One e-network member was not aware of ANY medical/scientific justification for leukoreducing autologous red cells. The member commented that WBCs in stored blood are known to release cytokines and are alleged to play a role in immunosuppression. However, this member commented that with regard to cytokine accumulation, the literature shows that accumulation of cytokines during blood component storage applies mainly to platelets, not whole blood or red blood cells. Thus, this member was not aware of ANY literature that indicates that any clinically significant levels of cytokines accumulate in red blood cells during refrigerated storage. The member further commented that with regard to transfusion-related immunosuppression, that there was absolutely NO clinical literature that demonstrates a benefit related to removal of autologous white blood cells. Finally, this member commented that the use of leukoreduction to reduce the risk of transmitting CMV or the risk of febrile reactions related to recipient antibodies to donor white cells, do not apply to autologous transfusions.

A second member commented that there was no reason for autologous blood to be leukocyte-reduced. This member stated that at their institution, they leukocyte-reduced about 30% of their red cell products and, unless mandated by regulatory agencies, they would not leukocyte-reduce products for the patients for whom they see no identifiable benefit. Thus it would make no sense to leukoreduce blood for autologous use. The ~$600,000 annual incremental cost could result in their hospital administration needing to fire at least 8-10 personnel.

A third member stated that they did not think that autologous donations should be leukocyte-reduced because the blood is going to be transfused back into the person that donated the blood. Therefore, there should not be any effect on the recipient's immune system unless the white cells have been immunologically altered.

ADDENDUM Nov. 11, 1999

1. The above opinions suggested that few, if any institutions were leukocyte reducing autologous blood components. As a result of this initial input, I requested a survey of CBBS member institutions to determine how many institutions did or did not perform leukocyte reduction of autologous blood components. Several institutions replied to the survey, and one individual CBBBS member offered additional input.

Here are the results of the survey and the additional CBBS membership comment:

1. Institutions that routinely leukocyte reduce autologous donations - 0
2. Institutions that do NOT leukocyte reduce autologous donations = 8 *. (See footnote below.)
3. Institutions that do not leukocyte reduce autologous donations, but might do so in the future = 1

(*) One of the institutions that reported NOT to leukocyte reduce autologous donations pointed out that the autologous platelets, pheresis donations they collect are automatically leukocyte reduced because of the collection technology that is used.

2. Finally, a CBBS member added that with the trend toward universal leukocyte reduction of all blood products, autologous units SHOULD be leukocyte reduced for the following reasons: First, microaggregate formation occurs in autologous blood just as it does in allogeneic blood. Second, studies indicate that when older non-WBC reduced units are transfused, a higher incidence of post-operative infection and lesser immune responsiveness may occur in recipients (see Bordin JO, Chiba, AK, Carvalho KIL et al. The effect of unmodified or prestorage white cell reduced allogeneic red cell transfusions on the immune responsiveness in orthopedic surgery patients. Transfusion 1999; 39:718-723). In this article the authors point out that immunomodulatory effects of allogeneic blood transfusions have been attributed to the white cells (WBCs) present in the cellular blood components transfused to patients. The authors attempted to evaluate the effect of the transfusion of allogeneic red cells (RBCs) or allogeneic prestorage WBC-reduced RBCs (WBC-reduced RBCs) on host immune responsiveness by measuring the lymphocyte subsets and the in-vitro cytokine production in response to phytohemagglutinin stimulation of WBCs of orthopedic surgery patients. Forty-seven patients undergoing hip replacement surgery were randomly assigned to receive allogeneic RBCs (n = 17) or WBC-reduced RBCs (n = 14; 99.95% WBC removal). Sixteen patients were not transfused. Patient blood samples taken before surgery and on Days 1 and 4 after surgery were tested for complete blood count, lymphocyte subset analysis, and measurement of cytokine levels. RESULTS: After surgery, the lymphocyte count was significantly decreased in patients transfused with 3 units of allogeneic RBCs (1.3 ± 0.5 vs. 2.0 ± 0.3 x 10⁹/L; p = 0.017), but not in patients transfused with 3 units of WBC-reduced RBCs (2.0 ± 0.9 vs. 1.7 ± 0.8 x 10⁹/L). Compared with preoperative levels, on Day 4 after surgery, patients transfused with 3 units of allogeneic RBCs also had a decrease in the number of natural killer cells (0.07 ± 0.05 vs. 0.04 ± 0.03 x 10⁹/L; p = 0.018). Postoperatively, interleukin-2 was decreased in one patient who received WBC-reduced RBCs compared with that in four patients transfused with allogeneic RBCs (p = 0.32), and eight untransfused patients (p = 0.01). On Day 4, about 70 percent of patients transfused with allogeneic RBCs showed a 20 percent decrease in the interferon gamma level.

The authors concluded that taken together, these data support the hypothesis that transfusion of 3 units of allogeneic RBCs is associated with early postoperative lymphopenia in otherwise healthy individuals undergoing . These findings were not observed in those individuals transfused with RBCs that had undergone prestorage WBC reduction. 

According to the CBBS member who pointed out the above article, it would seem logical that cytokines (or other factors) released from WBCs in an autologous unit might be potentially harmful to the recipient in the same way cytokines from allogeneic blood might be.

ADDENDUM March 15, 2005

3. Please see the new discussion HERE.

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator