Immunologic Effects of Packed red blood Cell Transfusion in critically ill children (IMPACT)

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1 Immunologic Effects of Packed red blood Cell Transfusion in critically ill children (IMPACT) J Muszynski, A Frazier, P Spinella, MW Hall BLOOD NET October, 2012

2 Immune function in the ICU Reduction in innate immune function is associated with nosocomial infection and death in critically ill adults and children Ex vivo TNF α response (pg/ml) * Day 1 Day 3 Day 7 * Monneret et al. Int Care Med 2006 The etiology of immunoparalysis is likely multifactorial RBC transfusion may contribute.. Hall et al. Immunoparalysis and nosocomial infection in children with multiple organ dysfunction syndrome. Intensive Care Med (37)2011: Monneret et al. Persisting low monocyte human leukocyte antigen-dr expression predicts mortality in septic shock. Intensive Care Med (32)2006:

3 Red cell transfusion in the ICU Up to 49% of children in the PICU for > 48 hours receive a red cell transfusion RBC transfusion has been identified as an independent risk factor for mortality in adults with trauma, adults with ARDS, and critically ill children RBC transfusion is associated with increased risk of nosocomial infection Taylor et al. Crit Care Med. (34)2006: Bateman, et al. Am J Resp Crit Care (178)2008: Malone et al. J Trauma. (54)2003: Kneyber et al. Intensive Care Med. (33)2007: Taylor et al. Crit Care Med. (34)2006:

4 Red cell storage age Adult trauma patients: storage age of transfused blood independent risk factor for development of infection Adult cardiopulmonary bypass patients: receipt of blood stored > 14 days associated with increased rates of sepsis and mortality Are RBC with longer storage times immunosuppressive? Koch et al. Duration of red-cell storage and complications after cardiac surgery. The New England Journal of Medicine. (358)2008: Offner et al Increased rate of infection associated with transfusion of old blood after severe injury. Arch Surg (137)2002:

5 Are RBC with longer storage times immunosuppressive? LPS-induced TNF α production (% of control) * ** RBC storage time (days) LPS-induced IL10 production (% of control) Muszynski, et al. Immunosuppressive effects of red blood cells on monocytes are related to both storage age and storage solution. Transfusion, RBC storage time (days) Cytokine production from monocytes exposed to RBC in transwells then stimulated with LPS RBCs with greater storage time were immunosuppressive

6 IMPACT Multi-center, prospective, observational feasibility study Hypothesis: A single PRBC transfusion will be associated with decreased function of the innate and adaptive immune system The degree of immunosuppression will be related to PRBC storage time. Inclusion: Age < 18 yrs; Admission to PICU at NCH or St. Louis Children s; catheter in place for painless blood draws Exclusion: Prior transfusion (w/in 1 month); WBC count less than 1,000; transplant recipient

7 Methods Blood sample drawn before (within 2 hours) and again hours after red cell transfusion Immune function measured by ex vivo stimulated cytokine response and flow cytometry PHA and LPS stimulation: PHA LPS 50 µl whole blood 4 hr at 37 C

8 Methods Flow Cytometry: Stained with antibody panel: CD 14 (monocyte) HLADR Regulatory T cells CD 4 CD 25 CD 127 Red cells lysed and samples washed Flow data acquired locally

9 Results: Patients 26 children enrolled to date Data from first 22 children presented here Median age: 52 [4.3 99] months Median time from ICU admit to transfusion: 2 [ ] days Median PRISMIII at the time of transfusion: 7.5 [ ] Median Hgb at the time of transfusion: 7.9 [ ]

10 Red cell storage age and innate immune function Ex vivo LPS-induced TNF α production (% of pre transfusion) pre-transfusion p=0.02; ANOVA post-transfusion Receipt of red cells stored for greater than 21 days is associated with a failure to improve innate immune function over time Storage age 21 d (n = 15) Storage age > 21 d (n = 7)

11 Ex vivo LPS-induced TNFα production (% of pre transfusion) Or put another way Storage age of blood AOB > 21 days associated with 4 fold increased risk of failure to improve innate immune function RR 4.2 [ ] Looking at only those patients who had suppressed innate immune function pretransfusion [TNF production capacity < 250 pg/ml (red) or < 500 pg/ml (yellow)]: Effect may be more pronounced Sample is size small

12 Patient Demographics Storage age of blood 21 D n = 15 Storage age of blood > 21 D n = 7 p Pt age (months) 50 [2-110] 88 [7-168] 0.4 Female gender, n (%) 5 (33) 2 (29) 1 PRISM III* 7 [3-13] 9 [6-18] 0.3 Plasma IL- 6* 76 [23-159] 88 [31-735] 0.5 Transfusion Time from ICU admit to txf (days) 1.6 [ ] 2.9 [ ] 0.5 Volume of transfusion (ml/kg) 15.9 [ ] 12.7 [ ] 0.07 PaSent hemoglobin* 7.8 [7.4-9] 7.9 [ ] 0.8 Storage age of blood 7 [6-17] 29 [27-33] Patient characteristics were similar between groups

13 Ex vivo PHA-induced IL-2 production (% pre-transfusion) Ex vivo PHA-induced IFN γ production (% pre-transfusion) Adaptive immune function: PHA stimulation data AOB > 21 D AOB > 21 D AOB 21 D AOB 21 D Ex vivo PHA-induced IL-4 production (% pre-transfusion) Ex vivo PHA-induced IL-10 production (% pre-transfusion) AOB > 21 D AOB > 21 D AOB 21 D AOB 21 D No significant differences seen in PHA-stimulated cytokine production (marker of T cell function) Red cell storage age may not be associated with change in T cell function Or, 24 hours may be too short a time frame to detect a difference

14 Flow cytometry data 200 Monocyte HLADR (% pre-transfusion) Regulatory T cells (% pre-transfusion) Pre Post 50 pre post AOB > 21 days (n=4) AOB 21 days (n=9) AOB > 21 days (n=4) AOB 21 days (n=9) No significant differences seen in monocyte HLA-DR expression or %regulatory t cells by flow cytometry

15 Challenge: Multi-center flow cytometry

16 Challenge: Multi-center flow cytometry

17 Potential solution: Lysing solution Antibody stain mix 15 minutes RT dark - 80 C

18 Multi-center flow cytometry staining with central data acquisition Single sample stained by lysed whole blood method, fixed and stored at 4C (top or stained, lysed (no wash) then stored at -80C (bottom) Both samples acquired three days later

19 Challenge: Patient enrollment To address this challenge: Daily screening of ICU census Consent and enrollment for children with risk of blood transfusion during ICU stay Intubated patients Septic shock N u m b e r o f p a tie n ts N o v D e c J a n F e b A pr M a y J u n P ts tra n s fu s e d P ts tra n s fu s e d P ts tra n s fu s e d 7 a m -3 p m W e e k d a y 7 a m -3 p m

20 Challenge: Patient heterogeneity Storage age of blood 21 D n = 15 Storage age of blood > 21 D n = 7 Diagnosis n, (%) Sepsis/sepSc shock 0 3 (43) Trauma 6 (40) 1 (14) CHD or cardiomyopathy 4 (27) 1 (14) BronchioliSs 3 (20) 1 (14) Cardiac arrest 2 (13) 0 Center 0.4 NaSonwide Children s 8 (53) 2 (29) St Louis Children s 7 (47) 5 (71) p

21 Solutions Enroll more patients through multi-center studies Target specific patient populations Contact us if you can help

22 Acknowledgements Immune Surveillance Laboratory at Nationwide Children s: Jyotsna Nateri, MS Lisa Hanson, BS Kristin Greathouse, MS, BSN Lisa Steele, BSN, CCRN Ryan Nofziger, MD Mark Hall, MD St. Louis Children s at Washington University: Ayu Frazier Phil Spinella Pediatric Blood Research Group (BLOOD NET) of PALISI Dr. Muszynski is supported by K12HD from the National Institute of Child Health and Development, and the Research Institute at Nationwide Children s

24 Red cell storage age Adult trauma patients: storage age of transfused blood independent risk factor for development of infection Adult cardiopulmonary bypass patients: receipt of blood stored > 14 days associated with increased rates of sepsis and mortality Are RBC with longer storage times immunosuppressive? Koch et al. Duration of red-cell storage and complications after cardiac surgery. The New England Journal of Medicine. (358)2008: Offner et al Increased rate of infection associated with transfusion of old blood after severe injury. Arch Surg (137)2002:

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