COVID-19convalescent plasma use in the oncology and geriatric patients: Ethical aspects in transfusion medicine.

Dear Sir,

We read with great interest the article entitled “Transfusion at the border of the «intention-to-treat», in the very aged person and palliative care: A debate” by Garraud. O [1]. We wish to share our thoughts related to this article. As discussed in the article [1], the ethical issues regarding blood transfusion in palliative care and geriatrics are mainly with the red blood cell and platelet transfusion and not with plasma transfusion because the latter is rarely prescribed for palliative care. However, the coronavirus disease (COVID-19) pandemic has changed this scenario, as COVID-19 convalescent plasma (CCP) has emerged as an important therapeutic option, especially in immunodeficient patients including oncology patients [2]. Herein, we discuss the important ethical aspects related to the use of CCP in the management of oncology and geriatric patients.

Non-maleficence

In elderly patients

Apart from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) neutralizing antibodies, CCP also contains non-neutralizing antibodies that can assist in the entry of the virus into macrophages [3]. The virus multiplies rapidly in the macrophages, thereby, producing a pro-inflammatory condition, which subsequently can result in worsening of the cytokine storm [3]. Maro-Rillo et al. reported a case of convalescent plasma transfusion induced acute respiratory distress syndrome in a patient with Ebola virus disease [4]. Moreover, elderly patients have an age-related mild inflammatory condition called “inflamm-ageing” and are more susceptible to developing a cytokine storm after COVID-19 infection [5]. Before a decision of transfusing CCP is made, in an elderly patient, these aspects must be kept in mind.

In oncology patients

The majority of oncology patients belong to the geriatric age group. Additionally, they generally have an immunocompromised state, and consequently, with defective viral clearance, they are more prone to develop chronic prolonged SARS-CoV-2 infection [6]. The current evidence that CCP administration in immunocompromised patients could accelerate the generation of SARS-CoV-2 variants [7] should also be kept in mind before planning a CCP transfusion in such a cohort of patients.

Beneficence

As per FDA emergency use authorization, only high titer CCP can be used in the patients that too only in the early stages of COVID-19, except for immunocompromised patients, in which case CCP could be, transfused at any stage of COVID-19 [8]. In India, in many instances, CCP was being administered either without doing any antibody titration and/or late in the course of infection [9]. Eventually, due to the indiscriminate use of CCP, it proved to be non-efficacious and ultimately led to the scrapping of CCP from the management protocols for COVID-19 in India [9]. Therefore, as suggested by Garraud O in the article [1], a careful risk-benefit analysis, should be undertaken before administering CCP in any patient. Rather, a scoring system may also be used for this purpose [10].

Ethical issues related to plasma donors should also be kept in mind. There have been reports of donors being offered financial incentives for the donation of CCP [11], [12]. Blood centres should ensure that the CCP donors are non-remunerated voluntary donors. At the same time, the process of informed consent and donor confidentiality also merits consideration [13]. Finally, ethical considerations must be the front line of the transfusion debate, especially in the matter of the very aged person or in palliative care [14]. The motto should be the best possible patient outcome and based on the underlying principle of justice with a pure intent to treat.

Funding resources

None.

Disclosure of interest

The authors declare that they have no competing interest.