Sorry, finding the time to post has been a little trickier of late, but we’re now on day 13 of induction 2 treatment. Noah’s final chemo of this round was early on Wednesday morning. He’s doing pretty well I think.
The other day we got the ceremonial removal of the blue cover over the toilet, which is a nice step meaning his output is mostly not cytotoxic after 48 hours since the last chemo. We did have a couple shifts with pregnant nurses that weren’t allowed to dump his urine until 76 hours so I guess that’s the real checkpoint.
We’re now in the phase where the counts are dropping rapidly. In the last five days, his ANC (absolute neutrophil count) has dropped all the way to 39 so I’d expect to hit 0 tomorrow or the next day. And then we wait for count recovery.
The doctor actually thought his ANC would already be 0, but all his numbers held up a bit this time around. Hemoglobin hung in for a few extra days and then dropped to 6.5 last night resulting in the first red blood cell transfusion of this round.
Usually platelets go before hemoglobin just because of a shorter lifespan; red blood cells last between 100-120 days while platelets only last for 9-12 days. However, his red blood cells had been hanging around only 9.5 the last few weeks. The transfusion threshold was 7.0 so it didn’t take much of a slow, steady drop to reach it. On the other hand, the platelets were all the way above 300 just a few days ago which is quite high. They had a long way to drop, but have tanked all the way to 28 in just about 5 days as those 9-12 days expire and new platelet production is suppressed. His threshold for platelets is set at 25 so he’ll surely be getting a transfusion in the middle of tonight.
His energy and mood continue to be good. He’s eating okay and drinking well. His weight is actually up. He’s been slamming little peanut butter single-serving containers and peanut butter pretzels of late to the extent that Mayumi is concerned about nutrition. It’s a valid concern and, if he can eat the most healthy things and in moderation that’s ideal. But I think eating too much of something is “a good problem to have” in the grand scheme of things.
Overall, there’s not a ton to report. We’re just working the plan and watching the counts day-by-day. Given the chemo and other medications he’s receiving are similar to the first round there’s just been less surprises. There are all kinds of risks, but the most top of mind in the coming weeks will be the infection risk with no immune system. No fevers as of yet; let’s hope that holds.
Now for a long digression; feel free to skip.
Related to transfusions, our neighbors organized a community blood drive yesterday. This was a mobile drive through Versiti (http://versiti.org/) at our community clubhouse. Originally, Versiti was only sending three people, but they staffed up due to really good turnout. Both Mayumi and I popped in at different times to donate and Versiti staff and our next door neighbors were running the show. We’re so thankful for everything they continue to do. On that note, the “For Noah” apparel shop is up again for the next week at https://midwestshirtco.chipply.com/fornoah/?apid=18625298. The first run was a great success and our neighbor’s company, Midwest Shirt Company, donated all proceeds ($1,500!) directly to Noah. Thank you!
I was talking to a Versiti staff member and he noted that most people don’t start donating blood until “something happens”. That’s true in my case; this was the first I’d ever donated. As with most humans, sometimes I have to be hit over the head with something to realize its importance. There’s a lot of important causes and opportunities to give back in this world, but this is a really good one. For anyone needing red blood cells, platelets, or plasma this is THE only option. Blood banks are often running into shortages and I can’t even fathom the thought of hearing “sorry, we don’t actually have the supply to transfuse right now”. Noah specifically has received many platelet and red blood cell transfusions already and that need will continue.
It’s interesting, going into this I knew nothing about blood. I’ve learned some things, but have significant gaps in the basics. For instance, I just showed up at the blood drive and signed up for “double red” naively thinking it was a choice between a single and a double donation of “just blood”. I quickly learned that this is a common misconception. The choices are actually “whole blood” or “double red”. The whole blood option is a donation of all of the blood (ergo, “whole”); so you’re donating red blood cells, platelets, and plasma (and white blood cells too, but that’s not something typically transfused). Blood is mostly plasma (~55%) and red blood cells (~45%), and white blood cells and platelets each make up less than a percent.
Most transfusions are not “whole blood” transfusions but, rather, transfusing a standalone component. So when you donate whole blood, they’re typically going to be separating into components and then transfusing separately. Since blood is mostly red blood cells and plasma, a whole blood donation will provide a solid unit of those components. However, it will have a very minimal yield of platelets. In order to get a transfusable unit of platelets from whole blood donations you need to pool 6 or more of these small amounts. This is not ideal as pooling multiplies the risk of an adverse reaction for the recipient.
As such, for platelets, dedicated donation is the best route. In this process, called apheresis, blood is taken from one arm, platelets separated out of it via centrifuge, and then the blood is returned (sans platelets) to the other arm. Science! This process results in a single transfusable unit with a single donor for lessened risk of adverse reaction. Platelets are often in low supply. It takes longer to donate and the machines to process them are typically only available at permanent blood centers rather than mobile blood drives. As mentioned, platelets have a short lifespan (9-12 days) AND a short donation shelf-life (5-7 days). We’ll discuss more below, but everything being equal, platelets are a really good option if you’re looking to help.
The shelf-life story for red blood cells (about 40 days) and plasma (a year) is much better, but these are always massively in demand as well. Similar to platelets, both red blood cells and plasma can leverage apheresis for dedicated donations. A dedicated plasma donation can yield 2 or 3 times more than that derived from a whole blood donation. The “double red” donation is the red blood cell version and coincidentally results in double the red cells. As we saw yesterday, the machines for a standalone double red blood cell donation can be conveniently available at mobile blood drives.
So, should you donate? Yes. Can you donate? Probably. There are some age, weight, vital requirements, etc., but nothing too crazy. The question then becomes “what is your ideal donation?”. ANY donation is great, but there are more factors to consider if you really want to maximize.
First, some of the basics that I didn’t know. Now, I did know that certain blood types can only receive from certain other blood types, but that’s about it.
This is just my high-level understanding since, um, yesterday, so keep that in mind. We’ve got two main things at play here with blood types: antigens and antibodies. Antigens are something that may trigger an immune response in the body. This might be a foreign substance like bacteria or a virus or it could be something produced by the body. In this case we’re talking about antigens produced by the body. There’s a whole bunch of antigens, but the three key ones for blood types are A, B, and Rh.
The most common blood types are dictated by two dimensions:
Do the red blood cells have the A antigen (blood type A), B antigen (blood type B), A and B antigens (AB blood type), or neither A nor B antigens (O blood type)? The “O” means “without” or “zero”. If it helps, you can think of this “O” as a 0 (zero).
Do the red blood cells have the Rhesus (Rh) factor or not? If they do have it, the blood type is positive. If not, the blood type is negative.
And that’s it. Well, that’s mostly it. I think most people know that they could receive blood from someone with exactly the same blood type, but it might not be obvious which other types could transfuse to you or which types you could transfuse to. You can find and memorize tables of which can donate to which, but I’m not a big fan of rote memorization except in very critical life skills like reciting the alphabet backwards or all 50 states in alphabetical order.
This brings us to the other major entity mentioned alongside antigens: antibodies. When an antigen triggers an immune response, that response may be in the form of an attack by an antibody. For the aforementioned antigens (A, B, and Rh) there can be three corresponding antibodies present in the plasma. The key thing is that, for example, an “A” antibody in the plasma can detect an A antigen on a red blood cell as a foreign attacker, try to bind to it, and DESTROY.
As such, we know that if someone has the A antigen on their red blood cells, they won’t have the A antibody in their plasma. Further, on the ABO dimension, if someone has only the A antigen, they will have the B antibody in their plasma; vice-versa with the B antigen and A antibody. If they’ve got A and B antigens they can’t have either antibody. And if they’ve got neither antigen, they’ve got both antibodies. The same general rules apply for the Rh factor; if you’re Rh negative you don’t have the antigen. It’s not quite the same in that you don’t just automatically have the Rh antibody in your plasma in this case. You have the “potential” to develop them after exposure to Rh positive red blood cells which ends up with a similar result.
This all means that if we know someone’s blood type we can already determine both which blood types they can donate to and receive from.
For example, Noah’s blood type is O+. What does this tell us? It tells us he has neither antigen A nor B on his red blood cells, so he must have the A and B antibodies in his plasma. This means that he cannot receive any blood type with red blood cells with the A and B antigens because his A and/or B antibodies will attack them. This rules out red blood cell transfusions of A, B, and AB types. That leaves only O. In terms of the Rh factor, the plus means that he does have the Rh antigen, so does not have the Rh antibody. This means he can receive either O+ or O- because there is no Rh antibody to attack the Rh antigen. O+ is the most common blood type and there are a lot of donations of it, but there’s also a massive demand for it. Yes, Noah can only receive O+ and O-, but there are many “rare” blood types that would be more problematic.
O- is an interesting one. The “O” means that it has no A and B antigens so whether a recipient of O- has any of the A and B antibodies is irrelevant because they’ll have nothing to attack. The minus means that the red blood cell does not have the Rh factor so whether another blood type has the Rh antibody is also irrelevant. This all means that O- can donate to any of these blood types. Unfortunately, it’s the inverse as a recipient. Since O- has both the A and B antibodies, it can’t receive A, B, or AB. And it can’t receive O+ because of the potential for Rh antibody development that attacks the O+ Rh antigens. They are the universal donor and the least universal recipient. This is the reason O- is the most highly sought after blood type for transfusions. If you’re O- and go to a blood center I’m guessing they’ll roll out the red carpet (pun originally unintended) for you to be a “double red” donor.
The best situation as a red blood recipient is AB+ as it has no A, B, or Rh antibodies to attack any red blood cells regardless of antigens. You can probably guess that AB+ is simultaneously the least universal donor as only AB+ can receive it.
The elegant thing about this dynamic is that we can also divine that the inverse rules apply for plasma. O- can only donate plasma to O-, but can receive from all. AB+ can donate plasma to all blood types, but can only receive from AB+.
This gets us back to “what is your ideal donation”? I’m sure a blood center would be able to tell you at any given time what’s most in demand and take into account all the nuance that is surely glossed over here. But we can probably assume that if you’re a universal donor of red blood cells (O-) the most bang for the buck is a “double red” (also called “super red”) donation. While you “could” donate plasma or platelets as an O- donor, your blood is just better utilized for red blood cell transfusions.
If you’re AB+, you should probably consider a standalone plasma donation and maybe less so the whole blood and double red donations. If you’re somewhere in between, you’ve got the general mechanics to consider which direction to go, but platelets seem like a real good middle option in which all the common blood types can typically work with each other and not be subject to these red blood and plasma rules. While it will take a couple hours per donation, you’ll get red blood cells and plasma back so likely to feel pretty okay after. Platelets also regenerate quickly; depending on the blood center you can donate every 7 days (more typically every two weeks up to 24 times per year).
Okay, I went super mega way too long on all that, but writing it down so I can read it once I forget in 24 hours. To summarize, again, Noah’s doing pretty well. We love you all and over and out!
