|Year : 2022 | Volume
| Issue : 2 | Page : 123-128
Storage lesions after irradiation: Comparison between blood stored in citrate phosphate dextrose adenine and saline adenine glucose mannitol
Pramanya Balasubramanyam1, Abhishekh Basavarajegowda1, Nandeesha Hanumanthappa2, Anusuya Ram3, Vir Singh Negi4
1 Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
4 Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||10-Jan-2022|
|Date of Decision||12-Apr-2022|
|Date of Acceptance||16-Aug-2022|
|Date of Web Publication||5-Nov-2022|
Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
Background and Objectives: Saline adenine glucose mannitol (SAGM) with citrate phosphate dextrose (CPD) or CPD adenine (CPDA) are two common red cell preservatives used in our country. This study analyzed and compared serial biochemical changes on different days of storage in irradiated packed red blood cells stored in CPDA and SAGM solutions. The aim of this study was to see if these changes are influenced by or different, if any, in these two storage solutions. Patients and Methods: Ninety units of RBCs were randomly chosen, with 45 units each collected in CPDA and SAGM, respectively. Nine units each were irradiated by gamma irradiator using cobalt 60 (BI 2000) on days 1, 7, 14, and 21 of their storage, respectively. Nine units were not irradiated and used as controls. All the units were weekly assessed for their plasma levels of potassium, sodium, glucose, lactate dehydrogenase (LDH), and lactate by Clinical Chemistry Auto-analyzer, Beckman Coulter AU680. The values were documented and analyzed by SPSS. Results: Baseline values on day 1 for potassium, lactate, and LDH were similar between SAGM- and CPDA-stored blood bags. Glucose and sodium levels were slightly higher in SAGM bags compared to CPDA. Postirradiation, the changes (increase in K+, Lactate, LDH and decrease in Na+, glucose) were higher in CPDA bags than SAGM bags, and the difference in this trend was not significantly different from that seen in nonirradiated blood bags stored in these two preservative solutions. Conclusion: Storage lesions (biochemical parameters) after irradiation were severe, but paralleled that observed in nonirradiated bags. The storage solution, either SAGM or CPDA, made no difference to these changes.
Keywords: Blood bags, citrate phosphate dextrose adenine, irradiation, saline adenine glucose mannitol
|How to cite this article:|
Balasubramanyam P, Basavarajegowda A, Hanumanthappa N, Ram A, Negi VS. Storage lesions after irradiation: Comparison between blood stored in citrate phosphate dextrose adenine and saline adenine glucose mannitol. Glob J Transfus Med 2022;7:123-8
|How to cite this URL:|
Balasubramanyam P, Basavarajegowda A, Hanumanthappa N, Ram A, Negi VS. Storage lesions after irradiation: Comparison between blood stored in citrate phosphate dextrose adenine and saline adenine glucose mannitol. Glob J Transfus Med [serial online] 2022 [cited 2022 Dec 8];7:123-8. Available from: https://www.gjtmonline.com/text.asp?2022/7/2/123/360483
| Introduction|| |
Saline adenine glucose mannitol (SAGM) with citrate phosphate dextrose (CPD) or CPD adenine (CPDA) alone are two common red cell preservatives in our country. The storage lesions in blood stored in CPDA alone are faster than those in CPD-SAGM. This has resulted in the shelf life for red blood cells (RBCs) stored in CPD-SAGM being a week longer than when stored in CPDA (42 days vs. 35 days).,,
Irradiation is performed on blood products to prevent transfusion-associated graft-versus-host disease (TA-GVHD). TA-GVHD is a potential complication associated with transfusion of any blood component containing viable T-lymphocytes; wherein, there is a degree of disparity in human leukocyte antigens (HLA) between donor and patient. There appears to be a particular risk when a donor and patient share an HLA haplotype, as occurs within families or in populations with restricted haplotypes. Under certain circumstances, these cells engraft and proliferate in the patient. Interaction between donor T-lymphocytes and recipient cells results in cellular damage., The storage lesions, including biochemical changes, are well known in irradiated blood, including increased potassium levels, lactate and lactate dehydrogenase (LDH), decreased sodium and glucose, etc. These biochemical changes might have clinical significance when irradiated blood is transfused to a particular population, like transfusing blood having higher potassium levels to renal failure patients and neonates.,,
Aims and objectives
This study analyzed and compared serial biochemical changes on different days of storage in irradiated packed RBCs (PRBCs) stored in CPDA and SAGM solutions. Biochemical changes with regard to plasma potassium, sodium, glucose, lactate, and LDH on different days of storage in nonirradiated blood stored in CPDA and SAGM were analyzed for comparison. The aim of this study was to see if these changes are influenced by or different, if any, in these two storage solutions.
| Methodology|| |
July 2017 to March 2018.
This descriptive longitudinal study compared two groups of blood units: PRBCs with CPDA as a preservative solution and those with SAGM. A total of 10 blood bags (5 each collected in CPDA and SAGM solutions) from blood collected on the first working day of every month. Each bag collected in CPDA and SAGM was assigned to the nonirradiation group. Each of the other four bags was designated to be irradiated once on Day 1, 7, 14, or 21. This was repeated for 9 months till we reached the sample size of 90 (45 in each group, CPDA and SAGM). The study design is summarized in [Figure 1].
|Figure 1: Flow diagram to show the study design and procedure. CPDA: Citrate phosphate dextrose adenine, SAGM: Saline adenine glucose mannitol, LDH: Lactate dehydrogenase|
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Sample size calculation
The study of a continuous response variable from independent groups with a 1:1 ratio was designed. The sample size was calculated assuming an expected difference between the groups as 1.5 mEq/dL with a standard deviation (SD) of 1 mEq/dL at a power of 80% and an alpha error of 0.05. The number needed to be studied in each group was eight. With a 10% adjustment, we included nine samples in each group. The sample size was calculated by Power and Sample Size Calculator 2013–2021 HyLown Consulting LLC Atlanta, GA.
Irradiation of the blood units was performed using a self-contained, turn-table gamma cell irradiator (BI 2000 Cobalt 60) with 810 curie activity. The dose delivered to each bag was a minimum of 25 Gy. Based on the decay rate, it required 4 min 30 s to 4 min 45 s of exposure. Samples were collected at weekly intervals on Days 1, 7, 14, 21, and 28 after repeatedly mixing the blood bags with their contents. The segments were stripped off the blood multiple times entirely, and the supernatant plasma was allowed to fill-up the segment of the bag. The segment was then sealed, and the sample was collected from it into a test tube. Clear supernatant plasma was obtained by centrifuging at 2000 rpm for 2 min and used for sample analysis.
The supernatant plasma potassium, sodium, glucose, lactate, and LDH were estimated by the Clinical Chemistry Auto-analyzer, Beckman Coulter AU680, as per the manufacturer's instructions.
The data were entered in Microsoft Excel, and statistical analysis was performed using SPSS for Windows version 20 (SPSS IBM Corp. Ltd. Armonk, NY, USA).
The distribution of data on categorical variables was expressed as percentages. The continuous data such as volume of PRBC, hematocrit in the bag, plasma sodium, potassium, lactate, LDH, and glucose levels were expressed as mean with SD. The association of continuous variables with irradiation was carried out by an independent student's t-test. A generalized linear model was used to assess the changes in Na+, K+, glucose, lactate, and LDH over time. Statistical analysis was carried out at a 5% level of significance.
| Results|| |
There were 90 PRBC bags; 45 were collected in CPDA, and 45 were SAGM bags. Of these 45 CPDA bags, nine were nonirradiated, and 36 were irradiated (9 each on days 1, 7, 14, and 21). The same was followed by blood collected in SAGM bags. There were five subgroups based on the day of irradiation in each group. Each subgroup had nine bags in CPDA and SAGM groups.
The mean volume was more in SAGM (313.96 ± 10.23) than in CPDA bags (223.89 ml ± 8.49), and the mean hematocrit percentage was more in CPDA (70.50 ± 3.66) bags than SAGM (60.11 ± 3.13).
The baseline comparison of the parameters on Day 1 showed that potassium, lactate, and LDH levels were higher; whereas sodium and glucose were lower in CPDA than in SAGM bags. The difference was statistically significant for potassium, sodium, and lactate. The difference almost paralleled weekly monitoring until the 28th day except in LDH levels, which were slightly higher in the SAGM bags. However, this was not statistically significant.
The details on the comparison of different biochemical parameters on different days in the nonirradiated group between CPDA and SAGM are given in [Table 1]. The mean potassium levels are significantly higher (P < 0.001) in CPDA than in SAGM. It also shows that mean sodium levels are significantly lower in CPDA than SAGM (P < 0.001) group. It was found that the difference in the mean levels of glucose on different days between CPDA and SAGM was not significantly different (P = 0.05). The mean lactate levels were significantly higher among CPDA than in the SAGM group (P < 0.001). Furthermore, there was no significant difference in the mean levels of LDH between the groups (P > 0.05). The comparison and tracings are shown in [Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6].
|Figure 2: Changes in serum potassium levels that were monitored serially on bags irradiated on Day 1. CPDA: Citrate phosphate dextrose adenine, SAGM: Saline adenine glucose mannitol|
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|Figure 3: Changes in serum sodium levels that were monitored serially on bags irradiated on Day 1. CPDA: Citrate phosphate dextrose adenine, SAGM: Saline adenine glucose mannitol|
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|Figure 4: Changes in serum glucose levels that were monitored serially on bags irradiated on Day 1. CPDA: Citrate phosphate dextrose adenine, SAGM: Saline adenine glucose mannitol|
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|Figure 5: Changes in serum lactate levels that were monitored serially on bags irradiated on Day 1. CPDA: Citrate phosphate dextrose adenine, SAGM: Saline adenine glucose mannitol|
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|Figure 6: Changes in serum LDH levels that were monitored serially on bags irradiated on Day 1 (Nonirradiated bags are shown for comparison). CPDA: Citrate phosphate dextrose adenine, SAGM: Saline adenine glucose mannitol, LDH: Lactate dehydrogenase|
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|Table 1: Serial monitoring of various biochemical parameters among citrate phosphate dextrose adenine and saline adenine glucose mannitol bags irradiated|
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| Discussion|| |
Storage lesions were more pronounced in CPDA bags than in SAGM bags.
The absolute mean levels of plasma potassium in CPDA-1 nonirradiated PRBC bags increased from a baseline of 4.25 mmol/L on Day 1 to 64.8 mmol/L on Day 28. Hence, the potassium levels have increased 15 times from baseline. The potassium levels on Day 28 in our study are comparable to those on a similar day in a study done by Jeter et al. The mean increased from 4.7 to 66 mmol/L in CPDA nonirradiated group. A study conducted by Patidar et al. showed an increase of the mean potassium level in nonirradiated CPDA bags to 45.08 mmol/L. This Day 28 value in Patidar et al.'s study was slightly lower than our values.
The plasma mean potassium values in SAGM nonirradiated bags increased from 3.87 mmol/L on Day 1 to 55.18 mmol/L on Day 28. In a study conducted by Jeter et al., the mean potassium values raised from 2.1 mmol/L to 42, and in a study done by Patidar et al., values increased to 38.07 mmol/L., The values on Day 28 in the other two studies mentioned above are comparatively on a lower side than the value present in our study. This infers that the mean plasma potassium values increased significantly more in CPDA than in SAGM bags, a finding similar to other studies.
The volume of the PRBC bag is higher with SAGM, and Hct is lower as the volume of SAGM is higher. This could also lead to a more significant dilution of K+ in SAGM additive solution, and hence, low values.
The value of K+ on Day 28 is comparatively less than that in CPDA due to the presence of additive solution, which dilutes the potassium levels, and the AS that is added provides nutrition, acts as a buffer to cells, and reduces storage lesions. Not having enough adenosine triphosphate (ATP) to keep the Na-K pump working leads sodium to start permeating the cell, and K leaks, leading to increased potassium and conversely reduced sodium.
Plasma mean potassium was not significantly different in samples collected within 2–3 h after irradiation. This means that irradiation has no immediate effects on red cell storage lesions.
A higher glucose concentration in SAGM RBC would be due to the additional 900 mg dextrose present in the additive solution (in 100 ml), which helps prolong RBCs' shelf life by ATP generation through the glycolytic pathway.,
Lactate is the end product of anaerobic metabolism in red cells. It increases with storage due to its accumulation in the blood bag with no scope for elimination. Quantity of adenine required for ATP generation being less in CPDA-1 RBCs than SAGM RBC could explain the same.
LDH is a marker for hemolysis. Hemolysis causes its release into plasma. The possible explanation for lesser hemolysis in SAGM bags compared to CPDA has been the presence of membrane stabilizers such as mannitol or citrate in the additive solutions.,
SAGM bags are generally avoided in neonates as a concern as the dose of adenine in them and its relation leads to renal toxicity. Due to its potent diuretic and effects on fluid dynamics, mannitol can result in fluctuations in the cerebral blood flow of preterm infants.,
Storage lesions in SAGM bags were lesser than in CPDA-1 bags. The dilution effect of metabolites in additive solution added could not be accounted for. The inconsistencies in the trend of levels of the parameters at some points could be due to repeated stripping of the segment in a few bags where enough plasma could not be procured.
In our study, irradiation was done at regular, frequent (weekly) intervals in contrast to most studies where irradiation was done at one point or at irregular intervals. The limitation of the study is that the preanalytical variables for the parameters could not be strictly controlled.
Other parameters such as ATP, pH, supernatant hemoglobin, and 2, 3-diphosphoglycerate, if included, could have helped in drawing more meaningful conclusions and correlations.
| Conclusion|| |
Storage lesions reflected by biochemical parameters are faster in blood stored in CPDA than SAGM. The trending difference parallelled after irradiation, especially with significantly lower sodium levels, whereas potassium and lactate levels were higher in CPDA than in SAGM.
This project was funded intramurally by our institute, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry.
Financial support and sponsorship
This study was intramurally funded by JIPMER, Puducherry.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Moore GL. Additive solutions for better blood preservation. Crit Rev Clin Lab Sci 1987;25:211-29.
Vavić N, Pagliariccio A, Bulajić M, Marinozzi M, Miletić G, Vlatković A. Blood donor satisfaction and the weak link in the chain of donation process. Transfus Apher Sci 2012;47:171-7.
Antonelou MH, Kriebardis AG, Stamoulis KE, Economou-Petersen E, Margaritis LH, Papassideri IS. Red blood cell aging markers during storage in citrate-phosphate-dextrose-saline-adenine-glucose-mannitol. Transfusion 2010;50:376-89.
Reddy P. Pathophysiology of acute graft-versus-host disease. Hematol Oncol 2003;21:149-61.
Dwyre DM, Holland PV. Transfusion-associated graft-versus-host disease. Vox Sang 2008;95:85-93.
Balasubramanyam P, Basavarajegowda A, Hanumanthappa N, Negi VS, Harichandrakumar KT. Irradiating stored blood and storing irradiated blood: Is it different? – A study of serial changes in biochemical parameters of red blood cell units. Asian J Transfus Sci 2021;15:172-8. [Full text]
Patidar GK, Joshi A, Marwaha N, Prasad R, Malhotra P, Sharma RR, et al.
Serial assessment of biochemical changes in irradiated red blood cells. Transfus Apher Sci 2014;50:479-87.
Mukherjee S, Marwaha N, Prasad R, Sharma RR, Thakral B. Serial assessment of biochemical parameters of red cell preparations to evaluate safety for neonatal transfusions. Indian J Med Res 2010;132:715-20.
] [Full text]
El Kenz H, Corazza F, Van Der Linden P, Chabab S, Vandenvelde C. Potassium content of irradiated packed red blood cells in different storage media: Is there a need for additive solution-dependent recommendations for infant transfusion? Transfus Apher Sci 2013;49:249-53.
Jeter EK, Gadsden RH, Cate JC 4th
. Irradiation effect on aging red blood cells. Ann Clin Lab Sci 1991;21:420-5.
Brugnara C, Churchill WH. Effect of irradiation on red cell cation content and transport. Transfusion 1992;32:246-52.
Moroff G, Holme S, AuBuchon JP, Heaton WA, Sweeney JD, Friedman LI. Viability and in vitro
properties of AS-1 red cells after gamma irradiation. Transfusion 1999;39:128-34.
Eshghifar N, Maghsudlu M, Amini Kafi-Abad S. The effect of pre-storage irradiation blood on quality of red blood cells. Int J Hematol Oncol Stem Cell Res 2021;15:1-6.
Katharia R, Chaudhary R, Agarwal P. Prestorage gamma irradiation induces oxidative injury to red cells. Transfus Apher Sci 2013;48:39-43.
Wong EC, Punzalan RC. Neonatal and pediatric transfusion practice. In: Cohn CS, Delaney M, Johnson ST, Katz L, editors. Technical Manual. Bethesda, Maryland: AABB Press; 2020. p. 673-703.
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