AIDSWEEKLY Plus; December 2, 2002
Lynn Yoffee, Senior Medical Writer

In a session entitled, "The blood supply is safer than it has ever been, or is it?" Richard K. Spence, MD, FACS, president, Society for the Advancement of Blood Management, and medical director, Alabama Center for Transfusion Alternatives, Birmingham, Alabama, outlined the old and new risks of blood transfusions.

Old diseases, such as malaria, HIV, hepatitis C virus, are now accompanied by a variety of new diseases to consider including West Nile virus, Simian Foamy virus, a new Creutzfeldt-Jakob agent, Banta disease virus, and hepatitis G, to name a few.

"The risk of transmission-transmitted diseases, such as malaria, HIV, hepatitis C, in the U.S. is 1 in 34,000," said Spence, who is also director of surgical education, Birmingham-Baptist Health System, Inc., and clinical professor of surgery at the University of Alabama School of Allied Health Professions.

Regarding attempts to control spread of mad cow disease, there's a ban on blood donors who have:

• spent 6 cumulative months in the U.K. from 1980-1996;

• spent 6 months in Europe since 1980;

• have been U.K. transfusion recipients;

• and been bovine insulin users.

"This affects 4-5% of our donor population and it's a serious hit," he said.

In addition to disease transmission, the risk of transfusion error is 1 in 37,000, he said.

"Transfusion reactions are still a major issue. They're caused primarily by clerical error, range from frequent to mild to rare and lethal," he said, adding that 1 in 15,000 donor exposures are at risk for transfusion reaction, a statistic that hasn't changed in many years.

"Yet, our way of dealing with this serious problem remains rooted in the dark ages. Many of our blood banks still rely on pen and ink to track blood resources and transfusion data. The local grocery store merchant has a better idea of what is on the shelves and in your basket than do many of our hospital blood bankers. Systems to reduce human error have been built into the automobiles, trains, and airplanes we travel in every day but somehow these ideas have escaped the transfusion community," he said.

The Red Cross has been criticized for failing to ensure the safety of the nation's blood supply due to having contaminated blood stored with blood for distribution, improper distribution, and inability to account for unsuitable blood products, he said.

"The current concept of blood safety is based primarily on the evidence that in 2002 the risk of getting HIV from a blood transfusion is 1 in 1 million, the risk of getting hepatitis C is 1 in 600,000, etc. compared to a risk of 1 in 10,000 ini 1982. We put a lot of faith is these risk estimates, but where is the clinical evidence to support them?" he said.

Spence reminded the mostly U.S.-based audience that, "If you travel overseas, be aware that only a little over 50% of the blood is actually tested. If you go to India, for example, you must pay to have it tested," he said.

Then there are issues related to immunosuppression in that, following a single unit transfusion, a patient may have an increased risk of cancer recurrence, increased risk of postoperative infections, and immunosuppression may be reduced by leukoreduction filter.

"The existence of transfusion-related immunomodulation has been staring at us for over 20 years, yet lack of education, tradition, or stubbornness keeps many from accepting it," he said. "That injecting a liquid, foreign tissue into another's body through an intravenous catheter is no different immunologically than transplanting a solid, foreign organ should be obvious to all. The scientific evidence is clear."

Spence also cited a number of studies, including one which connected transfusions with reduced risk of survival following mastectomy (Pysz M, J Surg Oncol 2000 Dec;75(4):258-63) and another that showed the survival of patients who, following subtotal esophagectomy, had transfusions and their median survival was 19 months compared with patients who didn't have a transfusion and survived 36 months (Dresner SN et al., Eur J Surg Oncol 2000 Aug;26(5):492-7.

"Almost every study out there shows shortened survival in cancer patients who receive transfusions. The numbers are there," he said.

In conclusion, Spence reminded physicians that because of the risks of blood transfusions, the Joint Commission on Accreditation of Healthcare Organizations requires physicians to discuss the risks, benefits, and alternatives to transfusions with patients followed by chart documentation.

"In the event of an untoward outcome, the hospital is liable if no consent was given on the chart and the physician is liable if no consent was obtained," he said.

This article was prepared by AIDS Weekly editors from staff and other reports.

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