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Mo A, Wood E, Shortt J, Charlton A, Evers D, Hoeks M, Pritchard E, Daly J, Hodgson C, Opat S, Bowen D, Reynolds J, Thi Phung Thao L, Stanworth SJ, McQuilten Z. Rethinking the transfusion pathway in myelodysplastic syndromes: Study protocol for a novel randomized feasibility n-of-1 trial of weekly-interval red cell transfusion in myelodysplastic syndromes. Transfusion 2024; 64:236-247. [PMID: 38214417 DOI: 10.1111/trf.17706] [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: 07/29/2023] [Revised: 11/30/2023] [Accepted: 12/07/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Anemia in myelodysplastic syndromes (MDS) is associated with poorer health-related quality of life (HRQoL) and physical function, and is frequently treated with transfusions. The current common practice of transfusing multiple red blood cells (RBC) units every 2-4 weeks may result in peaks/troughs in hemoglobin (Hb) level, yet maintaining a stable Hb may better improve HRQoL. We describe a study protocol aiming to investigate the feasibility of weekly low-dose RBC transfusion in MDS patients, including assessing HRQoL and physical function outcomes. STUDY DESIGN AND METHODS In this n-of-1 pilot study, patients receive two treatment arms, with randomly allocated treatment sequence: arm A (patient's usual transfusion schedule) and arm B (weekly transfusion, individualized per patient). To facilitate timely delivery of weekly transfusion, extended-matched RBCs are provided, with transfusion based upon the previous week's Hb/pre-transfusion testing results to eliminate delays of awaiting contemporaneous cross-matching. Primary outcome is the feasibility of delivering weekly transfusion. Secondary outcomes include HRQoL, functional activity measurements, RBC usage, and alloimmunization rates. A qualitative substudy explores patient and staff experiences. RESULTS The trial is open in Australia, Netherlands, and UK. The first patient was recruited in 2020. Inter-country differences in providing RBCs are observed, including patient genotyping versus serological phenotyping to select compatible units. DISCUSSION This pilot trial evaluates a novel personalized transfusion approach of weekly matched RBC transfusion and challenges the dogma of current routine pre-transfusion matching practice. Findings on study feasibility, HRQoL, and physical functional outcomes and the qualitative substudy will inform the design of a larger definitive trial powered for clinical outcomes.
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Affiliation(s)
- Allison Mo
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
- Department of Haematology, Monash Health, Clayton, Australia
- Austin Pathology & Department of Haematology, Austin Health, Heidelberg, Australia
| | - Erica Wood
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
- Department of Haematology, Monash Health, Clayton, Australia
| | - Jake Shortt
- Department of Haematology, Monash Health, Clayton, Australia
- Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Andrew Charlton
- Department of Haematology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Dorothea Evers
- Department of Haematology, Radboudumc, Nijmegen, The Netherlands
| | - Marlijn Hoeks
- Department of Haematology, Radboudumc, Nijmegen, The Netherlands
| | - Elizabeth Pritchard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - James Daly
- Australian Red Cross Lifeblood, Melbourne, Australia
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care-Research Centre, Monash University, Melbourne, Australia
- The Alfred, Melbourne, Australia
- The George Institute for Global Health, Sydney, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Stephen Opat
- Department of Haematology, Monash Health, Clayton, Australia
| | - David Bowen
- Department of Health Sciences, University of York, York, UK
| | - John Reynolds
- Department of Clinical Haematology, The Alfred, Melbourne, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - Le Thi Phung Thao
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
| | - Simon J 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, Oxford, UK
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
- Department of Haematology, Monash Health, Clayton, Australia
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Qiao J, Ray B, Singh V, Geno A, Abadie J. Lessons learned from patient outcomes when lowering hemoglobin transfusion thresholds during COVID-19 blood shortages. Am J Clin Pathol 2023; 160:175-184. [PMID: 37086488 DOI: 10.1093/ajcp/aqad033] [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: 12/25/2022] [Accepted: 03/06/2023] [Indexed: 04/24/2023] Open
Abstract
OBJECTIVES This study examines whether patient outcomes were affected when the hemoglobin (Hb) transfusion threshold was lowered by 1 g/dL during COVID-19-related blood shortages. METHODS Outcomes of lowered Hb thresholds (from <7 to <6 g/dL) were defined by 14-month intervals in 2 patient groups (prepandemic [January 2019-February 2020] and pandemic [April 2020-May 2021]). We evaluated patient admissions, pretransfusion (if transfused) or nadir admission (if not transfused) Hb levels between 5.0 and 8.0 g/dL, and total red blood cell (RBC) transfusions during admission (if transfused). Baseline variables and outcomes were selected from electronic health records. Primary COVID-19-related admissions were excluded. Regression analysis was conducted to determine outcomes. RESULTS Those in the prepandemic group (1976) and pandemic group (1547) were transfused. Fewer RBCs (2186, vs 3337) were used in the prepandemic group than in the pandemic group, respectively. Those in the prepandemic group had significantly higher rates of hypertension and diabetes as well as more smokers. Significant differences were observed when comparing the number of procedures and incidence of sepsis between the patient groups. Similar patterns were observed for the not transfused and transfused subgroups. CONCLUSIONS Patient outcomes were not affected after implementing lower Hb pretransfusion thresholds. Although confounding factors were mitigated, some may have been associated with procedures or sepsis. Proactive patient blood management strategies during COVID-19-related blood shortages may include adopting lower Hb thresholds.
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Affiliation(s)
- Jesse Qiao
- Department of Pathology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, US
| | - Bradford Ray
- Patient Blood Management and Research, University Medical Center of El Paso, El Paso, TX, US
| | - Vishwajeet Singh
- Department of Research, Biostatistics, and Epidemiology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, US
| | - Aaron Geno
- Department of Pathology, Dartmouth Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Lebanon, NH, US
| | - Jude Abadie
- Department of Pathology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, US
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Qadri SM, Liu Y, Barty RL, Heddle NM, Sheffield WP. A positive blood culture is associated with a lower haemoglobin increment in hospitalized patients after red blood cell transfusion. Vox Sang 2023; 118:33-40. [PMID: 36125492 DOI: 10.1111/vox.13362] [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: 06/10/2022] [Revised: 08/30/2022] [Accepted: 09/07/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Abundant clinical evidence supports the safety of red blood cell (RBC) concentrates for transfusion irrespective of storage age, but still, less is known about how recipient characteristics may affect post-transfusion RBC recovery and function. Septic patients are frequently transfused. We hypothesized that the recipient environment in patients with septicaemia would blunt the increase in post-transfusion blood haemoglobin (Hb). The main objective was to compare the post-transfusion Hb increment in hospitalized patients with or without a positive blood culture. MATERIALS AND METHODS A retrospective cohort study using data from the Transfusion Research, Utilization, Surveillance, and Tracking database (TRUST) was performed. All adult non-trauma in-patients transfused between 2010 and 2017 with ≥1 RBC unit, and for whom both pre- and post-transfusion complete blood count and pre-transfusion blood culture data were available were included. A general linear model with binary blood culture positivity was fit for continuous Hb increment after transfusion and was adjusted for patient demographic parameters and transfusion-related covariates. RESULTS Among 210,263 admitted patients, 6252 were transfused: 596 had positive cultures, and 5656 had negative blood cultures. A modelled Hb deficit of 1.50 g/L in blood culture-positive patients was found. All covariates had a significant effect on Hb increment, except for the age of the transfused RBC. CONCLUSION Recipient blood culture positivity was associated with a statistically significant but modestly lower post-transfusion Hb increment in hospitalized patients. In isolation, the effect is unlikely to be clinically significant, but it could become so in combination with other recipient characteristics.
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Affiliation(s)
- Syed M Qadri
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Yang Liu
- Department of Medicine and McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca L Barty
- Department of Medicine and McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada.,Southwest Region, Ontario Regional Blood Coordinating Network, Hamilton, Ontario, Canada
| | - Nancy M Heddle
- Department of Medicine and McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - William P Sheffield
- Canadian Blood Services, Medical Affairs and Innovation, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
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Mo A, Higgins AM. Restrictive transfusion thresholds: Have we left patient-centered outcomes behind? Transfusion 2022; 62:1929-1932. [PMID: 36120958 DOI: 10.1111/trf.17105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Allison Mo
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Australia and Monash Health, Melbourne, Victoria, Australia.,Monash Haematology, Monash Health, Clayton, Victoria, Australia.,Austin Pathology and Department of Clinical Haematology, Austin Health, Heidelberg, Victoria, Australia
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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