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Volume 43, December 2003

Blackwell Science, LtdOxford, UKTRFTransfusion0041-11322003 American Association of Blood BanksDecember 2003431216581660Editorial

EDITORIALEDITORIAL

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2003;43:1658-1660.

E D I T O R I A L

It’s time to end RBC shortages

he “time has come” for new strategies to helpalleviate and potentially end the chronic short-age of RBCs, especially group O and D– RBCs.The need for RBCs will continue to drive blood

collections in the US. Increasing the active donor base hasbeen the obvious and seemingly simple solution to endRBC shortages. Nevertheless, nothing is simple or easyand this approach alone has failed because we may besubtracting donors faster than we can add them. Newstrategies are needed

.

The use of automated RBC collec-tion technology has the potential to increase the totalnumber as well as the specific blood types of RBCs col-lected, without significantly increasing the number ofdonors or their frequency of donation.

1

In this issue of

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Snyder andcolleagues

2

describe their experience with a recently intro-duced automated collection system (Baxter-ALYX) bycollecting 2 RBC units from a single donor. Their workdescribes the advantages and safety of collections of dou-ble (2) units of leukoreduced RBCs (DRBC) as well as thequality of the RBC units collected by this technology.

2

Other investigators have also shown the safety and qualityof this collection system with respect to donors as well asthe RBC products.

3-6

This automated collection device is not the first, butis the third such device to be marketed in the US to collectRBC units through automated (apheresis) technology. Thefirst device to collect double RBC units was the Haemon-etics 8150, marketed approximately 7 years ago.

7,8

The sec-ond device to allow automated RBC collection and doubleautomated RBC collection is the Gambro Trima, initiallymarketed as a PLT collection device, but that also has mul-tiple-component collection capability. All three of thesedevices are multiple-blood-component collection devicesand can specifically collect DRBC units from appropriatedonors.

The transfusion medicine dictum of “Do not hurt thedonor” and “Do not hurt the recipient” remains a constantgoal. As part of a newer and more strategic approach toincrease RBC collections and specifically increase thecollection of the needed blood type of RBCs, automatedDRBC collection from a suitable donor can be done with-out in anyway endangering the donor. It is no longer

T

appropriate to just collect whole blood units throughmobile operations that cannot provide the right numberor the right type of units because of the random distribu-tion of blood types in the donating population. What mostblood centers have done is to use telerecruitment of themore needed types—almost always blood group O—to fillthe void. What clearly happens at most blood centers isthat the inventory of blood group A units generally is toohigh and the inventory of blood group O units is almostalways too low. The usage of blood group O (especiallyO–) exceeds the percentage of blood group O in the gen-eral and donor population. At the Oklahoma Blood Insti-tute, the usage of blood group O is in excess of 52 percentof the RBCs distributed and transfused whereas our donorpopulation is only 44 to 46 percent group O. In reality, theshortage of RBCs in the US is mainly a group O shortage,although group B supplies can be a problem in areaswhere African American recipients are a large portion ofthe population.

So, why don’t we get smart and disproportionatelycollect even more group O than we are currently collect-ing.

9

This disproportionate collection of blood group O byutilizing double RBC collection not only has the advantageof increasing the group O RBCs but also has the advantageof decreasing the group O plasma, which clearly has alimited transfusion requirement. At the Oklahoma BloodInstitute, extensive RBC automated collection is used butnot just for double RBCs. The need for a more universaltransfusable plasma is also present. By utilizing this sametechnology in the RBC plasma (RBCP) format, bloodgroup A+ donors can provide not only a single group ARBC but a double-volume (450–500 mL) plasma unit. The“double-plasma” unit being blood group A has the trans-fusion potential to be transfused into 85 to 90 percent ofthe patient population requiring plasma transfusions.This procedure (RBCP) has the advantage of limiting therelative glut of group A RBCs, while increasing the volumeof more useful blood group A plasma.

All three of the currently marketed devices (Baxter-ALYX, Gambro-Trima, and Haemonetics 8150) either cur-rently have multiple-component collection capability orwill have in the near future. The reality is that virtually nogroup AB RBCs or blood group O plasma is needed as longas there are enough RBCs and plasma of the “right type”in the system. From a realistic inventory standpoint anexcess of group O RBCs, Rh– RBC(s), and group AB plasma(or group A plasma) is valuable and feasible using auto-

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mated RBC collection technology as the DRBC, the RBCP,or plasma only collection.

If this sounds so easy, then why don’t we do it?Because nothing is simple and nothing is easy. There aredifficulties in educating donors as well as the blood col-lection staff who must learn to run an automated collec-tion device and convert former whole-blood donors toautomated RBC collection technology. There are problemsto overcome in moving equipment to mobile sites,although the Baxter ALYX and Haemonetics 8150 are quitemobile. There are problematic negotiations with manage-ment of any blood drive sponsor today to give the extratime necessary for automated collections because the“needle in–needle out” time is longer by 15 to 25 minutesdepending on the procedure (DRBC, RBCP, or plasmaonly). There are issues to be faced in donor selection inthat currently the DRBC procedure is limited almostexclusively to men because of height, weight, and Hctrestrictions. Cost is also an issue because the disposablesare significantly more expensive, especially if the proce-dure is incomplete.

10

Nevertheless, all of these difficultiescan be overcome.

The ability to infuse saline back to the donor reducesthe risk of hypovolemic or relative hypovolemic reac-tions.

11

Relative hypovolemia occurs when the donor doesnot vasoconstrict or, in fact, vasodilates in the immediateperiod after donation. This reaction may occur whenmoved from a cool environment to a warm postdonationarea resulting in vasodilatation or in some donors on anti-hypertensive medication who fail to vasoconstrict.

If one looks at the advantages of automated RBC col-lection and especially double RBC collection, there ismuch to be gained in reducing RBC shortages. Anotheradvantage of automated RBC collection is a more stan-dardized RBC unit. At least two of the technologies arefixed RBC mass collection devices, meaning that they willcollect a fixed predetermined RBC mass regardless of thedonor’s Hct. The RBC mass of whole-blood-derived RBCsis significantly more variable.

In terms of cost-effectiveness, we (at the OklahomaBlood Institute) have found that a DRBC and a RBCP pro-cedure are more cost-effective than whole-blood-derivedRBCs as long as the automated RBCs do not outdate or theprocedure for collection is not an incomplete procedure.Testing costs are reduced when allocated to an automatedcollection procedure that yields at least two full-dosetransfusable products (i.e., DRBC or 1 RBC unit + 1 doubleplasma unit). The overcollection of group A and AB+ RBCsfrom whole blood procedures is costly when they outdate.

There is a theoretical advantage to the patient if bothaliquots of the double RBC collection are transfused to thesame patient. Interestingly, we have had some hospitalsrefuse both RBC aliquots from the same donor becausetheir computer systems could not track both a blood unitidentification number and a product code and their com-

puter would not “accept” two RBC units with the sameblood unit identification number. This problem can befixed if an increased supply of double RBC collectionsjustifies the information technology investment.

The time has come to end RBC and especially groupO RBC shortages.

12-14

The technology for DRBC(s) is avail-able to disproportionately collect group O RBC(s), whichcan significantly increase the total number of the “righttype” and “right number” of RBCs needed in the US andfor the most part utilizing the existing donor bases. Donoracceptance of automated RBC collection technology isvery high. Its time has come and it’s time to end RBCshortages in the US. Patients and the hospitals that servethem demand a more reliable blood supply than we arecurrently achieving.

Ronald O. Gilcher, MD

Oklahoma Blood Institute1001 North Lincoln Boulevard

Oklahoma City, OK 73104e-mail: rgilcher@obi.org

REFERENCES

1. Illert W, Sanger W, Jahn-Jochem H, et al. Single-donor red

cell double-apheresis (SDR/MCS+1) production—quality—

stability. Trans Med Hemother 2003;30:9.

2. Snyder EL, Elfath MD, Taylor H, et al. Collection of two units

of leukoreduced RBCs from a single donation with a porta-

ble multiple-component collection system. Transfusion

2003;43:1695-705.

3. Gorlin J, Stefan M, Buckley M. Evaluation of adverse events

of donating two unit-red blood cells on a new automated

component collection system (abstract). Transfusion 2003;

43:75A.

4. Louie J, Greco BJ, Martinez S. Quality and characteristics of

red cells collected on a new automated portable component

collection system (abstract). Transfusion 2003;43:135A.

5. Gilcher RO, Smith JW, Forsberg JE, et al. Evaluation of

automated leukoreduction filtration of red cells collected

using a new portable component collection systems

(abstract). Transfusion 2003;43:57A.

6. Gorlin J, Stefan M, Buckley M. Evaluation of the effect of

donor gender and weight on the type and incidence of

adverse events reported during donation of two unit-red

blood cells (abstract). Transfusion 2003;43:11A.

7. Smith JW, Gilcher RO. Red blood cells, plasma, and other

new apheresis-derived blood products: improving product

quality and donor utilization. Transfus Med Rev 1999;13:

118-23.

8. Shi PA, Ness PM. Two-unit red cell apheresis and its

potential advantages over traditional whole-blood

donation. Transfusion 1999;39:218-25.

9. Hayward M, Moase G, Gardner J. Managing RBC inventory

in a multi center blood system: balancing on the tightrope

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of supply and demand with 2-RBC unit collections using the

MCS+8150. Transfusion 2001;41:135S.

10. Hayward M, Moase G, Gardner J, et al. Reaping the rewards.

maximizing the efficient use of automated technology

(abstract). Transfusion 2002;42:134S.

11. Popovsky MA. Vasovagal donor reactions. an important

issue with implications for the blood supply (editorial).

Transfusion 2002;42:1534-6.

12. Popovsky MA. Automated red blood cell collections: the

technologies and benefits. Blood Ther Med 2002;2:1-5.

13. Dalby JF. Blood donor recruitment to automated red cell

collections for fixed-site and mobile operations (abstract).

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14. Smith JW, Forsberg JE, Gilcher RO. Innovations in blood

donor screening and blood collection. Current Hematol

Reports 2002;1:129-33.