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Kulasekararaj A, Cavenagh J, Dokal I, Foukaneli T, Gandhi S, Garg M, Griffin M, Hillmen P, Ireland R, Killick S, Mansour S, Mufti G, Potter V, Snowden J, Stanworth S, Zuha R, Marsh J. Guidelines for the diagnosis and management of adult aplastic anaemia: A British Society for Haematology Guideline. Br J Haematol 2024; 204:784-804. [PMID: 38247114 DOI: 10.1111/bjh.19236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/26/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024]
Abstract
Pancytopenia with hypocellular bone marrow is the hallmark of aplastic anaemia (AA) and the diagnosis is confirmed after careful evaluation, following exclusion of alternate diagnosis including hypoplastic myelodysplastic syndromes. Emerging use of molecular cyto-genomics is helpful in delineating immune mediated AA from inherited bone marrow failures (IBMF). Camitta criteria is used to assess disease severity, which along with age and availability of human leucocyte antigen compatible donor are determinants for therapeutic decisions. Supportive care with blood and platelet transfusion support, along with anti-microbial prophylaxis and prompt management of opportunistic infections remain key throughout the disease course. The standard first-line treatment for newly diagnosed acquired severe/very severe AA patients is horse anti-thymocyte globulin and ciclosporin-based immunosuppressive therapy (IST) with eltrombopag or allogeneic haemopoietic stem cell transplant (HSCT) from a matched sibling donor. Unrelated donor HSCT in adults should be considered after lack of response to IST, and up front for young adults with severe infections and a readily available matched unrelated donor. Management of IBMF, AA in pregnancy and in elderly require special attention. In view of the rarity of AA and complexity of management, appropriate discussion in multidisciplinary meetings and involvement of expert centres is strongly recommended to improve patient outcomes.
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Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Jamie Cavenagh
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Inderjeet Dokal
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, UK
| | - Theodora Foukaneli
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NHS Blood and Transplant, Bristol, UK
| | - Shreyans Gandhi
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
- British Society Haematology Task Force Representative, London, UK
| | | | | | - Robin Ireland
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Sally Killick
- University Hospitals Dorset NHS Foundation Trust, The Royal Bournemouth Hospital, Bournemouth, UK
| | - Sahar Mansour
- St George's Hospital/St George's University of London, London, UK
| | - Ghulam Mufti
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Victoria Potter
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - John Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon 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 and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Roslin Zuha
- James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, England
| | - Judith Marsh
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
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2
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Killick SB, Ingram W, Culligan D, Enright H, Kell J, Payne EM, Krishnamurthy P, Kulasekararaj A, Raghavan M, Stanworth SJ, Green S, Mufti G, Quek L, Cargo C, Jones GL, Mills J, Sternberg A, Wiseman DH, Bowen D. British Society for Haematology guidelines for the management of adult myelodysplastic syndromes. Br J Haematol 2021; 194:267-281. [PMID: 34180045 DOI: 10.1111/bjh.17612] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Sally B Killick
- University Hospitals Dorset NHS Foundation Trust, The Royal Bournemouth Hospital, Bournemouth, UK
| | | | | | - Helen Enright
- Tallaght University Hospital, Dublin, Trinity College Medical School, Tallaght, UK
| | | | | | | | | | - Manoj Raghavan
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon J Stanworth
- Oxford University, Oxford University Hospitals NHS Trust & NHS Blood and Transplant, Oxford, UK
| | - Simone Green
- Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Ghulam Mufti
- Kings College Hospital NHS Foundation Trust, London, UK
| | - Lynn Quek
- Kings College Hospital NHS Foundation Trust, London, UK
| | - Catherine Cargo
- St.James's Institute of Oncology, Leeds Teaching Hospitals, Leeds, UK
| | - Gail L Jones
- Newcastle Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Juliet Mills
- Worcestershire Acute Hospitals NHS Trust and Birmingham NHS Foundation Trust, Worcester, UK
| | - Alex Sternberg
- Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | | | - David Bowen
- St.James's Institute of Oncology, Leeds Teaching Hospitals, Leeds, UK
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3
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Cornelissen LL, Caram-Deelder C, Meier RT, Zwaginga JJ, Evers D. Platelet transfusion and tranexamic acid to prevent bleeding in outpatients with a hematological disease: A Dutch nationwide survey. Eur J Haematol 2020; 106:362-370. [PMID: 33226659 PMCID: PMC7898625 DOI: 10.1111/ejh.13555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/19/2020] [Accepted: 11/19/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES There is scarce evidence about the effectiveness of anti-bleeding measures in hematological outpatients experiencing persistent severe thrombocytopenia. We aim to describe clinical practice and clinicians' considerations on the administration of prophylactic platelet transfusions and tranexamic acid (TXA) to outpatients with acute leukemia, myelodysplastic syndrome (MDS), or aplastic anemia (AA) in the Netherlands. METHODS We conducted an online survey among members of the Dutch Society for Hematology. RESULTS The survey was filled out by 73 respondents. Prophylactic platelet transfusions are widely used in acute leukemia and MDS outpatients receiving disease-modifying treatments (87%-98% of respondents). TXA is predominantly prescribed in case of bleeding (tendency) (71%-88% of respondents). Conditions potentially increasing bleeding risks highly variably influence clinicians' decision making on anti-bleeding regimens, which includes a wide range in adhered platelet thresholds. CONCLUSION Considering that both the contribution of prophylactic platelet transfusions as well as TXA to limiting bleeding is insufficiently evidence-based, there is an urgent need for trials on optimal anti-bleeding strategies in this outpatient population, which should encompass efficacy, logistic, financial, and quality-of-life aspects.
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Affiliation(s)
- Loes L Cornelissen
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin/LUMC, Leiden, The Netherlands.,Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Camila Caram-Deelder
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin/LUMC, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Romy T Meier
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin/LUMC, Leiden, The Netherlands.,Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap Jan Zwaginga
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin/LUMC, Leiden, The Netherlands.,Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dorothea Evers
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
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4
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Takami A, Matsushita T, Ogata M, Fujii N, Kubuki Y, Fujiwara S, Matsumoto M, Tomiyama Y. GUIDELINE FOR THE USE OF PLATELET TRANSFUSION CONCENTRATES BASED ON SCIENTIFIC EVIDENCE: UPDATE 2019. ACTA ACUST UNITED AC 2019. [DOI: 10.3925/jjtc.65.544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Akiyoshi Takami
- Division of Hematology, Department of Internal Medicine, Aichi Medical University School of Medicine
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
| | | | - Masao Ogata
- Blood Transfusion Center, Oita University Hospital
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
| | - Nobuharu Fujii
- Division of Transfusion, Okayama University Hospital
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
| | - Yoko Kubuki
- Department of Transfusion and Cell Therapy, University of Miyazaki Hospital
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
| | - Shinichiro Fujiwara
- Division of Hematology, Department of Medicine, Jichi Medical University
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
| | | | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
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5
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Malouf R, Ashraf A, Hadjinicolaou AV, Doree C, Hopewell S, Estcourt LJ. Comparison of a therapeutic-only versus prophylactic platelet transfusion policy for people with congenital or acquired bone marrow failure disorders. Cochrane Database Syst Rev 2018; 5:CD012342. [PMID: 29758592 PMCID: PMC5985156 DOI: 10.1002/14651858.cd012342.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Bone marrow disorders encompass a group of diseases characterised by reduced production of red cells, white cells, and platelets, or defects in their function, or both. The most common bone marrow disorder is myelodysplastic syndrome. Thrombocytopenia, a low platelet count, commonly occurs in people with bone marrow failure. Platetet transfusions are routinely used in people with thrombocytopenia secondary to bone marrow failure disorders to treat or prevent bleeding. Myelodysplastic syndrome is currently the most common reason for receiving a platelet transfusion in some Western countries. OBJECTIVES To determine whether a therapeutic-only platelet transfusion policy (transfusion given when patient is bleeding) is as effective and safe as a prophylactic platelet transfusion policy (transfusion given to prevent bleeding according to a prespecified platelet threshold) in people with congenital or acquired bone marrow failure disorders. SEARCH METHODS We searched for randomised controlled trials (RCTs), non-RCTs, and controlled before-after studies (CBAs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2017, Issue 9), Ovid MEDLINE (from 1946), Ovid Embase (from 1974), PubMed (e-publications only), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 12 October 2017. SELECTION CRITERIA We included RCTs, non-RCTs, and CBAs that involved the transfusion of platelet concentrates (prepared either from individual units of whole blood or by apheresis any dose, frequency, or transfusion trigger) and given to treat or prevent bleeding among people with congenital or acquired bone marrow failure disorders.We excluded uncontrolled studies, cross-sectional studies, and case-control studies. We excluded cluster-RCTs, non-randomised cluster trials, and CBAs with fewer than two intervention sites and two control sites due to the risk of confounding. We included all people with long-term bone marrow failure disorders that require platelet transfusions, including neonates. We excluded studies of alternatives to platelet transfusion, or studies of people receiving intensive chemotherapy or a stem cell transplant. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures outlined by Cochrane. Due to the absence of evidence we were unable to report on any of the review outcomes. MAIN RESULTS We identified one RCT that met the inclusion criteria for this review. The study enrolled only nine adults with MDS over a three-year study duration period. The trial was terminated due to poor recruitment rate (planned recruitment 60 participants over two years). Assessment of the risk of bias was not possible for all domains. The trial was a single-centre, single-blind trial. The clinical and demographic characteristics of the participants were never disclosed. The trial outcomes relevant to this review were bleeding assessments, mortality, quality of life, and length of hospital stay, but no data were available to report on any of these outcomes.We identified no completed non-RCTs or CBAs.We identified no ongoing RCTs, non-RCTs, or CBAs. AUTHORS' CONCLUSIONS We found no evidence to determine the safety and efficacy of therapeutic platelet transfusion compared with prophylactic platelet transfusion for people with long-term bone marrow failure disorders. This review underscores the urgency of prioritising research in this area. People with bone marrow failure depend on long-term platelet transfusion support, but the only trial that assessed a therapeutic strategy was halted. There is a need for good-quality studies comparing a therapeutic platelet transfusion strategy with a prophylactic platelet transfusion strategy; such trials should include outcomes that are important to patients, such as quality of life, length of hospital admission, and risk of bleeding.
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Affiliation(s)
- Reem Malouf
- University of OxfordNational Perinatal Epidemiology Unit (NPEU)Old Road CampusOxfordUKOX3 7LF
| | - Asma Ashraf
- Calvary Mater Hospital; University of NewcastleHaematologyCrn Edith street & Platt streetLevel 4 New Medical buildingWaratahNSWAustralia2298
| | - Andreas V Hadjinicolaou
- University of OxfordHuman Immunology Unit, Institute of Molecular Medicine, Radcliffe Department of MedicineMerton College, Merton StreetOxfordUKOX1 4JD
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Sally Hopewell
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
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6
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Karafin MS, Bruhn R, Westlake M, Sullivan MT, Bialkowski W, Edgren G, Roubinian NH, Hauser RG, Kor DJ, Fleischmann D, Gottschall JL, Murphy EL, Triulzi DJ. Demographic and epidemiologic characterization of transfusion recipients from four US regions: evidence from the REDS-III recipient database. Transfusion 2017; 57:2903-2913. [PMID: 29067705 DOI: 10.1111/trf.14370] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Blood transfusion is one of the most common medical procedures during hospitalization in the United States. To understand the benefits of transfusion while mitigating potential risks, a multicenter database containing detailed information on transfusion incidence and recipient outcomes would facilitate research. STUDY DESIGN AND METHODS The Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) program has developed a comprehensive transfusion recipient database utilizing data from hospital electronic health records at 12 participating hospitals in four geographic regions. Inpatient and outpatient data on transfusion recipients from January 1, 2013 to December 31, 2014 included patient age, sex, ethnicity, primary diagnosis, type of blood product provided, issue location, pretransfusion and post-transfusion hemoglobin (Hgb), and hospital outcomes. Transfusion incidence per encounter was calculated by blood product and various patient characteristics. RESULTS During the 2-year study period, 80,362 (12.5%) inpatient encounters involved transfusion. Among inpatients, the most commonly transfused blood products were red blood cells (RBCs; 10.9% of encounters), followed by platelets (3.2%) and plasma (2.9%). Among patients who received transfusions, the median number of RBC units was one, the pretransfusion Hgb level was 7.6 g/dL, and the Hgb increment per unit was 1.4 g/dL. Encounter mortality increased with patient age, the number of units transfused, and the use of platelet or plasma products. The most commonly reported transfusion reaction was febrile nonhemolytic. CONCLUSION The database contains comprehensive data regarding transfusion use and patient outcomes. The current report describes an evaluation of the first 2 years of a planned, 4-year, linked blood donor-component-recipient database, which represents a critical new resource for transfusion medicine researchers.
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Affiliation(s)
| | - Roberta Bruhn
- Blood Systems Research Institute, University of California San Francisco, San Francisco, California
| | - Matt Westlake
- RTI International, Rockville, Maryland.,RTI International, Research Triangle, North Carolina
| | - Marian T Sullivan
- RTI International, Rockville, Maryland.,RTI International, Research Triangle, North Carolina
| | | | - Gustaf Edgren
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Nareg H Roubinian
- Blood Systems Research Institute, University of California San Francisco, San Francisco, California
| | - Ronald G Hauser
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Debra Fleischmann
- RTI International, Rockville, Maryland.,RTI International, Research Triangle, North Carolina
| | | | - Edward L Murphy
- Blood Systems Research Institute, University of California San Francisco, San Francisco, California
| | - Darrell J Triulzi
- The Institute for Transfusion Medicine (ITXM) and University of Pittsburgh, Pittsburgh, Pennsylvania
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7
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Yan M, Lin Y, Callum J. British Committee for Standards in Haematology guidelines for aplastic anaemia: single centre retrospective review finds no compelling evidence for the recommended higher platelet count threshold of 20 × 10 9 /l. Br J Haematol 2017; 182:284-286. [PMID: 28677840 DOI: 10.1111/bjh.14767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Matthew Yan
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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8
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Estcourt LJ, Birchall J, Allard S, Bassey SJ, Hersey P, Kerr JP, Mumford AD, Stanworth SJ, Tinegate H. Guidelines for the use of platelet transfusions. Br J Haematol 2016; 176:365-394. [DOI: 10.1111/bjh.14423] [Citation(s) in RCA: 266] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Lise J. Estcourt
- NHSBT and Radcliffe Department of Medicine; University of Oxford; Oxford UK
| | - Janet Birchall
- NHSBT and Department of Haematology; North Bristol NHS Trust; Bristol UK
| | - Shubha Allard
- NHSBT and Department of Haematology; Royal London Hospital; London UK
| | - Stephen J. Bassey
- Department of Haematology; Royal Cornwall Hospital Trust; Cornwall UK
| | - Peter Hersey
- Department of Critical Care Medicine & Anaesthesia; City Hospitals Sunderland NHS Foundation Trust; Sunderland UK
| | - Jonathan Paul Kerr
- Department of Haematology; Royal Devon & Exeter NHS Foundation Trust; Exeter UK
| | - Andrew D. Mumford
- School of Cellular and Molecular Medicine; University of Bristol; Bristol UK
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9
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Ashraf A, Hadjinicolaou AV, Doree C, Hopewell S, Trivella M, Estcourt LJ. Comparison of a therapeutic-only versus prophylactic platelet transfusion policy for people with congenital or acquired bone marrow failure disorders. Cochrane Database Syst Rev 2016; 2016:CD012342. [PMID: 27660553 PMCID: PMC5027963 DOI: 10.1002/14651858.cd012342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This is the protocol for a review and there is no abstract. The objectives are as follows: To compare a therapeutic-only versus prophylactic platelet transfusion policy for people with myelodysplasia, inherited or acquired aplastic anaemia, and other congenital bone marrow failure disorders.
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Affiliation(s)
- Asma Ashraf
- Calvary Mater Hospital; University of NewcastleHaematologyCrn Edith street & Platt streetLevel 4 New Medical buildingWaratahAustralia2298
| | - Andreas V Hadjinicolaou
- University of OxfordHuman Immunology Unit, Institute of Molecular Medicine, Radcliffe Department of MedicineMerton College, Merton StreetOxfordUKOX1 4JD
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Sally Hopewell
- University of OxfordOxford Clinical Trials Research UnitNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesWindmill RoadOxfordUKOX3 7LD
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
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10
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Crighton GL, Estcourt LJ, Wood EM, Stanworth SJ. Platelet Transfusions in Patients with Hypoproliferative Thrombocytopenia. Hematol Oncol Clin North Am 2016; 30:541-60. [DOI: 10.1016/j.hoc.2016.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Estcourt LJ, Stanworth SJ, Doree C, Hopewell S, Trivella M, Murphy MF. Comparison of different platelet count thresholds to guide administration of prophylactic platelet transfusion for preventing bleeding in people with haematological disorders after myelosuppressive chemotherapy or stem cell transplantation. Cochrane Database Syst Rev 2015; 2015:CD010983. [PMID: 26576687 PMCID: PMC4717525 DOI: 10.1002/14651858.cd010983.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Platelet transfusions are used in modern clinical practice to prevent and treat bleeding in people who are thrombocytopenic due to bone marrow failure. Although considerable advances have been made in platelet transfusion therapy in the last 40 years, some areas continue to provoke debate, especially concerning the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding.This is an update of a Cochrane review first published in 2004, and previously updated in 2012 that addressed four separate questions: prophylactic versus therapeutic-only platelet transfusion policy; prophylactic platelet transfusion threshold; prophylactic platelet transfusion dose; and platelet transfusions compared to alternative treatments. This review has now been split into four smaller reviews looking at these questions individually; this review compares prophylactic platelet transfusion thresholds. OBJECTIVES To determine whether different platelet transfusion thresholds for administration of prophylactic platelet transfusions (platelet transfusions given to prevent bleeding) affect the efficacy and safety of prophylactic platelet transfusions in preventing bleeding in people with haematological disorders undergoing myelosuppressive chemotherapy or haematopoietic stem cell transplantation (HSCT). SEARCH METHODS We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2015, Issue 6, 23 July 2015), MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1937), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 23 July 2015. SELECTION CRITERIA We included RCTs involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people with haematological disorders (receiving myelosuppressive chemotherapy or undergoing HSCT) that compared different thresholds for administration of prophylactic platelet transfusions (low trigger (5 x 10(9)/L); standard trigger (10 x 10(9)/L); higher trigger (20 x 10(9)/L, 30 x 10(9)/L, 50 x 10(9)/L); or alternative platelet trigger (for example platelet mass)). DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS Three trials met our predefined inclusion criteria and were included for analysis in the review (499 participants). All three trials compared a standard trigger (10 x 10(9)/L) versus a higher trigger (20 x 10(9)/L or 30 x 10(9)/L). None of the trials compared a low trigger versus a standard trigger or an alternative platelet trigger. The trials were conducted between 1991 and 2001 and enrolled participants from fairly comparable patient populations.The original review contained four trials (658 participants); in the previous update of this review we excluded one trial (159 participants) because fewer than 80% of participants had a haematological disorder. We identified no new trials in this update of the review.Overall, the methodological quality of the studies was low across different outcomes according to GRADE methodology. None of the included studies were at low risk of bias in every domain, and all the included studies had some threats to validity.Three studies reported the number of participants with at least one clinically significant bleeding episode within 30 days from the start of the study. There was no evidence of a difference in the number of participants with a clinically significant bleeding episode between the standard and higher trigger groups (three studies; 499 participants; risk ratio (RR) 1.35, 95% confidence interval (CI) 0.95 to 1.90; low-quality evidence).One study reported the number of days with a clinically significant bleeding event (adjusted for repeated measures). There was no evidence of a difference in the number of days of bleeding per participant between the standard and higher trigger groups (one study; 255 participants; relative proportion of days with World Health Organization Grade 2 or worse bleeding (RR 1.71, 95% CI 0.84 to 3.48, P = 0.162; authors' own results; low-quality evidence).Two studies reported the number of participants with severe or life-threatening bleeding. There was no evidence of any difference in the number of participants with severe or life-threatening bleeding between a standard trigger level and a higher trigger level (two studies; 421 participants; RR 0.99, 95% CI 0.52 to 1.88; low-quality evidence).Only one study reported the time to first bleeding episode. There was no evidence of any difference in the time to the first bleeding episode between a standard trigger level and a higher trigger level (one study; 255 participants; hazard ratio 1.11, 95% CI 0.64 to 1.91; low-quality evidence).Only one study reported on all-cause mortality within 30 days from the start of the study. There was no evidence of any difference in all-cause mortality between standard and higher trigger groups (one study; 255 participants; RR 1.78, 95% CI 0.83 to 3.81; low-quality evidence).Three studies reported on the number of platelet transfusions per participant. Two studies reported on the mean number of platelet transfusions per participant. There was a significant reduction in the number of platelet transfusions per participant in the standard trigger group (two studies, mean difference -2.09, 95% CI -3.20 to -0.99; low-quality evidence).One study reported on the number of transfusion reactions. There was no evidence to demonstrate any difference in transfusion reactions between the standard and higher trigger groups (one study; 79 participants; RR 0.07, 95% CI 0.00 to 1.09).None of the studies reported on quality of life. AUTHORS' CONCLUSIONS In people with haematological disorders who are thrombocytopenic due to myelosuppressive chemotherapy or HSCT, we found low-quality evidence that a standard trigger level (10 x 10(9)/L) is associated with no increase in the risk of bleeding when compared to a higher trigger level (20 x 10(9)/L or 30 x 10(9)/L). There was low-quality evidence that a standard trigger level is associated with a decreased number of transfusion episodes when compared to a higher trigger level (20 x 10(9)/L or 30 x 10(9)/L).Findings from this review were based on three studies and 499 participants. Without further evidence, it is reasonable to continue with the current practice of administering prophylactic platelet transfusions using the standard trigger level (10 x 10(9)/L) in the absence of other risk factors for bleeding.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and the University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Sally Hopewell
- University of OxfordCentre for Statistics in MedicineWolfson CollegeLinton RoadOxfordOxfordshireUKOX2 6UD
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineWolfson CollegeLinton RoadOxfordOxfordshireUKOX2 6UD
| | - Michael F Murphy
- Oxford University Hospitals and the University of OxfordNHS Blood and Transplant; National Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe HospitalHeadingtonOxfordUK
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Killick SB, Bown N, Cavenagh J, Dokal I, Foukaneli T, Hill A, Hillmen P, Ireland R, Kulasekararaj A, Mufti G, Snowden JA, Samarasinghe S, Wood A, Marsh JCW. Guidelines for the diagnosis and management of adult aplastic anaemia. Br J Haematol 2015; 172:187-207. [PMID: 26568159 DOI: 10.1111/bjh.13853] [Citation(s) in RCA: 470] [Impact Index Per Article: 52.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Sally B Killick
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
| | - Nick Bown
- Northern Genetics Service, Newcastle upon Tyne, UK
| | - Jamie Cavenagh
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Inderjeet Dokal
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, UK
| | | | | | | | - Robin Ireland
- Kings College Hospital NHS Foundation Trust, London, UK
| | | | - Ghulam Mufti
- Kings College Hospital NHS Foundation Trust, London, UK
| | - John A Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Anna Wood
- West Hertfordshire NHS Trust, Watford, UK
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Estcourt LJ, Stanworth S, Doree C, Trivella M, Hopewell S, Blanco P, Murphy MF. Different doses of prophylactic platelet transfusion for preventing bleeding in people with haematological disorders after myelosuppressive chemotherapy or stem cell transplantation. Cochrane Database Syst Rev 2015; 2015:CD010984. [PMID: 26505729 PMCID: PMC4724938 DOI: 10.1002/14651858.cd010984.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Platelet transfusions are used in modern clinical practice to prevent and treat bleeding in people who are thrombocytopenic due to bone marrow failure. Although considerable advances have been made in platelet transfusion therapy in the last 40 years, some areas continue to provoke debate, especially concerning the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding.This is an update of a Cochrane review first published in 2004, and updated in 2012 that addressed four separate questions: prophylactic versus therapeutic-only platelet transfusion policy; prophylactic platelet transfusion threshold; prophylactic platelet transfusion dose; and platelet transfusions compared to alternative treatments. This review has now been split into four smaller reviews; this review compares different platelet transfusion doses. OBJECTIVES To determine whether different doses of prophylactic platelet transfusions (platelet transfusions given to prevent bleeding) affect their efficacy and safety in preventing bleeding in people with haematological disorders undergoing myelosuppressive chemotherapy with or without haematopoietic stem cell transplantation (HSCT). SEARCH METHODS We searched for randomised controlled trials in the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2015, Issue 6), MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1937), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 23 July 2015. SELECTION CRITERIA Randomised controlled trials involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people with malignant haematological disorders or undergoing HSCT that compared different platelet component doses (low dose 1.1 x 10(11)/m(2) ± 25%, standard dose 2.2 x 10(11)/m(2) ± 25%, high dose 4.4 x 10(11)/m(2) ± 25%). DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We included seven trials (1814 participants) in this review; six were conducted during one course of treatment (chemotherapy or HSCT).Overall the methodological quality of studies was low to moderate across different outcomes according to GRADE methodology. None of the included studies were at low risk of bias in every domain, and all the included studies had some threats to validity.Five studies reported the number of participants with at least one clinically significant bleeding episode within 30 days from the start of the study. There was no difference in the number of participants with a clinically significant bleeding episode between the low-dose and standard-dose groups (four studies; 1170 participants; risk ratio (RR) 1.04, 95% confidence interval (CI) 0.95 to 1.13; moderate-quality evidence); low-dose and high-dose groups (one study; 849 participants; RR 1.02, 95% CI 0.93 to 1.11; moderate-quality evidence); or high-dose and standard-dose groups (two studies; 951 participants; RR 1.02, 95% CI 0.93 to 1.11; moderate-quality evidence).Three studies reported the number of days with a clinically significant bleeding event per participant. There was no difference in the number of days of bleeding per participant between the low-dose and standard-dose groups (two studies; 230 participants; mean difference -0.17, 95% CI -0.51 to 0.17; low quality evidence). One study (855 participants) showed no difference in the number of days of bleeding per participant between high-dose and standard-dose groups, or between low-dose and high-dose groups (849 participants).Three studies reported the number of participants with severe or life-threatening bleeding. There was no difference in the number of participants with severe or life-threatening bleeding between a low-dose and a standard-dose platelet transfusion policy (three studies; 1059 participants; RR 1.33, 95% CI 0.91 to 1.92; low-quality evidence); low-dose and high-dose groups (one study; 849 participants; RR 1.20, 95% CI 0.82 to 1.77; low-quality evidence); or high-dose and standard-dose groups (one study; 855 participants; RR 1.11, 95% CI 0.73 to 1.68; low-quality evidence).Two studies reported the time to first bleeding episodes; we were unable to perform a meta-analysis. Both studies (959 participants) individually found that the time to first bleeding episode was either the same, or longer, in the low-dose group compared to the standard-dose group. One study (855 participants) found that the time to the first bleeding episode was the same in the high-dose group compared to the standard-dose group.Three studies reported all-cause mortality within 30 days from the start of the study. There was no difference in all-cause mortality between treatment arms (low-dose versus standard-dose: three studies; 1070 participants; RR 2.04, 95% CI 0.70 to 5.93; low-quality evidence; low-dose versus high-dose: one study; 849 participants; RR 1.33, 95% CI 0.50 to 3.54; low-quality evidence; and high-dose versus standard-dose: one study; 855 participants; RR 1.71, 95% CI 0.51 to 5.81; low-quality evidence).Six studies reported the number of platelet transfusions; we were unable to perform a meta-analysis. Two studies (959 participants) out of three (1070 participants) found that a low-dose transfusion strategy led to more transfusion episodes than a standard-dose. One study (849 participants) found that a low-dose transfusion strategy led to more transfusion episodes than a high-dose strategy. One study (855 participants) out of three (1007 participants) found no difference in the number of platelet transfusions between the high-dose and standard-dose groups.One study reported on transfusion reactions. This study's authors suggested that a high-dose platelet transfusion strategy may lead to a higher rate of transfusion-related adverse events.None of the studies reported quality-of-life. AUTHORS' CONCLUSIONS In haematology patients who are thrombocytopenic due to myelosuppressive chemotherapy or HSCT, we found no evidence to suggest that a low-dose platelet transfusion policy is associated with an increased bleeding risk compared to a standard-dose or high-dose policy, or that a high-dose platelet transfusion policy is associated with a decreased risk of bleeding when compared to a standard-dose policy.A low-dose platelet transfusion strategy leads to an increased number of transfusion episodes compared to a standard-dose strategy. A high-dose platelet transfusion strategy does not decrease the number of transfusion episodes per participant compared to a standard-dose regimen, and it may increase the number of transfusion-related adverse events.Findings from this review would suggest a change from current practice, with low-dose platelet transfusions used for people receiving in-patient treatment for their haematological disorder and high-dose platelet transfusion strategies not being used routinely.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Simon Stanworth
- Oxford University Hospitals and the University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreOxfordUKOX3 9BQ
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Sally Hopewell
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Patricia Blanco
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Michael F Murphy
- Oxford University Hospitals and the University of OxfordNHS Blood and Transplant; National Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe HospitalHeadingtonOxfordUK
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Crighton GL, Estcourt LJ, Wood EM, Trivella M, Doree C, Stanworth S. A therapeutic-only versus prophylactic platelet transfusion strategy for preventing bleeding in patients with haematological disorders after myelosuppressive chemotherapy or stem cell transplantation. Cochrane Database Syst Rev 2015; 2015:CD010981. [PMID: 26422767 PMCID: PMC4610062 DOI: 10.1002/14651858.cd010981.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Platelet transfusions are used in modern clinical practice to prevent and treat bleeding in thrombocytopenic patients with bone marrow failure. Although considerable advances have been made in platelet transfusion therapy in the last 40 years, some areas continue to provoke debate, especially concerning the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding.This is an update of a Cochrane review first published in 2004 and updated in 2012 that addressed four separate questions: therapeutic-only versus prophylactic platelet transfusion policy; prophylactic platelet transfusion threshold; prophylactic platelet transfusion dose; and platelet transfusions compared to alternative treatments. We have now split this review into four smaller reviews looking at these questions individually; this review is the first part of the original review. OBJECTIVES To determine whether a therapeutic-only platelet transfusion policy (platelet transfusions given when patient bleeds) is as effective and safe as a prophylactic platelet transfusion policy (platelet transfusions given to prevent bleeding, usually when the platelet count falls below a given trigger level) in patients with haematological disorders undergoing myelosuppressive chemotherapy or stem cell transplantation. SEARCH METHODS We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (Cochrane Library 2015, Issue 6), MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1937), the Transfusion Evidence Library (from 1950) and ongoing trial databases to 23 July 2015. SELECTION CRITERIA RCTs involving transfusions of platelet concentrates prepared either from individual units of whole blood or by apheresis, and given to prevent or treat bleeding in patients with malignant haematological disorders receiving myelosuppressive chemotherapy or undergoing HSCT. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We identified seven RCTs that compared therapeutic platelet transfusions to prophylactic platelet transfusions in haematology patients undergoing myelosuppressive chemotherapy or HSCT. One trial is still ongoing, leaving six trials eligible with a total of 1195 participants. These trials were conducted between 1978 and 2013 and enrolled participants from fairly comparable patient populations. We were able to critically appraise five of these studies, which contained separate data for each arm, and were unable to perform quantitative analysis on one study that did not report the numbers of participants in each treatment arm.Overall the quality of evidence per outcome was low to moderate according to the GRADE approach. None of the included studies were at low risk of bias in every domain, and all the studies identified had some threats to validity. We deemed only one study to be at low risk of bias in all domains other than blinding.Two RCTs (801 participants) reported at least one bleeding episode within 30 days of the start of the study. We were unable to perform a meta-analysis due to considerable statistical heterogeneity between studies. The statistical heterogeneity seen may relate to the different methods used in studies for the assessment and grading of bleeding. The underlying patient diagnostic and treatment categories also appeared to have some effect on bleeding risk. Individually these studies showed a similar effect, that a therapeutic-only platelet transfusion strategy was associated with an increased risk of clinically significant bleeding compared with a prophylactic platelet transfusion policy. Number of days with a clinically significant bleeding event per participant was higher in the therapeutic-only group than in the prophylactic group (one RCT; 600 participants; mean difference 0.50, 95% confidence interval (CI) 0.10 to 0.90; moderate-quality evidence). There was insufficient evidence to determine whether there was any difference in the number of participants with severe or life-threatening bleeding between a therapeutic-only transfusion policy and a prophylactic platelet transfusion policy (two RCTs; 801 participants; risk ratio (RR) 4.91, 95% CI 0.86 to 28.12; low-quality evidence). Two RCTs (801 participants) reported time to first bleeding episode. As there was considerable heterogeneity between the studies, we were unable to perform a meta-analysis. Both studies individually found that time to first bleeding episode was shorter in the therapeutic-only group compared with the prophylactic platelet transfusion group.There was insufficient evidence to determine any difference in all-cause mortality within 30 days of the start of the study using a therapeutic-only platelet transfusion policy compared with a prophylactic platelet transfusion policy (two RCTs; 629 participants). Mortality was a rare event, and therefore larger studies would be needed to establish the effect of these alternative strategies. There was a clear reduction in the number of platelet transfusions per participant in the therapeutic-only arm (two RCTs, 991 participants; standardised mean reduction of 0.50 platelet transfusions per participant, 95% CI -0.63 to -0.37; moderate-quality evidence). None of the studies reported quality of life. There was no evidence of any difference in the frequency of adverse events, such as transfusion reactions, between a therapeutic-only and prophylactic platelet transfusion policy (two RCTs; 991 participants; RR 1.02, 95% CI 0.62 to 1.68), although the confidence intervals were wide. AUTHORS' CONCLUSIONS We found low- to moderate-grade evidence that a therapeutic-only platelet transfusion policy is associated with increased risk of bleeding when compared with a prophylactic platelet transfusion policy in haematology patients who are thrombocytopenic due to myelosuppressive chemotherapy or HSCT. There is insufficient evidence to determine any difference in mortality rates and no evidence of any difference in adverse events between a therapeutic-only platelet transfusion policy and a prophylactic platelet transfusion policy. A therapeutic-only platelet transfusion policy is associated with a clear reduction in the number of platelet components administered.
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Affiliation(s)
- Gemma L Crighton
- Transfusion Outcome Research Collaborative, Department of Epidemiology and Preventive Medicine, Monash University and Australian Red Cross Blood Service, The Alfred Centre, 99 Commercial Road, Melbourne, VICTORIA, Australia, 3004
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Nahirniak S, Slichter SJ, Tanael S, Rebulla P, Pavenski K, Vassallo R, Fung M, Duquesnoy R, Saw CL, Stanworth S, Tinmouth A, Hume H, Ponnampalam A, Moltzan C, Berry B, Shehata N. Guidance on Platelet Transfusion for Patients With Hypoproliferative Thrombocytopenia. Transfus Med Rev 2015; 29:3-13. [DOI: 10.1016/j.tmrv.2014.11.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 11/17/2014] [Accepted: 11/20/2014] [Indexed: 01/19/2023]
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Fasano RM, Josephson CD. Platelet transfusion goals in oncology patients. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:462-470. [PMID: 26637759 DOI: 10.1182/asheducation-2015.1.462] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Despite the advances in platelet component preparation and transfusion support over the years, platelet products remain a limited resource due to their short (5 day) shelf life, and therefore their optimal use in the non-bleeding thrombocytopenic patient continue to draw much attention. There have been a number of national and international guidelines for platelet transfusion therapy in patients with hematologic diseases, some within the last 1-2 years that have incorporated key randomized controlled trials (RCTs) which address issues, such as the optimal platelet dose, the most appropriate threshold for prophylactic platelet transfusions, and whether prophylactic platelet transfusions are superior to therapeutic-only platelet transfusion practices for the prevention life-threatening bleeding in patients with hypoproliferative thrombocytopenia. This review highlights key RCTs and recent systematic reviews focused on optimal platelet transfusion therapy in adult and pediatric patients with hypoproliferative thrombocytopenia secondary to chemotherapy or hematopoietic stem cell transplant (HSCT), discuss how recent innovations in platelet component processing may affect transfusion efficiency, and introduce renewed concepts on adjuvant therapies to prevent bleeding in the hypoproliferative thrombocytopenic patient.
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Affiliation(s)
- Ross M Fasano
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Cassandra D Josephson
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
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Wandt H, Schäfer-Eckart K, Greinacher A. Platelet transfusion in hematology, oncology and surgery. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:809-15. [PMID: 25512006 PMCID: PMC4269073 DOI: 10.3238/arztebl.2014.0809] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 09/15/2014] [Accepted: 09/15/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND The standard recommendation to date has been that acute hypoproliferative thrombocytopenia should be treated with a prophylactic platelet transfusion if the morning platelet count is less than 10 000/μL, or less than 20 000/μL if there are additional risk factors. For chronic thrombocytopenia, transfusion has been recommended if the platelet count is less than 5000/μL. In Germany, half a million platelet transfusions are now being given every year, and the number is rising. New studies indicate, however, that a more restrictive transfusion strategy is justified. METHODS A selective literature search was carried out in PubMed, with additional attention to recommendations from Germany and abroad, and to the guidelines of medical specialty societies. RESULTS Prophylactic platelet transfusions should be given when clinically indicated in consideration of the individual hemorrhagic risk. To prevent severe hemorrhage, it is more important to respond to the first signs of bleeding than to pay exclusive attention to morning platelet counts below 10 000/μL. This threshold value remains standard for patients with acute leukemia. According to recent studies, however, clinically stable patients who are at low risk for bleeding-e.g., patients who have undergone autologous hematopoietic stem-cell transplantation-may be well served by a therapeutic, rather than prophylactic, platelet transfusion strategy, in which platelets are transfused only when evidence of bleeding has been observed. For cancer patients, intensive-care patients, and patients with other risk factors, a clinically oriented transfusion strategy is recommended, in addition to close attention to threshold platelet values. CONCLUSION The number of platelet transfusions could be safely lowered by a more restrictive transfusion strategy that takes account of the risk of bleeding, as recommended in the hemotherapy guidelines.
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Affiliation(s)
- Hannes Wandt
- Medical Clinic 5—Nuremberg Hospital: Internal Medicine, Oncology, Hematology
| | | | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, Ernst-Moritz-Arndt-University of Greifswald
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Chandra J, Ravi R, Singh V, Narayan S, Sharma S, Dutta AK. Bleeding manifestations in severely thrombocytopenic children with immune thrombocytopenic purpura. Hematology 2013; 11:131-3. [PMID: 16753855 DOI: 10.1080/10245330600574367] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To report the observations on various bleeding manifestations in children with immune thrombocytopenic purpura (ITP) having severe thrombocytopenia (platelet count (PC) < 20,000/microl) and to compare the differences in bleeding manifestations at levels of PC at < 10,000/microl compared with between 10,000 and 20,000/microl. STUDY DESIGN It is a retrospective analysis of bleeding manifestations in children with ITP (n = 58) having severe thrombocytopenia recorded between July 1999 and June 2002. A total of 164 episodes of severe thrombocytopenia were observed. During 31 episodes (18.9%), no bleeding manifestations were observed. When bleeding was observed cutaneous bleeds were the commonest manifestations occurring in 124 episodes. Of these 124 instances, in 82 (66.1%) episodes only cutaneous bleeding was observed while in remaining 42 (33.9%) episodes cutaneous bleeding was associated with other bleeding sites. Other common bleeds observed included epistaxis 22 (13.4%), oral bleeding 21 (12.8%) and gastro-intestinal bleeding 5 (3.04%). Comparison of the bleeding manifestations during episodes when the PC was < 10,000/microl and those between 10,000 and 20,000/microl showed that in 76.6% episodes with the count at > 10,000/microl no or only cutaneous bleeds were observed (clinically mild disease) compared to 59.45% episodes with episodes having PC < 10,000/microl (z score 2.37, p < 0.05). There was no statistically significant difference in proportion of patients having clinically mild disease during acute or chronic phase of the disease. CONCLUSION During episodes of severe thrombocytopenia, most children have clinically mild disease. When the PC is < 10,000/microl clinically mild disease is observed less often compared to episodes with PC 10,000-20,000/microl. Based on these observations, it can be recommended that during severe thrombocytopenia, particularly when the PC is between 10,000-20,22,000/microl, patients can be safely managed with watchful waiting without any specific therapeutic intervention.
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Affiliation(s)
- Jagdish Chandra
- Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, Division of Hematology, Department of Pediatrics, New Delhi, India.
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Wandt H, Schaefer-Eckart K, Wendelin K, Pilz B, Wilhelm M, Thalheimer M, Mahlknecht U, Ho A, Schaich M, Kramer M, Kaufmann M, Leimer L, Schwerdtfeger R, Conradi R, Dölken G, Klenner A, Hänel M, Herbst R, Junghanss C, Ehninger G. Therapeutic platelet transfusion versus routine prophylactic transfusion in patients with haematological malignancies: an open-label, multicentre, randomised study. Lancet 2012; 380:1309-16. [PMID: 22877506 DOI: 10.1016/s0140-6736(12)60689-8] [Citation(s) in RCA: 227] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Routine prophylactic platelet transfusion is the standard of care for patients with severe thrombocytopenia. We assessed the effect of a new strategy of therapeutic platelet transfusion on the number of transfusions and safety in patients with hypoproliferative thrombocytopenia. METHODS We did a multicentre, open-label, randomised parallel-group trial at eight haematology centres in Germany. Patients aged 16-80 years, who were undergoing intensive chemotherapy for acute myeloid leukaemia or autologous haemopoietic stem-cell transplantation for haematological cancers, were randomly assigned via a computer-generated randomisation sequence to receive either platelet transfusion when bleeding occurred (therapeutic strategy) or when morning platelet counts were 10×10(9) per L or lower (prophylactic strategy). Investigators undertaking interventions were not masked to group assignment. The primary endpoint was the number of platelet transfusions. Analysis was by intention to treat. This trial is registered, NCT00521664. FINDINGS 197 patients were assigned the prophylactic strategy and 199 the therapeutic strategy. Of 391 patients analysed, the therapeutic strategy reduced the mean number of platelet transfusions by 33·5% (95% CI 22·2-43·1; p<0·0001) in all patients (2·44 [2·22-2·67] in prophylactic group vs 1·63 [1·42-1·83] in therapeutic group), 31·6% (18·6-42·6; p<0·0001) in those with acute myeloid leukaemia (2·68 [2·35-3·01] vs 1·83 [1·58-2·10]), and 34·2% (6·6-53·7; p=0·0193) in those who had had autologous transplantation (1·80 [1·45-2·15] vs 1·18 [0·82-1·55]. We noted no increased risk of major haemorrhage in patients who had undergone autologous transplantation. In those with acute myeloid leukaemia, risk of non-fatal grade 4 (mostly CNS) bleeding was increased. We recorded 15 cases of non-fatal haemorrhage: four retinal in each transfusion group, and one vaginal and six cerebral in the therapeutic group. 12 patients died in the study: two from fatal cerebral haemorrhages in the therapeutic group, and ten (five in each treatment group) unrelated to major bleeding. INTERPRETATION The therapeutic strategy could become a new standard of care after autologous stem-cell transplantation; however, prophylactic platelet transfusion should remain the standard for patients with acute myeloid leukaemia. The new strategy should be used by some haematology centres only if the staff are well educated and experienced in the new approach and can react in a timely way to first signs of CNS bleeding. FUNDING Deutsche Krebshilfe eV (German Cancer Aid).
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Affiliation(s)
- Hannes Wandt
- Medical Clinic 5, Haematology and Oncology, Klinikum Nüremberg, Nüremberg, Germany.
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Ypma PF, Kerkhoffs JLH, van Hilten JA, Middelburg RA, Coccoris M, Zwaginga JJ, Beckers EM, Fijnheer R, van der Meer PF, Brand A. The observation of bleeding complications in haemato-oncological patients: stringent watching, relevant reporting. Transfus Med 2012; 22:426-31. [PMID: 23036067 DOI: 10.1111/j.1365-3148.2012.01193.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 08/30/2012] [Accepted: 09/06/2012] [Indexed: 12/01/2022]
Abstract
BACKGROUND The reported percentage of haemato-oncological patients experiencing bleeding complications is highly variable, ranging from 5 to 70%, posing a major problem for comparison of clinical platelet transfusion trials using bleeding complications as a primary endpoint. In a pilot study we assessed the impact of the design of scoring of bleeding on the percentage of patients with WHO grade 2 or higher bleeding grades. STUDY DESIGN AND METHODS We performed a prospective, observational study using a rigorous bleeding observation system in thrombocytopenic patients with haemato-oncological disorders. Endpoints of the study were the percentage of patients and days with bleeding WHO grade ≥ 2 comparing designs in which skin bleeding represent a continuation of a previous bleed or a new bleed. RESULTS In four participating hospitals 64 patients suffering 870 evaluable thrombocytopenic days (platelet count < 80 × 10(9) L(-1)) were included. At least one episode of bleeding grade ≥ 2 occurred in 36 patients (56%). Most grade 2 bleeding complications occurred mucocutaneously. The percentage of days with bleeding of grade ≥ 2 was 16% but decreases to 8% when only newly developed skin bleeding was included. CONCLUSION Rigorous daily observation results in a bleeding incidence that is comparable to recent reportings applying the same method. The results of this study show that censoring for stable skin bleeding has a profound effect on bleeding incidence per day. The clinical relevance of rigorous or clinically judged bleeding scores as an endpoint remains to be defined.
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Affiliation(s)
- P F Ypma
- Department of Haematology, HAGA Teaching Hospital Den Haag, The Hague, The Netherlands.
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Estcourt L, Stanworth S, Doree C, Hopewell S, Murphy MF, Tinmouth A, Heddle N. Prophylactic platelet transfusion for prevention of bleeding in patients with haematological disorders after chemotherapy and stem cell transplantation. Cochrane Database Syst Rev 2012:CD004269. [PMID: 22592695 DOI: 10.1002/14651858.cd004269.pub3] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Platelet transfusions are used in modern clinical practice to prevent and treat bleeding in thrombocytopenic patients with bone marrow failure. Although considerable advances have been made in platelet transfusion therapy in the last 40 years, some areas continue to provoke debate especially concerning the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding. OBJECTIVES To determine the most effective use of platelet transfusion for the prevention of bleeding in patients with haematological disorders undergoing chemotherapy or stem cell transplantation. SEARCH METHODS This is an update of a Cochrane review first published in 2004. We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2011), MEDLINE (1950 to Nov 2011), EMBASE (1980 to Nov 2011) and CINAHL (1982 to Nov 2011), using adaptations of the Cochrane RCT search filter, the UKBTS/SRI Transfusion Evidence Library, and ongoing trial databases to 10 November 2011. SELECTION CRITERIA RCTs involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in patients with haematological disorders. Four different types of prophylactic platelet transfusion trial were included. DATA COLLECTION AND ANALYSIS In the original review one author initially screened all electronically derived citations and abstracts of papers, identified by the review search strategy, for relevancy. Two authors performed this task in the updated review. Two authors independently assessed the full text of all potentially relevant trials for eligibility. Two authors completed data extraction independently. We requested missing data from the original investigators as appropriate. MAIN RESULTS There were 18 trials that were eligible for inclusion, five of these were still ongoing.Thirteen completed published trials (2331 participants) were included for analysis in the review. The original review contained nine trials (718 participants). This updated review includes six new trials (1818 participants).Two trials (205 participants) in the original review are now excluded because fewer than 80% of participants had a haematological disorder.The four different types of prophylactic platelet transfusion trial, that were the focus of this review, were included within these thirteen trials.Three trials compared prophylactic platelet transfusions versus therapeutic-only platelet transfusions. There was no statistical difference between the number of participants with clinically significant bleeding in the therapeutic and prophylactic arms but the confidence interval was wide (RR 1.66; 95% CI 0.9 to 3.04).The time taken for a clinically significant bleed to occur was longer in the prophylactic platelet transfusion arm. There was a clear reduction in platelet transfusion usage in the therapeutic arm. There was no statistical difference between the number of participants in the therapeutic and prophylactic arms with platelet refractoriness, the only adverse event reported.Three trials compared different platelet count thresholds to trigger administration of prophylactic platelet transfusions. No statistical difference was seen in the number of participants with clinically significant bleeding (RR 1.35; 95% CI 0.95 to 1.9), however, this type of bleeding occurred on fewer days in the group of patients transfused at a higher platelet count threshold (RR 1.72; 95% CI 1.33 to 2.22).The lack of a difference seen for the number of participants with clinically significant bleeding may be due to the studies, in combination, having insufficient power to demonstrate a difference, or due to masking of the effect by a higher number of protocol violations in the groups of patients with a lower platelet count threshold. Using a lower platelet count threshold led to a significant reduction in the number of platelet transfusions used. There were no statistical differences in the number of adverse events reported between the two groups.Six trials compared different doses of prophylactic platelet transfusions. There was no evidence to suggest that using a lower platelet transfusion dose increased: the number of participants with clinically significant (WHO grade 2 or above) (RR 1.02; 95% CI 0.93 to 1.11), or life-threatening (WHO grade 4) bleeding (RR 1.87; 95% CI 0.86 to 4.08). A higher platelet transfusion dose led to a reduction in the number of platelet transfusion episodes, but an increase in total platelet utilisation. Only one adverse event, wheezing after transfusion, had a significantly higher incidence when standard and high dose transfusions were compared but this difference was not seen when low dose and high dose transfusions were compared. It is therefore likely to be a type I error (false positive).One small trial compared prophylactic platelet transfusions versus platelet-poor plasma. The risk of a significant bleed was decreased in the prophylactic platelet transfusion arm (RR 0.47; 95% CI 0.23 to 0.95) and this was statistically significant.All studies had threats to validity; the majority of these were due to methodology of the studies not being described in adequate detail.Although it was not the main focus of the review, it was interesting to note that in one of the pre-specified sub-group analyses (treatment type) two studies showed that patients receiving an autologous transplant have a lower risk of bleeding than patients receiving intensive chemotherapy or an allogeneic transplant (RR 0.73, 95% CI 0.65 to 0.82). AUTHORS' CONCLUSIONS These conclusions refer to the four different types of platelet transfusion trial separately. Firstly, there is no evidence that a prophylactic platelet transfusion policy prevents bleeding. Two large trials comparing a therapeutic versus prophylactic platelet transfusion strategy, that have not yet been published, should provide important new data on this comparison. Secondly, there is no evidence, at the moment, to suggest a change from the current practice of using a platelet count of 10 x 10(9)/L. However, the evidence for a platelet count threshold of 10 x 10(9)/L being equivalent to 20 x 10(9)/L is not as definitive as it would first appear and further research is required. Thirdly, platelet dose does not affect the number of patients with significant bleeding, but whether it affects number of days each patient bleeds for is as yet undetermined. There is no evidence that platelet dose affects the incidence of WHO grade 4 bleeding.Prophylactic platelet transfusions were more effective than platelet-poor plasma at preventing bleeding.
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Affiliation(s)
- Lise Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.
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24
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Asymptomatic cerebral bleeds in patients with aplastic anemia. Ann Hematol 2012; 91:1187-91. [DOI: 10.1007/s00277-012-1448-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 03/11/2012] [Indexed: 10/28/2022]
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25
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Hedley BD, Keeney M, Chin-Yee I, Brown W. Initial performance evaluation of the UniCel® DxH 800 Coulter® cellular analysis system. Int J Lab Hematol 2011; 33:45-56. [PMID: 20491996 PMCID: PMC3044820 DOI: 10.1111/j.1751-553x.2010.01239.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The Beckman Coulter UniCel® DxH 800 is a hematology analyzer incorporating new electronic and mechanical design with advanced algorithm technology to perform CBC, white blood cell (WBC) differential, nucleated red blood cell (NRBC), and reticulocyte analysis. Evaluation of this instrument was performed in our 800-bed tertiary care hospital and specifically centered upon the correlation of WBC, NRBC, and platelet (PLT) enumeration when compared to a predicate analyzer, the Coulter® LH 780, and flow cytometry (FCM) reference methods. Of particular interest were those samples with morphologically confirmed interference and extreme leukocytosis (evaluated with respect to red blood cell parameter correction). The sample set (n=272) consisted of morphologically normal and hematologically abnormal patients. Correlation of the WBC, PLT, and NRBC showed r(2) values of 0.994, 0.985, and 0.910 for the DxH 800 vs. FCM, respectively. The presence of interfering particles did not affect the accuracy of the DxH 800 with respect to WBC counts. The DxH 800 showed accurate PLT and NRBC counts in the clinically significant low range when compared to FCM. Compared to the LH 780, flagging rates were significantly reduced (NRBC flag), or equivalent (WBC, PLT flag) on the DxH 800. The DxH 800 demonstrated higher sensitivity and specificity for PLTs and NRBCs and achieved a lower NRBC false negative rate compared to the LH 780. The UniCel® DxH 800 represents a significant improvement to previous impedance analyzers in accurately detecting the presence of NRBCs at counts >1/100 WBC. Furthermore, it provides accurate PLT and WBC counts in the presence of interference and improved NRBC flagging efficiency when compared to the LH 780. Correction of red blood cell parameters is appropriate and accurate in cases of extreme leukocytosis.
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Affiliation(s)
- B D Hedley
- Department of Hematology, London Health Sciences Centre, London, Ontario, Canada
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26
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Zeidler K, Arn K, Senn O, Schanz U, Stussi G. Optimal preprocedural platelet transfusion threshold for central venous catheter insertions in patients with thrombocytopenia. Transfusion 2011; 51:2269-76. [PMID: 21517892 DOI: 10.1111/j.1537-2995.2011.03147.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with severe thrombocytopenia are at risk for bleeding during insertion of central venous catheters (CVCs). Although most guidelines recommend preprocedural platelet (PLT) transfusions at a threshold of less than 50 × 10(9) /L, there is only weak evidence supporting such recommendations. STUDY DESIGN AND METHODS The current study aimed to establish a safe PLT transfusion trigger in patients with CVC placements. We performed a retrospective single-center analysis of 604 CVC insertions in 193 patients with acute leukemia receiving intensive chemotherapy or stem cell transplantation. RESULTS A total of 48% of the patients had a bleeding risk during CVC insertions, mostly due to thrombocytopenia. The bleeding incidence was 32% with 96% Grade 1 and 4% Grade 2 bleedings requiring prolonged local compression. There were no Grade 3 to 4 bleedings. Hemoglobin levels were similar before and 24 and 48 hours after the CVC insertion in the bleeding and nonbleeding group and there was no difference in the red blood cell (p = 0.72) and PLT transfusion requirements (p = 0.057) after CVC insertion. In multivariate analysis, only patients with PLT counts of less than 20 × 10(9) /L were at higher risk for bleeding before (p = 0.015) and after preprocedural PLT transfusions (p =0.006) compared to patients with PLT counts of 100 × 10(9) /L or more. CONCLUSION CVC placements can safely be performed in patients with PLT counts of 20 × 10(9) /L or more without preprocedural PLT transfusions.
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Affiliation(s)
- Kristin Zeidler
- Department of Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
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27
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Apelseth TO, Hervig T, Bruserud O. Current practice and future directions for optimization of platelet transfusions in patients with severe therapy-induced cytopenia. Blood Rev 2011; 25:113-22. [PMID: 21316823 DOI: 10.1016/j.blre.2011.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Torunn O Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Norway.
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28
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Affiliation(s)
- D C Buhrkuhl
- Haematology Department, Blood and Cancer Centre, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand.
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29
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Delaney M, Meyer E, Cserti-Gazdewich C, Haspel RL, Lin Y, Morris A, Pavenski K, Dzik WH, Murphy M, Slichter S, Wang G, Dumont LJ, Heddle N. A systematic assessment of the quality of reporting for platelet transfusion studies. Transfusion 2010; 50:2135-44. [PMID: 20497518 DOI: 10.1111/j.1537-2995.2010.02691.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND As evidence-based medicine assumes increasing importance, there is a need for high-quality reporting of clinical studies. A recent review of clinical platelet (PLT) studies indicated variability in reporting. We undertook a critical analysis of PLT transfusion studies to determine the quality of reporting. STUDY DESIGN AND METHODS A systematic MEDLINE search for clinical studies of PLT transfusion was performed to identify articles. Relevant observational studies (OBS) were critiqued using the STROBE checklist and randomized controlled clinical trials (RCTs) using the CONSORT checklist. Studies were further evaluated with a PLT-specific checklist developed by the authors. Observations were analyzed descriptively and using Pareto analysis. RESULTS A total of 772 articles were identified by the search. Eighty-six articles (23 RCTs and 63 OBS) met eligibility criteria. All RCTs, and a similar number of OBS (24), were randomly selected for analysis. Studies reported the scientific background and rationale, key results, and outcomes. OBS frequently did not consider bias and confounders. RCTs frequently did not explain bias, interim analyses, stopping rules, success of blinding, or weaknesses of multiple analyses. The PLT-specific critique found many studies adequately reported basics of the PLT product, PLT increment, and transfusion reactions. Studies frequently failed to report specific details of PLT compatibility, details of product preparation, and use of other blood products. CONCLUSION Recently published articles of clinical PLT transfusion share common strengths and weaknesses. The quality of reporting may be improved by providing guidelines to authors and journal editors that list the essential elements of a well-reported clinical study of PLT transfusion.
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Affiliation(s)
- Meghan Delaney
- Puget Sound Blood Center, Seattle, Washington 98104, USA.
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30
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Incidence and etiology of overt gastrointestinal bleeding in adult patients with aplastic anemia. Dig Dis Sci 2010; 55:73-81. [PMID: 19165598 DOI: 10.1007/s10620-008-0702-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Accepted: 12/30/2008] [Indexed: 12/30/2022]
Abstract
Patients with thrombocytopenia caused by various neoplastic and primary bone marrow diseases are susceptible to major hemorrhage. There are few reports addressing the incidence and outcome of gastrointestinal (GI) bleeding in patients with aplastic anemia characterized by long-standing thrombocytopenia. We sought to retrospectively determine the incidence, etiology, clinical outcomes, and risk factors associated with overt GI bleeding in patients with aplastic anemia. We analyzed the medical records of 508 patients with aplastic anemia after excluding patients below 15 years of age or those who underwent stem cell transplantation between January 1, 2002, and December 31, 2007. A total of 32 patients developed overt GI bleeding during this period. We evaluated the site, etiology, outcomes, and major risk factors in these patients who developed GI bleeding episodes. The incidence of GI bleeding was 6.3% (32 of 508 patients) in adult patients with aplastic anemia. The incidence increased to 12.6% (28 of 222 patients) in patients with severe disease. One patient died from massive GI bleeding. Bleeding sites included the esophagus (two patients, 6.3%), stomach (five, 16.3%), duodenum (two, 6.3%), small intestine (five, 15.6%), large intestine (seven, 21.6%), and unknown site (11, 34.4%). Lower GI bleeds mainly caused by neutropenic enterocolitis (NEC) and solitary ulcer developed more frequently than upper GI bleeds. The major risk factors for GI bleeding included old age (P = 0.004, odds ratio (OR) = 1.039), severe aplastic anemia (P < 0.001, OR = 11.934), non-response to therapy (P = 0.001, OR = 5.652), and major bleeding history in another organ (P < 0.001, OR = 6.677). Overt GI bleeding in patients with aplastic anemia more frequently develops in the lower tract than in the upper tract. The risk of GI bleeding is higher in patients with the following risk factors: older age, severe disease, poor response to treatment, and major bleeding history in another organ.
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31
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Rice TW, Wheeler AP. Coagulopathy in critically ill patients: part 1: platelet disorders. Chest 2009; 136:1622-1630. [PMID: 19995764 DOI: 10.1378/chest.08-2534] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Abnormalities of platelet number and function are the most common coagulation disorders seen among ICU patients. This article reviews the most frequent causes of thrombocytopenia by providing an overview of the following most common mechanisms: impaired production; sequestration; dilution; and destruction. Guidelines for treating thrombocytopenia and platelet dysfunction are also provided.
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Affiliation(s)
- Todd W Rice
- Medical Intensive Care Unit, Vanderbilt University Medical Center, Nashville, TN
| | - Arthur P Wheeler
- Medical Intensive Care Unit, Vanderbilt University Medical Center, Nashville, TN; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.
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32
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Thomas L, Kaidomar S, Kerob-Bauchet B, Moravie V, Brouste Y, King JP, Schmitt S, Besnier F, Abel S, Mehdaoui H, Plumelle Y, Najioullah F, Fonteau C, Richard P, Césaire R, Cabié A. Prospective observational study of low thresholds for platelet transfusion in adult dengue patients. Transfusion 2009; 49:1400-11. [DOI: 10.1111/j.1537-2995.2009.02132.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Nevo S, Fuller AK, Hartley E, Borinsky ME, Vogelsang GB. Acute bleeding complications in patients after hematopoietic stem cell transplantation with prophylactic platelet transfusion triggers of 10�נ109and 20�נ109per L. Transfusion 2007; 47:801-12. [PMID: 17465944 DOI: 10.1111/j.1537-2995.2007.01193.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prophylactic platelet (PLT) transfusions are given as a standard care in patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT). This retrospective analysis evaluates utilization of blood transfusions, risk of bleeding, and survival in 480 HSCT patients at 10 x 10(9) and 20 x 10(9) per L prophylactic trigger levels. STUDY DESIGN AND METHODS A total of 224 patients received prophylactic PLT transfusions at 20 x 10(9) per L threshold (1997-1998, SP1); 256 patients had prophylaxis at 10 x 10(9) per L (1999-2001, SP2). Bleeding scores were assigned daily. RESULTS A slight reduction in PLT transfusions per patient in SP2 compared with SP1 was not statistically significant (odds ratio, 0.82; 95% confidence interval, 0.51-1.33; p = 0.416), yet a significantly higher proportion of patients in SP2 had PLT counts less than or equal to 10 x 10(9) per L compared to SP1 (p < 0.001). In patients who bled, however, there was no excess exposure to low PLT counts before bleeding started. A substantial number of patients who bled received PLT transfusions above the goal before bleeding started (82.9% in SP2, 41.5% in SP1) because of medical complications that associated with increased risk of bleeding. Bleeding incidence was similar in both study periods (21.9% in SP1, 16.4% in SP2; p = 0.526). Bleeding was significantly associated with reduced survival in both study periods. CONCLUSIONS Patients who bled were usually placed on a higher threshold before the onset of their major bleeding event and were not exposed to additional risk of bleeding from thrombocytopenia. Similarity in bleeding incidence between study periods appears to associate with adjustments to high-risk conditions and may not reflect consequences of the lower transfusion threshold.
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Affiliation(s)
- Shoshan Nevo
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Bunting Blaustein Cancer Research Building, Baltimore, Maryland, USA.
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34
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Salacz ME, Lankiewicz MW, Weissman DE. Management of thrombocytopenia in bone marrow failure: a review. J Palliat Med 2007; 10:236-44. [PMID: 17298272 DOI: 10.1089/jpm.2006.0126] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The clinical course of many neoplastic and primary bone marrow diseases will result in cytopenias secondary to bone marrow failure or infiltration. Acute and chronic leukemias, the myelodysplastic syndromes (MDS), aplastic anemia, breast and prostate cancer, as well as other hematologic and solid tumors, all may lead to chronic, severe cytopenias. Management of anemia and neutropenia are well described in the medical literature. Less well detailed are management approaches for patients with chronic thrombocytopenia, with or without active bleeding. Severe thrombocytopenia presents many difficult management choices for caregivers, patients and their families, especially near the end of life. The use of platelet transfusions in this patient population presents complex issues; platelets are logistically more difficult to transfuse than red cells and carry risks including acute febrile episodes, alloimmunization, and infection. In this review, we discuss the association of chronic thrombocytopenia to serious bleeding and the role of various prophylactic and therapeutic interventions available to palliative care and hospice providers. Specifically, this review examines the following issues: What is the morbidity and mortality from chronic thrombocytopenia in the setting of cancer or other bone marrow failure states? Is there a role for prophylactic platelet transfusions in the palliative care setting, and if so, with what frequency of monitoring, and at what transfusion threshold? What is the impact of alloimmunization and how can it be minimized? What treatments are available besides, or in addition to, platelet transfusions for acute bleeding episodes?
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Affiliation(s)
- Michael E Salacz
- Specialists in Cancer Care, Saint Luke's Cancer Institute, 43212 Washington Drive, Kansas City, MO 64111, USA.
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35
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Greeno E, McCullough J, Weisdorf D. Platelet utilization and the transfusion trigger: a prospective analysis. Transfusion 2007; 47:201-5. [PMID: 17302764 DOI: 10.1111/j.1537-2995.2007.01089.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prophylactic platelet (PLT) transfusion practices have become more conservative as studies support a threshold for transfusions at 10 x 10(9) per L. This change in practice may reduce our use of PLT transfusions. STUDY DESIGN AND METHODS Data were prospectively collected to assess the impact at one academic hospital when the transition from a 20 x 10(9) to a 10 x 10(9) per L threshold prophylactic transfusion was made. RESULTS A total of 503 patients received 7401 PLT transfusions. Seventy-four percent of the transfusions were prophylactic. During the first phase of the study, only 53 percent of transfusions were given at a pretransfusion PLT count of less than 20 x 10(9) per L and 20 percent less than 10 x 10(9) per L. In the second phase of the study when the transfusion trigger was 10 x 10(9) per L, 28 percent of transfusions were given at this level. CONCLUSION Many prophylactic PLT transfusions were given at PLT counts higher than the recommended trigger. Although the new transfusion guidelines altered transfusion practice, only a minor change in overall PLT usage was observed. Other changes in transfusion practices, such as dose per transfusion or sampling interval, will be required before significant reduction in the costs and hazards of prophylactic PLT transfusions can be realized.
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Affiliation(s)
- Edward Greeno
- Department of Medicine and Laboratory Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, USA
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36
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Bosly A, Muylle L, Noens L, Pietersz R, Heims D, Hübner R, Selleslag D, Toungouz M, Ferrant A, Sondag D. Guidelines for the transfusion of platelets. Acta Clin Belg 2007; 62:36-47. [PMID: 17451144 DOI: 10.1179/acb.2007.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Recommendations aiming at standardising and rationalising clinical indications for the transfusion of platelets in Belgium were drawn up by a working group of the Superior Health Council. To this end the Superior Health Council organised an expert meeting devoted to "Guidelines for the transfusion of platelets" in collaboration with the Belgian Hematological Society. The experts discussed the indications for platelet transfusions, the ideal platelet concentrate and the optimal platelet transfusion therapy. The recommendations prepared by the experts were validated by the working group with the purpose of harmonising platelet transfusion in Belgian hospitals.
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Affiliation(s)
- A Bosly
- Service d'Hématologie, Hôpital universitaire Mont-Godinne (UCL), Yvoir, Belgique
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37
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Platelet Storage and Transfusion. Platelets 2007. [DOI: 10.1016/b978-012369367-9/50831-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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38
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Stanworth SJ, Hyde C, Brunskill S, Murphy MF. Platelet transfusion prophylaxis for patients with haematological malignancies: where to now? Br J Haematol 2006; 131:588-95. [PMID: 16351634 DOI: 10.1111/j.1365-2141.2005.05769.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
National guidelines for platelet transfusion in many countries recommend that the general platelet transfusion trigger for prophylaxis is 10x10(9)/l. This annotation reviews the evidence for this threshold level and discusses other current unresolved issues relevant to platelet transfusion practice such as the optimal dose and the clinical benefit of a strategy for the prophylactic use of platelet transfusions when the platelet count falls below a given threshold.
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Affiliation(s)
- S J Stanworth
- National Blood Service, John Radcliffe Hospital, Headington, Oxford, UK.
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Wandt H, Schaefer-Eckart K, Frank M, Birkmann J, Wilhelm M. A therapeutic platelet transfusion strategy is safe and feasible in patients after autologous peripheral blood stem cell transplantation. Bone Marrow Transplant 2006; 37:387-92. [PMID: 16400342 DOI: 10.1038/sj.bmt.1705246] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prophylactic platelet transfusions are considered as standard in most hematology centers, but there is a long-standing controversy as to whether standard prophylactic platelet transfusions are necessary or whether this strategy could be replaced by a therapeutic transfusion strategy. In 106 consecutive cases of patients receiving 140 autologous peripheral blood stem cell transplantations, we used a therapeutic platelet transfusion protocol when patients were in a clinically stable condition. Platelet transfusions were only used when relevant bleeding occurred (more than petechial). Median duration of thrombocytopenia <20 x 10(9)/l and <10 x 10(9)/l was 6 and 3 days, which resulted in a total of 989 and 508 days, respectively. In only 26 out of 140 transplants (19%), we observed clinically relevant bleeding of minor or moderate severity. No severe or life-threatening bleeding was registered. The median and mean number of single donor platelet transfusions was one per transplant (range 0-18). One-third of all transplants, and 47% after high-dose melphalan could be performed without any platelet transfusion. Compared with a historical control group, we could reduce the number of platelet transfusions by one half. This therapeutic platelet transfusion strategy can be performed safely resulting in a considerable reduction in prophylactic platelet transfusions.
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Affiliation(s)
- H Wandt
- BMT-Unit, Hematology/Oncology, Klinikum Nürnberg Nord, Nürnberg, Germany.
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Abstract
BACKGROUND Long-term survival rates among children diagnosed with severe aplastic anemia (SAA) are excellent due to the success of human leukocyte antigen (HLA)-identical related hematopoietic stem cell transplantation (HSCT), concurrent advances in immunosuppressive treatment (IST), and improved supportive care. The challenge in making treatment recommendations for children with SAA, therefore, is to balance the apparent chronicity and morbidity following IST, with the potential up-front toxicity and complications of HSCT. METHODS This review provides an update on the diagnosis and a risk-based treatment algorithm for children with acquired SAA. Recent experience using alternative donor HSCT and efforts to extend HSCT eligibility through advances in donor matching, de-escalation of conditioning regimens, and potential marrow graft engineering are highlighted. We discuss IST response rates, risks of relapse, and complications including clonal evolution. CONCLUSIONS While good treatment options exist for a majority of children diagnosed with SAA, novel non-transplantation treatments for unresponsive and relapsed patients without suitable transplant donors are needed. Further improvements in outcome will ultimately require a more complete understanding of the pathophysiology of aplastic anemia (AA).
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Affiliation(s)
- Peter Kurre
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239-3098, USA.
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41
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Diedrich B, Remberger M, Shanwell A, Svahn BM, Ringdén O. A prospective randomized trial of a prophylactic platelet transfusion trigger of 10 x 109 per L versus 30 x 109 per L in allogeneic hematopoietic progenitor cell transplant recipients. Transfusion 2005; 45:1064-72. [PMID: 15987349 DOI: 10.1111/j.1537-2995.2005.04157.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The impact of lowering the platelet (PLT) count threshold for prophylactic PLT transfusion on bleeding and PLT use in allogeneic hematopoietic progenitor cell (HPC) transplant recipients is a matter of debate. STUDY DESIGN AND METHODS In 166 patients, randomly assigned to receive prophylactic PLT transfusion at a trigger level less than 10 x 10(9) PLTs per L (T10; n = 79) or less than 30 x 10(9) per L (T30; n = 87), the number of PLT and red blood cell (RBC) transfusions given and the number of hemorrhagic events (WHO Grades 2-4) were recorded. RESULTS No significant differences were found between the two groups regarding the clinical outcome variables (i.e., bacteremia, engraftment, graft-vs.-host disease [GVHD], hospital stay, death, and survival) or in the median total number of RBC transfusions given. The incidence, in Group T10 18 percent (14/79) and in Group T30 15 percent (13/87), as well as the type of bleeding were comparable. No deaths were attributed to hemorrhages. The number of PLT units transfused, however, was significantly lower in Group T10 (median, 4; range, 0-32), than in Group T30 (median, 10; range, 0-48; p < 0.001). Apart from the trigger level, the day of engraftment, the presence of acute GVHD, or bacteremia also affected the number of PLT transfusions. CONCLUSION A prophylactic PLT transfusion trigger level of less than 10 x 10(9) PLTs per L instead of less than 30 x 10(9) PLTs per L in allogeneic HPC transplant recipients was found to be safe and resulted in a decreased use of PLTs.
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Affiliation(s)
- Beatrice Diedrich
- Department of Transfusion Medicine, Karolinska University Hospital at Huddinge, Stockholm, Sweden.
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42
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Wood L, Jogessar V, Ward P, Jacobs P. Estimation and predictive use of the corrected count increment—a proposed clinical guideline. Transfus Apher Sci 2005; 32:117-24. [PMID: 15737880 DOI: 10.1016/j.transci.2004.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2004] [Accepted: 10/01/2004] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Platelets are frequently given inappropriately. The accepted indication is symptomatic thrombocytopaenia due to bone marrow failure. In contrast replacement therapy is contraindicated in immune mediated peripheral sequestration because it is almost always ineffective and also aggravates the already rapid rate of the clearance due to superimposed isoimmunisation. Furthermore circulating levels, rather than the clinical situation, customarily trigger the request and would typically be at 20 x 10(9)/l. Usage is under evaluated and, accordingly, current practice has been scrutinised and a guideline proposed that is applicable to user and vendor alike. DESIGN AND METHODOLOGY Prospectively a consecutive series of eligible cases were selected and, with informed consent, all relevant information recorded. Specific observations were haematologic status, quality of the product and the impact of previous exposure to blood fractions on outcome. Additionally, factors that influence response were documented and included disseminated intravascular coagulation, splenomegaly and concurrent use of intravenous Amphotericin B. The absolute numbers infused, the increase in peripheral value recorded and this ratio which is designated as corrected count index generated in each instance. RESULTS The CCI was computed for each of the 85 megaunits given to 29 individuals and subsequently estimated for the entire sample population using regression analysis. Each of the variables was used to test the hypothesis that such a figure might differ depending on patient sub-population. This approach was accurate in 60% of the time and predicates a more rational use of donor characteristics. The cardinal measurement is that supplied by the transfusion service which can be used as a basis for clinically important predictors of anticipated benefit. CONCLUSION This data, in keeping with international practice, leads to the recommendation that commercial and other services routinely measure and specify absolute numbers. The clinicians, reciprocally, should always confirm this figure and then match anticipated to observed outcome. Failure to carry out these simple procedures lead to gross over utilisation of this expensive intervention, risks unnecessary sensitisation and furthers persistence with sub-optimum administration.
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Affiliation(s)
- Lucille Wood
- Department of Haematology and Bone Marrow Transplantation Unit, Incorporating the Searll Laboratory for Research in Cellular and Molecular Biology, Constantiaberg Medi-Clinic, P.O. Box 294, Burnham Road, Plumstead, Cape Town 7800, South Africa
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Abstract
Transfusion of allogeneic red blood cells (RBCs), fresh frozen plasma (FFP) and platelets is associated with risks, and outcome studies comparing liberal and restrictive transfusion regimens are lacking in surgical patients. Therefore, guidelines have been established. They recommend first maintaining normovolaemia by the use of crystalloids and colloids. RBC transfusions are recommended for haemoglobin levels < 6 g/dl and for physiological signs of inadequate oxygenation such as haemodynamic instability, oxygen extraction > 50% and myocardial ischaemia (new ST-segment depressions > 0.1 mV, new ST-segment elevations > 0.2 mV or new wall motion abnormalities in transoesophageal echocardiography). FFP transfusions are recommended for urgent reversal of anticoagulation, known coagulation factor deficiencies, microvascular bleeding in the presence of elevated (> 1.5 times normal) prothrombin time (PT) or partial thromboplastin time (PTT) and microvascular bleeding after the replacement of more than one blood volume when PT or PTT cannot be obtained. Platelet transfusions are recommended prior to major operations in patients with platelet counts < 50,000/microl, intraoperatively with microvascular bleeding at platelet counts < 50,000/microl and in the range of 50,000-100,0000/microl following cardiopulmonary bypass and in patients undergoing surgery where already minimal bleeding may cause major damage such as in neurosurgery.
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Affiliation(s)
- Donat R Spahn
- Department of Anesthesiology, University Hospital Lausanne Chuv, Ch-1011 Lausanne, Switzerland.
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Stanworth SJ, Hyde C, Heddle N, Rebulla P, Brunskill S, Murphy MF. Prophylactic platelet transfusion for haemorrhage after chemotherapy and stem cell transplantation. Cochrane Database Syst Rev 2004:CD004269. [PMID: 15495093 DOI: 10.1002/14651858.cd004269.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Platelet transfusions are used in modern clinical practice to prevent and treat bleeding in thrombocytopenic patients with bone marrow failure. Although considerable advances have been made in platelet transfusion therapy in the last 30 years, some areas continue to provoke debate, especially the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding. OBJECTIVES To determine the optimal use of platelet transfusion for the prevention of haemorrhage (prophylactic platelet transfusion) in patients with haematological malignancies undergoing chemotherapy or stem cell transplantation. SEARCH STRATEGY Randomised controlled trials (RCTs) were searched for in the Cochrane Central Register of Controlled Trials (CENTRAL). Searching was also undertaken on the OVID versions of MEDLINE and EMBASE using an RCT search filter strategy. SELECTION CRITERIA Randomised controlled trials involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given prophylactically to prevent bleeding in patients with haematological malignancies and receiving treatment with chemotherapy and/or stem cell transplantation. DATA COLLECTION AND ANALYSIS All electronically derived citations and abstracts of papers identified by the review search strategy were initially screened for relevancy by one reviewer. Studies clearly irrelevant were excluded at this stage. The full text of all potentially relevant trials was then formally assessed for eligibility by two reviewers independently. Two reviewers completed data extraction independently. Missing data were requested from the original investigators, as appropriate. Disagreements were resolved by discussion with the other reviewers. MAIN RESULTS Eight completed published trials, with a total of 390 participants in the intervention groups and 362 participants in the control groups, were included in the review for further analysis. The eight studies were classified as: * three trials relevant to prophylactic platelet transfusions versus therapeutic platelet transfusions; * three trials relevant to prophylactic platelet transfusion with one trigger level versus prophylactic platelet transfusion with another trigger level; * two trials relevant to prophylactic platelet transfusion with one dose schedule versus prophylactic platelet transfusion with another dose schedule. The few reports of controlled trials addressing prophylactic versus therapeutic transfusions contained small numbers of patients and were all undertaken over 25 years ago. None of these three studies explicitly clarified whether the lack of a reported difference was a reflection of insufficient power in the trials. The findings of the meta-analyses for this group of three small studies must be interpreted with caution. In contrast, more contemporary trials addressed the question of what platelet count thresholds should apply for prophylactic transfusion; three identified studies broadly compared platelet transfusion thresholds of 10 versus 20 x 109/litre for different clinical groups of patients. There were no statistically significant differences between the groups with regards to mortality, remission rates, number of participants with severe bleeding events or red cell transfusion requirements. However, it was unclear whether the studies had sufficient power to demonstrate in combination non-inferiority in terms of safety of the lower threshold, 10 x 109/litre. Insufficient randomised trials have been undertaken to make clinically relevant conclusions about the effect of different platelet doses. REVIEWERS' CONCLUSIONS There are no reasons to change current practice but uncertainty about the practice of prophylactic transfusion therapy should be recognised, particularly in the light of concerns about the scenario that blood products, including platelets, could become an increasingly scarce resource in the future and for which adequate alternatives do not exist. Consideration should be given to developing adequately powered trials comparing strategies of prophylaxis versus therapeutic platelet transfusion.
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Affiliation(s)
- S J Stanworth
- National Blood Service, UK National Health Service, Level 2 , John Ratcliffe Hospital, Heddington, Oxford, UK, OX3 9DU.
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Bombeli T, Spahn DR. Updates in perioperative coagulation: physiology and management of thromboembolism and haemorrhage. Br J Anaesth 2004; 93:275-87. [PMID: 15220183 DOI: 10.1093/bja/aeh174] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Understanding of blood coagulation has evolved significantly in recent years. Both new coagulation proteins and inhibitors have been found and new interactions among previously known components of the coagulation system have been discovered. This increased knowledge has led to the development of various new diagnostic coagulation tests and promising antithrombotic and haemostatic drugs. Several such agents are currently being introduced into clinical medicine for both the treatment or prophylaxis of thromboembolic disease and for the treatment of bleeding. This review aims to elucidate these new concepts and to outline some consequences for clinical anaesthesia and perioperative medicine.
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Affiliation(s)
- T Bombeli
- Coagulation Laboratory, Division of Haematology, University Hospital of Zürich, Sternwartstrasse 14, CH-8091 Zürich, Switzerland
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Gibson BES, Todd A, Roberts I, Pamphilon D, Rodeck C, Bolton-Maggs P, Burbin G, Duguid J, Boulton F, Cohen H, Smith N, McClelland DBL, Rowley M, Turner G. Transfusion guidelines for neonates and older children. Br J Haematol 2004; 124:433-53. [PMID: 14984493 DOI: 10.1111/j.1365-2141.2004.04815.x] [Citation(s) in RCA: 195] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abrams-Ogg AC. Triggers for prophylactic use of platelet transfusions and optimal platelet dosing in thrombocytopenic dogs and cats. Vet Clin North Am Small Anim Pract 2004; 33:1401-18. [PMID: 14664205 DOI: 10.1016/s0195-5616(03)00095-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Prophylactic platelet transfusions are frequently given to human patients with hypoproliferative thrombocytopenia. For several decades, the most common transfusion trigger was 20,000/microL, but the trend is now to use 10,000/microL in the absence of other risk factors for bleeding. This trigger seems to reduce the number of transfusions without increasing the risk of severe bleeding. Most studies involved in establishing platelet transfusion policies have involved patients with acute leukemia, with fewer studies involving patients undergoing hematopoietic stem cell transplantation or aggressive chemotherapy for other cancers and patients with aplastic anemia. In the presence of other risk factors for spontaneous bleeding, 20,000/microL is still considered an appropriate trigger. The trigger for prophylactic transfusion before surgery has not undergone the same recent scrutiny as has the trigger for spontaneous bleeding. The recommendation remains to raise the platelet count to 50,000 to 100,000/microL if possible, although it is recognized that surgery and other invasive procedures have been performed at lower platelet counts without major bleeding. Prophylactic transfusion is not used in disorders of platelet consumption and destruction to prevent spontaneous bleeding but is used before surgery. Because of the comparative lack of experience with platelet transfusion in veterinary medicine, it is difficult to make generalizations for dogs and cats. Using the guidelines established for therapeutic and prophylactic transfusion of human patients is a reasonable starting point, however. A therapeutic transfusion policy is suggested in the veterinary setting provided that the patient can be closely observed for critical bleeding and a prompt transfusion can be given. This policy should ultimately reduce the overall number of platelet transfusions given to hospital patients. If an animal cannot be closely observed or the ability to transfuse on demand is limited, prophylactic transfusion is recommended. The triggers for initiating a platelet transfusion in dogs are extrapolated from human data; these values are lower by 50% for cats. Because of the imprecision of platelet counting at low values, platelet counts must always be interpreted in conjunction with clinical signs of hemorrhage. If platelet-rich plasma or platelet concentrate is available, a dose of 1 platelet unit per 10 kg is recommended, although resources may dictate a smaller dose. This will raise the recipient platelet count by a maximum of about 40,000/microL. Assuming a trigger of 10,000/microL, a transfusion will probably be required approximately every 3 days. It must be remembered that the frequency of platelet transfusions may be greater in the presence of factors accelerating platelet loss or destruction. If fresh whole blood is used, a rule of thumb is to transfuse 10 mL/kg, which will raise the recipient platelet count by a maximum of approximately 10,000/microL. Daily transfusions or transfusions every other day will probably be required.
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Affiliation(s)
- Anthony C Abrams-Ogg
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario N1G 2W1, Canada.
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Therapie mit Thrombozyten. TRANSFUSIONSMEDIZIN 2004. [DOI: 10.1007/978-3-662-10597-9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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49
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Benjamin RJ, Anderson KC. What is the proper threshold for platelet transfusion in patients with chemotherapy-induced thrombocytopenia? Crit Rev Oncol Hematol 2002; 42:163-71. [PMID: 12007974 DOI: 10.1016/s1040-8428(01)00182-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Platelet transfusion therapy is an integral part of modern oncological practice and is used to treat hemorrhage associated with thrombocytopenia. More commonly, platelets are transfused to prevent hemorrhage in thrombocytopenic patients. Conventional wisdom has suggested a threshold for prophylactic transfusion of <20x10(9)/l. Many studies now support the safety of more conservative transfusion regimes that reduce patient exposure to donors and conserve precious resources, without an increase in risk of hemorrhage. This review presents the data to support the use of a prophylactic transfusion threshold of <10x10(9)/l in patients without risk factors for hemorrhage and who have ready access to emergent medical care.
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Affiliation(s)
- Richard J Benjamin
- Dana Farber/Partners Cancer Care, Harvard Medical School, Boston, MA, USA.
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50
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Wandt H, Ehninger G, Gallmeier WM. New strategies for prophylactic platelet transfusion in patients with hematologic diseases. Oncologist 2002; 6:446-50. [PMID: 11675523 DOI: 10.1634/theoncologist.6-5-446] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
There is an increasing demand for platelet transfusions due to intensive chemotherapy and blood stem cell or bone marrow transplantation for the treatment of hematologic and oncologic diseases. There has been a long-lasting debate over whether the traditional threshold for prophylactic platelet transfusion of 20,000/microl is really necessary to prevent hemorrhagic complications. During the last 10 years several studies with more than 1,000 patients together have proven the safety of a platelet transfusion trigger of 10,000/microl or even lower when patients are clinically stable without active bleeding. This experience has been mostly gathered in patients with acute leukemia. But this stringent platelet transfusion policy can be used also after blood stem cell and bone marrow transplantation. In stable patients with aplastic anemia and myelodysplasia, prophylactic transfusions should be replaced in most patients by a therapeutic transfusion strategy. Such restrictive platelet transfusion strategies decrease the risk of infectious disease transmission, immunization, and febrile transfusion reactions. Besides reduced hospital visits and a shorter hospital stay for the patients, the costs for platelet transfusions are lowered by 20%-30% compared with traditional transfusion strategies. The decision to administer platelet transfusions should incorporate individual clinical characteristics of the patients and not simply be a reflexive reaction to the platelet count. Further clinical studies are needed to answer the still open question of whether patients with acute leukemia should also be transfused therapeutically rather than prophylactically when they are in stable condition without signs of active bleeding.
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Affiliation(s)
- H Wandt
- 5th Medical Department and Institute of Medical Oncology and Hamatology, Nüremberg, Germany.
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