The reintroduction of nonleukoreduced blood: would patients and clinicians agree?

W ith today’s economic uncertainty, hospitals continue to look for new ways to reduce costs in a safe fashion. Some hospitals currently providing only leukoreduced blood have considered providing nonleukoreduced blood components for their patients, presumably assuming that nonleukoreduced blood is less expensive than leukoreduced blood. This commentary examines the safety of the reintroduction of nonleukoreduced blood components in hospitals that previously implemented universal leukoreduction. Because universal leukoreduction has been in place in most hospitals for almost a decade, many clinicians have never had to weigh the risks and benefits of leukoreduced and nonleukoreduced products, and currently they are not required to decide whether nonleukoreduced components would be seriously detrimental for their patients. In the past there was debate about whether universal leukoreduction was cost-effective, but the debate did not include a balancing of risks and benefits, because no true risks have been identified (aside from device failures). On the other hand, there is no question that transfusion with nonleukoreduced blood increases risk (defined below) for patients and its reintroduction provides no clinical benefit. The reason to reintroduce these components is to reduce cost. The decision to reintroduce nonleukoreduced components should involve many stakeholders at the hospital including committees dealing with transfusion practices, the quality of medical care, and risk management, and ultimately the decision should be considered by the medical board. If each of these stakeholders approves the reintroduction of nonleukoreduced blood, the changes to the transfusion medicine formulary must be communicated to the medical staff so that they can understand the medical implications of these actions, which we believe are not justified by the perception of cost reduction. Education and communication would be a key component of any program to introduce nonleukoreduced blood. Should leukoreduced blood remain the default product? If leukoreduced components are the default, would clinicians specifically order nonleukoreduced blood for any of their patients? It is not likely. To produce a change, nonleukoreduced blood would have to be the default product. How would the clinicians in each subspecialty be educated about the risks of the “new” standard components and participate in the development of new transfusions strategies for patients for whom this new component is not appropriate? The hospital deciding to switch from universally leukoreduced components to a dual inventory of leukoreduced and nonleukoreduced products should also consider the implications for their patients who may ultimately be transferred to other hospitals for advanced care. Among the patients who may be harmed by receiving nonleukoreduced blood components are those with hematologic malignancies and those in need of organ transplantation. These patients are often treated urgently before diagnosis in one hospital and referred to another for definitive therapy. If the diagnosing hospital reintroduced nonleukoreduced blood, patients with hematologic malignancy or those in need of transplantation may be adversely affected by transfusions that might promote alloimmunization or cytomegalovirus (CMV) seroconversion. Changes in transfusion policy in one hospital can lead to poor patient outcomes in another hospital due to unnecessary exposure to white blood cell (WBC) antigens or cell-associated viruses, even if the patient was transferred in what appeared to be “good condition.” ABBREVIATIONS: FNHTR(s) = febrile nonhemolytic transfusion reaction(s); TA-GVHD = transfusion-associated graftversus-host disease.