Autologous Blood Deposits and Transfusions in Cancer Patients
By Benjamin Lichtiger, M.D., Ph.D., and Yang O. Huh, M.D.
Copyright 1993-2010 The University of Texas MD Anderson Cancer Center, Houston, Texas. All rights reserved.
Allogeneic blood undergoes exacting testing in compliance with Food and Drug Administration (FDA) requirements. Prospective blood donors undergo relentless and highly privacy-invasive interrogations before they are allowed to be phlebotomized. However, in spite of all such measures and safeguards, allogeneic blood carries realistically unavoidable risks (1). These may include transmission of blood-borne viral diseases, potential alloimmunization, transfusion reactions, and other adverse effects. Furthermore, a considerable body of documentation now exists showing that allogeneic blood transfusions may induce a state of immune dysfunction that could adversely affect the clinical outcome of a cancer patient (2). Those factors may have serious consequences for long-term treatment, management, and prognosis.
Unquestionably, cancer patients do require the transfusion of blood and blood components. Some require transfusion with numerous units of different types of blood components because of bone marrow suppression by chemotherapy before their bone marrow recovers enough to make them independent of hemotherapy support. Others may require relatively small numbers of transfusions for the surgical removal of tumor burden. For the latter group of patients, the autologous option is considered the most important and safest alternative because such patients may be spared from the potential risks associated with allogeneic blood products (1).
Using autologous blood eliminates the possibilities of infecting the recipient with blood-borne viral diseases; prevents alloimmunization to erythrocyte, leukocyte, and platelet antigens; and, in general, saves the patient from all potential short- and long-term, alleged consequences of allogeneic blood transfusions. Therefore, autologous blood transfusions represent, nowadays, the safest transfusion alternative for any patient. This concept is thoroughly documented in the medical literature and even by the lay media (3).
Autologous blood deposit and transfusion is neither a new concept nor a new technology. Its advantages and beneficial effects have long been known (4,5). However, in the late 1960s and 1970s, its widespread access and use as a transfusion option suffered a slow growing process, without much interest from either the public or physicians. During the 1980s, though, the autologous blood alternative suddenly acquired an inordinate importance after it was documented that blood transfusions are indeed one of the vehicles for the transmission of HIV-1, HTLV-I, NonA-NonB hepatitis, and other viral and parasitic diseases (6). Although the chance of transmitting the above-mentioned organisms is very minuscule, many patients refuse to consider such risks, however low, and increasingly reject the notion of being transfused with allogeneic blood. In light of that information, an anxious and scared public began demanding and developing schemes to assure that the blood for their transfusion would be the safest. Patients informed through the lay media pressured healthcare providers for the opportunity to deposit their autologous blood for later use (2).
In 1989, the American Association of Blood Banks (AABB) reported that less than 7% (442,000 deposits) of all blood collections by its member organizations were destined for autologous transfusions (7). Since 1983, autologous blood deposits have increased over 12 fold. Currently, autologous blood deposit and transfusion is a highly desirable and recommended practice supported by the American Medical Association, the AABB, the American Red Cross, and the American College of Physicians (8,9). In addition, the Joint Commission on Accreditation of Health Organizations specifically requires documentation of autologous blood deposit activities and utilization.
Even though autologous blood deposits and transfusions have become a routine measure of standard of care, the percentage of patients undergoing elective surgery who avail themselves of this option is still rather low due to the lack of information or other logistical problems. For example, in a study of patients eligible for autologous deposit, Toy et al. found that less than 5% chose that option and that 29% had no discernible reason for not making autologous blood deposits (10). These data clearly show that a sizable number of patients, for reasons yet unclear, are not taking advantage of such an option (10).
As hemotherapeutic support for the patient scheduled for elective cancer surgery is planned, steps should be taken to minimize the potential exposure to allogeneic blood. It is at that particular time in the planning process that the thought and consideration of the autologous blood option must come into focus. Issues such as the probability of needing a transfusion during surgery, the number of autologous blood deposits for the anticipated surgery, and the possibility for perioperative phlebotomy with hemodilution should be discussed with and explained to the patient.
Kruskall and Axelbrod et al. recently proposed that certain surgical procedures could ideally be supported with autologous blood exclusively (11,12). This is not an objective easily achievable at MD Anderson owing to the very nature of the type of patients who are operated on. Notwithstanding this, we currently have in place an autologous blood deposit program that was implemented in 1982. In 1983, Swanson et al. reported their successful experience with autologous transfusion in 25 patients undergoing irradiation and radical cystectomy (13). As a result of that study, we embarked on a course to make this option available to patients undergoing planned oncologic surgery who had enough time to deposit the necessary number of units of blood as indicated by the surgeon or surgeons (1).
In consideration of logistical constraints experienced by some of the patients, we have adopted a highly flexible procedure to allow patients to avail themselves of this option. Usually the attending physician or the patient brings up the concern about the potential dangers of allogeneic transfusions. At that point, the patient is referred to the autologous blood donor room, where a Transfusion Medicine Physician (TMP) evaluates the patient, reviews the EKG on record, and determines the hemoglobin level, history of and type of medications taken by the patient, type of operation, and number of units to be drawn as suggested by the surgeon. If, in the TMP's opinion, it is safe for the patient to donate blood and if the type of surgical procedure is one that will, in all certainty, require a transfusion, then a schedule of blood deposits is worked out so that the patient can comfortably donate enough blood. If and when the patient needs to make an autologous blood deposit in his or her hometown, our service facilitates and coordinates all issues germane to time of drawing the blood, and to shipping and billing arrangements, so that the properly tested, labeled, and clearly identifiable unit is sent to our section in time for the scheduled transfusion or transfusions. In this fashion, eligible patients deposit their blood weeks in advance of surgery and may even make the last deposit on the day before the actual surgical intervention.
A recent review of 1075 patients who deposited autologous blood at our facility showed that 49.3% underwent phlebotomy for autologous deposit less than 4 days prior to surgery. In fact, 219 of these patients deposited their blood 1 day before surgery, without any reported untoward effect. For those patients who are screened out because they may not meet minimum criteria of safety for the autologous blood deposit, or because the type of scheduled surgery does not require or has a low probability for blood transfusion, the reasons for such actions are explained, and the steps taken are documented in the patients' charts.
The autologous blood is processed and tested as are units of donated allogeneic blood, in compliance with FDA recommendations. Units found to be reactive for HBsAg or HIV-1 Ab are destroyed and the surgeon so notified. One reason for such action is that it is extremely dangerous to keep units in inventory that are unsuitable for transfusion and reactive for these infectious disease markers; also, units could be released for transfusion, by mistake, to another patient, or a healthcare worker handling the contaminated unit could suffer a wound puncture and infection with HBsAg or HIV. Our experience was and is that surgeons, as well as patients, are very understanding of this measure and fully cognizant of the potential dangers. Furthermore, the patient is fully informed and made aware, before the blood deposit is made, of all the problems we may encounter at testing.
The blood drawn from the patients can be left in storage as whole blood up to 21 days or be fractionated into plasma and packed red blood cells (RBC) and stored for 42 days. Those patients scheduled for surgery beyond 42 days can have their blood stored frozen for up to 6 months. Autologous blood not transfused for the specific patient is allowed to become outdated in storage and then is autoclaved. In some cases, upon the surgeon's instruction, autologous fibrin glue is extracted from the fresh frozen plasma fraction; this glue is mostly used in urologic surgery at our institution (14).
A recent review of our autologous blood program for the period April 1-May 30, 1992, revealed that only 65.5% (228 of 348 units) of the blood so collected was transfused into patients who had deposited autologous blood and, furthermore, that only 63.9% (133 of 208 patients) of those patients who deposited autologous blood actually received such blood. The rest of the blood (120 of 348 units) was not used and eventually discarded, as autologous blood is not to be "crossed over" and released as allogeneic to other patients. These data are most revealing because they show that a number of patients deposit their blood as a measure of insurance for the remote possibility of a transfusion in surgery cases in which the use of blood transfusion is highly unlikely.
On the other hand, 53 patients (25.5%) had to be transfused with allogeneic blood to supplement an insufficient number of autologous units collected or as a response to unforeseen and unexpected bleeding during the surgical procedure or lack of sufficient time to accumulate the needed number of units of blood. This eventuality must be expected; therefore, there are going to be cases in which the number of units of blood deposited will not meet the needs that may arise unexpectedly during the surgery.
In a study of 612 autologous blood programs reported by Renner et al., it was found that 39% of the autologous blood was not used or was discarded since it was drawn for low-transfusion-risk procedures (15). However, no matter how refined the monitoring and screening process for autologous patients, there will always be a number of units of blood that will go to waste, mostly because of excellent surgical techniques and overestimation of the potential loss of blood. Therefore, the wastage rate will never decrease to 0%, nor should we expect it to. Further refinement in the criteria for evaluating patient candidates for autologous blood deposit should decrease the magnitude of that wastage. In addition, many physicians here and at other institutions may be responding to pressure from patients and to a fear of lawsuits related to transfusion-associated events when they choose not to use or to discard autologous blood.
An increasingly thorny issue that has arisen in the process of monitoring the efficient use of autologous transfusions is the following one: since the patient gave his own blood, why not transfuse the blood back to the patient? Transfusion of blood, allogeneic or autologous, must be guided by the same criteria, regardless of the source. A decision for transfusion of any type must be supported by a sound clinical judgement, objectively documented, that the transfusion will translate into a definite advantage and benefit for the patient. Besides, the act of transfusing a unit of blood components is not an inconsequential event. For example, the wrong unit could be mistakenly issued for the wrong patient, or the unit could become contaminated during storage or infusion and eventually lead to a serious and deleterious outcome. Orders and decisions for autologous transfusion call for as strict a screening criteria as those applied to allogeneic blood.
In conclusion, the option for autologous blood deposit is available at our institution. The transfusion consent form currently in use at MD Anderson clearly gives the patient the autologous option. Physicians requesting or recommending such alternatives may, therefore, want to consider the likelihood of blood transfusion for a given surgical procedure, so that wastage of autologous blood is minimized.
- Lichtiger B, Huh YO, Armintor M, Fischer HE. Autologous transfusion for cancer patients undergoing elective ablative surgery. J Surg Oncol 43:19-23, 1990.
- Blumberg N, Heal JM. Transfusion and recipient immune function. Arch Pathol Lab Med 113:246-253, 1989.
- Stipp D. Number of autotransfusions expected to rise due to AIDS Panel endorsement. The Wall Street Journal, p. 7, June 13, 1988.
- Cuello L, Vazquez E, Perez V, Raffucci FL. Autologous blood transfusion in cardiovascular surgery. Transfusion 7:309-315, 1967.
- Doggett WM, Gada PH, Leape LL, Scannell JG. Autologous blood transfusions in pulmonary surgery. J Thorac Cardiovasc Surg 59:546-550, 1970.
- Curran JW, Lawrence DN, Jaffe H, et al. Acquired immunodeficiency syndrome associated with transfusion. N Engl J Med 310:69-75, 1984.
- The AABB Annual Report. Arlington, VA: American Association of Blood Banks, 1990.
- Council on Scientific Affairs. Autologous blood transfusion. JAMA 256:2378-2380, 1986.
- American College of Physicians. Practice for elective red blood transfusion. Ann Intern Med 116:403-406, 1992.
- Toy PTCY, Strauss RG, Stehling LC, et al. Predeposited autologous blood for elective surgery: A national multicenter study. N Engl J Med 316:517-520, 1987.
- Kruskall MS. On measuring the success of all autologous blood donation programs. Transfusion 31:481-482, 1991.
- Axelrod FB, Pepkowitz SH, Goldfinger D. Establishment of a schedule of optimal preoperative collection of autologous blood. Transfusion 29:677-680, 1989.
- Swanson DA, Lo RK, Lichtiger B. Predeposit autologous blood transfusions in patients undergoing irradiation and radical cystectomy. J Urol 130:892-894, 1983.
- Levinson KA, Swanson DA, Johnson DE, et al. Fibrin glue for partial nephrectomy. Urology 38:314-316, 1991.
- Renner SW, Howanitz PJ, Bachner P. Preoperative autologous blood donations in 612 hospitals: A CAP Q'Probe study of quality issues in transfusion practice. Arch Pathol Lab Med 116:613-619, 1992.