Received Red Blood Cell Research Articles

Racial and ethnic differences in transfusion rates in adolescent scoliosis surgery: Preoperative anemia as a mediator of disparity

AbstractBackgroundPediatric patients from minoritized racial and ethnic groups receive red blood cell (RBC) transfusions more frequently while undergoing major surgical procedures. Our objective was to identify the contribution of preoperative anemia to racial and ethnic differences in RBC transfusion rates in adolescent spine surgery.Study Design and MethodsThis is a multicenter, retrospective cohort study of the National Surgical Quality Improvement Program Pediatric database, 2016 to 2021 for patients in the United States and Canada.ResultsAdolescents identifying as non‐Hispanic Black, Hispanic, and other race/ethnicity presented with higher rates of preoperative anemia than non‐Hispanic White adolescents (16.3%, 10.6%, and 9.9%, vs. 7.8%, respectively; p < .0001) and were transfused at higher rates (14.4%, 11.9%, 16.5%, vs. 10.0%, respectively; p < .0001). Minoritized groups demonstrated higher adjusted odds of RBC transfusion compared with non‐Hispanic Whites (non‐Hispanic Black: aOR 1.45 95% CI 1.26–1.65, Hispanic: aOR 1.17 95% CI 0.96–1.41, other race/ethnicity: aOR 1.63 95% CI 1.26–2.09). Of the total effect of minoritized race and/or ethnicity on RBC transfusion, 13.9% was attributed to the indirect effect through preoperative anemia.DiscussionIn this cohort study, patients from minoritized racial and ethnic groups received RBC transfusions at a higher rate than non‐Hispanic White patients, and the difference was partially mediated by preoperative anemia. Future efforts to minimize transfusions and improve health equity should target this modifiable risk factor alongside other sources of disparity and discrimination.

Sex Differences in Red Blood Cell Transfusions and 30-Day Mortality in Cardiac Surgery: A Single Center Observational Study.

In cardiac surgery, women have higher short-term mortality and a higher risk of receiving red blood cell (RBC) transfusions than men. This study's aim was to evaluate possible sex differences in RBC transfusions in cardiac surgery and their association with preoperative hemoglobin levels, body mass index, and 30-day mortality. A single-center retrospective study was conducted with 1583 patients (1181 men and 402 women) undergoing cardiac surgery. A total of 64.4% of the women and 33.0% of the men received an RBC transfusion. In a multivariable analysis, female sex was an independent predictor of RBC transfusion (OR 3.88, 95% CI 2.95-5.11, p < 0.001). Other independent predictors of RBC transfusion were age, preoperative hemoglobin level, and body mass index. The women were more likely to receive RBC transfusions than the men, regardless of the type of cardiac surgery. Decreased transfusion risk was found in all higher-than-normal weight categories in the women, but only in the severe obesity category in the men. Preoperative hemoglobin was similarly associated with RBC transfusion in the men and women. The crude 30-day mortality rate was higher in the women than in the men (2.5% vs. 0.9%, p = 0.018). In both sexes, RBC transfusion was associated with an increased probability of death within 30 days.

Transfusion practices in intensive care units: An Australian and New Zealand point prevalence study

ObjectiveTo describe current transfusion practices in intensive care units (ICUs) in Australia and New Zealand, compare them against national guidelines, and describe how viscoelastic haemostatic assays (VHAs) are used in guiding transfusion decisions. Design, setting and participantsProspective, multicentre, binational point-prevalence study. All adult patients admitted to participating ICUs on a single day in 2021. Main outcome measuresTransfusion types, amounts, clinical reasons, and triggers; use of anti-platelet medications, anti-coagulation, and VHA. ResultsOf 712 adult patients in 51 ICUs, 71 (10%) patients received a transfusion during the 24hr period of observation. Compared to patients not transfused, these patients had higher Acute Physiology and Chronic Health Evaluation II scores (19 versus 17, p = 0.02), a greater proportion were mechanically ventilated (49.3% versus 37.3%, p < 0.05), and more had systemic inflammatory response syndrome (70.4% versus 51.3%, p < 0.01). Overall, 63 (8.8%) patients received red blood cell (RBC) transfusions, 10 (1.4%) patients received platelet transfusions, 6 (0.8%) patients received fresh frozen plasma (FFP), and 5 (0.7%) patients received cryoprecipitate. VHA was available in 42 (82.4%) sites but only used in 6.6% of transfusion episodes when available. Alignment with guidelines was found for 98.6% of RBC transfusions, but only 61.6% for platelet, 28.6% for FFP, and 20% for cryoprecipitate transfusions. ConclusionsNon-RBC transfusion decisions are often not aligned with guidelines and VHA is commonly available but rarely used to guide transfusions. Better evidence to guide transfusions in ICUs is needed.

Safety and Efficacy of Mitapivat in Adult Patients with Erythrocyte Membranopathies (SATISFY)

Background: Membranopathies encompass hemolytic disorders arising from genetic defects in erythrocyte membrane proteins and include hereditary spherocytosis and stomatocytosis. Congenital dyserythropoietic anemia type II (CDA II) is associated with SEC23B gene variants and its phenotype may be similar to hereditary spherocytosis. Anemia with or without the need for chronic transfusion, jaundice, splenomegaly, iron overload are complications common in both hereditary membranopathies and CDA II. Current treatment options for membranopathies and CDA II 1, apart from splenectomy, are primarily supportive. Mitapivat, an investigational pyruvate kinase-R (PKR) activator, has demonstrated efficacy in improving anemia and reducing hemolysis in adult patients with PK deficiency, thalassemia, sickle cell disease, and a mouse model of hereditary spherocytosis. Study Design and Methods: This study (NCT05935202) is an investigator initiated, prospective, multicenter, single-arm phase 2 trial. The study will be conducted in the European Union in Denmark and The Netherlands. It is the first clinical study in the context of the European Reference Network EuroBloodNet and will be sponsored by its closely associated non-for-profit EuroBloodNet Association. A sibling study in Toronto, Canada will be registered separately, and data will be pooled in a prespecified statistical analysis plan. The study will include approximately twenty-five adult patients (aged 18 years and older) diagnosed with a membranopathy or CDA II. Diagnosis must be confirmed genetically. Average hemoglobin concentration (Hb) must be less than 13.0 g/dL for males and 11.0 g/dL for females. Patients with average Hb &amp;gt;10.0 g/dL for males and females at screening must meet at least one of the following additional criteria: Splenomegaly, fatigue attributed to hemolysis, or paraclinical hemolysis. Adequate organ function is required. Patients cannot be included if they have a diagnosis of PK deficiency or if they have received red blood cell (RBC) transfusions (≥5 units the last 12 months or any within the last 3 months). During the 8-week Dose Escalation Period, subjects will receive an initial dose of 50 mg mitapivat twice daily (BID). Based on safety and changes in Hb levels, dosing may be increased to 100 mg BID at week 4. Patients who tolerate mitapivat may be eligible to continue in two consecutive 24-week Fixed Dose Periods, with an interim analysis in between the two fixed dose periods. The primary objective of this study is to evaluate the safety of mitapivat, assessed through the occurrence of treatment-emergent adverse events. Secondary objectives include assessing the effects of mitapivat on Hb concentration (≥1.0 g/dL increase sustained at two scheduled visits), hemolysis, erythropoiesis, patient-reported outcome measures, and spleen size. Exploratory endpoints include enzyme activity and stability of PK, Hb oxygen affinity, proteomics and metabolomics. To assess how activation of PK will impact RBC function we will measure RBC deformability (osmotic gradient ektacytometry and cell membrane stability) in whole blood and in different RBC subpopulations. Acknowledgement: This project is carried out within the framework of European Reference Network on Rare Haematological Diseases (ERN-EuroBloodNet)-Project ID No 101085717. ERN-EuroBloodNet is partly co-funded by the European Union within the framework of the Fourth EU Health Programme. The study is funded by a grant from Agios Pharmaceuticals.

Age, CD34+ cell dose, conditioning and pre-transplant cytopenias can help predict transfusion support in lymphoma patients undergoing autologous stem cell transplantation.

Autologous stem cell transplant (ASCT) is a widely used therapy for lymphoma patients and can nowadays be performed on an outpatient basis. This study aimed to describe transfusion support in lymphoma patients undergoing ASCT and identify increased or prolonged transfusion requirement predictors. A retrospective study of all consecutive lymphoma patients undergoing ASCT between 2010 and 2020. Out of 226 patients, 145 (64%) received red blood cell (RBC) transfusions, whereas all 226 (100%) required platelet transfusion (PT). Transfusions between Day +1 and +30 were higher in patients over 60 (2 [1-4] vs. 2 [0-2] RBC; p = 0.001 and 4 [2-8] vs. 3 [2-4] PT; p < 0.001); patients with pre-transplant anaemia (4 [2.5-6] vs. 2 [0-2] RBC; p < 0.001 and 5 [3-9] vs. 3 [2-4] PT; p = 0.001); pre-transplant thrombocytopenia (2 [1-4] vs. 2 [0-2] RBC; p < 0.001 and 4 [3-8.5] vs. 2 [1-3] PT; p < 0.001) or CD34+ cell dose <4 × 106 /kg (2 [0-4] vs. 2 [0-2] RBC; p = 0.024 and 4 [2-6] vs. 2 [1-3.5] PT; p < 0.001). RBC transfusion independence was reached later in patients receiving carmustine, cytarabine, etoposide and melphalan (BEAM) (hazard ratio [HR] 1.6; confidence interval [CI] 1.1-2.3) and those requiring RBC before infusion and/or with pre-transplant anaemia (HR 2.2; CI 1.4-3.4). Age above 60 (HR 1.4; CI 1.0-1.9), BEAM conditioning (HR 1.4; CI 1.0-2.0) and pre-transplant thrombocytopenia and/or requiring PT before infusion (HR 1.8; CI 1.4-2.5) entailed longer time until PT independence. These four factors (age ≥60 years; BEAM conditioning, CD34+ dose <4 × 106 /kg and pre-transplant cytopenia and/or Day -10 to 0 transfusion) allowed dividing patients into three groups with significant differences between them regarding the time until transfusion independence.

Survey of transfusion practices in preterm infants in Europe

BackgroundPreterm infants commonly receive red blood cell (RBC), platelet and fresh frozen plasma (FFP) transfusions. The aim of this Neonatal Transfusion Network survey was to describe current transfusion practices in...

Workflow Improvement after Implementing Remote Blood Allocation Devices at an Academic Medical Center Blood Bank

Abstract Introduction/Objective Patients with hematological cancer routinely receive red blood cell (RBC) transfusions in the outpatient infusion clinical setting as part of their clinical therapy. Typically, RBCs are delivered to the outpatient infusion clinic via the pneumatic tube (P-tube). However, due to the recent expansion of the hospital footprint and the new location of the transfusion services, the P-tube encountered challenges that impacted the reliability of the delivery of RBC, which can delay patient care and affect patient satisfaction. This study’s purpose is to evaluate the pre-and post-implementation of the Haemobank-20 (HB20), remote blood storage and dispensing device, by reviewing the turn-around time (TAT) and the number of orders fulfilled outside of the transfusion service. Methods/Case Report Blood products are stocked to the HB in the infusion center. An electronic transfusion schedule is reviewed the night before scheduled transfusions to ensure appropriate inventory. When a patient is ready for the transfusion, the clinical nurse will use the device to retrieve blood products for the patient from the HB20. The average timed delivery time from the transfusion service to the outpatient infusion center is about 11 minutes. Data was retrospectively gathered from a 10-month interval before and after HB20 implementation to evaluate the number of orders fulfilled by the HB20. Results (if a Case Study enter NA) The HB has helped maintain nurse-to-patient ratios, reduced traffic at the blood bank issue window, and significantly sped up the turnaround time of RBCs from 11 minutes to less than 60 seconds. Before HB implementation, staff at the blood bank received 2853 units of RBCs through the blood bank window. This has been decreased by 61.2 percent to 1136 RBCs. Conclusion Implementing the Haemobank-20 in the outpatient infusion center has successfully reduced the turnaround time and the workload within the Transfusion Services. The current results study demonstrate that the remote blood-release system is safe and helpful in improving the efficiency of blood issue for patients in remote outpatient locations.

Revisiting Triggers: Optimal Thresholds for Transfusion in Gastrointestinal Bleeding May Be Higher Than Restrictive Guidelines

Acute upper gastrointestinal bleeding (AUGIB) is an acute medical emergency with an incidence of 48 to 180 cases and a case fatality of around 10%.1–4 Up to 50% of patients receive red blood cell (RBC) transfusion during resuscitation.4,5 Earlier guidelines recommended RBC transfusion when hemoglobin (Hb) fell lower than 10 g/dL, but following the results of clinical trials demonstrating the safety of more restrictive transfusion, clinical practice has shifted to a more conservative approach to transfusion for AUGIB,6–9 offering the potential to preserve global blood resources.

PB1926: REAL-WORLD ERYTHROPOIESIS-STIMULATING AGENT (ESA) TREATMENT PATTERNS AND OUTCOMES AMONG US PATIENTS WITH LOWER-RISK MYELODYSPLASTIC SYNDROMES (LR-MDS)

Background: ESAs are used in first-line treatment for symptomatic or transfusion-dependent anemia in patients with LR-MDS. Ultimately, the majority of patients with LR-MDS who receive an ESA will experience ESA treatment failure. Aims: This real-world (RW) study aims to describe patient characteristics, treatment patterns including ESA use, and outcomes in patients with LR-MDS. Methods: A retrospective, observational, US multisite, cohort chart review of adult patients diagnosed with LR-MDS between January 1, 2015 and June 24, 2020 was conducted. Eligible patients had not received luspatercept or participated in a clinical trial and had ≥ 1 year of follow-up after LR-MDS diagnosis, unless follow-up was < 1 year due to death during this interval. Demographics, clinical characteristics, treatment patterns, and outcomes were summarized using descriptive statistics. Median duration of therapy (DOT) was estimated using the Kaplan-Meier method. Results: Among 338 eligible patients, median age at LR-MDS diagnosis was 70 years (range: 19–100), 55% were female, 71% were White, 17% had known detection of del(5q), and ring sideroblast status was known to be positive for 7%. Transfusion independence within the 8 weeks prior to diagnosis (TI8) was reported for 48% of eligible patients and 17% had intermediate-1/ intermediate disease risk by IPSS/IPSS-R risk classification. Within the study follow-up time (median of 28.3 months from diagnosis), 76% of patients had received systemic therapy for MDS (median DOT: 29.2 months). An ESA was used in 56% (n = 190) of patients, of whom 38% received red blood cell (RBC) transfusions during ESA treatment. Of those receiving systemic treatment for LR-MDS, 11% were hospitalized for reasons that physicians reported were related to MDS treatment complications. At the time of data collection, 30% of patients had died. Among 38 patients determined to have failed ESA treatment by abstracting physicians, 11% had TI8, 34% had intermediate-1/ intermediate disease risk, 82% received RBC transfusions during ESA treatment, 26% required hospitalization that abstracting physicians reported was related to MDS treatment complications, 32% continued to receive ESA post-failure, and 53% were deceased at data collection. Summary/Conclusion: Results from this RW study indicate that a higher proportion of patients with LR-MDS who experienced ESA treatment failure according to abstracting physicians had intermediate-1/ intermediate disease risk at diagnosis, were transfusion dependent at diagnosis, required RBC transfusions during ESA treatment, were hospitalized for reasons related to MDS treatment complications, and had poor short-term survival. Nearly a third of patients who experienced ESA treatment failure still received an ESA after initial failure. In summary, findings from this study indicate that patients with LR-MDS who experience ESA treatment failure are likely to have worse outcomes.

Real-world erythropoiesis-stimulating agent (ESA) treatment patterns and outcomes among U.S. patients with lower-risk myelodysplastic syndromes (LR-MDS).

e19065 Background: ESAs are used in first-line treatment for symptomatic or transfusion-dependent anemia in patients (pts) with LR-MDS. Ultimately, the majority of pts with LR-MDS who receive an ESA will experience ESA treatment failure. This real-world (RW) study aims to describe pt characteristics, treatment patterns including ESA use, and outcomes in pts with LR-MDS. Methods: A retrospective, observational, US multisite, cohort chart review of adult pts diagnosed with LR-MDS between January 1, 2015 and June 24, 2020 was conducted. Eligible pts had not received luspatercept or participated in a clinical trial and had ≥ 1 year of follow-up after LR-MDS diagnosis, unless follow-up was &lt; 1 year due to death during this interval. Demographics, clinical characteristics, treatment patterns, and outcomes were summarized using descriptive statistics. Median duration of therapy (DOT) was estimated using the Kaplan-Meier method. Results: Among 338 eligible pts, median age at LR-MDS diagnosis was 70 years (range: 19–100), 55% were female, 71% were White, 17% had known detection of del(5q), and ring sideroblast status was known to be positive for 7%. Transfusion independence within the 8 weeks prior to diagnosis (TI8) was reported for 48% of eligible pts and 17% had intermediate-1/ intermediate disease risk by IPSS/ IPSS-R risk classification. Within the study follow-up time (median of 28.3 months from diagnosis), 76% of pts had received systemic therapy for MDS (median DOT: 29.2 months). An ESA was used in 56% (n = 190) of pts, of whom 38% received red blood cell (RBC) transfusions during ESA treatment. Of those receiving systemic treatment for LR-MDS, 11% were hospitalized for reasons that physicians reported were related to MDS treatment complications. At the time of data collection, 30% of pts had died. Among 38 pts determined to have failed ESA treatment by abstracting physicians, 11% had TI8, 34% had intermediate-1/ intermediate disease risk, 82% received RBC transfusions during ESA treatment, 26% required hospitalization that abstracting physicians reported was related to MDS treatment complications, 32% continued to receive ESA post-failure, and 53% were deceased at data collection. Conclusions: Results from this RW study indicate that a higher proportion of pts with LR-MDS who experienced ESA treatment failure according to abstracting physicians had intermediate-1/ intermediate disease risk at diagnosis, were transfusion dependent at diagnosis, required RBC transfusions during ESA treatment, were hospitalized for reasons related to MDS treatment complications, and had poor short-term survival. Nearly a third of pts who experienced ESA treatment failure still received an ESA after initial failure. In summary, findings from this study indicate that pts with LR-MDS who experience ESA treatment failure are likely to have worse outcomes.

Open-label, phase 2 study of roxadustat for treatment of anemia in patients receiving chemotherapy for non-myeloid malignancies.

12085 Background: Anemia is prevalent in patients (pts) receiving myelosuppressive chemotherapy (&gt; 60%) and exacerbated by repeated treatment cycles due to cytotoxic agent accumulation. Chemotherapy-induced anemia (CIA) management options are suboptimal. We evaluated the efficacy and safety of roxadustat in pts with anemia receiving myelosuppressive chemotherapy. Methods: This open-label, single-arm, proof-of-concept Phase 2 study included pts with mostly advanced, non-myeloid malignancies and CIA (hemoglobin [Hb] ≤10 g/dL) who had not received red blood cell (RBC) transfusion or erythropoietin-stimulating agents within 4 weeks of enrollment. Patients were treated with oral roxadustat for ≤16 weeks. The primary efficacy endpoint was maximum mean change in Hb within 16 weeks of baseline without RBC transfusion in pts who had received ≥1 dose of roxadustat and who had a baseline and ≥1 post-dose Hb assessment. Hb response and safety data were preliminarily assessed in pts receiving a starting dose of 2.0 mg/kg thrice weekly (TIW) for 4 weeks: doses of 100, 150, and 200 mg were given to pts weighing &lt; 70, 70–100, and &gt; 100 kg, respectively. Following a review of data from these pts, dose was increased to 2.5 mg/kg—150, 200, and 250 mg TIW to pts weighing &lt; 70, 70–100, and &gt; 100 kg, respectively—and adjusted every 4 weeks from Week 5 based on Hb response. Results: Patients were assigned to 2.0 mg/kg (n = 31) and 2.5 mg/kg (n = 61) starting doses, and 89 were assessed for efficacy. The maximum mean Hb change from baseline without RBC transfusion was 2.47±1.51 g/dL and 2.52±1.54 g/dL in the 2.0 mg/kg and 2.5 mg/kg cohorts, respectively. Hb increased by ≥1.5 g/dL in 73% of pts and ≥2.0 g/dL in 61% of pts. Median time to ≥2.0 g/dL Hb increase was 71.0 days. Both cohorts had higher proportions of pts with a Hb increase of ≥1, ≥1.5, or ≥2 g/dL at Week 16 compared with baseline. Median time to ≥1 and ≥2 g/dL Hb increase was shorter in pts who started on 2.5 mg/kg compared with 2.0 mg/kg doses (≥1 g/dL: 30 vs 44; ≥2 g/dL 57 vs 105, respectively). Fewer pts required an RBC transfusion (Week 5 to end of treatment) when starting on 2.5 mg/kg compared with 2.0 mg/kg doses (10.2% vs 20.0%). Subgroup analyses based on major tumor and baseline chemotherapy types demonstrated efficacy of roxadustat at both starting doses. The overall safety profile observed was consistent with the patient population under study. Overall, 92% of pts experienced an adverse event (AE). Most AEs were consistent with the underlying malignancies and chemotherapy regimens used. The incidence of deep vein thrombosis was 15.2% (n = 14) and pulmonary embolism was 9.8% (n = 9). There were 17 deaths (18.5%) during the study; none were attributed to roxadustat, and most were associated with disease progression. Conclusions: Roxadustat increased Hb in CIA regardless of tumor type and chemotherapy regimen. These data support additional clinical study. Clinical trial information: NCT04076943.

Red blood cell transfusion in myelodysplastic syndromes: A systematic review.

Patients with myelodysplastic syndrome (MDS) frequently receive red blood cell (RBC) transfusions for anaemia resulting from ineffective erythropoiesis. While RBC transfusions may rapidly increase haemoglobin values, their impact on clinical and health services outcomes in MDS patients has not previously been summarized. We conducted a systematic review of the literature to evaluate risks and benefits of RBC transfusions in MDS patients. We searched electronic databases (MEDLINE, Embase, CENTRAL, CINAHL) from inception through June 4, 2021 to identify studies reporting data on RBC transfusions in MDS patients. Full text publications that assessed RBC transfusions as an intervention and reported at least one clinical, laboratory, or healthcare outcome associated with transfusion were included. Study characteristics, transfusion information and transfusion-related outcomes were extracted and reported. We identified 1243 original studies, of which 38 met eligibility requirements and were included. Fourteen reported on survival following diagnosis of MDS, with the majority reporting poorer survival among patients receiving or requiring more frequent transfusions. Nine reported on transfusion-related iron overload and its complications. Other outcomes included rates of allo/autoimmunization and adverse transfusion reactions, and healthcare costs incurred by patients with a greater transfusion burden. Only two studies reported on symptom relief following transfusion. This review underscores transfusion dependence as a negative prognostic factor for MDS patients and highlights the paucity of evidence surrounding quality of life and symptom-related outcomes following RBC transfusions in this population. Further study of patient-important outcomes associated with transfusion in MDS patients is warranted to improve therapeutic recommendations and inform resource allocation.

Sex Differences in Anemia and Red Blood Cell Transfusions Among General Internal Medicine Inpatients

Background: Epidemiological data from the general population have shown that women have lower hemoglobin values compared to men. Previous research on surgical patients showed that women were significantly more likely to receive red blood cell (RBC) transfusions compared to men in the peri-operative period due to multiple factors including the application of absolute transfusion thresholds. Sex differences in RBC transfusion frequencies have not been well studied in non-surgical settings. Here we investigated sex differences in anemia and in RBC transfusion frequencies in patients admitted to General Internal Medicine (GIM) wards.Study design and methods: This was a retrospective cohort study using de-identified electronic patient data from all patients admitted to the GIM wards from the emergency department across 4 different hospitals between 2010 and 2017, who had at least 1 CBC test during their admission. Patients with multiple hospital admissions during the study period, those who were pregnant, those who underwent surgery during the admission, and those transferred to or from another service besides GIM during their admission were excluded. Severity of anemia was stratified using the WHO sex-specific quantitative thresholds for hemoglobin: mild anemia (110 to 119 g/L in women and 110 to 129 g/L in men), moderate anemia (80 to 109 g/L in both men and women) and severe anemia (lower than 80 g/L in both men and women).Results: The study cohort consisted of 51,073 inpatients (24,666 men and 26,407 women). The median hemoglobin at the time of admission was significantly higher (p < 0.001) in men (median 135 g/L, IQR 31) compared to women (median 127 g/L, IQR 25). The prevalence of moderate and severe anemia was significantly higher (p < 0.001) in female inpatients (56%) compared to males (44%). The proportion of patients who received RBC transfusions during their admission was not significantly different (p = 0.36) between men (49%) and women (51%). There was no significant sex difference (p = 0.28) observed in the median hemoglobin prior to RBC transfusions between men (median 68 g/L, IQR 10.5) and women (median 68 g/L, IQR 11). The number of patients with pre-transfusion hemoglobin less than 70 g/L, the commonly used threshold for transfusion in the in-patient setting, was not significantly different (p = 0.91) between men and women. However, among the patients with hemoglobin < 70 g/L, a significantly lower proportion (p < 0.001) of women (82%) received RBC transfusions compared to men (91%).Conclusions: In a large cohort of GIM inpatients, we observed significantly higher prevalence of moderate and severe anemia in women compared to men. While there was no sex difference in overall RBC transfusion frequencies in this inpatient population, there was a lower proportion of women receiving RBC transfusions compared to men in the subgroup of patients with hemoglobin less than 70 g/L. DisclosuresNo relevant conflicts of interest to declare.

Percutaneous coronary intervention on combined VA-ECMO and IMPELLA (ECPELLA) support may reduce myocardial damage in cardiogenic shock patients with STEMI who required mechanical circulatory support

Abstract Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an effective therapeutic modality for patients with cardiogenic shock (CS) including STEMI. The VA-ECMO maintains end-organ perfusion, however, it significantly increases damaged left ventricular (LV) afterload. Combined treatment of VA-ECMO and a micro-axial Impella pump, ECPELLA, simultaneously provides systemic circulatory support and LV loading reduction (LV unloading). Studies in ischemic animal models displayed that LV unloading reduced myocardial size. However, it remains unknown whether LV unloading effect by ECPELLA during percutaneous coronary intervention (PCI) can reduce myocardial damage in human STEMI patients with severe cardiogenic shock. Purpose This study was to assess whether PCI on ECPELLA support can reduce myocardial damage in STEMI patients with severe cardiogenic shock. Methods Sixteen consecutive patients with STEMI and lethal CS (SCAI stage E) were enrolled. All patients suffered from cardiac arrest. Fifteen patients (94%) underwent extracorporeal cardiopulmonary resuscitation using VA-ECMO. From October 2018 to November 2019, PCI was carried out on VA-ECMO support and the mechanical circulatory support (MCS) modality during PCI was switched to ECPELLA since December 2019. There were 8 patients who underwent PCI on ECPELLA support (ECPELLA-PCI) and 8 patients who underwent PCI on single VA-ECMO support (ECMO-PCI). All patients in ECMO-PCI group were escalated to ECPELLA after PCI. Therefore, the difference between groups was timing of LV unloading, i.e., pre-PCI or post-PCI condition. We assessed total MCS flow during PCI, and peak and time course changes in CK-MB levels from days 0 to 3. Results There were no significant differences in age, rate of male sex, body surface area, shockable rhythm, serum lactate levels, and door to MCS time. Patients in ECPELLA-PCI had significantly longer door to recanalization time (73min in ECPELLA vs. 49min in VA-ECMO, p&amp;lt;0.05), and higher total MCS flow during PCI (3.1 L/min/sqM vs. 2.0 L/min/sqM, p&amp;lt;0.05). Peak and the area under the curves (AUC) from day 0 to day 3 of CK-MB in ECPELLA-PCI were significantly lower than ECMO-PCI group (peak CK-MB 120 vs. 524 IU/L and CK-MB AUC 143 vs. 464 IU/L*Day, respectively, p&amp;lt;0.05). While all patients received red blood cell (RBC) and plasma (PL) transfusions, ECPELLA-PCI required larger amount of RBC and PL transfusions (p&amp;lt;0.05). Conclusion The ECPELLA-PCI appeared to reduce myocardial damage shown by peak and AUC of CK-MB levels. Lager amount of blood transfusion is a major drawback of this treatment modality. Further studies are necessary whether ECPELLA-PCI is an effective revascularization approach for myocardial damage reduction with favorable mid- and long-term outcome in patients with STEMI with severe cardiogenic shock. Funding Acknowledgement Type of funding sources: None. Total MCS FLow and Ttoal MCS flow indexPeak CK-MB and CK-MB AUC

Transfusion in orthopaedic surgery : a retrospective multicentre cohort study.

AimsOrthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements.MethodsWe performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma.ResultsOf the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon.ConclusionOrthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies.Cite this article: Bone Jt Open 2021;2(10):850–857.

The Effect of the Transfusion Protocol on Transfusion Rates and Short-term Outcomes of Preterm Infants in a Tertiary Neonatal Intensive Care Unit

Background: The aim of this study was to compare the epochs before and after the revision of the transfusion guideline, and determine their effects on transfusion rates and short-term outcomes in preterm infants. Materials and Methods: This retrospective study was conducted to investigate the effect of the new transfusion guideline. Infants who were born &lt;32 weeks of gestation and received red blood cell (RBC) transfusion in their first 6-weeks of life were divided into two epochs according to adopting the new transfusion guideline. The demographic and clinical data of the patients were compared between these two periods. Results: Fifty-six infants were included (Period 1, n=22; Period, n=34). The number of transfusions, total and cumulative volume of the transfusions were similar in the two periods. There was an inverse relationship between the gestational age and the number of transfusions in both periods (r=-0.575, p=0.005, and r=-0.494, p=0.003), and there was an inverse relationship between the birth weight and the number of transfusions in period 2 (r=-0.423, p=0.013). The ratio of total phlebotomy volume to estimated total blood volume was higher in period 2 (p=0.029). There was a direct relationship between the phlebotomy loss and volume of RBC transfused in period 2 (r=0.487, p=0.003). The incidence of morbidities was similar in the two periods. Conclusion: Changing only the transfusion protocol did not decrease the transfusion number. Although transfusion guidelines were adopted rigorously, it seems to be impossible to reduce RBC transfusion rates unless anemia prevention strategies were also in place.

Association of Blood Donor Sex and Age With Outcomes in Very Low-Birth-Weight Infants Receiving Blood Transfusion

There are conflicting data on the association between blood donor characteristics and outcomes among patients receiving transfusions. To evaluate the association of blood donor sex and age with mortality or serious morbidity in very low-birth-weight (VLBW) infants receiving blood transfusions. This is a cohort study using data collected from 3 hospitals in Atlanta, Georgia. VLBW infants (≤1500 g) who received red blood cell (RBC) transfusion from exclusively male or female donors were enrolled from January 2010 to February 2014. Infants received follow-up until 90 days, hospital discharge, transfer to a non-study-affiliated hospital, or death. Data analysis was performed from July 2019 to December 2020. Donor sex and mean donor age. The primary outcome was a composite outcome of death, necrotizing enterocolitis (Bell stage II or higher), retinopathy of prematurity (stage III or higher), or moderate-to-severe bronchopulmonary dysplasia. Modified Poisson regression, with consideration of covariate interactions, was used to estimate the association between donor sex and age with the primary outcome, with adjustment for the total number of transfusions and birth weight. In total, 181 infants were evaluated, with a mean (SD) birth weight of 919 (253) g and mean (SD) gestational age of 27.0 (2.2) weeks; 56 infants (31%) received RBC transfusion from exclusively female donors. The mean (SD) donor age was 46.6 (13.7) years. The primary outcome incidence was 21% (12 of 56 infants) among infants receiving RBCs from exclusively female donors, compared with 45% (56 of 125 infants) among those receiving RBCs from exclusively male donors. Significant interactions were detected between female donor and donor age (P for interaction = .005) and between female donor and number of transfusions (P for interaction < .001). For the typical infant, who received a median (interquartile range) of 2 (1-3) transfusions, RBC transfusion from exclusively female donors, compared with male donors, was associated with a lower risk of the primary outcome (relative risk, 0.29; 95% CI, 0.16-0.54). The protective association between RBC transfusions from female donors, compared with male donors, and the primary outcome increased as the donor age increased, but decreased as the number of transfusions increased. These findings suggest that RBC transfusion from female donors, particularly older female donors, is associated with a lower risk of death or serious morbidity in VLBW infants receiving transfusion. Larger studies confirming these findings and examining potential mechanisms are warranted.

The Association between Peri-Transplant RBC Transfusion and Graft Failure after Kidney Transplantation: A Nationwide Cohort Study.

Background: Patients undergoing kidney transplantation (KT) often receive red blood cell (RBC) transfusion during admission for KT which may increase the risk of allosensitization. The association between peri-transplant RBC transfusion and graft survival was evaluated using a nationwide cohort. Methods: This retrospective study analyzed 13,871 patients who underwent KT in Korea between 2007 and 2015. The outcomes were graft failure rate and overall patient survival depending on the amount of RBC transfusion. Results: The overall graft failure rate was 15.5%. Compared to the graft failure rate of 13.5% in the no transfusion group, the graft failure rate was 15.4% in the 1–2 units group (sHR 1.06 (95% CI 0.97–1.17), p = 0.216), 21.4% in the 3–5 units group (sHR 1.39 (1.21–1.61), p < 0.001), and 35.3% in the 6 or more units group (sHR 2.20 (1.70–2.85), p < 0.001). The overall survival rate was 97.5% in the no transfusion group, compared to 95.9% in the 1–2 units group (HR 1.50 (1.22–1.83), p < 0.001), 92.0% in the 3–5 units group (HR 2.43 (1.87–3.15), p < 0.001), and 67.5% in the 6 or more units group (HR 6.81 (5.03–9.22), p < 0.001). Conclusions: Peri-transplant RBC transfusion was independently associated with the increased risk of renal allograft failure and death in KT patients.

Effect of RBC Transfusion on Six Minute Walk Test Performance and Quality of Life in Outpatients

Patients with cancer or other diagnoses associated with chronic anemia often receive red blood cell (RBC) transfusion as outpatients for symptoms including fatigue. To determine the effect of RBC transfusion on functional status and quality of life (QoL), we measured 6-minute walk test distance and fatigue-related QoL scores before and after RBC transfusion in outpatients.MethodsThe Red Cells in Outpatients Transfusion Outcomes (RETRO) study was a prospective, observational study of subjects before and after RBC transfusion. Patients were recruited through hospital outpatient infusion units at 4 sites. To account for potential confounding effects of chemotherapy, patients were classified into 2 groups based on cancer treatment (CT) within 4 weeks before or after the study transfusion (CT group) or not (No CT group). Inclusion criteria were age ≥ 50, ambulatory, and chronic anemia with at least one prior RBC within 6 months. Exclusion criteria included active bleed and recent myocardial infarction. Walk test distance, QoL (FACIT-Fatigue Scale), and hemoglobin (Hgb) were measured before and at 5-10 days post-transfusion. Extra RBC transfusions given as part of clinical care and interim Emergency Department (ED) or hospital admissions during the study were recorded. Unadjusted results are expressed as median, interquartile range (IQR) and p values assigned using signed rank test. Regression analyses of change in walk test distance and change in QoL score were performed using backwards elimination to identify significant clinical variables. Minimum clinically important change in walk test distance was 20 meters (m) and in QoL score was 3 points based on literature review.ResultsA total of 221 patients with at least one benign or malignant hematology/oncology diagnosis enrolled and 200 (138 CT, 62 No CT) completed both pre- and post-transfusion walk tests. Mean subject age was 66 and 1 RBC (73%) or 2 RBC (27%) were transfused during the study transfusion episode; 18% received 1-3 additional RBC between walk tests. On average, walk test distance and QoL scores were higher after transfusion. In the No CT group, unadjusted median change in walk test distance was 30 m (IQR 0 to 50; p<0.001). In the CT group, median change in walk test was 16 m (IQR -11 to 45; p<0.001). Median change in QoL score pre- to post-transfusion in the no CT group was 4.0 points (IQR 0 to 11; p<0.001) and 2.5 points (IQR -3 to 7.5; p<0.003) in the CT group.In the regression model of change in walk test distance with RBC, no recent cancer treatment, absence of interim ED visits or hospitalizations, post-transfusion Hgb ≥8 g/dL, and total RBC dose predicted larger increases in walk distance (p<0.05) (Table). Patients with no recent CT had an estimated adjusted change in walk test distance of 24.2 m greater on average than CT patients. Grouped by post-transfusion Hgb, the mean change in walk test distance between patients with post-transfusion Hgb ≥8 and <8 g/dL was 31 m. The total number of RBC transfused between walk tests also predicted greater improvement in walk performance (estimated adjusted mean difference in walk test distance 17.9 m per RBC unit).In the regression model of QoL, baseline Hgb, and Karnofsky score were associated with change in fatigue-related QoL in addition to no CT and lack of interim events (p<0.05). Patients with higher baseline Hgb had larger increase in QoL score (adjusted mean difference 3.8 scale points per g/dL Hgb).The following variables were not significantly associated with change in either primary outcome with transfusion: age, sex, body mass index, number of previous RBC transfusions, and change in Hgb at 1 week.ConclusionsRBC transfusion in outpatients improves walk test performance and fatigue-related QoL. Patients who maintained Hgb 8 g/dL or greater at one week post RBC showed clinically important (>20 m) increases in mean walk test distance. Patients with higher baseline Hgb levels showed relatively larger improvement in QoL scores. For both outcomes, improvement with RBC was most apparent in clinically stable patients not on chemotherapy. The finding that increased RBC dose between walk tests predicted greater increase in walk distance suggests that more RBC transfusion may further improve functional status in some patients. Studies that measure patient-related outcomes, including functional status and QoL, are essential in deciding which oncology patients will benefit the most from RBC transfusion. [Display omitted] DisclosuresCarson:Terumo: Research Funding.

Iron Overload in Lower International Prognostic Scoring System Risk Myelodysplastic Syndromes Patients Receiving Red Blood Cell Transfusions: Relation to Infection and Possible Benefit of Iron Chelation Therapy

Background: Analyses in lower risk myelodysplastic syndromes (MDS) suggest inferior survival in patients (pts) with transfusional iron overload (IOL). Some studies suggest an increased incidence of infections and infection related mortality in transfused MDS pts. Reducing IOL with iron chelation therapy (ICT) appears to give clinical benefit. The literature suggests that IOL can predispose to bacterial, fungal and viral infections, as organisms use iron for metabolism and cell division, and IOL can adversely affect neutrophil function. There are no clinical studies examining infection risk in MDS pts with IOL in the non-stem cell transplant (SCT) setting, and whether this risk can be attenuated with ICT.Methods: We performed a retrospective analysis of pts with a bone marrow biopsy confirmed diagnosis of lower International Prognostic Scoring System (IPSS) risk MDS receiving red blood cell (RBC) transfusions. Pts were identified from the clinical database and charts reviewed. Clinical data extracted included baseline characteristics, serum ferritin level (SF), treatment, and infectious episodes requiring antibiotics, antifungal or antiviral medications. Statistical analyses were performed using SPSS for Windows, version 24.Results: Of 182 transfused MDS pts, 138 were lower IPSS risk. 44 pts were excluded for: not transfused as lower risk, n=19; higher IPSS risk, or received hypomethylating agent or SCT, n=13; and inadequate information, n=12. The median (range) age at first RBC transfusion was 72.5 (31-93) years and 78 (57%) pts were male. 59 pts received ICT: deferasirox (DFX), n=45 (76.3%); deferoxamine (DFO), n=13 (22.0%); and deferiprone, n=1 (1.7%); and 79 did not receive ICT. Median (range) time from 1st RBC transfusion to ICT was 22.5 (1.4-209) months and duration of ICT 13 (1-75) months. Clinical factors differing between ICT and non-ICT pts, respectively, were (median [range]): age at 1st RBC transfusion, 67 (31-88) and 75 (43-93) years; number of RBC units (U) transfused while lower risk, 76 (10-675) and 24 (2-200); number of RBCU/4 weeks, 2.2 (0.5-9.1) and 2.0 (0.1-5.4); SF 914 (49-15608) and 266 (12-5009) ng/mL; and other treatments received, 18 (30.5%) and 5 (6.3%); p</=0.04 for all. Factors not differing between groups were: gender; French American British or World Health Organization MDS diagnosis; marrow blast count; IPSS or IPSSR cytogenetic risk; IPSS or IPSSR risk; neutrophil count at first RBC transfusion or at first infection; and causes of death, p=NS for all. Infections included: bacterial, n=88; viral; fungal; and mycobacterial; n=2 each. In ICT and non-ICT pts, respectively, infections while lower IPSS risk were (number [%]): pts, 23 (40.0%) and 22 (27.8%); episodes (median [range]), 2 (1-6) and 2 (1-5); hospitalizations, 16 (27.1%) and 8 (10.1%); and infectious deaths, 0 (0%) and 1 (1.3%), p=NS for all. In ICT pts, infections occurred pre-ICT in 9 (15.3%); on DFX, n=10 (22.2%), and on DFO, n=4 (30.8%), p<0.0001. Median overall survival (OS) from 1st RBC transfusion while lower IPSS risk was not reached at 105, and 50.1 months for ICT and non-ICT pts, respectively, p=0.01. ICT remained significant for OS in a multivariate analysis (MVA) including: ICT; IPSS cytogenetic risk; and hospitalization for infection; (all p</=0.06 in univariate analysis), p=0.003, hazard ratio (HR) 0.3, 95% confidence intervals (CI) 0.2-0.7, and lost significance when number of RBCU received (p<0.0001) was added to the MVA. However, OS was significantly superior for ICT pts receiving >20 and >50 RBCU (p=0.02, and <0.0001, respectively). Median time to first infection (TTI) was 27 and 7.8 months for ICT and non-ICT pts, respectively, p<0.0001 (Figure 1). ICT remained significant for TTI in an MVA including: age; IPSS cytogenetic risk; marrow blast count; and number of RBCU received (p=0.03, HR 0.3, 95% CI 0.09-0.9). For TTI, marrow blast count was also significant in the MVA (p=0.04). TTI remained significantly longer for ICT pts with blast count <5% (p=0.004).Conclusions: In this retrospective, non-controlled analysis, for lower IPSS risk MDS patients receiving RBC transfusions, receiving iron chelation therapy was associated with superior overall survival. Though number and type of infections were similar between groups and despite similar neutrophil counts, time to first infection was significantly longer in ICT patients. These results should be confirmed in larger, prospective analyses. [Display omitted] DisclosuresLeitch:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Exjade: Speakers Bureau; Abbvie: Research Funding; Alexion: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.