Transfusion of patients undergoing bone marrow transplantation

The incidence of autoimmune hemolytic anemia in pediatric hematopoietic stem cell recipients post-first and post-second hematopoietic stem cell transplant

The reported incidence of post-allogeneic HSCT AIHA was between 4.4% and 6% following a single transplant. Cord blood transplantation, T-cell depletion, and chronic GvHD are significantly associated with post-transplant AIHA. During an 11-yr period, data for 500 pediatric HSCT recipients were eligible for evaluation of the incidence of AIHA post-first and post-second transplants. Demographic, transplant, and post-transplant-related variables were analyzed. Twelve of 500 (2.4%) recipients at a median of 273 days and seven of 72 (9.7%) recipients at a median of 157 days developed AIHA post-first and post-second HSCT, respectively. Post-first HSCT, none of the MRD recipients developed AIHA (0/175 MRD vs. 12/325 other donors, p = 0.04). Four of 12 required a second HSCT to control the AIHA. After the second HSCT, MUD was significantly associated with the development of AIHA. No other variables were associated with the post-second transplant AIHA. The incidence of AIHA post-first and post-second HSCT was less than the reported. The increased incidence of AIHA among recipients of second HSCT is most likely due to the profound immune dysregulation. A much larger, prospective study would be needed to evaluate the incidence, complications, and management of post-transplant AIHA.

Role of transfusion in stem cell transplantation: a freedom-from-transfusion (FFT), cost and survival analysis

BACKGROUND

Transfusion of blood products is often necessary for patients undergoing stem cell transplantation (SCT). The need for red cell and platelet transfusion may vary significantly depending on the type of transplantation and underlying disease.

METHODS

In an attempt to evaluate the need and volume of transfusions in patients undergoing SCT at University of Kansas Medical Center, the authors retrospectively evaluated the transfusion data of all patients who received SCT between 2000 and 2005.

RESULTS

A total of 138 (90%) out of 154 patients undergoing autologous SCT and 24 (43%) out of 56 patients with allogeneic SCT exhibited total hematopoietic engraftment and freedom from transfusion (FFT). Time to achieve FFT (median; range) for RBC units for autologous SCT (12; 0-183) was significantly shorter compared with allogeneic SCT (16.5; 0-373). Number of RBC units (median; range) transfused were significantly less in patients undergoing autologous SCT (4; 0-26) compared to patients undergoing allogeneic SCT (6.5; 0-54). The median cost of transfusion was significantly higher in patients undergoing allogeneic SCT (red cell: $2,015; platelet: $4,480) compared to patients undergoing autologous SCT (red cell: $1,240; platelet: $2,520). The authors recognize that this was a retrospective single-center study and practice guidelines may vary from center to center.

CONCLUSION

Authors conclude that transfusion of blood products is an expensive but integral part of SCT, more so for allogeneic SCT than for patients undergoing autologous SCT. Total FFT is a desirable long-term goal of successful marrow transplantation.

RBC transfusion requirements after allogeneic marrow transplantation: impact of the before-transplant Hb level on transfusion and early survival

BACKGROUND

Most patients undergoing allogeneic marrow transplantation (alloBMT) require transfusions of RBCs. A retrospective analysis was performed to evaluate the utilization and risk factors for RBC transfusions including age and sex of recipient, HLA matching between donor and recipient, disease status at time of BMT, the occurrence of GVHD, ABO blood group compatibility, the source of progenitor cells and the Hb level before BMT (PT-Hb).

STUDY DESIGN AND METHODS

Data from 519 consecutive patients receiving transplants between January 1995 and March 2000 were reviewed. The number of RBC transfusions was determined for the following periods: 0 to 60, 61 to 120, and 121 to 180 days after BMT.

RESULTS

The transfusion requirements were greatest during the first 60 days after BMT and decreased with time. The total number of units transfused to this cohort of patients was 5398, of which 3505 units were utilized within the first 2 months. The mean number +/- SD of units transfused per patient from 0 to 60 days was 6.8 +/- 6.4; 61 to 120 days, 3.2 +/- 5.5; and 121 to 180 days, 2.0 +/- 4.6. An increased transfusion requirement was associated with lower PT-Hb, major ABO mismatch between donor and recipient, BMT in patients with more advanced disease, use of unrelated donors, older age, and female sex by Spearman's correlation analysis. The source of progenitor cells and the development of GVHD did not influence transfusion requirements. Increased mortality during the 6-month period after transplant was associated with lower PT-Hb, use of unrelated donors, advanced disease status at BMT, and sex by Cox regression analysis. In a multivariate model, PT-Hb remained significant when controlling for the other risk factors.

CONCLUSION

The PT-Hb was identified as an independent risk factor for RBC transfusions during alloBMT. As well, a lower PT-Hb was found to be an independent risk factor for increased mortality during the 6-month study period.

A randomized trial comparing the use of fresh and stored platelets in the treatment of bone marrow transplant recipients

Patients undergoing allogeneic bone marrow transplantation (BMT) were randomized into two groups. One group (n = 21) received single donor platelet concentrates (PC) that were as fresh as possible, the other group (n = 18) received single donor PC stored for 2 to 5 days. Actual mean storage times for PC were 1.12 +/- 1.25 (mean +/- SD) and 2.67 +/- 1.30 d, respectively (p < 0.001). The total need for platelets during 60 d after BMT in patients receiving fresh PC was 22.1 +/- 17.8 x 10(9) platelet/liter blood volume/d, and for stored PC 29.2 +/- 19.2 x 10(9) platelets/liter blood volume/d (n.s.). A multiple regression analysis of the data showed no correlation between PC storage time and the PC requirement (p = 0.85). Posttransfusion corrected count increment (CCI) at 1 hour was 10.4 +/- 5.1 for PC stored 0-1 d, 10.3 +/- 7.0 for PC stored 2-3 d, and 11.4 +/- 9.2 for PC stored 4-5 d. The corresponding CCI, at 18 h were 6.5 +/- 4.4, 5.4 +/- 3.3 and 6.8 +/- 4.6. We conclude that there is no major difference between fresh and stored single donor PC.

Blood transfusion in marrow graft recipients

Of 182 consecutive patients undergoing allogeneic bone marrow transplantation (BMT), the relative numbers of those who received red blood cells (RBC), platelets (PLT), and granulocytes were 82%, 96%, and 26%, respectively. The transfused patients received an average of 1.26 (SD +/- 2.0) RBC units, 9.41 (SD +/- 13.2) PLT transfusions, and 0.33 (SD +/- 1.1) granulocyte concentrates per week per 50 kg body wt. in the period starting on the day of bone marrow transplantation (BMT) up to 60 days post BMT. The total number of units per transfused patient was 7.7 (range 1-63) RBC, 55.2 (range 2-394) PLT and 6.2 (range 1-36) granulocytes in the same period. Patients with grades II-IV acute graft-versus-host disease (GVHD) needed more RBC and PLT (p less than 0.001) than patients with grades 0-I acute GVHD. Patients with late engraftment required more granulocyte and PLT transfusion than those with early engraftment (p less than 0.05). Patients with high-risk malignancy had greater need for RBC and PLT than "low-risk patients" (p less than 0.02 and p less than 0.01), respectively). Patients with major ABO-incompatible donors showed a greater need for RBC than patients with minor ABO incompatibility (p = 0.02) or ABO identical donors (p = 0.01). Patients with relatively poor estimated survival required the most RBC and PLT.

Transplantation of major ABO-incompatible bone marrow depleted of red cells by hydroxyethyl starch

23 bone marrow transplant recipients whose donors where major ABO-incompatible received marrow depleted of red cells prior to infusion utilizing gravity sedimentation in hydroxyethyl starch. The in vitro red cell-depletion procedure effectively removed 97.8% (mean) of the red cells from the harvested marrows and preserved 86.8% of the nucleated cells and 98.2% of the CFU-C activity in 25.4% of the original volume. All recipients had a significant quantity of isohemagglutinins of both IgM and IgG classes demonstrable in their serum at the time of the marrow infusion. Patients were premedicated and well-hydrated prior to the infusion and tolerated the infusion well. These patients demonstrated bone marrow engraftment at the same rate as did those patients whose marrow donors were either ABO-identical or minor ABO-incompatible. There was no difference in the incidence of or time to development of graft versus host disease, the incidence of graft rejection, or patient survival among the groups. Recipients of red cell-depleted major ABO-incompatible bone marrow transplants demonstrated production of donor-type red cells somewhat later and required slightly more red cell transfusion support that did the other groups of recipients. This red cell-depletion technique is safe and effective in the management of major ABO-incompatible bone marrow transplantation.