Ironing out frequent blood donation
Authors: Dana V Devine
Journal: The Lancet Haematology (2019)

Until blood substitutes or transfusions from cultured cells become a reality, the ability to treat patients who require a blood transfusion depends on the successful operation of a blood service that collects blood from volunteers. Over the past few decades, most developed countries have seen a decrease in the number of eligible individuals who are willing to donate blood as a form of societal engagement. Thus, concern continues to build within blood services about maintaining a sufficient blood supply. That this situation has not yet become critical is simply because of the decrease in overall transfusion rates as a result of the application of patient blood management principles, namely only transfusing when truly necessary and when possible ensuring patients go into elective surgery with the least likelihood of requiring transfusion.1Mueller MM Van Remoortel H Meybohm P et al.Patient blood management: recommendations from the 2018 Frankfurt Consensus Conference.JAMA. 2019; 321: 983-997Crossref PubMed Scopus (287) Google Scholar However, a dwindling (and ageing) population of blood donors cannot be offset by reductions in use indefinitely. Periodic shortages of blood products are not uncommon in many countries, especially around holiday seasons. With the recognition of donors as a finite resource has come increasing attention to considerations of donor safety, especially to donor iron management.2Spencer B Bialkowski W Creel D et al.Elevated risk for iron depletion in high-school age blood donors.Transfusion. 2019; 59: 1706-1716Crossref PubMed Scopus (33) Google Scholar, 3Gorelin JB Iron replacement: precautionary principle versus risk-based decision making.Transfusion. 2019; 59: 1613-1615Crossref PubMed Scopus (6) Google Scholar, 4Sayers MH Iron supplementation? Ferritin screening? Why questions persist.Transfusion. 2019; 59: 1616-1619Crossref PubMed Scopus (7) Google Scholar Other concerns relate to the collection of blood from donors aged 16–19 years, especially in countries where iron deficiency anaemia is already a public health issue. There is an inherent tension between the need for donations and the establishment of policies that protect donor health. Before now, most countries, including the UK, have taken a fairly conservative approach to the frequency with which donors are permitted to donate over the course of a year and the inter-donation interval. In addition to an obligation as the donor's advocate not to endanger the donor's health, blood services recognise that for many donors a high frequency of donation leads to increased risk of deferral due to failure to maintain an adequate haemoglobin amount for donation. Donors who are deferred for low haemoglobin are less likely to return to donate than donors who were never deferred.5Custer B Schlumpf KS Wright D Simon TL Wilkinson S Ness PM NHLBI retrovirus epidemiology donor study-II: donor return after temporary deferral.Transfusion. 2011; 51: 1188-1196Crossref PubMed Scopus (44) Google Scholar Following the INTERVAL study,6Di Angelantonio E Thompson SG Kaptoge S et al.Efficiency and safety of varying the frequency of whole blood donation (INTERVAL): a randomised trial of 45 000 donors.Lancet. 2017; 390: 2360-2371Summary Full Text Full Text PDF PubMed Scopus (150) Google Scholar its 2-year extension7Kaptoge S Di Angelantonio E Moore C et al.Longer-term efficiency and safety of varying the frequency of whole blood donation (INTERVAL): extension study of a randomised trial of 20 757 blood donors.Lancet Hematology. 2019; (published online Aug 2.)http://dx.doi.org/10.1016/S2352-3026(19)30106-1Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar published in this issue of The Lancet Haematology, provides important information for the refinement of policy around blood donation frequency in the UK. The studies show that it is possible to reduce the inter-donation interval for many blood donors without causing anaemia to the extent that they can no longer donate. However, the longer an individual continues intensive donation practices, the greater the effect on donor iron depletion and potentially donor wellbeing. These data support a possible short-term solution to blood supply shortages, but do not support a long-term change unless other strategies are developed that reliably ensure the maintenance of donor iron stores. While iron replacement is widely recommended to frequent blood donors, it is not practiced by the majority of frequent donors, including in the INTERVAL extension study7Kaptoge S Di Angelantonio E Moore C et al.Longer-term efficiency and safety of varying the frequency of whole blood donation (INTERVAL): extension study of a randomised trial of 20 757 blood donors.Lancet Hematology. 2019; (published online Aug 2.)http://dx.doi.org/10.1016/S2352-3026(19)30106-1Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar where only 1396 (16%) of 8594 men and 1732 (22%) of 7803 women reported using iron supplements by the end of the extension study. It is also probable that frequent donation is associated with an increase in so-called donor fatigue, which arises when donors are tired of frequent donation for various reasons. Hints of this problem are seen in the INTERVAL trial in that only 20 757 (54·6%) of 38 035 participants who were invited from the original study were willing to continue into the extension study. Although having a strategy to respond to low blood stocks that is of little risk to donors will be useful for the UK blood service, it cannot be considered a long-term solution to the problem. Other ongoing research, including efforts made by the same investigators who did INTERVAL, is seeking to apply the principles of personalised medicine to blood donors such that personalised donation programmes can be created that take into account the features of an individual donor's iron management, both with respect to supplements and their individual physiology. Such algorithms could move us away from a one-size-fits-all donation policy and lead to high frequency donation by donors who can safely donate frequently (so-called super donors), and tailored inter-donation intervals for other donors who are at greater risk of anaemia. Social science research is necessary to address the questions around why such a small proportion of the eligible population donates blood. If we can understand how to engage our fellow citizens effectively, and help them manage their iron stores, blood services will have less to worry about and patients in need of transfusion will have a sufficient supply of life-saving products. I have received research funding in the past 3 years from TerumoBCT, Macopharma, and Hemanext. I am a member of the scientific advisory board of Macopharma. None of this research support is related to the subject of this commentary. Longer-term efficiency and safety of increasing the frequency of whole blood donation (INTERVAL): extension study of a randomised trial of 20 757 blood donorsDuring 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. Full-Text PDF Open Access