How many facilities are practicing universal irradiation?

The medical director of the blood bank at a well-known medical school in New York wants to get a feel for how many institutions practice universal irradiation for RBCs at tertiary care teaching hospitals. She writes "I am trying to get a sense of how many other centers are using universal irradiation for patient safety reasons. There is at least one other tertiary care hospital in NY that already has, despite the CMS reimbursement issues. And from prior CBBS posts, there are several other hospitals, in Maine, Philadelphia and Boston that are also on universal irradiation." Can other tertiary care teaching facilities chime in with their experience?

Editors' note: the following prior e-Network Forum discussions may be germane to this discussion:

• How do blood banks know when a patient should get irradiated blood, if the patient's doctor forgets to order the blood to be irradiated?
• Irradiation reimbursement
• Should we irradiate red cells transfused to patients with sickle cell anemia?

The following comments have been received in response.

ADDENDA Dec. 23, 2010

1. Dr. Kaufman, Medical Director, Adult Transfusion Service, Brigham and Women's Hospital (attribution used with permission) writes: Our facility is an 800-bed teaching hospital that is closely affiliated with the Dana-Farber Cancer Institute (DFCI). Our blood bank issues about 60,000 total blood products per year. All cellular products are irradiated. Several years ago, our primary strategy was to irradiate products for any patient with a DFCI medical record number (i.e. presumed diagnosis of cancer). However, there were still immunocompromised patients slipping through the cracks (e.g. bone marrow transplant recipient in the Emergency Dept. after a car crash; Dermatology patients on fludarabine). So we purchased a second irradiator, and several hours per day of blood bank tech time goes toward irradiating products. The only time non-irradiated units might be issued would be during a bleeding emergency when there is insufficient time to obtain irradiated units. Our approach was to make irradiation of all cellular products the official standard of care for our institution (it is a medical staff policy).
   
   
2. The Chief of Transfusion Medicine at a prominent University in one of the original 13 colonies writes "We practice universal leukoreduction for RBCs and platelets. We own 2 irradiators so it does not pose any significant financial burden as it would if we had to order all products irradiated from our blood supplier. We feel the time we spend irradiating is worth it, considering the consequences of not being informed by an ordering physician that irradiated products are needed."

ADDENDA Jan. 9, 2011

3. Several colleagues affiliated with a network of community based donor collection centers report that they are not aware that any of the hospitals served by their network have a policy of "universal" irradiation. This is confirmed by the Medical Directors at some of their major blood centers in Arizona, California and Nevada. Some Medical Affairs physicians are aware of institutions (outside of the responding colleagues organization's service area) that may have such policy. They believe that the commentary HERE (Transfusion subscription required to access content) is pertinent to this discussion.

ADDENDA Feb. 23, 2011

4. The Medical Director of a University Hospital in Southern Europe writes: At our facility, a tertiary level hospital with solid organ and hematopoietic transplant programs, we decided to irradiate all platelet products, and irradiate red cells only when it is clearly indicated. This was based on three considerations:
   1. More than 50% of platelets were used by hematology patients, and many of them are allogeneic transplantations, with an elevated risk of tGVHD due to transplant and fludarabine conditioning. Thus, it was much easier for everybody to manage the increasing complexity by irradiating all platelets.
   2. Irradiated red cells are mainly used by hematology patients, but their use is less intensive and can be easily programmed.
   3. Blood products are irradiated in house using the radiotherapy equipment, in big batches, that is cheap and fast. He adds "the compromise is working smoothly. However, one should take into account that reimbursement in European State-run hospitals may not relate to American reimbursement."

ADDENDA May 31, 2011

5. Kenneth E. Nollet, MD, PhD (an American blood banker in Japan) reports that Fukushima Medical University may have been the first, in 1988, to introduce universal irradiation of allogeneic cellular blood products. Ken adds that it is now standard practice in Japan, where the likelihood of a one-way HLA match is higher than other countries. He adds that there is not a one-size-fits-all answer. Every dollar, euro, or yen spent on one initiative is unavailable for another. Safety-oriented interventions such as irradiation and pathogen inactivation inflict some cellular damage. When teaching or discussing TA-GVHD, he still cites two articles that were essential reading when he was a trainee.^1,2 Other classic and contemporary references are cited in a new book chapter by Jed Gorlin.³
   1. Ohto H, Yasuda H, Noguchi M, Abe R. Risk of transfusion-associated graft-versus-host disease as a result of directed donations from relatives. Transfusion 1992 Sep;32(7):691-3.
   2. Wagner FF, Flegel WA. Transfusion-associated graft-versus-host disease: risk due to homozygous HLA haplotypes. Transfusion 1995 Apr;35(4):284-91.
   3. Gorlin JB. Transfusion-Associated Graft-vs-Host Disease and Component Manufacture. Chapter 8 (pp 209-230) in Lozano M, Blajchman MA, Cid J (editors). Blood Component Preparation: From Benchtop to Bedside. Bethesda, MD: AABB Press 2011.

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