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Wu YF, Shen CL, Huang WH, Chu SC, Li CC, Liu CZ, Wang TF. Improving platelet function following prophylactic platelet transfusion in patients with hematological malignancies. Int J Lab Hematol 2024; 46:722-730. [PMID: 38682289 DOI: 10.1111/ijlh.14283] [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: 11/18/2023] [Accepted: 04/01/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION Platelet transfusion is a standard treatment to prevent bleeding in patients with hematological malignancies. Although transfusions can improve platelet count, their impact on platelet function remains controversial. METHODS We conducted flow cytometry to assess platelet function before and after transfusion and performed subgroup analyses to examine differences based on blood type, corrected count increment (CCI), and platelet microparticles. RESULTS Overall, 50 patients who received prophylactic platelet transfusion were enrolled. CD42b expression increased, whereas CD41 expression decreased after transfusion. Apheresis platelets exhibited the lowest expression of PAC-1 and P-selectin when exposed to agonist stimulations. PAC-1 expression increased under high adenosine diphosphate (ADP) stimulation, while P-selectin expression increased under both high ADP and thrombin receptor-activating peptide stimulation. In the subgroup analysis, patients with a CCI >4500 and those with the same blood types exhibited a more significant increase in PAC-1 and P-selectin expression under agonist stimulation. When comparing apheresis platelets collected on different days, only the percentage of platelet-derived microparticles showed a significant increase. CONCLUSION Prophylactic transfusion improved platelet function. Platelet function significantly improved in patients with a CCI >4500, those with the same blood types as that of apheresis platelets, or those with platelet-derived microparticle levels <4.7%. No significant improvement in platelet function was noted after the transfusion of different blood types with acceptable compatibility or the transfusion of incompatible blood types. Our results suggest that transfusing platelets with the same blood type remains the optimal choice.
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Affiliation(s)
- Yi-Feng Wu
- Department of Hematology and Oncology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- College of Medicine, Tzu-Chi University, Hualien, Taiwan
- Ph.D. Program in Pharmacology and Toxicology, Tzu Chi University, Hualien, Taiwan
| | - Chih-Lung Shen
- Department of Hematology and Oncology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Wei-Han Huang
- Department of Hematology and Oncology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Department of Clinical Pathology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Sung-Chao Chu
- Department of Hematology and Oncology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- College of Medicine, Tzu-Chi University, Hualien, Taiwan
| | - Chi-Cheng Li
- Department of Hematology and Oncology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Center of Stem Cell & Precision Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Chao-Zong Liu
- Department of Pharmacology, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tso-Fu Wang
- Department of Hematology and Oncology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- College of Medicine, Tzu-Chi University, Hualien, Taiwan
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Ma YT, Xian-Yu CY, Yu YX, Zhang C. Perioperative fluid management for adult cardiac surgery: network meta-analysis pooling on twenty randomised controlled trials. Perioper Med (Lond) 2024; 13:76. [PMID: 39033296 PMCID: PMC11264963 DOI: 10.1186/s13741-024-00440-5] [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: 05/11/2024] [Accepted: 07/16/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND The aim of this study was to evaluate colloids and crystalloids used in perioperative fluid therapy for cardiac surgery patients to further investigate the optimal management strategies of different solutions. METHOD RCTs about adult surgical patients allocated to receive perioperative fluid therapy for electronic databases, including Ovid MEDLINE, EMBase, and Cochrane Central Register of Controlled Trials, were searched up to February 15, 2023. RESULTS None of the results based on network comparisons, including mortality, transfuse PLA, postoperative chest tube output over the first 24 h following surgery, and length of hospital stay, were statistically significant. Due to the small number of included studies, the results, including acute kidney injury, serum creatinine, serum microglobulin, and blood urea nitrogen, are from the direct comparison. For transfusion of RBCs, significant differences were observed in the comparisons of 3% gelatine vs. 6% HES 200/0.5, 4% albumin vs. 5% albumin, 4% gelatine vs. 5% albumin, 5% albumin vs. 6% HES 200/0.5, and 6% HES 130/0.4 vs. 6% HES 200/0.5. In transfusion of FFP, significant differences were observed in comparisons of 3% gelatine vs. 4% gelatine, 3% gelatine vs. 6% HES 200/0.5, 5% albumin vs. 6% HES 200/0.5, 4% gelatine vs. 5% albumin, 4% gelatine vs. 6% HES 200/0.4, and 6% HES 130/0.4 vs. 6% HES 200/0.5. For urinary output at 24 h after surgery, the results are deposited in the main text. CONCLUSION This study showed that 3% gelatin and 5% albumin can reduce the transfuse RBC and FFP. In addition, the use of hypertonic saline solution can increase urine output, and 5% albumin and 6% HES can shorten the length of ICU stay. However, none of the perioperative fluids showed an objective advantage in various outcomes, including mortality, transfuse PLA, postoperative chest tube output over the first 24 h following surgery, and length of hospital stay. The reliable and sufficient evidences on the injury of the kidney, including acute kidney injury, serum creatinine, serum microglobulin, and blood urea nitrogen, was still lacking. In general, perioperative fluids had advantages and disadvantages, and there were no evidences to support the recommendation of the optimal perioperative fluid for cardiac surgery.
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Affiliation(s)
- Yu-Tong Ma
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China
| | - Chen-Yang Xian-Yu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China
| | - Yun-Xiang Yu
- Department of Surgery, Taihe Hospital, Hubei University of Medicine, No.32, South Renmin Road, Shiyan, 442000, Hubei, China.
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, No.32, Renmin South Road, Shiyan, 442000, Hubei, China.
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Taneja S, Heddle NM, Hillis C, Lane S, Karunakaran M, Maze D, Modi D, Khalaf D, Arnold DM, Zahreddine H, Webert K, Hess L, Cook R, Stanworth S, Gernsheimer T, Vanstone M. Healthcare provider's perceptions of bleeding in patients with acute leukaemia undergoing induction chemotherapy: A qualitative study. Transfus Med 2024. [PMID: 39032121 DOI: 10.1111/tme.13070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 06/20/2024] [Accepted: 07/08/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND Bleeding is a primary outcome for many transfusion-related trials in acute leukaemia (AL) patients, typically graded using the World Health Organisation (WHO) bleeding scale (clinically significant bleed (CSB) is ≥grade 2). This composite outcome fails to differentiate minor bleeds that may not be significant, poorly represents the total burden of bleeding and lacks input from healthcare providers (HCPs) and patients. As part of a multi-step project to create a better bleeding tool for trials, our objective was to identify HCPs' perspectives on the components of CSB in AL patients. STUDY DESIGN AND METHODS Using qualitative description, we interviewed 19 physicians and nurses who care for AL patients undergoing induction chemotherapy. Participants were recruited from professional organisations, networks and social media. An inductive approach to conventional content analysis was used. RESULTS HCPs identified features of CSB as the anatomical site of bleeding, amount of bleeding, need for intervention and changes in vital signs. Using these characteristics, bleeding events were categorised into three groups: clinically significant, could evolve into a CSB and not clinically significant. HCPs considered the patient's condition, bleeding history and clinical intuitions when deciding whether a bleed could escalate into serious bleeding. DISCUSSION Using data from HCPs, we categorised bleeds as clinically significant, could evolve into a CSB, and not significant. A study of patients' perspectives on the importance of different kinds of bleeding is the next step to creating a bleeding definition that is informed by evidence, clinicians and patients.
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Affiliation(s)
- Shipra Taneja
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nancy M Heddle
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Christopher Hillis
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Shannon Lane
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Meera Karunakaran
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Dawn Maze
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Dimpy Modi
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Dina Khalaf
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Hassan Zahreddine
- Department of Oncology, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Kathryn Webert
- Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Canadian Blood Services, Ancaster, Ontario, Canada
| | - Laura Hess
- Patient Partner, Hamilton, Ontario, Canada
| | - Richard Cook
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Canada
| | - Simon Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- NHSBT, John Radcliffe Hospital, Oxford, UK
- NIHR Blood and Transplant Research Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Terry Gernsheimer
- Division of Hematology, University of Washington, Seattle, Washington, USA
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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van der Staaij H, Hooiveld NMA, Caram-Deelder C, Fustolo-Gunnink SF, Fijnvandraat K, Steggerda SJ, de Vries LS, van der Bom JG, Lopriore E. Most major bleeds in preterm infants occur in the absence of severe thrombocytopenia: an observational cohort study. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-326959. [PMID: 39009429 DOI: 10.1136/archdischild-2024-326959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 07/01/2024] [Indexed: 07/17/2024]
Abstract
OBJECTIVE To describe the incidence of major bleeds according to different platelet counts in very preterm infants, and to explore whether this association is influenced by other risk factors for bleeding. DESIGN Observational cohort study. SETTING A Dutch tertiary care neonatal intensive care unit. PATIENTS All consecutive infants with a gestational age at birth <32 weeks admitted between January 2004 and July 2022. EXPOSURE Infants were stratified into nine groups based on their nadir platelet count (×109/L) during admission (<10, 10-24, 25-49, 50-99, 100-149, 150-199, 200-249, 250-299 and ≥300), measured before the diagnosis of a major bleed and before any platelet transfusion was administered. MAIN OUTCOME MEASURE Incidence of major bleeds during admission. Logistic regression analysis was used to quantify the relationship between nadir platelet count and incidence of major bleeds. RESULTS Among 2772 included infants, 224 (8%) developed a major bleed. Of the infants with a major bleed, 92% (206/224) had a nadir platelet count ≥50×109/L. The incidence of major bleeds was 8% among infants with and without severe thrombocytopenia (platelet count <50×109/L), 18/231 (95% CI 5 to 12) and 206/2541 (95% CI 7 to 9), respectively. Similarly, after adjustment for measured confounders, there was no notable association between nadir platelet counts below versus above 50×109/L and the occurrence of major bleeds (OR 1.09, 95% CI 0.61 to 1.94). CONCLUSION In very preterm infants, the vast majority of major bleeds occur in infants without severe thrombocytopenia.
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Affiliation(s)
- Hilde van der Staaij
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
- Department of Paediatric Haematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nadine M A Hooiveld
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Camila Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Suzanne F Fustolo-Gunnink
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
- Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
- Department of Paediatric Haematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Institute for Advanced Study, University of Amsterdam, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
- Department of Paediatric Haematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sylke J Steggerda
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Linda S de Vries
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Johanna G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
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Berenger JB, Saillard C, Sannini A, Servan L, Gonzalez F, Faucher M, de Guibert JM, Hospital MA, Bisbal M, Chow-Chine L, Mokart D. Prophylactic versus restrictive platelet transfusion strategy in patients with haematological malignancies in the ICU setting, a propensity-score analysis. J Crit Care 2024; 83:154817. [PMID: 38805833 DOI: 10.1016/j.jcrc.2024.154817] [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: 02/14/2024] [Revised: 04/20/2024] [Accepted: 04/25/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE Prophylactic platelet transfusions (PT) aim to reduce bleeding. We assessed whether restrictive PT compared to prophylactic strategy could apply in ICU. MATERIAL AND METHODS We conducted a retrospective monocentric study including patients >18 yo with haematological malignancy admitted to the ICU with thrombocytopenia <20 G/L between 2018 and 2021. Patients were classified in 2 groups according transfusion strategy applied during the first 3 days: prophylactic or restrictive transfusion. RESULTS 180 patients were included, 87 and 93 in the restrictive and prophylactic groups respectively. After propensity-score analysis, 2 groups of 54 matched patients were analyzed. Restrictive strategy led to a significant reduction in PT with incidence rate for 100-ICU-patients-days of 34.9 and 49.9, incidence rate ratio = 0.699 [0.5-0.9], p = 0.006, representing a 31% decrease. Decreased PT persisted until day 28 with platelet concentrates transfusions-free days at day 28 of 21 [13-25] and 16.5 [10.2-21] in the 2 groups (p = 0.04). Restrictive strategy did not result in higher grade ≥ 2 bleeding. Transfusion efficiency was low with similar number of days with platelet <10 or < 20 G/L regardless of strategy. Platelet transfusion strategy was not associated with 28-day mortality. Platelet nadir <5G/L was associated with day-28 mortality with HR = 1.882 [1.011-3.055], p = 0.046. CONCLUSION A restrictive PT strategy appears feasible in the ICU.
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Affiliation(s)
- Jean-Baptiste Berenger
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Colombe Saillard
- Haematology Department, Institut Paoli Calmettes, Marseille, France
| | - Antoine Sannini
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Luca Servan
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Frederic Gonzalez
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Marion Faucher
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Jean-Manuel de Guibert
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | | | - Magali Bisbal
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Laurent Chow-Chine
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Djamel Mokart
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France.
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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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Shah A, Stanworth SJ, Doidge JC, Watkinson PJ. Prophylactic platelet transfusions in critical care: How low can you go? J Intensive Care Soc 2024; 25:123-127. [PMID: 38737301 PMCID: PMC11086719 DOI: 10.1177/17511437231206013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Affiliation(s)
- Akshay Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Simon J Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NHS Blood & Transplant, Oxford, UK
| | - James C Doidge
- Intensive Care National Audit and Research Centre, London, UK
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Cheng Y, Xie C, Tian Y, Wang F, Liu X, Cheng D. Discussion on the recruitment strategy for apheresis platelet donors in Chongqing during a public health emergency . Front Public Health 2024; 12:1365433. [PMID: 38651129 PMCID: PMC11034425 DOI: 10.3389/fpubh.2024.1365433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/08/2024] [Indexed: 04/25/2024] Open
Abstract
Objective This study aimed to analyze the population characteristics of apheresis platelet donors in Chongqing Province and provide a scientific basis for the development of precise and efficient recruitment strategies. The ultimate goal is to increase the number of regular platelet donors in preparation for public health emergencies. Methods This study involved 53,089 blood donors who donated apheresis platelets to the Chongqing Blood Center from 2020 to 2022. Data regarding age, sex, blood type, education level, occupation, and frequency of blood donation were collected and analyzed to identify factors influencing platelet donation. Results Between 2020 and 2022, the majority of apheresis platelet donors in Chongqing were aged 25-35 years, with a male-to-female ratio of 2.6:1. The ABO blood group distribution was O > A > B > AB. The apheresis platelet donors mainly consisted of college students, and the donors who had donated only once accounted for the greatest proportion. Conclusion Based on the population characteristics of apheresis platelet donors in Chongqing, blood collection and supply organizations must refine emergency blood collection and supply plans during public health emergencies. This study underscores the importance of developing precise and efficient recruitment strategies for apheresis platelet donors and expanding the pool of regular apheresis platelet donors. These measures are essential to ensure the timely, safe, and effective use of clinical blood resources during public health emergencies.
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Affiliation(s)
- Ying Cheng
- Chongqing Blood Center, Chongqing, China
| | | | - Yunbo Tian
- Chongqing Blood Center, Chongqing, China
| | - Fang Wang
- Chongqing Blood Center, Chongqing, China
| | - Xingchen Liu
- School of Public Health, Chongqing Medical University, Chongqing, China
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9
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Yohannan B, Martinez Gutierrez JC, Chen PR, Rios A. Middle Meningeal Artery Embolization in Acute Leukemia Patients Presenting With Subdural Hematoma. J Hematol 2024; 13:39-45. [PMID: 38644984 PMCID: PMC11027772 DOI: 10.14740/jh1215] [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: 11/11/2023] [Accepted: 12/30/2023] [Indexed: 04/23/2024] Open
Abstract
Intracerebral hemorrhage is a potentially fatal complication in patients with acute leukemia and contributing factors include thrombocytopenia and coagulopathy. Patients with acute leukemia may develop subdural hematoma (SDH) spontaneously or secondary to trauma. In patients with acute leukemia and SDH, the surgical evacuation of the hematoma causes significant morbidity and mortality. New approaches and strategies to reduce the need for surgical evacuation are needed to improve outcomes in patients with acute leukemia and intracerebral hemorrhage. We report two cases of acute SDH in patients with acute leukemia successfully treated with middle meningeal artery embolization, a minimally invasive interventional radiology technique, obviating the need for a surgical intervention. The first patient with acute promyelocytic leukemia (APL) presented with coagulopathy and developed an acute SDH after a fall. The second patient with acute myeloid leukemia presented with gum bleeding and also sustained an acute SDH after a fall. Both patients underwent middle meningeal artery embolization for treating their SDHs while actively receiving induction chemotherapy for acute leukemia. Both patients had resolution of their acute SDH and are in remission from their acute leukemia. Middle meningeal artery embolization is a very effective, and within the context of this setting, a novel, minimally invasive technique for management of SDH in acute leukemia patients, which can prevent the need for surgical interventions with its associated comorbidities and high risk of fatal outcomes in patients with acute leukemia and acute SDH.
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Affiliation(s)
- Binoy Yohannan
- Division of Hematology/Oncology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Juan Carlos Martinez Gutierrez
- Division of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Peng Roc Chen
- Division of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Adan Rios
- Division of Hematology/Oncology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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10
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Mo A, Weinkove R, Wood EM, Shortt J, Johnston A, McQuilten ZK. Use of platelet transfusions and tranexamic acid in patients with myelodysplastic syndromes: A clinical practice survey. Eur J Haematol 2024; 112:621-626. [PMID: 38123137 DOI: 10.1111/ejh.14156] [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: 10/13/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
AIM Thrombocytopenia and bleeding are common in myelodysplastic syndromes (MDS), but optimal management is unknown. We conducted a survey to identify current clinical practice regarding platelet transfusion (PLT-T) and tranexamic acid (TXA) to inform future trial design. METHOD A 25-question survey was distributed to members of the ALLG from December 2020 to July 2021. RESULTS Sixty-four clinicians across Australia, New Zealand and Singapore responded. Clinicians treated a median of 15 MDS patients annually. Twenty-nine (45%) reported having institutional guidelines regarding prophylactic PLT-T. Although 60 (94%) said they would consider using TXA, most (58/64; 91%) did not have institutional guidelines. Clinical scenarios showed prophylactic PLT-T was more likely administered for patients on disease-modifying therapy (49/64; 76%, commonest threshold <10 × 109 /L) or with minor bleeding (32/64 [50%] transfusing at threshold <20 × 109 /L, 23/64 [35%] at <10 × 109 /L). For stable untreated patients, 29/64 (45%) would not give PLT-T and 32/64 (50%) would. Most respondents (46/64; 72%) were interested in participating in trials in this area. Potential barriers included resource limitations, funding and patient/clinician acceptance. CONCLUSION Real-world management of MDS-related thrombocytopenia varies and there is a need for clinical trials to inform practice.
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Affiliation(s)
- Allison Mo
- Australasian Leukaemia & Lymphoma Group (ALLG), Richmond, Victoria, Australia
- Transfusion Research Unit, Monash University, Melbourne, Victoria, Australia
- Monash Haematology, Monash Health, Clayton, Victoria, Australia
- Department of Haematology and Austin Pathology, Austin Health, Heidelberg, Victoria, Australia
| | - Robert Weinkove
- Australasian Leukaemia & Lymphoma Group (ALLG), Richmond, Victoria, Australia
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Newtown, New Zealand
- Te Rerenga Ora Wellington Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital Coast & Hutt Valley, Wellington, New Zealand
| | - Erica M Wood
- Australasian Leukaemia & Lymphoma Group (ALLG), Richmond, Victoria, Australia
- Transfusion Research Unit, Monash University, Melbourne, Victoria, Australia
- Monash Haematology, Monash Health, Clayton, Victoria, Australia
| | - Jake Shortt
- Australasian Leukaemia & Lymphoma Group (ALLG), Richmond, Victoria, Australia
- Monash Haematology, Monash Health, Clayton, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Anna Johnston
- Australasian Leukaemia & Lymphoma Group (ALLG), Richmond, Victoria, Australia
- Department of Clinical Haematology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Zoe K McQuilten
- Australasian Leukaemia & Lymphoma Group (ALLG), Richmond, Victoria, Australia
- Transfusion Research Unit, Monash University, Melbourne, Victoria, Australia
- Monash Haematology, Monash Health, Clayton, Victoria, Australia
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11
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Adkins BD, Jacobs JW, Booth GS, Savani BN, Stephens LD. Transfusion Support in Hematopoietic Stem Cell Transplantation: A Contemporary Narrative Review. Clin Hematol Int 2024; 6:128-140. [PMID: 38817704 PMCID: PMC11086996 DOI: 10.46989/001c.94135] [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: 12/01/2023] [Accepted: 02/05/2024] [Indexed: 06/01/2024] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a cornerstone of modern medical practice, and can only be performed safely and effectively with appropriate transfusion medicine support. Patients undergoing HSCT often develop therapy-related cytopenia, necessitating differing blood product requirements in the pre-, peri-, and post-transplant periods. Moreover, ensuring optimal management for patients alloimmunized to human leukocyte antigens (HLA) and/or red blood cell (RBC) antigens, as well as for patients receiving ABO-incompatible transplants, requires close collaboration with transfusion medicine and blood bank professionals. Finally, as updated transfusion guidelines and novel blood product modifications emerge, the options available to the transplant practitioner continue to expand. Herein, we detail contemporary blood transfusion and transfusion medicine practices for patients undergoing HSCT.
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Affiliation(s)
- Brian D. Adkins
- PathologyThe University of Texas Southwestern Medical Center
| | | | - Garrett S. Booth
- Pathology, Microbiology, and ImmunologyVanderbilt University Medical Center
| | - Bipin N. Savani
- Internal Medicine, Division of Hematology/ OncologyVanderbilt University Medical Center
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12
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Kulasekararaj A, Cavenagh J, Dokal I, Foukaneli T, Gandhi S, Garg M, Griffin M, Hillmen P, Ireland R, Killick S, Mansour S, Mufti G, Potter V, Snowden J, Stanworth S, Zuha R, Marsh J. Guidelines for the diagnosis and management of adult aplastic anaemia: A British Society for Haematology Guideline. Br J Haematol 2024; 204:784-804. [PMID: 38247114 DOI: 10.1111/bjh.19236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/26/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024]
Abstract
Pancytopenia with hypocellular bone marrow is the hallmark of aplastic anaemia (AA) and the diagnosis is confirmed after careful evaluation, following exclusion of alternate diagnosis including hypoplastic myelodysplastic syndromes. Emerging use of molecular cyto-genomics is helpful in delineating immune mediated AA from inherited bone marrow failures (IBMF). Camitta criteria is used to assess disease severity, which along with age and availability of human leucocyte antigen compatible donor are determinants for therapeutic decisions. Supportive care with blood and platelet transfusion support, along with anti-microbial prophylaxis and prompt management of opportunistic infections remain key throughout the disease course. The standard first-line treatment for newly diagnosed acquired severe/very severe AA patients is horse anti-thymocyte globulin and ciclosporin-based immunosuppressive therapy (IST) with eltrombopag or allogeneic haemopoietic stem cell transplant (HSCT) from a matched sibling donor. Unrelated donor HSCT in adults should be considered after lack of response to IST, and up front for young adults with severe infections and a readily available matched unrelated donor. Management of IBMF, AA in pregnancy and in elderly require special attention. In view of the rarity of AA and complexity of management, appropriate discussion in multidisciplinary meetings and involvement of expert centres is strongly recommended to improve patient outcomes.
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Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Jamie Cavenagh
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Inderjeet Dokal
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, UK
| | - Theodora Foukaneli
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NHS Blood and Transplant, Bristol, UK
| | - Shreyans Gandhi
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
- British Society Haematology Task Force Representative, London, UK
| | | | | | - Robin Ireland
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Sally Killick
- University Hospitals Dorset NHS Foundation Trust, The Royal Bournemouth Hospital, Bournemouth, UK
| | - Sahar Mansour
- St George's Hospital/St George's University of London, London, UK
| | - Ghulam Mufti
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Victoria Potter
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - John Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Roslin Zuha
- James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, England
| | - Judith Marsh
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
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13
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Chen L, Ding S, Cheng Y, Zhou L, Yan J, Cheng Q, Jin A, Zhou X, Huang H, Hu Y. Application of thromboelastography to predict the severity of bleeding after chimeric antigen receptor (CAR)-T cell therapy in patients with hematological malignancy. Eur J Haematol 2024; 112:257-265. [PMID: 37698159 DOI: 10.1111/ejh.14099] [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: 06/19/2023] [Revised: 08/25/2023] [Accepted: 08/27/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES We aim to analyze the predictive value of thromboelastography on bleeding severity of patients with chimeric antigen receptor (CAR)-T cell therapy. METHODS A total of 80 patients with refractory/relapsed hematological malignancy were enrolled and divided into two groups: the severe bleeding group and the non-severe bleeding group. The thromboelastography data was collected on the day of CAR-T infusion and the 3rd, 7th, 10th, 13th, 17th, and 20th day after CAR-T cell infusion. RESULTS The patients of the severe bleeding group had lower platelet (p < .007), maximum amplitude (p = .002), coagulation index (p = .005), and longer coagulation time (p = .019). Increasing trend in reaction time and coagulation time and decreasing trend in Alpha, maximum amplitude, and coagulation index on Days 0-10, opposite on Days 10-20. Univariate logistic regression analysis and multivariable logistic regression analysis showed maximum amplitude on the 3rd day after CAR-T cell infusion (MA3) (OR = 0.9; 95% CI = 0.84-0.95; p < .001) and cytokine release syndrome grade (OR = 2.57; 95% CI = 1.35-5.32; p = .006) were significantly associated with high bleeding severity. CONCLUSIONS Thromboelastography was considered to be a good predictor of bleeding severity.
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Affiliation(s)
- Liu Chen
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuyi Ding
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yin Cheng
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Linghui Zhou
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Jiali Yan
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qiong Cheng
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Aiyun Jin
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoyu Zhou
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - He Huang
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yongxian Hu
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
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14
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Foy P, Friedman KD, Michaelis LC. How I diagnose and treat thrombocytopenia in geriatric patients. Blood 2024; 143:214-223. [PMID: 37956435 DOI: 10.1182/blood.2022017634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 07/31/2023] [Accepted: 08/16/2023] [Indexed: 11/15/2023] Open
Abstract
ABSTRACT Thrombocytopenia in older individuals is a common but diagnostically challenging condition that has variable clinical impact to those who are affected. Diagnostic approach requires evaluation of the preexisting clinical conditions, detailed review of medications, and assessment for disorders that warrant urgent treatment. In this article, we describe a systematic approach to diagnosis of thrombocytopenia and present a schematic review for management strategies. Three clinical scenarios are presented that are relevant for their prevalence and management challenges in an older adult population. The first scenario addresses primary immune thrombocytopenia (ITP) and reviews different treatment options. The second one addresses complications of thrombocytopenia in management of the myelodysplastic syndrome. The last one reviews diagnostic challenges of drug-induced ITP.
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Affiliation(s)
- Patrick Foy
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Laura C Michaelis
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
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15
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Al-Samkari H. Optimal management of chemotherapy-induced thrombocytopenia with thrombopoietin receptor agonists. Blood Rev 2024; 63:101139. [PMID: 37914568 PMCID: PMC10872905 DOI: 10.1016/j.blre.2023.101139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 11/03/2023]
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common complication of antineoplastic therapy, resulting in antineoplastic therapy dose reductions, treatment delays, treatment discontinuation, and morbid bleeding events. Despite several decades of research into thrombopoietic growth factors in CIT, there are presently no available U.S. FDA- or EMA-approved agents to treat CIT. However, a respectable body of evidence has been published evaluating the thrombopoietin receptor agonists (TPO-RAs) for the management and prevention of CIT in patients with solid tumors, and critical studies are ongoing with the TPO-RAs romiplostim and avatrombopag. When employed in the appropriate patient population and used properly, TPO-RAs can successfully and safely manage CIT for extended periods of time with minimal apparent risks. This comprehensive review discusses the evidence for TPO-RAs in CIT in patients with solid tumors, provides detailed guidance for their use in the clinic, and discusses ongoing essential clinical trials in management of CIT.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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16
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Malik M, Al-Ghafry M, Haimed A, Su J, Lema M, Shore-Lessersson L, Acharya SS. Exploration of rotational thromboelastometry (ROTEM) to characterize the coagulation profiles of newly diagnosed pediatric leukemia patients. Thromb Res 2024; 233:109-118. [PMID: 38039723 DOI: 10.1016/j.thromres.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/18/2023] [Accepted: 11/15/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Viscoelastic testing has been used in adult hematologic malignancies in conjunction with conventional coagulation tests (CCTs) to predict coagulopathies and tailor blood product replacement. However, there is a paucity of similar pediatric studies. OBJECTIVES Analyze and correlate leukemia-associated coagulopathy in newly diagnosed pediatric leukemia patients using CCT's and Rotational Thromboelastometry (ROTEM). METHODS Pediatric patients with newly diagnosed acute leukemia underwent testing with ROTEM and CCTs on days 0, 15 and 29 of induction chemotherapy. RESULTS Sixty-two patients were enrolled. At presentation, 54.8 % of patients had platelets <50 K/μL, 73 % had prolonged PT, 1.6 % had fibrinogen <150 mg/dL. Fifteen patients (24.2 %) had WHO grade 1 bleeding and two patients (3 %) had WHO grade 4 bleeding. EXTEM/INTEM values at presentation (day 0) reflected hypocoagulability, however FIBTEM revealed hypercoagulability. Patients showed a progressive hypocoagulability in all ROTEM assays by day 15 (day 0 vs day 15, p < 0.001), with improvement by day 29 (day 15 vs day 29, p < 0.001). Day 0 ROTEM parameters were comparable to day 29. Fibrinogen strongly correlated with ROTEM at all three time points (p < 0.0001), along with platelet count with moderate correlations (p < 0.001). CONCLUSION Fibrinogen and platelets appear to be the drivers of leukemia associated coagulopathy in the pediatric population, suggesting the utility of using CCTs and ROTEM in this population to better evaluate hemostatic function and guide blood product replacement.
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Affiliation(s)
- Marium Malik
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant - Cohen Children's Medical Center, New Hyde Park, New York, United States of America; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America
| | - Maha Al-Ghafry
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant - Cohen Children's Medical Center, New Hyde Park, New York, United States of America; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America
| | - Abraham Haimed
- Department of Pediatrics - Cohen Children's Medical Center, New Hyde Park, New York, United States of America; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America
| | - Julia Su
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America
| | - Maribel Lema
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America
| | - Linda Shore-Lessersson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America; Division of Anesthesiology, North Shore University Hospital, Manhasset, New York, United States of America
| | - Suchitra S Acharya
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant - Cohen Children's Medical Center, New Hyde Park, New York, United States of America; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America.
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17
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Anthon CT, Pène F, Perner A, Azoulay E, Puxty K, Van De Louw A, Barratt-Due A, Chawla S, Castro P, Póvoa P, Coelho L, Metaxa V, Kochanek M, Liebregts T, Kander T, Hästbacka J, Andreasen JB, Péju E, Nielsen LB, Hvas CL, Dufranc E, Canet E, Lundqvist L, Wright CJ, Schmidt J, Uhel F, Ait-Oufella H, Krag M, Cos Badia E, Díaz-Lagares C, Menat S, Voiriot G, Clausen NE, Lorentzen K, Kvåle R, Hildebrandt T, Holten AR, Strand K, Tzalavras A, Bestle MH, Klepstad P, Fernandez S, Vimpere D, Paulino C, Graça C, Lueck C, Juhl CS, Costa C, Bådstøløkken PM, Miranda T, Lêdo LSA, Sousa Torres JC, Granholm A, Møller MH, Russell L. Thrombocytopenia and platelet transfusions in ICU patients: an international inception cohort study (PLOT-ICU). Intensive Care Med 2023; 49:1327-1338. [PMID: 37812225 PMCID: PMC10622358 DOI: 10.1007/s00134-023-07225-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE Thrombocytopenia (platelet count < 150 × 109/L) is common in intensive care unit (ICU) patients and is likely associated with worse outcomes. In this study we present international contemporary data on thrombocytopenia in ICU patients. METHODS We conducted a prospective cohort study in adult ICU patients in 52 ICUs across 10 countries. We assessed frequencies of thrombocytopenia, use of platelet transfusions and clinical outcomes including mortality. We evaluated pre-selected potential risk factors for the development of thrombocytopenia during ICU stay and associations between thrombocytopenia at ICU admission and 90-day mortality using pre-specified logistic regression analyses. RESULTS We analysed 1166 ICU patients; the median age was 63 years and 39.5% were female. Overall, 43.2% (95% confidence interval (CI) 40.4-46.1) had thrombocytopenia; 23.4% (20-26) had thrombocytopenia at ICU admission, and 19.8% (17.6-22.2) developed thrombocytopenia during their ICU stay. Absence of acquired immune deficiency syndrome (AIDS), non-cancer-related immune deficiency, liver failure, male sex, septic shock, and bleeding at ICU admission were associated with the development of thrombocytopenia during ICU stay. Among patients with thrombocytopenia, 22.6% received platelet transfusion(s), and 64.3% of in-ICU transfusions were prophylactic. Patients with thrombocytopenia had higher occurrences of bleeding and death, fewer days alive without the use of life-support, and fewer days alive and out of hospital. Thrombocytopenia at ICU admission was associated with 90-day mortality (adjusted odds ratio 1.7; 95% CI 1.19-2.42). CONCLUSION Thrombocytopenia occurred in 43% of critically ill patients and was associated with worse outcomes including increased mortality. Platelet transfusions were given to 23% of patients with thrombocytopenia and most were prophylactic.
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Affiliation(s)
- Carl Thomas Anthon
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Frédéric Pène
- Médecine Intensive and Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Université Paris Cité, Paris, France
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Médecine Intensive and Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Elie Azoulay
- Médecine Intensive and Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Kathryn Puxty
- Department of Intensive Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Andry Van De Louw
- Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA, USA
| | - Andreas Barratt-Due
- Department of Anaesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Sanjay Chawla
- Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Pedro Póvoa
- Department of Intensive Care, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
- Nova Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, Odense University Hospital, Odense, Denmark
| | - Luis Coelho
- Department of Intensive Care, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
- Nova Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Tobias Liebregts
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thomas Kander
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Johanna Hästbacka
- Department of Perioperative and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Anaesthesiology and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Jo Bønding Andreasen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Edwige Péju
- Médecine Intensive and Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Université Paris Cité, Paris, France
| | | | - Christine Lodberg Hvas
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Etienne Dufranc
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Emmanuel Canet
- Médecine Intensive Réanimation, CHU de Nantes, Université de Nantes, Nantes, France
| | - Linda Lundqvist
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
| | | | - Julien Schmidt
- Service de Réanimation Médico-Chirurgicale, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Fabrice Uhel
- Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, DMU ESPRIT, Paris, France
- Institut Necker-Enfants Malades, Université Paris Cité, INSERMUMR-S1151, CNRSUMR-S8253, Paris, France
| | - Hafid Ait-Oufella
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Mette Krag
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care, Holbaek Hospital, Holbaek, Denmark
| | - Elisabet Cos Badia
- Department of Intensive Care, Hospital General Granollers, Barcelona, Spain
| | - Cándido Díaz-Lagares
- Intensive Care Department, Vall d'Hebron Hospital Universitari, Barcelona, Spain
- SODIR Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Sophie Menat
- Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Guillaume Voiriot
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Centre de Recherche Saint-Antoine UMRS_938 INSERM, Paris, France
| | - Niels Erikstrup Clausen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Kristian Lorentzen
- Department of Intensive Care, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Reidar Kvåle
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Thomas Hildebrandt
- Department of Intensive Care, Zealand University Hospital - Roskilde, Roskilde, Denmark
| | - Aleksander Rygh Holten
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Asterios Tzalavras
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Morten Heiberg Bestle
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Pål Klepstad
- Department of Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway
- Department Circulation and Medical Imaging, Norwegian University of Technology and Science, Trondheim, Norway
| | - Sara Fernandez
- Medical Intensive Care Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Damien Vimpere
- Médecine Intensive and Réanimation, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Carolina Paulino
- Nova Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
- Department of Intensive Care, Hospital da Luz Lisboa, Lisbon, Portugal
| | - Carina Graça
- Department of Intensive Care, Hospital Central do Funchal, Funchal, Portugal
| | - Catherina Lueck
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Christian Svendsen Juhl
- Department of Anaesthesiology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Carolina Costa
- Intensive Care Unit, Hospital Professor Doutor Fernando Fonseca, EPE, Amadora, Portugal
| | | | - Teresa Miranda
- Department of Intensive Care, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
| | - Lia Susana Aires Lêdo
- Department of Intensive Care Medicine-Unit 2, Hospital Egas Moniz-CHLO, EPE, Lisbon, Portugal
| | | | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
- Médecine Intensive and Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France.
- Department of Intensive Care, Copenhagen University Hospital - Gentofte, Hellerup, Denmark.
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18
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Jourdi G, Ramström S, Sharma R, Bakchoul T, Lordkipanidzé M. Consensus report on flow cytometry for platelet function testing in thrombocytopenic patients: communication from the SSC of the ISTH. J Thromb Haemost 2023; 21:2941-2952. [PMID: 37481072 DOI: 10.1016/j.jtha.2023.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Platelet count alone does not reliably predict bleeding risk, suggesting platelet function is important to monitor in patients with thrombocytopenia. There is still an unmet need for improved platelet function diagnostics in patients with low platelet count in many clinical situations. Flow cytometry is a promising tool allowing reliable platelet function study in this setting. OBJECTIVES The goal of this joint project between the International Society on Thrombosis and Haemostasis (ISTH) Scientific Standardization Committee (SSC) Subcommittees on Platelet Physiology and Platelet Immunology is to provide expert consensus guidance on the use of flow cytometry for the evaluation of platelet function, particularly activation, in patients with low platelet counts. METHODS A literature review was performed to identify relevant questions and areas of interest. An electronic expression of interest form was thereafter announced on the ISTH webpage, followed by a survey encompassing 37 issues regarding preanalytical, analytical, postanalytical, and performance aspects. Areas of disagreement or uncertainty were identified and formed the basis for 2 focus group discussions. RESULTS Consensus recommendations relative to patient sample collection, preanalytical variables, sample type, platelet-count cutoff, any potential specific modification of the standard flow cytometry protocol, and results expression and reporting are proposed based on the current practices of experts in the field as well as on literature review. CONCLUSION The proposed consensus recommendations would allow standardization of protocols in upcoming clinical studies. The clinical utility of platelet function testing using flow cytometry to predict bleeding risk still needs rigorous multicenter outcome studies in patients with thrombocytopenia.
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Affiliation(s)
- Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France; Service d'Hématologie Biologique, AP-HP, Hôpital Lariboisière, Paris, France
| | - Sofia Ramström
- Cardiovascular Research Centre, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Ruchika Sharma
- Versiti Blood Center of Wisconsin Pediatric Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Division of Hematology/Oncology/BMT, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tuebingen, University Hospital of Tuebingen, Tuebingen, Germany
| | - Marie Lordkipanidzé
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
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19
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Xia X, Zhou H, Zhang H, Deng W, Li R, Huang Q, Wang Y, Xiong H. Hetrombopag plus recombinant human thrombopoietin for chemotherapy-induced thrombocytopenia in patients with solid tumors. Res Pract Thromb Haemost 2023; 7:102231. [PMID: 38077816 PMCID: PMC10704501 DOI: 10.1016/j.rpth.2023.102231] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/05/2023] [Accepted: 09/22/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Chemotherapy-induced thrombocytopenia (CIT) is a common hematological complication in patients with cancer. Hetrombopag is a novel thrombopoietin receptor agonist that has shown an additive effect in stimulating platelet production when combined with recombinant human thrombopoietin (rhTPO). OBJECTIVES This multicenter retrospective cohort study aimed to evaluate the efficacy and safety of hetrombopag plus rhTPO compared with rhTPO alone for CIT. METHODS A total of 294 patients with solid tumors and CIT (platelet count, <50 × 109/L) who received either rhTPO plus hetrombopag (146 patients) or rhTPO alone (148 patients) at 3 centers from January to December 2022 were included in the study. The primary outcome was a platelet count at least 50 × 109/L higher than the baseline value within 14 days. Chemotherapy dose reductions/delays, bleeding, and adverse events were reported. RESULTS One hundred twenty patients (82.2%) in the rhTPO-hetrombopag group vs 100 patients (67.6%) in the rhTPO group achieved the primary outcome (P = .005). This significant difference persisted in adjusted analysis (odds ratio, 2.01; 95% CI, 1.12-3.60). A total of 115 patients (78.8%) in the rhTPO-hetrombopag group and 101 patients (68.2%) in the rhTPO group avoided chemotherapy dose reductions/delays (P = .041). There was no significant difference in bleeding rates, and adverse events were mild and similar between the 2 groups. No deaths occurred. CONCLUSION Compared to rhTPO alone, our findings suggest that the combination of hetrombopag and rhTPO is safe and more effective in patients with CIT.
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Affiliation(s)
- Xiaohui Xia
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haiting Zhou
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hao Zhang
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wanjun Deng
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Li
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiao Huang
- Department of Oncology, Yichang Central People’s Hospital, Yichang, China
| | - Yuehua Wang
- Department of Oncology, Xiangyang Central Hospital, Xiangyang, China
| | - Huihua Xiong
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Mo A, Wood E, Shortt J, Hu E, McQuilten Z. Platelet transfusions and predictors of bleeding in patients with myelodysplastic syndromes. Eur J Haematol 2023; 111:592-600. [PMID: 37452616 PMCID: PMC10952506 DOI: 10.1111/ejh.14049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES This study aimed to describe the burden of thrombocytopenia, supportive care practices, bleeding complications and predictors of bleeding in MDS patients within a large Australian hospital network, to better understand the use and effectiveness of platelet transfusions in MDS. METHODS A retrospective cohort study of patients aged ≥18 years with MDS, chronic myelomonocytic leukaemia or MDS/myeloproliferative overlap neoplasm admitted from 2016 to 2018 was conducted. Data were obtained from hospital medical records. RESULTS One hundred seventy-nine patients (median age 78 years, 61.5% male) were identified. The median platelet count at first admission was 90 × 109 /L. Twenty-eight (15.6%) patients had severe thrombocytopenia (platelet count <20 × 109 /L), of whom nine (32.1%) received prophylactic platelet transfusions, five (17.9%) received tranexamic acid (TXA), seven (25%) received both platelet transfusions and TXA, and seven (25%) received no treatment. Bleeding events requiring hospitalisation occurred in 20 (11.2%) patients. Bleeding was not predicted by presenting platelet count, TXA use, platelet transfusion or anticoagulant/antiplatelet therapies. Three patients died of bleeding, at varying platelet counts (18, 38 and 153 × 109 /L). CONCLUSION Thrombocytopenia is common in MDS. Although guidelines recommend otherwise, prophylactic platelet transfusions were commonly used for severe thrombocytopenia. Despite the majority of patients receiving platelet transfusions and/or TXA, 11% developed major bleeding occurring at a wide range of platelet counts.
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Affiliation(s)
- Allison Mo
- Transfusion Research Unit, School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Monash HaematologyMonash HealthMelbourneVictoriaAustralia
- Austin Pathology and Department of HaematologyAustin HealthMelbourneVictoriaAustralia
| | - Erica Wood
- Transfusion Research Unit, School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Monash HaematologyMonash HealthMelbourneVictoriaAustralia
| | - Jake Shortt
- Monash HaematologyMonash HealthMelbourneVictoriaAustralia
- School of Clinical Sciences, Faculty of Medicine, Nursing & Health SciencesMonash UniversityMelbourneVictoriaAustralia
| | - Erin Hu
- Pharmacy DepartmentMonash HealthMelbourneVictoriaAustralia
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Monash HaematologyMonash HealthMelbourneVictoriaAustralia
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21
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Reizine F, Le Marec S, Le Meur A, Consigny M, Berteau F, Bodenes L, Geslain M, McQuilten Z, Le Niger C, Huntzinger J, Seguin P, Thibert JB, Simon D, Reignier J, Egreteau PY, Tadié JM, Huet O, Asfar P, Ehrmann S, Aubron C. Prophylactic platelet transfusion response in critically ill patients: a prospective multicentre observational study. Crit Care 2023; 27:373. [PMID: 37759268 PMCID: PMC10537531 DOI: 10.1186/s13054-023-04650-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Response to prophylactic platelet transfusion is suspected to be inconsistent in critically ill patients questioning how to optimize transfusion practices. This study aimed to describe prophylactic platelet transfusion response, to identify factors associated with a suboptimal response, to analyse the correlation between corrected count increment and platelet count increment and to determine the association between poor platelet transfusion response and clinical outcomes. METHODS This prospective multicentre observational study recruited patients who received at least one prophylactic platelet transfusion in one of the nine participating intensive care units for a period up to 16 months. Poor platelet transfusion response was defined as a corrected count increment (CCI) that adjusts for platelet dose and body surface area, less than 7 at 18-24 h after platelet transfusion. Factors associated with poor platelet transfusion response were assessed in a mixed-effect model. Sensitivity analyses were conducted in patients with and without haematology malignancy and chemotherapy. RESULTS Poor platelet transfusion response occurred in 349 of the 472 (73.9%) prophylactic platelet transfusions and in 141/181 (77.9%) patients. The mixed-effect model identified haemoglobin at ICU admission (odds ratio (OR): 0.79 [95% confidence interval (CI) 0.7-0.89]) and body mass index (BMI) (OR: 0.93 [0.89-0.98]) being positively and independently associated with platelet transfusion response, while a haematological malignancy (OR 1.93 [1.09-3.43]), sepsis as primary ICU admission diagnosis (OR: 2.81 [1.57-5.03]), SOFA score (OR 1.10 [1.03; 1.17]) and maximum storage duration of platelet (OR: 1.24 [1.02-1.52]) were independently associated with a suboptimal platelet increment. Clinical outcomes did not differ between groups, nor the requirement for red blood cells. Poor platelet transfusion response was found in 93.5% of patients with haematology malignancy and chemotherapy. CONCLUSIONS In this study of critically ill patients, of whom more than half had bone marrow failure, almost three quarters of prophylactic platelet transfusions led to suboptimal platelet increment measured 18 to 24 h following platelet transfusion. Platelet storage duration was the only factor associated with poor platelet response that may be accessible to intervention. Trial registration in October 2017: ClinicalTrials.gov: NCT03325140.
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Affiliation(s)
- Florian Reizine
- Maladies Infectieuses Et Réanimation Médicale, CHU de Rennes, Rennes, France
- Service de Réanimation Polyvalente, CH de Vannes, Vannes, France
| | - Sarah Le Marec
- Service de Médecine Intensive Réanimation, Université de Bretagne Occidentale, Centre Hospitalo-Universitaire de Brest, Site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France
| | - Anthony Le Meur
- Service de Médecine Intensive Réanimation, CHU de Nantes, Nantes, France
| | | | - Florian Berteau
- Service de Réanimation Polyvalente, CH de Morlaix, Morlaix, France
| | - Laetitia Bodenes
- Service de Médecine Intensive Réanimation, Université de Bretagne Occidentale, Centre Hospitalo-Universitaire de Brest, Site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France
| | - Marie Geslain
- Département d'anesthésie-Réanimation, Université de Bretagne Occidentale, CHU de Brest, Brest, France
| | - Zoe McQuilten
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
| | | | | | - Philippe Seguin
- Service de Réanimation Chirurgicale, CHU de Rennes, Rennes, France
| | | | - David Simon
- Service de Biostatistiques, CHU de Brest, Brest, France
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, CHU de Nantes, Nantes, France
| | | | - Jean-Marc Tadié
- Maladies Infectieuses Et Réanimation Médicale, CHU de Rennes, Rennes, France
| | - Olivier Huet
- Département d'anesthésie-Réanimation, Université de Bretagne Occidentale, CHU de Brest, Brest, France
| | - Pierre Asfar
- Service de Médecine Intensive Réanimation, CHU d'Angers, Angers, France
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CHRU de Tours INSERM CIC 1415, CRICS-TriggerSEP F-CRIN Research Network, INSERM U1100, Université de Tours FR, Tours, France
| | - Cécile Aubron
- Service de Médecine Intensive Réanimation, Université de Bretagne Occidentale, Centre Hospitalo-Universitaire de Brest, Site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France.
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia.
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22
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Czempik PF, Herzyk J, Wilczek D. Let Us Know Transfusion Triggers for Prophylactic Use of Platelet Concentrate-Analysis of Compliance with Recent Transfusion Guidelines in a Large Academic Medical Center. J Clin Med 2023; 12:5885. [PMID: 37762827 PMCID: PMC10532288 DOI: 10.3390/jcm12185885] [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: 08/11/2023] [Revised: 09/01/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Platelet concentrate (PC) is a blood component that is used to prevent or manage bleeding associated with thrombocytopenia or impaired platelet function. The aim of our study was to assess the compliance of ordering physicians with the most recent PC transfusion guidelines in our academic medical center. All PC transfusions performed between January 2019 and December 2022 were analyzed. The appropriateness of PC transfusions was assessed based on the most recent PC transfusion guidelines. During 2019-2022, there were 362 (0.2%) PC recipients out of 161,762 hospitalized patients. There were 971 PCs transfused during the analyzed period. Inappropriate transfusions accounted for 53.3% of cases, and most of them were given prophylactically (80.2%). Compliance with platelet transfusion guidelines varied among departments. The overall percentage of inappropriately transfused PC ranged from 50.7% to 60.8% in successive years. Educational activities should target clinicians performing procedures associated with high rates of inappropriate PC transfusions. Implementing clinical decision support systems can help reduce unnecessary PC transfusions and associated costs. The majority of inappropriate PC transfusions in our medical center were given as prophylaxis against bleeding. Prescribers should be educated about evidence-based transfusion triggers for the prophylactic use of PC in various clinical scenarios.
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Affiliation(s)
- Piotr F. Czempik
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
- Transfusion Committee, University Clinical Center of Medical University of Silesia in Katowice, 40-752 Katowice, Poland
| | - Jan Herzyk
- Students’ Scientific Society, Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Dawid Wilczek
- Students’ Scientific Society, Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
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23
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Ang AL, Gan LSH, Tuy TT, Ang CH, Tan CW, Tan HH, Shu PH, Zhang Q, Cao Y, Moorakonda RB, Pokharkar Y, Lu J. A randomized cross-over study of cryopreserved platelets in prophylactic transfusions of thrombocytopenic patients. Transfusion 2023; 63:1649-1660. [PMID: 37596937 DOI: 10.1111/trf.17503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND The short shelf-life of liquid-stored platelets (LP) at 20-24°C poses shortage and wastage challenges. Cryopreserved platelets have significantly extended shelf-life, and were safe and efficacious for therapeutic transfusions of bleeding patients in the Afghanistan conflict and phase 2 randomized studies. Although hematology patients account for half of platelets demand, there is no randomized study on prophylactic cryopreserved platelet transfusions in them. METHODS We performed a phase 1b/2a randomized cross-over study comparing the safety and efficacy of cryopreserved buffy coat-derived pooled platelets (CP) to LP in the prophylactic transfusions of thrombocytopenic hematology patients. RESULTS A total of 18 adults were randomly assigned 1:1 to CP and LP for their first thrombocytopenic period (TP) of up to 28-days. A total of 14 crossed over to the other platelet-arm for the second TP. Overall, 17 subjects received 51 CP and 15 received 52 LP. CP-arm had more treatment emergent adverse event (29.4% vs. 13.3% of subjects, 9.8% vs. 3.8% of transfusions) than LP-arm but all were mild. No thromboembolism was observed. Both arms had similar bleeding rates (23.5% vs. 26.7% of subjects) which were all mild. Subjects in CP-arm had lower average corrected count increments than LP-arm (mean [SD] 5.6 [4.20] vs. 22.6 [9.68] ×109 /L at 1-4 h, p < .001; 5.3 [4.84] vs. 18.2 [9.52] ×109 /L at 18-30 h, p < .001). All TEG parameters at 1-4 h and maximum amplitude (MA) at 18-30 h improved from baseline post-CP transfusion (p < .05) though improvements in K-time and MA were lower than LP (p < .05). DISCUSSION During shortages, CP may supplement LP in prophylactic transfusions of thrombocytopenic patients.
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Affiliation(s)
- Ai Leen Ang
- Department of Hematology, Singapore General Hospital, Singapore
- Blood Services Group, Health Sciences Authority, Singapore
| | | | | | - Chieh Hwee Ang
- Department of Hematology, Singapore General Hospital, Singapore
| | - Chuen Wen Tan
- Department of Hematology, Singapore General Hospital, Singapore
| | - Hwee Huang Tan
- Blood Services Group, Health Sciences Authority, Singapore
| | - Pei Huey Shu
- Blood Services Group, Health Sciences Authority, Singapore
| | | | - Yang Cao
- Singapore Clinical Research Institute, Singapore
| | | | | | - Jia Lu
- DSO National Laboratories, Singapore
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24
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Khelfa M, Leclerc M, Kerbrat S, Boudjemai YNS, Benchouaia M, Neyrinck-Leglantier D, Cagnet L, Berradhia L, Tamagne M, Croisille L, Pirenne F, Maury S, Vingert B. Divergent CD4 + T-cell profiles are associated with anti-HLA alloimmunization status in platelet-transfused AML patients. Front Immunol 2023; 14:1165973. [PMID: 37701444 PMCID: PMC10493329 DOI: 10.3389/fimmu.2023.1165973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/17/2023] [Indexed: 09/14/2023] Open
Abstract
Introduction Acute myeloid leukemia (AML) is one of the commonest hematologic disorders. Due to the high frequency of disease- or treatment-related thrombocytopenia, AML requires treatment with multiple platelet transfusions, which can trigger a humoral response directed against platelets. Some, but not all, AML patients develop an anti-HLA immune response after multiple transfusions. We therefore hypothesized that different immune activation profiles might be associated with anti-HLA alloimmunization status. Methods We tested this hypothesis, by analyzing CD4+ T lymphocyte (TL) subsets and their immune control molecules in flow cytometry and single-cell multi-omics. Results A comparison of immunological status between anti-HLA alloimmunized and non-alloimmunized AML patients identified differences in the phenotype and function of CD4+ TLs. CD4+ TLs from alloimmunized patients displayed features of immune activation, with higher levels of CD40 and OX40 than the cells of healthy donors. However, the most notable differences were observed in non-alloimmunized patients. These patients had lower levels of CD40 and OX40 than alloimmunized patients and higher levels of PD1. Moreover, the Treg compartment of non-alloimmunized patients was larger and more functional than that in alloimmunized patients. These results were supported by a multi-omics analysis of immune response molecules in conventional CD4+ TLs, Tfh circulating cells, and Tregs. Discussion Our results thus reveal divergent CD4+ TL characteristics correlated with anti-HLA alloimmunization status in transfused AML patients. These differences, characterizing CD4+ TLs independently of any specific antigen, should be taken into account when considering the immune responses of patients to infections, vaccinations, or transplantations.
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Affiliation(s)
- Mehdi Khelfa
- Établissement Français du Sang, Île-de-France, France
- Univ Paris Est Creteil, INSERM, IMRB, Équipe Pirenne, Créteil, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Mathieu Leclerc
- Assistance Publique - Hôpitaux de Paris, Hôpital Henri Mondor, Service d’Hématologie clinique, Créteil, France
| | - Stéphane Kerbrat
- Univ Paris Est Creteil, INSERM, IMRB, Plateforme de Génomique, Créteil, France
| | | | - Médine Benchouaia
- Univ Paris Est Creteil, INSERM, IMRB, Plateforme de Génomique, Créteil, France
| | - Déborah Neyrinck-Leglantier
- Établissement Français du Sang, Île-de-France, France
- Univ Paris Est Creteil, INSERM, IMRB, Équipe Pirenne, Créteil, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Léonie Cagnet
- Établissement Français du Sang, Île-de-France, France
- Univ Paris Est Creteil, INSERM, IMRB, Équipe Pirenne, Créteil, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Lylia Berradhia
- Établissement Français du Sang, Île-de-France, France
- Univ Paris Est Creteil, INSERM, IMRB, Équipe Pirenne, Créteil, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Marie Tamagne
- Établissement Français du Sang, Île-de-France, France
- Univ Paris Est Creteil, INSERM, IMRB, Équipe Pirenne, Créteil, France
- Laboratory of Excellence GR-Ex, Paris, France
| | | | - France Pirenne
- Établissement Français du Sang, Île-de-France, France
- Univ Paris Est Creteil, INSERM, IMRB, Équipe Pirenne, Créteil, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Sébastien Maury
- Assistance Publique - Hôpitaux de Paris, Hôpital Henri Mondor, Service d’Hématologie clinique, Créteil, France
| | - Benoît Vingert
- Établissement Français du Sang, Île-de-France, France
- Univ Paris Est Creteil, INSERM, IMRB, Équipe Pirenne, Créteil, France
- Laboratory of Excellence GR-Ex, Paris, France
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Regalado-Artamendi I, García-Fasanella M, Medina L, Fernandez-Sojo J, Esquirol A, García-Cadenas I, Martino R, Briones J, Sierra J, Novelli S. Age, CD34+ cell dose, conditioning and pre-transplant cytopenias can help predict transfusion support in lymphoma patients undergoing autologous stem cell transplantation. Vox Sang 2023; 118:681-689. [PMID: 37356813 DOI: 10.1111/vox.13486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 05/26/2023] [Accepted: 06/07/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Autologous stem cell transplant (ASCT) is a widely used therapy for lymphoma patients and can nowadays be performed on an outpatient basis. This study aimed to describe transfusion support in lymphoma patients undergoing ASCT and identify increased or prolonged transfusion requirement predictors. MATERIALS AND METHODS A retrospective study of all consecutive lymphoma patients undergoing ASCT between 2010 and 2020. RESULTS Out of 226 patients, 145 (64%) received red blood cell (RBC) transfusions, whereas all 226 (100%) required platelet transfusion (PT). Transfusions between Day +1 and +30 were higher in patients over 60 (2 [1-4] vs. 2 [0-2] RBC; p = 0.001 and 4 [2-8] vs. 3 [2-4] PT; p < 0.001); patients with pre-transplant anaemia (4 [2.5-6] vs. 2 [0-2] RBC; p < 0.001 and 5 [3-9] vs. 3 [2-4] PT; p = 0.001); pre-transplant thrombocytopenia (2 [1-4] vs. 2 [0-2] RBC; p < 0.001 and 4 [3-8.5] vs. 2 [1-3] PT; p < 0.001) or CD34+ cell dose <4 × 106 /kg (2 [0-4] vs. 2 [0-2] RBC; p = 0.024 and 4 [2-6] vs. 2 [1-3.5] PT; p < 0.001). RBC transfusion independence was reached later in patients receiving carmustine, cytarabine, etoposide and melphalan (BEAM) (hazard ratio [HR] 1.6; confidence interval [CI] 1.1-2.3) and those requiring RBC before infusion and/or with pre-transplant anaemia (HR 2.2; CI 1.4-3.4). Age above 60 (HR 1.4; CI 1.0-1.9), BEAM conditioning (HR 1.4; CI 1.0-2.0) and pre-transplant thrombocytopenia and/or requiring PT before infusion (HR 1.8; CI 1.4-2.5) entailed longer time until PT independence. CONCLUSION These four factors (age ≥60 years; BEAM conditioning, CD34+ dose <4 × 106 /kg and pre-transplant cytopenia and/or Day -10 to 0 transfusion) allowed dividing patients into three groups with significant differences between them regarding the time until transfusion independence.
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Affiliation(s)
- Isabel Regalado-Artamendi
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | | | - Laura Medina
- Banc de Sang i Teixits de Catalunya, Barcelona, Spain
| | | | - Albert Esquirol
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona, Spain
- Instituto de Investigación contra la Leucemia Josep Carreras (IJC), Barcelona, Spain
- Universitat Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Irene García-Cadenas
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona, Spain
- Instituto de Investigación contra la Leucemia Josep Carreras (IJC), Barcelona, Spain
- Universitat Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Rodrigo Martino
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona, Spain
- Instituto de Investigación contra la Leucemia Josep Carreras (IJC), Barcelona, Spain
- Universitat Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Javier Briones
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona, Spain
- Instituto de Investigación contra la Leucemia Josep Carreras (IJC), Barcelona, Spain
- Universitat Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Jorge Sierra
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona, Spain
- Instituto de Investigación contra la Leucemia Josep Carreras (IJC), Barcelona, Spain
- Universitat Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Silvana Novelli
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona, Spain
- Instituto de Investigación contra la Leucemia Josep Carreras (IJC), Barcelona, Spain
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Péju E, Fouqué G, Charpentier J, Vigneron C, Jozwiak M, Cariou A, Mira JP, Jamme M, Pène F. Clinical significance of thrombocytopenia in patients with septic shock: An observational retrospective study. J Crit Care 2023; 76:154293. [PMID: 36989886 DOI: 10.1016/j.jcrc.2023.154293] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Whether thrombocytopenia in critically ill patients accounts for a bystander of severity or drives specific complications is unclear. We addressed the effect of thrombocytopenia on septic shock, with emphasis on intensive care unit (ICU)-acquired bleeding, infections and thrombotic complications. MATERIALS AND METHODS A retrospective (2008-2019) single-center study of patients with septic shock. Thrombocytopenia was assessed over the first seven days and was defined as severe (nadir <50 G/L), mild (nadir 50-150 G/L) and relative (30% decrease with nadir >150 G/L). Outcomes were ICU mortality and ICU-acquired complications defined by severe bleeding, infections and thrombotic events during the ICU stay. RESULTS The study comprised 1024 patients. Severe, mild and relative thrombocytopenia occurred in 33%, 40% and 9% of patients. The in-ICU mortality rate was 27%, independently associated with severe thrombocytopenia. ICU-acquired infections, hemorrhagic and thrombotic complications occurred in 27.5%, 13.3% and 11.6% of patients, respectively. Patients with severe, mild or relative thrombocytopenia exhibited higher incidences of bleeding events (20.3%, 15.3% and 14.4% vs. 3.6% in non-thrombocytopenic, p < 0.001), infections (35.2%, 21.9% and 33.3% vs. 23.1% in non-thrombocytopenic, p < 0.001) and thrombotic events (14.6%, 10.8% and 17.8% vs. 7.8% in non-thrombocytopenic, p = 0.03). Only severe thrombocytopenia remained independently associated with increased risk of bleeding. CONCLUSIONS Severe thrombocytopenia was independently associated with ICU mortality and increased risk of bleeding, but not with infectious and thrombotic events.
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Affiliation(s)
- Edwige Péju
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France; Université Paris Cité, Paris, France; Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris Cité, 22 rue Méchain, 75014 Paris, France
| | - Gaëlle Fouqué
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France
| | - Julien Charpentier
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France
| | - Clara Vigneron
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France; Université Paris Cité, Paris, France
| | - Mathieu Jozwiak
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France
| | - Alain Cariou
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France; Université Paris Cité, Paris, France
| | - Jean-Paul Mira
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France; Université Paris Cité, Paris, France; Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris Cité, 22 rue Méchain, 75014 Paris, France
| | - Matthieu Jamme
- Service de médecine intensive-réanimation, Hôpital Privé de l'Ouest Parisien, Ramsay Générale de Santé, 14 Rue Castiglione del Lago, 78190 Trappes, France; Centre de Recherche en Epidémiologie et Santé des Populations, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), INSERM U-1018, Université de Versailles Saint-Quentin, 16, avenue Paul Vaillant Couturier, 94807 Villejuif, France
| | - Frédéric Pène
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France; Université Paris Cité, Paris, France; Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris Cité, 22 rue Méchain, 75014 Paris, France.
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27
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Bønløkke ST, Severinsen MT, Ommen HB, Eriksen CF, Hvas A. Prophylaxis with low dose tranexamic acid in acute myeloid leukemia patients undergoing intensive chemotherapy. EJHAEM 2023; 4:690-694. [PMID: 37601861 PMCID: PMC10435677 DOI: 10.1002/jha2.699] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 08/22/2023]
Abstract
Patients suffering from acute myeloid leukemia (AML) carry a high risk of serious bleeding complications due to severe thrombocytopenia for long periods of time during treatment. Prior to prophylactic platelet transfusion becoming the standard of care, intracranial bleeding was a major contributor to death in AML patients. However, despite prophylactic platelet transfusions, up to 79% of patients with AML experience clinically significant bleeding during treatment. Antifibrinolytics are effective and well tolerated hemostatic agents widely used in many patient groups, and in this study, we investigated the effect of low dose tranexamic acid (TXA) in patients with AML and thrombocytopenia. We compared bleeding and thrombosis between 113 thrombocytopenic AML patients receiving TXA 500 mg three times daily (n = 36) versus no-TXA (n = 77). Clinical information was obtained systematically from electronic medical records, and laboratory data were collected from the laboratory information system. No difference was demonstrated in number of patients with at least one bleeding episode (TXA: 89% vs. no-TXA: 93%, p = 0.60), median number of bleeding days (TXA: 2.5 days vs. no-TXA 2.0 days, p = 0.30), bleeding location or transfusion needs between the two groups. However, platelet count was found to be a significant risk factor for bleeding, with a probability of bleeding of 35% with a platelet count below 5 × 109/L (logistic regression, p < 0.01). We found no difference in thromboembolic events between the two groups (TXA: 8% vs. no-TXA 10%, p = 0.99). In conclusion, treatment with low dose TXA is safe, but we found no evidence to suggest that it reduces bleeding in AML patients with thrombocytopenia.
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Affiliation(s)
- Søren Thorgaard Bønløkke
- Department of Clinical BiochemistryAarhus University HospitalAarhus NDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Marianne Tang Severinsen
- Department of Hematology, Clinical Cancer Research CentreAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Hans Beier Ommen
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of HematologyAarhus University HospitalAarhusDenmark
| | - Christian Fenger Eriksen
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of AnesthesiologyAarhus University HospitalAarhusDenmark
| | - Anne‐Mette Hvas
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
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28
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Hong Y, Shen Y, Liu Q, Dong J, Xiang J, Shen Y, Wu L, Zhou Y, Ye B, Wu D. Eltrombopag plus cyclosporine in refractory immune thrombocytopenia: a single-center study. Res Pract Thromb Haemost 2023; 7:100279. [PMID: 37456916 PMCID: PMC10339056 DOI: 10.1016/j.rpth.2023.100279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 04/18/2023] [Accepted: 04/22/2023] [Indexed: 07/18/2023] Open
Abstract
Background With the development of thrombopoietin receptor agonists, the prognosis of immune thrombocytopenia (ITP) in patients in whom there was a poor response to first-line treatment has greatly improved. However, there are still some patients who are refractory to eltrombopag. Objectives To explore the efficacy and safety of eltrombopag combined with low-dose cyclosporine in the management of patients with refractory ITP. Methods A total of 21 participants with ITP who failed to respond to multiple lines of therapy (including a daily dose of 75 mg of eltrombopag for at least 30 days) treated at The First Affiliated Hospital of Zhejiang Chinese Medical University between January 2018 and August 2022 were included. All enrolled patients subsequently received 50 mg of eltrombopag daily and low-dose cyclosporine (3 mg/kg/d, with an initial target concentration of 75-120 ng/mL). The efficacy and safety of the combined therapies were evaluated. Results A total of 76.2% (16/21) of the patients responded to the combination of cyclosporine and eltrombopag, with a median time to response of 14.5 (range, 5-37) days. A complete response (platelet count ≥ 100 × 109/L) was observed in 81.3% (13/16) of the patients, among whom 1 patient experienced relapse due to self-reduction in eltrombopag. During a median follow-up of 180 days, there were no relapses, and 70% (7/10) of the patients successfully stopped or decreased concomitant ITP medications. One patient had both a catheter-related deep vein thrombosis and a venous cerebral thrombotic event later; no other severe drug-related adverse events were observed. Conclusion Combining low-dose cyclosporine with eltrombopag may be an effective alternative for multirefractory ITP that is nonresponsive to eltrombopag alone.
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Affiliation(s)
- Yilei Hong
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yingying Shen
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qi Liu
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jingjie Dong
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jingjing Xiang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yiping Shen
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Liqiang Wu
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yuhong Zhou
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Baodong Ye
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Dijiong Wu
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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29
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Cagnet L, Neyrinck-Leglantier D, Tamagne M, Berradhia L, Khelfa M, Cleophax S, Pirenne F, Vingert B. CD27+ microparticle interactions and immunoregulation of CD4+ T lymphocytes. Front Immunol 2023; 14:1043255. [PMID: 36969173 PMCID: PMC10034125 DOI: 10.3389/fimmu.2023.1043255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/24/2023] [Indexed: 03/12/2023] Open
Abstract
IntroductionAplasia and hematological malignancies are treated with platelet transfusions, which can have major immunomodulatory effects. Platelet concentrates (PCs) contain many immunomodulatory elements, including the platelets themselves, residual leukocytes, extracellular vesicles, such as microparticles (MPs), cytokines and other soluble elements. Two of these components, MPs and a soluble form of CD27 (sCD27), have been shown to play a particularly important role in immune system modulation. The loss of CD27 expression is an irreversible marker of terminal effector CD3+ T-lymphocyte (TL) differentiation, and the CD27+ MPs present in PCs may maintain CD27 expression on the surface of TLs, and, thus, the activation of these cells.MethodsIn this study, we phenotyped the CD27-expressing MPs present in PCs by microscale flow cytometry and investigated the interaction of these particles with CD4+ TLs. We cocultured MPs and PBMCs and determined the origin of the CD27 expressed on the surface of CD4+ TLs with the aid of two fluorochromes (BV510 for CD27 originating from MPs and BV786 for cellular CD27).ResultsWe showed that the binding of CD27- expressing MPs involved the CD70 molecule, which was also present on these MPs. Finally, the maintenance of CD27 expression on the surface of TLs by sorted CD27+ MPs led to activation levels lower than those observed with other types of MPs.DiscussionThese results for CD27-expressing MPs and their CD70-mediated targeting open up new possibilities for immunotherapy based on the use of MPs to maintain a phenotype or to target immune cells, for example. Moreover, decreasing the levels of CD27-expressing MPs in transfused platelets might also increase the chances of success for anti-CD27 monoclonal immunotherapy.
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Affiliation(s)
- Léonie Cagnet
- Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
- Etablissement Français du Sang, Ivry sur Seine, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Déborah Neyrinck-Leglantier
- Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
- Etablissement Français du Sang, Ivry sur Seine, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Marie Tamagne
- Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
- Etablissement Français du Sang, Ivry sur Seine, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Lylia Berradhia
- Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
- Etablissement Français du Sang, Ivry sur Seine, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Mehdi Khelfa
- Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
- Etablissement Français du Sang, Ivry sur Seine, France
- Laboratory of Excellence GR-Ex, Paris, France
| | | | - France Pirenne
- Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
- Etablissement Français du Sang, Ivry sur Seine, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Benoît Vingert
- Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
- Etablissement Français du Sang, Ivry sur Seine, France
- Laboratory of Excellence GR-Ex, Paris, France
- *Correspondence: Benoît Vingert,
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30
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Garraud O, Hamzeh-Cognasse H, Chalayer E, Duchez AC, Tardy B, Oriol P, Haddad A, Guyotat D, Cognasse F. Platelet transfusion in adults: An update. Transfus Clin Biol 2023; 30:147-165. [PMID: 36031180 DOI: 10.1016/j.tracli.2022.08.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Many patients worldwide receive platelet components (PCs) through the transfusion of diverse types of blood components. PC transfusions are essential for the treatment of central thrombocytopenia of diverse causes, and such treatment is beneficial in patients at risk of severe bleeding. PC transfusions account for almost 10% of all the blood components supplied by blood services, but they are associated with about 3.25 times as many severe reactions (attributable to transfusion) than red blood cell transfusions after stringent in-process leukoreduction to less than 106 residual cells per blood component. PCs are not homogeneous, due to the considerable differences between donors. Furthermore, the modes of PC collection and preparation, the safety precautions taken to limit either the most common (allergic-type reactions and febrile non-hemolytic reactions) or the most severe (bacterial contamination, pulmonary lesions) adverse reactions, and storage and conservation methods can all result in so-called PC "storage lesions". Some storage lesions affect PC quality, with implications for patient outcome. Good transfusion practices should result in higher levels of platelet recovery and efficacy, and lower complication rates. These practices include a matching of tissue ABH antigens whenever possible, and of platelet HLA (and, to a lesser extent, HPA) antigens in immunization situations. This review provides an overview of all the available information relating to platelet transfusion, from donor and donation to bedside transfusion, and considers the impact of the measures applied to increase transfusion efficacy while improving safety and preventing transfusion inefficacy and refractoriness. It also considers alternatives to platelet component (PC) transfusion.
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Affiliation(s)
- O Garraud
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France.
| | | | - E Chalayer
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France; Saint-Etienne University Hospital, Department of Hematology and Cellular Therapy, Saint-Étienne, France
| | - A C Duchez
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France; Établissement Français du Sang Auvergne-Rhône-Alpes, Saint-Étienne, France
| | - B Tardy
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France; CHU de Saint-Etienne, INSERM and CIC EC 1408, Clinical Epidemiology, Saint-Étienne, France
| | - P Oriol
- CHU de Saint-Etienne, INSERM and CIC EC 1408, Clinical Epidemiology, Saint-Étienne, France
| | - A Haddad
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France; Sacré-Cœur Hospital, Beirut, Lebanon; Lebanese American University, Beirut, Lebanon
| | - D Guyotat
- Saint-Etienne University Hospital, Department of Hematology and Cellular Therapy, Saint-Étienne, France
| | - F Cognasse
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France; Établissement Français du Sang Auvergne-Rhône-Alpes, Saint-Étienne, France
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31
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Fizza Haider S, Sloss R, Jhanji S, Nicholson E, Creagh-Brown B. Management of adult patients with haematological malignancies in critical care. Anaesthesia 2023. [PMID: 36658786 DOI: 10.1111/anae.15955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2022] [Indexed: 01/21/2023]
Abstract
There are a diverse range of haematological malignancies with varying clinical presentations and prognoses. Patients with haematological malignancy may require admission to critical care at the time of diagnosis or due to treatment related effects and complications. Although the prognosis for such patients requiring critical care has improved, there remain uncertainties in optimal clinical management. Identification of patients who will benefit from critical care admission is challenging and selective involvement of palliative care may help to reduce unnecessary and non-beneficial treatments. While patients with haematological malignancy can present a challenge to critical care physicians, good outcomes can be achieved. In this narrative review, we provide a brief overview of relevant haematological malignancies for the critical care physician and a summary of recent treatment advances. Subsequently, we focus on critical care management for the patient with haematological malignancy including sepsis; acute respiratory failure; prevention and treatment of tumour lysis syndrome; thrombocytopaenia; and venous thromboembolism. We also discuss immunotherapeutic-specific related complications and their management, including cytokine release syndrome and immune effector cell associated neurotoxicity syndrome associated with chimeric antigen receptor T-cell therapy. While the management of haematological malignancies is highly specialised and increasingly centralised, acutely unwell patients often present to their local hospital with complications requiring critical care expertise. The aim of this review is to provide a contemporary overview of disease and management principles for non-specialist critical care teams.
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Affiliation(s)
- S Fizza Haider
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - R Sloss
- Department of Peri-Operative Medicine (Critical Care), St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - S Jhanji
- Department of Critical Care, Royal Marsden Hospital, London, UK.,Division of Cancer Biology, Institute of Cancer Research, London, UK
| | - E Nicholson
- Department of Haematology, Royal Marsden Hospital, London, UK.,Division of Cancer Therapeutics, Institute of Cancer Research, London, UK
| | - B Creagh-Brown
- Intensive Care Unit, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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32
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Liker M, Bašić Kinda S, Duraković N, Bojanić I, Aurer I, Golubić Ćepulić B. The appropriateness of platelet transfusions in hematological patients and the potential for improvement. Transfus Clin Biol 2022; 30:212-218. [PMID: 36493919 DOI: 10.1016/j.tracli.2022.11.007] [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: 11/15/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hematology patients are intensive platelet users. In clinical practice, a substantial proportion of platelet (PLT) transfusions are routinely administered outside the guidelines despite compelling evidence for recommendations. Those unnecessary PLT transfusions are an unjustified extra burden on a scarce healthcare resource and may also be detrimental to the patients. This study aims to evaluate indications and assess the appropriateness of PLT transfusion, as well as to identify common discrepancies and propose modalities for better compliance with guidelines. MATERIAL AND METHODS The audit of all PLT orders for adult hematological inpatients was conducted over 2 months. The assessment was performed using guidelines for PLT transfusion. Patient demographic, clinical, and transfusion data were collected from hospital electronic medical records. RESULTS Based on 286 PLT orders, 344 PCs were transfused to 67 patients: 235 (82.2%) prophylactical due to low PLT count, 34 (11.9%) preprocedural and 17 (5.9%) therapeutic. Overall, 105 (36.77%) PLT transfusions were inappropriate: 78 (33.2%) of all prophylactic PLT transfusions due to low PLT count, 17 (50%) off all preprocedural and 10 (58.8%) of all therapeutical transfusion. The major reason for PLT transfusion inappropriateness was transfusion above the recommended threshold. Double units of PCs were transfused in 36.7% of all PLT transfusions and 32.4% of them were considered inappropriate. CONCLUSION Our audit of PLT transfusion practice found a large proportion of inappropriate PLT transfusions. Based on the most common deviations from the guidelines a variety of targeted measures for improvement are proposed.
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Affiliation(s)
- Milica Liker
- Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia.
| | - Sandra Bašić Kinda
- Division of Hematology, Department of Internal Medicine, Zagreb, University Hospital Centre Zagreb, Croatia
| | - Nadira Duraković
- Division of Hematology, Department of Internal Medicine, Zagreb, University Hospital Centre Zagreb, Croatia; School of Medicine, University of Zagreb, Croatia
| | - Ines Bojanić
- Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia; School of Medicine, University of Zagreb, Croatia; University of Applied Health Sciences, Zagreb, Croatia
| | - Igor Aurer
- Division of Hematology, Department of Internal Medicine, Zagreb, University Hospital Centre Zagreb, Croatia; School of Medicine, University of Zagreb, Croatia
| | - Branka Golubić Ćepulić
- Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia; Division of Hematology, Department of Internal Medicine, Zagreb, University Hospital Centre Zagreb, Croatia; School of Medicine, University of Zagreb, Croatia; University of Applied Health Sciences, Zagreb, Croatia
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Abstract
Platelet transfusions are commonly administered for the prevention or treatment of bleeding in patients with acquired thrombocytopenia across a range of clinical contexts. Recent data, including randomized trials, have highlighted uncertainties in the risk-benefit balance of this therapy, which is the subject of this review. Hemovigilance systems report that platelets are the most frequently implicated component in transfusion reactions. There is considerable variation in platelet count increment after platelet transfusion, and limited evidence of efficacy for clinical outcomes, including prevention of bleeding. Bleeding events commonly occur despite the different policies for platelet transfusion prophylaxis. The underlying mechanisms of harm reported in randomized trials may be related to the role of platelets beyond hemostasis, including mediating inflammation. Research supports the implementation of a restrictive platelet transfusion policy. Research is needed to better understand the impact of platelet donation characteristics on outcomes, and to determine the optimal thresholds for platelet transfusion before invasive procedures or major surgery (eg, laparotomy). Platelet transfusion policies should move toward a risk-adapted approach that does not focus solely on platelet count.
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Anthon CT, Granholm A, Sivapalan P, Zellweger N, Pène F, Puxty K, Perner A, Møller MH, Russell L. Prophylactic platelet transfusions versus no prophylaxis in hospitalized patients with thrombocytopenia: A systematic review with meta-analysis. Transfusion 2022; 62:2117-2136. [PMID: 35986657 PMCID: PMC9805167 DOI: 10.1111/trf.17064] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/24/2022] [Accepted: 07/01/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Carl Thomas Anthon
- Department of Intensive CareCopenhagen University HospitalRigshospitaletDenmark
| | - Anders Granholm
- Department of Intensive CareCopenhagen University HospitalRigshospitaletDenmark
| | - Praleene Sivapalan
- Department of Intensive CareCopenhagen University HospitalRigshospitaletDenmark
| | - Núria Zellweger
- Department of Intensive CareUniversity Hospital BaselBaselSwitzerland
| | - Frédéric Pène
- Médecine Intensive and Réanimation, Hôpital Cochin, Assistance Publique‐Hôpitaux de ParisCentre—Université Paris CitéParisFrance
| | - Kathryn Puxty
- Department of Intensive CareGlasgow Royal InfirmaryGlasgowScotlandUK
| | - Anders Perner
- Department of Intensive CareCopenhagen University HospitalRigshospitaletDenmark,Copenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Morten Hylander Møller
- Department of Intensive CareCopenhagen University HospitalRigshospitaletDenmark,Copenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Lene Russell
- Department of Intensive CareCopenhagen University HospitalRigshospitaletDenmark,Copenhagen University Hospital, RigshospitaletCopenhagenDenmark
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Cui Y, He Y, Hu C, Tu C, Huang J, Zhu X, Zang C, Ding K, Zhan B, Zhao Y, Qian L. Avatrombopag for the treatment of thrombocytopenia induced by chemotherapy in patients with solid tumors: A multicenter, open-label, single-arm trial. Front Pharmacol 2022; 13:970978. [PMID: 36238568 PMCID: PMC9553127 DOI: 10.3389/fphar.2022.970978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: To explore the effect and safety of avatrombopag for chemotherapy-induced thrombocytopenia (CIT). Methods: This multicenter, open-label, single-arm trial enrolled CIT patients in eight centers from October 2020 to April 2021. The participants received avatrombopag tablets 60 mg once a day for 5–10 days. The main endpoint was the proportion of patients with platelet count ≥100×109/L or increased by ≥ 50×109/L or increased by ≥ 100% in the cycle after the start of treatment. Results: Seventy-four participants were enrolled with a mean age of 59.8 ± 11.62.2% were males. The cumulative effective rate (any criteria) was 70.3% at 4 weeks. 42 (56.8%) achieved platelet count ≥100×109/L, 44 (59.5%) increased by ≥ 50×109/L, and 27 (36.5%) increase by ≥ 100% from baseline. The duration of grade III and IV platelet reduction was 4.2 ± 5.3 days. The time of PLT recovery to ≥75×109/L was 9.4 ± 6.6 days. The time of PLT recovery to ≥100×109/L was 10.2 ± 6.4 days. The platelet count nadir was 57.9 ± 45.3×109/L. The most common adverse events were nausea (8.1%), fatigue (5.4%), and abdominal pain (1.4%). There were no cases of fever, headache, or peripheral edema. Conclusion: Although it was a single-arm trial without a control group, the application of avatrombopag in patients with CIT can increase the platelet count of the patients compared with baseline. Avatrombopag is safe and tolerable. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT04609891?term=04609891&draw=2&rank=1, identifier [NCT04609891]
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Affiliation(s)
- Yayun Cui
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Yifu He
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Changlu Hu
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Congyin Tu
- Department of Surgical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Jin Huang
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Xiaofeng Zhu
- Department of Gastroenterology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Chunbao Zang
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Kaiyang Ding
- Department of Hematology-Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Bihong Zhan
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Yufei Zhao
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Liting Qian
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
- *Correspondence: Liting Qian,
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36
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Tranexamic acid as a stopgap for low platelets? Blood 2022; 140:1185-1186. [PMID: 36107459 DOI: 10.1182/blood.2022017207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 11/20/2022] Open
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Prophylactic tranexamic acid in patients with hematologic malignancy: a placebo-controlled, randomized clinical trial. Blood 2022; 140:1254-1262. [PMID: 35667085 PMCID: PMC9479029 DOI: 10.1182/blood.2022016308] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/20/2022] [Indexed: 11/26/2022] Open
Abstract
Evidence of the effectiveness of prophylactic use of tranexamic acid (TXA) in thrombocytopenia is lacking. To determine whether TXA safely reduces bleeding incidence in patients undergoing treatment for hematologic malignancies, a randomized, double-blind clinical trial was conducted from June 2016 through June 2020. Of 3120 screened adults, 356 patients were eligible and enrolled, and 337 patients (mean age, 53.9; 141 [41.8%] women), randomized to 1300 mg TXA orally or 1000 mg TXA through IV (n = 168) vs placebo (n = 169) thrice daily for maximum 30 days. Three hundred thirty patients were activated when their platelet counts fell below 30 000 per µL; 279 (83%) had complete outcome ascertainment. World Health Organization (WHO) grade ≥2 bleeding was observed in the 30 days following activation in 50.3% (73/145) and 54.2% (78/144) of patients in the TXA and placebo groups, with an adjusted odds ratio of 0.83 (95% confidence interval [CI], 0.50-1.34; P = .44). There was no statistically significant difference in the mean number of platelet transfusions (mean difference, 0.1; 95% CI, -1.9 to 2.0), mean days alive without grade ≥2 bleeding (mean difference, 0.8; 95% CI, -0.4 to 2.0), thrombotic events (6/163 [3.7%] TXA, 9/163 [5.5%] placebo), or deaths due to serious bleeding. Most common adverse events were: diarrhea (116/164 [70.7%] TXA and 114/163 [69.9%] placebo); febrile neutropenia (111/164 [67.7%] TXA, 105/163 [64.4%] placebo); fatigue (106/164 [64.6%] TXA, 109/163 [66.9%] placebo); and nausea (104/164 [63.4%] TXA, 97/163 [59.5%] placebo). Among patients with hematologic malignancy undergoing chemotherapy or hematopoietic stem cell transplantation, prophylactic treatment with TXA compared with placebo did not significantly reduce the risk of WHO grade ≥2 bleeding.
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38
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Thachil J, Carrier M, Lisman T. Anticoagulation in thrombocytopenic patients - Time to rethink? J Thromb Haemost 2022; 20:1951-1956. [PMID: 35716055 DOI: 10.1111/jth.15789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 01/19/2023]
Abstract
One of the difficult clinical situations in the anticoagulation era is how to give these medications to patients with significantly reduced platelet counts. The concern is the heightened bleeding risk, and the current practice is to apply a certain platelet count threshold below which the use of anticoagulant is deemed unsafe. However, this is not an evidence-based approach especially because the thresholds arose from studies in patients with acute leukemia. In this forum article, we discuss the bleeding risk estimation in thrombocytopenic patients when the decreased counts may not be related to marrow underproduction and aim to identify possible markers which can help in this risk estimation beyond platelet counts. We exhort future studies to include a combination of these markers, which may then guide us to administer safe anticoagulation in patients with severe thrombocytopenia.
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Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
| | - Marc Carrier
- Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ton Lisman
- Department of Surgery, Surgical Research Laboratory, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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39
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Matsumoto M, Terada K, Tsuchimochi T, Takahashi S, Noguchi Y, Igarashi S. Efficacy of Eltrombopag in Children with Post-Stem Cell Transplant Prolonged Isolated Thrombocytopenia. Hematol Rep 2022; 14:240-244. [PMID: 35997400 PMCID: PMC9396996 DOI: 10.3390/hematolrep14030033] [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: 05/16/2022] [Revised: 06/30/2022] [Accepted: 07/19/2022] [Indexed: 12/04/2022] Open
Abstract
Prolonged isolated thrombocytopenia (PIT) is a complication following allogeneic hematopoietic cell transplantation that results in prolonged transfusion dependence. Recently, the efficacy of a thrombopoietin receptor agonist (eltrombopag) against PIT has been reported in adults; however, there are few reports in children. A 4-year-old male pediatric patient diagnosed with congenital pure red cell aplasia underwent allogeneic hematopoietic cell transplantation. Neutrophil engraftment was observed on post-transplant Day 26; however, platelet counts remained <10 × 109/L. Transfusions were required 1−2 times a week for at least 4 months. On post-transplant Day 124, oral eltrombopag (up to 2.4 mg/kg/day) was initiated. Thereafter, the platelet counts were maintained at ≥10 × 109/L, and the patient became transfusion independent. At 2 years and 6 months after the oral administration, no chromosomal abnormalities, thromboembolism, or myelofibrosis was observed. Thus, eltrombopag can be a potential treatment option for pediatric PIT.
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Affiliation(s)
- Megumi Matsumoto
- Department of Pediatrics, Japanese Red Cross Narita Hospital, Narita 286-8523, Japan; (M.M.); (T.T.); (S.T.); (Y.N.); (S.I.)
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan
| | - Kazuki Terada
- Department of Pediatrics, Japanese Red Cross Narita Hospital, Narita 286-8523, Japan; (M.M.); (T.T.); (S.T.); (Y.N.); (S.I.)
- Correspondence: ; Tel.: +81-476-22-2311; Fax: +81-476-22-6477
| | - Taichiro Tsuchimochi
- Department of Pediatrics, Japanese Red Cross Narita Hospital, Narita 286-8523, Japan; (M.M.); (T.T.); (S.T.); (Y.N.); (S.I.)
| | - Satoko Takahashi
- Department of Pediatrics, Japanese Red Cross Narita Hospital, Narita 286-8523, Japan; (M.M.); (T.T.); (S.T.); (Y.N.); (S.I.)
| | - Yasushi Noguchi
- Department of Pediatrics, Japanese Red Cross Narita Hospital, Narita 286-8523, Japan; (M.M.); (T.T.); (S.T.); (Y.N.); (S.I.)
| | - Shunji Igarashi
- Department of Pediatrics, Japanese Red Cross Narita Hospital, Narita 286-8523, Japan; (M.M.); (T.T.); (S.T.); (Y.N.); (S.I.)
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40
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Anthon CT, Pène F, Perner A, Azoulay E, Puxty K, Van De Louw A, Barret‐Due A, Chawla S, Castro P, Povoa P, Coelho L, Metaxa V, Munshi L, Kochanek M, Liebregts T, Kander T, Hästbacka J, Møller MH, Russell L, Anthon CT, Hildebrandt T, Vogelius MK, Clausen N, Bestle M, Lorentzen K, Nielsen LB, Andreasen JB, Hvas CL, Juhl CS, Lundqvist L, Lindquist E, Barret‐Due A, Bådstøløkken PM, Holten AR, Kvåle R, Strand K, Klepstad P, Hästbacka J, Jalkanen V, Reinikainen M, Péju E, Marin N, Pène F, Vimpere D, Menat S, Voiriot G, Schmidt J, Dufranc E, Uhel F, Lafarge A, Missri L, Ait‐Oufella H, Canet E, Metexa V, Puxty K, Wright C, Castro P, Costa C, Coelho L, Povoa P, Paulino MC, Graça C, Torres JCS, Chawla S, Voigt L, Van de Louw A, Munshi L, Lueck C, Kochanek M, Liebgrets T. Platelet transfusions and thrombocytopenia in intensive care units: protocol for an international inception cohort study (PLOT‐ICU). Acta Anaesthesiol Scand 2022; 66:1146-1155. [PMID: 36054145 PMCID: PMC9542787 DOI: 10.1111/aas.14124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022]
Abstract
Introduction Thrombocytopenia is frequent in intensive care unit (ICU) patients and has been associated with worse outcome. Platelet transfusions are often used in the management of ICU patients with severe thrombocytopenia. However, the reported frequencies of thrombocytopenia and platelet transfusion practices in the ICU vary considerably. Therefore, we aim to provide contemporary epidemiological data on thrombocytopenia and platelet transfusion practices in the ICU. Methods We will conduct an international inception cohort, including at least 1000 acutely admitted adult ICU patients. Routinely available data will be collected at baseline (ICU admission), and daily during ICU stay up to a maximum of 90 days. The primary outcome will be the number of patients with thrombocytopenia (a recorded platelet count < 150 × 109/L) at baseline and/or during ICU stay. Secondary outcomes include mortality, days alive and out of hospital, days alive without life‐support, the number of patients with at least one bleeding episode, at least one thromboembolic event and at least one platelet transfusion in the ICU, the number of platelet transfusions and the indications for transfusion. The primary and secondary outcomes will be presented descriptively. In addition, we will assess risk factors for developing thrombocytopenia during ICU stay and the association between thrombocytopenia at baseline and 90‐day mortality using logistic regression analyses. Conclusion The outlined international PLOT‐ICU cohort study will provide contemporary epidemiological data on the burden and clinical significance of thrombocytopenia in adult ICU patients and describe the current platelet transfusion practice.
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Affiliation(s)
- Carl Thomas Anthon
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Frédéric Pène
- Médecine Intensive & Réanimation, Hôpital Cochin, Assistance Publique – Hôpitaux de Paris Université Paris Cité Paris France
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Hôpital Saint‐Louis, Assistance Publique – Hôpitaux de Paris Université Paris Cité Paris France
| | - Kathryn Puxty
- Department of Intensive Care Glasgow Royal Infirmary Glasgow United Kingdom
| | - Andry Van De Louw
- Division of Pulmonary and Critical Care Penn State University College of Medicine Hershey PA USA
| | - Andreas Barret‐Due
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Rikshospitalet Oslo University Hospital Oslo Norway
| | - Sanjay Chawla
- Critical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine Memorial Sloan Kettering Cancer Center New York NY USA
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic of Barcelona; IDIBAPS; University of Barcelona Barcelona Spain
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal and NOVA Medical School New University of Lisbon Lisbon Portugal
| | - Luis Coelho
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal and NOVA Medical School New University of Lisbon Lisbon Portugal
| | - Victoria Metaxa
- Department of Critical Care King's College Hospital NHS Foundation Trust London United Kingdom
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network University of Toronto Toronto Ontario Canada
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne University of Cologne Cologne Germany
| | - Tobias Liebregts
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen University of Duisburg‐Essen Essen Germany
| | - Thomas Kander
- Department of Intensive and Perioperative Care, Skåne University Hospital, Sweden and Department of Clinical Sciences Lund University Sweden
| | - Johanna Hästbacka
- Department of Perioperative, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Lene Russell
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
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EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer. Hemasphere 2022; 6:e750. [PMID: 35924068 PMCID: PMC9281983 DOI: 10.1097/hs9.0000000000000750] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/01/2022] [Indexed: 01/19/2023] Open
Abstract
In cancer patients, thrombocytopenia can result from bone marrow infiltration or from anticancer medications and represents an important limitation for the use of antithrombotic treatments, including anticoagulant, antiplatelet, and fibrinolytic agents. These drugs are often required for prevention or treatment of cancer-associated thrombosis or for cardioembolic prevention in atrial fibrillation in an increasingly older cancer population. Data indicate that cancer remains an independent risk factor for thrombosis even in case of thrombocytopenia, since mild-to-moderate thrombocytopenia does not protect against arterial or venous thrombosis. In addition, cancer patients are at increased risk of antithrombotic drug-associated bleeding, further complicated by thrombocytopenia and acquired hemostatic defects. Furthermore, some anticancer treatments are associated with increased thrombotic risk and may generate interactions affecting the effectiveness or safety of antithrombotic drugs. In this complex scenario, the European Hematology Association in collaboration with the European Society of Cardiology has produced this scientific document to provide a clinical practice guideline to help clinicians in the management of patients with cancer and thrombocytopenia. The Guidelines focus on adult patients with active cancer and a clear indication for anticoagulation, single or dual antiplatelet therapy, their combination, or reperfusion therapy, who have concurrent thrombocytopenia because of either malignancy or anticancer medications. The level of evidence and the strength of the recommendations were discussed according to a Delphi procedure and graded according to the Oxford Centre for Evidence-Based Medicine.
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42
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Best practice & research: Clinical hematology review on thrombosis and bleeding in hematological malignancy. Best Pract Res Clin Haematol 2022; 35:101353. [DOI: 10.1016/j.beha.2022.101353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 01/19/2023]
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[Prognostic analysis and predictive model construction of bleeding events in allogeneic hematopoietic stem cell transplant patients]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:481-487. [PMID: 35968591 PMCID: PMC9800225 DOI: 10.3760/cma.j.issn.0253-2727.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective: To study hematopoietic stem cell transplantation-related bleeding prognosis and construct a bleeding prediction model. Methods: The clinical data of 555 patients with malignant hematologic diseases who underwent allogeneic hematopoietic stem cell transplantation between May 1(st) 2004, and April 1(st) 2012 was analyzed retrospectively, and a prediction model was constructed. Results: Of the 555 patients, a total of 302 (54.0% ) patients exhibited bleeding events of varying degrees, including 151 (27.0% ) with grade Ⅰ bleeding, 63 (11.0% ) with grade Ⅱ bleeding, 48 (9.0% ) with grade Ⅲ bleeding, and 40 (7.0% ) with grade Ⅳ bleeding. Multifactorial analysis showed that the overall mortality (HR=12.53, 95% CI 7.91-19.87, P<0.001) and non-recurrence mortality (HR=23.79, 95% CI 12.23-46.26, P<0.001) were higher in patients with higher bleeding grades (Ⅲ and Ⅳ bleeding) compared to those with lower bleeding grades. Additionally, the donor's underlying disease, graft-versus-host disease (GVHD) score, poor platelet reconstitution, and ineffective platelet transfusion were independently associated with bleeding risk. The bleeding model constructed using the above variables showed good accuracy (C-Index=0.934) , and its efficacy was significantly higher than previous bleeding models. Conclusion: Hematopoietic stem cell transplant patients are at increased risk of death after a bleeding event. The cross-validated bleeding risk prediction model is valuable for early intervention.
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There and Back Again: The Once and Current Developments in Donor-Derived Platelet Products for Products for Hemostatic Therapy. Blood 2022; 139:3688-3698. [PMID: 35482959 DOI: 10.1182/blood.2021014889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/20/2022] [Indexed: 01/19/2023] Open
Abstract
Over 100 years ago, Duke transfused whole blood to a thrombocytopenic patient to raise the platelet count and prevent bleeding. Since then, platelet transfusions have undergone numerous modifications from whole blood-derived platelet-rich plasma to apheresis-derived platelet concentrates. Similarly, the storage time and temperature have changed. The mandate to store platelets for a maximum of 5-7 days at room temperature has been challenged by recent clinical trial data, ongoing difficulties with transfusion-transmitted infections, and recurring periods of shortages, further exacerbated by the COVID-19 pandemic. Alternative platelet storage approaches are as old as the first platelet transfusions. Cold-stored platelets may offer increased storage times (days) and improved hemostatic potential at the expense of reduced circulation time. Frozen (cryopreserved) platelets extend the storage time to years but require storage at -80 °C and thawing before transfusion. Lyophilized platelets can be powder-stored for years at room temperature and reconstituted within minutes in sterile water but are probably the least explored alternative platelet product to date. Finally, whole blood offers the hemostatic spectrum of all blood components but has challenges, such as ABO incompatibility. While we know more than ever before about the in vitro properties of these products, clinical trial data on these products are accumulating. The purpose of this review is to summarize the findings of recent preclinical and clinical studies on alternative, donor-derived platelet products.
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O’Laughlin DJ, Bartlett MA, Fischer KM, Marshall AL, Pruthi RK, Casey PM. Bleeding Complications Associated With Intrauterine Contraception in Women Receiving Anticoagulation Therapy. Mayo Clin Proc Innov Qual Outcomes 2022; 6:98-105. [PMID: 35498393 PMCID: PMC9043296 DOI: 10.1016/j.mayocpiqo.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Objective Patients and Methods Results Conclusion
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Sola-Visner M, Leeman KT, Stanworth SJ. Neonatal platelet transfusions: New evidence and the challenges of translating evidence-based recommendations into clinical practice. J Thromb Haemost 2022; 20:556-564. [PMID: 35112471 DOI: 10.1111/jth.15664] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/28/2022] [Indexed: 01/19/2023]
Abstract
Platelet transfusions are a common intervention for thrombocytopenia. Although the main reason for transfusing platelets is to improve hemostasis, platelets have many additional physiological roles, including interactions with immune pathways. Much of the evidence base for safe and effective transfusions has been informed by randomized trials in adult patients with hematological malignancies. Only three randomized trials have been conducted in sick neonates. These trials have indicated evidence of harm, including a significantly higher rate of death or major bleeding within 28 days after randomization for the largest trial, which enrolled 660 infants. The overall research indicates limited effectiveness of platelet transfusions to reduce bleeding risk. It is important that the results of trials are implemented into practice, but uptake of research findings into neonatal medicine remains inconsistent, as for many areas of health care. There is a need to establish which potential implementation strategies (cost-) efficiently enact change, such as audit and feedback, automated reminder systems for ordering transfusions, and use of opinion leaders. Research is exploring potential mechanisms underlying the lack of effectiveness of platelet transfusions and the increased bleeding and mortality observed in neonatal randomized trials. One potential mechanism concerns the roles of platelets to promote excessive angiogenic signals during a vulnerable period of brain development. A further hypothesis explores the effects of transfusing "adult" platelets into "neonatal" thrombocytopenic blood on primary hemostasis and immune responses.
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Affiliation(s)
- Martha Sola-Visner
- Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristen T Leeman
- Pediatrics, Boston Children's Hospital, Harvard Neonatal-Perinatal Fellowship Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Simon J Stanworth
- Haematology and Transfusion Medicine, Department of Haematology, NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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Schiffer CA. Commentary on the prescient observations made by Emil J Freireich in Effectiveness of platelet transfusion in leukemia and aplastic anemia (Transfusion 1966; 6: 50-54). Transfusion 2022; 62:267-272. [PMID: 35146768 DOI: 10.1111/trf.16784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Charles A Schiffer
- Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan, USA
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Gao Y, Liu Q, Shen Y, Li Y, Shao K, Ye B, Shen Y, Zhou Y, Wu D. Effect of avatrombopag in the management of severe and refractory chemotherapy-induced thrombocytopenia (CIT) in patients with solid tumors. Platelets 2022; 33:1024-1030. [PMID: 35040375 DOI: 10.1080/09537104.2022.2026910] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common complication in cancer patients, especially after multiple cycles of chemotherapy, which leads to the delayed treatment or reduced dosage. The treatment of CIT is limited for refractory and severe cases. Herein we reported a single-center study of avatrombopag, a type of thrombopoietin receptor agonist (TPO-RA), for the treatment of severe and refractory (S/R) CIT who failed from multi-line treatments. A total of 13 cancer patients with S/R CIT were enrolled at the First Affiliated Hospital of Zhejiang Chinese Medical University from September 2020 to February 2021. All the patients were administered oral avatrombopag at an initial dose of 60 mg/day, which could be decreased as needed, over a period of 8 weeks. Eight (8/13, 61.5%) patients responded to avatrombopag (with a platelet count ≥50 × 109/L and transfusion independent), with a median response time of 27.5 (11-50) days, and the median cumulative day of platelet response was 79 (20-167). Ten of 13 patients (76.9%) no longer required platelet transfusion at the study endpoint. The predictor of response was the level of hemoglobin (HB) at study entry, patients with an HB over 90 g/L achieved a response rate of 88.9%. In addition, platelet count showed 87.5% sensitivity and 100% specificity to predict the treatment response at a cutoff value of 25.5× 109/L at the end of the third week management. No drug-related side effects were noticed during administration. Our study showed that avatrombopag could be a novel and effective drug for the treatment of severe and refractory CIT, especially for those with hemoglobin above 90 g/L. This study was registered at chictr.org.cn as # ChiCTR2100050646.
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Affiliation(s)
- Yanting Gao
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qi Liu
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yingying Shen
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yuzhu Li
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Keding Shao
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.,Office of Academic Research, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Baodong Ye
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yiping Shen
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yuhong Zhou
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Dijiong Wu
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.,The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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Garban F, Vilotitch A, Tiberghien P, Bosson JL. The impact of pathogen-reduced platelets in acute leukaemia treatment on the total blood product requirement: a subgroup analysis of an EFFIPAP randomised trial. Transfus Med 2022; 32:175-177. [PMID: 35019176 DOI: 10.1111/tme.12848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 12/08/2021] [Accepted: 12/30/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate the impact of pathogen-reduced (PR) platelet transfusions on blood products requirement for clinical practice. BACKGROUND PR platelets are increasing in use as standard blood products. However, few randomised trials have evaluated their impact on bleeding control or prevention. Furthermore, PR platelets recirculate less than untreated platelets. METHODS A subgroup study of the randomised clinical trial EFFIPAP compared three arms of platelet preparations (PR: P-PRP/PAS, additive solution: P-PAS and plasma P-P arms respectively). The subgroup of acute leukaemia patients, in their chemotherapy induction phase, included 392 patients (133 P-PRP/PAS arm, 132 P-PAS arm and 130 P-P arm). Blood requirements were analysed across over periods of 7 days. RESULTS The number of platelet transfusions per week was significantly higher in the P-PRP/PAS group 2.3 [1.6-3.3] compared to the control groups 1.9 [1.3-2.8] and 2.0 [1.3-3.0] for P-P and P-PAS groups respectively (p < 0.0001). However, the total number of platelets transfused per week was not different. The number of red blood cell concentrates (RBC) transfusion per week did not differ either. CONCLUSION In a homogeneous group of patients, platelet pathogen reduction resulted in an increased number of platelet units transfused per week while having no impact on the total number of platelets transfused or the number of RBC transfusion; resulting to an average requirement of 2 RBC and 2-3 platelets transfusions per week of marrow aplasia.
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Affiliation(s)
- Frédéric Garban
- Service d'Hématologie, Centre Hospitalier Universitaire de Grenoble Alpes (Grenoble Alps University Hospital), Grenoble, France.,CNRS, UMR 5525 Translationnal innovation in Medicine and Complexity, Université Grenoble Alpes, La Tronche, France
| | - Antoine Vilotitch
- Cellule d'ingénierie des données, Centre d'Investigation Clinique 1406 - Innovation Technologique, Centre Hospitalier Universitaire de Grenoble Alpes (Grenoble Alps University Hospital), Grenoble, France
| | - Pierre Tiberghien
- Etablissement Français du Sang, La Plaine Saint-Denis, Saint-Denis, France.,INSERM UMR 1098 RIGHT, Université de Franche-Comté, Etablissement Français du Sang, Besançon, France
| | - Jean Luc Bosson
- CNRS, UMR 5525 Translationnal innovation in Medicine and Complexity, Université Grenoble Alpes, La Tronche, France.,Cellule d'ingénierie des données, Centre d'Investigation Clinique 1406 - Innovation Technologique, Centre Hospitalier Universitaire de Grenoble Alpes (Grenoble Alps University Hospital), Grenoble, France
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Savoia C, McKeough N, Hickey B, Cochrane T. Comparison of a therapeutic platelet transfusion strategy to a prophylactic platelet transfusion strategy in autologous stem cell transplant (ASCT), a single centre experience. Bone Marrow Transplant 2022; 57:122-124. [PMID: 34616006 DOI: 10.1038/s41409-021-01482-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/03/2021] [Accepted: 09/22/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Camille Savoia
- Gold Coast University Hospital, Southport, QLD, Australia. .,Griffith University, Southport, QLD, Australia.
| | | | - Beth Hickey
- Gold Coast University Hospital, Southport, QLD, Australia.,Griffith University, Southport, QLD, Australia.,Queensland Institute of Medical Research (QIMR) Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Tara Cochrane
- Gold Coast University Hospital, Southport, QLD, Australia.,Griffith University, Southport, QLD, Australia
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