Asian Journal of Transfusion Science
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ORIGINAL ARTICLE  
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Altered color of plasma component – Unnecessary wastage of a precious resource


 Department of Immuno Hematology and Blood Transfusion, B. J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India

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Date of Submission11-Jul-2021
Date of Decision07-Sep-2021
Date of Acceptance05-Dec-2021
Date of Web Publication26-Sep-2022
 

   Abstract 

BACKGROUND AND OBJECTIVES: The present study was conducted to evaluate the etiology of altered color of plasma component of blood in transfusion practice.
MATERIALS AND METHODS: The study was conducted at the blood center of a tertiary care teaching hospital in western India for a period of 6 months. After component separation, all the plasma units with altered color were segregated and samples were taken for further evaluation. Altered colored plasma units were divided into three – green discoloration, yellow discoloration, and lipemic plasma. Donors were called, their detailed history was taken, and necessary investigations were done accordingly.
RESULTS: Forty plasma units out of 20,658 (0.19%) donations showed discoloration. Out of which, 3 plasma units showed green discoloration, 9 plasma units showed yellow discoloration, and the remaining 28 plasma units were lipemic. Among three donors whose plasma showed green discoloration, one female donor had a history of oral contraceptive pill usage and had higher values of copper and ceruloplasmin. All donors with yellow plasma had a higher value of unconjugated bilirubin. All the donors with lipemic plasma gave a history of intake of fatty meal prior to donating blood and showed higher values of triglyceride, cholesterol, and very-low-density lipoprotein.
CONCLUSION: Plasma component with altered color restricts its issue to the patient and also for use in fractionation. In our study, many of the altered color plasma units were safe to transfuse, but the decision regarding transfusion was debatable on consultation with the treating doctor. Further studies with a large sample size are recommended for the use of these plasma components.

Keywords: Bilirubin, discoloration, lipemic, plasma


How to cite this URL:
Patel DD, Shah MC, Bhatnagar NM, Patel TR, Shah SD, Soni S. Altered color of plasma component – Unnecessary wastage of a precious resource. Asian J Transfus Sci [Epub ahead of print] [cited 2022 Dec 4]. Available from: https://www.ajts.org/preprintarticle.asp?id=356901



   Introduction Top


One of the primary parameters of quality management system in blood transfusion services is to reduce the discard rate of precious blood and blood components. The reasons of discard of blood and blood components are many, some of which are avoidable, such as stringent screening of donor for transfusion-transmitted diseases. However, some reasons of discard are unavoidable like a discolored plasma component.

Normally the plasma component of blood is yellowish in color and the other blood cells are suspended in it. There may be a slight variation in the yellow color of plasma component from light yellow to dark yellow. However, grossly abnormal discoloration such as orange, green, brown, milky, or reddish may be due to specific reasons. The alteration in color of plasma component poses a question to transfusion services whether it is suitable for transfusion or not. Even though transfusion of these altered color plasma components has known to be causing no harmful effect, it is a dilemma to the transfusion specialists whether to discard it or keep in inventory. The present study was conducted to evaluate the causes of altered color plasma components and contemplation on whether they could be added to blood center inventory. As currently, there are no national guidelines or policy regarding the use of these altered color plasma components, most of these are discarded and there is an unnecessary loss of precious resources.


   Materials and Methods Top


This prospective study was done at the blood center of a tertiary care teaching hospital (having annual blood collection of more than 40,000 units) during the period of October 2020–March 2021. During visual inspection of blood components separation, all plasma components with altered color were segregated and kept quarantined till the reports of investigations were received. The donor's history was evaluated from donor registration and consent form and samples from those plasma components with altered color were sent for further investigations. Reddish plasma unit was not included due to RBC contamination.

Altered color plasma components were divided into three categories:

Plasma components with green discoloration

Samples from plasma components with green discoloration were sent to the microbiology laboratory for culture and samples from female donors were sent to the laboratory for copper and ceruloplasmin level estimation.

Plasma components with yellow discoloration

Samples from plasma components with yellow discoloration were sent to the biochemistry laboratory for total, direct, and indirect bilirubin, serum glutamic pyruvic transaminase (SGPT), serum glutamic-oxaloacetic transaminase (SGOT), and alkaline phosphatase (ALP). Tests mandatory for the viral markers (human immunodeficiency virus, hepatitis B surface antigen, hepatitis C virus, syphilis, and malaria) were done by a fully automated ELISA machine at our blood center.

Plasma components with milky white discoloration (lipemic plasma)

Samples from plasma components with milky white discoloration were sent to the biochemistry laboratory for lipid profile (triglycerides [TG], cholesterol, high-density lipoprotein, very-low-density lipoprotein [VLDL], and LDL). Donors were contacted and retrospectively asked again for the history of hypertension, diabetes, smoking, kidney diseases, and any ingestion of fatty food before donation.


   Results Top


During the 6-month period from October 2020 to March 2021, 40 plasma units out of 20,658 (0.19%) donations showed altered color [Table 1].
Table 1: Plasma components with altered color

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Out of 40 altered color plasma components, 3 plasma components showed green discoloration, 9 plasma components showed yellow discoloration and the remaining 28 (14 in-house and 14 camps) plasma components were lipemic. [Figure 1] and [Figure 2]
Figure 1: Greenish plasma, Icteric plasma, Lipemic plasma

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Figure 2: Plasma components with altered color

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Three plasma components out of forty showed greenish discoloration. Blood culture reports of all the three units were sterile, 1 female donor was taking oral contraceptive pills and showed higher values of copper and ceruloplasmin. The other female had no significant history. One male donor gave a history of ayurvedic remedies prophylactically during COVID-19 pandemic [Table 2].
Table: 2 Plasma components with green discoloration

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Nine plasma components out of forty showed yellow discoloration, all the units with yellow plasma tested negative for viral marker. Total bilirubin of all donors with yellowish plasma discoloration ranges from 1.6 to 2.7 mg/dl (normal range – 0.2–1.2 mg/dl). The mean value of Unconjugated bilirubin is 1.5 mg/dl, conjugated bilirubin: 0.5 mg/dl, and total bilirubin: 2.0 mg/dl. All units showed raised unconjugated bilirubin. The other test results for liver function such as SGPT, SGOT, and ALP were normal in range (normal range: ALP – 0.39–118 U/L, SGOT – 0–31 IU/L, and SGPT – 0–34 IU/L). There were no abnormal findings in peripheral blood smear examination. Direct and indirect antiglobulin tests and blood culture showing negative test results [Table 3].
Table 3: Plasma components with yellow discoloration

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Twenty-eight plasma (14 in-house and 14 camps) components out of forty showed milky white discoloration. All the donors with milky white discoloration of plasma had a history of fatty meals taken prior to blood donation. Most of them showed the higher value of TG, cholesterol, and VLDL. Donors were asked to come for a fasting lipid profile test, but only five donors had responded back and had a normal range of fasting lipid profile. No one had any history suggestive of hypertension, diabetes, smoking, and kidney disease [Table 4] and [Table 5].
Table 4: Plasma components with milky white discoloration (in-house)

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Table 5: Plasma components with milky white discoloration (Camp)

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   Discussion Top


Altered color plasma poses a big challenge to transfusion services. It is a dilemma whether these components are taken into inventory or not. This study was done to evaluate the etiology behind the discolorations and actions to be taken.

Green discoloration of plasma components

Green discoloration of the plasma may be due to increased levels of ceruloplasmin (copper-binding protein in plasma). Ceruloplasmin is a plasma glycoprotein (α2-globulin), which acts as a copper carrier and as an acute-phase reactant. Normal serum level of ceruloplasmin is 20–40 mg/dL in adults, with twofold elevations found in oral contraceptive therapy and pregnancy.[1]

Green discoloration of plasma components due to raised copper and ceruloplasmin may be seen in

  • Oral contraceptive therapy and pregnancy[1]
  • Rheumatoid arthritis (RA) and in high estrogen states.[2],[3]


Green discoloration of plasma can also result from Gram-negative cryophilic contaminants such as Pseudomonas species as a result of production of pyocyanin or pyoverdin pigments.[4]

Sood et al. have shown greenish discoloration of plasma in two female donors with a history suggestive of oral contraceptive pills usage and one male donor with no any significant history.[5]

Pai et al. have found a rare occurrence of green-colored plasma in a male blood donor with no significant history.[6]

Tovey and Lathe reported green plasma in young women on contraceptive pills and confirmed elevated ceruloplasmin levels in the units by immunodiffusion and oxidase method in their study.[7]

Wolf et al. also reported that elevated ceruloplasmin levels were found in 15 donors, all of them were taking oral contraceptives and had extremely green plasma.[8]

Canadian blood services have issued visual assessment guidelines where such green-discolored units due to intake of OCPs are acceptable for transfusion.[9]

In our study, all the components with green-colored plasma were sterile, so there was no possibility of Pseudomonas contamination. To rule out other possible causes, there was no history suggestive of RA (medication and joint pains or morning stiffness) in all three donors. Out of two female donors, one had a history of oral contraceptive pills usage showing a higher amount of ceruloplasmin and copper also. No reference was found for the ayurvedic home remedies showing green color of plasma in one of the male donors. No cause was found in the rest of the male and female donors.

Yellow discoloration of plasma components

Sometimes, healthy blood donor's plasma shows icteric color and serum bilirubin is mildly raised (normal: 0.2–1.2 mg/dl) with no history of jaundice.

Yellow (icteric) color of plasma component is present in the following conditions:

  • Congenital hyperbilirubinemia
  • Gilbert's syndrome
  • Crigler–Najjar syndrome
  • Hemolytic anemia
  • Drug-induced hepatitis
  • Other hepatic causes
  • Gallstones[10]


In our study, nine plasma components showed raised total bilirubin (mean: 2.0 mg/dl) and unconjugated bilirubin (mean: 1.5 mg/dl). All nine donors had no history suggestive of jaundice, drug intake, or alcohol intake. There was no possibility of hemolytic anemia as all donors had normal Hb with normal peripheral blood smear findings. SGPT, SGOT, and ALP values among all nine donors were normal in range that ruled out primary liver disease and cholestasis from the differential diagnosis. Predominant factor found among all nine donors was raised unconjugated bilirubin, so the most probable diagnosis could be congenital hyperbilirubinemia or Gilbert's syndrome.

Congenital hyperbilirubinemia is a chronic disease characterized by mild persistent unconjugated hyperbilirubinemia. The patient usually is symptomless and unaware of disease until it is detected by routine laboratory testing for other reasons. Gilbert's syndrome is the most common hereditary cause of increased bilirubin and is found in up to 3–5% of the population.[11]

Sood et al. have shown total bilirubin of all the five units with yellow discoloration ranged from 10.6 to 2.3 mg/dl in their study.[5]

Jain et al. have shown in their study that in the donor unit with abnormal yellow discoloration, total bilirubin was 5.01 mg/dl and direct bilirubin was 1.5 mg/dl. The donor had history of jaundice 3 years back with unconjugated hyperbilirubinemia and was diagnosed with Gilbert's syndrome.[12]

Arora et al. had found 27 icteric plasma units, total serum bilirubin levels ranged from 1.6 to 3.1 with a mean level of 2.19 mg/dl. Serum unconjugated levels ranged from 1.2 to 2.8 mg/dl with a mean level of 1.82 mg/dl. They had a prevalence of 0.91% for asymptomatic hyperbilirubinemia in their study.[13]

Jashnani et al. also showed 253 blood units with icteric plasma in their study with elevated unconjugated hyperbilirubinemia (bilirubin levels between 1.2 and 2.5 mg/dl).[14]

Lipemic plasma components (milky white discoloration)

It is very common to see lipemic plasma in a blood center. As blood donors are encouraged to eat and drink before donating blood, the majority of turbid donations represent not fasting but postprandial lipemia which is usually associated with TG levels of more than 200 mg/dL.

Peffer et al. address the issue of lipemic donations with a case–control study of 272 donors of milky, turbid plasma. They outline many well-known risks for postprandial hypertriglyceridemia and correlate visual and spectrophotometric measures of turbidity. American Society of Red Cross in Philadelphia used TG concentration determination to qualify lipemic samples for infectious disease testing (1 per 320 samples sufficiently turbid to be tested; acceptable TG of <3000 mg/dL), only 1 in 130,000 samples is rejected.[15]

Lipemic plasma components due to hypertriglyceridemia is present in following conditions:

  • Obesity
  • Diabetes mellitus
  • Chylomicronemia
  • Cushing disease
  • Acromegaly
  • Nephrotic syndrome
  • Hypothyroidism
  • Pregnancy
  • Various medications[16]


Canadian blood services consider lipemic units acceptable for transfusion, but when excessive lipemia interferes with testing, all components are discarded.[9]

Heath et al. showed the contribution of dietary fatty acids to early postprandial VLDL TG in 8 healthy volunteers.[17]

In our study, among 28 lipemic plasma (14 in-house and 14 camps), most of them showed elevated TG levels and VLDL levels. All donors had a history of taking fatty meal before donation. All donors were asked for fasting serum lipid profile, but only five donors had given response back and fasting lipid profile showed normal findings. All samples were negative for transfusion-transmitted infection testing.

Even though transfusion of these altered color plasma components has no harmful effect on the recipient, still according to our blood center policy, we do not issue any altered colored plasma product for transfusion and fractionation. Even if blood center policy allows to issue such component then big dilemma on clinical side whether to accept such component for transfusion or not as everyone wants to be safe on their counterpart. Hence, altered color of plasma component is a real dilemma for transfusion. Convincing clinician regarding the safety of such components is a challenge.


   Conclusion Top


Although supportive evidence shows the actual reasons for plasma discolorations, it is still a dilemma for the transfusion specialist regarding utilization of these altered color plasma components for safe transfusion and fractionation. To make the uniform transfusion practices and to avoid unnecessary wastage of blood components, there should be a national guideline regarding the use of these discolored plasma products. There are few studies regarding altered color blood components; still, further studies with large sample size are required for the use of these components and avoidance of unnecessary discard of blood products and for better inventory management.

Acknowledgment

The authors wish to thank the technical staff of component area of the department for their help and support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Burrows S, Pekala B. Serum copper and ceruloplasmin in pregnancy. Am J Obstet Gynecol 1971;109:907-9.  Back to cited text no. 1
    
2.
Scheinberg IH, Cook CD, Murphy JA. Concentration of copper and ceruloplasmin in maternal and infant plasma at delivery. J Clin Invest 1954;33:963.  Back to cited text no. 2
    
3.
Koskelo P, Kekki M, Virkkunen M, Lassus A, Somer T. Serum ceruloplasmin concentration in rheumatoid arthritis, ankylosing spondylitis, psoriasis and sarcoidosis. Acta Rheumatol Scand 1966;12:261-6.  Back to cited text no. 3
    
4.
Elkassabany NM, Meny GM, Doria RR, Marcucci C. Green plasma-revisited. Anesthesiology 2008;108:764-5.  Back to cited text no. 4
    
5.
Sood T, Bedi RK, Mittal K. Discolored blood and blood components: A dilemma for transfusion specialists. Transfus Apher Sci 2014;50:255-9.  Back to cited text no. 5
    
6.
Pai S, Hasan Z, Jena M. Green colored plasma discovered in a male blood donor: A cause for concern? Glob J Transfus Med 2020;5:93-5.  Back to cited text no. 6
  [Full text]  
7.
Tovey LA, Lathe GH. Caeruloplasmin and green plasma in women taking oral contraceptives, in pregnant women, and in patients with rheumatoid arthritis. Lancet 1968;2:596-600.  Back to cited text no. 7
    
8.
Wolf P, Enlander D, Dalziel J, Swanson J. Green plasma in blood donors. N Engl J Med 1969;281:205.  Back to cited text no. 8
    
9.
Visual assessment guide-Canadian Blood Services; T05 021 January 2009. Available from: https://professionaleducation.blood.ca/sites/default/files/VAG_en.pdf  Back to cited text no. 9
    
10.
Lehmann HP, Henry JB. SI Units, Henry's Clinical Diagnosis and Management. 21st ed. Elsevier, China; 2007. p. 1408-9.  Back to cited text no. 10
    
11.
Naiman JL, Sugasawara EJ, Benkosky SL, Mailhot EA. Icteric plasma suggests Gilbert's syndrome in the blood donor. Transfusion 1996;36:974-8.  Back to cited text no. 11
    
12.
Jain A, Khetan D. Unconjugated hyperbilirubinemia in a blood donor: Chance finding due to unusual plasma discoloration. Asian J Transfus Sci 2018;12:8-9.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Arora V, Kulkarni RK, Cherian S, Pillai R, Shivali M. Hyperbilirubinemia in normal healthy donors. Asian J Transfus Sci 2009;3:70-2.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Jashnani KD, Karwande A, Puranik G. Icteric donor plasma: To transfuse or to discard? Indian J Pathol Microbiol 2012;55:604-5.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Peffer K, de Kort WL, Slot E, Doggen CJ. Turbid plasma donations in whole blood donors: Fat chance? Transfusion 2011;51:1179-87.  Back to cited text no. 15
    
16.
Vassallo RR, Stearns FM. Lipemic plasma: A renaissance. Transfusion 2011;51:1136-9.  Back to cited text no. 16
    
17.
Heath RB, Karpe F, Milne RW, Burdge GC, Wootton SA, Frayn KN. Selective partitioning of dietary fatty acids into the VLDL TG pool in the early postprandial period. J Lipid Res 2003;44:2065-72.  Back to cited text no. 17
    

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Correspondence Address:
Dhara Darshan Patel,
E-503, Satyamev Vista, Off. S. G. Highway, Near Gota Cross Roads, Gota, Ahmedabad - 382 481, Gujarat
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajts.ajts_97_21



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