1
|
Gilmore LE, Chou ST, Ghavam S, Thom CS. Consensus transfusion guidelines for a large neonatal intensive care network. Transfusion 2024; 64:1562-1569. [PMID: 38884350 DOI: 10.1111/trf.17914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 04/30/2024] [Accepted: 05/22/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Lindsay E Gilmore
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stella T Chou
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sarvin Ghavam
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher S Thom
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
2
|
van der Staaij H, Hooiveld NMA, Caram-Deelder C, Fustolo-Gunnink SF, Fijnvandraat K, Steggerda SJ, de Vries LS, van der Bom JG, Lopriore E. Most major bleeds in preterm infants occur in the absence of severe thrombocytopenia: an observational cohort study. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-326959. [PMID: 39009429 DOI: 10.1136/archdischild-2024-326959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 07/01/2024] [Indexed: 07/17/2024]
Abstract
OBJECTIVE To describe the incidence of major bleeds according to different platelet counts in very preterm infants, and to explore whether this association is influenced by other risk factors for bleeding. DESIGN Observational cohort study. SETTING A Dutch tertiary care neonatal intensive care unit. PATIENTS All consecutive infants with a gestational age at birth <32 weeks admitted between January 2004 and July 2022. EXPOSURE Infants were stratified into nine groups based on their nadir platelet count (×109/L) during admission (<10, 10-24, 25-49, 50-99, 100-149, 150-199, 200-249, 250-299 and ≥300), measured before the diagnosis of a major bleed and before any platelet transfusion was administered. MAIN OUTCOME MEASURE Incidence of major bleeds during admission. Logistic regression analysis was used to quantify the relationship between nadir platelet count and incidence of major bleeds. RESULTS Among 2772 included infants, 224 (8%) developed a major bleed. Of the infants with a major bleed, 92% (206/224) had a nadir platelet count ≥50×109/L. The incidence of major bleeds was 8% among infants with and without severe thrombocytopenia (platelet count <50×109/L), 18/231 (95% CI 5 to 12) and 206/2541 (95% CI 7 to 9), respectively. Similarly, after adjustment for measured confounders, there was no notable association between nadir platelet counts below versus above 50×109/L and the occurrence of major bleeds (OR 1.09, 95% CI 0.61 to 1.94). CONCLUSION In very preterm infants, the vast majority of major bleeds occur in infants without severe thrombocytopenia.
Collapse
Affiliation(s)
- Hilde van der Staaij
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
- Department of Paediatric Haematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nadine M A Hooiveld
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Camila Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Suzanne F Fustolo-Gunnink
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
- Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
- Department of Paediatric Haematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Institute for Advanced Study, University of Amsterdam, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
- Department of Paediatric Haematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sylke J Steggerda
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Linda S de Vries
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Johanna G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| |
Collapse
|
3
|
Liu C, Fu C, Sun Y, You Y, Wang T, Zhang Y, Xia H, Wang X. Itaconic acid regulation of TFEB-mediated autophagy flux alleviates hyperoxia-induced bronchopulmonary dysplasia. Redox Biol 2024; 72:103115. [PMID: 38554522 PMCID: PMC10998238 DOI: 10.1016/j.redox.2024.103115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/03/2024] [Accepted: 03/05/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Premature infants often require oxygen supplementation, which can elicit bronchopulmonary dysplasia (BPD) and lead to mitochondrial dysfunction. Mitochondria play important roles in lung development, in both normal metabolism and apoptosis. Enhancing our comprehension of the underlying mechanisms in BPD development can facilitate the effective treatments. METHODS Plasma samples from BPD and non-BPD infants were collected at 36 weeks post-menstrual age and used for metabolomic analysis. Based on hyperoxia-induced animal and cell models, changes in mitophagy and apoptosis were evaluated following treatment with itaconic acid (ITA). Finally, the mechanism of action of ITA in lung development was comprehensively demonstrated through rescue strategies and administration of corresponding inhibitors. RESULTS An imbalance in the tricarboxylic acid (TCA) cycle significantly affected lung development, with ITA serving as a significant metabolic marker for the outcomes of lung development. ITA improved the morphological changes in BPD rats, promoted SP-C expression, and inhibited the degree of alveolar type II epithelial cells (AEC II) apoptosis. Mechanistically, ITA mainly promotes the nuclear translocation of transcription factor EB (TFEB) to facilitate dysfunctional mitochondrial clearance and reduces apoptosis in AEC II cells by regulating autophagic flux. CONCLUSION The metabolic imbalance in the TCA cycle is closely related to lung development. ITA can improve lung development by regulating autophagic flux and promote the nuclear translocation of TFEB, implying its potential therapeutic utility in the treatment of BPD.
Collapse
Affiliation(s)
- Chengbo Liu
- Department of Pediatrics, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200093, China
| | - Changchang Fu
- Department of Pediatrics, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200093, China; Department of Neonatology, Children's Hospital of Soochow University, Suzhou, 215025, China
| | - Yazhou Sun
- Department of Pediatrics, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, Henan, 453000, China
| | - You You
- Department of Pediatrics, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200093, China
| | - Tengfei Wang
- Hongqiao International Institute of Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336, China.
| | - Yongjun Zhang
- Department of Pediatrics, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200093, China.
| | - Hongping Xia
- Department of Pediatrics, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200093, China.
| | - Xingyun Wang
- Hongqiao International Institute of Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336, China.
| |
Collapse
|
4
|
Burns CD, Bracey AW, Shander A, Tibi PR, Yates SG. Special Communication: Response to "Ensuring a Reliable Platelet Supply in the United States". Anesth Analg 2024; 138:925-927. [PMID: 38407593 DOI: 10.1213/ane.0000000000006742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Affiliation(s)
- Carolyn D Burns
- From the Society for the Advancement of Patient Blood Management
- PBM Physician Consultant
- Collaborative Clinical Consulting, LLC, Louisville, Kentucky
| | - Arthur W Bracey
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas
| | - Aryeh Shander
- TeamHealth
- Emeritus Chief Department of Anesthesiology, Critical Care and Hyperbaric Medicine
- Englewood Health, UF College of Medicine
- Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York
- Department of Anesthesiology and Critical Care, Rutgers University, Newark, New Jersey
| | - Pierre R Tibi
- Cardiothoracic Department, Yavapai Regional Medical Center, Prescott, Arizona
| | - Sean G Yates
- Department of Pathology, Coagulation and Patient Blood Management Services, William P. Clements Jr. University Hospital, Coagulation and Apheresis Services, Parkland Health and Hospital System, Dallas, Texas
| |
Collapse
|
5
|
Blumberg N, Asante AA, Nguyen PLT, Heal JM. Platelet Transfusions: The Good, the Bad, and the Ugly. Anesth Analg 2024; 138:921-924. [PMID: 38621279 DOI: 10.1213/ane.0000000000006918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Affiliation(s)
- Neil Blumberg
- From the Transfusion Medicine Division, Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, New York
| | | | | | | |
Collapse
|
6
|
Wittenmeier E, Piekarski F, Steinbicker AU. Blood Product Transfusions for Children in the Perioperative Period and for Critically Ill Children. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:58-65. [PMID: 38051160 PMCID: PMC10979439 DOI: 10.3238/arztebl.m2023.0243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Approximately 1% to 2% of all hospitalized children receive a transfusion of blood products, in Germany as in other countries. High-quality scientific evidence on transfusions in children is scarce. The available evidence is discussed in this review. METHODS This review is based on publications on blood product transfusions in children that were retrieved by a literature search, including clinical studies, international guideline recommendations, the recommendations of the German cross-sectional guideline, and results of other recent, relevant publications. RESULTS A restrictive transfusion strategy is recommended for all children, including those who are critically ill. Randomized controlled trials have shown that a restrictive strategy for erythrocyte concentrate transfusion in the intensive care unit is safe for children, including neonates. No robust data are available to enable the definition of a suitable threshold for the intraoperative administration of red blood cell concentrates in children undergoing extracardiac surgery. On the basis of studies from pediatric intensive care units, transfusions for hemodynamically stable children with a hemoglobin concentration of more than 7 g/dL are recommended only in exceptional cases. Therapeutic plasma is not recommended as volume replacement, except in massive transfusion. Platelet concentrate transfusions are indicated in case of active hemorrhage, and only rarely for prophylaxis. CONCLUSION There is a broad lack of evidence from randomized controlled trials concerning the indications for transfusions in children. A restrictive transfusion strategy, which has been found safe in the intensive-care setting, is favored by the guidelines in the perioperative setting as well. Further studies are needed to evaluate transfusion triggers and indications for all types of blood products, especially therapeutic plasma. Until more evidence is available, physicians should be aware of what the current evidence supports, and blood products should be given restrictively, and not prophylactically.
Collapse
Affiliation(s)
- Eva Wittenmeier
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- German Working Group on Paediatric Anesthesia (WAKKA)
| | - Florian Piekarski
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Andrea U. Steinbicker
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
- German Working Group on Paediatric Anesthesia (WAKKA)
| |
Collapse
|
7
|
Chan B, Singh Y. Personalized Evidence-Based Management of Patent Ductus Arteriosus in Preterm Infants. J Cardiovasc Dev Dis 2023; 11:7. [PMID: 38248877 PMCID: PMC10816643 DOI: 10.3390/jcdd11010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/05/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
There is no universal consensus on management of patent ductus arteriosus (PDA) in preterm infants and it varies significantly worldwide, even among the clinicians within units. The decision to treat requires a thorough understanding of the clinical status of the patient, clinical evaluation of PDA, echocardiographic diagnosis, and hemodynamic impact of ductal shunt on the pulmonary and systemic circulation. In this article, updated evidence on the efficacy and adverse effects of pharmacological treatment options and expectant management are presented, while highlighting the long-term benefits of PDA treatment remains equivocal and controversial. The authors propose a schematic targeted PDA treatment approach based on gestational and chronological age for practical clinical use, and they emphasize important future directions including advancement in PDA device closure techniques, diagnostic echo-parameters, hemodynamic evaluation to assess the impact on other organs, and understanding the long-term outcomes.
Collapse
Affiliation(s)
- Belinda Chan
- Neonatology Division, Department of Pediatrics, University of Utah, Salt Lake City, UT 84113, USA;
- Department of Radiology and Imaging Science, University of Utah, Salt Lake City, UT 84113, USA
| | - Yogen Singh
- Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA
- Department of Pediatrics, Division of Neonatology, University of Southern California (USC), Los Angeles, CA 90007, USA
| |
Collapse
|
8
|
Davenport P, Soule-Albridge E, Sola-Visner M. Hemostatic and Immunologic Effects of Platelet Transfusions in Neonates. Clin Perinatol 2023; 50:793-803. [PMID: 37866848 DOI: 10.1016/j.clp.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Liberal platelet transfusions are associated with increased morbidity and mortality among preterm neonates, and it is now recognized that platelets are both hemostatic and immune cells. Neonatal and adult platelets are functionally distinct, and adult platelets have the potential to be more immuno-active. Preclinical studies suggest that platelet transfusions (from adult donors) can trigger dysregulated immune responses in neonates, which might mediate the increased morbidity and mortality observed in clinical studies. More research is needed to understand how neonatal and adult platelets differ in their immune functions and the consequences of these differences in the setting of neonatal platelet transfusions.
Collapse
Affiliation(s)
- Patricia Davenport
- Division of Newborn Medicine, Boston Children's Hospital, 300 Longwood Avenue, Enders 954, Boston, MA 02115, USA.
| | - Erin Soule-Albridge
- Division of Newborn Medicine, Boston Children's Hospital, 300 Longwood Avenue, Enders 950.5, Boston, MA 02115, USA
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital, 300 Longwood Avenue, Enders 961, Boston, MA 02115, USA
| |
Collapse
|
9
|
van der Staaij H, Stanworth SJ, Fustolo-Gunnink SF. Prophylactic Platelet Transfusions: Why Less Is More. Clin Perinatol 2023; 50:775-792. [PMID: 37866847 DOI: 10.1016/j.clp.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Preterm neonates are a highly transfused patient group, with platelet transfusions being the second most transfused cellular blood component. Historically, however, evidence to inform optimal platelet transfusion practice has been limited. In pediatrics, much of the evidence has been inferred from studies in adult patients, although neonatologists have generally applied more cautious and liberal platelet transfusion thresholds to mitigate the complications of intraventricular hemorrhage. A total of three randomized controlled trials have now been published comparing different platelet transfusion strategies in neonates.
Collapse
Affiliation(s)
- Hilde van der Staaij
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, the Netherlands; Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, Plesmanlaan 125, 1066 CX, the Netherlands; Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Simon J Stanworth
- NHSBT, Oxford University Hospitals, NHS Foundation Trust, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, United Kingdom
| | - Susanna F Fustolo-Gunnink
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, the Netherlands; Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, Plesmanlaan 125, 1066 CX, the Netherlands; Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| |
Collapse
|
10
|
Moore CM, O'Reilly D, McCallion N, Curley AE. Changes in inflammatory proteins following platelet transfusion in a neonatal population. Pediatr Res 2023; 94:1973-1977. [PMID: 37443343 PMCID: PMC10665178 DOI: 10.1038/s41390-023-02731-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/16/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Studies have demonstrated increased morbidity and mortality with platelet transfusions in the neonatal period. Platelets are as important for host immunity and inflammation as for hemostasis. Increased inflammation may explain the dose-associated increase in mortality, bleeding, and lung disease. OBJECTIVE This study aims to assess if there are any changes in inflammatory cytokines post-platelet transfusion in babies in NICU. METHODS This prospective observational study recruited babies due to receive a non-emergency platelet transfusion. Dried whole blood samples were collected prior to and 2 h post-transfusion. Samples were processed using multiplex immunoassay to enable analysis of tiny blood volumes. Statistical analysis was performed using R. RESULTS Seventeen babies underwent 26 platelet transfusions across two centers. Median birthweight was 1545 g (535-3960 g) and median birth gestation was 31 weeks and 1 day (23 + 1 to 40 + 5). Median pre-transfusion platelet count was 19.5 × 109/l. There was a significant increase in levels of CXCL5 (p < 0.001), CD40 (p = 0.001), and TGF-β (p = 0.001) in neonatal blood samples post-platelet transfusion in the study group. CONCLUSION The increase in the cytokines CXCL5, CD40 and TGF-β after platelet transfusion in babies in NICU could potentiate existing inflammation, NEC, lung, or white matter injury. This could potentially explain long-term harm from platelet transfusion in babies. IMPACT There is a change in levels of immunomodulatory proteins CXCL5, CD40, and TGF-β after platelet transfusion in babies in NICU. Murine neonatal models have demonstrated an increase in cytokine levels after platelet transfusions. This is the first time that this has been demonstrated in human neonates. The increase in proinflammatory cytokines could potentially explain the long-term harm from platelet transfusion in babies, as they could potentiate existing inflammation, NEC, lung injury, or white matter injury.
Collapse
Affiliation(s)
- Carmel Maria Moore
- University College Dublin, Belfield, Dublin 4, Ireland.
- National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Daniel O'Reilly
- University College Dublin, Belfield, Dublin 4, Ireland
- Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Naomi McCallion
- Rotunda Hospital, Parnell Square, Dublin 1, Ireland
- Royal College of Surgeons in Ireland, St Stephen's Green, Dublin 2, Ireland
| | - Anna E Curley
- University College Dublin, Belfield, Dublin 4, Ireland
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| |
Collapse
|
11
|
Chen YX, Xiao TT, Chen HY, Chen X, Wang YQ, Ni Q, Wu BB, Wang HJ, Lu YL, Hu LY, Cao Y, Cheng GQ, Wang LS, Xiao FF, Yang L, Dong XR, Zhou WH. Risk stratification of hemodynamically significant patent ductus arteriosus by clinical and genetic factors. World J Pediatr 2023; 19:1192-1202. [PMID: 37318723 DOI: 10.1007/s12519-023-00733-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/10/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Hemodynamically significant patent ductus arteriosus (hsPDA) is associated with increased comorbidities in neonates. Early evaluation of hsPDA risk is critical to implement individualized intervention. The aim of the study was to provide a powerful reference for the early identification of high-risk hsPDA population and early treatment decisions. METHODS We enrolled infants who were diagnosed with PDA and performed exome sequencing. The collapsing analyses were used to find the risk gene set (RGS) of hsPDA for model construction. The credibility of RGS was proven by RNA sequencing. Multivariate logistic regression was performed to establish models combining clinical and genetic features. The models were evaluated by area under the receiver operating curve (AUC) and decision curve analysis (DCA). RESULTS In this retrospective cohort study of 2199 PDA patients, 549 (25.0%) infants were diagnosed with hsPDA. The model [all clinical characteristics selected by least absolute shrinkage and selection operator regression (all CCs)] based on six clinical variables was acquired within three days of life, including gestational age (GA), respiratory distress syndrome (RDS), the lowest platelet count, invasive mechanical ventilation, and positive inotropic and vasoactive drugs. It has an AUC of 0.790 [95% confidence interval (CI) = 0.749-0.832], while the simplified model (basic clinical characteristic model) including GA and RDS has an AUC of 0.753 (95% CI = 0.706-0.799). There was a certain consistency between RGS and differentially expressed genes of the ductus arteriosus in mice. The AUC of the models was improved by RGS, and the improvement was significant (all CCs vs. all CCs + RGS: 0.790 vs. 0.817, P < 0.001). DCA demonstrated that all models were clinically useful. CONCLUSIONS Models based on clinical factors were developed to accurately stratify the risk of hsPDA in the first three days of life. Genetic features might further improve the model performance. Video Abstract (MP4 86834 kb).
Collapse
Affiliation(s)
- Yu-Xi Chen
- Center for Molecular Medicine of Children's Hospital of Fudan University, Institutes of Biomedical Sciences, Fudan University, 138 Yi Xue Yuan Road, Shanghai, China
| | - Tian-Tian Xiao
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Hui-Yao Chen
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Xiang Chen
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Ya-Qiong Wang
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Qi Ni
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Bing-Bing Wu
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Hui-Jun Wang
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Yu-Lan Lu
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Li-Yuan Hu
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Guo-Qiang Cheng
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Lai-Shuan Wang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Fei-Fan Xiao
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Lin Yang
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Xin-Ran Dong
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China.
| | - Wen-Hao Zhou
- Center for Molecular Medicine of Children's Hospital of Fudan University, Institutes of Biomedical Sciences, Fudan University, 138 Yi Xue Yuan Road, Shanghai, China.
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.
| |
Collapse
|
12
|
Maier CL, Stanworth SJ, Sola-Visner M, Kor D, Mast AE, Fasano R, Josephson CD, Triulzi DJ, Nellis ME. Prophylactic Platelet Transfusion: Is There Evidence of Benefit, Harm, or No Effect? Transfus Med Rev 2023; 37:150751. [PMID: 37599188 DOI: 10.1016/j.tmrv.2023.150751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 08/22/2023]
Abstract
The optimal use of prophylactic platelet transfusion remains uncertain in a number of clinical scenarios. Platelet count thresholds have been established in patients with hematologic malignancies, yet thresholds backed by scientific data are limited or do not exist for many patient populations. Clinical scenarios involving transfusion thresholds for thrombocytopenic patients with critical illness, need for surgery or invasive procedures, or those involving specials populations like children and neonates, lack clear evidence for discerning favorable outcomes without undue risk related to platelet transfusion. In addition, while prophylactic platelet transfusions are administered with the goal of enhancing hemostasis, increasing evidence supports critical nonhemostatic roles for platelets related to innate and adaptive immunity, inflammation, and angiogenesis, which may impact patient responses and outcomes. Here we review several recent studies conducted in adult or pediatric patients that highlight the limitations in our current understanding of prophylactic platelet transfusion. Together, these studies underscore the need for additional research, especially in the form of robust randomized clinical trials and integrating additional parameters beyond the platelet count. Future research at the basic, translational, and clinical levels will best define the optimal role for prophylactic transfusion across the lifespan and its broader impact on health and disease.
Collapse
Affiliation(s)
- Cheryl L Maier
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Simon J Stanworth
- NHSBT; Oxford University Hospitals NHS Foundation Trust; Radcliffe Department of Medicine, University of Oxford; Oxford, United Kingdom
| | | | - Daryl Kor
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Allan E Mast
- Department of Cell Biology, Neurobiology and Anatomy, Versiti Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ross Fasano
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Cassandra D Josephson
- Department of Oncology, Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Darrell J Triulzi
- Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
13
|
Moore CM, D'Amore A, Fustolo-Gunnink S, Hudson C, Newton A, Santamaria BL, Deary A, Hodge R, Hopkins V, Mora A, Llewelyn C, Venkatesh V, Khan R, Willoughby K, Onland W, Fijnvandraat K, New HV, Clarke P, Lopriore E, Watts T, Stanworth S, Curley A. Two-year outcomes following a randomised platelet transfusion trial in preterm infants. Arch Dis Child Fetal Neonatal Ed 2023; 108:452-457. [PMID: 36810309 PMCID: PMC10447411 DOI: 10.1136/archdischild-2022-324915] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/13/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE Assess mortality and neurodevelopmental outcomes at 2 years of corrected age in children who participated in the PlaNeT-2/MATISSE (Platelets for Neonatal Transfusion - 2/Management of Thrombocytopenia in Special Subgroup) study, which reported that a higher platelet transfusion threshold was associated with significantly increased mortality or major bleeding compared to a lower one. DESIGN Randomised clinical trial, enrolling from June 2011 to August 2017. Follow-up was complete by January 2020. Caregivers were not blinded; however, outcome assessors were blinded to treatment group. SETTING 43 level II/III/IV neonatal intensive care units (NICUs) across UK, Netherlands and Ireland. PATIENTS 660 infants born at less than 34 weeks' gestation with platelet counts less than 50×109/L. INTERVENTIONS Infants were randomised to undergo a platelet transfusion at platelet count thresholds of 50×109/L (higher threshold group) or 25×109/L (lower threshold group). MAIN OUTCOMES MEASURES Our prespecified long-term follow-up outcome was a composite of death or neurodevelopmental impairment (developmental delay, cerebral palsy, seizure disorder, profound hearing or vision loss) at 2 years of corrected age. RESULTS Follow-up data were available for 601 of 653 (92%) eligible participants. Of the 296 infants assigned to the higher threshold group, 147 (50%) died or survived with neurodevelopmental impairment, as compared with 120 (39%) of 305 infants assigned to the lower threshold group (OR 1.54, 95% CI 1.09 to 2.17, p=0.017). CONCLUSIONS Infants randomised to a higher platelet transfusion threshold of 50×109/L compared with 25×109/L had a higher rate of death or significant neurodevelopmental impairment at a corrected age of 2 years. This further supports evidence of harm caused by high prophylactic platelet transfusion thresholds in preterm infants. TRIAL REGISTRATION NUMBER ISRCTN87736839.
Collapse
Affiliation(s)
- Carmel Maria Moore
- School of Medicine, University College Dublin, Dublin, Ireland
- Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Angela D'Amore
- Neonatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Cara Hudson
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | - Alice Newton
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | - Alison Deary
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | - Renate Hodge
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | - Ana Mora
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | | | - Rizwan Khan
- NICU, University Maternity Hospital Limerick, Limerick, Ireland
| | - Karen Willoughby
- Neonatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Wes Onland
- Neonatology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Pediatrics, Emma Children's Hospital, Pediatric Hematology, University of Amsterdam, Amsterdam, The Netherlands
| | - Helen V New
- Paediatric Transfusion Medicine, NHS Blood and Transplant, London, UK
| | - Paul Clarke
- Neonatal Intensive Care Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Enrico Lopriore
- Neonatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Timothy Watts
- Neonatal Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon Stanworth
- National Health Service Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anna Curley
- School of Medicine, University College Dublin, Dublin, Ireland
- Neonatology, National Maternity Hospital, Dublin, Ireland
| |
Collapse
|
14
|
Okbay Gunes A, Geter S, Avlanmis ME. The Usability of Platelet Mass Index Thresholds to Assess the Repeated Platelet Transfusion Requirements in Neonates. Indian J Hematol Blood Transfus 2023; 39:464-469. [PMID: 37304486 PMCID: PMC10247627 DOI: 10.1007/s12288-022-01604-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 10/19/2022] [Indexed: 11/09/2022] Open
Abstract
To evaluate the usability of platelet mass index (PMI) thresholds to assess the repeated platelet transfusion requirements in neonates who have received transfusion within the previous six days. This is a retrospective cross-sectional study conducted with neonates who received prophylactic platelet transfusion. The PMI was calculated as platelet count (× 1000/mm3) × mean platelet volume (MPV) (fL). Platelet transfusions were divided into two groups as first (Group 1) and repeated transfusions (Group 2). The increment and percentage of increment in platelet counts, MPV and PMI after transfusion were compared between the two groups. The amounts of changes were calculated as: (Post-transfusion) - (Pre-transfusion values). The percentages of changes were calculated as: ([Post-transfusion - Pre-transfusion values]/Pre-tansfusion values) × 100. Eighty three platelet transfusions were analyzed in 28 neonates. The median gestational age and birth weight were 34.5 (26-37) weeks, and 2225 (752.5-2937.5) grams, respectively. There were 20 (24.1%) transfusions in Group 1, and 63 (75.9%) transfusions in Group 2. There were no differences in the amounts of changes in platelet counts, MPV and PMI between the groups (p > 0.05). When the percentages of changes were analyzed, it was found that the platelet counts and PMI in Group 1 increased to a greater extent compared to Group 2 (p = 0.026, p = 0.039, respectively), but no significant difference was found in MPV between the groups (p = 0.081). The lower percentage of change in PMI in Group 2 was associated with the lower percentage of change in platelet counts. Being transfused with adult platelets did not affect platelet volume of the neonates. Therefore, PMI thresholds can be used in neonates with a history of platelet transfusion.
Collapse
Affiliation(s)
- Asli Okbay Gunes
- Neonatal Intensive Care Unit, Sanliurfa Training and Research Hospital, Sanliurfa, Turkey
| | - Suleyman Geter
- Neonatal Intensive Care Unit, Sanliurfa Training and Research Hospital, Sanliurfa, Turkey
| | - Mehmet Emin Avlanmis
- Neonatal Intensive Care Unit, Sanliurfa Training and Research Hospital, Sanliurfa, Turkey
| |
Collapse
|
15
|
Razak A, Patel W, Durrani NUR, Pullattayil AK. Interventions to Reduce Severe Brain Injury Risk in Preterm Neonates: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e237473. [PMID: 37052920 PMCID: PMC10102877 DOI: 10.1001/jamanetworkopen.2023.7473] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/23/2023] [Indexed: 04/14/2023] Open
Abstract
Importance Interventions to reduce severe brain injury risk are the prime focus in neonatal clinical trials. Objective To evaluate multiple perinatal interventions across clinical settings for reducing the risk of severe intraventricular hemorrhage (sIVH) and cystic periventricular leukomalacia (cPVL) in preterm neonates. Data Sources MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception until September 8, 2022, using prespecified search terms and no language restrictions. Study Selection Randomized clinical trials (RCTs) that evaluated perinatal interventions, chosen a priori, and reported 1 or more outcomes (sIVH, cPVL, and severe brain injury) were included. Data Extraction and Synthesis Two co-authors independently extracted the data, assessed the quality of the trials, and evaluated the certainty of the evidence using the Cochrane GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Fixed-effects pairwise meta-analysis was used for data synthesis. Main Outcomes and Measures The 3 prespecified outcomes were sIVH, cPVL, and severe brain injury. Results A total of 221 RCTs that assessed 44 perinatal interventions (6 antenatal, 6 delivery room, and 32 neonatal) were included. Meta-analysis showed with moderate certainty that antenatal corticosteroids were associated with small reduction in sIVH risk (risk ratio [RR], 0.54 [95% CI, 0.35-0.82]; absolute risk difference [ARD], -1% [95% CI, -2% to 0%]; number needed to treat [NNT], 80 [95% CI, 48-232]), whereas indomethacin prophylaxis was associated with moderate reduction in sIVH risk (RR, 0.64 [95% CI, 0.52-0.79]; ARD, -5% [95% CI, -8% to -3%]; NNT, 20 [95% CI, 13-39]). Similarly, the meta-analysis showed with low certainty that volume-targeted ventilation was associated with large reduction in risk of sIVH (RR, 0.51 [95% CI, 0.36-0.72]; ARD, -9% [95% CI, -13% to -5%]; NNT, 11 [95% CI, 7-23]). Additionally, early erythropoiesis-stimulating agents (RR, 0.68 [95% CI, 0.57-0.83]; ARD, -3% [95% CI, -4% to -1%]; NNT, 34 [95% CI, 22-67]) and prophylactic ethamsylate (RR, 0.68 [95% CI, 0.48-0.97]; ARD, -4% [95% CI, -7% to 0%]; NNT, 26 [95% CI, 13-372]) were associated with moderate reduction in sIVH risk (low certainty). The meta-analysis also showed with low certainty that compared with delayed cord clamping, umbilical cord milking was associated with a moderate increase in sIVH risk (RR, 1.82 [95% CI, 1.03-3.21]; ARD, 3% [95% CI, 0%-6%]; NNT, -30 [95% CI, -368 to -16]). Conclusions and Relevance Results of this study suggest that a few interventions, including antenatal corticosteroids and indomethacin prophylaxis, were associated with reduction in sIVH risk (moderate certainty), and volume-targeted ventilation, early erythropoiesis-stimulating agents, and prophylactic ethamsylate were associated with reduction in sIVH risk (low certainty) in preterm neonates. However, clinicians should carefully consider all of the critical factors that may affect applicability in these interventions, including certainty of the evidence, before applying them to clinical practice.
Collapse
Affiliation(s)
- Abdul Razak
- Department of Pediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, Victoria, Australia
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Waseemoddin Patel
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
| | - Naveed Ur Rehman Durrani
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
- Department of Pediatrics, Weill Cornell Medicine–Qatar, Doha, Qatar
| | | |
Collapse
|
16
|
Bahr TM, Christensen TR, Henry E, Astin M, Ilstrup SJ, Ohls RK, Christensen RD. Platelet Transfusions in a Multi-NICU Healthcare Organization Before And After Publication of the PlaNeT-2 Clinical Trial. J Pediatr 2023:113388. [PMID: 36933765 DOI: 10.1016/j.jpeds.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 03/06/2023] [Accepted: 03/12/2023] [Indexed: 03/20/2023]
Abstract
OBJECTIVES To evaluate whether implementing more restrictive NICU platelet transfusion guidelines following the PlaNeT-2 randomized controlled trial (transfusion threshold changed from 50,000/μL to 25,000/μL for most neonates) was associated with fewer NICU patients receiving a platelet transfusion, without adversely affecting outcomes. STUDY DESIGN Multi-NICU retrospective analysis of platelet transfusions, patient characteristics, and outcomes during three years before vs. three years after revising system-wide guidelines. RESULTS During the first period, 130 neonates received one or more platelet transfusions; this fell to 106 during the second. The transfusion rate was 15.9/1000 NICU admissions in the first period vs. 12.9 in the second (p=0.106). During the second period, a smaller proportion of transfusions was administered when the platelet count was in the 50,000 - 100,000/μL range (p=0.017), and a larger proportion when it was <25,000/μL (p=0.083). We also saw a fall in the platelet counts that preceded the order for transfusion from 43,100/μL to 38,000/μL (p=0.044). The incidence of adverse outcomes did not change. CONCLUSIONS Changing platelet transfusion guidelines in a multi-NICU network to a more restrictive practice was not associated with a significant reduction in number of neonates receiving a platelet transfusion. The guideline implementation was associated with a reduction in the mean platelet count triggering a transfusion. We speculate that further reductions in platelet transfusions can safely occur with additional education and accountability tracking.
Collapse
Affiliation(s)
- Timothy M Bahr
- Obstetric and Neonatal Operations, Intermountain Healthcare, Murray, UT;; Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT;.
| | | | - Erick Henry
- Obstetric and Neonatal Operations, Intermountain Healthcare, Murray, UT
| | - Mark Astin
- Intermountain Healthcare Transfusion Services and Department of Pathology, Intermountain Medical Center, Murray, UT
| | - Sarah J Ilstrup
- Intermountain Healthcare Transfusion Services and Department of Pathology, Intermountain Medical Center, Murray, UT
| | - Robin K Ohls
- Obstetric and Neonatal Operations, Intermountain Healthcare, Murray, UT;; Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT
| | - Robert D Christensen
- Obstetric and Neonatal Operations, Intermountain Healthcare, Murray, UT;; Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT
| |
Collapse
|
17
|
Abstract
Platelet plug formation is critically involved in murine ductus arteriosus closure and thrombocytopenia in preterm infants seems to negatively affect spontaneous and pharmacologically induced ductal closure. Furthermore, platelet dysfunction may contribute to ductal patency, especially in extremely immature infants. Neonatal platelets likely have multifaceted roles during ductal closure, such as secretion of several signaling molecules and facilitation of specific cell-cell interactions. The only available randomized-controlled trial on platelet transfusions in preterm infants with patent ductus arteriosus demonstrated that a liberal transfusion regimen did not promote ductal closure, but was associated with an increased rate of intraventricular hemorrhage. Herein, we discuss the available mechanistic evidence on the role of platelets in ductus arteriosus closure and their potential clinical implications in preterm infants. We further briefly outline future research directions aimed at a better understanding of platelet-endothelial interactions in neonatal health and disease.
Collapse
Affiliation(s)
- Hannes Sallmon
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany; Division of Pediatric Cardiology, Graz Medical University, Graz, Austria.
| | - Cassidy A Delaney
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora CO, USA
| |
Collapse
|
18
|
Liu TX, Zheng JX, Chen Z, Zhang ZC, Li D, Shi LP. An interpretable machine-learning model for predicting the efficacy of nonsteroidal anti-inflammatory drugs for closing hemodynamically significant patent ductus arteriosus in preterm infants. Front Pediatr 2023; 11:1097950. [PMID: 37082702 PMCID: PMC10110971 DOI: 10.3389/fped.2023.1097950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/22/2023] [Indexed: 04/22/2023] Open
Abstract
Background Nonsteroidal anti-inflammatory drugs (NSAIDs) have been widely used in the closure of ductus arteriosus in premature infants. We aimed to develop and validate an interpretable machine-learning model for predicting the efficacy of NSAIDs for closing hemodynamically significant patent ductus arteriosus (hsPDA) in preterm infants. Methods We assessed 182 preterm infants ≤ 30 weeks of gestational age first treated with NSAIDs to close hsPDA. According to the treatment outcome, patients were divided into a "success" group and "failure" group. Variables for analysis were demographic features, clinical features, as well as laboratory and echocardiographic parameters within 72 h before medication use. We developed the machine-learning model using random forests. Model performance was assessed by the area under the receiver operating characteristic curve (AUC). Variable-importance and marginal-effect plots were constructed to explain the predictive model. The model was validated using an external cohort of two preterm infants who received ibuprofen (p.o.) to treat hsPDA. Results Eighty-three cases (45.6%) were in the success group and 99 (54.4%) in the failure group. Infants in the success group were associated with maternal chorioamnionitis (p = 0.002), multiple births (p = 0.007), gestational age at birth (p = 0.020), use of indometacin (p = 0.007), use of inotropic agents (p < 0.001), noninvasive ventilation (p = 0.001), plasma albumin level (p < 0.001), PDA size (p = 0.038) and Vmax (p = 0.013). Multivariable binary logistic regression analysis showed that maternal chorioamnionitis, multiple births, use of indomethacin, use of inotropic agents, plasma albumin level, and PDA size were independent risk factors influencing the efficacy of NSAIDs (p < 0.05). The AUC of the random forest model was 0.792. The top-three features contributing most to the model in the variable-importance plot were the plasma albumin level and platelet count 72 h before treatment and 24-h urine volume before treatment. In the external cohort, treatment succeeded in one case and failed in the other. The probabilities of success and failure predicted by the random forest model were 60.2% and 48.4%, respectively. Conclusion Based on clinical, laboratory, and echocardiographic features before first-time NSAIDs treatment, we constructed an interpretable machine-learning model, which has a certain reference value for predicting the closure of hsPDA in premature infants under 30 weeks of gestational age.
Collapse
Affiliation(s)
- Tai-Xiang Liu
- Department of NICU, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jin-Xin Zheng
- Department of Nephrology, Ruijin Hospital, Institute of Nephrology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- School of Global Health, Chinese Center for Tropical Diseases Research, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zheng Chen
- Department of NICU, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Yiwu Branch, Children's Hospital Zhejiang University School of Medicine, Yiwu, China
| | - Zi-Chen Zhang
- Department of NICU, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Dan Li
- Department of NICU, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Li-Ping Shi
- Department of NICU, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Correspondence: Li-Ping Shi
| |
Collapse
|
19
|
Yang Y, Gowda SH, Hagan JL, Hensch L, Teruya J, Fernandes CJ, Hui SKR. Blood transfusion is associated with increased mortality for neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation support. Vox Sang 2022; 117:1391-1397. [PMID: 36121192 DOI: 10.1111/vox.13363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/29/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Blood transfusion is frequently needed to maintain adequate haemostasis and improve oxygenation for patients treated with extracorporeal membrane oxygenation (ECMO). It is more so for neonates with immature coagulation systems who require surgical intervention such as congenital diaphragmatic hernia (CDH) repair. There is growing evidence suggesting an association between blood transfusions and increased mortality. The aim of this study is to evaluate the association of blood transfusions during the peri-operative period of CDH repair, among other clinical parameters, with mortality in neonates undergoing on-ECMO CDH repair. MATERIALS AND METHODS We performed a single centre retrospective chart review of all neonates with CDH undergoing on-ECMO surgical repair from January 2010 to December 2020. Logistic regression was used to investigate associations with survival status. RESULTS Sixty-two patients met the inclusion criteria. Platelet transfusions (odds ratio [OR] 1.42, 95% confidence interval [CI]: 1.06-1.90) in the post-operative period and ECMO duration (OR 1.17, 95% CI: 1.05-1.30) were associated with increased mortality. Major bleeding complications had the strongest association with mortality (OR 10.98, 95% CI: 3.27-36.91). Gestational age, birth weight, Apgar scores, sex, blood type, right versus left CDH, venovenous versus venoarterial ECMO and duration of ECMO before CDH repair and circuit change after adjusting for ECMO duration were not significantly associated with survival. CONCLUSION Platelet transfusion in the post-operative period and major bleeding are associated with increased mortality in CDH neonates with surgical repair. The data suggest a need to develop robust plans for monitoring and preventing coagulation aberrancies during neonatal ECMO support.
Collapse
Affiliation(s)
- Yu Yang
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sharada H Gowda
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Joseph L Hagan
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Lisa Hensch
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jun Teruya
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Shiu-Ki R Hui
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
20
|
Abstract
Platelet transfusions are commonly administered for the prevention or treatment of bleeding in patients with acquired thrombocytopenia across a range of clinical contexts. Recent data, including randomized trials, have highlighted uncertainties in the risk-benefit balance of this therapy, which is the subject of this review. Hemovigilance systems report that platelets are the most frequently implicated component in transfusion reactions. There is considerable variation in platelet count increment after platelet transfusion, and limited evidence of efficacy for clinical outcomes, including prevention of bleeding. Bleeding events commonly occur despite the different policies for platelet transfusion prophylaxis. The underlying mechanisms of harm reported in randomized trials may be related to the role of platelets beyond hemostasis, including mediating inflammation. Research supports the implementation of a restrictive platelet transfusion policy. Research is needed to better understand the impact of platelet donation characteristics on outcomes, and to determine the optimal thresholds for platelet transfusion before invasive procedures or major surgery (eg, laparotomy). Platelet transfusion policies should move toward a risk-adapted approach that does not focus solely on platelet count.
Collapse
|
21
|
Davenport P, Fan HH, Nolton E, Feldman HA, Lorenz V, Canas J, Acosta-Zaldívar M, Yakah W, Arthur C, Martin C, Stowell S, Koehler J, Mager D, Sola-Visner M. Platelet transfusions in a murine model of neonatal polymicrobial sepsis: Divergent effects on inflammation and mortality. Transfusion 2022; 62:1177-1187. [PMID: 35522536 DOI: 10.1111/trf.16895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/11/2022] [Accepted: 03/18/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Platelet transfusions (PTxs) are often given to septic preterm neonates at high platelet count thresholds in an attempt to reduce bleeding risk. However, the largest randomized controlled trial (RCT) of neonatal transfusion thresholds found higher mortality and/or major bleeding in infants transfused at higher thresholds. Using a murine model, we investigated the effects of adult PTx on neonatal sepsis-induced mortality, systemic inflammation, and platelet consumption. STUDY DESIGN AND METHODS Polymicrobial sepsis was induced via intraperitoneal injection of cecal slurry preparations (CS1, 2, 3) into P10 pups. Two hours after infection, pups were transfused with washed adult Green Flourescent Protein (GFP+) platelets or control. Weights, platelet counts, and GFP% were measured before 4 and 24 h post-infection. At 24 h, blood was collected for quantification of plasma cytokines. RESULTS The CS batches varied in 24 h mortality (11%, 73%, and 30% in CS1, 2, and 3, respectively), due to differences in bacterial composition. PTx had differential effects on sepsis-induced mortality and systemic inflammatory cytokines, increasing both in mice infected with CS1 (low mortality) and decreasing both in mice infected with CS2 and 3. In a mathematical model of platelet kinetics, the consumption of transfused adult platelets was higher than that of endogenous neonatal platelets, regardless of CS batch. DISCUSSION Our findings support the hypothesis that transfused adult platelets are consumed faster than endogenous neonatal platelets in sepsis and demonstrate that PTx can enhance or attenuate neonatal inflammation and mortality in a model of murine polymicrobial sepsis, depending on the composition of the inoculum and/or the severity of sepsis.
Collapse
Affiliation(s)
- Patricia Davenport
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Hsuan-Hao Fan
- Department of Pharmaceutical Sciences, University of Buffalo, State University of New York, Buffalo, New York, USA
| | - Emily Nolton
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Henry A Feldman
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Viola Lorenz
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge Canas
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - William Yakah
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Neonatology, Beth Israel Medical Center, Boston, Massachusetts, USA
| | - Connie Arthur
- Division of Transfusion Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Camilia Martin
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Neonatology, Beth Israel Medical Center, Boston, Massachusetts, USA
| | - Sean Stowell
- Division of Transfusion Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Julia Koehler
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Donald Mager
- Department of Pharmaceutical Sciences, University of Buffalo, State University of New York, Buffalo, New York, USA
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
22
|
Abiramalatha T, Vadakkencherry Ramaswamy V, Thanigainathan S. Platelet transfusions in neonates-Unresolved aspects and future directions. Pediatr Blood Cancer 2022; 69:e29608. [PMID: 35187787 DOI: 10.1002/pbc.29608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India.,Department of Neonatology, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | | | - Sivam Thanigainathan
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| |
Collapse
|
23
|
Yarboro MT, Gopal SH, Su RL, Morgan TM, Reese J. Mouse models of patent ductus arteriosus (PDA) and their relevance for human PDA. Dev Dyn 2022; 251:424-443. [PMID: 34350653 PMCID: PMC8814064 DOI: 10.1002/dvdy.408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/16/2021] [Accepted: 07/27/2021] [Indexed: 12/15/2022] Open
Abstract
The ductus arteriosus (DA) is a unique fetal vascular shunt, which allows blood to bypass the developing lungs in utero. After birth, changes in complex signaling pathways lead to constriction and permanent closure of the DA. The persistent patency of the DA (PDA) is a common disorder in preterm infants, yet the underlying causes of PDA are not fully defined. Although limits on the availability of human DA tissues prevent comprehensive studies on the mechanisms of DA function, mouse models have been developed that reveal critical pathways in DA regulation. Over 20 different transgenic models of PDA in mice have been described, with implications for human DA biology. Similarly, we enumerate 224 human single-gene syndromes that are associated with PDA, including a small subset that consistently feature PDA as a prominent phenotype. Comparison and functional analyses of these genes provide insight into DA development and identify key regulatory pathways that may serve as potential therapeutic targets for the management of PDA.
Collapse
Affiliation(s)
- Michael T Yarboro
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee, USA
| | - Srirupa H Gopal
- Department of Pediatrics, Erlanger Health System, Chattanooga, Tennessee, USA
| | - Rachel L Su
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas M Morgan
- Division of Medical Genetics and Genomic Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeff Reese
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee, USA.,Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
24
|
Sola-Visner M, Leeman KT, Stanworth SJ. Neonatal platelet transfusions: New evidence and the challenges of translating evidence-based recommendations into clinical practice. J Thromb Haemost 2022; 20:556-564. [PMID: 35112471 DOI: 10.1111/jth.15664] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/28/2022] [Indexed: 01/19/2023]
Abstract
Platelet transfusions are a common intervention for thrombocytopenia. Although the main reason for transfusing platelets is to improve hemostasis, platelets have many additional physiological roles, including interactions with immune pathways. Much of the evidence base for safe and effective transfusions has been informed by randomized trials in adult patients with hematological malignancies. Only three randomized trials have been conducted in sick neonates. These trials have indicated evidence of harm, including a significantly higher rate of death or major bleeding within 28 days after randomization for the largest trial, which enrolled 660 infants. The overall research indicates limited effectiveness of platelet transfusions to reduce bleeding risk. It is important that the results of trials are implemented into practice, but uptake of research findings into neonatal medicine remains inconsistent, as for many areas of health care. There is a need to establish which potential implementation strategies (cost-) efficiently enact change, such as audit and feedback, automated reminder systems for ordering transfusions, and use of opinion leaders. Research is exploring potential mechanisms underlying the lack of effectiveness of platelet transfusions and the increased bleeding and mortality observed in neonatal randomized trials. One potential mechanism concerns the roles of platelets to promote excessive angiogenic signals during a vulnerable period of brain development. A further hypothesis explores the effects of transfusing "adult" platelets into "neonatal" thrombocytopenic blood on primary hemostasis and immune responses.
Collapse
Affiliation(s)
- Martha Sola-Visner
- Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristen T Leeman
- Pediatrics, Boston Children's Hospital, Harvard Neonatal-Perinatal Fellowship Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Simon J Stanworth
- Haematology and Transfusion Medicine, Department of Haematology, NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
25
|
Abstract
The neonatal hemostatic system is different from that of adults. The differences in levels of procoagulant and anticoagulant factors and the evolving equilibrium in secondary hemostasis during the transition from fetal/neonatal life to infancy, childhood, and adult life are known as "developmental hemostasis." In regard to primary hemostasis, while the number (150,000-450,000/µl) and structure of platelets in healthy neonates closely resemble those of adults, there are significant functional differences between neonatal and adult platelets. Specifically, platelets derived from both cord blood and neonatal peripheral blood are less reactive than adult platelets to agonists, such as adenosine diphosphate (ADP), epinephrine, collagen, thrombin, and thromboxane (TXA2) analogs. This platelet hyporeactivity is due to differences in expression levels of key surface receptors and/or in signaling pathways, and is more pronounced in preterm neonates. Despite these differences in platelet function, bleeding times and PFA-100 closure times (an in vitro test of whole-blood primary hemostasis) are shorter in healthy full-term infants than in adults, reflecting enhanced primary hemostasis. This paradoxical finding is explained by the presence of factors in neonatal blood that increase the platelet-vessel wall interaction, such as high von Willebrand factor (vWF) levels, predominance of ultralong vWF multimers, high hematocrit, and high red cell mean corpuscular volume. Thus, the hyporeactivity of neonatal platelets should not be viewed as a developmental deficiency, but rather as an integral part of a developmentally unique, but well balanced, primary hemostatic system. In clinical practice, due to the high incidence of bleeding (especially intraventricular hemorrhage, IVH) among preterm infants, neonatologists frequently transfuse platelets to non-bleeding neonates when platelet counts fall below an arbitrary limit, typically higher than that used in older children and adults. However, recent studies have shown that prophylactic platelet transfusions not only fail to decrease bleeding in preterm neonates, but are associated with increased neonatal morbidity and mortality. In this review, we will describe the developmental differences in platelet function and primary hemostasis between neonates and adults, and will analyze the implications of these differences to platelet transfusion decisions.
Collapse
Affiliation(s)
- Francisca Ferrer-Marín
- Hematology and Medical Oncology Department. Hospital UniversitarioMorales-Meseguer. Centro Regional de Hemodonación. IMIB-Arrixaca. Murcia, Spain,CIBERER CB15/00055, Murcia, Spain,Grado de Medicina. Universidad Católica San Antonio (UCAM)
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| |
Collapse
|
26
|
Shi Y, Ji J, Wang C. Exploring the NT-proBNP expression in Premature Infants with Patent Ductus Arteriosus (PDA) by Echocardiography. Pak J Med Sci 2021; 37:1615-1619. [PMID: 34712293 PMCID: PMC8520382 DOI: 10.12669/pjms.37.6-wit.4853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/08/2021] [Accepted: 07/06/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives: To investigate the correlation between echocardiographic indicators and the expression level of N-terminal pro-brain natriuretic peptide (NT-proBNP) in premature infants (PIs) with patent ductus arteriosus (PDA) and the value of NT-proBNP in diagnosing symptomatic PDA (sPDA) in PIs whose gestational age (GA) was less than 32 weeks. Methods: Ninty premature infants were selected as the research objects, including 52 in the non-PDA group and 38 in the PDA group (26 sPDA cases and 12 cases with asymptomatic PDA (asPDA)) from February 2019 to March 2020. The general information of these infants was recorded, including gender, delivery method, maternal infection, and serum NT-proBNP level on the 3rd day after birth. They were screened by echocardiographic indicators under an artificial intelligence convolutional neural network (AI-CNN). The Receiver Operating Characteristic (ROC) curves were illustrated to decide serum NT-proBNP expression levels, thereby determining specificity and sensitivity of sPDA and the correlation between serum sPDA NT-proBNP expression and echocardiographic indicators. Results: The expression level of serum NT-proBNP in the sPDA group was greater than that in the asPDA group and the non-PDA group (P<0.001). The serum NT-proBNP expression level was positively correlated with the diameter of the ductus arteriosus in the sPDA group (r=0.462, P<0.001); it was also positively correlated with the ratio of left atrium/aorta (LA/AO) (r=0.573, P<0.001), but was not correlated with left ventricular ejection fraction (LVEF) (r=-0.015, P=0.747). Conclusion: The combination of serum NT-proBNP expression and echocardiography had clinical values in early diagnosis of PDA.
Collapse
Affiliation(s)
- Yunlong Shi
- Yunlong Shi, Attending Physician. Department of Neonatology, Yiwu Central Hospital, No. 519 Nanmen Road, Yiwu City, Zhejiang Province, 322000, China
| | - Jianwei Ji
- Jianwei Ji, Attending Physician. Department of Neonatology, Yiwu Central Hospital, No. 519 Nanmen Road, Yiwu City, Zhejiang Province, 322000, China
| | - Chunying Wang
- Chunying Wang, Attending Physician. Department of Neonatology, Yiwu Central Hospital, No. 519 Nanmen Road, Yiwu City, Zhejiang Province, 322000, China
| |
Collapse
|
27
|
Huang HW, Lin C, Hsu KH, Hsu SY, Mok TY, Wu IH, Lai MY, Lien R. Protective factors against preterm infants to develop significant patent ductus arteriosus. Pediatr Neonatol 2021; 62:379-386. [PMID: 33931344 DOI: 10.1016/j.pedneo.2021.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 01/17/2021] [Accepted: 03/29/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Identifying preterm infants with a higher likelihood of spontaneous patent ductus arteriosus (PDA) closure would be desirable. This study aimed to examine daily PDA status during the first week of life for very low birthweight (VLBW, <1500 g) preterm infants and to develop a scoring system to predict spontaneous PDA closure. METHODS We enrolled VLBW infants admitted between January 2016 and January 2017 and performed daily echocardiographic screening for PDA existence. Oxygen index (OI, mean airway pressure × fraction of inspired oxygen/partial pressure of arterial oxygen) was applied to represent the respiratory condition. RESULTS A total of 215 VLBW infants were enrolled, and the accumulative incidence of spontaneous PDA closure by age 1 week was 80%, 70%, and 34% for infants born of gestational age (GA) ≥30, 28-29, and ≤27 weeks, respectively. Of these 215 infants, 184 infants entered the second phase to establish the scoring system. Infants with spontaneous PDA closure were more mature (GA 29.2 ± 2.3 vs. 26.9 ± 2.3 weeks, p < 0.001), had lower OI (2.8 ± 2.2 vs. 5.6 ± 5.3, p < 0.001) and were less likely to need endotracheal intubation (23% vs. 68%, p < 0.001). Using the receiver operating characteristics curve, OI <2.5 was determined favoring higher PDA closure incidence. The score was calculated based on the odds ratio generated in multiple regression: 4, 3 and 1 points for GA ≥30, 28-29 and ≤27 weeks, 2 and 1 points for OI <2.5 and ≥2.5, and 3 and 1 points for without and with endotracheal intubation. Using score ≥6 to predict PDA closure, the sensitivity and specificity were 0.77 and 0.72. CONCLUSION A score made up of GA, OI and need for intubation was proposed to predict spontaneous PDA closure by age 1 week, which could be helpful to clinicians in the management of PDA in preterm infants.
Collapse
Affiliation(s)
- Hsiao-Wen Huang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Chih Lin
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Kai-Hsiang Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Science, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Yun Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan; Division of Neonatology, Department of Pediatrics, New Taipei City Tucheng Hospital, New Taipei City, Taiwan
| | - Tze-Yee Mok
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan; Division of Neonatology, Department of Pediatrics, New Taipei City Tucheng Hospital, New Taipei City, Taiwan
| | - I-Hsyuan Wu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yin Lai
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Science, Chang Gung University, Taoyuan, Taiwan
| | - Reyin Lien
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan.
| |
Collapse
|
28
|
Moore CM, Curley AE. Neonatal Platelet Transfusions: Starting Again. Transfus Med Rev 2021; 35:29-35. [PMID: 34312045 DOI: 10.1016/j.tmrv.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 10/21/2022]
Abstract
Preterm neonates with severe thrombocytopenia are frequently prescribed prophylactic platelet transfusions despite no evidence of benefit. Neonatal platelet transfusion practice varies, both nationally and internationally. Volumes and rates of transfusion in neonatology are based on historic precedent and lack an evidence base. The etiology of harm from platelet transfusions is poorly understood. Neonates are expected to be the longest surviving recipients of blood produce transfusions, and so avoiding transfusion associated harm is critical in this cohort. This article reviews the evidence for and against platelet transfusion in the neonate and identifies areas of future potential neonatal platelet transfusion research.
Collapse
Affiliation(s)
- Carmel Maria Moore
- Department of Neonatology, National Maternity Hospital, Dublin 2, D02YH21, Ireland.
| | - Anna E Curley
- Department of Neonatology, National Maternity Hospital, Dublin 2, D02YH21, Ireland
| |
Collapse
|
29
|
Patent ductus arteriosus treatment trends and associated morbidities in neonates. Sci Rep 2021; 11:10689. [PMID: 34021202 PMCID: PMC8139968 DOI: 10.1038/s41598-021-89868-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/28/2021] [Indexed: 01/28/2023] Open
Abstract
To evaluate national epidemiologic data on infants treated for patent ductus arteriosus (PDA) in Korea and analyze outcomes associated with different PDA treatments. We retrospectively evaluated data on 12,336 patients diagnosed with PDA (International Classification of Diseases-10 code: Q250) between 2015 and 2018 from the Health Insurance Review and Assessment database. Among them, 1623 patients underwent surgical ligation (code: O1671). We used birth certificate data from Statistics Korea to estimate the prevalence, diagnosis, and treatment of PDA. The prevalence of infants with PDA was 81 infants per 10,000 live births and 45.2% in very low birth weight (VLBW) infants, which increased from 2015 to 2018. PDA ligation was performed in 2571 infants and 22% VLBW infants. Medical treatment was administered to 4202 infants, which decreased significantly, especially in VLBW infants (62% to 53%). The proportion of treatment was as follows: conservative treatment (53.1%), intravenous ibuprofen (24.4%), surgery (20.4%), and oral ibuprofen (10.7%); that among 4854 VLBW infants was as follows: intravenous ibuprofen (46.3%), conservative treatment (33.2%), surgery (22.2%), and oral ibuprofen (14.2%). Surgical treatment had a significantly higher risk (odds ratio 1.36) of mortality than conservative treatment. Surgical and/or medical treatments were associated with a higher risk of morbidity. Recently, increased use of conservative management of PDA has contributed to improved neonatal outcomes in VLBW infants. Select patients may still benefit from surgical ligation following careful consideration.
Collapse
|
30
|
Wang J, Ma X, Zhang Q, Chen Y, Wu D, Zhao P, Yu Y. The Interaction Analysis of SNP Variants and DNA Methylation Identifies Novel Methylated Pathogenesis Genes in Congenital Heart Diseases. Front Cell Dev Biol 2021; 9:665514. [PMID: 34041244 PMCID: PMC8143053 DOI: 10.3389/fcell.2021.665514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/16/2021] [Indexed: 11/17/2022] Open
Abstract
Congenital heart defect (CHD) is a rare and complicated disease with a high mortality rate. Its etiology remains unclear and includes many aspects. DNA methylation has been indicated to be involved in heart development in the early stage of life, and aberrant methylation level was related to CHDs. This study provides the first evidence of the cross talk of SNP variants and DNA methylation in clarifying CHD underlying genomic cause. We gathered whole exome sequencing (WES) data for Group 1 consisting of patients with PA (n = 78), TOF (n = 20), TAPVC (n = 78), and PDA (n = 40), and 100 healthy children as control group. Rare non-synonymous mutations and novel genes were found and highlighted. Meanwhile, we carried out the second analysis of DNA methylation data from patients with PA (n = 3), TAPVC (n = 3), TOF (n = 3), and PDA (n = 2), and five healthy controls using 850 K array in Group 2. DNA methylation was linked to WES data, and we explored an obvious overlap of hyper/hypomethylated genes. Next, we identified some candidate genes by Fisher’s exact test and Burden analysis; then, those methylated genes were figured out by the criteria of the mutation located in the CpG islands of the genome, differential methylation sites (DMS), and DNA methylation quantitative trait loci (meQTLs) in the database, respectively. Also, the interaction of differentially methylated candidate genes with known CHD pathogenetic genes was depicted in a molecular network. Taken together, our findings show that nine novel genes (ANGPTL4, VEGFA, PAX3, MUC4, HLA-DRB1, TJP2, BCR, PKD1, and HK2) in methylation level are critical to CHD and reveal a new insight into the molecular pathogenesis of CHD.
Collapse
Affiliation(s)
- Jing Wang
- Department of Pediatric, Yangpu District Shidong Hospital, Shanghai, China.,Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoqin Ma
- Department of Pediatric, Yangpu District Shidong Hospital, Shanghai, China
| | - Qi Zhang
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yinghui Chen
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dan Wu
- Department of Pediatric, Yangpu District Shidong Hospital, Shanghai, China
| | - Pengjun Zhao
- Department of Pediatric Cardiology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Yu
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
31
|
de Waal K, Prasad R, Kluckow M. Patent ductus arteriosus management and the drift towards therapeutic nihilism - What is the evidence? Semin Fetal Neonatal Med 2021; 26:101219. [PMID: 33653600 DOI: 10.1016/j.siny.2021.101219] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The published literature on patent ductus arteriosus (PDA) management is challenging to interpret due to poorly designed trials with high rates of open label treatments, homogenisation of patients with varying physiological subtypes, poor treatment efficacy, and spontaneous closure in more mature infants. The perceived lack of clinical benefit has led to a drift away from medical and surgical treatment of all infants with a PDA. This therapeutic nihilism as a default response to PDA management fails to recognise the physiological relevance of a left-to-right shunt with early haemodynamic instability after birth and subsequent pulmonary volume overload with prolonged exposure. Clinicians need to know if therapeutic nihilism is safe. This review will provide an overview of the available data on the efficacy of known PDA treatments, conservative management and supportive care measures that are currently applied.
Collapse
Affiliation(s)
- Koert de Waal
- John Hunter Children's Hospital Department of Neonatology and University of Newcastle, Newcastle, NSW, Australia.
| | - Rahul Prasad
- Randwick Children's Hospital Department of Neonatology, Sydney, NSW, Australia
| | - Martin Kluckow
- Royal North Shore Hospital Department of Neonatology and University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
32
|
Hasan R, Saifee NH. Benefits of lower neonatal platelet transfusion thresholds. Transfusion 2021; 61:1672-1675. [PMID: 33786866 DOI: 10.1111/trf.16386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 03/20/2021] [Indexed: 01/22/2023]
Abstract
Degree of thrombocytopenia is not a predictor of bleeding risk in neonates, yet most platelet transfusions are given prophylactically in non-bleeding premature infants. Recent data support a lower platelet transfusion threshold of 25 × 109 /L in non-bleeding premature neonates and indicate that higher transfusion thresholds may be associated with harm including increased risk of death and bleeding. The mechanism of increased adverse events with higher platelet transfusion threshold is unknown, but considerations include adult platelets disrupting the neonatal hemostatic balance of hypoactive platelets in a hypercoagulable and fragile environment and having a pro-inflammatory effect.
Collapse
Affiliation(s)
- Rida Hasan
- Bloodworks Northwest, Seattle, Washington, USA
| | - Nabiha H Saifee
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital and University of Washington Seattle, Seattle, Washington, USA
| |
Collapse
|
33
|
The relationship between platelet indices and patent ductus arteriosus in preterm infants: a systematic review and meta-analysis. Eur J Pediatr 2021; 180:699-708. [PMID: 32949292 DOI: 10.1007/s00431-020-03802-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/12/2020] [Accepted: 09/04/2020] [Indexed: 01/11/2023]
Abstract
Patent ductus arteriosus (PDA), one of the most common disorders in newborns, is associated with many complications in premature infants such as respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD). However, the diagnosis of hemodynamically significant patent ductus arteriosus (hsPDA) is still an ongoing debate. The relationship between platelet parameters and hsPDA has been explored in many studies over the last decade, but there is still no definite conclusion. We aim to explain the relationship between platelet parameters and hsPDA through this meta-analysis. Therefore, we used PubMed, Embase, the Cochrane Library, and Web of Science databases as well as the Google Scholar to search for studies up to May 2020. Three reviewers independently screened the articles, evaluated the quality of the articles, and collected the data. The random-effects model and fixed-effects model were used to evaluate pooled results. We used the I-square (I2) test to examine heterogeneity and the funnel plot; Egger's test and meta-regression analysis were used to test for publication bias. Influence analysis was also carried out in this study. Stata version 12.0 software was used for data analysis. Fourteen studies, which included 3330 newborns, were extracted from 986 studies. The weighted mean difference (WMD) of the platelet count was - 17.98 (p < 0.001), the platelet distribution width (PDW) was 0.27 (p = 0.266), the mean platelet volume (MPV) was 0.01 (p = 0.958), the plateletcrit (PCT) was - 0.03 (p < 0.001), and the platelet mass was - 150.10 (p = 0.001).Conclusion: Platelet count, PCT, and platelet mass of the first 3 days of life are potentially helpful in identifying premature infants at risk of hsPDA. More prospective studies on the relationship between different degrees of thrombocytopenia and platelet function and hsPDA should be conducted. What is Known: • Platelets are involved in the formation of thrombi during closure of the arterial duct. • The diagnosis of hsPDA by Doppler echocardiography and clinical signs is not precise enough. What is New: • Preterm newborns with hsPDA in the first week of life demonstrated a significant reduction in platelet count, platelet mass, and plateletcrit in the first 3 days of life. • No significant difference was shown between hsPDA and non-hsPDA infants in platelet distribution width and mean platelet volume in the first 3 days of life.
Collapse
|
34
|
Mo YD, Delaney M. Transfusion in Pediatric Patients: Review of Evidence-Based Guidelines. Clin Lab Med 2021; 41:1-14. [PMID: 33494878 DOI: 10.1016/j.cll.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Children require transfusion of blood components for a vast array of medical conditions, including acute hemorrhage, hematologic and nonhematologic malignancies, hemoglobinopathy, and allogeneic and autologous stem cell transplant. Evidence-based literature on pediatric transfusion practices is limited, particularly for non-red blood cell products, and many recommendations are extrapolated from studies in adult populations. Recognition of these knowledge gaps has led to increasing numbers of clinical trials focusing on children and establishment of pediatric transfusion working groups in recent years. This article reviews existing literature on pediatric transfusion therapy within the larger context of analogous data in adult populations.
Collapse
Affiliation(s)
- Yunchuan Delores Mo
- Transfusion Medicine, Children's National Hospital, 111 Michigan Avenue Northwest, Laboratory Administration, Suite 2100, Washington, DC 20010, USA.
| | - Meghan Delaney
- Pathology and Laboratory Medicine Division, Transfusion Medicine, Children's National Hospital, 111 Michigan Avenue Northwest, Laboratory Administration, Suite 2100, Washington, DC 20010, USA
| |
Collapse
|
35
|
Sallmon H, Timme N, Atasay B, Erdeve Ö, Hansmann G, Singh Y, Weber SC, Shelton EL. Current Controversy on Platelets and Patent Ductus Arteriosus Closure in Preterm Infants. Front Pediatr 2021; 9:612242. [PMID: 33718298 PMCID: PMC7946843 DOI: 10.3389/fped.2021.612242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/03/2021] [Indexed: 12/13/2022] Open
Abstract
Platelets are critically involved in murine patent ductus arteriosus (PDA) closure. To date, the clinical significance of these findings in human preterm infants with PDA is still controversial. We discuss the available study data on the role of platelets for PDA closure in preterm infants: Several mostly retrospective studies have yielded conflicting results on whether thrombocytopenia contributes to failed spontaneous ductal closure. The same applies to investigations on the role of thrombocytopenia as a risk factor for unsuccessful ductus arteriosus closure by pharmacological treatment with cyclooxygenase inhibitors. Nonetheless, recent meta-analyses have concluded that thrombocytopenia constitutes an independent risk factor for both failed spontaneous and pharmacological PDA closure in preterm infants. However, the available investigations differ in regard to patient characteristics, diagnostic strategies, and treatment protocols. Several studies suggest that impaired platelet function rather than platelet number is critically involved in failure of ductus arteriosus closure in the preterm infant. A recent randomized-controlled trial on platelet transfusions in preterm infants with PDA failed to show any benefit for liberal vs. restrictive transfusion thresholds on PDA closure rates. Importantly, liberal transfusions were associated with an increased rate of intraventricular hemorrhage, and thus should be avoided. In conclusion, the available evidence suggests that thrombocytopenia and platelet dysfunction contribute to failure of spontaneous and pharmacological PDA closure in preterm infants. However, these platelet effects on PDA seem to be of only moderate clinical significance. Furthermore, platelet transfusions in thrombocytopenic preterm infants in order to facilitate PDA closure appear to cause more harm than good.
Collapse
Affiliation(s)
- Hannes Sallmon
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Natalie Timme
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | - Begüm Atasay
- Division of Neonatology, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Ömer Erdeve
- Division of Neonatology, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Georg Hansmann
- Department of Pediatric Cardiology and Intensive Care Medicine, Medizinische Hochschule Hannover, Hanover, Germany
| | - Yogen Singh
- Department of Neonatology and Pediatric Cardiology, Cambridge University Hospitals, Cambridge, United Kingdom
- University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Sven C. Weber
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | - Elaine L. Shelton
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, United States
| |
Collapse
|
36
|
González-Luis G, Ghirardello S, Bas-Suárez P, Cavallaro G, Mosca F, Clyman RI, Villamor E. Platelet Counts and Patent Ductus Arteriosus in Preterm Infants: An Updated Systematic Review and Meta-Analysis. Front Pediatr 2021; 8:613766. [PMID: 33553072 PMCID: PMC7854898 DOI: 10.3389/fped.2020.613766] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/21/2020] [Indexed: 12/15/2022] Open
Abstract
Background: A meta-analysis published in 2015 showed a significant association between low platelet counts in the first day(s) of life and risk of patent ductus arteriosus (PDA). The meta-analysis pooled data from 11 studies cohorts (3,479 preterm infants). Objective: To update the meta-analysis by adding new studies on the topic and including other platelet parameters different from platelet counts. Methods: PubMed/Medline and Embase databases were searched. Random-effects risk ratios (RR) and differences in means (DM) and 95% confidence intervals (CI) were calculated. Results: We included 31 studies (7,638 infants). Meta-analysis showed that the risk of developing any PDA was significantly associated with platelet counts<150 × 109/L (11 studies, RR 1.58, 95% CI 1.28 to 1.95), and <100 x 109/L (7 studies, RR 1.61, 95% CI 1.14 to 2.28), but not <50 x 109/L (4 studies, RR 1.34, 95% CI 0.77 to 2.32). Risk of developing hemodynamically significant PDA (hsPDA) was significantly associated with platelet counts<150 x 109/L (12 studies, RR 1.33, 95% CI 1.09 to 1.63), and <100 x 109/L (7 studies, RR 1.39, 95% CI 1.06 to 1.82), but not <50 x 109/L (6 studies, RR 1.24, 95% CI 0.86 to 1.79). Infants with hsPDA had significantly lower mean platelet counts (19 studies, DM 22.0 x 109, 95% CI 14.9 to 29.1) and platelet mass (11 studies, DM 214.4, 95% CI 131.2 to 297.5) and significantly higher platelet distribution width (PDW, 9 studies, DM -0.53, 95% CI -1.01 to -0.05) than infants without hsPDA. Meta-analysis could not demonstrate significant differences in mean platelet volume (MPV). Conclusion: Compared to the previous analysis, this updated meta-analysis included 21 additional studies that provide stronger evidence of the association between low platelet counts and PDA/hsPDA. Other platelet parameters such as platelet mass and PDW are also associated with hsPDA risk. However, the low number of platelets may be an epiphenomenon associated with the maturity and clinical stability of preterm infants rather than a contributing factor in the pathogenesis of PDA.
Collapse
Affiliation(s)
- Gema González-Luis
- Department of Neonatology, Complejo Hospitalario Universitario Insular Materno-Infantil (CHUIMI) de Canarias, Las Palmas de Gran Canaria, Spain
| | - Stefano Ghirardello
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pilar Bas-Suárez
- Department of Pediatrics, Hospital Vithas Santa Catalina, Las Palmas de Gran Canaria, Spain
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Ronald I Clyman
- Cardiovascular Research Institute, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), Maastricht, Netherlands
| |
Collapse
|
37
|
Zhong J, Lin B, Fu Y, Yu Y, Zhao J, Zhao D, Yang C, Chen X. Platelet Count Might Be Associated With the Closure of Hemodynamically Significant Patent Ductus Arteriosus. Front Pediatr 2021; 9:729461. [PMID: 34708010 PMCID: PMC8544944 DOI: 10.3389/fped.2021.729461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/02/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Platelet-rich thrombosis leads to the occlusion of arteries. Whether the association between platelet count and closure of hemodynamically significant patent ductus arteriosus (hsPDA) exists remains inconclusive. Given that neonatal platelet count is significantly affected by infection, this study aims to evaluate the association of platelet parameters before ibuprofen treatment with the closure of hsPDA in very low birth weight (VLBW) infants without concurrent infection. Methods: A retrospective study was conducted at the NICU of Shenzhen Maternity and Child Healthcare Hospital from January 2016 to August 2020. VLBW infants diagnosed with hsPDA, treated with oral ibuprofen and without concurrent infection were included in this study. The platelet parameters were retrieved from the whole-blood test routinely performed within 24 h before starting treatment of oral ibuprofen. A multiple regression model was built to evaluate the association between platelet parameters before ibuprofen treatment and successful closure of hsPDA. Results: A total of 129 premature infants with hsPDA were analyzed in this study. After oral ibuprofen treatment, successful closure of hsPDA was achieved in 70 (54.3%) infants. The gestational age at birth and birth weight in infants with successful or failed closure of hsPDA after ibuprofen treatment were 28.3 vs. 27.6 weeks (p = 0.016) and 1,120 vs. 960 g (p = 0.043), respectively. The rate of mechanical ventilation in infants with successful closure of hsPDA was significantly lower compared to those with failed closure of hsPDA, 31.4 vs. 54.2%, p = 0.014. The platelet count in infants with successful closure of hsPDA after ibuprofen treatment was significantly higher compared to those with failed closure of hsPDA, 212 vs. 183 (in a unit of 109/L), respectively (p = 0.024). Multivariate logistic regression analysis showed that a higher platelet count (≥181 × 109/L) before ibuprofen treatment was independently associated with successful closure of hsPDA [odds ratio 2.556, 95% confidence interval (1.101-5.932), p = 0.029]. Conclusion: The findings in this study suggest that a higher platelet count before oral ibuprofen treatment may predict the probability of successful closure of hsPDA in VLBW infants.
Collapse
Affiliation(s)
- Junyan Zhong
- Department of Neonatology, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Binchun Lin
- Department of Neonatology, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Yongping Fu
- Department of Neonatology, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Yanliang Yu
- Department of Neonatology, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Jie Zhao
- Department of Neonatology, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Depeng Zhao
- Department of Reproductive Medicine, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Chuanzhong Yang
- Department of Neonatology, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Xueyu Chen
- Department of Neonatology, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, China
| |
Collapse
|
38
|
Reibel NJ, Dame C, Bührer C, Muehlbacher T. Aberrant Hematopoiesis and Morbidity in Extremely Preterm Infants With Intrauterine Growth Restriction. Front Pediatr 2021; 9:728607. [PMID: 34869097 PMCID: PMC8633541 DOI: 10.3389/fped.2021.728607] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/06/2021] [Indexed: 12/16/2022] Open
Abstract
Background and Objective: Intrauterine growth restriction (IUGR) poses additional challenges in extremely low gestational age newborns (ELGANs). We assessed disturbed hematopoiesis and morbidities associated with this disorder. Methods: This single-center retrospective case-control study compared perinatal hematological profiles, major morbidities, and mortality of 49 infants (gestational age <28 weeks, birth weight ≤ 3rd percentile, and compromised placental function) and 98 infants (birth weight >10th percentile) matched for gestational age, year, and sex. Results: IUGR-ELGANs had significantly elevated nucleated red blood cells and lower neutrophil and platelet counts at birth and on the third day of life. During the first week of life, IUGR-ELGANs received more red blood cell, platelet, and plasma transfusions and were more intensively treated with antibiotics. Rates of infections acquired during the first week (59.2 vs. 17.3%, p < 0.001), severe bronchopulmonary dysplasia or death (42.9 vs. 17.3%, p < 0.01), and mortality (36.7 vs. 7.1%, p < 0.001) were markedly elevated in IUGR-ELGANs, but not of hemorrhages or other morbidities. Conclusions: IUGR-ELGANs have high rates of acquired infections during the first week of life and display severe pulmonary morbidity leading to bronchopulmonary dysplasia or death. The high rate of transfusions observed in these infants warrants further scrutiny.
Collapse
Affiliation(s)
- Nora J Reibel
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christof Dame
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Muehlbacher
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
39
|
Zerra PE, Josephson CD. Transfusion in Neonatal Patients: Review of Evidence-Based Guidelines. Clin Lab Med 2020; 41:15-34. [PMID: 33494882 DOI: 10.1016/j.cll.2020.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Transfusion of red blood cells, platelets, and fresh frozen plasma in neonatal patients has not been well characterized in the literature, with guidelines varying greatly between institutions. However, anemia and thrombocytopenia are highly prevalent, especially in preterm neonates. When transfusing a neonatal patient, clinicians must take into consideration physiologic differences, gestational and postnatal age, congenital disorders, and maternal factors while weighing the risks and benefits of transfusion. This review of existing literature summarizes current evidence-based neonatal transfusion guidelines and highlights areas of current ongoing research and those in need of future studies.
Collapse
Affiliation(s)
- Patricia E Zerra
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA 30322, USA; Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Egleston Hospital, 1405 Clifton Rd, Atlanta, GA 30322, USA
| | - Cassandra D Josephson
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA 30322, USA; Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Egleston Hospital, 1405 Clifton Rd, Atlanta, GA 30322, USA.
| |
Collapse
|
40
|
Hamrick SEG, Sallmon H, Rose AT, Porras D, Shelton EL, Reese J, Hansmann G. Patent Ductus Arteriosus of the Preterm Infant. Pediatrics 2020; 146:e20201209. [PMID: 33093140 PMCID: PMC7605084 DOI: 10.1542/peds.2020-1209] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2020] [Indexed: 02/07/2023] Open
Abstract
Postnatal ductal closure is stimulated by rising oxygen tension and withdrawal of vasodilatory mediators (prostaglandins, nitric oxide, adenosine) and by vasoconstrictors (endothelin-1, catecholamines, contractile prostanoids), ion channels, calcium flux, platelets, morphologic maturity, and a favorable genetic predisposition. A persistently patent ductus arteriosus (PDA) in preterm infants can have clinical consequences. Decreasing pulmonary vascular resistance, especially in extremely low gestational age newborns, increases left-to-right shunting through the ductus and increases pulmonary blood flow further, leading to interstitial pulmonary edema and volume load to the left heart. Potential consequences of left-to-right shunting via a hemodynamically significant patent ductus arteriosus (hsPDA) include increased risk for prolonged ventilation, bronchopulmonary dysplasia, necrotizing enterocolitis or focal intestinal perforation, intraventricular hemorrhage, and death. In the last decade, there has been a trend toward less aggressive treatment of PDA in preterm infants. However, there is a subgroup of infants who will likely benefit from intervention, be it pharmacologic, interventional, or surgical: (1) prophylactic intravenous indomethacin in highly selected extremely low gestational age newborns with PDA (<26 + 0/7 weeks' gestation, <750 g birth weight), (2) early targeted therapy of PDA in selected preterm infants at particular high risk for PDA-associated complications, and (3) PDA ligation, catheter intervention, or oral paracetamol may be considered as rescue options for hsPDA closure. The impact of catheter-based closure of hsPDA on clinical outcomes should be determined in future prospective studies. Finally, we provide a novel treatment algorithm for PDA in preterm infants that integrates the several treatment modalities in a staged approach.
Collapse
Affiliation(s)
- Shannon E G Hamrick
- Divisions of Neonatology and
- Cardiology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | | | - Diego Porras
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Elaine L Shelton
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Jeff Reese
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| |
Collapse
|
41
|
Kim J, Lee JW, Kim DY. Analysis of Characteristics of Peripheral Arterial Ischemia in Premature Babies and Effects of Nitroglycerin Patch Application. CHILD HEALTH NURSING RESEARCH 2020; 26:434-444. [PMID: 35004487 PMCID: PMC8650864 DOI: 10.4094/chnr.2020.26.4.434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 09/27/2020] [Accepted: 09/30/2020] [Indexed: 11/06/2022] Open
Abstract
Purpose: The aim of this retrospective study was to analyze the characteristics of peripheral arterial ischemia and tissue necrosis in premature babies, as well as the effects of nitroglycerin.Methods: In total, 513 newborns were enrolled who were admitted to the neonatal intensive care unit with a gestational age of 34 weeks or younger. Data were collected on general personal and clinical information, peripheral arterial ischemia, and nitroglycerin patch application in the premature infants. The collected data were analyzed using the x<sup>2</sup> test, t-test, Mann-Whitney U test, logistic regression.Results: Thirty-six (7.0%) infants had peripheral arterial ischemia, while 477 (93.0%) infants did not. Lower gestational age (x<sup>2</sup>=35.97, p<.001), lower birth weight (x<sup>2</sup>=29.40, p<.001), lower blood pressure (x<sup>2</sup>=23.10, p<.001), and insertion of an umbilical artery catheter (p<.001) were significantly associated with the occurrence of peripheral arterial ischemia. Among the preterm infants in whom nitroglycerin patches were applied, 30 (83.3%) premature infants without necrosis improved without complications, 4 (11.1%) showed hypotension, and 2 (5.6%) showed skin damage.Conclusion: Based on a review of our experiences with nitroglycerin patches, we recommend closely observing skin color and using nitroglycerin patches on the skin to help improve flow in premature infants with peripheral arterial ischemia.
Collapse
Affiliation(s)
- Jeongeun Kim
- Registered Nurse, Neonatal Intensive Care Unit, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jin Won Lee
- Registered Nurse, Neonatal Intensive Care Unit, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Dong Yeon Kim
- Unit Manager, Hematology Intensive Care Unit, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
42
|
Stubbs JR, Homer MJ, Silverman T, Cap AP. The current state of the platelet supply in the US and proposed options to decrease the risk of critical shortages. Transfusion 2020; 61:303-312. [PMID: 33098328 DOI: 10.1111/trf.16140] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 12/22/2022]
Abstract
Due to circumstances such as increased demand and an aging donor pool, the likelihood of critical platelet shortages is increasing. The platelet supply could be improved through the expansion of the donor pool, the identification and sustained utilization of high-quality donors, and changes in component processing and storage that result in a longer platelet shelf-life. Refrigerated platelets, stored at 1° to 6°C, have the potential to improve patient safety by decreasing the risk of bacterial contamination while concurrently allowing for a longer storage period (eg, 14 days) and improved hemostatic effectiveness in actively bleeding patients. An approach utilizing remuneration of apheresis platelet donors combined with pathogen reduction of the platelet components could be used as a means to increase the donor pool and identify and sustain safe, reliable, high-quality donors. Remuneration might provide an incentive for underutilized populations (eg, individuals <30 years old) to enter the apheresis platelet donor population resulting in a significant expansion of the platelet donor pool. Over time, approaches such as the use of refrigerated platelets, platelet donor remuneration, and the application of pathogen reduction technology, might serve to attract a large, reliable, and safe donor base that provides platelet collections with high yields, longer shelf-lives and, excellent hemostatic function.
Collapse
Affiliation(s)
- James R Stubbs
- Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary J Homer
- Department of Health and Human Services, Biomedical Advanced Research and Development Authority (BARDA), Washington, DC, USA
| | - Toby Silverman
- Department of Health and Human Services, Biomedical Advanced Research and Development Authority (BARDA), Washington, DC, USA
| | - Andrew P Cap
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, US Army Institute of Surgical Research and Uniformed Services University, JBSA-FT Sam Houston, Texas, USA
| |
Collapse
|
43
|
Abstract
INTRODUCTION Thrombocytopaenia is one of the most common haemostatic abnormalities among neonates. It affects approximately one-quarter of neonates admitted into neonatal intensive care units and may lead to a high risk of bleeding and mortality, which are substantial causes for concern by neonatologists. Platelet transfusion (PT) is a specific treatment for thrombocytopaenia. To date, PT thresholds are diverse since the associations between low platelet count and negative outcomes are not clear. We propose this protocol for a systematic review to collect and assess evidence concerning the best PT threshold to reduce mortality, bleeding and major morbidity among neonates with thrombocytopaenia. METHODS AND ANALYSIS The systematic review will be performed according to the Cochrane Handbook for Systematic Review of Interventions, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and the Grading of Recommendations Assessment, Development and Evaluation system. Two independent researchers will perform the study selection, data extraction/coding, quality assessment and further analyses of the included studies, with disagreements being resolved by a third researcher. A systematic search of the literature will be conducted in the PubMed, Cochrane Library and Embase databases from database inception through 13 October 2020. All randomised controlled trials, cohort studies and case-control studies will be included without any restrictions regarding publication date or language. The primary outcomes will comprise in-hospital mortality and bleeding episodes. Endnote X9 and Review Manager V.5.3 software will be used to manage the selection process and statistical analysis, respectively. If the included studies are sufficient and homogeneous for any of the outcomes, a quantitative synthesis (meta-analysis) may be performed. Otherwise, we will conduct a narrative systematic review of the results. ETHICS AND DISSEMINATION Ethical approval is not required for this study because the data will be obtained from published studies and will not include individual patient data. The results of this study are anticipated to be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42020169262.
Collapse
Affiliation(s)
- Dengjun Liu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Sichuan University, Chengdu, China
| | - Jinlin Wu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Sichuan University, Chengdu, China
| | - Tao Xiong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Sichuan University, Chengdu, China
| | - Yan Yue
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Sichuan University, Chengdu, China
| | - Jun Tang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Sichuan University, Chengdu, China
| |
Collapse
|
44
|
Abstract
PURPOSE OF REVIEW In this review, we focus on three specific concepts related to platelet transfusion in the neonatal and pediatric population: choice of transfusion threshold; use of ABO-mismatched platelets; transfusion of pathogen-reduced or inactivated platelets. RECENT FINDINGS Recent trials support the use of lower platelet transfusion thresholds (25 000/μl) in preterm neonates, although data is limited to guide transfusion among more mature neonates. In children, there is low-level evidence as to what the prophylactic platelet transfusion threshold should be in many situations of thrombocytopenia, revealing major variability in platelet transfusion practices. Most pediatric guidelines are extrapolated from adult studies with the most evidence in treatment-associated hypoproliferative thrombocytopenia varying between a platelet transfusion threshold of 10 000/μl to 20 000/μl. Although pathogen-reduced platelets may lower the risks of transfusion-transmitted infection, the effects on platelet refractoriness and transfusion burden in this population warrant additional study. SUMMARY Our review highlights recent advances in neonatal and pediatric platelet transfusion and also emphasizes the urgent need for better evidence to guide practice given recent studies showing the potential harms of platelet transfusion, particularly with liberal use.
Collapse
|
45
|
Abstract
BACKGROUND Thrombocytopenia is a risk factor for patent ductus arteriosus. Immature and mature platelets exhibit distinct haemostatic properties; however, whether platelet maturity plays a role in postnatal, ductus arteriosus closure is unknown. METHODS In this observational study, counts of immature and mature platelets (=total platelet count - immature platelet count) were assessed on days 1, 3, and 7 of life in very low birth weight infants (<1500 g birth weight). We performed echocardiographic screening for haemodynamically significant patent ductus arteriosus on day 7. RESULTS Counts of mature platelets did not differ on day 1 in infants with (n = 24) and without (n = 45) haemodynamically significant patent ductus arteriosus, while infants with significant patent ductus arteriosus exhibited lower counts of mature platelet on postnatal days 3 and 7. Relative counts of immature platelets (fraction, in %) were higher in infants with patent ductus arteriosus on day 7 but not on days 1 and 3. Receiver operating characteristic curve analysis unraveled associations between both lower mature platelet counts and higher immature platelet fraction (percentage) values on days 3 and 7, with haemodynamically significant ductus arteriosus. Logistic regression analysis revealed that mature platelet counts, but not immature platelet fraction values, were independent predictors of haemodynamically significant patent ductus arteriosus. CONCLUSION During the first week of postnatal life, lower counts of mature platelets and higher immature platelet fraction values are associated with haemodynamically significant patent ductus arteriosus. Lower counts of mature platelet were found to be independent predictors of haemodynamically significant patent ductus arteriosus.
Collapse
|
46
|
Waubert de Puiseau M, Sciesielski LK, Meyer O, Liu ZJ, Badur CA, Schönfeld H, Tauber R, Pruß A, Sola-Visner MC, Dame C. Pooling, room temperature, and extended storage time increase the release of adult-specific biologic response modifiers in platelet concentrates: a hidden transfusion risk for neonates? Transfusion 2020; 60:1828-1836. [PMID: 32339309 DOI: 10.1111/trf.15827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Adult donor platelets (PLTs) are frequently transfused to prevent or stop bleeding in neonates with thrombocytopenia. There is evidence for PLT transfusion-related morbidity and mortality, leading to the hypothesis on immunomodulatory effects of transfusing adult PLTs into neonates. Candidate factors are biologic response modifiers (BRMs) that are expressed at higher rates in adult than in neonatal PLTs. This study investigated whether storage conditions or preparation methods impact on the release of those differentially expressed BRMs. STUDY DESIGN AND METHODS Pooled PLT concentrates (PCs) and apheresis PCs (APCs) were stored under agitation for up to 7 days at room temperature (RT) or at 2 to 8°C. The BRMs CCL5/RANTES, TGFβ1, TSP1, and DKK1 were measured in PCs' supernatant, lysate, and corresponding plasma. PLT function was assessed by light transmission aggregometry. RESULTS Concerning the preparation method, higher concentrations of DKK1 were found in pooled PCs compared to APCs. In supernatants, the concentrations of CCL5, TGFβ1, TSP1, and DKK1 significantly increased, both over standard (≤4 days) and over extended storage times (7 days). Each of the four BRMs showed an up to twofold increase in concentration after storage at RT compared to cold storage (CS). There was no difference in the aggregation capacity. CONCLUSION This analysis shows that the release of adult-specific BRMs during storage is lowest in short- and CS APCs. Our study points to strategies for reducing the exposure of sick neonates to BRMs that can be specifically associated to PLT transfusion-related morbidity.
Collapse
Affiliation(s)
| | - Lina K Sciesielski
- Klinik für Neonatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Meyer
- Institute of Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Zhi-Jian Liu
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston/MA, USA
| | | | - Helge Schönfeld
- Institut für Laboratoriumsmedizin, Klinische Chemie und Pathobiochemie Charité - Universitätsmedizin Berlin, and Labor Berlin Charité Vivantes GmbH, Berlin
| | - Rudolf Tauber
- Institut für Laboratoriumsmedizin, Klinische Chemie und Pathobiochemie Charité - Universitätsmedizin Berlin, and Labor Berlin Charité Vivantes GmbH, Berlin
| | - Axel Pruß
- Institute of Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Martha C Sola-Visner
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston/MA, USA
| | - Christof Dame
- Klinik für Neonatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
47
|
Pediatric non-red cell blood product transfusion practices: what's the evidence to guide transfusion of the 'yellow' blood products? Curr Opin Anaesthesiol 2020; 33:259-267. [PMID: 32049883 DOI: 10.1097/aco.0000000000000838] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Research studies pertaining to the management of pediatric non-red cell blood product transfusion is limited. Clinical practices vary within disciplines and regions. Anesthesiologists need evidence-based guidelines to make appropriate and safe decisions regarding transfusion of the 'yellow' blood products for pediatric patients. RECENT FINDINGS This review outlines clinical indications for transfusion of fresh frozen plasma, cryoprecipitate, platelets, and fibrinogen concentrate in pediatrics. Recent studies of non-red blood cell transfusions in critical, but stable situations are highlighted. Recommendations to guide transfusion of the 'yellow' blood products in operative and non-operative settings are summarized. Special attention is drawn to guidelines in massive hemorrhage and trauma situations. SUMMARY Evidence-based guidelines and expert consensus recommendations exist to guide the transfusion of pediatric non-red blood products and should be followed when transfusing the 'yellow' blood components. As high-quality studies in neonates, infants and children are limited, future research should broaden our knowledge in this direction with the goal to use restrictive strategies to improve patient outcomes.
Collapse
|
48
|
Bardanzellu F, Piras C, Atzei A, Neroni P, Fanos V. Early Urinary Metabolomics in Patent Ductus Arteriosus Anticipates the Fate: Preliminary Data. Front Pediatr 2020; 8:613749. [PMID: 33409262 PMCID: PMC7779766 DOI: 10.3389/fped.2020.613749] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 11/24/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction: In premature neonates, the persistence of hemodynamically significant ductus arteriosus (hsPDA) can be associated with short- and long-term consequences, impairing their outcome. The correct strategy of management for such condition is under debate, especially regarding contraindications and/or side effects. In recent years, metabolomics was applied to several perinatal, pediatric, and adult conditions to investigate potential biomarkers of disease, which have become useful for early diagnosis and/or therapeutic management. Aim of the Study: The main purpose of our exploratory study was to asses, through 1H-NMR metabolomics analysis of urinary samples at birth, possible metabolic pathways differentiating, with a significant predictive power, those preterm neonates who will subsequently develop hsPDA and neonates of comparable gestational age (GA) who will undergo spontaneous ductal closure or the persistence of an irrelevant PDA (no-hsPDA). Moreover, we investigated potential prenatal or perinatal clinical factors potentially influencing the development of hsPDA. Materials and Methods: We enrolled n = 35 preterm neonates with GA between 24 and 32 weeks; urinary samples were collected within the first 12 h of life. Patients were closely monitored regarding intensive care, respiratory support, fluid balance and administered drugs; an echocardiogram was performed at 48-72 h. Results: Our results reported a significant correlation between lower GA at birth and the development of hsPDA. Moreover, neonates with GA ≤ 30w developing hsPDA were characterized by lower Apgar scores at 1' and 5', higher rates of perinatal asphyxia, higher need of delivery room resuscitation and subsequent surfactant administration. Interestingly, metabolomics analysis at birth detected a clear separation between the 1H-NMR urinary spectra of subjects GA ≤ 30w not developing hsPDA (n = 19) and those of subjects born at GA ≤ 30w in which hsPDA was confirmed at 48-72 h of life (n = 5). Conclusions: This is the first study applying metabolomics to investigate the PDA condition. Although preliminary and conducted on a limited sample, our results reveal that metabolomics could be a promising tool in the early identification of hsPDA, potentially superior to the clinical or laboratory predictive tools explored to date and even to the clinical observations and correlations in our sample, through the detection of specific urinary metabolites.
Collapse
Affiliation(s)
- Flaminia Bardanzellu
- Neonatal Intensive Care Unit, Department of Surgical Sciences, Azienda Ospedaliero-Universitaria and University of Cagliari, Cagliari, Italy
| | - Cristina Piras
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Alessandra Atzei
- Neonatal Intensive Care Unit, Department of Surgical Sciences, Azienda Ospedaliero-Universitaria and University of Cagliari, Cagliari, Italy
| | - Paola Neroni
- Neonatal Intensive Care Unit, Department of Surgical Sciences, Azienda Ospedaliero-Universitaria and University of Cagliari, Cagliari, Italy
| | - Vassilios Fanos
- Neonatal Intensive Care Unit, Department of Surgical Sciences, Azienda Ospedaliero-Universitaria and University of Cagliari, Cagliari, Italy
| |
Collapse
|
49
|
Ghirardello S, Raffaeli G, Crippa BL, Gulden S, Amodeo I, Consonni D, Cavallaro G, Schena F, Mosca F. The Thromboelastographic Profile at Birth in Very Preterm Newborns with Patent Ductus Arteriosus. Neonatology 2020; 117:316-323. [PMID: 32485708 DOI: 10.1159/000507553] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The role of hemostasis in the closure of patent ductus arteriosus (PDA) in preterm infants is controversial. OBJECTIVE To assess thromboelastography (TEG) at birth in very-low-birth-weight (VLBW) infants affected by PDA. METHODS This was an ancillary study of a prospective observational study aimed at defining the TEG profile in healthy VLBW infants in the first month of life. In this analysis, we included neonates of <33 weeks' gestational age (GA) with PDA and compared TEG traces based on (1) spontaneous closure versus the need for pharmacological treatment and (2) treatment response. We collected blood samples in the 1st day of life to perform recalcified native-blood TEG (reaction time, maximum amplitude, and lysis at 30 min [Ly30)]), standard coagulation tests, and a full blood count. RESULTS We enrolled 151 infants with a PDA at the first echocardiogram; 111 experienced spontaneous PDA closure while 40 required treatment. Mean GA was 29.7 ± 1.7 and 27.6 ± 2.1 weeks, and birth weight was 1,158 ± 256 and 933 ± 263 g in the 2 groups, respectively (p < 0.001). The hemostatic profile was similar between groups. Median hematocrit (44.6 and 48.7%; p = 0.01) and platelet count (187 and 216 × 103/μL; p = 0.04) were lower in the treated group, although differences lost significance after controlling for GA and illness severity in the multivariate analysis. Responders to PDA treatment (n = 20) had a significantly lower median Ly30 than nonresponders (0 and 0.7%; p = 0.02). CONCLUSION TEG at birth does not predict spontaneous PDA closure in preterm newborns. Fibrinolysis is enhanced in nonresponders to PDA treatment; this observation warrants further investigation.
Collapse
Affiliation(s)
- Stefano Ghirardello
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy,
| | | | - Silvia Gulden
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Ilaria Amodeo
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Schena
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
50
|
Abstract
Thrombocytopenia is common in preterm neonates. Thresholds for prophylactic platelet transfusion vary widely due to lack of evidence. The results of the PlaNet-2/MATISSE Study identified harm in the form of mortality and major bleed in babies prophylactically transfused below a platelet count of 50 × 109/L compared to 25 × 109/L. Neonatal platelet transfusions are administered at volumes based on historical practice which greatly exceed those routinely used in adults. Rate of transfusion is also based around practice in trauma and does not take into account the physiology of the preterm infant. There are multiple ways in which platelets may be mediating harm and this review discusses these potential mechanisms including immunological, inflammatory and blood group incompatibility. Much of the difficulty in assessing harm relates to problems in classification of transfusion-associated adverse events in babies. Thrombocytopenia and timing, efficacy and adverse effects of platelet transfusion are poorly understood. Further research is essential.
Collapse
Affiliation(s)
| | - Anna Curley
- National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| |
Collapse
|