- Email: [email protected]
Single automated donor plateletpheresis increases the plasma level of proinflammatory cytokine tumor necrosis factor-α which does not associate with endothelial release markers von Willebrand factor and fibronectin
Transfusion Science 23 (2000) 171±175
www.elsevier.com/locate/transci
Single automated donor plateletpheresis increases the plasma level of proin¯ammatory cytokine tumor necrosis factor-a which does not associate with endothelial release markers von Willebrand factor and ®bronectin * _ Ihsan Karado gan, Mustafa Ozdo gan, Levent Undar Division of Hematology, Department of Internal Medicine, School of Medicine, Akdeniz University, 07070 Antalya, Turkey Received 19 July 2000; accepted 18 August 2000
Abstract The eect of plateletpheresis on endothelium, which has strong eects on blood coagulation, ®brinolysis and platelet function, is not known. Activation of leukocytes and subsequent generation of proin¯ammatory cytokines during the extracorporeal circulation may activate the endothelium. To test this hypothesis we measured plasma levels of tumor necrosis factor (TNF)-a as a prototype of the proin¯ammatory cytokines, and von Willebrand factor (vWF) and ®bronectin as endothelial release/damage markers before and after a single plateletpheresis procedure on an intermittent¯ow machine Haemonetics MCS 3p in 17 healthy donors. We found a signi®cant increase in median plasma level of TNF-a following plateletpheresis (3.5 vs 26.5 pg/ml, P 0:02). Such increases in vWF and ®bronectin were not observed. The increase in plasma TNF-a indicates that a single plateletpheresis procedure causes leukocyte activation which does not seemingly impair endothelial cell function. The relation of plateletpheresis-induced proin¯ammatory cytokine release to some adverse eects observed in both donors and recipients, and the eect of repeated plateletpheresis on endothelium deserve further studies. Ó 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction The transfusion of apheresis platelets is an essential supportive therapy in patients with severe thrombocytopenia, especially those undergoing intensive chemotherapy. During the apheresis procedure, an extracorporeal circulation, the blood taken from the donor is exposed to an arti®cial membrane and external forces such as
* Corresponding author. Tel.: +90-242-227- 43-43 (ext: 35342); fax: +90-242-349-60-50. È ndar). E-mail address: [email protected] (L. U
centrifugation. The activation of platelets during the apheresis procedures has been reported before [1,2]. The eect of plateletpheresis on the blood coagulation and ®brinolysis, however, are not well-known. Endothelium plays a key role in platelet activation, coagulation and ®brinolysis. Extracorporeal circulation can activate leukocytes [3,4], and subsequent generation of proin¯ammatory cytokines such as interleukine (IL)-1b, tumor necrosis factor (TNF)-a, IL-6 and chemokine IL-8 may activate the endothelium [5,6]. Upon activation, endothelium might release some factors into the circulation, such as tissue-type plasminogen activator, plasminogen activator inhibitor-1, von
0955-3886/00/$ - see front matter Ó 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 9 5 5 - 3 8 8 6 ( 0 0 ) 0 0 0 8 4 - 9
172
I. Karado gan et al. / Transfusion Science 23 (2000) 171±175
Willebrand factor (vWF), thrombomodulin and ®bronectin which are commonly used to show endothelial release/damage in various disorders such as atherosclerosis, vasculitis, and preeclampsia [7±11]. To investigate whether the plateletpheresis procedure activates/damages endothelium, and if so, whether this activation is related to the proin¯ammatory cytokine generation via leukocyte activation, we measured plasma vWF and ®bronectin levels as endothelial cell activation markers, and plasma TNF-a level as a prototype of the proin¯ammatory cytokines before and after a single plateletpheresis procedure on an intermittent-¯ow machine Haemonetics MCS 3p in 17 healthy donors. 2. Materials and methods 2.1. Study subjects Seventeen volunteer plateletpheresis donors (3 women, 14 men) between the ages of 19 and 47 (median 35) were included in the study after obtaining informed consents. All ful®lled the usual requirements for blood donation and were donating for the ®rst time. None had taken aspirin, aspirin containing drugs or non-steroidal anti-in¯ammatory agents within 10 days prior to study. All were non-smokers. 2.2. Plateletpheresis procedure Intermittent-¯ow automated plateletpheresis was performed with Haemonetics MCS 3p Blood Cell Separator (Haemonetics, Braintree, MA, USA) according to the manufacturer's recommendations. Acid-citrate-dextrose (ACD) was used as the anticoagulant. None of the donors experienced any procedure-induced complications during or following the plateletpheresis. 2.3. Sample collection Blood samples were drawn immediately before and after the plateletpheresis procedure. Preplateletpheresis samples were drawn through the
large-bore donation needle before connecting it to the apheresis machine, and post-plateletpheresis samples by venipuncture of the opposite arm with minimum stasis through a 21-gauge needle into evacuated tubes containing 3.8% sodium citrate with a blood:anticoagulation ratio of 9:1. All blood samples were immediately immersed in an ice bath, centrifuged at 2500 g at 4°C for 20 min, and plasma stored in aliquots at ÿ70°C until analysis. 2.4. Measurement of vWF, ®bronectin and TNF-a Plasma vWF level was measured by latex immune assay (LIA Test vWF, Diagnostica Stago, Asnieres, France). Fibronectin and TNF-a levels were determined by enzyme immune assay (Asserachrom Fibronectin, Diagnostica Stago, Asnieres, France; and Quantikine human TNF-a, R&D Systems, Minneapolis, USA, respectively). All tests were done in duplicate. Manufacturers' recommendations were meticulously followed. 2.5. Statistics Plateletpheresis-induced changes were assessed using the Wilcoxon signed rank test for paired data. Spearman's rank correlation coecients were used for the correlation of parameters. All values were expressed as the median (minimum± maximum). A P value below 0.05 was considered signi®cant. 3. Results For each donor 8±10 cycles of apheresis were performed with a presumptive yield of a minimum of 3:5 1011 platelets. A median of 3.8 3:0±4:7 1011 platelets were collected within a median apheresis time of 70 (60±85) minutes and the median ACD consumption was 380 (350±425) ml per procedure. The median pre-plateletpheresis platelet count was 290 220±340 109=l, and post-plateletpheresis platelet count was 240 190±280 109=l, which corresponded to a median decrease of 19 (13±24)%. No in¯uences on TNF-a levels of donor weight, age, sex, ACD
I. Karado gan et al. / Transfusion Science 23 (2000) 171±175
173
Table 1 Median plasma TNF-a, vWF and ®bronectin levels before and after the plateletpheresis procedure in healthy donors
Tumor necrosis factor (pg/ml) von Willebrand factor (% of normal) Fibronectin (ng/ml)
Before plateletpheresis Median (minimum±maximum)
After plateletpheresis Median (minimum±maximum)
P
3.5 (0.2±27.3) 0.65 (0.55±1.10) 178 (160±202)
26.5 (1.9±53.3) 0.63 (0.59±0.77) 178 (170±192)
0.02 >0.05 >0.05
consumption, duration of apheresis, and pre-apheresis platelet counts were found. There were no signi®cant changes in plasma levels of vWF and ®bronectin before or after the plateletpheresis procedure (Table 1). Median TNF-a level was 3.5 (0.2±27.3) pg/ml before the plateletpheresis and increased signi®cantly to 26.5 (1.9±53.3) pg/ml following the procedure P 0:02. No correlation was found among TNF-a, vWF and ®bronectin levels. 4. Discussion In this study we found a signi®cant increase in plasma levels of TNF-a following a plateletpheresis procedure. However, such increases in vWF and ®bronectin were not observed. Both pre- and postplateletpheresis plasma levels of TNF-a showed a marked interindividual variation which can presumably be in an analogy with the so-called ``acute phase proteins'' in healthy individuals [12,13]. Extracorporeal circulation during open heart surgery and hemodialysis has been recognized as having a large in¯uence on platelet function, blood coagulation and ®brinolysis [14±16]. Recently, both automated plasmapheresis and plateletpheresis procedures have been shown to cause in vivo platelet activation [1,2,17]. The mechanisms of platelet activation during the apheresis are not known exactly. Besides direct activation of platelets by extracorporeal circulation, activation of leukocytes and subsequent release of cytokines may activate platelets indirectly, as well. Once activated, platelets release many soluble factors, initiate blood coagulation, and interfere with endothelial cells. Although it is well known that extracorporeal circulation during hemodialysis and open heart
surgery might cause granulocyte and mononuclear cell activation, data about apheresis are very limited. In a recent study of Stohlawetz et al. [18], plateletpheresis has been shown not to cause neutrophil activation, namely decreased L-selectin expression, and the formation of neutrophilplatelet aggregates. Barnard et al. [19] have reported similar results. In the disposable bowl, however, they found greater levels of activated granulocytes than in the pre-plateletpheresis donor blood sample indicating the existence of apheresisinduced granulocyte activation. In the present study, we did not measure any leukocyte activation marker. However, a signi®cant increase in plasma TNF-a levels following plateletpheresis suggests that such an activation occurred in our donors. TNF-a is one of the products of the activated monocytes/macrophages, ®broblasts, mast cells, and some T and natural killer cells [20]. Neither of these two studies included data on the activation of the monocytes, and/or lymphocytes, nor did we know the cellular origin of increased TNF-a levels in our donors. TNF-a has been known to induce vWF release from endothelial cells both in pathologic conditions and healthy humans [7]. However, we did not ®nd an increase in endothelial release/damage markers vWF and ®bronectin. Post-plateletpheresis samples were drawn immediately after the procedure in this study, whereas TNF-induced increase in plasma vWF levels in healthy individuals has been shown to peak after 4 h [7]. Alternatively, the level of plateletpheresis-induced TNF-a release may not be strong enough to activate endothelium to release vWF and ®bronectin, while this might be enough to release other endothelial factors not measured in this study. Although no donor experienced any procedure-related complication during or following the plateletpheresis,
174
I. Karado gan et al. / Transfusion Science 23 (2000) 171±175
increased TNF-a levels can be considered as indirect evidence of proin¯ammatory cytokine release during the apheresis which may relate to some adverse eects such as hypotension, fever, acute phase reactions, leukocytosis and platelet activation observed on volunteer donors. Since we did not measure post-plateletpheresis plasma TNF-a levels serially we do not know the duration of TNF-a increase and hence its responsibility in such adverse events. On the other hand, the recipients may experience febrile non-hemolytic transfusion reactions due to increased levels of TNF-a and possibly other cytokines in the products. An increase in IL1b, IL-6, TNF-a, and IL-8 levels is well known during storage of platelet concentrates, and removal of leukocytes by ®ltration prior to storage is highly eective in the prevention of cytokine generation in the bag [21,22]. Our ®ndings suggest that cytokine levels may have been increased in the product even before storage, which cannot be removed by leukocyte ®ltration. In this study donors experienced a single plateletpheresis procedure which does not seemingly impair endothelial cell function in terms of vWF and ®bronectin releases. In some situations, however, it may be dicult to ®nd suitable donors for some patients, so some donors undergo patient-oriented repeated plateletpheresis. Data on the consequences of repeated plateletpheresis for the donor are not known. Studies are needed to compare the eects of single and repeated plateletpheresis on the activation of platelets, blood coagulation and ®brinolysis, leukocytes, endothelium, and cytokine/chemokine release.
References [1] Gutensohn K, Bartsch N, Kuehnl P. Flow cytometric analysis of platelet membrane antigens during and after continuous-¯ow plateletpheresis. Transfusion 1997;37: 809±15. [2] Wun T, Paglieroni T, Holland P. Prolonged circulation of activated platelets following plasmapheresis. J Clin Apheresis 1994;9:10±6. [3] Hernandez MR, Galan AM, Lozano M, Bozzo J, Cases A, Escolar G, Calls J, Ordinas A. Platelet-leukocyte activation during hemodialysis detected with a monoclonal
[4] [5] [6]
[7]
[8] [9] [10]
[11]
[12]
[13]
[14]
[15] [16]
[17] [18]
antibody to leukocyte integrin CD11b. Nephron 1998;80:197±203. Larson DF, Bowers M, Schechner HW. Neutrophil activation during cardiopulmonary bypass in pediatric and adult patients. Perfusion 1996;11:21±7. Patel KD. Mechanisms of selective leukocyte recruitment from whole blood on cytokine-activated endothelial cells under ¯ow conditions. J Immunol 1999;162:6209±16. Homann MW, Wonigeit K, Steinho G, Herzbeck H, Flad HD, Pichlmayr R. Production of cytokines (TNFalpha, IL-1-beta) and endothelial cell activation in human liver allograft rejection. Transplantation 1993;55:329±35. van der Poll T, van Deventer SJ, Pasterkamp G, van Mourik JA, Buller HR, ten Cate JW. Tumor necrosis factor induces von Willebrand factor release in healthy humans. Thromb Haemost 1992;67:623±6. Lip GY, Blann A. von Willebrand factor: a marker of endothelial dysfunction in vascular disorders. Cardiovasc Res 1997;34:255±65. Blann A, Seigneur M. Soluble markers of endothelial cell function. Clin Hemorheol Microcirc 1997;17:3±11. Hayman R, Brockelsby J, Kenny L, Baker P. Preeclampsia: the endothelium, circulating factor(s) and vascular endothelial growth factor. J Soc Gynecol Investig 1999;6:3±10. Voskuyl AE, Emeis JJ, Hazes JM, van Hogezand RA, Biemond I, Breedveld FC. Levels of circulating cellular ®bronectin are increased in patients with rheumatoid vasculitis. Clin Exp Rheumatol 1998;16:429±34. Ballou SP, Lozanski GB, Hodder S, Rzewnicki DL, Mion LC, Sipe JD, Ford AB, Kushner I. Quantitative and qualitative alterations of acute-phase proteins in healthy elderly persons. Age and Ageing 1996;25(3):224±7. _ Ozt Undar L, Karado gan I, urk F. Plasma protein Z levels inversely correlate with plasma interleukin-6 levels in patients with acute leukemia and non-Hodgkin's lymphoma. Thromb Res 1999;94:131±4. Rinder CS, Mathew JP, Rinder HM, Bonan J, Ault KA, Smith BR. Modulation of platelet surface adhesion receptors during cardiopulmonary bypass. Anesthesiology 1991;75:563±70. Hakim RM, Schafer AI. Hemodialysis-associated platelet activation and thrombocytopenia. Am J Med 1985;78:575±80. _ S Karado gan I, uleymanlar G, Sapan M, Ersoy F, Yakupo glu G, Undar L. Fibrinolytic system and natural coagulation inhibitors in patients with chronic renal failure before and after hemodialysis. Nephrol Dial Transplant 1996;11:A211. _ Undar Karado gan I, L. Automated plateletpheresis does not cause an increase in platelet activation in volunteer donors. Therapeutic Apheresis 1997;1:174±7. Stohlawetz P, Kapiotis S, Seidl D, Hergovich N, Zellner M, Eichler HG, Stiegler G, Leitner G, H ocker P, Jilma B. Safety issues of plateletpheresis: comparison of the eects of two cell separators on the activation of coagulation, ®brinolysis, and neutrophils and on the
I. Karado gan et al. / Transfusion Science 23 (2000) 171±175 formation of neutrophil-platelet aggregates. Transfusion 1999;39:420±7. [19] Barnard MR, MacGregor H, Mercier R, Ragno G, Pivacek LE, Hechtman HB, Michelson AD, Valeri CR. Platelet surface p-selectin, platelet-granulocyte heterotypic aggregates, and plasma-soluble p-selectin during plateletpheresis. Transfusion 1999;39:735±41. [20] Vilcek J, Lee TH. Tumor necrosis factor. J Biol Chem 1991;266:7313±6.
175
[21] Wadhwa M, Seghatchian MJ, Lubenko A, Contreras M, Dilger P, Bird C, Thorpe R. Cytokine levels in platelet concentrates: quantitation by bioassays and immunoassays. Br J Haematol 1996;93(1):225±34. [22] Chalandon Y, Mermillod B, Beris P, Doucet A, Chapuis B, Roux-Lombard P, Dayer JM. Bene®t of prestorage leukocyte depletion of single-donor platelet concentrates. Vox Sang 1999;76(1):27±37.
www.elsevier.com/locate/transci
Single automated donor plateletpheresis increases the plasma level of proin¯ammatory cytokine tumor necrosis factor-a which does not associate with endothelial release markers von Willebrand factor and ®bronectin * _ Ihsan Karado gan, Mustafa Ozdo gan, Levent Undar Division of Hematology, Department of Internal Medicine, School of Medicine, Akdeniz University, 07070 Antalya, Turkey Received 19 July 2000; accepted 18 August 2000
Abstract The eect of plateletpheresis on endothelium, which has strong eects on blood coagulation, ®brinolysis and platelet function, is not known. Activation of leukocytes and subsequent generation of proin¯ammatory cytokines during the extracorporeal circulation may activate the endothelium. To test this hypothesis we measured plasma levels of tumor necrosis factor (TNF)-a as a prototype of the proin¯ammatory cytokines, and von Willebrand factor (vWF) and ®bronectin as endothelial release/damage markers before and after a single plateletpheresis procedure on an intermittent¯ow machine Haemonetics MCS 3p in 17 healthy donors. We found a signi®cant increase in median plasma level of TNF-a following plateletpheresis (3.5 vs 26.5 pg/ml, P 0:02). Such increases in vWF and ®bronectin were not observed. The increase in plasma TNF-a indicates that a single plateletpheresis procedure causes leukocyte activation which does not seemingly impair endothelial cell function. The relation of plateletpheresis-induced proin¯ammatory cytokine release to some adverse eects observed in both donors and recipients, and the eect of repeated plateletpheresis on endothelium deserve further studies. Ó 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction The transfusion of apheresis platelets is an essential supportive therapy in patients with severe thrombocytopenia, especially those undergoing intensive chemotherapy. During the apheresis procedure, an extracorporeal circulation, the blood taken from the donor is exposed to an arti®cial membrane and external forces such as
* Corresponding author. Tel.: +90-242-227- 43-43 (ext: 35342); fax: +90-242-349-60-50. È ndar). E-mail address: [email protected] (L. U
centrifugation. The activation of platelets during the apheresis procedures has been reported before [1,2]. The eect of plateletpheresis on the blood coagulation and ®brinolysis, however, are not well-known. Endothelium plays a key role in platelet activation, coagulation and ®brinolysis. Extracorporeal circulation can activate leukocytes [3,4], and subsequent generation of proin¯ammatory cytokines such as interleukine (IL)-1b, tumor necrosis factor (TNF)-a, IL-6 and chemokine IL-8 may activate the endothelium [5,6]. Upon activation, endothelium might release some factors into the circulation, such as tissue-type plasminogen activator, plasminogen activator inhibitor-1, von
0955-3886/00/$ - see front matter Ó 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 9 5 5 - 3 8 8 6 ( 0 0 ) 0 0 0 8 4 - 9
172
I. Karado gan et al. / Transfusion Science 23 (2000) 171±175
Willebrand factor (vWF), thrombomodulin and ®bronectin which are commonly used to show endothelial release/damage in various disorders such as atherosclerosis, vasculitis, and preeclampsia [7±11]. To investigate whether the plateletpheresis procedure activates/damages endothelium, and if so, whether this activation is related to the proin¯ammatory cytokine generation via leukocyte activation, we measured plasma vWF and ®bronectin levels as endothelial cell activation markers, and plasma TNF-a level as a prototype of the proin¯ammatory cytokines before and after a single plateletpheresis procedure on an intermittent-¯ow machine Haemonetics MCS 3p in 17 healthy donors. 2. Materials and methods 2.1. Study subjects Seventeen volunteer plateletpheresis donors (3 women, 14 men) between the ages of 19 and 47 (median 35) were included in the study after obtaining informed consents. All ful®lled the usual requirements for blood donation and were donating for the ®rst time. None had taken aspirin, aspirin containing drugs or non-steroidal anti-in¯ammatory agents within 10 days prior to study. All were non-smokers. 2.2. Plateletpheresis procedure Intermittent-¯ow automated plateletpheresis was performed with Haemonetics MCS 3p Blood Cell Separator (Haemonetics, Braintree, MA, USA) according to the manufacturer's recommendations. Acid-citrate-dextrose (ACD) was used as the anticoagulant. None of the donors experienced any procedure-induced complications during or following the plateletpheresis. 2.3. Sample collection Blood samples were drawn immediately before and after the plateletpheresis procedure. Preplateletpheresis samples were drawn through the
large-bore donation needle before connecting it to the apheresis machine, and post-plateletpheresis samples by venipuncture of the opposite arm with minimum stasis through a 21-gauge needle into evacuated tubes containing 3.8% sodium citrate with a blood:anticoagulation ratio of 9:1. All blood samples were immediately immersed in an ice bath, centrifuged at 2500 g at 4°C for 20 min, and plasma stored in aliquots at ÿ70°C until analysis. 2.4. Measurement of vWF, ®bronectin and TNF-a Plasma vWF level was measured by latex immune assay (LIA Test vWF, Diagnostica Stago, Asnieres, France). Fibronectin and TNF-a levels were determined by enzyme immune assay (Asserachrom Fibronectin, Diagnostica Stago, Asnieres, France; and Quantikine human TNF-a, R&D Systems, Minneapolis, USA, respectively). All tests were done in duplicate. Manufacturers' recommendations were meticulously followed. 2.5. Statistics Plateletpheresis-induced changes were assessed using the Wilcoxon signed rank test for paired data. Spearman's rank correlation coecients were used for the correlation of parameters. All values were expressed as the median (minimum± maximum). A P value below 0.05 was considered signi®cant. 3. Results For each donor 8±10 cycles of apheresis were performed with a presumptive yield of a minimum of 3:5 1011 platelets. A median of 3.8 3:0±4:7 1011 platelets were collected within a median apheresis time of 70 (60±85) minutes and the median ACD consumption was 380 (350±425) ml per procedure. The median pre-plateletpheresis platelet count was 290 220±340 109=l, and post-plateletpheresis platelet count was 240 190±280 109=l, which corresponded to a median decrease of 19 (13±24)%. No in¯uences on TNF-a levels of donor weight, age, sex, ACD
I. Karado gan et al. / Transfusion Science 23 (2000) 171±175
173
Table 1 Median plasma TNF-a, vWF and ®bronectin levels before and after the plateletpheresis procedure in healthy donors
Tumor necrosis factor (pg/ml) von Willebrand factor (% of normal) Fibronectin (ng/ml)
Before plateletpheresis Median (minimum±maximum)
After plateletpheresis Median (minimum±maximum)
P
3.5 (0.2±27.3) 0.65 (0.55±1.10) 178 (160±202)
26.5 (1.9±53.3) 0.63 (0.59±0.77) 178 (170±192)
0.02 >0.05 >0.05
consumption, duration of apheresis, and pre-apheresis platelet counts were found. There were no signi®cant changes in plasma levels of vWF and ®bronectin before or after the plateletpheresis procedure (Table 1). Median TNF-a level was 3.5 (0.2±27.3) pg/ml before the plateletpheresis and increased signi®cantly to 26.5 (1.9±53.3) pg/ml following the procedure P 0:02. No correlation was found among TNF-a, vWF and ®bronectin levels. 4. Discussion In this study we found a signi®cant increase in plasma levels of TNF-a following a plateletpheresis procedure. However, such increases in vWF and ®bronectin were not observed. Both pre- and postplateletpheresis plasma levels of TNF-a showed a marked interindividual variation which can presumably be in an analogy with the so-called ``acute phase proteins'' in healthy individuals [12,13]. Extracorporeal circulation during open heart surgery and hemodialysis has been recognized as having a large in¯uence on platelet function, blood coagulation and ®brinolysis [14±16]. Recently, both automated plasmapheresis and plateletpheresis procedures have been shown to cause in vivo platelet activation [1,2,17]. The mechanisms of platelet activation during the apheresis are not known exactly. Besides direct activation of platelets by extracorporeal circulation, activation of leukocytes and subsequent release of cytokines may activate platelets indirectly, as well. Once activated, platelets release many soluble factors, initiate blood coagulation, and interfere with endothelial cells. Although it is well known that extracorporeal circulation during hemodialysis and open heart
surgery might cause granulocyte and mononuclear cell activation, data about apheresis are very limited. In a recent study of Stohlawetz et al. [18], plateletpheresis has been shown not to cause neutrophil activation, namely decreased L-selectin expression, and the formation of neutrophilplatelet aggregates. Barnard et al. [19] have reported similar results. In the disposable bowl, however, they found greater levels of activated granulocytes than in the pre-plateletpheresis donor blood sample indicating the existence of apheresisinduced granulocyte activation. In the present study, we did not measure any leukocyte activation marker. However, a signi®cant increase in plasma TNF-a levels following plateletpheresis suggests that such an activation occurred in our donors. TNF-a is one of the products of the activated monocytes/macrophages, ®broblasts, mast cells, and some T and natural killer cells [20]. Neither of these two studies included data on the activation of the monocytes, and/or lymphocytes, nor did we know the cellular origin of increased TNF-a levels in our donors. TNF-a has been known to induce vWF release from endothelial cells both in pathologic conditions and healthy humans [7]. However, we did not ®nd an increase in endothelial release/damage markers vWF and ®bronectin. Post-plateletpheresis samples were drawn immediately after the procedure in this study, whereas TNF-induced increase in plasma vWF levels in healthy individuals has been shown to peak after 4 h [7]. Alternatively, the level of plateletpheresis-induced TNF-a release may not be strong enough to activate endothelium to release vWF and ®bronectin, while this might be enough to release other endothelial factors not measured in this study. Although no donor experienced any procedure-related complication during or following the plateletpheresis,
174
I. Karado gan et al. / Transfusion Science 23 (2000) 171±175
increased TNF-a levels can be considered as indirect evidence of proin¯ammatory cytokine release during the apheresis which may relate to some adverse eects such as hypotension, fever, acute phase reactions, leukocytosis and platelet activation observed on volunteer donors. Since we did not measure post-plateletpheresis plasma TNF-a levels serially we do not know the duration of TNF-a increase and hence its responsibility in such adverse events. On the other hand, the recipients may experience febrile non-hemolytic transfusion reactions due to increased levels of TNF-a and possibly other cytokines in the products. An increase in IL1b, IL-6, TNF-a, and IL-8 levels is well known during storage of platelet concentrates, and removal of leukocytes by ®ltration prior to storage is highly eective in the prevention of cytokine generation in the bag [21,22]. Our ®ndings suggest that cytokine levels may have been increased in the product even before storage, which cannot be removed by leukocyte ®ltration. In this study donors experienced a single plateletpheresis procedure which does not seemingly impair endothelial cell function in terms of vWF and ®bronectin releases. In some situations, however, it may be dicult to ®nd suitable donors for some patients, so some donors undergo patient-oriented repeated plateletpheresis. Data on the consequences of repeated plateletpheresis for the donor are not known. Studies are needed to compare the eects of single and repeated plateletpheresis on the activation of platelets, blood coagulation and ®brinolysis, leukocytes, endothelium, and cytokine/chemokine release.
References [1] Gutensohn K, Bartsch N, Kuehnl P. Flow cytometric analysis of platelet membrane antigens during and after continuous-¯ow plateletpheresis. Transfusion 1997;37: 809±15. [2] Wun T, Paglieroni T, Holland P. Prolonged circulation of activated platelets following plasmapheresis. J Clin Apheresis 1994;9:10±6. [3] Hernandez MR, Galan AM, Lozano M, Bozzo J, Cases A, Escolar G, Calls J, Ordinas A. Platelet-leukocyte activation during hemodialysis detected with a monoclonal
[4] [5] [6]
[7]
[8] [9] [10]
[11]
[12]
[13]
[14]
[15] [16]
[17] [18]
antibody to leukocyte integrin CD11b. Nephron 1998;80:197±203. Larson DF, Bowers M, Schechner HW. Neutrophil activation during cardiopulmonary bypass in pediatric and adult patients. Perfusion 1996;11:21±7. Patel KD. Mechanisms of selective leukocyte recruitment from whole blood on cytokine-activated endothelial cells under ¯ow conditions. J Immunol 1999;162:6209±16. Homann MW, Wonigeit K, Steinho G, Herzbeck H, Flad HD, Pichlmayr R. Production of cytokines (TNFalpha, IL-1-beta) and endothelial cell activation in human liver allograft rejection. Transplantation 1993;55:329±35. van der Poll T, van Deventer SJ, Pasterkamp G, van Mourik JA, Buller HR, ten Cate JW. Tumor necrosis factor induces von Willebrand factor release in healthy humans. Thromb Haemost 1992;67:623±6. Lip GY, Blann A. von Willebrand factor: a marker of endothelial dysfunction in vascular disorders. Cardiovasc Res 1997;34:255±65. Blann A, Seigneur M. Soluble markers of endothelial cell function. Clin Hemorheol Microcirc 1997;17:3±11. Hayman R, Brockelsby J, Kenny L, Baker P. Preeclampsia: the endothelium, circulating factor(s) and vascular endothelial growth factor. J Soc Gynecol Investig 1999;6:3±10. Voskuyl AE, Emeis JJ, Hazes JM, van Hogezand RA, Biemond I, Breedveld FC. Levels of circulating cellular ®bronectin are increased in patients with rheumatoid vasculitis. Clin Exp Rheumatol 1998;16:429±34. Ballou SP, Lozanski GB, Hodder S, Rzewnicki DL, Mion LC, Sipe JD, Ford AB, Kushner I. Quantitative and qualitative alterations of acute-phase proteins in healthy elderly persons. Age and Ageing 1996;25(3):224±7. _ Ozt Undar L, Karado gan I, urk F. Plasma protein Z levels inversely correlate with plasma interleukin-6 levels in patients with acute leukemia and non-Hodgkin's lymphoma. Thromb Res 1999;94:131±4. Rinder CS, Mathew JP, Rinder HM, Bonan J, Ault KA, Smith BR. Modulation of platelet surface adhesion receptors during cardiopulmonary bypass. Anesthesiology 1991;75:563±70. Hakim RM, Schafer AI. Hemodialysis-associated platelet activation and thrombocytopenia. Am J Med 1985;78:575±80. _ S Karado gan I, uleymanlar G, Sapan M, Ersoy F, Yakupo glu G, Undar L. Fibrinolytic system and natural coagulation inhibitors in patients with chronic renal failure before and after hemodialysis. Nephrol Dial Transplant 1996;11:A211. _ Undar Karado gan I, L. Automated plateletpheresis does not cause an increase in platelet activation in volunteer donors. Therapeutic Apheresis 1997;1:174±7. Stohlawetz P, Kapiotis S, Seidl D, Hergovich N, Zellner M, Eichler HG, Stiegler G, Leitner G, H ocker P, Jilma B. Safety issues of plateletpheresis: comparison of the eects of two cell separators on the activation of coagulation, ®brinolysis, and neutrophils and on the
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