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Carson JL, Stanworth SJ, Dennis JA, Trivella M, Roubinian N, Fergusson DA, Triulzi D, Dorée C, Hébert PC. Transfusion thresholds for guiding red blood cell transfusion. Cochrane Database Syst Rev 2021; 12:CD002042. [PMID: 34932836 PMCID: PMC8691808 DOI: 10.1002/14651858.cd002042.pub5] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The optimal haemoglobin threshold for use of red blood cell (RBC) transfusions in anaemic patients remains an active field of research. Blood is a scarce resource, and in some countries, transfusions are less safe than in others because of inadequate testing for viral pathogens. If a liberal transfusion policy does not improve clinical outcomes, or if it is equivalent, then adopting a more restrictive approach could be recognised as the standard of care. OBJECTIVES: The aim of this review update was to compare 30-day mortality and other clinical outcomes for participants randomised to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all clinical conditions. The restrictive transfusion threshold uses a lower haemoglobin concentration as a threshold for transfusion (most commonly, 7.0 g/dL to 8.0 g/dL), and the liberal transfusion threshold uses a higher haemoglobin concentration as a threshold for transfusion (most commonly, 9.0 g/dL to 10.0 g/dL). SEARCH METHODS We identified trials through updated searches: CENTRAL (2020, Issue 11), MEDLINE (1946 to November 2020), Embase (1974 to November 2020), Transfusion Evidence Library (1950 to November 2020), Web of Science Conference Proceedings Citation Index (1990 to November 2020), and trial registries (November 2020). We checked the reference lists of other published reviews and relevant papers to identify additional trials. We were aware of one trial identified in earlier searching that was in the process of being published (in February 2021), and we were able to include it before this review was finalised. SELECTION CRITERIA We included randomised trials of surgical or medical participants that recruited adults or children, or both. We excluded studies that focused on neonates. Eligible trials assigned intervention groups on the basis of different transfusion schedules or thresholds or 'triggers'. These thresholds would be defined by a haemoglobin (Hb) or haematocrit (Hct) concentration below which an RBC transfusion would be administered; the haemoglobin concentration remains the most commonly applied marker of the need for RBC transfusion in clinical practice. We included trials in which investigators had allocated participants to higher thresholds or more liberal transfusion strategies compared to more restrictive ones, which might include no transfusion. As in previous versions of this review, we did not exclude unregistered trials published after 2010 (as per the policy of the Cochrane Injuries Group, 2015), however, we did conduct analyses to consider the differential impact of results of trials for which prospective registration could not be confirmed. DATA COLLECTION AND ANALYSIS: We identified trials for inclusion and extracted data using Cochrane methods. We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two review authors independently extracted data and assessed risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as being in the 'restrictive transfusion' group and those randomly allocated to the higher transfusion threshold as being in the 'liberal transfusion' group. MAIN RESULTS A total of 48 trials, involving data from 21,433 participants (at baseline), across a range of clinical contexts (e.g. orthopaedic, cardiac, or vascular surgery; critical care; acute blood loss (including gastrointestinal bleeding); acute coronary syndrome; cancer; leukaemia; haematological malignancies), met the eligibility criteria. The haemoglobin concentration used to define the restrictive transfusion group in most trials (36) was between 7.0 g/dL and 8.0 g/dL. Most trials included only adults; three trials focused on children. The included studies were generally at low risk of bias for key domains including allocation concealment and incomplete outcome data. Restrictive transfusion strategies reduced the risk of receiving at least one RBC transfusion by 41% across a broad range of clinical contexts (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.53 to 0.66; 42 studies, 20,057 participants; high-quality evidence), with a large amount of heterogeneity between trials (I² = 96%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.99, 95% CI 0.86 to 1.15; 31 studies, 16,729 participants; I² = 30%; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (all high-quality evidence)). High-quality evidence shows that the liberal transfusion threshold did not affect the risk of infection (pneumonia, wound infection, or bacteraemia). Transfusion-specific reactions are uncommon and were inconsistently reported within trials. We noted less certainty in the strength of evidence to support the safety of restrictive transfusion thresholds for the following predefined clinical subgroups: myocardial infarction, vascular surgery, haematological malignancies, and chronic bone-marrow disorders. AUTHORS' CONCLUSIONS Transfusion at a restrictive haemoglobin concentration decreased the proportion of people exposed to RBC transfusion by 41% across a broad range of clinical contexts. Across all trials, no evidence suggests that a restrictive transfusion strategy impacted 30-day mortality, mortality at other time points, or morbidity (i.e. cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. Despite including 17 more randomised trials (and 8846 participants), data remain insufficient to inform the safety of transfusion policies in important and selected clinical contexts, such as myocardial infarction, chronic cardiovascular disease, neurological injury or traumatic brain injury, stroke, thrombocytopenia, and cancer or haematological malignancies, including chronic bone marrow failure. Further work is needed to improve our understanding of outcomes other than mortality. Most trials compared only two separate thresholds for haemoglobin concentration, which may not identify the actual optimal threshold for transfusion in a particular patient. Haemoglobin concentration may not be the most informative marker of the need for transfusion in individual patients with different degrees of physiological adaptation to anaemia. Notwithstanding these issues, overall findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds between the range of 7.0 g/dL and 8.0 g/dL. Some patient subgroups might benefit from RBCs to maintain higher haemoglobin concentrations; research efforts should focus on these clinical contexts.
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Affiliation(s)
- Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Simon J Stanworth
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Jane A Dennis
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Nareg Roubinian
- Kaiser Permanente Division of Research Northern California, Oakland, California, USA
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Darrell Triulzi
- The Institute for Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Paul C Hébert
- Centre for Research, University of Montreal Hospital Research Centre, Montreal, Canada
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Tamai Y, Ohto H, Yasuda H, Takeshita A, Fujii N, Ogo H, Yazawa Y, Hato T, Mitani K, Suzuki K, Yokohama A, Kato Y, Abe M, Kumagawa M, Ueda Y, Nollet KE, Cooling L, Kitazawa J. Allo-anti-M: Detection peaks around 2 years of age, but may be attenuated by red blood cell transfusion. Transfusion 2021; 61:2718-2726. [PMID: 34287925 PMCID: PMC8518975 DOI: 10.1111/trf.16594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/14/2021] [Accepted: 06/25/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anti-M is frequently observed as a naturally occurring antibody of little clinical significance. Naturally occurring anti-M is often found in children although the specific triggers of production, persistence, and evanescence of anti-M have yet to be elucidated. METHODS In a retrospective, multicenter, nationwide cohort survey conducted from 2001 to 2015, alloantibody screening was performed before and after transfusion in 18,944 recipients younger than 20 years. Recipients were categorized into six cohorts based on their age at transfusion; within and among these cohorts, allo-anti-M was analyzed in regard to its production, persistence, and evanescence. RESULTS In 44 patients, anti-M detected before and/or after transfusion was an age-related phenomenon, with a median age of 2 years and an interquartile range of 1-3 years; anti-M was most frequently detected in a cohort of children 1 to <5 years (0.77%, 31 of 4035). At least five patients were presumed to have concurrent infections. Among 1575 adolescents/young adults (15 to <20 years), no anti-M was detected. Of 29 patients with anti-M prior to transfusion, the antibody fell to undetectable levels in 17 recipients (89.5%, of whom at least 13 received only M-negative red cells) after anywhere from 5 days to 5.8 years; anti-M persisted in 2, and was not tested in 10. Only 15 recipients (0.08%) produced new anti-M after transfusion. CONCLUSION Naturally occurring anti-M is a phenomenon of younger ages, predominantly between 1 and 3 years. After transfusion, it often falls to undetectable levels.
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Affiliation(s)
- Yoshiko Tamai
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Department of Transfusion and Cell Therapy MedicineHirosaki University Post‐Graduate School of MedicineHirosakiJapan
| | - Hitoshi Ohto
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Department of Blood Transfusion and Transplantation ImmunologyFukushima Medical UniversityFukushimaJapan
| | - Hiroyasu Yasuda
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Department of Medical TechnologyFukushima Prefectural Hygiene InstituteFukushimaJapan
| | - Akihiro Takeshita
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Department of Transfusion and Cell TherapyHamamatsu University School of MedicineHamamatsuJapan
| | - Nobuharu Fujii
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Division of Blood TransfusionOkayama University HospitalOkayamaJapan
| | - Hiroaki Ogo
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Division of Blood TransfusionOkayama University HospitalOkayamaJapan
| | - Yurika Yazawa
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Transfusion LaboratoryTokyo Metropolitan Children's Medical CenterTokyoJapan
| | - Takaaki Hato
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Division of Blood Transfusion and Cell TherapyEhime University HospitalToonJapan
| | - Kinuko Mitani
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Blood Transfusion DepartmentDokkyo Medical University HospitalShimotsuga‐gunJapan
| | - Keijiro Suzuki
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Division of Transfusion MedicineIwate Medical University HospitalMoriokaJapan
| | - Akihiko Yokohama
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Division of Blood Transfusion ServiceGunma University HospitalMaebashiJapan
| | - Yoko Kato
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Department of Transfusion Medicine and Cell TherapyThe Jikei University HospitalTokyoJapan
| | - Misao Abe
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Department of Transfusion Medicine and Cell TherapyKansai Medical University HospitalHirakataJapan
| | - Midori Kumagawa
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Division of Transfusion MedicineFukuoka University HospitalFukuokaJapan
| | - Yasunori Ueda
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Transfusion and Hemapheresis CenterKurashiki Central HospitalKurashikiJapan
| | - Kenneth E. Nollet
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Department of Blood Transfusion and Transplantation ImmunologyFukushima Medical UniversityFukushimaJapan
| | - Laura Cooling
- Department of PathologyThe University of MichiganAnn ArborMichiganUSA
| | - Junichi Kitazawa
- Japan Society of Blood Transfusion and Cell TherapyTokyoJapan
- Division of Clinical Laboratory and Department of Clinical GeneticsAomori Prefectural Central HospitalAomoriJapan
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Furumaki H, Takeshita A, Ohto H, Yamada C, Fujihara H, Ishizuka K, Shibata H, Shinba T, Nemoto N, Ino K, Ozawa A, Watanabe H, Kawabata K, Obata Y. A newly devised flow cytometric antibody binding assay helps evaluation of dithiothreitol treatment for the inactivation of CD38 on red blood cells. Vox Sang 2020; 116:725-734. [PMID: 33314130 DOI: 10.1111/vox.13052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/27/2020] [Accepted: 11/29/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Anti-CD38 monoclonal antibodies, including daratumumab and isatuximab, often interfere with pretransfusion testing. Dithiothreitol (DTT) treatment of red blood cells (RBCs) negates this interference. However, the optimum DTT concentration and treatment time have not been well defined. Here, we quantified CD38 on RBCs before and after DTT treatment using a flow cytometric antibody binding assay (FABA) to specify the optimum conditions for CD38 inactivation. MATERIALS AND METHODS For FABA, untreated or DTT-treated RBCs were incubated with fluorescein isothiocyanate-labelled anti-CD38 antibody, in the presence or absence of 100-fold or more excess of unlabelled anti-CD38 antibody, and then analysed by flow cytometry (FCM). Dissociation of CD38-positive and control histograms was determined from the D-value using the Kolmogorov-Smirnov test. The results from FABA were compared with those from conventional FCM, indirect antiglobulin test (IAT) and Western blotting. RESULTS The results from FABA were more consistent than those from conventional FCM. The D-value was found to be reliable in the analysis of difference between CD38 before and after DTT treatment. Our data showed that 0·0075 mol/l DTT for 30 min is sufficient to inactivate CD38 on RBCs. These results were stable and consistent with the findings from IAT. CONCLUSION Flow cytometric antibody binding assay is an objective way of evaluating the efficacy of DTT treatment for CD38 on RBCs. This approach allows the detection of a small number of cell surface antigens and will be useful for assessing the various chemical treatments to denature RBC antigens.
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Affiliation(s)
- Hiroaki Furumaki
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akihiro Takeshita
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hitoshi Ohto
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan
| | - Chiaki Yamada
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Harumi Fujihara
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Keiko Ishizuka
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroki Shibata
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takahito Shinba
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoki Nemoto
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kaede Ino
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akari Ozawa
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroko Watanabe
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kinuyo Kawabata
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan
| | - Yukako Obata
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Takeshita A, Watanabe H, Yamada C, Nadarajan VS, Permpikul P, Sinkitjasub A, Natalie CPH, Zhao S, Han KS, Kim DW, Suh JS, Kim HO, Kawabata K, Ishimaru K, Ohtomo N, Yamada N, Tomoda Y, Yurugi K, Ohto H. Erythrocyte Alloimmunity and Genetic Variance: Results from the Collaborative Study of Alloimmunity to Antigen Diversity in Asian Populations (All ADP). Transfus Apher Sci 2020; 59:102944. [PMID: 33228922 DOI: 10.1016/j.transci.2020.102944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
As an East-Asian international study, we evaluated erythrocyte alloimmunity by gender and history of transfusion or pregnancy. In total, data from more than 1,826,000 patients were analyzed, from whom 26,170 irregular erythrocyte antibodies were detected in 22,653 cases. Antibody frequencies in these cases were as follows: anti-E, 26.8%; anti-Lea, 20.0%; anti-P1, 7.1%; anti-M, 6.4%; anti-Mia, 5.6%; anti-c + E, 5.6%; anti-Leb, 4.6%; anti-D, 2.8%; anti-Fyb, 2.6%; anti-Lea+Leb, 2.5%; anti-Dia, 2.0%; and others. For pregnant patients, anti-D (12.7%) was statistically more frequent. For transfused patients, anti-E (37.3%), anti-c + E (9.5%), anti-C + e (3.3%) and anti-Jka (3.1%) were significantly more frequent.
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Affiliation(s)
- Akihiro Takeshita
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan.
| | - Hiroko Watanabe
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Chiaki Yamada
- Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | | | - Parichart Permpikul
- Transfusion Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Attapong Sinkitjasub
- Blood Bank, Taksin Hospital, Medical Service Department of Bangkok Metropolitan, Bangkok, Thailand
| | - Chan Pui Ha Natalie
- Blood Bank, Prince of Wales Hospital, Hong Kong Special Administrative Region
| | - Shuming Zhao
- Transfusion Medicine, Southwest Hospital, Third Military Medical University, Chongqing, China
| | | | - Dae Won Kim
- Laboratory Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Soul, South Korea
| | - Jang Soo Suh
- Laboratory Medicine, Kyungpook National University Hospital, Kyungpook National University, School of Medicine, Daegu, South Korea
| | - Hyun Ok Kim
- Laboratory Medicine, Yonsei University College of Medicine, Soul, South Korea
| | - Kinuyo Kawabata
- Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan
| | - Ken Ishimaru
- Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
| | - Naoki Ohtomo
- Center for Transfusion Medicine and Cell Therapy, Tokyo Medical and Dental University, Tokyo, Japan
| | - Naotomo Yamada
- Department of Transfusion Medicine, Saga University, Saga, Japan
| | - Yutaka Tomoda
- Laboratory Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kimiko Yurugi
- Clinical Laboratory, Kyoto University Hospital, Kyoto, Japan
| | - Hitoshi Ohto
- Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
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