Page 1of27 between this versionandtheVersionofrecord. Pleasecitethis articleasdoi:10.1111/trf.14488. through thecopyediting, typesetting, pagination andproofreading process,whichmay lead todifferences This istheauthor manuscriptaccepted forpublicationandhas undergonefullpeerreview buthasnotbeen Netherlands; Affiliations: Affiliations: (Blo Network Research Blood Care Critical Pediatric Institute, San Francisco, CA; CA; Francisco, Institute,San Kenneth E. Remy MD, MHSc MD, Remy KennethE. Hospital, Columbus, OH; Columbus, Hospital, Pediatrics, Division of Pediatric Critical Care, An Critical of Pediatric Division Pediatrics, Keywords: Keywords: 3333 count: Word [email protected] 2862830 Office:(314) Louis,63110 MO St. 8208 Box Ave. Campus Euclid S. 660 MHSc. MD, Remy, KennethE. Author Corresponding OH; 5 1 MD OH; OH; and Laboratory Medicine, University of Rochester, R Rochester, University of LaboratoryMedicine, and Philip J. Norris MD Norris J. Philip California, San Francisco, San Francisco, CA; CA; Francisco, San Francisco, San California, Critical Care, St. Louis, MO; Louis,MO; Care, St. Critical Department of Intensive Care Medicine, Academic Med Academic Care Intensive Medicine, Departmentof Departmen of Medicine, School University Washington 5 , Kathleen Nicol MD Kathleen , Nicol 4 7 Mechanisms of Red Blood Cell Transfusion-Related Im Transfusion-Related Cell Blood Red Mechanismsof Pediatric Critical Care and Cardiology, University Care and Cardiology, Critical Pediatric Transfusion Medicine/Blood Bank and Clinical Labora and Clinical Bank Medicine/Blood Transfusion

6 transfusion, immunomodulation, RBC, plasma immunomodulation, transfusion,

Author ManuscriptHosp Children’s Nationwide of Pathology, Department

8,9

, Mary , PhD Dahmer K. : : This article isprotected by copyright. All rights reserved. 6 3 , Allan Doctor MD Allan , The Research Institute at Nationwide Children’s Hos Children’s Instituteat Nationwide TheResearch 2 9 1 Division of Critical Care Medicine, Nationwide Chil of Critical Care Nationwide Medicine, Division Departments of Laboratory Medicine and Medicine, Un Medicine, and Laboratory Medicine of Departments , Mark W. Hall MD Hall Mark , W. Transfusion 10 1 10 , and Jennifer A. Muszynski MD, MPH MD, Muszynski A. and Jennifer , , Neil Blumberg MD Neil , University of Michigan, Department of Department Universityof Michigan, n Arbor, MI. n 2,3 , Jill Cholette , MD Jill od Net) Net) od ochester, NY; of Rochester, Rochester, NY; NY; Rochester, ofRochester, t of Pediatrics, Division of Pediatric of Pediatric Division of Pediatrics, t ical Center, Amsterdam, the the Amsterdam, ical Center, tories, Departments of Pathology of Pathology Departments tories,

munomodulation (TRIM) munomodulation 8 7 Blood Systems Research Research Systems Blood , Philip C. Spinella MD Spinella C. Philip , ital, Columbus, Columbus, ital, 4 , Nicole P. Juffermans , Juffermans P. Nicole pital, Columbus, Columbus, pital, dren's 2,3 2,3 iversity of iversity for the 1 , ,

researchdirections. immunomodulati transfusionrelated of RBC mediators In this products. of RBC effects immunomodulatory requires an complexities these factors.Unpacking produ blood betweeninteractions individual complex pati transfused in of RBCs effects immunomodulatory Defini effects. andimmunosuppressive inflammatory Thes cellfunction. immune and alter interactwith mult a contain products RBC adverse with outcomes. crit in common is cell(RBC) transfusion blood Red systemic inflammation both whom in trauma patients Abstract

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This article isprotected by copyright. All rights reserved. Transfusion e interactions can lead to both pro both lead to can einteractions in depth understanding of the mechanisms of mechanisms the of understanding depth in ct characteristics and patientspecific risk risk patientspecific and characteristics ct review, we outline and classify potential potential classify and review,we outline itude of immunomodulatory mediators that that mediators of immunomodulatory itude and immune suppression are associated are suppression associated andimmune ng clinical outcomes related to ngoutcomes clinical ents remains a challenge, likely due to to due likely a remains challenge, ents on and provide suggestions for future for suggestions and provide on ically ill, postsurgical, and post postsurgical, icallyill, Page 2of27 Page 3of27 particularly for critically ill patients. ill critically for particularly blood products. Clinically, RBC transfusion is ass is transfusion RBC Clinically, products. blood In the United States, 11 to 16 million red blood c red blood million 16 to 11 States, United In the a RBC to equating decade, last annuallythe during INTRODUCTION and increased mortality and morbidity; mechanisms o morbidity; mechanisms and mortality andincreased betwee associations independent demonstrate studies hospitalization. r ICU patients of 3760% with suites, andoperating emergenc in commonplace particularly is transfusion dysregulated recipient immune responses. immune recipient dysregulated infectio of nosocomial development the dysfunction, and immunosuppressive effects of RBC product exposu product of RBC effects andimmunosuppressive More rece transfusion. RBC allogeneic leukoreduced transfusion. renal cadaveric higher in significantly kidneyswas observatio the with (TRIM) relatedimmunomodulation Immunomodulation Transfusion-Related Cell Blood Red criticalknowledge. mediat potential classify relatedimmunomodulation, current literat summarize will review Thefollowing Beginning in 1973, Opelz and colleagues provided in and colleagues provided Opelz 1973, in Beginning ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100

Author13,27 Manuscript 612 These findings strongly suggested immunosuppress suggested These findings strongly

Nonetheless, RBC transfusion may deleteriou have Nonetheless, transfusion RBC

This article isprotected by copyright. All rights reserved. 13,14 Mounting evidence from predominantly observationa from predominantly Mounting evidence 13,14,21,2832 Transfusion ociated with new or worsening organ organ worsening new or ociatedwith transplant patients who received RBC RBC received who patients transplant transfusion every 2 seconds. 2 every transfusion eceiving a transfusion during eceivinga transfusion ure on mechanisms of RBC transfusion RBC of uremechanisms on The extent to which RBC which to The transfusion extent n, and cancer recurrence, suggesting suggesting and cancer n, recurrence, ors, and propose a research agenda to fill fill to agenda aresearch and propose ors, n RBC transfusion, dysregulated immunity immunity dysregulated transfusion, RBC n y departments, intensive care units (ICUs) care units yintensive departments, f which are only partly understood. only fare which partly nt findings suggest both proinflammatory proinflammatory both suggest findings nt n that the survival rate of transplanted of transplanted rate survival the that n re, including prestorage leukoreduced re,leukoreduced including prestorage ell (RBC) units were administered were (RBC) administered units ell

itial evidence for RBC transfusion evidence for itial RBC ive effects of non effects ive s immunologic effects, effects, immunologic s 15 RBC RBC 1526

l l

presentation, suppression of lymphocyte proliferati suppression presentation, blood products on individual patients and to mitiga and to patients individual on products blood blood products and the multitude of potentially imm of potentially multitude and the products blood function. impaired natural killer cell function, alterations alterations function, cell natural killer impaired 1). (Figure vesicles extracellular iron (heme, contents hemolytic component mediators, i have been mediators potential many characterized, mechanisms of RBC transfusionrelated immunomodulat transfusionrelated of RBC mechanisms re Future challenging. remains patients individual ef immunomodulatory total sum the Overall,defining activation, and inflammatory cytokine release. cytokine and inflammatory activation, neut enhanced priming, leukocyte including: effects models Inof preclinical a variety cellfunction. that demonstrates evidence aofwealth preclinical i dysregulation immunologic to contributes directly inflammation and immune suppression are significant are suppression and immune inflammation for critic relevant be particularly may transfusion i Indeed,mixed effects surprising. not are mixed effects of RBC transfusion may seem contradictory, contradictory, may seem transfusion of RBC effects While mechanisms for RBC transfusionrelated immuno transfusionrelated for RBC mechanisms While 14,3640

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Author Manuscript proinflammatory both evidence While supporting

This article isprotected by copyright. All rights reserved.

Transfusion 13,17,21,31,3335 in T lymphocyte ratios, defective antigen antigen defective ratios, lymphocyte T in , RBC product exposure results in inflammatory in results exposure product RBC , ally ill patients in whom both excess excess both whom in patients ill ally mmunomodulatory potential of RBC of RBC potential mmunomodulatory search to determine the effects of individual of individual effects the searchdetermine to RBC products can directly modulate immune immune modulate can products directly RBC on, and decreased macrophage phagocytic phagocytic and decreased on, macrophage te potential risks depends on understanding understanding on depends risks te potential n transfused patients remains unclear, though unclear, though remains transfused n patients rophil chemotaxis, monocyte/macrophage chemotaxis, rophil dentified. These include leukocytederived leukocytederived These include dentified. unomodulatory mediators contained therein, therein, contained mediators unomodulatory given the complex nature of transfused nature of transfused complex given the fects of particular RBC products in in products RBC of particular fects ly associated with adverse outcomes. adverse with lyassociated release), plateletderived factors, and factors, release), plateletderived ion. ion. Immunosuppressive effects include include effects Immunosuppressive modulation are not yetare not fully modulation and immunosuppressive andimmunosuppressive 14

Page 4of27 Page 5of27 be harmful via immunomodulatory mechanisms. Althou mechanisms. immunomodulatory bevia harmful may reduce transfusionassociated cancer metastasis transfusionassociated mayreduce these data suggest that residual leukocytes or leuk leukocytes residual that thesedata suggest current leukoreduction technologies. currentleukoreduction intact leukocytes and/or soluble leukocytederived leukocytederived soluble and/or leukocytes intact

1. Leukocytes and Leukocyte-derived Mediators Mediators Leukocyte-derived and Leukocytes 1. MECHANISMS PROPOSED infections. restrictedtransfus or autologous leukoreduced, the thres transfusion RBC liberal orversus restrictive autologo RBCs, nonleukoreduced versus leukoreduced t Randomized outcomes. clinical appearsimprove to ce blood white residual most removes Leukoreduction when leukoreduced RBCs are utilized. RBCs whenleukoreduced wi cardiacsurgery, following response inflammatory of postoperative infection.of postoperative WBC allogeneic residual to exposure (whichdecrease allogeneic to exposure (which prevent transfusions substantial number of residual leukocytes (~5000 to to (~5000 leukocytes of residual number substantial mitigat to leukoreduced prestorage transfusedare The observation that prestorage leukoreduction may leukoreduction prestorage that Theobservation 15,4547

ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100 Author Manuscript Likewise, metaanalyses demonstrate that leukored that demonstrate metaanalyses Likewise,

This article isprotected by copyright. All rights reserved. 15,45,47 RBC unit leukoreduction may also attenuate the sy the attenuate also may leukoreduction unit RBC 5052 48 Lastly, animal models demonstrate that leukoreduc that demonstrate models Lastly, animal

Transfusion holds demonstrate that in each case, subjects in in case,each subjects in that demonstrate holds ocytederived mediators in RBC products may may products RBC in mediators ocytederived ion arms developed fewer nosocomial nosocomial developedarms fewer ion e these risks, it is worth noting that a notingthat worth is it etheserisks, mediators play a role in its development. its a role play in mediators WBCs) and restrictive transfusion thresholds thresholds transfusion and restrictive WBCs) and T cellapoptosis. and T ~ 5 x 10 x 5 ~ th a dosedependent increase in survival survival in increase a dosedependent th rials in surgical patients receiving either receiving either patients surgical in rials s) are each associated with decreased risk risk decreased with associated s)are each lls from stored blood components and components blood stored from lls us versus allogeneic RBC transfusions, transfusions, RBC allogeneic versus us gh in the US, 7580% of RBC units units of RBC 7580% ghUS, the in mitigate TRIM suggests that either that suggests TRIM mitigate 6 leukocytes/unit) remain despite remain despite leukocytes/unit) uction, autologous RBC RBC autologous uction, 29,49 Taken together, stemic stemic 4144 tion tion

posttransfusion immune suppression is currently la is suppression immune posttransfusion lymphocytes may result in either alloimmunization o either alloimmunization in result lymphocytesmay IImole MHC betweendonor interactions transfusion, an antigens processed present to function molecules induce immune tolerance or alloimmunization. tolerance immune induce dete recipient likely the of state inflammatory the functionality the compatibility, of HLA degree the (Tcell) suppression. RBC allogenic for amechanism proposed tolerance is storage, leukocytes undergoapoptosis. storage,leukocytes an immune response and become “accepted” by the rec the by become“accepted” response and animmune recip transfusion blood allogenic in microchimerism demonstration of direct causal links between HLA mo betweenHLA links causal of direct demonstration common in trauma patients and may persist for up to for up and may persist trauma patients in common In addition to residual functional allogeneic leuk functional residual to Inaddition s immune induce also may products RBC in leukocytes signals would be expected to produceantigenspecif to expected be signalswould with cells T recipient engage which allogeneicAPCs immunosuppressive T immunosuppressive microchim andassociated tolerance Moreover,immune Antigen presenting cells ( cells Antigen presenting leukocytes Residual histocompatibility complex (MHC) II( (MHC) molecules complex histocompatibility

ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100 Author Manuscript 21 H T cell immune tolerance may also be responsible f beresponsible also may tolerance T cellimmune 2 responses following blood transfusion. blood responsesfollowing 2 This article isprotected by copyright. All rights reserved. i.e. monocytes and dendritic cells)major carry and dendritic monocytes 64 One of the early steps in apoptosis involves expo involves apoptosis One in earlyof the steps Transfusion 21 In the case of immune suppression, residual residual suppression, Inimmune case the of rmine whether residual allogeneic leukocytes leukocytes allogeneic whether residual rmine i.e. of donor antigen presenting cells (APCs), and (APCs), cells presenting antigen ofdonor cking. cking. d activate lymphocytes. Following activate d lymphocytes. ic T cell anergy. cell T ic ients, whereby donor leukocytes fail to elicit elicit to fail leukocytes whereby donor ients, two years following transfusion.years two following r immune suppression. rimmune HLADR) on their cell surfaces. MHC II surfaces. MHC cell their HLADR) on out necessary secondary or costimulatory costimulatory necessary or out secondary cules on residual leukocytes and recipient and recipient leukocytes residual culeson transfusionrelated adaptive immune cell immune adaptive transfusionrelated lecules on residual allogeneic APCs and APCs allogeneic residual leculeson ipient. uppression. erism may explain the observed shift to to observed the shift explain may erism ocytes, it is possible that apoptotic apoptotic that possible is it ocytes, 57 Microchimerism may be may Microchimerism be 38,5962 63 During collection and During collection 21 However, clear clear However, The resulting immune The resulting immune or development of development or 5356 Features as such 57,58

sureof Page 6of27 Page 7of27 blood products.blood phosphatidyl serine on the outer leaflet of the cel of the outerleaflet serinethe on phosphatidyl the immune response. immune the FASL, andsol soluble products, celldegranulation natural killer cellactivity. naturalkiller i cellapoptosis, immune innate induce maydirectly likely that soluble mediators also play a role in T a role play in also mediators soluble likelythat strongest evidence suggesting that they may promote may they that evidencesuggesting strongest TGFβ is a known antiinflammatory cytokine with bro with cytokine antiinflammatory a TGFβknown is cells. and predomin activation, of APC inhibition release, inh IL10 and TGFβ, cytokines ofantiinflammatory im induce to has beenshown serine and phosphatidyl immunomodulation can be recapitulated using RBC uni RBC using can berecapitulated immunomodulation and surgery patients cardiac pediatric responsein Soluble leukocyte-derived mediators mediators leukocyte-derived Soluble fragmentsor microparticles. p to response be seen in also responsesmay similar remains setting clinical the in suppression immune 63,65 There are multiple soluble leukocytederived factor leukocytederived soluble areTheremultiple Removal of supernatant from stored RBC units by was by units RBC stored from of supernatant Removal The degree to which apoptotic residual leukocytes residual apoptotic which The degree to

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Invitro 68,69 This article isprotected by copyright. All rights reserved. Of these, sFASL and the antiinflammatory cytokin antiinflammatory andthe Of sFASLthese, 36,69,70 studies indicate that sFASL and TGFβ found in blo in found sFASL and TGFβ that indicate studies Immunosuppressive effects may not be limited to t to Immunosuppressive belimited not may effects Transfusion l membrane. Interaction between immune cells cells betweenimmune Interaction membrane. l RIM pathogenesis. pathogenesis. RIM preclinical studies suggest that RBCinduced RBCinduced that suggest studies preclinical hosphatidyl serinecontaining membrane membrane serinecontaining hosphatidyl notingthat worth is it However, unknown. mpair neutrophil chemotaxis, and decrease chemotaxis, neutrophil mpair uble HLA molecules, which directly inhibit inhibit directly which HLA molecules, uble ance of immunosuppressive regulatory T anceof immunosuppressive TRIM, particularly in nonleukoreduced nonleukoreduced in TRIM, particularly munosuppressive signals, including release including signals, munosuppressive ibition of proinflammatory cytokine cytokine of proinflammatory ibition ad immunosuppressive effects. effects. adimmunosuppressive t supernatants. t s, including cytokines, white blood blood white cytokines, including s, in RBC units contribute to recipient to contribute units RBC in hing reduces the inflammatory inflammatory the reduces hing 24,25,66,67 Thus, seems Thus, it e, TGFβ have the the e,TGFβ have od components components od hese,as

in RBC products such that levels are undetectable. are levels that such products RBC in th decrease substantially to appears leukoreduction involved. likel is it era, postleukoreduction the in remains med soluble leukocytes and leukocytederived While leuk prestorage by reduced likely are effects such function. str to are enough high concentrations whether their and eosinophil cationic protein have been detected detected have been protein cationic andeosinophil accumulate in blood products during storage. products blood accumulatein microparticles, as well as accumulation of cellfre accumulation as well as microparticles, lact increased pH, reduced lead to can transfusion) Decompartment and StorageLesion Cell Blood Red 2. also reduce T cell proliferation. T reduce also cell prolifera and decrease T chemotaxis neutrophil exam For potential. immunomodulatory has mediators ability to vasoregulate. to ability i changes affinity, oxygen in changes derangements, morphology byRBC altered are characterized lesions “st adescribed well conditions, underrefrigerated Another potential mechanism for TRIM arises from th arisesforfrom TRIM mechanism Another potential proinf cytokines, antiinflammatory to Inaddition 73,74 14 ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100

Author Manuscriptcelldegran Incytokines, blood to white addition 7885 This article isprotected by copyright. All rights reserved. In addition, RBC hemolysis (both during storage an storage during (both In hemolysis RBC addition, 76,77

Transfusion 7174 y that nonWBC derived factors are also also are derived factors y nonWBC that However, in some reports prestorage prestorage reports some in However, e hemoglobin (CFH), heme, and iron. (CFH), heme, ehemoglobin orage lesion(s)” develops. The RBC storage The RBC develops. oragelesion(s)” oreduction. Because evidence for TRIM TRIM for evidence Because oreduction. 72,74 ate and other metabolic wastes, release ofreleasewastes, ateand othermetabolic e accumulation of proinflammatory cytokines cytokines of proinflammatory eaccumulation ongly influence recipient immune immune recipient onglyinfluence in red blood cellcomponents. red in blood tion, while eosinophilic cationic protein may may protein cationic eosinophilic while tion, n osmotic regulation, and changes in the the changes regulation,in and osmotic n , rheological changes, metabolic metabolic changes, rheological , When cytokines are detected, it is unclear unclear is detected, it cytokines are When ple, histamine has been shown to inhibit inhibit to has been shown histamine ple, lammatory cytokines may also also may cytokines lammatory alized RBC Contents Contents RBC alized iators appear to promote TRIM, promote to appear iators e RBC, itself. itself. eRBC, ulation products such as histamine as histamine such products ulation A s RBC units age units RBC s d post d 75 Each of these 26,78,8690

Page 8of27 Page 9of27 barriers and to immunity. andto barriers release ci andaugmented of NTBI form the in iron increased response was not observed. observed. not responsewas NT circulating increased significantly fresherRBCs coagulation, vascular, and immune systems. immune and vascular, coagulation, and balance redox plasma disturb can hemolysis RBC wel the (PLI).Given iron labile (NTBI),or plasma boun ofform transferrin the bein can Iron content migration, upregulation of adhesion molecules, and and molecules, of adhesion upregulation migration, ch of otherradical promotion (ROS), oxygenspecies of iron.. furtherrelease can Freeheme freeheme. releasing methemoglobin, hemog extracellular When hemoglobin. extracellular plasmabindin mayoverwhelm intravascularhemolysis macrophages removal by were increased post transfusion, NTBI levels were n were NTBIlevels transfusion, post wereincreased of a study in said, That underlyinginflammation). be not may transfusion RBC responseto inflammatory and mice between differences may to relate studies associated with significant tissue damage, presumab tissue significant associatedwith . In normal physiology, plasma haptoglobin sequesters haptoglobin plasma physiology, Innormal 22,23,105,106

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However, in human healthy volunteers, while tran while volunteers, healthy However, human in 67,9397 22,93,98104 This article isprotected by copyright. All rights reserved. via 91,105,107 CD163. Accumulation of uncomplexed heme and iron in pl in hemeof anduncomplexed iron Accumulation In murine models, transfusion of longstored RBCs of longstored transfusion In models, murine The lack of observed inflammatory response in the in response The lack of observed inflammatory 18,22,23,93 Transfusion 4,22,23,78,86,91,92 However in critical illness, even moderate even moderate However illness, critical in d iron (TBI), non transferrin bound iron iron bound (TBI), transferrin non iron d 33 premature neonates, while levels of NTBI of NTBI levels while neonates, premature 33 ldescribed bioactivities of these species, of thesespecies, ldescribed bioactivities humans, relative transfusion dose; or the dose; relative transfusion humans, BI levels, a proinflammatory cytokine cytokine a proinflammatory BIlevels, subsequent deleterious effects to tissue tissue to effects deleterious subsequent ly by ironcatalyzed generation of reactive of reactive generation lyironcatalyzed by ot associated with increases in plasma plasma in increases associated with ot ains, increases in leukocyte activation and activation leukocyte in increases ains, rculating proinflammatory cytokine cytokine proinflammatory rculating lobin is unbound, it becomes oxidized to to becomesoxidized it unbound, is lobin then undergo the Fenton Reaction to cause to Reaction Fenton the undergo then broadly disrupt normal signaling in in signaling normal disrupt broadly apparent in healthy subjects (without (without subjects healthy in apparent g capacity resulting in unbound unbound in gresulting capacity

CFH, forming a complex for acomplex CFH, forming sfusion with olderversus with sfusion asma is asmais led to to led human human

blunting LPSinduced TNFα production while augmenti while production LPSinducedTNFα blunting protein present in a variety of cell types. RBCs c RBCs celltypes. of a variety present in protein promote immune suppression by impairing proliferati byimpairing suppression immune promote of RBCs by macrophages ( byofRBCs macrophages ironrelated reactive oxygen species. oxygen reactive ironrelated process this signaling; and NFκB NLRP3 via release caninflammasome trigger a that degree to andiron RBC transfusion may also burden the mononuclear ph mononuclear burdenthe also may transfusion RBC mon to contents and RBC of hemoglobin largeamounts minimal. iron may directly promote bacterial growth. bacterial promote may iron directly Additionally, extracellular ubiquitin found in RBC RBC in found ubiquitin extracellular Additionally, inflammatory cytokines. inflammatory the antiinflammatory cytokine, IL10. cytokine, antiinflammatory the upregu (M2) via profile towardan immunosuppressive the from phenotype macrophage bias also of heme may Finally, an additional compound of interest is ubi is of interest compound anadditional Finally, duringstorage. has been fo ubiquitin and extracellular celltypes, cells. compromise phagocytic and microbicidal macrophage a macrophage andmicrobicidal phagocytic compromise II nitric andimpairing MHC of reducingexpression sec IFNγmediated bysuppression inhibiting immune 111 Additionally, independent of direct effects on im on effects of direct Additionally, independent ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100

Author112 Manuscript Extracellular ubiquitin has varied effects on imm variedhas on effects Extracellular ubiquitin

108 This article isprotected by copyright. All rights reserved. These data suggest that proinflammatory effects effects proinflammatory These data suggest that i. e. extravascular hemolysis) increases macrophage in macrophage increases e.hemolysis) extravascular 93 Conversely, macrophage exposure to high concentrat to exposure Conversely, macrophage 109 Similarly, macrophage iron loading may promote promote may loading Similarly, iron macrophage Transfusion 78,93,105 und to accumulate in RBC unit supernatants supernatants unit RBC accumulate in to und arry large amounts of ubiquitin relative to other relative to of ubiquitin amounts large arry

units may skew helper T cell function toward cellfunction may T skew helper units activation and proinflammatory cytokine cytokine and proinflammatory activation oxide synthesis. Cumulatively, these effects effects these Cumulatively, synthesis. oxide is further exacerbated by generationof by further is exacerbated on and activation of T, B, and natural killer killer B, and natural of T, and activation on retion of proinflammatory cytokines, cytokines, of proinflammatory retion lation of hemeoxygenase 1 and release ofrelease and 1 of hemeoxygenase lation activated/inflammatory (M1) phenotype phenotype (M1) activated/inflammatory ocytes andmacrophages.ocytes ctivity. ng LPSinduced IL8LPSinduced production. ng quitin, an intracellular regulatory an intracellular regulatory quitin, mune cells, uncomplexed heme and uncomplexed cells, mune agocyte system (MPS), delivering (MPS), agocytesystem 110 Iron further also may overload une cell function, including function, unecell of NTBI may be may of NTBI tracellular heme tracellular 93 Phagocytosis Phagocytosis 112114 ions ions

Page 10of27 Page 11of27 ag e” compa in results days 17.9 of US the storage in RBC difficu proven >21days) whichhas cutoffs (i.e. RBC 3. Residual Platelets and Platelet-derived Factors Platelet-derived Platelets and Residual 3. ubiquitin. exposedto PBMCs LPSstimulated by IFNγ production by as evidenced phenotype, Th2 animmunosuppressive While less is known about plateletderived factors plateletderived about known is less While and plateletderiv platelets that stronglysuggests

contributes to patientspecific immune modulation, modulation, immune patientspecific to contributes contents RBC decompartmentalized interplay between largely remains suppression, or immune inflammation part patients, individual for RBCderivedmediators of infla relative impact evaluated.The adequately inflammation, baseline settingof moresignificant ubiquitin mirrors immunomodulatory effects observed effects immunomodulatory mirrors ubiquitin and may explain mixed responses reported mixed explain andmay RCTs beendemonstra not have thesefindings RBCs, stored and increased survival worsened show studies animal ef pleiotropic likely have mediators andindividual 87,116 4,16,78,87,115

In summary, soluble mediators resulting from RBC ag RBC resulting from mediators soluble Insummary, . Additionally, storage duration effects may be may be Additionally, effects . storage duration 112,114 ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100

Author Manuscriptimmunosuppressive and The mix of proinflammatory . This may be because animals studies can carefull studies animals may This . because be

This article isprotected by copyright. All rights reserved. Transfusion in vivo in ed factors have important immunomodulatory immunomodulatory important factors have ed . . mmatory and immunosuppressive effects of of effects andimmunosuppressive mmatory though to date this question has not been not has question date this though to fects on recipient immune response. Although response. immune fectsrecipient on icularly in the setting of baseline baseline setting of the in icularly a topic of active ongoing research. research. of active aongoing topic lt in human RCTs, where a mean duration of where duration RCTs, human a in mean lt risons between “fresh” vs. “middle vs. “fresh” between risons

ted in recently published human human recently published in ted inflammation from transfusion with longer longer with transfusion from inflammation unknown. It is likely that a complex complex Ita likely that is unknown. in response to RBC supernatants supernatants RBC response to in and underlying host immune response immune host and underlying increased IL4 production and decreased and decreased IL4 production increased 35dayold stored RBC supernatant or supernatant RBC stored 35dayold as TRIM mediators, emerging data data emerging as TRIM mediators, more robust if transfusion occurs in the occursthe in transfusion if morerobust eing and breakdown are varied, and breakdown eing y old” vs. “fresh delineate effects of extracellular of extracellular effects

in vitro in

potential. by LPS, induce acute lung injury providing eviden providing injury lung acute induce LPS, by immune cell suppression and activation. cellsuppression immune within leukoreduced red blood cell products is unkn is cell products blood red leukoreduced within immu Likewise,the evaluated. was cells not immune of effects however beimmunomodulatory, to expected lipids, such as lysophosphatidylcholines, appears t appears as lysophosphatidylcholines, such lipids, including transfusionrelated acute lung injury (TR lung injury acute transfusionrelated including inflamma to contribute may and units RBC storagein acid, and their metabolites accumulate in RBC units RBC accumulate in acid,metabolites and their a including acids, fatty varietyof polyunsaturated Bioactive Lipids Lipids Bioactive with immune cell apoptosis and monocyte tissue fact and monocyte tissue cellapoptosis immune with accumulate plateletleukoc have to beenshown units immunomo to contribute likely products RBC in found and health both responsein cell immune modulating demonstrating the presence of lipids with neutrophi with of lipids presence the demonstrating of priming neutrophils ofneutrophils priming fr when isolated metabolites, oxidized acidand its 4. Bioactive Lipids and Extracellular Vesicles and Vesicles Extracellular Lipids Bioactive 4. secondhit in the twohit model of nonantibody med of nonantibody model twohit the in secondhit Bioactive lipids with proinflammatory and procoag proinflammatory with Bioactivelipids 117119 ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100

Author Manuscriptare microparticles For plateletderived instance, in vitro in This article isprotected by copyright. All rights reserved. . Further, infusion of these bioactive lipids in r in lipids ofthese bioactive Further, . infusion 120,121 Transfusion Platelets themselves may play important roles in in roles important playmay Platelets themselves rachidonic acid, linoleic acid, docosahexaenoic docosahexaenoic acid, linoleic acid, rachidonic om older stored RBC supernatants, are capable capable are supernatants, RBC olderstored om o be reduced by leukoreduction. by beo reduced ALI). l priming activity in the plasma of TRALI of TRALI plasma the activity priming in l own. own. ce that bioactive lipids may provide the the may provide lipids ce bioactive that despite leukoreduction. despite yte aggregates over time, which correlate which time, yteover aggregates orexpression. iated TRALI. iated disease, suggesting that residual platelets platelets residual that disease,suggesting tory complications of RBC transfusion, transfusion, RBC of complications tory nodulatory potential of residual platelets of platelets residual nodulatory potential plateletleukocyte aggregates on recipient recipient on aggregates plateletleukocyte dulation. Nonleukocyte reduced RBC RBC Nonleukocytereduced dulation. 83,123

ulant activity accumulate during accumulate activity ulant Accumulation of some bioactive bioactive of some Accumulation capable of inducing both inducing both capableof 125,126 122 These are changes Observational studies 123,125 ats that are primed are that ats primed Arachidonic 124 However, a Page 12of27 Page 13of27 In vitro In patients provide additional supportive evidence of of evidence supportive additional provide patients been appreciated that plasma from healthy subjects subjects healthy from plasma that beenappreciated during storage, while plateletderived EV counts pe counts EV plateletderived while duringstorage, The term extracellular vesicle (EV) broadly encomp (EV) broadly vesicle extracellular The term (50 bodies and apoptotic nm) (30150 exosomes nm), Extracellular vesicle count and profile in blood pr in blood profile and count vesicle Extracellular vesicles Extracellular study. ofdeserving further topic outsi function of immune or modulation inflammation antibody mediated TRALI. antibodymediated from leukocytes, platelets, RBCs and endothelial ce and endothelial RBCs platelets, leukocytes, from EV counts in RBC products increase with storage du storage with increase products RBC in counts EV EVs. contribute leukocytes and platelets residual while bysh accompanied are RBCs changesto morphological storageduration. v have may products individual that such conditions co by influenced are significantly andaccumulation 135138 evidence for EV TRIM effects effects TRIM EV for evidence Tracking EV cell of origin reveals that RBCderiv that reveals cellof origin Tracking EV

ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100 Author Manuscript 140,141 140,141

This article isprotected by copyright. All rights reserved. 127 The extent to which bioactive lipids may which contribu to lipids bioactive The extent

Transfusion to plateletderived and leukocytederived andleukocytederived plateletderived to the link between bioactive lipids and non lipids between bioactive link the ak at 34 weeks of storage. of akweeks 34at contains EVs, including exosomes, derived exosomes, including EVs, contains lls. mponent manufacture processes andstorage processes manufacture mponent ery different EV profiles despite similar similar despite EV profiles erydifferent oducts de of TRALI remains unclear and is a andis unclear deremains of TRALI 500 nm). 500 131133 edding and release of RBCderived EVs, EVs, ofRBCderived andrelease edding asses larger microvesicles (2001200 (2001200 microvesicles asseslarger

ration.

ed EVs increase continuously continuously increase edEVs 128130 86,134 For over a decade, it has For it over a decade, Storagerelated 86,139 te to systemic to te EV releaseEV

In vivo In indicating that exogenous EVs can modulate a can nascen EVs modulate exogenous indicatingthat IgGfor center and germinal stimulate production to (CD40L)ex CD154 of transfer adoptive Additionally, suppressing inflammatory responses. suppressinginflammatory halflife of EVs appears to be fairly short, less t less befairly short, to appears halflifeof EVs signaling, both in normal physiology and in disease and in physiology normal in both signaling, bioactivity without debris considered Thoughonce role i central playinga as recognized increasingly monocytes andmacrophages. monocytes has been exploited by several groups as agroups potential as byseveral has beenexploited immunosuppressive effects. immunosuppressive d have from plasma isolated EVs celltypes, various kidneys, and lungs in mice. andlungs in kidneys, rapid are EVs injected example, For concentration. E to likely related is of EVs biologicactivity the and activate neutrophils andactivate neutrophils Given the incomplete understanding of how EVs from EVs of how understanding incomplete the Given surprising that not is it cells after EV uptake by these cells. these uptakeEV by after cells activati direct from resulting effects inflammatory potentially effects immunosuppressive varies,with recipient mouse can activate responding T cells in in cells T responding activate can recipientmouse evidence for EV TRIM effects effects TRIM EV for evidence

ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100 Author Manuscript in vivo in in vitro, in This article isprotected by copyright. All rights reserved. 147 139,146 135, Donor dendritic cellderived EV uptake by dendrit by uptake EV cellderived dendritic Donor evidence of an EVbased role in TRIM is scant. The scant. is TRIM role in anEVbased of evidence and have antiinflammatory or proinflammatory eff proinflammatory or and have antiinflammatory

143,144 The proposed mechanism of action of bloodderived of action mechanism The proposed 139,146 130,145 Neutrophil and RBCderived EVs are also capable o capable also are EVs Neutrophil and RBCderived

Similar to the variability in effects of EVs from of EVs effects variability the in to Similar Transfusion han 1520 minutes in a rat model.a rat in minutes 1520 han V uptake by target cells rather than plasma plasma than rather cells target uptake by V n the body’s complex network of intercellular networkof intercellular complex body’sthe n on of monocytes and other antigenpresenting antigenpresenting andother of monocytes on an antigenspecific manner. anantigenspecific vaccine delivery approach. vaccine delivery . mediated by FasL expression byand EVs, expression FasL by mediated ly and widely distributed to the spleen, liver, liver, spleen, the to lydistributed and widely mation in mice after adenovirus vaccination, vaccination, adenovirus after mice in mation ual proinflammatory and and proinflammatory ual 142 t immune response immune t pressing plateletderived EVs is sufficient sufficient is EVs pressing plateletderived EVs derived from stored platelets bind to to bind platelets derived EVs stored from and discounted as artifact, EVs are EVs as artifact, anddiscounted different cells of origin might act, might of origin cells different 152 . The significance. of 149151 148 This propertyThis 86 ic cells in a in cells ic However, circulating circulating

ects on ectson EVs EVs

f Page 14of27 Page 15of27 both exaggerated systemic inflammation and immune s and immune inflammation exaggeratedsystemic both potentially immunomodulatory mediators vary not onl vary not mediators immunomodulatory potentially products, one might conclude that RBC TRIM does not TRIM RBC does that conclude one might products, studies that fail to demonstrate benefit to fresh to R benefit demonstrate to fail that studies transfused pat in effects of TRIM evidence clinical of mechanism through cellfunction a variety immune FUTUREDIRECTIONS patients.hospitalized con the and in immunomodulation transfusionrelated of thi manipulation allow would system immune human Bett research. of active and an area question open blood in found of EVs effects immunomodulatory the influences the immunologic response to transfusion. to response immunologic influences the supp immune and/or of inflammation underlyingstate potentia and subsequent contents, unit RBC methods, interp complex the understand to are beginning only donor characteristics, manufacturer, storage soluti storage manufacturer, characteristics, donor In this context, one would expect that immunologic immunologic that expect one would Incontext, this mechanisms. dur storage RBC or that products blood leukoreduced Ample evidence exists that RBC products are capable are that products RBC exists evidence Ample

ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100

Author87,115,153,154 Manuscript

However, emerging evidence suggests that the conc the that evidence suggests emerging However, This article isprotected by copyright. All rights reserved. Transfusion BC transfusion compared to longer stored longer stored compared to transfusion BC on, and other processing factors. and other processing on, er understanding EV interaction with the the with interaction EV erunderstanding ients remains elusive. Given recent clinical clinical recent Given elusive. remains ients effects of RBC transfusion might vary might transfusion of RBC effects Critically ill patients, in particular, exhibit particular,exhibit in patients, ill Critically lay between storage duration, processing processing duration, storage between lay l TRIM effects. Similarly, a patient’s a patient’s Similarly, TRIM l effects. ation does not contribute to TRIM to contribute not does ation s and mediators; however, conclusive however, conclusive and mediators; s text of immune perturbation seen in many many seen in perturbation of immune text ression at the time of transfusion likely of transfusion time the at ression y with storage duration, but also with with also but ystorage duration, with products transfusion recipients remains an remains recipients transfusion products uppression that fluctuate over time. fluctuate that uppression exist era the in of prestorage exist s pathway, both in the context of context the in pathway, both s of interacting with and modulating modulating and with of interacting entrations of entrations 88,155158 We 159164

pretransfusion immune function. Additionally, pat Additionally, function. immune pretransfusion also receive other blood products, which may have d have may which products, receiveother blood also charact sufficiently to date have to failed studies recipie of the state underlying the on widely based characteristics and patientspecific risk factors w factors risk and patientspecific characteristics interactio understand to remains work Overall,much Lisaforher Feurer thank to like would Theauthors Acknowledgements for those effects TRIM andameliorating definingat p future can inform then mediators immunomodulatory condit and storage processing product donor, ofRBC cons clinical and related effects TRIM forspecific benecessa will studies observational TRIM biology, Next function. immune of host context in mediators approac bedside benchto A bedside. the at effects recipient immunity modulate may thesemediators how Defining immunomodulatory mediators found within bl within found mediators Definingimmunomodulatory

ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100 Author Manuscript

This article isprotected by copyright. All rights reserved. Transfusion erize or account for individual differences in differences in individual or account for erize ith respect to clinical consequences of TRIM. of TRIM. consequences respect clinical to ith equences. Moreover, delineation of the effects effects of the delineation Moreover, equences. nt’s immunologic response. However, most most However, response. immunologic nt’s h must carefully attempt to define these to carefully attempt must h assistance with figure preparation. preparation. figure with assistance ients who are transfused with RBCs often RBCs with are who ients transfused patients most at risk. risk. at most patients , guided by an enhanced understanding of understanding guided , enhanced byan ry to determine patientspecific risk factors risk determine patientspecific ryto ifferent or additive TRIM effects. TRIM or additive ifferent ns between individual blood product product blood betweenns individual ions upon accumulation of accumulation upon ions is essential to identify potential TRIM TRIM identify to potential essential is rospective and interventional trials aimed aimed trials and interventional rospective ood products, and understanding and understanding products, ood 14,165

Page 16of27 Page 17of27 23. Hod EA, Zhang EA, SokolN, Hod SA,al. et Transfusion of effectsare harmful that bymediated iron andinfla 23. 21. Vamvakas Blajchman Vamvakas EC, MA.Transfusion-related 21. 22. Hod EA, Spitalnik EA, Hod Stored SL. bloodcell red tra infection. 22. Rev 20. Neal MD, RavalJS, MD, Neal Triulzi DJ,Inna Simmons RL. bloodcells. red 20. Suppl 2010;8 3:s26-30. 19. Sparrow Red Sparrow bloodRL. cell andtransfusstorage 19. 14. Muszynski JA, Muszynski Spinella PC, JM, etCholette al. literatureand implications the forpediatric criti 14. 1. Lacroix J, HebertJ, Hutchison Lacroix JS,etPC, Transal. 1. References care units. care 13. Vamvakas Blajchman Vamvakas EC, MA.clinical Deleterious factimmunomodulation: or fiction? 13. Hebert A, PC, Tinmouth CorwinH.Anemia and red Care Med 12. 8. Demaret P,Tucci Demaret M,DucruetT, TrottierH, Lacro children(CME). 8. 7. Bateman ST, ST, J, Bateman Lacroix BovenAnemia,al. K, et b Americanchildreninthe intensive care unit. 7. 2005;33(11):2637-2644. 11. Corwin HL, Gettinger Corwin A, al. RG, PearlCR et The criticallyclinicalill--current in Un practice the 11. 516. 16. Wang D, Sun SolomonJ, D, Wang SB, HG, Klein Natanson C a meta-analysis.death: 16. Critical care TrialsCritical Group. Transfusion Hebert requirementsPC. incritical clinical controlled study. TransfusionRequirements IndustryML.Blood Wald Shrinks Transfusions as 3. 2. 17. Bilgin YM, Brand BilginYM, A.Transfusion-related immunom cascade? 17. 15. Rohde JM, Rohde Blumberg Dimcheff N,Healtal. DE, et systematictransfusion: a review and meta-analysis. 15. 9. Lacroix J, Lacroix Tucci Pont-Thibodeau M, Du G. blo Red children.ill 9. 6. Armano R, Gauvin R, ArmanoF, DucruetT, Lacroix J.Determ critical pediatric care unit: prospective,descri a The Services DoHaH. Blood National 2011 Collecti 6. 5. Natanson WA, Flegel Klein C, prolonged HG.Does Haematol 4. 18. Ozment CP,Mamo Ozment Campbell LB, LokhnyginaML, Y, andfree effects hemoglobin, andiron. heme, 18. 10. Corwin HL. Anemia Corwin and red blood cell transfusio 10. . 2007;21(6):327-348.. Vox Vox Sang . 2003;31(12. Suppl):S672-677. . 2014;165(1):3-16.. TransfusClinBiol N EnglMedJ ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100 Curr OpinCurr Pediatr

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JAMA nsfusions:Iron, inflammation, immunity, and Transfusion-relatedimmunomodulation: review of fusion strategies fusion forpatients inpediatric intensi ITStudy: Anemia andblood transfusion inthe teimmune activation aftertransfusion stored of care(TRICC): a multicentre, randomized, red blood red after prolonged cells producesstorage lood loss, andloss,loodblood transfusions inNorth ion-relatedimmunomodulation. ix J.Red ix bloodcell transfusion incriticallyill nin the criticallyill. hcare-associatedinfection after bloodcell red od od celldecision transfusion making incritically Crit Crit CareMed Decline. The New YorkDecline.The Times; 2014:A1. effects oftransfusion-associated inantsred bloodof cell transfusions in a . 2013;53(4):732-740.. on and on Survey Utilization Report; 2011. . Transfusion. ofbloodolder stored and risk of . 2014;311(13):1317-1326.. storagebloodof red cells causeharm? odulation:secondhit a ininflammatoryan immunomodulation (TRIM):an update. Transfusion cellin transfusion criticallyill patients. GhioJL.AJ,Turi Transfusion-related biologic Blood . 2010;115(21):4284-4292.. . 2017;57(1):195-206.. . 2008;178(1):26-33.. . 2004;32(1):39-52. CritCare Med SeminDial . 2006;19(6):513- BloodTransfus . BrJ Crit Blood ve .

42. Blumberg N, FineN, Blumberg L,Heal Gettings KF, JM. Decre coincident devices implementation with ofuniversal 42. BassuniWY,Blajchman MA, Al-Moshary imMA. Why Oncol Hematol Stem Cell Ther 41. 2007;47(8):1395-1404. 2005;45(10):1632-1639. 38. Long K, Meier Ward Long C, M, D,WilliamsWoodward J cells using inblood vitro models of transfusion. 38. 2014;54(5):1340-1347. factor-beta1 by neutrophils: factor-beta1by rolethe immunoglob of 37. Long K, Meier Bernard Long C, A, D,WilliamsDavenpo cells is blood dependent cellson andis intact c a 37. 36. Ghio M, Contini Ghio P,Negrini M, C, Mazzei S,Zocchi M cell-mediated cytolysiskiller bloodinduced by tra 36. soluble Fas ligand,Fas andsoluble humansolubleI Class leuko 39. Muszynski J, J, Muszynski Nateri Nicol Greathouse K, K, H cells blood on aremonocytes relatedbothto storag 39. 35. Hendrickson JE, Hendrickson Hod Hudson EA, KE,Spitalnik SL cells reverses blood adverse effects of olderstore 35. Suppl2012;73(2 1):S128-133. 34. Belizaire RM, AT, Belizaire CampionMakley EM,etResal. decreasesunits cell the proinflammatory response i 34. 2008;38(2):117-125. 40. Ottonello L, L, Ottonello Ghio M, Nonleukoal. Contini P, et inhibitionsustained neutrophil chemotaxisof by st 40. 2012;52(4):794-802. 33. Cardo LJ, Wilder Cardo J.D, Salata priminNeutrophil red packed bloodcell units, abrogated is by leukoc 33. 30. Blajchman Bordin Blajchman MA, JO. Mechanisms of transfus 30. 32. Dzik S, BlajchmanS, Dzik N,MA, Blumberg H SA, Kirkley immunomodulatoryallogeneiceffect of bloodtransfu 32. Transfus Med Rev Vamvakas Blajchman S, MA, SweeneyDzik J,EC, S transfusion-inducedimmunomodulation: summary ofth 31. Hematol transfer using spleentransfer cells. Bardossy Blajchman MA, SastryA,L, R, Carmen S tumor enhancement growth: of animal two show models 29. 28. Blajchman Immunomodulatory Blajchman MA. allog effects of manifestationsand mechanisms. 28. 24. Wang D, SolomonD, Wang Piknova B, SB,Inal. r et vivo oxyhemoglobinresults invasoconstrictionin canine 24. 27. Opelz G, Terasaki G, Improvement Opelz PI. of kidney-gra transfusions. 27. 25. Cortes-Puch I, Cortes-Puch WangSun al. D, et J,Washing ol iron andplasma improves in outcomes experimental c 25. 26. Wang D, D, WangCortes-Puch SunI, al. et J,Transfusio depending canines on the presenceandseverity p of 26. . 1994;1(6):457-461.. ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100

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.1978;299(15):799-803. Blood This article isprotected by copyright. All rights reserved. . 2008;1(2):106-123.. . 1993;81(7):1880-1882.. Vox Vox Sang . 1998;74. Suppl 2:315-319. Transfusion J Surg Res onsequenceblood processing.bank of nsfusion:role of transforminggrowth factor-beta(1 dred blood cells. yte collection. depletion at yte imulatingproduction invivo oftransforminggrowth cyteantigen. s. e time and time e solution.storage n afterhemorrhage. mice leukoreduction ofblood transfusions. ulinliketranscript 1,sFasL, and sHLA-I. neumonia. nofolder bloodstored inworsens outcomes sion. sion. Transfusion g, causedg, cell membranesby and microvesiclesin anson anson ImmunosuppressiveL, HallM. red effects of anine pneumonia.anine reducedbloodcell red transfusion induces a der blood der beforeunits transfusion reduces eductionofcell-free methemoglobin to asedsepsis relatedindwellingto access venous ,Zimring fresh JC.Transfusion of red murine R, R, Poggiregulation A.Down human of natural eal JM, Woodeal K. research Current the on ftsurvival increased numberswith blood of uscitation washed packedagedwith red blood e proceedings e state-of-the-artof a conference. rt rt J. D, suppressionWoodward T-cell by red ingalAllogeneic DP. bloodtransfusion-induced ingamelioration by leukodepletion andpassive . 2013;184(1):567-571.. nyder EL. Clinicalnyder EL. andmolecular of basis ion-associatedimmunosuppression. , Bernard , A.Immunologicprofiles of red Vox Vox Sang eneicbloodtransfusions: clinical plementuniversal leukoreduction? Transfusion Transfusion . 2013;53(12):3149-3163. Transfusion . 1996;70(4):187-194.. Blood . 2014;54(7):1712-1724.. . 2011;51(7):1567-1573. Transfus Apher TransfusApher Sci J TraumaJ Acute Care Surg . 2014;123(9):1403-1411. . 2011;51(12):2695-2702. Transfusion Transfusion Transfusion Transfusion . Curr OpinCurr . . ), . .

. Page 18of27 Page 19of27 Anaesth 45. Blumberg N, ZhaoN, H, Blumberg Wang MessingH,Heal S, JM, and trials clinical meta-analysesleukoreduced of b 45. 62. Leal-Noval SR, Leal-Noval Munoz-Gomez Arellano M, etal V, T-helper CD4+ cells immune inpatientsresponse und 62. 2010;164(1):43-49. 46. Fergusson D, Khanna Fergusson A,TinmouthD, MP, Hebert PC. postoperativedecrease may infections: two meta-ana 46. 2007;47(4):573-581. 43. Hebert PC, Fergusson Hebert Blajchman PC, D, Cl al. MA, et leukoreductionCanadian universal program b for red 43. clinical trial.clinical de van WateringHermansLM, HoubiersJ, etJG, bloodtransfused postoperative complicationson in 48. 7 VanderlindeHealBlumberg ES, N.JM, Autologous 47. 60. Fragkou PC, Torrance Fragkou HD,PC, Pearse RM,etPerial. transcription profilegene characteristicimmuno of 60. 44. Lannan KL, Sahler J, SpinelliJ, LannanSahlerKL, SL, Bl RP,Phipps forleukoreduced case and washed(perhaps) transfus 44. 1949. 61. Gafter U, Kalechman Gafter Sredni Y, transfusBlood B. andtransforminggrowthfactor in beta humans. 61. 2014;18(5):541. patients. patients. TH, Lee T,Paglieroni Ohto HollandPV,H,Busch inimmunocompetent transfusion recipients: frequent 58. 57. Reed Lee Norris Reed W, TH, PJ, Busch GH, Utter MP. complicationofblood transfusions inseverely inju 57. 50. Sharma RR, Marwaha Sharma N. Leukoreducedbloodcompon indeveloping implementation countries. 50. Transfusion HashimotoMN, KimuraEY,Bordin Yamamoto JO. M, cells ofT experimental animals afterunmodified or 49. 59. Bernard A, Bernard C, Meier et Ward al. b M, red Packed involvingcell-cellprocess contact. 59. 51. Sut C, Tariket S,Tariket C, Sut Chou etDurational.ML, r of generation. 51. 52. Shapiro MJ. To filterTo MJ. blood Shapiro universal leukor or 52. 56. Patel SR, Zimring SR, Patel JC.Transfusion-induced bone m histocompatibilityantigens. 56. model. Cadwell Desmarets CM, M, KR,PetersonNeades R, transfused on leukoreduced red bloodof unitscells 55. 53. Storb R, RudolphRH, Storb Graham TC, Thomas ED. The upon donors grafts marrow histocompatible between c 53. Suppl 2:S27-30. 54. Storb R, Epstein Storb RB, RudolphThomas RH, ED. The histocompatible between canine siblings. 54. Blood . 2004;51(5):417-424.. Blood ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100

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Author. 1999;93(9):3127-3139. Manuscript . 1998;97(6):562-568.. .2017;15(2):145-152. This article isprotected by copyright. All rights reserved. TransfusMed Rev J TraumaJ AsianTransfusJ Sci J ImmunolJ . 2010;69(2):320-329.. Transfusion . 2013;27(4):241-248. Clin (Lond) Sci red patients. loodtransfusions insurgicalpatients. suppression:prospective a study. cohort leukoreduced allogeneicblood transfusions. induce bone marrowtransplant rejection in a mouse patientsundergoing cardiac randomized a surgery: . 1970;105(3):627-633.. umbergN. immunomodulation--the Transfusion ed blood ed storage cell and inflammatory marker lood cell transfusions. ergoing cardiac ergoing surgery. ions. eduction:whatthe is answer? lysesrandomized of controlled trials. long-term microchimerism insevere trauma anine siblings.anine SurvivalMP. donor of leukocyte subpopulations operativeblood transfusionassociated is with a ionenhances production of T-helper-2cytokines inical following outcomes institution ofthe Transfusion-associated microchimerism:new a lood suppress cells T-cell proliferation through a al. Beneficialal. leukocyte effects of depletionof . Influence. blood red of cell transfusion on effect ofprioreffect transfusion on marrow grafts arrowrejectiontransplant due minorto transfusion. Transfusionofleukoreduced red bloodcells influencetransfusions from of unrelated Lyman GH.The Lyman intention-to-treat principlein BloodCells Mol Dis ZimringJC.Minorhistocompatibility antigens . 2010;4(1):3-8. Expression ofandligandFas Fas spleen on ents: Advantages ents: andstrategies forits . 1996;91(4):519-523. SeminHematol J ImmunolJ BMJ . 2002;324(7340):772-775. JAMA J SurgJRes .2013;50(1):61-68. . 2007;44(1):24-31. . 1971;107(2):409-413.. . 2003;289(15):1941- . Crit Care . Transfusion CanJ CritCare . 2004;8. . .

Apher Sci Apher prospective,randomized, controlledclinical trial. JM, Henrichs Cholette KF, GM,et Alfieris W al. surgery cardiac reduces postoperative inflammation 66. 67. Muszynski JA, J, Muszynski Bale al. Nateri et J,Supernat 67. 64. Frabetti F, Frabetti Musiani etD, Marinial. M, White c 64. ClinBiol P,Angelot Saas Bardiaux F, Seilles E, L, Garna cell by-productsexpressing intransfusion:pro-iA 63. 65. Doffek ChenSugg Doffek K, SL,X, J. Shilyansky Phosph inhuman activation derived monocyte dendritic cell 65. 1998;38(11-12):1082-1089. RBC-derivedmicrovesicles, monocytefunctisuppress 68. Ghio M, Contini Ghio P,Ubezio M, Ansaldi SettiG, F, M 68. 2017;57(4):1019-1030. 74. Nagura Y, Tsuno Nagura NH,Tanaka Y, M, Matsuhashi M,Tak leukocyte reductionblood cytokines/chemokines on l 74. 2013;73(1):75-79. Fas ligandFasdo molecules: theyplay role a inautolo 69. Ghio M, Contini Ghio P, M, Mazzei imet Inal. vitro C, 69. Suppl1:s105-108. 77. Peterson CG, Skoog CG, PetersonVenge V, Human P. eosinophil suppressive effects lymphocyte proliferation.on 77. 71. Benson AW,Beck Benson DD, Burdine Brekken MS, R, Sill cytokines cancer fractionin the plasma ofp stored 71. Transfusion Bonnefoy R, Vallion al.F, et A,TransforDaoui blood during white cells red storage blood cell pro 70. 996. 9 AlshalaniRedAcker JP. A, blood cell membrane storage. vivo 79. 78. Remy KE, Natanson Remy C,KE, Kleininfluence HG.The of transfusion. 78. 72. Karam O, O, Karam Tucci BJ,al. M, Toledano et Length of prestorage by leukoreduced bloodcells. red 72. 468. 75. Nielsen HJ,Reimert Nielsen CM, AN,et al. Pedersen Tim bioactiveand platelet-derived substances from stor 75. 76. Bury TB, JL,Corhay Bury Radermecker Histamine-i MF. andT-lymphocyte proliferation in man. 76. 965. 73. Keir AK, McPheeAJ,Andersen Keir Stark CC, Plas MJ. increase activation afterpacked red bloodcell tra 73. 80. D'Alessandro A, Gray D'AlessandroA, AD, Szczepiorkowski ZM,Ha metabolic responses refrigeratedtostorage, rejuve 80. factor insolublefactor HLA-I-mediated transfusion-modula solublecontaminating HLA-I levels correlate with o . 2012;19(3):90-97.. . 2013;49(2):223-230. ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100 . 2015;55(7):1721-1735. Curr OpinCurr Pediatr

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Immunobiology Pediatr CritCarePediatr Med nflammatoryan or anti-inflammatory effect? nsfusioninthe preterm infant. gous blood transfusion? motes transfusion-inducedmotes alloimmunomodulation. ackedcells. red f solubleinf CD8 recipients'new a controlplasma; nation,andfrozen storage. edblood.human s. munosuppressiveactivity ofsoluble class HLA andI tedimmunomodulation? ants from ants blood red stored (RBC) cell butnounits, andtransfusions: number a of results of che-OttouS.PerrucheF, Phosphatidylserine- on invitro. ming growth ming factor-beta released apoptotic by evels inautologous evels CPDA-1 blood.whole ell apoptosis ell in packedcells. red ashingbloodcells red and platelets intransfused Mol Immunol Mol , Tripodi , transfusionsBlood G. withhighof levels atidylserineinhibits NFkappaB and p38 MAPK storage andin vitro immunomodulation induced water increases permeability with oflengthex e-dependent,spontaneous release ofwhite cell- . 2009;49(11):2326-2334.. maandcytokines endothelial markers of thelesion(s) storage pediatric cellon red imanBarnettCC, CC, Jr.Accumulation pro- of nducedinhibition neutrophil of chemotaxis nsenHerschel LH,K, Dumont LJ. bloodcell Red cationic proteinscationic and(ECPEPX) and their ahashiThe K. pre-storageeffect of whole- . 1986;171(1-2):1-13. 1986;171(1-2):1-13. . Transfusion J GastrointestJ Surg . 2011;48(15-16):1771-1777.. Transfusion . 2012;13(3):290-299. Transfusion . 2015.. BloodTransfus Transfusion Pediatr ResPediatr .1996;36(11-12):960- . 2012;16(3):460- . 2001;41(8):988-. Transfusion . . . 2014;12 Transfus Transfus . t

Page 20of27 Page 21of27 gleaned through biochemistrythroughgleaned and technologies omics 82. Spinella PC, Sparrow SpinellaPC, RL,Hess NorrisJR, Pr PJ. andvascular immune reactivity. 82. 99. Ganz T, Nemeth GanzIronT, E. homeostasis inhostdefe 99. 83. Zimrin AB, Hess AB, JR. Current Zimrin relating issues t to 83. 81. D'Alessandro A, Kriebardis D'AlessandroA, RinalducciS, AG, et 81. 1443. 98. Ganz T. Systemiciron Ganz T. homeostasis. 98. 95. Liang X, X, T, Liang Lin SunBeasley-Topliffe G, Cava L, proinflammatory LPS-induced fromcytokines macropha 95. 2011;50(1):1-9. 97. Rifkind JM, JG, RifkindJM, Mohanty Nagababu pathoph The E. associated enhanced with reactions. oxidative 97. 2012;189(4):2017-2022. 96. Lin T, Sammy T, Lin H,Yang F, et Identificational. o inhibitsofsynergyhemoglobin HMGB1 with insteril 96. 89. Baek JH, Baek YalamanogluA, GaoY, etIronal. acce diseased guineainvascular pigstransfusfollowing 89. Hematol 101. Ganz T, Nemeth GanzHepcidinT, E. homeostasi andiron 101. Nemeth GanzIronT, E. metabolism:interaction Harb ColdSpring Perspect Med 100. 2015;15(8):500-510. 88. Remy KE, Spinella Remy RedKE, PC. cell storage blood ag 88. 92. L'Acqua C, Bandyopadhyay L'AcquaC, FrancisRO,S, etal. hemolysis increased andan phase inacute response 92. 2011;118(25):6675-6682. 84. D'Alessandro A, Nemkov D'AlessandroA, T, KelherM, et Routal. solution-3: additive comprehensive a investigation 84. 2009;96(2):93-103. 94. Cherayil BJ. role Cherayil iron The of immune inthe res 94. Storedred Spitalnik SL. bloodcell transfusion Transfusion 93. 2015. therapy. therapy. JH, Vallelian Baek F, D'Agnillo et F,Hemog al. theconsequence blood red of celllesion storage th 90. 91. Hod EA, Brittenham EA, Hod GM,Billote al. GB, et Trans bloodcells red produces extravascular hemolysisan 91. yet be to yet established: a meta-analysis. 85. Delobel J, Delobel Prudent M, CrettazRubin Tisso O, D, bloodcells red reveals compartment-based a protein 85. 2015;55(6):1155-1168. 86. Donadee C, Donadee Raat NJ,Kanias et Nitrical. T, oxi hemoglobincell-free a for as mechanism red the cel 86. No.:181-193. Spec 87. Remy KE, Sun J, Remy KE, D,Wanget Transfusional. ofr notimprove does survivalin comparison with curren 87. . 2016;9(11):1011-1013.. J ClinJInvest ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100

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This article isprotected by copyright. All rights reserved. . 2012;2(5):a011668.. Transfusion VoxSang Physiol Rev Physiol . 2011;51(4):894-900.. Transfusion Front Physiol . 2016;111(1):43-54. ionstored of blood. of the RBC of metabolome. at at canattenuatedinguinea be haptoglobinpigs by d circulatingnon-transferrin-bound iron. l lesion.storage eandinfectious inflammation. de scavenging de bloodcell red by microparticlesand illon HS.JM, Hemopexin Warren down-regulates t t practice, while the safety storedoldest of units a subset of critically subset a of children.ill lobin-drivenpathophysiology an is in vivo fhemopexinan as anti-inflammatoryfactor that carbonylation evolution. s: iron, inflammation, s: immunity, and infection. operties of stored operties blood of red understandingcells: hetransfusion ofredstored blood cells. . al. Anal.update on blood cell red storage a lesions, ponsebacterialto infection. ecently (fresh)ecently red donated bloodcells (RBCs) lerates hemoglobin increasing oxidation mortality t JD, Liont N. Subcellular fractionation ofstored . 2013;93(4):1721-1741.. Redbloodcell transfusion associated is with e - e what fromweknow clinical trials. Transfusion fusionhuman of volunteers with stored older, s s with andnormaldisordered erythropoiesis. ges. ine storageine red bloodof cell (RBC)inunits nce andinflammation. s. ysiology of hemoglobinextracellular BiochimBiophysActa . 2014;5:500.. J Leukoc Leukoc J Biol . 2015;55(1):205-219. Circulation JCIInsight . 2009;86(2):229-235.. Transfusion J Proteomics . 2011;124(4):465-476. NatRev Immunol . 2012;1823(9):1434-. .2017;2(9). ImmunolRes J ImmunolJ Am J HematolJ Am . . 2012;76 Expert Rev Expert Blood . Vox Vox Sang . . . . is s .

119. Stolla M, Refaai Stolla HealM, MA, JM, etal. Platelet 119. microparticlesin vitro. ChangHC, HW, Lin Hsiao SH, Seghatchi Chou ML, THP-1 trigger monocyticcellandreleas aggregation 120. Immunol Front 116. Aubron C, Bailey Aubron C, M, al. Z, McQuilten et Duratio criticallypatients.ill 116. 117. Cognasse F, Nguyen Cognasse KA, al. Damien In P, et The Receptors.Siglec 117. 118. Hamzeh-Cognasse H, Hamzeh-Cognasse DamienA, P,Chabert Pozzet complexinfections-interactions bacteria. with 118. 115. Steiner ME, Ness Steiner ME, Assmann PM, al. SF,et Effect undergoingsurgery. cardiac 115. 2012;47(3):305-311. 2. Sadallah Schmied S, L, CharoudehEken C, HN,A ReduceEctosomes NK Cell Function. 121. 112. Patel MB,Proctor Patel KG, Majetschak Extracellu M. duringunits storage. 112. Clinical and Laboratory Science 111. Walker EM, Walker SM.EM,Walker Walker Review: Effects ofiron 111. 2005;18(4):359-367. 110. Theurl I, FritscheI, Theurl G, GarimorthLudwiczekS, K factory cellular interphaseat the iron between and 110. Bao Yazdanbakhsh ZhongK, W, H.Immunoregulator HematologyAm Hematol Soc EducProgram 109. Andersen Keir Stark AK, MJ, DoesCC. non-trans immune-modulation related inpreterms? 108. 114. Zhu X, Yu B, Yu You Zhu etX, Ubiquitinal. i P, released expressionpromotes mRNA Th2 cytokines of andTh2-i 114. hyporesponsivenessincritical illness. Majetschak M, Krehmeier Bardenheuer U, M,et a endotoxintoresponse inperipheral blood mononucle 113. 102. Maccio A, Maccio C,Madeddu GramignanoG, etTheal. incancer-related status anemia: results large a of 102. 122. Keating FK, Butenas Keating FungS, SchneiderMK, DJ. andprocoagulant apoptosis, activityred instored 122. 106. Hod EA, Brittenham EA, Hod GM,Spitalnik The SL. role 106. 107. Berra L, Coppadoro Berra A, BL,et Yu Transfusioal. Hyperemia Reactive inIndex Volunteers. Healthy 107. Blood 103. Porto BN, AlvesBN, Porto Fernandez LS, etHemeal. PL, generation species through signaling pathwayschara 103. 2015;100(1):124-132. 105. Hod EA, Spitalnik EA, Hod Harmful SL. oftrans effects inflammation. 105. 104. Graca-Souza AV, ArrudaAV, Graca-Souza FreitasMA, de Barj MS, implications heme: forinflammatory processes. 104. 2007;282(33):24430-24436. . 2012;120(21).. ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100 Transfusion Author2015;6:28.. Manuscript

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J CritJCare J SurgJRes Transfus Apher TransfusApher Sci . 2011;51(4):881-885.. This article isprotected by copyright. All rights reserved. N EnglNMedJ . 2014;29(3):476. e471-478. . 2000;30(4):354-365.. . 2006;135(2):226-232. . 2015;6:83.. J ImmunolJ Blood . 2015;372(15):1419-1429. . 2015;53(2):246-252.. Arch Arch DisChildNeonatal Fetal Ed . 2003;101(5):1882-1890. . 2011;2011:466-469. Transfusion . 2016;197(5):1663-1671.. FrontImmunol Blood , prospective, , observationalstudy. Anesthesiology bloodcells. immunity for control the infections. of e of pro-coagulant e of tissue factor-expressing transfusion - the newtransfusion immunologythe - therapy. ofold an n plasma the of bloodduringwhole storage fusion stored bloodof red older ironcells: and cteristic of chemotactic cteristic of receptors. nStored of Autologous Blood Alter Does Not , Bellmann-Weiler , R, WeissG. The macrophage:A . 2002;99(11):4160-4165.. ar cells andregulates cells ar endotoxin inducesneutrophil andmigrationreactive oxygen s of red-cell s storage of duration patients on of iron of intoxicityofredstored bloodcell units. Platelet-white blood Platelet-white cell (WBC)interaction, WBC nducingfactors. transcription flammatoryRole of Plateletsvia Their andTLRs nred storage blood of cells and in outcome overloadthe immuneon system. ferrin contribute boundiron transfusionto lar ubiquitininlar increases packed red bloodcell micarella F, Schifferli JA.SchifferliF, micarella Platelet-Derived a-Fidalgo C, NeutrophilPL.Oliveira by activation roleinflammation, of iron, and nutritional an J,an T. Burnouf Platelet-derivedmicroparticles l.Extracellularubiquitin inhibits the TNF-alpha to B,to GarraudCognasseF, O. Plateletsand y y ofredstored effects blood cells. Transfusion . 2015;6:82.. . 2012;117(1):56-63.. . 2011;51(5):1086-1095.. . 2013;98(5):F424-429. Haematologica TransfusApher Sci J BiolJ Chem Annalsof Biometals . . .

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Page 22of27 Page 23of27 134. Rubin O, Crettaz Rubin Tissot O, JD, D, LionN. Pre-ana cell microparticleproteomics. 134. 129. Piccin A, Smith Piccin Murphy CirculatingWG, OP. mic implications. 129. 136. Rubin O, Crettaz Rubin Canellini O, JD, Tissot D, G, Li using approach cytometryflow andproteomic tools. 136. isolated from human from isolated atherosclerotic plaques. 131. Leroyer AS, IsobeAS,H, Leroyer LesecheCellulaal. G, et 131. 2. MathivananSimpsonJiH,S, RJ.Exosomes: extr communication. 128. 133. Dey-Hazra E, Hertel Dey-Hazra E, Kirsch B, etal. T, Detect ofinfluencecentrifugation, filtrationof buffer, 133. 132. Caby MP, MP, Caby LankarD,Vincendeau-Scherrer C, Rapo inhuman present bloodplasma. 132. 126. Silliman CC, Clay CC, Silliman JohnsonThurmanKL, CA,GW, develop that during routine the bloodstorage of an 126. 127. Silliman CC, Boshkov CC, Silliman LK, Mehdizadehkashiet Z, prospectiveandepidemiology a analysis ofetiologi 127. Med injury. CC, Silliman EE,Moore KelherSY,MR,Khan Gel during routineaccumulate the prestoragestorage of 125. 2366. 141. Bicalho B, Pereira Bicalho AckerAS, Buffy (tJP. coat red produced cell concentratesdiffer in size of ex 141. 142. Cocucci E, Racchetti E, Cocucci G, Meldolesi J.Shedding 142. 135. Jy W, W, WW,Horstman Mao Jy AhnJ, Tao L, PlateYS. in neutrophils vitro. 135. 130. Sadallah S, Eken C, SadallahSchifferliEken S, JA. Erythrocyte properties. 130. 3. Baj-Krzyworzeka al. M, M, Majka Pratico D, et survival, proliferation, adhesion, and chemotaxis o 137. 138. Raposo G, Nijman G, HW, Raposo Stoorvogel al. W, ly et B 138. 459. 140. Bakkour S, AckerS,JP, Bakkour Chafets etal. DM, Manufa andreleaseextracellular vesicle composition inst 140. 139. Danesh A, Danesh Inglis JackmanHC, et RP, Exosomal. andinduceproinflammatory cytokines, boostingT-ce 139. Med Exp 124. Vlaar AP, AP, VlaarNieuwlandKulik W, etAccumulal. R, is butproducts notcell plasma derived andtempera 124. 143. Sadallah S, Eken C, SadallahMartinEken S, JA.Schifferli PJ, downregulateplatelets and macrophages modify the d 143. 2009;19(2):43-51. 123. Fu X, Felcyn JR, Fu X, Odem-DavisZimring K, JC. Bioa leukoreduction: despite a targeted stumetabolomics 123. 2011;186(11):6543-6552. . 1994;124(5):684-694.. Transfusion . 1996;183(3):1161-1172.. ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100 J LeukocJ Biol

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. 2011;51(12):2549-2554.. Blood Mol DisCells . 2007;21(3):157-171.. . 2008;84(5):1316-1325.. This article isprotected by copyright. All rights reserved. . 2010;73(10):1907-1920.. Talanta IntImmunol . 2010;82(1):1-8.. . 1995;21(3):217-231;. discussion 231a. . 2005;17(7):879-887. Transfusion JAm Coll Cardiol andfreezing. tracellular vesicles. ored bloodcells. red f hematopoieticf cells. Microparticles(ectosomes) by shed humanstored on N. on Microparticlesinstored blood red ancells: c factors. c d neutrophil prime the NADPH oxidase. -derived have ectosomes immunosuppressive op/bottom)-andwhole-blood filtration (top/top)- ioncirculating of microparticlesby flow cytometry ture dependent. ture r and origins thrombogenic activity ofmicroparticl leukoreduced red bloodcells andcause acutelung lytical andmethodological challenges bloodin red VoxSang dy. dy. llinresponses vitro. microvesicles: microvesicles: no artefacts more. Platelet-derived Platelet-derived microparticlesstimulate ationofbioactive lipids during ofbloodstorage es from redes bloodcell bindunits monocytesto ctivelipidsinstored accumulate red bloodcells cturing affects method mitochondrial DNA evelopment of dendritic evelopment of cells. acellularorganellesimportant inintercellular mphocytessecrete antigen-presenting vesicles. lar L,lar Elzi Identification DJ. lipids of that roparticles:pathophysiology and clinical Ambruso DR. Partial characterizationoflipids al. Transfusion-relatedacute lung injury: let microparticlesbind, activate and aggregate Transfusion soG, Bonnerot Exosomal-likeC. are vesicles VascHealthRiskManag Blood . 2008;95(4):288-297.. . 2007;49(7):772-777.. . 2003;101(2):454-462.. . 2016;56(10):2560-2570.. VoxSang Transfusion Vox Vox Sang Exp Hematol Exp Blood . 2015;109(3):214-220.. . 2014;123(5):687-696. . 2016;111(1):22-32.. . 2011;51(11):2358-. . 2010;6:1125-1133.. J ImmunolJ . 2002;30(5):450-. TrendsBiol Cell J Lab ClinLabJ . : : . es es J

162. Wong HR, Wong Cvijanovich WheelerN, Intal. DS, et interventional involving trials septic sh pediatric 162. 160. Muszynski JA, Muszynski Nofziger Greathouse R, K, etal. nosocomial infection of in criticallyinjuredchild 160. 155. Ramirez-Arcos S, Ramirez-Arcos Marks Sheffield DC,AckerJP, 155. 2012;308(14):1443-1451. 156. Chasse M, Tinmouth Chasse EnglishM, A, etAssocal. SW, After Red Survival Blood Cell Transfusion. 156. Transfus 159. Hall MW, Geyer SM, Geyer Guo HallMW, CY, etimmunInnateal. 159. 164. Muszynski JA, Muszynski Nofziger Greathouse R, K, etal. septic shock:prospective with a observational stud 164. 163. Boomer JS,To Boomer Chang KC,K, Immunosuppreal. et failure. organ 163. with influenza:a with multicenter study. 157. Almizraq RJ, YiRJ, Almizraq QL,AckerJP, Biomedical Excel andassay variation reporting on hemolysis of inst 157. 161. Hall MW, Knatz NL, Knatz HallMW, Vetterly Immunopaal. C, et dysfunctionmultiple organ syndrome. 161. 153. Lacroix J, HebertJ, Fergusson Lacroix PC, etAgeal. DA, 153. Immunol 154. Fergusson Hebert Fergusson Hogan DA, al.DL, P, et Effec inpremature, outcomes low-birth-weight very infant 154. Med 158. Acker JP, Acker DC,MarksSheffield WP. Quality Asse ComponentsforTransfusion. 158. 2017;468:90-97. 146. Ren Y, Y, XieJ,Yang Ren R, etExosomal-likeal. ves plasmainhuman andinduce can apoptosiCD4+ T-cell 146. 145. Gasser Schifferli Gasser O, JA.polymorphon Activated microparticlesby ectocytosis. 145. 4. VasinaEM,Cauwenberghs HeemskerFeijge S, MA, apoptotic from platelets resident promote macrophag 144. 150. Kim OY, Hong OY, BS, Kim Immunizational. KS, Park et bacteria-induced protects lethality via Th1 andTh1 150. 2683. 149. Qazi KR, KR, QaziGehrmann U, Domange JordoE, Karlsson induce alone Th1-type memory B-cell-depen a through 149. 148. Thery C, Duban Segura Thery L, E, Veron P, Lantz O, by cell-deriveddendriticcells exosomes. 148. a multimodal a imaging reporter. 147. Lai CP, Lai O, Mardini Ericssonet al. M, Dynamic 147. 152. Assinger A. AssingerPlateletsand infection emergan- 152. immunity. Choi WH, HI,Hong Lee SW,Gho KS, Kim Jeon YS, derived extracellular protects againstvesicles bac 151. . 2015;372(15):1410-1418.. . 2016;2016:2482157. . 2014;5:649.. ExpMol Med ScholarOne, 375GreenbrierDrive,Charlottesville, VA,22901 1 (434)964-4100

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. 2011;306(23):2594-2605.. . 2015;47:e183. This article isprotected by copyright. All rights reserved. J BloodJTransfus Blood ACSNano . 2004;104(8):2543-2548.. CritCare Med IntensiveCare Med Nat ImmunolNat . 2014;8(1):483-494.. JAMAIntern Med . 2016;2016:4860284. Transfusion ren. ock. ock. teria-inducedvialethality both humoraland cellul . 2013;41(1):224-236.. ored red bloodcellored red products. 7 cell responses. 7 y. y. icles with immune-modulatoryicles with features are present Shock AmCritRespirJ CareMed s: the ARIPI s:randomizedthe trial. lencefor Transfusion Safer ImpactC. of technical of transfusedbloodincritically ill adults. biodistributionofextracellular vesiclesin u vivo Crit Care Crit ingroleplatelets of inviral infection. Innate immuneInnate function predicts the development Earlyadaptive immune suppression inchildren AmigorenaactivationS. Indirect CD4+ Tof naive s in vitro. invitro. s . 2002;3(12):1156-1162.. toffresh bloodcell red transfusions clinical on e differentiation. e WP. QualityandSafety Blood of Products. with Escherichia coliwith membraneouter vesicles uclear disseminate neutrophils anti-inflammatory erleukin-8 as aerleukin-8 as stratification tool for ssmentEstablished andof Emerging Blood dent mechanism. dent iation ofDonorBloodand Age Sex Recipient With ralysis infection andnosocomial in childrenwith SG.Vaccination with Klebsiellapneumoniae- ssion die inpatients who sepsis andmultiple of e function e and incritically mortality childrenill MC, S. Gabrielsson Antigen-loaded exosomes . 2011;37(3):525-532.. . 2014;42(4):313-321.. k JW, k WeberC, Koenen RR. Microparticles . 2016;176(9):1307-1314.. . 2014;18(4):R145. Transfusion J ImmunolJ CellDeath Dis Blood . 2011;51(5):1002-1011. . 2013;190(8):4092-4102. . 2008;178(3):276-282. . 2009;113(12):2673-. ClinActa Chim JAMA . 2011;2:e211. . Front Front . N EnglNJ J BloodJ ar sing

Page 24of27 Page 25of27 2016;6(1):67. charact recipient and unit individual on based vary reci on transfusion RBC of effects immunomodulatory suc As changes. immunosuppressive and inflammatory imm on these mediators of Effects factors. derived platelet cell-derived, blood red leukocyte-derived, immunom multiple contain cell(RBC) units blood Red Figure1 LJ, Engele Straat M,IH,van al. Rooijen et Tr associated independently nosocomial infectionswith 165.

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This article isprotected by copyright. All rights reserved. Transfusion elated Immune Modulation Immune elated

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This article isprotected by copyright. All rights reserved. 254x190mm (96 x 96 DPI) 254x190mm(9696DPI) x Transfusion