|Year : 2021 | Volume
| Issue : 1 | Page : 50-55
Snapshot on physicians’ view on safe blood transfusion in multiply transfused patients in Nigeria
Chilota C Efobi1, Angela O Ugwu2, Esther I Obi3, Edmund N Ossai4, Sunday Ocheni2
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 Submission||11-May-2020|
|Date of Decision||20-Jul-2020|
|Date of Acceptance||13-Aug-2020|
|Date of Web Publication||21-Oct-2020|
Angela O Ugwu
Department of Haematology & Immunology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu.
Source of Support: None, Conflict of Interest: None
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|| |
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.,, 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.
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. Several studies have shown high prevalence of TTI among multitransfused patients (MTPs).,, This practice of multiple blood transfusions also exposes the patients to myriads of red cell antigens from the donors leading to alloimmunization. Alloimmunization is the body’s immunological response to the presence of red cell antigens that are foreign to the recipient. 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.,,,, There is also resultant reduction in red cell life span all culminating in increased transfusion requirement for the individual. 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.,, In most hospitals in Nigeria, antibody screening is not routinely done during pretransfusion compatibility testing. 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. 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|| |
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.
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.
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.
Ethical clearance for this study was obtained from the Ethics Committee of Chukwuemeka Odumegwu Ojukwu University Teaching Hospital.
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|| |
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].
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].
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%])
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|| |
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.
This finding is in keeping with Erabor et al. 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.
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.,,,
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.,, As the body has limited mechanisms of excreting excess iron, transfusional iron overload usually results following transfusion of 10–20 units of blood. Iron overload impairs immune system, leads to organ damage and increased mortality., 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. 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., 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. According to the World Health Organization (WHO), transfusion trigger hemoglobin for chronic anemias is 7g/dL. This was also recommended by other authors.,,,,,, 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 .
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.,, Therefore active HBV immunization as well as stringent donor screening will play a major role in protecting MTPs from HBV infection.,
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,, 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.
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|| |
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yaseen A, Suleiman S, Zenah OA, Abu Taha A Red blood-cell alloantibodies in multiply transfused patients in the occupied Palestinian territory: A pilot study. Lancet 2018;391:S4.
Sood R, Makroo RN, Riana V, Rosamma NL Detection of alloimmunization to ensure safer transfusion practice. Asian J Transfus Sci 2013;7:135-9.
Pandey H, Das SS, Chaudhary R Red cell alloimmunization in transfused patients: A silent epidemic revisited. Asian J Transfus Sci 2014;8:75-7.
Obi EI, Pughikumo CO, Oko-Jaja RI Red blood cell alloimmunization in multi-transfused patients with chronic kidney disease in Port Harcourt, South-South Nigeria. Afr Health Sci 2018;18:979-87.
Davies SC, Olatunji PO Blood transfusion in sickle cell disease. Vox Sang 1995;68:145-51.
Ahmed Kiani R, Anwar M, Waheed U, Asad MJ, Abbasi S, Abbas Zaheer H Epidemiology of transfusion transmitted infection among patients with β-thalassaemia major in Pakistan. J Blood Transfus 2016;2016:8135649.
Sidhu M, Meenia R, Yasmeen I, Sawhney V, Dutt N Prevalence of transfusion-transmitted infections in multiple blood transfused thalassemia patients: A report from a tertiary care center in North India. Ann Trop Med Public Health 2015;8:202-5.
Aneke JC, Okocha CE Blood transfusion safety: Current status and challenges in Nigeria. Asian J Transfus Sci 2017;11:1-5.
Jariwala K, Mishra K, Ghosh K Comparative study of alloimmunization against red cell antigens in sickle cell disease & thalassaemia major patients on regular red cell transfusion. Indian J Med Res 2019;149:34-40.
Kangiwa U, Ibegbulam O, Ocheni S, Madu A, Mohammed N Pattern and prevalence of alloimmunization in multiply transfused patients with sickle cell disease in Nigeria. Biomark Res 2015;3:26.
Bhuva DK, Vachhani JH Red cell alloimmunization in repeatedly transfused patients. Asian J Transfus Sci 2017;11:115-20.
Natukunda B, Brand A, Schonewille H Red blood cell alloimmunization from an African perspective. Curr Opin Hematol 2010;17:565-70.
Bajpai M, Gupta S, Jain P Alloimmunization in multitransfused liver disease patients: Impact of underlying disease. Asian J Transfus Sci 2016;10:136-9.
Ugwu NI, Awodu OA, Bazuaye GN, Okoye AE Red cell alloimmunization in multi-transfused patients with sickle cell anemia in Benin city, Nigeria. Niger J Clin Pract 2015;18:522-6.
Boateng LA, Ngoma AM, Bates I, Schonewille H Red blood cell alloimmunization in transfused patients with sickle cell disease in sub-Saharan Africa: A systematic review and meta-analysis. Transfus Med Rev 2019;33:162-9.
Hoffbrand AV, Taher A, Cappellini MD How I treat transfusional iron overload. Blood 2012;120:3657-69.
Osaro E, Charles AT The challenges of meeting the blood transfusion requirements in sub-Saharan Africa: The need for the development of alternatives to allogenic blood. J Blood Med 2011;2:7-21.
Ugwu A, Gwarzo G, Nwagha T, Gwarzo A, Andreas A Transfusion in limited infrastructure locations – where to go decades after safe blood initiative by World Health Organization? ISBT Sci Ser2020;15:118-25.
Ware AD, Jacquot C, Tobian AAR, Gehrie EA, Ness PM, Bloch EM Pathogen reduction and blood transfusion safety in Africa: Strengths, limitations and challenges of implementation in low-resource settings. Vox Sang 2018;113:3-12.
Zachee P, Vandekerckhove P How to implement a small blood bank in low and middle-income countries work in progress. Trop Med Surg 2020;8:227.
Diaku-Akinwumi IN, Abubakar SB, Adegoke SA, Adeleke S, Adewoye O, Adeyemo T, et al
. Blood transfusion services for patients with sickle cell disease in Nigeria. Int Health 2016;8:330-5.
de Jongh AD, van Beers EJ, de Vooght KMK, Schutgens REG Screening for hemosiderosis in patients receiving multiple red blood cell transfusions. Eur J Haematol 2017;98:478-84.
Karunaratna AMDS, Ranasingha JGS, Mudiyanse RM Iron overload in beta thalassemia major patients. Int J Blood Transfus Immunohematol 2017;7:33-40.
Rerambiah LK, Rerambiah LE, Etomba AM, Mouguiama RM, Issanga PB, Biyoghe AS Blood transfusion, serum ferritin, and iron in hemodialysis patients in Africa. J Blood Transfus 2015;2015:1-5.
Gao C, Li L, Chen B, Song H, Cheng J, Zhang X, et al
. Clinical outcomes of transfusion-associated iron overload in patients with refractory chronic anemia. Patient Prefer Adherence 2014;8:513-7.
Mishra AK, Tiwari A Iron overload in beta thalassaemia major and intermedia patients. Maedica (Buchar) 2013;8:328-32.
de Montalembert M, Ribeil JA, Brousse V, Guerci-Bresler A, Stamatoullas A, Vannier JP, et al
. Cardiac iron overload in chronically transfused patients with thalassemia, sickle cell anemia, or myelodysplastic syndrome. PLoS One 2017;12:e0172147.
Erhabor O, Adias TC, Mainasara AS Provision of safe blood transfusion services in a low income setting in West Africa. Case Study of Nigeria. In: Leon V. Berhardt, editor. Blood transfusions: Procedures, risks and role in disease treatment. 1st ed. New York, USA: Nova Science Publishers; 2013. pp. 1-58.
Yaddanapudi S, Yaddanapudi L Indications for blood and blood product transfusion. Indian J Anaesth 2014;58:538-42.
World Health Organization. Clinical transfusion practice guidelines for medical interns. Available from: . [Last accessed on 2020 Jun 3].
Retter A, Wyncoll D, Pearse R, Carson D, McKechnie S, Stanworth S, et al
; British Committee for Standards in Haematology. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol 2013;160:445-64.
Ansari S, Szallasi A Blood management by transfusion triggers: When less is more. Blood Transfus 2012;10:28-33.
García-Roa M, Del Carmen Vicente-Ayuso M, Bobes AM, Pedraza AC, González-Fernández A, Martín MP, et al
. Red blood cell storage time and transfusion: Current practice, concerns and future perspectives. Blood Transfus 2017;15:222-31.
Franchini M, Marano G, Veropalumbo E, Masiello F, Pati I, Candura F, et al
. Patient blood management: A revolutionary approach to transfusion medicine. Blood Transfus 2019;17:191-5.
Ali N Red blood cell transfusion in infants and children: Current perspectives. Pediatr Neonatol 2018;59:227-30.
Doctor A, Cholette JM, Remy KE, Argent A, Carson JL, Valentine SL, et al
; Pediatric Critical Care Transfusion and Anemia Expertise Initiative (TAXI); Pediatric Critical Care Blood Research Network (BloodNet), and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Recommendations on RBC transfusion in general critically ill children based on hemoglobin and/or physiologic thresholds from the pediatric critical care transfusion and anemia expertise initiative. Pediatr Crit Care Med 2018;19:S98-S113.
Omotowo IB, Meka IA, Ijoma UN, Okoli VE, Obienu O, Nwagha T, et al
. Uptake of hepatitis B vaccination and its determinants among health care workers in a tertiary health facility in Enugu, South-East, Nigeria. BMC Infect Dis 2018;18:288.
Ugwu AO, Madu AJ, Efobi CC, Ibegbulam OG Pattern of blood donation and characteristics of blood donors in Enugu, Southeast Nigeria. Niger J Clin Pract 2018;21:1438-43.
Olayinka AT, Oyemakinde A, Balogun MS, Ajudua A, Nguku P, Aderinola M, et al
. Seroprevalence of hepatitis B infection in Nigeria: A national survey. Am J Trop Med Hyg 2016;95:902-7.
Oluyinka OO, Tong HV, Bui Tien S, Fagbami AH, Adekanle O, Ojurongbe O, et al
. Occult hepatitis B virus infection in Nigerian blood donors and hepatitis B virus transmission risks. PLoS One 2015;10:e0131912.
Vidja PJ, Vachhani JH, Sheikh SS, Santwani PM Blood transfusion transmitted infections in multiple blood transfused patients of beta thalassaemia. Indian J Hematol Blood Transfus 2011;27:65-9.
Jain R, Perkins J, Johnson ST, Desai P, Khatri A, Chudgar U, et al
. A prospective study for prevalence and/or development of transfusion-transmitted infections in multiply transfused thalassemia major patients. Asian J Transfus Sci 2012;6:151-4.
] [Full text]
Motayo BO, Faneye AO, Udo UA, Olusola BA, Ezeani I, Ogiogwa JI Seroprevalence of transfusion transmissible infections (TTI), in first time blood donors in Abeokuta, Nigeria. Afr Health Sci 2015;15:19-24.
Okoroiwu HU, Okafor IM, Asemota EA, Okpokam DC Seroprevalence of transfusion-transmissible infections (HBV, HCV, syphilis and HIV) among prospective blood donors in a tertiary health care facility in Calabar, Nigeria; an eleven years evaluation. BMC Public Health 2018;18:645.
World Health Organization. Blood safety and availability. Available from: https://www.who.int/news-room/fact-sheets/detail/blood-safety-and-availability. [Last accessed on 2020 Jun 7].
[Table 1], [Table 2], [Table 3]