Effects of blood storage age on immune, coagulation, and nitric oxide parameters in transfused patients undergoing cardiac surgery

Abstract

Background: Retrospective studies suggested that storage age of RBCs is associated with inflammation and thromboembolism. The Red Cell Storage Duration Study (RECESS) trial randomized subjects undergoing complex cardiac surgery to receive RBCs stored for shorter versus longer periods, and no difference was seen in the primary outcome of change in multiple organ dysfunction score.

Study design and methods: In the current study, 90 subjects from the RECESS trial were studied intensively using a range of hemostasis, immunologic, and nitric oxide parameters. Samples were collected before transfusion and on Days 2, 6, 28, and 180 after transfusion.

Results: Of 71 parameters tested, only 4 showed a significant difference after transfusion between study arms: CD8+ T-cell interferon-γ secretion and the concentration of extracellular vesicles bearing the B-cell marker CD19 were higher, and plasma endothelial growth factor levels were lower in recipients of fresh versus aged RBCs. Plasma interleukin-6 was higher at Day 2 and lower at Days 6 and 28 in recipients of fresh versus aged RBCs. Multiple parameters showed significant modulation after surgery and transfusion. Most analytes that changed after surgery did not differ based on transfusion status. Several extracellular vesicle markers, including two associated with platelets (CD41a and CD62P), decreased in transfused patients more than in those who underwent surgery without transfusion.

Conclusions: Transfusion of fresh versus aged RBCs does not result in substantial changes in hemostasis, immune, or nitric oxide parameters. It is possible that transfusion modulates the level of platelet-derived extracellular vesicles, which will require study of patients randomly assigned to receipt of transfusion to define.

Fig. 1.

Longitudinal analysis of coagulation parameters after transfusion. Mean levels of coagulation parameters that changed significantly over time are shown on Days 0 (before transfusion) and 2, 6, and 28 after transfusion in recipients of fresh (red) and standard (blue) aged blood. (A) Values as a percentage of normal control plasma levels are shown for analytes that decreased after Day 0. (B) Analytes that increased in at least one treatment arm after Day 0 are shown. Analytes for which the change from Day 0 to Day 2 was significant are indicated by asterisks. Error bars represent standard error of the mean. *p < 0.05, **p < 0.01, ****p < 0.0001, comparing Day 0 to Day 2 values independent of treatment arm effect.

Fig. 2.

Longitudinal analysis of cytokine levels after transfusion. Mean levels of analytes are shown on Days 0 (before transfusion) and 2, 6, and 28 after transfusion in recipients of fresh (red) and standard (blue) aged blood. (A) Cytokines that decreased after Day 0 are shown. Only EGF significantly differed after baseline between the fresh and aged RBC arms. (B) Cytokines that increased after Day 0 are shown. (C) EV levels that decreased after Day 0 are shown. Analytes for which the change from Day 0 to Day 2 was significant are indicated by asterisks. Error bars represent standard error of the mean. IP-10 = CXCL10; ITAC = CXCL11; MIP-1β = CCL4; MPO = myeloperoxidase; RANTES = CCL5. *p < 0.05, **p < 0.01, ***, p < 0.001, ****p < 0.0001, comparing Day 0 to Day 2 values independent of treatment arm effect; ∇ p < 0.05, ∇∇ p < 0.01 comparing treatment arms at noted time point.

Fig. 2.

Longitudinal analysis of cytokine levels after transfusion. Mean levels of analytes are shown on Days 0 (before transfusion) and 2, 6, and 28 after transfusion in recipients of fresh (red) and standard (blue) aged blood. (A) Cytokines that decreased after Day 0 are shown. Only EGF significantly differed after baseline between the fresh and aged RBC arms. (B) Cytokines that increased after Day 0 are shown. (C) EV levels that decreased after Day 0 are shown. Analytes for which the change from Day 0 to Day 2 was significant are indicated by asterisks. Error bars represent standard error of the mean. IP-10 = CXCL10; ITAC = CXCL11; MIP-1β = CCL4; MPO = myeloperoxidase; RANTES = CCL5. *p < 0.05, **p < 0.01, ***, p < 0.001, ****p < 0.0001, comparing Day 0 to Day 2 values independent of treatment arm effect; ∇ p < 0.05, ∇∇ p < 0.01 comparing treatment arms at noted time point.

Fig. 3.

Parameters that evolved differently in transfused and nontransfused subjects. The change in levels from Day 0 to Day 2 for all parameters measured were compared between transfused (red) and nontransfused (blue) subjects. Mean levels of the six analytes for which the Day 0 to Day 2 change between the two groups differed are shown (p < 0.05). Error bars represent standard error of the mean.