Science / Medicine : Sickle-Cell Transfusions Raise Medical, Ethical Issues : Blood: A study suggests that donations from blacks are better for victims of the disease. But identifying donors may violate privacy and stir racial problems.
Doctors have become embroiled in a delicate ethical debate after a recent study suggested that patients with sickle-cell anemia may avoid transfusion complications if given blood donated by blacks.
At issue is whether blood banks should ask donors to volunteer information about their racial backgrounds, making the search for compatible blood easier, and whether blood banks should routinely provide extensive protein-matching of donor and recipient blood. Both procedures would decrease the chances of sickle-cell patients developing transfusion complications, but they would also require more money and raise serious issues of confidentiality.
More than 90% of the nearly 60,000 people nationwide with sickle-cell disease--an inherited blood disorder that affects blacks almost exclusively--have received at least one transfusion before the age of 18. Roughly 30% of these patients, however, develop antibodies against foreign proteins called antigens in the blood they receive, a condition known as alloimmunization.
Once antibodies form, it becomes increasingly difficult--and sometimes nearly impossible--to find compatible blood for subsequent transfusions, increasing the likelihood that recipients will suffer from transfusion reactions such as jaundice, severe anemia and kidney disease.
The research suggests that genetic differences in certain blood antigens between whites and blacks may explain, in part, why sickle-cell patients make antibodies, said Dr. Elliott P. Vichinsky, co-author of a recent study published in the New England Journal of Medicine.
Researchers at Children’s Hospital in Oakland found that 30% of the 107 black sickle-cell anemia patients studied who received transfusions developed antibodies. Moreover, the scientists discovered that 82% of the antibodies sickle-cell patients produced were against four antigens that commonly occur in blood donated from whites. In the study, 90% of the blood transfused was donated by whites.
“For sickle-cell patients who have already developed antibodies, knowing which donors are black could mean a smaller haystack to go looking for the needle in,” said Dr. Samuel Charache, a hematologist at Johns Hopkins University School of Medicine in Baltimore. In an accompanying editorial, Charache encourages blood banks and physicians to debate the merits of asking donors to indicate their race, and keeping the information confidential.
Despite suggestions that blacks with sickle-cell anemia may benefit from blood donors volunteering information about race, the procedure also raises ethical issues. “Black blood for black people and white blood for white people sounds like a white water fountain for white people and a colored water fountain for colored people. It could be twisted into something totally awful,” Charache said.
The problem of providing sickle-cell patients with racially matched blood is compounded by a tremendous lack of black donors. A 1986 American Red Cross survey found that 95% of all blood donors surveyed were white, while 4% were black.
Some medical experts, while agreeing that knowledge of a donor’s race may help in finding more compatible blood for sickle-cell patients, worry about the misuse of such information. Dr. Darlene Powers, a pediatric hematologist at the USC Medical Center, is concerned that, because blacks tend to carry fewer of the most potent antigens that cause transfusion reactions, it is possible that blood designated for the benefit of sickle-cell patients might be given to whites for a variety of reasons, she said.
To avoid such controversies, some physicians recommend that blood banks simply provide antigen-matched (rather than race-specific) blood to sickle-cell patients even before antibodies develop. But for various reasons, blood banks argue that such a service would lead to increased costs and unnecessary delays.
Dr. Steven Kleinman of the Los Angeles County American Red Cross said providing antigen-matched blood is less expensive and better matches can be found if matching is done only for those who develop antibodies to previous transfusions. Moreover, transfusing all sickle-cell patients with antigen-matched blood would probably exhaust the rare blood supply and result in transfusion delays, he said.
Dr. Gerald Sandler, medical director of the national American Red Cross in Washington, D.C., remains firm in his stand against altering the Red Cross blood banking program, which provides half of the nation’s blood supply.
Sandler remains confident that the Red Cross can continue to meet the needs of sickle-cell patients through the rare-donor registry program. “We don’t have to invoke race to find a satisfactory solution to the problem.”
Yet Vichinsky says the crisis for sickle-cell patients “will increase with time unless there’s a shift in transfusion practices.”
