BLOOD MEDICINE

Besides the possibility of contracting AIDS or hepatitis, blood transfusion carries a host of other risks, perhaps even aiding recurrences of cancer.

Perhaps no medical procedure is linked so much with saving lives as blood transfusions. When we think of the emergency rescue of someone who has suffered a life threatening trauma, invariably we imagine a stretcher and an intravenous drip of life giving blood.As it happens, that particular image strictly belongs to Hollywood. The Red Cross now admits that even in the most dire of emergencies blood transfusions oftentimes only add to complications or increase a person’s chances of dying. Although the recent spectre of AIDS and HIV virus contaminated blood has curtailed blood donation and transfusions, it is still routine for most surgery and emergencies in many cases, without any medical justification whatsoever for its use or guidelines as to when it is necessary.

To find out about the dangers of blood transfusions, we paid a visit to a group with an uncompromising axe to grind in this particular area: the Jehovah’s Witnesses. The Witnesses’ objection to blood transfusion is a religious one in their view, the Bible strictly prohibits it. Nevertheless, they have fought their many legal battles strictly on medical grounds; the British and American headquarters both have employees whose specific job is to scour the medical literature for studies proving various dangers of taking in foreign blood.

The British headquarters of the Witnesses in North London kindly loaned us what amounts to two telephone book sized collections of medical articles.Their position has forced doctors to re examine their practices, many now concluding that transfusion is almost never necessary.

Like so many other practices in medicine,the reasons doctors have used for deciding when to give a transfusion have been adopted with very little scientific basis. An estimated one third to three quarters of those given blood are transfused inappropriately to treat a diminished volume of blood or a low nutritional status (ie, anaemia). Writing in the World Journal of Surgery (1987), Anthony Britten of the American Red Cross Blood Services admitted that there is “gross overuse of blood products like albumin and plasma and also whole blood or red blood cells. Usage patterns vary so widely from place to place that it is clear that common standards do not exist for their use.”

A US Office of Technology Assessment Task Force examining this issue in a 1989 publication entitled Blood Technologies, Services and Issues, estimated that as much as 20 to 25 per cent of red blood cells, 90 per cent of albumin and 95 per cent of fresh frozen plasma transfused into patients are not needed. Indeed, a common “transfusion trigger” is the measurement of haemoglobin (a compound in red blood cells transporting oxygen to the cells). Medicine uses the same “trigger” level for men and women, even though women naturally have lower red blood cell counts than do men. “Iron deficiency anaemia continues to be among the leading reasons for transfusions, even though it rarely warrants [them],” said the report.

Many in medicine have begun to question some of the most established practices for administering blood before and during surgery. After surveying 1000 American anaesthesiologists, L. C. Stehling of the SUNY Upstate Medical Center in Syracuse, NY and his fellow authors concluded in Vox Sanguinis, the International Journal of Transfusion Medicine (Vol 52 No. 1-2, 1987): there were “wide variations in transfusions practices” among anaesthesiologists based on “habit rather than scientific data.”

One such habit is the automatic administration of blood before operations in patients whose haemoglobin level is below 10gm/per 100 ml of blood (see box, p 2). At a National Institutes of Health Conference on red blood cell transfusion during operations, medical author Howard L. Zauder, argued that this practice was “cloaked in tradition, shrouded in obscurity and unsubstantiated by clinical or experimental evidence”. Zauder claims the practice arose from a misreading by a haemotologist of a study of dogs, which was accepted as gospel and preached to an entire generation of anaesthesiology students.

Ronald A. Sacher, of the division of haemotology, Georgetown University Medical Center in Washington DC, has challenged most of the transfusion practices for mother and baby during birth or in cases of prematurity. Premature infants probably get more transfusions than any other body of patients in hospital (other than haemophiliacs). In one study, (Transfusion Medical Reviews January 1989) 2.5 per cent of a population of preemies received blood transfusions, over two thirds of whom received more than one. Transfusion is automatic if a baby is under 1500g (about three pounds).

Elsewhere (Transfusion Medicine, Blackwell Scientific Publications, 1988), Sacher called these practices: “often empiric”, with “many unanswered questions” and “few randomized clinical trials.”

Even if you believe that giving and getting blood is warranted, the number of blood borne diseases you can contract from other people might well change your mind. The arrival of AIDS has of course given blood transfusion the quality of Russian Roulette.

Because we really don’t understand what causes AIDS or whether there needs to be another co-factor to convert HIV to AIDS(as Luc Montagnier, the co-discoverer of the AIDS virus now maintains), we also don’t understand how long the HIV virus (if indeed that is the cause of AIDS) incubates before transforming into full blown disease.

The latent “window” period during which no blood tests can detect the presence of HIV in an infected individual can be as long as eight years! In a letter to the New England Journal of Medicine (May 9, 1985) a group of doctors from Atlanta, Georgia reported that an 11 year old child had developed AIDS after a single blood transfusion five and a half years before. At a symposium on haematology held in 1987, chairman Dr Peter Levine declared that the Centers for Disease Control had concluded that the latency period was six years. (Every year this estimate keeps lengthening.)

Furthermore, a certain number of AIDS victims don’t come up positive on the ELISA tests, the standard test for antibodies to the AIDS virus.

In the New England Journal of Medicine, Dr Allan M. Salzberg of the Veterans Administration Medical Center in Miles City, Montana, concluded that in about “7 per cent of carriers, HIV infection cannot be detected by present HIV antibody tests”.

As AIDS co-discoverer Montagnier points out, writing in AIDS: The Safety of Blood and Blood Products (John Wiley & Sons, 1987), large scale screening of blood donors is virtually useless because the blood test kits cannot trace any of the various mutants of the AIDS virus.

The risk of contracting hepatitis is even higher than AIDS. According to an August 1988 issue of Gastroenterology, the big risk of transfusion is contracting a new form of hepatitis, aptly labelled (to reflect medicine’s puzzlement about its origins) “Non-A, Non-B Hepatitis” (NANBH). This editorial in Gastroenterology estimated that hepatitis from transfusions develops in 7 to 10 per cent of blood recipients from unpaid donors in the US. The percentage multiplies three to four times among recipients of the blood of paid donors. This translates into up to 230,000 new cases of NANBH in the US every year after transfusions, estimates Surgery Annual (Appleton Century Crofts, Norwalk, Conn ecticut). The reason for the epidemic of cases is that there is, to date, no reliable or sensitive enough test to detect the agents that cause the disease. There is also a high risk of contracting human T-cell leukaemia (HTLV-1). A study in the New England Journal of Medicine (4 May 1989) put the risk of HTLV-1 at tenfold higher than the risk of contracting HIV. Sacher cites another study where preemies of a few pounds in weight were given blood from more than 10 donors and, in another study, an average of 9 donors, placing them at considerable risk of contracting any one of the blood borne diseases.

Besides the various diseases you can contract from someone else’s blood, copious studies show that blood transfusion in a cancer patient may depress the immune system, causing or in some way aiding a recurrence. In one study (Annals Otology, Rhinology & Laryngology, March 1989), the recurrence rate for patients with cancer of the larynx was 14 per cent among those who didn’t receive blood transfusions, and 65 per cent among those who did. Of those with cancer of the oral cavity, pharynx and nose, the recurrence rate was 31 per cent without transfusions and 71 per cent with them.

A poorer outcome was also experienced after surgery for lung cancer in patients receiving blood transfusions (Annals ofThoracic Surgery March 1989), as well as for those with colonic, rectal, cervical and prostate cancers (British Medical Journal 30 August 1986). There also seemed to be a higher incidence of recurrence among patients receiving whole blood (52 per cent) rather than simply red blood cells alone (23 per cent). And at least four studies demonstrate that having a transfusion during an operation increases your chances of infection. (Transfusion, June 1989; British Journal of Surgery, August 1988; Archives of Surgery, February 1988; Archives of Surgery, January 1987).

P. I. Tartter and others from New York’s Mount Sinai Medical Centre wrote (British Journal of Surgery August 1988), that in a study of colorectal cancer patients, “Blood transfusions were associated with infectious complications when given preoperatively, intraoperatively or postoperatively. . . None of the patients had infectious complications before receiving the first unit of blood.”

Another study of patients with cancer noted, “A direct relationship existed between the number of transfusions administered and the decrease in disease free and overall survival; the larger the number of transfusions, the worse the prognosis.”

Then there are the many complications that patients show up with after being given blood. Although the usual reactions include hives, fever or chills, some patients have a severe reaction in the lungs, sometimes fatal, with some kinds of plasma, a risk that is higher than previously thought.

(Vox Sanguinis Vol 57 No 1 1989) There are also substantial risks of general infection, anaphylactic shock (extreme allergic reaction) or graft versus host disease (a rejection of the blood by the recipient, affecting the joints, the heart and blood cells), as well as other sexually transmitted diseases like cytomegalovirus (CMV).

Another study showed that in patients undergoing major abdominal surgery, blood transfusion was the most significant contributor to organ system failure.

These findings can only lead one to conclude (as a Journal of the American Medical Association editorial of 31 October 1986) did, that blood, like fingerprints, is uniquely untransferably individual:

“The unavoidable, biological (and now legally recognized) fact is that each person’s blood contains a multiplicity of antibodies, antigens and infectious agents, many of which have yet to be identified by scientists and cannot presently be detected. ‘Pure blood’ . . . is finally understood by courts to be imaginary.’