Transfusion and Apheresis Science 55 (2016) 159–163

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Transfusion and Apheresis Science

j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / t r a n s c i

Serum ferritin in plateletpheresis and whole blood donors

Frances Duggan a, Kathleen O’Sullivan b, Joan P. Power a,c, Michael Healy d,
William G. Murphy e,f,*
a Irish Blood Transfusion Service, Munster Regional Transfusion Centre, St. Finbarr’s Hospital, Douglas Road, Cork, Ireland
b Dept. of Statistics, University College Cork, College Road, Cork, Ireland
c
School of Medicine, University College Cork, College Road, Cork, Ireland
d Dept. of Biological Sciences, Cork Institute of Technology, Rossa Avenue, Bishopstown, Cork, Ireland
e Irish Blood Transfusion Service, National Blood Centre, James’s Street, Dublin 8, Ireland
f
School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland

A R T I C L E I N F O A B S T R A C T

Article history: Background and Objectives: We performed a prospective analysis of iron status in
Received 12 February 2016 plateletpheresis donors, using whole blood donors as a control group, to assess the haematinic
Received in revised form 6 April 2016 effects of regular anti-coagulated extracorporeal circulation and platelet collection.
Accepted 10 June 2016
Materials and Methods: Ferritin levels were measured in samples from 31 regular male
plateletpheresis donors and from 14 first time male whole blood donors, immediately before
Keywords:
and immediately after donation, and immediately before the next donation. An addition-
Iron
al 33 regular male plateletpheresis donors and 17 first time male whole blood donors had
Ferritin
Iron deficiency anaemia serum ferritin levels checked predonation.
Results: Male plateletpheresis donors had a statistically significant fall in serum ferritin
after donation (P = 0.005)*. In addition, male platelet donors had significantly lower serum
ferritin levels than first time male blood donors: ferritin <20 μg/L was found in 6/64 (9%)
of regular platelet donors and 1/31 (3%) of first time blood donors (P < 0.001)*.
Discussion: Our studies support the value of serum ferritin measurement in apheresis donor
management.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction [4]. Plateletpheresis donors can donate more frequently than

Regular blood donors undergo a progressive decline in
iron reserves, total body first and later red cells. The prev-
alence of iron depletion increases progressively as the rate
of donation increases [1]. An increase in donation frequen-
cy is accompanied by a significant decrease in serum ferritin.
Haemoglobin estimation alone in blood donors may not be
adequate; serum ferritin estimation may need to be per-
formed to detect pre-clinical iron depletion states [2,3]. A
plateletpheresis donor may lose 80–100 mL of whole blood
* Corresponding author. Irish Blood Transfusion Service, Munster
Regional Transfusion Centre, St. Finbarr’s Hospital, Douglas Road, Cork,
Ireland. Tel.: +353 1 4322872; fax: +353 1 4322932.
E-mail address: nmd@indigo.ie (W.G. Murphy).
whole blood donors, and can donate more platelets per do-
nation, as there is less red cell loss (40 mL of red cells) from
both sampling and set harness dead space in comparison
to whole blood loss of 450 mL ± 10% (200 mL loss of red cells)
during whole blood donation.
Anaemia affects one-fourth of the world’s population, ac-
counting for 8.8% of the total global burden of disease [5,6].
Iron deficiency is the predominant cause, disproportion-
ately affecting women and children [7]. Blood donation is
a common cause of iron deficiency with or without anaemia
in developed societies [1].
Iron store deficiency is a common side effect of whole
blood donation. A single 450 mL whole blood donation
results in the loss of 213–236 mg of iron [8–10]. Iron loss
can lead to iron deficiency symptoms such as fatigue, de-
creased physical and job performance, then gradually
resulting in iron deficiency anaemia (IDA) [11].

http://dx.doi.org/10.1016/j.transci.2016.06.004
1473-0502/© 2016 Elsevier Ltd. All rights reserved.
160 F. Duggan et al. / Transfusion and Apheresis Science 55 (2016) 159–163
Introduction of systematic serum ferritin measure-
ments allowed an optimised management of donors with
iron deficiency and efficacious prevention of iron deficien-
cy anaemia. It may be of interest from the point of view of
platelet donation that iron deficiency is also associated with
reactive thrombocytosis [12]. The mechanism behind this
phenomenon remains unclear. Studies in adult women show
a correlation between platelet count and serum iron – more
severe iron deficiency is associated with higher counts [13].
This study constructed an in-depth analysis of iron status
in plateletpheresis and whole blood donors using serum
ferritin measurements.
2. Materials and methods
2.1. Ethics
Ethics approval was granted for this study by the Clin-
ical Research Ethics Committee of the Cork Teaching
Hospitals.
2.2. Donor selection
Sequentially presenting long term plateletpheresis male
donors – who had donated at least six platelet donations
by apheresis in the previous year – were recruited. First time
whole blood donors, who had never donated either whole
blood or platelets, were used as the control group. Statis-
tical sample size calculation was performed using an α level
of 0.05 (5%) and statistical power set at 80% to detect a large
effect size of 0.8. It was estimated that for each donor group,
26 donors were required per group to perform group com-
parisons and 14 donors per group were required to provide
post and follow up samples for between group compari-
sons. To avoid selection bias, all platelet donors presenting
on each study day were assessed for inclusion – all eligi-
ble donors (>6 donations in previous 12 months) were asked
for consent; no donor withheld consent, and all were
included.
2.3. Sample collection
Pre-donation samples were filled from the sample pouch
attached to the blood collection pack using a 16-French
gauge cannula integral to the collection pack supplied by
the relevant manufacturer (Terumo for Plateletpheresis col-
lection system and Macopharma (Tourcoing, France) for
Whole Blood collection system).
Additional peripheral blood samples were procured from
the plateletpheresis and whole blood donors immediately
Table 1
Means (standard deviations), t-test results and difference between the means of both donor groups and the 95% confidence interval of the difference for
serum ferritin measured at baseline, pre-donation for donors with complete records for all three time points of measurement.
Test parameter Plateletpheresis donors Whole blood donors
(n = 31) mean (SD) (n = 14) mean (SD)
Ferritin (μg/L) 38.6 (22.5) 76.9 (40.6)
Hb (g/dL) 15.3 (0.7) 15.1 (1.3)
Age (years) 42.2 (7.1) 41.8 (10.2)
postdonation. These blood samples were taken from the
donor’s other arm using a 21-French gauge needle.
Additional peripheral blood samples were procured from
the plateletpheresis and whole blood donors prior to do-
nating their next donation i.e. greater than twenty-eight (28)
days later for plateletpheresis donors and greater than ninety
(90) days later for whole blood donors. These blood samples
were filled from the sample pouch attached to the blood
and platelet component collection system using a 16-
French gauge cannula, integral to the collection system
supplied by the relevant manufacturer.
Predonation, postdonation and follow-up measure-
ments of plateletpheresis participants occurred between
February and May. Predonation and postdonation measure-
ments of first time whole blood donor participants occurred
in May and follow-up measurements were procured in
September.
2.4. Equipment, reagents, apparatus
Pre-, post-, and follow up samples for serum ferritin were
collected into Greiner Bio-One Vacuette® 4 mL Z Serum Sep
Clot Activator Tubes, centrifuged at 3800 rpm, at room tem-
perature for 6 minutes, and tested on the Siemens ADVIA
Centaur XP Immunoassay Analyser (Siemens, Germany).
2.5. Statistical methods
All statistical analyses were performed using SPSS
Statistics version 19.0 for Windows.
3. Results
3.1. Predonation: differences between apheresis and whole
blood donors
Samples from 31 regular male plateletpheresis donors
and from 14 first time male whole blood donors were tested
pre and immediately postdonation, and immediately pre
next donation, for serum ferritin. Independent two-sample
t-tests were used to test for significant differences between
groups for ferritin and haemoglobin (Hb) results and age
(Table 1). The whole blood donor group had significantly
higher predonation serum ferritin levels than the
plateletpheresis donor group (P < 0.05*). However, donor
groups did not differ at baseline (P > 0.05) for Hb measure-
ments and age.
An additional 33 regular male plateletpheresis donors
and 17 first time male whole blood donors had serum fer-
ritin levels checked predonation. Independent two-sample
Mean difference (Δ) 95% Confidence interval P-value
of difference
−38.3 (−62.7, −13.8) 0.004
0.2 (−0.6, 1.0) 0.623
2.6 (−4.9, 5.7) 0.408
 F. Duggan et al. / Transfusion and Apheresis Science 55 (2016) 159–163 161

Table 2
Means (standard deviations), t-test results and difference between the means of both donor groups and the 95% confidence interval of the difference for
serum ferritin measured from all donors who provided samples pre-donation.

Test parameter Plateletpheresis donors Whole blood donors Mean difference (Δ) 95% Confidence interval P-value
(n = 64) mean (SD) (n = 14) mean (SD) of difference

Ferritin (μg/L) 44.7 (30.1) 103.5 (71.2) −58.8 (−65.9, −31.7) <0.001
Hb (g/dL) 15.3 (0.8) 15.3 (1.1) 0.06 (−0.4, 0.5) 0.794
Age (years) 43.7 (7.7) 39.2 (10.6) 4.5 (0.2, 8.8) 0.040

t-tests were conducted to investigate if significant differ-
ences existed between plateletpheresis and whole blood
donor groups predonation for this larger sample size
(Table 2). Results in Table 2 indicate that the whole blood
donor group achieved significantly higher serum ferritin
levels (P < 0.001*). However, donor groups did not differ at
baseline (P > 0.05) for Hb measurements. Results for hae-
moglobin in plateletpheresis and whole blood donors ranged
13.5–17.1 g/dL and 13.0–17.3 g/dL respectively. Results for
serum ferritin in plateletpheresis and whole blood donors
ranged 11.4–181.8 μg/L and 7.6–295.6 μg/L respectively. The
plateletpheresis donor group achieved significantly higher
age measurement compared to the whole blood donor group
at predonation. However, donors from both donor groups
who provided samples at all three time points were com-
parable in age at predonation.
3.2. Analyses of changes within groups
For each donor group separately, ferritin was com-
pared between pre donation, immediately post donation,
and follow-up, using repeated measures ANOVA to deter-
mine if significant differences occurred between the three
time points of measurements. The results of repeated mea-
sures ANOVA tests for serum ferritin measured at the three
time points within the plateletpheresis donor group are pre-
sented in Table 3a. There was a significant difference
between the three time points for ferritin (P = 0.001*) mea-
surements within the plateletpheresis donor group.
The results of repeated measures ANOVA tests for serum
ferritin, measured at the three time points within the whole
blood donor group, are presented in Table 3b. There was a
significant difference between the three time points for fer-
ritin (P = 0.034*) measurements within the whole blood
donor group.
Pairwise comparison tests were conducted in order to
determine between which time points the serum ferritin
became significantly different, using Bonferroni correc-
tion (to adjust for multiplicity of testing), along with a 0.05
level of significance.
The pairwise comparison test results for the plateletpheresis
donor group and whole blood donor group are presented in
Table 4. As shown in Table 4a, the plateletpheresis group had
higher mean predonation serum ferritin than at follow-up
(P = 0.005*); postdonation ferritin was higher than the follow-
up (P = 0.006*). As shown in Table 4b, there was no significant
difference between any of the three time point measure-
ments for ferritin in the whole blood donor group (P > 0.05*).
4. Discussion
The serum ferritin results of this research confirm that
regular plateletpheresis donations lower ferritin levels and
lead to iron deficiency. Ferritin <20 μg/L was found in 6/64
(9%) of plateletpheresis donors and only 1/31 (3%) of persons
presenting for whole blood donation. Regular blood donors
undergo a progressive decline in iron reserves, total body
first and later red cells. However, donor groups did not differ

Table 3
Repeated measures ANOVA for serum ferritin measured at all the three time points for plateletpheresis donor group [(a) n = 31] and the whole blood donor
group [(b) n = 14]: means (standard deviations), standard errors, 95% confidence intervals and p-values.

Test parameter Predonation Postdonation Follow-up P-value

Mean (SD) SE 95% CI Mean (SD) SE 95% CI Mean (SD) (SE) 95% CI

(a)
Ferritin (μg/L) 38.6 (22.5) 4.0 30.4–46.9 38.1 (20.8) 3.7 30.5–45.8 33.0 (19.4) 3.5 25.9–40.1 0.001
(b)
Ferritin (μg/L) 76.9 (40.6) 10.9 53.5–100.3 75.6 (43.8) 11.7 50.3–100.9 66.3 (36.5) 9.8 45.2–87.4 0.034

Table 4
Pairwise comparison tests for the plateletpheresis donor group [(a) n = 31] and the whole blood donor group [(b) n = 14]: means (standard errors), 95%
confidence intervals and p-values for serum ferritin measured at the three time points.

Test parameter Pre versus post Pre versus follow-up Post versus follow-up

Mean (SE) 95% CI P-value Mean (SE) 95% CI P-value Mean (SE) 95% CI P-value

(a)
Ferritin (μg/L) 0.5 (0.6) −1.1 to 2.0 1.000 5.6 (1.6) 1.5 to 9.8 0.005 5.2 (1.5) 1.3 to 9.0 0.006
(b)
Ferritin (μg/L) 1.3 (2.9) −6.8 to 9.3 1.000 10.6 (4.8) −2.7 to 23.9 0.141 9.3 (4.5) −3.0 to 21.7 0.173
162 F. Duggan et al. / Transfusion and Apheresis Science 55 (2016) 159–163
at baseline (P > 0.05) for haemoglobin measurements. The
prevalence of iron depletion increases progressively as the
rate of donation increases [1]. An increase in donation fre-
quency was accompanied by a significant decrease in serum
ferritin. Haemoglobin estimation alone in blood donors may
not be adequate; serum ferritin estimation may need to be
performed to detect pre-clinical iron depletion states [2,3].
A plateletpheresis donor may lose 80–100 mL of whole blood
[4]. Plateletpheresis donors can donate more frequently than
whole blood donors, and can donate more platelets per do-
nation, as there is less red cell loss (40 mL of red cells) from
both sampling and set harness dead space in comparison
to whole blood loss of 450 mL ± 10% (200 mL loss of red cells)
during whole blood donation.
Haemoglobin was deemed a poor indicator of iron status
as observed in our results, and was of limited value in de-
tecting iron depletion in blood donors in several studies
[14–16]. Plasma ferritin provides a specific and sensitive
marker of iron stores, particularly in otherwise healthy in-
dividuals [8,10,15,17–19]. Serum ferritin is a universally
available and well standardised measurement that has been
the single most important laboratory measure of iron status
during the past 25 years [20]. In order to identify and prevent
iron deficiency in blood donors, many authors recom-
mend: measurement of serum/plasma ferritin, replace iron
following donation – provided directly at the blood centre,
or obtained by the donor over-the-counter, lengthening the
interdonation interval or restrict maximum annual whole
blood and plateletpheresis donation limits [15,16,21,22].
The daily iron requirement for an adult male is 1.0 mg
and for an adult menstruating female 1.5–2 mg [4]. A blood
donation of 470 mL plus 30 mL of samples contains ap-
proximately 250 mg of iron, so that a donor will need to
absorb 0.7 mg of iron daily (250/365) for each unit donated
per year. A person eating a western diet can expect to absorb
between 1 and 4 mg of iron per day. Therefore, anyone who
donates blood 3–4 times per year might have difficulty main-
taining adequate iron stores [23].
In IDA, several changes in platelets have been reported.
Thrombocytosis was noted in 24 of 86 female patients,
where platelet counts were increased when serum iron and
ferritin and mean platelet volume were decreased [24].
Previous studies observed diphasic patterns of platelet
response in patients with IDA. Thrombocytosis may disap-
pear after iron supplementation, suggesting that a
relationship between iron metabolism and thrombopoi-
esis should be considered [25,26]. Iron deficiency anaemia
is frequently associated with reactive thrombocytosis and
it will resolve when bleeding source and iron deficiency is
corrected [12,27–29].
The mechanisms causing reactive thrombocytosis in IDA
are not completely understood. Iron is an important regu-
lator of thrombopoiesis. Whereas normal iron levels are
required to prevent thrombocytosis by inhibiting throm-
bopoiesis, a minimum amount of iron is required to maintain
platelet production [30]. Studies on thrombopoietic cytokines
failed to show any effect on reactive thrombocytosis in iron
deficiency [12].
Frequently chronic anaemia due to ID is accompanied by
increased platelet count and this thrombocytosis resolves
with iron repletion [31–33].
Oral iron supplementation has a significant effect on
storage iron, and is an extremely useful strategy to reduce
iron deficiency in blood donors [34]. However, supplemen-
tation programmes can be difficult to implement and
maintain. Poor compliance is a known limitation, due to the
gastrointestinal side effects of iron. It may be unlikely that
regular blood donors will tolerate such side effects in order
to continue donating.
5. Conclusion
The serum ferritin results of this research confirm that
regular plateletpheresis donations lower ferritin levels and
lead to iron deficiency. Ferritin <20 μg/L was found in 6/64
(9%) of plateletpheresis donors and only 1/31 (3%) of persons
presenting for whole blood donation. The prevalence of iron
depletion in donation frequency is accompanied by a sig-
nificant decrease in serum ferritin. In an earlier IBTS study,
ferritin levels of 144 regular whole blood donors were tested
at the National Blood Centre, IBTS. The results showed that
18% of males and 22% of females had ferritin levels <20 μg/L.
This confirmed that regular whole blood donations lower
ferritin levels and lead to iron deficiency [3].
All plateletpheresis donors in this study fell within
the normal platelet count of 140–400 × 10 9 /L. The 6
plateletpheresis donors with ferritin <20 μg/L had platelet
counts varying between 238 × 109/L and 300 × 109/L.
Haemoglobin estimation alone in both whole blood and
plateletpheresis donors may not be adequate. Serum fer-
ritin estimation may need to be performed to detect pre-
clinical iron depletion status, and these results support the
value of serum ferritin measurement in donor welfare
management.
Institute where work was conducted
Irish Blood Transfusion Service, Munster Regional Trans-
fusion Centre, St. Finbarr’s Hospital, Douglas Road, Cork,
Ireland.
Funding source
This research was funded by the Irish Blood Transfu-
sion Service.
Contributors
F.D., W.M., J.P., and M.H. developed and performed the
study, evaluated the data and wrote the manuscript; F.D. per-
formed the laboratory work; K.O.S. was responsible for
statistical analyses; F.D., W.M., J.P. and M.H. were involved
in critical revision of the manuscript. All authors have ap-
proved the final article.
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