Evidence-based criteria for the care and selection of blood donors, with some comments on the relationship to blood supply, and emphasis on the management of donation-induced iron depletion

Review of blood donor deferral with emphasis on donor and patient safety

INTRODUCTION

Blood donor deferral is a part and parcel of the commitment of the blood transfusion services to assure the safety and health of the blood donor as well as the recipient. Periodic review of blood donor deferral is to incorporate or revoke deferral reasons based on the evidence generated in the process of review. Therefore, emphasis must be laid on preparing strategies to only judiciously defer blood donors, recruit and retain first time blood donors, which needs critical appraisal of the existing deferral policies, so that the evidence based changes can be done.

MATERIAL AND METHODS

A retrospective analysis of deferral in blood donors who presented at the blood donation centre of an institute of national importance over a span of nine years (2011-2019). Donors were screened as per the Drugs and Cosmetics Act 1940 and Rules 1945 given by the Ministry of Health and Family Welfare, Govt of India.

RESULTS

There were 1,37,935 donors attempts, out of which 20,167 (14.6%) donors were deferred from donating blood. Most of the deferred donors were male (88.5%), first time (86.1%) and temporarily deferred (87.6%). Almost comparable number of donors (49.1 % & 48.5%) were deferred for donor safety and patient safety reasons respectively. Overall the three most common reasons for deferral were low hemoglobin (21.6%), hypertension (11.4%) and history of jaundice (9%). In donor safety reasons, low hemoglobin (43.4%), hypertension (22.9%) and low blood pressure (4.5%), and in patient safety, a history of jaundice (18.6%), common cold (15.8%), and high-risk behavior (8.8%) emerged as the three most common reasons for deferral respectively.

CONCLUSION

Blood donor deferral is an essential quality indicator of the blood donor selection process. Initiatives like fortification of dietary ingredients with iron, optimizing protein in diet served in schools under mid-day meal program, screening for iron deficiency, hypertension and education about high-risk behavior in schools and colleges may have long term effects of promotion of better health.

Impact of donor ferritin testing on iron deficiency prevention and blood availability in France: A cohort simulation study

BACKGROUND AND OBJECTIVES

Implementing a ferritin testing policy for whole blood (WB) donors may prevent iron deficiency (ID, ferritin <26 ng/mL) and anaemia, but may induce donation losses. As part of a national prevention plan in France, we aimed to estimate its impact on ID, anaemias and WB donations among donors at high risk of ID.

MATERIALS AND METHODS

A micro-simulation model was developed to evaluate different scenarios compared to the current situation without ferritin testing as a reference scenario. The following scenarios were simulated: a minimum scenario with a 6-month deferral for donors with absent iron store (AIS, ferritinemia <15 ng/ml), a main scenario with additional delayed invitations for donors with ferritinemia 15-25 ng/ml and a supplementation scenario with additional iron supplementation for 50% of the donors with AIS.

RESULTS

In the main scenario, 52,699 WB donations per year were estimated to be lost after 1 year (-8%), falling to 27,687 (-4.7%) after 5 years. IDs and anaemias were reduced by 13.6% and 29.3%, respectively, after 1 year. The supplementation scenario increased the number of prevented IDs and anaemias to 24.1% and 35.4%, respectively, after 1 year, and halved the number of anaemias at 5 years. The latter scenario also had the least impact on the number of donations (-3.2% after 5 years).

CONCLUSION

A ferritin testing policy resulting in delayed donations for ID donors is effective in reducing IDs and anaemias, but significantly impacts the number of donations, thereby posing a self-sufficiency challenge.

Donation-induced iron depletion is significantly associated with low hemoglobin at subsequent donations

BACKGROUND

Blood donation is associated with a loss of hemoglobin (Hb)-bound iron. Hb levels recover relatively fast by using stored iron. However, it takes more time to replenish iron stores, potentially resulting in iron deficiency.

STUDY DESIGN

Hb and ferritin levels were measured in 5056 new, first-time, and repeat whole blood donors. We investigated whether increasing numbers of donations are associated with lower ferritin levels. Furthermore, we tested whether low ferritin levels are associated with low-Hb deferral at the subsequent donation attempt by performing logistic regression adjusted for age and stratified by sex.

RESULTS

Whereas mean Hb levels are relatively stable, ferritin levels significantly decrease with increasing numbers of donations and were approximately 50% lower for donors with >50 donations compared with those with 2-10 donations. Despite the poor correlation of ferritin and Hb levels, cross-sectional, iron-deficient donors (ferritin <15 ng/ml) had 21.8 (8.5-55.6) higher odds in men, 10.1 (6.1-16.5) in premenopausal women, and 11.7 (5.2-26.4) in postmenopausal women for Hb deferral at a subsequent visit.

DISCUSSION

To conclude, repeated donations may induce iron deficiency, which corresponds with an over tenfold increased risk of having insufficiently restored Hb levels at a subsequent donation attempt. Longer donation intervals and/or higher dietary or supplemental iron intake are warranted to prevent accumulated iron depletion and subsequent low-Hb deferral in whole blood donors.

Blood donation and heavy metal poisoning in developing nations: Any link?

Long term health effects of heavy metal exposure from both occupational and environmental settings involve multi-organ toxicities including but not limited to disturbances of neurological, cognitive, and metabolic processes, immune system dysregulation, carcinogenesis and sometimes permanent disabilities. Humans are exposed to toxic metals through various sources and routes of entry. The risk of heavy metal poisoning from donor blood has been the subject of many scientific investigations. In this review we highlight how the access to a safe and adequate blood transfusion with minimal risk of toxic metals to recipients is a public health challenge, especially in developing nations. For quality assurance purposes, blood donors are screened for various blood-borne pathogens, but screening for toxic metal levels is not routine. Evidence from scientific studies used in this review lends credence to the risk of heavy metal poisoning from donors with high blood concentrations of these heavy metals. The risk of toxicity is exceptionally high in vulnerable populations such as neonates and preterm infants, as well as in pregnant women and other individuals with conditions requiring multiple blood transfusions. This is worse in developing countries where some members of the population engage in illegal refining and artisanal mining activities. In order to reduce toxic metal exposure in vulnerable populations, blood meant for transfusion in vulnerable subjects, e.g. children, should be routinely screened for heavy metal concentrations. Patients receiving multiple blood transfusions should also be monitored for iron overload and its attendant toxicities.

Whole blood donors' post-donation symptoms diminish quickly but are discouraging: Results from 6-day symptom diaries

BACKGROUND

Whole blood donors may experience post-donation symptoms such as fatigue, dizziness, or headache after blood donation, which could influence donor retention. We aimed to examine post-donation symptoms during 1 week after whole blood donation, investigate donor characteristics associated with symptoms, and evaluate associations between symptoms and donor return.

METHODS

During 1 week, whole blood donors who donated successfully at one of the collection centers in The Netherlands were invited to participate. Three thousand seventy six donors filled in a diary, assessing post-donation symptoms during days 1 to 6 after donation. We used linear mixed models analyses to determine the change in post-donation symptoms after donation for male and female donors separately. Furthermore, we investigated associations between post-donation symptoms and donors' physical characteristics using multivariable regression and determined associations between symptoms and donor return.

RESULTS

Donors reported fatigue as the most common symptom, with approximately 3% of donors experiencing severe problems at the first day after donation. Multiple symptoms improved significantly up to day 3 after whole blood donation. Age, BMI, blood pressure (male donors), and blood volume (female donors) were significantly associated with post-donation symptoms. Donors with less fatigue after whole blood donation were more likely to return for their next donation within 31 days after receiving an invitation.

CONCLUSION

Post-symptoms improve up to 3 days after whole blood donation. Our results may help blood collection centers to identify donors more prone to post-donation symptoms and provide personalized information about the presence and course of post-donation symptoms, possibly increasing donor return rates.

Whole blood donor behavior and availability after deferral: Consequences of a new ferritin monitoring policy

Background

To prevent (negative consequences of) temporary deferral due to low hemoglobin, the Dutch national blood service Sanquin introduced a ferritin monitoring policy in 2017. Ferritin is measured after the donation (as opposed to before donation for hemoglobin), and low ferritin levels lead to deferral of 6 (ferritin 15‐30 ng/mL) or 12 months (ferritin <15 ng/mL). We explored the consequences of this policy on donor behavior and availability.

Study Design and Methods

We included all Dutch whole blood donors who made a donation (attempt) between 13 November and 31 December 2017. At that point, the ferritin monitoring policy was randomly implemented in 8 of 29 regional clusters of collection centers. We extracted information from Sanquin's donor database about donors' deferrals, subsequent donation attempts, and donation cessation (up to 31 December 2019). Donors deferred for low ferritin were compared to those deferred for low hemoglobin or other reasons, as well as to donors who were not deferred.

Results

A total of 55 644 donors were included (11% deferred). For donor behavior, we found that donors deferred for low ferritin less often unsubscribed and switched to other donation types, yet also made fewer donations in the follow‐up period. For availability, we found they were less often deferred, yet they were unavailable to donate for a longer period.

Conclusion

Results suggest that the implementation of a ferritin monitoring policy may lead to a decrease in donor availability and reduced donations. However, the policy is successful in retaining more donors and reducing low hemoglobin deferrals.

Comparison of the effects of zinc oxide and zinc oxide nanoparticles on the expression of hepcidin gene in rat liver

OBJECTIVES

Nanoparticles have special properties, such as increased intestinal absorption, permeability, and so on. Zinc oxide (ZnO) nanoparticles have medical applications such as using in drug production. Studies of ZnO nanoparticles have shown the role of these particles in reducing or increasing the genes expression. Given the important role of hepcidin in the development of anemia and iron overload diseases, this study investigated the effect of ZnO nanoparticles on the hepatic expression of the hepcidin gene to help find a way to treat these diseases.

METHODS

In this experimental study, 24 male Westar rats were divided into three groups: control, ZnO treating group and ZnO nanoparticle treating group. Both ZnO and ZnO nanoparticles were injected with 50 mg/kg body weight for 14 days. At the end, serums were collected and iron, ferritin and IL-6 levels were measured. Expression of the hepcidin gene was done by Real Time PCR.

RESULTS

ZnO and the ZnO nanoparticle significantly increased the expression of the hepcidin gene relative to the control group. The increase in expression of the hepcidin gene in ZnO nanoparticles was more significant than in the ZnO.

CONCLUSION

ZnO nanoparticles led to significant increase in expression of the hepcidin gene.

Ferritin measurement IN Donors-Effectiveness of iron Monitoring to diminish iron deficiency and low haemoglobin in whole blood donors (FIND'EM): study protocol for a stepped wedge cluster randomised trial

Background

Blood donors are at risk for reduced iron stores, because of which donor iron monitoring received increased attention in the last decade. Despite the importance for donor health, international consensus on an appropriate policy for iron monitoring is lacking. Therefore, we conduct a trial to evaluate to what extent ferritin-guided donation intervals are effective in increasing haemoglobin and ferritin levels, decreasing low-haemoglobin deferral, increasing donor return and improving the health of whole blood donors in the Netherlands.

Methods

Sanquin Blood Bank is implementing ferritin-guided donation intervals to prevent donors from increasing iron loss at repeated donations. Using a stepped wedge cluster randomised trial approach, the design involves a random crossover of 29 clusters of blood collection centres from the existing policy without ferritin measurements to a ferritin-guided donation interval policy. This new policy includes ferritin measurements for all new donors and at every 5th whole blood donation, extending donation intervals to 6 months if ferritin is 15–≤ 30 ng/mL and to 12 months if ferritin is < 15 ng/mL. We measure ferritin levels of whole blood donors from stored plasma samples and collect haemoglobin levels and information on low-haemoglobin deferral and donor return from the donor database before, during and after the implementation period. We measure donor health during and after the implementation period using questionnaires, assessing physical and mental wellbeing and iron deficiency- and donation-related symptoms. We use multilevel analyses to investigate differences in ferritin and haemoglobin levels, low-haemoglobin deferral rates, donor return and donor health from whole blood donors, between blood collection centres that have versus those that have not yet implemented the ferritin-guided donation interval policy.

Discussion

This stepped wedge cluster randomised trial will provide insight into the effectiveness of ferritin-guided donation intervals in lowering iron deficiency, decreasing donor deferrals due to low haemoglobin and improving donor health. We will evaluate a policy that is implemented nationwide in a real-life setting. Our study is therefore not limited to a small experimental setting and the results will guide policymakers seeking an appropriate policy for iron monitoring.

Trial registration

The Dutch trial registry NTR6738. Registered on 29 September 2017. Retrospectively registered.

Iron deficiency among French whole-blood donors: first assessment and identification of predictive factors

BACKGROUND

The objectives of this study are to estimate the prevalence of iron deficiency (ID) among French whole-blood (WB) donors to identify factors associated with ID and to generate decision trees.

STUDY DESIGN AND METHODS

A prospective National multicentre study was performed on WB donors from March 11, to April 5th, 2019. Samples were selected randomly to perform serum ferritin. ID was defined as ferritin value under 26 ng/ml. All results were stratified by sex. Factors associated with ID were analysed using multivariate logistic regression model. CART algorithm was used for decision trees.

RESULTS

Eleven thousand two hundred fifty eight WB donors were included. ID was more frequent in women (39·5%) than in men (18·0%). Among 7200 repeated donors, women below 50 yo had a higher risk (OR = 2·37; [1·97-2·85] IC95) than those above 50 yo. Factors associated with ID were: haemoglobin level under the threshold at donation n-1 except for women and n-2 donation; a low mean corpuscular haemoglobin at n-1 and n-2 donations; a shorter interval since n-1 donation and between n-1 and n-2 donations except for women; and women who had given three or four times in the last year. CART algorithm defined high risk of ID subgroups within three populations of donors, new female donors, repeated male donors and repeated female donors. In these identified subgroups, prevalence of ID was up to 72·1%.

CONCLUSIONS

Our study showed the high prevalence of ID among French WB donors, identified well-known and new factors associated with ID and defined algorithms predicting ID in three populations.

Classification of potential blood donors using machine learning algorithms approach

Blood donation is the process of taking blood from someone used for blood transfusions. Blood type, sex, age, blood pressure, and hemoglobin are blood donor criteria that must be met and processed manually to classify blood donor eligibility. The manual process resulted in an irregular blood supply because blood donor candidates did not meet the criteria. This study implements machine learning algorithms includes kNN, naïve Bayes, and neural network methods to determine the eligibility of blood donors. This study used 600 training data divided into two classes, namely potential and non-potential donors. The test results show that the accuracy of the neural network is 84.3 %, higher than kNN and naïve Bayes, respectively of 75 % and 84.17 %. It indicates that the neural network method outperforms comparing with kNN and naïve Bayes.

Utility of zinc protoporphyrin in management of whole blood donors

BACKGROUND

Deferral for low hemoglobin (Hb) increases the likelihood that donors do not return for future donations. Zinc protoporphyrin (ZPP) has been described as a sensitive marker of iron-deficient erythropoiesis, before Hb decreases. It is a relatively cheap, rapid, and easy-to-perform measurement in a drop of whole blood. To assess the utility of ZPP measurement in donor management we examined whether ZPP and Hb levels among first-time donors differ from repeat donors. We further explored whether ZPP increases over subsequent donations at a donor population level and whether increasing ZPP levels coincide with decreasing Hb levels and donor deferral.

STUDY DESIGN AND METHODS

We included first-time (n = 4983) and repeat (n = 3533) whole blood donors from the ZPP and Iron in the Netherlands Cohort (ZINC) study. ZPP and Hb were measured at each subsequent donation during a 4-year period after inclusion in the study.

RESULTS

Median ZPP levels were higher in repeat than in first-time donors. In first-time donors, especially women, ZPP levels were increased with a corresponding decline in Hb levels over subsequent donations. ZPP levels were increased among first-time donors deferred for low Hb.

CONCLUSION

Our results suggest that adding ZPP to Hb measurements in the daily blood collection setting, especially for first-time donors and first-time female donors may add to the identification of a donor subpopulation with low functional iron stores.

Anonymizing datasets with demographics and diagnosis codes in the presence of utility constraints

Publishing data about patients that contain both demographics and diagnosis codes is essential to perform large-scale, low-cost medical studies. However, preserving the privacy and utility of such data is challenging, because it requires: (i) guarding against identity disclosure (re-identification) attacks based on both demographics and diagnosis codes, (ii) ensuring that the anonymized data remain useful in intended analysis tasks, and (iii) minimizing the information loss, incurred by anonymization, to preserve the utility of general analysis tasks that are difficult to determine before data publishing. Existing anonymization approaches are not suitable for being used in this setting, because they cannot satisfy all three requirements. Therefore, in this work, we propose a new approach to deal with this problem. We enforce the requirement (i) by applying (k,k^m)-anonymity, a privacy principle that prevents re-identification from attackers who know the demographics of a patient and up to m of their diagnosis codes, where k and m are tunable parameters. To capture the requirement (ii), we propose the concept of utility constraint for both demographics and diagnosis codes. Utility constraints limit the amount of generalization and are specified by data owners (e.g., the healthcare institution that performs anonymization). We also capture requirement (iii), by employing well-established information loss measures for demographics and for diagnosis codes. To realize our approach, we develop an algorithm that enforces (k,k^m)-anonymity on a dataset containing both demographics and diagnosis codes, in a way that satisfies the specified utility constraints and with minimal information loss, according to the measures. Our experiments with a large dataset containing more than 200,000 electronic health records show the effectiveness and efficiency of our algorithm.

A high throughput biochemical fluorometric method for measuring lipid peroxidation in HDL

Current cell-based assays for determining the functional properties of high-density lipoproteins (HDL) have limitations. We report here the development of a new, robust fluorometric cell-free biochemical assay that measures HDL lipid peroxidation (HDLox) based on the oxidation of the fluorochrome Amplex Red. HDLox correlated with previously validated cell-based (r = 0.47, p<0.001) and cell-free assays (r = 0.46, p<0.001). HDLox distinguished dysfunctional HDL in established animal models of atherosclerosis and Human Immunodeficiency Virus (HIV) patients. Using an immunoaffinity method for capturing HDL, we demonstrate the utility of this novel assay for measuring HDLox in a high throughput format. Furthermore, HDLox correlated significantly with measures of cardiovascular diseases including carotid intima media thickness (r = 0.35, p<0.01) and subendocardial viability ratio (r = -0.21, p = 0.05) and physiological parameters such as metabolic and anthropometric parameters (p<0.05). In conclusion, we report the development of a new fluorometric method that offers a reproducible and rapid means for determining HDL function/quality that is suitable for high throughput implementation.

Mobilization characteristics and strategies to improve hematopoietic progenitor cell mobilization and collection in patients with chronic granulomatous disease and severe combined immunodeficiency

BACKGROUND

Granulocyte-colony-stimulating factor (G-CSF)-mobilized autologous hematopoietic progenitor cells (HPCs) may be collected by apheresis of patients with chronic granulomatous disease (CGD) and severe combined immunodeficiency (SCID) for use in gene therapy trials. CD34+ cell mobilization has not been well characterized in such patients.

STUDY DESIGN AND METHODS

We retrospectively evaluated CD34+ cell mobilization and collection in 73 consecutive CGD and SCID patients and in 99 age-, weight-, and G-CSF dose-matched healthy allogeneic controls.

RESULTS

In subjects aged not more than 20 years, Day 5 preapheresis circulating CD34+ counts were significantly lower in CGD and SCID patients than in controls; mean peak CD34+ cell counts were 58 × 10(6) , 64 × 10(6) , and 87 × 10(6) /L, respectively (p = 0.01). The SCIDs had lower CD34+ collection efficiency than CGDs and controls; mean efficiencies were 40, 63, and 57%, respectively (p = 0.003). In subjects aged more than 20 years, the CGDs had significantly lower CD34+ cell mobilization than controls; mean peak CD34+ cell counts were 41 × 10(6) and 113 × 10(6) /L, respectively (p < 0.0001). In a multivariate analysis, lower erythrocyte sedimentation rate (ESR) at mobilization was significantly correlated with better CD34+ cell mobilization (p = 0.007). In SCIDs, CD34 collection efficiency was positively correlated with higher red blood cell (RBC) indices (mean RBC volume, R(2)  = 0.77; mean corpuscular hemoglobin [Hb], R(2)  = 0.94; mean corpuscular Hb concentration, R(2)  = 0.7; p < 0.007) but not Hb.

CONCLUSIONS

CGD and SCID populations are characterized by significantly less robust CD34+ HPC mobilization than healthy controls. The presence of active inflammation or infection as suggested by an elevated ESR may negatively impact mobilization. Among SCIDs, markedly reduced CD34 collection efficiencies were related to iron deficiency, wherein decreased RBC size and density may impair apheresis cell separation mechanics.

Blood donation by elderly repeat blood donors

BACKGROUND

Upper age limits for blood donors are intended to protect elderly blood donors from donor reactions. However, due to a lack of data about adverse reactions in elderly blood donors, upper age limits are arbitrary and vary considerably between different countries.

METHODS

Here we present data from 171,231 voluntary repeat whole blood donors beyond the age of 68 years.

RESULTS

Blood donations from repeat blood donors beyond the age of 68 years increased from 2,114 in 2005 to 38,432 in 2012 (from 0,2% to 4.2% of all whole blood donations). Adverse donor reactions in repeat donors decreased with age and were lower than in the whole group (0.26%), even in donors older than 71 years (0.16%). However, from the age of 68 years, the time to complete recovery after donor reactions increased. Donor deferrals were highest in young blood donors (21.4%), but increased again in elderly blood donors beyond 71 years (12.6%).

CONCLUSION

Blood donation by regular repeat blood donors older than 71 years may be safely continued. However, due to a lack of data for donors older than 75 years, blood donation in these donors should be handled with great caution.

Hemorrhage-adjusted iron requirements, hematinics and hepcidin define hereditary hemorrhagic telangiectasia as a model of hemorrhagic iron deficiency

Background

Iron deficiency anemia remains a major global health problem. Higher iron demands provide the potential for a targeted preventative approach before anemia develops. The primary study objective was to develop and validate a metric that stratifies recommended dietary iron intake to compensate for patient-specific non-menstrual hemorrhagic losses. The secondary objective was to examine whether iron deficiency can be attributed to under-replacement of epistaxis (nosebleed) hemorrhagic iron losses in hereditary hemorrhagic telangiectasia (HHT).

Methodology/Principal Findings

The hemorrhage adjusted iron requirement (HAIR) sums the recommended dietary allowance, and iron required to replace additional quantified hemorrhagic losses, based on the pre-menopausal increment to compensate for menstrual losses (formula provided). In a study population of 50 HHT patients completing concurrent dietary and nosebleed questionnaires, 43/50 (86%) met their recommended dietary allowance, but only 10/50 (20%) met their HAIR. Higher HAIR was a powerful predictor of lower hemoglobin (p = 0.009), lower mean corpuscular hemoglobin content (p<0.001), lower log-transformed serum iron (p = 0.009), and higher log-transformed red cell distribution width (p<0.001). There was no evidence of generalised abnormalities in iron handling Ferritin and ferritin² explained 60% of the hepcidin variance (p<0.001), and the mean hepcidinferritin ratio was similar to reported controls. Iron supplement use increased the proportion of individuals meeting their HAIR, and blunted associations between HAIR and hematinic indices. Once adjusted for supplement use however, reciprocal relationships between HAIR and hemoglobin/serum iron persisted. Of 568 individuals using iron tablets, most reported problems completing the course. For patients with hereditary hemorrhagic telangiectasia, persistent anemia was reported three-times more frequently if iron tablets caused diarrhea or needed to be stopped.

Conclusions/significance

HAIR values, providing an indication of individuals’ iron requirements, may be a useful tool in prevention, assessment and management of iron deficiency. Iron deficiency in HHT can be explained by under-replacement of nosebleed hemorrhagic iron losses.

Effect of increasing hemoglobin cutoff in male donors and increasing interdonation interval in whole blood donors at a hospital-based blood donor center

BACKGROUND

The NHANES-III survey found hemoglobin (Hb) concentrations of more than 13.5 g/dL and more than 12.0 g/dL in normal Caucasian males and females. In the United States, a Hb of least 12.5 g/dL is required for blood donation, which allows "anemic" males to donate while excluding "normal" females. Low Hb is the major cause of deferral in donors and deferrals are associated with decreased donor return rates. Additionally, frequent blood donations are associated with depletion of body iron stores. Analysis of the effect of various Hb cutoffs and interdonation intervals on our center's blood supply is presented.

STUDY DESIGN AND METHODS

Whole blood donor data for a 12-month period were studied. Potential effects on the blood supply by increasing male Hb eligibility levels and/or increasing the interdonation interval were analyzed.

RESULTS

A total of 13,519 individuals (females, 56%) donated 30,678 units (mean frequency, male 2.7 and females 2.1) with the majority (42%) donating once. Increasing the male Hb eligibility to at least 13.5 g/dL will decrease collections by 1457 (5%) units. In addition, decreasing the female Hb eligibility to at least 12.0 g/dL will result in total gain of 307 (1%) units. Considering 12-week interdonation interval and Hb eligibility of at least 13.5 g/dL (male) and at least 12.5 g/dL (female) results in decrease of 11% (3352) units.

CONCLUSIONS

Increasing the Hb cutoff for male donors and/or interdonation interval for all donors will decrease available blood, some of which may be reduced by decreasing the Hb cutoff for females to at least 12.0 g/dL. As a majority of the donors donate only once with mean donation frequency being 2.4, it may be possible to overcome this shortfall by targeted recruitment of donors donating once.

Population-based screening for anemia using first-time blood donors

Anemia is an important public health concern. Data from population-based surveys such as the National Health and Nutrition Examination Survey (NHANES) are the gold standard, but are obtained infrequently and include only small samples from certain minority groups. We assessed whether readily available databases of blood donor hemoglobin values could be used as a surrogate for population hemoglobin values from NHANES. Blood donor venous and fingerstick hemoglobin values were compared to 10,254 NHANES 2005-2008 venous hemoglobin values using demographically stratified analyses and ANOVA. Fingerstick hemoglobins or hematocrits were converted to venous hemoglobin estimates using regression analysis. Venous hemoglobin values from 1,609 first time donors correlated extremely well with NHANES data across different ages, genders, and demographic groups. Cigarette smoking increased hemoglobin by 0.26-0.59 g/dL depending on the intensity. Converted fingerstick hemoglobin from 36,793 first time donors agreed well with NHANES hemoglobin (weighted mean hemoglobin of 15.53 g/dL for donors and 15.73 g/dL for NHANES) with similar variation in mean hemoglobin by age. However, compared to NHANES, the larger donor data set showed reduced differences in mean hemoglobin between Blacks and other races/ethnicities. Overall, first-time donor fingerstick hemoglobins approximate US population data and represent a readily available public health resource for ongoing anemia surveillance.

Clinical evaluation of iron treatment efficiency among non-anemic but iron-deficient female blood donors: a randomized controlled trial

BACKGROUND

Iron deficiency without anemia is related to adverse symptoms that can be relieved by supplementation. Since a blood donation can induce such an iron deficiency, we investigated the clinical impact of iron treatment after a blood donation.

METHODS

One week after donation, we randomly assigned 154 female donors with iron deficiency without anemia, aged below 50 years, to a four-week oral treatment of ferrous sulfate versus a placebo. The main outcome was the change in the level of fatigue before and after the intervention. Aerobic capacity, mood disorder, quality of life, compliance and adverse events were also evaluated. Hemoglobin and ferritin were used as biological markers.

RESULTS

The effect of the treatment from baseline to four weeks of iron treatment was an increase in hemoglobin and ferritin levels to 5.2 g/L (P < 0.01) and 14.8 ng/mL (P < 0.01), respectively. No significant clinical effect was observed for fatigue (-0.15 points, 95% confidence interval -0.9 points to 0.6 points, P = 0.697) or for other outcomes. Compliance and interruption for side effects was similar in both groups. Additionally, blood donation did not induce overt symptoms of fatigue in spite of the significant biological changes it produces.

CONCLUSIONS

These data are valuable as they enable us to conclude that donors with iron deficiency without anemia after a blood donation would not clinically benefit from iron supplementation.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00981877.

A proposal and prototype for a Research Risk Repository to improve the protection of research participants

Background Accurate and consistent risk assessment is vital for the protection of research participants. Yet, current evaluation of the risks of research interventions often does not take into account the relevant empirical data. This approach raises concern that current practice may not be protecting research participants adequately, or that it may be thwarting acceptable research.

Purpose To propose and evaluate the possibility of creating and maintaining a Research Risk Repository which would make empirical data on the risks of research interventions available to institutional review boards, investigators, funders, and others.

Methods Analysis of the usefulness of a Research Risk Repository and evaluation of whether currently available empirical data are sufficient to establish such a repository.

Results Creation of a Research Risk Repository would provide a vital resource for systematically and accurately evaluating the risks of biomedical research. Realizing this goal requires data that have at least 4 characteristics: (1) trustworthy: to ensure credibility to all stakeholders; (2) robust: to support confident risk determinations; (3) inclusive: to cover all potential harms of the interventions under review; and (4) comprehensive: to determine which factors influence the risks of the interventions under review. Evaluation of existing data reveals that they satisfy these requirements for only a few research interventions and, even in those cases, only to a limited extent. Gaps in the currently available evidence highlight the need for systematic collection and maintenance of data on the risks posed by research interventions.

Limitations Creation and maintenance of a Research Risk Repository would be costly and require regular updating as new data are collected, and new practices and interventions emerge.

Conclusions A Research Risk Repository has the potential to significantly improve the consistency and accuracy of the evaluation of research risks. However, currently available data are generally insufficient for this purpose. Future collection and maintenance of data on the risks posed by research interventions will help to ensure that research participants receive appropriate protection and promote important research consistent with adequate subject protection.

Clinical and epidemiological profile of blood donors with positive serology for viral hepatitis in southern Brazil

INTRODUCTION: Positive serological tests for hepatitis viruses B and C at blood banks are an important reason for blood deferral. Additionally, high residual risk for transfusing hepatitis-contaminated blood has been estimated in southern Brazil. This study aimed to identify risk factors for positive serological tests for viral hepatitis (VH) in blood donors (BD). METHODS: A case-control study included consecutive BD with positive serology for VH, between 2008 and 2009. Cases and controls (BD with negative serology for VH) were paired 1:1 by sex and donation date. Assessment of clinical and epidemiological characteristics related to viral hepatitis was conducted. RESULTS: Among 1,282 blood donors (641 cases and 641 controls), those with positive serology for viral hepatitis had higher mean age (p<0.001); higher proportion of replacement donation (p<0.001); first donation (p<0.001); and interviewer deferment (p=0.037), compared to controls. Furthermore, donors with positive tests were less regular donors (p<0.001), had less previous history of rejection (p=0.003) and showed lower hematocrit median before donation (p=0.019). Multivariate analysis demonstrated that age (OR=1.056, 95%CI 1.042-1.069, p<0.001), replacement donation (OR=1.545, 95%CI 1.171-2.038, p=0.002) and first donation (OR=9.931, 95%CI 7.486-13.173, p<0.001) were independently associated with positivity of serological tests for viral hepatitis. CONCLUSIONS: Specific characteristics of blood donors were associated with positive serology for viral hepatitis. These peculiarities should be taken into account when assessing candidates for blood donation.

The safety of blood donation by elderly blood donors

BACKGROUND  Due to the ageing population, blood donation by the elderly is necessary to maintain blood supply. We initiated a prospective study, to assess whether there is an increased risk of donor reactions in elderly donors. STUDY DESIGN AND METHODS  In this prospective study, regular donors aged from 66 to 68 and 69 to 71 years were invited to continue blood donation on mobile collection sites of the German Red Cross Blood Service West. A control group (50-52 years) was established. Admission of donors in all groups followed the German national guidelines for blood donation. Donor deferrals and all kinds of donor reactions during donation (on-site) and in the 48 h following donation (off-site) were monitored. RESULTS  A total of 64 260 valid cases were entered in the study. Donor deferrals increased with age from 1·12% in the control group up to 8·74 in female donors aged 69-71 years. Adverse reactions to blood donation were rare with an overall reaction rate of 0·63% (0·05% on-site; 0·58% off-site). Off-site reactions significantly decreased with increasing age. The relative risk (RR) for adverse reactions in elderly donors compared to the control group (50-52 years) was slightly increased for on-site reactions in the 69- to 71-year-old donors (RR 1·0309; 95% CI 1·0292-1·0325). In all other comparisons, the RR for adverse reactions was distinctively lower in elderly donors (RR 0·3785 - 0·7778). CONCLUSIONS  Our data confirm that elderly regular blood donors may safely continue blood donation at least to the age of 71. Based on these data, we increased the upper age limit.

Blood center practice and education for blood donors with anemia

BACKGROUND

Anemia is an early indicator of many diseases, yet blood donors with low hematocrit (Hct) often receive inadequate information about its medical importance. We sought to understand the types of information that are and should be provided to these donors.

STUDY DESIGN AND METHODS

Two companion studies were performed. The first investigated blood center practices for care of donors with low Hct including deferral length, information provided, and cutoff values used when referring donors for medical attention. The second was a randomized prospective pilot study comparing behavior of deferred donors receiving an "older" pamphlet providing a list of iron-rich foods or a "newer" pamphlet providing descriptions of common causes of anemia and advice for seeking medical attention.

RESULTS

More than 70% of centers defer donors for 1 day. Only 6% defer donors for more than 2 weeks. Most centers provide written and/or verbal information about low Hct. Only 35% have a cutoff value defining significant anemia that requires additional medical attention. In the study of donors with low Hct, significant disease was identified within 3 months after deferral in 2 of 104 subjects: metastatic lung cancer and acute lymphocytic leukemia. Only donors receiving the newer pamphlet reported that it "definitely improved" their ability to speak with their doctor about anemia.

CONCLUSIONS

The diagnosis of anemia in blood donors may be an indicator of significant undiagnosed disease. There are wide variations in how centers care for and educate donors with anemia. Donors with anemia should be provided improved and consistent educational information.

Improved safety for young whole blood donors with new selection criteria for total estimated blood volume

BACKGROUND

Young age, first-time donation status, and estimated blood volume (EBV) are leading determinants of syncopal complications after whole blood donation. We evaluated a multifaceted safety initiative and more restrictive selection criteria for whole blood donation by individuals younger than 19 years.

STUDY DESIGN AND METHODS

Measures introduced over 2 years addressed donor education, drive environment and supervision, and new eligibility criteria for EBV of 3.5 L or more based on height, weight, and sex for individuals younger than 19 years. Presyncopal and syncopal reactions after whole blood donation during the school year in the baseline, transitional (2008), and full implementation (2009) periods were evaluated.

RESULTS

Young donors (16- to 18-years-olds) gave 754,402 and 710,922 whole blood donations in the 2008 and 2009 school years accounting for 16% of the total collections in both 9-month study periods. The new selection criteria were associated with a significant reduction in the reaction rates among 16- to 18-year-olds. Sixteen-year-old donors had the greatest decrease in 2009 compared to baseline for presyncopal reactions (10.5% vs. 7.3%; odds ratio [OR], 0.67; 95% confidence interval [CI], 0.65-0.69) and syncope (43.1 vs. 37.1 per 10,000 donations; OR, 0.86; 95% CI, 0.77-0.96). Donor subgroup analysis by sex, age, and donation status demonstrated that age-related differences in reaction rates were eliminated in 2009.

CONCLUSION

The safety initiative with new selection criteria for EBV led to decreased complications among donors 16 to 18 years old, such that the risk for 16-year-olds was no longer different from that observed for 19-year-olds in the analysis stratified by age, sex, and donation status.

The value of routine ferritin measurement in blood donors

BACKGROUND

Iron store deficiency is a common side effect of whole blood donation. Early recognition and reversal of excessive iron loss may avoid symptomatic iron store depletion in blood donors and reduce volunteer loss due to iron deficiency (ID) anemia.

STUDY DESIGN AND METHODS

Between 1996 and 2009, a total of 160,612 visits with the intention to donate blood by 23,557 healthy volunteers were recorded at our center. As of 2004, routine serum ferritin testing and additional counseling of donors at risk for donation-induced anemia were implemented. We analyzed the impact of this measure on the hemoglobin (Hb) levels and anemia occurrence in our donor population and in particular in women of childbearing age. Donation rejections due to low Hb counts, the intervals to next donation, and return rates thereafter were also assessed.

RESULTS

The introduction of routine serum ferritin analysis resulted in an increase of mean Hb levels in blood donors particularly in women of childbearing age. The incidence of predonation anemia and donation ineligibility due to a low Hb concentration decreased significantly. The return intervals of donors rejected on account of low Hb levels were shortened; however, the return rates thereafter were also curtailed.

CONCLUSIONS

Systematic serum ferritin measurements allowed an optimized management of ID in our donors and efficacious prevention of ID anemia.

Serum hepcidin as a diagnostic test of iron deficiency in premenopausal female blood donors

BACKGROUND

Currently used indicators of iron status have limitations. Hepcidin, a key regulator of iron metabolism, is reduced in iron deficiency. We sought to determine the properties of hepcidin as a diagnostic test of iron deficiency.

DESIGN AND METHODS

Sera from female, non-anemic, whole blood donors were analyzed for hepcidin (enzyme-linked immunosorbent assay), ferritin, soluble transferrin receptor and C-reactive protein. Iron deficiency was defined as (i) serum ferritin less than 15 ng/mL or (ii) soluble transferrin receptor /log(ferritin) index greater than 3.2 if the C-reactive protein concentration was less than 10 mg/L, or greater than 2.2 if the C-reactive protein concentration was greater than 10 mg/L). Receiver operating characteristic curves were plotted to determine the overall utility and identify optimal cut-points of hepcidin as a test of iron deficiency.

RESULTS

In 261 blood donors the prevalence of iron deficiency defined by ferritin concentration was 59/261 [22.6% (17.5, 27.7)], whereas defined by soluble transferrin receptor/log(ferritin) index it was 53/261 [20.4% (15.4, 25.2)]. The 95% reference range of hepcidin concentration in the iron-replete population was 8.2-199.7 ng/mL. The area under the receiver operating characteristic curve for hepcidin compared with ferritin concentration less than 15 ng/mL was 0.87 (0.82, 0.92), while that compared with the soluble transferrin receptor /log(ferritin) index was 0.89 (95% CI 0.84, 0.93). For a diagnosis of iron deficiency defined by the soluble transferrin receptor/log(ferritin) index, hepcidin less than 8 ng/mL had a sensitivity of 41.5% and a specificity of 97.6%, while hepcidin less than 18 ng/mL had a sensitivity of 79.2% and a specificity of 85.6%.

CONCLUSIONS

Serum hepcidin concentration may be a useful indicator of deficient iron stores. Further studies are required to evaluate the role of hepcidin in the diagnosis of iron deficiency in other groups of patients.

Demographic correlates of low hemoglobin deferral among prospective whole blood donors

BACKGROUND

Approximately 10% of attempted blood donations are not allowed because of low hemoglobin (Hb) deferral.

STUDY DESIGN AND METHODS

Low Hb deferrals were tracked in more 715,000 whole blood donors at six blood centers across the United States. A multivariable logistic regression model was developed to comprehensively assess demographic correlates for low Hb deferral.

RESULTS

Demographic factors significantly associated with low Hb deferral include female sex (11 times greater odds than males), increasing age in men (men over 80 have 29 times greater odds than men under 20), African American race (2-2.5 times greater odds than Caucasians), Hispanic ethnicity in women (1.29 times greater odds than Caucasian women), and weight in men (men under 124 pounds have 2.5 times greater odds than men over 200 pounds). Interestingly, increasing donation frequency is associated with decreased odds for low Hb deferral (women with one donation in the previous 12 months have two times greater odds than those with six donations).

CONCLUSIONS

Low Hb deferral is associated with female sex, older age, African American race/ethnicity, and lower body weight in men. An inverse association with donation frequency suggests a selection bias in favor of donors able to give more frequently. These data provide useful information that can be utilized to manage blood donors to limit low Hb deferrals and assist in policy decisions such as changing the Hb cutoff or permissible frequency of donation. They also generate hypotheses for new research of the causes of anemia in defined groups of donors.

Selection criteria to protect the blood donor in North America and Europe: past (dogma), present (evidence), and future (hemovigilance)

The safety of the blood supply depends on measures to protect not only the transfusion recipient but also the blood donor. Donor selection criteria have been voluntarily adopted or enforced through regulation in different countries, but review of practices in different blood centers reveals wide disparity in the current approaches. Such variability in practice suggests that the criteria for the protection of donor are often arbitrary or reflect deeply engrained precautionary practices and exposes the inherent uncertainty about the best way to minimize risk to the donor. Certain selection criteria introduced years ago have become dogma in some countries but were never subjected to systematic study and persist despite available evidence that the measures do not measurably improve donor safety. Current efforts to define a rational, evidence-based approach are crucial to eliminate practices that lead to the unnecessary deferral of large numbers of blood donors without improving the safety of the donation process. Future prospects to improve the safety of the donation process rest with hemovigilance initiatives to monitor the effectiveness of interventions to minimize the risks to blood donors.

Influence of blood donation on levels of water-soluble vitamins

Iron depletion is a well-known side effect of blood donation. Research evidence also suggests an increasing prevalence of vitamin deficiency in apparently healthy subjects, but there is little information regarding the relationship between blood donation and vitamin status. A total of 217 volunteers (80 first-time and 137 repeat blood donors) were consecutively enrolled in the study. All subjects completed self-administered medical history and food intake forms, which included questions regarding alcohol consumption and smoking as well as on vitamin supplement, iron and contraceptive use (females). Vitamin B6, folic acid, vitamin B12 and biotin levels were measured using standard techniques. The mean vitamin levels of first-time and repeat blood donors did not significantly differ. Vitamin deficiencies occurred in both first-time and repeat blood donors but not on vitamin supplements. Vitamin status was affected by alcohol, nicotine and contraceptives. Blood donation does not decrease the level of water-soluble vitamins. Vitamin deficiencies occur in apparently healthy first-time as well as in repeat blood donors and can be prevented by vitamin supplementation.