Trends in Transfusion Among Children With Sickle Cell Disease

Abstract

Source: Raphael JL, Oyeku SO, Kowalkowski MA, et al. Trends in blood transfusion among hospitalized children with sickle cell disease. Pediatr Blood Cancer. 2013; 60(11): 1753– 1758; doi: 10.1002/pbc.24630Investigators from multiple institutions examined trends in use of blood transfusion for hospitalized children with sickle cell disease (SCD) in the United States between 1997 and 2009. The investigators reviewed the Kid’s Inpatient Database (KID), a database sponsored by the Agency of Healthcare Research and Quality and designed to report hospital use and outcomes in children every 3 years. Children ≤18 years of age with a primary or secondary discharge ICD-9 diagnosis associated with SCD were included. The primary outcome was the proportion of hospitalizations for children with SCD requiring transfusions. Child demographics, clinical diagnoses associated with SCD (such as vaso-occlusive crises [VOC] and acute chest syndrome [ACS]/pneumonia), transfusion type (packed red blood cell [pRBC] and exchange), and hospital characteristics were also collected. Multivariate logistic regression was used to identify both specific trends in use of transfusions over time and diagnoses that led to transfusion after accounting for potential demographic, diagnostic, and hospital-level confounders.Over the course of the study period investigators found that the percentage of children hospitalized with SCD who received blood transfusions increased significantly, from 14.2% in 1997 to 28.8% in 2009, and did so incrementally over the study period (16.8% in 2000, 20.4% in 2003, and 24.7% in 2006). The percentage of hospitalizations in which pRBC transfusions were given significantly increased from 13.9% in 1997 to 27.8% in 2009, while exchange transfusions significantly decreased from 2.1% to 1.7%. VOC as a principal diagnosis accounted for 56% of SCD-related hospitalizations when transfusions were administered; ACS/pneumonia accounted for 5.5%. In multivariate analyses, there were significantly higher odds of blood transfusion among all SCD-related hospitalizations for each successive 3-year study interval (adjusted odds ratio [aOR] = 1.23; 95% CI, 1.15–1.32). There were also significantly higher odds of blood transfusion for each successive 3-year study interval among hospitalizations where VOC (aOR = 1.35; 95% CI, 1.27–1.43) and ACS/pneumonia (aOR = 1.24; 95% CI, 1.13–1.35) were the principal diagnoses.The investigators conclude that blood transfusion for hospitalized children with SCD is increasing over time.Dr Onyekwere has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Blood transfusions remain an essential therapeutic option for patients with SCD. However, children with SCD are at risk of developing transfusional iron overload, alloimmunization to transfused blood products, and transfusion-induced bone marrow transplant rejection1 from multiple blood transfusions (over 10 units of pRBC). Iron is accumulated in the liver, endocrine organs, and heart resulting in multi-organ dysfunction. Multiple transfusions and significant RBC antigen mismatch predisposes the individual to alloimmunization, which leads to life-threatening events.2 Indiscriminate blood transfusion practices cause more harm than good.The results of the current study complement those of earlier work in which investigators have documented that the rate of transfusion in children with SCD in both outpatient and inpatient settings has increased over the years, especially in general hospitals and in outpatient settings.3,4 To prevent associated morbidity and mortality, blood banks should develop a standardized high-quality and effective transfusion therapeutic regimen. In addition, physicians should work to develop transfusion and management guidelines for individuals with sickle cell disease for community and ambulatory care.