The Light at the End of the Tunnel, Or Is It an Iron Horse?
Back again to opine about iron.
- Iron depletion is a public health issue independent of blood donation…
- …but blood donation does contribute to iron depletion in the population.
- There is no agreement about the clinical impacts of donor iron depletion.
- Concern centers on teens, who are the foundation of our mission for decades to come, but includes menstruating women and “frequent” donors.
- Assessing the impacts is a difficult, lengthy task so…
- …the “precautionary principle” has been invoked, telling us to do something until we know more—i.e. primum non nocere.
Who is and who ought to be driving the train?
- We (i.e., docs) in the blood community are the prime movers—this is fundamentally a question of science and medicine.
- “Civilians” in the blood community are the stakeholders who will foot the bill for “doing the right thing(s).”
- Donors need to be informed, engaged, and heard.
- The larger clinical and public health communities need to take ownership of population iron status, including the contribution of blood donation. We need these folks on board, giving their audiences positive, balanced messages about blood donation.
Where is the train headed?
- An ad-hoc group of experienced collection facility docs, convened by ABC, American Red Cross, and Blood Systems, Inc. (alphabetical order) reached consensus in April that the long-term goal should be preventing iron depletion by blood donation in ALL donors.
- AABB Association Bulletin (17-02) suggested a series of complementary (as opposed to alternative) strategies, including a list of at-risk donor cohorts to target for initial interventions. A formal risk-based decision-making process to evaluate those options is underway (with robust participation from ABC members). Expect to see an interim AABB Standard by the first of the year (my guess without inside information or any clear sense of its content).
- Ordered, as I see them, from most to least likely to work considering both donor iron balance and robustness of the blood supply, are interventions I would consider (if I worked at a blood center).
- Hand replacement iron and a positive message to appropriate donors when they are sitting in front of you (my preferred approach).
- If you can’t/won’t hand it to them, facilitate access to iron via vouchers or some similar expedient.
- Limit donation frequency for the highest risk donors (e.g., teens) who cannot or will not commit to taking iron supplements, recognizing the impact on the blood supply.
- Measure iron stores in those at risk and respond appropriately, ex-post facto, to the lab test.
- Tell donors about iron, that they should increase their iron intake, how they can do so, and hope for the best.
One size will not fit all, despite my oft repeated (ad nauseum?) opinion “we are taking it out and we should be putting it back”. However you combine these options, measure the impact or we will never learn the optimal strategies.
Louis Katz, MD; Chief Medical Officer