DISCOVERIES 2014, Jan-Mar, 2(1): e11 DOI: 10.15190/d.2014.3 Blood Transfusion in the 21st Century REVIEW Article Blood Transfusion in the 21st Century Mark T. Friedman1,*, Vaidehi Avadhani1, Sandra Gilmore2, Emilio Madrigal1 1Department of Pathology, Blood Bank and Transfusion Services, 2Blood Management, Bloodless Medicine and Surgery, Mount Sinai Health System, St. Luke’s, Roosevelt, and Beth Israel Hospitals, Icahn School of Medicine at Mount Sinai, New York, NY 10019, USA Corresponding author: Mark T. Friedman, DO, Mount Sinai Roosevelt Hospital, Medical Director of Blood Bank and Transfusion Service, 1000 Tenth Avenue, New York, NY 10019. Phone: 212-523-7242; Fax: 212- 523-6394; [email protected]. Submitted: March 11, 2014; Published after revision: March 31, 2014; Citation: Friedman MT, Avadhani V, Gilmore S, Madrigal E. Blood Transfusion in the 21st Century. Discoveries 2014, Jan-Mar; 2(1): e11. DOI: 10.15190/d.2014.3 ABSTRACT implement appropriate patient blood management Blood transfusion is a common procedure in the strategies. This review will examine these issues hospital setting, and the safety of the blood supply along with newer blood safety technological has been vastly improved over the past few decades innovations and further highlight contributing largely due to improvements in screening for viral studies from our institutions. transmissible diseases, especially human immunodeficiency virus (HIV) and viral hepatitis. Keywords: Blood substitutes; factor concentrates; However, more recent efforts to improve blood hemovigilance; patient blood management; safety have focused on non-transmissible disease transfusion medicine education; transfusion safety. risks such as transfusion-related acute lung injury (TRALI), non-viral transmissible diseases such as Abbreviations bacterial contamination of blood products American Association of Blood Banks (AABB); Centers (especially platelet components which are stored at for Disease Control and Prevention (CDC); room temperature) and Chagas disease (a parasitic Cytomegalovirus (CMV); Food and Drug Administration disease caused by Trypanosoma cruzi), and prion (FDA); Hemoglobin-based oxygen carriers (HBOC’s); transmissible agents (e.g., variant Creutzfeldt-Jakob Human immunodeficiency virus (HIV); Human disease, also known as the agent of mad cow leukocyte antigen (HLA); Patient blood management (PBM); Perfluorocarbons (PFC’s); Serious Hazards of disease) as well as more recently-recognized Transfusion (SHOT); The Joint Commission (TJC); transmissible viral disease risks such as West Nile Transfusion-associated graft-vs-host disease (TA- virus. Appropriate blood utilization has also come GVHD); Transfusion-related acute lung injury (TRALI); under more intense scrutiny in recent times due to Transfusion-related immunomodulation (TRIM); United healthcare costs and the recognition that many Kingdom (U.K.); Variant Creutzfeldt-Jakob disease blood transfusions are given under circumstances in (vCJD). which the benefit to the patients is unclear and may be potentially harmful due to the above risks as well SUMMARY as the emerging concept that blood transfusions 1. Introduction may cause long-term damage to the immune system 2. Safety of the blood supply resulting in worse patient morbidity and mortality 3. Quality of the blood supply outcomes. Toward that end, accreditation agencies 4. Transfusion medicine education such as the Joint Commission and the American 5. Patient blood management Association of Blood Banks (AABB) are 6. Future technology advocating for healthcare organizations to 7. Concluding remarks www.discoveriesjournals.org/discoveries 1 Blood Transfusion in the 21st Century 1. Introduction with the fact that published transfusion guidelines have been updated over the years to reflect a more Blood transfusion is one of the most common conservative approach to blood utilization9,10, procedures performed in hospitals. Accordingly, it clinicians have been slow to adopt these transfusion was reported that there were nearly 15 million practices and in many cases, transfusion practices whole blood and red blood cell units transfused in remain inconsistent even amongst physicians of the the United States alone in 2008, representing a same specialty practicing within a localized region nearly 6% increase in transfusions from the prior or even within the same institution11. This review surveyed year of 20061. This is because anemia is a will further discuss issues surrounding blood common comorbidity that can be found in a variety utilization, including the safety and quality of the of patients, including patients with cancer, patients blood supply and patient blood management. undergoing surgical procedures or hemodialysis, patients with autoimmune or bone marrow disorders 2. Safety of the blood supply (such as myelodysplastic syndrome), patients with congenital anemia (such as sickle cell anemia and Over the years, the safety of the blood supply has thalassemia), trauma patients, obstetrical patients, dramatically improved. Early efforts to reduce risk and patients with nutritional deficiencies, such as focused on reliance on volunteer donors while iron deficiency. While it is certainly known that screening out donors with high-risk behavior, such anemia can have adverse effects on patients, as male-to-male sex, for human immunodeficiency particularly in cardiovascular and neurocritical care virus (HIV) and viral hepatitis (hepatitis B and patients2-4, what is becoming more evident is that hepatitis C) as well as the implementation of correction of anemia via blood transfusion is not highly-sensitive testing to reduce the infectious beneficial to many patients, and in fact, may be window period, that is, the time between exposure more harmful, unless the patient is acutely to viral infection and ability of the blood test to symptomatic (e.g., shortness of breath, low blood detect the virus when the donor may be infectious pressure, rapid heart rate, dizziness, or chest pain) though the test result is negative. Such strategies from the anemia. Thus, it is considered problematic have reduced the risk of HIV and hepatitis C that many blood transfusions are administered transmission through blood to about 1 in 2 million unnecessarily, driving up healthcare costs, (or roughly the equivalent of the risk of getting expending a valuable resource (i.e., blood struck by lightning)12. More recently, testing for components) in short supply (because only a West Nile virus and Chagas disease (Trypanosoma minority of eligible blood donors in the U.S. give cruzi) has been added to address those emerging blood), and exposing patients to all the risks and transmissible disease threats to the blood complications (like fluid and iron overload) of supply13,14, and standards were adopted for reducing blood transfusions. Hèbert et al. published their the risk of bacterial contamination of platelet landmark study 15 years ago which demonstrated components (which must be stored at room the lack of benefit of a liberal transfusion strategy temperature to maintain platelet hemostatic over that of a restrictive one in critical care function)15. Still, there remain transmissible disease patients5. Since then, additional studies have been risks that are not tested for owing to the fact that published demonstrating similar outcomes in other U.S. Food and Drug Administration (FDA)- patient populations such as elderly patients approved testing is unavailable. Perhaps most undergoing orthopedic (e.g., hip replacement) problematic in the U.S. is babesiosis, a parasitic surgery, pediatric patients, and patients with agent that infects red blood cells à-la malaria but gastrointestinal bleeding6-8. Despite these data that is endemic in the northeastern U.S.; supportive of restrictive transfusion strategies along transmission of babesiosis through blood has been reported16, and the FDA may consider Although blood transfusions are commonly implementation of testing in the near future. Yet used to treat anemia, restrictive transfusion another transmissible agent for which testing is practices (i.e., fewer transfusions) have been unavailable is variant Creutzfeldt-Jakob disease shown to be as effective if not better than liberal (vCJD, the prion agent of bovine spongiform transfusion practices. encephalopathy or mad cow disease); human cases have been attributed to transfusion of blood www.discoveriesjournals.org/discoveries 2 Blood Transfusion in the 21st Century components in the United Kingdom17. To address implemented by most hospital transfusion services, this, prospective blood donors in the U.S. who have such as the requirement for a second sample to traveled for a defined period of time to the U.K. confirm the ABO blood type prior to crossmatch (cumulative 3 month travel between 1980 and and strict blood administration policies for bedside 1996) or western Europe (cumulative 5 years patient identification at the time of transfusion. between 1980 and present) are currently excluded; Nevertheless, TRALI and group ABO-incompatible however, this is problematic as a number of transfusion occurrence estimates remain much otherwise-eligible blood donors are unable to greater than for transmission of HIV and hepatitis donate, representing a small but not insignificant and are amongst the highest causes of transfusion- loss of U.S. blood donors18. Transfusion- related fatalities21,22. Transfusion-associated graft- transmitted cases of hepatitis E virus have also been vs.-host disease (TA-GVHD) is yet