We wish to thank the team of Dr. Egea for its scientific contribution to the debate on blood donation in brain death (BD).1 In effect, the inflammatory and coagulopathic processes, together with the preservation fluids in the case of organ and tissue donations, could affect the quality of the donated blood, and as a result, the latter could only be used under very limited circumstances.

However, thanks to the processing or “washing” of whole blood or of packed red cells with saline solution or other means for removing proteins, cytokines and other mediators, with or without filtration, it is currently possible to obtain standardized components in all transfusion centers and services for patients with a history of post-transfusion allergic reactions, severe respiratory distress or IgA deficiencies. New devices are being developed that allow safe removal of the entire aforementioned inflammatory and immune-modulating cascade, as has been so well described by Jiménez-Guerra et al.2 Many of these techniques are already being successfully used to standardize and improve the quality of the “recovered” blood.3

For the time being, the procedure could be considered for the obtainment and subsequent cryopreservation of red cells corresponding to “rare” or “low prevalence” blood groups (<1 in 1000 subjects), for although the Bombay blood group is the best known, there are also others. In a global context, the International Society of Blood Transfusion (ISBT) endorses collaboration in searching for these rare donors. Most developed countries have collaboration networks, with localized donors and hundreds of cryopreserved and phenotypes blood units available for use when needed. The management of post-transfusion allosensitized patients constitutes a genuine logistic challenge, and a recent example of this is the case of a critical and bleeding patient sensitized with an anti-Tja in a national hospital (personal communication, Dr. Esther Chica). Hence we propose that this debate should also be carried out contemplating the non-heart beating donation scenario.

Lastly, we totally agree with the authors that the excuse cannot be a decrease in blood donation and an increased dependency on external plasma and blood products due to probable inadequate use of many of them, and that it is not acceptable to favor or promote qualitative laxity or place the safety of donation or transfusion at risk. In addition, while we are still in wait for the data corresponding to 2020, the recorded decrease in blood donation during the COVID-19 pandemic has further worsened in Spain.4

Nevertheless, all the measures must be publicly debated and should be based on evidence and not on the scarcity of blood components. Accordingly, it is now more important than ever to implement Patient Blood Management (PBM) programs, working on their three basic elements: a) the study, prevention and treatment of anemia; b) the improvement of hemostasis, the prevention and early management of coagulopathy, bleeding recovery and the avoidance of “vampirism”; and c) the improvement of tolerance of anemia, ameliorating the hemodynamic and cardiorespiratory response, and applying restrictive transfusion criteria.5 In sum, we need a Spanish national PBM plan, as well as a plasmapheresis protocol for the provision of blood and plasma products, and should also establish a common donor and patient database.6,7