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Radford M, Estcourt LJ, Sirotich E, Pitre T, Britto J, Watson M, Brunskill SJ, Fergusson DA, Dorée C, Arnold DM. Restrictive versus liberal red blood cell transfusion strategies for people with haematological malignancies treated with intensive chemotherapy or radiotherapy, or both, with or without haematopoietic stem cell support. Cochrane Database Syst Rev 2024; 5:CD011305. [PMID: 38780066 PMCID: PMC11112982 DOI: 10.1002/14651858.cd011305.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND An estimated one-quarter to one-half of people diagnosed with haematological malignancies experience anaemia. There are different strategies for red blood cell (RBC) transfusions to treat anaemia. A restrictive transfusion strategy permits a lower haemoglobin (Hb) level whereas a liberal transfusion strategy aims to maintain a higher Hb. The most effective and safest strategy is unknown. OBJECTIVES To determine the efficacy and safety of restrictive versus liberal RBC transfusion strategies for people diagnosed with haematological malignancies treated with intensive chemotherapy or radiotherapy, or both, with or without a haematopoietic stem cell transplant (HSCT). SEARCH METHODS We searched for randomised controlled trials (RCTs) and non-randomised studies (NRS) in MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1982), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2023, Issue 2), and eight other databases (including three trial registries) to 21 March 2023. We also searched grey literature and contacted experts in transfusion for additional trials. There were no language, date or publication status restrictions. SELECTION CRITERIA We included RCTs and prospective NRS that evaluated restrictive versus liberal RBC transfusion strategies in children or adults with malignant haematological disorders receiving intensive chemotherapy or radiotherapy, or both, with or without HSCT. DATA COLLECTION AND ANALYSIS Two authors independently screened references, full-text reports of potentially relevant studies, extracted data from the studies, and assessed the risk of bias. Any disagreement was discussed and resolved with a third review author. Dichotomous outcomes were presented as a risk ratio (RR) with a 95% confidence interval (CI). Narrative syntheses were used for heterogeneous outcome measures. Review Manager Web was used to meta-analyse the data. Main outcomes of interest included: all-cause mortality at 31 to 100 days, quality of life, number of participants with any bleeding, number of participants with clinically significant bleeding, serious infections, length of hospital admission (days) and hospital readmission at 0 to 3 months. The certainty of the evidence was assessed using GRADE. MAIN RESULTS Nine studies met eligibility; eight RCTs and one NRS. Six hundred and forty-four participants were included from six completed RCTs (n = 560) and one completed NRS (n = 84), with two ongoing RCTs consisting of 294 participants (260 adult and 34 paediatric) pending inclusion. Only one completed RCT included children receiving HSCT (n = 6); the other five RCTs only included adults: 239 with acute leukaemia receiving chemotherapy and 315 receiving HSCT (166 allogeneic and 149 autologous). The transfusion threshold ranged from 70 g/L to 80 g/L for restrictive and from 80 g/L to 120 g/L for liberal strategies. Effects were reported in the summary of findings tables only for the trials that included adults to reduce indirectness due to the limited evidence contributed by the prematurely terminated paediatric trial. Evidence from RCTs Overall, there may be little to no difference in the number of participants who die within 31 to 100 days using a restrictive compared to a liberal transfusion strategy, but the evidence is very uncertain (three studies; 451 participants; RR 1.00, 95% CI 0.27 to 3.70, P=0.99; very low-certainty evidence). There may be little to no difference in quality of life at 0 to 3 months using a restrictive compared to a liberal transfusion strategy, but the evidence is very uncertain (three studies; 431 participants; analysis unable to be completed due to heterogeneity; very low-certainty evidence). There may be little to no difference in the number of participants who suffer from any bleeding at 0 to 3 months using a restrictive compared to a liberal transfusion strategy (three studies; 448 participants; RR 0.91, 95% CI 0.78 to 1.06, P = 0.22; low-certainty evidence). There may be little to no difference in the number of participants who suffer from clinically significant bleeding at 0 to 3 months using a restrictive compared to a liberal transfusion strategy (four studies; 511 participants; RR: 0.94, 95% CI 0.74 to 1.19, P = 0.60; low-certainty evidence). There may be little to no difference in the number of participants who experience serious infections at 0 to 3 months using a restrictive compared to a liberal transfusion strategy (three studies, 451 participants; RR: 1.20, 95% CI 0.93 to 1.55, P = 0.17; low-certainty evidence). A restrictive transfusion strategy likely results in little to no difference in the length of hospital admission at 0 to 3 months compared to a liberal strategy (two studies; 388 participants; analysis unable to be completed due to heterogeneity in reporting; moderate-certainty evidence). There may be little to no difference between hospital readmission using a restrictive transfusion strategy compared to a liberal transfusion strategy (one study, 299 participants; RR: 0.89, 95% CI 0.52 to 1.50; P = 0.65; low-certainty evidence). Evidence from NRS The evidence is very uncertain whether a restrictive RBC transfusion strategy: reduces the risk of death within 100 days (one study, 84 participants, restrictive 1 death; liberal 1 death; very low-certainty evidence); or decreases the risk of clinically significant bleeding (one study, 84 participants, restrictive 3; liberal 8; very low-certainty evidence). No NRS reported on the other eligible outcomes. AUTHORS' CONCLUSIONS Findings from this review were based on seven studies and 644 participants. Definite conclusions are challenging given the relatively few included studies, low number of included participants, heterogeneity of intervention and outcome reporting, and overall certainty of evidence. To increase the certainty of the true effect of a restrictive RBC transfusion strategy on clinical outcomes, there is a need for rigorously designed and executed studies. The evidence is largely based on two populations: adults with acute leukaemia receiving intensive chemotherapy and adults with haematologic malignancy requiring HSCT. Despite the addition of 405 participants from three RCTs to the previous review's results, there is still insufficient evidence to answer this review's primary outcome. If we assume a mortality rate of 3% within 100 days, we would need a total of 1492 participants to have an 80% chance of detecting, at a 5% level of significance, an increase in all-cause mortality from 3% to 6%. Further RCTs are needed overall, particularly in children.
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Affiliation(s)
- Michael Radford
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Canada
- Department of Oncology, Hamilton Health Sciences Centre, Hamilton, Canada
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Emily Sirotich
- Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tyler Pitre
- Medicine, University of Toronto, Toronto, Canada
| | - Joanne Britto
- Oncology, Hamilton Health Sciences Centre, Hamilton, Canada
| | - Megan Watson
- Medicine, University of Toronto, Toronto, Canada
| | - Susan J Brunskill
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Carolyn Dorée
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Donald M Arnold
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Ontario, Canada
- McMaster University, Hamilton, Canada
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Binder AF, Hossain A, Doshi R, Vivero A, Gonzalez KM, Gentsch A, Wilde L, Rising KL. Patient and caregiver perceptions of the possibility of home blood transfusions. Transfusion 2024; 64:483-492. [PMID: 38263774 DOI: 10.1111/trf.17728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Patients with hematologic malignancies (HM) often develop transfusion dependence. The patient and caregiver burdens associated with the need for frequent transfusions are high. Home blood transfusions has the potential to reduce these burdens, but is not widely practiced in the United States. We designed a qualitative study to evaluate the patient and caregiver perceptions of the potential for a home blood transfusion program. STUDY DESIGN AND METHODS Eligible patients included Adult (≥18 years) patients who were English speaking and met the definition for transfusion dependence within 3 months of study enrollment. We identified and interviewed eligible participants (patients and caregivers), using a semi-structured interview guide to elicit patient perceptions of the acceptability, barriers, and benefits related to home blood product transfusions. Interviews were audio recorded and transcribed. Results were imported into NVivo 12 (version 12; QSR International, Burlington, VT) for coding and analysis. RESULTS We recruited participants until we reached thematic saturation, which occurred at 29 participants (20 patients, 9 caregivers). Among the 20 patient participants, nine had MDS (45%) and 11 had acute leukemia (55%). Most of the patients (60%) reported getting one transfusion per week. Four themes emerged when the participants discussed their perception regarding the potential of a home blood transfusion program: (1) current in-person experience, (2) caregiver burden, (3) perceptions of home blood transfusions, and (4) interest in participating in a home blood transfusion program. CONCLUSION The concept of home blood transfusions was well received and further research to study its implementation is warranted.
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Affiliation(s)
- Adam F Binder
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alavi Hossain
- Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Riyana Doshi
- Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Angelica Vivero
- Department of Pathology and Genomic Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Karla Martin Gonzalez
- Department of Emergency Medicine, Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexzandra Gentsch
- Department of Emergency Medicine, Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lindsay Wilde
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kristin L Rising
- Department of Emergency Medicine, Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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3
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Miller L, Freed-Freundlich M, Shimoni A, Hellou T, Avigdor A, Misgav M, Canaani J. Defining Current Patterns of Blood Product Use during Intensive Induction Chemotherapy in Newly Diagnosed Acute Myeloid Leukemia Patients. Transfus Med Hemother 2023; 50:456-468. [PMID: 37899992 PMCID: PMC10601600 DOI: 10.1159/000529595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 02/06/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Blood product transfusion retains a critical role in the supportive care of patients with acute myeloid leukemia (AML). Whereas previous studies have shown increased transfusion dependency to portend inferior outcome, predictive factors of an increased transfusion burden and the prognostic impact of transfusion support have not been assessed recently. Methods/Patients We performed a retrospective analysis on a recent cohort of patients given intensive induction chemotherapy in 2014-2022. Results The analysis comprised 180 patients with a median age of 57 years with 80% designated as de novo AML. Fifty-four patients (31%) were FLT3-ITD mutated, and 73 patients (42%) harbored NPM1. Favorable risk and intermediate risk ELN 2017 patients accounted for 43% and 34% of patients, respectively. The median number of red blood cell (RBC) and platelet units given during induction were 9 and 7 units, respectively. Seventeen patients (9%) received cryoprecipitate, and fresh frozen plasma (FFP) was given to 12 patients (7%). Lower initial hemoglobin and platelet levels were predictive of increased use of RBC (p < 0.0001) and platelet transfusions (p < 0.0001). FFP was significantly associated with induction related mortality (42% vs. 5%; p < 0.0001) and with FLT3-ITD (72% vs. 28%; p = 0.004). Blood group AB experienced improved mean overall survival compared to blood group O patients (4.1 years vs. 2.8 years; p = 0.025). In multivariate analysis, increased number of FFP (hazard ratio [HR], 4.23; 95% confidence interval [CI], 2.1-8.6; p < 0.001) and RBC units (HR, 1.8; 95% CI, 1.2-2.8; p = 0.008) given was associated with inferior survival. Conclusion Transfusion needs during induction crucially impact the clinical trajectory of AML patients.
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Affiliation(s)
- Liron Miller
- Blood Bank and Transfusion Service, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Mor Freed-Freundlich
- Hematology Division, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Avichai Shimoni
- Hematology Division, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Tamer Hellou
- Hematology Division, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Abraham Avigdor
- Hematology Division, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Mudi Misgav
- Blood Bank and Transfusion Service, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Jonathan Canaani
- Hematology Division, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
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Kuang XC, Zhang SH, Cen YJ, Zhang JB, Liu YS. Blood typing and transfusion therapy in a patient with A2 subtype acute myeloid leukemia M2: A case report. World J Clin Cases 2023; 11:3813-3821. [PMID: 37383120 PMCID: PMC10294153 DOI: 10.12998/wjcc.v11.i16.3813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/25/2023] [Accepted: 04/20/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Acute myeloid leukemia (AML) is one of the most common types of leukemia in adults. However, AML is relatively rare in the population overall, accounting for only about 1 percent of all cancers. Treatment for AML can be very effective for some patients, yet it leaves others with serious and even life-threatening side effects. Chemotherapy is still the primary treatment for most AML, but over time, leukemia cells become resistant to chemotherapy drugs. In addition, stem cell transplantation, targeted therapy, and immunotherapy are currently available. At the same time, with the progression of the disease, the patient may have corresponding complications, such as coagulation dysfunction, anemia, granulocytopenia, and repeated infection, so transfusion supportive therapy will be involved in the overall treatment regime. To date, few articles have reported on blood transfusion treatment options for patients with ABO subtypes AML-M2. Blood transfusion therapy is an important supportive treatment for AML-M2, and accurate determination of patients' blood type is one of the most important steps in the treatment process. In this study, we explored blood typing and supportive treatment strategies for a patient with A2 subtype AML-M2 to provide the basis for treatment for all patients.
CASE SUMMARY In order to determine the blood type of the patient, serological and molecular biological methods were used for reference tests, and the genetic background was studied to determine the patient's final blood type and select the appropriate blood products for infusion treatment. According to the results obtained by serological and molecular biological methods, the blood type of the patient was A2 subtype; the genotype was A02/001; the irregular antibody screening was negative, and anti-A1 was found in the plasma. According to the overall treatment plan, active anti-infection, elevated cells, component blood transfusion support, and other rescue and supportive treatments were given, and the patient successfully passed the stage of myelosuppression after chemotherapy. Re-examination of bone marrow smears showed that AL was in complete remission of bone marrow signs, and minimal residual leukemia lesions suggested no cells with obvious abnormal immunophenotype (residual leukemia cells < 10-4).
CONCLUSION The infusion of patients with A2 subtype AML-M2 with A irradiated platelets and O washing red blood cells can meet the needs of clinical treatment.
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Affiliation(s)
- Xiao-Chuan Kuang
- Department of Clinical Laboratory, Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, Chengdu 610000, Sichuan Province, China
| | - Shi-Hua Zhang
- Department of Gastroenterology, Pidu District People's Hospital, Chengdu 610000, Sichuan Province, China
| | - Yi-Jing Cen
- Department of Clinical Laboratory, Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, Chengdu 610000, Sichuan Province, China
| | - Jian-Bo Zhang
- Department of Clinical Laboratory, Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, Chengdu 610000, Sichuan Province, China
| | - Yu-Song Liu
- Department of Clinical Laboratory, Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, Chengdu 610000, Sichuan Province, China
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5
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Transfusional iron overload in heavily transfused patients: real-life data from a 10-year retrospective study of 611 cases managed in a French general hospital. Transfus Clin Biol 2022; 29:236-242. [PMID: 35476962 DOI: 10.1016/j.tracli.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Epidemiological studies on transfusional iron overload (TIO) in the general population of heavily transfused patients are scarce. The aim of this work was to provide a picture on the distribution and management of this complication within the context of unselected individuals attending a general hospital. METHODS We retrospectively assessed the characteristics of 611 patients from a single institution having received at least 20 red blood cell (RBC) units over a 10-year period. RESULTS About two-thirds of these individuals were males and their median age at the 20th RBC was 72 years (range: 10-98). Myelodysplastic syndromes (MDS) and acute myeloid leukemia represented the most frequent underlying conditions (53%) but lymphoid malignancies and solid malignancies accounted for 13.6 and 7.3% respectively. In the vast majority of cases various comorbidities (range: 1-6 per patient) were registered including especially cardiovascular disorders. The highest cumulative RBC numbers were observed in MDS patients. Serum ferritin was assessed in 451 patients (73.8%) and ≥ 1000 μg/L in 250 cases, ≥ 2000 μg/L in 100 cases and ≥ 2500 μg/L in 71 cases. Only 97 patients (15.9%) received a treatment for TIO using either a chelator (n=93) or phlebotomy (n=4). CONCLUSION TIO is not limited to MDS or hemoglobin disorders. Its assessment and management are suboptimal in clinical practice. The ratio of patients receiving iron chelation is markedly lower than theoretically expected mainly because of comorbidities or drug intolerance.
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Murugesan M, Raghavan V, Nair C, Nayanar S. Influence of blood transfusion during induction chemotherapy on treatment outcomes in acute myeloid leukemia. Asian J Transfus Sci 2022. [DOI: 10.4103/ajts.ajts_123_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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7
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Zhang TY, Dutta R, Benard B, Zhao F, Yin R, Majeti R. IL-6 blockade reverses bone marrow failure induced by human acute myeloid leukemia. Sci Transl Med 2021; 12:12/538/eaax5104. [PMID: 32269167 DOI: 10.1126/scitranslmed.aax5104] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 12/04/2019] [Accepted: 01/31/2020] [Indexed: 12/18/2022]
Abstract
Most patients with acute myeloid leukemia (AML) die from complications arising from cytopenias resulting from bone marrow (BM) failure. The common presumption among physicians is that AML-induced BM failure is primarily due to overcrowding, yet BM failure is observed even with low burden of disease. Here, we use large clinical datasets to show the lack of correlation between BM blast burden and degree of cytopenias at the time of diagnosis. We develop a splenectomized xenograft model to demonstrate that transplantation of human primary AML into immunocompromised mice recapitulates the human disease course by induction of BM failure via depletion of mouse hematopoietic stem and progenitor populations. Using unbiased approaches, we show that AML-elaborated IL-6 acts to block erythroid differentiation at the proerythroblast stage and that blocking antibodies against human IL-6 can improve AML-induced anemia and prolong overall survival, suggesting a potential therapeutic approach.
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Affiliation(s)
- Tian Yi Zhang
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA 94305, USA.,Stanford School of Medicine, Stanford, CA 94305, USA.,Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA 94305, USA
| | - Ritika Dutta
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA 94305, USA.,Stanford School of Medicine, Stanford, CA 94305, USA
| | - Brooks Benard
- Cancer Biology Program, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Feifei Zhao
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA 94305, USA.,Stanford School of Medicine, Stanford, CA 94305, USA.,Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA 94305, USA
| | - Raymond Yin
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA 94305, USA.,Stanford School of Medicine, Stanford, CA 94305, USA.,Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA 94305, USA
| | - Ravindra Majeti
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA 94305, USA. .,Stanford School of Medicine, Stanford, CA 94305, USA.,Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA 94305, USA
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8
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Weber S, Parmon A, Kurrle N, Schnütgen F, Serve H. The Clinical Significance of Iron Overload and Iron Metabolism in Myelodysplastic Syndrome and Acute Myeloid Leukemia. Front Immunol 2021; 11:627662. [PMID: 33679722 PMCID: PMC7933218 DOI: 10.3389/fimmu.2020.627662] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/31/2020] [Indexed: 12/11/2022] Open
Abstract
Myelodysplasticsyndrome (MDS) and acute myeloid leukemia (AML) are clonal hematopoietic stem cell diseases leading to an insufficient formation of functional blood cells. Disease-immanent factors as insufficient erythropoiesis and treatment-related factors as recurrent treatment with red blood cell transfusions frequently lead to systemic iron overload in MDS and AML patients. In addition, alterations of function and expression of proteins associated with iron metabolism are increasingly recognized to be pathogenetic factors and potential vulnerabilities of these diseases. Iron is known to be involved in multiple intracellular and extracellular processes. It is essential for cell metabolism as well as for cell proliferation and closely linked to the formation of reactive oxygen species. Therefore, iron can influence the course of clonal myeloid disorders, the leukemic environment and the occurrence as well as the defense of infections. Imbalances of iron homeostasis may induce cell death of normal but also of malignant cells. New potential treatment strategies utilizing the importance of the iron homeostasis include iron chelation, modulation of proteins involved in iron metabolism, induction of leukemic cell death via ferroptosis and exploitation of iron proteins for the delivery of antileukemic drugs. Here, we provide an overview of some of the latest findings about the function, the prognostic impact and potential treatment strategies of iron in patients with MDS and AML.
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Affiliation(s)
- Sarah Weber
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Anastasia Parmon
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Nina Kurrle
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute, Goethe University, Frankfurt am Main, Germany
| | - Frank Schnütgen
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute, Goethe University, Frankfurt am Main, Germany
| | - Hubert Serve
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute, Goethe University, Frankfurt am Main, Germany
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Dutta R, Zhang TY, Köhnke T, Thomas D, Linde M, Gars E, Stafford M, Kaur S, Nakauchi Y, Yin R, Azizi A, Narla A, Majeti R. Enasidenib drives human erythroid differentiation independently of isocitrate dehydrogenase 2. J Clin Invest 2020; 130:1843-1849. [PMID: 31895700 DOI: 10.1172/jci133344] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/23/2019] [Indexed: 12/13/2022] Open
Abstract
Cancer-related anemia is present in more than 60% of newly diagnosed cancer patients and is associated with substantial morbidity and high medical costs. Drugs that enhance erythropoiesis are urgently required to decrease transfusion rates and improve quality of life. Clinical studies have observed an unexpected improvement in hemoglobin and RBC transfusion-independence in patients with acute myeloid leukemia (AML) treated with the isocitrate dehydrogenase 2 (IDH2) mutant-specific inhibitor enasidenib, leading to improved quality of life without a reduction in AML disease burden. Here, we demonstrate that enasidenib enhanced human erythroid differentiation of hematopoietic progenitors. The phenomenon was not observed with other IDH1/2 inhibitors and occurred in IDH2-deficient CRISPR-engineered progenitors independently of D-2-hydroxyglutarate. The effect of enasidenib on hematopoietic progenitors was mediated by protoporphyrin accumulation, driving heme production and erythroid differentiation in committed CD71+ progenitors rather than hematopoietic stem cells. Our results position enasidenib as a promising therapeutic agent for improvement of anemia and provide the basis for a clinical trial using enasidenib to decrease transfusion dependence in a wide array of clinical contexts.
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Affiliation(s)
- Ritika Dutta
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA.,Stanford School of Medicine, Stanford, California, USA
| | - Tian Yi Zhang
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA.,Stanford School of Medicine, Stanford, California, USA
| | - Thomas Köhnke
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA
| | - Daniel Thomas
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA
| | - Miles Linde
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA
| | - Eric Gars
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA
| | - Melissa Stafford
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA
| | - Satinder Kaur
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA
| | - Yusuke Nakauchi
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA
| | - Raymond Yin
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA
| | - Armon Azizi
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA
| | - Anupama Narla
- Department of Pediatrics, Division of Hematology/Oncology, Stanford University, Stanford, California, USA
| | - Ravindra Majeti
- Department of Medicine, Division of Hematology, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA.,Stanford School of Medicine, Stanford, California, USA
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11
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Leahy MF, Trentino KM, May C, Swain SG, Chuah H, Farmer SL. Blood use in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation: the impact of a health system-wide patient blood management program. Transfusion 2017; 57:2189-2196. [PMID: 28671296 DOI: 10.1111/trf.14191] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/23/2017] [Accepted: 04/24/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Little is published on patient blood management (PBM) programs in hematology. In 2008 Western Australia announced a health system-wide PBM program with PBM staff appointments commencing in November 2009. Our aim was to assess the impact this program had on blood utilization and patient outcomes in intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation. STUDY DESIGN AND METHODS A retrospective study of 695 admissions at two tertiary hospitals receiving intensive chemotherapy for acute leukemia or undergoing hematopoietic stem cell transplantation between July 2010 and December 2014 was conducted. Main outcomes included pre-red blood cell (RBC) transfusion hemoglobin (Hb) levels, single-unit RBC transfusions, number of RBC and platelet (PLT) units transfused per admission, subsequent day case transfusions, length of stay, serious bleeding, and in-hospital mortality. RESULTS Over the study period, the mean RBC units transfused per admission decreased 39% from 6.1 to 3.7 (p < 0.001), and the mean PLT units transfused decreased 35% from 6.3 to 4.1 (p < 0.001), with mean RBC and PLT units transfused for follow-up day cases decreasing from 0.6 to 0.4 units (p < 0.001). Mean pre-RBC transfusion Hb level decreased from 8.0 to 6.8 g/dL (p < 0.001), and single-unit RBC transfusions increased 39% to 67% (p < 0.001). This reduction represents blood product cost savings of AU$694,886 (US$654,007). There were no significant changes in unadjusted or adjusted length of stay, serious bleeding events, or in-hospital mortality over the study. CONCLUSION The health system-wide PBM program had a significant impact, reducing blood product use and costs without increased morbidity or mortality in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation.
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Affiliation(s)
- Michael F Leahy
- School of Medicine and Pharmacology
- Department of Haematology
- PathWest Laboratory Medicine, Royal Perth Hospital
| | | | | | - Stuart G Swain
- Business Intelligence Unit, South Metropolitan Health Service
| | | | - Shannon L Farmer
- School of Surgery, Faculty of Medicine Dentistry and Health Sciences, The University of Western Australia
- Centre for Population Health Research, Faculty of Health, Sciences, Curtin University, Perth, Western Australia, Australia
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DeZern AE, Williams K, Zahurak M, Hand W, Stephens RS, King KE, Frank SM, Ness PM. Red blood cell transfusion triggers in acute leukemia: a randomized pilot study. Transfusion 2016; 56:1750-7. [PMID: 27198129 DOI: 10.1111/trf.13658] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 04/02/2016] [Accepted: 04/02/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Red blood cell (RBC) transfusion thresholds have yet to be examined in large randomized trials in hematologic malignancies. This pilot study in acute leukemia uses a restrictive compared to a liberal transfusion strategy. STUDY DESIGN AND METHODS A randomized (2:1) study was conducted of restrictive (LOW) hemoglobin (Hb) trigger (7 g/dL) compared to higher (HIGH) Hb trigger (8 g/dL). The primary outcome was feasibility of conducting a larger trial. The four requirements for success required that more than 50% of the eligible patients could be consented, more than 75% of the patients randomized to the LOW arm tolerated the transfusion trigger, fewer than 15% of patients crossed over from the LOW arm to the HIGH arm, and no indication for the need to pause the study for safety concerns. Secondary outcomes included fatigue, bleeding, and RBCs and platelets transfused. RESULTS Ninety patients were consented and randomly assigned to LOW to HIGH. The four criteria for the primary objective of feasibility were met. When the number of units transfused was compared, adjusting for baseline Hb, the LOW arm was transfused on average 8.0 (95% confidence interval [CI], 6.9-9.1) units/patient while the HIGH arm received 11.7 (95% CI, 10.1-13.2) units (p = 0.0003). There was no significant difference in bleeding events or neutropenic fevers between study arms. CONCLUSION This study establishes feasibility for trial of Hb thresholds in leukemia through demonstration of success in all primary outcome metrics and a favorable safety profile. This population requires further study to evaluate the equivalence of liberal and restrictive transfusion thresholds in this unique clinical setting.
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Affiliation(s)
- Amy E DeZern
- The Sidney Kimmel Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Katherine Williams
- The Sidney Kimmel Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Marianna Zahurak
- The Sidney Kimmel Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Wesley Hand
- The Sidney Kimmel Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - R Scott Stephens
- The Sidney Kimmel Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, Baltimore, Maryland.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Karen E King
- The Sidney Kimmel Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, Baltimore, Maryland.,Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland
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Cannas G, Fattoum J, Boukhit M, Thomas X. Economic analysis of blood product transfusions according to the treatment of acute myeloid leukemia in the elderly. Transfus Clin Biol 2015; 22:341-7. [PMID: 26184429 DOI: 10.1016/j.tracli.2015.06.249] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 06/16/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Blood transfusion requirement represents one of the most significant cost driver associated with acute myeloid leukemia (AML). Low-intensity treatments (low-dose cytarabine, hypomethylating agents) have the potential to reduce transfusion dependence, and improve health-related quality of life. PATIENTS AND METHODS We assessed the cost-effectiveness of treatment types regarding blood product transfusions in a cohort of 214 AML patients aged ≥ 70 years. RESULTS Analyzes did not indicate any significant overall survival (OS) advantage of intensive chemotherapy comparatively to low-intensity treatment. The difference was significant when compared to best supportive care (BSC) (P<0.0001). Blood products transfusion cost per patient was 1.3 times lower with low-intensity therapy and 2.7 times lower with BSC than with intensive chemotherapy. Mean transfusion cost per patient according to OS varied from 2.4 to 1.3 times less with low-intensity treatment comparatively to intensive chemotherapy for patients having OS ≤ 13.3 months. Costs varied from 3.5 to 2.6 times less with BSC comparatively to intensive chemotherapy. In contrast, mean transfusion costs were comparable among treatments for patients with OS>13.3 months. CONCLUSION Low-intensity treatments represent a cost-effective alternative to BSC and require a reduced number of transfused blood products comparatively to intensive chemotherapy, while OS was not significantly different.
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Affiliation(s)
- G Cannas
- Hospices civils de Lyon, Edouard-Herriot Hospital, Lyon, France; Croix-Rousse Hospital, Lyon, France
| | - J Fattoum
- Hospices civils de Lyon, Edouard-Herriot Hospital, Lyon, France
| | - M Boukhit
- Hospices civils de Lyon, Edouard-Herriot Hospital, Lyon, France
| | - X Thomas
- Hematology, hospices civils de Lyon, Lyon-Sud Hospital, pavillon Marcel-Bérard, bâtiment 1G, 69495 Pierre-Bénite, France.
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