Letter to editor: an observational study of red cell transfusion in specialist palliative care

Home transfusions are implemented using diverse approaches in Japan

BACKGROUND AND OBJECTIVES

Japan's ageing society has increased the need for home healthcare, including home transfusions. We hence aimed to elucidate the purpose and utilization of home transfusions in Japan, which has not been clarified to date.

MATERIALS AND METHODS

Clinics throughout Japan that provide home care and have experience in performing blood transfusions were surveyed. The study period was February to December 2019, and information of patients receiving home red blood cell transfusions, including patient background, pre-transfusion laboratory data and the purpose of the transfusions, was collected.

RESULTS

Haematological malignancies and solid tumours accounted for 70% of the patients' underlying diseases, with the former being significantly more common in urban areas. Regarding the purpose of the home transfusions, haematologists focused on symptom improvement, whereas gastroenterology surgeons focused on life support. Furthermore, maintenance of life was more likely to be the aim in the group of patients with the lowest level of activities of daily living. The main items that were significantly associated with a low haemoglobin level before transfusion included age ≥90 years and a gastroenterologist being the physician in charge.

CONCLUSION

Home transfusions were found to be performed in a restrictive and diverse manner in Japan. Life support is the second most common purpose of home transfusion in Japan, and optimizing effective home transfusion remains a challenge.

Red blood cell transfusion and associated outcomes in patients referred for palliative care: A retrospective cohort study

BACKGROUND

We aim to describe the occurrence of red blood cell transfusion and associated predictive factors and outcomes among patients referred for palliative care.

STUDY DESIGN AND METHODS

This retrospective cohort study used linked health administrative data of adults referred for palliative care at an academic hospital from 2014 to 2018. Multivariable regression models were employed to evaluate patient characteristics associated with transfusion and the relationship between transfusion status and location of death. Survival analyses were performed using log-rank tests and Cox proportional hazards modeling.

RESULTS

Of 6980 evaluated patients, 885 (12.7%) were transfused following palliative care consultation. Covariate factors associated with transfusion included younger age, higher performance status, lower baseline hemoglobin, and a diagnosis of hematologic malignancy (OR = 2.97, 95% CI 2.20-4.01) or solid organ tumor (OR = 1.37, 95% CI 1.10-1.71) vs. noncancer diagnosis. Median survival from palliative care consultation was 19 (IQR 5-75) days; 83 (32-305) days in those transfused and 15 (4-57) days in the nontransfused group (p < .0001). Median survival following transfusion was 56 (19-200) days. Solid organ tumor diagnosis was independently associated with poor survival (HR = 1.7, 95% CI 1.39-2.09 vs. non-cancer diagnosis). Among individuals who survived ≥30 days, transfusion was associated with a higher likelihood of death in hospital (OR = 2.15, 95% CI 1.71-2.70 vs. home/subacute setting).

DISCUSSION

Transfusions commonly occurred in patients receiving palliative care, associated with cancer diagnoses and favorable baseline prognostic factors. Poor survival following transfusion, particularly in solid organ tumor patients, and the twofold likelihood of death in hospital associated with this intervention have important implications in prescribing transfusion for this population.

Transfusion practices at end of life for hematopoietic stem cell transplant patients

PURPOSE

Limited data exist regarding transfusion practices at end of life (EOL) for hematopoietic stem cell transplant (HSCT) patients. The purpose of this study was to examine red blood cell (RBC) and platelet transfusion practices in HSCT patients who enrolled or did not enroll in hospice.

METHODS

This was a single-center, retrospective chart review in deceased HSCT patients. The primary objective was to determine the mean difference between the last transfusion and death in HSCT patients (n = 116) who enrolled or did not enroll in hospice.

RESULTS

Sixteen (14%) and 100 (86%) patients were enrolled in hospice and not enrolled in hospice, respectively. Hospice patients observed a larger mean difference between death and last transfusion (45.9 ± 66.7 vs. 14.6 ± 48.1 days, p < 0.0001). A higher amount of platelet, but not RBC, transfusions occurred in patients not enrolled in hospice (p = 0.04). The last transfusion that occurred more than 96 h before death was observed in 12 (75%) and 22 (22%) in hospice and non-hospice patients, respectively. For HSCT patients not enrolled in hospice, 17 patients received a transfusion on the same day of death and 31 patients received the last transfusion 24 h before death.

CONCLUSIONS

Blood transfusion practices differed in HSCT patients enrolled and not enrolled in hospice. For most patients not enrolled in hospice, the last transfusion occurred 24 h before death. Future efforts should explore if limited access to blood products is a barrier to hospice enrollment for HSCT patients.

Blood transfusions for anaemia in patients with advanced cancer

BACKGROUND

Anaemia occurs in 68% to 77% of patients with advanced cancer, however, only a minority of patients who are admitted to a hospice receive a blood transfusion. It is unclear what the benefit of blood transfusion is in advanced cancer, who is most likely to respond and also for how long. Hence we conducted a systematic review to assess the use of blood transfusion in advanced cancer.

OBJECTIVES

To synthesise the existing clinical evidence and summarise knowledge gaps regarding blood transfusions for treating anaemia in patients with advanced cancer.

SEARCH METHODS

We searched MEDLINE, EMBASE, CINAHL, Web of Science, ZETOC and CENTRAL in November 2011. In addition, we checked and citation-tracked the reference lists of all relevant studies and reports. We contacted investigators who were known to be researching this area for unpublished data or knowledge of the grey literature.

SELECTION CRITERIA

Randomised controlled trials (RCTs), before and after studies and interrupted time series (ITS) studies in adults and children, reporting the outcome of blood transfusions in advanced cancer.

DATA COLLECTION AND ANALYSIS

Two independent (NP and AH) review authors extracted data and quality scored studies. There were insufficient data to carry out an analysis.

MAIN RESULTS

No RCTs were found. We identified 12 before and after studies which included 653 participants and showed a subjective response rate of 31% to 70%. Five studies specifically assessed response using a range of fatigue scales which indicated an early response post transfusion, which was beginning to wane by day 14. Similar results were found for breathlessness. Overall survival ranged from two to 293 days but there was a significant proportion of participants (23% to 35%) who died within two weeks of their transfusion.

AUTHORS' CONCLUSIONS

Higher-quality studies are required to determine the effectiveness of blood transfusion at the end of life and, in particular, to determine which patients are most likely to respond and which are not, and the duration of any response. Potential harms of blood transfusion at the end of life (indicated by high 14-day mortality) need to be distinguished from inappropriate transfusion in patients who are dying from advanced cancer.

Assessment of fatigue after blood transfusion in palliative care patients: a feasibility study

BACKGROUND

Blood transfusions are often used as a potential treatment for cancer-related fatigue in anaemic palliative care patients. However, evidence of benefit using validated outcomes measures is lacking.

AIM

The aim of this study was to test the feasibility of using two such tools; the Brief Fatigue Inventory and FACT F-fatigue subscale, to measure change in fatigue following a blood transfusion.

METHOD

Anemic cancer patients receiving specialist palliative care and undergoing transfusion for fatigue, completed the tools pre- and 3 days post-transfusion.

RESULTS

Thirty patients with cancer-related fatigue who received a blood transfusion completed the study. Both measures were capable of detecting statistical and clinically significant change in fatigue following transfusion. Furthermore, the measures showed significant differences between patients that did, or did not, report an overall improvement in fatigue. Patients found the measures easy to complete with no preference for one over another. Future clinical trials of blood transfusion for the management of fatigue should incorporate these validated outcome measures.