A blood banker in Southern California wonders if any colleagues are routinely leukocyte-reducing autologous RBC (or platelet) units. Her institution maintains a dual inventory of leukoreduced and non-leukoreduced ALLOGENEIC units, but a 100% inventory of NON-leukocyte reduced AUTOLOGOUS units. Her institution has a policy to give leukoreduced allogeneic units to heart surgery patients, cancer patients, and other frequently transfused patients (sickle cells, dialysis), as well as to those patients who have had previous febrile reactions. However, if any of those patients banked their own autologous blood, their autogous transfusion would be non-leukocyte reduced. Since her staff occasionally errs and fails to select a leukocyte-reduced allogeneic product for a patient who should get one, she is thinking of converting their entire RBC and platelet inventory to 100% leukoreduced to avoid such a mishap. She acknowledges that nearly 60% of the autologous units that they collect on site are not transfused, and she would hate to go to the effort and expense of leukoreducing autologous units that are not used. However, she would consider leukoreducing autologous units for heart patients (and possibly other patients as well) if experience in the field and the literature supported it.

The Editor recommends review of a similar issue posted on this forum in 1999, when the subject of universal leukoreduction was first being discussed.

ADDENDA Mar. 16, 2005

The following comments have been received.

1. Dr. Breanndan Moore of the Mayo Clinic in Rochester MN (attribution used with permission) reports that they recently converted their cellular blood product inventory to an all-leukoreduced supply. He acknowledges their rationale as follows;

• An ever growing proportion of transfused patients have established indications for leukoreduction, e.g. Transplants, immunocompromised, need for CMV protection, neonates etc.
• They already reached a point where about 70% of their platelets were leukoreduced (either apheresis or random pools) and about 50% of their RBCs were leukoreduced.
• Partly due to maintaining a "dual" blood supply (leukoreduced and non-leukoreduced) and partly due to medical or surgical residents forgetting to order leukoreduced products when indicated, they were beginning to see situations where patients who really should have been getting leukoreduced blood products, did not always receive them.
• They recognized that the list of clinical situations where leukoreduction was considered likely to be beneficial to patients, was growing.
• They could greatly simplify the blood ordering, blood processing, labeling and storage by eliminating the question of leukoreduction altogether.

In his opinion, by employing a 'universal leukoreduction' policy, they were able to simplify the processes in their Component Preparation laboratory, which in turn greatly reduced the opportunity for error in that lab and by clinicians (faculty and those in-training) who are sometimes mesmerized by the complexity of blood products and their appropriate indications. While there is a financial cost to universal leukoreduction, he believes that the consolidation and simplification of their process pays for itself. He believes that the arguments used to justify a decision to provide a leukocyte-reduced blood product inventory applies equally to autologous blood that they collect preoperatively.

2. A transfusion medicine physician in New York reports that his hospital's allogeneic blood supply has been 100% leukoreduced since July 2000, but they store all autologous units as whole blood, non-leukoreduced. The autologous whole blood units have completely different labels than the allogeneic units (something they had to get the FDA's approval on). As far as risks, he cautions that he is aware of a case report of possible TRALI due to autologous transfusion, but there is very little data to date to suggest that leukoreduction has any demonstrable benefits for autologous units. That's not to say that such data won't be forthcoming, as there are a plethora of mediators, such as IL-6, IL-8 and CD40L that accumulate in the supernatant of non-leukoreduced red cells (and platelets) that some day might be shown to have deleterious effects in some susceptible patients.

ADDENDA Mar. 19, 2005

3. According to Martha Cox of Medic Regional Blood Center in Knoxville Tennessee (attribution used with permission) her blood center began to process autologous whole blood collections as leukocyte reduced RBCs almost two years ago. This policy decision was driven primarily as a process consistency step to improve their manufacturing operations. However, she points out a second benefit, since the autologous donors seem to have a greater number of “slow bleed” donations, with an apparent increase in clotted units. Since they filter the units to leukoreduce them, the patient and physician can be informed ahead of time if a unit will not be available due to the presence of a clot at filtration. Previously, the clot might not have been visible on visual inspection and they might not have known about the clot until they tried to transfuse the unit.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator