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Packed red blood cells used in blood transfusions can be stored for up to six weeks, according to federal rules. But a new study has renewed questions about whether the blood deteriorates sooner, causing serious problems in some patients.
By JoNel Aleccia Health writer
msnbc.com
updated 3/19/2008 5:00:42 PM ET 2008-03-19T21:00:42

Any shopper who’s ever pulled a gallon of milk from the back of the dairy case knows that’s the way to get the freshest product.

So news that using older blood for transfusions may cause serious problems in some patients might seem to have an easy answer:  Don’t take the blood from the front of the fridge.

It’s not that simple, however, in a nation where officials say the safety and efficacy of blood stored for transfusions must be weighed against a tight balance of supply and demand.

“If we started handing it out last-in, first-out, we would run out,” said Dr. James AuBuchon, an officer of the AABB, the agency formerly known as the American Association of Blood Banks.

Some 5 million patients receive 14 million units of blood during U.S. transfusions each year. Federal Food and Drug administration rules allow red blood cells to be stored for up to six weeks, but a new study in this week's New England Journal of Medicine has renewed questions about whether that's too long.

While scientists hash it out, consumers worried about ill effects from older blood may wonder whether they can simply tap into the newer supply. But experts said the current blood inventory system cannot handle preferential requests.

“Patients can ask, but it’s unlikely they will be accommodated,” said Dr. John W. Adamson, a professor of hematology and oncology at the University of California, San Diego, who wrote an editorial that accompanied the study.

Instead, experts said, the best patients can do is work with their doctors to reduce the need for transfusions — and accept the blood that’s available.

That doesn’t sit well with heart surgery patients like Donnette Smith, 60, of Huntsville, Ala., who had her aortic valve replaced twice and needed transfusions both times. If a study shows that cardiac patients do better using blood less than two weeks old, then that’s what they should get, she said.  

“Going into heart surgery, you want to make sure everything is right. I want what’s going to help me,” she said. “I would really question whether the blood was fresh.”

Older blood caused problems in patients
At issue is a study by Cleveland Clinic researchers who found that cardiac surgery patients who received blood more than two weeks old suffered significantly more complications and higher death rates than those who got fresher blood.

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The problem is that blood begins deteriorating within hours of collection — and only gets worse, said Dr. Colleen Gorman Koch, the study’s lead author. Chemical, structural and functional changes called "storage lesion" occur over time, gradually limiting the blood’s ability to circulate and to supply oxygen.

The damage can occur well within the 42-day deadline set for red blood cell storage by the FDA, she added.  For comparison, consumers can think of perishable food products that spoil before the pull date on the package.

“The best analogy would be meat or produce,” said Koch. “When you open a package of lunchmeat, you have five or six days ... and then you have to toss it out.”

Blood industry experts dispute some details of Koch’s study, which was a retrospective examination of some 6,000 cardiac patients over eight years.  Because it wasn’t a prospective, randomized trial, it doesn’t settle a decades-old argument over whether to shorten FDA storage guidelines.

“I certainly don’t think we should jump on board this one particular study and change our national practices,” said Dr. Richard Benjamin, chief medical officer for the American Red Cross.

The nation’s blood stores are the insurance that allows surgeons to conduct lifesaving operations, Benjamin said. But it's a precariously balanced system.

“We live on such a knife edge in terms of inventory and supply,” he said.

FDA officials called the study "provocative," but said more research would be needed to prompt regulatory changes.

But Koch and her colleagues said there's room for improvement. The median storage time in Koch's study was 15 days, but she said it's not unusual for blood, especially rare types such as AB, to reach the expiration limit.

"There's an opportunity to talk about moving inventory in a more efficient manner," she said.

Prepare in advance for transfusions
In the meantime, instead of demanding newer blood, potential transfusion patients would do better to ensure that they don’t need as much blood — or any at all, said Dr. Louis Katz, executive vice president of the Mississippi Valley Regional Blood Center in Davenport, Iowa.

"For a consumer, the short answer is you need to be convinced you need the blood," he said.

About 30 percent to 40 percent of transfused blood is used for elective surgery, with another 30 percent to 40 percent going to cancer patients and about 20 percent used in emergencies, Katz estimated.

People facing non-emergency surgery should talk to their doctors and make sure potential problems such as anemia — a low level of red blood cells — are addressed well before an operation.

“See about treating it, go on iron supplements,” suggested Koch. “Get in the best shape you can before the elective surgery.”

Patients also should research the blood management practices at their local hospitals and the transfusion philosophies of their surgeons, said AuBuchon, a professor of pathology at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. Increasing numbers of hospitals have adopted medication rules and other techniques that make it less likely patients will need transfusions.

Overall, rates of transfusion vary widely, with some doctors using extra blood far more often than others.

“Ask: ‘What proportion of patients with my kind of condition do you transfuse?’” said AuBuchon, who suggested the answer should not be higher than 50 percent. “Ask: ‘At what point would you think my hemoglobin would be so low that you would want to transfuse?’”

Normal hemoglobin levels range from about 14 to 17 grams per deciliter of whole blood for men and about 12 to 15 grams per deciliter for women. If the doctor’s answer is higher than about 9 grams per deciliter, that could mean the surgeon has a low trigger for transfusion, he added.

Designated donations are an option
In rare cases, patients may be able to donate their own blood shortly before surgery, or ask friends and relatives to donate.

That’s not possible, of course, when the surgery candidate is anemic or too ill to donate blood in advance, or when the donation might jeopardize the operation. Blood center officials discourage designated donations from family and friends, saying it can take as long to properly screen those donors as it does to use anonymous blood.

Private donation, however, was the best choice for Smith, the heart surgery patient from Alabama. Friends and relatives crowded a local blood center the week before each of her operations in 1988 and 1993 to help out.

“I just felt comfortable going into the surgery knowing where the blood came from,” Smith said.

At the time, worries about contracting HIV, hepatitis or other infections were foremost in her mind. But if it turns out fresh blood is better, that would have been another reason to solicit donations, Smith said.

“Oh, absolutely,” she said. “I would want the fresher blood.”

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