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Editorial

www.thelancet.com/haematology

Vol 4 October 2017

e452

The big business of blood plasma

China, a country that holds the questionable honour of

being aworld leader in liver disease, is nowalso the highest

consumer of serum albumin, using 300 tonnes annually,

roughly half of the worldwide total use, according to

an article in the

Financial Times

. Serum albumin is most

commonly derived from blood plasma, and over half

of the albumin in China is imported. This increasing

demand is driving up prices, and fake products billed

as albumin have been found. Liver disease is a growing

problem in China, primarily because of the high burden

of viral hepatitis in Asia, but also because of the growing

prevalence of non-alcoholic fatty liver disease. Advanced

stages of liver disease are characterised by protein wasting

and can result in albumin depletion, which can have major

e ects on the cardiovascular system, renal system, and

risk of infection.

Human serum albumin is the most abundant

protein found in the blood. It is a multifunctional non-

glycosylated, negatively charged plasma protein that

is synthesised primarily in the liver. Albumin regulates

colloid oncotic pressure by its role in the intravascular

protein pool, managing water retention, and via the

Gibbs-Donnan e ect. Albumin has long been used for

various medical indications from trauma resuscitation to

treatment of liver damage. Although there is con icting

evidence about just how useful human serum albumin

is for certain liver indications, it is generally accepted as a

useful treatment for those with liver damage.

The proportion of individuals who donate blood in

China is low, due to a myriad of reasons. In the 1990s,

Henan Province had become a blood farm built on a

criminalised plasma economy. Thousands of Chinese

donors became infected with HIV and hepatitis C

because of contaminated equipment. Although now

disproven, the boasting of a young woman about her

lavish lifestyle while working for the Red Cross Society

of China had seriously damaged the reputation of the

charity that helps the government collect blood. In

1998, China introduced a blood donation law banning

the commercial sale of blood and encouraging voluntary

donation instead. It also tightened rules on plasma

collection and increased blood testing. However, Chinese

law also limits individual whole-blood donations to twice

a year, and provinces rarely share blood. Chinese law now

encourages patients who require a blood transfusion to

present a certi cate showing that they, their friends or

relatives, have donated blood when they need to access

the national supply. For those who can a ord it, they can

overcome this requirement by accessing the black market

in which mediators pay people o the street to donate

blood at a state blood bank and sell their donation

certi cates to those who need them.

Adding to the complexity of the issue is that there are

two separate blood markets, one for whole blood and

another for blood plasma. While whole-blood donations

are primarily used for clinical transfusions, the plasma

industry uses plasma to produce various blood products,

including clotting factors, intravenous immunoglobulin,

and albumin. Globally, the plasma industry is a big

business. Companies that specialise in plasma have been

regularly subjected to takeovers, and the industry is

growing. It is generally accepted (and recommended by

WHO) that the safest blood supplies are those freely given

by carefully screened donors who have no vested interest.

However, the model is di erent for plasma. Plasma donors

are often paid and can donate much more frequently

than whole-blood donors. Although most countries set a

plasma donation limit of once every 2 weeks, in the USA,

individuals are able to donate twice a week. The nancial

incentive can be appealing for those who struggle to

raise funds by other means, which can encourage lying

during medical screening and could adversely a ect

the health of the donors as well. With some companies

pooling hundreds of thousands of donations together

for processing, this can be an important safety risk.

There have been suggestions that the USA use plasma

to close the trade de cit between the USA and China.

However, this economic relationship would need careful

consideration and regulation to be viable on all sides.

In view of the challenges of a safe and adequate supply

of serum albumin from human blood, it is important

to look for safe alternatives. Global e orts to eliminate

viral hepatitis by 2030 will no doubt help to address

the problem of liver disease in the future, and there

are currently studies underway to produce human

serum albumin from transgenic rice seeds. Prevention,

alternative sources, and better regulation will hopefully

enable the protection of the health of not only those

who require human serum albumin, but also those who

provide it.

The Lancet Haematology

For the

report on albumin use in

China

see

https://www.ft.com/ content/40ba0978-6abc-11e7- bfeb-33fe0c5b7eaa

See

Comment

Lancet Haematol

2016;

3:

e60–62 and

Editorial

Lancet Haematol

2015;

2:

e222.

For

trade suggestion

see

https:// www.forbes.com/sites/ patrickwwatson/2017/08/28/ why-trump-should-literally-start- selling-american-blood-to- china/#6e9252cf6f88

For the

transgenic article

see

http://www.pnas.org/ content/108/47/19078.long

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