Stefania Vaglio

Time-course investigation of SAGM-stored leukocyte-filtered red bood cell concentrates: from metabolism to proteomics

Background Results from recent, highly debated, retrospective studies raised concerns and prompted considerations about further testing the quality of long stored red blood cells from a biochemical standpoint. Design and Methods We performed an integrated mass spectrometry-based metabolomics and proteomics time-course investigation on SAGM-stored red blood cells. In parallel, structural changes during storage were monitored through scanning electron microscopy. Results We detected increased levels of glycolytic metabolites over the first 2 weeks of storage. From day 14 onwards, we observed a significant consumption of all metabolic species, and diversion towards the oxidative phase of the pentose phosphate pathway. These phenomena coincided with the accumulation of reactive oxygen species and markers of oxidation (protein carbonylation and malondialdehyde accumulation) up to day 28. Proteomics evidenced changes at the membrane protein level from day 14 onwards. Changes included fragmentation of membrane structural proteins (spectrin, band 3, band 4.1), membrane accumulation of hemoglobin, anti-oxidant enzymes (peroxiredoxin-2) and chaperones. While the integrity of red blood cells did not show major deviations at day 14, at day 21 scanning electron microscope images revealed that 50% of the erythrocytes had severely altered shape. We could correlate the scanning electron microscopy observations with the onset of vesiculation, through a proteomics snapshot of the difference in the membrane proteome at day 0 and day 35. We detected proteins involved in vesicle formation and docking to the membrane, such as SNAP alpha. Conclusions Biochemical and structural parameters did not show significant alterations in the first 2 weeks of storage, but then declined constantly from day 14 onwards. We highlighted several parallelisms between red blood cells stored for a long time and the red blood cells of patients with hereditary spherocytosis.

Peroxiredoxin-2 as a candidate biomarker to test oxidative stress levels of stored red blood cells under blood bank conditions

BACKGROUND: Several researches on aging red blood cells (RBCs)—performed both in vivo and under blood bank conditions—revealed that RBC membrane proteins undergo a number of irreversible alterations, mainly due to oxidative stress. The individuation of proteins to be used as indicators of irreversible RBC injury and to be proposed as candidate biomarkers of oxidative damage or aging status during blood storage is therefore of great interest.

Hepatitis E: an old infection with new implications.

The availability of safe blood and blood products is an important public health issue. Improvements in donor screening and testing, pathogen inactivation1 and removal methods, the use of serological tests with greater diagnostic efficacy and the introduction of nucleic acid testing (NAT) have resulted in a substantial drop in transfusion-transmitted infections over the last two decades2. Nonetheless, blood supplies remain vulnerable to emerging and re-emerging infections. In recent years, numerous infectious agents found worldwide have been identified or reconsidered as potential threats to blood supplies3–5. n nHepatitis E virus (HEV) has long been considered an enterically transmitted virus causing self-limiting acute viral hepatitis. The disease is endemic in many developing countries, but in recent years an increasing number of autochthonous and sporadic HEV infections have been described in developed countries6. This virus usually causes an acute self-limiting hepatitis, but in some cases fulminant hepatic failure resulting in morbidity and mortality may occur, especially in at-risk groups such as the elderly, pregnant women and patients with pre-existing liver disease or those who are immunocompromised. Furthermore, recent seroprevalence studies are questioning the concept of the low circulation of HEV in developed countries7. n nThis narrative review aims at providing a comprehensive view of HEV and its possible “role” in transfusion medicine.

Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults

Patient Blood Management (PBM) is a holistic approach to the management of blood as a resource for each, single patient; it is a multimodal strategy that is implemented through the use of a set of techniques that can be applied in individual cases. Indeed, the overall outcome resulting from the implementation of PBM cannot be fully appreciated and explained simply by summing the effects of the single strategies and techniques used, since these can only produce the expected optimal outcome if used in combination1. PBM is, therefore, a patient-centred, multiprofessional, multidisciplinary and multimodal approach to the optimal management of anaemia and haemostasis (also during surgery), to limiting allogeneic transfusion needs in the peri-operative period, and to appropriate use of blood components and, when relevant, plasma-derived medicinal products2. The concept of PBM is not centred on a specific pathology or procedure, nor on a specific discipline or sector of medicine, but is aimed at managing a resource, “the patient’s blood”, shifting attention from the blood component to the patient who, therefore, acquires a central and pre-eminent role3,4. n nPBM combines the dual purposes of improving the outcomes of patients and reducing costs, being based on the patient rather than on allogeneic blood as the resource. For this reason, PBM goes beyond the concept of appropriate use of blood components and plasma-derived medicinal products, since its purpose is to avoid or significantly reduce their use, managing, in good time, all the modifiable risk factors that can lead to a transfusion being required5. These aims can be achieved through the so-called “three pillars of PBM” (Table I)5, which are crucial for making the paradigmatic shift that characterises the innovative, patient-centred approach: (i) optimising the patient’s erythropoiesis; (ii) minimising bleeding; and (iii) optimising and exploiting an individual’s physiological reserve to tolerate anaemia5. Each of these three key points is a strategic response to clinical circumstances that can cause adverse outcomes and necessitate the use of allogeneic transfusion therapy, namely anaemia, blood loss and hypoxia, respectively. n n n nTable I n nThe three pillars of Patient Blood Management (modified from Hofmann A et al.5). n n n nPBM is, therefore, intended to guarantee all patients a series of personalised programmes, based on surgical requirements and the characteristics of the patients themselves, with the dual purposes of using allogeneic transfusion support appropriately and reducing the need for this resource. For this reason, PBM requires multidisciplinary and multimodal strategies to systematically identify, evaluate and manage anaemia (boosting, if necessary, individual physiological reserves) and to avoid or minimise blood losses. n nIt seems necessary to produce specific national standards. In fact, in the USA, PBM is the object of attention from the Association for Advancing Transfusions and Cellular Therapies (formerly known as the American Association of Blood Banks - AABB) which recently published the first edition of “Standards for a Patient Blood Management Program” precisely with the aim of supplying healthcare structures with solid elements for the standardisation of procedures and activities for implementing and/or optimising a PBM programme. The Society for the Advancement of Blood Management (SABM), also in the USA, has published a second edition of “Administrative and Clinical Standards for Patient Blood Management Programs”6 and the Joint Commission has published seven parameters for measuring the performance of healthcare structures in the field of PBM7.

Human T-lymphotropic virus and transfusion safety: does one size fit all?

Human T‐cell leukemia viruses (HTLV‐1 and HTLV‐2) are associated with a variety of human diseases, including some severe ones. Transfusion transmission of HTLV through cellular blood components is undeniable. HTLV screening of blood donations became mandatory in different countries to improve the safety of blood supplies. In Japan and Europe, most HTLV‐infected donors are HTLV‐1 positive, whereas in the United States a higher prevalence of HTLV‐2 is reported. Many industrialized countries have also introduced universal leukoreduction of blood components, and pathogen inactivation technologies might be another effective preventive strategy, especially if and when generalized to all blood cellular products. Considering all measures available to minimize HTLV blood transmission, the question is what would be the most suitable and cost‐effective strategy to ensure a high level of blood safety regarding these viruses, considering that there is no solution that can be deemed optimal for all countries.

Proteomic analysis of plasma derived from platelet buffy coats during storage at room temperature. An application of ProteoMiner™ technology.

The present study was aimed at revealing new insights into the analysis of storage-related processes occurring in the supernatants of platelet concentrates (PCs) derived from pooled buffy coats suspended in whole plasma. To reduce the dynamic range of plasma protein concentrations and access low-abundance proteins, we made use of a solid-phase combinatorial peptide ligand library, known under the trade name of ProteoMiner™. Afterwards, two-dimensional electrophoresis (2-DE) was coupled with mass spectrometry (MS) to reveal changes in proteomic profiles. Several storage-induced protein alterations were identified including changes to major plasma proteins. In particular, a precursor of the secretory form of clusterin was shown to accumulate during storage of PC supernatants, together with platelet-derived tropomyosin, suggesting a progressive loss of platelet integrity. Platelet-released proteins following activation have also been detected (alpha-1-B-glycoprotein, kininogen-1, and serpin proteinase inhibitor 8). Moreover, specific protein fragments (vitronectin, plakoglobin, hornerin, and apolipoprotein A-IV) were found to be modulated upon storage, possibly indicating a time-dependent buffy-coat PC deterioration. Globally, our findings provided the disclosure of unique proteins in PC supernatants with respect to previous studies conducted in similar experimental conditions, suggesting ProteoMiner enrichment technology to be a possible complementary tool in the identification of diagnostically relevant proteins as age/quality biomarkers of therapeutic products.

Plasma-derived medicinal products in Italy: information sources and flows.

For the purpose of a systematic analysis of the manufacturing, marketing and usage of plasma-derived medicinal products (PMPs), it is essential to define all stages of the medicinal product life-cycle and to properly identify all information sources suitable for detecting and quantifying the information related to the assessment of each stage. n nThe PMPs present some peculiarities. Their biological active substances are obtained by an industrial extraction process of human plasma derived from voluntary donations, instead of chemical synthesis. As a raw material, plasma can be a vehicle of blood born infectious diseases. Therefore, the Italian and European legislations identified several measures aimed at reducing the risk of infection, such as: donor selection, biological validation tests, methods of pathogen removal and inactivation; moreover, the adoption of prescriptive measures is envisaged in order to guarantee both traceability and pharmacovigilance of all PMPs1–11. n nAnother peculiar feature of PMPs is related to the ownership of the raw material and of the derived medicinal products. In Italy, as regards the national plasma collected by Regional Blood Transfusion Services, Regions and Autonomous Provinces (henceforth referred to as ‘Regions’) retain the ownership of both of them within the toll fractionation agreements with the authorised manufacturer. On the contrary, the commercial product ownership is assigned to pharmaceutical companies, which obtain the raw material from blood establishments in all other countries where plasma provision for commercial use is allowed. n nThe aim of this manuscript is to provide an exhaustive critical description of all data sources available in Italy for the study and monitoring of the entire medicinal product life-cycle and then to highlight the degree of overlap of various information sources and to demonstrate the feasible analyses that might be developed using each of them.

Lymphocyte T subsets and natural killer cells in Italian and Philippino blood donors.

Background and Objectives The characterization of lymphocyte subsets in blood donors has been utilized to determine the normal ranges that can be related to race. A study was performed in blood donors from two racial groups – Caucasian (Italians) and Asian (Philippinos) – to define respective T‐lymphocyte subsets and levels of cytokines.

Paroxysmal cold haemoglobinuria as a tardive complication of idiopathic myelofibrosis

Abstract:u2002 Paroxysmal cold haemoglobinuria (PCH) is an autoimmune haemolytic anaemia caused by the Donath–Landsteiner antibody. It is classically described in association with chronic syphilis or after acute viral infections. We describe the first case of PCH presented as a late manifestation of advanced myelofibrosis associated with antiphospholipid syndrome, that promptly responded to high dosage of prednisone.

Safety of intravenous tranexamic acid in patients undergoing major orthopaedic surgery: A meta-analysis of randomised controlled trials

Among the various pharmacological options to decrease peri-operative bleeding, tranexamic acid appears to be one of the most interesting. Several trials have consistently documented the efficacy of this synthetic drug in reducing the risk of blood loss and the need for allogeneic blood transfusion in patients undergoing total hip and knee arthroplasty. The safety of intravenous tranexamic acid in major orthopaedic surgery, particularly regarding the risk of venous thromboembolism, was systematically analysed in this review. A systematic search of the literature identified 73 randomised controlled trials involving 4,174 patients and 2,779 controls. The raw overall incidence of venous thromboembolism was 2.1% in patients who received intravenous tranexamic acid and 2.0% in controls. A meta-analytic pooling showed that the risk of venous thromboembolism in tranexamic acid-treated patients was not significantly different from that of controls (risk difference: 0.01%, 95% confidence interval [CI]: -0.05%, 0.07%; risk ratio: 1.067, 95% CI: 0.760-1.496). Other severe drug-related adverse events occurred very rarely (0.1%). In conclusion, the results of this systematic review and meta-analysis show that intravenous tranexamic acid is a safe pharmacological treatment to reduce blood loss and transfusion requirements in patients undergoing major orthopaedic surgery.