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BACKGROUNDRBC transfusion effectiveness varies due to donor, component, and recipient factors. Prior studies identified characteristics associated with variation in hemoglobin increments following transfusion. We extended these observations, examining donor genetic and nongenetic factors affecting transfusion effectiveness.METHODSThis is a multicenter retrospective study of 46,705 patients and 102,043 evaluable RBC transfusions from 2013 to 2016 across 12 hospitals. Transfusion effectiveness was defined as hemoglobin, bilirubin, or creatinine increments following single RBC unit transfusion. Models incorporated a subset of donors with data on single nucleotide polymorphisms associated with osmotic and oxidative hemolysis in vitro. Mixed modeling accounting for repeated transfusion episodes identified predictors of transfusion effectiveness.RESULTSBlood donor (sex, Rh status, fingerstick hemoglobin, smoking), component (storage duration, γ irradiation, leukoreduction, apheresis collection, storage solution), and recipient (sex, BMI, race and ethnicity, age) characteristics were associated with hemoglobin and bilirubin, but not creatinine, increments following RBC transfusions. Increased storage duration was associated with increased bilirubin and decreased hemoglobin increments, suggestive of in vivo hemolysis following transfusion. Donor G6PD deficiency and polymorphisms in SEC14L4, HBA2, and MYO9B genes were associated with decreased hemoglobin increments. Donor G6PD deficiency and polymorphisms in SEC14L4 were associated with increased transfusion requirements in the subsequent 48 hours.CONCLUSIONDonor genetic and other factors, such as RBC storage duration, affect transfusion effectiveness as defined by decreased hemoglobin or increased bilirubin increments. Addressing these factors will provide a precision medicine approach to improve patient outcomes, particularly for chronically transfused RBC recipients, who would most benefit from more effective transfusion products.FUNDINGFunding was provided by HHSN 75N92019D00032, HHSN 75N92019D00034, 75N92019D00035, HHSN 75N92019D00036, and HHSN 75N92019D00037; R01HL126130; and the National Institute of Child Health and Human Development (NICHD).

The European Union Water Framework Directive (WFD) requires a good chemical and ecological status of European surface waters by 2015. Integrated, risk-based management of river basins is presumed to be an appropriate approach to achieve that goal. The approach of focusing on distinct hazardous substances in surface waters together with investment in best available technology for treatment of industrial and domestic effluents was successful in significantly reducing excessive contamination of several European river basins. The use of the concept of chemical status in the WFD is based on this experience and focuses on chemicals for which there is a general agreement that they should be phased out. However, the chemical status, based primarily on a list of 33 priority substances and 8 priority hazardous substances, considers only a small portion of possible toxicants and does not address all causes of ecotoxicological stress in general. Recommendations for further development of this concept are 1) to focus on river basin-specific toxicants, 2) to regularly update priority lists with a focus on emerging toxicants, 3) to consider state-of-the-art mixture toxicity concepts and bioavailability to link chemical and ecological status, and 4) to add a short list of priority effects and to develop environmental quality standards for these effects. The ecological status reflected by ecological quality ratios is a leading principle of the WFD. While on the European scale the improvement of hydromorphological conditions and control of eutrophication are crucial to achieve a good ecological status, on a local and regional scale managers have to deal with multiple pressures. On this scale, toxic pollution may play an important role. Strategic research is necessary 1) to identify dominant pressures, 2) to predict multistressor effects, 3) to develop stressor- and type-specific metrics of pressures, and 4) to better understand the ecology of recovery. The concept of reference conditions to define the ecological status is hard to apply and tends to ignore the fact that ecosystems can be highly dynamic. A better understanding of ecosystem responses to changes as well as early warning systems and concepts sensitive to various stressors to discriminate disturbances from natural variation are required. Because ecosystems are closely interconnected, an integrated monitoring, diagnosis, and stressors-based management of the whole water, sediment, groundwater, soil, and air system is required considering land use and the interaction with a changing climate. Extending this holistic approach beyond a consideration of existing pressures by anticipating on future ones to use and protect the aquatic environment in a sustainable way is one of the big challenges.