Turbid plasma donations in whole blood donors: fat chance?

Preparation of Cryoprecipitate and Cryo-depleted Plasma for Proteomic Research Analysis

When frozen plasma is slowly thawed in cold conditions (1-6 °C), high-molecular-weight plasma proteins precipitate forming a concentrate known as cryoprecipitate. The concentrate is enriched with several important coagulation proteins, including fibrinogen, antihemophilic factor (factor VIII), von Willebrand factor, fibrin stabilizing factor (factor XIII), fibronectin, and small amounts of other plasma proteins. In current medical practice, clinical-grade preparations of cryoprecipitate are used mostly to correct fibrinogen deficiency caused by acute blood loss or due to functional abnormalities of the fibrinogen protein. In the past, cryoprecipitate was used to treat von Willebrand disease and hemophilia A (factor VIII deficiency), but the availability of more highly purified coagulation factor concentrates or recombinant protein preparations has superseded the use of cryoprecipitate for these coagulopathies. Cryo-depleted plasma (also called cryosupernatant) is the plasma supernatant remaining following removal of the cryoprecipitate from frozen-thawed plasma and contains all the remaining soluble plasma proteins. This protocol describes the research-scale preparation of cryoprecipitate and cryo-depleted plasma suitable for proteomic studies and is based on the procedures used to prepare clinical-grade cryoprecipitate.

Altered color of plasma component - Unnecessary wastage of a precious resource

BACKGROUND AND OBJECTIVES

The present study was conducted to evaluate the etiology of altered color of plasma component of blood in transfusion practice.

MATERIALS AND METHODS

The study was conducted at the blood center of a tertiary care teaching hospital in western India for a period of 6 months. After component separation, all the plasma units with altered color were segregated and samples were taken for further evaluation. Altered colored plasma units were divided into three - green discoloration, yellow discoloration, and lipemic plasma. Donors were called, their detailed history was taken, and necessary investigations were done accordingly.

RESULTS

Forty plasma units out of 20,658 (0.19%) donations showed discoloration. Out of which, 3 plasma units showed green discoloration, 9 plasma units showed yellow discoloration, and the remaining 28 plasma units were lipemic. Among three donors whose plasma showed green discoloration, one female donor had a history of oral contraceptive pill usage and had higher values of copper and ceruloplasmin. All donors with yellow plasma had a higher value of unconjugated bilirubin. All the donors with lipemic plasma gave a history of intake of fatty meal prior to donating blood and showed higher values of triglyceride, cholesterol, and very-low-density lipoprotein.

CONCLUSION

Plasma component with altered color restricts its issue to the patient and also for use in fractionation. In our study, many of the altered color plasma units were safe to transfuse, but the decision regarding transfusion was debatable on consultation with the treating doctor. Further studies with a large sample size are recommended for the use of these plasma components.

Plasma lipemia: When the blood donor becomes a patient

Lipemic plasma donations are not a strange phenomenon to blood bankers. According to quality standards for plasma fractionation, lipemic plasma donations must be discarded. Beyond quality control and inventory aspects, plasma lipemia is also an important risk factor for cardiovascular diseases, acute pancreatitis and is associated with overall mortality, however little attention is given to the management of these donors in the literature. A retrospective analysis of every whole blood donation that yielded lipemic plasma between January 1st 2018 and December 31st 2019 was made. The medical examination and donor history for the respective donation was reviewed and the available data was collected regarding hour of donation, gender, age, drugs and coexisting pathologies. Whether the donor was called back for a follow up evaluation regarding the lipemic plasma was also noted. Our blood center received 18274 whole blood donations of which 115 (0,63 %) were reported as having plasma lipemia, in the period of this study. Of these 115 donors, 103 (89,57 %) were male. The average age was 47,63 ± 10,65 years. A clear peak in lipemic plasma donations 4 hours after the classic lunch hours is visible. For 88,70 % of the donors, this was the first time their hypertriglyceridemia was identified. The nonfasting elevation of plasma triglycerides in these donors represents a true metabolic derangement. This is a golden opportunity for early intervention and follow up evaluation is indicated. More attention must be given during the medical evaluation to properly identify donors at risk of lipemic donations.

Current Understanding of the Relationship between Blood Donor Variability and Blood Component Quality

While differences among donors has long challenged meeting quality standards for the production of blood components for transfusion, only recently has the molecular basis for many of these differences become understood. This review article will examine our current understanding of the molecular differences that impact the quality of red blood cells (RBC), platelets, and plasma components. Factors affecting RBC quality include cytoskeletal elements and membrane proteins associated with the oxidative response as well as known enzyme polymorphisms and hemoglobin variants. Donor age and health status may also be important. Platelet quality is impacted by variables that are less well understood, but that include platelet storage sensitive metabolic parameters, responsiveness to agonists accumulating in storage containers and factors affecting the maintenance of pH. An increased understanding of these variables can be used to improve the quality of blood components for transfusion by using donor management algorithms based on a donors individual molecular and genetic profile.

Strawberry milky-white blood donor's plasma: signaling uncontrolled diabetic lipemia

Intake of a fatty meal before donating blood can lead to an increased level of plasma triglyceride concentration for several hours. This may cause either turbid and or "milky-white" appearance of their venous plasma samples. We, however, report a peculiar case about a male blood donor from India, whose plasma appeared to be "strawberry milky-white" in colour. On inquiry, he gave a history of poorly controlled diabetes mellitus type-II. Further, this was affirmed by his high blood glucose concentration [nearly 326mg/dL] and HbA1c [13.7%] respectively. Moreover, his plasma triglyceride concentration was elevated up to 376mg/dL. His treatment was started at our hospital and the strawberry colour of his plasma, dramatically recovered to normal straw-colour after achieving a fairly good glycemic control with the insulin therapy.

Deciphering the reasons for milky-white blood donor plasma

Donors who eat a fatty meal before donating blood are known to have an increased level of plasma triglyceride concentrations for several hours. This may contribute to "milky-white" appearance of their plasma samples. We herein report the case of a blood donor who gave a history of the intake of a fatty meal, on the night prior to donation. This was affirmed by his serum lipid concentration done on the following day and on repeating the same subsequently after two weeks of donation respectively.

Lifestyle behaviours are not associated with haemolysis: results from Donor InSight

BACKGROUND

Lifestyle behaviours such as physical activity, sedentary behaviour and dietary habits have been shown to influence blood lipid levels, and both lifestyle and blood lipids may be associated with haemolysis during storage of blood products. We aimed to investigate whether lifestyle behaviours are associated with degree of haemolysis in red cell concentrates (RCC), and if such associations are mediated by low-density lipoprotein (LDL) cholesterol and triglyceride levels.

MATERIALS AND METHODS

Cross-sectional analyses were performed in data from 760 Dutch blood donors participating in Donor InSight, an observational cohort study. Linear regression analyses were conducted to assess associations of lifestyle behaviours with haemolysis levels in RCC 28 days after blood sampling. Lifestyle behaviours included moderate-to-vigorous physical activity and sedentary behaviour measured by accelerometry, and self-reported intake of a selection of foods potentially related to blood lipids, i.e. consumption of eggs, meat, nuts and fish. Potential mediating roles of both LDL cholesterol and triglyceride levels were investigated separately. All analyses were adjusted for relevant confounders.

RESULTS

No statistically significant nor substantial associations of any of the lifestyle behaviours with haemolysis in RCC were found, nor were there any associations between lifestyle behaviours and blood lipids. We did find consistent positive associations of LDL cholesterol and triglyceride levels with haemolysis in RCC during storage.

DISCUSSION

In this large cohort, blood lipid levels were consistently associated with haemolysis in RCC. Nonetheless, there was no evidence for an association between lifestyle behaviours and haemolysis in RCC, or for mediating effects by blood lipid levels.

Red blood cell components: time to revisit the sources of variability

Quality and safety of red blood cell (RBC) components is managed by screening of donors and strict regulatory controls of blood collection, processing and storage procedures. Despite these efforts, variations in RBC component quality exist as exemplified by the wide range in storage-induced haemolysis. This article provides a brief overview of the variables that contribute or potentially contribute to the quality of stored RBC components, including blood collection, processing, and donor-related variables. Particular focus is made on donor health and lifestyle factors that are not specifically screened and may impact on the physicobiochemical properties of RBCs and their storability. Inflammatory and oxidative stress states may be especially relevant as RBCs are susceptible to oxidative injury. Few studies have investigated the effect of specific donor-related variables on the quality of stored RBC components. Donor-related variables may be unaccounted confounders in the "age of blood" clinical studies that compared outcomes following transfusion of fresher or longer-stored RBC components. The conclusion is drawn that the blood donor is the greatest source of RBC component variability and the least "regulated" aspect of blood component production. It is proposed that more research is needed to better understand the connection between donor-related variables and quality consistency of stored RBC components. This could be very important given the impact of modern lifestyles that sees escalating rates of non-communicable health conditions that are associated with increased oxidative stress, such as hypertension, obesity and diabetes in children and adults, as well as an ageing population in many countries. The effect of these changes to global health and population demographics will impact on blood donor panels, and without significant new research, the consequences on the quality of stored blood components and transfusion outcomes are unknown.

A Protocol for the Preparation of Cryoprecipitate and Cryo-depleted Plasma for Proteomic Studies

Cryoprecipitate is a concentrate of high-molecular-weight plasma proteins that precipitate when frozen plasma is slowly thawed at 1-6 °C. The concentrate contains factor VIII (antihemophilic factor), von Willebrand factor (vWF), fibrinogen, factor XIII, fibronectin, and small amounts of other plasma proteins. Clinical grade preparations of cryoprecipitate are mainly used to treat fibrinogen deficiency caused by acute bleeding or functional abnormalities of the fibrinogen protein. In the past, cryoprecipitate was used to treat von Willebrand disease and hemophilia A (factor VIII deficiency), but the availability of more highly purified coagulation factor concentrates or recombinant protein preparations has superseded the use of cryoprecipitate for these coagulopathies. Cryo-depleted plasma ("cryosupernatant") is the plasma supernatant remaining following removal of the cryoprecipitate from frozen-thawed plasma. It contains all the other plasma proteins and clotting factors present in plasma that remain soluble during cold-temperature thawing of the plasma. This protocol describes the clinical-scale preparation of cryoprecipitate and cryo-depleted plasma for proteomic studies.

Genetic variations of CD36 and low platelet CD36 expression - a risk factor for lipemic plasma donation in Taiwanese apheresis donors

BACKGROUND

New CD36 mutations are constantly being identified, although no study has specifically targeted a Taiwanese population. CD36 deficiency can result in dyslipid state and slow clearance of chylomicron. This could be linked to more frequent lipemic donations.

STUDY DESIGN AND METHODS

We used flow cytometric methods to study the CD36 deficiency in 640 regular volunteer platelet apheresis donors from Taipei blood centre. The coding exons of CD36 gene were sequenced in CD36-deficient individuals, and the allele frequencies of CD36 variants were determined in the larger population by mutation-specific PCR and oligonucleotide hybridization. Visual inspection of lipemic plasma was routinely performed on samples taken before commencement of apheresis. Individuals found to have lipemic plasma are deferred until next donation. We investigated the link between positive lipemic deferral record and low platelet CD36 expression status.

RESULTS

We found four donors (0·6%) with type I CD36 deficiency (both platelets and monocytes CD36(null) ) and six (1·0%) with type II CD36 deficiency (PLT: CD36(null) , monocyte: CD36(low) ). Six CD36 genetic variants were identified, two of them were novel, all but one are found exclusively in CD36(null) and CD36(low) expressors. Subjects with CD36 genetic variants also displayed deficient or reduced CD36 on monocytes. Donors with null or low PLT CD36 expression were more likely to have a lipemic deferral record than control subjects with normal PLT CD36 expression (X(2) = 27·36, odds ratio = 2·6, 95% conference interval: 1·8-3·8, P < 0·0001).

CONCLUSION

Through this study, we established a donor registry to supply CD36-negative platelets for patients in need.

Challenge study of the pathogen reduction capacity of the THERAFLEX MB-Plasma technology

BACKGROUND AND OBJECTIVES

Although most pathogen reduction systems for plasma primarily target viruses, bacterial contamination may also occur. This study aimed to investigate the bacterial reduction capacity of a methylene blue (MB) treatment process and its virus inactivation capacity in lipaemic plasma.

MATERIALS AND METHODS

Bacterial concentrations in plasma units spiked with different bacterial strains were measured before and after the following steps of the THERAFLEX MB-Plasma procedure: leucocyte filtration, MB/light treatment and MB filtration. Virus inactivation was investigated for three virus types in non-lipaemic, borderline lipaemic and highly lipaemic plasma.

RESULTS

Leucocyte filtration alone efficiently eliminated most of the tested bacteria by more than 4 logs (Staphylococcus epidermidis and Staphylococcus aureus) or to the limit of detection (LOD) (≥ 4.8 logs; Escherichia coli, Bacillus cereus and Klebsiella pneumoniae). MB/light and MB filtration further reduced Staphylococcus epidermidis and Staphylococcus aureus to below the LOD. The small bacterium Brevundimonas diminuta was reduced by 1.7 logs by leucocyte filtration alone, and to below the LOD by additional MB/light treatment and MB filtration (≥ 3.7 logs). Suid herpesvirus 1, bovine viral diarrhoea virus and human immunodeficiency virus 1 were efficiently inactivated by THERAFLEX MB-Plasma, independent of the degree of lipaemia.

CONCLUSION

THERAFLEX MB-Plasma efficiently reduces bacteria, mainly via the integrated filtration system. Its virus inactivation capacity is sufficient to compensate for reduced light transparency due to lipaemia.

Discolored blood and blood components: a dilemma for transfusion specialists

BACKGROUND AND OBJECTIVES

It is not uncommon in transfusion practice to see blood/components with abnormal colored plasma. The present study was conducted to identify and determine the etiology of blood and/or blood components showing altered color.

MATERIAL AND METHODS

The present study was conducted in the Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh over a period of seven months. All the blood units/components having an abnormal appearance were segregated as: 1. Green discoloration. 2. Yellow discoloration. 3. Bright cherry red color. 4. Lipemic plasma. The donor's history was carefully evaluated and relevant investigations were done depending on discoloration.

RESULTS

Seventeen units out of 7370 (0.23%) donations showed discoloration. In 3 units the plasma was green, 5 units were yellow, in 3 units PRBC/WB unit was bright cherry red and in the remaining 6 units the plasma was lipemic. Total bilirubin of all the 5 donors with yellowish plasma ranged from 1.6 to 2.3mg/dl. The hemoglobin and hematocrit of two out of three donors with cherry red discoloration of PRBC/WB was low. All the donors with lipemic plasma gave history of intake of fatty meal prior to donating blood.

CONCLUSION

The existing rules prohibit issue of blood and blood components if the plasma is abnormal in color. Our study showed that many of the discolored units could have been safely transfused but further larger studies are required to confirm the safety of recipients receiving such units.

Lipaemic donations: truth and consequences

The problem of using material of unsuitable quality, including "nontransparent turbid milky plasma" or more simply "turbid plasma", for producing blood components is not trivial for several epidemiological, technical, analytical, clinical and economical reasons. With some exception, most national and international guidelines mandate that blood components should preferably not be produced from lipaemic donations. The origin of lipaemic blood is variegated, and includes physiological or paraphysiological causes and metabolic disorders, whereas a broad range of common diseases and drugs can also be associated with hypertriglyceridaemia. Overall, the frequency of lipaemic donations ranges between 0.31% and 0.35%, although sporadic reports have highlighted that the frequency might be much higher, up to 13%. Lipaemic donations pose two leading problems in transfusion medicine, that are interference during laboratory testing, and safety of producing blood components from hypertriglyceridaemic materials. While the former issue can be overcome by using chemical or mechanical methods, the clinical use of lipaemic blood for producing components remains an unresolved question. Transfusion medicine should thereby embark on a landmark effort to find a universal agreement of behaviours and harmonization of policies worldwide.

Lipaemic plasma induces haemolysis in resuspended red cell concentrate

INTRODUCTION

We investigated whether haemolysis in red cells suspended in plasma was affected by the lipid content and/or methylene blue (MB) treatment of fresh-frozen plasma (FFP). We also investigated whether haemolysis was affected by the conditions under which lipaemic plasma was stored.

METHODS

Study 1: Visibly lipaemic (n = 22) or nonlipaemic FFP (n = 24) units were thawed, pooled and split into identical pairs, one of which was MB treated. These units were used to resuspend red cell concentrates (RCC) and tested for haemolysis immediately and after 24 and 48 h of storage at 2-6°C. Study 2: Fresh plasma was aliquoted into 15-ml tubes and stored in one of four ways as follows: room temperature; 2-6°C; frozen and thawed; or twice frozen and thawed. A sample of RCC was resuspended in each of these plasmas and haemolysis measured after 2 h. Study 3: Plasma was divided into 15-ml tubes and stored as in study 2 followed by storage left standing upright in a refrigerator (2-6°C) for 24 h (with the exception of the room temperature sample). Plasma was separated into top, middle and bottom fractions and used to resuspend RCC that were assessed for haemolysis after 2 h.

RESULTS

The levels of haemolysis in RCC were immediately greater when suspended in lipaemic plasma (0·70 ± 0·53% v 0·05 ± 0·06% for nonlipaemic plasma), which increased further on subsequent storage for 48 h (1·22 ± 0·40% v 0·15 ± 0·14% for nonlipaemic plasma). This was irrespective of whether plasma was MB treated. Lipaemic plasma stored frozen and then thawed resulted in the greatest haemolysis. In lipaemic plasma stored at 2-6°C, the chylomicron-rich top fraction caused the highest level of haemolysis.

CONCLUSION

Haemolysis in red cells is increased in those suspended in lipaemic plasma and is dependent upon the storage conditions of that plasma prior to suspension. These data are relevant to the choice of plasma used to suspend red cells for neonatal exchange transfusion.