Transfusion Medicine—Is Its Future Secure?

“Transfusion medicine will continue to be a little like walking through a tropical rainforest, where the known paths are clear but still require careful navigation, and new and unseen threats may still lurk around the next corner to trap the unwary.”—Ian M. Franklin, professor of transfusion medicine.

AFTER the worldwide AIDS epidemic cast the spotlight on blood in the 1980’s, efforts to eliminate its “unseen threats” intensified. Still, huge obstacles remain. In June 2005, the World Health Organization acknowledged: “The chance of receiving a safe transfusion . . . varies enormously from one country to another.” Why?

In many lands there are no nationally coordinated programs to ensure safety standards for the collection, testing, and transport of blood and blood products. Sometimes blood supplies are even stored dangerously—in poorly maintained domestic refrigerators and picnic boxes! Without safety standards in place, patients can be adversely affected by the blood drawn from someone who lives hundreds—if not thousands—of miles away.

Disease-Free Blood—A Moving Target

Some countries claim that their blood supply has never been safer. Yet, there are still reasons for caution. A “Circular of Information” prepared jointly by three U.S. blood agencies states on its first page: “WARNING: Because whole blood and blood components are made from human blood, they may carry a risk of transmitting infectious agents, eg, viruses. . . . Careful donor selection and available laboratory tests do not eliminate the hazard.”

Not without reason does Peter Carolan, the senior officer of the International Federation of Red Cross and Red Crescent Societies, say: “Absolute guarantees on blood supplies can never be given.” He adds: “There will always be new infections for which at that moment there is no test.”

What if a new infectious agent were to appear—one that, like AIDS, remains in an undetectable carrier state for a long time and is readily transmitted by means of blood? Speaking at a medical conference in Prague, Czech Republic, in April 2005, Dr. Harvey G. Klein of the U.S. National Institutes of Health called that prospect sobering. He added: “The blood component collectors would be scarcely better prepared to interdict a transfusion-transmitted epidemic than they were during the early days of AIDS.”

Mistakes and Transfusion Reactions

What are the greatest transfusion-related threats to patients in developed countries? Errors and immunologic reactions. Regarding a 2001 Canadian study, the Globe and Mail newspaper reported that thousands of blood transfusions involved near-misses because of “collecting blood samples from the wrong patient, mislabelling samples and requesting blood for the wrong patient.” Such mistakes cost the lives of at least 441 people in the United States between 1995 and 2001.

Those who receive blood from another person face risks essentially similar to those undergoing an organ transplant. Immune responses tend to reject foreign tissue. In some cases, blood transfusions can actually prevent the activation of natural immune responses. Such immunosuppression leaves the patient vulnerable to postoperative infections and to viruses that had previously been inactive. It is no wonder that Professor Ian M. Franklin, quoted at the outset of this article, encourages clinicians to “think once, twice and three times before transfusing patients.”

Experts Speak Out

Armed with such knowledge, a growing number of health-care workers are taking a more critical look at transfusion medicine. Reports the reference work Dailey’s Notes on Blood: “Some physicians maintain that allogeneic blood [blood from another human] is a dangerous drug and that its use would be banned if it were evaluated by the same standards as other drugs.”

Late in 2004, Professor Bruce Spiess said the following about transfusing a primary blood component into patients undergoing heart surgery: “There are few if any [medical] articles that support transfusion actually improving patient outcome.” In fact, he writes that many such transfusions “may do more harm than good in virtually every instance except trauma,” increasing “the risk of pneumonia, infections, heart attacks and strokes.”

It surprises many to learn that the standards for administering blood are not nearly as uniform as one would expect. Dr. Gabriel Pedraza recently reminded his colleagues in Chile that “transfusion is a poorly defined practice,” one that makes it “difficult to . . . apply universally accepted guidelines.” No wonder Brian McClelland, director of Edinburgh and Scotland Blood Transfusion Service, asks doctors to “remember that a transfusion is a transplant and therefore not a trivial decision.” He suggests that doctors ponder the question, “If this was myself or my child, would I agree to the transfusion?”

In truth, more than a few health-care workers express themselves as did one hematologist, who told Awake!: “We transfusion-medicine specialists do not like to get or to give blood.” If this is the feeling among some well-trained individuals in the medical community, how should patients feel?

Will Medicine Change?

‘If transfusion medicine is so fraught with dangers,’ you might wonder, ‘why is blood still used so extensively, particularly when there are alternatives?’ One reason is that many doctors are simply reluctant to change treatment methods or are unaware of therapies that are currently used as alternatives to transfusions. According to an article in the journal Transfusion, “physicians make transfusion decisions based upon their past teaching, enculturation, and ‘clinical judgment.’”

A surgeon’s skills also make a difference. Dr. Beverley Hunt, of London, England, writes that “blood loss is highly variable between surgeons, and there is increasing interest in training surgeons in adequate surgical haemostasis [methods to stop bleeding].” Others claim that the costs of transfusion alternatives are too high, although reports are emerging that prove otherwise. Many doctors, however, would agree with medical director Dr. Michael Rose, who says: “Any patient who receives bloodless medicine is, in essence, the recipient of the highest quality surgery that is possible.”*

The highest quality of medical care—is that not what you would want? If so, you have something in common with the people who brought you this magazine. Please read on to learn about their remarkable stance on the matter of blood transfusions.

[Footnote]

See the box “Alternatives to Blood Transfusion,” on page 8.

[Blurb on page 6]

“Think once, twice and three times before transfusing patients.”—Professor Ian M. Franklin

[Blurb on page 6]

“If this was myself or my child, would I agree to the transfusion?”—Brian McClelland

[Box/Picture on page 7]

Death by TRALI

  Transfusion-related acute lung injury (TRALI), first reported in the early 1990’s, is a life-threatening immune reaction following a blood transfusion. It is now known that TRALI causes hundreds of deaths each year. Experts, however, suspect that the numbers are much higher, as many health-care workers do not recognize the symptoms. Although it is not clear what causes the reaction, according to the magazine New Scientist, the blood that causes it “appears to come primarily from people who have been exposed to a variety of blood groups in the past, such as . . . people who have had multiple transfusions.” One report states that TRALI is now near the top of the list for causes of transfusion-related deaths in the United States and Britain, making it “a bigger problem for blood banks than high-profile diseases like HIV.”

[Box/Diagram on page 8, 9]

The Composition of Blood

  Blood donors generally give whole blood. In many cases, though, they donate plasma. While some countries transfuse whole blood, more commonly, blood is separated into its primary components before it is tested and used in transfusion medicine. Note the four primary components, their function, and the percentage of total blood volume each represents.

PLASMA constitutes between 52 and 62 percent of whole blood. It is a straw-colored fluid in which blood cells, proteins, and other substances are suspended and transported.

Water constitutes 91.5 percent of plasma. Proteins, from which plasma fractions are derived, constitute 7 percent of the plasma (including albumins, which make up about 4 percent of the plasma; globulins, about 3 percent; and fibrinogen, less than 1 percent). The remaining 1.5 percent of plasma is made up of other substances, such as nutrients, hormones, respiratory gases, electrolytes, vitamins, and nitrogenous wastes.

WHITE BLOOD CELLS (leukocytes) constitute less than 1 percent of whole blood. These attack and destroy potentially harmful foreign matter.

PLATELETS (thrombocytes) constitute less than 1 percent of whole blood. These form clots, blocking blood from exiting wounds.

RED BLOOD CELLS (erythrocytes) constitute between 38 and 48 percent of whole blood. These cells keep tissue alive by bringing oxygen to it and taking carbon dioxide away.

  Just as blood plasma can be a source of various fractions, other primary components can be processed to isolate smaller parts, or fractions. For example, hemoglobin is a fraction of the red blood cell.

[Diagram]

PLASMA

  WATER 91.5%

  PROTEINS 7%

    ALBUMINS

    GLOBULINS

    FIBRINOGEN

  OTHER SUBSTANCES 1.5%

    NUTRIENTS

    HORMONES

    RESPIRATORY GASES

    ELECTROLYTES

    VITAMINS

    NITROGENOUS WASTES

[Credit Line]

Page 9: Blood components in circles: This project has been funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under contract N01-CO-12400. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government

[Box/Picture on page 8, 9]

Alternatives to Blood Transfusion

  Over the past six years, Hospital Liaison Committees for Jehovah’s Witnesses worldwide have distributed tens of thousands of copies of the video program Transfusion-Alternative Strategies—Simple, Safe, Effective in some 25 languages to those within the medical community.* The program shows world-renowned physicians discussing effective strategies currently used to treat patients without blood transfusions. People are taking note. For example, after viewing the program in late 2001, the National Blood Service (NBS) in the United Kingdom sent a letter with a copy of this video to all blood-bank managers and consultant hematologists throughout the country. They were encouraged to watch the program because of “increasing recognition that one of the aims of good clinical care is to avoid blood transfusion wherever possible.” The letter acknowledged that “the general message [in the video] is praiseworthy and is one the NBS strongly supports.”

[Footnote]

Contact one of Jehovah’s Witnesses to view the DVD program Transfusion Alternatives—Documentary Series, published by Jehovah’s Witnesses.

[Box/Picture on page 9]

Fractionation—The Use of Blood’s Lesser Ingredients in Medicine

  Science and technology make it possible to identify and extract elements from blood through a process called fractionation. To illustrate: Seawater, which is 96.5 percent water, can be divided through fractionation processes in order to capture the remaining substances present, such as magnesium, bromine and, of course, salt. Likewise, blood plasma, which makes up more than half the volume of whole blood, is over 90 percent water and can be processed to harvest fractions including proteins, such as albumin, fibrinogen, and various globulins.

  As part of a treatment or therapy, a doctor might recommend concentrated amounts of a plasma fraction. An example of such is protein-rich cryoprecipitate, which is obtained by freezing and then thawing plasma. This insoluble portion of plasma is rich in coagulation factors and is usually given to patients to stop bleeding. Other treatments may involve a product that contains a blood fraction, whether in trace amounts or as a primary ingredient.* Some plasma proteins are used in routine injections that can help to increase immunity after exposure to infectious agents. Nearly all blood fractions being used in medical applications consist of the proteins found in blood plasma.

  According to Science News, “scientists have identified only several hundred of the estimated thousands of proteins typically coursing through a person’s bloodstream.” As understanding of blood grows in the future, new products derived from these proteins may emerge.

[Footnote]

Fractions from animal blood are also used in some products.

[Picture on page 6, 7]

Some medical workers are very cautious about coming into contact with blood