From donor biology to donor health protection: Three (very) short stories

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1 From donor biology to donor health protection: Three (very) short stories Steven L. Spitalnik, M.D. Laboratory of Transfusion Biology

2 Potential Conflicts of Interest Hemanext: Tioma, Inc: Advisory Board Consultant

3 This is the focus of our interest

4 This is the focus of our interest Are there characteristics of the donor that will make better products and affect donor health?

5 What do we know about refrigerator-stored RBCs?

6 What do we know about refrigerator-stored RBCs? As storage time increases (FDA criteria):

7 What do we know about refrigerator-stored RBCs? As storage time increases (FDA criteria): Increasing hemolysis ex vivo (<1.0%) Infuse free hemoglobin, etc.

8 What do we know about refrigerator-stored RBCs? As storage time increases (FDA criteria): Increasing hemolysis ex vivo (<1.0%) Infuse free hemoglobin, etc. Decreasing 24-hr post-transfusion recovery in vivo (~>75%) Less than optimal dose

9 What happens to the RBCs during refrigerated storage?

10 The RBC storage lesion Day 0 Blasi, D Alessandro, et al. Transfusion Medicine 22:90-96, 2012

11 The RBC storage lesion Day 0 Day 42 Blasi, D Alessandro, et al. Transfusion Medicine 22:90-96, 2012

12 The RBC storage lesion 2,3-DPG, GSH, ATP Nitric oxide Protein oxidation Membrane- & cytoskeletal-associated hemoglobin Membrane lipid peroxidation Lysophosphatidylcholine species Vesiculation and membrane loss Deformability Phosphatidylserine exposure CD47

13 The RBC storage lesion 2,3-DPG, GSH, ATP Nitric oxide Protein oxidation Membrane- & cytoskeletal-associated hemoglobin Membrane lipid peroxidation Lysophosphatidylcholine species Vesiculation and membrane loss Deformability Phosphatidylserine exposure CD47

14 The RBC storage lesion Final common pathway? Metabolic dysfunction & oxidative stress Deformability Eat me signals (phosphatidylserine) Don t eat me signals (CD47) Hemolysis in vitro RBC clearance in vivo Intravascular and extravascular hemolysis

15 RBC Clearance Variability

16 RBC Recovery Study 5-15 ml Centrifuge Wash Incubate 51-Cr Wash IV push Serial blood draws

17 24-hr RBC recovery in 641 healthy volunteers Dumont et al. Transfusion 48: , 2008.

18 24-hr RBC recovery in 641 healthy volunteers Dumont et al. Transfusion 48: , 2008.

19 24-hr RBC recovery in 641 healthy volunteers Poor storers Dumont et al. Transfusion 48: , 2008.

20 24-hr RBC recovery in 641 healthy volunteers Poor storers Super storers Dumont et al. Transfusion 48: , 2008.

21 Is old blood bad? Infection? Inflammation? Thrombosis? Mortality? Not going to talk about it now We can discuss it later

22 Is old blood bad? Infection? Inflammation? Thrombosis? Mortality?

23 Is old blood bad? Infection? Inflammation? Thrombosis? Mortality? Not going to talk about these now

24 Is old blood bad? Infection? Inflammation? Thrombosis? Mortality? Not going to talk about these now We can discuss these later, if you would like

25 Is old blood bad? RBC refrigerated storage time RBC storage lesion in vitro RBC recovery in vivo

26 Is old blood bad? Why is transfusion of less than a full dose OK? Transfused RBCs that don t circulate cannot provide their pharmaceutical function (e.g., O 2 delivery) What other drug to we give whose potency decreases over time? And that s OK?

27 Is old blood bad? Why is transfusion of less than a full dose OK? Transfused RBCs that don t circulate cannot deliver O 2 What other drug to we give whose potency decreases over time? And that s OK?

28 When do RBCs go bad?

29 When do RBCs go bad? Journal of Clinical Investigation 127: , 2017

30 60 healthy volunteers enrolled 52 completed study Randomized to 1, 2, 3, 4, 5, 6 weeks of storage Leukoreduced; AS-3 Transfused entire unit 51 Cr-labeled post-transfusion recovery

31 When do RBCs go bad?

32 When do RBCs go bad? 6 Weeks

33 When do RBCs go bad? 6 Weeks Similar pattern with serum iron, NTBI, etc. No evidence of intravascular hemolysis

34 When do RBCs go bad? 6 Weeks Similar pattern with serum iron, NTBI, etc. No evidence of intravascular hemolysis

35 When do RBCs go bad?

36 When do RBCs go bad?

37 When do RBCs go bad?

38 When do RBCs go bad?

39 What donor characteristics influence variation in post-transfusion recovery?

40 Story #1: Genetics: G6PD deficiency Richard O. Francis, M.D., Ph.D.

41 The RBC storage lesion Final common pathway? Metabolic dysfunction & oxidative stress Deformability Eat me signals Don t eat me signals Hemolysis in vitro RBC clearance in vivo Intravascular and extravascular hemolysis

42 Inherited Hemolytic Anemias Final common pathway Metabolic dysfunction & oxidative stress Deformability Eat me signals Don t eat me signals Hemolysis in vitro RBC clearance in vivo Intravascular and extravascular hemolysis

43 What are the consequences of the clearance of stored RBCs? RBC storage lesion in vitro Decreased RBC recovery in vivo

44 What are the consequences of the clearance of stored RBCs? Insufficient protection against oxidative stress in vitro Decreased RBC recovery in vivo

45 The case for G6PD: Homeostasis SOD2 O 2 -. Glc Hexokinase NADP+ NADPH CAT H 2 O 2 H 2 O GPX1 GSH GSSG GSR NADP+ NADPH Glc-6-PO 4 G6PD 6-PGL Lactonase 6-PG 6-PGD Rib-5-PO 4

46 The case for G6PD: Homeostasis SOD2 O 2 -. Glc Hexokinase NADP+ NADPH CAT H 2 O 2 H 2 O GPX1 GSH GSSG GSR NADP+ NADPH Glc-6-PO 4 G6PD 6-PGL Lactonase 6-PG 6-PGD Rib-5-PO 4

47 The case for G6PD: Homeostasis SOD2 O 2 -. Glc Hexokinase NADP+ NADPH CAT H 2 O 2 H 2 O GPX1 GSH GSSG GSR NADP+ NADPH Glc-6-PO 4 G6PD 6-PGL Lactonase 6-PG 6-PGD Rib-5-PO 4

48 The case for G6PD: Homeostasis SOD2 O 2 -. Glc Hexokinase NADP+ NADPH CAT H 2 O 2 H 2 O GPX1 GSH GSSG GSR NADP+ NADPH Glc-6-PO 4 G6PD 6-PGL Lactonase 6-PG 6-PGD Rib-5-PO 4

49 The case for G6PD: Homeostasis SOD2 O 2 -. Glc Hexokinase NADP+ NADPH CAT H 2 O 2 H 2 O GPX1 GSH GSSG GSR NADP+ NADPH Glc-6-PO 4 G6PD 6-PGL Lactonase 6-PG 6-PGD Rib-5-PO 4

50 The case for G6PD: Homeostasis SOD2 O 2 -. Glc Hexokinase NADP+ NADPH CAT H 2 O 2 H 2 O GPX1 GSH GSSG GSR NADP+ NADPH Glc-6-PO 4 G6PD 6-PGL Lactonase 6-PG 6-PGD Rib-5-PO 4

51 The case for G6PD: G6PD-deficiency SOD2 O 2 -. Glc Hexokinase NADP+ NADPH CAT H 2 O 2 H 2 O GPX1 GSH GSSG GSR NADP+ NADPH X G6PD Glc-6-PO 4 6-PGL Lactonase 6-PG 6-PGD Rib-5-PO 4

52 The case for G6PD: G6PD-deficiency SOD2 O 2 -. Glc Hexokinase NADP+ X NADPH CAT H 2 O 2 X H 2 O GPX1 XGSH GSSG GSR NADP+ X NADPH X X X G6PD Glc-6-PO 4 6-PGL Lactonase 6-PG 6-PGD Rib-5-PO 4

53 The case for G6PD: G6PD-deficiency SOD2 O 2 -. OH. Glc Hexokinase NADP+ X NADPH CAT H 2 O 2 X H 2 O GPX1 XGSH GSSG GSR NADP+ X NADPH X X X G6PD Glc-6-PO 4 6-PGL Lactonase 6-PG 6-PGD Rib-5-PO 4

54 The case for G6PD: G6PD-deficiency SOD2 O 2 -. OH. Glc Hexokinase NADP+ X NADPH CAT H 2 O 2 X H 2 O GPX1 XGSH GSSG GSR NADP+ X NADPH X X X G6PD Glc-6-PO 4 6-PGL Lactonase 6-PG 6-PGD Rib-5-PO 4

55 The case for G6PD: G6PD-deficiency Unrelieved oxidative stress: RBC structural damage Intravascular hemolysis (hemoglobinemia) Extravascular hemolysis (Bilirubin, serum iron)

56 The case for G6PD: G6PD-deficiency Most common human enzymopathy ~400 million affected individuals Genetically-induced enzyme variation: Severely decreased activity Normal activity Increased activity

57 The case for G6PD: G6PD-deficiency Most common human enzymopathy ~400 million affected individuals Genetically-induced enzyme variation: Severely decreased activity Normal activity Increased activity

58 The case for G6PD: G6PD-deficiency Most common human enzymopathy ~400 million affected individuals Genetically-induced enzyme variation: Severely decreased activity Normal activity Increased activity

59 The case for G6PD: G6PD-deficiency Most common human enzymopathy ~400 million affected individuals Genetically-induced enzyme variation: Severely decreased activity: poor storers? Normal activity Increased activity

60 The case for G6PD: G6PD-deficiency Most common human enzymopathy ~400 million affected individuals Genetically-induced enzyme variation: Severely decreased activity: poor storers? Normal activity Increased activity: super storers?

61 The case for G6PD: G6PD-deficiency

62 The case for G6PD: G6PD-deficiency

63 The case for G6PD: G6PD-deficiency Prevalence of G6PD-deficiency in normal donors at our hospital: Random donors: 0.3% Francis et al. Transfusion 53: , 2013

64 The case for G6PD: G6PD-deficiency Prevalence of G6PD-deficiency in normal donors at our hospital: Random donors: 0.3% R 0 R 0 /R 0 r donors: 12.3% Francis et al. Transfusion 53: , 2013

65 The case for G6PD: G6PD-deficiency Prevalence of G6PD-deficiency in normal donors at our hospital: Random donors: 0.3% R 0 R 0 /R 0 r donors: 12.3% Exchange Transfusions for Sickle Cell Disease Francis et al. Transfusion 53: , 2013

66 Study Design Volunteers: G6PD-deficient Matched controls Donate 1 unit: Pre-storage leukoreduced Store for days in AS-3 24h 51-Cr post-transfusion recovery

67 Study Design Enroll: 10 G6PD-deficient + 30 controls G6PD-deficient variants: 9 African, 1 Mediterranean None with hemoglobin variant or thalassemia trait

68 The case for G6PD: G6PD-deficiency 86.8% 81.0%

69 The case for G6PD: G6PD-deficiency 86.8% 81.0%

70 The case for G6PD: G6PD-deficiency 86.8% 81.0% FDA failures in G6PD-deficient group

71 The case for G6PD: G6PD-deficiency 86.8% 81.0% No correlation between PTR and G6PD enzyme activity within groups

72 The case for G6PD: G6PD-deficiency 86.8% 81.0% No difference in hemolysis in the bag at outdate

73 The case for G6PD: G6PD-deficiency 86.8% 81.0% Would 24-hour post-transfusion recoveries be worse in ill recipients?

74 Conclusions (G6PD) RBCs from G6PD-deficient volunteers have inferior storage quality: 5.8% (p=0.001) The intrinsic ability of RBCs to resist oxidative stress affects storage quality Should we test donors to provide better products? Should we counsel G6PD-deficient donors?

77 Should we counsel G6PD-deficient donors regarding their condition?

78 Story #2: Diet: Iron deficiency Eldad Hod, M.D. Gary Brittenham, M.D.

79 The RBC storage lesion Final common pathway? Metabolic dysfunction & oxidative stress Deformability Eat me signals Don t eat me signals Hemolysis in vitro RBC clearance in vivo Intravascular and extravascular hemolysis

80 Iron deficiency (without anemia) is very common in blood donors

81 Iron deficiency (without anemia) is very common in blood donors Iron-deficient erythropoiesis (IDE)

82 Iron deficiency anemia affects RBC lifespan & transfusion recovery Resistance to oxidative stress Oxidative damage Resistance to low ph Phosphatidylserine exposure Deformability Splenic clearance

83 Iron deficiency anemia affects RBC lifespan & transfusion recovery Resistance to oxidative stress Oxidative damage Resistance to low ph Phosphatidylserine exposure Deformability Splenic clearance Is this relevant in IDE?

84 Mouse model Weanling, male C57BL/6 mice: 1. Control diet: 45 ppm of iron (normal) 2. Iron-deficient diet: 0-4 ppm of iron (IDE) 3. Iron-deficient diet + weekly phlebotomy (IDA)

85 Mouse model At 10 weeks of age: Exsanguinated, pooled, leukoreduced, packed, stored in CPDA-1 for 12 days Transfused into GFP-transgenic recipients 24-hour post-transfusion recovery by flow cytometry

86 Results All comparisons: p<0.001

87 RBCs from normal donors had normal recovery

88 RBCs from donors with IDA had poor recovery ***: p<0.001

89 RBCs from donors with IDE had sub-normal recovery *: p<0.05

90 Would this be true for human recipients of RBC transfusions from donors with IDE?

91 Would this be true for human recipients of RBC transfusions from donors with IDE?

92 Would this be true for human recipients of RBC transfusions from donors with IDE?

93 Would this be true for human recipients of RBC transfusions from donors with IDE?

94 Conclusions (Iron) Should we screen donors for iron-deficient erythropoiesis? Should we collect & transfuse RBCs from such donors? Should we counsel & treat iron-deficient donors?

95 Story #3: Environment : Lead Tiffany Thomas, Ph.D.

96 Lead

97 Lead Neurotoxicant (synapses, myelin, etc.)

98 Lead Neurotoxicant (synapses, myelin, etc.) No threshold effect

99 Lead Neurotoxicant (synapses, myelin, etc.) No threshold effect Young children particularly vulnerable

100 Lead Neurotoxicant (synapses, myelin, etc.) No threshold effect Young children particularly vulnerable Premature babies are relatively Fe deficient

101 Lead Neurotoxicant (synapses, myelin, etc.) No threshold effect Young children particularly vulnerable Premature babies are relatively Fe deficient blood lead level: >5 μg/dl ( μmol/l)

102 Lead Neurotoxicant (synapses, myelin, etc.) No threshold effect Young children particularly vulnerable Premature babies are relatively Fe deficient blood lead level: >5 μg/dl ( μmol/l) In whole blood, 75% of lead is in RBCs

103 Lead Do donor prbc units contain high lead levels?

104 Lead Do donor prbc units contain high lead levels? If so, who cares?

105 Lead

106 Lead Toxic levels in ~10% of their donor population

107 Lead

108 Lead

109 Lead

110 Our data

111 Our data

112 Our data

113 Conclusions: Lead Should we screen units destined for premature infants? Should we inform donors of their lead toxicity?

114 Future Directions Making better products: Ideal RBC unit

115 Future Directions Making better products: Ideal RBC unit Optimal post-transfusion recovery & lifespan Equivalent to fresh

116 Future Directions Making better products: Ideal RBC unit Optimal post-transfusion recovery & lifespan Equivalent to fresh No WBCs Avoid febrile NHTRs, HLA alloimmunization, TA-GVHD

117 Future Directions Making better products: Ideal RBC unit Optimal post-transfusion recovery & lifespan Equivalent to fresh No WBCs Avoid febrile NHTRs, HLA alloimmunization, TA-GVHD No plasma Avoid allergic NHTRs, anaphylactic NHTRs, and TRALI

118 Future Directions Making better products: Ideal RBC unit Optimal post-transfusion recovery & lifespan Equivalent to fresh No WBCs Avoid febrile NHTRs, HLA alloimmunization, TA-GVHD No plasma Avoid allergic NHTRs, anaphylactic NHTRs, and TRALI Lacking clinically-significant RBC blood group antigens Avoid RBC alloimmunization and HTRs

119 Future Directions But, should we create better donors? What ethical obligations do we have to protect and inform our donors?

120 Future Directions But, should we create better donors? If so, what ethical obligations do we have to protect and inform our donors?

121 Thank you

Thinking Twice About Transfusions: When TACOS and TRALIs Turn Treatment Into Tragedy. Megan Boysen Osborn, MD, MHPE

Thinking Twice About Transfusions: When TACOS and TRALIs Turn Treatment Into Tragedy Megan Boysen Osborn, MD, MHPE Let s TACO bout Transfusion Reactions Megan Boysen Osborn, MD, MHPE Let s TACO bout Transfusion