Patient and product factors affecting platelet transfusion results

Effect of post-storage filters vs. pre-storage filters for leukoreduction of blood components on clinical outcomes: a systematic review and meta-analysis

BACKGROUND

Leukoreduction has been used to limit the risk of adverse events. The most commonly used methodology is filtration (pre- or post-storage). However, whether pre-storage filtration is better than post-storage filtration needs to be clearly defined, particularly for countries that still use post-storage filtration. This study aimed to synthesize the best available evidence on the effectiveness of pre-storage filters compared with post-storage filters for transfusion reactions, for the occurrence of infections, for the length of hospital stay, and for the death of patients undergoing leukoreduced transfusion.

METHODS

We searched the MEDLINE (PubMed), CINAHL (EBSCO), PsycINFO (APA), Scopus (Elsevier), The Cochrane Library (J. Wiley), Web of Science Core Collection (Clarivate Analytics), Embase (Elsevier), and LILACS (VHL) databases and gray literature for eligible studies in August 2020 and updated the search in October 2023. The Joanna Briggs Institute critical assessment tools were applied to analyze the quality appraisal of the studies. GRADE was used to determine the certainty of the evidence.

RESULTS

The meta-analysis showed that pre-storage filtration was a protective factor for the occurrence of febrile non-hemolytic transfusion reaction in red blood cells (RR 0.49, 95% CI 0.41-0.59) and platelet concentrate transfusions (RR 0.16, 95% CI 0.12-0.22). The same did not occur for post-surgical infection after platelet concentrate transfusions (RR 0.82, 95% CI 0.65-1.04). Only one study analyzed the length of hospital stay and showed no significant difference between patients who received leukoreduced transfusions according to the type of filter used. According to the GRADE criteria, the certainty of the evidence for febrile non-hemolytic transfusion reactions was low for red blood cells and very low for platelet concentrate due to the high risk of bias. Infection was a low risk due to imprecision.

CONCLUSIONS

The results of this review showed that the certainty of recommending the best type of filter (pre- or post-storage) for the benefit of the outcomes analyzed is still fragile; therefore, more robust evidence is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020192202.

What Laboratory Tests and Physiologic Triggers Should Guide the Decision to Administer a Platelet or Plasma Transfusion in Critically Ill Children and What Product Attributes Are Optimal to Guide Specific Product Selection? From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding

OBJECTIVES

To present consensus statements and supporting literature for plasma and platelet product variables and related laboratory testing for transfusions in general critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.

DESIGN

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

SETTING

Not applicable.

PATIENTS

Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for laboratory testing and blood product attributes for platelet and plasma transfusions. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed five expert consensus statements and two recommendations in answer to two questions: what laboratory tests and physiologic triggers should guide the decision to administer a platelet or plasma transfusion in critically ill children; and what product attributes are optimal to guide specific product selection?

CONCLUSIONS

The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program provides some guidance and expert consensus for the laboratory and blood product attributes used for decision-making for plasma and platelet transfusions in critically ill pediatric patients.

Platelet transfusion improves clot formation and platelet function in severely thrombocytopenic haematology patients

Prophylactic platelet (PLT) transfusion is a common practice in severely thrombocytopenic patients that reduces mortality, but responses to platelet transfusions are variable and difficult to predict in individual patients. In this prospective study, we evaluated the outcome of PLT transfusions in 40 patients with haematological malignancies, linking corrected count increment (CCI) to clot formation and agonist-induced platelet activation after transfusion. The CCI was highly variable between patients and 34% showed no response (1-h CCI < 7,5). Short time since the last PLT transfusion and extended storage time of the PLT product were linked to poor transfusion response, while patient sex, C-reactive protein or the number of chemotherapy cycles prior to transfusion did not influence transfusion outcome. High CCI and good PLT responsiveness to agonist stimulation predicted efficient clot formation in rotational thromboelastometry, but transfusion did not restore poor PLT function in patients to the level of healthy controls. Our study provides new insights into factors affecting PLT transfusion outcome in haematology patients with severe thrombocytopenia, and suggests that the thrombocytopenic environment, or disease-associated factors, may hamper platelet responsiveness.

Effect of post-storage filters vs. pre-storage filters for leukoreduction of blood components on clinical outcomes: a systematic review protocol

OBJECTIVE

This review will synthesize the best available evidence on the effectiveness of leukocyte reduction by comparing post-storage and pre-storage filters. The review will consider the following clinical outcomes: transfusion reactions, bacterial infection, length of stay, and mortality.

INTRODUCTION

Transfusion is a relevant therapy, but it is not risk-free. Leukocyte reduction can be performed either by apheresis or by pre- or post-storage filters in order to reduce the risk of transfusion reactions, transmission of some diseases, alloimmunization, and platelet refractoriness. It can also reduce the length of hospital stay and the use of antibiotics.

INCLUSION CRITERIA

Studies comparing the transfusion of leukocyte reduction through post-storage filters with pre-storage filters in patients of any age who received a transfusion and the clinical outcomes resulting from the transfusion will be considered for inclusion. Studies in Portuguese, English, and Spanish will be considered, with no publication time limit.

METHODS

The research sources will include MEDLINE (PubMed), CINAHL (EBSCO), PsycINFO, Scopus, The Cochrane Library, Web of Science Core Collection, Embase, LILACS, and gray literature sources. The selection of titles and abstracts will be carried out by two independent reviewers, and the critical evaluation of the studies will be based on JBI tools. The data of interest for the review question will be extracted using JBI SUMARI. A narrative synthesis will be performed as will a meta-analysis and risk assessment of publication bias, if possible.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020192202.

Platelet transfusion practice and related transfusion reactions in a large teaching hospital

BACKGROUND

Platelet transfusion practice varies widely since many aspects of platelet concentrate (PC) use have not been definitively determined. The objectives of this retrospective study were to present platelet transfusion practice and evaluate PC and patient characteristics, as well as their association with transfusion reaction (TR) rate.

MATERIAL AND METHODS

Platelet transfusions over a 5-year period were analysed regarding PC characteristics (the ABO and RhD compatibility, product type, and storage duration), patient characteristics (most responsible diagnosis, age, and gender), and TR type.

RESULTS

A total of 46,351 PCs were transfused: 76.4% whole blood-derived (WBD) and 23.6% single donor apheresis (SDA). Three thousand seven hundred seventy-six patients received platelet transfusions: 24.7% paediatric and 75.3% adult patients, 79.6% outpatients and 20.4% inpatients. As much as 63.1% of all transfused PCs were fresh (stored for≤3 days), 98.0% ABO-identical, and 87.3% of all PCs given to RhD- patients were RhD-. PCs were mainly transfused to haemato-oncology (76.8%) and cardiovascular surgery patients (6.5%). Overall, 84 (0.18%) TRs were reported, with allergic TRs (ATRs) being the most common. Although PC ABO compatibility and storage duration, as well as patient age and gender, showed differences in TR rate, only the use of PCs in platelet additive solution (PAS) showed a statistically significant reduction of TRs (P<0.001).

CONCLUSION

Transfusion practice at the University Hospital Centre Zagreb resulted in almost all patients receiving ABO and RhD identical PCs, and most of them were fresh PCs. The most important factor affecting the incidence of TRs was platelet storage solution. The use of PAS effectively reduced the rate of TRs, particularly allergic TRs.

The quality of platelet concentrates related to corrected count increment: linking in vitro to in vivo

BACKGROUND

Storage of platelet concentrates (PCs) results in reduced recovery and survival of transfused platelets (PLTs). Upon storage PLTs develop storage lesion that can be monitored by several laboratory tests. However, correlation of these descriptive tests with corrected count increments (CCIs), a marker frequently used to establish the effectiveness of PLT transfusions, is limited or unknown. This study investigated to what extent a functional test or a combined in vitro rating score improves the correlation of laboratory tests with 1-hour CCI.

STUDY DESIGN AND METHODS

PCs were analyzed using six different laboratory tests (n = 123) before transfusion in a prophylactic setting to 74 hematooncologic patients. Linear regression and Spearman correlation were used to determine associations between descriptive (either separately or combined in an in vitro rating score) or functional test results and 1-hour CCIs obtained after transfusion.

RESULTS

CD62P expression (r = -0.45), annexin V binding (r = -0.36), the updated in vitro rating score (r = 0.50), and PLT responsiveness after thrombin receptor activator for peptide-6 (TRAP) (r = 0.43-0.57) or adenosine diphosphate stimulation (r = 0.11-0.51) significantly correlated to 1-hour CCIs obtained after transfusion, whereas lactate concentration, ThromboLUX score, and thromboelastography measurements did not. The strongest correlations were observed for in vitro rating score and PLT responsiveness after TRAP stimulation and these tests could explain 24 and 33% of the observed variation in 1-hour CCI, respectively.

CONCLUSION

Combining descriptive markers in one in vitro rating score improved correlation to 1-hour CCI compared to the tests separately. Of all tests investigated, mean PLT responsiveness after TRAP stimulation showed the strongest clinical correlation and was best able to predict the 1-hour CCI.

Platelet storage duration and its clinical and transfusion outcomes: a systematic review

Background

Platelets (PLTs) are usually stored for up to 5 days prior to transfusion, although in some blood services the storage period is extended to 7 days. During storage, changes occur in both PLT and storage medium, which may lead to PLT activation and dysfunction. The clinical significance of these changes remains uncertain.

Methods

We performed a systematic review to assess the association between PLT storage time and clinical or transfusion outcomes in patients receiving allogeneic PLT transfusion. We searched studies published in English between January 2000 and July 2017 identified from MEDLINE, Embase, PubMed and the Cochrane Libraries.

Results

Of the 18 studies identified, five included 4719 critically ill patients (trauma, post-cardiac surgery and a heterogeneous population of critically ill patients) and 13 included 8569 haematology patients. The five studies in critically ill patients were retrospective and did not find any association between PLT storage time when PLTs were stored for up to 5 days and mortality. There was also no association between older PLTs and sepsis in the two largest studies (n = 4008 patients). Of the 13 studies in haematology patients, seven analysed prolonged storage time up to 6.5 or 7 days. Administration of fresh PLTs (less than 2 or 3 days) was associated with a significant increase in corrected count increment (CCI) compared to older PLTs in seven of the eight studies analysing this outcome. One single centre retrospective study found an increase in bleeding events in patients receiving older PLTs.

Conclusions

PLT storage time does not appear to be associated with clinical outcomes, including bleeding, sepsis or mortality, in critically ill patients or haematology patients. The freshest PLTs (less than 3 days) were associated with a better CCI, although there was no impact on bleeding events, questioning the clinical significance of this association. However, there is an absence of evidence to draw definitive conclusions, especially in critically ill patients.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2114-x) contains supplementary material, which is available to authorized users.

Factors related to the outcome of prophylactic platelet transfusions in patients with hematologic malignancies: an observational study

BACKGROUND

A better knowledge of the connections between platelet concentrate (PC) characteristics and transfusion outcomes in day-to-day practice would help improve the selection process of the most appropriate PC.

STUDY DESIGN AND METHODS

In this study of prophylactic platelet transfusions in patients with hematologic malignancies between 2002 and 2012, outcome criteria were corrected count increments (CCIs) and platelet transfusion intervals (TIs, in days). Studied characteristics were ABO matching status, platelet source, dose, storage duration, irradiation, washing, and transfusion sequence number (TSN). The analysis consisted of multivariable linear mixed-effects models with adjustments for patient diagnosis, sex, and type of treatment.

RESULTS

Overall, 869 patients and 6662 platelet transfusions were analyzed. For each day after the second day of storage, the CCI and TI decreased by 0.88 and 0.06 day, respectively. Compared to ABO-identical, transfusion with major ABO-incompatible PCs decreased the CCI and TI by 0.79 and 0.21 day, respectively. Platelet washing reduced the CCI and TI by 2.28 and 0.24 day, respectively. There was no significant association between platelet source or irradiation and CCI or TI. TI increased as the platelet dose per kg increased. Both CCI and TI decreased as the TSN increased.

CONCLUSION

Transfusion outcomes were significantly related to several PC-related factors. Associations for ABO matching status and storage duration were stronger than previously reported. Taking into account such factors when selecting a PC for transfusion could be beneficial to the recipient.

The Non-Hemostatic Aspects of Transfused Platelets

Platelets transfusion is a safe process, but during or after the process, the recipient may experience an adverse reaction and occasionally a serious adverse reaction (SAR). In this review, we focus on the inflammatory potential of platelet components (PCs) and their involvement in SARs. Recent evidence has highlighted a central role for platelets in the host inflammatory and immune responses. Blood platelets are involved in inflammation and various other aspects of innate immunity through the release of a plethora of immunomodulatory cytokines, chemokines, and associated molecules, collectively termed biological response modifiers that behave like ligands for endothelial and leukocyte receptors and for platelets themselves. The involvement of PCs in SARs—particularly on a critically ill patient’s context—could be related, at least in part, to the inflammatory functions of platelets, acquired during storage lesions. Moreover, we focus on causal link between platelet activation and immune-mediated disorders (transfusion-associated immunomodulation, platelets, polyanions, and bacterial defense and alloimmunization). This is linked to the platelets’ propensity to be activated even in the absence of deliberate stimuli and to the occurrence of time-dependent storage lesions.

Effects of platelet concentrate storage time reduction in patients after blood stem cell transplantation

OBJECTIVE

To evaluate the clinical effect of platelet concentrate (PC) transfusions after PC storage time reduction to 4 days.

PATIENTS AND METHODS

This was a single-centre cohort study comparing two 3-month periods of time, before and after the reduction of PC storage time from 5 to 4 days. Seventy-seven consecutive patients with PC transfusions were enrolled after blood stem cell transplantation. Corrected platelet count increment (CCI) on the morning after transfusion, time to next platelet transfusion, need for red blood cell (RBC) transfusion and clinical bleeding symptoms were compared.

RESULTS

Platelet concentrate storage time was reduced between period 1 (storage for up to 5 days, median storage time 78 h, range 11-136 h) and period 2 (storage for up to 4 days, median storage time 53 h, range 11-112 h). Patients were comparable for age, weight, body surface area, underlying disorder, type of transplantation and transfused platelet dose. The CCI increased from a median of 4 (range 0-20) to 8 (0-68) × 10(9) /l per 10(11) platelets/m(2) (P < 0·0001). Time to next PC transfusion increased from 1·1 to 2·0 days (P < 0·0001). Any bleeding symptom was noted in 20 of 36 patients (56%) vs. 9/41 patients (22%, P < 0·01). Nose bleeds, haematuria and bleeding at more than one site were significantly reduced. Frequency of RBC transfusion within 5 days after PC transfusion was reduced from 74 to 58% (P < 0·0001).

CONCLUSION

Platelet concentrate storage time shortening was associated with highly significant CCI increase, reduced RC needs and lower patient numbers with bleeding events.

Role of donor and recipient sex in platelet transfusion

BACKGROUND

H-Y proteins are ubiquitously expressed Y chromosome-encoded minor histocompatibility antigens, which are relevant in the transplantation of hematopoietic stem cells (HSCT) and solid organs. No studies have so far analyzed whether H-Y incompatibility influences the outcome of platelet (PLT) transfusion.

STUDY DESIGN AND METHODS

We studied the effect of donor and recipient sex on outcome of 9038 single-donor PLT transfusions.

RESULTS

Using standard corrected count increment or percent PLT recovery (PPR) calculations, male patients showed inferior recovery rates, irrespective of donor sex. Using an adjusted PPR, which takes into account differences in blood volume between males and females, neither donor nor recipient sex played any role in PLT recovery after transfusion. Similarly, the time to next PLT transfusion was unaffected by both donor and recipient sex. In a subgroup analysis of patients with graft-versus-host disease after allogeneic HSCT, male recipients of a female allograft-which may carry anti-H-Y T cells and antibodies-had significantly lower time to next PLT transfusion. However, this occurred after both male donor and female donor PLT transfusions, arguing against an involvement of alloreactivity against H-Y antigens on PLTs.

CONCLUSION

This large analysis found no evidence that donor-recipient sex matching influences the outcome of PLT transfusion.

Pathogen-inactivation of platelet components with the INTERCEPT Blood System ™: a cohort study

INTRODUCTION

INTERCEPT treatment is used to reduce platelet transfusion associated bacterial infections. Limited data are available in Switzerland.

PATIENTS AND METHODS

Patients with thrombocytopenia or thrombocyte dysfunction requiring platelet transfusions were enrolled in a prospective cohort study on safety (primary endpoint) and efficacy (secondary endpoint) of INTERCEPT treated platelets (I-PLTs). I-PLTs were produced from double-dose apheresis products. Data on safety were actively recorded for each transfusion.

RESULTS

A total of 551 I-PLT units (mean platelet dose: 2.6 ± 0.4 × 10(11)/unit) were transfused to 46 patients (mean number of platelet transfusions per patient: 12 ± 12.5). Fifty-one (9%) transfusions were associated with adverse events and 12 (2%) with acute transfusion reactions. Eleven serious adverse events were observed, none considered as related to the administration of I-PLT. Mean 1-4h and 16-24h CCIs were 10.1 ± 8.1 and 3.6 ± 6.6, respectively.

CONCLUSION

The transfusion of I-PLT was associated with a good safety profile and adequate platelet count increments at 1-4h.

Current practice and future directions for optimization of platelet transfusions in patients with severe therapy-induced cytopenia

Platelet transfusions are mainly used for patients with thrombocytopenia due to bone marrow failure, especially cancer patients developing severe chemotherapy-induced thrombocytopenia (e.g. patients with acute leukemia or other hematologic malignancies). A prophylactic transfusion strategy is now generally accepted in developed countries. Some clinical data, however, support the use of a therapeutic transfusion strategy at least for certain subsets of these patients. Several methodological approaches can then be used to evaluate the outcome of platelet transfusions, including peripheral blood platelet increments and bleeding assessments. Several factors will influence the efficiency of platelet transfusions; fever and ongoing hemorrhage are among the most important patient-dependent factors, but the number and quality of the transfused platelets are also important. The quality of transfused platelets can be evaluated by analyzing platelet activation, metabolism or senescence/apoptosis. Only evaluation of metabolism is included in international guidelines, but high-throughput methods for evaluation of activation and senescence/apoptosis are available and should be incorporated into routine clinical practice if future studies demonstrate that they reflect clinically relevant platelet characteristics. Finally, platelet transfusions have additional biological effects that may cause immunomodulation or altered angioregulation; at present it is not known whether these effects will influence the long-time prognosis of cancer patients. Thus, several questions with regard to the optimal use of platelet transfusions in cancer patients still need to be answered.

Identification of platelet refractoriness in oncohematologic patients

OBJECTIVES

To identify the occurrence and the causes of platelet refractoriness in oncohematologic patients.

INTRODUCTION

Platelet refractoriness (unsatisfactory post-transfusion platelet increment) is a severe problem that impairs the treatment of oncohematologic patients and is not routinely investigated in most Brazilian services.

METHODS

Forty-four episodes of platelet concentrate transfusion were evaluated in 16 patients according to the following parameters: corrected count increment, clinical conditions and detection of anti-platelet antibodies by the platelet immunofluorescence test (PIFT) and panel reactive antibodies against human leukocyte antigen class I (PRA-HLA).

RESULTS

Of the 16 patients evaluated (median age: 53 years), nine (56%) were women, seven of them with a history of pregnancy. An unsatisfactory increment was observed in 43% of the transfusion events, being more frequent in transfusions of random platelet concentrates (54%). Platelet refractoriness was confirmed in three patients (19%), who presented immunologic and non-immunologic causes. Alloantibodies were identified in eight patients (50%) by the PIFT and in three (19%) by the PRA-HLA. Among alloimmunized patients, nine (64%) had a history of transfusion, and three as a result of pregnancy (43%). Of the former, two were refractory (29%). No significant differences were observed, probably as a result of the small sample size.

CONCLUSION

The high rate of unsatisfactory platelet increment, refractoriness and alloimmunization observed support the need to set up protocols for the investigation of this complication in all chronically transfused patients, a fundamental requirement for the guarantee of adequate management.