Challenges in red blood cell transfusion in resource-limited settings: A narrative review
Main Article Content
Keywords
blood compatibility, blood safety, blood supply, red blood cell transfusion, resource-limited settings
Abstract
Introduction: Red blood cell (RBC) transfusion remains an essential life-saving intervention for patients with hemorrhage, anemia, surgery-related blood loss, and chronic disease. In resource-limited settings, however, transfusion practice is shaped by constraints that affect safety, availability, compatibility testing, and timely delivery. This narrative review aims to examine the major challenges affecting RBC transfusion in resource-limited settings, with particular attention to blood safety, supply sustainability, compatibility testing, infrastructure limitations, logistics, hemovigilance, and sociocultural barriers to donation and transfusion.
Methods: This narrative review synthesizes current challenges in RBC transfusion in resource-limited settings, with emphasis on transfusion safety, blood supply systems, immunohematological compatibility, infrastructure, logistics, and sociocultural barriers to donation.
Results: Key challenges include persistent risks of transfusion-transmitted infections where screening coverage, laboratory quality assurance, and pathogen detection capacity are limited. Low voluntary donation rates, weak donor retention, seasonal fluctuations, and inadequate storage capacity frequently drive blood shortages. Compatibility-related problems, including limited blood grouping, crossmatching, and antibody screening, may increase the risk of acute or delayed transfusion reactions. Infrastructure limitations, such as insufficient cold chain systems, unreliable transportation, limited trained personnel, and fragmented hemovigilance, further compromise timely and safe access to RBC products. Cultural beliefs, misconceptions, and ethical concerns may also reduce donor participation and acceptance of transfusion.
Conclusion: RBC transfusion in resource-limited settings requires more than blood availability; it depends on integrated systems that strengthen donor recruitment, screening quality, compatibility testing, storage, transport, and hemovigilance. Targeted, context-appropriate improvements are essential to make transfusion safer, more reliable, and more equitable.
References
2. World Health Organization. Blood transfusion safety [Internet]. 2020. Available from: https://www.who.int/health-topics/blood-transfusion-safety#tab=tab_1
3. Carson JL, Stanworth SJ, Guyatt G, Valentine S, Dennis J, Bakhtary S, et al. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA. 2023;330(19):1892–902. Available from: http://dx.doi.org/10.1001/jama.2023.12914
4. World Health Organization. Global status report on blood safety and availability 2021 [Internet]. 2022. Available from: https://www.who.int/publications/i/item/9789240051683
5. Roberts DJ, Field S, Delaney M, Bates I. Problems and Approaches for Blood Transfusion in the Developing Countries. Hematol Oncol Clin North Am. 2016;30(2):477–95. Available from: http://dx.doi.org/10.1016/j.hoc.2015.11.011
6. Hébert PC, Yetisir E, Martin C, Blajchman MA, Wells G, Marshall J, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med. 2001;29:S181–8. Available from: http://dx.doi.org/10.1097/00003246-200109001-00007
7. World Health Organization. Blood safety and availability [Internet]. 2026. Available from: https://www.who.int/en/news-room/fact-sheets/detail/blood-safety-and-availability
8. Bolton-Maggs PHB, Cohen H. Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety. Br J Haematol. 2013;163(3):303–14. Available from: http://dx.doi.org/10.1111/bjh.12547
9. Starr D. Blood: Blood: An Epic History of Medicine and Commerce. JAMA. 1999;282(8):797–8. Available from: https://doi.org/10.1001/jama.282.8.797
10. Schmidt PJ, Leacock AG. Forgotten transfusion history: John Leacock of Barbados. BMJ. 2002;325(7378):1485–7. Available from: http://dx.doi.org/10.1136/bmj.325.7378.1485
11. Landsteiner K. On Agglutination of Normal Human Blood. Transfusion. 1961;1(1):5–8. Available from: http://dx.doi.org/10.1111/j.1537-2995.1961.tb00005.x
12. Hess JR, Thomas MJG. Blood use in war and disaster: lessons from the past century. Transfusion. 2003;43(11):1622–33. Available from: http://dx.doi.org/10.1046/j.1537-2995.2003.00576.x
13. Ter Woorst J, Sjatskig J, Soliman-Hamad M, Akca F, Haanschoten M, van Straten A. Evolution of perioperative blood transfusion practice after coronary artery bypass grafting in the past two decades. J Card Surg. 2020;35(6):1220–7. Available from: http://dx.doi.org/10.1111/jocs.14573
14. Carson JL, Guyatt G, Heddle NM, Grossman BJ, Cohn CS, Fung MK, et al. Clinical Practice Guidelines From the AABB. JAMA. 2016;316(19):2025. Available from: http://dx.doi.org/10.1001/jama.2016.9185
15. Shander A, Javidroozi M, Ozawa S, Hare GMT. What is really dangerous: anaemia or transfusion? Br J Anaesth. 2011;107:i41–59. Available from: http://dx.doi.org/10.1093/bja/aer350
16. Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care. N Engl J Med. 1999;340(6):409–17. Available from: http://dx.doi.org/10.1056/nejm199902113400601
17. Taher AT, Musallam KM, Karimi M, Cappellini MD. Contemporary approaches to treatment of beta-thalassemia intermedia. Blood Rev. 2012;26:S24–7. Available from: http://dx.doi.org/10.1016/s0268-960x(12)70008-5
18. Docherty AB, O’Donnell R, Brunskill S, Trivella M, Doree C, Holst LB, et al. Effect of restrictive versus liberal transfusion strategies on outcomes in patients with cardiovascular disease in a non-cardiac surgery setting: systematic review and meta-analysis. BMJ. 2016;i1351. Available from: http://dx.doi.org/10.1136/bmj.i1351
19. Nagervadze M, Tsintsadze I, Akhvlediani L, Koiava T, Tskvitinidze S, Khukhunaishvili R, et al. ABO system combination with Rh, Kell and MN group in Georgian blood donors. Am J Blood Res. 2021;11(2):132–9. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8165715/
20. Avent ND, Reid ME. The Rh blood group system: A review. Blood. 2000;95(2):375–87. Available from: http://dx.doi.org/10.1182/blood.v95.2.375
21. Reid ME, Lomas-Francis C, Olsson ML. Blood Group Collections [Internet]. The Blood Group Antigen FactsBook. Philadelphia: Elsevier; 2012. 647–650 p. Available from: http://dx.doi.org/10.1016/b978-0-12-415849-8.00036-3
22. Hendrickson JE, Eisenbarth SC, Tormey CA. Red blood cell alloimmunization: new findings at the bench and new recommendations for the bedside. Curr Opin Hematol. 2016;23(6):543–9. Available from: http://dx.doi.org/10.1097/MOH.0000000000000277
23. Yazdanbakhsh K, Ware RE, Noizat-Pirenne F. Red blood cell alloimmunization in sickle cell disease: pathophysiology, risk factors, and transfusion management. Blood. 2012;120(3):528–37. Available from: http://dx.doi.org/10.1182/blood-2011-11-327361
24. Zimring JC. Established and theoretical factors to consider in assessing the red cell storage lesion. Blood. 2015;125(14):2185–90. Available from: http://dx.doi.org/10.1182/blood-2014-11-567750
25. Tormey CA, Hendrickson JE. Transfusion-related red blood cell alloantibodies: induction and consequences. Blood. 2019;133(17):1821–30. Available from: http://dx.doi.org/10.1182/blood-2018-08-833962
26. AABB. Technical manual 20th edition methods and appendices [Internet]. 2020. Available from: https://www.aabb.org/docs/default-source/default-document-library/publications/technical-manual-20th-edition-methods-and-appendices.docx?sfvrsn=8c9876fe_2
27. Storry JR, Castilho L, Daniels G, Flegel WA, Garratty G, Francis CL, et al. International Society of Blood Transfusion Working Party on red cell immunogenetics and blood group terminology: Berlin report. Vox Sang. 2011;101(1):77–82. Available from: http://dx.doi.org/10.1111/j.1423-0410.2010.01462.x
28. Roback JD. Evidence-Based Guidelines for Blood Transfusion. J Infus Nurs. 2012;35(3):187–90. Available from: http://dx.doi.org/10.1097/nan.0b013e31824d29fe
29. Franchini M, Forni GL, Marano G, Cruciani M, Mengoli C, Pinto V, et al. Red blood cell alloimmunisation in transfusion-dependent thalassaemia: a systematic review. Blood Transfus. 2019;17(1):4–15. Available from: http://dx.doi.org/10.2450/2019.0229-18
30. Pirenne F, Floch A, Diop S. Alloimmunisation against red blood cells in sickle cell disease: transfusion challenges in high-income and low-income countries. Lancet Haematol. 2023;10(6):e468–76. Available from: http://dx.doi.org/10.1016/S2352-3026(23)00066-2
31. Sachan D, Tiwari AK, Dara R, Jothimani D, Kaliamoorthy I, Reddy SM, et al. Patient blood management in a patient with multiple red cell antibodies (anti-C, anti-e, and anti-K) undergoing liver transplant in South India: A team approach. Asian J Transfus Sci. 2020;14(1):74–8. Available from: http://dx.doi.org/10.4103/ajts.AJTS_54_18
32. Allain J-P, Stramer SL, Carneiro-Proietti ABF, Martins ML, Lopes da Silva SN, Ribeiro M, et al. Transfusion-transmitted infectious diseases. Biologicals. 2009;37(2):71–7. Available from: http://dx.doi.org/10.1016/j.biologicals.2009.01.002
33. Yoshida T, Prudent M, D’alessandro A. Red blood cell storage lesion: causes and potential clinical consequences. Blood Transfus. 2019;17(1):27–52. Available from: http://dx.doi.org/10.2450/2019.0217-18
34. Tagny CT, Owusu-Ofori S, Mbanya D, Deneys V. The blood donor in sub-Saharan Africa: a review. Transfus Med. 2010;20(1):1–10. Available from: http://dx.doi.org/10.1111/j.1365-3148.2009.00958.x
35. Oyebamiji T, Abioro I, Bello O, Amaefule CE, Osundeyi O. Improving access to safe blood is critical to reducing maternal mortality in sub-Saharan Africa. Commun Med. 2025;6(1):13. Available from: http://dx.doi.org/10.1038/s43856-025-01267-x
36. Spahn D, Kocian R. Artificial O2 Carriers: Status in 2005. Curr Pharm Des. 2005;11(31):4099–114. Available from: http://dx.doi.org/10.2174/138161205774913354
37. Liu QP, Sulzenbacher G, Yuan H, Bennett EP, Pietz G, Saunders K, et al. Bacterial glycosidases for the production of universal red blood cells. Nat Biotechnol. 2007;25(4):454–64. Available from: http://dx.doi.org/10.1038/nbt1298
38. Goodrich RP, Edrich RA, Li J, Seghatchian J. The MirasolTM PRT system for pathogen reduction of platelets and plasma: An overview of current status and future trends. Transfus Apher Sci. 2006;35(1):5–17. Available from: http://dx.doi.org/10.1016/j.transci.2006.01.007
39. Kaira P, Mhango P, Chipeta E, Singogo E, Mwapasa V, Muula A, et al. Alternative strategies to promote voluntary blood donation in secondary schools in Malawi: Enhancing participation and impact—Malawi BLOODSAFE program. Transfus Med. 2026;(April):1–8. Available from: http://dx.doi.org/10.1111/tme.70089
40. D’Alessandro A, Zimring JC, Busch M. Chronological storage age and metabolic age of stored red blood cells: are they the same? Transfusion. 2019;59(5):1620–3. Available from: http://dx.doi.org/10.1111/trf.15248