Patients may be their own best blood donors

High costs and poor publicity hinder process from gaining greater popularity, Yang Wanli and He Na in Beijing, and Tang Yue in Tianjin report.

Li Dongliang, 47, had his right knee replaced in early September. He used 1,900 cubic centimeters of donated blood during the surgery in Yunnan.

Because there is always a shortage of donated blood, three of his relatives contributed 1,100 cc at the local donation center to reduce Li's waiting time for the operation.

Prior to the operation nobody mentioned a better option - autotransfusion.

"What's that?" Li's wife asked.

After being told it's a process that allows patients to bank their own blood ahead of time or for blood to be salvaged during surgery, she said: "No doctor told us about it. If we had known earlier, we would have asked for it instead of using donor blood."

The primary advantage of autotransfusion is that it eliminates the introduction of undetected disease. It also is considered to be the most effective and economical way to manage blood loss in emergencies.

But it is little used in China. The equipment is expensive, and some hospitals are not set up to store the blood properly. Some people fear that self-donating blood might be too taxing, or that their blood might be misused, or that the process isn't sufficiently regulated.

The biggest reason, however, is that too few people know about it.

"I haven't met a single person who raised the question of autotransfusion to me. Never," said Cheng Gang, deputy director of Jinan Blood Station in Shandong province.

Out of 25 people lined up to register at Beijing's Sino-Japanese Friendship Hospital on a Wednesday morning, only one had even heard the word before.

It isn't new

The first documented use of autotransfusion was in the 1920s in England. Now in Japan and some other developed countries, most blood for clinical use comes from the patients themselves.

Beijing SciTech reported that 80 to 90 per cent of non-emergency surgery in European countries is done with autotransfusion - but only 1 per cent in Beijing, which has the best medical resources in China.

The country's Blood Donation Law, which took effect in 1998, has clear rules for autotransfusion. Article 15 encourages patients who are planning non-emergency surgery to provide their own blood in advance, so that sufficient other, donated blood will be available for use in emergencies.

Precious resource

Blood shortage has long been a problem in China. The Beijing Red Cross Blood Center issued an emergency call for donors in October. The response pushed the amount of blood at the center to 8,000 units, but that is still far below its standard of 12,000 units.

"The inadequacy of voluntary donation, the rising demand in clinical use and disproportionate demand in different regions have all contributed to the problem," said Ministry of Health spokesman Deng Haihua.

The number of voluntary, unpaid donors in China rose from 6.75 million in 2006 to 11.8 million last year, and the volume of blood increased from 2,995 to 3,935 tons. But it can't keep up with demand. Deng said the blood supply rose about 7 per cent last year and the number of surgeries increased 18 per cent.

China is among 70 countries worldwide with a blood donation rate of less than 1 per cent of the population, a rate the World Health Organization considers to be the minimum necessary. The average in high-income countries is about 4 per cent.

"Everyone who works in the blood center in China knows how precious every single drop of blood is," said Yang Wenling, director of Tianjin Blood Center.

"I used to love rain and snow very much but now they worry me a lot," she said. "Every morning when I draw back the curtain, I'm afraid to see a rainy or snowy day, because it leads to fewer people on the street donating their blood in the mobile blood collection bus."

To solve the shortage problem, some companies and government departments organize blood drives among their staffs. Instead of being unpaid volunteers, these donors get an allowance and an extra holiday.

Yang doesn't like the idea. "It used to be a very important source of the blood in our center and it still is in many cities. But it is not good for the long-term development of blood donation."

Real volunteer, unpaid donors may feel it's unfair, Yang said. And compensating donors hints that donating blood is harmful, which is why you need something in return.

"So on one hand, we hope there are more blood donors," she said. "On the other hand, there is still a lot of space for autotransfusion to develop in China."

'Why not?'

"We strongly encourage more patients to use autotransfusion," said Bai Lianjun, director of the blood center at Peking Union Medical College Hospital.

Some diseases can't be detected during the "window period" - the time between the onset of an infection and the appearance of detectable antibodies to virus - but using your own blood eliminates that risk.

"It is safe and can also save donor blood for urgent cases. Especially for pregnant women and those waiting for bone surgery, autotransfusion can be easily practiced," Bai said.

Patients who are waiting for surgeries at his hospital are routinely told about autotransfusion. Wei Yinyun, 28, was given the option before she had a liver tumor removed in late September.

"They explained how it works and the advantages. I think it's great!" she said.

Although she finished the surgery without requiring any blood, Wei said she would tell her friends about the procedure. "More people should know about it, benefiting both yourself and others. Why not?"

Some obstacles

Autotransfusion, which is used in a number of orthopedic, trauma and cardiac cases, is recommended in many cities. Tianjin's health department requires that it be used in at least 10 per cent of surgeries that might call for extra blood, although the regulation has not been fully implemented.

For non-urgent surgery that is expected to require about 400 to 600 ml of replacement blood, doctors can take blood from the patient a week before surgery. The method seems to be a perfect option. However, Bai said there are high standards for blood storage that many small and mid-size hospitals cannot meet.

He also said only a limited number of hospitals in Beijing have the autotransfusion equipment. A device known as a "cell saver" is used in surgeries - such as those for aneurysms, total joint replacements and spinal operations - with the potential for heavy blood loss. The machine suctions blood that is lost, filters it and returns it to the patient's body.

It is valuable, and expensive for patients. While Bai said a "cell saver" costs about 11,000 yuan ($1,740) to buy, the patient is charged 1,100 to 1,900 yuan ($174-$300) for its use. A unit of donor blood costs 230 yuan ($36).

"Some patients are worried about the price, but more people don't choose it because of a lack of knowledge," Bai said.

"I haven't heard of autotransfusion before. In my mind the only way to have blood transfusion is to buy others' blood in the hospital," said Li Yongliang, 29, a budgeting specialist for a Beijing real estate company.

"My wife's due date is in July next year. I will be worried to death if the doctor withdraws blood from her several days before my kid's birth. So no matter how many advantages autotransfusion has, I won't take it this time.

"The patient is already very weak if he needs an operation," Li said. "Can his body afford a blood withdrawal? I quite doubt it."

Bai said doctors would recommend autotransfusion only when it's suitable for the patient. And a pregnant woman could be given saline, with no discomfort, to replace the volume of blood lost to self-donation. "The procedure is very useful, especially to people with rare blood types," he said.

Other difficulties

If they aren't worried about the procedure itself, some people express their concern about improper conduct without a detailed law on autotransfusion. In China, all donor blood comes from blood centers, but autotransfusion is conducted in the hospital.

"I don't trust such pre-storing. If I store my blood two weeks before surgery and there is an emergency need for my type, maybe my blood will be used," said a man whose blood is Rh-negative.

"So far there is no regulation to control hospital abuse of stored blood," said Kong Xin, director of the blood bank at a well-known hospital in Northeast China's Jilin province. "If a hospital encourages patients to use autotransfusion, it is hard for the health department to control the blood market."

Kong said her hospital doesn't use autotransfusion now but the hospital director has put it on the agenda. She doesn't think the technique will find much favor among the staff.

"As doctors we all know the advantages of autotransfusion," she said. "But autotransfusion is not included in the medical staff's performance review and it will not put an extra penny in your pocket, so who will bother to promote it?"