Blood use in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation: the impact of a health system-wide patient blood management program

Patient Blood Management and Its Role in Supporting Blood Supply

Blood donors and voluntary blood donations are essential for ensuring the blood supply that can be maintained by good patient blood management (PBM) practices. This review article explores the role of blood donation in PBM and highlights the importance of donor screening and selection processes in different regions worldwide. The donor health questionnaires and the focused physical examination guidelines have changed in the last decade to increase donor and recipient safety. This article also discusses the status of transfusion practices, including the challenges of ensuring a safe blood supply. Significant among these are the effects of the COVID-19 pandemic on the blood supply chain and the impact of an aging donor population, especially. Promoting autologous donations and other blood conservation strategies are suggested to mitigate these issues. The role of replacement donors and the upper age limit for voluntary blood donation may be decided based on the demography and donor pool. The involvement of C-suite executives is also critical in implementing and running a successful PBM program. The review highlights how these different aspects of blood donation are integral to a successful PBM program and the safety of patients who receive blood transfusions.

Data and Metrics for Patient Blood Management: A Narrative Review and Practical Guide

Data collection, analysis, and reporting are fundamental for a successful hospital-based patient blood management program; however, very little has been published on the topic. Our aim was to synthesize evidence from a literature review to provide a detailed, practical list of outcome metrics, and the required data collection(s) to inform implementation. Ovid MEDLINE and PubMed were searched for any full-text original research articles published from inception to the year 2020. We included any studies reporting the implementation of interventions or programs study authors defined as "patient blood management" and extracted information on data collected and metrics reported. We included 45 studies describing the implementation of a patient blood management program and/or strategies. The outcomes reported by these studies were grouped into 1 of 36 metrics. We compiled a list of 65 relevant data elements to collect, and their potential source hospital information systems: patient administration, laboratory, transfusion/blood bank, operating room, pharmacy, emergency department, and intensive care unit. We further categorized patient blood management data systems into basic, intermediate, and advanced based on the combination of different information systems sourced. The results of this review can be used to inform patient blood management programs in planning what data collection(s) are needed, where these data can be sourced from, and how they can be analyzed.

Transfusion support in hematopoietic stem cell transplantation

Transfusion support for hematopoietic stem cell transplantation (HSCT) is an essential part of supportive care, and compatible blood should be transfused into recipients. As leukocyte antigen (HLA) matching is considered first and as the blood group does not impede HSCT, major, minor, bidirectional, and RhD incompatibilities occur that might hinder transfusion and cause adverse events. Leukocyte reduction in blood products is frequently used, and irradiation should be performed for blood products, except for plasma. To mitigate incompatibility and adverse events, local transfusion guidelines, hospital transfusion committees, and patient management should be considered.

Perioperative inappropriate red blood cell transfusions significantly increase total costs in elective surgical patients, representing an important economic burden for hospitals

Background

Red blood cell (RBC) transfusions in surgical patients are associated with increased morbidity a hospital stay. However, little is known about how clinical and economic outcomes differ between appropriately and inappropriately transfused patients. We hypothesized that inappropriate RBC transfusions in elective surgical patients would significantly increase hospital cost. The aim of this study was to quantify the economic burden associated with inappropriate RBC transfusions.

Methods

We retrospectively included all adult patients admitted for elective non-cardiac surgery between January 2014 and March 2020. Patients were divided into three groups (not transfused, appropriately transfused and inappropriately transfused). The primary outcome was the excess in hospital cost in patients inappropriately transfused compared to non-transfused patients. Costs were calculated using a bottom–up approach and involving cost calculation on a granular level. According to international guidelines, transfusions were considered appropriate if administered with an ASA score of 1–2 and the last hemoglobin level measured before transfusion < 70 g/L, or with an ASA score ≥ 3 and the last hemoglobin level < 80 g/L. Cases where RBC transfusions were deemed necessary regardless of the Hb levels were reviewed by the patient blood management (PBM) board and classified accordingly. Secondary outcomes included total transfusion rate, transfusion index, and length of hospital stay. Statistical analysis was carried out by multivariable regression models.

Results

During the study period there were 54,922 consecutive surgical admissions, of these 1,997 received an RBC transfusion, with 1,125 considered inappropriate. The adjusted cost of each inappropriate RBC transfusions was estimated in United States dollars (USD) 9,779 (95% CI, 9,358 – 10,199; p < 0.001) and totaled USD 11,001,410 in our series. Inappropriately transfused patients stayed 1.6 times (95% CI, 1.5–1.6; p < 0.001) longer in hospital (10.6 days vs. 6.7 days) than non-transfused patients and a mean 2.35 RBC units per patient were administered.

Conclusion

Inappropriate RBC transfusions in elective surgical patients seem to be common and may represent a significant economic burden. In our experience, inappropriate transfusions significantly increased hospital costs by an average of USD 9,779 compared to non-transfused patients. Through specific PBM policy, hospitals may improve cost-effectiveness of their elective surgical activity by lowering inappropriate transfusions.

Safety, efficacy and cost of intra-operative cell salvage during open radical prostatectomy

Background

We aim to examine the safety and efficacy of intra-operative cell salvage (ICS) in radical prostatectomy.

Methods

A retrospective cohort study was performed, enrolling consecutive patients undergoing open radical prostatectomy at two institutions during 01/01/18–31/12/19. Patients were grouped by ICS use. Primary outcomes were allogeneic transfusion rates, and biochemical recurrence (prostate specific antigen >0.2 mg/mL). Secondary outcomes were use of adjuvant therapies, Clavien-Dindo complications and transfusion-related cost (allogeneic transfusion + ICS setup + ICS reinfusion).

Results

In total, 168 men were enrolled. Patients were grouped based on whether they received no blood conservation technique (126 men) or ICS (42 men). Groups were similar in median age, pre- and post-operative haemoglobin and length of stay. They also had similar post-operative tumour Gleason score, TNM-stage and positive surgical margin rates. Compared with controls, the ICS group had shorter follow up (336 vs. 225 days; P=0.003). The groups had similar rates of biochemical recurrence (17% vs. 14%; P=0.90), adjuvant therapy use (30% vs. 29%; P=0.85) and complications (14% vs. 19% patients; P=0.46). There was no metastatic progression or cancer-specific mortality in either group. Although a similar proportion of patients received allogenic transfusion (2.4% vs. 4.8%; P=0.33) and units of packed red blood cells (PRBC) (9 vs. 5 units), transfusion-related costs were higher amongst the ICS group (AUD $11,422 vs. $43,227).

Conclusions

ICS use in radical prostatectomy was not associated with altered rates of allogeneic transfusion, complications, biochemical recurrence or adjuvant or salvage therapies. Transfusion related costs were higher in the ICS group.

Postoperative patient blood management: transfusion appropriateness in cancer patients

BACKGROUND

While patient blood management (PBM) principles are not specific to cancer patients, their application contains the pathophysiological premises that could also benefit this patient population. In this study, we assessed the effects of implementing a PBM bundle for cancer patients in the postoperative period.

MATERIALS AND METHODS

The Azienda USL-IRCCS of Reggio Emilia implemented a two-step PBM bundle for the postoperative period of cancer patients hospitalised in the semi-intensive post-surgery (SIPO) ward. Step 1 included seminars and lessons specifically targeting SIPO personnel; Step 2 introduced Points of Care (POCs) for the continuous monitoring of haemoglobin (Radical7, Masimo Corp, Irvine, CA, USA). We conducted 3 audits on 600 cancer patients recruited between 2014 and 2017: Audit 1 on 200 patients before the application of our PBM bundle; Audit 2 after Step 1 on 200 patients; Audit 3 after Step 2 on 200 patients monitored with POCs. Red blood cell (RBC) transfusion appropriateness in the postoperative period was evaluated using the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) recommendations.

RESULTS

RBC transfusion appropriateness in the postoperative period of cancer patients rose from 38% to 75% after seminars, and reached 79% after the introduction of POC. The mean number of RBC units each patient received remained unchanged after training sessions (1.8 units/patient) while the introduction of POCs saw a simultaneous decrease in the number of prescribed units (1.3 units/patient).

DISCUSSION

Our PBM bundle positively impacted RBC transfusion appropriateness in postsurgical cancer patients, both in terms of quality and quantity. A structured PBM programme specifically dedicated to surgical oncology should cover the entire perioperative period and might further improve transfusion appropriateness in these patients. The publication of guidelines on the management of anaemia in surgical oncology should be a priority.

Patient Blood Management

Patient blood management is a highly successful and cost-effective concept that improves patient outcome by correction of anemia with hematinic medication and reduction of blood loss perioperatively by meticulous surgical techniques and individualized coagulation management.

Liberal Versus Restrictive Red Blood Cell Transfusion Thresholds in Hematopoietic Cell Transplantation: A Randomized, Open Label, Phase III, Noninferiority Trial

PURPOSE

Evidence regarding red blood cell (RBC) transfusion practices and their impact on hematopoietic cell transplantation (HCT) outcomes are poorly understood.

PATIENTS AND METHODS

We performed a noninferiority randomized controlled trial in four different centers that evaluated patients with hematologic malignancies requiring HCT who were randomly assigned to either a restrictive (hemoglobin [Hb] threshold < 70 g/L) or liberal (Hb threshold < 90 g/L) RBC transfusion strategy between day 0 and day 100. The noninferiority margin corresponds to a 12% absolute difference between groups in Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) score relative to baseline. The primary outcome was health-related quality of life (HRQOL) measured by FACT-BMT score at day 100. Additional end points were collected: HRQOL by FACT-BMT score at baseline and at days 7, 14, 28, 60, and 100; transplantation-related mortality; length of hospital stay; intensive care unit admissions; acute graft-versus-host disease; Bearman toxicity score; sinusoidal obstruction syndrome; serious infections; WHO Bleeding Scale; transfusion requirements; and reactions to therapy.

RESULTS

A total of 300 patients were randomly assigned to either restrictive-strategy or liberal-strategy treatment groups between 2011 and 2016 at four Canadian adult HCT centers. After HCT, mean pre-transfusion Hb levels were 70.9 g/L in the restrictive-strategy group and 84.6 g/L in the liberal-strategy group (P < .0001). The number of RBC units transfused was lower in the restrictive-strategy group than in the liberal-strategy group (mean, 2.73 units [standard deviation, 4.81 units] v 5.02 units [standard deviation, 6.13 units]; P = .0004). After adjusting for transfusion type and baseline FACT-BMT score, the restrictive-strategy group had a higher FACT-BMT score at day 100 (difference of 1.6 points; 95% CI, -2.5 to 5.6 points), which was noninferior compared with that of the liberal-strategy group. There were no significant differences in clinical outcomes between the transfusion strategies.

CONCLUSION

In patients undergoing HCT, the use of a restrictive RBC transfusion strategy threshold of 70 g/L was as effective as a threshold of 90 g/L and resulted in similar HRQOL and HCT outcomes with fewer transfusions.

The long and winding road to pathogen reduction of platelets, red blood cells and whole blood

Pathogen reduction technologies (PRTs) have been developed to further reduce the current very low risks of acquiring transfusion-transmitted infections and promptly respond to emerging infectious threats. An entire portfolio of PRTs suitable for all blood components is not available, but the field is steadily progressing. While PRTs for plasma have been used for many years, PRTs for platelets, red blood cells (RBC) and whole blood (WB) were developed more slowly, due to difficulties in preserving cell functions during storage. Two commercial platelet PRTs use ultra violet (UV) A and UVB light in the presence of amotosalen or riboflavin to inactivate pathogens' nucleic acids, while a third experimental PRT uses UVC light only. Two PRTs for WB and RBC have been tested in experimental clinical trials with storage limited to 21 or 35 days, due to unacceptably high RBC storage lesion beyond these time limits. This review summarizes pre-clinical investigations and selected outcomes from clinical trials using the above PRTs. Further studies are warranted to decrease cell storage lesions after PRT treatment and to test PRTs in different medical and surgical conditions. Affordability remains a major administrative obstacle to PRT use, particularly so in geographical regions with higher risks of transfusion-transmissible infections.

Implementation of a patient blood management program in hematopoietic stem cell transplantation (Editorial, p. 2763)

BACKGROUND

Recipients of hematopoietic stem cell transplantation (HSCT) are among the highest consumers of allogeneic red blood cell (RBC) and platelet (PLT) components. The impact of patient blood management (PBM) efforts on HSCT recipients is poorly understood.

STUDY DESIGN AND METHODS

This observational study assessed changes in blood product use and patient-centered outcomes before and after implementing a multidisciplinary PBM program for patients undergoing HSCT at a large academic medical center. The pre-PBM cohort was treated from January 1 through September 31, 2013; the post-PBM cohort was treated from January 1 through September 31, 2015.

RESULTS

We identified 708 patients; 284 of 352 (80.7%) in the pre-PBM group and 225 of 356 (63.2%) in the post-PBM group received allogeneic RBCs (p < 0.001). Median (interquartile range [IQR]) RBC volumes were higher before PBM than after PBM (3 [2-4] units vs. 2 [1-4] units; p = 0.004). A total of 259 of 284 pre-PBM patients (91.2%) and 57 of 225 (25.3%) post-PBM patients received RBC transfusions when hemoglobin levels were more than 7 g/dL (p < 0.001). The median (IQR) PLT transfusion quantities was 3 (2-5) units for pre-PBM patients and 2 (1-4) units for post-PBM patients (p < 0.001). For patients with PLT counts of more than 10 × 10⁹ /L, a total of 1219 PLT units (73.4%) were transfused before PBM and 691 units (48.8%) were transfused after PBM (p < 0.001). Estimated transfusion expenditures were reduced by $617,152 (18.3%). We noted no differences in clinical outcomes or transfusion-related adverse events.

CONCLUSION

Patient blood management implementation for HSCT recipients was associated with marked reductions in allogeneic RBC and PLT transfusions and decreased transfusion-related costs with no detrimental impact on clinical outcomes.

Red blood cell product utilization in patients undergoing allogeneic stem cell transplantation

BACKGROUND

The risk of transfusion reactions (TR) and the cost of blood has led to efforts to reduce blood use. We changed our practice to transfuse just one instead of two units of red blood cells (RBC) when hemoglobin ≤8 g/dL due to patient blood management (PBM) recommendations.

METHODS AND MATERIALS

We compared RBC utilization in patients receiving allogeneic HCT in the 10 months before (control arm) and 13 months after implementation of this new practice (intervention arm). We used regression models to estimate the independent effect of transfusion practice, length of hospitalization, the conditioning regimen, and donor type for patients who received at least one RBC unit. The outcome variable was total number of inpatient transfusions. In addition, a survey assessed the impact of this.

RESULTS

Cohorts were matched for age, primary diagnosis, graft source, and conditioning regimen. The median number of RBC units transfused/patient was identical in both arms (4; interquartile range 19 units/patient). Using the regression model, only length of stay (relative increase of 1.035 units/day; 95%CI, 1.0271.043) was an independent predictor of the number of RBC units a patient received. When data were normalized/1000 patient days, the control arm received 240 units vs the intervention arm, which received 193 units, resulting in a reduction of 47 units transfused/1000-patient-days, which was not statistically significant (p-value = 0.32). The survey of RNs showed that it positively affected the workflow.

CONCLUSIONS

There was a modest reduction in RBC utilization based on units transfused/1000-patient-days. There was a positive impact on RN workflow.

Patterns of care in Jehovah's Witnesses patients with solid tumours and lymphoma

BACKGROUND

Supportive care of Jehovah's Witnesses (JWs) diagnosed with cancer can be challenging, as they do not accept red blood cell (RBC) transfusions.

AIM

The study was designed to determine treatment preferences and pattern of care offered to JWs diagnosed with cancer and its impact on cancer management.

METHODS AND RESULTS

A retrospective cohort study of JWs with solid malignancies or lymphoma in our institution between 2005 and 2015 was conducted. Survival statistics were estimated using Kaplan Meier survival curves and Cox proportional regression model. A total of 63 JWs were identified with a median age of 70 years. At diagnosis, 34% (n = 22) had anaemia. All 63 declined RBC transfusion, including 19 patients who later developed transfusion threshold during anti-cancer treatment. Forty-three percent (n = 27) JWs had advanced (stage 4) disease, and 76% (n = 48) had Eastern Cooperative Oncology Group of 0 to 1. JWs were willing to accept surgery and radiation rather than chemotherapy. Treatment was deemed to be suboptimal in 22% (n = 14) JWs due to early treatment discontinuation, administration of non-standard chemotherapy regimen, or dose reduction due to anaemia and denial of blood transfusion. Twenty-seven percent (n = 17) received hematopoietic growth factors (erythropoiesis-stimulating agents and pegfilgrastim). There was no mortality directly attributed to anaemia or refusal of blood transfusion in the entire cohort.

CONCLUSION

Jehovah's Witnesses declined RBC transfusion at diagnosis and during cancer therapy even if medically indicated. Management pathways need to be prospectively defined for this group of patients.

The impact of intra-operative cell salvage during open nephrectomy

Objective

To assess the impact of intra-operative cell salvage on outcomes in open nephrectomy.

Methods

A retrospective cohort study was performed of all patients undergoing open nephrectomy for suspected malignancy from 1 October 2013 to 1 October 2017. Patients were grouped and compared based on whether they received intra-operative cell salvage (ICS). Primary outcomes were allogeneic transfusion rates (ATRs), and if histology confirmed cancer, disease recurrence. Secondary outcomes were complications and transfusion-related cost.

Results

Forty patients underwent open nephrectomy for suspected malignancy during the enrolment period. Sixteen patients received ICS while 24 did not (standard group). Compared with the standard group, ICS patients had similar median age (63.5 vs. 61.0 years; p = 0.83) but fewer females (19% vs. 58%; p = 0.013). The groups were similar in pre-operative and discharge haemoglobin, Charlson Comorbidity Index, length of hospital stay and proportion with thoracoabdominal surgical approach. The ICS group had a smaller proportion undergoing partial nephrectomy (19% vs. 54%; p = 0.025) and shorter median follow-up (278 vs. 827 days; p = 0.0005). Histology was malignant for 14 ICS and 15 standard patients. The ICS group had more frequent ≥T2 disease (79% vs. 27%; p = 0.005). There were no positive margins. Both groups had similar ATRs (6% vs. 4%; p = 0.96), complication rates (19% vs. 29%; p = 0.46) and recurrence rates (18% vs. 7%; p = 0.40). Transfusion costs were higher amongst ICS patients (AUD $878.18 vs. $49.65 per patient).

Conclusion

ICS appears safe, with low rates of recurrence and complication. Both groups had low ATRs, and therefore cost benefit for ICS was not seen.

Intra-operative cell salvage in urological surgery: a systematic review and meta-analysis of comparative studies

OBJECTIVE

To evaluate systematically the safety and efficacy of intra-operative cell salvage (ICS) in urology.

METHODS

A search of Medline, Embase and Cochrane Library to August 2017 was performed using methods pre-published on PROSPERO. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible titles were comparative studies published in English that used ICS in urology. Primary outcomes were allogeneic transfusion rates (ATRs) and tumour recurrence. Secondary outcomes were complications and cost.

RESULTS

Fourteen observational studies were identified, with a total of 4 536 patients. ICS was compared with no the blood conservation technique (seven studies), preoperative autologous donation (PAD; five studies) or both (two studies). Cohorts underwent open prostatectomy (11 studies), open cystectomy (two studies) or open partial nephrectomy (one study). Meta-analysis was possible only for ATRs within prostatectomy studies. In this setting, ICS reduced ATR compared with no the blood conservation technique (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.15-0.76) but not PAD (OR 0.76, 95% CI 0.39-1.31). In the non-prostatectomy setting, ATRs amongst patients who underwent ICS were significantly higher or similar in one and two studies, respectively. Tumour recurrence was found to be significantly less common (two studies), similar (eight studies) or not measured (four studies). All six studies reporting complications found no difference in their ICS cohorts. Regarding cost, one study from 1995 found ICS more expensive than PAD, while two more recent studies found ICS to be cheaper than no blood conservation technique. As a result of inter-study heterogeneity, meta-analyses were not possible for recurrence, complications or cost.

CONCLUSION

Low-level evidence exists that, compared with other blood conservation techniques, ICS reduces ATR and cost while not affecting complications. It does not appear to increase tumour recurrence post-prostatectomy, although follow-up durations were short. Small study sizes and short follow-ups mean conclusions cannot be drawn with regard to recurrence after nephrectomy or cystectomy. Randomized trials with long-term follow-up evaluating ICS in urology are required.

The impact of intra-operative cell salvage during open radical prostatectomy

Background

To examine the effect of intra-operative cell salvage (ICS) in open radical prostatectomy.

Methods

In this retrospective cohort study, all patients undergoing open radical prostatectomy for malignancy at our institution between 10/04/2013 and 10/04/2017 were enrolled. Patients were grouped and compared based on whether they received ICS. Primary outcomes were allogeneic transfusion rates, and disease recurrence. Secondary outcomes were complications and transfusion-related cost.

Results

Fifty-nine men were enrolled; 30 used no blood conservation technique, while 29 employed ICS. There were no significant differences between groups in age, pre- or post-operative haemoglobin, Charlson comorbidity index, operation duration or length of stay. Tumour characteristics were also similar between groups, including pre-operative prostate specific antigen, post-operative Gleason score, T-stage, nodal status and rates of margin positivity. Compared with controls, the ICS group had longer follow up (945 vs. 989 days; P=0.0016). The control and ICS groups were not significantly different in rates of tumour recurrence (6 vs. 3 patients; P=0.30) or complications (10 vs. 5 patients; P=0.16). While the proportion of patients receiving allogenic transfusion was similar (9 vs. 6 patients; P=0.41), fewer red blood products transfused (40 vs. 12 units) meant transfusion related costs were lower in ICS patients (AUD $47,666 vs. $37,429).

Conclusions

ICS reduced transfusion related costs, without affecting allogeneic transfusion rates, tumour recurrence or complication rates. These findings extend the literature supporting ICS in oncological surgery. Prospective randomised studies are needed to confirm the existing level III evidence.

Prognostic Significance of Blood Transfusion in Elderly Patients with Primary Diffuse Large B-Cell Lymphoma

The current study sought to evaluate whether blood transfusions affect survival of elderly patients with primary diffuse large B-cell lymphoma (DLBCL). A total of 104 patients aged 60 years and over were enrolled and divided into two groups: 24 patients who received transfusions and 80 patients who did not. Statistical analyses showed significant differences in LDH levels, platelet (Plt) counts, and hemoglobin (Hb) and albumin (Alb) levels between the two groups. Univariate analyses showed that LDH level ≥ 245 IU/L, cell of origin (germinal center/nongerminal center), and blood transfusion were associated with both overall survival (OS) and progression-free survival (PFS). Higher IPI (3–5), Alb level < 35 g/L, and rituximab usage were associated with OS. Appearance of B symptoms was associated with PFS. Multivariate analyses showed that cell of origin and rituximab usage were independent factors for OS and LDH level was an independent factor for PFS. Blood transfusion was an independent factor for PFS, but not for OS. Our preliminary results suggested that elderly patients with primary DLBCL may benefit from a restrictive blood transfusion strategy.