Effect of premedication guidelines and leukoreduction on the rate of febrile nonhaemolytic platelet transfusion reactions

The abrogated role of premedication in the prevention of transfusion-associated adverse reactions in outpatients receiving leukocyte-reduced blood components

BACKGROUND AND OBJECTIVES

Although it remains controversial, premedication before transfusion is a common clinical practice to prevent transfusion-associated adverse reactions (TAARs) in Taiwan. Thus, we aimed to investigate whether premedication prevented outpatients from developing TAARs and whether an educational programme could improve the understanding of physicians related to the unnecessary use of premedication, and this could elicit changes in their prescribing activities without affecting the occurrence of TAARs.

MATERIALS AND METHODS

Clinical data from outpatients receiving transfusion therapy, including predisposing diseases, histories of transfusion and TAARs, premedication and the occurrence of TAARs in the period April 2017 to October 2018, were retrospectively obtained. The evidence-based transfusion programme implemented to educate physicians was started in January 2018.

RESULTS

A total of 5018 blood units were transfused to 803 outpatients, with 2493 transfusion events reported in the study interval. The most frequently transfused component was leukocyte-reduced packed red cells (n = 4338), followed by leukocyte-reduced apheresis platelets (n = 540) and other blood components. The overall premedication rate significantly decreased from 92.4% to 76.7% after the educational programme (p < 0.001). There was no remarkable change in the occurrence of TAARs per patient event between the periods before and after the educational programme (1.11% vs. 1.14%, p = 0.964). Besides, it was shown that the occurrence of TAARs was associated with the history of TAARs and inversely related to multiple transfusions, but not premedication.

CONCLUSION

Decreased premedication was not associated with increased incidence of TAARs in outpatients; these findings provide important evidence to support the need to revise clinical practices in the era of leukocyte-reduced blood products.

Augmented weighting estimators for the additive rates model under multivariate recurrent event data with missing event type

Multivariate recurrent event data are frequently encountered in biomedical and epidemiological studies when subjects experience multiple types of recurrent events. In practice, the event type information may be missing due to a variety of reasons. In this article, we consider a semiparametric additive rates model for multivariate recurrent event data with missing event types. We develop the augmented inverse probability weighting technique to handle event types that are missing at random. The nonparametric kernel-assisted proposals for the missing mechanisms are studied. The resulting estimator is shown to be consistent and asymptotically normal. Extensive simulation studies and a real data application are provided to illustrate the validity and practical utility of the proposed method.

Blood Transfusion Reactions-A Comprehensive Review of the Literature including a Swiss Perspective

Blood transfusions have been the cornerstone of life support since the introduction of the ABO classification in the 20th century. The physiologic goal is to restore adequate tissue oxygenation when the demand exceeds the offer. Although it can be a life-saving therapy, blood transfusions can lead to serious adverse effects, and it is essential that physicians remain up to date with the current literature and are aware of the pathophysiology, initial management and risks of each type of transfusion reaction. We aim to provide a structured overview of the pathophysiology, clinical presentation, diagnostic approach and management of acute transfusion reactions based on the literature available in 2022. The numbers of blood transfusions, transfusion reactions and the reporting rate of transfusion reactions differ between countries in Europe. The most frequent transfusion reactions in 2020 were alloimmunizations, febrile non-hemolytic transfusion reactions and allergic transfusion reactions. Transfusion-related acute lung injury, transfusion-associated circulatory overload and septic transfusion reactions were less frequent. Furthermore, the COVID-19 pandemic has challenged the healthcare system with decreasing blood donations and blood supplies, as well as rising concerns within the medical community but also in patients about blood safety and transfusion reactions in COVID-19 patients. The best way to prevent transfusion reactions is to avoid unnecessary blood transfusions and maintain a transfusion-restrictive strategy. Any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system. The initial management of blood transfusion reactions requires early identification, immediate interruption of the transfusion, early consultation of the hematologic and ICU departments and fluid resuscitation.

Association of Veterinary Hematology and Transfusion Medicine (AVHTM) Transfusion Reaction Small Animal Consensus Statement (TRACS) Part 2: Prevention and monitoring

OBJECTIVE

To systematically review available evidence to develop guidelines for the prevention of transfusion reactions and monitoring of transfusion administration in dogs and cats.

DESIGN

Evidence evaluation of the literature (identified through Medline searches through Pubmed and Google Scholar searches) was carried out for identified transfusion reaction types in dogs and cats. Evidence was evaluated using PICO (Population, Intervention, Comparison, Outcome) questions generated for each reaction type. Evidence was categorized by level of evidence (LOE) and quality (Good, Fair, or Poor). Guidelines for prevention and monitoring were generated based on the synthesis of the evidence. Consensus on the final recommendations and a proposed transfusion administration monitoring form was achieved through Delphi-style surveys. Draft recommendations and the monitoring form were made available through veterinary specialty listservs and comments were incorporated.

RESULTS

Twenty-nine guidelines and a transfusion administration monitoring form were formulated from the evidence review with a high degree of consensus CONCLUSIONS: This systematic evidence evaluation process yielded recommended prevention and monitoring guidelines and a proposed transfusion administration form. However, significant knowledge gaps were identified, demonstrating the need for additional research in veterinary transfusion medicine.

Transfusion practice in Australia: an internet-based survey

OBJECTIVE

To describe small animal transfusion practices in Australia, including access to blood products and frequency of pre-transfusion compatibility testing and medication administration.

METHODS

An online survey was disseminated to target Australian veterinarians treating dogs and cats. Information collected included demographics, sources of blood products, blood storage, recipient compatibility testing and administration of medications pre-transfusion. Associations between the use of compatibility tests and premedications were assessed using the χ² test. Significance was set at P < 0.05.

RESULTS

A total of 199 Australian veterinarians were included; however, there was some attrition of respondents over the course of the survey. The majority of respondents were in general practice (n = 133/199). Access to fresh whole blood was commonly reported for dogs (n = 179/199) and cats (n = 131/198), whereas blood components were less commonly available (canine red blood cells [RBC], n = 52/199 and plasma, n = 157/199; feline RBC, n = 9/198 and plasma, n = 21/198). Most blood was sourced from the pets of owners affiliated with the veterinary clinic (n = 179/196). The respondents who did not blood type or crossmatch dogs were significantly more likely to use premedication than those who did these tests (both comparisons: P < 0.001). Likewise, the respondents who did not blood-type cats were significantly more likely to use premedication (P = 0.003); however, there was no association between crossmatching and using premedication in cats (P = 0.183).

CONCLUSION

This is the first survey to describe transfusion practices across a variety of practice types throughout Australia. Future work is needed to determine how representative these results are of current transfusion practices across Australia, and if so, what can be done to optimise them.

Premedication for the prevention of nonhemolytic transfusion reactions: a systematic review and meta-analysis

BACKGROUND

The efficacy of premedication for the prevention of nonhemolytic transfusion reactions remains controversial. This systematic review and meta-analysis assessed the effect of premedication on the rate of nonhemolytic transfusion reactions after allogeneic blood transfusion.

STUDY DESIGN AND METHODS

We searched the literature using CENTRAL, MEDLINE, EMBASE, ISI Web of Science, and clinicaltrials.gov databases from inception until October 31, 2018. We included all randomized controlled trials comparing premedication to placebo or no treatment in patients receiving any labile blood product. Outcome measures were reported as relative risks (RRs) with 95% confidence intervals (CIs). Data were combined for similar outcomes where appropriate using a random-effects model. Analyses were done at both the patient and transfusion level.

RESULTS

Three randomized trials using acetaminophen and antihistamine as premedication met the inclusion criteria. A total of 517 patients received 4444 red blood cell or platelet transfusions. Pooled patient-level estimates with premedication for all nonhemolytic, febrile nonhemolytic, and minor allergic reactions were RR, 0.92 (95% CI, 0.63-1.35); RR, 0.54 (95% CI, 0.26-1.1); and RR, 1.37 (95% CI 0.81-2.31), respectively. Transfusion-level analyses also showed no benefit with premedication. Of 517 patients randomized, only 27 (5.2%) had a history of transfusion reactions.

CONCLUSION

Routine premedication with acetaminophen and antihistamines did not prevent nonhemolytic transfusion reactions; however, the estimate of effect was greatest for febrile reactions. The impact of premedication in patients with a prior history of transfusion reactions remains unknown and requires further evaluation in future clinical trials.

A retrospective cost analysis of the frequency and cost of transfusion premedications

BACKGROUND

Acetaminophen and diphenhydramine are routinely administered to prevent febrile non-hemolytic and allergic blood transfusion reactions despite multiple randomized controlled trials demonstrating that this practice lacks efficacy. As a result, patients are exposed to the adverse effects of these medications and their financial burdens with no expected benefit. The aim of this study was to quantify the frequency and cost of transfusion premedications in patients with acute myeloid leukemia (AML).

STUDY DESIGN AND METHODS

This was a retrospective study of patients with AML admitted to Vanderbilt University Medical Center (VUMC) for induction chemotherapy between January 2008 and December 2016. Data were collected on the number of platelet and packed red blood cell (PRBC) transfusions each patient received during the initial inpatient encounter for AML, as well as on the administration of premedications prior to each transfusion.

RESULTS

During the 9-year study period, 948 AML patients received a total of 19,820 transfusions. Of these, 30% were preceded by oral diphenhydramine, 8% by intravenous diphenhydramine, and 39% by oral acetaminophen. The percentage of patients that received a transfusion preceded by a premedication increased over the study period (p = 0.03), as did the percentage of transfusions preceded by a premedication (p = 0.02). The total unadjusted cost of pre-transfusion medications to the institution during the study period was $50,309.77, or $52.67 per patient with AML. The cost of premedications per patient did not increase over the study period (p = .45).

CONCLUSIONS

Routine transfusion premedication administration is common in AML patients and not well-supported by available evidence.

Feeling the burn: the significant burden of febrile nonhemolytic transfusion reactions

BACKGROUND

Febrile nonhemolytic transfusion reactions (FNHTRs) are characterized by a post-transfusion temperature rise (of ≥ 1°C, to ≥ 38°C) or chills/rigors unrelated to the underlying condition. FNHTRs are provoked by inflammatory cytokines in the product or by host antileukocyte antibodies against residual donor leukocytes. FNHTRs are among the most commonly reported transfusion disturbances and are generally deemed nonserious events. However, their impact on patients and hospitals may be underestimated.

STUDY DESIGN AND METHODS

A search through two hemovigilance databases identified all known possible-to-definite FNHTRs over 3 years (2013-2015) at four academic hospitals using prestorage leukoreduced components. FNHTRs were assessed for frequency by product (red blood cells [RBCs], platelets [PLTs], intravenous immunoglobulin), diagnostics (bedside, chest imaging, serology, microbiology), and management (medications, disposition change). The definition of FNHTR was derived from Canada's Transfusion-Transmitted Injuries Surveillance System.

RESULTS

For 437 FNHTRs, the overall per-product rate across all sites was 0.24%, or 0.17% with RBCs alone and 0.25% with PLTs alone. One-third of patients had significant fevers (≥ 39.0°C or a rise by ≥ 2.0°C). Approximately one-quarter underwent chest imaging within 48 hours, and 79% had blood cultures. A hospital admission directly attributable to the FNHTR, to exclude other causes of fever, occurred in 15% of FNHTR outpatients.

CONCLUSION

An analysis of FNHTRs reveals a substantial burden of postreaction clinical activity in addition to the disturbance itself. Efforts to avoid this adverse event may save resources, reduce patient distress, and encourage compliance with more restrictive transfusion strategies.

Secretome profiling of apheresis platelet supernatants during routine storage via antibody-based microarray

Platelet storage lesions (PSLs) occur during platelet concentrate (PC) storage. Adverse transfusion reactions (ATRs) have been demonstrated to be more frequent in older PCs and removal of the supernatant prior to transfusion reduces their occurrence. Proteomic profiling of PC supernatants was thus performed to identify proteins associated with PSLs and ATRs. Twenty-four PCs were investigated daily from day 0 to day 9 for platelet pre-activation (PPA), platelet-derived extracellular vesicles (PEVs), and platelet function. Using antibody microarrays, 673 extracellular proteins were analysed in PC supernatants on days 0, 3, 5, 7, and 9. During 5days of storage, PPA and PEVs continuously increased (P<0.0001). Platelet function was observed to remain stable within the first 5days (P=0.1751) and decreased thereafter. Comparison of all time points to day 0 revealed the identification of 136 proteins that were significantly changed in abundance during storage, of which 72 were expressed by platelets. Network analysis identified these proteins to be predominantly associated with exosomes (P=4.61×10^-8, n=45 genes) and two clusters with distinct functions were found with one being associated with haemostasis and the other with RNA binding. These findings may provide an explanation for ATRs.

SIGNIFICANCE

Changes in platelet concentrate (PC) supernatants during storage have been so far only poorly addressed and high abundant proteins burden the identification of quantitative changes in the secretome. We applied a high-throughput antibody microarray allowing for the sensitive quantification of 673 extracellular factors. PCs account for the highest number of adverse transfusion reactions (ATRs). ATRs have been demonstrated to be more frequent in older PCs and removal of the supernatant prior to transfusion reduces their occurrence. Comprehensive interpretation of the changing proteins in the secretome during platelet storage under blood banking conditions may help to identify mechanisms leading to the occurrence of adverse transfusion reactions.

Effect of premedication and other factors on the occurrence of acute transfusion reactions in dogs

OBJECTIVE

To evaluate the effect of premedication on transfusion reactions (TRs) within 24 hours after blood product transfusions in dogs.

DESIGN

Retrospective study between 2008 and 2011.

SETTING

Private veterinary referral hospital.

ANIMALS

Nine hundred and thirty-five transfusion events in 558 dogs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Medical records of dogs receiving blood product transfusions were reviewed. Information collected included signalment, weight, transfusion product type, reason for transfusion, first or subsequent transfusion, whether an acute reaction occurred, type of reaction, whether the reaction was treated, premedication prior to the transfusion and the premedication used, other medications the animal was given, whether the animal had an immune-mediated process, and whether the transfusion was administered in the perioperative period. A total of 144 (15%) acute TRs were documented in 136 dogs. The most common TRs were fever alone (77/144 [53%]) and vomiting alone (26/144 [18%]). Six dogs died due to the TR (4%). TR was not associated with age (P = 0.257), sex (P = 0.754), weight (P = 0.829), or premedication (P = 0.312). The type of blood product transfused (P < 0.001) was significantly associated with TRs, with packed RBCs most likely associated with a TR, and plasma least likely. Immune disease (P = 0.015) was significantly associated with occurrence of a TR. Significantly fewer reactions were documented following transfusions given in the perioperative period (P = 0.023).

CONCLUSIONS

While most TRs were mild, there were some serious reactions observed including hemolysis, dyspnea, and 6 deaths. Immune-mediated disease was associated with development of a TR, while transfusion during the perioperative period was associated with lower likelihood of reaction. Packed RBC transfusions were associated with development of acute TRs. Overall occurrence of TR was not significantly altered with premedication; however, when evaluated alone, antihistamines decreased the incidence of acute allergic reactions.

Effects of Leukoreduction and Premedication With Acetaminophen and Diphenhydramine in Minimizing Febrile Nonhemolytic Transfusion Reactions and Allergic Transfusion Reactions During and After Blood Product Administration

Transfusion-related reactions cause unwanted interruptions in blood-product administration and potential complications for patients. The most common reactions are febrile nonhemolytic transfusion reactions (FNHTRs) and allergic transfusion reactions (ATRs). The presence of leukocytes in blood products has been associated with these reactions, and efficacy of leukoreduction in minimizing FNHTRs and ATRs has recently been investigated. In addition, premedication with acetaminophen and diphenhydramine is the most widely used practice in minimizing FNHTRs and ATRs, yet the benefit of this is not supported by research. The aim of this systematic literature review was to evaluate the potential benefits of both of these interventions in minimizing FNHTRs and ATRs and provide recommendations for practice. We found moderate quality evidence with strong recommendations for the practice of leukoreduction in minimizing FNHTRs but not ATRs. We did not find evidence to support the use of premedications in minimizing transfusion-related reactions, and we question the need for this practice in settings where leukoreduction is used.

The impact of platelet additive solution apheresis platelets on allergic transfusion reactions and corrected count increment (CME)

BACKGROUND

Allergic transfusion reaction (ATR) incidence ranges from 1% to 3% of all transfusions. We evaluated the impact of InterSol platelet additive solution (PAS) apheresis platelets (APs) on the incidence of ATRs and the posttransfusion platelet (PLT) increment.

STUDY DESIGN AND METHODS

This retrospective study evaluated all ATRs among patients at a university hospital that maintained a mixed inventory of PAS APs and non-PAS APs (standard plasma-suspended PLTs). Corrected count increments (CCIs) were calculated for AP transfusions of individuals who received both a PAS and a non-PAS AP transfusion within a 7-day period. Hypothesis testing was performed with chi-square test for dichotomous variables and t tests for continuous variables.

RESULTS

The incidence of ATRs among the non-PAS APs was 1.85% (72 ATRs/3884 transfusions) and 1.01% (12 ATRs/1194 transfusions) for PAS APs (risk ratio [RR], 0.54; 95% confidence interval [CI]=0.30-0.99; p=0.04). However, there was no difference in the incidence of febrile nonhemolytic transfusion reactions between non-PAS APs (incidence, 0.70%; 27/3884) compared to PAS APs (incidence, 0.59%; 7/1194; p=0.69). Among 223 individuals with paired non-PAS and PAS AP transfusions, the mean CCI at 1 to 4 hours after transfusion was 4932 (95% CI, 4452-5412) for non-PAS APs and was lower for PAS APs (CCI, 3766; 95% CI, 3375-4158; p ≤ 0.001). However, there was no significant difference in mean CCI at 12 to 24 hours between non-PAS (CCI, 2135; 95% CI, 1696-2573) and PAS APs (CCI, 1745; 95% CI, 1272-2217; p=0.14).

CONCLUSIONS

PAS APs substantially reduce the number of ATRs. CCIs for PAS APs were lower immediately after transfusion, but not significantly different at 12 to 24 hours.

Pathogen reduction treatment alters the immunomodulatory capacity of buffy coat-derived platelet concentrates

BACKGROUND

Storage of platelet concentrates (PCs) after Mirasol pathogen reduction technology (PRT) treatment changes platelet (PLT) surface marker expression and secretion of immunomodulatory factors. Given that PLTs are known to participate in immune function, PRT may alter the way PLTs interact with the immune cells of a recipient upon transfusion. As such, the aim of this study was to assess the effects of PRT treatment on the functional ability of PLTs to interact with peripheral blood mononuclear cells (PBMNCs).

STUDY DESIGN AND METHODS

Buffy coat-derived PCs were pooled and split to obtain matched pairs. One unit was treated using the Mirasol PRT system, while the control PC remained untreated. After 5 days of storage, either the PLTs or the PLT supernatants from the PCs were cocultured with PBMNCs, with or without lipopolysaccharide (LPS). The immunomodulatory factors secreted into culture medium after coculture were examined.

RESULTS

PRT-treated PLTs and PLT supernatant significantly increased the interleukin (IL)-8 concentration, which was manifested only in the presence of LPS. Conversely, PRT-treated PLTs secreted less soluble P-selectin (sCD62P) upon coculture with PBMNCs.

CONCLUSION

PRT-treatment induced differential secretion of IL-8 and sCD62P during coculture, which may be attributed to either bioactive substances present in PLT supernatant or as a result of cell-cell interactions.

The prevention of adverse reactions to transfusions in patients with haemoglobinopathies: a proposed algorithm

BACKGROUND

Transfusion therapy remains the main treatment for patients with severe haemoglobinopathies, but can cause adverse reactions which may be classified as immediate or delayed. The use of targeted prevention with drugs and treatments of blood components in selected patients can contribute to reducing the development of some reactions.The aim of our study was to develop an algorithm capable of guiding behaviours to adopt in order to reduce the incidence of immediate transfusion reactions.

MATERIALS AND METHODS

Immediate transfusion reactions occurring over a 7-year period in 81 patients with transfusion-dependent haemoglobinopathies were recorded. The patients received transfusions with red cell concentrates that had been filtered prestorage. Various measures were undertaken to prevent transfusion reactions: leucoreduction, washing the red blood cells, prophylactic administration of an antihistamine (loratidine 10 mg tablet) or an antipyretic (paracetamol 500 mg tablet).

RESULTS

Over the study period 20,668 red cell concentrates were transfused and 64 adverse transfusion reactions were recorded in 36 patients. The mean incidence of reactions in the 7 years of observation was 3.1‰. Over the years the incidence gradually decreased from 6.8‰ in 2004 to 0.9‰ in 2010.

DISCUSSION

Preventive measures are not required for patients who have an occasional reaction, because the probability that such a type of reaction recurs is very low. In contrast, the targeted use of drugs such as loratidine or paracetamol, sometimes combined with washing and/or double filtration of red blood cells, can reduce the rate of recurrent (allergic) reactions to about 0.9‰. The system for detecting adverse reactions and training staff involved in transfusion therapy are critical points for reliable collection of data and standardisation of the detection system is recommended for those wanting to monitor the incidence of all adverse reactions, including minor ones.

Umbilical cord blood transplantation: review of factors affecting the hospitalized patient

The use of umbilical cord blood (UCB) as a stem cell donor source has dramatically increased over the last 2 decades. Patients undergoing UCB transplantation share medical management issues with patients receiving a hematopoietic stem cell transplantion using adult donor sources (peripheral blood stem cells or bone marrow stem cells) and may also have more complex medical issues that appear to be related to delayed immune recovery from UCB-derived stem cells. The interface with critical care providers is likely to occur in the transplant and posttransplant setting. Patients may experience UCB infusion reactions that range from mild to rarely severe. Following transplant, patients are transfusion dependent for long periods due to the prolonged engraftment of UCB cells. They are at high risk of infection, particularly viral. Once engrafted, UCB transplant patients have a lower rate of graft versus host disease compared to other donor sources. Some of the other complications that are seen in patients undergoing UCB transplant are posttransplant lymphoproliferative disease, diffuse alveolar hemorrhage, and posterior reversible encephalopathy will also be discussed.

Guideline on the investigation and management of acute transfusion reactions. Prepared by the BCSH Blood Transfusion Task Force

Although acute non-haemolytic febrile or allergic reactions (ATRs) are a common complication of transfusion and often result in little or no morbidity, prompt recognition and management are essential. The serious hazards of transfusion haemovigilance organisation (SHOT) receives 30-40 reports of anaphylactic reactions each year. Other serious complications of transfusion, such as acute haemolysis, bacterial contamination, transfusion-related acute lung injury (TRALI) or transfusion-associated circulatory overload (TACO) may present with similar clinical features to ATR. This guideline describes the approach to a patient developing adverse symptoms and signs related to transfusion, including initial recognition, establishing a likely cause, treatment, investigations, planning future transfusion and reporting within the hospital and to haemovigilance organisations. Key recommendations are that adrenaline should be used as first line treatment of anaphylaxis, and that transfusions should only be carried out where patients can be directly observed and where staff are trained in manging complications of transfusion, particularly anaphylaxis. Management of ATRs is not dependent on classification but should be guided by symptoms and signs. Patients who have experienced an anaphylactic reaction should be discussed with an allergist or immunologist, in keeping with UK resuscitation council guidelines.

Scratching the surface of allergic transfusion reactions

Allergic transfusion reactions (ATRs) are a spectrum of hypersensitivity reactions that are the most common adverse reaction to platelets and plasma, occurring in up to 2% of transfusions. Despite the ubiquity of these reactions, little is known about their mechanism. In a small subset of severe reactions, specific antibody has been implicated as causal, although this mechanism does not explain all ATRs. Evidence suggests that donor, product, and recipient factors are involved, and it is possible that many ATRs are multifactorial. Further understanding of the mechanisms of ATRs is necessary so that rationally designed and cost-effective prevention measures can be developed.

Immunomodulatory mediators in platelet transfusion reactions

Our appreciation of the roles that platelets play in vascular biology is constantly expanding. One of the major roles of platelets is in initiating and accelerating immune responses. Platelet transfusion may be associated with adverse inflammatory outcomes manifested as fever, discomfort, tachycardia, and respiratory issues. This may in part be due to immune mediators either expressed by activated platelets or released into the platelet media during platelet storage. This review will highlight some more recent knowledge gained regarding the platelet storage lesion and potential mediators of platelet transfusion reactions.

Pharmacological interventions for the prevention of allergic and febrile non-haemolytic transfusion reactions

BACKGROUND

Allergic and febrile non-haemolytic transfusion reactions (NHTRs) are the two most common forms of transfusion reaction. Pretransfusion medication with anti-inflammatory drugs is used in NHTR prevention, however its efficacy and safety remains unclear.

OBJECTIVES

To assess the clinical effects and safety of pharmacological interventions for preventing NHTR in patients with and without a history of transfusion reactions.

SEARCH STRATEGY

The search strategy included The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 4, 2008), Cochrane Injuries Group's Specialised Register (December 17, 2008), MEDLINE (1950 to November (week 3) 2008), EMBASE (1988 to November (week 3) 2008), LILACS (1982 to January 12, 2009), CINAHL (1982 to December 2008), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED): 1970 to December 2008). There was no language restriction.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing the effectiveness of interventions for the prevention of NHTR.

DATA COLLECTION AND ANALYSIS

Authors independently selected studies, assessed the risks of bias and extracted data. Relative risks (RR) were estimated in RCTs with parallel design (PD). Odds ratio (OR) was estimated for one RCT with crossover design (CD). No meta-analysis was attempted due to differences in the pharmacotherapy of pre-transfusion medication and methodology between the studies; a per-protocol analysis was used.

MAIN RESULTS

This review includes three RCTs (two PD and one CD). The PD-RCTs employed disparate units of randomisation (UofR); patient or transfusion, while the CD-RCT applied the patient as the UofR. The PD-RCTs administered leukodepleted blood products. Both PD-RCTs compared acetaminophen plus diphenhydramine (ApD) at different regimens with placebo, while the CD-RCT contrasted hydrocortisone pharmacotherapy with diphenhydramine. Both PD-RCTs found no statistically significant difference in allergic reactions (RR 0.13, 95% confidence interval (CI) 0.01 to 2.39, RR 1.46, 95% CI 0.78 to 2.73) and febrile reactions (RR 0.52, 95% CI 0.22 to 1.26). The CD-RCT found a statistically significant difference in the odds of febrile reactions (OR 2.38, 95% CI 1.07 to 5.27). The trials did not report anaphylactic reactions, deaths related to transfusion reactions or other adverse events.

AUTHORS' CONCLUSIONS

None of the three studies found that medication prior to transfusion reduces NHTR. This applied regardless of the patient's history of NHTR and the use of leukodepleted blood products in the transfusion. However, this conclusion is based on three trials of moderate to low quality. A better-powered RCT is necessary to evaluate the role of pretransfusion medication in the prevention of NHTR. Inclusion criteria should be restricted to patients at high risk of developing NHTR, with no restriction by age, history of transfusion reactions and type of blood products (leukodepleted or not).

Removing Meperidine from the Health-System Formulary—Frequently Asked Questions

Meperidine is FDA-approved for relieving moderate to severe pain and has been widely used since its introduction in the 1930s. However, the drug is no longer considered a first-line analgesic. Many clinicians recommend that meperidine be removed from health-systems or that its use be restricted, due to concerns about adverse reactions, drug interactions, and normeperidine neurotoxicity. In addition, clinical evidence shows that meperidine has no advantage over other opioids for biliary colic or pancreatitis. The formulary status of meperidine has been extensively discussed at University of Utah Hospitals and Clinics. The Pharmacy and Therapeutics Committee has been working with hospital staff to assess the impact of either removing meperidine from the formulary, or limiting its use. The Drug Information Service developed this document to help pharmacists respond to prescribers' questions and to alleviate the prescribers' concerns about these changes. Information is provided comparing meperidine with other opioids, including dosage equivalency, pharmacodynamics, pharmacokinetics, cost, adverse effects, and drug interactions. Where available, alternatives to meperidine are suggested for various indications.

Proteomic analysis of supernatant from pooled buffy-coat platelet concentrates throughout 7-day storage

BACKGROUND

The platelet (PLT) storage lesion remains incompletely understood. To gain a greater insight into the PLT storage lesion, a proteomic analysis of supernatant from leukofiltered pooled buffy-coat PLT concentrates (PCs) was undertaken.

STUDY DESIGN AND METHODS

PCs were prepared in PLT additive solution and stored according to standard blood bank procedures. Supernatant samples were collected throughout 7 days of storage. Maps of supernatant proteins were generated by two-dimensional (2D) gel electrophoresis and mass spectrometry. Cytokine antibody microarrays and enzyme-linked immunosorbent assay were used to investigate bioactive molecules.

RESULTS

The 2D gel maps of PC supernatant proteins displayed many features of plasma protein maps. Several storage-induced protein changes were identified including modifications to major plasma proteins. PLT-derived proteins were also identified, including tremlike transcript 1 and integrin-linked kinase, which may influence PLT-endothelium interactions. Cytokine antibody microarrays revealed a number of bioactive proteins that have not been previously associated with PCs produced for transfusion, such as brain-derived neurotrophic factor (BDNF). The concentration of PLT-derived cytokines including BDNF, CXCL7, epidermal growth factor, PLT-derived growth factor (PDGF), and CCL5 significantly increased during storage of PCs. Extended storage from Day 5 to Day 7 caused significantly increased levels of BDNF, PDGF, and CCL5 in PC supernatant.

CONCLUSION

Proteomic techniques provide valuable new insight into the effects of storage on PCs and the contribution of soluble proteins to the development of the PLT storage lesion and recipient responses to PLT transfusion.

Noninfectious complications of blood transfusion

CONTEXT

Serious noninfectious complications are far more likely to occur than viral disease transmission from blood component transfusion.

OBJECTIVE

To compile a comprehensive list of the noninfectious risks of transfusion, examples of published risk estimates, and summaries of recent information regarding cause, prevention, or management of noninfectious transfusion risks.

DATA SOURCES

Information was obtained from peer-reviewed English-language medical journal publications since 1990.

CONCLUSIONS

Early complications, although potentially more serious, usually occur less frequently (<1 in 1000 transfusions) than late complications, which often affect more than 1% of recipients. Areas of active investigation and discussion include acute hemolytic reactions, transfusion-related acute lung injury, red cell alloimmunization, platelet transfusion refractoriness, and transfusion immunosuppression. Continued effort toward research and education to promote recognition and prevention of noninfectious complications associated with blood components is warranted.

Release of biologically active CD154 during collection and storage of platelet concentrates prepared for transfusion

BACKGROUND

Millions of platelet transfusions are given each year. Transfusion reactions occur in as many as 30% of patients receiving unmodified platelet transfusions. The cause of some transfusion reactions remains unclear. The current paradigm suggests that platelet concentrates (PC) contain proinflammatory mediators that are released by white blood cells during collection, processing and storage. CD154 (CD40 ligand, CD40L) is a potent inflammatory mediator, normally sequestered inside the resting platelet, that is known to translocate to the platelet membrane and be shed into plasma in response to agonist activation. We hypothesized that platelet-soluble CD154 (sCD154) is 'spontaneously' released by transfused platelets and plays a major role in transfusion reactions.

OBJECTIVES

To determine the time course and biological properties of CD154 translocation and release during collection and storage of platelets for transfusion.

METHODS

We measured surface and sCD154 in platelets prepared by the platelet-rich plasma method or apheresis by fluorescence-activated cell sorting and enzyme-linked immunosorbent assay, respectively. The specific biological activity of platelet sCD154 was assayed by stimulation of the CD154/CD40 pathway in known CD40-positive cells with PC-derived supernatants.

RESULTS AND CONCLUSIONS

We demonstrate that PCs prepared for transfusion have high levels of membrane-bound CD154 and sCD154, with maximum levels being seen 72 h after platelet collection. Importantly, we show that platelet-derived sCD154 potently stimulates CD40-positive cells. We propose that platelet-derived CD154 is a key 'cytokine' responsible for adverse reactions associated with platelet transfusions. Improved methods of platelet collection and/or storage, which limit CD154 expression, could reduce the risks of transfusion reaction.

Acetaminophen and diphenhydramine premedication for allergic and febrile nonhemolytic transfusion reactions: good prophylaxis or bad practice?

Febrile nonhemolytic and allergic reactions are the most common transfusion reactions, but usually do not cause significant morbidity. In an attempt to prevent these reactions, US physicians prescribe acetaminophen or diphenhydramine premedication before more than 50% of blood component transfusions. Acetaminophen and diphenhydramine are effective therapies for fever and allergy, respectively, so their use in transfusion has some biologic rationale. However, these medications also have potential toxicity, particularly in ill patients, and in the studies performed to date, they have failed to prevent transfusion reactions. Whether the benefits of routine prophylaxis with acetaminophen and diphenhydramine outweigh their risks and cost requires reexamination, particularly in light of the low reaction rates reported at many institutions even when premedication is not prescribed.

An association of soluble CD40 ligand (CD154) with adverse reactions to platelet transfusions

BACKGROUND

Removal of stored supernatant abrogates most transfusion reactions to leukoreduced platelets (PLTs), suggesting that PLT-derived soluble mediators are involved. PLTs are the primary source of soluble CD40 ligand (sCD40L). Engagement of the receptor for CD40L induces synthesis of proinflammatory mediators including interleukin (IL)-6, IL-8, and monocyte chemotactic protein-1 (MCP-1).

STUDY DESIGN AND METHODS

Supernatants from poststorage leukoreduced PLT concentrates were assayed for white cell- (IL-6, IL-8, MCP-1) and PLT-derived (sCD40L, RANTES) inflammatory mediators. These levels were correlated with clinical outcomes.

RESULTS

Of 534 transfusions, there were 12 reported (2.2%) and 2 unreported reactions (0.4%)--10 febrile and 4 allergic. Transfusions with reactions had significantly higher levels of IL-6 (2.3-fold higher; p = 0.005), IL-8 (2.2-fold higher; p = 0.001), MCP-1 (2.6-fold higher; p = 0.002), and sCD40L (1.24-fold higher; p = 0.015), but not RANTES. (1.14-fold higher; p = 0.22). The vast majority (>93%) of patients transfused with mediator levels in the highest quintile had no reactions. When levels of all five mediators were summed, the reaction rates in the first through fifth quintiles increased from 1 to 7 percent (p = 0.027). All but one reaction occurred in patients with hematologic malignancies (13 reactions/380 transfusions; 3.4%; p = 0.04 vs. other diagnoses).

CONCLUSIONS

These are the first data demonstrating that a PLT-derived mediator, sCD40L, is associated with adverse transfusion events. Existing clinical factors, for example, inflammation or leukopenia, may influence whether infused mediators cause reactions.

Universal Leukocyte Reduction

This article discusses the evidence for the generally accepted uses of leukocyte-reduced blood and the controversy over leukocyte reduction and transfusion-related immunomodulation. A perspective is provided on the continued need for leukocyte reduction on the part of all patients in the United States.

Platelet activation during plasma-reduced multicomponent PLT collection: a comparison between COBE Trima and Spectra LRS turbo cell separators

BACKGROUND

The wide diffusion of multicomponent collection in donor apheresis has led to the yielding of different components, such as plasma-reduced platelet-pheresis at high PLT concentration. We investigated whether this collection modality could induce more PLT activation compared to standard plateletpheresis.

STUDY DESIGN AND METHODS

Forty-one plateletpheresis collections (20 Trima and 21 Spectra LRS Turbo v.7.0, COBE) were evaluated. Donor, procedure, and product data were recorded. ADP, collagen, and U46619 (a thromboxane-A2 analog)-induced PLT aggregation was investigated in basal (donor) and final (plateletpheresis unit) samples. The expression of PLT activation marker P-selectin (CD62P) was studied using flow cytometry in basal and final samples. In all cases, P-selectin was investigated in final samples after stimulation with ADP to assess for a possible further release of the antigen. Four additional plateletpheresis procedures were performed in donors from Group A, using the traditional, nonplasma-reduced program.

RESULTS

Plateletpheresis obtained by means of the Trima device showed a lower response to in-vitro induced PLT aggregation and a higher percentage of P-selectin-expressing PLT when compared to products obtained using the Spectra device. Moreover, P-selectin release after ADP stimulation was reduced in plateletpheresis units obtained using the Trima device. These differences disappeared when a nonplasma-reduced collection program was used. In-vivo evaluation did not detect any difference between plateletpheresis obtained by means of the two cell separators.

CONCLUSIONS

Plateletpheresis units obtained by means of multicomponent collection show a higher degree of PLT activation compared to traditional plateletpheresis procedures when high-concentration plasma-reduced products are collected. Randomized clinical studies are needed to assess the real impact of these findings in terms of in-vivo efficacy of plasma-reduced plateletpheresis units.

The effect of prestorage WBC reduction on the rates of febrile nonhemolytic transfusion reactions to platelet concentrates and RBC

BACKGROUND

Febrile non-hemolytic transfusion reactions (FNHTRs) are a common complication of platelet concentrate (PC) and RBC transfusions, usually ascribed to cytokines released by WBCs and perhaps the platelets themselves during storage. Prestorage WBC reduction should abrogate the accumulation of these cytokines reducing the number of FNHTRs.

STUDY DESIGN AND METHODS

A retrospective analysis of FNHTR to PCs and RBCs before universal WBC reduction (PrUR) (July 1997-January 1998 for PCs, July 1997-July 1999 for RBCs) and after its introduction (PoUR) (February 1998-August 2001 for PC, August 1999-August 2001 for RBCs) was undertaken. All transfusion reactions were stratified based on component and date of reaction. Other adverse transfusion reactions were grouped into three periods: July 1997-January 1998, February 1998-July 1999, and August 1999-August 2001. A chi-square test was performed to determine the significance of the differences between groups.

RESULTS

In the PRUR group, there were: 231 FNHTRs in 70,396 RBC units transfused (0.33%) and 29 FNHTRs in 6502 PC units transfused (0.45% percent). In the PoUR group, there were 136 FNHTRs in 72,949 RBC units transfused (0.19%, p < 0.001) and 56 FNHTRs in 50,555 PC units transfused (0.11%, p < 0.001). Of the other adverse events, only TRALI reactions were significantly reduced.

CONCLUSION

Prestorage WBC reduction significantly reduced the rate of FNHTRs to PCs and RBCs.