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2021, vol. 78, br. 2, str. 202-206
Ispitivanje statusa gvožđa kod davalaca krvi vraćenih zbog niskog nivoa hemoglobina
aUniversity of Belgrade, Blood Transfusion Institute of Serbia, Belgrade + Univerzitet u Beogradu, Medicinski fakultet
bUniversity of Belgrade, Blood Transfusion Institute of Serbia, Belgrade
cUniverzitet u Beogradu, Institut za molekularnu genetiku i genetičko inženjerstvo

e-adresamkovac008@gmail.com
Projekat:
Kompleksne bolesti kao model sistem za proučavanje modulacije fenotipa-strukturna i funkcionalna analiza molekularnih biomarkera (MPNTR - 173008)

Sažetak
Uvod/Cilj. Određivanje nivoa hemoglobin (Hb) je rutinski deo selekcije dobrovoljnih davalaca krvi. Prethodno publikovane studije pokazale su da se nedostatak gvožđa javlja kod redovnih davalaca krvi. Cilj ove prospektivne studije je bio da se utvrdi status gvožđa kod davalaca kod kojih je pre davanja utvrđen nizak nivo Hb i da se proceni stepen korelacije kapilarnih metoda, sa referentnom metodom određivanja Hb iz venske krvi, kao i sa i nivoom feritina. Metode. U periodu od februara 2017. do decembra 2018. godine, bilo je uključeno 200 dobrovoljnih davalaca sa niskim nivoima Hb, starosne dobi 19-64 godine (medijana 39 godina). Hb je određivan primenom metode bakar sulfat, kapilarnom metodom "HemoCue", i iz venske krvi u sklopu određivanja kompletne krvne slike (KKS). Nivo feritina određivan je primenom turbodimetrijske metode. Rezultati. Nizak nivo feritina utvrđen je kod 42,7% muškaraca i 57,3% žena (p = 0,008). U odnosu na nivo feritina < 12 mg/L, odnosno > 50 mg/L, zabeležena je značajna razlika između polova (p = 0,023, odnosno p = 0,022). Poređenje vrednosti Hb dobijenih kapilarnim metodama u odnosu na referentne vrednosti Hb, određene iz KKS, pokazalo je da metoda s bakar sulfatom daje lažno niske vrednosti Hb kod 10,5% slučajeva (p < 0,001). Vrednosti Hb dobijene metodom "HemoCue-a" značajno su korelirale sa vrednostima Hb iz KKS, dok korelacija između nivoa feritina i Hb, određenog pomoću obe kapilarne metode, nije uočena. Zaključak. Kod 51,5% naših davalaca krvi koji su vraćeni zbog niskih vrednosti Hb utvrđen je snižen nivo feritina. Na osnovu ovih rezultata neophodno je odrediti algoritam za detekciju nedostatka gvožđa, dok je kapilarna metoda (HemoCue) pogodnija metoda za testiranje Hb pre davanja krvi.

Introduction

Blood donor selection is one of the most important measures used in blood transfusion centres in order to ensure blood safety [1][2][3][4][5]. Determining haemoglobin (Hb) level is a routine part of the donor selection process in order to ensure high quality of the red cell concentrates collected and, at the same time, protect the health of a potential donor [1][6]. However, iron deficiency has been found to be common in frequent blood donors, particularly women, while the Hb level measured may not accurately reflect iron stores [7][8][9][10]. Determining Hb levels during the donor selection process using capillary methods distinctly saves time and expenditure without endangering blood donors [11]. Data from the forum investigation [12] state that the capillary copper sulphate procedure is used to determine Hb level before donation in three European countries (the United Kingdom, Spain, and Croatia); in one country, both capillary methods are employed, and in the remaining European countries, the capillary photometric method is preferred, most often HemoCue®. In Serbian transfusion centres, we use the capillary copper sulphate method, considering the minimum acceptable Hb level to be > 135 g/L for male and > 125 g/L for female donors.

Low circulating Hb is globally the most common reason for deferral of prospective blood donors [13][14][15][16]. During 2017, the total rate of all deferrals in our centre was 14.2%, among which 30.5% were due to low Hb level. Considering the relatively high proportion of deferrals due to low Hb among our voluntary blood donors, we performed a prospective study aimed to determine iron status among such blood donors. In order to indicate the most appropriate procedures in our blood transfusion centre, the second aim was to evaluate the agreement between values for Hb obtained using capillary methods with reference hemoglobin values obtained from the complete blood count (CBC) test and their association with ferritin level.

Methods

Between February 2017 and December 2018, this prospective study included 200 consecutively recruited regular blood donors (102 male and 98 female) with low Hb, aged 19 to 64 years (median 39). The term regular blood donor was defined as someone who had routinely donated blood in the same centre within the previous 2 years, in accordance with minimum time intervals [17]. The total number of previous blood donations in the study group was 3,340, and the median time interval between them was 5.3 months. All study participants were recruited from the Blood Transfusion Institute of Serbia, Belgrade. In the Serbian transfusion service, copper sulphate is used as the standard method for Hb determination in a finger prick sample. This method was applied during the recruitment of the study participants. Another capillary method for a finger prick sample was applied, and Hb was measured photometrically using the HemoCue® Hb 201+ System (Mission Viejo, Ca, USA). In addition, Hb was determined in a venous blood sample taken into EDTA tubes, using a haematology analyzer (Horiba Medical ABX Micros ES 60 blood counter, France). Ferritin concentration was determined turbidimetrically in a second venous blood sample collected in plastic tubes for biochemical analysis, using test reagents from Linear Chemicals, Spain. The reference range designated as normal by the manufacturer was 20-250 μg/L for males and 20-200 μg/L for females. In particular, a plasma ferritin level < 12 μg/L is defined as absent iron stores (AIS), and ferritin concentration < 29 μg/L is defined as depletion [18]. These were used in statistical analyses in order to point to the iron status of blood donors deferred due to low Hb.

All study participants were approached with the standard questionnaires for voluntary blood donors. Data related to age, gender, number of previous donations, date of the last donation, dietary regime, and health problems since the last donation, such as haemorrhage, menstrual bleeding, fever, respiratory infection, and stomach problems, were analyzed.

Institutional approval for the study was granted by the Local Research Ethics Committee (EK-number 7767/2016) in accordance with the internationally accepted ethical standards. Each participant signed the informed consent form.

Statistical methods

The Statistical Package for Social Sciences 20.0 for Windows (SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis. The Mann-Whitney U-test, Fisher's exact test, and Pearson Chi-squared (χ2) test were employed to evaluate differences in the demographic and haemoglobin/ferritin test characteristics among the study participants. The probability p < 0.05 was considered statistically significant.

Spearman's tests were used for correlation analysis, and p < 0.01 was taken as statistically significant.

Results

Referring to their state of health, 25% of our subjects reported fatigue, 6.5% nutrition changes (diets, fasts), 7% bleeding episodes, and 61.5% good health. Considering the lower limit of the reference range to be 20 μg/L, a decreased ferritin level was found in 103/200 (51.5%) subjects (Table 1).

Table 1. Demographic characteristics of the patients

Characteristics Value
Total number of patients, n (%) 200 (100)
Age (years), median (range) 39 (19–64)
Gender (M/F), n 102/98
Total number of previous donations, n 3,340
Interval from last donation (months),median (range) 5.3 (3.0–9.5)
Condition status, n (%)
fatigue 50 (25)
diet 13 (6.5)
recently bleeding 14 (7)
good condition 123 (61.5)
Patients with low ferritin level, n (%) 103 (51.5)

M – male; F – female.

Equal frequencies of reduced Hb levels for the genders were indicated with all three methods (p = 0.323, p = 0.796, and p = 0.422, respectively). Statistically significant differences were found between male and female donors regarding age, the total number of donations, and the time interval following the previous donation (p < 0.001). Concerning ferritin levels, 44 (42.7%) males and 59 (57.3%) females had low ferritin concentrations, the difference being statistically significant (p = 0.008) (Table 2).

Table 2. Haemoglobin (Hb) and ferritin levels in relation to gender

Parameters Malen = 102 Femalen = 98 p
Age (years), median (range) 43 (22–64) 30 (19–64) < 0.001
Total number of previous donations, median (range) 16 (2–120) 5 (2–48) < 0.001
Interval from last donation (months), median (range) 4 (3–9.5) 5 (4–17) 0.001
Number with low Hb level by copper sulphate, n
<135 g/L M, < 125 g/L F
102 (100) 98 (100) 0.323*
Number of patients with low Hb level by HemoCue, n 90 (88.2) 89 (90.8) 0.796
Number of patients with low Hb from BC, n 89 (87.2) 90 (91.8) 0.422
Hb level (g/L), median (range)
by HemoCue 128 (92–145) 118 (84–136) < 0.001
from BC 127 (93–149) 114 (83–136) < 0.001
Number of patients with low ferritin, n (%) 44 (42.7) 59 (57.3) 0.008
Ferritin level (μg/L), median (range) 22.5 (4–209) 15 (2–349) 0.002

M – male; F – female; BC – blood count; p (Mann-Whitney test; *Fisher test).
Difference with regard to number with low Hb – copper sulphate vs. BC (p < 0.001). The reference ranges for ferritin designated as normal by the manufacturer were 20–250 μg/Lfor males and 20–200 μg/L for females.

Moreover, the median plasma ferritin for females (15.0 μg/L) was lower than that for males (22.5 μg/L; p = 0.002). For ferritin levels defined as < 12 μg/L or > 50 μg/L, significant differences between male and female donors were also observed (p = 0.023 and p = 0.022, respectively) (Table 3).

Table 3. Iron status in relation to the different ferritin levels and gender

Ferritin level
(μg/L)
Male (n = 102)
n (%)
Female (n = 98)
n (%)
p
(Pearson χ2 test)
<12 30 (29.4) 44 (45) 0.023
<29 32 (31) 28 (28.5) 0.659
30–50 16 (15.6) 15 (15) 0.942
> 50 24 (23.5) 11 (11.5) 0.022

Comparison of the results from the capillary methods with the reference Hb values obtained from BC showed that the copper sulphate method pointed to false fails in 21 (10.5%) donors, 13 male and 8 female (p < 0.001). Values for Hb obtained with the capillary HemoCue method were positively correlated with those from BC (p < 0.001) (Figure 1) but not with plasma ferritin level (p = 0.393) (Figure 2).

Figure 1 Correlation of haemoglobin (Hb) level measured by the HemoCue capillary method with reference Hb from BC (for correlation analysis, Spearmanʼs tests were used, p < 0.001).

Figure 2 Correlation of haemoglobin (Hb) level measured by the HemoCue capillary method with ferritin level (for correlation analysis, Spearman’s tests were used, p = 0.393).

However, in relation to ferritin level defined as AIS (< 12 μg/L), a significant correlation was observed in the case of the capillary HemoCue method and ferritin level in female donors (p < 0.001), but not in male donors (p = 0.148). There were no significant correlations when results for Hb levels using the copper sulphate method were compared with those from BC (p = 0.209) or ferritin level (p = 0.855).

Discussion

Our evaluation of iron status among blood donors deferred due to low Hb level showed that half of them had decreased plasma ferritin concentrations, while a quarter of them reported fatigue prior to donation. The frequency of low ferritin levels was significantly higher in females, and a greater proportion of women had ferritin levels lower than 12 μg/L, defined as AIS.

A negative correlation between blood donation and the total iron reserve was demonstrated over three decades ago [19][20] and has been confirmed in recently published studies [7][8][9][10]. Our results indicated the same. Based on all these data, additional measures are needed to improve the health of blood donors in order to prevent iron deficiency anemia. Several studies have aimed to determine the best approach for preventing iron deficiency in blood donors [21][22][23][24][25][26][27]. Their findings point to a need to re-evaluate current criteria in blood donor selection concerning the interval between donations, optimal testing strategy for measuring iron stores, and the necessity of iron supplementation [28][29]. A plasma ferritin level below 12 μg/L, defined as AIS, or less than 29 μg/L, defined as depletion, requires deferral of blood donation and confirmation [28]. In Italy, donors with iron deficiency are invited to lengthen the interval between whole blood donations. In Denmark, if plasma ferritin is less than 15 μg/L, the donor is sent 100 iron tablets by post. When the ferritin level is 15-40 μg/L, the donor is given 60 iron tablets for supplementation [12].

In our study, 60% of male and 73.5% of female donors had ferritin values that required deferral of blood donation for three to six months. We should point out that almost half of our low Hb female donors (45%) were observed in the group with ferritin < 12 μg/L, while only 11.5% of them had a ferritin concentration that indicated optimal iron status.

It should be emphasized that donor selection criteria have generally been adopted through health system regulations, but practice according to the current approach in vary among different transfusion centers [30]. Although the demand for blood supplies is decreasing in many countries due to the implementation of Patient Blood Management, in Serbia, this demand is constantly increasing because of the aging of the population and a relatively high incidence of malignant diseases. Another problem of the Serbian society is the emigration of young people during the last few decades for economic reasons. Therefore, defining a rational, evidence-based donor selection process in our transfusion services is crucial in order to minimize unnecessary rejection of voluntary blood donors and to prepare them for future donation so that continuous blood supply is maintained.

Determining Hb levels before donation with two capillary methods and comparing them with the value obtained from BC showed that the copper sulphate method gave false fails in 10.5% of donors. On the other hand, the capillary HemoCue method provided Hb values comparable with those obtained from BC. Moreover, in female donors with ferritin below 12 μg/L, there was a significant association with Hb level obtained with the capillary HemoCue method. Regarding that, every effort should be made to improve the accuracy of Hb screening in our centres. This implies a recommendation that the capillary photometric method should be introduced to replace the copper sulphate procedure for Hb determination. In addition, taking our results for iron status into consideration, determining the algorithm for detecting iron deficiency together with iron supplementation should be included in the Serbian transfusion services.

Our study has limitations that should be considered. Namely, the number of participants was relatively small. Concerning the study design, no selection was made during recruitment; thus, all donors with identified low Hb were included. Therefore, differences among donors regarding age and number of previous donations could have an implication that resulted in recall bias. However, this is the first study conducted among Serbian voluntary donors, and the results obtained need to be confirmed in further investigations involving a larger number of participants.

Conclusion

For determining hemoglobin prior to donation, the HemoCue capillary method is more suitable than the copper sulphate method. A low plasma ferritin concentration was observed in 51.5% of Serbian blood donors deferred due to low hemoglobin. Our findings indicated that determining the algorithm for detecting iron deficiency is necessary. However, in addition to the optimal testing strategy for measuring iron stores, the necessity of iron supplementation and treatment of iron deficiency anemia among blood donors are extremely important.

Dodatak

Acknowledgement

This study was supported by grant no. 173008 of the Ministry of Education, Science and Technological Development of the Republic of Serbia.

References

1.Eder A. Evidence-based selection criteria to protect blood donors. J Clin Apher. 2010;25(6):331-337. [Crossref]
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8.Cable RG, Glynn SA, Kiss JE, Mast AE, Steele WR, Murphy EL, et al. Iron deficiency in blood donors: The REDS-II Donor Iron Status Evaluation (RISE) study. Transfusion. 2012;52(4):702-711. [Crossref] [PubMed] [PMC]
9.Rigas AS, Sørensen CJ, Pedersen OB, Petersen MS, Thørner LW, Kotzé S, et al. Predictors of iron levels in 14,737 Danish blood donors: Results from the Danish blood study. Transfusion. 2014;54(3 Pt 2):789-796.
10.Gorlin J. Iron man pentathlon or 'we have met the enemy and they is us!'. Transfusion. 2014;54(3 pt 2):747-749. [Crossref]
11.Lotfi R, Wernet D, Starke U, Northoff H, Cassens U. A noninvasive strategy for screening prospective blood donors for anemia. Transfusion. 2005;45(10):1585-1592. [Crossref]
12.Vuk T, Magnussen K, de Kort W, Folléa G, Liumbruno GM, Schennach H, et al. International forum: An investigation of iron status in blood donors. Blood Transfus. 2017;15(1):20-41.
13.Hillgrove T, Moore V, Doherty K, Ryan P. The impact of temporary deferral due to low hemoglobin: Future return, time to return, and frequency of subsequent donation. Transfusion. 2011;51(3):539-547. [Crossref]
14.Custer B, Chinn A, Hirschler NV, Busch MP, Murphy EL. The consequences of temporary deferral on future whole blood donation. Transfusion. 2007;47(8):1514-1523. [Crossref]
15.Williamson LM, Devine DV. Challenges in the management of the blood supply. Lancet. 2013;381(9880):1866-1875. [Crossref]
16.Carson JL, Guyatt G, Heddle NM, Grossman BJ, Cohn CS, Fung MK, et al. Clinical practice guidelines from the AABB: Red blood cell transfusion thresholds and storage. JAMA. 2016;316(19):2025-35.
17.Council of Europe. Guide to preparation, use and quality assurance of blood components, 19th ed. Strasbourg, France: European Directorate for the Quality of Medicines & Health-Care. 2016.
18.World Health Organization (WHO). Serum ferritin concentrations for the assessment of iron status and iron deficiency in populations. Vitamin and Mineral Nutrition Information System. 2011. [accessed 2017 June 28]. Available from: www.who.int/vmnis/indicators/serum_ferritin.pdf.
19.Finch CA, Cook JD, Labbe RF, Culala M. Effect of blood donation on iron stores as evaluated by serum ferritin. Blood. 1977;50(3):441-447. [Crossref]
20.Simon TL, Garry PJ, Hooper EM. Iron stores in blood donors. JAMA. 1981;245(20):2038-2043. [Crossref]
21.Low MS, Speedy J, Styles CE, De-Regil LM, Pasricha SR. Daily iron supplementation for improving anaemia, iron status and health in menstruating women. Cochrane Database Syst Rev. 2016;4:CD009747. [Crossref]
22.Smith GA, Fisher SA, Doree C, di Angelantonio E, Roberts DJ. Oral or parenteral iron supplementation to reduce deferral, iron deficiency and/or anaemia in blood donors. Cochrane Database Syst Rev. 2014;7:CD009532. [Crossref]
23.Kiss JE, Brambilla D, Glynn SA, Mast AE, Spencer BR, Stone M, et al. Oral iron supplementation after blood donation: A randomized clinical trial. JAMA. 2015;313(6):575-583.
24.Magnussen K, Ladelund S. Handling low hemoglobin and iron deficiency in a blood donor population: 2 years' experience. Transfusion. 2015;55(10):2473-2478. [Crossref]
25.Mast AE, Bialkowski W, Bryant BJ, Wright DJ, Birch R, Kiss JE, et al. A randomized, blinded, placebo-controlled trial of education and iron supplementation for mitigation of iron deficiency in regular blood donors. Transfusion. 2016;56(6 pt 2):1588-1597. [Crossref] [PubMed] [PMC]
26.Cable RG, Brambilla D, Glynn SA, Kleinman S, Mast AE, Spencer BR, et al. Effect of iron supplementation on iron stores and total body iron after whole blood donation. Transfusion. 2016;56(8):2005-2012. [Crossref] [PubMed] [PMC]
27.Bryant BJ, Yau YY, Arceo SM, Daniel-Johnson J, Hopkins JA, Leitman SF, et al. Iron replacement therapy in the routine management of blood donors. Transfusion. 2012;52(7):1566-1575. [Crossref] [PubMed] [PMC]
28.Spencer B. Blood donor iron status: Are we bleeding them dry? Curr Opin Hematol. 2013;20(6):533-539.
29.AABB. Updated strategies to limit or prevent iron deficiency in blood donors. Association Bulletin. [Internet].;17(02). Available from: http://www.aabb.org/resources/publications/bulletins/Pages/ab17-023.aspx.
30.Eder A, Goldman M, Rossmann S, Waxman D, Bianco C. Selection criteria to protect the blood donor in North America and Europe: Past (dogma), present (evidence), and future (hemovigilance). Transfus Med Rev. 2009;23(3):205-220. [Crossref]
Reference
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Baart, A. M., van den Hurk, K., de Kort, W.L.A.M. (2015) Minimum donation intervals should be reconsidered to decrease low hemoglobin deferral in whole blood donors: An observational study. Transfusion, 55(11): 2641-2644
Boulton, F. (2008) Evidence-based criteria for the care and selection of blood donors, with some comments on the relationship to blood supply, and emphasis on the management of donation-induced iron depletion. Transfus Med, 18(1): 13-27
Bryant, B.J., Yau, Y.Y., Arceo, S.M., Daniel-Johnson, J., Hopkins, J.A., Leitman, S.F. (2012) Iron replacement therapy in the routine management of blood donors. Transfusion, 52(7): 1566-1575
Cable, R.G., Brambilla, D., Glynn, S.A., Kleinman, S., Mast, A.E., Spencer, B.R., Stone, M., Kiss, J.E. (2016) Effect of iron supplementation on iron stores and total body iron after whole blood donation. Transfusion, 56(8): 2005-2012
Cable, R.G., Glynn, S.A., Kiss, J.E., Mast, A.E., Steele, W.R., Murphy, E.L., Wright, D.J., Sacher, R.A., Gottschall, J.L., Tobler, L.H., Simon, T.L. (2012) Iron deficiency in blood donors: The REDS-II Donor Iron Status Evaluation (RISE) study. Transfusion, 52(4): 702-711
Carson, J.L., Guyatt, G., Heddle, N.M., Grossman, B.J., Cohn, C.S., Fung, M.K., et al. (2016) Clinical practice guidelines from the AABB: Red blood cell transfusion thresholds and storage. JAMA, 316(19): 2025-35
Council of Europe (2017) Guide to preparation, use and quality assurance of blood components. Strasbourg, France: European Directorate for the Quality of Medicines & Health-Care
Custer, B., Chinn, A., Hirschler, N.V., Busch, M.P., Murphy, E.L. (2007) The consequences of temporary deferral on future whole blood donation. Transfusion, 47(8): 1514-1523
Eder, A. (2010) Evidence-based selection criteria to protect blood donors. J Clin Apher, 25(6): 331-337
Eder, A., Goldman, M., Rossmann, S., Waxman, D., Bianco, C. (2009) Selection criteria to protect the blood donor in North America and Europe: Past (dogma), present (evidence), and future (hemovigilance). Transfus Med Rev, 23(3): 205-220
Finch, C.A., Cook, J.D., Labbe, R.F., Culala, M. (1977) Effect of blood donation on iron stores as evaluated by serum ferritin. Blood, 50(3): 441-447
Goldman, M., Magnussen, K., Gorlin, J., Lozano, M., Speedy, J., Keller, A., Pink, J., Leung, J.N.S., Chu, C.C.Y., Lee, C.-K., Faed, J., Chay, J., Tan, H.H., Teo, D., Djoudi, R., Woimant, G., Fillet, A.-M., Castrén, J., Miflin, G., Vandewalle, G.C., Compernolle, V. (2016) International Forum regarding practices related to donor haemoglobin and iron. Vox Sang, 111(4): 449-455
Gorlin, J. (2014) Iron man pentathlon or 'we have met the enemy and they is us!'. Transfusion, 54(3 pt 2): 747-749
Hillgrove, T., Moore, V., Doherty, K., Ryan, P. (2011) The impact of temporary deferral due to low hemoglobin: Future return, time to return, and frequency of subsequent donation. Transfusion, 51(3): 539-547
Kiss, J.E., Brambilla, D., Glynn, S.A., Mast, A.E., Spencer, B.R., Stone, M., et al. (2015) Oral iron supplementation after blood donation: A randomized clinical trial. JAMA, 313(6): 575-83
Lotfi, R., Wernet, D., Starke, U., Northoff, H., Cassens, U. (2005) A noninvasive strategy for screening prospective blood donors for anemia. Transfusion, 45(10): 1585-1592
Low, M.S.Y., Speedy, J., Styles, C.E., De-Regil, L.M., Pasricha, S. (2016) Daily iron supplementation for improving anaemia, iron status and health in menstruating women. Cochrane Database Syst Rev, 4: CD009747
Magnussen, K., Ladelund, S. (2015) Handling low hemoglobin and iron deficiency in a blood donor population: 2 years' experience. Transfusion, 55(10): 2473-2478
Mast, A.E. (2014) Low hemoglobin deferral in blood donors. Transfus Med Rev, 28(1): 18-22
Mast, A.E., Bialkowski, W., Bryant, B.J., Wright, D.J., Birch, R., Kiss, J.E., d'Andrea Pam,, Cable, R.G., Spencer, B.R. (2016) A randomized, blinded, placebo-controlled trial of education and iron supplementation for mitigation of iron deficiency in regular blood donors. Transfusion, 56(6 pt 2): 1588-1597
Rigas, A.S., Sørensen, C.J., Pedersen, O.B., Petersen, M.S., Thørner, L.W., Kotzé, S., et al. (2014) Predictors of iron levels in 14,737 Danish blood donors: Results from the Danish blood study. Transfusion, 54(3 Pt 2): 789-96
Simon, T.L., Garry, P.J., Hooper, E.M. (1981) Iron stores in blood donors. JAMA, 245(20): 2038-43
Smith, G.A., Fisher, S.A., Doree, C., di Angelantonio, E., Roberts, D.J. (2014) Oral or parenteral iron supplementation to reduce deferral, iron deficiency and/or anaemia in blood donors. Cochrane Database Syst Rev, 7: CD009532
Spencer, B. (2013) Blood donor iron status: Are we bleeding them dry?. Curr Opin Hematol, 20(6): 533-9
Spencer, B.R., Johnson, B., Wright, D.J., Kleinman, S., Glynn, S.A., Cable, R.G., et al. (2016) Potential impact on blood availability and donor iron status of changes to donor hemoglobin cutoff and interdonation intervals. Transfusion, 56(8): 1994-2004
Vuk, T., Magnussen, K., de Kort, W., Folléa, G., Liumbruno, G.M., Schennach, H., et al. (2017) International forum: An investigation of iron status in blood donors. Blood Transfus, 15(1): 20-41
WHO Blood safety and availability. http://www.who.int/mediacentre/factsheets/fs279/en/ [accessed 2017 June 28]
Williamson, L.M., Devine, D.V. (2013) Challenges in the management of the blood supply. Lancet, 381(9880): 1866-1875
World Health Organization (WHO), Vitamin and Mineral Nutrition Information System (2011) Serum ferritin concentrations for the assessment of iron status and iron deficiency in populations. WHO/NMH/NHD/MNM/11.2, http://www.who.int/vmnis/indicators/serum_ferritin.pdf [accessed 2017 June 28]
 

O članku

jezik rada: engleski
vrsta rada: izvorni naučni članak
DOI: 10.2298/VSP190327063K
primljen: 10.05.2019.
prihvaćen: 10.05.2019.
objavljen onlajn: 15.05.2019.
objavljen u SCIndeksu: 12.03.2021.
metod recenzije: dvostruko anoniman
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