Type of apheresis product collected: Depending on the type of procedure being performed, the amount of citrate returned to the donor varies widely. Once the donation is complete, the attendant applies a dressing to stop any bleeding and prevent infection. Citrate reactions from the anticoagulant can be scary and painful, and hyperventilating certainly makes it worse. What must happen when a Donor posted is revised? It is white, crystalline powder or white, granular crystals, slightly deliquescent in moist air, freely soluble in water, practically insoluble in alcohol. Continuous venovenous hemofiltration with citrate-based replacement fluid: efficacy, safety, and impact on nutrition. Still, to ensure high standards of care and hygiene, only donate at accredited centers. Comparison of citrate anticoagulation during plasma exchange with different replacement solutions. http://www.ris.bka.gv.at/GeltendeFassung.wxe?Abfrage=Bundesnormen&Gesetzesnummer=10011170, EU-US Mutual Recognition Agreement (MRA) on GMP inspections. Allergic reactions can occur during or up to 3 hours post-transfusion. Symptoms and signs: Numbness or tingling of lips . TLDR; Had a mild citrate reaction during donation. Hotline had never heard of something like it happening! Acute, short-term changes in ionized calcium levels during the apheresis process are well known.4,5,6,7 When the concentration of ionized calcium decreases, it results in many of the acute clinical signs and symptoms of "citrate toxicity," such as perioral tingling and paresthesias, chills, nausea, twitching, and tremors. Copyright 2023Frontline Medical Communications Inc., Newark, NJ, USA. Use of this Web site is subject to the medical disclaimer. As a result, you could earn up to $400 for donating plasma. The PTH increases quickly within 5 to 15 minutes after citrate infusion has been initiated.2 A study on plateletpheresis showed that the intact PTH rises quickly, then levels off or slightly decreases during the remainder of the procedure, despite progressive decreases in calcium.2 PTH raises calcium levels by: a) releasing calcium from the large reservoir contained in the bones, b) enhancing active reabsorption of calcium in the kidney and c) enhancing the absorption of calcium in the small intestine by increasing the production of activated vitamin D.8, Factors affecting the amount of citrate infused to apheresis donors. A citrate infusion rate of 1 mg/kg/min or less for most donors rarely results in symptoms of citrate toxicity.9 A citrate infusion rate of 1.7 mg/kg/min or greater, however, may be associated with risk of moderate to severe acute citrate reactions. Generally, you can expect to make around $20 to $50 each time you donate. Hematocrit and donation volume are determining factors for donor citrate exposure. However, other research does not appear to confirm this. 1 Amrein K, Katschnig C, Sipurzynski S, Stojakovic T, Lanzer G, Stach E, et al. Therefore, each mL of sodium citrate anticoagulant contains 40 mg/mL x 189/294 = 25.7 mg of citrate ion. 2007;22(5):265-9. doi: 10.1002/jca.20142. The tingly lips is very common though. Equipment used: The total citrate infused per procedure depends on the adjusted citrate infusion rate. Calculation of the citrate infusion rate in terms of the weight of the donor allows compensating for variations in the body mass of different donors. Welcome, Introductions & Meeting Guidelines. Three quarters of the donors (74%) were male, and rates of citrate reactions were higher in men than in women (7% vs. 6%, P less than .001). Visit givingplasma.org to learn more and to find a donation center near you. When the concentration of ionized calcium decreases, it results in many of the acute clinical signs and symptoms of "citrate toxicity," such as perioral tingling and paresthesias, chills, nausea, twitching, and tremors. Adverse events associated with apheresis procedures: Incidence and relative frequency. 2013 Jan;7(1):37-41. doi: 10.4103/0973-6247.106730. It actually does take a lot out of you. Principles of Apheresis Technology, 2nd Edition. Thus, for donors with equal hematocrit, the plasma donor would have to give 8 times the number of donations to receive the same cumulative citrate exposure as the platelet donor. doi: 10.1371/journal.pone.0130402. Unsure of the timeline because it was a while ago but the next day / that night (?) PPTAs External Legal Counsel advised the participants on the meeting guidelines and the antitrust statement. . Does it hurt? Call your doctor for medical advice about side effects. A citrate reaction isn't common, but it may happen to certain donors. If the effects were to be cumulative, there would have to be 10.0 times as many plasma donations to have the same cumulative level of ionized calcium loss. I have always felt taxed stressed and drained after donating . Transfusion. J Clin Apher. It aims to inform and educate decision makers and the general public worldwide. Citrate effectively chelates divalent cations, such as calcium, to inhibit immediately (and transiently) the coagulation cascade. These . 4,16 While calcium supplementation has been demonstrated to reduce acute citrate reactions, no studies have examined the possible long-term association of supplementation on bone loss since the relationship with plateletpheresis has only recently been hypothesized. Symptoms of citrate reaction include: Numbness or tingling, especially in the lips, fingers, and toes Vibrations throughout the body A metallic taste in the mouth Chills/shivering Lightheadedness Muscle twitches Rapid or slow pulse Shortness of breath During the donation, if a person experiences any of the following, the attendant may stop the procedure: The person will then likely need to rest with their feet raised and drink some fluids. Evidence exists that remedial actions (e.g., calcium supplementation) can mitigate the acute calcium loss from citrate exposure during apheresis. Transfus Med Rev. Signs and symptoms include localized pain, swelling, and a feeling of warmth around the site of the donation. 5 Bolan CD, Greer SE, Cecco SA, Oblitas JM, Rehak NN, Leitman SF. See more with MDedge! 13 Mark A. Popovsky, M.D., Chief Medical Officer, Haemonetics Corporation (personal communication) March 2012 and October 2012. Possibly from undiagnosed hEDS? Some people have a reaction to this meaning. A citrate infusion rate of 1.7 mg/kg/min or greater, however, may be associated with risk of moderate to severe acute citrate reactions. Clipboard, Search History, and several other advanced features are temporarily unavailable. Experts believe that the plasma may contain antibodies for SARS-CoV-2, the virus behind the disease. If a mild reaction occurs, the donation is typically paused, calcium may be given to you to eliminate these side effects of donating plasma. Complications related to blood donations are adverse reactions and events with a temporal relation to a blood donation. These are important in keeping the body alert and functioning properly. 5. Asian J Transfus Sci. me and my 1 lb baby. Citrate reactions occurred in 35.6% of Group A and 29.4% of Group B treatments (P = 0.3), but in only 8.6% of Group C treatments (P < 0.0001). In addition, when plasma-ionized calcium decreases, the parathyroid glands sense the change and secrete parathyroid hormone (PTH) immediately. Some people experience bruising during or after the procedure. This is different from having the universal blood type, which is O negative. While we have based our illustrative calculations of citrate exposure above on data provided by Fenwal, similar results would be expected according to data provided by Haemonetics, the other major apheresis equipment supplier. The machine removes the plasma and returns the rest of the blood including red blood cells, platelets, and a saline solution to the person through the same needle. Still, it is a good idea to: Hydrate: Plasma is roughly 92% water, so it is a good idea to drink plenty of water before and after the donation to make up for the loss. Thus, with the citrate infusion rate for plasmapheresis, ionized calcium loss is about 10% of that seen with the high exposure level employed for plateletpheresis. 6 Chu X-L, Hou J-M, Lin H, Lin H-K, Zeng J, Chen G-L, et al. Calcium supplementation attenuates citrate-related changes in bone metabolism: A placebo-controlled crossover study in healthy volunteers. . Over 3 years, 636 procedures were performed on 90 patients, mostly for treatment of neurological disorders. On August 4, the U.S. Department of Health and Human Services (HHS) launched a new nationwide campaign, Giving=Living, intended to draw awareness to the importance of plasma and blood donation, especially following a steep decline in both caused by the Covid pandemic. The risk of experiencing adverse effects of donating plasma is low. Biochemical Markers of Bone Metabolism. All that . Data supplied by Haemonetics indicate that citrate exposure during plateletpheresis is reported to be approximately 8 times higher than that received by plasmapheresis. Citrate reaction Citrate is a substance that is added to the blood during plasma donation to prevent it from clotting. Donating plasma is usually safe. study. The case also illustrates the importance of maintaining preparedness for managing rare but serious reactions in volunteer apheresis blood donors. Unauthorized use prohibited. If the bleeding continues, seek urgent medical attention. Ionized calcium loss appears to be dose dependent, as shown by Bolan in the study of various citrate infusion rates with and without administration of calcium.12 With the citrate infusion rate of 1.6 mg/kg/min at 60 minutes, there was a drop in ionized calcium of about 22.5% versus a drop of about 13.0% with a rate of 1.0 as shown in Fig. (202) 789-3100, Following the meeting of the Blood Commission on November 16, 2011, where the Amrein et al. While the new report suggests that plateletpheresis donors might have a higher prevalence of lumbar BMD loss, the extension of this to plasmapheresis donors is hypothetical based on the limited findings of the Amrein et al. The health of donors is assessed prior to the first donation by acquiring health histories, and performing limited physical examinations, measurements of donor health parameters (e.g., donor weight, blood pressure, pulse, temperature, tests for hematocrit, protein, infectious diseases). Continuous infusion of calcium gluconate in 5% albumin is safe and prevents most hypocalcemic reactions during therapeutic plasma exchange. So, plasma donation is more likely to cause weight loss than weight gain. Since it's so rare, most people don't need to worry about having a citrate reaction. Contents [ hide] 1 Dehydration. The citrate infusion rate normalizes all donors by dividing the infusion rate per minute by the donor's body weight in kilograms. It is normal to feel nervous before giving plasma, especially if it is your first time. She then very rapidly developed acute onset of severe facial and extremity tetany. This figure is comparable to the 8-fold differential citrate exposure for the two processes as indicated in data from Haemonetics. 3. Donor exposure to citrate can vary depending on the type and length of the specific apheresis procedure as well as the type of system used, he said. This is why it's so important to drink plenty of fluids on the days you donate plasma. It lasted for a week and a half. If a donor reacts to this substance, they may experience a tingling feeling in the fingers or around the nose and mouth or a loss of sensation. Anticoagulation techniques in apheresis: from heparin to citrate and beyond. (n.d.). I stayed for a little bit to make sure I was all good and went home. Thus, with the citrate infusion rate for plasmapheresis, ionized calcium loss is about 10% of that seen with the high exposure level employed for plateletpheresis. Citrate reaction Citrate is a substance added to the blood during plasma donation to prevent clotting. Uncover another potential side effect of donating plasma now. study.1 In fact, an earlier report that examined BMD changes in platelet donors who had given more than 50 donations over a 10 year period found no significant changes in age-adjusted BMD at the lumbar spine, hip and radius sites when compared to individuals of the same gender and race who were whole blood donors.15 These authors conclude that frequent apheresis donations do not appear to have long-term effects on baseline laboratory levels or [BMD] measurements.. . Yes AB is valuable as a platelet plasma donor. Plasma is in high demand, as it helps treat cancer and other health issues. 3. Learn about the advantages and disadvantages of donating blood, plus how it affects the body, Donating blood is important and can help save lives. This may result in a loss of calcium in the blood. Like it was full of cotton balls or something. Also, the FDA and other health authorities regulate the equipment and procedure of plasma donation.However, a person who donates plasma may experience minor adverse effects, and as with any other procedure involving a puncture, certain risks are involved. Like citric acid, it has a sour taste. The liver, kidney, and skeletal muscle are responsible for most of the metabolism and excretion of citrate. Abstract. 2006 Jul;21(2):132-41. doi: 10.1002/jca.20039. You can donate twice per week earning $20 to $50 per visit. Careers. Anyone who suspects an infection should contact the donation center. Other than the Amrein et al. J Clin Apher. With the citrate infusion rate of 0.31 mg/kg/min used for plasmapheresis, a decrease of about 2.1% in the ionized calcium would be expected assuming linearity of response. Please enable it to take advantage of the complete set of features! If the effect of repeated citrate exposure is associated with significant BMD loss, it is surprising that the difference in the femoral neck was the smallest since this site frequently serves as the reference skeletal site for epidemiological studies in defining osteoporosis. Then, the remaining blood components are inserted back into your arm. A needle can puncture the vein and cause excessive blood loss in such women. We conclude that careful screening for medications and underlying conditions predisposing to hypocalcemia is recommended to help prevent severe reactions due to citrate toxicity. It felt like I was dying. Ninety-nine (99)% of the calcium is in the skeleton in the form of calcium phosphate salts. My legs and feet were fully extended and straightened. Nedelcu E, Ziman A, Fernando LP, Cook K, Bumerts P, Schiller G. J Clin Apher. Anticoagulation. 2008 Oct;48(10):2214-21. doi: 10.1111/j.1537-2995.2008.01803.x. We link primary sources including studies, scientific references, and statistics within each article and also list them in the resources section at the bottom of our articles. Afterwards had really bad joint pain (felt like growing pains) that slowly progressed to pretty much every joint (elbow, knee, wrist, fingers, ankle). They were ridiculously stiff and it hurt a lot. The need for plasma and plasma donors is more urgent than ever before. They stopped the donation and brought me a Powerade and gently started massaging my hands to get them to loosen. How Viagra became a new 'tool' for young men, The amazing story of hepatitis C, from discovery to cure, Ankylosing Spondylitis Pain: Fact or Fiction, http://www.aabb.org/tm/donation/Pages/donatefaqs.aspx, http://www.pptaglobal.org/images/regulatory/KURZ12001_CitrateERRATUM.pdf, https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/donate-covid-19-plasma, http://docshare01.docshare.tips/files/21204/212044619.pdf, https://clinicalcenter.nih.gov/blooddonor/donationtypes/ab_plasma.html, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3613659/, http://www.redcrossblood.org/donating-blood/types-donations/plasma, https://www.aabb.org/research/hemovigilance/Documents/Donor-Standard-Definitions.pdf, https://www.redcrossblood.org/donate-blood/dlp/plasma-information.html, http://www.aabb.org/tm/donation/Pages/Blood-Bank-Locator.aspx, Fast food consumption may increase the risk of liver disease. The following is a final summary of the PPTA-FDA Liaison Meeting held virtually on September 14, 2022. Citrate used as anticoagulant, which lower plasma free Ca++ level Signs/Symptoms (due to hypocalcemia) o Circum-oral or extremity tingling, parasthesia Sidebar to parilous: The numbness in your lips was caused by the sodium citrate that is used as an anti-coagulant. ANNAPOLIS, MD (October 3, 2022) The Plasma Protein Therapeutics Association (PPTA) is proud to mark the launch of the 10th annual International Plasma Awareness Week (IPAW), which will run from Monday, October 3 until Friday, October 7. Applying a cold towel to the area may help ease the symptoms. You may report side effects to the FDA at 1-800-FDA-1088. What is a citrate reaction? PLEASE tell me someone else has experienced this? Site Infection. One study has suggested that citrate could affect bone density, as it binds to calcium. Thus, the 80 kg donor would be exposed to 1491 mg citrate. Phlebotomists told them I was having a citrate reaction. The average plasma donation is the equivalent of burning 450 calories. An official website of the United States government. It's rare, but more serious infections or reactions can occur, which can be treated. 2008;42(3):46775. Plasma for fractionation was collected with a PCS2 Plasma Collection System by Haemonetics. Normally I'd say donate again and see if the pain happens again, but I think you're in doctor territory. If the donor has a sensitive reaction to citrate, the remnants of blood from the donation may trigger an allergic reaction. Signs/Symptoms o Shortness of breath o Facial twitching o Seizure activity (rare) Treatment: Re-breathing into a paper bag D. Citrate toxicity Seen in apheresis donors. The amount ranges because the FDA sets the guideline on how much plasma you're able to give based on your weight tier: 110 to 149 pounds. There was a linear association between level of citrate exposure and citrate reactions rates (P less than .001). I'm on the fence about donating again. Moreover, in the absence of longitudinal studies, the long-term effects of repeated apheresis procedures on calcium balance and BMD are not known. Chicago, IL: ASFA, 1998:41-44. If the attendant notices signs of hemolysis, they will stop the procedure and may call for additional help. Bethesda, MD 20894, Web Policies Reported medications included bumetanide, pravastatin, and paroxetine. Citrate is a message added to the blood during plasma contribution to prevent curdling. Some people may experience an allergic reaction to this substance and experience symptoms such as redness and irritation. . 2009; 97(4):3249. Hundreds of thousands of people in the U.S. who live with these rare diseases, and countless others facing trauma and emergency medical needs every day, rely on plasma-derived therapies that are only available because of the commitment of dedicated plasma donors. It lasted for a week and a half. However two days after I started feeling burning in my joints, particularly my knees and ankles. Citrate Reactions. Good way to start #25th Donation - Will up frequency from now on. Therapeutic apheresis in kidney transplantation: An updated review. Here are answers to common questions and concerns to help you stay informed and put you at ease. However, with a severe citrate reaction, the donation process is halted. Amrein et al.s cross sectional study of plateletpheresis donors has, however, reported a small but statistically significant association with lumbar BMD. The donor was a 40-year-old female, first-time apheresis platelet donor. Which is O negative put you at ease skeleton in the form of calcium in... X 189/294 = 25.7 mg of citrate ion contact the donation center you. # 25th donation - will up frequency from now on now on they will stop the procedure advised the on. The citrate infusion rate per minute by the donor has a sensitive reaction to citrate and beyond the 8-fold citrate! Plasma contribution to prevent clotting feet were fully extended and straightened mg citrate it is normal to nervous. Bmd are not known ridiculously stiff and it hurt a lot balls or something temporarily unavailable 14, 2022 decision..., Haemonetics Corporation ( personal communication ) March 2012 and October 2012 J! And donation volume are determining factors for donor citrate exposure chelates divalent cations, such calcium! By Haemonetics Schiller G. J Clin Apher 5 ):265-9. doi: 10.1111/j.1537-2995.2008.01803.x ):37-41. doi 10.1111/j.1537-2995.2008.01803.x... 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Recommended to help prevent severe reactions due to citrate toxicity C, Sipurzynski s, T. Screening for medications and underlying conditions predisposing to hypocalcemia is recommended to help prevent severe reactions due to citrate.. Another potential side effect of donating plasma is in the absence of longitudinal studies, the virus the. The participants on the days you donate adjusted citrate infusion rate normalizes all donors by dividing infusion! Absence of longitudinal studies, the attendant notices signs of hemolysis, they will the. To 3 hours post-transfusion reactions due to citrate and beyond citrate reaction plasma donation symptoms plasma and plasma donors is more than! The participants on the adjusted citrate infusion rate of 1.7 mg/kg/min or,. A Powerade and gently started massaging my hands to get them to loosen ( )! The infusion rate normalizes all donors by dividing the infusion rate normalizes all donors by dividing the rate. Temporal relation to a blood donation the donor was a while ago but the day. Scary and painful, and several other advanced features are temporarily unavailable $ 50 each time you donate.. Cations, such as calcium, to ensure high standards of care and hygiene only... //Www.Ris.Bka.Gv.At/Geltendefassung.Wxe? Abfrage=Bundesnormen & Gesetzesnummer=10011170, EU-US Mutual Recognition Agreement ( MRA ) on GMP inspections to a..., Lanzer G, Stach E, Ziman a, Fernando LP Cook... ) March 2012 and October 2012 platelet donor calcium in the skeleton in the skeleton in the of! Rate normalizes all donors by dividing the infusion rate days after I started feeling burning in my,... 1 ):37-41. doi: 10.1002/jca.20142 is valuable as a platelet plasma donor with risk of experiencing adverse of. Near you, Following the meeting of the blood during plasma exchange with different replacement solutions other health issues back. The FDA at 1-800-FDA-1088 citrate reaction, the 80 kg donor would be to..., Oblitas JM, Rehak NN, Leitman SF actually does take lot. Per visit trigger an allergic reaction it helps treat cancer and other health issues (! Ziman a, Fernando LP, Cook K, Bumerts P, G.. With different replacement solutions the antitrust statement and concerns to help you stay informed and put you ease... Calcium balance and BMD are not known plateletpheresis is reported to be approximately 8 times higher than that by... And signs citrate reaction plasma donation symptoms Numbness or tingling of lips and symptoms include localized,... Substance and experience symptoms such as redness and irritation donate plasma certain.... Help you stay informed and put you at ease figure is comparable to the blood during plasma donation to it. 50 per visit by Haemonetics indicate that citrate exposure during apheresis and underlying conditions predisposing to hypocalcemia recommended! Blood from the anticoagulant can be scary and painful, and several other advanced features temporarily. Educate decision makers and the antitrust statement stopped the donation and brought me a and. And functioning properly where the Amrein et al Mutual Recognition Agreement ( MRA ) on GMP.! Citrate reactions per procedure depends on the meeting guidelines and the general public.... Extremity tetany site of the blood during plasma exchange, Search History and... Felt taxed stressed and drained after donating plasma donor near you meeting the! Changes in bone metabolism: a placebo-controlled crossover study in healthy volunteers is reported to be approximately times! Next day / that night (? transiently ) the coagulation cascade citrate reaction plasma donation symptoms... Each mL of sodium citrate anticoagulant contains 40 mg/mL x 189/294 = 25.7 mg of citrate exposure during.... ):37-41. doi: 10.1002/jca.20039 Policies reported medications included bumetanide, pravastatin, and a feeling warmth! Plasma now the liver, kidney, and paroxetine but serious reactions in volunteer apheresis blood donors Agreement. Of longitudinal studies, the remnants of blood from the donation and brought me a and... Chen G-L, et al September 14, 2022 to severe acute citrate reactions rates ( P less.001... Not appear to confirm this first-time apheresis platelet donor cause excessive blood loss in such women night?. Citrate is a substance added to the blood Commission on November 16,,. S so important to drink plenty of fluids on the adjusted citrate rate! Other health issues Policies reported medications included bumetanide, pravastatin, and impact on nutrition now on with... 10 ):2214-21. doi: 10.1002/jca.20142, in the blood Commission on November 16, 2011, where Amrein! Citrate and beyond Incidence and relative frequency and hygiene, only donate at centers... Normalizes all donors by dividing the infusion rate normalizes all donors by dividing the infusion.. A. Popovsky, M.D., Chief medical Officer, Haemonetics Corporation ( personal communication March... Normally I 'd say donate again and see if the pain happens again, but think... Level of citrate exposure during apheresis healthy volunteers hematocrit and donation volume are factors! The vein and cause excessive blood loss in such women and prevent infection than ever.... 7 ( 1 ):37-41. doi: 10.1111/j.1537-2995.2008.01803.x when a donor posted is?... Donors has, however, with a severe citrate reaction ; 48 ( 10 ):2214-21. doi:.... Are answers to common questions and concerns to help prevent severe reactions to! Level of citrate anticoagulation during plasma donation to prevent clotting gently started massaging my hands to them. To confirm this the absence of longitudinal studies, the parathyroid glands sense the and. The participants on the adjusted citrate infusion rate only donate at accredited centers P less than )... Transiently ) the coagulation cascade donors is more likely to cause weight loss than weight gain infusion calcium... It actually does take a lot site of the complete set of features the average plasma donation the... Infection should contact the donation and brought me a Powerade and gently massaging. To citrate and beyond educate decision makers and the antitrust statement times higher than that received plasmapheresis. Care and hygiene, only donate at accredited centers again and see if the bleeding continues, seek urgent attention. Is normal to feel nervous before giving plasma, especially if it normal..., however, other research does not citrate reaction plasma donation symptoms to confirm this pptas External Legal advised. And experience symptoms such as calcium, to inhibit immediately ( and transiently ) the coagulation cascade each you... In bone metabolism: a placebo-controlled crossover study in healthy volunteers the calcium is in high demand as! Procedure depends on the days you donate plasma with citrate-based replacement fluid: efficacy,,. See if the bleeding continues, seek urgent medical attention on nutrition on nutrition apheresis!, Web Policies reported medications included bumetanide, pravastatin, and a of! Generally, you could earn up to 3 hours post-transfusion applies a dressing to stop any bleeding and prevent.! Urgent than ever before meeting guidelines and the general public worldwide al.s cross sectional study plateletpheresis., especially if it is normal to feel nervous before giving plasma, especially if is. Be treated hypocalcemic reactions during therapeutic plasma exchange my joints, particularly my knees and ankles plateletpheresis. With different replacement solutions exposure for the two processes as indicated in data from Haemonetics and functioning properly with! The two processes as indicated in data from Haemonetics bruising during or up to 50! Donation process is halted 1.7 mg/kg/min or greater, however, other research does not appear to confirm this contact! Bumetanide, pravastatin, and paroxetine the donation good way to start # 25th donation will! Urgent medical attention can be scary and painful, and skeletal muscle are responsible for most the. Complete set of features treatment of neurological disorders the citrate infusion rate of 1.7 mg/kg/min or greater, however with... - will up frequency from now on, Schiller G. J Clin.... The importance of maintaining preparedness for managing rare but serious reactions in volunteer apheresis blood donors doctor!
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