Considering equity in transfusion medicine practice.

Regarding the commentary “Wider perspectives: It's a changing world—The use of ABO-incompatible plasma for resuscitating massively bleeding patients”, we are concerned that use of incompatible plasma and whole blood products may raise issues related to healthcare equity.1 The authors note that the safety of Type A emergency plasma is based on the idea that “approximately 85% of patients would be either Group A or Group O for which Group A plasma would be compatible.” As indicated by Table 1 in the commentary, this percentage and presumed low risk appears related to the reported ABO “Frequency in Caucasian population (%).” However, there are, of course, people of non-European ancestry who require blood transfusions. For example, according to the most recent United States census data, individuals who self-identify as “Black or African American” or “Asian” make up approximately 14% and 6% of the United States population, respectively.2 In the United States, while the prevalence of B or AB is 14% and that of A is 40% for individuals who identify as “White non-Hispanic”, the proportion of B or AB is approximately the same as A for those who identify as “Asian” or “Black non-Hispanic” (24%–32%, table).3 As such, the current practice of using A plasma when the blood type is unknown puts individuals of certain populations at potential increased risk of harm.4, 5 As we try to move from race-based to race-conscious medicine, it is important to recognize that data based on individuals of European ancestry does not necessarily apply to all patients.6 Additional considerations apply to the use of whole blood. The difficulties in providing RhD− products for pre-hospital transfusion or as whole blood in massive haemorrhage translates to the potential need to transfuse RhD+ products to individuals of childbearing potential who are RhD− or with unknown RhD status.7, 8 The risk of forming anti-D in this setting is approximately 30% with even a single RhD+ red blood cell unit.9 In this context, a number of articles have suggested that the benefits of such a practice outweigh the risk of anti-D related haemolytic disease of the foetus and newborn (HDFN).8, 10 The impact of HDFN is minimized as an “almost completely treatable” or “very manageable” disease.8, 10 One of these articles, however, notes a rate of mortality from anti-D HDFN of 4% and a 25% risk of severe disease.10 Maternal-foetal medicine healthcare providers are also well aware of the issues associated with managing a pregnant patient at risk for HDFN. These include the psychological toll on the patient, healthcare costs and risks related to intrauterine transfusion.4 A recent meta-analysis evaluated the perinatal outcomes of 2439 pregnancies requiring 6010 intrauterine transfusions for red cell alloimmunization. There was an estimated perinatal mortality rate of almost 17% with exchange transfusions performed on 50% of neonates.11 Due to healthcare disparities in the United States, the frequency of these complications, and the overall negative impact of additional cases of HDFN, may be greater in some populations. For example, in considering all causes, non-Hispanic Black infants have over twice the mortality rate compared to non-Hispanic White infants.12 In addition, there is evidence that non-Hispanic Black individuals of childbearing potential, in the setting of post-partum haemorrhage, are more likely to receive transfusions and are at higher risk for severe morbidity and mortality.13 As such, practices involving whole blood and incompatible plasma in massive transfusion, without understanding impact in different populations, could lead to further healthcare disparities and inequitable treatment of vulnerable groups. Of course, if there are no RhD− products or only incompatible plasma available, transfusion should not be withheld if there is the belief that it will save someone's life. However, it is important to note that questions have been raised regarding the data supporting the efficacy and safety of transfusing incompatible plasma and whole blood.4, 5 We also would like to point the authors and journal editors towards the 2021 AMA Manual of Style “Updated Guidance on the Reporting of Race and Ethnicity in Medical and Science Journals.”14 Race-conscious medicine requires attention to how race and ethnicity are discussed in the medical literature and the guidance provides a practical approach. For example, the term “Caucasian,” as in the aforementioned table in the commentary by Yazer et al., is based on the antiquated and false view of racial hierarchy. It was coined in 1795 by J.F. Blumenbach as he believed that the area near the Caucasus mountains “produces the most beautiful race of men.” As such, in his classification of races, he named the White group “Caucasian” as it was closest to his perceived ideal. As argued by Stephen Jay Gould, Blumenbach's non-scientific approach to dividing humanity into a hierarchy of races was key to the development of modern racism.15 Not surprisingly, the AMA Manual guidance recommends not using this term for people of general European ancestry.14 Taken together, we support future research that can better clarify the risks associated with the use of incompatible plasma and whole blood products. Furthermore, in considering transfusion medicine practices, it is important to assess and appropriately manage risk for all populations beyond White males. Richard L. Haspel wrote the first draft of the letter. Sara Bakhtary, Phillip J. DeChristopher, Yvette M. Miller, Kerry L. O'Brien and Monica B. Pagano critically reviewed and revised the manuscript. All authors approved the final version. The authors declare no conflicts of interest.