RBC Transfusion In Patients Research Articles

Laboratory evaluation of RBC transfusion in patients with coronary artery disease

Laboratory evaluation of RBC transfusion in patients with coronary artery disease

The ongoing challenge of RBC alloimmunization in the management of patients with sickle cell disease

RBC transfusion remains a cornerstone in the treatment of sickle cell disease (SCD). However, as with many interventions, transfusion of RBCs is not without risk. Allogeneic RBC exposure can result in the development of alloantibodies, which can make it difficult to find compatible RBCs for future transfusion and increases the likelihood of life-threatening complications. The development of RBC alloantibodies occurs when a patient's immune system produces alloantibodies against foreign alloantigens present on RBCs. Despite its longstanding recognition, RBC alloimmunization has increasingly become a challenge when caring for patients with SCD. The growing prominence of alloimmunization can be attributed to several factors, including expanded indications for transfusions, increased lifespan of patients with SCD, and inadequate approaches to prevent alloimmunization. Recognizing these challenges, recent observational studies and preclinical models have begun to elucidate the immune pathways that underpin RBC alloimmunization. These emerging data hold promise in paving the way for innovative prevention strategies, with the goal of increasing the safety and efficacy of RBC transfusion in patients with SCD who are most vulnerable to alloimmunization.

Patients with Asian-type DEL can safely be transfused with RhD-positive blood

AbstractRed blood cells (RBCs) of Asian-type DEL phenotype express few RhD proteins and are typed as serologic RhD-negative (D–) phenotype in routine testing. RhD-positive (D+) RBC transfusion for patients with Asian-type DEL has been proposed but has not been generally adopted because of a lack of direct evidence regarding its safety and the underlying mechanism. We performed a single-arm multicenter clinical trial to document the outcome of D+ RBC transfusion in patients with Asian-type DEL; none of the recipients (0/42; 95% confidence interval, 0-8.40) developed alloanti-D after a median follow-up of 226 days. We conducted a large retrospective study to detect alloanti-D immunization in 4045 serologic D– pregnant women throughout China; alloanti-D was found only in individuals with true D– (2.63%, 79/3009), but not in those with Asian-type DEL (0/1032). We further retrospectively examined 127 serologic D– pregnant women who had developed alloanti-D and found none with Asian-type DEL (0/127). Finally, we analyzed RHD transcripts from Asian-type DEL erythroblasts and examined antigen epitopes expressed by various RHD transcripts in vitro, finding a low abundance of full-length RHD transcripts (0.18% of the total) expressing RhD antigens carrying the entire repertoire of epitopes, which could explain the immune tolerance against D+ RBCs. Our results provide multiple lines of evidence that individuals with Asian-type DEL cannot produce alloanti-D when exposed to D+ RBCs after transfusion or pregnancy. Therefore, we recommend considering D+ RBC transfusion and discontinuing anti-D prophylaxis in patients with Asian-type DEL, including pregnant women. This clinical trial is registered at www.clinicaltrials.gov as #NCT03727230.

ANTIGEN FREQUENCY OF KELL, DUFFY, KIDD, MNS AND LUTHERAN BLOOD GROUP SYSTEM IN POPULATION OF NORTH MACEDONIA – TOWARDS RARE BLOOD GROUP REGISTRY

The aim of this study is to perform RBC antigen typing of: Kell, Duffy, Kidd, MNS and Lutheran systems and to calculate antigen and phenotype frequency In 920 blood donors, RBC typing of K, k, Kpa, Kpb, Fya, Fyb, Jka, Jkb, S, s, Lua and Lub antigens was performed using specific monoclonal antisera, antihuman globulin and column agglutination technique with gel cards (BioRad). Antigen and phenotype frequencies were calculated from the statistics module of the donor information system (database for blood donors). The prevalence of Kell antigens is 7.5% for K and 99.94% for k. The phenotype (K+k-) is present in 21 (0.06%) blood donors. The frequency of other clinically significant antigens is as follows: 1.1% (Kpa), 100.0% (Kpb), 60.3% (Jka), 76.2% (Jkb), 65.5% (Fya), 79.5% (Fyb), 59.8% (S), 86.5 (s), 7.2% (Lua) and 92.8% (Lub). The most frequent phenotypes are Jk(a+b+) with 41.5%, Fy(a+b+) with 48.5%, (S+ s+) with 46.3% and Lu(a-b+) with 92.8%. Fy(a-b-) phenotype was detected in 0.21% of blood donors. The estimated RBC antigen frequency in our blood donor population differs from the antigen frequency in different populations. Because of that extended RBC typing is necessary for identifying rare blood group donors within the local population. This strategy enables to meet the needs for RBC transfusion in patients with rare phenotypes and with antibodies against high frequency antigens or multiple antibodies, as well as to prevent RBC alloimmunization in polytransfused patients providing antigen matched RBC.

ALLOIMMUNIZATION PREVALENCE IN PATIENTS WITH SICKLE CELL DISEASE (SCD): ASSESSMENT OF THREE TRANSFUSION PROTOCOLS

RBC alloimmunization is a major complication associated with RBC transfusion in patients with SCD with serious complications for the patient including life-threatening delayed hemolytic transfusion reactions and an increase in the risks inherent to transfusion such as TRALI, infectious diseases and the hyperhemolysis syndrome. In addition, the presence of alloantibodies, which is often associated with the concomitant presence of autoantibodies, can lead to difficulty in finding compatible units, which can cause transfusion delays. The prevalence of alloimmunization vary according to the transfusion protocols used and may be reduced by matching for RBC antigens. Based on this, the aim of this study was to assess the prevalence of RBC alloimmunization in patients receiving transfusions with ABO and D matching, with phenotype matching for C, E and K antigens and with extended minor RBC antigen matching. A total of 368 patients with SCD, homozygous for HbS were enrolled. In this period, 81 patients received RBC units matched for ABO and RhD, 188 patients were matched for C, E and K and 99 patients were matched for ABO, Rh, K, Fya/Fy/b, Jka/Jkb and S/s antigens. Transfusion and antibody histories were obtained from our records, and antibody screening was done to assess the alloimmunization prevalence. Molecular typing was performed in all patients who had recent transfusions or a positive direct antiglobulin test by Laboratory Developed Tests (LDT) and HEA BeadChip (Immucor) to predict their antigen profile. RH variant alleles were determined in patient's antigen-positive who developed Rh antibodies using RHD and RHCE BeadChips (Immucor). Adsorption onto autologous RBC was also performed to aid the differentiation of autoantibodies from alloantibodies. Of the 368 patients evaluated, 128 were male and 240 female. Mean age was 37.4 years (range 18-60) and they received an average of 74 RBC units. Prevalence of alloimmunization in the SCD patients with ABO/RhD matched only units (n=81) was 54%. For individuals transfused with C, E and K matched units (n=188), alloimmunization prevalence was 13% and patients transfused with extended-matching units (n=99) the prevalence of alloimmunization was 0.8%. Antibody specificities developed by the patients receiving Rh and K matched units were: Anti-e, -D, -Jk a , -Jk b , -S, -Di a , -V and by the patients receiving extended matching were anti-C, -e, -V, -VS. The variant RHCE*ceS , RHCE*ceMO , RHD*DIIIa-CE(4-7)-D and RHD*DAU3 alleles were associated with the production of Rh antibodies in these patients and 9.8% of the alloimmunized patients developed autoantibodies. RBC alloimmunization rates shown to decrease to 24 % in patients with SCD transfused with RBCs matched for C, E and K antigens and to 1.5 % to patients with extended matching. Provision of RBC transfusions with limited and extended antigen matching is essential to reduce the rates of alloimmunization and hemolytic transfusion reactions in patients with SCD.

Optimizing Utilization of Blood Products in the Hematologic Malignancy Clinic: Less Is More.

There are no universal guidelines for blood product transfusions in patients with hematologic malignancies (HMs). Excess utilization of platelet and RBC transfusion in patients with HM increases the cost of care and likelihood of adverse events. We aim to decrease the total number of transfused units and multiunit orders of platelets and RBCs in the HM clinic by 25% from March 2020 to December 2020. A multidisciplinary, interprofessional team was formed. Baseline rates of blood product utilization were determined using Qlik Analytic software. Strategies to improve utilization were developed, and three interventions were initiated. Data were collected on monthly intervals. Data for total number of platelet and RBC units ordered, total multiunit orders, average number of units ordered per encounter, and pretransfusion hemoglobin thresholds were collected from May 2019 to December 2020. Through our Plan-Do-Study-Act cycles from March 2020 to December 2020, the total number of platelet transfusion orders per month decreased from 164 to 98, multiunit platelet orders decreased from 63 to 2, and the average number of platelet transfusions per encounter decreased from 1.62 to 1.03. The total number of RBC transfusion orders decreased from 172 to 141, multiunit RBC orders decreased from 25 to 16, and the average number of RBC transfusions per encounter decreased from 1.21 to 1.18. Implementation of our multidisciplinary interventions led to more appropriate use of blood products in the outpatient setting. Ongoing efforts are underway to continue to improve utilization in the inpatient and outpatient setting.

Is antivitamin K reversal required in patients with cirrhosis undergoing liver transplantation?

Antivitamin K agent (AVK) reversal in patients with cirrhosis awaiting liver transplantation (LT) is not defined in guidelines. We investigated the effect of reversion with prothrombin complex concentrate (PCC) on intraoperative transfusion, bleeding, and safety in LT patients on AVK. In 511 patients undergoing LT, we identified 25 patients treated with AVK (AVK group) and 13 patients with incidental portal vein thrombosis (PVT) without AVK (incidental PVT group). Fifty patients who underwent LT without PVT or AVK matched by age, model for end stage of liver disease (MELD), body mass index (BMI), and cirrhosis etiology were selected as the control group. There were no significant differences between the three groups in intraoperative blood loss, transfusion, and postoperative bleeding. In the AVK group, there were no differences between patients who received PCC and those who did not in intraoperative blood loss, red blood cells, fibrinogen, and platelet transfusion, or postoperative bleeding. PCC use had no effect on RBC transfusion in patients who had international normalized ratio or clotting time above versus below median values of the two parameters at baseline (2.3 and 103 s, respectively). No thrombotic events were detected in patients who received PCC. These data suggest that systematic administration of PCC to revert AVK prior to LT should be reconsidered.

A retrospective analysis of venous thromboembolism trends in chemotherapy-induced anemia.

e15515 Background: Anemia is a common and unfortunate consequence of chemotherapy. Patients receiving a variety of chemotherapy regimens often develop chemotherapy–induced anemia (CIA), which contributes to poor outcomes, including increased mortality. Prompt and effective treatment of CIA is essential to prevent fewer chemotherapy dose delays and reductions. Despite the baseline coagulopathies present in patients with malignancy, administration of RBC transfusions is associated with venous thromboembolism (VTE). It remains unknown whether the risk of VTE in patients with CIA is greater among patients who receive single or multiple RBC transfusions. Methods: A retrospective study analyzed 10,269 University of Pennsylvania Health System patients with malignancies of various type, stage, and histopathology who developed CIA between 5/1/08-12/31/17. We analyzed rates of VTE development after adjusting for RBC intervention with a 95% confidence interval during the 90 days following CIA diagnosis. Results: Among the 10,269 patients with CIA, 2,008 patients (19.6%) received only RBC transfusion as anemia treatment; of that group, 545 (27.1%) developed a VTE. Transfusion of 2+ units RBC compared with 1 unit of RBC was associated with an increase in VTE development (RR = 1.37, 95% CI 1.09-1.72). The relationship of higher VTE development with increasing number of transfusions is displayed below. Conclusions: While RBC transfusion in patients with CIA is independently associated with VTE, our data further suggests an exponential risk of VTE development with increasing numbers of RBC transfusions. [Table: see text] [Table: see text]

Adjusted preoperative variables to predict perioperative red blood cell transfusion in coronary artery bypass grafting.

The variables for predicting blood transfusion perioperatively are not completely clear in coronary artery bypass grafting (CABG) patients. To construct a comprehensive model to predict perioperative RBC transfusion in patients undergoing isolated CABG using adjusted preoperative variables. Perioperative data of 1253 patients who underwent isolated CABG by the same surgical team were collected from April 2018 to March 2019. Logistic regression analyses were used to establish equations to construct two models for predicting intraoperative and postoperative RBC transfusions, respectively. All significant variables included in the two models were combined to form a comprehensive model to predict perioperative RBC transfusion. Area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the discriminatory power of the models. The total RBC transfusion rate for CABG patients during hospitalization was 29.05%. The rate of intraoperative and postoperative RBC transfusions was 6.9% and 26.7%, respectively. Eight variables in a total of 30 risk factors constituted the intraoperative prediction model, 12 variables constituted the postoperative prediction model, and 13 variables for the combined model. The AUC of the three models were 0.87, 0.82, and 0.83, respectively, demonstrating moderate discriminatory power for RBC transfusion during the intraoperative, postoperative, and perioperative periods. The comprehensive model combined with all variables of predicting intraoperative and postoperative RBC transfusion is feasible for predicting perioperative RBC transfusion.

Evolution of perioperative blood transfusion practice after coronary artery bypass grafting in the past two decades.

Transfusion of blood products after coronary artery bypass grafting (CABG) is associated with increased morbidity and mortality. We evaluated the perioperative use of blood products in patients undergoing CABG in our institution over the past two decades. The study included 18 992 patients who underwent isolated CABG at our hospital between 1998 and 2017. Baseline characteristics of patients and the number of perioperative transfusions during their hospital stay (including red blood cells [RBCs], platelets, and fresh frozen plasma [FFP]) were assessed. Logistic regression models were used to identify risk factors for perioperative transfusion. The rates of perioperative RBC transfusion decreased for all patients undergoing isolated CABG (52.1% in 1998 vs 18.6% in 2017) in our institution. The mean number of transfused RBC units was significantly higher in women than in men (1.57 ± 2.2 vs 0.68 ± 1.84; P < .005); this difference remained significant over the years. After adjusting the results for other risk factors, female sex was a significant independent risk factor for perioperative RBC transfusion. The platelet transfusion rate increased over the past two decades (1.4% in 1998 vs 9.7% in 2017). The number of FFP transfusions remained unchanged. Over the past two decades, we observed a decrease in the incidence of perioperative RBC transfusions in patients undergoing isolated CABG, whereas platelet transfusions increased. Female sex was an independent predictor of perioperative RBC transfusion.

114 Roxadustat Lowers Risk of RBC Transfusion in Patients with Anemia of CKD

114 Roxadustat Lowers Risk of RBC Transfusion in Patients with Anemia of CKD

Fatal Delayed Hemolytic Transfusion Reaction and Hyperhemolysiswithout Detectable Alloantibodies or Autoantibodies in a Patient withSickle Cell Disease: A Case Report and Literature Review

Background: Sickle cell disease (SCD) is one of the most commonly inherited diseases worldwide and one of the most frequently occurring genetic disorders in France. Delayed hemolytic transfusion reaction (DHTR) is a classic complication in patients with SCD who undergo blood transfusions, and this condition may lead to hyperhemolysis syndrome (HS). DHTR is described as a transfusion complication and is often associated with anti-RBC antibodies. Case report: We report the death of a 47-year-old man of Martinican origin, with sickle cell disease (SCD) and no history of alloimmunization, who was admitted to the Sens Medical Center in July 2015 due to a vaso-occlusive crisis (VOC). An antibody screening test based on the gel technique was conducted and no anti-RBC antibodies were detected. The patient was readmitted with a VOC two days after discharge and subsequently developed DHTR/HS after transfusion episodes. He succumbed to acute complications involving severe multiple organ failure after being transferred to Henri-Mondor University Hospital in Creteil. This case report was made available thanks to our Haemovigilance Network. Conclusion: This case demonstrates the importance of DHTR prevention using national guidelines to carefully assess indications for RBC transfusion in patients with SCD. Early diagnosis is crucial to prevent this life-threatening complication. Special attention should be given to less well-known and less-well monitored patients who may be at high risk for DHTR. In any event, DHTR/HS without detectable anti-RBC antibodies presents a clinical and biological challenge to our understanding of this disorder.

Epidemiology of RBC Transfusions in Patients With Severe Acute Kidney Injury: Analysis From the Randomized Evaluation of Normal Versus Augmented Level Study.

To assess the epidemiology and outcomes associated with RBC transfusion in patients with severe acute kidney injury requiring continuous renal replacement therapy. Post hoc analysis of data from a multicenter, randomized, controlled trial. Thirty-five ICUs in Australia and New Zealand. Cohort of 1,465 patients enrolled in the Randomized Evaluation of Normal versus Augmented Level replacement therapy study. Daily information on morning hemoglobin level and amount of RBC transfused were prospectively collected in the Randomized Evaluation of Normal versus Augmented Level study. We analyzed the epidemiology of such transfusions and their association with clinical outcomes. Overall, 977 patients(66.7%) received a total of 1,192 RBC units. By day 5, 785 of 977 transfused patients (80.4%) had received at least one RBC transfusion. Hemoglobin at randomization was lower in transfused than in nontransfused patients (94 vs 111 g/L; p < 0.001). Mean daily hemoglobin was 88 ± 7 and 99 ± 12 g/L in transfused and nontransfused patients. Among transfused patients, 228 (46.7%) had died by day 90 when compared with 426 (43.6%) of nontransfused patients (p = 0.27). Survivors received on average 316 ± 261 mL of RBC, whereas nonsurvivors received 302 ± 362 mL (p = 0.42). On multivariate Cox regression analysis, RBC transfusion was independently associated with lower 90-day mortality (hazard ratio, 0.55; 95% CI, 0.38-0.79). However, we found no independent association between RBC transfusions and mortality when the analyses were restricted to patients surviving at least 5 days (hazard ratio, 1.29; 95% CI, 0.90-1.85). We found no independent association between RBC transfusion and renal replacement therapy-free days, mechanical ventilator-free days, or length of stay in ICU or hospital. In patients with severe acute kidney injury treated with continuous renal replacement therapy, we found no association of RBC transfusion with 90-day mortality or other patient-centered outcomes. The optimal hemoglobin threshold for RBC transfusion in such patients needs to be determined in future randomized controlled trials.

Diagnosis and treatment of autoimmune hemolytic anemia: classic approach and recent advances.

Diagnosis and treatment of autoimmune hemolytic anemia: classic approach and recent advances.

Serological characteristics and transfusion efficacy evaluation in 61 cases of autoimmune hemolytic anemia

This study was aimed to analyze the serological characteristics, efficacy and safety of incompatible RBC transfusion in patients with autoimmune hemolytic anemia (AIHA). The patients with idiopathic or secondary AIHA were analyzed retrospectively, then the serological characteristics and the incidence of adverse transfusion reactions were investigated, and the efficacy and safety of incompatible RBC transfusion were evaluated according to the different autoantibody type and infused different RBC components. The results showed that out of 61 cases of AIHA, 21 cases were idiopathic, and 40 cases were secondary. 8 cases (13.1%) had IgM cold autoantibody, 50 cases (82.0%) had IgG warm autoantibody, and 3 cases (4.9%) had IgM and IgG autoantibodies simultaneously. There were 18 cases (29.5%) combined with alloantibodies. After the exclusion of alloantibodies interference, 113 incompatible RBC transfusions were performed for 36 patients with AIHA, total efficiency rate, total partial efficiency rate and total inefficiency rate were 56.6%, 15.1% and 28.3%, respectively. Incompatible RBC transfusions were divided into non-washed RBC group and washed RBC group. The efficiency rate, partial efficiency rate and inefficiency rate in non-washed RBC group were 57.6%, 13.0% and 29.4%, respectively. The efficiency rate, partial efficiency rate and inefficiency rate in washed RBC group were 53.6%, 21.4% and 25.0%, respectively. There was no significant difference of transfusion efficacy (P > 0.05) in two groups. Incompatible RBC transfusions were also divided into IgM cold autoantibody group and IgG warm autoantibody group. The efficiency rate, partial efficiency rate and inefficiency rate in IgM cold autoantibody group were 46.2%, 30.8% and 29.4%, respectively. The efficiency rate, partial efficiency rate and inefficiency rate in IgG warm autoantibody group were 56.7%, 13.4% and 29.9%, respectively. There was no significant difference of transfusion efficacy (P > 0.05 ) in two groups. Hemolytic transfusion reaction was not observed in all incompatible RBC transfusions. It is concluded that the same ABO type of non-washed RBC transfusion and O type washed RBC transfusion are all relatively safe for the AIHA patients with severe anemia after the exclusion of alloantibodies interference. There is no significant difference of transfusion efficacy in two groups. The same ABO type of non-washed RBC transfusion is more convenient and efficient than washed RBC transfusion, and excessive use of type O RBCs can also be avoided.

Prevalence of Allo and Auto Antibodies in Adults with SCD

AbstractAbstract 4379 Introduction:Allo- and auto- antibody formation is one of the major and serious complications of RBC transfusion in patients with sickle cell disease. This problem appears to be more common than in other diseases requiring chronic transfusion that leads to acute and delayed hemolytic transfusion reactions, serious morbidity and occasional life threatening problems. Although there have been reports describing prevalence of immunization in SCD patients, data specific for adult population with SCD is lacking. We report the prevalence of allo- and auto-immunization in adult SCD patients. Methods:Patients aged 18 and above with diagnoses of SCD, confirmed by standard hemoglobin electrophoresis, who had at least one type and cross match done from 1995 through 2011 were considered eligible. To facilitate patient management all data on antibody identification, screening and transfusions were routinely recorded in the electronic database of the Georgia Comprehensive Sickle Cell Program at Grady Health System. We gathered red cell antigen phenotype, dates and results of antibody screens, antibody specificity, and demographics which include but not limited to age in years and gender of all transfused patients. Results:A total of 424 patients 230 females and 194 males were identified with SCD who have been tested for antibodies during this period. The average age of the patients is 34 (range 18–84). A total of 138/32.5% of patients had antibodies. The most common antibodies were E (14%), C (10%) and K (8%). This may be an under estimations because antibodies disappear over time without repeated exposure. A total of 82 (19.3%) of patients developed autoantibodies. Detailed results described in Table 1. Conclusion:Allo and auto antibody formation remains significant limiting factor in finding compatible blood resulting in delays in availability of blood for transfusion that can compromise patient care in SCD. With better supportive care and hydroxyurea, adult population is growing resulting in increased need for blood transfusion and risk of antibody formation. Our practice is to do limited phenotypic matching in all patients and extended phenotype matching once antibodies are produced. Despite this practice allo- and autoimmunization continues to be a significant problem. Studies need to be done to understand pathophysiology of antibody formation in SCD and prospective randomized trials are required to define best preventive clinical practices.Table 1AntibodyNumber of patientsPercentage %C4110c3<1D164E5914e7<2K348k00Jka5<2Jkb246Fya276.35Fyb2<1S317.3Auto Antibodies8219.3M123Bga4<1A14<1Jsa102.35Lea92.11Leb2<1HTLA6<2Goa5<2Kpa1<1f1<1C+E+215C+K+123E+K+174C+E+K+7<2 Disclosures:No relevant conflicts of interest to declare.

A Stratified Metaanalysis of Desmopressin (DDAVP) for Minimising Perioperative Allogeneic Blood Transfusion.

Abstract 1306Poster Board I-328 BackgroundDDAVP has been evaluated in post-operative surgery patients without inherited bleeding disorders to determine whether it decreases blood loss and can minimise exposure to allogeneic transfusion. Previous reviews with overall negative results have not discriminated between prophylactic and therapeutic indications for DDAVP (Carless et al. 2006). The aim of this analysis was to create a systematic metaanalysis stratified for prophylactic administration of DDAVP to all patients as compared to a therapeutic indication, defined as blood loss >1l in the control group or prior aspirin medication. MethodsStudies were evaluated in the metaanalysis when they were controlled trials in which adult patients, scheduled for non-urgent surgery, were randomised to DDAVP, or to a control group, who did not receive the intervention. ResultsEighteen trials of DDAVP (n=1295) reported data on the number of patients transfused with allogeneic RBC transfusion. In subjects treated with DDAVP for therapeutic reasons, the pooled relative risk of exposure to perioperative allogeneic RBC transfusion was 0.36 (95%CI = 0.19 to 0.66). The use of DDAVP did significantly reduce blood loss; weighted mean difference (WMD) =-386 ml: 95% confidence interval (95%CI) =-542 to -231ml per patient) or the volume of RBC transfused (WMD = -340 ml: 95%CI = -547 to -134 ml per patient). In contrast, in subjects treated with DDAVP for prophylactic reasons, no significant benefit from using DDAVP was found. ConclusionsDesmopressin administered for therapeutic indications significantly minimises perioperative allogeneic RBC transfusion in patients who do not have congenital bleeding disorders. DisclosuresZotz:CSL Behring: Research Funding. Off Label Use: DDAVP is a widely used drug for increasing coagulation factor VIII and von Willebrand Factor activities.

Safety Update on Erythropoiesis-Stimulating Agents: Trials Within and Outside the Accepted Indications

Certain studies in which erythropoiesis-stimulating agents (ESAs) have been given not with the aim of correcting anemia but to achieve higher target levels of hemoglobin have shown significantly poorer survival among treated patients. However, studies in which ESAs were administered with the aim of reducing the need for RBC transfusions in patients with chemotherapy-associated anemia demonstrate that the use of these agents is not associated with any adverse effect on survival when compared with placebo controls. We can therefore be reassured that using ESAs within the labeled indications will not adversely affect patient outcome.

Absence of HBV and HCV, HTLV‐I and ‐II, and human herpes virus‐8 activation after allogeneic RBC transfusion in patients with advanced HIV‐1 infection

The Viral Activation Transfusion Study was a prospective, randomized, double-blind comparison of transfusion with WBC-reduced versus non-WBC-reduced RBCs to HIV+ patients. The primary study characterized the effect of transfusion on HIV and CMV activation by monitoring viral load changes. The present study analyzed HBV, HCV, HTLV-I and -II, and human herpes virus-8 (HHV-8) viral load before and after transfusion to evaluate the further hypothesis that global immune stimulation following allogeneic RBC transfusion results in activation and increased viral proliferation of chronic viral infections other than HIV and CMV. Baseline samples from 519 to 523 subjects were screened for HBV, HCV, HTLV-I and -II, and HHV-8 infection, and baseline, serial weekly, and quarterly blood samples from infected subjects in the non-WBC-reduced arm were evaluated for changes from baseline in viral nucleic acid and ALT levels. Seroprevalence of HBV, HCV, HTLV-I and -II, and HHV-8 was 68, 25, 5, and 30 percent, respectively. No significant induction of HBV, HCV, HHV-8, or HTLV-I and -II viral replication following allogeneic transfusion of non-WBC-reduced blood was observed. A significant, albeit small, association was observed between transfusion and ALT. Based on these results and our previous finding that no adverse effect on HIV and CMV viral load and disease progression results from allogeneic transfusion, no evidence is found to support the selective use of WBC-reduced blood components for HIV-infected patients.

Cardiovascular and metabolic response to red blood cell transfusion in critically ill volume-resuscitated nonsurgical patients

We examined the cardiovascular and metabolic response to RBC transfusion in patients with circulatory shock after volume resuscitation. Data were analyzed from 36 transfusions in 32 patients who were undergoing continuous hemodynamic monitoring. Transfusions were administered for moderate to severe anemia, mean Hgb 8.3 g/dl. The diagnosis were sepsis (19/36), cardiogenic shock (14/36), connective tissue disease (2/36), and severe hypocalcemia (1/36). Benefit from transfusion was defined as an improvement in tissue oxygen utilization (increased oxygen consumption [VO2] or decreased lactate), a decrease in myocardial VO2 (MAP x HR), or a decrease in myocardial work (left ventricular work index). Mean transfusion volume was 577 ml over 4.5 h. Hgb and oxygen delivery (DO2) increased by 27% and 28%, respectively, while pulmonary artery wedge pressure and cardiac index were unchanged. No significant change was noted in VO2, or lactate, after augmentation of red cell mass. An increase occurred in myocardial work indices and MAP x HR. No changes were identified when subgroups were analyzed based on diagnosis, pretransfusion Hgb, lactate, or VO2 levels. We conclude that selective increase in DO2 by augmentation of RBC mass and oxygen-carrying capacity did not improve the shock state in these volume-resuscitated patients, regardless of the etiology of the shock.