When Blood Transfusion Translates To An Early Death

Kat Piper

Mounting evidence that routinely giving blood transfusions to patients could actually increase their risk of death or other complications has prompted calls for medical staff to be more cautious about who they administer transfusions to.

Jehovah's Witnesses refuse blood transfusions based on a passage from the Bible, which forbids them to "eat blood," but many still successfully undergo operations including open-heart surgery. This, say some surgeons and anaesthetists, should be the way most operations are performed.

Higher death rates
The danger is not from infections such as HIV but from something to do with the blood itself. Many studies over the past ten years have shown that transfusions, particularly of those involving red blood cells, are linked to higher death rates in patients who have had a heart attack, heart surgery, or who are in critical care.

Although the exact nature of the link is not yet known, it seems likely that chemical changes in ageing blood, their impact on the immune system, and the blood's ability to deliver oxygen are key. "Probably 40 to 60 percent of blood transfusions are not good for the patients," said Bruce Spiess, a cardiac anaesthesiologist at Virginia Commonwealth University in Richmond, to New Scientist.

Transfusions first became part of medical procedure during World War One when they were used as a last resort to treat soldiers who had lost a lot of blood. Its usage is now no longer confined to cases of catastrophic bleeding, but is often employed as a routine treatment for patients undergoing surgery or intensive care.

Background
The rationale behind giving transfusions is that by giving patients red blood cells, oxygen is better transported around the body thereby increasing the chances of survival. A healthy person has 120 to 170 grams per liter of haemoglobin—the oxygen-carrying protein in red cells—in their blood, usually with 35 to 50 percent of their blood volume being composed of red cells. Doctors commonly decide to give patients a transfusion if the haemoglobin levels fall to between 70 and 100 grams per litre.

Less effective blood
A 1999 Canadian study of 838 critical care patients found that significantly fewer patients (22 versus 28 percent) died in hospital when treatment with transfusion was limited to patients with haemoglobin levels of less than 70 grams per litre. In 2004, a study published in the Journal of the American Medical Association showed that heart attack patients with red blood cell levels of over 25 percent were three times more likely to die or have another heart attack within 30 days of having a transfusion.

A U.K. study of almost 9,000 heart surgery patients between 1996 and 2003 supports this finding, and indicates a six-fold increase in the risk of death after 30 days with a three-fold increase in the risk within one year following surgery. Transfusions were also associated with more infections and higher incidences of stroke, heart attack, and kidney failure. These complications were usually linked to a lack of oxygen to body tissues.

Little benefit
"There is virtually no high-quality study in surgery, or in intensive or acute care—outside of when you are bleeding to death—that shows that blood transfusion is beneficial and many that show it is bad for you," said Gavin Murphy, a cardiac surgeon at the Bristol Heart Institute and leader of the U.K. study.

Recommendations ignored
Many experts are now worried that guidelines are being ignored. They suggest that transfusions should only be given as a last resort and that preventing blood loss in the first place whilst ensuring patients are not anaemic before they undergo surgery should be prioritised.

"Usually when there is any clinical uncertainty about a treatment you don't give it, but with transfusions we do," said James Isbister of the Royal North Shore Hospital in Sydney, Australia, who is an adviser to the Australian Red Cross Blood Service. But Mr. Isbister still encourages people to donate blood as it is used to treat other conditions as well as extreme blood loss.

The specific reasons why blood transfusions appear to be harmful to some patients are not yet fully understood and further research is being strongly encouraged by health authorities, including the U.S. National Institutes of Health.

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Angolan Men Hide Their HIV Status From Their Spouses

Maria Antónia* began to wonder about her husband's frequent trips to neighbouring South Africa, especially when he was away for 15 days without contacting her on one occasion.

She decided to investigate whether he was going to South Africa to see another woman, but discovered that he was going to get antiretroviral (ARV) medication because he was HIV positive.

Miguel André's wife died in 2001, officially from typhoid fever, but before she died she told her child's godmother that she had AIDS. She never found the courage to tell her husband, but the news spread and soon everyone in Benguela, a coastal town in central Angola, was talking about it. André was the last to find out that his wife had been HIV positive.

Stories like these are repeated time and again in Angola, but fear of a partner's reaction, fear of being abandoned, fear of discrimination, even fear of shame, are just some of the reasons that prevent people living with HIV from telling those dear to them.

Many only discover the HIV status of their partners after they have died, and then learn that they are also infected, but it is often hard to know who infected whom, or how. An estimated 2.5 percent of Angola's 16 million people are living with HIV/AIDS.

To tell or not to tell?

The debate in Angola about the role of healthcare workers in disclosing the HIV status of their patients has been heated. On the one hand there are those who believe that health workers should do their utmost to find the spouses of patients living with HIV, as was once the case with syphilis, and there should be compulsory notification. Others say doctor-patient confidentiality should be preserved at all costs.

António Coelho, executive secretary of the Network of AIDS Service Organisations (known by the Portuguese acronym Anaso), feels there should not be mandatory notification of spouses, but rather awareness-raising to enable HIV-positive patients to tell their partners.

He stressed that by law "infected persons have the duty to inform those people with whom they have or intend to have sexual relations about their serological status."

But Catarina Saldanha, executive secretary of Mwenho, an association of HIV-positive women, believes that doctors should inform their patients' spouses.

Saldanha, who is HIV positive, told IRIN/PlusNews this was to protect the partners of people living with HIV, because the network of sexual relations is often not restricted to spouses, but extends to previous partners and extra-spousal relations.

She said some doctors in Angola were already doing this: they told patients that they could continue treatment only if their spouse or partner also came to the next appointment.

The country's network of people living with HIV/AIDS is calling for a compromise. "First, the doctor should exhaust every possibility of changing the infected person's behaviour. If this doesn't work, the doctor should make his position clear regarding intentional infection - that it is a crime punishable by law," said Noé Mateus, the network's executive secretary.

"But confidentiality can and should be discarded as soon as the physician realises that the infected person's behaviour places his or her spouse or others at risk of becoming infected."

The mysterious cassette tape

UNAIDS official Roberto Campos said confidentiality should be maintained in all instances, without exception. "People have to have the sovereignty to reveal their serological status to whomever they wish. They and they alone have this right, under any and all circumstances."

Campos stressed that because of the extremely high levels of stigma still associated with HIV/AIDS, doctors could place patients at risk of being publicly condemned by revealing their seropositivity. "Health professionals must be competent enough to give patients all the information they need to make the decision," he added.

António Feijó, the director of Hospital Esperança ("Hope" in Portuguese), a healthcare facility for HIV patients in the capital, Luanda, said doctors should encourage their patients to tell. "Notifying a patient's spouse about his or her serological status cannot be decided in an arbitrary manner ... It's immoral to treat one of them and leave the other's life at risk."

When she was 17, Suzana* married her first boyfriend. After 25 years of marriage her husband died in her arms, but she only learned that he had died of an AIDS-related illness when, during the funeral, she heard a cassette tape on which he confessed to being HIV-positive.

Her husband had given the cassette to a nephew, who thought it contained his wishes regarding his estate and it would therefore be appropriate to play the tape at the funeral.

With clearer rules covering confidentiality and HIV, the final message left by Suzana's husband could have been a message of love, or even about his estate, rather than a painful confession of his positive status.

* Not their real names

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The U.S. FDA Approves Raltegravir Tablets As New HIV Drug

The U.S. Food and Drug Administration (FDA) has approved raltegravir tablets for treatment of Human Immunodeficiency Virus (HIV)-1 infection in combination with other antiretroviral agents in treatment-experienced adult patients who have evidence of viral replication and HIV-1 strains resistant to multiple antiretroviral agents.

Raltegravir is the first agent of the pharmacological class known as HIV integrase strand transfer inhibitors, designed to interfere with the enzyme that HIV-1 needs to multiply. Raltegravir, sold under the trade name Isentress, received a priority review by the FDA.

“This is an important new product for many HIV-infected patients whose infections are not being controlled by currently available medications,” said Janet Woodcock, M.D., FDA’s deputy commissioner for scientific and medical programs, chief medical officer and acting director, Center for Drug Evaluation and Research.

When used with other anti-HIV medicines, raltegravir may reduce the amount of HIV in the blood and may increase white blood cells, called CD4+ (T) cells, that help fight off other infections.

FDA’s approval of raltegravir is based on data from two double-blind, placebo-controlled studies in 699 HIV-1 infected adult patients with histories of extensive antiretroviral use. A greater proportion of the patients who received raltegravir in combination with other anti-HIV drugs experienced reductions in the amount of HIV in the blood, compared with patients who received placebo in combination with other anti-HIV drugs.

The most common adverse events reported with raltegravir were diarrhea, nausea, and headache. Blood tests also showed abnormal elevated levels of a muscle enzyme in some patients receiving raltegravir. Caution is advised when using raltegravir in patients at increased risk for certain types of muscle problems, including those who use other medications that can cause muscle problems.

Patients taking raltegravir may still develop infections, including opportunistic infections or other conditions that may develop in patients living with HIV-1 infection. The long-term effects of raltegravir are not known, and its safety and effectiveness in children less than 16 years of age has not been studied.

Raltegravir also has not been studied in pregnant women. Women who are taking HIV medications when they get pregnant are advised to talk with their physician or other health care professional about use of this drug during pregnancy, and about registering with the Antiviral Pregnancy Registry if they use raltegravir.

Raltegravir is distributed by New Jersey-based Merck & Co., Inc.

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Some 20 Million Condoms Recalled In South Africa

South Africa's health department said Tuesday it has recalled 20 million potentially defective condoms approved by an official accused of taking bribes from a manufacturer.

Unsafe sex is especially risky in South Africa, which has one of the world's highest HIV infection rates with an estimated 12 percent of its 47 million people infected with the virus.

There are up to 1,000 AIDS-related deaths in South Africa every day and free condom distribution is a crucial part of the government's efforts to combat the spread of the epidemic.

"An official of the South African Bureau of Standards (SABS), has put millions of people at risk by illegally passing millions of condoms, which had not met the quality assurance requirements," said health department spokesman Sibani Mngadi.

Mngadi said even though only a batch of 7 million condoms was affected, the department decided to recall all 20 million condoms supplied by the manufacturer since last year, and will no longer be dealing with that company.

The SABS official accused of taking bribes and two directors of the manufacturing company have been arrested and are out on bail, said the spokesman. They will be appearing in a Pretoria court on September 10 to face charges of corruption and fraud.

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LEGAL ACTION

The condoms did not meet several standard tests for strength, pressure and lubrication, said Mngadi.

The SABS Web site alerted the public, saying the faulty condoms were distributed by brand names including Ultramour, Randy Rat and Positions.

SABS said it had instructed Latex Surgical Products (LSP) to recall the condoms and that it would take legal action against the manufacturer.

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The Health Department is also recalling condoms produced by LSP from its national HIV/AIDS supply chain.

LSP was not immediately available to comment.

Besides a struggling health-care system characterized by a lack of doctors and nurses, many of whom have left the country for better pay abroad, the fight against AIDS has been hampered by conflicting messages from senior government officials.

Researchers, scientists and health-care workers said in a conference in South Africa in June that they were encouraged by the government's fresh approach to the crisis and improved weapons to protect those most at risk of infection.

But fresh controversy over the government's AIDS policies has erupted.

President Thabo Mbeki sacked Deputy Health Minister Nozizwe Madlala-Routledge this month for insubordination, sparking an outcry from AIDS activists who strongly backed her policies and critics who say she was fired for political reasons.

Madlala-Routledge had clashed with Health Minister Manto Tshabalala-Msimang, dubbed "Dr Beetroot," who had horrified

AIDS activists with her advocacy of garlic, lemon and African potatoes over conventional anti-retroviral drugs.

The health department said it does not know how many of the defective condoms have been used, and it is urging the public to return them.

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