Donors presenting to donate blood in order to decrease hematocrit

The medical director of a blood center reports that donors occasionally say that their physicians have recommended that they donate blood. The most common reason is increasing hematocrit in men on testosterone therapy, although other reasons are also given. None of these donors has a medical condition or other reason for deferral that would preclude donation. In the opinion of the director, these donors should be treated as therapeutic phlebotomy patients rather than volunteer allogeneic blood donors because they are donating to gain a perceived medical benefit instead of for altruistic reasons. The director thinks a prescription for phlebotomy should be required and the donor units discarded. However, the treating physicians often decline to write a prescription for phlebotomy since they don't see blood donation as a treatment for disease. The director is curious as to how others handle this situation.

Editors' Notes: A similar question was submitted to CBBS regarding referrals for therapeutic phlebotomies for patients with elevated hematocrits:

• Therapeutic Phlebotomy for Testosterone Replacement?

Erythrocytosis is a known effect of testosterone supplementation. Testosterone injections are associated with a greater risk of erythrocytosis than topical preparations (1). In hypogonadal men treated with testosterone, 44% receiving intramuscular injections had at least one documented hematocrit greater than 52% during the course of treatment (2). The indication for therapeutic phlebotomy to treat polycythemia in these patients is unclear, although monitoring of hemoglobin/hematocrit has been recommended (1, 2).

1. Rhoden EL and Morgentaler A. Risks of testosterone-replacement therapy and recommendations for monitoring. NEJM 2004;350:482.
2. Dobs AS et al. Pharmacokinetics, efficacy, and safety of permeation-enhanced testosterone transdermal system in comparison with bi-weekly injections of testosterone enanthate for the treatment of hypogonadal men. J Clin Endo Metab 1999;84:3469.

ADDENDA

1. A transfusion service physician in Southern California writes "we have always had these patients come as therapeutic phlebotomy patients. In our area, the number one reason for testosterone therapy is HIV, and some of these patients are very reluctant to disclose that they have the virus or are homosexual."

ADDENDA  Aug. 2, 2012

2. Dr. Jay Brooks, Director of Transfusion Medicine at University of Florida/Shands (attribution used with permission), states that in his opinion these donors are receiving a therapeutic phlebotomy and should be appropriately characterized as such. The doctors who refuse to write prescriptions for therapeutic phlebotomy are correct in that voluntary allogeneic blood donation is not a treatment for disease (that would be therapeutic phlebotomy). The rationale for routine therapeutic phlebotomy in patients on testosterone remains unclear. However, phlebotomy to reduce hematocrit for the medical benefit of the donor is still a therapeutic phlebotomy regardless of whether the indication is questionable. Dr. Brooks wonders if the doctors who refuse to write prescriptions are simply being cautious and not wanting to commit to a treatment with questionable rationale. In any event, this is NOT a volunteer allogeneic blood donation. If the FDA wants to classify these donations as they have for hemochromatosis then we can have another discussion.

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