Transfusion and Apheresis Science 49 (2013) 181–184

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Transfusion and Apheresis Science

journal homepage: www.elsevier.com/locate/transci

Review

Lipaemic donations: Truth and consequences

Giuseppe Lippi a,⇑, Massimo Franchini b
a
Unità Operativa di Diagnostica Ematochimica, Dipartimento di Patologia e Medicina di Laboratorio, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
b
Dipartimento di Medicina Trasfusionale ed Ematologia, Azienda Ospedaliera Carlo Poma, Mantova, Italy

a r t i c l e i n f o a b s t r a c t

Article history: The problem of using material of unsuitable quality, including ‘‘nontransparent turbid
Received 31 May 2012 milky plasma’’ or more simply ‘‘turbid plasma’’, for producing blood components is not
Received in revised form 14 October 2012 trivial for several epidemiological, technical, analytical, clinical and economical reasons.
Accepted 22 October 2012
With some exception, most national and international guidelines mandate that blood com-
ponents should preferably not be produced from lipaemic donations. The origin of lipaemic
blood is variegated, and includes physiological or paraphysiological causes and metabolic
Keywords:
disorders, whereas a broad range of common diseases and drugs can also be associated
Transfusion medicine
Patient safety
with hypertriglyceridaemia. Overall, the frequency of lipaemic donations ranges between
Hypertriglyceridemia 0.31% and 0.35%, although sporadic reports have highlighted that the frequency might be
Lipaemia much higher, up to 13%. Lipaemic donations pose two leading problems in transfusion
Interference medicine, that are interference during laboratory testing, and safety of producing blood
components from hypertriglyceridaemic materials. While the former issue can be over-
come by using chemical or mechanical methods, the clinical use of lipaemic blood for pro-
ducing components remains an unresolved question. Transfusion medicine should thereby
embark on a landmark effort to find a universal agreement of behaviours and harmoniza-
tion of policies worldwide.
Ó 2012 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
2. Epidemiology of lipaemic donations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
3. Technical issues for inspecting blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
4. Analytical and clinical issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
5. Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

1. Introduction [1], most national and international guidelines mandate

that blood components should preferably not be produced
With some notable exceptions, such as the Visual from lipaemic, icteric or hemolyzed donations, whereas
Assessment Guide released by the Canadian Blood Services standard operating procedures (SOPs) should also be avail-
able for reliably assessing these findings [2,3]. The problem
of using material of unsuitable quality, including ‘‘non-
⇑ Corresponding author. Address: U.O. Diagnostica Ematochimica, transparent turbid milky plasma’’ or more simply ‘‘turbid
Azienda Ospedaliero-Universitaria di Parma, Via Gramsci, 14, 43100
plasma’’, for producing blood components is not trivial
Parma, Italy. Tel.: +39 0521 703050, +39 0521 703791.
E-mail addresses: giuseppe.lippi@univr.it, ulippi@tin.it, glippi@ao.pr.it
for several epidemiological, technical, analytical, clinical
(G. Lippi). and economical reasons.

1473-0502/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.transci.2012.10.001
182 G. Lippi, M. Franchini / Transfusion and Apheresis Science 49 (2013) 181–184
2. Epidemiology of lipaemic donations
The origin of lipaemic blood is variegated, and includes
physiological (i.e., postprandial metabolism), paraphysio-
logical causes (e.g., IV administration of lipids), along with
metabolic disorders (e.g., hypertriglyceridaemia) [4]. A
broad range of common diseases can also be associated
with hypertriglyceridaemia, including diabetes, ethanol
use, chronic kidney disease, hypothyroidism, acute pancre-
atitis, multiple myeloma, primary biliary cirrhosis, sys-
temic lupus erythematosus, as well as medications such
as protease inhibitors, estrogen and steroids [5].
Following gastrointestinal absorption, plasma triglycer-
ides appear almost immediately in blood (i.e., after 30–
60 min), and remain in circulation mainly as chylomicrons
and their metabolic products (i.e., remnants) for 4–12 h.
Besides anecdotal or scarcely reliable reports, there is scant
scientific literature about the frequency of lipaemic dona-
tions. Overall, the frequency of blood donations with
acceptable levels of lipaemia for being tested (i.e., triglyc-
erides < 3000 mg/dL) has been reported to range between
0.31% [6] and 0.35% [7]. Nevertheless, a very modest
minority of all lipaemic donations would be deem unsuit-
able for producing blood components (i.e., only 1 in
130,000) [6]. More recently, Vuk et al. provided rather dif-
ferent figures, estimating that the frequency of lipaemic
donations, as defined according to macroscopic plasma
examination, may be as high as 13% [8]. Lipaemia seems
however a broader problem, that also dramatically affects
laboratory medicine, wherein more precise information
about the burden of lipaemic samples is available, ranging
from 0.02% [4] to 0.3% in serum or plasma specimens [9],
and up to 11% in whole blood samples [10].
These different figures reflect a basic problem, that is
the different methods and criteria established to define
‘‘lipaemia’’ in blood donations throughout different Coun-
tries and healthcare facilities. The precise definition of
quality criteria for blood, serum and plasma typically en-
tails qualitative and roughly vague notions, such as ‘‘hemo-
lysis’’, ‘‘icterus’’, ‘‘lipaemia’’ or ‘‘turbidity’’, and rarely these
concepts are translated into quantitative and objective
expressions. This is mainly due to the lack of universal
agreement on thresholds of unsuitability for ‘‘intereferents’’
and, even more importantly, to the scarce evidence that
testing or processing blood that exceeds definite cut-offs
for bilirubin, cell-free hemoglobin or lipids would translate
into a direct or indirect harm for the patient (see below).
3. Technical issues for inspecting blood
In the Adult Treatment Panel III (ATP III) issued by the
National Cholesterol Education Program (NCEP), a normal
triglycerides concentration is defined as <150 mg/dL,
borderline-high (i.e., hypertriglyceridemia) as comprised
between 150 and 199 mg/dL, high when comprised
between 200 and 499 mg/dL, and very high when P
500 mg/dL [11]. Technically speaking, lipaemia is com-
monly defined as visually detectable turbidity of plasma
due to elevated lipoproteins concentration. The conven-
tional thresholds for visual detection of lipaemia are
1000 mg/dL (i.e., 11.3 mmol/L) on whole blood and
300 mg/dL (i.e., 3.4 mmol/L) in blood after centrifugation
(i.e., plasma or serum), respectively [12] (Table 1).
Although the practice of visual inspection of samples has
represented the only suitable approach for establishing
the presence of interfering substances such as cell-free
hemoglobin, hyperbilirubinemia and lipaemia for decades,
it carries several inherent limits, since it is qualitative,
poorly standardized, subjective and it is also highly unreli-
able as compared with analytical assessment of turbidity
(i.e., mean weighted kappa agreement lower than 0.7)
[13]. Moreover, a sufficiently transparent sample container
is always necessary to reliably identify the presence of
lipaemia.
Among the various innovations in laboratory tech-
nique, a major breakthrough has been represented by
the widespread introduction of the ‘‘serum indices’’ (SI),
which entail automatic detection of hemolysis, hyperbili-
rubinemia and lipaemia. These novel tools encompass
systematic monitoring of serum or plasma absorbance at
various wavelengths (traditionally ranging from 340 to
700 nm, most frequently with bichromatic analysis at
660 and 700 nm for lipaemia). After solving predefined
equations, each index is calculated, and the final result
linearly correlates with the concentration of bilirubin (Ic-
terus Index, II), cell-free hemoglobin (Hemolysis Index,
HI) and turbidity (Lipaemic Index, LI) in the sample
[12]. The evident advantages of routine use of SI include
high throughput, reduced turnaround time, objective
and quantitative expression of results, overcoming of
the high degree of inter-observer variability and uncer-
tainty in the ‘‘grey zone’’ (e.g., around triglycerides con-
centration of 300 mg/dL), possibility of automatic
transmission and storage into the laboratory information
system. Analytical evaluations of both the HI and LI have
found that these measure have a high correlation with
hemoglobin (correlation of 1.00) [14] and triglycerides
values (correlation greater than 0.84) [15] as measured
with the reference assays. It is thereby advisable that
the practice for quality assessment of blood for producing
blood components should urgently shift from visual to
automatic detection of ‘‘inteferents’’. Since sporadic cases
of LI falsely elevated for interference due to non-lipaemic
causes such as paraproteins (IgM kappa and lambda) have
been reported [16], it is advisable that all samples with
extremely high LI values should be visually inspected
for true lipaemia before being tested or being further
processed.
Table 1
Correlation between lipaemic index (LI) of plasma, visual (gross) appear-
ance and conventional laboratory testing.
Triglycerides Gross appearance Conventional
concentration (mg/dL) laboratory testing
<300 No turbidity Suitable
300–600 Slightly turbid Suitable
(hazy)
600–1000 Moderately turbid Suitable
(‘‘milky’’)
>1000 Markedly turbid Unsuitable
(‘‘creamy’’)
 G. Lippi, M. Franchini / Transfusion and Apheresis Science 49 (2013) 181–184
4. Analytical and clinical issues
Interference is a rather common problem in diagnostic
(in vitro) testing [17]. The presence of lipids into donated
blood may generate two leading drawbacks, i.e., analytical
and clinical problems. As for the former issue, blood dona-
tions are routinely subjected to laboratory testing for
assessing the blood phenotype and haemovigilance (i.e.,
for maximizing donor and recipient safety), by compliance
with the same strict criteria as those conventionally de-
signed for laboratory medicine [18–20]. The interference
caused by lipaemia is substantially different from that
caused by the presence of excess bilirubin (i.e., hyperbiliru-
binemia or icterus) or cell-free hemoglobin (i.e., spurious
hemolysis). In lipaemic samples, chylomicrons and very
low density lipoproteins (VLDLs) scatter the light and
thereby generate a kind of turbidity mimicking that of
the milk. Therefore, lipaemia mainly – but not only – pro-
duces interference on laboratory tests based on transmis-
sion of light as part of the detection scheme (i.e.,
immunoturbidimetric and, to a lesser extent, immuno-
nephelometric assays) [5]. Coagulation [21] and hemato-
logical testing [22] might also be substantially biased by
the presence of hypertigliceridemia. It is noteworthy that
while neutrophils and mean corpuscular volume (MCV)
both clinically increase in lipaemic samples, lymphocytes,
eosinophils, hemoglobin and hematocrit values signifi-
cantly decrease due to increased light scattering of the
lipoprotein particles [22]. Additional problems may arise
when performing conventional immunoassays, since the
epitope/s recognition by the cocktail of antibodies may
be challenged by the presence of lipoproteins in excess,
which might block or mask the binding sites. Likewise,
the results of electrophoresis and chromatographic tech-
niques may be influenced by the lipids present in the sam-
ple matrix. Finally, it is also widely acknowledged that
hypertriglyceridaemia strongly interferes with serum amy-
lase assays [23], as well as serum potassium, sodium and
chloride when measured by indirect ion-selective elec-
trode technique due to the well known volume exclusion
effect [24]. An additional problem of hyperlipidaemia is
the potential association with spurious haemolysis (i.e.,
the ‘‘strawberry milk appearance’’), which has been attrib-
uted to an increased erythrocyte membrane fragility due to
modifications of the lipid content of the plasma mem-
brane, that contributes to render the erythrocyte more sen-
sitive to traumatic injury as they move through collection
needles and gel pores of primary blood collection tubes
[25]. The precise bias due to lipaemia interference on test
results is barely predictable and even more hardly abolish-
able, since it largely depends on the heterogeneous compo-
sition of reagents (e.g., those containing trace amounts of
detergents might be less sensitive), as well as on the lipo-
protein particle composition and the phase-partitioning of
the analytes in the samples [15].
As regards the clinical issues, the metric itself is prob-
lematic. Overall, although there is hence general agree-
ment on the definition of hypertriglyceridaemia and the
threshold of triglycerides concentration above which labo-
ratory testing would be unsuitable and blood sample be re-
jected or treated before testing (i.e., 1000 mg/dL for
183
conventional clinical chemistry or hematological testing,
and 3000 mg/dL for US FDA-approved assays for transfu-
sion-transmitted infectious antigens and relevant antibod-
ies) (Table 1) [6], in spite of a paucity of evidence much
controversy surrounds the cut-off level above which the
blood should be considered unsuitable for producing blood
components. This is not a trivial issue, inasmuch as the
reduction of lipaemia by mechanical of technical methods
is feasible and thereby the blood might still be considered
safe and suitable for being processed. In some countries
such as the Netherlands, the blood components are pro-
duced when the plasma exhibits no more than ‘‘slight tur-
bidity’’ [2]. In the United States and other European
Countries the exclusion of turbid plasma is supported by
the potential analytical interference of suspended lipid
particles with infectious disease testing, whereas in Can-
ada lipaemic donations are considered safe and suitable
for producing blood components [1]. Such an heteroge-
neous approach highlight the absence of general agree-
ment and, even more surprisingly, of any objective
criteria for establishing a ‘‘rejection threshold’’. Besides
analytical problems, the infusion of blood components de-
rived from lipaemic blood is usually discouraged based on
the seminal article of Shafiroff, Mulholland and Baron, pub-
lished nearly 60 years ago [26]. No other similar reports
were published afterwards, and this is inevitably a key
point in the blood transfusion agenda, whereby we should
embark on a landmark effort to reply to some crucial ques-
tions that have remained unanswered and establish (a)
which is (and for what precise reasons) the suitable lipa-
emia threshold for using blood in transfusion medicine
and (b) whether hypertriglyceridaemia is a real, absolute
contraindication for donating blood due to potential pres-
ence of underlining pathological conditions such as dysli-
pidemia or renal disease [27], since it predictable that
infusion of erythrocytes, leukocytes, platelets and plasma
components produced from (serologically safe) lipaemic
blood would generate no clinically meaningful effects
other than those typically associated with alimentary fats
[6]. It is also noteworthy that the largely prevailing causes
of lipaemic donations are physiological, especially dinner
before donation [27].
5. Management
The management of lipaemic blood is double faceted
and entails either interference removal for testing, or elim-
ination of lipids for producing blood components. The for-
mer aspects is much easier to be managed and entails a
variety of opportunities. The recommended approach by
the Clinical and Laboratory Standards Institute (CLSI) is
based on ultracentrifugation for at least 30 min at a speed
above 40,000g [28], which is however time consuming, re-
quires specific instrumentation (i.e., ultracentrifuge), and is
thereby unsuitable in most laboratories and transfusion
centers. An additional and most suitable approach is the
use of high speed micro-centrifuges, which entails a double
centrifugation step at 21,885g for 15 min, is effective for
abating lipid levels and thus represents a suitable alterna-
tive to ultracentrifugation. Extraction of lipids with organic
184 G. Lippi, M. Franchini / Transfusion and Apheresis Science 49 (2013) 181–184
solvents such as fluorine chlorinated hydrocarbon or use of
lipid clearing agents such as LipoClear and n-hexane has
also been suggested, but there are some reports that these
techniques would produce unacceptable recovery of some
analytes, especially gamma-glutamyltransferase (GGT),
creatine kinase (CK), total cholesterol, high density lipo-
protein-cholesterol (HDL-C) and C reactive protein [29].
Unlike the interference due to spurious hemolysis, which
cannot be virtually abolished [30], it is usually advisable
to routinely reduce the lipids content of the sample and
perform laboratory testing, for both economical (no need
to use another equipment for blood drawing and addi-
tional blood tubes), organizational (no need to repeat test-
ing), and relational problems (i.e., no need to recall the
patient for collecting another sample) [31]. Different ap-
proach can be used with coagulation testing. Although per-
forming most clotting tests on lipaemic specimens with
optical detection is strongly discouraged, the CLSI cur-
rently support the use of mechanical and/or electrome-
chanical methods in all samples containing substances
that interfere with light transmission, and thereby includ-
ing lipids [32].
As regards the clinical use of lipaemic blood for produc-
ing components, important questions remain since there is
no current indication to use mechanical – and especially
chemical – approaches to reduce or abolish lipaemia. In-
deed, no indications are provided by the current European
Guideline on blood components [33] on the management
of lipaemic donations and there is thereby is a compelling
need to find a universal agreement of behaviours and har-
monization of policies worldwide. The strategy at out
transfusion center entails eliminating all lipaemic blood
donations without separating (and eliminating) plasma
from red blood cells. This is mainly due to the fact that,
as previously mentioned, lipaemic samples may create
problems for serological and nucleic acid testing (NAT) vir-
al determinations. These tests are essential for the valida-
tion of the blood unit. Blood donors with triglycerides
concentrations higher than 300 mg/dL are suspended from
donation until the normalization of abnormal laboratory
parameters.
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