collection and storage of red blood cells with anticoagulant and additive solution with a...

O R I G I N A L A R T I C L E

Collection and storage of red blood cells with anticoagulant andadditive solution with a physiologic pH_3472 1..8

Patrick Burger, Herbert Korsten, Arthur J. Verhoeven, Dirk de Korte, and Robin van Bruggen

BACKGROUND: A donation of whole blood is mostcommonly collected in acidic citrate-phosphate-dextrose(CPD) variants with pH 5.2 to 6.2 as anticoagulants.Previously, we have shown that the initial pH after redblood cell (RBC) preparation can have an effect onRBCs during storage. First, we investigated the effect ofthe pH of the anticoagulant on RBCs. Second, weinvestigated the possibility of decreasing the pH of ournew additive solution (AS) phosphate-adenine-glucose-guanosine-gluconate-mannitol (PAGGGM) from pH 8.2to 7.4 in combination with an anticoagulant with aphysiologic pH.STUDY DESIGN AND METHODS: Whole blood wascollected in CPD (pH 5.6) or trisodiumcitrate (TNC; pH7.4), and leukoreduced units were prepared usingsaline-adenine-glucose-mannitol as AS. Second, wholeblood was collected in TNC (pH 7.4), and leukoreducedunits were prepared using PAGGGM (pH 7.4) orPAGGGM (pH 8.2) as AS. During cold storage, severalin vitro characteristics were analyzed.RESULTS: In agreement with our previous findings, theinitial pH of whole blood has an effect during storage ofRBCs. In the second part we show that there are nodifferences between PAGGGM (pH 7.4) and PAGGGM(pH 8.2) units when an anticoagulant with a physiologicpH was used.CONCLUSION: These results indicate that the pH ofthe anticoagulant used during whole blood collectionhas an effect during storage of RBCs. When an antico-agulant with a physiologic pH is used during wholeblood collection, the pH of PAGGGM can be decreasedto physiologic levels, while maintaining adenosine triph-osphate and 2,3-diphosphoglycerate levels.

Adonation of whole blood is usually separated

to yield different products for different transfu-sion purposes. As anticoagulant, most com-monly used are the acidic citrate-phosphate-

dextrose (CPD) variants with a pH ranging from 5.2 to 6.2.This low pH is needed, since glucose will caramelizeduring the sterilization process when a higher pH is used.However, in a recent study, we have shown that the initialpH after red blood cell (RBC) preparation can have aneffect on RBC in vitro storage variables throughout theentire storage period.1 Therefore, from a storage point ofview, collecting whole blood in an anticoagulant with amore physiologic pH might improve the quality of thestored RBCs.

During routine storage of RBCs, 2,3-diphosphoglycerate (2,3-DPG) declines rapidly and isdepleted within 2 weeks of storage, while the adenosinetriphosphate (ATP) levels decrease more slowly.2 Both areimportant for the normal function of RBCs, as the levels of2,3-DPG determine the affinity of hemoglobin (Hb) to oxy-gen,3,4 while the ATP levels play an important role in

ABBREVIATIONS: PAGGGM = phosphate-adenine-glucose-

guanosine-gluconate-mannitol; pHe = extracellular pH;

pHi = intracellular pH; SAGM = saline-adenine-glucose-

mannitol; TNC = trisodiumcitrate.

From the Department of Blood Cell Research, Sanquin

Research; the Department of Product and Process Develop-

ment, Sanquin Blood Bank; and the Department of Medical

Biochemistry, Academic Medical Centre, University of Amster-

dam, Amsterdam, the Netherlands.

Address correspondence to: Robin van Bruggen, Depart-

ment of Blood Cell Research, Sanquin Research, Plesmanlaan

125, 1066 CX Amsterdam, The Netherlands; e-mail:

[email protected].

This research is supported by Grant PPOC-07-20 from

Sanquin, Amsterdam, the Netherlands.

Received for publication September 19, 2011; revision

received October 18, 2011, and accepted October 19, 2011.

doi: 10.1111/j.1537-2995.2011.03472.x

TRANSFUSION **;**:**-**.

Volume **, ** ** TRANSFUSION 1

maintaining the phospholipid asymme-try of the RBC membrane.5

In recent studies published by ourgroup1,2 we have shown that a newlyformulated additive solution (AS),phosphate-adenine-glucose-guanosine-gluconate-mannitol (PAGGGM), hasimproved in vitro storage characteristicscompared to the AS frequently used inEurope, that is, saline-adenine-glucose-mannitol (SAGM; see Table 1 for AS com-positions). The composition of PAGGGMis based on the hypothesis of Merymanand Hornblower6 that a chloride-free ASwith a high pH (i.e., pH 8.2 compared toSAGM with a pH of 6.2) would result in an increased rate ofglycolysis. This resulted in the combined maintenance of2,3-DPG and ATP levels throughout the storage period.However, we hypothesized that a physiologic pH ofPAGGGM would be possible if whole blood would be col-lected in an anticoagulant with a physiologic pH.

In this study we first determined the effect of collect-ing whole blood in an anticoagulant with a physiologicpH. To this end, whole blood was collected in either CPDwith a pH 5.6 or trisodiumcitrate (TNC) with a pH of 7.4.Subsequently, leukoreduced RBCs were prepared usingSAGM as an AS. In line with our expectations, SAGMunits collected in TNC already maintained 2,3-DPG for alonger period compared to SAGM units collected in CPD.However, the 2,3-DPG was still depleted after 3 weeks ofstorage. In the second part of the study, we explored thepossibility to combine anticoagulant TNC with our ASPAGGGM both at physiologic pH.

MATERIALS AND METHODS

Isolation and storage of RBCsWhole blood was collected from 12 healthy volunteers.During collection, CPD (pH 5.6) or TNC (pH 7.4; seeTable 2 for anticoagulant compositions) were mixed withwhole blood in a final ratio of 1:7 in bottom-and-topblood collection systems with integrated leukoreduc-tion filters (T3941, Fresenius HemoCare, EmmerCompascuum, the Netherlands; if applicable CPD wasreplaced by TNC). Leukoreduced RBCs were preparedby centrifugation of whole blood collections (8 min,2800 ¥ g), which had been stored for 12 to 18 hours at 20to 24°C. After removal of the buffy coat, 110 mL of AS(sterilized by filtration over 0.2-mm filters, stored atroom temperature for maximal 2 weeks, variable compo-sition; see Table 1) was added, and filtration of the RBCsuspension was carried out to remove residual whiteblood cells (WBCs). To adjust for the difference inglucose levels between CPD and TNC, units manufac-tured from whole blood collected in TNC had an AS with

a higher glucose concentration (see Table 1). The differ-ence in pH between PAGGGM (pH 7.4) and PAGGGM(pH 8.2) was obtained by adding less 5 mol/L NaOHwhile manufacturing PAGGGM. The resulting PAGGGMASs had a similar osmolarity. The resulting RBCs had avolume of 275 to 320 mL, a hematocrit (Hct) of approxi-mately 60% (vol/vol) and contained fewer than 1 ¥ 106

WBCs per unit (as determined with a Nageotte hemocy-tometer), whereas platelet (PLT) counts were belowdetection limit (determined with an Advia 2120, SiemensMedical Solutions Diagnostics, Breda, the Netherlands).After preparation, the RBCs were stored in 600-mL poly-vinylchloride storage bags (Fresenius Hemocare) at 2 to6°C in a standard blood bank refrigerator.

2,3-DPG, ATP, and lactate measurements in RBCs2,3-DPG, ATP, and lactate were measured as described else-where.1 In short, extracts were made by diluting 600 mL ofRBCs with 900 mL of phosphate-buffered saline and thenacidified with 60 mL of perchloric acid (70% wt/vol). After30 minutes on ice, the extracts were centrifuged at 4°C at6000 ¥ g and 56 mL of 5 mol/L K2CO3 was added to 1 mLdeproteinized supernatant for neutralization. Sampleswere kept frozen until analysis.

2,3-DPG was measured with the 2,3-DPG kit of Roche(Mannheim, Germany). Lactate was analyzed with the kitfrom Trinity Biotech (St Louis, MO). ATP was analyzedwith the glucose-hexokinase reaction as describedelsewhere.1

TABLE 1. Composition of ASs*

Ingredients

SAGM TNC collections

CPDcollections

TNCcollections

PAGGGMpH 7.4

PAGGGMpH 8.2

Glucose, anhydrous (mmol/L) 50 100 97.5 97.5Adenine (mmol/L) 1.25 1.25 1.44 1.44Guanosine (mmol/L) 1.44 1.44NaCl (mmol/L) 150 150Na-gluconate (mmol/L) 40 40NaH2PO4·2H2O (mmol/L) 8 8Na2HPO4·2H2O (mmol/L) 8 8Mannitol (mmol/L) 29 29 55 55pH 6.2 6.2 7.4 8.2

* Glucose in PAGGGM higher than originally reported (de Korte et al.1), due to collectionin TNC.

TABLE 2. Composition of anticoagulantsIngredients CPD TNC

Na3citrate·2H2O (mmol/L) 89.4 136Citric acid·H2O (mmol/L) 15.5Na2HPO4·2H2O (mmol/L) 14.1glucose·H2O (mmol/L) 128.6pH 5.6 7.4

BURGER ET AL.

2 TRANSFUSION Volume **, ** **

HemolysisHemolysis was determined as described previously.1

Briefly, free Hb was determined by absorbance measure-ment of cell supernatant at 415 or 514 nm by a spec-trophotometer (Rosys Anthos ht3, Anthos LabtecInstruments GmbH, Salzburg, Austria), with correction forplasma absorption if necessary. Hemolysis was expressedas a percentage of total Hb present in RBCs after correc-tion for Hct.

Measurement of intracellular pHIntracellular pH (pHi) was measured as described.6 Briefly,1-mL RBC samples were centrifuged for 5 minutes at21,000 ¥ g after which the supernatant was removed. Sub-sequently, the dry pellet was frozen in liquid nitrogen.After thawing, 300 to 350 mL of deionized water was added

and the pH of the resulting lysate was measured in a bloodgas analyzer (Rapidlab 860, Siemens Medical SolutionsDiagnostics, Breda, the Netherlands).

Potassium, sodium, glucose, and extracellularpH measurementsPotassium, sodium, glucose, and extracellular pH (pHe)were measured with a blood gas analyzer (Rapidlab 860,Siemens Medical Solution Diagnostics).

Statistical analysisData were analyzed using computer software (GraphPadPrism 5.01 for Windows, GraphPad Software, La Jolla, CA).Statistical analysis was performed by two-way analysis ofvariance tests with the Bonferroni posttests to comparemeans over time.

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Fig. 1. Effect of physiologic pH of the anticoagulant on pH, potassium concentrations, and hemolysis of RBCs in standard SAGM

during storage. Whole blood was collected in CPD (�) or in TNC ( ). Subsequently, RBC units were prepared with SAGM as AS as

described under Materials and Methods. Results shown represent mean � 1 SD of 3 units. *p < 0.05; **p < 0.01; ***p < 0.001.

RBC STORAGE AT PHYSIOLOGIC pH


RESULTS

In a previous study, we found that depending on themethod of preparation, 2,3-DPG levels were better main-tained when the units had an initial higher pHi when com-pared to units with an initial lower pHi.1 This suggestedthat there might be a memory effect, which influencesglycolysis for a long period. To further explore the effect ofa difference in the initial pH during blood collection andstorage, we collected whole blood units with CPD (pH 5.6)or with TNC (pH 7.4) as an anticoagulant. After leukore-duction, SAGM was added to the RBCs. During the first 2weeks of storage, the TNC units had both a significantlyhigher pHi and a significantly higher pHe (Figs. 1A and 1B;p < 0.05). After 2 weeks of storage the potassium leakagewas higher in the TNC units (Fig. 1C; p < 0.05), althoughthere was no difference in hemolysis, which remained well

below the limit of international standards (Fig. 1D). Theconsumption of glucose and production of lactate showedno differences (Figs. 2A and 2B). Also, the ATP levelsremained similar throughout storage (Fig. 2C). However,the 2,3-DPG levels were significantly higher in TNC unitsthan in CPD units during the first 2 weeks of storage(p < 0.01; Fig. 2D). This seems to correlate with theincreased pH seen during the first 2 weeks of storage.

Next, we tested the feasibility of lowering the pH ofour new AS PAGGGM “alkaline pH” to a physiologic pH, incombination with an anticoagulant with a physiologic pH.We collected whole blood in TNC (pH 7.4) and, after leu-koreduction, PAGGGM with a pH of 7.4 or PAGGGM with apH of 8.2 was added. Despite the fact that there was adifference in starting pH between the two ASs, there wasno significant difference in pHi or pHe during storage(Figs. 3A and 3B). The potassium leakage was similar

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Fig. 2. Effect of physiologic pH of the anticoagulant on glucose, lactate, ATP, and 2,3-DPG levels of RBCs in standard SAGM during

storage. The same units as described in the legend to Fig. 1, where whole blood was collected in CPD (�) or in TNC ( ), were ana-

lyzed. RBC units were prepared with SAGM as AS as described under Materials and Methods. Results shown represent mean � 1 SD

of 3 units. *p < 0.05; **p < 0.01; ***p < 0.001.

BURGER ET AL.


(Fig. 3C) and hemolysis remained below the limit of inter-national standards (Fig. 3D). Because there was no differ-ence in pH we did not expect a difference in the rate ofglycolysis. Indeed, there was no significant difference inglucose and lactate levels during storage (Figs. 4A and 4B).ATP and 2,3-DPG levels were also similar during thestorage period (Figs. 4C and 4D).

SAGM and PAGGGM (pH 7.4 and pH 8.2) units pre-pared from whole blood collected in TNC were compared.Compared to the SAGM units manufactured from TNCwhole blood, the PAGGGM units showed the same pHi andpHe values (Figs. 5A and 5B). The potassium leakage washigher in SAGM units in Weeks 2 and 3 of storage(p < 0.05), but was similar after that (data not shown).There were no differences in the levels of hemolysis either,which remained minimal over the whole storage period.The glucose levels were decreased throughout storage inPAGGGM units, but only significantly different from Week3 onward (p < 0.001) and the lactate levels were increasedfrom Week 2 in PAGGGM units when compared to SAGMunits (p < 0.01; data not shown). Despite this, the ATPlevels were increased in PAGGGM units from Week 3 on(p < 0.05) and the 2,3-DPG levels were increased fromWeek 1 on (p < 0.01) in PAGGGM units (Figs. 5C and 5D).The glucose consumption and lactate production (per

week of storage) were only significantly increased duringthe first week (Figs. 6A and 6B) in PAGGGM units.

DISCUSSION

For a long time now, whole blood has been collected inCPD, CPD-A, or CP2D, all with a low pH. The main reasonfor this is that glucose can only be sterilized at a low pH.Sterilizing glucose at a pH of 6 or above will result in car-melization. However, for storage of RBCs, the glucose doesnot need to be present in the anticoagulant, as glucose ispresent in the ASs used to supplement the RBC suspen-sion. When the glucose normally present in CPD would beadded to the AS, the glucose would no longer be needed inthe anticoagulant. This would make the use of an antico-agulant with a higher pH possible. Moreover, in our previ-ous study we found evidence that the initial pH in RBCsmight have an effect throughout the entire storage periodof RBCs.1 Therefore, we hypothesized that collectingwhole blood in an anticoagulant with a higher pH thanCPD might improve the quality of RBCs.

When we consider the 2,3-DPG levels of RBCs col-lected in either CPD or TNC and stored in SAGM, we canindeed conclude that the higher pH of TNC has a positiveeffect on the in vitro quality variables of the RBCs (Fig. 1).

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Fig. 3. pH, potassium concentrations, and hemolysis of RBCs stored in PAGGGM with different pH. Whole blood was collected in

TNC (pH 7.4) and RBC units were prepared with PAGGGM with a pH of 7.4 (�) or PAGGGM with a pH of 8.2 (�). Results shown rep-

resent mean � 1 SD of 3 units.



It could be that this is caused by the increased pHi and pHe

of the TNC units at the start of the study (Fig. 2). However,although the TNC units maintained 2,3-DPG for a longertime, 2,3-DPG was still depleted after 3 weeks of storage.

The units collected in TNC (pH 7.4) and stored inPAGGGM (pH 7.4) maintained 2,3-DPG and ATP levelsmuch better than during storage in SAGM (Figs. 5C and5D). This is comparable, both in absolute levels as inkinetics to what we observed in previous studies withPAGGGM (pH 8.2) units collected in CPD.1,2 Surprisingly,although chloride depletion has been proposed toincrease the pHi, we observed no differences in pHi or pHe

between PAGGGM and SAGM units (Figs. 5A and 5B).6

Because PAGGGM does show an effect on 2,3-DPG andATP levels, chloride depletion probably does not exert itseffect via an increase in pHi, but via another, yet unknown,way. In line with this hypothesis is the absence of differ-

ences in pHe or pHi in PAGGGM (pH 7.4) and PAGGGM(pH 8.2) units.

With the use of an anticoagulant and AS with a physi-ologic pH, several issues arise. First of all, as stated previ-ously, the main reason for using an acidic anticoagulantand AS is that this allows heat sterilization of the glucosepresent in the solutions. At a higher pH, such as thatpresent in TNC and PAGGGM, glucose will caramelizeduring heat sterilization. However, several manufacturershave produced and published divided systems, in whichthe glucose is kept separate from the other components ofthe AS.7-9 By keeping the glucose separate, heat steriliza-tion of the solution will be possible.

Second, whole blood collected with TNC will have alower glucose concentration than whole blood collectedwith CPD and will be less acidic. Therefore, one must takeinto account the effect this will have on the other isolated

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Fig. 4. Glucose, lactate, ATP, and 2,3-DPG levels of RBCs stored in PAGGGM with different pH. The same units as described in the

legend to Fig. 3, where whole blood was collected in TNC (pH 7.4) and RBC units were prepared with PAGGGM with a pH of 7.4 (�)

or PAGGGM with a pH of 8.2 (�), were analyzed. Results shown represent mean � 1 SD of 3 units.

BURGER ET AL.


blood components, namely, plasma and PLTs. Plasma isoften collected via plasmapheresis, in which TNC is usedas an anticoagulant.10,11 Therefore, we do not expect anynegative impact on the quality of plasma when we collectwhole blood with TNC as anticoagulant.

Unlike plasma, PLTs need glucose, which is normallysupplied by CPD added during whole blood collection.When TNC is used as an anticoagulant, PLT concentratescan only use glucose already present in the plasma. Inplasma, glucose levels range from 4 to 6 mmol/L. Undernormal conditions, PLT concentrates use 5 mmol/Lglucose during their 7 days of storage,12 which suggeststhat the glucose present in the plasma might not beenough and should be added during preparation. A pos-sibility could be to use an AS, which contains glucoseand/or other metabolites like acetate, for storage of the

PLT concentrates. Further analysis of PLT concentratesobtained from whole blood collected with TNC as antico-agulant would be required to show the feasibility of thisapproach.

In conclusion, this study shows that the pH of theanticoagulant does have an effect that influences RBC invitro variables throughout the storage period. The resultsshow that an increased initial pH in SAGM units maintains2,3-DPG for a longer period, but it is not enough to main-tain 2,3-DPG during 5 weeks of storage. However, thecombination of both anticoagulant and PAGGGM with aphysiologic pH is able to maintain ATP and 2,3-DPGthroughout storage. Even though this does not result inlarge changes in both pHi and pHe from SAGM units col-lected in CPD, the metabolic variables of these units arefar better. A next logical step would be to test in vivo if this

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Fig. 5. Comparison of units collected in TNC (pH 7.4) and stored in SAGM, PAGGGM (pH 7.4), and PAGGGM (pH 8.2). For compari-

son, data from SAGM units collected in TNC ( ) and PAGGGM (pH 7.4; �) and PAGGGM (pH 8.2; �) units collected in TNC were

merged. Statistical analyses were performed comparing SAGM units with PAGGGM units and were only considered different when

both PAGGGM ASs were significantly different from the SAGM units. Results shown represent mean � 1 SD of 3 units. *p < 0.05;

**p < 0.01; ***p < 0.001.



improved metabolic quality will also result in a betterposttransfusion recovery and survival of the stored RBCs.

CONFLICT OF INTEREST

There are no conflicts of interest of any of the authors.

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ctio

n(m

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s)

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Fig. 6. Glucose consumption and lactate production in RBCs stored in PAGGGM with different pH. The same units as described in

the legend to Fig. 3, where whole blood was collected in TNC (pH 7.4) and RBC units were prepared with PAGGGM with a pH of 7.4

(�) or PAGGGM with a pH of 8.2 (�), were analyzed. Glucose consumption and lactate production were calculated from the glucose

and lactate levels measured once every week during storage. For comparison, data are also shown from units collected in TNC with

SAGM as AS (�). Results shown represent mean � 1 SD of 3 units. *p < 0.05.

BURGER ET AL.


collection and storage of red blood cells with anticoagulant and additive solution with a...

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