Storage with ethanol attenuates the red blood cell storage lesion

Published:September 12, 2022DOI:



      Current management of hemorrhagic shock relies on control of surgical bleeding along with resuscitation with packed red blood cells and plasma in a 1-to-1 ratio. Transfusion, however, is not without consequence as red blood cells develop a series of biochemical and physical changes during storage termed “the red blood cell storage lesion.” Previous data has suggested that ethanol may stabilize the red blood cell membrane, resulting in improved deformability. We hypothesized that storage of packed red blood cells with ethanol would alter the red blood cell storage lesion.


      Mice underwent donation and storage of red blood cells with standard storage conditions in AS-3 alone or ethanol at concentrations of 0.07%, 0.14%, and 0.28%. The red blood cell storage lesion parameters of microvesicles, Band-3, free hemoglobin, annexin V, and erythrocyte osmotic fragility were measured and compared. In additional experiments, the mice underwent hemorrhage and resuscitation with stored packed red blood cells to further evaluate the in vivo inflammatory impact.


      Red blood cells stored with ethanol demonstrated decreased microvesicle accumulation and Band-3 levels. There were no differences in phosphatidylserine or cell-free hemoglobin levels. After hemorrhage and resuscitation with packed red blood cells stored with 0.07% ethanol, mice demonstrated decreased serum levels of interleukin-6, macrophage inflammatory protein-1α, keratinocyte chemokine, and tumor necrosis factor α compared to those mice receiving packed red blood cells stored with additive solution-3.


      Storage of murine red blood cells with low-dose ethanol results in decreased red blood cell storage lesion severity. Resuscitation with packed red blood cells stored with 0.07% ethanol also resulted in a decreased systemic inflammatory response in a murine model of hemorrhage.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Borgman M.A.
        • Spinella P.C.
        • Perkins J.G.
        • et al.
        The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital.
        J Trauma. 2007; 63: 805-813
        • Cantle P.M.
        • Cotton B.A.
        Balanced resuscitation in trauma management.
        Surg Clin North Am. 2017; 97: 999-1014
        • Holcomb J.B.
        • Tilley B.C.
        • Baraniuk S.
        • et al.
        Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.
        JAMA. 2015; 313: 471-482
        • Holcomb J.B.
        • Wade C.E.
        • Michalek J.E.
        • et al.
        Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients.
        Ann Surg. 2008; 248: 447-458
        • Yoshida T.
        • Prudent M.
        • D’Alessandro A.
        Red blood cell storage lesion: causes and potential clinical consequences.
        Blood Transfus. 2019; 17: 27-52
        • Thomas T.
        • Spitalnik S.L.
        Hitchhiker’s guide to the red blood cell storage lesion.
        Blood Transfus. 2019; 17: 1-3
        • Wang D.
        • Sun J.
        • Solomon S.B.
        • et al.
        Transfusion of older stored blood and risk of death: a meta-analysis.
        Transfusion. 2012; 52: 1184-1195
        • Escobar G.A.
        • Cheng A.M.
        • Moore E.E.
        • et al.
        Stored packed red blood cell transfusion up-regulates inflammatory gene expression in circulating leukocytes.
        Ann Surg. 2007; 246: 129-134
        • Grimshaw K.
        • Sahler J.
        • Spinelli S.L.
        • et al.
        New frontiers in transfusion biology: identification and significance of mediators of morbidity and mortality in stored red blood cells.
        Transfusion. 2011; 51: 874-880
        • Zallen G.
        • Offner P.J.
        • Moore E.E.
        • et al.
        Age of transfused blood is an independent risk factor for postinjury multiple organ failure.
        Am J Surg. 1999; 178: 570-572
        • Putter J.S.
        • Seghatchian J.
        Cumulative erythrocyte damage in blood storage and relevance to massive transfusions: selective insights into serial morphological and biochemical findings.
        Blood Transfus. 2017; 15: 348-356
        • Graw J.A.
        • Bünger V.
        • Materne L.A.
        • et al.
        Age of red cells for transfusion and outcomes in patients with ARDS.
        J Clin Med. 2022; 11: 245
        • Oonishi T.
        • Sakashita K.
        Ethanol improves decreased filterability of human red blood cells through modulation of intracellular signaling pathways.
        Alcohol Clin Exp Res. 2000; 24: 352-356
        • Rabai M.
        • Detterich J.A.
        • Wenby R.B.
        • et al.
        Effects of ethanol on red blood cell rheological behavior.
        Clin Hemorheol Microcirc. 2014; 56: 87-99
        • Lee S.Y.
        • Park H.J.
        • Best-Popescu C.
        • et al.
        The effects of ethanol on the morphological and biochemical properties of individual human red blood cells.
        PLoS One. 2015; 10e0145327
        • Makley A.T.
        • Goodman M.D.
        • Friend L.A.
        • et al.
        Murine blood banking: characterization and comparisons to human blood.
        Shock. 2010; 34: 40-45
        • Chang A.L.
        • Hoehn R.S.
        • Jernigan P.
        • et al.
        Previous cryopreservation alters the natural history of the red blood cell storage lesion.
        Shock. 2016; 46: 89-95
        • Pulliam K.E.
        • Joseph B.
        • Veile R.A.
        • et al.
        Expired but not yet dead: examining the red blood cell storage lesion in extended-storage whole blood.
        Shock. 2021; 55: 526-535
        • Belizaire R.M.
        • Makley A.T.
        • Campion E.M.
        • et al.
        Resuscitation with washed aged packed red blood cell units decreases the proinflammatory response in mice after hemorrhage.
        J Trauma Acute Care Surg. 2012; 73: S128-133
        • Makley A.T.
        • Goodman M.D.
        • Friend L.A.
        • et al.
        Resuscitation with fresh whole blood ameliorates the inflammatory response after hemorrhagic shock.
        J Trauma. 2010; 68: 305-311
        • Chang A.L.
        • Kim Y.
        • Seitz A.P.
        • et al.
        pH modulation ameliorates the red blood cell storage lesion in a murine model of transfusion.
        J Surg Res. 2017; 212: 54-59
        • Chen Y.
        • Li G.
        • Liu M.L.
        Microvesicles as emerging biomarkers and therapeutic targets in cardiometabolic diseases.
        Genomics Proteomics Bioinformatics. 2018; 16: 50-62
        • Kim Y.
        • Goodman M.D.
        • Jung A.D.
        • et al.
        Microparticles from aged packed red blood cell units stimulate pulmonary microthrombus formation via P-selectin.
        Thromb Res. 2020; 185: 160-166
        • Kim Y.
        • Abplanalp W.A.
        • Jung A.D.
        • et al.
        Endocytosis of red blood cell microparticles by pulmonary endothelial cells is mediated by Rab5.
        Shock. 2018; 49: 288-294
        • Chang A.L.
        • Kim Y.
        • Seitz A.P.
        • et al.
        Erythrocyte-derived microparticles activate pulmonary endothelial cells in a murine model of transfusion.
        Shock. 2017; 47: 632-637
        • Fischer D.
        • Bussow J.
        • Meybohm P.
        • et al.
        Microparticles from stored red blood cells enhance procoagulant and proinflammatory activity.
        Transfusion. 2017; 57: 2701-2711
        • Levin G.Y.
        • Sukhareva E.
        Antithrombin activity in microvesicles derived from stored red blood cells.
        Blood Transfus. 2015; 13: 688-689
        • Belizaire R.M.
        • Prakash P.S.
        • Richter J.R.
        • et al.
        Microparticles from stored red blood cells activate neutrophils and cause lung injury after hemorrhage and resuscitation.
        J Am Coll Surg. 2012; 214 (discussion 656–657): 648-655
      1. Wang DN. Band 3 protein: structure, flexibility and function. FEBS Lett. 19946;346:26–31.

        • Bosman G.J.
        • Stappers M.
        • Novotny V.M.
        Changes in band 3 structure as determinants of erythrocyte integrity during storage and survival after transfusion.
        Blood Transfus. 2010; 8: S48-52
        • Lutz H.U.
        Naturally occurring anti-band 3 antibodies in clearance of senescent and oxidatively stressed human red blood cells.
        Transfus Med Hemother. 2012; 39: 321-327
        • Liu C.
        • Liu X.
        • Janes J.
        • et al.
        Mechanism of faster NO scavenging by older stored red blood cells.
        Redox Biol. 2014; 2: 211-219
        • Gladwin M.T.
        • Kanias T.
        • Kim-Shapiro D.B.
        Hemolysis and cell-free hemoglobin drive an intrinsic mechanism for human disease.
        J Clin Invest. 2012; 122: 1205-1208
        • Kucherenko Y.V.
        • Bernhardt I.
        Natural antioxidants improve red blood cell “survival” in non-leukoreduced blood samples.
        Cell Physiol Biochem. 2015; 35: 2055-2068
        • Hess J.R.
        • Biomedical Excellence for Safer Transfusion Collaborative
        Scientific problems in the regulation of red blood cell products.
        Transfusion. 2012; 52: 1827-1835
        • Goral J.
        • Karavitis J.
        • Kovacs E.J.
        Exposure-dependent effects of ethanol on the innate immune system.
        Alcohol. 2008; 42: 237-247
        • Happel K.I.
        • Rudner X.
        • Quinton L.J.
        • et al.
        Acute alcohol intoxication suppresses the pulmonary ELR-negative CXC chemokine response to lipopolysaccharide.
        Alcohol. 2007; 41: 325-333
        • Bagby G.J.
        • Zhang P.
        • Stoltz D.A.
        • et al.
        Suppression of the granulocyte colony-stimulating factor response to Escherichia coli challenge by alcohol intoxication.
        Alcohol Clin Exp Res. 1998; 22: 1740-1745
        • Boe D.M.
        • Nelson S.
        • Zhang P.
        • et al.
        Alcohol-induced suppression of lung chemokine production and the host defense response to Streptococcus pneumoniae.
        Alcohol Clin Exp Res. 2003; 27: 1838-1845
        • Kanias T.
        • Gladwin M.T.
        Nitric oxide, hemolysis, and the red blood cell storage lesion: interactions between transfusion, donor, and recipient.
        Transfusion. 2012; 52: 1388-1392
        • Raval J.S.
        • Waters J.H.
        • Seltsam A.
        • et al.
        Menopausal status affects the susceptibility of stored, 2011 stored RBCs to mechanical stress.
        Vox Sang. 2011; 100: 418-421