Could the frequency of lipaemic donations be reduced by educational activities?

Dear Sir,

One of the primary quality goals in a transfusion service is to ensure adequate amounts of good quality, safe blood products. This implies that transfusion institutions have professional and ethical obligations to use the necessary measures to minimise nonconformities in input material and final products. Since the introduction of the quality management system in the Croatian Institute of Transfusion Medicine (CITM), lipaemia has been recognised as one of the leading non-conformities, and investigation of its causes and possible ways to reduce it is one of the priorities. Recent study reports on lipaemic donations^1,2 have stimulated us to present our own experiences in the investigation, surveillance and prevention of this problem. The results presented are based on macroscopic plasma examination, and the criteria for evaluating lipaemia remained unchanged throughout the study period. Results of our 1998 study³ revealed a higher frequency of lipaemic plasma in middle-aged and elderly donors and in those presenting for blood collection in the afternoon. The study was conducted from 1 August 1997 to 31 July 1998. During the study period, 58,306 plasma units were manufactured from blood collected from 38,023 donors. A total of 1,540 (2.64%) plasma units (intended for clinical use and for fractionation) were declared non-conforming because of lipaemia. The mean age of donors with lipaemia was 40 years, as compared with the mean age of 32 years in all donors during the study period. The frequency of lipaemic plasma according to timing of the blood collection and donors’ age is shown in Table I. Along with the obvious continuous increase in the frequency of lipaemic donations recorded from the morning to the afternoon, χ²-test confirmed the statistical significance of differences in the prevalence of lipaemia between donations collected before and after 2:00 p.m. (1.44% vs. 3.93%; P<0.001; OR=2.8). The effect of blood collection timing on the frequency of lipaemic donations was investigated again in 2010, yielding almost identical results and statistically significant difference (1.49% and 3.68% of lipaemic donations before and after 2:00 p.m., respectively; P<0.001; OR=2.45).

Table I.

Frequency of lipaemic plasma according to time of blood collection and donors’ age (1997/1998).

Lipaemia and time of blood collection
Completion of blood collection (h)	Before 10:00	10:00–12:00	12:00–14:00	14:00–16:00	After 16:00
FFP units manufactured (n)	14, 949	7,545	7,594	18,752	9,466
Lipaemic plasma units (n)	123	88	221	732	376
Lipaemic plasma units (%)	0.82	1.17	2.91	3.90	3.97

Lipaemia and donors’ age
Donors’ age (yrs)	≤20	21–25	26–30	31–35	36–40	41–45	46–50	51–55	56–60	>60
Blood donors (n)	9,530	6,795	3,210	3,462	3,948	4,126	3,294	2,088	1,105	465
Blood donors with lipaemia (n)	95	92	103	164	257	273	221	127	59	23
Blood donors with lipaemia (%)	1.0	1.35	3.21	4.74	6.51	6.62	6.71	6.08	5.34	4.95

Since 1998, lipaemia of fresh-frozen plasma (FFP) for clinical use is one of quality indicators at CITM. The decision to monitor lipaemia frequency on FFP units for clinical use instead of on the overall plasma units manufactured (which also include plasma units intended for fractionation) was based on the more stringent criteria for macroscopic FFP assessment, according to which even slight turbidity is considered as a non-conformity. During the 1998–2003 period, an incremental frequency of lipaemic FFP units was recorded, as illustrated in Figure 1. This increase was due to a number of factors, mostly an increase in the mean age of the donors and a larger number of donors presenting for blood donation in the afternoon.

Figure 1.

Frequency of lipaemic FFP units 1998–2011 (I–VI).

Since 1998, when the mean donor age was 32 years, the mean donor age has steadily increased to 39 years in 2011. More detailed analysis of donor age structure showed that the greatest decline was in the under 25-year old donor age group (from 39.6% in 1998 to 15.0% in the first 4 months of 2011), along with a larger proportion of those aged over 55 years (from 5.6% in 1998 to 13.95% in the first 4 months of 2011). The decrease in the frequency of young donors generally correlated with phasing out of army blood collection. In 1998, as many as 26.8% of blood donations were collected in the army, whereas in 2003 the proportion had fallen to only 5.5% (until complete phasing out of these collections in 2007). In addition, the proportion of blood collections completed by 2:00 p.m. was 51.6% in 1998, significantly higher than the 23.6% in 2010. Unlike donor age and timing of blood collection, the impact of modifications in the population’s dietary habits is more difficult to assess; nevertheless, the available data suggest that obesity is one of the leading (and increasing) causes of health problems in Croatia.

As shown in Figure 1, the frequency of lipaemic FFP reached 12.7% in 2003, when a corrective measure was launched aimed at modifying donor dietary habits prior to blood collection. A specific educational leaflet was designed to warn donors of the issue of lipaemia and offering advice on desirable dietary habits in the 12 hours preceding blood collection. The leaflet contains a list of low- and high-fat foodstuffs. It was decided to administer the leaflet to each donor presenting for blood collection in the subsequent 2 years, and then only to those presenting for blood donation for the first time. As illustrated in Figure 1, this measure reduced the frequency of lipaemic FFP units to 6.6% in 2007, yielding a statistically significant reduction as compared with 2003 (P<0.001).

At the end of 2008, a restructuration of the transfusion service was initiated, with CITM taking over donors from the four minor centres in the area, which was reflected by an increased frequency of lipaemic plasma, statistically significantly higher in 2009 than in 2007 (P<0.001). The corrective measure started in 2003 was, therefore, repeated and its efficiency reduced the frequency of lipaemic FFP units to 6.3% in 2010, and to 5.0% in the first 6 months of 2011 (P<0.001). Since 2005, all donors with marked lipaemia (testing impossible) recorded on two consecutive occasions are informed in writing of the finding and required to undergo medical examination. The efficiency of the measures introduced support the opinion that systematic implementation of educational activities can influence the rate of lipaemia in blood donations, to the benefit of donors, transfusion service and patients. We believe that the results presented here may help all transfusion institutions in which the frequency of lipaemia is a major problem.