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LETTER TO EDITOR  
Year : 2012  |  Volume : 55  |  Issue : 4  |  Page : 604-605
Icteric donor plasma: To transfuse or to discard?


Department of Pathology, T.N. Medical College and BYL Nair Ch. Hospital, Mumbai, India

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Date of Web Publication4-Mar-2013
 

How to cite this article:
Jashnani KD, Karwande A, Puranik G. Icteric donor plasma: To transfuse or to discard?. Indian J Pathol Microbiol 2012;55:604-5

How to cite this URL:
Jashnani KD, Karwande A, Puranik G. Icteric donor plasma: To transfuse or to discard?. Indian J Pathol Microbiol [serial online] 2012 [cited 2020 Sep 28];55:604-5. Available from: http://www.ijpmonline.org/text.asp?2012/55/4/604/107853


Sir,

Approximately 1.5% of the blood units collected annually, in our blood bank, show icteric plasma [Figure 1] and are therefore discarded. We decided to carry out a prospective study over a period of 18 months. A total of 20,786 samples were collected from healthy donors according to State Blood Transfusion Council (S.B.T.C.) and FDA guidelines for donor selection. The blood units were screened for HIV, HBsAg, HCV, VDRL, and malaria. Of these, 253 blood units with icteric plasma were screened for serum bilirubin which revealed unconjugated hyperbilirubinemia (bilirubin levels between 1.2 and 2.5 mg/dl).
Figure 1: Color of plasma in pilot tubes varies from normal, lipemic, icteric and hemolyzed (from right to left)

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These 253 units were further subjected to alanine transaminase (ALT), aspartate transaminase (AST) and alkaline phosphatase (AlkPO4) peripheral smear examination for RBC morphology, lactate dehydrogenase (LDH) levels, and direct and indirect antiglobulin test and blood culture.

The maximum numbers of donors were males in the age group of 18-30 years. All samples showed serum AST, ALT, and alkaline phosphatase levels within normal limits. Serum LDH levels were elevated (two times) in six cases, rest showed normal LDH. Peripheral smear examination showed normal RBC morphology in all except one case which showed a positive antiglobulin test, elevated LDH, and schistocytes on peripheral smear suspicious of mild hemolytic anemia. The raised LDH levels in remaining five cases can be explained by in vitro hemolysis during blood donation, storage, transport or handling.

Blood for culture was sent in 84% of cases and was negative in all. So what could be the possible cause of hyperbilirubinemia in otherwise normal healthy donors? As there was no history of any drug intake elicited, drug-induced hemolysis was excluded. Hemolytic anemia was ruled out based on normal hemoglobin concentration as found in these donors except for one case. The normal alanine aminotransferases levels exclude liver disease sufficient to account for the increased serum bilirubin concentration. Cholestasis requires conjugated hyperbilirubinemia and elevated alkaline phosphatase for its diagnosis and is therefore excluded. Hyperbilirubinemia due to alcoholism is also ruled out due to the same reason as stated above.

Thus congenital unconjugated hyperbilirubinemia [1] remains the most probable cause for icterus in the present study. Criggler-Najjar syndrome, characterized by a very severe form of hyperbilirubinemia with kernicterus manifests during early childhood, is excluded. Hence a possibility of Gilbert's syndrome can be considered in these cases as all of them showed mild unconjugated hyperbilirubinemia. [2],[3],[4]

There were certain interesting findings in this study: (i) there were two donors who had donated twice at an appropriate interval and at both the times their bilirubin levels were found to be raised and thus the blood units and components were discarded at both the times. Especially in setup like ours where financial constraints are already in place we need to be more economical. In another instance in the present study (ii) there were two pairs of siblings who had donated and their plasma revealed raised bilirubin levels which confirms the familial nature of the condition. Thus we can consider the asymptomatic hyperbilirubinemia in these cases to be due to Gilbert's syndrome.

We feel that three issues need urgent attention Central FDA should set a single value of total serum bilirubin as a cut-off for icteric plasma for all the blood banks.

If we decide to release these icteric blood component units for transfusion, then LFT and tests for overt hemolysis including plasma haptoglobin, CBC with reticulocyte count, specific tests like NAT [5] or PCR at least on these icteric samples are recommended. The clinician should be informed about the safety of these icteric units, so that they are not esthetically put off by the color of plasma.

If we decide to discard the blood components of icteric plasma, same tests should be carried out as described above. If all negative, we can label these donors as having Gilbert's Syndrome by exclusion. The donors should be informed about their icteric plasma status and prevented from future donations.

 
   References Top

1.Naimen JL, Sugasawara EJ, Benkosky SL, Mailhot EA. Icteric plasma suggests Gilbert's syndrome in the blood donors. Transfusion 1996;36:974-8.  Back to cited text no. 1
    
2.Koul P A, Geelani S A, Mudasir S. Benign jaundice in healthy blood donors in the Kashmir valley of Indian subcontinent. Internet J Intern Med Available from: http://www.ispub.com/. [Last cited on 2006].  Back to cited text no. 2
    
3.Arora V, Kulkarni RK, Cherian S, Pillai R, Shivali M. Hyperbilirubinemia in normal healthy donors. Asian J Transfus Sci 2009;3:70-1.  Back to cited text no. 3
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4.Schwertner HA, Vítek L. "Gilbert syndrome, UGT1A1 * 28 allele, and cardiovascular disease risk: Possible protective effects and therapeutic applications of bilirubin." Atherosclerosis 2008;198:1-11.  Back to cited text no. 4
    
5.U.S. Food and Drug Administration. FDA approves first nucleic acid test (NAT) systems to screen plasma for human immunodeficiency virus (HIV) and hepatitis c virus (HCV). February 28, 2002. Available from: http://www.thebody.com/content/art13891.html. [Last accessed on 2002 Feb 28].  Back to cited text no. 5
    

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Correspondence Address:
Kusum D Jashnani
8, Aashirvad, Opposite Kakad Industrial Estate, L J X Rd 3, Mahim Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.107853

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