Plasma testosterone heterogeneity reveals genetic and demographic determinants of donor health and red blood cell quality

Testosterone is a key determinant of red blood cell (RBC) biology and susceptibility to hemolysis; however, its contribution to donor-dependent variation in RBC quality and transfusion effectiveness remains unclear. Using data from 2,357 male participants in the NHLBI REDS-III RBC-Omics study, we quantified plasma total testosterone, free testosterone (bioavailable form), and androstenedione and evaluated their associations with donor characteristics, RBC hemolysis, and recipient post-transfusion hemoglobin increments, a clinical measure of RBC transfusion effectiveness. Subphysiological testosterone concentrations were common (~35%) and independently associated with increased storage and osmotic hemolysis. Frequent blood donations were independently associated with lower circulating free testosterone concentrations, even after adjustment for demographic and hematologic factors. Genome-wide association analyses identified loci associated with circulating testosterone, including regions near SHBG , TNFSF12 , and the long noncoding RNA BALR6 . Several testosterone variants were associated with RBC transfusion effectiveness. Specifically, variants associated with lower testosterone (e.g., TNFSF12 ) corresponded to higher post-transfusion hemoglobin increments (+9%), whereas BALR6 variants associated with higher testosterone were linked to reduced hemoglobin increments (–40%). In contrast, androstenedione-associated variants were not related to hemolysis or transfusion outcomes. Together, these findings demonstrate that genetic and physiologic variation in testosterone contributes to inter-individual variability in RBC quality and transfusion effectiveness.