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Platelet storage media
Transfusion and Apheresis Science 24 (2001) 241±244
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Platelet storage media Hans Gulliksson * Transfusion Medicine, Soder Hospital, S-11883, Stockholm, Sweden
Abstract Platelet additive solutions (PASs) can be used as a substitute for plasma for the storage of platelet concentrates (PCs) in order to recover plasma for other purposes, to avoid transfusion of large volumes of plasma to patients, to improve storage conditions, and to make possible photochemical treatment for viral inactivation of PCs. The eects on platelet metabolism associated with dierent factors and compounds in PAS are only partly known. Available studies suggest that: (1) The presence of glucose in the platelet storage medium during the entire storage period is necessary for platelet metabolism. (2) Acetate is used as a substrate for platelet metabolism reducing production of lactate by platelets. By formation of bicarbonate, it maintains stable pH levels during storage. (3) The fall in pH can be rapid in PAS-containing media, due to the very limited buering capacity of PAS compared with that of plasma. (4) Platelets stored in PAS at a citrate concentration of 8 mmol/l produce only half the quantity of lactate as that of platelets at 14±26 mmol/l of citrate. (5) Free fatty acids from plasma can be used as substrate for platelet metabolism and are supposed to be made available by the hydrolysis of plasma triglycerides. (6) For apheresis PCs with ACD anticoagulant, the presence of phosphate in PAS seems to be a critical factor to avoid low adenine nucleotide levels during storage. The results of available studies suggest that PAS for storing platelets has a great potential for wide use in transfusion medicine. A number of interesting questions regarding the eects of dierent compounds in PAS are still to be answered. It is expected that answers to these questions will be provided over the next few years. Ó 2001 Elsevier Science Ltd. All rights reserved.
Since the ®rst report in 1985, there has been an increasing interest in using platelet additive solutions (PASs) for the storage of platelet concentrates (PCs) [1±5]. PAS is used as a substitute for plasma in order to: (1) reduce the amount of plasma transfused with platelets and to recover additional plasma for other purposes, primarily fractionation, (2) avoid transfusion of large volumes of plasma with possible adverse reactions and circulatory overload, (3) improve storage conditions to increase the shelf-life of the platelets *
Present address: Huddinge University Hospital, SE±141 86, Stockholm, Sweden. Tel.: +46-8616-4212; fax: +46-8616-4201. E-mail address: [email protected] (H. Gulliksson).
while maintaining the viability and hemostatic function at a high level, and (4) make possible to carry out photochemical treatment for viral inactivation of PCs. The eects on platelet metabolism associated with dierent components in PAS are only partly known. However, a number of eects have been observed that can be assigned to speci®c ingredients in PAS. The composition of some platelet additive solutions is presented in Table 1.
1. Eects of glucose Generally, glucose has a dual role as a substrate for cell metabolism, on one hand for
1473-0502/01/$ - see front matter Ó 2001 Elsevier Science Ltd. All rights reserved. PII: S 1 4 7 3 - 0 5 0 2 ( 0 1 ) 0 0 0 6 2 - 3
242
H. Gulliksson / Transfusion and Apheresis Science 24 (2001) 241±244
Table 1 Composition of some platelet additive solutions (mM)
NaCl KCl MgCl2 =MgSO4 Na3 -citrate NaH2 PO4 =Na2 HPO4 Na-acetate Na-gluconate Glucose Maltose D-mannitol
Plasma Lyte A Adams, Rock [6]
PAS (1) Eriksson, H ogman [20]
Setosol Shimizu, Murphy [13]
PAS-2 (T-Sol) Gulliksson et al. [15]
PAS-3 Lin et al. [21]
90.0 5.0 3.0 ± ± 27.0 23.0 ± ± ±
70.0 10.0 ± 30.0 5.0 ± ± ± ± 30.0
90.0 5.0 3.0 17.0 25.0 23.0 ± 23.5 28.8 ±
115.5 ± ± 10.0 ± 30.0 ± ± ± ±
115.0 ± ± 10.0 26.0 30.0 ± ± ± ±
glycolysis resulting in decomposition to lactic acid, on the other for oxidative processes with carbon dioxide and water as end products. Data suggest that the major part (85%) of energy generation in platelets during storage is derived through oxidative metabolism [7]. Alternative substrates for this process have been suggested [7,8]. On the other hand, depletion of glucose and, in the next step, signi®cantly reduced levels of adenine nucleotides have been associated with loss of platelet viability [2,9,10]. The results of studies available today suggest that the presence of glucose in the platelet storage medium during the entire storage period is necessary for platelet metabolism.
2. Eects of acetate Acetate enters into platelet metabolism by the tricarboxylic acid cycle and is further oxidized in the respiratory chain. The end products are carbon dioxide, from the ®rst step, and water, from the second step. Acetate is used as a substrate for platelet metabolism [11,12]. The presence of acetate in PAS has been shown to reduce production of lactate by platelets [6,13,14]. Consumption of acetate in PCs is associated with increased oxygen consumption [2]. An additional important eect of acetate is its ability, by formation of bicarbonate, to maintain stable pH levels during storage of PCs [13,14].
3. pH The fall in pH to levels approaching 6.0 in PCs stored in plasma is associated with substantial loss of platelet viability. The buering capacity in PAScontaining media is very limited compared with that of plasma. While plasma reaches a pH level of 6.0 at a lactate concentration of approximately 30 mmol/l, the corresponding lactate concentration for media containing PAS is 10±15 mmol/l [13,14]. Though the fall in pH can be rapid in PAS-containing media, it will stop when glucose is totally consumed. On that speci®c occasion, the pH level can be signi®cantly higher than 6.0. Similar eects on various in vitro variables associated with loss of viability are observed in PAS, as those seen in plasma at pH levels approaching 6.0. These observations include a decrease in adenine nucleotide levels, declining lactate production, and disintegration of the platelets [10].
4. Eects of citrate Eects on the rate of glucose consumption and lactate production related to the concentration of citrate in PAS-containing media have been observed. Platelets stored in a medium with a citrate concentration of 8 mmol/l produced only half the quantity of lactate as did platelets in a similar medium with a citrate concentration of 14± 26 mmol/l [15]. No negative eects, which can be
H. Gulliksson / Transfusion and Apheresis Science 24 (2001) 241±244
associated with generation of energy within the platelets, were observed (e.g., on adenine nucleotide levels). These results suggest that PASs should preferably include citrate at low concentrations in order to avoid excessive lactate production and a fall in pH. However, a citrate concentration of about 8 mmol/l seems to be a minimum level, since clotting problems due to activation of coagulation can be expected at lower concentrations [16]. There also seems to be a link between the concentration of citrate and the eect of acetate to reduce the production of lactate by platelets. In a medium with a citrate concentration of 8 mmol/l, lactate production is kept at a low level irrespective of the presence of acetate. At 14 mmol/l of citrate, lactate production can be signi®cantly reduced by addition of acetate [15]. 5. Eects of plasma inclusion Previous studies suggest that platelets can use free fatty acids as a substrate for metabolism [8]. Fatty acids are transferred into the platelet mitochondria by a series of reactions. They are then broken down to acetyl CoA by beta-oxidation. These fatty acids are made available by the hydrolysis of plasma triglycerides. Thus, there should not be a problem with availability of free fatty acids for oxidative metabolism even when the plasma carryover is quite low. On the other hand, unsatisfactory in vitro results were observed with washed platelets or platelets in a medium with less than 2% CPDplasma compared to PCs with 8±15% plasma. These ®ndings may suggest that plasma constituents such as plasma proteins have a bene®cial effect in the maintenance of platelet membrane integrity during storage [2]. 6. Eects of phosphate Generally, phosphate has two possible roles during storage of PCs, on one hand by acting as a buer to prevent the fall in pH caused by the production of lactic acid by platelet glycolysis, on the other, by stimulation of platelet glycolysis. In
243
regard to the ®rst eect, studies suggest that the presence of phosphate or, alternatively, more than 12.5% plasma inclusion would be necessary to maintain a stable pH during storage [13]. The second situation is likely to occur when ACD solution is used as an anticoagulant. ACD, in contrast to CPD, does not contain phosphate and is routinely used for the preparation of apheresis platelets. Eects similar to those observed in the absence of glucose [2,9,10] have been observed, e.g. low adenine nucleotide levels that may be associated with the use of an ACD solution in combination with the non-phosphate additive solution PAS-2 [17]. These ®ndings are con®rmed in a recent study [18]. With respect to apheresis PCs using ACD anticoagulant, the presence of phosphate in the PAS seems to be a critical factor to avoid low adenine nucleotide levels during storage. In a dierent study, satisfactory post transfusion recovery and survival were found, using 111 indiumlabeled platelets prepared by apheresis and stored for 5 days with 35% plasma and 65% PAS-3 containing phosphate [19].
References [1] Rock G, Swenson SD, Adams GA. Platelet storage in a plasma-free medium. Transfusion 1985;25:551±6. [2] Holme S. Eect of additive solutions on platelet biochemistry. Blood Cells 1992;18:421±30. [3] H ogman CF. Aspects of platelet storage. Transfus Sci 1994;15:351±5. [4] Murphy S, Heaton WA, Rebulla P. Platelet production in the old world and the new. Transfusion 1996;36:751±4. [5] Murphy S. The ecacy of synthetic media in the storage of human platelets for transfusion. Transfus Med Rev 1999;13:153±63. [6] Adams GA, Rock G. Storage of human platelet concentrates in an arti®cial medium without dextrose. Transfusion 1988;28:217±20. [7] Kilkson H, Holme S, Murphy S. Platelet metabolism during storage of platelet concentrates at 22°C. Blood 1984;64:406±14. [8] Cesar J, DiMinno G, Alam I, Silver M, Murphy S. Plasma free fatty acid metabolism during storage of platelet concentrates for transfusion. Transfusion 1987;27:434±7. [9] Holme S, Heaton WA, Courtright M. Platelet storage lesion in second-generation containers: Correlation with platelet ATP levels. Vox Sang 1987;53:214±20. [10] Gulliksson H, Sallander S, Pedajas I, Christenson M, Wiechel B. Storage of platelets in additive solutions: A
244
[11] [12]
[13]
[14] [15] [16]
H. Gulliksson / Transfusion and Apheresis Science 24 (2001) 241±244 new method for storage using sodium chloride solution. Transfusion 1992;32:435±40. Guppy M, Whisson ME, Sabaratnam R, Withers P, Brand K. Alternative fuels for platelet storage: A metabolic study. Vox Sang 1990;59:146±52. Murphy S. The oxidation of exogenously added organic anions by platelets facilitates maintenance of pH during their storage for transfusion at 22°C. Blood 1995;85:1929± 35. Shimizu T, Murphy S. Roles of acetate and phosphate in the successful storage of platelet concentrates prepared with an acetate-containing additive solution. Transfusion 1993;33:304±10. Bertolini F, Murphy S, Rebulla P, Sirchia G. Role of acetate during platelet storage in a synthetic medium. Transfusion 1992;32:152±6. Gulliksson H. Storage of platelets in additive solutions: The eect of citrate and acetate in vitro studies. Transfusion 1993;33:301±3. Prowse C, Waterston YG, Dawes J, Farrugia A. Studies on the procurement of blood coagulation factor VIII in
[17]
[18] [19] [20] [21]
vitro studies on blood components prepared in halfstrength citrate anticoagulant. Vox Sang 1987;52:257±64. Gulliksson H, Larsson S, Shanwell A, Pedajas I, Joie M, Flament J. A system for the supply of platelets suspended in a storage medium including buy-coat-derived platelet concentrates in combination with ``split'' apheresis platelets. Transfus Sci 1997;18:33±40. Gulliksson H, Larsson S, Kumlien G, Shanwell A. Storage of platelets in additive solutions: Eects of phosphate. In vitro studies. Vox Sang 2000;78:176±84. Corash L, Behrman B, Rheinschmidt M. Posttransfusion viability and tolerability of photochemically treated platelet concentrates PC. Blood 1997;90:267A abstract. Eriksson L, H ogman CF. Platelet concentrates in an additive solution prepared from pooled buy coats. 1. In vitro studies. Vox Sang 1990;59:140±5. Lin L, Cook DN, Wiesehahn GP, Alfonso R, Behrman B, Cimino GD, et al. Photochemical inactivation of viruses and bacteria in platelet concentrates by use of a novel psoralen and long-wavelength ultraviolet light. Transfusion 1997;37:423±35.
www.elsevier.com/locate/transci
Platelet storage media Hans Gulliksson * Transfusion Medicine, Soder Hospital, S-11883, Stockholm, Sweden
Abstract Platelet additive solutions (PASs) can be used as a substitute for plasma for the storage of platelet concentrates (PCs) in order to recover plasma for other purposes, to avoid transfusion of large volumes of plasma to patients, to improve storage conditions, and to make possible photochemical treatment for viral inactivation of PCs. The eects on platelet metabolism associated with dierent factors and compounds in PAS are only partly known. Available studies suggest that: (1) The presence of glucose in the platelet storage medium during the entire storage period is necessary for platelet metabolism. (2) Acetate is used as a substrate for platelet metabolism reducing production of lactate by platelets. By formation of bicarbonate, it maintains stable pH levels during storage. (3) The fall in pH can be rapid in PAS-containing media, due to the very limited buering capacity of PAS compared with that of plasma. (4) Platelets stored in PAS at a citrate concentration of 8 mmol/l produce only half the quantity of lactate as that of platelets at 14±26 mmol/l of citrate. (5) Free fatty acids from plasma can be used as substrate for platelet metabolism and are supposed to be made available by the hydrolysis of plasma triglycerides. (6) For apheresis PCs with ACD anticoagulant, the presence of phosphate in PAS seems to be a critical factor to avoid low adenine nucleotide levels during storage. The results of available studies suggest that PAS for storing platelets has a great potential for wide use in transfusion medicine. A number of interesting questions regarding the eects of dierent compounds in PAS are still to be answered. It is expected that answers to these questions will be provided over the next few years. Ó 2001 Elsevier Science Ltd. All rights reserved.
Since the ®rst report in 1985, there has been an increasing interest in using platelet additive solutions (PASs) for the storage of platelet concentrates (PCs) [1±5]. PAS is used as a substitute for plasma in order to: (1) reduce the amount of plasma transfused with platelets and to recover additional plasma for other purposes, primarily fractionation, (2) avoid transfusion of large volumes of plasma with possible adverse reactions and circulatory overload, (3) improve storage conditions to increase the shelf-life of the platelets *
Present address: Huddinge University Hospital, SE±141 86, Stockholm, Sweden. Tel.: +46-8616-4212; fax: +46-8616-4201. E-mail address: [email protected] (H. Gulliksson).
while maintaining the viability and hemostatic function at a high level, and (4) make possible to carry out photochemical treatment for viral inactivation of PCs. The eects on platelet metabolism associated with dierent components in PAS are only partly known. However, a number of eects have been observed that can be assigned to speci®c ingredients in PAS. The composition of some platelet additive solutions is presented in Table 1.
1. Eects of glucose Generally, glucose has a dual role as a substrate for cell metabolism, on one hand for
1473-0502/01/$ - see front matter Ó 2001 Elsevier Science Ltd. All rights reserved. PII: S 1 4 7 3 - 0 5 0 2 ( 0 1 ) 0 0 0 6 2 - 3
242
H. Gulliksson / Transfusion and Apheresis Science 24 (2001) 241±244
Table 1 Composition of some platelet additive solutions (mM)
NaCl KCl MgCl2 =MgSO4 Na3 -citrate NaH2 PO4 =Na2 HPO4 Na-acetate Na-gluconate Glucose Maltose D-mannitol
Plasma Lyte A Adams, Rock [6]
PAS (1) Eriksson, H ogman [20]
Setosol Shimizu, Murphy [13]
PAS-2 (T-Sol) Gulliksson et al. [15]
PAS-3 Lin et al. [21]
90.0 5.0 3.0 ± ± 27.0 23.0 ± ± ±
70.0 10.0 ± 30.0 5.0 ± ± ± ± 30.0
90.0 5.0 3.0 17.0 25.0 23.0 ± 23.5 28.8 ±
115.5 ± ± 10.0 ± 30.0 ± ± ± ±
115.0 ± ± 10.0 26.0 30.0 ± ± ± ±
glycolysis resulting in decomposition to lactic acid, on the other for oxidative processes with carbon dioxide and water as end products. Data suggest that the major part (85%) of energy generation in platelets during storage is derived through oxidative metabolism [7]. Alternative substrates for this process have been suggested [7,8]. On the other hand, depletion of glucose and, in the next step, signi®cantly reduced levels of adenine nucleotides have been associated with loss of platelet viability [2,9,10]. The results of studies available today suggest that the presence of glucose in the platelet storage medium during the entire storage period is necessary for platelet metabolism.
2. Eects of acetate Acetate enters into platelet metabolism by the tricarboxylic acid cycle and is further oxidized in the respiratory chain. The end products are carbon dioxide, from the ®rst step, and water, from the second step. Acetate is used as a substrate for platelet metabolism [11,12]. The presence of acetate in PAS has been shown to reduce production of lactate by platelets [6,13,14]. Consumption of acetate in PCs is associated with increased oxygen consumption [2]. An additional important eect of acetate is its ability, by formation of bicarbonate, to maintain stable pH levels during storage of PCs [13,14].
3. pH The fall in pH to levels approaching 6.0 in PCs stored in plasma is associated with substantial loss of platelet viability. The buering capacity in PAScontaining media is very limited compared with that of plasma. While plasma reaches a pH level of 6.0 at a lactate concentration of approximately 30 mmol/l, the corresponding lactate concentration for media containing PAS is 10±15 mmol/l [13,14]. Though the fall in pH can be rapid in PAS-containing media, it will stop when glucose is totally consumed. On that speci®c occasion, the pH level can be signi®cantly higher than 6.0. Similar eects on various in vitro variables associated with loss of viability are observed in PAS, as those seen in plasma at pH levels approaching 6.0. These observations include a decrease in adenine nucleotide levels, declining lactate production, and disintegration of the platelets [10].
4. Eects of citrate Eects on the rate of glucose consumption and lactate production related to the concentration of citrate in PAS-containing media have been observed. Platelets stored in a medium with a citrate concentration of 8 mmol/l produced only half the quantity of lactate as did platelets in a similar medium with a citrate concentration of 14± 26 mmol/l [15]. No negative eects, which can be
H. Gulliksson / Transfusion and Apheresis Science 24 (2001) 241±244
associated with generation of energy within the platelets, were observed (e.g., on adenine nucleotide levels). These results suggest that PASs should preferably include citrate at low concentrations in order to avoid excessive lactate production and a fall in pH. However, a citrate concentration of about 8 mmol/l seems to be a minimum level, since clotting problems due to activation of coagulation can be expected at lower concentrations [16]. There also seems to be a link between the concentration of citrate and the eect of acetate to reduce the production of lactate by platelets. In a medium with a citrate concentration of 8 mmol/l, lactate production is kept at a low level irrespective of the presence of acetate. At 14 mmol/l of citrate, lactate production can be signi®cantly reduced by addition of acetate [15]. 5. Eects of plasma inclusion Previous studies suggest that platelets can use free fatty acids as a substrate for metabolism [8]. Fatty acids are transferred into the platelet mitochondria by a series of reactions. They are then broken down to acetyl CoA by beta-oxidation. These fatty acids are made available by the hydrolysis of plasma triglycerides. Thus, there should not be a problem with availability of free fatty acids for oxidative metabolism even when the plasma carryover is quite low. On the other hand, unsatisfactory in vitro results were observed with washed platelets or platelets in a medium with less than 2% CPDplasma compared to PCs with 8±15% plasma. These ®ndings may suggest that plasma constituents such as plasma proteins have a bene®cial effect in the maintenance of platelet membrane integrity during storage [2]. 6. Eects of phosphate Generally, phosphate has two possible roles during storage of PCs, on one hand by acting as a buer to prevent the fall in pH caused by the production of lactic acid by platelet glycolysis, on the other, by stimulation of platelet glycolysis. In
243
regard to the ®rst eect, studies suggest that the presence of phosphate or, alternatively, more than 12.5% plasma inclusion would be necessary to maintain a stable pH during storage [13]. The second situation is likely to occur when ACD solution is used as an anticoagulant. ACD, in contrast to CPD, does not contain phosphate and is routinely used for the preparation of apheresis platelets. Eects similar to those observed in the absence of glucose [2,9,10] have been observed, e.g. low adenine nucleotide levels that may be associated with the use of an ACD solution in combination with the non-phosphate additive solution PAS-2 [17]. These ®ndings are con®rmed in a recent study [18]. With respect to apheresis PCs using ACD anticoagulant, the presence of phosphate in the PAS seems to be a critical factor to avoid low adenine nucleotide levels during storage. In a dierent study, satisfactory post transfusion recovery and survival were found, using 111 indiumlabeled platelets prepared by apheresis and stored for 5 days with 35% plasma and 65% PAS-3 containing phosphate [19].
References [1] Rock G, Swenson SD, Adams GA. Platelet storage in a plasma-free medium. Transfusion 1985;25:551±6. [2] Holme S. Eect of additive solutions on platelet biochemistry. Blood Cells 1992;18:421±30. [3] H ogman CF. Aspects of platelet storage. Transfus Sci 1994;15:351±5. [4] Murphy S, Heaton WA, Rebulla P. Platelet production in the old world and the new. Transfusion 1996;36:751±4. [5] Murphy S. The ecacy of synthetic media in the storage of human platelets for transfusion. Transfus Med Rev 1999;13:153±63. [6] Adams GA, Rock G. Storage of human platelet concentrates in an arti®cial medium without dextrose. Transfusion 1988;28:217±20. [7] Kilkson H, Holme S, Murphy S. Platelet metabolism during storage of platelet concentrates at 22°C. Blood 1984;64:406±14. [8] Cesar J, DiMinno G, Alam I, Silver M, Murphy S. Plasma free fatty acid metabolism during storage of platelet concentrates for transfusion. Transfusion 1987;27:434±7. [9] Holme S, Heaton WA, Courtright M. Platelet storage lesion in second-generation containers: Correlation with platelet ATP levels. Vox Sang 1987;53:214±20. [10] Gulliksson H, Sallander S, Pedajas I, Christenson M, Wiechel B. Storage of platelets in additive solutions: A
244
[11] [12]
[13]
[14] [15] [16]
H. Gulliksson / Transfusion and Apheresis Science 24 (2001) 241±244 new method for storage using sodium chloride solution. Transfusion 1992;32:435±40. Guppy M, Whisson ME, Sabaratnam R, Withers P, Brand K. Alternative fuels for platelet storage: A metabolic study. Vox Sang 1990;59:146±52. Murphy S. The oxidation of exogenously added organic anions by platelets facilitates maintenance of pH during their storage for transfusion at 22°C. Blood 1995;85:1929± 35. Shimizu T, Murphy S. Roles of acetate and phosphate in the successful storage of platelet concentrates prepared with an acetate-containing additive solution. Transfusion 1993;33:304±10. Bertolini F, Murphy S, Rebulla P, Sirchia G. Role of acetate during platelet storage in a synthetic medium. Transfusion 1992;32:152±6. Gulliksson H. Storage of platelets in additive solutions: The eect of citrate and acetate in vitro studies. Transfusion 1993;33:301±3. Prowse C, Waterston YG, Dawes J, Farrugia A. Studies on the procurement of blood coagulation factor VIII in
[17]
[18] [19] [20] [21]
vitro studies on blood components prepared in halfstrength citrate anticoagulant. Vox Sang 1987;52:257±64. Gulliksson H, Larsson S, Shanwell A, Pedajas I, Joie M, Flament J. A system for the supply of platelets suspended in a storage medium including buy-coat-derived platelet concentrates in combination with ``split'' apheresis platelets. Transfus Sci 1997;18:33±40. Gulliksson H, Larsson S, Kumlien G, Shanwell A. Storage of platelets in additive solutions: Eects of phosphate. In vitro studies. Vox Sang 2000;78:176±84. Corash L, Behrman B, Rheinschmidt M. Posttransfusion viability and tolerability of photochemically treated platelet concentrates PC. Blood 1997;90:267A abstract. Eriksson L, H ogman CF. Platelet concentrates in an additive solution prepared from pooled buy coats. 1. In vitro studies. Vox Sang 1990;59:140±5. Lin L, Cook DN, Wiesehahn GP, Alfonso R, Behrman B, Cimino GD, et al. Photochemical inactivation of viruses and bacteria in platelet concentrates by use of a novel psoralen and long-wavelength ultraviolet light. Transfusion 1997;37:423±35.