A Pathologist’s Journey to Transfusion Medicine
What it takes to become a transfusion medicine specialist and manage one of life’s most precious resources
Adriana María Knopfelmacher Couchonal, MD
Board-certified pathologist and assistant professor of laboratory medicine at the University of Texas MD Anderson Cancer Center, Adriana María Knopfelmacher Couchonal, MD, recalls her childhood as introspective. Like many, she did not initially set out to become a doctor. But through an intercontinental journey, she found her footing as a transfusion medicine specialist.
Today, not much has changed for the soft-spoken and ever-inquisitive introvert. As the acting medical director of the MD Anderson Blood Bank, Knopfelmacher Couchonal devotes her attention to collecting blood products, managing the transfusion service inventory at MD Anderson, and educating the public, patients, and medical professionals on the body’s most specialized fluid—blood.
Guided by a strong inner compass, and learning from her life experiences, the Paraguayan American said her medical career continues to reward her with challenges that include tackling inventory shortages while undertaking hemovigilance for alloimmunization risks, for which she has recently explored the use of AI to predict patient responses to blood donations.
Today's Clinical Lab spoke with the MD Anderson pathologist about what it takes to become a transfusion medicine specialist and manage one of life’s most precious resources.
Following your instincts can prepare you for medicine
Growing up in Paraguay, Knopfelmacher Couchonal was happy to lose herself in her thoughts, not minding being alone. “Even though I was introverted, I was one of those kids who was always very eager to help others; it brought a sense of purpose,” she says. “I was fascinated by how the human body works, but not just humans, also plants and animals.” For Knopfelmacher Couchonal, the idea of interconnection in health was also influenced by her upbringing in Paraguay, which has been affected by Chagas disease, a vector-, food-, and blood-borne disease, since 1924.
Being ever curious with a knack for problem solving, unsurprisingly, her favorite subjects in school were biology and chemistry, which provided her with a foundational appreciation for the inextricable nature of medicine. The latter attracted her most and eventually led to her becoming a transfusion medicine specialist.
“There is so much complexity behind giving a unit of blood to a patient.”
As a budding undergraduate scientist, Knopfelmacher Couchonal journeyed to the University of Iowa to pursue an undergraduate degree in biology, where she became transfixed by understanding the inner workings of living things to find better solutions to life’s challenges and dreamed of becoming a geneticist. Then, her life took a different turn.
Thyroid problems impacted her physical and psychological health and forced her back to Paraguay, where she underwent treatment by a multidisciplinary team of endocrinologists, nuclear medicine specialists, surgery specialists, and a pathologist for about a year. Overcome with gratitude by the role doctors played in her recovery, she understood then the challenges she wanted to solve resided in medicine.
The time she spent under their care sparked her curiosity: how could something not visible to the human eye and localized to one tissue have such a vast impact? Though she did not receive blood transfusions during that time, she was fascinated by how the surplus of hormones produced by her thyroid traveled through her blood reaching so many cells and tissues where they had profound effects.
At the Universidad Nacional de Asunción, nestled in Paraguay’s capital, where Knopfelmacher Couchonal obtained her Doctor of Medicine and Surgery degree, she realized her introversion and curiosity for cells and tissues made her ideally suited to pathology.
| Table 1. Education Snapshot | ||
|---|---|---|
| Year | Degree | Focus |
| 1998–2000 | BSc in biology, University of Iowa, Iowa, United States | Genetics (not completed due to illness) |
| 2003–2008 | Doctor in Medicine and Surgery, Universidad Nacional de Asunción, Asunción, Paraguay | Medicine |
Sacrifices are part of medicine: Cultivating resilience
But her path would lead her away from Paraguay as historically, Paraguay has struggled with education. “I came to the US to pursue university and residency because I knew I was going to have a broader path and more options, and probably a better education,” says Knopfelmacher Couchonal.
For the ambitious Paraguayan American, US universities and institutions signified greater prospects, but choosing this path meant leaving behind her home and family. “When you don’t have the emotional support of a network of family and friends, life can be difficult; you may question your decisions,” the transfusion specialist says about the difficulties in pursuing international education, something many doctors, who often relocate for residency and fellowships, will understand. But though the journey was arduous, she became more resilient to the winding path of medicine.
Knopfelmacher Couchonal went on to complete pathology residences and fellowships in the US at Montefiore Health System, Vidant Medical Center, and MD Anderson Cancer Center, where she realized that pathologists could also be involved in laboratory medicine.
Then, through a rotation in blood banking, she finally found her calling. “I became captivated by blood groups and antibodies,” she remarked. She now focuses on immnunohematology, routine transfusion testing, inventory management, and donor hemovigilance, with a focus on alloimmunization, a common noninfectious complication.
| Table 2. Training Snapshot | ||
|---|---|---|
| Year | Experience | Focus |
| 2012–2016 | Residency at Montefiore Health System, Bronx, New York, New York, US | Pathology |
| 2016 | American Board of Pathology Certification | Anatomical and clinical pathology |
| 2016–2017 | Fellowship at Vidant Medical Center, Greenville, North Carolina, US | Surgical pathology |
| 2017–2019 | Fellowship at MD Anderson Cancer Center, Houston, Texas, US | Blood bank/ transfusion medicine |
| 2019 | American Board of Pathology Certification | Transfusion medicine and blood banking |
Managing life’s most precious resource
Knopfelmacher Couchonal’s current dedication to transfusion medicine lies in the way the discipline bridges interconnected scientific challenges with helping people. “There is so much complexity behind giving a unit of blood to a patient,” she says. The steps involved in managing blood products include screening for pathogens and potentially deadly immune reactions.
“The risk of acquiring an infectious agent by transfusion of blood components has been largely reduced, and the risk in morbidity and mortality following transfusion of blood is due mostly to its noninfectious complications,” wrote Knopfelmacher Couchonal in “Transfusion Reactions” in Oncologic Critical Care, published by Springer Nature in 2019.
At the lab, Knopelmacher Couchonal and lab staff examine the hematocrit or hemoglobin count to determine whether blood types and/or antibodies could interfere with treatment, or even obscure results about the safety of transfusion. “There are many monoclonal antibody therapies that target specific antigens related to a cancer in a patient, but sometimes they may interact with the antigens present in the surface of red blood cells, and even platelets,” she says. “We try to obtain blood that is as closely matched to the molecular profile of the patient, because we may not be able to rely on compatibility testing in these scenarios.”
“I’m driven by the need to support patients through one of the most difficult challenges in their lives.”
Research in transfusion medicine is underway to remove A and B antigens and generate universal blood, but it’s not yet available. For now, she noted that using antibodies or other binding agents to provide custom blood products can also come with its own risks of alloimmunization.
Though difficult, these technical challenges and risks motivate the introspective pathologist to troubleshoot complications often further convoluted by a scarcity in blood products—on September 11, 2023, the US declared a national blood shortage, which continues to be a difficult part of her job.
Sharing your knowledge as a way to reinforce and grow your understanding
To deal with the paucity in blood donations during the early days of the COVID-19 pandemic, Knopfelmacher Couchonal and a nursing education team that included scientific writers and illustrators, graphic designers, and even narrators, looked for ways to educate people on the importance of donating blood. Through these efforts, the transfusion specialist has found another calling.
“It is extremely important to transmit some of my transfusion medicine knowledge so that physicians, clinicians, nurses, and other medical staff who do not practice transfusion medicine can understand the risks associated with receiving blood,” she says, adding this empowers them to provide better care to their patients.
As an assistant professor, she also shares her knowledge with post-graduate trainees—the future oncologists and hematologists that may one day care for cancer patients. Beyond this, her everyday practice as a transfusion physician emphasizes teamwork and knowledge sharing to empower the multidisciplinary care teams within which she works, ensuring transfusions are safe.
“I’m driven by the need to support patients through one of the most difficult challenges in their lives, and by knowing that we are providing them with blood products that adhere to the highest standards of safety, quality, purity, and potency,” she says. “There is just so much I could focus on right now—I will never stop learning, or sharing knowledge.”
