A physician in Northern California reports that his center treats several patients who have Sickle Cell Disease with erythrocytapheresis, in order to maintain their percent hemoglobin S level below 30% and their hemoglobin level around 9-10g/dL. They routinely transfuse these Sickle Cell Disease patients with "phenotypically matched" donor red cells. In addition, some of the patients have experienced well documented, recalcitrant urticaria, and for those patients, the donor RBC units used are typically "saline washed". However, the physician acknowledges that they would prefer not to saline wash RBC units because the washing procedure reduces the effective red cell dose. Recently, they attempted to take one of their erythrocytapheresis patients with recalcitrant urticaria off of saline washed RBCs. The patient did well for a few transfusions, but eventually the allergic reactions became problematic again. The hemapheresis service tends NOT to treat patients prophylactically with diphenhydramine or acetaminophen in advance of an erythrocytapheresis procedure, although they occasionally give loratidine for anti-pruritic treatment. The inquiring colleague is interested in comments from others regarding the use of saline washed RBCs versus premedications for patients with Sickle Cell Disease and occasional mild to moderate urticarial reactions. He asks "Should we treat the patient or treat the blood?"

The following comments have been received.

ADDENDA Sept. 12, 2006

1. In the opinion of an experienced transfusion medicine physician in New York state, the answer to the question posed by this discussion should be whichever strategy is better for the patient in terms of efficacy and safety, within the limits of feasibility and reasonable cost. In the instance provided, at his hospital, he would treat the blood component. In his experience, there is virtually no incremental risk to a patient to receive washed red cells versus unwashed red cells. On the other hand, medications given to prevent or minimize the severity of an allergic reaction present an incremental risk of a drug reaction. Washed red cells are fairly well documented to reduce the severity and/or occurrence of allergic reactions. Benadryl makes many patients sleepy and can cause more serious side effects in a small minority of patients. Other drugs have similar risk profiles or worse. He asks "Why give the patient a drug when treating the blood component is safe and efficacious?" Finally, concerns that a washed red cell unit has lost a significant number of cells during the washing process may be addressed by washing pre-storage leukoreduced red cells without using a red cell override, so that the 'supernatant out' is halted at the first appearance of hemoglobin in the outlet line.

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