Clinical and Economic Issues in Multiply Transfused Sickle Cell Disease (SCD) Patients.

Abstract

Aim: To study alloantibody (alloAB)/autoAB formation and transfusion reactions in SCD patients before and after instituting the practice of transfusing C, E, K blood type negative (CEKneg) packed red blood cell (pRBC) units.Material and Methods: We retrospectively reviewed blood bank records of all SCD patients transfused pRBCs. Statistical analysis was performed using the Chi square test and Fischer's exact test.Results: During 1990–2004, 500 SCD patients received 16,617 pRBCs in our hospital. 387 received pRBCs crossmatched for ABO and Rh only; 121 (31.3%) developed alloantibodies (alloABs).Table 1:Transfusion characteristics of patients forming alloABsData on pts forming alloABsCEK matched patientsCEK unmatched pRBC Transfusion (Tn) patients (387)≥ 1 ABs≥ 2 ABs≥ 3 ABs≥ 4 ABs≥ 5 ABsNumber of patients (% of total)6/113 (5%)121/387(31%)57/121 (47%)29/57 (51%)16/29 (55%)11/29 (69%)# of Tn before AB-Median (range)9.5 (0-106)7(0-270)2 (0-106)0 (0-89)0 (0-180)0 (0-16)# of pts with > 5 Tn before AB4/6 (67%)68/121(56%)21/57 (37%)5/29 (17%)4/16 (25%)1/11 (9%)# of pts with >30 Tn before AB1124210There were 37 transfusion reactions: 9 febrile, 24 allergic and 4 dHTRs, none was life-threatening. 21 pts developed multiple alloABs simultaneously after a single transfusion; 15 additionally developed warm autoABs. >13% patients transfused CEK unmatched units developed ABs to C, E, K and other antigens. Once allosensitized, there was an ↑ chance of subsequent development of multiple alloABs with fewer transfusions.Table 2:Incidence of antibody formation in patient groupsMajor patient groupsTotal # of ptsTotal # of transfusionsNumber of allo ABs (%of pts) [Incidence/1000 pRBCs]Number of autoABs (%of pts) [Incidence/1000 pRBCs]AllNon-CEKTotalWarmP value (CEK vs Regular) - # of pts<0.0010.030.0050.02CEKmatched11323546 (5%)[2.55]5(4%)[2.12]1 (0.88%)[0.425]1 (1%)[0.46]Regular (ABORh)38714263240(31%)[16.8]76 (13%)[5.33]39 (10%)[2.73]30 (8%)[2.1]alloAB forming pts1217338240[32.71]76[10.36]34 (28%)[4.63]30 (25%)[4.1]No alloAB pts2666925N/AN/A5 (2%)[0.7]0P value(alloAB vs non-alloAB) - # of ptsN/AN/A<0.001<0.001Of 266 patients who did not develop any alloABs, 5 had cold and no warm autoABs. 113 patients received 2354 CEKneg pRBCs only (from 1997), 6 (p<0.01) had one alloAB each, 1 warm autoAB and no reactions. Technologists required 30 more minutes and $153 extra in reagent costs for extended CEK match. 90% of our donors are Caucasian.Conclusions: Utilizing CEK negative pRBCs ↓↓ alloAB(p<0.01), autoAB (p<0.001) formation and eliminated transfusion reactions in our multiply transfused SCD patients. Universal availability of leukopoor pRBCs (from 1997) may have eliminated febrile reactions. There was ↓ alloAB formation for C, E, K and other blood group antigens. Though unlikely, Rh neg and CEKneg pRBCs may also be negative for other minor antigens. AutoAB formation (and allergic reactions)especially ↑ in patients with multiple and simultaneous alloAB formation. CEK matching made it easier to find pRBCs due to less formation of alloABs. However, it resulted in marked overuse of Rh neg pRBCs and extra cost and effort to find CEKneg pRBCs for every transfusion. For cost efficacy, one might consider CEKneg pRBCs after first alloAB.