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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 26  |  Issue : 1  |  Page : 50-55

Snapshot on physicians’ view on safe blood transfusion in multiply transfused patients in Nigeria


1 Department of Haematology and Blood Transfusion, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Nigeria
2 Department of Haematology & Immunology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
3 Department of Haematology, Federal Medical Center Yenogoa, Yenagoa, Nigeria
4 Department of Community Medicine, College of Health Sciences, Ebonyi State University, Abakaliki, Nigeria

Date of Submission11-May-2020
Date of Decision20-Jul-2020
Date of Acceptance13-Aug-2020
Date of Web Publication21-Oct-2020

Correspondence Address:
Angela O Ugwu
Department of Haematology & Immunology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_30_20

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  Abstract 

Background: Multiply transfused patients (MTPs) are often at risk of alloimmunization and other transfusion-associated complications. These complications could be ameliorated through extended blood typing prior to transfusion of blood and blood products. Objective: The aim of this study was to assess the knowledge and practice of safe blood transfusion in MTPs by physicians. Materials and Methods: This was a cross-sectional questionnaire-based study of physicians who attended a scientific conference of the West Africa College of Physicians in Asaba, Delta State. Result: Most of the respondents (68%) managed patients requiring multiple blood transfusions. Forty-seven respondents (68.1%) had a blood transfusion policy for MTPs in their respective centers, and 43 (68.1%) had no transfusion trigger hemoglobin level in their respective health facilities. Respondents who had a blood transfusion policy in their centers had a better knowledge of safe blood transfusion than those that did not, P = 0.008. None of the respondents reported carrying out antibody screening before and after multiply transfusing the patients. Although 100% performed initial screening for transfusion transmissible infections (TTIs), only 11.6% repeated screening for TTIs annually. Conclusion: Practice of safe blood transfusion in MTPs was found to be poor among physicians in Nigeria. Hospitals and training institutions should design ways to update knowledge of physicians on safe blood transfusion especially in MTPs and by so doing optimize safe blood transfusion practices, so as to improve the quality of life of patients.

Keywords: Alloimmunization, hemoglobin trigger, multiply transfused patients, safe blood transfusion, target hemoglobin


How to cite this article:
Efobi CC, Ugwu AO, Obi EI, Ossai EN, Ocheni S. Snapshot on physicians’ view on safe blood transfusion in multiply transfused patients in Nigeria. Int J Med Health Dev 2021;26:50-5

How to cite this URL:
Efobi CC, Ugwu AO, Obi EI, Ossai EN, Ocheni S. Snapshot on physicians’ view on safe blood transfusion in multiply transfused patients in Nigeria. Int J Med Health Dev [serial online] 2021 [cited 2021 Jan 20];26:50-5. Available from: https://www.ijmhdev.com/text.asp?2021/26/1/50/298782




  Introduction Top


A good number of disease conditions do warrant the need for repeated blood transfusions. These include patients with complications of sickle cell disease and severe thalassemia syndromes; patients with end-stage renal disease, organ transplant, severe aplastic anemia, and several malignancies.[1],[2],[3] Multiple blood transfusions is defined as receipt of more than one unit of whole blood within a month or at least 10 units of whole blood within 3 months.[4]

Multiple blood transfusions may be complicated by iron overload and transfusion-transmitted infections (TTIs) such as human immunodeficiency virus (HIV) infection, hepatitis B and C, and syphilis.[5] Several studies have shown high prevalence of TTI among multitransfused patients (MTPs).[6],[7],[8] This practice of multiple blood transfusions also exposes the patients to myriads of red cell antigens from the donors leading to alloimmunization.[9] Alloimmunization is the body’s immunological response to the presence of red cell antigens that are foreign to the recipient.[4] It is not surprising then when these patients have delayed blood transfusion reactions or difficulties with procurement of compatible blood units when they require blood transfusion in the future.[1],[10],[11],[12],[13] There is also resultant reduction in red cell life span all culminating in increased transfusion requirement for the individual.[3] Antibody production against red cell antigens thus contributes to increased morbidity and mortality besides the difficulty blood bank staff experience in trying to procure matching blood units for the patients. Several authors have also reported the incidence of alloantibodies in MTPs.[4],[10],[14] In most hospitals in Nigeria, antibody screening is not routinely done during pretransfusion compatibility testing.[15] The patients on chronic blood transfusions are therefore at increased risks of developing (1) alloantibodies against the various antigens they were exposed to and (2) at risk of transfusional iron overload.[16] Due to the increasing incidence of repeat transfusions, the managing physicians should know, understand, and practice the rudiments of transfusion principles as it affects MTPs.

In this study, we aimed to ascertain the various ways physicians in Nigeria adopt in managing patients who require multiple blood transfusion practice of safe blood transfusion in MTPs by physicians in Nigeria.


  Materials and Methods Top


Study area

This study was conducted in Asaba, Delta State, Nigeria. Asaba is a fast-developing urban area in the West of the bank of River Niger.

Study population

It was a cross-sectional study carried out among the participants at the Annual General and Scientific Meeting of the West African College of Physicians in July 2017. The College is organized into faculties, made up of specialists in each of the major disciplines in medicine. There were 120 physicians from various hospitals spread across Nigeria who were willing to participate in the study. They gave verbal consent and were consecutively selected for the study. The questionnaire was self-administered. Any doubts regarding questionnaire were clarified by investigator.

Pilot study

The questionnaire was pretested among doctors working at Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Amaku (COOUTH) Awka. The questionnaire was checked for its completeness, clarity, and understandability before distributing to the actual respondents.

Data were collected by using a self-administered questionnaire, which was prepared in English language. Information sought for included sociodemographic characteristics of the participants like age, sex, number of years of practice, designation, and parameters, which were designed to assess the practices of safe blood among the MTPs.

Ethics

Ethical clearance for this study was obtained from the Ethics Committee of Chukwuemeka Odumegwu Ojukwu University Teaching Hospital.

Statistics

Data were compiled and entered in Microsoft Excel sheet. Analysis was both descriptive and inferential using the Statistical Package for the Social Sciences (SPSS) software program, version 21.0 (Chicago, Illinois). A value of P < 0.05 was considered statistically significant.


  Results Top


One hundred and twenty questionnaires were distributed during the West African College of Physicians annual scientific conference in 2017. Only 69 questionnaires were completely filled giving a response rate of 57.5%. There were 31 (44.9%) males and 38 (55.1%) females with a mean age of 41.8 ± 8.3 years. Over two-thirds 47 (68.1%) of the respondents were consultants in various fields of medicine. Other details are as shown in [Table 1].
Table 1: Social demographic characteristics of respondents

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Also, most of the respondents (68%) manage patients requiring multiple blood transfusions. Forty-seven respondents (68.1%) had a blood transfusion policy for MTPs in their respective centers, whereas 43 (68.1%) had no transfusion trigger hemoglobin level in their respective health facilities. This is as shown in [Table 2].
Table 2: Respondents’ practice of blood transfusion 1

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As shown in [Table 3], more than two-thirds of the respondents kept a comprehensive transfusion record of their patients 48 (69.6%) and screen patients for TTIs at first contact (66.7%). Majority 49 (71%) of the respondents did not immunize their MTPs against hepatitis B virus infection nor screen MTPs annually for TTIs (61 [88.4%])
Table 3: Respondents’ practice of blood transfusion 2

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Those who have a blood transfusion policy in their centers appeared to have a better knowledge of safe blood transfusion that those that do not, P = 0.008.


  Discussion Top


Practice of safe blood transfusion in MTPs was found to be poor in majority of our respondents. The MTPs are not screened for the presence of lytic antibodies which may cause hemolytic transfusion reactions either before the initial blood transfusion or following repeated blood transfusions. This may be partly because many blood banks in the country do not perform antibody screening routinely to detect clinically significant autoantibodies and alloantibodies during the process of compatibility testing.[8]

This finding is in keeping with Erabor et al.[17] who noted that antibody screening is not done in many hospitals in sub-Saharan Africa. The major challenge in our environment is poor funding and lack of facilities for antibody screening and detection which is probably the major reason majority of our respondents do not request for such for their patients. Some blood transfusion facilities in Nigeria rely only on blood grouping as criteria for compatibility without performing a complete cross match.[18]

We also found that 94.2% of respondents reported transfusion of leukodepleted red cells. This is not surprising as a good number of hospitals in the country have limited infrastructure and reagents for blood component therapy. Transfusion of whole blood is still practiced on a wide scale in many parts of Nigeria and sub-Saharan Africa.[18],[19],[20],[21]

Another complication of frequent blood transfusion is the transfusional iron overload also called transfusional hemosiderosis. High prevalence of transfusional hemosiderosis has been reported in MTPs.[22],[23],[24] As the body has limited mechanisms of excreting excess iron, transfusional iron overload usually results following transfusion of 10–20 units of blood.[25] Iron overload impairs immune system, leads to organ damage and increased mortality.[26],[27] Our study found that only 24.6% of respondents screen patients for Iron overload. This is also similar to the finding from Diaku-Akinwumi et al.[21] that noted that only a quarter of blood banks they studied could test for iron overload.

We noted, however, that over two-thirds of the doctors had a blood transfusion policy in their respective centers. This is at variance with the finding of unavailability of National blood transfusion policies in Nigeria and in many sub-Saharan countries.[18],[28] Availability of effective blood transfusion centers and blood transfusion policies will enable a streamlined blood transfusion practice, such that health facilities where these policies are implemented will have well-defined trigger hemoglobin and a target posttransfusion hemoglobin.

Over two-thirds of them do not have established blood transfusion trigger. The hemoglobin level below which blood transfusion is needed is called the transfusion trigger.[29] According to the World Health Organization (WHO), transfusion trigger hemoglobin for chronic anemias is 7g/dL.[30] This was also recommended by other authors.[29],[31],[32],[33],[34],[35],[36] Transfusion trigger is necessary so as to prevent unnecessary blood transfusion and thus prevent undue exposure to potential hazards of multiple transfusions.

We observed that whereas majority of the respondents screen donor units for TTIs before every transfusion, vaccination of the MTPs is not a routine practice. This may stem from a generally poor uptake of Hepatitis B vaccination among the population which is ascribed to ignorance, exorbitant cost of the vaccine, and in some cases, unavailability of the vaccine itself .[37]

Chronic hepatitis B infection is transmitted via blood transfusion and is a cause of acute and chronic liver disease including primary liver cell carcinoma. The seropositivity of Hepatitis B virus among blood donors in Nigeria varies with a rate of 3.6% to 17% depending on the region studied.[38],[39],[40] Therefore active HBV immunization as well as stringent donor screening will play a major role in protecting MTPs from HBV infection.[41],[42]

Annual screening of MTPs for TTIs was done routinely by only 8 out of 69 respondents. Considering the increased burden of transfusion transmissible infections in Nigeria,[43],[44] our screening techniques and frequency of screening should be upgraded to meet up with the provision of safe blood and blood products as envisioned by the World Health Organization.[45]

Limitations of the study

The major limitation of this study is the non-use of Likert scale in assessing the opinion of the respondents. This would have improved the reproducibility of the study


  Conclusion Top


As only ABO and Rh(D) antigens are matched during compatibility testing, the risk of alloimmunization in the minor blood groups is very high. To forestall this, extended antigen typing and issuing of antigen matched blood units should be practiced. We recommend that MTPs should be screened for TTIs and get immunized against TTIs. Screening for iron overload should be routinely done.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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