Xenotransfusion, past and present

Abstract

The first blood transfusions in humans were xenotransfusions, carried out by Jean-Baptiste Denis beginning in 1667. Richard Lower, Matthäus Purmann and Georges Mercklin also experimented with the use of animal blood for transfusion until this practice was forbidden in 1670, after the death of one of Denis's patients. In the middle of the 19th century, xenotransfusion was rescued from oblivion by the work of Pierre Cyprien Oré. Franz Gesellius and Oscar Hasse fervently defended xenotransfusion, but Emil Ponfick and Leonard Landois stressed the potentially harmful effects of inter-species transfusion from 1874 onward. Xenotransfusion was abandoned completely following the discovery of blood groups by Karl Landsteiner in 1900. From 2000, because of progress in xenotransplantation and the need of blood supply, xenotransfusion is again being considered. Pigs are the best potential donors. The development of alpha-1,3-galactosyltransferase gene-knockout pigs has overcome the first hurdle to xenotransfusion. The main obstacle to porcine red blood cell transfusion is now the cellular response involving macrophages or natural killer cells.

Full text

Review Article
Xenotransfusions, past and present
The transfusion of blood from animals is one
possible solution to improve the blood supply for
humans. This article describes the history of
xenotransfusion and current progress in this field.
History of xenotransfusion
The first blood transfusions in humans were
carried out with animal blood. Indeed, xenotrans-
fusion was the starting point for both xenotrans-
plantation and human blood transfusion. This
review describes the pioneering work in this field.
The work of Jean-Baptiste Denis—underlying principles
The idea of blood transfusion originated in Paris, at
the scientific society founded by Henri Louis
Habert de Montmort (c 1600 to 1679), which
eventually gave rise to the French Academy of
Sciences. A French monk, Dom Robert des Gabets
(1610 to 1678) described the principle of transfusion
at a meeting of this society held in July 1658 [1,2].
Even at this early point, the possibility of xeno-
transfusion was raised: ‘‘By the transfer of blood, I
mean the actual passage of blood from a man or
from another animal, into the veins of a weak or
sick man.’’
An Englishman, Richard Lower (1631 to 1691)
also claimed to be the first to come up with the idea
of transfusion. He performed the first transfusion
between two dogs in February 1665 in Oxford,
England [3,4]. French and English claims to the
invention of transfusion have caused considerable
controversy [5–7].
The first experiments
A Frenchman, Jean-Baptiste Denis (Fig. 1) (c
1635 to 1704), physician to King Louis XIV,
performed the first documented transfusion of
blood from an animal to a man. Inspired by the
work of Lower, Denis transfused blood between
two dogs on March 3, 1667 [8]. He then transfused
the blood of three calves into three dogs [9,10]. He
wrote: ‘‘Great advantages will follow upon the
mixture of different bloods’’ and ‘‘the blood of
animals is less full of impurities than that of men
because debauchery and irregularity in eating and
drinking are not so common in them as in us’’
[11,12].
Roux FA, Saı
¨P, Deschamps J-Y. Xenotransfusions, past and present.
Xenotransplantation 2007; 14: 208–216. !Blackwell Munksgaard, 2007
Abstract: The first blood transfusions in humans were xenotransfusions,
carried out by Jean-Baptiste Denis beginning in 1667. Richard Lower,
Mattha
¨us Purmann and Georges Mercklin also experimented with the
use of animal blood for transfusion until this practice was forbidden in
1670, after the death of one of Denis’s patients. In the middle of the 19th
century, xenotransfusion was rescued from oblivion by the work of
Pierre Cyprien Ore
´. Franz Gesellius and Oscar Hasse fervently defended
xenotransfusion, but Emil Ponfick and Leonard Landois stressed the
potentially harmful effects of inter-species transfusion from 1874
onward. Xenotransfusion was abandoned completely following the
discovery of blood groups by Karl Landsteiner in 1900. From 2000,
because of progress in xenotransplantation and the need of blood sup-
ply, xenotransfusion is again being considered. Pigs are the best
potential donors. The development of a-1,3-galactosyltransferase gene-
knockout pigs has overcome the first hurdle to xenotransfusion. The
main obstacle to porcine red blood cell transfusion is now the cellular
response involving macrophages or natural killer cells.
FranÅoise A. Roux, Pierre Sa!and
Jack-Yves Deschamps
Department of Cellular and Molecular Immuno-
Endocrinology, INRA, Nantes School of Veterinary
Medicine, Nantes Cedex, France
Key words: blood – history – transfusion –
xenotransfusion – xenotransplantation
Abbreviations: aGal, a-1,3-galactosyltransferase;
NeuGc, N-glycolylneuraminic acid; PEG, polyethy-
lene glycol; PERVs, porcine endogenous retrovi-
ruses; pRBCs, porcine red blood cells; RBCs, red
blood cells; SPF, specified pathogen-free; XT,
xenotransplantation; XTF, xenotransfusion.
Address reprint requests to Jack-Yves Deschamps,
Emergency and Critical Care Unit, Nantes School of
Veterinary Medicine, Atlanpole, La Chantrerie,
BP 40706, 44307 Nantes Cedex 03, France
(E-mail: deschamps@vet-nantes.fr)
Received 1 February 2007;
Accepted 20 March 2007
Xenotransplantation 2007: 14: 208–216
Printed in Singapore. All rights reserved
doi: 10.1111/j.1399-3089.2007.00404.x
Copyright !Blackwell Munksgaard 2007
XENOTRANSPLANTATION
208

On June 15, 1667, in Paris, Denis carried out a
blood transfusion in a 15-yr-old male patient
suffering from a violent fever that had led his
doctors to bleed him 20 times. Denis attributed the
patient’s condition to the resulting major loss of
blood and decided to carry out a transfusion, with
the help of a surgeon, Paul Emmerez. At 5 am,
they opened a vein in the patient’s inner elbow and
allowed the blood to run into a dish. The blood
was thick and black. A total of 3 ounces (about
90 ml) was withdrawn. Denis and Emmerez then
introduced carotid artery blood from a lamb into
the patient’s vein. They injected three times the
volume of blood collected in the dish. The patient
said that he felt strong heat moving through his
arm. He subsequently worked and ate normally
and was calm and jovial. He suffered a minor
nosebleed 11 h after the transfusion [11]. The first
transfusion to a human was thus a xenotransfu-
sion.
Other experiments
The second xenotransfusion performed by Denis in
June 1667 (exact date unknown) involved a healthy
45-yr-old man, who was paid for his participation.
Denis withdrew 10 ounces (about 300 ml) of the
subject’s blood, and injected the same amount of
arterial blood taken from a lamb [11]. This subject
also reported feeling strong heat moving through
his arm. This experiment showed no advantageous
effects of transfusion in a healthy subject, demon-
strating at most the innocuousness of the proce-
dure.
The third transfusion was performed on June 24,
1667 on Baron Bonde, a young Swedish nobleman
who fell ill in Paris. He was so sick that four
previous physicians had bled him. When Denis and
Emmerez arrived, the patient was unable to speak,
practically unconscious, and had vomited. As soon
as he received 6 ounces of blood from a calf, he
began to speak. Over the next 24 h he felt better,
but his condition then worsened again. Denis
began another transfusion and the patient showed
mild signs of recovery, but then died shortly
afterward [6].
For the fourth attempt, on Monday December
19, 1667, Denis transfused a deranged 34-yr-old
man named Antoine Mauroy (c 1633 to 1668) who
had been running naked through Paris day and
night for 4 months. His mental illness had begun
8 yr previously and he had been bled 18 times to
treat it. Emmerez drew 10 ounces of blood from a
vein in the patient’s arm and then opened the
crural artery of a calf and transfused 5 or 6 ounces
of calf’s blood into the patient [13–15]. As the
improvement in the patient’s condition was only
slight, Denis carried out a second transfusion
2 days later, on December 21, 1667, with more
than one pound of calf’s blood. The patient
complained of heat running through his arm and
strong pain in his kidneys. During the next few
days his urine was black ‘‘as if it had been mixed
with the soot of chimneys;’’ this is the first report of
a post-transfusional acute hemolytic reaction.
On February 10, 1668, Denis transfused a
paralytic woman, who had been bled five times,
with 12 ounces of arterial blood from a lamb [1].
Her paralysis disappeared almost immediately.
Antoine Mauroy remained healthy for 2 months
after his second transfusion, but then felt ill again.
His wife urged Denis to carry out a third transfu-
sion. Denis refused because her husband was not in
a suitable condition for this procedure. However,
she begged him and Denis eventually gave in. He
inserted a tube into a vein in Mauroy’s foot to
draw offsome of the old blood. The patient
suffered violent seizures, obliging Denis to remove
the tube without opening the calf’s artery and
without carrying out the transfusion. Mauroy died
the following day [16,17].
Opposition and prohibition
Transfusion has been a source of considerable
controversy. Guillaume Lamy (1644 to 1683) [15,
18,19] and Pierre Martin de la Martinie
`re (1634 to
1676) [20,21] were strongly opposed to this prac-
tice. Taking advantage of Mauroy’s death, Denis’s
detractors persuaded Mauroy’s wife to take legal
action. The verdict was delivered on April 17, 1668,
at the Chaˆ telet in Paris [22,23]. Denis was found
innocent; it was established that Mauroy’s wife had
Fig. 1. Jean-Baptiste Denis (c 1635 to 1704) (courtesy of
Muse
´e d’Histoire de la Me
´decine, Faculte
´de Me
´decine de
Paris).
Xenotransfusions, past and present
209

been poisoning him with arsenic. However, the
court decided that ‘‘for the future no transfusion
should be made upon any human body except with
the approbation of the physicians of the Parisian
Faculty.’’ On January 10, 1670, the French Parlia-
ment prohibited transfusions, with the English
Parliament rapidly following suit. This ban was
still in force in France at the end of the 19th
century.
Other attempts
Before the ban on transfusion came into effect,
several other attempts at transfusion were made in
Europe.
On November 23, 1667, shortly after Denis’s
first experiment, Richard Lower (1631 to 1691) and
Edmund King (1629 to 1709) transfused the blood
of a lamb into a 22-yr-old patient named Arthur
Coga (1645 to ?)—a bachelor of arts who was paid
20 shillings for his participation in the experiment
[24]—in London. Six days after the transfusion,
Coga reported that he felt much better than before
the transfusion. In fact, it is possible that Coga did
not receive much blood [6,24]. On December 14,
1667, Lower and King performed a second trans-
fusion that was not reported in Philosophical
Transactions; the results of this experiment were
instead communicated to the Royal Society via a
letter written by Coga; there was no effect.
In 1668, in Frankfurt (Oder, Germany), Matt-
ha
¨us Gottfried Purmann (1649 to 1711) claimed to
have cured a leper by transfusing him with lamb’s
blood, but failed to cure two ‘‘scorbutic soldiers’’
and a fisherman suffering from ‘‘devouring erup-
tion’’ [25], as cited by Ore
´[26]. He reported the
case of a woman who developed the sheep’s
melancholy after receiving blood from a sheep, as
cited by Ryser [27]. In the 17th century, popular
wisdom was that the heart was the originator of
emotion and soul; blood was its messenger. The
therapy of the day was blood-letting. The entire
thrust of xenotransfusion was to bring the ‘‘spirit’’
of the animal, i.e. the happy lamb or calf, to the
recipient.
In Purmann’s book [25], a drawing shows a man
receiving the blood of a lamb (Fig. 2). Another
drawing was printed in 1671 in Armentarium
chirurgicum (Techniques of Surgery), a book
written by Johannes Schultetus (Fig. 3) [28], and
another one on the title page of the anatomical
plates of Pietro da Cortona, published in 1741
(Fig. 4) [29].
In 1679, Georges Abraham Mercklin (1644 to
1700), a German physician, described the first
attempts at transfusion in his book, De ortu et
occasu transfusionis sanguinis (On the Rise and Fall
of Blood Transfusion),and reported several cases of
transfusion of animal blood to humans. He
emphasized the dangers of transfusion and clearly
doubted the usefulness of this technique. The
frontispiece of this book includes a copperplate
Fig. 2. Physician transfusing a lamb’s blood into a man from
Grosser und gantz neugewundener Lorbeer-Krantz oder Wund-
Artzney (1692), p. 285, by Mattha
¨us Gottfried Purmann [25]
(courtesy of Bibliothe
`que Interuniversitaire de Me
´decine,
Paris).
Fig. 3. Two physicians transfusing a dog’s blood into a man
from Armamentarium chirurgicum (1671), Pl. 11, p. 28 by
Johannes Scultetus [28] (courtesy of Bibliothe
`que Interuni-
versitaire de Me
´decine, Paris).
Roux et al.
210

engraving showing a transfusion of blood from an
animal (a calf or a goat) to a man (Fig. 5) [30].
Resurrection through animal blood transfusion
More than one century later, on December 14,
1799, two physicians bled George Washington four
times for hoarseness, resulting in the loss of almost
2.5 l of blood [31]. The patient died shortly after
10 pm. Fourteen hours later, his relatives arrived
with William Thornton (1761 to 1828), a physician
who identified the cause of death as suffocation
and blood loss. He proposed ‘‘to open a passage to
the lungs by the trachea, and to inflate them with
air (…) and to transfuse blood into him from a
lamb.’’ The relatives did not accept this proposed
attempt at resurrection.
Discovery of the incompatibility of heterologous blood
In 1816, John Henry Leacock, a Scottish physician
working in Edinburgh, showed, in eight trials of
transfusion between animals, that the best results
were obtained if the donor and recipient were of
the same species. This led him to recommend inter-
human transfusion [32].
In 1818, a British obstetrician aware of Lea-
cock’s work, James Blundell (1791 to 1878),
demonstrated the incompatibility of heterologous
blood in repeated transfusions of dogs with sheep
blood in London. In 1825, he wrote ‘‘the blood of
one sort of animal cannot, with impunity, be
substituted indifferently, and in large quantities,
for that of another sort of animal; it follows, of
course, that in performing the operation of trans-
fusion on the human body, human blood should
alone be employed’’ [33,34]. In 1829, he carried out
the first recognized human-to-human blood trans-
fusion on a woman with postpartum hemorrhage
[35,36]. The first allotransfusion thus took place
more than one and a half centuries after the first
xenotransfusion.
The golden age of xenotransfusion
Having been abandoned for almost two centuries,
transfusion and xenotransfusion became the focus
of renewed interest in the second half of the 19th
century, which could be considered the golden age
of these technologies. In the absence of techniques
for preventing coagulation (such techniques were
not used until after 1914), transfusions consisted
essentially of the immediate injection of whole
blood from an artery or vein into the patient’s vein.
In most cases, the xenotransfusion was preceded by
a bleeding and concerned only a small amount of
blood. It is likely that in most cases, the recovery
was not due to the introduction of animal blood,
but to the cessation of the bleeding [6]. Infections
were probably frequent, because the importance of
sterilizing instruments and antiseptic methods were
not known (the work of Louis Pasteur dates from
1865 and that of Joseph Lister from 1867).
Fig. 4. The title page of the anatomical plates of Pietro da
Cortona (1596 to 1669) published in 1741 shows a man
receiving blood from a sheep [29].
Fig. 5. A man receiving a transfusion from a calf or a goat
from Tractatio medico curiosa de ortu et occasu transfusionis
sanguinis (1679) by Georges Abraham Mercklin [30], engraving
by Cornelius Nicolaus Sehurk (courtesy of Bibliothe
`que
Interuniversitaire de Me
´decine, Paris).
Xenotransfusions, past and present
211

The work of Pierre Cyprien Ore
´(1828 to 1890), a
French physiologist, rescued transfusion from
oblivion. In 1863, then in a second edition in
1876, Ore
´described 154 human transfusions with
blood from animals (lambs, sheep, calves) in his
book, Etudes historiques, physiologiques et cliniques
sur la transfusion du sang (Historical, Physiological
and Clinical Studies on Blood Transfusion) [26,37].
He counted 64 cures, 20 improvements, 43
unchanged, one doubtful case and 26 deaths. Ore
´
highlighted the advantages of animal blood—inex-
haustible supply, continuous availability, and the
absence of risk to a human donor.
In 1872, an Italian, Giuseppe Albini (1827 to
1911), described two transfusions of sheep blood to
a woman [38].
In 1873, Franz Gesellius, a physician and
surgeon (Wilna, Poland), who had previously
carried out 22 transfusions of blood from sheep
to dogs, expressed his support for the use of blood
from sheep or calves in 19 human transfusions [39].
He also tried to demonstrate the greater dangers
associated with the use of human blood.
In 1874, Oscar Hasse (1837 to 1898) (Nordhau-
sen, Germany) published Die Lammblut-Transfu-
sion beim Menschen (Transfusion of Blood from
Lamb to Humans), in which he reported the results
of 31 cases of lamb’s blood transfusion in humans
(Fig. 6) [40]. Some of the patients died and many
had severe adverse effects, such as blood in the
urine and jaundice, but Hasse fervently defended
xenotransfusion
On June 15, 1874, Henry Gradle (1855 to 1911),
Professor of Physiology (Chicago, IL, USA),
reported transfusion of lamb’s blood in two men
[41]. He described adverse effects, such as fever,
urticaria and ‘‘a strong odor of lamb.’’
In 1874, Emil Ponfick (1844 to 1913), a German
pathologist, reported in the Association of Baltic
Physicians the death of a 34-yr-old woman who
had received blood from a sheep. He noticed for
the first time lyzed red blood cells in the serum and
hemoglobinuria (rather than hematuria, as previ-
ously reported), resulting from the destruction of
donor red cells. The following year, Ponfick
confirmed his observations during transfusions of
sheep blood into dogs [42].
In 1875, Leonard Landois (1837 to 1905), a
German physiologist, in his book, Die Transfu-
sion des Blutes (Blood Transfusion),collected 129
cases of transfusion with animal blood, and
compared them with 347 cases of inter-human
transfusion [43]. During the war between France
and Germany in 1870, transfusion with animal
blood again became commonplace. Landois
showed that red cells from animals were lyzed
in human blood because of the presence of
natural antibodies, heterohemolysins or hetero-
agglutinins. In 1898, Jules Bordet (1870 to 1961),
a Belgian who worked at the Pasteur Institute in
Paris, showed that titers of the two types of
antibody increased after immunization [44],
accounting for the hemolytic event experienced
by Antoine Mauroy after Denis’s second trans-
fusion.
In 1882, F. Dedolph reported having treated a
patient who had bled for 12 days with a transfu-
sion of 240 ml of sheep blood. The bleeding
stopped immediately once 8 ounces of blood had
been injected [45], cited by Davis [46].
Abandonment
After the warnings issued by Ponfick and Landois,
xenotransfusion was practically abandoned.
Nonetheless, inter-human transfusion remained a
source of severe hemolytic accidents. The discov-
ery of blood groups A, B and O by the Austrian
Karl Landsteiner (1868 to 1943) in 1900 paved the
way for inter-human blood transfusion and soun-
ded the death knell of xenotransfusion [47].
Another century was to pass before the issue of
xenotransfusion would be raised again. During
this period, an attempt was performed by Alex-
ander S. Wiener (1907 to 1976) in 1955 in the
United States [48]. Bovine red blood cells were
given to a 62-yr-old widow in desperate need of
compatible blood, but the transfusion had to be
stopped after 50 ml as the patient became severely
dyspneic.
Fig. 6. A woman receiving blood from a sheep from Die
Lammblut-Transfusion beim Menschen (1874) by Oscar Hasse
[40].
Roux et al.
212

Dhaniram Baruah
On the night of December 31, 1996, Dhaniram
Baruah (from Sonapur near Guwahati, India)
transplanted the heart of a pig into Purno Saikia,
a 32-yr-old man with ventricular septal defect
(Baruah, unpublished data) [49]. The patient died
from septic shock 7 days later. Baruah was arres-
ted on January 9, 1997 for violating the Human
Organ Transplantation Act of 1994 [50]; he was
detained for 40 days, but vowed to continue his
xenotransplantation attempts. In 2000, Baruah
administered more than half a pint of pig blood
to a 22-yr-old laborer named Hussan Ali, who was
suffering from severe anemia [51]. Four weeks
later, the patient was still alive and was discharged
from the hospital. Test results confirmed that he
had circulating blood cells of nonhuman origin
(Baruah, unpublished data). This is the only report
of the use of a pig as the donor, and the only recent
report of xenotransfusion in a human. This xeno-
transfusion was empirical and arose from a
situation in which the possibility of using animal
blood for human transfusion once again presented
itself.
Xenotransfusion today
Recent progress in overcoming immunological
barriers to xenotransplantation can be applied to
tissues and cells. The need of blood supply for
transfusion led Alex Zhu (New York, NY, USA)
to propose in 2000 using porcine red blood cells
(pRBCs) [52]. So, 100 years after its abandonment,
xenotransfusion is once again on the agenda.
The use of an animal source would provide an
unlimited amount of blood on demand, would
eliminate the risk of transmission of inter-human
infectious diseases (hepatitis C, HIV, etc.). As
mature red blood cells contain no DNA, the use of
an animal source would not be associated with the
risks due to porcine endogenous retroviruses
(PERVs).
The pig is thought to be the best potential blood
donor. James Johnstone (Halifax, Canada) and
coworkers have investigated the feasibility of
bovine erythrocyte xenotransfusion [53]. Because
of the need for genetic manipulation of the donor,
it is more likely that the pig, already the animal of
choice for xenotransplantation, will be chosen as
the source of blood for xenotransfusion.
In 2003, David Cooper (Boston, MA, USA)
enumerated the advantages of the pig as a donor
and the hurdles to be overcome [54]. pRBCs have
many characteristics in common with human
RBCs [55]. Human hemoglobin genes can be
expressed in transgenic pigs [56]. The pig blood
group AO system is related to the human ABO
system [57], and uniform pig herds in which all
animals are of blood type O already exist. pRBCs
do not express swine leukocyte antigens [58], which
may possibly prove an advantage for xenotransfu-
sion. Current evidence is that pRBCs will likely
function normally in humans [52,54]. Even if some
of the major recent human infectious diseases have
come from animals, pig-specific infectious agents
are less liable to cross the species barrier and to
develop in humans. Because of their economic
impact, the infectious agents which affect pigs are
well known, and sensitive tests for their detection
already exist.
The transfusion of pRBCs to a nonhuman
primate leads to the immediate (<5 min) hemo-
lysis of the transfused cells [59] because serum from
primates, human and nonhuman, has natural
preformed antibodies against pRBCs [60]. The
a-1,3-galactosyltransferase (aGal) epitope, the
major xenoantigen recognized by human natural
antibodies [61–64], is present on the surface of
pRBCs [52,61].
The aGal epitope can be removed with a-galac-
tosidase [65]. In 2000, Zhu showed that a-galac-
tosidase treatment of pRBCs does not prevent
binding to human natural antibodies [66], consis-
tent with the existence of non-aGal xenoantigens
on pRBCs [67]. Similarly, Leslie MacLaren et al.
(Halifax, Canada) showed in 2002 that the removal
of anti-aGal antibody from human serum reduces,
but does not eliminate, hemagglutination [68].
The N-glycolylneuraminic acid (NeuGc) epitope
is present in most animals, including nonhuman
primates and pigs, but is absent from humans. In
2002, Alex Zhu showed that this epitope is the
major non-aGal xenoantigen present on the sur-
face of pRBCs [69]. The prevention of pRBC
hemolysis would require prior treatment with both
a-galactosidase and neuraminidase [59]. Mature
blood cells have no intracellular organelles, so this
treatment permanently removes both aGal and
NeuGc epitopes from the cell surface [59]. Simi-
larly, deletion of the aGal gene would be sufficient
for the definitive removal of the aGal epitope.
Another strategy would involve camouflaging
the antigens, to produce pRBCs that cannot be
detected by the human immune system [70,71].
This approach is based on covalent binding to
polyethylene glycol (PEG) [72]. In 2004, Jay
Doucet et al. (Halifax, Canada) showed in vitro
that both PEG and a-galactosidase treatment
significantly reduced hemagglutination [73]. Such
treatment may prolong pRBC survival but residual
immunity, splenic sequestration or cell fragility
Xenotransfusions, past and present
213

result in pRBCs having a much shorter lifespan in
vivo than allogeneic blood cells [59].
In 2002, a1,3-galactosyltransferase gene-knock-
out (GalT-KO) pigs became available [74,75]. Pigs
expressing neither aGal nor NeuGc could be used
for human transfusion, although NeuGc-KO pigs
have not yet been produced. Crosses between
GalT-KO pigs and NeuGc-KO pigs would produce
some double-KO pigs, but this would not be
enough to prevent pRBC destruction. Baboons
express NeuGc and therefore produce no antibod-
ies against NeuGc [76]; however, in 2004, Foad
Rouhani et al. (Boston, MA, USA) showed that
the transfusion of a small volume of pRBCs from
aGalT-KO pigs to baboons led to the rapid
removal or destruction of these pRBCs [77]. These
authors hypothesized that neoantigens could sub-
stitute for the aGal epitope [77]. Indeed, a-galac-
tosidase treatment exposes NAcLac [78], and
NAcLac may therefore also be exposed in aGalT-
KO pigs, although there is currently no evidence to
support this hypothesis [79]. Franck Dor et al.
(Boston, MA, USA) suggested replacing the aGal
epitopes with the H (O) blood group oligosaccha-
ride, which would not bind to human antibodies
[80]. Human a1,2-fucosyltransferase (H-transf-
erase) expression modifies the cell surface, resulting
in expression of the universal donor O (H) antigen;
transgenic pigs expressing H-transferase have
already been produced to decrease natural xeno-
geneic antibody reactivity [81–84]. The mechanism
by which these pRBCs are rapidly destroyed
remains unknown. Phagocytosis by macrophages
or natural killer cell-mediated destruction may
occur [77]. Indeed, macrophages mediate phago-
cytosis of pRBCs [85,86] that is not prevented by
the elimination of aGal epitopes [87]. The receptors
directly recognizing xenogeneic erythrocytes may
be the lectins used by the innate immune system to
differentiate self from non-self [88].
With the generation of homozygous GalT-KO
pigs, the first hurdle to xenotransfusion has been
overcome, but new immunological problems have
appeared. The main obstacle to pRBC transfusion
is now the cellular response involving macrophages
or natural killer cells.
Conclusion
In the past, ignorance about incompatibility led to
abandonment of the use of animal blood for
human transfusion. Gaining control over these
phenomena may lead to the resurgence of xeno-
transfusion. Progress in xenotransfusion is thus
dependent on progress in xenotransplantation. As
there is no risk of porcine endogenous retrovirus
infection, it may be easier to introduce xenotrans-
fusion for clinical application than to introduce the
xenotransplantation of organs, tissues and cells.
Once rejection mechanisms have been controlled,
the pig could become a universal donor of blood
for transfusion in humans.
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