Three key points from the document: 1. Severe hypertriglyceridemia was identified in Puerto Rican blood donors, presenting as turbid plasma. The affected donors were mostly overweight males with an average age of 44.5 years. 2. Donations resulting in milky serum must be discarded as they cannot be properly tested. Screening donors for cardiovascular and metabolic risks could help address problems with recruitment and retention. 3. The study provides the first data correlating turbid plasma donations in Puerto Rico with gender, age, region, and blood type. The most common blood type was O, Rh(+), followed by A, Rh(+). Further research is needed on the role of blood donation

1. ABSTRACT SEVERE
HYPERTRIGLYCERIDEMIA
Puerto Rico blood donor issues has
been identified in cases of severe hy- IN PUERTO RICO BLOOD
pertriglyceridemia presenting as tur- DONORS:
bid. Blood donations resulting in milky
serum must be discarded. They are A Population Study
discarded because we cannot properly 2009-2011
test the donation. This is the first report
where we correlate turbidity and cardio-
vascular risk factors in the Puerto Rico Raúl H. Morales-Borges MDa*, Carmen Merced
population as well as blood types O MT b
and A, Rh (+) with dyslipidemia. Blood
donors should be screened in more
details regarding cardiovascular and
metabolic risks to avoid problems with a
Medical Director, American Red Cross, Puerto Rico Region,
recruitment and retention strategies. San Juan, Puerto Rico.
b
Manager, Donor Information, American Red Cross, Puerto
Rico Region, San Juan, Puerto Rico.
Index words: severe, hypertriglyceride- *Corresponding author: Raúl H. Morales-Borges MD - Medi-
mia, Puerto Rico, blood, donors, popu- cal Director, American Red Cross, Puerto Rico Region, PO
lation Box 366046 San Juan, Puerto Rico 00936. E-mail: Raul.Mo-
rales@redcross.org
INTRODUCTION
Hyperlipidemia, defined as an abnormal elevation of plas- If a sample appears excessively turbid and fails visual exa-
ma cholesterol and/or triglyceride levels, is one of the most mination for lipemia, the National Testing Laboratory (NTL)
common clinical problems confronting the clinician in daily performs a quantitative triglyceride analysis. Samples with
practice (1). Although these disorders appear to be common triglycerides value less or equal than 3000 mg/dl are con-
in the general population, it seems not a major issue in blood sidered acceptable for testing; but samples with a triglyce-
donor’s population. A French study published by Terrier et al ride value more than 3000 mg/dl are unsuitable for testing.
(2) with 1184 blood donors found a correlation between high Approximately 99% of samples pass the visual examina-
blood pressure, obesity, blood group O, and type II-b Hyper- tion for turbidity and therefore do not require a quantitative
lipoproteinemias in 32 cases. Another study from Brazil by triglyceride analysis. Of those samples that fail the visual
MG Ferreira et al (3) evaluated the accuracy of anthropo- examination for turbidity, greater than half have a quantitati-
metric fat location indices as predictors of dyslipidemia. One ve value less or equal than 3000 mg/dl and are determined
study from the Netherlands provided important knowledge acceptable for testing. Only a few samples a day fails the
about demographic distributions and cardiovascular risk visual examination for turbidity and have a triglyceride level
factors within whole blood and plasma donors (4). Another > 3000 mg/dl.
study also from the Netherlands reported that donors who
provided a turbid donation have a less favorable cardio- The NTL uses the result of the triglyceride testing to deter-
vascular profile compared to other donors (5). One study mine sample suitability and is required to report the results
about fasting blood sugar in 1188 blood donors from Mexico to the region or to the donor. It should be noted that the
showed that the prevalence of impaired fasting glucose was triglyceride test performed by the Charlotte NTL is to be per-
higher than expected and 70% of those subjects showed formed on non-fasting sample, which is usually the case for
hypertriglyceridemia, comparing with other populations re- our donor samples. The expected value for a fasting sample
ported in the literature (6). We wanted to demonstrate the is < 200 mg/dl. The package insert does not include any
needs of further research on the role of blood donation in expected values for non-fasting samples. Because there is
cardiovascular risk reduction, correlation between blood no expected value for a non-fasting sample, the testing is
type and groups with dyslipidemia. We are presenting data performed to determine sample suitability for infectious di-
from 50248 whole blood donors from March 1 to October 31 sease testing (8)
of 2011 from which 5 were identified to have a triglyceride
level above 3000 mg/dl. There is additional data from April of Once the donors are identified we pulled the blood donors
2009 to December of 2010 with a total of 9 donors identified registry, known as BDR, of them and we reviewed to chart
with high triglyceride levels identified when the BHQ Medi- the data of age, gender, weight, blood type and group, town
cal Office asked the National’s Testing Laboratory (NTL) to or city of living, collection date, and serum triglyceride level.
systemically notify the regional physicians of donations that
could not be tested because of high triglyceride levels. Puerto Rico has 78 municipalities and we colored the muni-
cipalities or cities of the affected donors.
METHODS
RESULTS
We obtained the cases were a visual examination of all
blood tubes is performed as part of the National’s Testing Five blood donors were identified to have turbid plasma with
Laboratory sample suitability evaluation. Lipemia is one of triglycerides over 3000 mg/dl. Four were male and the avera-
the variables assessed during this initial visual examination ge/median age was 46 years with a range of 41 to 50 years old.
as shown also in a study from K Peffer et al and commented The average weight was 184 pounds with a range of 140 to 240
by RR Vassallo and FM Stearns with 272 donors (5, 7). pounds. Four of the blood donors were identified overweight.
15

2. Four were identified the blood type and group with three of One study determined 32% as the overall prevalence of the
them as A, Rh (+). Three of them are from the north area of metabolic syndrome (defined as diabetes, hypertension,
the Island and one from the south and central area respec- obesity, dyslipidemia, glucose intolerance, and hyperinsu-
tively. The lowest triglyceride level was 3038 mg/dl and the linemia) among a determined Puerto Rican population (9).
highest was 5701 mg/dl with an average level of 3912 mg/ Cox stated that despite clear and consistent clinical-trial
dl (See Table 1). 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
From 2009 to 2010 we identified nine male donors with an good health habits and cardiovascular risks. Also discarding
average age of 44 years and a range of 30 to 56 years old. donations may have a negative impact on donor satisfaction
Five of them have blood type and group O, Rh (+). The geo- and retention, although the educational material informs all
graphic distribution varies with four from the Central region, donors that their donation may not be tested, but ARC does
three from the North, and two from the Metropolitan region. not inform donors if their donations are discarded.
The lowest triglyceride level was 2153 mg/dl, the highest
was 5396 mg/dl with an average 3545 mg/dl (See Table 2). Regarding turbid plasma donations, Peffer et al (5) mentio-
ned that in the Netherlands, 3 to 4 per 1000 whole blood
In general we are reporting 14 cases with an average age donations reveal turbid plasma. Familial hypertriglyceride-
of 44.5 years and the majority were males from the North mia or chylomicronemia has been reported, but commonly
Central Municipalities of the Island (See Figure 1). 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
DISCUSSION seem more liable to develop atherosclerosis than those with
blood group non-A. This data correlates with an Italian study
This is the first publication were we identified turbid plasma from Clara Carpeggiani et al (12) where they demonstrated
in Puerto Rico blood donors with a correlation of gender, that a significant association between group non-O and fa-
age, regional area where they live, and blood type/group. mily history of ischemic heart disease, hypercholesterolemia
16

3. 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
and presence of coronary atheros- racy of waist
clerosis. Their higher predictor group circumference and waist-to-hip ratio as predictors of dys-
were patients aged < 65 years old and lipidemia in a cross-sectional
women. JL Cronenwett et al (13) with study among blood donors in Cuiaba, Mato Grosso State,
73 women requiring aortoiliac recons- Brazil. Cad Saude Publica
truction for atherosclerotic occlusive 2006 Feb; 22(2): 307-314.
disease demonstrated that women 4. Atsma F, Veldhuizen I, de Vegt F, Doggen C, de Kort W:
with blood group A had increased fre- Cardiovascular and
quency as comparable to published demographic characteristics in whole blood and plasma
data. The only study that does not co- donors: results from the Donor InSight study. Transfusion
rrelate with this data is the one from 2011 Feb; 51(2): 412-420.
North Carolina, USA with 1198 pa- 5. Peffer K, de Kort WL, Slot E, Doggen CJ: Turbid plasma
tients who underwent percutaneous donations in whole blood
coronary intervention and patients donors: fat chance? Transfusion 2011 Jun; 51(6): 1179-
with O blood type were slightly older 1187.
(62 years old), had a higher prevalen- 6. Munguia-Miranda C, Sánchez-Barrera RG, Tuz K, Alon-
ce of hypercholesterolemia and had so-García AL, Cruz M:
a higher burden of atherosclerosis Impaired casting glucose detection in blood donor’s popu-
with more vascular disease (14). This lation. Rev Med Inst Mex
fact is important regarding blood do- Seguro Soc. 2009 Jan-Feb; 47(1): 17-24.
nations. A study must be performing 7. Vassallo RR, Stearns FM: Lipemic plasma: a renaissan-
to correlate the blood type/group and ce. Transfusion 2011 Feb;
dyslipidemia because it may be a 51(6): 1136-1139.
coincidental finding. 8. Stearns FM, Stramer SL, Alvarez AW: Verification of Vi-
sual Lipemia Sample
Another piece of information regarding Suitability by Quantitative Triglyceride Testing. Transfu-
strategies for blood drives is that the sion 2005; 45, Supplement,
majority of the small groups were from SP199, p89A.
the north and central areas of Puerto
Rico. This is important, although, the 9. Gomez M, Ramirez M, Disdier O: Prevalence of the meta-
finding of a few donors with isolated bolic syndrome among a
high triglyceride levels does not have determined Puerto Rican population. PR Health Sci J.
any implications for planning blood 2006 Jun; 25(2): 111-116.
drives. 10. Cox RA: The hyperlipidemias. Bol Asoc Med PR. 2003
Sep-Oct; 95(5): 36-44.
CONCLUSIONS 11. Hørby J, Gyrtrup HJ, Grande P, Vestergaard A: Relation
of serum lipoproteins and
This data provided important lipids to the ABO blood groups in patients with intermit-
knowledge about lipemic plasma and tent claudication.
demographics of our blood donor’s J Cardiovasc Surg (Torino) 1989 Jul-Aug; 30(4):533-
population. It was confirmed that the 537.
main blood type and group O, Rh (+) 12. Carpeggiani C, Coceani M, Landi P, Michelassi C,
is related with dyslipidemia as well as L’abbate A: ABO blood group
A, Rh (+) by our small sample and alleles: A risk factor for coronary artery disease. An an-
they are mostly located in the north giographic study.
central municipalities of Puerto Rico. Atherosclerosis 2010 Aug; 211(2): 461-466.
What is most interesting is Figure 1 13. Cronenwett JL, Davis JT Jr, Garret HE: ABO blood group
per 130,000 of severe hypertriglyce- and serum lipids in female
ridemia in which Ralph R. Vassallo atherosclerosis. J Cardiovasc Surg (Torino) 1983 Nov-
and Frank M. Stearns (7) reported for Dec; 24(6): 658-661.
the Philadelphia NTL were our donors 14. Ketch TR, Turner SJ, Sacrinty MT, Lingle KC, Applegate
17

4. RJ, Kutcher MA, Sane RESUMEN
DC: ABO blood types: Influence on infarct size, procedural
characteristics and Se ha identificado un asunto en cuanto a donantes de sangre
prognosis. Thromb Res 2008; 123(2): 200-205. 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
ACKNOWLEDEDGMENTS lechoso usualmente son descartadas. Se descartan porque
no se pueden realizar las pruebas a las donaciones. Este es
The authors thank Dr. Anne F. Eder, Dr. Ralph R. Vassallo, and el primer reporte donde nosotros correlacionamos la turbiedad
Dr. Frank M. Stearns from the American Red Cross for their y los factores de riesgo cardiovasculares en la población de
editing support and comments. 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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