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SEVEREHYPERTRIGLYCERIDEMIA

IN PUERTO RICO BLOOD DONORS:

A Population Study2009-2011

Raúl H. Morales-Borges MDa*, Carmen Merced MT b

aMedical Director, American Red Cross, Puerto Rico Region, San Juan, Puerto Rico.bManager, Donor Information, American Red Cross, Puerto Rico Region, San Juan, Puerto Rico.*Corresponding author: Raúl H. Morales-Borges MD - Medi-cal Director, American Red Cross, Puerto Rico Region, PO Box 366046 San Juan, Puerto Rico 00936. E-mail: Raul.Mo-rales@redcross.org

ABSTRACT

Puerto Rico blood donor issues has been identified in cases of severe hy-pertriglyceridemia presenting as tur-bid. Blood donations resulting in milky serum must be discarded. They are discarded because we cannot properly test the donation. This is the first report where we correlate turbidity and cardio-vascular risk factors in the Puerto Rico population as well as blood types O and A, Rh (+) with dyslipidemia. Blood donors should be screened in more details regarding cardiovascular and metabolic risks to avoid problems with recruitment and retention strategies.

Index words: severe, hypertriglyceride-mia, Puerto Rico, blood, donors, popu-lation

INTRODUCTION

Hyperlipidemia, defined as an abnormal elevation of plas-ma cholesterol and/or triglyceride levels, is one of the most common clinical problems confronting the clinician in daily practice (1). Although these disorders appear to be common in the general population, it seems not a major issue in blood donor’s population. A French study published by Terrier et al (2) with 1184 blood donors found a correlation between high blood pressure, obesity, blood group O, and type II-b Hyper-lipoproteinemias in 32 cases. Another study from Brazil by MG Ferreira et al (3) evaluated the accuracy of anthropo-metric fat location indices as predictors of dyslipidemia. One study from the Netherlands provided important knowledge about demographic distributions and cardiovascular risk factors within whole blood and plasma donors (4). Another study also from the Netherlands reported that donors who provided a turbid donation have a less favorable cardio-vascular profile compared to other donors (5). One study about fasting blood sugar in 1188 blood donors from Mexico showed that the prevalence of impaired fasting glucose was higher than expected and 70% of those subjects showed hypertriglyceridemia, comparing with other populations re-ported in the literature (6). We wanted to demonstrate the needs of further research on the role of blood donation in cardiovascular risk reduction, correlation between blood type and groups with dyslipidemia. We are presenting data from 50248 whole blood donors from March 1 to October 31 of 2011 from which 5 were identified to have a triglyceride level above 3000 mg/dl. There is additional data from April of 2009 to December of 2010 with a total of 9 donors identified with high triglyceride levels identified when the BHQ Medi-cal Office asked the National’s Testing Laboratory (NTL) to systemically notify the regional physicians of donations that could not be tested because of high triglyceride levels.

METHODS

We obtained the cases were a visual examination of all blood tubes is performed as part of the National’s Testing Laboratory sample suitability evaluation. Lipemia is one of the variables assessed during this initial visual examination as shown also in a study from K Peffer et al and commented by RR Vassallo and FM Stearns with 272 donors (5, 7).

If a sample appears excessively turbid and fails visual exa-mination for lipemia, the National Testing Laboratory (NTL) performs a quantitative triglyceride analysis. Samples with triglycerides value less or equal than 3000 mg/dl are con-sidered acceptable for testing; but samples with a triglyce-ride value more than 3000 mg/dl are unsuitable for testing. Approximately 99% of samples pass the visual examina-tion for turbidity and therefore do not require a quantitative triglyceride analysis. Of those samples that fail the visual examination for turbidity, greater than half have a quantitati-ve value less or equal than 3000 mg/dl and are determined acceptable for testing. Only a few samples a day fails the visual examination for turbidity and have a triglyceride level > 3000 mg/dl.

The NTL uses the result of the triglyceride testing to deter-mine sample suitability and is required to report the results to the region or to the donor. It should be noted that the triglyceride test performed by the Charlotte NTL is to be per-formed on non-fasting sample, which is usually the case for our donor samples. The expected value for a fasting sample is < 200 mg/dl. The package insert does not include any expected values for non-fasting samples. Because there is no expected value for a non-fasting sample, the testing is performed to determine sample suitability for infectious di-sease testing (8)

Once the donors are identified we pulled the blood donors registry, known as BDR, of them and we reviewed to chart the data of age, gender, weight, blood type and group, town or city of living, collection date, and serum triglyceride level.

Puerto Rico has 78 municipalities and we colored the muni-cipalities or cities of the affected donors.

RESULTS

Five blood donors were identified to have turbid plasma with triglycerides over 3000 mg/dl. Four were male and the avera-ge/median age was 46 years with a range of 41 to 50 years old. The average weight was 184 pounds with a range of 140 to 240 pounds. Four of the blood donors were identified overweight.

Four were identified the blood type and group with three of them as A, Rh (+). Three of them are from the north area of the Island and one from the south and central area respec-tively. The lowest triglyceride level was 3038 mg/dl and the highest was 5701 mg/dl with an average level of 3912 mg/dl (See Table 1).

From 2009 to 2010 we identified nine male donors with an average age of 44 years and a range of 30 to 56 years old. Five of them have blood type and group O, Rh (+). The geo-graphic distribution varies with four from the Central region, three from the North, and two from the Metropolitan region. The lowest triglyceride level was 2153 mg/dl, the highest was 5396 mg/dl with an average 3545 mg/dl (See Table 2).

In general we are reporting 14 cases with an average age of 44.5 years and the majority were males from the North Central Municipalities of the Island (See Figure 1).

DISCUSSION

This is the first publication were we identified turbid plasma in Puerto Rico blood donors with a correlation of gender, age, regional area where they live, and blood type/group.

One study determined 32% as the overall prevalence of the metabolic syndrome (defined as diabetes, hypertension, obesity, dyslipidemia, glucose intolerance, and hyperinsu-linemia) among a determined Puerto Rican population (9). Cox stated that despite clear and consistent clinical-trial evidence establishing a causal link between lipid disorders

and coronary heart di-sease and that choles-terol-lowering therapy dramatically reduces the risk for that disease and its complications, many patients for whom such treatment is indicated re-main either unidentified or untreated (10).

With that in mind we found that dyslipidemia might be a problem in this population, but our data is on isolated non-fasting triglyceride levels. This might be taken in consideration when we are doing blood drives and we need to educate more our people about

good health habits and cardiovascular risks. Also discarding donations may have a negative impact on donor satisfaction and retention, although the educational material informs all donors that their donation may not be tested, but ARC does not inform donors if their donations are discarded.

Regarding turbid plasma donations, Peffer et al (5) mentio-ned that in the Netherlands, 3 to 4 per 1000 whole blood donations reveal turbid plasma. Familial hypertriglyceride-mia or chylomicronemia has been reported, but commonly occurs among donors who ate a fatty meal before donation

as well in obese diabetic donors with unfavorable cardiovascular profile. They found no difference between plasma or whole blood donors. The mean age of participating cases was 46.1 years as well as in our small num-ber of blood donors on 2011, although the average age of the 14 cases was 44.5 years. Men were more frequent in their study along with ours. One im-portant data from their study was the question of when was their last meal before donation and we missed this information. Without this information and without any follow-up on the do-nors, it is impossible to interpret the relevance of an isolated high triglyce-ride level.

The main blood type and group of our groups was O, Rh (+) followed by A, Rh (+). This is the first report from our knowledge regarding a Puerto Rico population. There is one paper by J Hørby et al from Denmark (11) where they showed a small group study of a relation of serum lipids to the ABO blood groups in 66 patients with inter-mittent claudication. The concluded that the serum lipoprotein and lipid le-vels do not give an obvious explana-tion why patients with blood group A

seem more liable to develop atherosclerosis than those with blood group non-A. This data correlates with an Italian study from Clara Carpeggiani et al (12) where they demonstrated that a significant association between group non-O and fa-mily history of ischemic heart disease, hypercholesterolemia

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and presence of coronary atheros-clerosis. Their higher predictor group were patients aged < 65 years old and women. JL Cronenwett et al (13) with 73 women requiring aortoiliac recons-truction for atherosclerotic occlusive disease demonstrated that women with blood group A had increased fre-quency as comparable to published data. The only study that does not co-rrelate with this data is the one from North Carolina, USA with 1198 pa-tients who underwent percutaneous coronary intervention and patients with O blood type were slightly older (62 years old), had a higher prevalen-ce of hypercholesterolemia and had a higher burden of atherosclerosis with more vascular disease (14). This fact is important regarding blood do-nations. A study must be performing to correlate the blood type/group and dyslipidemia because it may be a coincidental finding.

Another piece of information regarding strategies for blood drives is that the majority of the small groups were from the north and central areas of Puerto Rico. This is important, although, the finding of a few donors with isolated high triglyceride levels does not have any implications for planning blood drives.

CONCLUSIONS

This data provided important knowledge about lipemic plasma and demographics of our blood donor’s population. It was confirmed that the main blood type and group O, Rh (+) is related with dyslipidemia as well as A, Rh (+) by our small sample and they are mostly located in the north central municipalities of Puerto Rico. What is most interesting is Figure 1 per 130,000 of severe hypertriglyce-ridemia in which Ralph R. Vassallo and Frank M. Stearns (7) reported for the Philadelphia NTL were our donors

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had a rate 10-times higher.

Blood donors should be screened in more details regarding cardio-vascular and metabolic risks to avoid problems with recruitment and retention strategies. A future and larger study is recommended.

REFERENCES

1. Witztum JL, Steinberg D: The Hyperlipoproteinemias (Chapter 206). In Goldman L, Bennett JC, eds. Cecil Textbook of Medicine. Philadelphia: W.B. Saunders Company, 2000: 1090-1100.2. Terrier E, Baillet M, Jaulmes B: Detection of lipid abnormalities in blood donors. Rev Fr Transfus Immunohema-tol. 1979 Mar; 22(2): 147-158. 3. Ferreira MG, Valente JG, Gon-calves-Silva RM, Sichieri R: Accu

racy of waist circumference and waist-to-hip ratio as predictors of dys-lipidemia in a cross-sectional study among blood donors in Cuiaba, Mato Grosso State, Brazil. Cad Saude Publica 2006 Feb; 22(2): 307-314.4. Atsma F, Veldhuizen I, de Vegt F, Doggen C, de Kort W: Cardiovascular and demographic characteristics in whole blood and plasma donors: results from the Donor InSight study. Transfusion 2011 Feb; 51(2): 412-420.5. Peffer K, de Kort WL, Slot E, Doggen CJ: Turbid plasma donations in whole blood donors: fat chance? Transfusion 2011 Jun; 51(6): 1179-1187.6. Munguia-Miranda C, Sánchez-Barrera RG, Tuz K, Alon-so-García AL, Cruz M: Impaired casting glucose detection in blood donor’s popu-lation. Rev Med Inst Mex Seguro Soc. 2009 Jan-Feb; 47(1): 17-24. 7. Vassallo RR, Stearns FM: Lipemic plasma: a renaissan-ce. Transfusion 2011 Feb; 51(6): 1136-1139.8. Stearns FM, Stramer SL, Alvarez AW: Verification of Vi-sual Lipemia Sample Suitability by Quantitative Triglyceride Testing. Transfu-sion 2005; 45, Supplement, SP199, p89A.

9. Gomez M, Ramirez M, Disdier O: Prevalence of the meta-bolic syndrome among a determined Puerto Rican population. PR Health Sci J. 2006 Jun; 25(2): 111-116.10. Cox RA: The hyperlipidemias. Bol Asoc Med PR. 2003 Sep-Oct; 95(5): 36-44.11. Hørby J, Gyrtrup HJ, Grande P, Vestergaard A: Relation of serum lipoproteins and lipids to the ABO blood groups in patients with intermit-tent claudication. J Cardiovasc Surg (Torino) 1989 Jul-Aug; 30(4):533-537.12. Carpeggiani C, Coceani M, Landi P, Michelassi C, L’abbate A: ABO blood group alleles: A risk factor for coronary artery disease. An an-giographic study. Atherosclerosis 2010 Aug; 211(2): 461-466.13. Cronenwett JL, Davis JT Jr, Garret HE: ABO blood group and serum lipids in female atherosclerosis. J Cardiovasc Surg (Torino) 1983 Nov-Dec; 24(6): 658-661.14. Ketch TR, Turner SJ, Sacrinty MT, Lingle KC, Applegate

RJ, Kutcher MA, Sane DC: ABO blood types: Influence on infarct size, procedural characteristics and prognosis. Thromb Res 2008; 123(2): 200-205.

ACKNOWLEDEDGMENTS

The authors thank Dr. Anne F. Eder, Dr. Ralph R. Vassallo, and Dr. Frank M. Stearns from the American Red Cross for their editing support and comments.

RESUMEN

Se ha identificado un asunto en cuanto a donantes de sangre puertorriqueños con hipertrigliceridemia presentándose como plasma turbio en hombres con sobre peso y una edad prome-dio 44.5 años. Las donaciones de sangre resultantes en suero lechoso usualmente son descartadas. Se descartan porque no se pueden realizar las pruebas a las donaciones. Este es el primer reporte donde nosotros correlacionamos la turbiedad y los factores de riesgo cardiovasculares en la población de Puerto Rico asi como los tipos y grupos sanguíneos O y A, Rh (+) con dislipidemia. Los donantes de sangre deben recibir un cernimiento mas detallado sobre los riesgos de padecer enfermedad cardiovascular o síndrome metabólico para evitar problemas con su reclutamiento.

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