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Iron-related adverse effects from stored blood.

In this issue of Blood , Cortes-Puch and colleagues investigate a strategy to improve the quality of stored red blood cells (RBCs) by washing the blood, thereby removing “noxious” substances, including cell-free hemoglobin, transferrin-bound iron, non–transferrin-bound iron (NTBI), and plasma labile iron, that accumulate during storage. 1 Cortes-Puch and colleagues found that in a canine model of Staphylococcus aureus pneumonia, transfusion of “old” (42-day) blood was associated with impaired hemodynamics, greater lung injury and shock index, and reduced survival. These outcomes were improved upon when washing RBCs, which was associated with a reduction of NTBI in the circulation. Importantly, washing “fresh” (7-day) RBCs had the opposite effect, reversing the improved survival that was observed after exchange transfusion with younger RBCs; this effect was also related to an increased release of NTBI.