Impact of informing donors of low ferritin results

A rapid review of strategies to manage low iron levels in adults donating whole-blood: A focus on donor behaviour

In recognition of the impact of whole-blood donation on body iron stores, there has been an increased focus assessing the efficacy of strategies to minimise the risk of iron deficiency (ID). Whilst donor behaviour is an important determinant of success, this literature is yet to be fully synthesised to help guide blood collection agencies when implementing these strategies into routine practice. This rapid review identifies strategies for management of low iron, how they have been communicated to donors, donor compliance with advice, donor use of external health services and their effect on donor retention. Web of Science, Medline, CINAHL and Wiley online library databases were searched from 2012 to November 2023, with 29 studies meeting inclusion criteria. Five iron management strategies were identified: oral iron supplementation (IS), education, dietary advice, lengthening inter-donation interval and switching donation type. Most studies (n = 16) focused on IS, with only four reporting how they communicated this to donors. Donor use of IS was high in controlled research environments but has not been evaluated when implemented into routine practice. None of the four studies on dietary advice included findings on donor acceptability. The proportion of donors consulting their doctor about a low iron result or their risk of ID was found to be suboptimal. However, in general, the identified strategies and communications had a positive effect on donor retention. More evidence is needed on how to increase donor knowledge and awareness of donation-related risk of ID as well as to identify how to effectively communicate strategies to donors to ensure optimal acceptability and use.

Iron supplementation: A qualitative study on the perception of blood donors, blood collection staff and donor physicians

BACKGROUND AND OBJECTIVES

Iron supplementation is an effective strategy to mitigate donation-induced iron deficiency in blood donors. However, evidence on the perception of individuals involved in blood donation on iron supplementation as a blood service policy is lacking. This study aimed to evaluate the knowledge and perception of whole blood donors (donors), blood collection staff (collection staff) and donor physicians (physicians) regarding donation-induced iron loss and iron supplementation.

MATERIALS AND METHODS

Online focus group discussions had four to six participants and followed a structured questioning approach. All participants had to be fluent in Dutch to participate, and donors had donated at least five times. Sixteen donors, eight collection staff members and four physicians participated in this study. Recordings were transcribed, coded and analysed using a grounded theory approach.

RESULTS

Awareness of donation-induced iron loss was limited in donors. Donors and physicians were predominantly positive towards iron supplementation; the primary motivator for donors was to prevent deferral and reduce iron-deficiency-related symptoms. Improving donor health was the main argument for physicians to advocate iron supplementation. Staff had a critical view on iron supplementation as a policy, as they perceived it as unethical and possibly ineffective. A knowledge gap might underlie their concerns.

CONCLUSION

Most individuals involved in blood donation are positive towards iron supplementation as a blood service policy. If implemented, guidance and monitoring is desired and adequate education of all stakeholders is required.

Iron Deficiency and Blood Donation: Links, Risks and Management

The purpose of this review is to raise awareness about the frequently underappreciated association of blood donation with iron deficiency, and to describe methods for its prevention and management. Blood donors cannot expect any health benefits from the donation but have justified expectations of no harm. Iron deficiency without anemia (IDWA) and iron deficiency anemia (IDA) are common consequences of regular blood donation, and this activity is the most important factor affecting iron status in regular blood donors. Awareness of blood donation as a primary cause of sideropenia is surprisingly low among physicians. Blood donation screening identifies potential donors with IDA but is frequently inadequate to detect IDWA. For the assessment of body iron stores, plasma or serum ferritin, transferrin saturation (TSAT) and soluble transferrin receptors (sTfR) concentrations are the most widely used biochemical markers, although the percentage of hypochromic mature erythrocytes and the hemoglobin content of reticulocytes are also useful. IDWA can be prevented by limiting the total volume of blood collected, by iron deficiency screening and deferral of sideropenic donors, by prolonging the interdonation intervals, and by iron supplementation between donations. IDWA tends to be more prevalent in younger people, females, and high-intensity donors. A potentially effective strategy to address sideropenia in blood donors is serum ferritin testing, but this may lead to a higher rate of deferral. Most regular blood donors cannot replenish their iron deficit by an iron-rich diet alone and will benefit from low-dose oral iron administration with various commercially available products post-donation, a well-tolerated strategy. However, valid concerns exist regarding the possibility of worsening the iron overload in donors with undiagnosed hemochromatosis or masking the symptoms of a clinically important gastrointestinal hemorrhage or other underlying medical condition. Finally, educational efforts should be intensified to improve the awareness of blood donation as a primary cause of iron deficiency among physicians of all specialties.

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.

Longer-term efficiency and safety of increasing the frequency of whole blood donation (INTERVAL): extension study of a randomised trial of 20 757 blood donors

BACKGROUND

The INTERVAL trial showed that, over a 2-year period, inter-donation intervals for whole blood donation can be safely reduced to meet blood shortages. We extended the INTERVAL trial for a further 2 years to evaluate the longer-term risks and benefits of varying inter-donation intervals, and to compare routine versus more intensive reminders to help donors keep appointments.

METHODS

The INTERVAL trial was a parallel group, pragmatic, randomised trial that recruited blood donors aged 18 years or older from 25 static donor centres of NHS Blood and Transplant across England, UK. Here we report on the prespecified analyses after 4 years of follow-up. Participants were whole blood donors who agreed to continue trial participation on their originally allocated inter-donation intervals (men: 12, 10, and 8 weeks; women: 16, 14, and 12 weeks). They were further block-randomised (1:1) to routine versus more intensive reminders using computer-generated random sequences. The prespecified primary outcome was units of blood collected per year analysed in the intention-to-treat population. Secondary outcomes related to safety were quality of life, self-reported symptoms potentially related to donation, haemoglobin and ferritin concentrations, and deferrals because of low haemoglobin and other factors. This trial is registered with ISRCTN, number ISRCTN24760606, and has completed.

FINDINGS

Between Oct 19, 2014, and May 3, 2016, 20 757 of the 38 035 invited blood donors (10 843 [58%] men, 9914 [51%] women) participated in the extension study. 10 378 (50%) were randomly assigned to routine reminders and 10 379 (50%) were randomly assigned to more intensive reminders. Median follow-up was 1·1 years (IQR 0·7-1·3). Compared with routine reminders, more intensive reminders increased blood collection by a mean of 0·11 units per year (95% CI 0·04-0·17; p=0·0003) in men and 0·06 units per year (0·01-0·11; p=0·0094) in women. During the extension study, each week shorter inter-donation interval increased blood collection by a mean of 0·23 units per year (0·21-0·25) in men and 0·14 units per year (0·12-0·15) in women (both p<0·0001). More frequent donation resulted in more deferrals for low haemoglobin (odds ratio per week shorter inter-donation interval 1·19 [95% CI 1·15-1·22] in men and 1·10 [1·06-1·14] in women), and lower mean haemoglobin (difference per week shorter inter-donation interval -0·84 g/L [95% CI -0·99 to -0·70] in men and -0·45 g/L [-0·59 to -0·31] in women) and ferritin concentrations (percentage difference per week shorter inter-donation interval -6·5% [95% CI -7·6 to -5·5] in men and -5·3% [-6·5 to -4·2] in women; all p<0·0001). No differences were observed in quality of life, serious adverse events, or self-reported symptoms (p>0.0001 for tests of linear trend by inter-donation intervals) other than a higher reported frequency of doctor-diagnosed low iron concentrations and prescription of iron supplements in men (p<0·0001).

INTERPRETATION

During a period of up to 4 years, shorter inter-donation intervals and more intensive reminders resulted in more blood being collected without a detectable effect on donors' mental and physical wellbeing. However, donors had decreased haemoglobin concentrations and more self-reported symptoms compared with the initial 2 years of the trial. Our findings suggest that blood collection services could safely use shorter donation intervals and more intensive reminders to meet shortages, for donors who maintain adequate haemoglobin concentrations and iron stores.

FUNDING

NHS Blood and Transplant, UK National Institute for Health Research, UK Medical Research Council, and British Heart Foundation.

The operational implications of donor behaviors following enrollment in STRIDE (Strategies to Reduce Iron Deficiency in blood donors)

BACKGROUND

Donor behaviors in STRIDE (Strategies to Reduce Iron Deficiency), a trial to reduce iron deficiency, were examined.

STUDY DESIGN AND METHODS

Six hundred ninety-two frequent donors were randomized to receive either 19 or 38 mg iron for 60 days or an educational letter based on their predonation ferritin. Compliance with assigned pills, response to written recommendations, change in donation frequency, and future willingness to take iron supplements were examined.

RESULTS

Donors who were randomized to receive iron pills had increased red blood cell donations and decreased hemoglobin deferrals compared with controls or with pre-STRIDE donations. Donors who were randomized to receive educational letters had fewer hemoglobin deferrals compared with controls. Of those who received a letter advising of low ferritin levels with recommendations to take iron supplements or delay future donations, 57% reported that they initiated iron supplementation, which was five times as many as those who received letters lacking a specific recommendation. The proportion reporting delayed donation was not statistically different (32% vs. 20%). Of donors who were assigned pills, 58% reported taking them "frequently," and forgetting was the primary reason for non-compliance. Approximately 80% of participants indicated that they would take iron supplements if provided by the center.

CONCLUSIONS

Donors who were assigned iron pills had acceptable compliance, producing increased red blood cell donations and decreased low hemoglobin deferrals compared with controls or with pre-STRIDE rates. The majority of donors assigned to an educational letter took action after receiving a low ferritin result, with more donors choosing to take iron than delay donation. Providing donors with information on iron status with personalized recommendations was an effective alternative to directly providing iron supplements.