Vox Sanguinis (2015) 109, 52–61 © 2015 International Society of Blood Transfusion DOI: 10.1111/vox.12249
ORIGINAL PAPER
Haemostatic function and biomarkers of endothelial damage before and after RBC transfusion in patients with haematologic disease A. M. Larsen,1 E. B. Leinøe,2 P. I. Johansson,3,4 H. Birgens1 & S. R. Ostrowski3 1
Department of Haematology, Copenhagen University Hospital, Herlev, Denmark Department of Haematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark 3 Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark 4 Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research, CeTIR, University of Texas Medical School at Houston, Houston, TX, USA 2
Background and objectives Transfusion of red blood cells (RBC) is beneficial for the patient but can also be harmful, as randomized trials have demonstrated increased infection rates, bleeding and mortality. The study aim was to investigate the response of the vascular system (the haemostatic function and the endothelium) to RBC transfusion. Materials and Methods Blood was sampled from patients with various transfusion-dependent haematologic diseases before 1 and 24 h after RBC transfusion. Primary and secondary haemostasis was evaluated by whole-blood impedance aggregometry (Multiplate) and by thromboelastography (TEG). Samples were analysed by ELISA for biomarkers reflecting endothelial activation and damage (sICAM-1, syndecan-1, sThrombomodulin (sTM), sVE-Cadherin), platelet activation (sCD40L) and inflammation (hsCRP). Results A total of 58 patients were enrolled in the study. Median age was 71 years. Compared to before transfusion, patients had slightly reduced coagulability 1 h after RBC transfusion, assessed by TEG. However, transfusion of older RBC products (>14 days) was associated with increased coagulability (all P < 005). The level of syndecan-1 increased slightly 24 h after transfusion (median 124 (IQR 9–23) vs. 132 (9–25) ng/ml, P < 001), indicating increased glycocalyx degradation.
Received: 29 October 2014, revised 8 December 2014, accepted 15 December 2014, published online 6 March 2015
Conclusion Overall, RBC transfusion was associated with reduced coagulability and endothelial glycocalyx degradation. Transfusion of older RBCs was however associated with increased coagulability. The changes observed were small to moderate and the clinical relevance of these findings should be investigated in larger studies. Key words: haematologic disease, haemostasis, RBC transfusion, the vascular endothelium.
Introduction Transfusion of red blood cells (RBC) is beneficial for the patient but can also be harmful. The obvious risks of Correspondence: Anne Mette Larsen, Department of Hematology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, DK-2730 Herlev, Denmark E-mail: [email protected]
52
direct transfusion-transmitted infections and ABO incompatibility have been widely eliminated, instead some less obvious short- and long-term risks of increased infection rates, bleeding and mortality have been demonstrated in randomized trials [1, 2]. The connection between RBC transfusion and adverse events is a possible suppression of the immune system, referred to as transfusion-related immune modulation (TRIM) [3]. The TRIM effect entails a transfusion-mediated
Endothelium in RBC transfusion 53
pro-inflammatory stimulus causing cytokine release, T-cell subset changes, impaired natural killer cell function and micro-chimerism in the recipient, all though these mechanisms are not yet fully understood [3, 4]. The duration of the RBC storage time period is also associated with worse clinical outcomes [5–7]. The storage lesion of the RBCs comprises, for example increased procoagulant activity due to RBC phosphatidyl-serine exposure [8] and increased RBC adhesion to endothelial cells [9]. The endothelial cells, covered by a thin glycocalyx, regulate fluid filtration and harbour the adhesion molecules, important in leucocyte recruitment, and the proteins that function and balance haemostasis [10]. These cells orchestrate blood cell recruitment in inflammation and in innate immunity, and potentially also in transfusion of allogeneic substances and cells, considering transfusion as a host invasion of foreign antigens. The endothelial cells are among the first recipient cells to interact with the transfused RBCs, and we speculated that transfused RBCs cause a measurable impact on the endothelium, in patients with transfusion-dependent chronic stable haematologic disease. Therefore, we investigated the state of the endothelium in a pre- and post-transfusion setting, hypothesizing that transfusion of RBCs would impact on the coagulation system and the endothelium, potentially influenced by the degree of inflammation in both the donor, the blood product (storage time) and the recipient.
Materials and methods Patients All patients were included in this observational prospective study in the period between April 2012 and August 2013 at the Departments of Haematology (section for leukaemia and myeloproliferative disease), Copenhagen University Hospital, Herlev and Rigshospitalet. The number of included patients in this explorative study was set by the accessibility of patients during the time–course at the two clinical centres. One physician included the patients. Informed consent was given by all patients in accordance with the Second Declaration of Helsinki, and the study was approved by the local ethics committee (registration number H-4-2011-008) and the Danish Data Protection Agency (registration number 2011-41-6404). We chose patients who had transfusion-dependent chronic stable haematological disease, because this gave us the opportunity to investigate the basic mechanisms of the interaction between the endothelium and the transfusate, without prior activation of the endothelium by acute illness such as, sepsis, trauma or severe bleeding. © 2015 International Society of Blood Transfusion Vox Sanguinis (2015) 109, 52–61
Outpatients with any blood disease (excluding acute myeloid leukaemia) were selected based on several daily reviews of planned transfusions in the Department of Haematology, followed by an immediate evaluation of the patient’s eligibility according to the study inclusion criteria. Each patient could be included only once and patients could have one or more units of RBC’s. Exclusion criteria were as follows: age 4 days difference in storage time). The storage time period was divided into short (≤14 days) or long (>14 days), as done in previous studies demonstrating clinical adverse effects after transfusion of RBC products stored for more than 14 days and significant storage lesions after 14 days of storage [8, 12, 13]. P-values
ORIGINAL PAPER
Haemostatic function and biomarkers of endothelial damage before and after RBC transfusion in patients with haematologic disease A. M. Larsen,1 E. B. Leinøe,2 P. I. Johansson,3,4 H. Birgens1 & S. R. Ostrowski3 1
Department of Haematology, Copenhagen University Hospital, Herlev, Denmark Department of Haematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark 3 Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark 4 Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research, CeTIR, University of Texas Medical School at Houston, Houston, TX, USA 2
Background and objectives Transfusion of red blood cells (RBC) is beneficial for the patient but can also be harmful, as randomized trials have demonstrated increased infection rates, bleeding and mortality. The study aim was to investigate the response of the vascular system (the haemostatic function and the endothelium) to RBC transfusion. Materials and Methods Blood was sampled from patients with various transfusion-dependent haematologic diseases before 1 and 24 h after RBC transfusion. Primary and secondary haemostasis was evaluated by whole-blood impedance aggregometry (Multiplate) and by thromboelastography (TEG). Samples were analysed by ELISA for biomarkers reflecting endothelial activation and damage (sICAM-1, syndecan-1, sThrombomodulin (sTM), sVE-Cadherin), platelet activation (sCD40L) and inflammation (hsCRP). Results A total of 58 patients were enrolled in the study. Median age was 71 years. Compared to before transfusion, patients had slightly reduced coagulability 1 h after RBC transfusion, assessed by TEG. However, transfusion of older RBC products (>14 days) was associated with increased coagulability (all P < 005). The level of syndecan-1 increased slightly 24 h after transfusion (median 124 (IQR 9–23) vs. 132 (9–25) ng/ml, P < 001), indicating increased glycocalyx degradation.
Received: 29 October 2014, revised 8 December 2014, accepted 15 December 2014, published online 6 March 2015
Conclusion Overall, RBC transfusion was associated with reduced coagulability and endothelial glycocalyx degradation. Transfusion of older RBCs was however associated with increased coagulability. The changes observed were small to moderate and the clinical relevance of these findings should be investigated in larger studies. Key words: haematologic disease, haemostasis, RBC transfusion, the vascular endothelium.
Introduction Transfusion of red blood cells (RBC) is beneficial for the patient but can also be harmful. The obvious risks of Correspondence: Anne Mette Larsen, Department of Hematology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, DK-2730 Herlev, Denmark E-mail: [email protected]
52
direct transfusion-transmitted infections and ABO incompatibility have been widely eliminated, instead some less obvious short- and long-term risks of increased infection rates, bleeding and mortality have been demonstrated in randomized trials [1, 2]. The connection between RBC transfusion and adverse events is a possible suppression of the immune system, referred to as transfusion-related immune modulation (TRIM) [3]. The TRIM effect entails a transfusion-mediated
Endothelium in RBC transfusion 53
pro-inflammatory stimulus causing cytokine release, T-cell subset changes, impaired natural killer cell function and micro-chimerism in the recipient, all though these mechanisms are not yet fully understood [3, 4]. The duration of the RBC storage time period is also associated with worse clinical outcomes [5–7]. The storage lesion of the RBCs comprises, for example increased procoagulant activity due to RBC phosphatidyl-serine exposure [8] and increased RBC adhesion to endothelial cells [9]. The endothelial cells, covered by a thin glycocalyx, regulate fluid filtration and harbour the adhesion molecules, important in leucocyte recruitment, and the proteins that function and balance haemostasis [10]. These cells orchestrate blood cell recruitment in inflammation and in innate immunity, and potentially also in transfusion of allogeneic substances and cells, considering transfusion as a host invasion of foreign antigens. The endothelial cells are among the first recipient cells to interact with the transfused RBCs, and we speculated that transfused RBCs cause a measurable impact on the endothelium, in patients with transfusion-dependent chronic stable haematologic disease. Therefore, we investigated the state of the endothelium in a pre- and post-transfusion setting, hypothesizing that transfusion of RBCs would impact on the coagulation system and the endothelium, potentially influenced by the degree of inflammation in both the donor, the blood product (storage time) and the recipient.
Materials and methods Patients All patients were included in this observational prospective study in the period between April 2012 and August 2013 at the Departments of Haematology (section for leukaemia and myeloproliferative disease), Copenhagen University Hospital, Herlev and Rigshospitalet. The number of included patients in this explorative study was set by the accessibility of patients during the time–course at the two clinical centres. One physician included the patients. Informed consent was given by all patients in accordance with the Second Declaration of Helsinki, and the study was approved by the local ethics committee (registration number H-4-2011-008) and the Danish Data Protection Agency (registration number 2011-41-6404). We chose patients who had transfusion-dependent chronic stable haematological disease, because this gave us the opportunity to investigate the basic mechanisms of the interaction between the endothelium and the transfusate, without prior activation of the endothelium by acute illness such as, sepsis, trauma or severe bleeding. © 2015 International Society of Blood Transfusion Vox Sanguinis (2015) 109, 52–61
Outpatients with any blood disease (excluding acute myeloid leukaemia) were selected based on several daily reviews of planned transfusions in the Department of Haematology, followed by an immediate evaluation of the patient’s eligibility according to the study inclusion criteria. Each patient could be included only once and patients could have one or more units of RBC’s. Exclusion criteria were as follows: age 4 days difference in storage time). The storage time period was divided into short (≤14 days) or long (>14 days), as done in previous studies demonstrating clinical adverse effects after transfusion of RBC products stored for more than 14 days and significant storage lesions after 14 days of storage [8, 12, 13]. P-values
