Hemolysis .. ?

Public release date: 8-Oct-2007

Duke University Medical Center

Banked blood loses ability to deliver oxygen to tissues
DURHAM, N.C. -Almost immediately after it is donated, human blood
begins to lose a key gas that opens up blood vessels to facilitate the
transfer of oxygen from red blood cells to oxygen-starved tissues.

Thus, millions of patients are apparently receiving transfusions with
blood that is impaired in its ability to deliver oxygen, according to
Duke University Medical Center researchers, who reported the results
of their studies in two separate papers appearing early on-line in the
Proceedings of the National Academy of Sciences.

They also found that adding this gas back to stored blood before
transfusion appears to restore red blood cells' ability to transfer
oxygen to tissues. These studies go a long way toward answering a
major problem which many physicians are beginning to appreciate -
blood transfusions with banked human blood may do more harm than good
for a majority of patients, according to the researchers.

Over the past five years, many studies, including some performed at
Duke, have demonstrated that patients who receive blood transfusions
have higher incidences of heart attack, heart failure, stroke and even
death. While it is known that the banked blood is not the same as
blood in the body, the reasons behind blood's association with worse
outcomes have not been well-understood.

The key to the current findings is that nitric oxide in red blood
cells is crucial to the delivery of oxygen to tissues. Nitric oxide
keeps the blood vessels open. The new studies demonstrated that nitric
oxide in red blood cells begins breaking down almost immediately after
red blood cells leave the body.

"It doesn't matter how much oxygen is being carried by red blood
cells, it cannot get to the tissues that need it without nitric
oxide," said Duke's Jonathan Stamler, M.D., senior author of one of
the PNAS papers, whose group originally discovered the role of red
blood cell nitric oxide in oxygen delivery. "Nitric oxide opens up the
tiny blood vessels, allowing red blood cells to pass and deliver
oxygen. If the blood vessels cannot open, the red blood cells back up
in the vessel and tissues go without oxygen. The result can be a heart
attack or even death.

"The issue of transfused blood being potentially harmful to patients
is one of the biggest problems facing American medicine," continued
Stamler, who is a professor of cardiovascular and pulmonary medicine.
"Most people do not appreciate that blood has the intrinsic capacity
to open blood vessels, thereby enabling oxygen to get to tissues.
Banked blood cannot do this properly."

However, transfusions are still critically important, Stamler said.

"Banked blood is truly a national treasure that needs to be
protected," Stamler said. "Blood can be life saving, only it is not
helping the way we had hoped and in many cases it may be making things
worse. In principle, we now have a solution to the nitric oxide
problem--we can put it back--but it needs to be proven in a clinical
trial."

It is estimated that close to 14 million units of red blood cells are
administered to about 4.8 million Americans each year. National blood
banks require that blood be stored for no more than 42 days after
donation. After that time, unused blood must be discarded.

One team of Duke researchers, led by Timothy McMahon, M.D., Ph.D.,
wanted to document exactly what happens to banked blood over those 42
days. Using human blood stored according to national standards, the
researchers sampled the blood at regular intervals.

"We were surprised at how quickly the blood changes - we saw clear
indications of nitric oxide depletion within the first three hours,"
said McMahon, an associate professor of pulmonary medicine. "Of
concern to us is that nitric oxide levels become depressed soon after
collection, suggesting that even 'fresh' blood may have adverse
biological characteristics."

Nitric oxide is not only needed for red blood cells to off-load
oxygen, it may also influence the flexibility of the saucer-shaped
cells. As nitric oxide levels decrease, the red blood cells become
stiffer, making it more difficult for them to deform their shape in
order to squeeze through tiny blood vessels.

Stamler's team confirmed that nitric oxide levels started dropping
quickly in stored human blood, and that this resulted loss of its
ability to dilate blood vessels. So they wanted to see if adding the
gas back to stored blood might restore the ability to open vessels,
using dogs as a model.

Since blood is often given to patients to prevent heart attacks, and
yet paradoxically may cause heart attacks, the investigators measured
blood flow to the hearts of oxygen-deprived animals.

"When we gave stored blood it couldn't increase blood flow properly,"
Stamler said. "However, after replacing the nitric oxide, blood flow
to the heart was increased, reflecting increased blood vessel
dilation. This suggests that adding nitric oxide to human banked blood
could theoretically improve its ability dilate blood vessels and thus
prevent heart attacks and even death in patients."

Both McMahon and Stamler believe that a large-scale randomized
clinical trial in humans is needed, arguing that blood has both
benefits and risks, and therefore should be evaluated in the same
manner as medications.

"There is little doubt that transfused blood can be harmful," said
Stamler. "We are only uncertain about how serious the problem is. The
availability of a potential solution will hopefully focus the
attention of the medical community on the potential magnitude of this
problem."

###
Stamler's research was supported by the National Institutes of Health
and Duke Anesthesiology Fund. McMahon's study was supported by the
American Heart Association and N30 Pharma, a company that has a
license agreement with Duke to develop nitric oxide-based therapies.

Contact: Richard Merritt
Merri006@mc.duke.edu
919-660-1309

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