hour after cessation of transfusion. The National Healthcare Safety Network (NHSN) hemovigilance protocol defines hypotensive transfusion reactions as the occurrence of hypotension during or within one hour after cessation of transfusion.

Criteria for adults, 18 years or older, includes:

• a drop in systolic blood pressure greater than or equal to 30 mm Hg AND
• Systolic blood pressure less than or equal to 80 mm Hg.

Criterion for infants, children and adolescents (1 year to less than 18years old) is:

• Greater than 25% drop in systolic blood pressure from baseline.

Criterion for neonates and small infants less than 1 year old and less than 12 kg body weight is greater than 25% drop in blood pressure from baseline value.

All other adverse reactions presenting with hypotension should be excluded before making this diagnosis. These include acute hemolytic transfusion reactions, anaphylaxis, transfusion related acute lung injury (TRALI) and sepsis.

Patients typically respond quickly to cessation of transfusion and supportive treatment.

References

Arnold DM, et al. Hypotensive transfusion reactions can occur with blood products that are leukocyte reduced before storage, Transfusion September 2004;44:1361-66.

Pagano, MB, et al. Hypotensive transfusion reactions in the era of prestorage leukoreduction. Transfusion 2015;55:1668-74.

A delayed serologic transfusion reaction (DSTR) occurs when a recipient develops new antibodies against red blood cells between 24 hours and 28 days after a transfusion without exhibiting any clinical symptoms or laboratory evidence of hemolysis. The frequency of DSTR during a 12 year interval at the Mayo Clinic was 1 case per 2990 units red blood cells tranfused.

The National Healthcare Safety Network (NHSN) hemovigilance protocol defines DSTR as the absence of clinical signs of hemolysis AND demonstration of new, clinically significant antibodies against red blood cells BY EITHER positive direct antiglobulin test (DAT) OR positive antibody screen with newly identified RBC alloantibody.

DSTR must be distinguished from a delayed hemolytic transfusion reaction, in which there is evidence of hemolysis such as an inadequate rise of post-transfusion hemoglobin level or a rapid fall in hemoglobin back to the pre-transfusion level.

Ness PM, et al. The differentiation of delayed serologic and delayed hemolytic transfusion reactions: incidence, long-term serologic findings, and clinical significance. Transfusion.1990 Oct;30(8):688-93.

Post-transfusion purpura (PTP) is characterized by an abrupt drop in platelet count in the first 3 weeks after platelet transfusion. Affected individuals have a prior history of sensitization to platelet antigens from pregnancy or previous transfusion. Upon subsequent transfusion the recipient mounts an anamnestic antibody response against a platelet specific antigen on the donor platelets, that he or she lacks. In most cases the antibody is directed towards HPA-1 antigen. Thrombocytopenia occurs between 1 and 24 days (mean 9 days) after transfusion.

Through some unknown mechanism, recipient’s own antigen negative platelets are destroyed along with transfused antigen positive platelets. Thrombocytopenia is often severe with platelet counts falling below 10, 000/uL. The National Healthcare Safety Network (NHSN) hemovigilance criterion is that the post-transfusion platelet count decreases to less than 20% of the pre-transfusion platelet count.

Thrombocytopenia may persist for several weeks if not treated. Mortality rates between 10 and 15% have been reported. Treatment usually consists of intravenous immune globulin (IVIG), corticosteroids, or both.

Even though a patient’s own antigen negative platelets have been destroyed, transfusion of HPA-1 antigen negative platelets may be efficacious in life threatening situations, such as intracranial hemorrhage.

Red blood cells and platelets can be irradiated to inactivate lymphocytes and prevent transfusion associated graft versus host disease (GVHD). Leukocyte reduction does not remove sufficient numbers of lymphocytes to prevent GVHD. Plasma and cryoprecipitate do not need to be irradiated.

Irradiation does not affect cell survival or function but does damage the red blood cell membrane sodium-potassium pump, causing leakage of potassium across the cell membrane into the plasma. Plasma potassium levels increase almost twofold within 24 hours. This potassium load is not harmful to most adults, but can significantly elevate potassium levels in neonates and fetuses. This potential problem can be avoided by irradiating units just prior to transfusion.

Clinical indications for ordering irradiated blood include:

• Recipients of allogenic and autologous hematopoietic progenitor cell transplantation
• Children with severe congenital immune deficiency syndromes
• Granulocyte transfusions
• Recipients of transfusions from blood relatives
• Treatment with purine analogue drugs (fludarabine, cladribine, deoxycoformycin)
• Treatment with Campath (anti-CD52)
• Treatment with anti-thymocyte globulin
• HLA matched or partially matched platelet transfusions
• Hodgkin’s Disease
• Acute leukemia if patient is a transplant candidate
• Non-Hodgkin lymphoma if patient is a transplant candidate
• Intrauterine (fetal) transfusions
• Neonates who received irradiated components as fetuses
• Neonatal exchange transfusions

Administration of irradiated products is the same as the administration of non-irradiated products.

The U.S. Food and Drug Administration has approved the Intercept Blood System (Cerus Corporation, Concord, California) for pathogen reduction for plasma and single donor apheresis platelets. Potential pathogens and lymphocytes are inactivated by adding amotosalen, which binds to DNA and RNA. Exposure to ultraviolet light disrupts the nucleic acids. The Intercept System decreases the risk of transfusion-transmitted infections such as HIV, hepatitis B, hepatitis C, West Nile virus as well as Gram negative and Gram positive bacteria. T cells are also decreased enough to lower the risk of transfusion-associated graft-versus-host disease (TA-GvHD). Bacterial spores and non-enveloped viruses, such as human parvovirus B19, hepatitis E, hepatitis are resistant to treatment.

FDA recently granted Investigational Device Exemption status to the system for two studies, one on reducing the risk of transfusion transmission of the chikungunya and dengue viruses and another in which researchers are preparing Ebola convalescent plasma to treat those infected with Ebola virus disease, or EVD. To increase U.S. preparedness for Ebola, researchers are creating a stockpile of convalescent plasma that has been treated with Intercept.